First French experiences of total body irradiations using helical TomoTherapy®.

PURPOSE: Dynamic conformal radiotherapy with helical TomoTherapy® (HT) offers a more quantitative paradigm for total body irradiation. Treatment planning, delivery, dose verification of the first French experiences of total body irradiation using helical TomoTherapy® are presented. MATERIALS AND METHODS: Patients planned for total body irradiation at our institution from February 2012 to May 2013 were reported. Total body irradiation consisted in a single fraction of 2Gy. Planning target volume was divided in two due to the limited translation length of the table. Delivery quality assurance was performed with cylindrical phantom, ionization chamber and films. Thermoluminescent dosimeters and radiochromic films were used for in vivo dosimetry and junction region heterogeneity assessment. RESULTS: Six patients were included. One finally did not receive the treatment but dosimetric data were analyzed. Planned V95% was covered by D95% and V2% did not exceed D107% for five of the six patients. The mean relative difference between measured and calculated absolute dose of the Delivery quality assurance was always less than 2.5% (mean value±SD: 1%±0.67%). Gamma index (3%; 3mm) was less than 1 for at least 93% of the points (value±SD: 97.4±1.6% and 96.6±2.5% for upper and lower part of treatment respectively). Difference between in vivo measured and calculated dose was above 5% for only two out of 15 points (maximum: 10.2%, mean: 0.73±4.6%). Junction region heterogeneity was in average 5.8±1%. The total treatment session of total body irradiation lasted 120min, with a mean beam on time of 17.2±0.6 and 11.2±1.6min for upper and lower part of the body respectively. CONCLUSION: Total body irradiation using helical TomoTherapy® guaranteed high dose homogeneity throughout the body and dose verification was achievable, showing small difference between planned and delivered doses.

Iris metastasis from prostate carcinoma: a case report and review of the literature.

Despite the high incidence of prostate carcinoma, metastases of the uvea are very rare and the iris localization is even more. Only a few cases worldwide have been described so far. We report here the case of a 66-year-old man diagnosed with a metastatic prostate carcinoma. Nine months later, he developed brain and skin metastases. A couple of weeks later, the metastatic lesion appeared on his left iris. He has received whole brain radiation therapy including the iris lesion in the radiation fields. Through this case report and a literature review, we discuss the incidence, the different clinical presentations and the impact on the survival prognosis of this uncommon metastatic site.

[Pain management in radiation oncology]. / Situations difficiles lors d'une irradiation : la douleur.

The goal of this article is to propose some practical means of pain management in radiation departments. Pain management in radiation oncology is difficult because of the high proportion of painful patients, underestimation by medical teams, and limited therapeutic options. Pain can cause mobilization difficulties, set-up errors, treatment interruption. According to procedure steps, a preventive attitude (for pre-radiation consultation) or an active attitude (for treatment) to quickly relieve the patient can be planned. This work is a brain storming about pain management. It is not a review about analgesic radiotherapy. The practical situations apply to patients to whom radiotherapy is indicated. Teamwork and anticipation are keywords to relieve patients. All proposed means are not always available for different reasons (time, finance, staff, training). The idea is to establish simple procedures that are appropriate to each center to fluidify acts, to optimize time for a successful irradiation.

Prophylactic cranial irradiation in lung cancer.

As multi-modality treatments are now able to ensure better local control and a lower rate of extra cranial metastases, brain relapse has become a major concern in lung cancer. As survival is poor after development of brain metastases in spite of specific treatment, prophylactic cranial irradiation (PCI) has been introduced in the 70's. PCI has been evaluated in randomized trials in both small-cell (SCLC) and non-small-cell (NSCLC) lung cancers to reduce the incidence of brain metastases and possibly increase survival. PCI reduces significantly the BM rate in both limited disease (LD) and extensive disease (ED) SCLC and in non-metastatic NSCLC. Considering SCLC, PCI significantly improves overall survival in LD (from 15% to 20% at 3 years) and ED (from 13% to 27% at 1 year) in patients who respond to first-line treatment; it should thus be part of the standard treatment in all responders in ED and in good responders in LD. No dose-effect relationship for PCI was demonstrated in LD SCLC patients so that the recommended dose is 25Gy in 10 fractions. In NSCLC, even if the risk of brain dissemination is lower than in SCLC, it has become a challenging issue. Studies have identified subgroups at higher risk of brain failure. There are more local treatment possibilities for NSCLC patients with BM, but most of them will eventually recur so that PCI should be reconsidered. Few randomized trials have been performed and they were not able to show an effect on survival as they were underpowered. New trials are needed.

[Prognostic factors in Hodgkin and non-Hodgkin lymphomas]. / Facteurs pronostiques dans les lymphomes non hodgkiniens et les lymphomes de Hodgkin.

Hodgkin's and non-Hodgkin's lymphomas are frequent and represent a heterogenic group of haematologic diseases. Prognostic factors allow to classify patients into homogeneic risk groups, to adapt treatment proposal to disease's risk and, in some cases, to avoid over-treatment. For all lymphomas, the first step is to determine the stage of the disease in Ann Arbor's classification, using physical examination, radiological and functional imaging. However, this classification is not optimal to predict disease evolution. Specific scores corresponding to the histological subtype of the lymphoma have been determined: IPI (international prognostic index) for aggressive lymphomas, FLIPI (follicular lymphoma international prognostic index) for indolent lymphomas and IPS (international prognostic score) for advanced Hodgkin's lymphomas. Functional imaging by PET (position emission tomography) is of prognostic significance in aggressive and Hodgkin lymphomas to evaluate early response to treatment, before autografting and at the end of the treatment. Several kinds of molecular prognostic markers have been studied: circulating rates of proteins, over expression of genes, presence of specific cells in the tumour... But these factors are not yet used in clinical practice, as they have not been validated on large cohorts and their interactions with other prognostic factors and between them are not well known. Although molecular biology has made some recent progress, only classical prognostic factors (physical examination, radiological and functional imaging) are used by now.