Fully 4D list-mode reconstruction applied to respiratory-gated PET scans.

(18)F-fluoro-deoxy-glucose ((18)F-FDG) positron emission tomography (PET) is one of the most sensitive and specific imaging modalities for the diagnosis of non-small cell lung cancer. A drawback of PET is that it requires several minutes of acquisition per bed position, which results in images being affected by respiratory blur. Respiratory gating techniques have been developed to deal with respiratory motion in the PET images. However, these techniques considerably increase the level of noise in the reconstructed images unless the acquisition time is increased. The aim of this paper is to evaluate a four-dimensional (4D) image reconstruction algorithm that combines the acquired events in all the gates whilst preserving the motion deblurring. This algorithm was compared to classic ordered subset expectation maximization (OSEM) reconstruction of gated and non-gated images, and to temporal filtering of gated images reconstructed with OSEM. Two datasets were used for comparing the different reconstruction approaches: one involving the NEMA IEC/2001 body phantom in motion, the other obtained using Monte-Carlo simulations of the NCAT breathing phantom. Results show that 4D reconstruction reaches a similar performance in terms of the signal-to-noise ratio (SNR) as non-gated reconstruction whilst preserving the motion deblurring. In particular, 4D reconstruction improves the SNR compared to respiratory-gated images reconstructed with the OSEM algorithm. Temporal filtering of the OSEM-reconstructed images helps improve the SNR, but does not achieve the same performance as 4D reconstruction. 4D reconstruction of respiratory-gated images thus appears as a promising tool to reach the same performance in terms of the SNR as non-gated acquisitions while reducing the motion blur, without increasing the acquisition time.

ICRP publication 112. A report of preventing accidental exposures from new external beam radiation therapy technologies.

Disseminating the knowledge and lessons learned from accidental exposures is crucial in preventing re-occurrence. This is particularly important in radiation therapy; the only application of radiation in which very high radiation doses are deliberately given to patients to achieve cure or palliation of disease. Lessons from accidental exposures are, therefore, an invaluable resource for revealing vulnerable aspects of the practice of radiotherapy, and for providing guidance for the prevention of future occurrences. These lessons have successfully been applied to avoid catastrophic events with conventional technologies and techniques. Recommendations, for example, include the independent verification of beam calibration and independent calculation of the treatment times and monitor units for external beam radiotherapy, and the monitoring of patients and their clothes immediately after brachytherapy. New technologies are meant to bring substantial improvement to radiation therapy. However, this is often achieved with a considerable increase in complexity, which in turn brings opportunities for new types of human error and problems with equipment. Dissemination of information on these errors or mistakes as soon as it becomes available is crucial in radiation therapy with new technologies. In addition, information on circumstances that almost resulted in serious consequences (near-misses) is also important, as the same type of events may occur elsewhere. Sharing information about near-misses is thus a complementary important aspect of prevention. Lessons from retrospective information are provided in Sections 2 and 4 of this report. Disseminating lessons learned for serious incidents is necessary but not sufficient when dealing with new technologies. It is of utmost importance to be proactive and continually strive to answer questions such as 'What else can go wrong', 'How likely is it?' and 'What kind of cost-effective choices do I have for prevention?'. These questions are addressed in Sections 3 and 5 of this report. Section 6 contains the conclusions and recommendations. This report is expected to be a valuable resource for radiation oncologists, hospital administrators, medical physicists, technologists, dosimetrists, maintenance engineers, radiation safety specialists, and regulators. While the report applies specifically to new external beam therapies, the general principles for prevention are applicable to the broad range of radiotherapy practices where mistakes could result in serious consequences for the patient and practitioner.

[Practical recommendations for breathing-adapted radiotherapy]. / Bonnes pratiques pour la radiothérapie asservie à la respiration.

Respiration-gated radiotherapy offers a significant potential for improvement in the irradiation of tumor sites affected by respiratory motion such as lung, breast and liver tumors. An increased conformality of irradiation fields leading to decreased complications rates of organs at risk (lung, heart...) is expected. Respiratory gating is in line with the need for improved precision required by radiotherapy techniques such as 3D conformal radiotherapy or intensity modulated radiotherapy. Reduction of respiratory motion can be achieved by using either breath-hold techniques or respiration synchronized gating techniques. Breath-hold techniques can be achieved with active techniques, in which airflow of the patient is temporarily blocked by a valve, or passive techniques, in which the patient voluntarily holds his/her breath. Synchronized gating techniques use external devices to predict the phase of the respiration cycle while the patient breaths freely. This work summarizes the different experiences of the centers of the STIC 2003 project. It describes the different techniques, gives an overview of the literature and proposes a practice based on our experience.

[Clinical and dosimetric analysis of 469 prostate cancer patients treated in France in 2005 by permanent implant brachytherapy using the Iodin 125 seeds IsoSeed Bebig: report to the French Economic committee of health products (CEPS)]. / Analyse clinique et dosimétrique de 469 patients traités en France en 2005 par implantation prostatique de grains d'iode 125 IsoSeed Bebig: rapport pour le Comité économique des produits de santé (CEPS).

A French decree of February 3rd 2005, allowed the Iodin 125 seeds from several companies to be reimbursed after a permanent implantation brachytherapy for a prostate cancer. Within this frame, the French "Comité économique des produits de santé" (CEPS; Economic committee for health products) made mandatory the annual writing and publication of a follow-up study with three main aims; make sure that the seeds were used for prostate cancer patients with criterias corresponding to the national recommendations, analyze the quality of the dosimetric data, and report all side effects, complications and possible accidents. We therefore report here a clinical and dosimetric analysis of 469 patient cases treated in France in nine centers in 2005 with the Iodin 125 IsoSeed Bebig. This analysis shows that: 1) The national recommendations for selecting patients for exclusive prostate brachytherapy have been taken into account in 97% of the cases; 2) The dosimetric quality criterias totally fulfilled the recommendations in a large majority of cases; the intra-operative D90 was found to be superior to 145 Gy in 98% of the patients, and the intra-operative V100 was superior to 95% in 96% of the cases; 3) The early toxicity (mainly urinary) was found to be at the lower range of what is reported in the literature, with in particular a retention rate of 2.4%.

[PSA bounce after permanent implant prostate brachytherapy may mimic a biochemical failure]. / Influence sur les résultats des rebonds du PSA après curiethérapie de prostate: étude de 295 cas avec trois ans de suivi.

PURPOSE: To assess the frequency of the PSA "bouncing" phenomenon after a significant follow-up in a series of patients treated by permanent implant brachytherapy for a prostate cancer. To look for the clinical and dosimetric parameters possibly linked to this transitory secondary PSA increase. To evaluate in which percentage of cases this bouncing could have mimicked a biochemical relapse according to the ASTRO consensus criteria. PATIENTS AND METHODS: From January 1999, to December 2001, 295 patients were treated by a permanent prostate implantation (real-time technique, with free (125)I seeds- Isoseed Bebig-) by the Institut Curie-Hôpital Cochin-Hôpital Necker Paris group. The mean follow-up is 40.3 months (9-66 months). The PSA level was regularly checked, at least every 6 months. We defined as a "bouncing" all increase in PSA, starting at 0.1 ng/ml, subsequently followed by a spontaneous (without any treatment) decrease, with return to the previous level or lower. We particularly focused on the patients fulfilling the criteria for a biochemical relapse according to the ASTRO consensus (Three successive increases in PSA). A multivariate analysis tried to identify independent factors among the usual clinical and dosimetric parameters. RESULTS: In our series, 161 patients (55%) showed a transitory PSA increase (bouncing) of at least 0.1 ng/ml; 145 patients (49%) a bouncing of 0.2 ng/ml, 93 patients (32%) a bouncing of 0.4 ng/ml and 43 patients (15%) a bouncing of at least 1 ng/ml. Mean PSA bounce was 0.8 ng/ml (0.1-4.1), and mean time to bounce was 19 months. Thirty-two patients (11% of the total number) presented three successive PSA increases with a significant (3 months) interval between the dosages, and therefore were to be considered as being in biochemical relapse according to the ASTRO consensus criteria. Actually, among those 32 patients, 18 (56%) subsequently showed a complete normalization of their PSA, without any treatment. Ten patients went on increasing their PSA, and were considered to be really in biochemical relapse. For the last 4 patients, the situation still remains ambiguous. In multivariate analysis, age<70 years (P<0.00001) and D90>200 Gy (P<0.003) were identified as independent factors for a PSA bouncing of at least 0.4 ng/ml. CONCLUSIONS: The observed rate of 32% of patients showing a PSA bouncing of at least 0.4 ng/ml in our series is in good agreement with what has been previously reported in the literature. Age<70 years and D90>200 Gy were found to be independent factors predicting for such a secondary transitory increase in PSA. Interestingly, among 32 patients fulfilling the classical criteria of the ASTRO for a biochemical relapse, 18 (56%) subsequently showed a spontaneous PSA decrease, demonstrating that the ASTRO consensus is not well adapted to the biochemical follow-up of our patients undergoing permanent implant prostate Brachytherapy.

[Comparative study and clinical implementation of two breathing-adapted radiotherapy techniques: dosimetric benefits for lung cancer treatment]. / Etude comparative et mise en oeuvre clinique de deux systèmes de radiothérapie asservie à la respiration : bénéfice dosimétrique pour le traitement du cancer du poumon.

Breathing can lead to organ motions up to several centimeters. For radiotherapy of lung, these motions are generally taken into account by adding a specific margin around the target. Thus, treated volumes are often too large to allow for the high-dose values requested for local control. To manage respiratory motion, deep-inspiration breath-hold technique (DIBH) and gated radiotherapy are starting being used clinically. DIBH consists in asking the patient to perform breath-hold during the treatment and the image acquisition, DIBH level being measured by a spirometer. Gated radiotherapy consists in treating the patient at a certain phase of the free breathing. Linac is synchronized with the motion of a marker located on the patient chest. Planning images are obtained by a four-dimensional CT (4D-CT) using the same marker. We have assessed the value of these two methods. For lung treatment, compared to a standard treatment, toxicity reduction was mainly due to the lung total volume increase. It is therefore more significant for breath-hold approach. It is also due to the reduction of safety margins, which is similar for both methods. These two techniques, which have specific advantages and drawbacks, are used routinely at Curie Institute for a large proportion of lung patients, but also for some breast, liver or even Hodgkin disease treatments.

[Brachytherapy for prostate cancer: old concept, new techniques]. / La curiethérapie du cancer prostatique: une idée ancienne, des techniques modernes.

Whereas it has been proposed almost one century ago, brachytherapy for prostate cancer has only recently emerged, especially thanks to endorectal echography, allowing to visualize seed implantation, to the development of seeds for permanent delivery and of micro-sources for high-dose rate delivery, and also to the development of three-dimension dosimetry programs allowing real-time implantations. For selected patients with localized prostate cancer (PSA < 10, Gleason < 7, no extracapsular extension, volume < 50-60 g), prostate brachytherapy with permanent implants (iodine 125 or, less frequently, palladium 103) gives results which appear at 10-15 years comparable to those of surgery. Incontinence and impotence rates appear lower than those of classical surgery. However, the first post-implant months are usually accompanied by urinary toxicity that should not be minimized. High-dose rate brachytherapy (HDR) could find its indications, in combination with conformal radiotherapy, in the treatment of more advanced forms, presenting an intermediate risk. It could also be an alternative to brachytherapy with permanent implants for the low-risk forms mentioned above, especially in developing countries where the cost of radioactive seeds slows down the use of this technique. Brachytherapy for prostate cancer should, therefore, find more and more indications, because of the increased incidence of prostate cancer, due to population ageing, of the increased proportion of localized forms, due to better detection, of the patient's request for less toxicity, and of the expecting lowering of the costs, which are now equivalent to those of surgery and should further lower.

Breast radiotherapy in women with pectus excavatum (funnel chest): is the lateral decubitus technique an answer? A dosimetric study.

Breast radiotherapy is a technical challenge in women with pectus excavatum. We aim to assess isocentric lateral decubitus (ILD) technique as a means to irradiate breasts for patients with pectus excavatum. Four women presenting with left-sided breast cancers and found to have pectus excavatum were offered breast-conserving treatments. Post-operative breast radiotherapy was indicated (50 Gy) in two patients, with an additional boost to the tumour bed (16 Gy). Both ILD and supine techniques were simulated. We report the dosimetric comparison of these techniques and the acute skin toxicity of ILD radiotherapy. ILD permitted the same breast dose-homogeneity as the supine technique while decreasing breast thickness by 4.5-6.8 cm. The width of lung and/or heart receiving > 20 Gy ranged between 2.1 cm and 4.3 cm with the supine technique and between 0.5 cm and 1.1 cm with ILD. The estimated percentage of ipsilateral lung receiving > 20 Gy ranged from 21% to 34% with the supine technique and from 0% to 5% with ILD. Acute skin toxicity was scored 1 for all patients at completion of ILD radiotherapy. ILD is an effective breast radiotherapy technique for patients with pectus excavatum that preserves the underlying heart and lung from unnecessary toxicity.

[Radiotherapy for breast cancer: respiratory and set-up uncertainties]. / Irradiation du cancer du sein: incertitudes liées aux mouvements respiratoires et au repositionnement.

Adjuvant Radiotherapy has been shown to significantly reduce locoregional recurrence but this advantage is associated with increased cardiovascular and pulmonary morbidities. All uncertainties inherent to conformal radiation therapy must be identified in order to increase the precision of treatment; misestimation of these uncertainties increases the potential risk of geometrical misses with, as a consequence, underdosage of the tumor and/or overdosage of healthy tissues. Geometric uncertainties due to respiratory movements or set-up errors are well known. Two strategies have been proposed to limit their effect: quantification of these uncertainties, which are then taken into account in the final calculation of safety margins and/or reduction of respiratory and set-up uncertainties by an efficient immobilization or gating systems. Measured on portal films with two tangential fields, CLD (central lung distance), defined as the distance between the deep field edge and the interior chest wall at the central axis, seems to be the best predictor of set-up uncertainties. Using CLD, estimated mean set-up errors from the literature are 3.8 and 3.2 mm for the systematic and random errors respectively. These depend partly on the type of immobilization device and could be reduced by the use of portal imaging systems. Furthermore, breast is mobile during respiration with motion amplitude as high as 0.8 to 10 mm in the anteroposterior direction. Respiratory gating techniques, currently on evaluation, have the potential to reduce effect of these movements. Each radiotherapy department should perform its own assessments and determine the geometric uncertainties with respect of the equipment used and its particular treatment practices. This paper is a review of the main geometric uncertainties in breast treatment, due to respiration and set-up, and solutions proposed to limit their impact.

The sliding slit test for dynamic IMRT: a useful tool for adjustment of MLC related parameters.

For treatments with dynamic intensity modulated radiotherapy (IMRT), the adjustment of multileaf collimator (MLC) parameters affecting both the optimization algorithm and dose distributions is crucial. The main parameters characterizing the MLC are the transmission (T) and the dosimetric leaf separation (DLS). The aim of this study is twofold: a methodology based on the 'sliding slit' test is proposed to determine (T, DLS) combinations inducing the best conformity between calculations and measurements. Secondly, the effects of the MLC adjustment on measured dose and on optimization are presented for different configurations as the chair test and for the patient dosimetric quality control (DQC). Tests were performed with a Varian 23EX linac operated at 20 MV and equipped with a 120 leaf Millenium dynamic collimator. The treatment planning system was CadPlan/Helios (version 6.3.6). Results demonstrated that the sliding width (SW) strongly depends on the (T, DLS) combinations, and the measured dose is a linear function of the SW. Different (T, DLS) combinations induced a good agreement between calculations and measurements. The influence of the MLC calibration was found to be particularly important on the 'sliding slit' test (11.8% for a gap change of 0.8 mm) but not so much on the chair test and on the DQC. To detect small variations in leaf adjustment and to ensure consistency between calculation and actual dose delivered to patients, a daily check called IMRT MU check is proposed.

[Constraints and dosage for prostate cancer patients treated with conformal radiotherapy and intensity modulated radiation therapy]. / Choix des contraintes et amélioration dosimétrique d'une radiothérapie conformationnelle du cancer de la prostate modulée en intensité pendant une partie du traitement.

PURPOSE: Intensity modulated radiation therapy (IMRT) is based on a methodology called inverse planning. Starting from dosimetric objectives, constraints of optimization are fixed and given to the inverse planning system, which in turn calculates the modulated intensity to apply to each beam. Since the algorithms allow the constraints to be violated, the results of optimization may differ from the initial dosimetric objectives. Consequently, the user is compelled to adapt the choice of the constraints according to the type of modulation and until satisfactory results are found. The purpose of this work is to present our experience in the choice of these constraints for prostate cancer treatments, as we moved from conformal radiotherapy to IMRT. Treatments were performed with a Varian 23EX linac and calculations were realized with the Varian CadPlan-Helios planning system. PATIENTS AND METHODS: The approach used for the first 12 patients treated at institut Curie with IMRT from June 2002 was analysed. The treatment always consisted of a combination of conformal radiotherapy with and without intensity modulation. RESULTS AND CONCLUSION: Results showed that, a larger fraction of the treatment performed with IMRT induced a better sparing of the organs at risk for the same homogeneous dose distribution to the target volume. Apart from the dose-volume constraint for the rectum, a fixed set of constraints, slightly more restrictive than the dosimetric objectives, could be used for all patients. Compared with conformal radiotherapy, the conformation factor for IMRT increased up to 16%. A specific study was undertaken in view of treatments completely performed with IMRT. The optimal technique consisted in performing separated IMRT plans for the two target volumes, the prostate volume and the prostate plus seminal vesicles volume respectively. Another satisfactory possibility was to define new constraints on two separated planning target volumes, prostate and seminal vesicles. This last approach is now routinely implemented for our IMRT patients.

[Iodin 125 seed migration after prostate brachytherapy: a study of 170 patients]. / Migration des grains d'iode 125 après curiethérapie prostatique: étude d'une série de 170 patients.

PURPOSE: To study the number of migrating seeds, the anatomical site of migration and possible predictive parameters of migration, after prostate cancer brachytherapy using a loose-seed (I125) implantation technique. PATIENTS AND METHODS: The charts of the 170 patients consecutively treated by the Institut Curie/Hospital Cochin/Hospital Necker Group between September 1, 2001 and August 31, 2002, were analysed. All seeds having migrated to the lungs and seen on the chest X-ray systematically performed at 2 months, have been recorded, as well as the seeds lost by the urines (after sieving) or in the sperm (condom). RESULTS: Among 12,179 implanted seeds, 44 were found to have migrated (0.36%). Most of the migrating seeds (32/44; 73%), were found in the lungs. Overall, one or several seed migrations were observed in 35 patients (21% of the total number of patients in this series). In the majority of cases (77%), only one seed migrated. A significant relationship (P = 0.04) was found between the number of migrating seeds and the number of implanted ones (or with the prostate volume, but those two parameters were closely linked in our series). More specifically, a significant relationship (P = 0.02) could be demonstrated between the number of seeds implanted at the periphery of the prostate and the number of seeds migrating to the lungs. CONCLUSION: The percentage of migrating seeds observed in this series is low, actually one of the lowest found in the literature when using the loose-seed technique. There was no clinical consequences and the loss of-usually-only one seed is very unlikely to alter the quality of the dose distribution. However, the predominance of pulmonary migrations in our series led us to slightly modify our implantation technique. We now try to avoid too "peripheral" seed implantations, due to the risk of migration towards the periprostatic veins, and subsequently to the lungs.

[Treatment of uveal melanoma with iodine 125 plaques or proton beam therapy: indications and comparison of local recurrence rates]. / Traitement du mélanome choroïdien par disque d'iode 125 et faisceau de protons: indications respectives et comparaison des taux de récidive.

INTRODUCTION: This retrospective study compared the rate of local recurrence after irradiation of uveal melanoma treated with iodine 125 plaques or proton beam therapy. PATIENTS AND METHODS: Iodine 125 plaques were used to treat all uveal melanomas between the end of 1989 and 1991. Since 1991, we have used iodine plaques for small anterior tumors and proton beam for other tumors. We use a plaque with a larger diameter than the tumor diameter (2-4mm) with a dose of 90Gy at the apex. Proton beam therapy is used for all tumors at the equator or posterior to the equator not thicker than 12mm. The dose given is 60Gy cobalt equivalent in four fractions. For each patient, the initial size and location of the tumor were noted as well as the follow-up each year: the outcome for the eye (local recurrence, ocular conservation, and functional results), the occurrence of metastasis, and survival. A statistical analysis was performed. RESULTS: Between December 1989 and September 1998, 1272 patients were treated: 926 (72.8%) were treated with proton beam irradiation and 346 (27.8%) with iodine 125 plaques. The median follow-up was 5 years (60 months). For the patients treated with proton beam therapy, the mean age was 58 years, the tumor location was anterior to the equator for 3.8%, at the equator for 43.6%, and posterior to the equator for 52.6%. The mean tumor diameter was 13.4mm and the mean tumor thickness was 5.69mm. For the patients treated with iodine 125 plaques, the mean age was 61.5 years. The location of the tumor was anterior to the equator for 34.4%, at the equator for 46.5%, and posterior to the equator for 19.1%. The mean tumor diameter was 11.5mm and the mean tumor thickness was 5.12mm. The recurrence rate was 4% for the proton beam treatment and 3.75% for iodine plaques. There was no statistical difference. DISCUSSION: In the literature, the rate of local recurrence is usually higher with iodine 125 plaques than proton beam therapy. We discuss the risk factors for local recurrence after iodine 125 plaques: tumor diameter, lower dose to the tumor apex and lower dose rate, and posterior location of the tumor. We found a higher mortality rate in patients who presented local recurrence. CONCLUSION: When we use iodine 125 plaques for anterior tumors with the proper dose and dose rate to the apex of the tumor, we do not find more recurrence than with proton beam therapy.

[CT and MR image fusion using two different methods after prostate brachytherapy: impact on post-implant dosimetric assessment]. / Comparaison de deux méthodes de recalage d'images de scanographie et d'IRM en curiethérapie prostatique. Intérêt pour l'évaluation thérapeutique.

PURPOSE: To study different methods of CT and MR images fusion in patient treated by brachytherapy for localized prostate cancer. To compare the results of the dosimetric study realized on CT slices and images fusion. MATERIALS AND METHODS: Fourteen cases of patients treated by I125 were retrospectively studied. The CT examinations were realized with contiguous section of 5mm thickness, and MR images were obtained with a surface coil with contiguous section of 3 mm thickness. For the images fusion process, only the T2 weighted MR sequence was used. Two processes of images fusion were realized for each patient, using as reference marks the bones of the pelvis and the implanted seeds. A quantitative and qualitative appreciation was made by the operators, for each patient and both methods of images fusion. The dosimetric study obtained by a dedicated software was realized on CT images and all types of images fusion. The usual dosimetric indexes (D90, V100 and V150) were compared for each type of image. RESULTS: The quantitative results given by the software of images fusion showed a superior accuracy to the one obtained by the pelvic bony reference marks. Conversely, qualitative and quantitative results obtained by the operators showed a better accuracy of the images fusion based on iodine seeds. For two patients out of three presenting a D90 inferior to 145 Gy on CT examination, the D90 was superior to this norm when the dosimetry was based on images fusion, whatever the method used. CONCLUSION: The images fusion method based on implanted seed matching seems to be more precise than the one using bony reference marks. The dosimetric study realized on images fusion could allow to rectify possible errors, mainly due to difficulties in surrounding prostate contour delimitation on CT images.

[Respiration-gated radiotherapy: current techniques and potential benefits]. / La radiothérapie asservie à la respiration: techniques actuelles et bénéfices attendus.

Respiration-gated radiotherapy offers a significant potential for improvement in the irradiation of tumor sites affected by respiratory motion such as lung, breast and liver tumors. An increased conformality of irradiation fields leading to decreased complications rates of organs at risk (lung, heart...) is expected. Respiratory gating is in line with the need for improved precision required by radiotherapy techniques such as 3D conformal radiotherapy or intensity modulated radiotherapy. Reduction of respiratory motion can be achieved by using either breath hold techniques or respiration synchronized gating techniques. Breathhold techniques can be achieved with active, in which airflow of the patient is temporarily blocked by a valve, or passive techniques, in which the patient voluntarily breath-hold. Synchronized gating techniques use external devices to predict the phase of the respiration cycle while the patient breaths freely. These techniques presently investigated in several medical centers worldwide. Although promising, the first results obtained in lung and liver cancer patients require confirmation. Physical, technical and physiological questions still remain to be answered. This paper describes the most frequently used gated techniques and the main published clinical reports on the use of respiration-gated radiotherapy in order to evaluate the impact of these techniques.

[Indications for curietherapy of the prostate using permanent implants]. / Les indications de la curiethérapie de prostate par implantation permanente.

In the last decade, brachytherapy emerged as a particularly appealing new way ot treating localized prostate cancer. Recently published 10-12 years biochemical control results appear to be superimposable to the best percentages achieved by surgery or conformal radiotherapy, with a small percentage of complications. This applied to severely patients. Only patients with T1/T2, PSA < 10 ng/mL, and Gleason score < 7 should be proposed such a treatment. The potential benefit of exploring patients with a endorectal coil MRI is being evaluated. The number of positive biopsies is also a parameter which should probably be considered in the therapeutic choice. Moreover, a prostate volume > 60 g, hip mobility limitations, a urinary obstructive syndrome and previous transurethral resection lead to difficulties in technical implantation and therefore must be taken into account when discussing brachytherapy. In conclusion, for adequately selected patients, brachytherapy offers a particularly applied alternative to surgery and external radiotherapy, with satisfactory long term biochemical control rates and limited complications.

[Upper aerodigestive tract cancers: clinical benefits of conformal radiotherapy and intensity modulation]. / Cancers des voies aérodigestives supérieures: bénéfices cliniques de la radiothérapie conformationnelle et de la modulation d'intensité.

The conformal radiotherapy approach, three-dimensional conformal radiotherapy (3DCRT) or intensity-modulated radiotherapy (IMRT), is based on modern imaging modalities, efficient 3D treatment planning systems, sophisticated immobilization systems and rigorous quality assurance and treatment verification. The central objective of conformal radiotherapy is to ensure a high dose distribution tailored to the limits of the target volume while reducing exposure of normal tissues. These techniques would then allow further tumor dose escalation. Head-and-neck tumors are some of the most attractive localizations to test conformal radiotherapy. They combine ballistic difficulties due to particularly complex shapes (nasopharynx, ethmoid) and problems due to the number and low tolerance of neighbouring organs like parotids, eyes, brainstem and spinal cord. The therapeutic irradiation of head-and-neck tumors thus remains a challenge for the radiation oncologist. Conformal radiotherapy does have a significant potential for improving local control and reducing toxicity when compared to standard radiotherapy. However, in the absence of prospective randomized trials, it is somewhat difficult at present to evaluate the real benefits drawn from 3DCRT and IMRT. The published clinical reports on the use of conformal radiotherapy are essentially dealing with dosimetric comparisons on relatively small numbers of patients. Recently, a few publications have emphasized the clinical experience of several precursor teams with a suitable follow-up. This paper describes the current state-of-the-art of 3DCRT and IMRT in order to evaluate the impact of these techniques on head-and-neck cancers irradiation.

[Non-small-cell bronchial cancers: improvement of survival probability by conformal radiotherapy]. / Cancers bronchiques non à petites cellules: amélioration des chances de survie par la radiothérapie conformationnelle?

The conformal radiotherapy approach, three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT), is based on modern imaging modalities, efficient 3D treatment planning systems, sophisticated immobilization devices and demanding quality assurance and treatment verification. The main goal of conformal radiotherapy is to ensure a high dose distribution tailored to the limits of the target volume while reducing exposure of healthy tissues. These techniques would then allow a further dose escalation increasing local control and survival. Non-small cell lung cancer (NSCLC) is one of the most difficult malignant tumors to be treated. It combines geometrical difficulties due to respiratory motion, and number of low tolerance neighboring organs, and dosimetric difficulties because of the presence of huge inhomogeneities. This localization is an attractive and ambitious example for the evaluation of new techniques. However, the published clinical reports in the last years described very heterogeneous techniques and, in the absence of prospective randomized trials, it is somewhat difficult at present to evaluate the real benefits drawn from those conformal radiotherapy techniques. After reviewing the rationale for 3DCRT for NSCLC, this paper will describe the main studies of 3DCRT, in order to evaluate its impact on lung cancer treatment. Then, the current state-of-the-art of IMRT and the last technical and therapeutic innovations in NSCLC will be discussed.

[Safety in radiotherapy: Control of software and informatics systems]. / Sécurité en radiothérapie: le contrôle des logiciels et des systèmes informatiques.

The development of computerized systems in radiotherapy opens new challenging possibilities. There is however a major risk of specific errors if the use of such systems is not properly controlled. On the other hand, the software sophistication, such as encountered in modern treatment planning systems (TPS), makes it very difficult to set up efficient quality assurance programs compatible with the workload of users in charge of daily routine. From the analysis of previous accidents involving TPS, we can conclude that the major risks are erroneous calculations of monitor units resulting from a poor understanding of the software capabilities combined to a lack of vigilance with respect to the data obtained from a computer. To reduce the risks, it is necessary to setup a comprehensive quality assurance program covering all steps of the process, including commissioning of a new system and systematic checks of individual treatment plans. Such a program offers the users the opportunity to acquire a deeper understanding of the system and avoid potential pitfalls. There is presently a lack of consensus for an international protocol related to quality assurance of computerized systems in radiotherapy. It is therefore important to define protocols at the national level, with special consideration of the aspects which are more likely to generate significant errors.

Conformal radiotherapy (CRT) planning for lung cancer: analysis of intrathoracic organ motion during extreme phases of breathing.

PURPOSE: Conformal radiotherapy beams are defined on the basis of static computed tomography acquisitions by taking into account setup errors and organ/tumor motion during breathing. In the absence of precise data, the size of the margins is estimated arbitrarily. The objective of this study was to evaluate the amplitude of maximum intrathoracic organ motion during breathing. METHODS AND MATERIALS: Twenty patients treated for non-small-cell lung cancer were included in the study: 10 patients at the Institut Curie with a personalized alpha cradle immobilization and 10 patients at Tenon Hospital with just the Posirest device below their arms. Three computed tomography acquisitions were performed in the treatment position: the first during free breathing and the other two during deep breath-hold inspiration and expiration. For each acquisition, the displacements of the various intrathoracic structures were measured in three dimensions. RESULTS: Patients from the two centers were comparable in terms of age, weight, height, tumor site, and stage. In the overall population, the greatest displacements were observed for the diaphragm, and the smallest displacements were observed for the lung apices and carina. The relative amplitude of motion was comparable between the two centers. The use of a personalized immobilization device reduced lateral thoracic movements (p < 0.02) and lung apex movements (p < 0.02). CONCLUSION: Intrathoracic organ movements during extreme phases of breathing are considerable. Quantification of organ motion is necessary for definition of the safety margins. A personalized immobilization device appears to effectively reduce apical and lateral displacement.