[Partial delegation to radiation therapists of the control by cone beam CT of prostate positioning]. / Délégation partielle du contrôle quotidien de position de la prostate par tomographie conique aux manipulateurs en électroradiologie médicale.

PURPOSE: Intensity modulated radiotherapy for prostate cancer involves daily monitoring of the positioning of the prostate, possible with cone beam CT (CBCT). It allows increased accuracy compared to readjustments but induces an increase in the time dedicated to these medical checks. The aim of the study was to evaluate the possibility of delegation of this task to the radiation therapists by comparing their readjustments to the doctors. PATIENTS AND METHODS: Five consecutive patients treated with radiation for prostate cancer (76Gy) were analysed. All had a daily CBCT for position control. The movements of the prostate relative to the bony part, the positional variations of the prostate measured by the radiation therapists and the doctors and medical time required to analyse imagery (filling of the rectum and bladder and perform a recalibration) were measured. RESULTS: One hundred seventy-six CBCT were analysed or 980 steps in the three axes. The movements of the prostate relative to bony part were respectively at least 5mm in 19%, 7% and 3% in the anterior-posterior, upper-lower and right-left axes. Changes readjustments between radiation therapists and doctors were in 95% of cases at the most 4mm in the anterior-posterior and upper-lower axis, and 3mm in the left-right axis. The time for medical use of the CBCT averaged 8min 40 [4 to 22min]. CONCLUSION: The daily readjustment on the prostate using CBCT may be delegated to radiation therapists with acceptable concordance of less than 4mm for 95% of measurements. An initial and ongoing training will ensure treatment safety.

[Salvage concomitant chemoradiation therapy for non-metastatic inflammatory breast cancer after chemotherapy failure]. / Chimioradiothérapie concomitante des cancers du sein inflammatoire, non métastatiques, non répondeurs à une chimiothérapie première.

PURPOSE: To evaluate the surgical possibility following concomitant chemoradiotherapy for inflammatory breast cancer, after unsucessful neoadjuvant chemotherapy. PATIENTS AND METHODS: The data from ten patients with inflammatory breast cancer treated between 1996 and 2010 by concomitant chemoradiotherapy after unsucessful neoadjuvant chemotherapy were analysed. All patients had an invasive carcinoma. All patients received a neoadjuvant chemotherapy, including anthracyclin, six patients received taxan and one received trastuzumab. Radiotherapy was delivered to the breast and regional lymph nodes in all patients at a dose of 50Gy; a boost of 20Gy was delivered to one patient. Concomitant chemotherapy was based on weekly cisplatin for six patients, on cisplatin and 5-fluorouracil the first and last weeks of radiotherapy for four patients. RESULTS: The median follow-up for all patients was 44 months. Mastectomy was performed in nine patients. Two- and 5-year overall survival rates were respectively 70 % and 60 %. Median local recurrence delay was 5 months; six patients died (all from cancer), seven developped metastasis. Grade 1 and 2 epithelite was respectively observed in six and two patients, grade 2 renal toxicity in three patients, grade 2 neutropenia in one patient. CONCLUSION: Concomitant chemoradiotherapy for inflammatory breast cancer after unsucessful neoadjuvant chemotherapy may control the disease in some patients and lead to mastectomy. These results have to be confirmed through a multicentric study with more patients.

[Image-guided radiotherapy and partial delegation to radiotherapy technicians: Clermont-Ferrand experience]. / Radiothérapie guidée par l'image et partage des tâches avec les manipulateurs en électroradiologie : expérience de Clermont-Ferrand.

The various image-guided radiotherapy techniques raise the question of how to achieve the control of patient positioning before irradiation session and sharing of tasks between radiation oncologists and radiotherapy technicians. We have put in place procedures and operating methods to make a partial delegation of tasks to radiotherapy technicians and secure the process in three situations: control by orthogonal kV imaging (kV-kV) of bony landmarks, control by kV-kV imaging of intraprostatic fiducial goldmarkers and control by cone beam CT (CBCT) imaging for prostate cancer. Significant medical overtime is required to control these three IGRT techniques. Because of their competence in imaging, these daily controls can be delegated to radiotherapy technicians. However, to secure the process, initial training and regular evaluation are essential. The analysis of the comparison of the use of kV/kV on bone structures allowed us to achieve a partial delegation of control to radiotherapy technicians. Controlling the positioning of the prostate through the use and automatic registration of fiducial goldmarkers allows better tracking of the prostate and can be easily delegated to radiotherapy technicians. The analysis of the use of daily cone beam CT for patients treated with intensity modulated irradiation is underway, and a comparison of practices between radiotherapy technicians and radiation oncologists is ongoing to know if a partial delegation of this control is possible.

[Delineation for oral cavity and oropharyngeal cancers]. / Délinéation des cancers de la cavité buccale et de l'oropharynx.

The aim of this article is to present the determination and the delineation of target volumes for oral cavity and oropharyngeal carcinomas treated with intensity-modulated irradiation. The delineation on the computerized tomography scanner (CT scan) requires a precise method because of the complexity of the head-and-neck anatomy. Different elements are necessary: clinical examination, diagram of the initial tumor, surgical and pathological reports and medical imaging (CT scan, magnetic resonance imaging and fluorodeoxyglucose positron emission tomography). The clinical target volumes, the planning target volumes, the organs at risk and the planning organs at risk volumes are discussed. The concept of selectivity of the potential subclinical disease near the primary tumour and the selection of neck nodal targets are specified according to the literature.

[Partial delegation to radiation therapists of the control by onboard imaging of patient positioning]. / Délégation partielle du contrôle de position du patient par imagerie embarquée aux manipulateurs en électroradiologie.

PURPOSE: Daily set up of patients with prostate cancer using orthogonal kV/kV imaging and weekly set up control require 1h to 1h30 of off line revision by a radio-oncologist per day and per accelerator. The aim of this study was to evaluate the possibility to delegate this control to radiation therapists. MATERIAL AND METHODS: The files of 33 patients (including 13 with prostate cancer) treated from November 2010 to February 2011 on a Varian™ Clinac IX accelerator with an OBI™ system were evaluated. Radiation therapists made the daily kV/kV imaging. Radiation therapists made the online control by kV/kV for patient repositioning and radio-oncologists made the offline reviews; the results were compared and analysed (seven radiation therapists and seven radio-oncologists). For an isocentre displacement of 5mm, the radiation therapist had to call the radio-oncologist to make a medical decision (treatment or patient displacement). The difference of measures and the concordance of decisions between radiation therapists and radio-oncologists were calculated. RESULTS: Five hundred and fifty-six measures were made for 33 treatments, including 226 measures for prostate cancer treatment. The difference of measures between radiation therapists and radio-oncologists was 3mm or less in 93.7% for all treatments and 96.2% for prostate cancer treatment. The concordance of decision between radiation therapists and radio-oncologists for measures up to 4mm was 97% (CI95±2%) vs. 57% (CI95±10%) for measures equal to or higher than 5mm (P<0.0001). CONCLUSION: Radiation therapists are able to do daily set up using kV/kV on the bony structures of patients with prostate cancer, with a risk of disagreement higher than 3mm less than 4%. The weekly set up controls (different primaries) can be delegated to the radiation therapists, subject to an accurate procedure using a medical alert for a given threshold. Training and competence certification are required to secure the process.

[Whole brain radiotherapy for brain metastases: the technique of irradiation influences the dose to parotid glands]. / Irradiation panencéphalique des métastases cérébrales : la technique d'irradiation influence la dose aux glandes parotides.

In the treatment of brain metastases, whole brain radiotherapy can be carried out according two distinct methods: one using multileaf collimator for field shaping and protection of organs at risk, and a second one is to make a rotation of the field to avoid the eyes. The aim of the study was to compare for 10 patients the dose distributions at organs at risk for each method. Patients received 30 Gy in 10 fractions. Except for parotid glands, the dose received by organs at risk and the planning target volume was the same with each method. For whole brain radiotherapy, excluding the cisterna cerebellomedullaris, the mean parotid dose was 9.63 Gy using the multileaf collimator versus 12.32 Gy using the field rotation (P=0.04). For whole brain radiotherapy including the cisterna cerebellomedullaris, the mean parotid dose was 11.12 Gy using the multileaf collimator versus 20.06 Gy using field rotation (P<0.001). Using the multileaf collimator seems recommended for whole brain radiotherapy, to reduce the dose to the parotids.

Lack of effect of delta F508 mutation on aerobic capacity in patients with cystic fibrosis.

OBJECTIVE: As aerobic exercise capacity, as defined by VO2max, is associated with patient functioning and possibly prognosis in cystic fibrosis (CF), correlations between VO2max phenotype and genotype may be of value. DESIGN: Retrospective clinical series. SETTING: Cystic fibrosis referral clinic. PATIENTS: Convenience sample of 35 patients with CF consecutively referred for exercise testing. MAIN OUTCOME MEASURES: Blood samples were examined for mutations of cystic fibrosis transmembrane regulator (CFTR), Height, wight, pulmonary function, resting-energy expenditure, VO2max, and other exercise variables were assessed in each referred patient. RESULTS: Statistical comparison of 10 patients who were homozygous for the dF508 mutation of CFTR with 20 patients heterozygous for dF508 revealed no significant differences for height, weight, pulmonary function, resting-energy expenditure, VO2max, or any other exercise variables. CONCLUSIONS: These results imply a limited effect of the mutation status on overall patient functioning and prognosis. Future identification of more rare CFTR mutations and other genes and subsequent classification of patients in a manner reflective of the cellular physiology may lead to different results.

[Surgery for aneurysms of the subrenal abdominal aorta after the age of 70 years: survival and quality of life]. / La chirurgie des anévrismes de l'aorte abdominale sous-rénale après 70 ans: survie et qualité de vie.

The aim of this study was to assess results of surgery for aneurysms of the abdominal aorta in patients over 70 years of age. Survival and quality of life were used as assessment criteria. Files of 277 patients over 70 years of age who had undergone surgery for an aneurysm of the subrenal abdominal aorta between 1974 and 1992 were examined retrospectively. There were 246 men and 31 women of whom 230 were under 80 and 47 over 80 years of age. The operation was programmed in 145 cases and was an emergency procedure in 132 (45 ruptures and 87 painful fissurations). Perioperative mortality was 1.4% in programmed surgery and 19.7% in emergency surgery. Overall actuarial survival was 60.07% at 5 years and 26.04% at 10 years. Quality of life after the operation was unchanged in 56.1%, improved in 19.3% and worse in 24.6%. Surgery for aneurysm of the subrenal abdominal aorta is justified in patients over 70 years of age. It can provide satisfactory survival in good quality of life conditions.