Management of oligometastatic/metastatic sarcomas and place of local treatments with focus on modern radiotherapy approaches.

Soft tissue sarcomas are a rare and heterogeneous disease. For localized disease, treatment is based on surgery and radiotherapy with or without chemotherapy depending on risk factors. Upfront metastases are present in 7 to 20% of cases, and are localized to the lungs in most of cases. Disseminated disease is generally considered incurable but in selected cases, aggressive local treatment of metastases allowed long survival. Treatment of primary tumour is often debated. Our purpose is to evaluate the literature concerning the role of radiotherapy in the management of primary metastatic soft tissue sarcomas.

Is oligometastatic disease an applicable and useful concept in haematologic malignancies? A narrative review of radiation therapy standards, modern techniques, and innovations.

PURPOSE: Haematologic malignancies are particular in that they can generally be cured, even when distant metastases are present at diagnosis, unlike solid malignancies. Systemic treatments, including chemotherapy, targeted therapies, and immunotherapy, are the standard of care with excellent results. The considerable progress made in the management of these diseases in the last 20years has redefined the role of radiation therapy as minor in many clinical situations. We propose a literature review of data, showing that radiation therapy still has a role in curative, salvage, and palliative therapy situations. MATERIAL AND METHODS: A document and literature search was carried out in the following databases: Medline and ClinicalTrial.gov, for the terms "radiotherapy", "haematologic malignancies", "Hodgkin lymphoma", "non-Hodgkin lymphoma", "CAR T cells", "multiple myeloma", "solitary plasmocytoma", "intensity-modulated radiotherapy", "extracranial stereotactic body radiation therapy" and "proton therapy references". RESULTS: Haemopathological malignancies include a wide range of diseases and radiation therapy indications have been assessed over the past 20years. Currently, radiation therapy is indicated for localized disease (solitary plasmocytoma), as an adjuvant (Hodgkin lymphoma), in palliative settings, or after systemic treatment in relapsed patients (chimeric antigen receptor [CAR] T-cells) with a low recurrence burden, which can therefore be considered "oligorecurrence". Radiation therapy, through total body irradiation, has important indications, thanks to its immunomodulatory and/or myeloablative effects. Moreover, recent technological developments have made possible significant improvement in safety, contributing to radiation therapy being positioned in the treatment strategy of several indications. CONCLUSIONS: Given the effectiveness of systemic treatments in hematologic malignancies, the oligometastasis stage is of little importance. A curative intent after local radiation therapy, even advanced stage, is possible, both with residual disease for advanced Hodgkin lymphoma, aggressive non-Hodgkin lymphoma, or solitary plasmocytoma, and even without evidence of disease after chemotherapy for Hodgkin or non-Hodgkin lymphoma. The role of new treatments, such as CAR T cells, allows us to consider radiation therapy after systemic treatment of relapsed diseases with low volume recurrence, which can be considered oligorecurrence.

[French careers in oncology radiotherapy: Crossing views]. / Carrières en oncologie radiothérapie : réflexions croisées SFjRO-SFRO-SNRO.

The French Society of Young Radiation Oncologists (SFjRO), the National Union of Radiation Oncologists (SNRO) and the French Society of Oncological Radiotherapy (SFRO) aim to reconcile career opportunities and demographic needs in oncology. In 2021, 932 radiation oncologists (RO) are in regular activity in France, this represents an increase of more than 20% in ten years. Physician distribution is changing in public hospitals, cancer centers and private clinics. Currently one third of ROs works in each sector. In addition, fifteen percent of ROs have a mixed activity. In 2021, 180 young RO (trainees and residents) were questioned by SFjRO board about their training, internship, coaching and career guidance. An interactive communication was organized during the 32nd SFRO Meeting in 2021. It was an opportunity to bring the results of this study. More than 70% RO interviewed answered to the survey, for 55% among them, career choice was difficult. In order to help young ROs in their professional approach, three RO made an oral presentation during this session, about radiotherapy in public hospitals, private centers or with a mixed practice. The aim of this article is to summarize the highlights of the last SFjRO/SFRO session: expectations of young RO, career prospects and trends.

[Characteristics of radiotherapy for adolescents and young adults]. / Caractéristiques de la radiothérapie chez les adolescents et les jeunes adultes.

Radiotherapy for adolescents and young adults is complex in several aspects. The population is very heterogeneous and has characteristics derived from both paediatric and adult populations both in terms of pathology (anatomical pathology, response to treatment) and the patient's physical, biological and psychological characteristics. This article reviews the characteristics to be taken into account in adolescent and young adult patients radiotherapy and more particularly in some of the most common diseases.

[Clinical research in radiation oncology: how to move from the laboratory to the patient?] / Recherche clinique en oncologie radiothérapie : comment passer du laboratoire au patient ?

Translational research in radiation oncology is undergoing intense development. An increasingly rapid transfer is taking place from the laboratory to the patients, both in the selection of patients who can benefit from radiotherapy and in the development of innovative irradiation strategies or the development of combinations with drugs. Accelerating the passage of discoveries from the laboratory to the clinic represents the ideal of any translational research program but requires taking into account the multiple obstacles that can slow this progress. The ambition of the RadioTransNet network, a project to structure preclinical research in radiation oncology in France, is precisely to promote scientific and clinical interactions at the interface of radiotherapy and radiobiology, in its preclinical positioning, in order to identify priorities for strategic research dedicated to innovation in radiotherapy. The multidisciplinary radiotherapy teams with experts in biology, medicine, medical physics, mathematics and engineering sciences are able to meet these new challenges which will allow these advances to be made available to patients as quickly as possible.

Interactions of radiation therapy with common and innovative systemic treatments: Antidiabetic treatments, antihypertensives, lipid-lowering medications, immunosuppressive medications and other radiosensitizing methods.

The invention and approval of innovative anticancer therapies in the last decade have revolutionized oncology treatment. Radiotherapy is one of the three traditional pillars in oncology treatment with surgery and systemic therapies. Some standard-of-care combinations of chemoradiotherapy widened the therapeutic window of radiation, while some other chemotherapies such as gemcitabine caused unacceptable toxicities when combined with radiation in lung cancers. Fast-paced progress are specially focused on immunotherapies, targeted-therapies, anti-angiogenic treatment, DNA repair inhibitors, hormonotherapy and cell cycle inhibitors. New anticancer therapeutic arsenals provided new possibilities of combined oncological treatments. The interactions of the radiotherapy with other systemic treatments, such as non-anticancer immunomodulatory/immunosuppressive medications are sometimes overlooked even though they could offer a real therapeutic benefit. In this review, we summarize the new opportunities and the risks of historical and novel combined therapies with radiation: non-anticancer immunomodulatory/immunosuppressive drugs, systemic reoxygenation, new therapies such as nanoparticles and SMAC mimetics. Key biological mechanisms, pre-clinical and available clinical data will be provided to demonstrate the promising opportunities in the years to come.

Best practice in brachytherapy.

The 2020 recommendations for good brachytherapy procedures ("Recorad") are updated based on the 2016 article. This new brachytherapy article took into account recent data published in the literature as well as international recommendations. The different brachytherapy steps are successively described from the treatment preparation (brachytherapy technique prescription; procedure and material, dedicated images for planification, dose distribution analysis and validation) to the end of the procedure as well as post-treatment surveillance.

[Combination radiotherapy-immunotherapy in genitourinary cancer]. / Combinaison radiothérapie-immunothérapie en cancérologie génito-urinaire.

Immunotherapy occupies a growing place in urologic oncology, mainly for kidney and bladder cancers. On the basis of encouraging preclinical work, the combination of immunotherapy with radiotherapy aims to increase the tumor response, including in metastatic tumors, which raises many hopes, which this article reviews.

Survival of Coelaenomenodera lameensis (Coleoptera: Chrysomelidae) in Relation to the Physical Characteristics of Different Oil Palm (Elaeis sp.) Breeding Populations.

The edibility of different Elaeis sp. breeding populations present in Benin was tested for the leaf miner Coelaenomenodera lameensis Berti (Coleoptera: Chrysomelidae), a major oil palm pest in Africa. Experiments carried out in sleeves revealed the oviposition capacities of females and the mortality rates for the different developmental stages by comparing the populations found on two breeding populations of Elaeis oleifera (HBK) Cortes, four of Elaeis guineensis Jacquin and four (E. guineensis × E. oleifera) × E. guineensis backcrosses. Females laid their eggs similarly on all breeding populations, with a preference for the E. guineensis La Mé origin. The average hatching rate reached 80% for the La Mé origin as opposed to 28% for the Deli origin. The mortality rates for the larval instars were greater on E. oleifera, on certain backcrosses and on the Deli origin of E. guineensis. Development at the second- and third- larval instars was the most affected, with a mortality rate of three to five times greater than that seen on La Mé. Epidermis and cuticle measurements indicated which breeding populations were suitable or unsuitable for the development of C. lameensis. E. guineensis, with its thin epidermis (12 µm) and cuticle (2 µm), proved to be highly susceptible to C. lameensis attacks. On the other hand, E. oleifera, which is very resistant, exhibited a thicker epidermis (17 µm) and cuticle (4 µm). The breeding populations were thus classified according to the positive or negative influence they exerted on the insect's egg laying and feeding.

Tumour growth kinetics assessment: added value to RECIST in cancer patients treated with molecularly targeted agents.

BACKGROUND: Treatment effect is categorised into four classes by RECIST based on the evolution of the size of target lesions and the occurrence of new lesions, irrespective of tumour growth kinetics before treatment. This study aimed at evaluating the added value of tumour growth kinetics assessment to RECIST in patients treated with molecularly targeted agents (MTAs). METHODS: On-study imaging, along with pre-baseline imaging, of patients treated with MTA(s) in clinical trials at Institut Curie were centrally reviewed. The tumour growth ratio (TGr), defined as the ratio of the slope of tumour growth before treatment and the slope of tumour growth on treatment between the nadir and disease progression, was calculated for each patient. RESULTS: A total of 50 patients included in 18 trials were eligible for the study. Among the 44 patients who withdrew from the study because of disease progression according to the investigators' assessment, 18 patients (41%) had a TGr <0.9. Among these 18 patients, 5 had disease progression according to RECIST 1.1 based on our retrospective reassessment of on-study imaging and occurrence of no new lesion during study treatment. CONCLUSION: Our preliminary results suggest that a substantial proportion of patients treated with MTAs have discontinued treatment although being potentially benefitted from them.

Vacuum-assisted biopsies under MR guidance: results of 72 procedures.

OBJECTIVE: To investigate the clinical accuracy of magnetic resonance imaging-guided breast vacuum-assisted biopsy (MR-VAB). METHODS: Of 97 scheduled MR-VAB for single MRI lesions (negative second-look sonography) categorised as BI-RADS 4 or 5, 4 were cancelled (undetected lesion = 2, technical problems = 2). Twenty-one patients lost to follow-up were excluded. RESULTS: Twenty-three patients (median age 51 years) were at high risk (BRCA1 = 11, BRCA2 = 7, familial risk = 5), 23 had a suspected local recurrence of breast cancer. Seventy-two imaged lesions (focus = 1, mass enhancement = 32, non-mass-like enhancement = 39) were targeted with a 10-gauge VAB probe using MRI guidance, with a median of 18 specimens per lesion (median procedural time 72 min, range 50-131 min) followed by clip placement. In the case of benignity, MRI follow-up was performed (19 patients, median 389 days, range 33-1,592) or mammography (3 patients, median 420 days, range 372-1,354). According to histopathology results, 29 lesions were benign, 10 were high-risk (papillary = 2, radial scar = 1, atypical epithelial hyperplasia = 7) and 33 malignant (ductal carcinoma in situ = 8, invasive cancers = 25). Three false negative results and 3 complications occurred (1 malaise, 1 skin defect, 1 infection). CONCLUSION: MRI-guided VAB represents an accurate tool for the histological diagnosis of lesions visible only at MRI.

[Dose finding methods for targeted agents: new perspectives]. / Méthodes pour la recherche de dose de traitements ciblés : nouvelles pistes.

BACKGROUND: The definition of the optimal dose of a new compound and the design for identifying this dose have been set up for treatment with cytotoxic activity. The optimal dose is typically the Maximum Tolerated Dose (MTD) defined by the occurrence of severe toxic side effects during the first course of treatment. In the era of molecularly targeted therapies (MTA), where the mechanistic relations between the dose, the activity and the toxicity are probably different, how relevant these definitions and designs are? METHODS: We present here a review of the outcomes of potential interest for defining the optimal dose and we present several statistical innovative dose finding methods. Longitudinal data (tumour growth, repeated evaluation of toxic side effects) and continuous outcomes appear particularly promising for early phase trials. CONCLUSIONS: Phase I dose finding method for molecularly targeted agents should continue to identify the MTD, but the dose recommended for phase II trials should not be systematically defined as the MTD and should incorporate other endpoints. In particular, more sensitive and more discriminatory endpoints are necessary. They needn't be good surrogate of the clinical benefit, but they should allow for ranking several doses. Experience from other medical specialties, such as phase II dose-ranging trials could be considered.

Patient experiences and preferences: development of practice guidelines in a cancer imaging department.

OBJECTIVE: To improve patient management based on analysis of the results of a survey conducted during their visit to the imaging department of a cancer centre. MATERIALS AND METHODS: A questionnaire comprising 30 single-response questions on a dichotomous scale or a 3- or 4-modality scale was developed by three radiologists specialized in oncology, the head of our quality assurance department, a psycho-oncologist, a psycho-sociologist, a biostatistician and a member of our institute's Patient Committee. Questions concerned reception, information provided about the examinations, examination experiences, the relational qualities and availability of health care professionals, the interview with the radiologist and announcement of the examination results. RESULTS: The questionnaire was given to 190 patients in the waiting room before a standard radiography or ultrasound examination (33%), mammography and breast ultrasound (33%), computed tomography (CT) or magnetic resonance imaging (MRI) (34%). The return rate was 81%. This article analyses the responses to the various questions in terms of either percentages or detailed replies and suggestions. CONCLUSION: Analysis of the patients' experience and their suggestions provided objective elements concerning their real wishes in relation to each step of their management and identified changes and improvements to be made to the organization and daily functioning of the department.

[MR breast screening in patients with genetic mutation]. / Dépistage du cancer du sein par IRM chez les femmes porteuses d'une mutation génétique.

PURPOSE: To compare screening breast MRI with conventional screening techniques in high-risk patients with genetic mutation. MATERIALS AND METHODS: Prospective study of 85 patients (mean age of 43 years) with genetic mutation and screening > or = 2 years (mean of 2.7 years, 231 screening examinations). BI-RADS lesions 3-5 were biopsied; isolated BI-RADS 3 lesions on MRI were followed. Results from both techniques were compared. The number of short interval follow-up examinations and biopsy results were reviewed. RESULTS: Eight cancers were diagnosed (3 in situ, 5 invasive carcinomas including an interval cancer, mean size of 14 mm). The sensitivity values for mammography, US and MRI were 12.5%, 50% and 95%, and specificity values were 98.7%, 97.3% and 94.8% respectively. Nineteen short interval follow-up MRI examinations were performed (19%): 14% of patients at initial screening and 5% and 6% at the the second and third screenings. Thirty-two biopsies were performed in 17 patients, including 18 after MRI (PPV of cytology: 30%, and biopsy: 58%). CONCLUSION: Our results confirm the value of MRI for screening of high-risk patients with genetic mutation.

Imaging of sacral tumours.

All components of the sacrum (bone, cartilage, bone marrow, meninges, nerves, notochord remnants, etc.) can give rise to benign or malignant tumours. Bone metastases and intraosseous sites of haematological malignancies, lymphoma and multiple myeloma are the most frequent aetiologies, while primary bone tumours and meningeal or nerve tumours are less common. Some histological types have a predilection for the sacrum, especially chordoma and giant cell tumour. Clinical signs are usually minor, and sacral tumours are often discovered in the context of nerve root or pelvic organ compression. The roles of conventional radiology, CT and MRI are described and compared with the histological features of the main tumours. The impact of imaging on treatment decisions and follow-up is also reviewed.

PET/CT imaging: what radiologists need to know.

Positron emission tomography (PET)/computed tomography (CT) imaging is frequently requested in Oncology. Radiologists and nuclear medicine physicians are often asked to perform a panel of imaging examinations as part of the initial staging or follow-up of cancer patients. Medical imaging must therefore integrate polyvalent skills enabling imaging specialists to understand and interpret all types of images. In this context, PET imaging combined with non-enhanced CT, and diagnostic quality contrast-enhanced CT scan and optimisation of CT settings, is part of this multidisciplinary approach requiring the specific skills of a radiologist and a nuclear medicine physician. This approach must therefore be conducted in both directions: radiologists and nuclear medicine physicians should both know how to correlate PET and CT images, while preserving the specificities of each discipline. Radiologists need to be aware of several aspects of PET imaging: PET technology, the examination procedure and injection of iodinated contrast agent for high quality diagnostic CT, ideally followed by double interpretation of CT images, PET images and fused images. Radiologists should be familiar with PET imaging, as this procedure may be associated with several pitfalls and artefacts that need interpretation by a trained specialist. The authors analyse the examination technique of PET combined with non-enhanced and/or contrast-enhanced CT and the proposals for optimal interpretation of normal or pathological PET/CT fusion images.

[Indications of MRI in the initial local staging of early-stage breast cancer]. / Mise au point sur la place de l'IRM dans le bilan initial du cancer du sein localisé

MR Imaging is the most sensitive technique for detecting breast cancer. In patients with breast cancer, the additional value of MRI is validated in patients candidates for a breast-conserving surgery and when: cancer is occult, size evaluation is difficult at standard imaging, parietal involvement is suspected, and before neoadjuvant chemotherapy. In fatty breasts, MRI is not routinely recommended, because of same performances as in standard imaging. In dense breasts, MRI becomes significantly more sensitive than mammography for detecting multifocality and multicentricity with a positive predictive value of 60% for detected additional foci. Thus, a decision of mastectomy should not be made solely on the basis of MRI and may require additional tissue sampling of areas of concern identified by breast MRI. The additional value of breast MRI is particularly useful in patients with dense breasts and high risk factors for local recurrence: young age (< 40 years), familial high risk, or because of a high-grade invasive cancer greater than 2 cm in size. Performing breast MRI in such patients underlies requirements: an expert breast imaging team, optimal MRI protocols, and radiologists working in concert with the multidisciplinary treatment team.

[Usefulness of magnetic resonance imaging in Paget disease of the breast]. / Apport de l'IRM dans la maladie de Paget du sein.

OBJECTIVE: Evaluate the usefulness of MRI in local staging of Paget disease of the breast. MATERIALS AND METHODS: Clinical, radiological (mammographies, MRI), and histological data were analyzed in six female patients presenting Paget disease of the breast. The criteria for analysis in MRI were the following: morphology of the aureola-nipple plaque (thickening, regularity of the contour) and the type of enhancement after injection of contrast medium (signal intensity/time curve), detection of abnormal enhancing in the mammary gland, and ganglion areas. RESULTS: None of the patients presented a palpable mass or a suspicious anomaly on mammography. On MRI, the aureola-nipple plaque was morphologically abnormal in four cases, with suspicious enhancement in two cases (two cases of ductal carcinoma in situ) and normal enhancement in two cases (one case of ductal carcinoma in situ). In the two other cases, the aureola-nipple plaque was normal (one case of ductal carcinoma in situ). Distant abnormal enhancement of the aureola-nipple plaque was noted in two cases (one case of ductal carcinoma in situ and one benign lesion). CONCLUSION: The MRI aspect of the aureola-nipple plaque in Paget disease shows little concordance with the histological results. MRI can be useful in detecting distant lesions when there is no clinical sign nor a suspicious mammography.

[Communication between radiologist and cancer patients]. / Dialogue entre le radiologue et le patient atteint d'un cancer.

Along with advances in medicine and social evolution, we are seeing an increase in the number of patients afflicted with cancer, and a change in the doctor-patient relationship. Patients' rights are now registered in the Hospitalised Patient's Charter, the Huriet Act and the Act of March 4, 2002. The evolution in cancer diseases is monitored by a range of imaging examinations, putting the radiologist in the front line. Lesions are typically first detected by the radiologist. This task is complicated by the fact that radiologists usually have no formal training with regards to the disclosure of cancer diagnoses to patients. There is a great risk of inappropriate responses which can have a profoundly damaging effect on the patient's state of mind. Even if we have the best of ideals and intentions, there is a great need for us to examine and improve our modes of interaction, in dealing with the patient's need for information. The radiologist possesses technical know-how, but technique alone is not enough - the right amount of information, based on clinical competence, is required; but so is empathy towards the patient, and respect for his or her wishes and rights.

[Improving overall patient care during imaging studies: the radiologist's CREDO and PERLES]. / Améliorer la prise en charge des malades en imagerie médicale: le CREDO et les PERLES du radiologue.

The protocols specifying the basic rules of the doctor-patient relationship that have been proposed in the literature are primarily intended for referring physicians, in particular oncologists. With regard to the improving radiologists' communication skills, a simple tool, RADPED, was developed to help residents in pediatric radiology to memorize the main points of the patient-radiologist interaction. We suggest a protocol, CREDO, more precisely appropriated to the everyday practice of medical imaging, in particular in oncology. This protocol relates not only to the radiologist-patient relationship, but also to the rules common to the department's entire team. The aims are to establish a partnership with the patient (for this purpose, we suggest using the PERLES model: partnership, excuses (apology), respect, legitimization, empathy, support), carrying out the examination under optimal conditions, listening to what the patient has to say, giving information and, above all, organizing the imaging department around the patient.