[State of the art and advances in radiotherapy for bladder cancer]. / Techniques et innovations en radiothérapie pour le traitement conservateur des cancers infiltrants localisés de vessie.

Radical cystectomy is the treatment of choice for nonmetastatic, muscle-infiltrating bladder cancer. However, bladder-sparing approaches can be discussed in carefully selected patients. Bladder-preservation protocols aim to guaranty local control and survival with a functional bladder and a good quality of life. Such strategies include combinations of transurethral resection and radiochemotherapy, partial cystectomy and brachytherapy, radiotherapy-cystotomy and electrontherapy. Strict selection criteria and close follow-up are mandatory. New irradiation techniques hold the promise to improve local control by selectively boosting the dose to the tumor while better sparing the organs at risk. Such advances include the use of multimodal imaging, image-guided radiotherapy, concomitant boost with conformal irradiation+/-intensity modulated radiation therapy. Brachytherapy, either high-dose or pulsed-rate, is a promising technique for selected cases. Highly-conformal irradiation with tumor tracking using the Cyberknifetrade mark technology may also provide opportunities to boost the tumor while reducing toxicities. Specific innovative irradiation techniques are discussed.

Effective delivery of palliative radiotherapy: A prospective study.

PURPOSE: The main goal of palliative radiotherapy is to reduce patient's discomfort. But sometimes patients do not receive any benefits from this treatment because of rapid worsening of their general condition. This prospective monocentric study assessed the effective delivery of palliative radiotherapy. MATERIALS AND METHODS: From 1st December 2015 to 29th February 2016, all consecutive patients receiving palliative radiotherapy in our hospital were included. The primary endpoint was the effective delivery of palliative radiotherapy according to the initial prescription (total dose, overall treatment time and fractionation). The secondary endpoints were the number of treatment breaks, the clinical benefit, the number of deaths and the delays for admission in the palliative care unit. RESULTS: Fifty-nine patients were included and 64 treatments were analysed. The treatment sites were: bone (70.3%) and brain (21.9%). The treatment goals were: pain control only (43.8%), decompression only (21.9%), pain control and decompression (32.8%), haemostatic aim (1.6%). Palliative treatment was achieved in 57 cases (89%). Temporary interruption of the radiotherapy treatment was necessary in six cases (9.4%; three for medical reason, three for logistic reason). The main reason of permanent interruption was worsening of performance status (seven cases). Palliation of symptoms (complete or partial responses) was obtained in 44 cases (68.8%). Seven patients (11.9%) died during the month after the end of the treatment. No delay or cancellation for admission in the palliative care unit were observed. CONCLUSION: Palliative radiotherapy was completed as originally planned in 51 cases (79.9%) with a clinical benefit for 44 cases (68.8%). Radiation therapy must not be neglected as a palliative treatment at the end-of-life.

Skin metastasis of head and neck carcinoma predictive for dismal outcome.

A 64-year-old female with locally advanced oropharyngeal carcinoma presented with an innocuous appearing macule on the abdomen. The lesion rapidly enlarged over 2 weeks into an inflammatory 5 cm fleshy nodule that was diagnosed as squamous cell carcinoma (SCC) and was found to overexpress epidermal growth factor receptor (EGFR). A fatal outcome occurred 3 months after the initial diagnosis of cancer, in spite of chemotherapy and treatment with EGFR inhibitors (cetuximab). Cutaneous metastases occur in 10 percent of squamous cell carcinomas of the head and neck. Contiguous cutaneous metastases in the head and neck areas are by far the most common. Conversely, isolated infradiaphragmatic cutaneous metastases are exceedingly rare and are associated with an aggressive clinical course. In a patient with cancer, the possibility of distant skin metastasis should be considered whenever new cutaneous nodules appear.

[Postoperative treatment of malignant tumors of the parotid gland: radiotherapy, concomitant chemotherapy and radiation therapy?]. / Tumeurs malignes de la parotide: prise en charge multidisciplinaire, rôle de la radiothérapie.

The low incidence, the wide histological spectrum and the natural, sometimes slow, evolution of malignant parotid gland tumours do not allow to easily establish the impact of their treatments. At present, clinical data come from retrospective cohort analysis, whereas randomized phase II-III trials are confidential. Moreover conclusions from these studies are controversial. We present here the therapeutic highlights of parotid cancers: surgery, with the particular concern of facial nerve preservation; and adjuvant treatment essentially based on radiotherapy. This review focused on adjuvant care explores the indications and the technical aspects of radiation, as well as the role of concurrent chemotherapy.

[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%.

Multimodal management of primary adenocarcinoma of the female urethra: About four cases.

PURPOSE: To retrospectively analyse female patients treated for urethral adenocarcinoma, modalities of treatment and long-term outcomes. PATIENTS: Four cases of primary female urethral adenocarcinoma were treated in the departments of urology and radiation-oncology at Georges-Pompidou and Necker hospitals (France) over a 7-year period. RESULTS: All of them underwent surgery, with three presenting stage pT3-pT4 and one a positive cytology on inguinal node. Three patients received adjuvant cisplatin-based chemoradiotherapy up to 60Gy, and one preoperative chemoradiotherapy at 45Gy. Two recurrences were observed: one local relapse occurred at 9months from the diagnosis and was treated by anterior pelvic exenteration followed by chemoradiotherapy, with no recurrence. One tumour relapsed both at the local level and on distant metastatic sites at 9months from the diagnosis, and died 21months after this progression. Median survival and progression-free survival are respectively 4.2years and 13months. Three patients are alive at 7, 4.5 and 3years from diagnosis. CONCLUSION: Female urethral adenocarcinoma is a very rare entity and often present in locally advanced stages. Initial extensive surgery with pelvic exenteration should be considered, followed by chemoradiotherapy according to the surgical margins and lymph nodes involvement.

Serum tissue polypeptide antigen in bladder cancer as a tumor marker: a prospective study.

PURPOSE: Tissue polypeptide antigen (TPA) is a differentiation and proliferation tissue marker of epithelia. Increased serum levels were found in some patients with invasive bladder cancer. We present the results of a prospective study that evaluated the role of serum TPA (S-TPA) in bladder carcinoma. PATIENTS AND METHODS: The series included 167 patients treated for invasive bladder cancer between 1989 and 1996. S-TPA concentrations were measured by radioimmunoassay before treatment, at the end of treatment, and during follow-up evaluation. The upper normal limit of the test was set at 80 UI/L. RESULTS: With a specificity of 100%, the diagnostic sensitivity was 46%. Pretherapeutic S-TPA levels were significantly correlated with tumor stage (T2 v T3 and T4; P = .02), with nodal stage (N0 v N1 and N2; P = .00001), and with metastatic stage (M0 v M1; P = 10[-6]), but not with histologic grading (grade 1 and 2 v 3). In the subset of patients with normal pretherapeutic S-TPA levels, 95% had no residual disease at the end of treatment, compared with 53% of patients with initial elevated S-TPA (P = 10[-8]). Among patients who achieved a complete response, 27% experienced a relapse, with an increase of S-TPA in 72% of cases. The mean follow-up time was 20 +/- 17 months. For patients with normal pretherapeutic S-TPA levels, 3-year overall survival and disease-free survival rates were 76% and 67% respectively. These were 46% (P = .001) and 25% (P = 10[-7]), respectively, for patients with high pretherapeutic S-TPA. Multivariate analysis showed that S-TPA was an independent prognostic factor for survival (P = .03). CONCLUSION: In invasive bladder cancer, S-TPA level is correlated with initial tumor stage. It is a valuable parameter for follow-up evaluation and appears to be a prognostic factor in multivariate analysis.

Combined radiation and chemotherapy for invasive transitional-cell carcinoma of the bladder: a prospective study.

PURPOSE: To improve the results obtained by cystectomy alone and to determine the possibilities of conservative treatment in invasive bladder cancer, we designed a prospective study using a combination of fluorouracil (5-FU) plus cisplatin and concomitant radiation therapy, followed by either cystectomy or additional chemoradiotherapy. PATIENTS AND METHODS: Fifty-four patients with stage T2 to T4 operable untreated invasive bladder cancer were entered onto the study. Treatment was begun in all patients by transurethral resection (TUR) and followed by the 5-FU-cisplatin combination with concomitant bifractionated split-course radiation therapy. A control cystoscopy was performed 6 weeks after completion of the neoadjuvant program. Patients with persistent tumor underwent cystectomy. Complete responders were treated by either additional chemoradiotherapy (group A) or cystectomy (group B). RESULTS: At control cystoscopy, 40 of 54 patients (74%) had a histologically documented complete response. Four responders developed recurrent pelvic disease after a mean follow-up time of 27 +/- 12 months (three in group A and one in group B). Metastatic disease, which developed in 16 patients, occurred more frequently in the nonresponders (71%) than in responders (15%). The disease-free survival rate at 3 years was 62%; it was significantly better in responders (77%) than in nonresponders (23%). There was no difference in survival between groups A and B. CONCLUSION: This neoadjuvant chemoradiotherapy combination, easy to implement and well tolerated even in elderly patients, provides a high complete response rate. It may prove to be effective in inoperable patients and may be proposed as conservative treatment in patients with a complete response to the initial course of chemoradiation.

[Overall treatment time assessment of radiotherapy delivered in a curative intent: A prospective study]. / Respect de l'étalement de la radiothérapie à visée curative : étude prospective.

PURPOSE: To assess the overall treatment time of radiotherapy delivered with curative intent in a cohort of 185 consecutive patients and the causes of this possible delay. If delay, to propose corrective actions. MATERIALS AND METHODS: We report a single-center prospective study including all consecutive patients receiving a radiation therapy with curative intent, from 1st December 2013 to 28th February 2014, on the three linear accelerators of the radiotherapy department. For each fraction missed, the causes of non-completion were prospectively collected. This analysis took into account the following parameters: age, sex, occupation, transport type and duration, tumour localization, radiation dose, concomitant chemotherapy, hospitalization, type of linear accelerator. RESULTS: One hundred and fifty-five patients were included in the study (183 evaluable, two did not complete treatment). The overall treatment time was respected for 31 patients (17%). It was lengthened on 4.6 days (d) (0-29 d; median: 3d). The mean number of delayed fractions was 3.4 (0-17; median: 2). The reasons of delay were: breakdown 32.2%; maintenance 29.3%; holiday 11%; treatment toxicity 9.4%; inadequate planning 8.6%; other disease 3.9%; treatment refusal 2.1%; unspecified personal reasons 1.5%; refusal to wait 0.8%; transportation 0.3%; error of communication 0.3%; other 0.6%. Two parameters had a significant impact on the overall treatment time: the type of linear accelerator in relation to breakdown occurrence (P<0.001) and transportation duration (more or less than 40 min, P=0.022). One hundred and thirty-eight patients (75%) and 79 patients (43%) were treated on one or more than two Saturdays. Treatment on Saturday significantly reduced the overall treatment time (median, 1.9 d; P<0.001). CONCLUSION: The overall treatment time was globally respected excluding break down and maintenance. Their impact on the overall treatment time is minimized by the systematic opening of the department on Saturdays.

Positive clinical experience with misonidazole in brachytherapy and external radiotherapy.

We performed a clinical evaluation of Misonidazole (MISO) radiosensitization in brachytherapy and two schedules of hypofractionated external radiotherapy in 3 non randomized studies. MISO (1 g/m2/d) was administered to patients with ENT tumors treated by brachytherapy, two applications of 35 Gy each with an interval of 1 month. For 46 patients with tumor responses less than 50% (in the largest dimension) at time of second application, 21 received MISO and 25 did not. For these poorly radiosensitive tumors, the addition of MISO significantly increased the rate of complete remission from 9/25 (36%) in controls to 14/21 (67%) (p less than 0.05). We studied MISO with radiation hypofractionation for conservative breast cancer with 4 fractions over 17 days (5 Gy on days 1, 3 and 6.5 Gy on days 15 and 17). Brachytherapy alone was delivered three weeks later. MISO (1 g/m2/d) was given to 38 patients with 87 acting as controls. Radiosensitization was measured by mean tumor diameter at brachytherapy, which showed a residual mass of 33% in the group without MISO and only 17% in the group with MISO (p less than 0.05). We also studied MISO with radiation hypofractionation for large ENT tumors with 14 fractions over 45 days, 2 sessions with a 4 hour interval per day for totals of 6 Gy on days 1 and 3; 8 Gy on days 15, 17, 29, 31; and 6 Gy on day 45. MISO (1 g/m2/d) was given to 49 patients with 21 acting as controls. MISO increased the rate of complete remission from 7/21 (33%) in controls to 32/49 (65%) (p less than 0.02).

A retrospective study of three treatment techniques for T1-T2 base of tongue lesions: surgery plus postoperative radiation, external radiation plus interstitial implantation and external radiation alone.

One hundred and ten patients with base of tongue tumors less than or equal to 4 cm in diameter (T1 and T2 by the UICC staging system) were treated according to three different methods; surgery followed by external radiation in 27 cases, external radiation followed by interstitial implantation in 29 cases, and external radiation alone in 54 cases. The median follow-up is 8 years with a minimum of 4 years. Local failure occurred twice as often in patients treated by external radiation alone (43%) compared to the other two therapeutic modalities (20.5% for external radiation plus implantation and 18.5% for surgery plus radiation). Ninety per cent of recurrences occurred within the first 2 years. The 5-year survival rate for N0 and N1 nodal disease is 30.5% for patients treated by external radiation alone and 50% for the other two methods. This survival difference is related to poorer local control. Surgery plus external radiation gives identical results to those of external radiation and interstitial implantation, but surgery is only practical for peripheral base of tongue tumors and it has poorer functional results. External radiation followed by interstitial implantation is, in our opinion, the best of the three therapeutic techniques for T1 and T2 base of tongue tumors.

The use of a specific hypofractionated radiation therapy regimen versus classical fractionation in the treatment of breast cancer: a randomized study of 230 patients.

An ongoing randomized study of a specific regimen of hypofractionated radiation therapy (IHF) versus classical or standard radiation therapy (IC) for breast cancer was begun in the Department of Radiation Therapy of the Necker Hospital, Paris France, in January 1982. Breast cancer patients entered into this study received either IC to deliver 45 Gy in 25 fractions over 33 days or a specific IHF regimen to deliver 23 Gy in 4 fractions over 17 days. As of June 1989, 525 patients had been entered into the study. The first 230 patients treated from 1982 through December 1984 had a minimum follow-up of 4 years (range: 4 to 7 years). Preliminary analysis of the results in these first 230 patients are presented. The distribution of patients in this initial group according to clinical staging, associated treatments, and pathological nodes is as follows: T1 = 22%, T2 = 61%, T3 + T4 = 17%, palpable nodes = 28%, inflammatory signs = 7%, surgical treatment = 79% (mastectomy = 35%, tumorectomy + Ir.192 = 44%), radiation alone + neoadjuvant chemotherapy = 21%, N+ = 50% of patients undergoing surgery. Loco-regional recurrences developed in 7% (9/125) of patients in the IHF group and in 5% (5/105) of patients in the IC group. Complications were minor. The addition of the percentage of each complication noted results in a total of 23% for the IHF group and 19% for the IC group (one patient could present several complications). As we had previously observed when comparing these two fractionation regimens in other studies with other tumors, these preliminary results showed no evident difference in the effectiveness and rate of complications whether IHF or IC was used to treat patients with breast cancer.

Iridium 192 plesiocurietherapy using silicone elastomer plates for extensive locally recurrent breast cancer following chest wall irradiation.

From July 1985 to October 1988, 11 patients with prior treatment for breast cancer, and presenting an isolated superficial widespread inoperable chest wall recurrence, underwent plesiocurietherapy for salvage. Most patients (91%) had had a mastectomy. The recurrences developed in tissue that had previously been irradiated to 45-55 Gy in three patients and 65 Gy in eight patients. Salvage was attempted using two or three courses of plesiocurietherapy at monthly intervals to decrease treatment complications. The position of the active sources was maintained parallel but slightly shifted at each application. A total dose of 60 Gy was delivered to a Reference Isodose (R.I.) located 2 to 4 mm under the skin surface. The guide system consisted of plastic tubes inserted at 1.5 cm intervals into flexible silicone plates that were applied to the skin surface to maintain the actives lines 0.5 cm above the skin surface. The high dose sleeves surrounding the actives lines (dose greater than 2 x R.I.) were contained within the thickness of the silicone plate. The mean surface treated was 480 cm2 (range 30-1030 cm2). Two patients had continued progression of the lesions within the treated volume during and after curietherapy and died rapidly of metastatic disease. Nine (89%) patients showed complete regression of treated lesions. But two patients developed a new recurrence outside the treated volume. Complications were acceptable: five patients experienced regressive moderate to severe radiation dermatitis and one had skin necrosis that healed in 2 months. These preliminary results have shown that even when tumor extension and previous treatment theorically counter-indicate further local therapy for locally recurrent breast cancer, it is possible to obtain immediate and, at times, lasting control of local disease using two or three courses of plesiocurietherapy with a source shift.

Split course interstitial brachytherapy with a source shift: the results of a new technique for salvage irradiation in recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm diameter in 23 patients.

Between June 1981 and December 1986, 23 patients with prior irradiation of the neck for epithelial ENT tumors underwent salvage irradiation for isolated recurrent inoperable cervical lymphadenopathy greater than or equal to 4 cm. The initial irradiation had delivered 45-80 Gy to the cervical lymph nodes. Split course interstitial brachytherapy was used with a source shift in an attempt to decrease treatment complications. The first and second course of the split course implants delivered 35 Gy and 30 Gy at a 1 month interval. The active lines of the second implant were placed parallel to and in between the position of the lines of the first implant. Three patients did not receive the second implant (one death, one disease evolution, one necrosis). For the patient who died between the first and second implants the local control rate could not be determined. The immediate overall local control rate was 73% (16/22) with a later recurrence rate of 62% (10/16), but only in three cases was recurrence within the treated volume (19%-3/16). The local control rate was better (3/9) if the initial lymphadenopathy was greater than or equal to 4 cm less than or equal to 6 cm but worse (3/13) in those with initial lymphadenopathy greater than 6 cm. Survival of these patients overall was poor with 26% survival at 1 year and 13% at 2 years. Tolerance overall was acceptable with tissue necrosis occurring in 36.5% of cases including those with initial skin involvement. If these cases were excluded the necrosis rate was only 15.5%. In this patient population with inoperable recurrent cervical lymphadenopathy in whom a further dose of external irradiation is not possible interstitial brachytherapy should be considered. Our technique of implantation, split over two sessions with a source shift, is practicable with an acceptable toxicity. It may be used even after high dose external beam irradiation and in large volumes of disease, and it gives better results than classical brachytherapy.

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.

Split course interstitial brachytherapy with a source shift: the results of a new iridium implant technique versus single course implants for salvage irradiation of base of tongue cancers in 55 patients.

Between January 1973 and December 1984, 55 patients with prior irradiation of the oropharynx underwent salvage irradiation for recurrent (26 patients) or second cancers (29 patients) of the base of tongue. The initial irradiation had delivered from 45 to 80 Gy to the base of tongue. One of two techniques of Iridium implantation was used for salvage. Single course implants, delivering 60 Gy, were used until June 1981 in a total of 31 patients. After June 1981, split course implants with a source shift were used in 24 patients in the hope of decreasing treatment complications. The first and second course of the split course implants delivered 35 and 30 Gy, respectively, at a 1-month interval. The active lines of the second implant were placed parallel to and between the position of the lines of the first implant. This shift in the source position resulted in a more uniform dose within the treated volume with a 60% reduction in the high dose sleeves. The overall 3-year survival was 19% (28% T less than or equal to 3 cm). The overall local failure rate was 45.5% (25/55). The difference between the local failure rate after single course implants (52%) and after split course implants (37.5%) was not statistically significative. The response observed after the first course of a split course implant proved to be a reliable indication of the probability of achieving local control after a full course of treatment: 2/14 failures (14%) if the response was greater than or equal to 75% versus 7/10 (70%) if the response was less than 75% (p less than 0.01). The only complication noted in the 40 patients achieving immediate local control after either implant technique was mucosal necrosis. The introduction of split course implants was followed by a two and a half fold decrease in the incidence of necrosis: 43% (9/21) in the single course group and 16% (3/19) in the split course group (p = 0.05). Interstitial brachytherapy offers an effective and reasonable option for salvage therapy in patients with recurrent and second cancers occurring in the base of tongue even when the tumor arises in a zone that has previously received high dose irradiation. The use of split course implants with a shift in the position of the active lines at the time of the second implant significantly decreases the risk of radionecrosis.

High-dose-rate brachytherapy for early breast cancer: an ambulatory technique.

PURPOSE: To evaluate tolerance and efficiency of a boost dose delivered by high-dose-rate brachytherapy (HDRB) in conservative treatment of breast cancer. To evaluate the feasibility of brachytherapy on an out-patient basis. METHODS: One hundred and six patients with T1-T2, N0-N1 breast cancers (108 breasts) have been treated with lumpectomy, external irradiation (45 Gy in 5 weeks), and a boost dose on the tumor bed with HDR iridium brachytherapy. Two fractions of 5 Gy were delivered 6 or 24 hours apart. Implantation was done during the lumpectomy (group A: 24 cases) or 3 to 4 weeks after the end of external irradiation (group B: 84 cases). For group B, the application was performed on local anesthesia, and did not require hospitalization. Characteristics of the population were as follows: T1: 77 (71.3%); T2: 31 (28.7%); median tumor size: 1.5 cm; histology: intraductal carcinomas (DCIS): 14 (13%); infiltrative ductal carcinomas (IDC): 84 (77.8%); others: 10 (9.2%). For IDC, surgical margins were found positive in 15 cases, and an extensive intraductal component was present in 22 cases. RESULTS: All ambulatory HDR implants were performed as planned. No immediate toxicity was noticed, except 5 local hematomas. With a median follow-up of 45 months, 5 local relapses were observed (5-year local relapse rate: 5.1%). Only histological grade III was significantly correlated with local relapse. The 5-year disease-free survival and overall survival were respectively 93.8% and 93.3%. Cosmetic result was evaluated in 87 cases, and was good or excellent in 48 cases (63.2%), acceptable in 27 cases, and poor in 5 cases. CONCLUSION: HDRB allows the boost dose to be performed on an out-patient basis. It seems to offer the same local control as other boost techniques for localized breast cancer with acceptable cosmetic results.

CT and (18)F-deoxyglucose (FDG) image fusion for optimization of conformal radiotherapy of lung cancers.

PURPOSE: To validate a computed tomography (CT) and (18)F-deoxyglucose (FDG) image fusion procedure and to evaluate its usefulness to facilitate target definition and treatment planning in three-dimensional conformal radiation therapy (3D-CRT) for non-small-cell lung cancer. METHODS AND MATERIALS: Twelve patients were assessed by CT and FDG-coincidence mode dual-head gamma camera (CDET) before radiotherapy. The patients were placed in a similar position during CT and FDG-CDET. Matching was achieved by minimizing the cost function by 3D translation and rotation between four landmarks drawn on the patient's skin. Virtual simulation was performed from image fusion and estimated dose-volume histograms (DVH) were calculated. RESULTS: Quantitative analysis indicated that the matching error was < 5 mm. Fusion of anatomic and metabolic data corrected staging of lymph nodes (N) for 4 patients and staging of metastases for 1 patient. In these 5 patients, DVH revealed that the lung volume irradiated at 20 Gy (Vl(20)) was decreased by an average of 22.8%, and tumor volume irradiated at the 95% isodose (V(95)) was increased by 22% and 8% for 2 patients, respectively, and was decreased by an average of 59% for 3 patients after fusion. No difference in terms of Vl(20) and V(95) was observed for the other 7 patients. CONCLUSION: We have validated CT and FDG-CDET lung image fusion to facilitate determination of lung cancer volumes, which improved the accuracy of 3D-CRT.

Evaluation of microscopic tumor extension in non-small-cell lung cancer for three-dimensional conformal radiotherapy planning.

PURPOSE: One of the most difficult steps of the three-dimensional conformal radiotherapy (3DCRT) is to define the clinical target volume (CTV) according to the degree of local microscopic extension (ME). In this study, we tried to quantify this ME in non-small-cell lung cancer (NSCLC). MATERIAL AND METHODS: Seventy NSCLC surgical resection specimens for which the border between tumor and adjacent lung parenchyma were examined on routine sections. This border was identified with the naked eye, outlined with a marker pen, and the value of the local ME outside of this border was measured with an eyepiece micrometer. The pattern of histologic spread was also determined. RESULTS: A total of 354 slides were examined, corresponding to 176 slides for adenocarcinoma (ADC) and 178 slides for squamous cell carcinoma (SCC). The mean value of ME was 2.69 mm for ADC and 1.48 mm for SCC (p = 0.01). The usual 5-mm margin covers 80% of the ME for ADC and 91% for SCC. To take into account 95% of the ME, a margin of 8 mm and 6 mm must be chosen for ADC and SCC, respectively. Aerogenous dissemination was the most frequent pattern observed for all groups, followed by lymphatic invasion for ADC and interstitial extension for SCC. CONCLUSION: The ME was different between ADC and SCC. The usual CTV margin of 5 mm appears inadequate to cover the ME for either group, and it must be increased to 8 mm and 6 mm for ADC and SCC, respectively, to cover 95% of the ME. This approach is obviously integrated into the overall 3DCRT procedure and with other margins.