[Place of stereotactic radiotherapy in oligoprogressive non-small cell lung cancer]. / Place de la radiothérapie stéréotaxique dans le cancer du poumon non à petites cellules en oligoprogression.

This review of the literature provides an overview of the combination of stereotactic radiotherapy (SBRT) with immune checkpoint inhibitors (ICI) and tyrosine kinase inhibitors (TKI) in oligo-progressive non-small cell lung neoplasia. This combination showed local control of 76-100% and distant response rates of 8-60%. They reported progression-free survival of 2.7-24 months and overall survival of 13.4-41.2 months. All-grade toxicity rates ranged from 0% to 42%, with grade≥3 toxicity ranging from 0% to 14%. The combination of SBRT with ICI or TKIs exhibits a safe profile with high rates of local control with this combination. This could delay the use of a new line of systemic therapy in these patients with often limited therapeutic resources.

Cette revue de la littérature réalise un état des lieux de l'association de la radiothérapie stéréotaxique (SBRT) aux inhibiteurs de points de contrôle immunitaire (IPCI) et inhibiteurs de la tyrosine kinase (ITK) dans les néoplasies pulmonaires non à petites cellules en oligoprogression. Cette association montrait un contrôle local entre 76 et 100 % et un taux de réponse à distance entre 8 et 60 %. Elle était associée à une survie sans progression de 2,7 à 24 mois et une survie globale de 13,4 à 41,2 mois. Les taux de toxicité tous grades confondus étaient de 0 à 42 %, dont ceux de grade ≥ 3 entre 0 et 14 %. L'association de la SBRT aux IPCI ou ITK arbore un profil de sécurité avec des taux élevés de contrôle local avec cette combinaison. Cela pourrait retarder le recours à une nouvelle ligne de traitement systémique chez ces patients aux ressources thérapeutiques souvent limitées.

International assessment of interobserver reproducibility of flap delineation in head and neck carcinoma.

Background: Several reports have suggested that radiotherapy after reconstructive surgery for head and neck cancer (HNC), could have deleterious effects on the flaps with respect to functional outcomes. To predict and prevent toxicities, flap delineation should be accurate and reproducible. The objective of the present study was to evaluate the interobserver variability of frequent types of flaps used in HNC, based on the recent GORTEC atlas.Materials and methods: Each member of an international working group (WG) consisting of 14 experts delineated the flaps on a CT set from six patients. Each patient had one of the five most commonly used flaps in HNC: a regional pedicled pectoralis major myocutaneous flap, a local pedicled rotational soft tissue facial artery musculo-mucosal (FAMM) (2 patients), a fasciocutaneous radial forearm free flap, a soft tissue anterolateral thigh (ALT) free flap, or a fibular free flap. The WG's contours were compared to a reference contour, validated by a surgeon and a radiologist specializing in HNC. Contours were considered as reproducible if the median Dice Similarity Coefficient (DSC) was > 0.7.Results: The median volumes of the six flaps delineated by the WG were close to the reference contour value, with approximately 50 cc for the pectoral, fibula, and ALT flaps, 20 cc for the radial forearm, and up to 10 cc for the FAMM. The volumetric ratio was thus close to the optimal value of 100% for all flaps. The median DSC obtained by the WG compared to the reference for the pectoralis flap, the FAMM, the radial forearm flap, ALT flap, and the fibular flap were 0.82, 0.40, 0.76, 0.81, and 0.76, respectively.Conclusions: This study showed that the delineation of four main flaps used for HNC was reproducible. The delineation of the FAMM, however, requires close cooperation between radiologist, surgeon and radiation oncologist because of the poor visibility of this flap on CT and its small size.

Interval between planning and frameless stereotactic radiosurgery for brain metastases: are our margins still accurate?

BACKGROUND: Advances in intracranial stereotactic radiosurgery (SRS) have led to dramatically reduced planning target volume (PTV) margins. However, tumor growth between planning and treatment may lead to treatment failure. Our purpose was to assess the kinetics of tumor growth before SRS for brain metastases. METHODS: This retrospective, monocentric study included all consecutive patients (pts) treated for brain metastases secondary to melanoma (ML) and non-small cell lung cancer (NSCLC) between June 2015 and May 2016. All pts underwent diagnostic brain imaging and a radiosurgery planning MRI, during which gross tumor volume (GTV) was delineated. Linear and exponential models were used to extrapolate a theoretical GTV at first day of treatment, and theoretical time to outgrow the PTV margins. RESULTS: Twenty-three ML and 31 NSCLC brain metastases (42 pts, 84 brain imaging scans) were analyzed. Comparison of GTV at diagnosis and planning showed increased tumor volume for 20 ML pts (96%) and 22 NSCLC pts (71%). The shortest time to outgrow a 1 mm margin was 6 days and 3 days for ML and 14 and 8 days for NSCLC with linear and exponential models, respectively. CONCLUSIONS: Physicians should bear in mind the interval between SRS planning and treatment. A mathematical model could screen rapidly progressing tumors.

10-Year Locoregional Control with Postoperative External Beam Radiotherapy in Patients with Locally Advanced High-Risk Non-Anaplastic Thyroid Carcinoma De Novo or at Relapse, a Propensity Score Analysis.

(1) Background: To assess the role of postoperative external beam radiotherapy (pEBRT) on locoregional failure (LRF) for patients with locally advanced high-risk non-anaplastic thyroid carcinoma (naTC) at primary event or relapse. (2) Methods: Between 1995 and 2015, postoperative naTC patients with a theoretical indication for EBRT were included based on criteria that were common to American-British-French current guidelines, i.e., pT3-4, pN+, gross or microscopic residual disease. Inverse probability of treatment weighting (IPTW) after multiple imputation was used to reduce selection biases. (3) Results: Of 254 naTC patients, 216 patients underwent pEBRT (106 de novo, 110 at relapse, median dose 60 Gy) and 38 underwent surgery only. pEBRT patients had more gross residual disease, a major prognostic factor (p = 0.027) but less perineural invasion (p = 0.008) or lymphovascular emboli (p = 0.009). pEBRT patients more frequently underwent radioiodine therapy (p = 0.026). The 10-year cumulative incidence of LRF was 56% (95% CI, 32-74%) in operated patients, and 23% (95% CI, 17-30%) in pEBRT patients. After IPTW method, pEBRT reduced the risk of LRF (hazard ratio 0.30; 95% CI [0.18-0.49], p < 0.001), but had no impact on OS. In the pEBRT group, non-Intensity Modulated RadioTherapy (IMRT) plans and interruption of the radiotherapy were associated with poorer survival, while extended versus limited field strategy and dose were not. (4) Conclusions: In naTC patients who have pT3-4, pN+ disease or R1-2 resection, pEBRT improved LRF. Limited-field IMRT is preferred.

Neck management in head and neck squamous cell carcinomas: where do we stand?

Head and neck squamous-cell carcinomas (HNSCCs) have a significant lymph node tropism. This varies considerably depending on the primary tumor site and the Human Papillomavirus (HPV) status of the disease. The best therapeutic option, between up-front lymph node dissection and chemoradiotherapy (CRT) +/- followed by lymph node dissection in case of persistent lymphadenopathy or regional relapse, remains unclear. The purpose of this review is to discuss the pros and cons related to the different approaches of the neck management in HNSCC. A narrative review of the management of the cervical lymph nodes was undertaken. Searches of PubMed database were performed using the terms 'neck management' OR 'cervical lymphadenopathies' AND 'head and neck neoplasms'. Recent advances in imaging, pathological analysis, surgery and radiotherapy let to personalize the type of lymph node dissection and, the volumes of radiation therapy. Excluding inoperable patients and unresectable diseases, N3 lymphadenopathies, as well as bulky N2 stages, specifically HPV- or necrotic nodes, would be in favor of an up-front surgical approach, while HPV+ diseases, and lymphadenopathies of unknown primary would support CRT first. However, efficacy of such strategies is challenged by a significant morbidity in the medium and long terms. In the absence of higher level of evidence, the decision-making tools for the neck dissection before or after the CRT are based on the Mehanna's trial and retrospective studies with significant biases. Consequently, the approaches and the ensuing outcomes remain not homogenous depending on the centers' experience, in the context of limited data, especially for N2-3 HPV- HNSCC.

Management of locally advanced anal canal carcinoma with intensity-modulated radiotherapy and concurrent chemotherapy.

The best curative option for locally advanced (stages II-III) squamous-cell carcinomas of the anal canal (SCCAC) is concurrent chemo-radiotherapy delivering 36-45 Gy to the prophylactic planning target volume with an additional boost of 14-20 Gy to the gross tumor volume with or without a gap-period between these two sequences. Although 3-dimensional conformal radiotherapy led to suboptimal tumor coverage because of field junctions, this modality remains a standard of care. Recently, intensity-modulated radiotherapy (IMRT) techniques improved tumor coverage while decreasing doses delivered to organs at risk. Sparing healthy tissues results in fewer severe acute toxicities. Consequently, IMRT could potentially avoid a gap-period that may increase the risk of local failure. Furthermore, these modalities reduce severe late toxicities of the gastrointestinal tract as well as better functional conservation of anorectal sphincter. This report aims to critically review contemporary trends in the management of locally advanced SCCAC using IMRT and concurrent chemotherapy.

[Advances in the management of cervical lymphadenopathies of unknown primary: advances in diagnostic imaging and surgical modalities and new international staging system]. / Évolutions dans la prise en charge des métastases ganglionnaires cervicales sans cancer primitif retrouvé : avancées diagnostiques et nouvelle classification TNM.

INTRODUCTION: Cervical lymphadenopathies of unknown primary represent 3 % of head and neck cancers. Their diagnostic work up has largely changed in recent years. This review provides an update on diagnostic developments and their potential therapeutic impact. MATERIALS AND METHODS: This is a systematic review of the literature. RESULTS: In recent years, changes in epidemiology-based prognostic factors such as human papilloma virus (HPV) cancers, advances in imaging and minimally invasive surgery have been integrated in the management of cervical lymphadenopathies of unknown primary. In particular, systematic use of PET scanner and increasing practice of robotic or laser surgery have contributed to increasing detection rate of primary cancers. These allow more adapted and personalized treatments. The impact of changes in the eighth TNM staging system is discussed. CONCLUSION: The management of cervical lymphadenopathies of unknown primary cancer has changed significantly in the last 10 years. On the other hand, practice changes will have to be assessed.