Does Breast Surgery Type Alter Incidental Axillary Irradiation? A Dosimetric Analysis of the "Sentinel Envahi et Randomisation du Curage" SERC Trial.

BACKGROUND: An incidental axillary dose of adjuvant radiotherapy using tangential beams is usually given after breast-conserving surgery for breast cancer. The goal of this sub-study was to evaluate this incidental dose in the setting of post-mastectomy radiotherapy (PMRT) according to two different radiotherapy techniques. METHODS: Patients participating in a randomized SERC trial who received PMRT in a single center were included. We collected the incidental axillary dose delivered to the Berg level 1 using different dosimetric parameters and compared two techniques using Student's t-test: three-dimensional conformal radiotherapy (3D-CRT) and volumetric arc therapy (VMAT). RESULTS: We analyzed radiotherapy plans from 52 patients who received PMRT from 2012 to 2021. The mean dose delivered to the Berg level 1 was 37.2 Gy. It was significantly higher with VMAT than with 3D-CRT-43.6 Gy (SD = 3.1 Gy) versus 34.8 Gy (SD = 8.6 Gy) p < 0.001. Eighty-four percent of the Berg level 1 was covered by 40 Gy isodose in the VMAT group versus 55.5% in the 3D-CRT group p < 0.001. CONCLUSIONS: On the Berg level 1, PMRT gives a dose at least equivalent to the one given by post-breast-conserving surgery radiotherapy, making it possible to limit completion axillary lymph node dissections in select pN1a patients treated with a mastectomy. Modern radiotherapy techniques like VMAT tend to increase this incidental dose.

Dosimetric comparison of VMAT standard optimization (SO) and multi-criteria optimization (MCO) treatment plans with standard mode delivery (STD) or sliding window (SW) for head and neck cancer.

PURPOSE: A new development on the RayStation treatment planning system (TPS) allows a plan to be planned by imposing a constraint on the leaf sequencing: all leaves move in the same direction before moving again in the opposite direction to create a succession of sliding windows (SWs). The study aims to investigate this new leaf sequencing, coupled with standard optimization (SO) and multi-criteria optimization (MCO) and to compare it with the standard sequencing (STD). METHODS: Sixty plans were replanned for 10 head and neck cancer patients (two dose levels simultaneously SIB, 56 and 70 Gy in 35 fractions). All plans were compared, and a Wilcoxon signed-rank test was performed. Pre-processing QA and metrics of multileaf collimator (MLC) complexity were studied. RESULTS: All methodologies met the dose requirements for the planning target volumes (PTVs) and organs at risk (OARs). SO demonstrates significantly best results for homogeneity index (HI), conformity index (CI), and target coverage (TC). SO-SW gives best results for PTVs (D98% and D2% ) but the differences between techniques are less than 1%. Only the D2%,PTV-56 Gy is higher with both MCO methods. MCO-STD offer the best sparing OARs (parotids, spinal cord, larynx, oral cavity). The gamma passing rates (GPRs) with 3%/3 mm criteria between the measured and calculated dose distributions are higher than 95%, slightly lowest with SW. The number of monitor units (MUs) and MLC metrics are higher in SW show a higher modulation. CONCLUSIONS: All plans are feasible for the treatment. A clear advantage of SO-SW is that the treatment plan is more straightforward to planning by the user due to the more advanced modulation. MCO stands out for its ease of use and will allow a less experienced user to offer a better plan than in SO. In addition, MCO-STD will reduce the dose to the OARs while maintaining good TC.

[Start of activity with the MRIdian® system: The first 200 patients treated at the Institut Paoli-Calmettes]. / Retour d'expérience clinique à propos des 200 premiers patients traités au MRIdian® à l'Institut Paoli-Calmettes.

INTRODUCTION: Several centers have recently been equipped with MRI-guided radiotherapy systems, including the Paoli-Calmettes Institute which was the first French center to start this activity. We report in this article our early experience. METHODS: Data related to patients treated on the MRIdian® (Viewray®) were prospectively collected. Procedures concerning the implementation of the system and internal organizational issues were summarized. RESULTS: Between February 2019 and March 2020, 201 patients were treated: 40% of treatments were normofractionated (n=70) and 60% used hypofractionation (n=105). The reported monthly occupancy rate at one, six and twelve months was 30%, 62%, and 90%. The distribution of normofractionated treatments was dominated by prostatic (29%) and pancreatic (26%) cancers, followed by abdomino-pelvic irradiations for gynecological cancers (12%) or lymph node diseases (12%) and boosts for rectal or vaginal cancers (11%). Regarding treatments with moderate hypofractionation (dose by fraction between 3 and 5Gy), they corresponded mainly to integrated boost for abdomino-pelvic lymph nodes (38%), while the stereotaxic treatments primarily concerned hepatic lesions (15%), bones (30%). DISCUSSION: The MRIdian® was initially used widely in our service corresponding to a learning curve for MRI guidance. This new tool for image-guided radiotherapy helped us to secure our practice providing solutions for both inter and intra-fraction movements making it possible to reduce the additional margin in order to better protect the organs at risk. The main technical difference with conventional accelerators is the possibility of performing adaptive radiotherapy in real time, the start of which was more gradual.

Safety and benefit of using a virtual bolus during treatment planning for breast cancer treated with arc therapy.

PURPOSE: This study evaluates the benefit of a virtual bolus method for volumetric modulated arc therapy (VMAT) plan optimization to compensate breast modifications that may occur during breast treatment. METHODS: Ten files were replanned with VMAT giving 50 Gy to the breast and 47 Gy to the nodes within 25 fractions. The planning process used a virtual bolus for the first optimization, then the monitors units were reoptimized without bolus, after fixing the segments shapes. Structures and treatment planning were exported on a second scanner (CT) performed during treatment as a consequence to modifications in patient's anatomy. The comparative end-point was clinical target volume's coverage. The first analysis compared the VMAT plans made using the virtual bolus method (VB-VMAT) to the plans without using it (NoVB-VMAT) on the first simulation CT. Then, the same analysis was performed on the second CT. Finally, the level of degradation of target volume coverage between the two CT using VB-VMAT was compared to results using a standard technique of forward-planned multisegment technique (Tan-IMRT). RESULTS: Using a virtual bolus for VMAT does not degrade dosimetric results on the first CT. No significant result in favor of the NoVB-VMAT plans was noted. The VB-VMAT method led to significant better dose distribution on a second CT with modified anatomies compared to NoVB-VMAT. The clinical target volume's coverage by 95% (V95%) of the prescribed dose was 98.9% [96.1-99.6] on the second CT for VB-VMAT compared to 92.6% [85.2-97.7] for NoVB-VMAT (P = 0.0002). The degradation of the target volume coverage for VB-VMAT is not worse than for Tan-IMRT: the median differential of V95% between the two CT was 0.9% for VMAT and 0.7% for Tan-IMRT (P = 1). CONCLUSION: This study confirms the safety and benefit of using a virtual bolus during the VMAT planning process to compensate potential breast shape modifications.

Flattening Filter Free vs. Flattened Beams for Lung Stereotactic Body Radiation Therapy.

BACKGROUND/AIM: To assess the clinical impact of high dose rate stereotactic body radiation therapy (SBRT) in patients with lung neoplastic lesions. PATIENTS AND METHODS: From January 2014 to June 2016, a single-center retrospective analysis was performed including all patients treated by either flattening filter free (FFF) beams or flattening filter beams (FF) three-dimensional (3D) SBRT for lung neoplastic lesions. RESULTS: A total of 99 SBRT were performed on 75 patients. Among these, 29 SBRT were performed using a FFF technique while 70 other SBRT were done using a FF technique. Median follow-up time was 12.9 months. Overall, no difference between the two groups was found except for the mean beam on time which was reduced by 3.3 to 0.9 minutes in the FFF group (p<0.001). CONCLUSION: We report a low toxicity rate and a shortened beam on time in patients treated with 3D FFF SBRT for lung neoplastic lesions.

Dilated Cardiomyopathy Revealing Cushing Disease: A Case Report and Literature Review.

Cardiovascular impairments are frequent in Cushing's syndrome and the hypercortisolism can result in cardiac structural and functional changes that lead in rare cases to dilated cardiomyopathy (DCM). Such cardiac impairment may be reversible in response to a eucortisolaemic state.A 43-year-old man with a medical past of hypertension and history of smoking presented to the emergency department with global heart failure. Coronary angiography showed a significant stenosis of a marginal branch and cardiac MRI revealed a nonischemic DCM. The left ventricular ejection fraction (LVEF) was estimated as 28% to 30%. Clinicobiological features and pituitary imaging pointed toward Cushing's disease and administration of adrenolytic drugs (metyrapone and ketoconazole) was initiated. Despite the normalization of cortisol which had been achieved 2 months later, the patient presented an acute heart failure. A massive mitral regurgitation secondary to posterior papillary muscle rupture was diagnosed as a complication of the occlusion of the marginal branch. After 6 months of optimal pharmacological treatment for systolic heart failure, as well as treatment with inhibitors of steroidogenesis, there was no improvement of LVEF. The percutaneous mitral valve was therefore repaired and a defibrillator implanted. The severity of heart failure contraindicated pituitary surgery and the patient was instead treated by stereotaxic radiotherapy.This is the first case reporting a Cushing's syndrome DCM without improvement of LVEF despite normalization of serum cortisol levels.

Experience of multidisciplinary team meetings in vestibular schwannoma: a preliminary report.

To assess the contribution of multidisciplinary team meetings (MTM) on vestibular schwannoma management as well as to (1) compare professional compliance to national guidelines and (2) study the percentage of loss to follow-up in cases of conservative management by radiologic observation. A retrospective descriptive study of MTMs held between January 2011 and May 2013 in a tertiary referral center. Patients were classified in three groups according to the MTM decision (observation, surgery or radiotherapy). A total of 363 cases were discussed during the study period (29 months). One hundred and ninety-four decisions (53.4%) were for conservative management with radiologic observation, 130 (35.8%) for surgery, and 39 (10.7%) for radiation therapy. The sex ratio was 0.94, and the patients had a median age of 59 years (range 18-86 years). Most of the vestibular schwannomas (74.2%) were small (stages I and II). Global concordance between the MTM decision and International Radiosurgery Association guidelines was 88.7%. Twenty-three percent of the 104 files that were discussed in MTMs between January 2011 and July 2012, for which conservative management was decided, were lost to follow-up by 18 months. Management of vestibular schwannoma remains controversial, but it usually depends on the evolutive status. MTMs improve practice and facilitate the creation and maintenance of local registries. Future studies in MTMs are warranted to evaluate the benefit and evaluated if MTM could optimize long-term follow-up, limiting loss to follow-up in the observation of vestibular schwannomas that may be evolutive.

Curative treatment can be an option for patients with metastatic squamous cell cancer of the head and neck.

BACKGROUND: No specific study has focused on patients with metastatic squamous cell carcinoma of the head and neck (SCCHN) at diagnosis. Due to high response rates of induction chemotherapy in chemo-naïve patients with localized disease, their prognosis should be better than patients with recurrent disease. METHODS: From January 1, 2008 to July 1, 2012, we retrospectively collected all patients' records with SCCHN diagnosed as metastatic. Patients, disease, treatment and its results were analyzed. Survival was calculated using the Kaplan-Meier method. RESULTS: Of the 749 new patients treated for SCCHN in our institution, 16 (2.1%) were metastatic at diagnosis, of whom five had cytological results to prove it. Six patients died before treatment or had palliative care and ten received initial chemotherapy and then surgery and/or radiotherapy according to the primary response. Four patients treated with first-line chemotherapy with docetaxel-5FU-cisplatin (TPF) showed a complete response of metastatic lesions allowing locoregional treatment. The overall survival at 1 year and 3 years was 50% and 24%, respectively. The median survival was 7 months (1-72 months). Seven patients (43.7%) had a higher survival at 12 months, including five (31.5%) who are still alive without recurrence with a mean follow-up of 30 months. There was a significant difference in overall survival (P<0.01) between patients who had chemotherapy with TPF versus other therapeutic protocols. The median survival of patients with lung metastases only was 15 months (1-72 months), significantly higher than that of patients with liver and/or bone localizations, which was 2 months (1-9 months). CONCLUSION: Patients with metastatic SCCHN treated by TPF followed by multimodal treatment could achieve long survival.

A pyriform sinus cancer organ preservation strategy comprising induction chemotherapy with docetaxel, cisplatin, and 5-fluorouracil, followed by potentiated radiotherapy: a multicenter, retrospective study.

No specific study has evaluated the role of neoadjuvant DCF (docetaxel, cisplatin, 5-fluorouracil) followed by radiotherapy in pyriform sinus cancer, which are often included in studies focusing on laryngeal and hypopharyngeal cancer. We assessed the proportion of patients treated sequentially for a pyriform sinus cancer with a preserved larynx. Overall survival, event-free survival (EFS), survival with 'local control', and treatment tolerance were assessed as well. We retrospectively reviewed 88 patients with advanced pyriform sinus squamous cell carcinoma treated with DCF between 2005 and 2010. After induction, radiation could be potentiated with cetuximab or cisplatin. Most patients (82%) had been treated with organ preservation intent. The response rate to DCF was 85%, including 42% with complete response. Primary tumor was operated in 13 patients (eight with total laryngectomy). Radiotherapy had been delivered to 78 (89%) patients (30 with cisplatin, 39 with cetuximab). Potentiation had been achieved as planned in 52 and 79% of patients treated with cisplatin and cetuximab, respectively. Twenty-three local and three neck recurrences were found. Median overall survival was 16.8 months and 38.3% at 3 years. EFS at 3 years was 29.1% with a hazard ratio for partial responders versus nonresponders of 0.18 (P<0.001), and 0.13 (P<0.001) for complete responders versus nonresponders. Thirty-five percent of patients were alive with their larynx preserved at 3 years. This study confirms the efficacy of induction followed by chemoradiation for pyriform sinus cancer and that response to DCF is predictive of EFS.

Neoadjuvant TPF in locally advanced head and neck cancer can be followed by radiotherapy combined with cisplatin or cetuximab: a study of 157 patients.

Neoadjuvant TPF (docetaxel, cisplatin, 5-fluorouracil), followed by radiotherapy or chemoradiotherapy with weekly carboplatin, increases overall survival and organ preservation. We assessed whether TPF could be used in routine practice and whether radiotherapy potentiated with cisplatin or cetuximab was feasible and could increase survival. We retrospectively reviewed 157 patients with advanced head and neck squamous cell carcinoma treated with TPF in four French institutions between May 2005 and March 2009. After induction, operable patients had undergone surgery and were irradiated, and potentiated in some cases with cetuximab or cisplatin. Most patients (79%) had been treated with organ preservation strategies. The two most common sites were the hypopharynx (34%) and the oropharynx (30%). The response rate to TPF was 84%, including 26% with a complete response. Radiotherapy had been provided to 144 (92%) patients (of whom 17 had received radiotherapy alone, 46 had received q3w cisplatin, 30 had received q1w cisplatin, and 37 had received cetuximab). Potentiation had been achieved as planned in 59, 63, and 62% of patients treated with q3w cisplatin, q1w cisplatin, and cetuximab, respectively. After a median follow-up of 39.9 months, the median overall survival was 43 months. No significant difference was observed in progression-free survival or overall survival according to the type of potentiation. This study confirms the efficacy and tolerability of TPF induction, followed by chemoradiation, with outcomes similar to those for patients irradiated without induction. The best potentiation of radiotherapy after induction has not yet been determined.

Intensity-modulated radiotherapy in head and neck cancer: results of the prospective study GORTEC 2004-03.

BACKGROUND AND PURPOSE: In 2003, the French Authority for Health (HAS) recommended the use of intensity modulated radiotherapy (IMRT) in prospective trial before its routine use. The Oncology and Radiotherapy Group for Head and Neck Cancer (GORTEC) proposed to evaluate prospectively acute and late toxicities, locoregional control and overall survival for patients treated for head and neck cancer (HNC) with IMRT and bilateral neck irradiation. MATERIALS AND METHODS: Between 2002 and 2008, 208 patients with HNC were treated with IMRT in 8 centres. There were 38 nasopharynx, 117 oropharynx, 25 pharyngo-larynx, 24 oral cavity and 4 unknown primary (28.5% stage I-II and 71% Stage III-IV). Ninety-three patients (46%) had postoperative IMRT and 78 patients (37.5%) received concurrent chemotherapy. The doses were 70 Gy to the gross tumour, 66 Gy to the high-risk postoperative sites and 50 Gy to the subclinical disease. Toxicities were graded according to the RTOG-EORTC scales. RESULTS: The median follow-up was 25.3 months (range: 0.4-72 months). There were 29 local-regional failures: 24 were in-field, three were marginal and one was out-field. The two-year loco-regional control and overall survival were 86% and 86.7%, respectively. At 18 months, grade ≥ 2 xerostomia was 16.1%. A mean dose to the spared parotid below 28 Gy led to significantly less grade ≥ 2 xerostomia (8.5% vs 24%) with a relative risk of 1.2 [95% CI: 1.02-1.41, p = 0.03]. Grade ≥ 2 xerostomia increased by approximately 3% per Gy of mean parotid dose up to 28, Gy then 7% per Gy above 33 Gy. CONCLUSIONS: IMRT for HN cancer seems to reduce late toxicities without jeopardising local control and overall survival.

Concomitant chemoradiotherapy versus acceleration of radiotherapy with or without concomitant chemotherapy in locally advanced head and neck carcinoma (GORTEC 99-02): an open-label phase 3 randomised trial.

BACKGROUND: Concomitant chemoradiotherapy and accelerated radiotherapy independently improve outcomes for patients with locally advanced head and neck squamous-cell carcinoma (HNSCC). We aimed to assess the efficacy and safety of a combination of these approaches. METHODS: In our open-label phase 3 randomised trial, we enrolled patients with locally advanced, stage III and IV (non-metastatic) HNSCC and an Eastern Cooperative Oncology Group performance status of 0-2. We randomly allocated patients centrally with a computer program (with centre, T stage, N stage, and localisation as minimisation factors) in a 1:1:1 ratio to receive conventional chemoradiotherapy (70 Gy in 7 weeks plus three cycles of 4 days' concomitant carboplatin-fluorouracil), accelerated radiotherapy-chemotherapy (70 Gy in 6 weeks plus two cycles of 5 days' concomitant carboplatin-fluorouracil), or very accelerated radiotherapy alone (64·8 Gy [1·8 Gy twice daily] in 3·5 weeks). The primary endpoint, progression-free survival (PFS), was assessed in all enrolled patients. This trial is completed. The trial is registered with ClinicalTrials.gov, number NCT00828386. FINDINGS: Between Feb 29, 2000, and May 9, 2007, we randomly allocated 279 patients to receive conventional chemoradiotherapy, 280 to accelerated radiotherapy-chemotherapy, and 281 to very accelerated radiotherapy. Median follow-up was 5·2 years (IQR 4·9-6·2); rates of chemotherapy and radiotherapy compliance were good in all groups. Accelerated radiotherapy-chemotherapy offered no PFS benefit compared with conventional chemoradiotherapy (HR 1·02, 95% CI 0·84-1·23; p=0·88) or very accelerated radiotherapy (0·83, 0·69-1·01; p=0·060); conventional chemoradiotherapy improved PFS compared with very accelerated radiotherapy (0·82, 0·67-0·99; p=0·041). 3-year PFS was 37·6% (95% CI 32·1-43·4) after conventional chemoradiotherapy, 34·1% (28·7-39·8) after accelerated radiotherapy-chemotherapy, and 32·2% (27·0-37·9) after very accelerated radiotherapy. More patients in the very accelerated radiotherapy group had RTOG grade 3-4 acute mucosal toxicity (226 [84%] of 268 patients) compared with accelerated radiotherapy-chemotherapy (205 [76%] of 271 patients) or conventional chemoradiotherapy (180 [69%] of 262; p=0·0001). 158 (60%) of 265 patients in the conventional chemoradiotherapy group, 176 (64%) of 276 patients in the accelerated radiotherapy-chemotherapy group, and 190 (70%) of 272 patients in the very accelerated radiotherapy group were intubated with feeding tubes during treatment (p=0·045). INTERPRETATION: Chemotherapy has a substantial treatment effect given concomitantly with radiotherapy and acceleration of radiotherapy cannot compensate for the absence of chemotherapy. We noted the most favourable outcomes for conventional chemoradiotherapy, suggesting that acceleration of radiotherapy is probably not beneficial in concomitant chemoradiotherapy schedules. FUNDING: French Ministry of Health.

New targeted therapies in pituitary carcinoma resistant to temozolomide.

To evaluate the antitumoral efficacy of everolimus in pituitary carcinoma resistant to temozolomide, the correlation with mammalian target of rapamycin (mTOR) signaling in the tumor and to present recent advances and future treatments of pituitary carcinomas. Pituitary carcinomas are rare and largely unresponsive to current treatment options. Recent reports on the antitumoral efficacy of temozolomide in some such patients are encouraging, yet most patients appear to show resistance to its actions. As a potential alternative, the mTOR inhibitor, everolimus, has been shown to potently inhibit pituitary cell proliferation highlighting mTOR inhibition as a promising therapeutic approach for pituitary carcinomas. We described the tumoral effects of a combination therapy with everolimus (5 mg/day) and octreotide (30 mg/month) and the mTOR signalling expression in a patient with pituitary ACTH carcinoma, compared to 17 other ACTH adenomas. Clinical and biochemical evaluation were performed every month, and imaging after 3 month of treatment. mTOR signaling was assessed by microarray expression analysis of each of the 18 adenoma tissues. Combined therapy failed to control pituitary tumor growth and ACTH secretion. Slight activation of mTOR signaling was found in all ACTH tumors alongside important variations between tumors. Low antitumor efficacy shown by everolimus might be explained by the weak activation of mTOR pathway in ACTH tumors. Everolimus treatment was inefficient at controlling secretion and tumor growth of one ACTH pituitary carcinoma. More clinical cases, with mTOR signalling expression analysis of the tumor, must be published before any conclusions can be drawn.

A retrospective, multicenter study of the tolerance of induction chemotherapy with docetaxel, Cisplatin, and 5-Fluorouracil followed by radiotherapy with concomitant cetuximab in 46 cases of squamous cell carcinoma of the head and neck.

PURPOSE: To investigate, in a multicenter study, the tolerance of induction chemotherapy (ICT) and external radiotherapy (ERT) with concomitant cetuximab in the treatment of patients with squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS: Clinical data from 46 patients with Stage III or IV nonmetastatic SCCHN who received docetaxel, cisplatin, and 5-fluorouracil as ICT, followed by ERT with concomitant cetuximab, were retrospectively analyzed. Clinical safety (weight, allergy, mucositis, and dermatitis) and paraclinical safety (levels of hemoglobin, polynuclear neutrophils, and creatinine clearance) were studied. The primary objective was the proportion of patients who completed the protocol. RESULTS: The percentage of patients completing ICT was 73.9%, ERT 93.5%, and cetuximab 69.6%. Induction chemotherapy was better tolerated than that previously reported. The rates of temporary suspensions of radiation (39.1%, mean duration of 13 days) and hospitalization (26.1%) during ERT with concomitant cetuximab were high. Weight loss during treatment (21.4% of patients lost >10% of their body weight), radiodermatitis, and radiomucositis were the main causes of temporary suspension of treatment, although Grade 4 dermatitis was not experienced. There were no allergic reactions to cetuximab. CONCLUSION: The completed protocol rate for SCCHN patients receiving ICT and ERT with concomitant cetuximab is high and the toxicity acceptable. Future improvements to protocol will be possible through early action and systematic implementation of nutritional support coupled with antibiotic treatment upon the first signs of radiodermatitis. These data could be useful for prospective studies on the safety and efficacy of this protocol.

Randomized clinical trial of post-operative radiotherapy versus concomitant carboplatin and radiotherapy for head and neck cancers with lymph node involvement.

BACKGROUND AND PURPOSE: Post-operative radiotherapy is indicated for the treatment of head and neck cancers. In vitro, chemotherapy potentiates the cytotoxic effects of radiation. We report the results of a randomized trial testing post-operative radiotherapy alone versus concomitant carboplatin and radiotherapy for head and neck cancers with lymph node involvement. MATERIALS AND METHODS: The study involved patients undergoing curative-intent surgery for head and neck cancers with histological evidence of lymph node involvement. Patients were randomly assigned to receive radiotherapy alone (54-72Gy, 30-40 fractions, 6-8 weeks) or identical treatment plus concomitant Carboplatin (50mg/m(2) administered by IV infusion twice weekly). RESULTS: Between February 1994 and June 2002, 144 patients were included. With a median follow-up of 106 months (95% confidence interval (CI) [92-119]), the 2-year rate of loco-regional control was 73% (95% CI: 0.61-0.84) in the combined treatment group and 68% (95% CI: 0.57-0.80) in the radiotherapy group (p=0.26). Overall survival did not differ significantly between groups (hazard ratio for death, 1.05; 95% CI: 0.69-1.60; p=0.81). CONCLUSIONS: Twice-weekly administration of carboplatin concomitant to post-operative radiotherapy did not improve local control or overall survival rates in this population of patients with node-positive head and neck cancers.

Shared medical information: expectations of breast cancer patients.

UNLABELLED: Allowing cancer patients to hold medical records containing essential information for managing their disease may improve their satisfaction and the coordination of their medical care. OBJECTIVE: Our aim was to determine breast cancer patients' interest in and expectations of such medical records and the exchange of information during their treatment. METHODS: Eighty-six hospital physicians were selected to distribute an anonymous questionnaire to all of the breast cancer patients they saw in consultations. RESULTS: Out of 194 patients asked, 140 (72%) participated in the survey. Forty-eight percent were "highly satisfied", 47% were "quite satisfied" with their involvement in their treatment and 43% preferred to play a relatively passive role in decisions concerning treatments. When offered, 79% agreed to hold paper medical records containing test results, reports and letters. Many found these medical records to be useful and a possible means for improving communication. Others, however, expressed reservations concerning privacy or losing or forgetting the records. CONCLUSION: The principle of shared medical records could satisfy the majority of breast cancer patients. Experimenting with this concept in the field would enable practitioners to better determine the content of the records and how they can be used on a practical basis.

Prognostic factors of squamous cell carcinoma of the anal margin treated by radiotherapy: the Lyon experience.

BACKGROUND: To report our patient experience with squamous cell carcinoma of the anal margin and to evaluate the prognostic factors influencing outcome. MATERIALS AND METHODS: Between 1980 and 2001, 26 patients with anal margin squamous cell carcinoma were treated in Lyon-Sud: 7 T1, 14 T2, 4 T3, and 1 T4 with 20 N0, 3 N1, and 3 N2. The anal canal was invaded in five patients. Treatment consisted of definitive external irradiation in 14 patients and adjuvant irradiation (after a local excision) in 12 patients. External irradiation was combined with chemotherapy in seven patients, brachytherapy in four patients, and both brachytherapy and chemotherapy in one patient. RESULTS: The local control rate was initially 61.4%, and it was 80.8% after salvage treatment. The 5-year overall and specific survival rates were 71 and 88.3%, respectively. Three factors correlated with specific survival: cell differentiation (P=0.038) and T (P=0.001) and N category (P=0.0005). A salvage abdominoperineal resection was successfully employed in five of seven local recurrences. Four grade 3 and two grade 4 toxicities were observed. Sphincter preservation was possible in 66% of alive patients. CONCLUSION: Our results confirm the dominating place of definitive irradiation and radiochemotherapy in the treatment of anal margin squamous cell carcinoma. The indications for abdominoperineal resection must be limited to local relapse. The prognosis of squamous cell carcinoma is correlated to T and N staging and cell differentiation.

[The cost of intensity modulated radiation therapy in head and neck cancers: results of the 2002 STIC study]. / Le coût de la radiothérapie conformationnelle avec modulation d'intensité dans les cancers ORL: l'étude STIC 2002.

An economic evaluation of intensity modulated radiotherapy (IMRT) in head and neck cancer was carried out to assess the cost of treatment and compare it to reimbursement paid to hospitals in the French Prospective Payment System. Planning required in average 20 hours of work for the physician and 6 hours for the radiation oncologist. Radiation consisted of 33 fractions in average and required 29 hours of work for the radiotherapy technician, 8 hours for the physician and 3 hours for the radiation oncologist. Mean cost of IMRT treatment was estimated at euro 10,916 (euro 2,773 for planning and euro 8,143 for radiation). The variability of costs was important and was in a large extent attributable to learning effects. As more patients were treated, unit cost of treatment was decreasing. In the French Prospective Payment System, mean reimbursement of IMRT was euro 6,987. For 70 % of the patients, reimbursement did not offset the cost of treatment. A financial support for hospitals implementing the technique is essential during the whole learning period.

Exclusive brachytherapy for T1 and T2 squamous cell carcinomas of the velotonsillar area: results in 44 patients.

PURPOSE: To evaluate the role of interstitial brachytherapy as an exclusive radiotherapy modality for primary T1-T2 squamous cell carcinomas (SCC) of the velotonsillar area. METHODS AND MATERIALS: Between 1992 and 2000, 44 patients with T1-T2 SCC of the tonsil (n = 36) and soft palate (n = 8) were treated to the primary with brachytherapy alone (37 patients) or after a limited resection (7 patients). Eight patients had prior external beam radiation therapy (EBRT) for previous head-and-neck carcinoma. Nineteen patients had initial neck dissection. The mean brachytherapy dose was 58.7 Gy, and the mean reference dose rate and Ir-192 linear activity were 58.2 cGy/h and 1.51 mCi/cm respectively. RESULTS: With a 75-month median follow-up, 1 patient recurred locally. Isolated nodal relapses occurred in 4 patients, none of whom had initial neck dissection, and salvage therapy was successful in 2. Five-year overall and progression-free survival rates were 76% and 68%, respectively. Full-course radiation therapy was possible in 7 of 12 patients who developed a second primary head-and-neck carcinoma. Late toxicity was limited to 6 mild soft-tissue necroses, and was significantly associated with previous surgery to the primary and high linear activity. CONCLUSIONS: Exclusive brachytherapy for T1-T2 velotonsillar carcinomas is safe and effective, and permits definitive reirradiation for a second head-and-neck cancer. Initial neck dissection should be performed for optimal selection for exclusive brachytherapy.

Preoperative radiotherapy for rectal adenocarcinoma: Which are strong prognostic factors?

PURPOSE: This retrospective 12-year study evaluated the prognostic value of initial and postoperative staging of rectal tumors. METHODS AND MATERIALS: Between 1985 and 1996, 297 patients were treated with preoperative radiotherapy (39 Gy in 13 fractions) and surgery for Stage T2-T4N0-N1M0 rectal adenocarcinoma. Pretreatment staging included a clinical examination and endorectal ultrasonography (EUS) since 1988. Clinical staging was performed by digital rectal examination and rigid proctoscopy. EUS was performed in 236 patients. Postoperative staging was performed by examination of the pathologic specimen. RESULTS: The median follow-up was 49 months. The overall 5-year survival rate was 67%, with a local failure rate of 9%. The rate of sphincter preservation was 65%. The clinical examination findings were strong prognostic factor for both cT stage (p < 0.001) and cN stage (p < 0.006) but had poor specificity for cN stage (only 25 lymph nodes detected). In both univariate and multivariate analyses, EUS had a statistically significant prognostic value for uT (p < 0.014) but not for uN (p < 0.47) stage. In contrast, pT and pN stages were strong prognostic factors (p < 0.001 and p < 0.001, respectively). CONCLUSION: Pretreatment staging, including clinical examination and EUS, seemed accurate enough to present a high prognostic value for the T stage. EUS was insufficient to stage lymph node involvement. Owing to its lack of specificity, uN stage was not a reliable prognostic factor. An improvement in N staging is necessary and essential. Despite downstaging, postoperative staging remained a very strong prognostic factor for both T and N stages.