[Radiation induced brachial plexopathy: Diagnosis, risk factors, principles of care]. / La plexite radique : épidémiologie, diagnostic, facteurs de risque et prise en charge.

Radiation plexitis, also known as radiation-induced brachial neuropathy is a rare toxicity following axillary, breast, cervical or thoracic radiotherapy, first described in 1966 by Stoll and Andrew. Although improvements in radiotherapy techniques have greatly reduced its risk over the past seventy years, its severe form remains a dreaded complication that is difficult to manage in patients with increased life expectancy. This article summarizes the epidemiological elements, risk factors, diagnostic methods, doses and constraints to be respected in radiotherapy and the treatment strategies of radiation plexitis.

[Securing the information system of health care organisations]. / Sécurisation du système d'information des structures médicales.

The information system involves all the resources managing information within a team. It mainly relies on the computer network. Prevention and protection measures are vital, especially in a radiotherapy department. They will aim to preserve the whole staff from potential risks connected with passwords, suspicious emails, specific websites, or USB flash drives. Also, they will consist in maintaining updated operating systems and software, activating antivirus programs and firewalls, and getting a map of the whole network and its users. Finally, it is necessary to anticipate failure scenarios and to set up recovery plans to continue the activity with lower resources.

[Low dose radiotherapy for COVID-19 pneumopathy: Biological rationale and literature review]. / Radiothérapie de faible dose pour la pneumopathie covid-19 : rationnel biologique et revue de la littérature.

The world has now been facing the coronavirus disease 2019 (COVID-19) pandemic due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) since over a year. If most of clinical presentations are benign, fragile patients are at greater risk of developing severe or fatal lung disease. Many therapies have been explored with very low impact on mortality. In this context, Kirkby et Mackenzie have published in April 2020 a report reminding the anti-inflammatory properties of low-dose radiotherapy (delivering less than 1Gy) and its use in the treatment of viral and bacterial pneumopathies before antibiotics era. Large in vivo and in vitro data have demonstrated the biological rationale and anti-inflammatory activity of low-dose radiotherapy in many pathologies. Over the past year, three phase I/II clinical trials have been published, as well as one randomized controlled trial, reporting the feasibility and the clinical and biological improvement of a 0.5 to 1Gy treatment dose to the entire lung. 13 other studies, including a randomized phase III trial, are currently ongoing worldwide. These studies may provide data in the effect of low-dose radiotherapy in the treatment of SARS-CoV-2 pneumonia. This article explains biological rationale of low-dose radiotherapy, and reports already published or ongoing studies on low-dose radiotherapy for SARS-CoV-2 pneumonia.

[Treatment de-intensification strategies for HPV-driven oropharyngeal cancer: A short review]. / Désescalade thérapeutique dans les cancers de l'oropharynx induit par les HPV : mise au point.

The incidence of oropharyngeal cancer induced by human papillomavirus (HPV) infection is steadily increasing in developed countries. These tumors are more chemoradiosensitive and have a better prognosis than HPV-negative one. In addition, they occur in younger and better-off patients with longer life expectancy. Current radiotherapy and chemotherapy protocols are currently being questioned as they may expose HPV-positive patients to excessive treatment and unnecessary toxic effects. Less intensive treatment regimens could possibly achieve similar efficacy with lower toxicity and improved quality of life. The aim of this work was to summarize the knowledge on these tumors and their implications for radiation oncologists. In this update, we will discuss ongoing de-escalation trials and highlight the issues raised by these studies. We will also comment on the results of recently published de-intensification studies. Three main strategies are analyzed in the present article: the de-escalation of the drug associated with radiotherapy, the de-escalation of the radiotherapy dose (in concomitant chemoradiotherapy, after induction chemotherapy, in a postoperative setting) and de-escalation of radiation target volumes. Our findings ultimately indicate that clinicians should not change the management of oropharyngeal cancer patients outside of clinical trials.

Use of 4D-CT for radiotherapy planning and reality in France: Data from a national survey.

PURPOSE: Lung and some digestive tumours move during a respiratory cycle. Four-dimensional scanography (4D-CT) is commonly used in treatment planning to account for respiratory motion. Although many French radiotherapy centres are now equipped, there are no guidelines on this subject to date. We wanted to draw up a description of the use of the 4D-CT for the treatment planning in France. METHODS AND MATERIAL: We conducted a survey in all French radiotherapy centres between March and April 2017. RESULTS: One hundred and seventy-two were contacted. The participation rate was 88.37%. The use of the 4D-CT seems to be common and concerned planning for 15.28% of kidney and adrenal cancers, 19.72% of pancreatic cancers, 27.78% of oesophageal cancers and 73.24% of lung cancers in case of normofractionated treatments. The use of the 4D-CT was also widespread in the case of stereotactic body radiation therapy: with 61.11% in the case of pulmonary irradiation and 34.72% in the case of hepatic irradiation. Many centres declared they carried out several 4D-CT for treatment planning (29, 55% in case of stereotactic body radiation therapy for lung tumours and 20% for liver tumours). Private centres tend to repeat 4D-CT more. CONCLUSION: Although the use of the 4D-CT appears to be developing, it remains very heterogeneous. To date, the repetition of the 4D-CT has been very poorly studied and could be the subject of clinical studies, allowing to define in which indications and for which populations there is a real benefit.

[Medical prevention and treatment of radiation-induced urological and nephrological complications]. / Prévention médicale et traitement des complications urologiques et néphrologiques secondaires à la radiothérapie.

Abdominal and pelvic irradiations play a major place in the management of patients with cancer and present a risk of acute and late side effects. Radiation-induced lesions can affect kidney or urological structures. These side effects can have an impact in the quality of life of patients. The aim of this article is to describe the physiopathology, the symptomatology, and the principles of management of radiation-induced nephropathy, uretheritis, cystitis, and urethritis.

Outcomes and treatments of IB1 cervical cancers with high recurrence risk: A 13 years' experience.

PURPOSE: The aim of the present study was to identify management strategies and outcomes of patients with stage IB1 cervical cancer with high recurrence risk. MATERIALS AND METHODS: Medical files of all consecutive patients treated between 2004 and 2017 with external beam radiotherapy and/or brachytherapy for IB1 cervical cancer, whatever the lymph node status, were retrospectively reviewed. RESULTS: Forty-two patients were included, with a median age of 49.8 years old. Median tumour size, estimated with the initial pelvic magnetic resonance imaging, was 26mm (interquartile range [IQR]=19.5-35). Histological types were mainly squamous cell carcinoma (59.5%) and adenocarcinoma (33.3%). Lymphovascular invasion was reported for 38.1% of patients. Pelvic lymph nodes were involved for eight patients (19.0%). Surgery was performed for 39 patients (92.9%). A neoadjuvant treatment was delivered for 20 patients (47.6%), an adjuvant treatment for 19 patients (45.2%) and an exclusive radiotherapy (with or without chemotherapy) followed by brachytherapy for three patients (7.1%). Pathologic complete response was achieved in 61.5% of patients. With a median follow-up of 5.8 years (IQR=2.6-9.4), five patients (11.9%) experienced a tumour relapse. The five-year disease-free survival was 79.5% (95% confident interval [CI]=66.9-94.4), the five-year overall survival was 87.8% (95% CI=77.2-99.8), and the five-year disease-specific survival was 94.2% (95% CI=86.7-100). CONCLUSION: In current clinical practice, tailored treatments are delivered, and seems to give correct therapeutic index. However, clinical trials are needed to standardise treatment according to patient characteristics and recurrence risk factors.

Harnessing drug/radiation interaction through daily routine practice: Leverage medical and methodological point of view (MORSE 02-17 study).

BACKGROUND: Safety profile of the interaction between anticancer drugs and radiation is a recurrent question. However, there are little data regarding the non-anticancer treatment (NACT)/radiation combinations. The aim of the present study was to investigate concomitant NACTs in patients undergoing radiotherapy in a French comprehensive cancer center. METHODS: A prospective cross-sectional study was conducted. All cancer patients undergoing a palliative or curative radiotherapy were consecutively screened for six weeks in 2016. Data on NACTs were collected. RESULTS: Out of 214 included patients, a NACT was concomitantly prescribed to 155 patients (72%), with a median number of 5 NACTs per patient (range: 1-12). The most prescribed drugs were anti-hypertensive drugs (101 patients, 47.2%), psychotropic drugs (n = 74, 34.6%), analgesics (n = 78, 36.4%), hypolipidemic drugs (n = 57, 26.6%), proton pump inhibitors (n = 46, 21.5%) and antiplatelet drugs (n = 38, 17.8%). Although 833 different molecules were reported, only 20 possible modifiers of cancer biological pathways (prescribed to 74 patients (34.5%)) were identified. Eight out of the 833 molecules (0.9%), belonging to six drug families, have been investigated in 28 ongoing or published clinical trials in combo with radiotherapy. They were prescribed to 63 patients (29.4%). CONCLUSION: Drug-radiation interaction remains a subject of major interest, not only for conventional anticancer drugs, but also for NACTs. New trial designs are thus required.

[Medical prevention and treatment of radiation-induced pulmonary complications]. / Prévention médicale et traitement des complications pulmonaires secondaires à la radiothérapie.

Radiation-induced lung injuries mainly include the (acute or sub-acute) radiation pneumonitis, the lung fibrosis and the bronchiolitis obliterans organizing pneumonia (BOOP). The present review aims at describing the diagnostic process, the current physiopathological knowledge, and the available (non dosimetric) preventive and curative treatments. Radiation-induced lung injury is a diagnosis of exclusion, since clinical, radiological, or biological pathognomonic evidences do not exist. Investigations should necessarily include a thoracic high resolution CT-scan and lung function tests with a diffusing capacity of the lung for carbon monoxide. No treatment ever really showed efficacy to prevent acute radiation-induced lung injury, or to treat radiation-induced lung fibrosis. The most promising drugs in order to prevent radiation-induced lung injury are amifostine, angiotensin-converting-enzyme inhibitors and pentoxifylline. Inhibitors of collagen synthesis are currently tested at a pre-clinical stage to limit the radiation-induced lung fibrosis. Regarding available treatments of radiation-induced pneumonitis, corticoids can be considered the cornerstone. However, no standardized program or guidelines concerning the initial dose and the gradual tapering have been scientifically established. Alternative treatments can be prescribed, based on clinical cases reporting on the efficacy of immunosuppressive drugs. Such data highlight the major role of the lung dosimetric protection in order to efficiently prevent radiation-induced lung injury.

Bilateral Breast Cancer After Prophylactic Bilateral Pulmonary Irradiation.

The purpose of this article is to report a new case of a probably radio-induced bilateral breast cancer occurred after prophylactic bilateral pulmonary irradiation in the treatment of osteosarcoma. A 42-year-old woman, treated at the age of 12 years for osteosarcoma at the right lower limb with chemotherapy (methotrexate, adriamycin and cisplatin) followed by non-conservative surgery and adjuvant radiotherapy. Eighteen years after, she developed her first breast cancer, and five years later, her second contralateral breast cancer. The patient was treated for her two non-metastatic cancers and is currently in complete remission. This publication adds to several previous publications the very probable effect of ionizing radiation in the occurrence of secondary cancers.

[Ototoxicity in head and neck cancers after radiotherapy and chemoradiotherapy: From primary prevention to tertiary prevention]. / Ototoxicité radio-induite et chimio-induite dans les cancers ORL : de la prévention primaire à la prévention tertiaire.

Each year, 15,000 head and neck cancer are treated in France. Prognosis is steadily improving. Consequently, limitation of late toxicities becomes essential. Ototoxicity is common, disabling and undervalued. We aimed to inventory primary, secondary and tertiary prevention measures to reduce ototoxicity induced by radiotherapy and chemotherapy, as well as its impact on quality of life of patients treated for head and neck cancer. External radiation therapy induced 30 to 40% of ototoxicity, including irreversible sensorineural hearing loss. Primary prevention of this risk is based on limiting the dose to the cochlea: 40Gy in case of radiotherapy alone, 10Gy during concomitant chemoradiotherapy with cisplatin. Dose gradients allowed by intensity-modulated radiotherapy help respecting these limits. Concurrent chemotherapy with high dose cisplatin (100mg/m2) also causes hearing loss by cochlear damages. Prescription of carboplatin-5-fluorouracil combination or cetuximab should be preferred in case of high risk of ototoxicity. This risk must be precisely evaluated before treatment. Ototoxicity monitoring during treatment allows early management, and lower long-term impact. Radiosensitivity predictive tests and research of genetic factors predisposing to chemo-induced ototoxicity should enable optimization of therapeutic choices and monitoring.

Real-life efficacy of volumetric modulated arc therapy in head and neck squamous cell carcinoma.

OBJECTIVES: There is paucity of data on the efficacy of volumetric modulated arc therapy (VMAT) in head and neck squamous cell carcinoma (HNSCC). The objective of the present study was to investigate outcomes and patterns of recurrence in locally advanced HNSCC treated by VMAT. METHODS: A retrospective study included all patients with stage III or IV HNSCC undergoing curative VMAT. RESULTS: From 2010 to 2013, 130 patients were treated for locally advanced oropharynx (n=55; 42%), hypopharynx (n=38; 29%), larynx (n=22; 17%) or oral cavity (n=15; 12%) SCC. Median age was 60 years (range, 39-85). Median follow-up was 18.1 months (range, 0-43.7). By end of follow-up, 60 patients (46%) had died. Two-year progression-free and overall survival were respectively 63.6% and 77.3% for laryngeal tumors, 60% and 60% for oral cavity tumors, 52.6% and 57.6% for oropharyngeal tumors, and 38.8% and 54.7% for hypopharyngeal tumors. Most recurrences were located within or marginal to radiation therapy fields. CONCLUSION: This retrospective analysis is, to our knowledge, the largest study of the efficacy of VMAT in HNSCC. Recurrence patterns and outcomes were consistent with those previously reported for intensity-modulated radiotherapy.

[Prostate cancer of elderly patients: Place and role of geriatric assessment]. / Cancer de prostate des sujets âgés : place et rôle de l'évaluation gériatrique.

INTRODUCTION: The aim of this study was to appreciate the place and role of geriatric assessment in elderly patients with prostate cancer. MATERIALS AND METHODS: We performed a retrospective analysis of prostate cancer patients who underwent geriatric assessment during the therapeutic management from 2008 to 2014. Patient, tumor, treatment characteristics and their associated toxicity as well as the parameters of geriatric assessment were studied. The occurrence of geriatric assessment within the 3 months preceding a therapeutic decision was reviewed. RESULTS: Data of seventy-four patients were analyzed with a median follow-up of 15.6 years. The average age at diagnosis was 74.3 and 80.6 at the geriatric assessment. At the time of the geriatric assessment 64 patients had metastatic disease, 39 were in poor condition more than 50% of patients had walking ability disorders. Thirteen patients underwent radical surgery, 28 received radiotherapy, 30 patients had chemotherapy and hormonotherapy was prescribed for 72 patients. The geriatric assessment, requested on average 15 years after diagnosis, was not carried out within the 3 months preceding treatment decision for 55 patients. CONCLUSION: The recourse to geriatric assessment is predominantly used to endorse a decision of supportive care for elderly patients with prostate cancer. An early intervention by a geriatrician consultant for the initial management and then at each therapeutic event is a sine qua non condition for efficient personalized therapeutic management suitable to every patient according to physiological age. LEVEL OF EVIDENCE: 4.

[Radiotherapy phase I trials' methodology: Features]. / Méthodologie des essais de phase I en radiothérapie : particularités.

In clinical research, biostatistical methods allow the rigorous analysis of data collection and should be defined from the trial design to obtain the appropriate experimental approach. Thus, if the main purpose of phase I is to determine the dose to use during phase II, methodology should be finely adjusted to experimental treatment(s). Today, the methodology for chemotherapy and targeted therapy is well known. For radiotherapy and chemoradiotherapy phase I trials, the primary endpoint must reflect both effectiveness and potential treatment toxicities. Methodology should probably be complex to limit failures in the following phases. However, there are very few data about methodology design in the literature. The present study focuses on these particular trials and their characteristics. It should help to raise existing methodological patterns shortcomings in order to propose new and better-suited designs.

[Hyperbaric oxygen and radiotherapy: From myth to reality]. / Oxygénothérapie hyperbare et radiothérapie : entre mythe et réalité.

Worldwide, more than a million people receive each year a curative radiotherapy. While local control and overall survival are steadily increasing, 5 to 15% of patients still develop above grade 2 late toxicities. Late toxicities treatments are complex. Hyperbaric oxygenation was shown to induce revascularization and healing of injured tissues, but indications are still debated. Through a literature review, we summarized the hyperbaric oxygenation indications in radiation-induced late toxicities. We also studied the knowledge and practice of French local radiation therapists. It seems that hyperbaric oxygen therapy can be a conservative treatment of haemorrhagic cystitis and radiation-induced pain, in case of drug therapies failure. Often associated with a significant morbidity and mortality, surgery could be avoided. The risk of complications in case of tooth extraction in irradiated tissues is also reduced. However, the role of hyperbaric oxygenation for mandibular osteoradionecrosis, radiation-induced proctitis, enteritis, lymphoedema, brachial plexopathy, skin and neurological sequelae seems more questionable since studies results are conflicting. Future outcomes of phase III studies are expected to clarify the role of hyperbaric oxygenation in the management of radio-induced toxicities, including for head and necks complications.

[Rhabdomyosarcoma of adult genital tract: A short review]. / Rhabdomyosarcomes d'origine gynécologique chez l'adulte : revue générale et principes de prise en charge.

Rhabdomyosarcoma, most common soft tissue tumor in children, represent 8% of solid tumors in children. Conversely, in adults, this histology is very rare and no consensual recommendation is supported. If gynecological localization is one of the most frequent in children, it is a minority in adults. The management of this type of tumor is based on treatment multimodality combining surgery, chemotherapy, radiotherapy and brachytherapy. This pathological separate entity differs from other sarcomas by its greater sensitivity to chemotherapy and radiotherapy. The aim of this study is to conduct a general review of diagnostic and treatment of genital tract rhabdomyosarcoma in adults, and to report pathological characteristics of this type of tumor.

Conflict of interests for radiation oncologists: Harnessing disclosures from policy to reality.

PURPOSE: An increasing attention is being paid to disclosures of conflicts of interests in the field of oncology. The purpose of this study was to examine how radiation oncologists report their conflicts of interests with pharmaceutical or technology industries. MATERIALS AND METHODS: We collected the data of conflicts of interests disclosures in the abstract books from the annual 2012 and 2013 meetings of the American Society for Radiation Oncology (ASTRO) in Miami (FL, USA), and in Atlanta (GA, USA), respectively. Geographic origins of abstracts as well other factors were examined. RESULTS: We identified a total of 4219 abstracts published in the past two years. The total number of involved authors was of 28,283. All of the published abstracts had conflicts of interests disclosures. Amongst them, 563 abstracts (13.4%) reported at least one potential conflict of interests, in which 1264 (4.5%) declared a potential conflict of interests in their disclosures. Geographic distribution of abstracts with financial relationship was as following: 67.9%, 15.5%, 7.7% and 7.7% for USA, Europe, Asia/Pacifica, and Canada, respectively. Abstracts with conflict of interest originated from North America in 75.6% of cases. USA distribution was 70.6% and 29.4% for Eastern and Western, respectively. CONCLUSIONS: The proportion of physicians declaring financial conflicts of interests remains extremely low, whichever geographic area authors are from. In comparison to the rest of the world, the US proved itself better at declaring potential links. Changes in medical culture and education could represent a significant step to improve the process of revealing conflicts of interest in medical journal as well as in international meetings.

[Carcinomatous meningitis: The radiation therapist's point of view]. / Méningite carcinomateuse: le point de vue de l'oncologue radiothérapeute.

Carcinomatous meningitis complicates 5 to 10% of cancers, essentially with breast cancers, lung cancers and melanomas. The incidence probably increased because of therapeutic advances in oncology. Treatment is based on external beam radiotherapy, systemic treatment, intrathecal chemotherapy and supportive care. The aim of this work was to review data on external radiation therapy and carcinomatous meningitis. There are few evidences on the subject, but it is a major topic of interest. A whole brain radiation therapy is indicated in case of brain metastases or clinical encephalitis. Focal radiation therapy is recommended on symptomatic, bulky or obstructive sites. The dose depends on performance status (20 to 40 Gy in five to 20 fractions), volume to treat and available techniques (classic fractionation or hypofractionation via stereotactic radiosurgery). The objective of radiation therapy is to improve quality of life. Association with systemic therapy improves overall survival. Administration of sequential intrathecal chemotherapy may also improve overall survival, but induces more toxicity. The use of new radiotherapy techniques and development of radiosensitizing molecules in patients with good performance status could improve survival in this frequent complication of cancer.