Stereotactic magnetic resonance imaging-guided radiotherapy for intracardiac metastases: A case report.

Adrenocortical carcinoma is a malignant tumor with a poor prognosis and a frequent metastatic extension. In very rare cases, a cardiac metastatic disease may occur, and surgical resection is essential for its management. MR-guided stereotactic radiotherapy is an attractive radiotherapy modality for the treatment of mobile thoracic tumors, enabling the target to be monitored continuously during irradiation, while the dosimetric plan can be adapted daily if necessary. We report here the case of a patient with intracardiac metastasis secondary to malignant adrenocortical carcinoma, treated with magnetic resonance imaging-guided stereotactic radiotherapy.

The role of radiation therapy for de novo metastatic bladder and renal cancers.

Metastatic bladder and renal cancers account respectively for 2.1% and 1.8% of cancer deaths worldwide. The advent of immune checkpoint inhibitors has revolutionized the management of metastatic disease, by demonstrating considerable improvements in overall survival. However, despite initial sensitivity to immune checkpoint inhibitors for most patients, both bladder and renal cancer are associated with short progression-free survival and overall survival, raising the need for further strategies to improve their efficacy. Combining systemic therapies with local approaches is a longstanding concept in urological oncology, in clinical settings including both oligometastatic and polymetastatic disease. Radiation therapy has been increasingly studied with either cytoreductive, consolidative, ablative or immune boosting purposes, but the long-term impact of this strategy remains unclear. This review intends to address the impact of radiation therapy with either curative or palliative intent, for synchronous de novo metastatic bladder and renal cancers.

[Last year of residency for radiation oncologists in France: Overview and perspectives]. / Phase de consolidation (docteur junior) en oncologie­radiothérapie en France : état des lieux et perspectives.

PURPOSE: The last year of the radiotherapy oncology internship in France has become a phase of empowerment, called "junior doctor", allowing interns to validate acts previously reserved only for senior doctors. This study focused on the responsibilities given to the first promotion of junior doctors in France and their feelings on this new status. MATERIAL AND METHODS: A cross-sectional survey was carried out by the French associations of interns and young doctors in oncology, Aerio and SFjRO. A questionnaire was sent to the class referents of each city for transmission to the junior doctors of the year 2021-2022 from September 1st to November 30th, 2022. The questions concerned training, the modalities of this year and the feelings. Responses were analyzed anonymously using R. 4.3.1 software. RESULTS: For radiation oncology, 33 responses were obtained from 21 cities. For most junior doctors, three to four localizations (51%) were performed with an average of five new patients per week. The contours were reviewed either systematically (51%) or only at the beginning (32%). Dosimetry was reported as never countersigned in 19%; 80% of junior doctors described having been the only radiation oncologist during multidisciplinary staff meetings. The two main areas of improvement were theoretical training (45%) and legal frameworks/contracts (42%). CONCLUSION: These results relating to the first class of junior doctors showed an overall agreement with the recommendations of the Cnec. Feedback from interns was positive. The supervision of brachytherapy and dosimetry activities, the presence alone in multidisciplinary panel remained points of vigilance.

[Predictive factors assessment of pathological response to neoadjuvant radiotherapy of soft tissue sarcomas]. / Évaluation de facteurs prédictifs de réponse pathologique à la radiothérapie néoadjuvante des sarcomes des tissus mous.

PURPOSE: Conserving surgery combined with radiotherapy in presence of local recurrence risk factors is standard treatment of soft tissue sarcomas, a group of rare and heterogeneous tumours. Radiotherapy is performed before or after surgery. In neoadjuvant setting, late radiation-induced toxicity is reduced and pathological response to radiotherapy could be achieved. A complete pathological response to radiotherapy has recently been shown to predict better survival. Our study aims at identifying predictive factors of pathological response to neoadjuvant radiotherapy (clinical, radiological or histological) of soft tissue sarcomas. PATIENTS AND METHODS: Clinical, imaging (MRI: perilesional oedema, necrosis, tumour heterogeneity, vasculonervous relationships) and pathological (pathological subtype, tumour grade, anticipated/obtained resection quality) data were retrospectively collected. Tumour response (imaging and pathological), patient outcome, acute and late radiation-induced toxicity, predictive factors of pathological response to neoadjuvant radiotherapy were studied. The 2-test or exact-Fisher test (qualitative variables) and by Student's t-test or Kruskal-Wallis test (quantitative variables) were used for statistical analysis. RESULTS: From April 2017 to April 2021, neoadjuvant radiotherapy (50Gy in 25 fractions) followed by surgical excision was performed to 36 consecutive patients with liposarcomas (n=17/36), or undifferentiated sarcomas (n=8/36). MRI response was complete in 1 patient, partial in 9 patients (n=9/36, 25%), stable in 21 patients (n=21/36, 58%) or in progression in 5 patients (n=5/36, 14%). Pathological response was observed in 22 patients (61%). No grade 3-4 acute radiation-induced toxicity was observed. Regarding late toxicity, 28% of patients had grade 1-2 oedema (n=10/36), 39% had a grade 1 fibrosis (n=14/36), and 30% grade 1 pain (n=11/36). No predictive factors of response to radiotherapy was statistically significant. CONCLUSIONS: Neoadjuvant radiotherapy is well-tolerated. No clinical, radiological or pathological predictive factors was identified for radiotherapy tumour response.

[Interprofessional recommendations on behalf of Société française de radiothérapie oncologique for the prevention, protection and management of cyberattacks in radiation oncology]. / Prévention, protection, et gestion des cyberattaques en oncologie radiothérapie : recommandations interprofessionnelles au nom de la Société française de radiothérapie oncologique.

Cybersecurity is currently a major issue. Large hospitals are no longer the only main targets of attacks, but all healthcare organizations and establishments, without distinction of size or activities. The information system is defined as all the resources needed to collect images, store and process them with general distribution of multiple information within an organization. Systems are therefore crucial for the functioning of a medical department. Radiation oncology is one of the specialties most dependent on digital resources, for imaging, data transfer, dosimetry, treatment and so on.. Radiation oncology departments are therefore a prime target for ransomware attacks, which have increased significantly in recent years. Cybersecurity can be likened to a viral or bacterial attack. It is based on the two usual pillars of antimicrobial protection : hygiene and prophylaxis. In this article, we will detail by analogy the three classic levels of prevention of a bacillary attack: "primary prevention", which acts upstream of the infection; "secondary prevention", which acts at an early stage of its evolution; and "tertiary prevention", which acts on complications and risks of recurrence. This article is the result of an interprofessional group on behalf of SFRO, the French society of radiation oncology, with the aim of helping all teams to implement safety adapted to the specificities of a radiation oncology department in France.

[Bladder tumors in the Hérault department: Results of the Hérault tumor registry registration from1987 to 2019]. / Les tumeurs de la vessie dans le département de l'Hérault : résultats de l'enregistrement du registre des tumeurs de l'Hérault de1987 à 2019.

OBJECTIVES: The Hérault Tumor Registry (RTH) is a general registry qualified by the national committee of registries since 1987. The objective of this study is to present the evolution of the epidemiology of bladder cancer (stage≥T1) in the Hérault department based on data collected by the RTH over a period from 1987 to 2019. MATERIAL AND METHODS: We analyzed trends in bladder cancer incidence in Hérault between 1987 and 2019 by sex, age, and stage, as well as mortality trends between 1987 and 2017. For the years 2018-2019, which are the last two years validated by the registry, we described relative frequencies, sex ratio, mean and median age at diagnosis, cumulative risk, stages at diagnosis, pathology data, and primary treatments. Observed and net survival data are analyzed for those diagnosed between 01/01/2000 and 12/31/2015 with a point date of 06/30/2018. RESULTS: In 2018-2019, bladder cancer was the 7th most common cancer in Hérault (5th in men and 12th in women) with an incidence sex ratio of 3.9 men to one woman. The mean age at diagnosis was 75.3 years for men and 77.8 years for women. The probability of having bladder cancer before the age of 75 years was 1.68% for a man (1/59) and 0.34% for a woman (1/295). Urothelial carcinomas accounted for 90.7% of cancers. Between 1987 and 2019, bladder cancer incidence TSMs (worldwide standardized rates) decreased by 0.8% per year in men and remained stable in women. Mortality TSMs between 1987 and 2017 followed the same trends with a decrease of 2.2% per year in men and stability in women. For the 3304 bladder cancers diagnosed between 01/01/2000 and 12/31/2015, the observed 5-year survival was 38% (34% in women and 38% in men). CONCLUSIONS: Bladder cancer incidence and mortality rates have decreased slightly in men but remain stable in women in the Hérault. Registries collect only a limited number of variables for each patient. In 2018 the Hérault Registry Specialized in Onco-Urology (RHESOU) was created, to have comprehensive data.

[Stereotactic Body Radiation Therapy for less than 3cm (stage I) and 5cm (stage II) inoperable lung tumors: 10 years experience of Montpellier Cancer Institute]. / Radiothérapie stéréotaxique (RTST) pulmonaire des tumeurs de moins de 3cm (stade I) et 5cm (stade II) non opérées : 10 ans d'expérience de l'Institut du Cancer de Montpellier (ICM).

PURPOSE: Search for predictive factors on survival and local control for less than 3 centimeters (cm) (stage I) and 5cm (stage II) inoperable lung tumors treated by Stereotactic Body Radiation Therapy (SBRT) in a retrospective monocentric study from Montpellier Cancer Institute (ICM) PATIENTS AND METHOD: Every patients treated at ICM for a stage I or II inoperable lung tumors from 2009 to 2019 were analyzed. RESULTS: One hundred and seventy nine lesions were treated in 176 patients, with a major part (82,7%) in operated due to chronic obstructive pulmonary disease. Median overall survival for all patients was 71,7 months with a 35 months follow-up and the 2 years loco-regional free survival was 94,0 months. Better associated outcomes were stage I (median overall survival 71,7 versus 29,0 months P=0,004 ; HR=2,37 P=0,005), BED≥150Gy (median time-to-progression not reached versus 76,7 months P=0,025), small size of Planning Target Volume (PTV) (HR=0,42 P=0,032 when PTV<15,6 cc). 7,3% of all patients developed radiation pneumonitis. CONCLUSION: SBRT is associated with an excellent overall survival and a high rate of local control for less than 3cm (stage I) and 5cm (stage II) lung tumors but a low rate of toxicities. For these patients with many comorbidities, BED over 150Gy seems to be associated with a better loco-regional free survival, while cause of death is often other than lung cancer.

[The morbidity and mortality review meetings in radiotherapy departments: Procedure, implementation and prospects of the "Proust" French national project]. / Revue de morbidité et mortalité en radiothérapie : procédure, implémentation et perspectives du projet national français « Proust ¼.

Radiation-induced acute and late toxicity depends on several parameters. The type, severity and duration of morbidity are mainly related to irradiated volume, total dose and its fractionation and the intrinsic radiosensitivity of the patients. The follow-up of these toxicities is essential. However, unlike many specialties, morbidity and mortality reviews procedures are not developed as part of quality governance programs in radiation therapy departments for the monitoring of toxicity which sometimes hinder the patients' quality of life. One French survey published within the framework of the project entitled Prospective Registration of Morbidity and Mortality, Individual Radiosensitivity and Radiation Technique (Proust), conclude that there was a lack of knowledge of morbidity and mortality reviews and considerable confusion between these reviews and other quality processes without perspective for the local morbidity and mortality reviews development in a large number of the participated centers. In this article, we will discuss the procedure of the "ideal morbidity and mortality reviews" and its implementation through a monocentric experience started in 2015. Thus, the Proust project is a unique opportunity to implement and standardize a national morbidity and mortality reviews implementation in radiation therapy departments by involving the French regions.

Acceptance, commissioning and quality assurance of the MRIdian®: Site experience and three years follow-up.

PURPOSE: This study presents the methodology and results of the acceptance and periodical quality controls on the MRIdian®. MATERIALS AND METHODS: The impact of the magnetic field on other machines was investigated by controlling nearby linacs dose profiles. The image quality of the 0.345T MR scanner was evaluated, also assessing the integrated linear accelerator influence. The photon beams lateral and depth dose profiles were measured in motorized water tanks, along dose rate and output factors, and compared to Monte Carlo (MC) calculations. The isocenter position, gantry angles and multi-leaf collimator (MLC) position were controlled using film dosimetry. Gating latency and dosimetric accuracy were controlled with a dynamic phantom. RESULTS: The magnetic field had no significant impact on other nearby linacs. Image quality was within tolerances and did not vary over time. Dose profiles measured showed good agreement with MC data, with maximum differences of 1.3% in-field. Output factors were within 0.8% of calculated values. Imaging and radiative isocenter matched within 0.9±0.4mm over all monthly controls. Gantry rotation was precise within -0.1±0.2°, with an isocenter variation of 1.4±0.3mm diameter. The average MLC position was within 0.4±0.1mm of theoretical value. Finally, the gating latency was 0.14±0.07sec and the gated dose within 0.3% of base value. CONCLUSION: All results are within the tolerances fixed by ViewRay® and show low variations over 2 years, comforting the use of small margins and gating for high-dose adaptive treatments.

Comprehensive commissioning and quality assurance validation of Ethos™ therapy.

PURPOSE: Adaptive radiotherapy with the Ethos® therapy Varian system has been recently implemented at the Montpellier Cancer Institute, France. This article details the commissioning performed before the implementation of this new treatment planning system (TPS). MATERIAL AND METHODS: To validate the golden beam data of the machine (Halcyon linear accelerator), percentage depth doses (PDD) and profiles were measured for several field sizes and at different depths with a microdiamond chamber. The final doses calculated for different plan types with the Ethos Acuros XB algorithm and the Halcyon Eclipse Analytic Anisotropic Algorithm were compared using the gamma index method. Lastly, for the patient quality assurance (QA) process, the patient treatment plan results obtained with the Mobius3D QA platform (Varian) were compared with the portal dosimetry results obtained with Epiqa (Epidos). RESULTS: Minor differences were observed for the PDD and profile curves (mean difference of 0.2% and 2%, respectively). The χ index pass rate was above 98% for all measures using the 1%/1mm and 2%/2mm criteria for PDD and profile evaluations. The Ethos AXB algorithm was validated for every configuration (fixed fields, standard IMRT and VMAT fields, and clinical plans) with 2D/3D gamma index values>99%. Seventy-three 3-arcs-VMAT QA plans and 27 9-fields-IMRT QA plans were evaluated. Both showed excellent agreement with the TPS calculations (mean gamma pass rate higher than 99%). No difference was observed between IMRT and VMAT. CONCLUSION: The beam delivery, the Ethos AXB algorithm, and the patient QA were comprehensively validated using independent tools.

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

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

[Adhesion of urologists to the recommendations of the French Urological Association Cancer Committee (CCAFU) in the imaging work-up of localized prostate cancer]. / L'adhésion des urologues aux recommandations du comité de cancérologie de l'association Française d'urologie (CCAFU) dans le bilan d'imagerie du cancer localisé de la prostate.

OBJECTIVES: The literature review shows a low adhesion of urologists to the recommendations of learned societies in the imaging work-up of localized prostate cancer (CaP), especially for low and intermediate risks of the D'Amico classification. We analyzed the adhesion of urologists in the Hérault region (France) to the CCAFU 2016/2018, 2018/2020 recommendations. MATERIAL AND METHODS: From the Hérault Onco Urology Registry (RHESOU) database, we identified localized CaP diagnosed between 01/01/2017 and 31/12/2019, and then classified them into 3 distinct risk groups according to the D'Amico classification. We compared the imaging workup performed by each patient to the CCAFU 2016/2018, 2018/2020 recommendations, according to the risk group. RESULTS: Of the 2,049 localized CaPs included in our study, 591 belonged to the low-risk group, 1059 to the intermediate-risk group, and 399 to the high-risk group. In the low-risk group 45.2% of the cases did not follow the CCAFU 2016/2018, 2018/2020 recommendations in the imaging workup, 77.3% in the intermediate-risk group and 80.9% in the high-risk group. For our entire study, 1,408 patients (68.7%) had an imaging workup that did not follow the CCAFU recommendations. CONCLUSION: Our results show a low adhesion of urologists to the CCAFU recommendations in the imaging assessment of localized CaP. The causes of this non-adhesion are multifactorial and difficult to analyze.

[Stereotactic body radiotherapy of primary liver tumours: Indications and new techniques]. / Radiothérapie stéréotaxique des tumeurs primitives hépatiques : indications et nouvelles techniques.

The incidence of primary hepatic tumours is increasing and the reference treatments by liver transplantation or surgical resection do not allow to compensate for this increase because of the lack of grafts, or the low proportion of initially resectable tumours. The challenges for radiotherapy of primary liver tumors are multiple: physical, biological, medical and technological. Liver stereotactic body radiotherapy is sometimes the only local treatment option and is progressively finding its place for these tumors, even if the recognition of the indications would deserve a better standardization of international recommendations. The heterogeneity of practices and techniques is a major obstacle to the development of randomized studies, despite the excellent oncological results published. The latest ASTRO 2022 guidelines, the recent publication of the guidelines from the French society for radiation oncology on external radiotherapy and brachytherapy procedures ("RecoRad™ 2.0"), and the inclusion in prospective clinical trials will help to homogenize protocols and improve recognition of the technique. The first data from the new techniques of adaptive radiotherapy and MR-guided radiotherapy, whose objectives are to improve targeting and reduce liver or gastrointestinal toxicity, confirm the excellent results of liver SBRT and allow the potential indications to be extended to locations that were previously difficult to treat.

[Clinical trials in Radiation Oncology: Methodologic approach]. / Essais cliniques en Oncologie Radiothérapie : réflexion méthodologique.

In the context of the clinical development of radiation oncology, the specificities of curative treatments and the necessary follow-ups for the acute and late tolerance evaluation require rigourous and up-dated methodological approaches given the limited feasibility of some studies to demonstrate their effectiveness. Indeed, the diversity of treatments in terms of delivery, type of radiation and multiple technologies render difficult the medical assessment. Although the randomized controlled trial is the gold standard for demonstrating the causal link of the treatment effect size, a state of the art of current limits is presented and proposals for new methodological approaches are discussed as alternative or complementary possibilities. Co-primary endpoints or pragmatic composite endpoints are to be used with adequate statistical analyses, the use of Bayesian methods, the re-use of observational data for the external control arms identification and the development of Real World Data registers is to be preferred to respond to this colossal challenge.

News in magnetic resonance imaging use for radiation oncology.

The purpose of this article is to give a summary of the progress of magnetic resonance imaging (MRI) in radiotherapy. MRI is an important imaging modality for treatment planning in radiotherapy. However, the registration step with the simulation scanner can be a source of errors, motivating the implementation of all-MRI simulation methods and new accelerators coupled with on-board MRI. First, practical MRI imaging for radiotherapy is detailed, but also the importance of a coherent imaging workflow incorporating all imaging modalities. Second, future evolutions and research domains such as quantitative imaging biomarkers, MRI-only pseudo computed tomography and radiomics are discussed. Finally, the application of MRI during radiotherapy treatment is reviewed: the use of MR-linear accelerators. MRI is increasingly integrated into radiotherapy. Advances in diagnostic imaging can thus benefit radiotherapy, but specific radiotherapy constraints lead to additional challenges and require close collaboration between radiologists, radiation oncologists, technologists and physicists. The integration of quantitative imaging biomarkers in the radiotherapy process will result in mutual benefit for diagnostic imaging and radiotherapy. MRI-guided radiotherapy has already been used for several years in clinical routine. Abdominopelvic neoplasias (pancreas, liver, prostate) are the preferred locations for treatment because of their favourable contrast in MRI, their movement during irradiation and their proximity to organs at risk of radiation exposure, making the tracking and daily adaptation of the plan essential. MRI has emerged as an increasingly necessary imaging modality for radiotherapy planning. Inclusion of patients in clinical trials evaluating new MRI-guided radiotherapy techniques and associated quantitative imaging biomarkers will be necessary to assess the benefits.

Guidelines for external radiotherapy and brachytherapy procedures: 3rd edition.

The purpose of the first two editions of the guidelines for external radiotherapy procedures, published in 2007 and 2016 respectively, was to issue recommendations aimed at optimising, harmonising and standardising practices. The purpose of this third edition, which includes brachytherapy, is identical while also taking into account recent technological improvements (intensity modulation radiation therapy, stereotactic radiotherapy, and three-dimension brachytherapy) along with findings from literature. Part one describes the daily use of general principles (quality, security, image-guided radiation therapy); part two describes each treatment step for the main types of cancer.

Tumour and normal tissue radiosensitivity.

The place of personalized treatments is highly increasing in medical and radiation oncology. During the last decades, a huge number of assays have been developed to predict responses of normal tissues and tumours. These tests have not yet been included into daily clinical practice but the recent developments of radiation oncology are paving the way of personalized strategies including the risk of tumour recurrence and normal tissue reactions. Concerning tumor radiosensitivity prediction, no test are currently used, even if the radiosensitivity index and the genome-based model for adjusting radiotherapy dose assays seem the most promising with level II of evidence. Commercial developments are under progress. Concerning normal tissue radiosensitivity prediction, single nucleotide polymorphims of prostate cancer patients and radiation-induced CD8 T-lymphocyte apoptosis breast and prostate assays are of level I of evidence. They can be proposed before the beginning of radiotherapy in order to propose personalized treatments according to both risks of tumour and normal tissue radiosensitivity. Commercial developments are also under way.

Specificities of clinical research in radiotherapy.

The aim of this review is to present the specificities of clinical research in radiation oncology. Objectives are similar to all research in oncology: to improve the efficacy and to decrease toxic effects. Phase III trials remain the main methodology to demonstrate an improvement in efficiency, but phase I-II and registers are also important tools to validate an improvement in the therapeutic index with new technologies. In this article we discuss the special features of end-points, selection of population, and design for radiation oncology clinical trials. Quality control of delivered treatments is an important component of these protocols. Financial issues are also discussed, in the particular context of France.