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ABSTRACT: Economic data in the literature for brachytherapy are still sparse and heterogeneous, with few controlled prospective studies and a perspective most often limited to those of the provider (health insurances). Moreover, these observation and conclusions are difficult to generalize in France. The prospective health economic studies performed in France in the framework of a national program to sustain innovative and costly therapies (STIC program) launched by the French cancer national institute are therefore of most importance. With the exception of prostate brachytherapy with permanent seeds, the valorisation of the brachytherapy activity by the French national health insurance does not take into account the degree of complexity and the real costs supported by health institutions (i.e. no specific valorisation for 3D image-based treatment planning and dose optimization and for the use of pulsed dose rate brachytherapy).
Cancer/Radiothérapie 04/2013; · 1.49 Impact Factor
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ABSTRACT: During the last decade, the organization of brachytherapy in France moved to 62 units in 173 radiotherapy centres in 2009. More than 7500 patients were treated in 2009, quite exclusively with curative intent, for 80% in public or associated hospitals. The techniques improved to high tech 3D dosimetry and optimization of the dose distribution. Brachytherapy, despite representing only 5% of the treatments by irradiation, is a reference treatment for several tumors.
Cancer/Radiothérapie 04/2013; · 1.49 Impact Factor
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ABSTRACT: Low dose-rate brachytherapy as a boost after concomitant chemoradiation therapy is a standard of care for locally advanced anal carcinoma, providing a rigorous selection taking into account the initial staging and tumor response to external beam radiotherapy. Local control is likely to be superior when the boost is performed with brachytherapy than with external beam radiotherapy. The several steps of the brachytherapy procedure are described. The standard treatment scheme is a concomitant chemoradiation therapy, including 45Gy (1,8Gy×5) pelvic external beam radiotherapy and two courses of 5-fluorouracil and mitomycin-C, followed by a 15Gy brachytherapy boost with a gap limited to 2 to 3weeks. Higher irradiation dose for the most advanced cases has not yet demonstrated a therapeutic gain in terms of colostomy free survival. Exclusive brachytherapy for in-situ carcinoma or invasive carcinoma less than 10mm is not recommended due to a high risk of local recurrence. Pulsed dose rate brachytherapy is an alternative to low dose rate brachytherapy (iridium wires) providing the respect of the recommended dose rate (0.5 to 1Gy/hour). High dose rate brachytherapy is still under evaluation.
Cancer/Radiothérapie 04/2013; · 1.49 Impact Factor
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ABSTRACT: The main indications of brachytherapy for head and neck cancers are limited tumours of the oral cavity, the oropharynx and the nasopharynx. This technique can be exclusive, associated with external radiotherapy or postoperative. This is also a treatment for second localizations in previously irradiated areas. If low-dose rate brachytherapy is the reference, the pulse dose rate brachytherapy by control of the dose rate and optimisation of the dose distribution is the technique to be preferred. High-dose rate brachytherapy is an option. The major prognosis factors of local control and complications are the use of a leaded protection of the mandible, the intersource spacing (1.2-1.4cm), the volume treated (30cm(3), i.e. three loops), the safety margin (5mm), the dose rate (0.5Gy/h), the total dose (65Gy in case of exclusive brachytherapy, 25Gy in case of a combination of external beam irradiation [50Gy] and brachytherapy in the oropharyngeal carcinomas, 35Gy in case of a combination of external beam irradiation [40Gy] and brachytherapy in the oral cavity carcinomas, 60Gy in case of a second localization in previous irradiated tissues), the delay between external irradiation and brachytherapy (<20days), the dose per fraction and the treated volume for high-dose rate brachytherapy. Brachytherapy, when possible, is the optimal method of irradiation of head and neck carcinomas with limited volume.
Cancer/Radiothérapie 03/2013; · 1.49 Impact Factor
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ABSTRACT: With an experience of more than 25 years for the pioneers (and more than 14 years in France), permanent implant brachytherapy using iodine 125 seeds (essentially) is now recognized as a valuable alternative therapy for localized low-risk prostate cancer patients. The possible extension of the indications of exclusive brachytherapy towards selected patients in the intermediate-risk group has now been confirmed by several studies. Moreover, for the other patients in the intermediate-risk group and for the patients in the high-risk group, brachytherapy, as an addition to external radiotherapy, could represent one of the best ways to escalate the dose. Different permanent implant brachytherapy techniques have been proposed; preplanning or real-time procedure, loose or stranded seeds (or both), manual or automatic injection of the seeds. The main point here is the ability to perfectly master the procedure and to comply with the dosimetric constraints, which have been recently redefined by the international societies, such as the GEC-ESTRO group. Mid- and long-term results, which are now available in the literature, indicate relapse-free survival rates of about 90% at 5-10 years, the best results being obtained with satisfactory dosimetric data. Comparative data have shown that the incontinence and impotence rates after brachytherapy seemed to be significantly inferior to what is currently observed after surgery. However, a risk of about 3 to 5% of urinary retention is usually reported after brachytherapy, as well as an irritative urinary syndrome, which may significantly alter the quality of life of the patients, and last several months. In spite of those drawbacks, with excellent long-term results, low rates of incontinence and impotence, and emerging new indications (focal brachytherapy, salvage brachytherapy after localized failure of an external irradiation), permanent implant prostate brachytherapy can be expected to be proposed to an increasing number of patients in the next future.
Cancer/Radiothérapie 03/2013; · 1.49 Impact Factor
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ABSTRACT: No technique can now be used without previously considering the safety of patients, staff and public and risk management. This is the case for brachytherapy. The various aspects of brachytherapy are discussed for both the patient and the staff. For all, the risks must be minimized while achieving a treatment of quality. It is therefore necessary to establish a list as comprehensive as possible regardless of the type of brachytherapy (low, high, pulsed dose-rate). Then, their importance must be assessed with the help of their criticality. Radiation protection of personnel and public must take into account the many existing regulation texts. Four axes have been defined for the risk management for patients: organization, preparation, planning and implementation of treatment. For each axis, a review of risks is presented, as well as administrative, technical and medical dispositions for staff and the public.
Cancer/Radiothérapie 03/2013; · 1.49 Impact Factor
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ABSTRACT: Treatment technique training needs theoretical and practical knowledge allowing proposing the right treatment for the right patient, but also allowing performing the technical gesture in the best conditions for an optimal result with a maximal security. The evolution of the brachytherapy techniques needs the set up of specific theoretical and practical training sessions. The present article focuses on the importance of the brachytherapy training as well as the different means currently available for the young radiation oncologist community for perfecting their education. National and international trainings are presented. The role of the simulation principle in the frame of brachytherapy is also discussed. Even if brachytherapy is not always an easy technique, its efficacy and its medico-economical impact need to be passed down to motivated students with the implementation of relevant educational means.
Cancer/Radiothérapie 02/2013; · 1.49 Impact Factor
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Cancer/Radiothérapie 01/2013; · 1.49 Impact Factor
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ABSTRACT: PURPOSE: Intensity modulated radiotherapy (IMRT) allows a better coverage of the target volume and a better saving of organs at risk with a decrease of toxicity in head and neck cancers. It requires more human labor and materials compared to conformational radiotherapy. If they are insufficient, a selection of the patients receiving IMRT may be necessary, raising an ethical problem. MATERIAL AND METHODS: We collected the motives guiding the choice of the technique of radiotherapy for head and neck cancers during a month of physicists' shortage. RESULTS: Nineteen patients received IMRT and eight conformational radiotherapy. Conformational irradiation was chosen in palliative and postsurgery treatments, to reduce delay, in laryngeal tumors and re-irradiation. IMRT was preferred for complex target volumes and the localizations at risk of important xerostomia following conformational radiotherapy. These choices were confronted with the bioethics criteria of Beauchamp and Childress. The beneficence justified the use of IMRT or conformational radiotherapy depending on the circumstances. The non-maleficence attempted to decrease the toxicity with IMRT. Justice was questioned by the selection. The autonomy of patients was not totally respected in the choice. CONCLUSION: To help in the choice of the patients receiving an IMRT in a crisis situation, we proposed a hierarchical organization of selection criteria: complex volumes close to critical organs at risk, localization with high risk of xerostomia, long life expectancy and postoperative delay constraints.
Cancer/Radiothérapie 12/2012; · 1.49 Impact Factor
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ABSTRACT: PURPOSE: This document presents a systematic and structured approach for functional modeling for risk analysis in radiotherapy, aiming to reconcile the need, on one hand, for a method that can be applied generally and, on the other hand, for a method that provides a highly precise model. MATERIALS AND METHODS: The approach relies on new functional structuring patterns and flux analysis, derived from system engineering and knowledge engineering. RESULTS: The method affords strong support for the development of detailed models of the patient's process through a department of radiotherapy. Lack of structure of the actual process in a particular department may be easily identified leading to the development of specific procedures for the improvement of security. CONCLUSION: Modeling approach derived from engineering may be used for functional modeling for risk analysis in radiotherapy.
Cancer/Radiothérapie 11/2012; · 1.49 Impact Factor
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ABSTRACT: PURPOSE: We previously presented a systematic and structured approach to acquire an accurate functional model of the patient's process in radiotherapy. This approach relied on new functional structuring patterns, derived from system engineering and knowledge engineering. Additionally, we propose a complementary methodical process for the dysfunctional analysis of the obtained functional model. MATERIALS AND METHODS: The procedure is based on joint implementation of two qualitative methods named "Failure modes and effects analysis" (FMEA) and "Hazard and operability" (HazOp). RESULTS: All the technical, the human and the organizational dimensions of the patient's process are pooled in a unique, exhaustive and detailed dysfunctional analysis. The application of this systematic approach within a particular institution can precisely identify the risks incurred by patients in care, but also highlight the logical sequence between precursor events and incidents. CONCLUSION: The dysfunctional analysis presented in this document will be used for the development still in process of quantified risk models.
Cancer/Radiothérapie 11/2012; · 1.49 Impact Factor
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D Azria,
J-M Ardiet,
B Chauvet,
F Denis,
F Eschwège,
C Hennequin,
E Lartigau,
F Rocher,
M-A Mahé,
P Maingon,
J-J Mazeron,
Y Metayer, D Peiffert,
S Thureau,
F Mornex
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ABSTRACT: Many clinical studies have showed the key role of radiotherapy in anticancer treatment strategy. Radiations are delivered alone or in combination with systemic therapies. In recent years, the main goal of all clinical developments has focused on improving clinical benefit, with an increased tumour control and a higher normal tissue protection. This research was designed to reduce local recurrences, to increase recurrence-free or overall survival and to decrease acute and late effects. Technological and biological evolutions (or revolutions) accompanied clinicians to improve clinical benefit, namely with strong progress in radiology and better understanding of radiobiology, particularly at the molecular level. Differences in tumour and normal tissues radiosensitivity are nowadays integrated in daily clinical practice of radiation oncologists. The current report details the last 5-year developments of clinical and translational research in radiation oncology, especially the role of French teams in the development of personalized treatment.
Cancer/Radiothérapie 08/2012; 16(5-6):386-91. · 1.49 Impact Factor
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ABSTRACT: This review describes the ballistic quality assurance for stereotactic intracranial irradiation treatments delivered with Gamma Knife® either dedicated or adapted medical linear accelerators. Specific and periodic controls should be performed in order to check the mechanical stability for both irradiation and collimation systems. If this step remains under the responsibility of the medical physicist, it should be done in agreement with the manufacturer's technical support. At this time, there are no recent published guidelines. With technological developments, both frequency and accuracy should be assessed in each institution according to the treatment mode: single versus hypofractionnated dose, circular collimator versus micro-multileaf collimators. In addition, "end-to-end" techniques are mandatory to find the origin of potential discrepancies and to estimate the global ballistic accuracy of the delivered treatment. Indeed, they include frames, non-invasive immobilization devices, localizers, multimodal imaging for delineation and in-room positioning imaging systems. The final precision that could be reasonably achieved is more or less 1mm.
Cancer/Radiothérapie 05/2012; 16 Suppl:S30-7. · 1.49 Impact Factor
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Cancer/Radiothérapie 05/2012; 16(3):244-5. · 1.49 Impact Factor
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ABSTRACT: Concurrent radiochemotherapy is the standard treatment for locally advanced cervical cancer. This treatment is responsible for bowel and hematologic toxicities. The use of intensity-modulated radiotherapy (IMRT), in static beams, allows a decrease of this toxicity. The technique of RapidArc(®) IMRT could lower the dose delivered to the organs at risk and improve the homogeneity of the planning target volume coverage, while decreasing the processing time.
For 20 patients, treatment plans performed with IMRT and RapidArc(®) were compared. The target volumes were: the clinical target volume (gross tumour volume, uterus, upper third of the vagina, the hypogastric, iliac and presacral nodal regions), and the planning target volume (clinical target volume+1cm). The delineated organs at risk were: rectum, bladder, bowel and bone marrow. The dose was 45 Gy in 25 fractions. IMRT were delivered with five beams and RapidArc(®) with two arcs. The comparisons were made by the non-parametric test of Wilcoxon.
Medium coverage of the planning target volume was better with RapidArc(®) (P=0.01). It was also better regarding the sparing of bowel (P=0.01) and IMRT was better regarding the sparing of bladder (P=0.01) and rectum (P=0.05). The total volume receiving 20 Gy was less important with RapidArc(®) (P<0.001). RapidArc(®) allowed to decrease the treatment time (3 versus 12 minutes with IMRT) and the number of monitor units (MU) (376.5 versus 962.2, on average, P=0.0001).
The technique of RapidArc(®) seems to obtain better dosimetric results compared to RCMI, with fewer MU, and a significant decrease in treatment time.
Cancer/Radiothérapie 04/2012; 16(3):209-14. · 1.49 Impact Factor
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ABSTRACT: Surgical resection remains the standard treatment for patients with resectable retroperitoneal sarcomas. The aim of this study was to retrospectively analyse the outcomes of patients with primary retroperitoneal sarcoma.
We analysed data of 50 patients with primary retroperitoneal sarcoma who underwent curative-intent resection from 1975 to 2008. External beam radiotherapy and chemotherapy were delivered postoperatively. Demographics, surgical, pathological variables and chemo/radiation therapy were analysed as prognosis factors.
There were 22 males and 28 females (mean age 54 ± 13 years). Surgery required visceral resections in 30 patients. There were 16 leiomyosarcomas, 25 liposarcomas and eight other sub-types. Twenty-one patients had clear surgical margins. Twenty-eight patients received postoperative external beam radiotherapy (median 45 Gy) and 15 received chemotherapy. At the end of the follow-up (median 55 months), local recurrence occurred in 39% (n=14) among R0/R1 resection group (n=36). Postoperative external beam radiotherapy tends to increase the time of local recurrence from surgery (27 vs. 13 months, P=0.05). The overall survival rates were 81%, 55% and 46% at 1, 3 and 5 years, respectively. Although R0 resection (P=0.01), well tumour differentiation (P=0.004) and postoperative external beam radiotherapy (P=0.02) significantly influenced overall survival in univariate analysis, only R0 resection was an independent prognostic factor in a multivariate analysis.
We confirm the pre-eminence of radical surgery with negative margins as major prognostic factor and the benefit of postoperative radiotherapy.
Cancer/Radiothérapie 03/2012; 16(3):194-200. · 1.49 Impact Factor
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ABSTRACT: Anal canal carcinoma are highly curable by irradiation, combined with chemotherapy in locally advanced disease, with preservation of sphincter function. The clinical target volume for the nodes is extended, often including the inguinal nodes, which is not usual for other pelvic tumours. Acute and late effects are correlated with the volume and dose delivered to organs at risk, i. e. small bowel, bladder and increased by concomitant chemotherapy. Intensity modulated irradiation (IMRT) makes it possible to optimize the dose distribution in this "complex U shaped" volume, while maintaining the dose distribution for the target volumes. The conversion from conformal irradiation to IMRT necessitates good knowledge of the definition and skills to delineate target volumes and organs at risk, including new volumes needed to optimize the dose distribution. Dosimetric and clinical benefits of IMRT are described, based on early descriptions and evidence-based publication. The growing development of IMRT in anal canal radiotherapy must be encouraged, and long-term benefits should be soon published. Radiation oncologists should precisely learn IMRT recommendations before starting the technique, and evaluate its early and late results for adverse effects, but also for long-term tumour control.
Cancer/Radiothérapie 08/2011; 15(6-7):549-54. · 1.49 Impact Factor
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ABSTRACT: This study aimed at analyzing the evolution and type of recurrence in patients treated for stage I endometrial carcinomas, in order to define the respective roles of adjuvant radiotherapy and brachytherapy.
This monocentric retrospective study was conducted at Centre Alexis-Vautrin, Nancy, France, between January 1995 and December 2000 on all the patients surgically treated for an endometrial cancer, and then treated with high dose rate vaginal brachytherapy. The brachytherapy was delivered in two or three fractions of 7 Gy at 5 mm from the applicator.
In the good prognosis group, the specific and overall survivals at 5 years were respectively 96.5 and 94.2% with no local recurrence demonstrated. In the intermediate prognostic group, the specific and overall survivals at 5 years were respectively 88 and 85%, with six locoregional recurrences observed among those who did not undergo lymphadenectomy; the overall survival at 5 years was significantly decreased in the absence of external radiation. In the group of poor prognosis (stages II and III), the specific survival at 5 years was respectively 72.8 and 67 %, and the overall survival at 5 years 66.7 and 56.4%.
Results for local control and survival as well as for tolerance were good. So we have decided to deliver high rate brachytherapy for all intermediate or poor prognosis patients and we have abandoned pelvic radiotherapy for good prognosis tumours (stages IA: no myometrium invasion with grade 3 and >50% of myometrium invasion with grades 1 and 2), whatever the lymph nodes surgery they had. We now propose pelvic radiotherapy only for intermediate prognosis tumours (such as IA>50% of myometrium invasion with grade 3 and IB stages), if patients did not have any lymphatic surgery, or for bad prognosis tumours.
Cancer/Radiothérapie 01/2011; 15(3):169-75. · 1.49 Impact Factor
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Cancer Radiotherapie - CANCER RADIOTHER. 01/2011; 15(6):582-583.
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ABSTRACT: To understand management strategies and outcomes of patients diagnosed with a head and neck tumour and a synchronous second cancer developed at another anatomic site.
Retrospective analysis of all patients diagnosed with a head and neck carcinoma and a synchronous cancer and engaged in curative-intent treatments. To evaluate therapeutic strategies, each patient's treatment process was divided into sequential therapeutic modalities and corresponding targets (head and neck and/or synchronous tumour) were identified. Patient outcome was analysed with an intent-to-treat approach.
Forty-three patients were entered into the study (mean age=57.4 years). Synchronous tumours concerned the lung (57.8%), oesophagus (31.1%) or other sites (11.1%). Treatments were complex, including one to four consecutive modalities, with a mean duration of 4.6 months. When both tumours were advanced, treatments were frequently initiated with dual-spectrum chemotherapy (66.7%). In other situations, a locoregional treatment was often (81.1%) proposed immediately. When both tumours were in early stages, this initial locoregional treatment could be extended to target both tumours together (30.0%). For patients whose tumours differed in severity, this locoregional treatment targeted only one tumour (85%); priority was given to the most advanced one (76.5%). Nine patients had definitive treatment interruption. Associated risk factors were a low body mass index (P=0.03) and advanced-stage tumours (P=0.01). Thirty-one patients died (72.1%) with a median time to death of 7.7 months. The median follow-up for survivors was 46.2 months. Three-year overall survival was 33.9%. Low body mass index (P=0.001), advanced-stage synchronous tumours (P=0.03) and oesophageal primaries (P=0.03) altered the overall survival. Three-year locoregional and metastatic progression-free survival was 40.8 and 62.5%, respectively. Low body mass index (P=0.01) and advanced-stage synchronous tumours (P=0.01) increased the risk of disease failure.
Head and neck tumours diagnosed with a synchronous cancer are a complex challenge. Despite a severe prognosis, patients who are not underweight, presenting with lower-stage tumours (especially the synchronous tumour) and without oesophageal involvement could most benefit from aggressive treatments.
Clinical Oncology 12/2010; 23(3):174-81. · 2.07 Impact Factor
