Mathieu Minsat

Volumetric-modulated arc therapy for left-sided breast cancer and all regional nodes improves target volumes coverage and reduces treatment time and doses to the heart and left coronary artery, compared with a field-in-field technique

We compared two intensity-modulated radiotherapy techniques for left-sided breast treatment, involving lymph node irradiation including the internal mammary chain. Inverse planned arc-therapy (VMAT) was compared with a forward-planned multi-segment technique with a mono-isocenter (MONOISO). Ten files were planned per technique, delivering a 50-Gy dose to the breast and 46.95 Gy to nodes, within 25 fractions. Comparative endpoints were planning target volume (PTV) coverage, dose to surrounding structures, and treatment delivery time. PTV coverage, homogeneity and conformality were better for two arc VMAT plans; V95%PTV-T was 96% for VMAT vs 89.2% for MONOISO. Homogeneity index (HI)PTV-T was 0.1 and HIPTV-N was 0.1 for VMAT vs 0.6 and 0.5 for MONOISO. Treatment delivery time was reduced by a factor of two using VMAT relative to MONOISO (84 s vs 180 s). High doses to organs at risk were reduced (V30left lung = 14% using VMAT vs 24.4% with MONOISO; dose to 2% of the volume (D2%)heart = 26.1 Gy vs 32 Gy), especially to the left coronary artery (LCA) (D2%LCA = 34.4 Gy vs 40.3 Gy). However, VMAT delivered low doses to a larger volume, including contralateral organs (mean dose [Dmean]right lung = 4 Gy and Dmeanright breast = 3.2 Gy). These were better protected using MONOISO plans (Dmeanright lung = 0.8 Gy and Dmeanright breast = 0.4 Gy). VMAT improved PTV coverage and dose homogeneity, but clinical benefits remain unclear. Decreased dose exposure to the LCA may be clinically relevant. VMAT could be used for complex treatments that are difficult with conventional techniques. Patient age should be considered because of uncertainties concerning secondary malignancies.

Value of Dynamic Contrast-enhanced and Diffusion-weighted MR Imaging in the Detection of Pathologic Complete Response in Cervical Cancer after Neoadjuvant Therapy: A Retrospective Observational Study

Purpose To evaluate the association between dynamic contrast material-enhanced (DCE) and diffusion-weighted (DW) magnetic resonance (MR) imaging with pathologic complete response after preoperative combined chemotherapy and radiation therapy for cervical carcinoma and evaluate the risk of local recurrence. Materials and Methods The institutional ethics committee approved the study and waived the requirement to obtain informed consent. The study comprised 52 patients with locally advanced carcinoma, treated first with combined chemotherapy and radiation therapy, who underwent MR imaging before final surgery between June 2011 and July 2015. Three radiologists evaluated conventional, DW, and DCE MR images to identify a complete response. The standard of reference was surgical-pathologic findings. Results An initial increase in signal intensity on DCE MR images that was greater in the cervical lesion than in the myometrium was defined as time-signal intensity curve type B and showed a significant association with incomplete response (P = .0004). DCE MR imaging parameters (ie, maximum slope enhancement, area under the gadolinium concentration-time curve during the first 90 seconds after gadolinium injection [AUGC90], and volume transfer constant [Ktrans]) and a low signal intensity on apparent diffusion coefficient (ADC) maps were significantly associated with an incomplete response (P = .027, P = .041, P = .037, and P = .032, respectively). A mean ADC of 0.0014 m2/sec or less (hazard ratio [HR] = 8.3), low ADC signal intensity (HR = 7.3), high signal intensity at DW imaging (HR = 7.1), and time-signal intensity curve type B (HR = 4.3) were associated with earlier recurrence (P < .05). Excellent agreement between readers was found for time-signal intensity curve analysis (κ > 0.9) and the following parameters: AUGC90, Ktrans, and maximum slope enhancement (intraclass correlation coefficient, >0.9). Conclusion DCE MR imaging parameters, especially the time-signal intensity curve, and DW imaging are associated with complete response and incomplete response and could potentially help oncologists with management decisions. Moreover, DCE and DW MR imaging could help oncologists accentuate the follow-up for patients with a high risk of local recurrence to assess for recurrence.

Impact of preoperative magnetic resonance imaging in breast cancer patients candidates for an intraoperative partial breast irradiation

Objective: Partial breast irradiation (PBI) could be a reasonable option in patients with early breast cancer (BC) provided that an adequate patient selection, based on robustly established criteria is performed. A preoperative magnetic resonance imaging (MRI) in patient selection for PBI is not consensual. The aim of this retrospective study was to assess the impact of preoperative MRI on patient eligibility for PBI. Methods: Since March 2012, patients with early BC, meeting the Inca’s criteria for PBI were offered the possibility of shortened treatment through intra-operative radiation therapy, either in a prospective trial or off protocol. Eligibility criteria based on physical examination, mammography and ultrasound, and a pathological exam of biopsy, were as follows: menopaused woman 55 years or older with a T1, N0, hormonal-receptor-positive and HER2-negative, invasive, non-lobular epithelioma, without extensive intraductal component (defined as more than 25% of ductal component on biopsy), non-fast-growing tumor, without lymphovascular invasion (LVI), without criteria for adjuvant chemotherapy. A contrast-enhanced MRI was not routinely performed, but at the discretion of the physician as was the rule in TARGIT-A trial. We assessed the rate of additional cancer revealed by the preoperative MRI, remote in the same breast not detected by mammography and/or ultrasound. Results: Between March 2012 and February 2014, 179 early BC patients meeting the required criteria were planned for an intraoperative radiotherapy (IORT)-PBI. Seventy nine percent of them (141/179) underwent a breast MRI as part of preoperative assessment. ACR3-ACR4 abnormalities not detected by mammograms or ultrasound were found in 44 patients (31%), which prompted a focused mammary ultra-sound, and a biopsy was realized in 29/141 patients (21%). A second breast carcinoma was found in 10 patients (7% of patients with a preoperative MRI, 4 ipsilateral lesions, 5 contralateral lesions, and one both ipsi- and contralateral lesion, precluding IORT-PBI in 5/141 patients (4%). Conclusions: The use of preoperative MRI in patient staging leads to diagnosis of an ipsilateral second BC in 4% of cases, which appears substantial in a highly selected population. We therefore support the routine use of this exam for the staging of patient candidate for a PBI.

Eligibility criteria for intraoperative radiotherapy for breast cancer: study employing 12,025 patients treated in two cohorts

BackgroundWe wished to estimate the proportion of patients with breast cancer eligible for an exclusive targeted intraoperative radiotherapy (TARGIT) and to evaluate their survival without local recurrence.MethodsWe undertook a retrospective study examining two cohorts. The first cohort was multicentric (G3S) and contained 7580 patients. The second cohort was monocentric (cohort 2) comprising 4445 patients. All patients underwent conservative surgery followed by external radiotherapy for invasive breast cancer (T0–T3, N0–N1) between 1980 and 2005. Within each cohort, two groups were isolated according to the inclusion criteria of the TARGIT A study (T group) and RIOP trial (R group).In the multicentric cohort (G3S) eligible patients for TARGIT A and RIOP trials were T1E and R1E subgroups, respectively. In cohort number 2, the corresponding subgroups were T2E and R2E. Similarly, non-eligible patients were T1nE, R1nE and T2nE, and R2nE.The eligible groups in the TARGIT A study that were not eligible in the RIOP trial (TE–RE) were also studied. The proportion of patients eligible for TARGIT was calculated according to the criteria of each study. A comparison was made of the 5-year survival without local or locoregional recurrence between the TE versus TnE, RE versus RnE, and RE versus (TE–RE) groups.ResultsIn G3S and cohort 2, the proportion of patients eligible for TARGIT was, respectively, 53.2% and 33.9% according the criteria of the TARGIT A study, and 21% and 8% according the criteria of the RIOP trial. Survival without five-year locoregional recurrence was significantly different between T1E and T1nE groups (97.6% versus 97% [log rank =0.009]), R1E and R1nE groups (98% versus 97.1% [log rank =0.011]), T2E and T2nE groups (96.6% versus 93.1% [log rank <0. 0001]) and R2E and R2nE groups (98.6% versus 94% [log rank =0.001]). In both cohorts, no significant difference was found between RE and (TE–RE) groups.ConclusionsAlmost 50% of T0-2 N0 patients could be eligible for TARGIT.

Locoregional treatment of early breast cancer with isolated tumor cells or micrometastases on sentinel lymph node biopsy

The advent of sentinel lymph-node technique has led to a shift in lymph-node staging, due to the emergence of new entities namely micrometastases (pN1mi) and isolated tumor cells [pN0(i+)]. The prognostic significance of this low positivity in axillary lymph nodes is currently debated, as is, therefore its management. This article provides updates evidence-based medicine data to take into account for treatment decision-making in this setting, discussing the locoregional treatment in pN0(i+) and pN1mi patients (completion axillary dissection, axillary irradiation with or without regional nodes irradiation, or observation), according to systemic treatment, with the goal to help physicians in their daily practice.

Calcifications and tungsten deposits after breast-conserving surgery and intraoperative radiotherapy for breast cancer

AIM To describe the presence of atypical calcifications on post-operative mammography after breast-conserving surgery (BCS) and intraoperative radiotherapy (IORT). MATERIALS AND METHODS We retrospectively include all patients followed after BCS and IORT for breast cancer (n=271). All follow-up mammograms at 6 months after surgery were retrospectively evaluated by two board-certified radiologists. The radiologists had to notify the presence or the absence of atypical calcifications. RESULTS Five patients had on follow-up mammography the presence of atypical calcifications. Two patients had a stereotactic breast biopsy. The pathologic examination showed the presence of small tungsten particles located in the breast parenchyma. CONCLUSION The presence of atypical calcifications after BCS and IORT, presenting as multiple, scattered, round calcifications, should be rated as BIRADS 2 and do not require biopsy. They corresponded on tungsten deposits.

Cancer of the Penis, Anus, and Vulva

Cancer of the anus, vulva, and penis are rare diseases. They are associated with human papillomavirus (HPV) infection. HIV-infected patients have a higher risk of developing these cancers in comparison with the general population. Anal, vulvar, and penile cancers are lymphophilic tumors, and lymph node involvement is the most important predictor of prognosis. Surgery with lymph node dissection is the standard treatment of invasive vulvar and penile cancers. Depending on the surgical pathology result following, adjuvant radiotherapy may be indicated. Radiotherapy with or without concurrent chemotherapy is the standard treatment of anal cancer; salvage abdominoperineal resection is indicated in case of local relapse after radiotherapy.