P. Blanchard

Dose de tolérance à l’irradiation des tissus sains : le rectum

Radiation proctitis is among the most frequent radiation-induced toxicities. This is related to the high frequency of pelvic tumours and the key role of radiotherapy in the treatment of these tumours. Late rectal toxicity usually occurs within the first two years after the completion of a radiotherapy course. Rectal bleeding and a rectal syndrome are the main symptoms, and can be associated to fistulas or rectal ulcers. Clinical factors, such as diabetes mellitus, a severe acute radiation toxicity, small rectal volume or radiation hypersensitivity, are associated with late rectal toxicity. Dosimetric factors derived from the analysis of dose-volume histograms can also predict the occurrence of radiation proctitis, and help to adapt the prescribed dose and the ballistic of irradiation.

Le cancer du rectum

Resume Les cancers du rectum sont une entite frequente avec une incidence annuelle en France d’environ 12000 nouveaux cas par an. La chimioradiotherapie concomitante preoperatoire a base de fluoropyrimidine suivie d’une chirurgie avec exerese totale du mesorectum est devenue le standard therapeutique des tumeurs localement evoluees (classees T3-4) ou atteignant les ganglions (N+) du bas ou du moyen rectum. Les modalites d’irradiation varient selon le siege de la tumeur (bas/moyen) et son extension locale. Le volume cible anatomoclinique (CTV) couvre toujours l’ensemble du mesorectum, qui s’etend de la ligne de reflexion peritoneale (a hauteur de S3) au plan des muscles releveurs de l’anus, ainsi que les aires ganglionnaires iliaques internes jusqu’a la bifurcation iliaque interne - iliaque externe. L’objectif de cet article est de rappeler les particularites epidemiologiques, anatomiques, radiologiques et de pronostic des cancers du rectum essentielles a la definition des modalites optimales de l’irradiation conformationnelle. La definition des volumes cibles et des organes a risque, les doses a prescrire et les contraintes de dose sont abordees. Ces propos sont illustres par un cas clinique concernant une tumeur du moyen rectum.

Démographie des internes en oncologie–radiothérapie en France en 2008 : état et perspectives pour les trois prochaines années

PURPOSEnAlthough a recent increase in number of young radiation oncologists in training has been observed during the past decade, the general demographic evolution of radiation oncologists covers partially future needs.nnnMATERIAL AND METHODnDuring the seven past national annual courses, which were organised and supported by the Société française des jeunes radiothérapeutes oncologues (SFJRO), the Société française de radiothérapie oncologique (SFRO), the Collège national des enseignants de cancérologie (CNEC) and the Institut national du cancer (Inca), different types of surveys were realized in order to analyse demography, quality of training and motivations of French residents in radiation oncology. The latest results were collected during the last national course, which took place in March 2008. Seventy-five young French radiation oncologists (internes des hopitaux or residents) out of 110 participants who attended the national course and 75 questionnaires were analysed.nnnRESULTSnSince 2002, the total number of residents increased regularly (50, 75, 103 and 109 residents respectively in 2000, 2005, 2007 and 2008). Men and women are presently 48.5% and 51.5% respectively. Qualitative analysis of practical and theoretical training was performed using a visual analogical scale from zero to 10. Scores of 56 and 61 were respectively observed. Other descriptions of local training in the different universities (clinical skills, clinical cases analysis, bibliography session...) are described. Finally, analysis of the motivations for choosing the radiation oncology speciality demonstrates common interests in both medical practice and technical aspects in oncology. Innovation, technology, imaging and research are also widely mentioned. Sixteen residents will finish their training by the end of 2008, 42 are expected in 2009 and 27 in 2010. Almost all residents believe that a postgraduate position is necessary to complete their training as assistant professor (chefs de clinique-assistants des hôpitaux) in a university hospital or a cancer centre. Unfortunately, only 36 assistant professor positions are available in France, representing half of the need. Only 21 residents out of 104 already have a position as assistant professor. The availability of such a position remains undetermined for the rest of them.nnnCONCLUSIONSnDespite the recent increase in the number of residents in radiation oncology in France, the need to create new assistant professor positions is crucial to assure quality of training for this both medical and technical speciality. Since 2002, the establishment of SFJRO has facilitated national links among residents, between residents and professors (CNEC), and between the French society (SFRO) and the European society (ESTRO).

Radiothérapie des cancers du nasopharynx

Nasapharyngeal carcinoma is a rare disease. Oftenly, the diagnostic is made for advanced disease. Localized tumors, T1xa0or T2xa0NO observed a good prognosis and are locally controlled in more than 90xa0% of the cases by radiotherapy alone. The standard treatment of locally advanced disease is combined chemoradiation. A special vigilance of fast decrease of the volume of the pathological lymph nodes, sometimes associated to loss of weight might indicate an adaptive dosimetric revision. The treatment of recurrent disease is of great importance. Surgical indications are limited but should be discussed in multidisciplinary tumor board when possible. Surgical nodal sampling has to be proposed for nodal recurrence as well as reirradiation, which could be indicated according to the technical issues.

Modalités d’évolution des cancers du col utérin avec atteinte ganglionnaire locorégionale à la TEP-FDG

PURPOSEnTo assess the outcome of cervical carcinoma with positive nodes on fluorodesoxyglucose positon emission tomography scans (FDG-PET).nnnPATIENTS AND METHODSnPatients with cervical carcinoma who had pelvic and/or para-aortic lymph nodes involvement by FDG-PET and treated with a curative intent from 2003 to 2007 were retrospectively studied. All patients received pelvic (and possibly para-aortic) radiotherapy with chemotherapy, followed by brachytherapy, and possibly surgery. The first site of relapse was classified as follows: local, nodal (pelvic or para-aortic) or metastatic.nnnRESULTSnForty patients were included the study. Median age was 47 years (range: 28-78). Thirty patients had nodal involvement limited to pelvic area and ten had a para-aortic involvement. Median follow-up was 42.5 months (range: 11-85). There were 22 relapses and 20 deaths: 20 due to relapse and one due to late toxicity. Three-year survival is 50 % (95 % confidence interval [CI]: 36-65). First relapse was: metastatic for 33 % (13/40), local for 20 % (8/40) and isolated nodal for 5 % (2/40). Multivariate analysis has revealed that only staging according to International Federation of Gynecology and Obstetrics (FIGO) and para-aortic involvement had a significant impact on survival. Three-year survival was 58 % (CI: 39-74) and 24 % (CI: 7-57) (P=0.009) in patient without and with para-aortic involvement, respectively.nnnCONCLUSIONnPara-aortic involvement by FDG-PET is a significant prognostic factor for overall survival. Local control at primary site remains of paramount importance for patient with nodal involvement. Isolated nodal failures are scarce.

Cancers de la cavité buccale chez les sujets jeunes: Résultats thérapeutiques et analyse de facteurs pronostiques

PURPOSEnSquamous cell carcinomas of the oral cavity occurring in young people represent a specific entity. Its management and prognosis are controversial. We performed a retrospective chart review of all patients aged less than 40 years old and treated at Gustave-Roussy Cancer Centre for a squamous cell carcinomas of the oral cavity between 1999 and 2011.nnnMETHODSnPatients and tumour characteristics, type of treatment and follow-up data were collected. Survival data were analysed according to the methods of Kaplan-Meier and both univariate and multivariate analyses were performed to look for prognostic factors regarding overall survival and progression-free survival.nnnRESULTSnSixty-three patients were identified. Median follow-up was 64 months. Most of the tumours were initially located in the mobile tongue (n=54, 85.7%). Overall 17 patients had died, including 15 from the treated cancer. Overall and progression-free survival rates at 5 years were respectively 79.6% and 68.6%. The corresponding 5 years local, regional and metastatic relapse free survival rates were 80%, 91% and 89% respectively. In the multivariate analysis only the absence of initial surgery (hazard ratio [HR]: 13.5 [2.0; 90.5]; P=0.007) was prognostic for overall survival, while alcohol abuse (HR: 0.37 [0.15; 0.9]; P=0.03) and the absence of surgery (HR: 13.6 [2.5; 74.2]; P=0.002) were associated with a decreased progression-free survival. A younger age (less than 30 year old) was not associated with the risk of recurrence or death.nnnCONCLUSIONnSurvival rates and tumour control probabilities are relatively high among young patients suffering from squamous cell carcinomas of the oral cavity treated at a tertiary centre. The early identification of patients at risk of relapse is currently difficult. The balance between recurrence and treatment toxicity warrants further studies, both on the clinical level and for the development of prognostic biomarkers.