Low skeletal muscle mass is a well-known prognostic factor for patients treated for a non-small-cell lung cancer by surgery or chemotherapy. However, its impact in patients treated by exclusive ...radiochemotherapy has never been explored. Our study tries to evaluate the prognostic value of low skeletal muscle mass and other antropometric parameters on this population. Clinical, nutritional and anthropometric date were collected for 93 patients treated by radiochemotherapy for a NSCLC. Anthropometric parameters were measured on the PET/CT by two methods. The first method was a manual segmentation at level L3, used to define Muscle Body Area (MBA
), Visceral Fat Area (VFA
) and Subcutaneous Fat Area (SCFA
). The second method was an software (Anthropometer3D), allowing an automatic multislice measurement of Lean Body Mass (LBM
), Fat Body Mass (FBM
), Muscle Body Mass (MBM
), Visceral Fat Mass (VFM
), and Sub-Cutaneous Fat Mass (SCFM
) on the PET/CT. All anthropometrics parameters were normalised by the patient's height. The primary end point was overall survival time. Univariate and then stepwise multivariate cox analysis were performed for significant parameters. Finally, Spearman's correlation between MBA
and MBM
was assessed. Forty-one (44%) patients had low skeletal muscle mass. The median overall survival was 18 months for low skeletal muscle mass patients versus 36 months for non-low skeletal muscle mass patients (p = 0.019). Low skeletal muscle mass (HR = 1.806, IC95% 1.09-2.98), serums albumin level < 35 g/l (HR = 2.203 1.19-4.09), Buzby Index < 97.5 (HR = 2.31 1.23-4.33), WHO score = 0 (HR = 0.59 0.31-0.86 and MBM
< 8.56 kg/m
(HR = 2.36 1.41-3.90) were the only significant features in univariates analysis. In the stepwise multivariate Cox analysis, only MBM
< 8.56 kg/m
(HR = 2.16, p = 0.003) and WHO score = 0 (HR = 0.59, p = 0.04) were significant. Finally, muscle quantified by MBA
and MBM
were found to be highly correlated (Spearman = 0.9). Low skeletal muscle mass, assessed on the pre-treatment PET/CT is a powerful prognostic factor in patient treated by radiochemotherapy for a NSCLC. The automatic software Anthropometer3D can easily identify patients a risk that could benefit an adapted therapy.
Ultracentral (UC) lung lesions are generally defined by the presence of the tumour or the Planning Target Volume (PTV) abutting proximal bronchial tree (PBT) or the esophagus. Initial reports rose ...awareness regarding the potential toxicity of stereotactic body radiotherapy (SBRT) when delivered to UC lesions. Major concerns include necrosis, stenosis, and bleeding of the PBT. Technological improvements now enable the delivery of more accurate treatments, possibly redefining the historical “no-fly zone”. In this review, studies focusing on the treatment of UC lesions with SBRT are presented. The narrow therapeutic window requires a multidisciplinary approach.
Les lésions pulmonaires ultracentrales sont généralement définies par le contact ou l’infiltration par la tumeur ou le volume cible prévisionnel (PTV) de l’arbre trachéobronchique ou de l’œsophage. Les premières études ont fait état d’une surtoxicité potentielle de la radiothérapie stéréotaxique lorsqu’elle était délivrée en regard de lésions ultracentrales. La principale toxicité rapportée concernait la nécrose, la sténose et l’hémorragie de l’arbre trachéobronchique. Les améliorations technologiques permettent aujourd’hui d’administrer des traitements plus précis, pouvant éventuellement conduire à une redéfinition de l’historique « no-fly zone ». Cette revue présente les études portant sur le traitement par irradiation stéréotaxique des lésions ultracentrales. L’étroitesse de la fenêtre thérapeutique impose une approche multidisciplinaire.
To propose an easily applicable segmentation method (perPET-RT) for delineation of tumour volume during radiotherapy on interim fluorine 18 fluorodeoxyglucose (FDG) positron emission ...tomography/computed tomography (PET/CT) in patients with non-small cell lung cancer (NSCLC).
Sixty-seven patients (51 primary tumours, 60 lymph nodes), from 4 prospective studies, underwent an FDG PET/CT scan during the fifth week of radiation therapy, using different generations of PET/CT. Per-therapeutic PET/CT scans were delineated in consensus by two experienced physicians leading to the gold standard threshold to be applied. The mathematical expression of Th
, the optimal threshold to be applied as a function of the maximum standard uptake value (SUV
), was determined. The performance of this method (perPET-RT) was assessed by computing the DICE similarity coefficient (DSC) and was compared with 8 fixed threshold values and 3 adaptive thresholding methods.
Th
verified the following expression: Th
= A.ln(1/SUV
) + B where A and B were 2 constants. A and B were independent from the generation of PET/CT, but depended on the type of lesions (primary lung tumours vs. lymph nodes). PerPET-RT showed good to very good agreement in comparison to the gold standard. The mean and standard deviation of DSC value was 0.81 ± 0.13 for lung lesions and 0.78 ± 0.15 for lymph nodes. PerPET-RT showed a significant better agreement than the other segmentation methods (p < 0.001), except for one of the adaptive thresholding method ADT (p = 0.11).
On the database used, perPET-RT has proven its reliability and accuracy for tumour delineation on per-therapeutic FDG PET/CT using only SUV
measurement. This method may be used to delineate tumour volume for dose-escalation planning.
NCT01261598 , NCT01261585 , NCT01576796 .
Stereotaxic radiotherapy is performed regularly for the irradiation of non-spine bone metastases, but its place is not well understood.
This article in stereotaxic radiotherapy of non-spine bones ...oligometastases presents the current scientific data relating to the indications, to virtual simulation, to the delineation of target volumes, to the total dose and fractionation, to the efficacy and tolerance.
Oligometastatic patients are classified into 4 categories: oligorecurrences, oligometastasis, oligopersistence, oligoprogression. The prognosis will be evaluated according to the following characteristics: primary tumor, quantitative characteristics, kinetics, qualitative characteristics. The delineation of GTV includes extensions to the soft tissue and bone marrow with the aid of MRI and PET. The CTV corresponds to a margin of 2 to 5mm and the PTV to a margin of 2mm. The most widely used irradiation schemes are: 1 single fraction of 18 to 24Gy/1 fr; 24Gy/2 fr; 27 to 30Gy/3 fr; 30 to 35Gy/5 fr. Stereotaxis provides 90% local control at 1 year and good pain control. The side effects are not very marked.
Stereotaxic radiotherapy is feasible, non-invasive, minimally toxic and effective with good local control and good pain relief. The main issue remains selecting the patients most likely to benefit from it.
Computed tomography (CT) in the treatment position is currently indispensable for planning radiation therapy. Other imaging modalities, such as magnetic resonance imaging (MRI) and positron ...emission-tomography (PET), can be used to improve the definition of the tumour and/or healthy tissue but also to provide functional data of the target volume. Accurate image registration is essential for treatment planning, so MRI and PET scans should be registered at the planning CT scan. Hybrid PET/MRI scans with a hard plane can be used but pose the problem of the absence of CT scans. Finally, techniques for moving the patient on a rigid air-cushioned table allow PET/CT/MRI scans to be performed in the treatment position while limiting the patient's movements exist. At the same time, the advent of MRI–linear accelerator systems allows to redefine image-guided radiotherapy and to propose treatments with daily recalculation of the dose. The place of PET during treatment remains more confidential and currently only in research and prototype status. The same development of imaging during radiotherapy is underway in proton therapy.
La tomodensitométrie en position de traitement est actuellement indispensable pour la planification de la radiothérapie. D’autres modalités d’imagerie, comme l’imagerie par résonance magnétique (IRM) et la tomographie par émission de positons (TEP), peuvent être utilisées pour améliorer la définition de la tumeur et/ou des tissus sains mais également donner des données fonctionnelles du volume cible. Un recalage précis des images étant indispensable pour la planification thérapeutique, l’IRM et la TEP doivent être recalées à la scanographie de planification. La TEP/IRM hybride avec un plan dur, peut être utilisée mais pose le problème de l’absence de scanographie. Enfin, des techniques de déplacement du patient installé sur une table rigide sur coussin d’air permettent de réaliser des TEP/scanographie/IRM en position de traitement en limitant les mouvements du patient existent. En parallèle l’apparition d’accélérateurs avec IRM embarquée permet de redéfinir la radiothérapie guidée par l’image et de proposer des traitements avec recalcul quotidien de la dose. La place de la TEP au cours du traitement reste plus confidentielle et actuellement uniquement au statut de recherche et de prototype. Ce même développement de l’imagerie en cours de radiothérapie est en cours en protonthérapie.
Head and neck carcinomas are initially metastatic in about 15% of cases. Radiotherapy is a cornerstone in the multimodal strategy at the locoregional phase. In patients with head and neck cancer, ...often heavily pretreated and with comorbidities, who relapse locoregionally or at distant sites, radiotherapy has also become increasingly important at the metastatic phase. Data on the optimal sequence of systemic treatments and metastasis-directed treatments including stereotactic irradiation are still lacking. Several randomized head and neck trials have been initiated that should provide important answers, including one recent GORTEC trial.
Les carcinomes de la tête et du cou sont métastatiques d’emblée dans environ 15 % des cas. Chez ces patients souvent lourdement traités et atteints de comorbidité, la radiothérapie est une pierre angulaire de la stratégie multimodale, tant en phase locorégionale qu’en phase métastatique. Les données sur la séquence optimale des traitements et le rôle de l’irradiation stéréotaxique font encore défaut. Plusieurs essais randomisés sur les cancers de la tête et le cou ont été mis en place et devraient apporter des éléments de réponse, dont un essai récemment terminé du GORTEC.
Therapeutic effectiveness in radiotherapy is partly related to correct staging of the disease and then precise therapeutic targeting. Positron emission tomography (PET) allows the stage of many ...cancers to be determined and therefore is essential before deciding on radiation treatment. The definition of the therapeutic target is essential to obtain correct tumour control and limit side effects. The part of adaptive radiotherapy remains to be defined, but PET by its functional nature makes it possible to define the prognosis of many cancers and to consider radiotherapy adapted to the initial response allowing an increase over the entire metabolic volume, or targeted at a subvolume at risk per dose painting, or with a decrease in the dose in case of good response at interim assessment.
L’efficacité thérapeutique en radiothérapie est en partie liée à un bilan correct de la maladie et ensuite à une définition précise de la cible thérapeutique. La tomographie par émission de positrons (TEP) permet de préciser le stade de nombreux cancers et est donc essentielle avant de décider d’une radiothérapie. Par la suite, elle permet de définir de manière précise le volume cible, étape essentielle pour obtenir un contrôle correct de la tumeur et limiter les effets secondaires. La partie de la radiothérapie adaptative reste à définir, mais la TEP par sa nature fonctionnelle permet de définir le pronostic de nombreux cancers et d’envisager une radiothérapie adaptée à la réponse initiale permettant une augmentation sur l’ensemble du volume métabolique, ou de cibler sur un sous-volume à risque par « dose painting », ou encore une diminution de la dose en cas de bonne réponse lors du bilan pendant la radiothérapie.
Standard treatment stage of non-small cell lung cancer is currently surgery. For inoperable patients, stereotactic body radiotherapy is the reference treatment. This non-invasive technique has ...developed considerably and its excellent results in terms of carcinological control and tolerance raise the question of its indication for operable patients, especially for old patients and/or with comorbidities. This article reviews the available data in the literature of the place of stereotactic body radiotherapy for medically operable patients with stage I non-small cell lung cancer.
Stereotactic body radiation therapy is effective for the local management of oligometastases (at most five metastases) with a benefit in survival and local control. Most studies on the management of ...oligometastases focus on all oligometastatic sites in primary cancer and very few focus on a single oligometastatic site. In particular, there are few data on bone oligometastases, which represent one of the preferred sites for secondary cancer locations. This article focuses on the benefit of stereotactic radiotherapy for bone oligometastases of all cancers by histological types, and reviews the results of major studies in this field.
La radiothérapie stéréotaxique a fait ses preuves dans la prise en charge locale des oligométastases (au plus cinq métastases) avec un bénéfice sur la survie et le contrôle local. La plupart des études sur les oligométastases s’intéressent à l’ensemble des sites oligométastatiques d’un cancer primitif et très peu s’intéressent à un seul site oligométastatique. En particulier, il existe peu de données sur les oligométastases osseuses, qui représentent un des sites privilégiés de localisations secondaires cancéreuses. Cet article s’intéresse au bénéfice de la radiothérapie stéréotaxique des oligométastases osseuses tous cancers confondus et par types histologiques, et reprend les résultats des grands essais dans ce domaine.
We present an update of the French society of oncological radiotherapy recommendation regarding indication, doses, and technique of radiotherapy for intrathoracic metastases. The recommendations for ...delineation of the target volumes and critical organs are detailed.
Nous présentons la mise à jour des recommandations de la Société française de radiothérapie oncologique sur les indications et les modalités techniques de réalisation de la radiothérapie des métastases intrapulmonaires.
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