Promising Candidate Prognostic Biomarkers in [18F]FDG PET Images: Evaluation in Independent Cohorts of Non-Small Cell Lung Cancer Patients

The normalized distances from the hot spot of radiotracer uptake (SUVmax) to the tumor centroid (NHOC) and to the tumor perimeter (NHOP) have recently been suggested as novel PET features reflecting tumor aggressiveness. These biomarkers characterizing the shift of SUVmax toward the lesion edge during tumor progression have been shown to be prognostic factors in breast and non-small cell lung cancer (NSCLC) patients. We assessed the impact of imaging parameters on NHOC and NHOP, their complementarity to conventional PET features, and their prognostic value for advanced-NSCLC patients. Methods: This retrospective study investigated baseline [18F]FDG PET scans: cohort 1 included 99 NSCLC patients with no treatment-related inclusion criteria (robustness study); cohort 2 included 244 NSCLC patients (survival analysis) treated with targeted therapy (93), immunotherapy (63), or immunochemotherapy (88). Although 98% of patients had metastases, radiomic features including SUVs were extracted from the primary tumor only. NHOCs and NHOPs were computed using 2 approaches: the normalized distance from the localization of SUVmax or SUVpeak to the tumor centroid or perimeter. Bland-Altman analyses were performed to investigate the impact of both spatial resolution (comparing PET images with and without gaussian postfiltering) and image sampling (comparing 2 voxel sizes) on feature values. The correlation of NHOCs and NHOPs with other features was studied using Spearman correlation coefficients (r). The ability of NHOCs and NHOPs to predict overall survival (OS) was estimated using the Kaplan-Meier method. Results: In cohort 1, NHOC and NHOP features were more robust to image filtering and to resampling than were SUVs. The correlations were weak between NHOCs and NHOPs (r ≤ 0.45) and between NHOCs or NHOPs and any other radiomic features (r ≤ 0.60). In cohort 2, the patients with short OS demonstrated higher NHOCs and lower NHOPs than those with long OS. NHOCs significantly distinguished 2 survival profiles in patients treated with immunotherapy (log-rank test, P < 0.01), whereas NHOPs stratified patients regarding OS in the targeted therapy (P = 0.02) and immunotherapy (P < 0.01) subcohorts. Conclusion: Our findings suggest that even in advanced NSCLC patients, NHOC and NHOP features pertaining to the primary tumor have prognostic potential. Moreover, these features appeared to be robust with respect to imaging protocol parameters and complementary to other radiomic features and are now available in LIFEx software to be independently tested by others.

Consore: A Powerful Federated Data Mining Tool Driving a French Research Network to Accelerate Cancer Research

BACKGROUND

Real-world data (RWD) related to the health status and care of cancer patients reflect the ongoing medical practice, and their analysis yields essential real-world evidence. Advanced information technologies are vital for their collection, qualification, and reuse in research projects.

METHODS

UNICANCER, the French federation of comprehensive cancer centres, has innovated a unique research network: Consore. This potent federated tool enables the analysis of data from millions of cancer patients across eleven French hospitals.

RESULTS

Currently operational within eleven French cancer centres, Consore employs natural language processing to structure the therapeutic management data of approximately 1.3 million cancer patients. These data originate from their electronic medical records, encompassing about 65 million medical records. Thanks to the structured data, which are harmonized within a common data model, and its federated search tool, Consore can create patient cohorts based on patient or tumor characteristics, and treatment modalities. This ability to derive larger cohorts is particularly attractive when studying rare cancers.

CONCLUSIONS

Consore serves as a tremendous data mining instrument that propels French cancer centres into the big data era. With its federated technical architecture and unique shared data model, Consore facilitates compliance with regulations and acceleration of cancer research projects.

How to Improve Cancer Patients ENrollment in Clinical Trials From rEal-Life Databases Using the Observational Medical Outcomes Partnership Oncology Extension: Results of the PENELOPE Initiative in Urologic Cancers

PURPOSE

To compare the computability of Observational Medical Outcomes Partnership (OMOP)-based queries related to prescreening of patients using two versions of the OMOP common data model (CDM; v5.3 and v5.4) and to assess the performance of the Greater Paris University Hospital (APHP) prescreening tool.

MATERIALS AND METHODS

We identified the prescreening information items being relevant for prescreening of patients with cancer. We randomly selected 15 academic and industry-sponsored urology phase I-IV clinical trials (CTs) launched at APHP between 2016 and 2021. The computability of the related prescreening criteria (PC) was defined by their translation rate in OMOP-compliant queries and by their execution rate on the APHP clinical data warehouse (CDW) containing data of 205,977 patients with cancer. The overall performance of the prescreening tool was assessed by the rate of true- and false-positive cases of three randomly selected CTs.

RESULTS

We defined a list of 15 minimal information items being relevant for patients' prescreening. We identified 83 PC of the 534 eligibility criteria from the 15 CTs. We translated 33 and 62 PC in queries on the basis of OMOP CDM v5.3 and v5.4, respectively (translation rates of 40% and 75%, respectively). Of the 33 PC translated in the v5.3 of the OMOP CDM, 19 could be executed on the APHP CDW (execution rate of 58%). Of 83 PC, the computability rate on the APHP CDW reached 23%. On the basis of three CTs, we identified 17, 32, and 63 patients as being potentially eligible for inclusion in those CTs, resulting in positive predictive values of 53%, 41%, and 21%, respectively.

CONCLUSION

We showed that PC could be formalized according to the OMOP CDM and that the oncology extension increased their translation rate through better representation of cancer natural history.

Treatment patterns and outcomes among patients with small-cell lung cancer (SCLC) in Europe: a retrospective cohort study

OBJECTIVE

Describe characteristics, treatment patterns and clinical outcomes of patients with small-cell lung cancer (SCLC).

DESIGN

Retrospective chart review study defining several cohorts: (1) limited-stage disease (LD) SCLC initiating 1L therapy (1 L LD-SCLC), (2) extensive-stage disease (ED) SCLC initiating 1L therapy (1L ED-SCLC) and (3) patients initiating 2L therapy.

SETTING

39 physicians (medical oncologists, thoracic oncologists and/or pulmonologists) from France, Italy and the UK.

PARTICIPANTS

Patients >18 years of age with a confirmed diagnosis of LD-SCLC or ED-SCLC and a full oncology medical history. Patients included initiated a 1L (2013-2015) or 2L (2013-2016) treatment (chemotherapy and/or radiotherapy-RT).

PRIMARY AND SECONDARY OUTCOME MEASURES

Overall survival (OS) and progression-free survival (PFS).

RESULTS

231 patients in 1L LD-SCLC, 308 in 1L ED-SCLC and 225 with relapse/refractory SCLC initiating 2L treatment were included. The proportion of men was higher across all groups (56.8% to 68.5%) and mean age at time of diagnosis was 66.0 and 65.4 years in 1L LD-SCLC and 2L ED-SCLC cohorts. The majority of patients in LD-SCLC 1L group received chemotherapy with RT (76.2%). Patients initiating 2L therapy predominantly received chemotherapy alone (79.6%).Median OS in 1 L patients was 17.3 months in LD-SCLC and 8.8 months in ED-SCLC. Median PFS was 11.6 months in LD-SCLC and 6.1 months in ED-SCLC patients. Median OS in patients initiating 2L treatment was 6.6 months. OS from start of 2L treatment was lower in patients initially diagnosed with ED (5.1 months) than in patients initially diagnosed with LD (9.3 months) (p<0.0001). OS and PFS were assessed from the start of 1L or 2L therapy, depending on the cohort.

CONCLUSIONS

Despite the availability of a high number of treatments and combinations, the prognosis of SCLC is still unsatisfactory, especially for those patients diagnosed with ED-SCLC, indicating high unmet need in this patient population.

Federated learning for predicting histological response to neoadjuvant chemotherapy in triple-negative breast cancer

Triple-negative breast cancer (TNBC) is a rare cancer, characterized by high metastatic potential and poor prognosis, and has limited treatment options. The current standard of care in nonmetastatic settings is neoadjuvant chemotherapy (NACT), but treatment efficacy varies substantially across patients. This heterogeneity is still poorly understood, partly due to the paucity of curated TNBC data. Here we investigate the use of machine learning (ML) leveraging whole-slide images and clinical information to predict, at diagnosis, the histological response to NACT for early TNBC women patients. To overcome the biases of small-scale studies while respecting data privacy, we conducted a multicentric TNBC study using federated learning, in which patient data remain secured behind hospitals' firewalls. We show that local ML models relying on whole-slide images can predict response to NACT but that collaborative training of ML models further improves performance, on par with the best current approaches in which ML models are trained using time-consuming expert annotations. Our ML model is interpretable and is sensitive to specific histological patterns. This proof of concept study, in which federated learning is applied to real-world datasets, paves the way for future biomarker discovery using unprecedentedly large datasets.

Collaborative federated learning behind hospitals’ firewalls for predicting histological complete response to neoadjuvant chemotherapy in triple-negative breast cancer

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Background: Triple-Negative Breast Cancer (TNBC) is characterized by high metastatic potential and poor prognosis with limited treatment options. Neoadjuvant chemotherapy (NACT) is the standard of care in non-metastastic setting due to the ability to assess pathologic responses providing important prognostic information and guidance in adjuvant therapy decisions. However, the histological response heterogeneity is still poorly understood. We investigate the use of Machine Learning (ML) to predict from diagnosis Whole-Slide Images (WSI) of early TNBC the positive histological Complete Response (pCR) to NACT on surgical specimens. To overcome the known biases of small scale studies while respecting data privacy, we conduct a study in a multi-centric fashion behind hospitals’ firewalls using collaborative Federated Learning (FL). Thereby allowing access to enough TNBC data to sustain a complete response heterogeneity investigation. Methods: We collected in both comprehensive cancer centers: Centre Léon Bérard (A)(n=99) and Institut Curie (B) (n=420), WSI of biopsies performed at diagnosis and relevant clinical variables. We use traditional Multiple Instance Learning pipelines by tiling the matter on each WSI with a pre-trained Neural Network (NN). We train a second NN to predict the NACT pCR using the mean feature of each WSI. ML trainings are performed using either one cohort in isolation (NN Local) or both cohorts using FL. We compare the performance of this federated WSI based model to the best clinical model (Clin.) simulating clinical practice (using grade and Tumor-Infiltrating Lymphocytes (TILs) percentage) on both centers. Results: Performance of models to predict NACT pCR (AUC). All results are evaluated in 5 repeated 4-folds cross validations. Conclusions: The final ML model, that was trained in a privacy preserving fashion on both hospitals, provides better prediction of NACT pCR than current clinical standards. This study shows that 1. Not all relevant information is routinely extracted from WSI and 2. Non simulated FL is possible in Healthcare and gives better results than siloed studies on open medical questions. Additional interpretability results of the model show that it has re-discovered known biomarkers such as TILs and apocrine tumor cells without any tile-level annotation, and hints at potential new biomarkers. [Table: see text]

Identification of Tissue of Origin and Guided Therapeutic Applications in Cancers of Unknown Primary Using Deep Learning and RNA Sequencing (TransCUPtomics)

Cancers of unknown primary (CUP) are metastatic cancers for which the primary tumor is not found despite thorough diagnostic investigations. Multiple molecular assays have been proposed to identify the tissue of origin (TOO) and inform clinical care; however, none has been able to combine accuracy, interpretability, and easy access for routine use. We developed a classifier tool based on the training of a variational autoencoder to predict tissue of origin based on RNA-sequencing data. We used as training data 20,918 samples corresponding to 94 different categories, including 39 cancer types and 55 normal tissues. The TransCUPtomics classifier was applied to a retrospective cohort of 37 CUP patients and 11 prospective patients. TransCUPtomics exhibited an overall accuracy of 96% on reference data for TOO prediction. The TOO could be identified in 38 (79%) of 48 CUP patients. Eight of 11 prospective CUP patients (73%) could receive first-line therapy guided by TransCUPtomics prediction, with responses observed in most patients. The variational autoencoder added further utility by enabling prediction interpretability, and diagnostic predictions could be matched to detection of gene fusions and expressed variants. TransCUPtomics confidently predicted TOO for CUP and enabled tailored treatments leading to significant clinical responses. The interpretability of our approach is a powerful addition to improve the management of CUP patients.

Discontinuation of immune checkpoint inhibitor (ICI) above 18 months of treatment in real-life patients with non-small cell lung cancer (NSCLC): INTEPI, a multicentric retrospective study

9082

Background: The optimal treatment duration of ICIs for patients with NSCLC remains uncertain. In phase 3 clinical trials, treatment continued for two years or until disease progression, and results from CheckMate 153 trial suggest to continue beyond one year. Real life data are missing. Methods: This multi-centric retrospective study presents data on real-life patients who discontinued treatment after at least 18 months of ICI monotherapy, their tumour being still controlled. Their characteristics, the causes of discontinuation of ICI, and their outcome are described. Results: Between July 2015 and May 2018, 107 patients had their tumour controlled after at least 18 months of treatment. Among them, 54 (50%) patients discontinued ICI: 76% male, median age 63, 91% PS 0-1, 54% adenocarcinoma, 20% with brain metastases, PD-L1 expression level available for 18 (33%) patients (2 < 1%, 8 btw 1-50% and 8 > 50%), 93% treated after 1st line. The median duration of treatment was 26 months. Treatment was stopped by choice of the prescriber and toxicity in 46% and 22% respectively. With a median follow up of 21 months from ICI discontinuation, 18 (33%) patients had a tumor progression with a median time of 10 months (2-33). From discontinuation, overall survival (OS) and progression free survival (PFS) were 90% and 71% respectively at 12 months and 84% and 63% respectively at 24 months. Duration of disease control after ICI cessation seemed to be correlated to the best tumor response at treatment discontinuation, with a PFS rates at 12 months of 73% for complete response (CR n = 11), 77% for partial response (PR n = 37), 22% for patients with stable disease (SD n = 6), 80% for CR and/or complete metabolic response with 18F-FDG PET/CT (CMR) and 65% for others. Fourteen patients out of the 18 in the relapse group received a subsequent treatment : 7 were retreated with ICI (with best response 14% PR and 86% SD) and 5 received a localized therapy with 60% CR. Conclusions: Our study in real life provides new insight into the long-term outcomes of patients treated with ICI for at least 18 months before discontinuation in the absence of PD. CR and CMR with FDG-PET before therapy discontinuation may be a positive factor for a prolonged disease control upon discontinuation.

Impact of COVID-19 on the management of patients with thoracic cancers in a tertiary referral center

Introduction

Severe acute respiratory syndrome coronavirus (SARS-CoV)-2 has spread worldwide in 2020 leading the World Health Organization to declare a pandemic. Patients with thoracic cancers have been reported at higher risk to develop severe disease, and die from COVID-19. In this setting, clinical practice recommendations for the management of patients were published. We report here how these guidelines were implemented in a routine practice setting.

Methods

We retrospectively collected the characteristics, treatment regimen and modification, as well as COVID-19 status and death for all patients with thoracic malignancies scheduled for an appointment at Institute Curie from March 23^rd to April 17^th 2020.

Results

A total of 339 patients were included. Treatment strategy was modified for a total of 110 (32 %) patients because of COVID-19; these modifications were in accordance with guidelines for 92 % of patients. The majority of dose modifications were related to immune checkpoint inhibitors, for which switch to flat dosing every 4–6 weeks was made. A total of 5 (1.5 %) patients were diagnosed with COVID-19 disease, 1 of whom died from disease complication.

Conclusion

Our study provides a unique insight in the decision making for patients with thoracic malignancies in the setting of COVID-19 outbreak, showing how guidelines were implemented in the clinic, and what may be optimized in the clinical practice of thoracic oncology in the future.

[Immunotherapy in lung cancer: New concepts]

Improvements in knowledge about the complexity of the tumor microenvironment have paved the way for a revolution in lung cancer treatment with the emergence of immune checkpoint inhibitors. The immune checkpoints negatively regulate immune cells and lead to a dormant state: the immune cells are then unable to interact effectively with their targets. The immune checkpoint inhibitors are monoclonal antibodies that block immune checkpoints and permit reactivation of the immune response against the tumor. Although immune checkpoint inhibitors are effective as monotherapy, several other immune targets exist. The better understanding of the involvement of these new targets in the immune response against tumors is leading to the design of new compounds and new therapeutic approaches.

Abstract P3-06-11: Withdrawn

This abstract was withdrawn by the authors.

Abstract P2-03-04: Lymphovascular invasion in breast carcinoma following neodjuvant chemotherapy is a strong prognosis factor

Purpose : Lymphovascular invasion (LVI) is a poor prognosis factor in breast cancer (BC), but data on its value in the neoadjuvant setting is scarce. This study evaluates the relationships between post-NAC LVI and prognosis in BC.

Methods: We identified 1197 patients with primary BC receiving NAC +/- trastuzumab between 2002 and 2011. Information on LVI in post-NAC surgical specimen was retrieved from review of medical charts. Univariate and multivariate analyses were performed to assess the association of clinical, pathological factors with disease free survival (DFS) and overall survival (OS) was assessed using a cox proportional hazard model.

Results: On 1197 tumors, 528 were luminal (44.1%), 375 were triple negative breast cancer (TNBC) (31.3%) and 294 were HER2-positive (24.6%). On post-NAC surgical specimens, LVI was present in 302 (25.2%), absent in 531 (44.4%), and was not mentionned in 364 cases (30.4%). The presence of post-NAC LVI was associated with an impaired DFS (HR=2.17, 95 CI [1.65 - 2.86], p&lt;0.001) and the magnitude of this impact varied by BC subtype (p-value for interaction=0.02), (luminal BC: HR=1.75, p=0.006; TNBC : HR=2.77, p&lt;0.001 ; HER2-positive BC : HR=5.12, p&lt;0.001).

Table 1 Univariate analysis and multivariate analysis on DFS (whole population)   Univariate  Multivariate VariableClassHRClpHRCIpAge&lt; 451 0.35    45-550.82[0.62 - 1.08]     &gt;550.87[0.64 - 1.19]    Menopausal statuspremenopausal1.04[0.81 - 1.34]0.75    postmenopausal1     BMI class19-251      &lt; 191.24[0.75 - 2.05]0.41    &gt; 251.36[1.06 - 1.75]0.01   Tumor sizeT1-T21      T31.77[1.38 - 2.27]&lt;0.011.77[ 1.32 - 2.38 ]&lt;0.001Clinical nodal statusN01      N1-N2-N31.35[1.05 - 1.72]0.021.43[ 1.07 - 1.91 ]0.016HistologyDuctal1      Other1.24[0.87 - 1.78]0.24   GradeGrade I-II1      III1.24[0.87 - 1.78]0.07   Ki 67&lt;201      &gt;201.54[1.06 - 2.22]0.02   Mitotic index≤221      &gt;221.18[0.9 - 1.53]0.23   DCIS componentno1      yes1.33[0.88 - 2.01]0.18   Pre-NAC LVIno1      yes1.35[0.88 - 2.01]0.09   ER statusnegative1      positive0.72[0.56 - 0.91]&lt;0.01   PR statusnegative1      positive0.66[0.51 - 0.85]&lt;0.01   HER2 statusnegative1      positive0.84[0.62 - 1.14]0.26   BC subtypeluminal1      TNBC1.53[1.17 - 2]&lt;0.012.67[ 1.93 - 3.69 ]&lt;0.001 HER20.99[0.72 - 1.38]0.971.25[ 0.82 - 1.88 ]0.299Post NAC parametersPost-NAC LVI (breast)no1      yes2.17[1.65 - 2.86]&lt;0.012.3[ 1.72 - 3.08 ]&lt;0.001pCRNo pCR1      pCR0,4[0.27 - 0.59]&lt;0.01   Pathological nodal involvement0       1-31.48[1.11 - 1.97]&lt;0.01    ≥4 N+3.13[2.34 - 4.19]&lt;0.01   RCB class01      10.97[0.36 - 2.64]0.96    22.88[1.69 - 4.89]&lt;0.01    35.21[3.01 - 9.02]&lt;0.01   ER: oestrogene receptor PR: progesteron receptor RCB: residual cancer burden

Post-NAC LVI was an independent predictor of poor DFS, that overwhelmed the prognostic impact of pathological complete response in all 3 BC subtypes. Post-NAC LVI was also an independent predictor of poor OS in the whole cohort and in all BC subtypes.

Table 1 resumes univariate and multivariate analysis on DFS in whole population.

Conclusion: Post-NAC LVI is a strong independent prognostic factor associated with poor DFS and OS, that (i) should be systematically mentioned in pathological reports following NAC and (ii) could be used to select high risk patients candidates to second line trials in the post-neoadjuvant window.

Citation Format: Hamy-Petit A-S, Lam G-T, Laas E, Darrigues L, Balezeau T, Guerin J, Livartowski A, Sadacca B, Pierga J-Y, Vincent-Salomon A, Bidard F-C, Lerebours F, Brain E, Becette V, Rouzier R, Lae M, Reyal F. Lymphovascular invasion in breast carcinoma following neodjuvant chemotherapy is a strong prognosis factor [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-04.

Lymphovascular invasion after neoadjuvant chemotherapy is strongly associated with poor prognosis in breast carcinoma

PURPOSE

Few studies evaluated the prognostic value of the presence of lymphovascular invasion (LVI) after neoadjuvant chemotherapy (NAC) for breast cancer (BC).

METHODS

The association between LVI and survival was evaluated in a cohort of BC patients treated by NAC between 2002 and 2011. Five post-NAC prognostic scores (ypAJCC, RCB, CPS, CPS + EG and Neo-Bioscore) were evaluated and compared with or without the addition of LVI.

RESULTS

Out of 1033 tumors, LVI was present on surgical specimens in 29.2% and absent in 70.8% of the cases. Post-NAC LVI was associated with impaired disease-free survival (DFS) (HR 2.54; 95% CI 1.96-3.31; P < 0.001), and the magnitude of this effect depended on BC subtype (P_interaction = 0.003), (luminal BC: HR 1.83; P = 0.003; triple negative BC: HR 3.73; P < 0.001; HER2-positive BC: HR 6.21; P < 0.001). Post-NAC LVI was an independent predictor of local relapse, distant metastasis, and overall survival; and increased the accuracy of all five post-NAC prognostic scoring systems.

CONCLUSIONS

Post-NAC LVI is a strong independent prognostic factor that: (i) should be systematically reported in pathology reports; (ii) should be used as stratification factor after NAC to propose inclusion in second-line trials or adjuvant treatment; (iii) should be included in post-NAC scoring systems.

Percutaneous vertebroplasty in vertebral metastases from breast cancer: interest in terms of pain relief and quality of life

Percutaneous vertebroplasty (PV) is a therapeutic option in patients with vertebral metastases (VM). However its efficacy in pain relief, improvement in quality of life and safety in patients with VM from breast cancer has not been reported. We present a longitudinal retrospective study of 31 consecutively treated female patients with VM from breast cancer where 88 vertebrae were treated in 44 sessions of PV, in which osteolytic, osteoblastic and mixed lesions were recorded. The visual analogue pain scale (VAS) was used to evaluate pain pre-PV, at one, three, six and 12 months post-PV. The Eastern Cooperative Group (ECOG) performance status scale was used at the same time intervals to measure quality of life: 90.3% pain relief was identified with a VAS reduction from 5.7 ± 2.0 pre-PV to 2.9 ± 2.2 post-PV at one-month follow-up (p<0.001) and 0.6 ± 1.0 at 12-month follow-up (p<0.001). In our series 48.4% of patients were classified as having an ECOG grade 0 and 1 pre-PV, which increased to 80.8% at the 12-month follow-up. While 22.6% of the patients were classified at ECOG grades 3 and 4 pre-PV, this improved to 0% at 12 months follow-up. The morbidity rate for this procedure was 12.9% immediately and only 3.2% at 30 days post-PV with all complications being resolved medically or with CT-guided infiltration. PV is a safe procedure with a high efficacy in pain relief, and improvement of quality of life in patients with diverse types of VM from breast cancer.

Abstract P4-13-14: Lung cancer after treatment of breast cancer:retrospective study from Curie Institut

Background: Few studies have evaluated the effects of adjuvant radiotherapy (RT)of breast cancer(BC). The relation between the risk of lung carcinoma and radiotherapy have been controversial.

Methods and materials: We retrospectively studied 127 patients treated at the Institut Curie with non metastatic breast cancer and lung carcinoma between 2000 and 2011(2/3 of BC apperead befor lung). Confirmation Diagnosis bronchial cancer obtained by: biopsy: histological data:architecture, IHC (HR, HER 2, TTF1), EGFR, Kras statut clinical and radiological Correlation. Comparison with breast tumor

Results: BC: median age at diagnosis 54 years, predominatly invasive ductual carcinoma(IDC), lumpectomy 78%, mastectomy 21%. Lung cancer: median age at diagnosis: 63 years, 67 smokers. histology: 52 % Adenocarcinoma, 18.1 % scamous cell carcinoma, 18.1% large cell carcinoma, 13.4 % small cell carcinoma. EGFR mutation in 4.3%. 109 patients underwent RT (3 cases of lung cancer befor BC):Region: internal mammary chain: 46, supracalvicular: 42, axillary: 21. Technique: lateral decubitus position: 44, dorsal decubitus position: 57. Interval between breast and lung cancer: 0–3 years: 24.4%, 3–5 years: 15%, 6–10years: 16.5%, 11–20 years: 28%, &gt;20 years: peak of incidence of lung cancer in the 3 years of diagnosis of breast cancer: 24.4 %. There was no apparent relation between treatment of BC and relative risk of developing lung carcinoma. 2nd peak between 11–20 years: 32 % patients, suggest that RT may increase risk of lung carcinoma (latency period for radiation induced second malignancy).

Conclusion: This study suggest that adjuvant RT is associated with a real but small risk of developing lung carcinoma.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-14.

Cabazitaxel in patients with advanced solid tumours: results of a Phase I and pharmacokinetic study

BACKGROUND

Although the taxanes paclitaxel and docetaxel are among the most active agents for the treatment of a wide range of cancers, tumours often develop resistance to these treatments. Cabazitaxel is a novel taxane active in both preclinical models of chemotherapy-sensitive and -resistant human tumours and patients with advanced prostate cancer that progressed following docetaxel treatment.

AIM

To establish the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of cabazitaxel.

PATIENTS AND METHODS

Cabazitaxel was administered every 3 weeks to patients with advanced solid tumours. The design allowed intrapatient dose escalation. The primary objective was to determine the MTD. Secondary objectives were to describe the safety profile, establish an appropriate dose, determine the pharmacokinetic (PK) profile of cabazitaxel, and assess antitumour activity.

RESULTS

Twenty-one patients were recruited. The MTD was reached at 30 mg/m(2), at which three of five patients experienced haematologic DLTs during the first cycle. DLTs during subsequent cycles were mainly haematologic and reported at 25 and 30 mg/m(2) dosing levels. Nail disorders and severe alopecia were not reported, and neurotoxicity, fluid retention and hypersensitivity were mild and infrequent. Cabazitaxel demonstrated linear PK, a triphasic elimination profile, with a long half-life and high clearance. Of the 19 patients evaluable for response, one unconfirmed partial response and six occurrences of stable disease were reported.

CONCLUSIONS

The 25mg/m(2) dose of cabazitaxel was recommended for use in future clinical studies. In this study, cabazitaxel had an acceptable tolerability profile and activity in cervical, colorectal, endometrial and lung cancers.

Cost comparison of axillary sentinel lymph node detection and axillary lymphadenectomy in early breast cancer. A national study based on a prospective multi-institutional series of 985 patients 'on behalf of the Group of Surgeons from the French Unicancer Federation'

BACKGROUND

Our objective was to assess the global cost of the sentinel lymph node detection [axillary sentinel lymph node detection (ASLND)] compared with standard axillary lymphadenectomy [axillary lymph node dissection (ALND)] for early breast cancer patients.

PATIENTS AND METHODS

We conducted a prospective, multi-institutional, observational, cost comparative analysis. Cost calculations were realized with the micro-costing method from the diagnosis until 1 month after the last surgery.

RESULTS

Eight hundred and thirty nine patients were included in the ASLND group and 146 in the ALND group. The cost generated for a patient with an ASLND, with one preoperative scintigraphy, a combined method for sentinel node detection, an intraoperative pathological analysis without lymphadenectomy, was lower than the cost generated for a patient with lymphadenectomy [€ 2947 (σ = 580) versus € 3331 (σ = 902); P = 0.0001].

CONCLUSION

ASLND, involving expensive techniques, was finally less expensive than ALND. The length of hospital stay was the cost driver of these procedures. The current observational study points the heterogeneous practices for this validated and largely diffused technique. Several technical choices have an impact on the cost of ASLND, as intraoperative analysis allowing to reduce rehospitalization rate for secondary lymphadenectomy or preoperative scintigraphy, suggesting possible savings on hospital resources.

Perception of care and experience of examination in women at risk of breast cancer undergoing intensive surveillance by standard imaging with or without MRI

OBJECTIVE

Intensive surveillance in women at breast cancer risk is currently investigated in a French prospective, non-randomized, multicenter study, in which standard imaging--mammography±ultrasound ('Mx') and standard imaging combined with magnetic resonance imaging ('MRI') are compared with regard to perception of care and examination experience.

METHODS

1561 women were invited to complete the STAI-State Anxiety Inventory and breast cancer risk perception items at baseline (T0), and MGQ (MammoGraphy Questionnaire) and MRI discomfort items within 2 days after examinations (T1).

RESULTS

Baseline compliance was high (>91%). Women from the 'MRI' group were significantly younger and displayed higher education level and risk perception. MRI discomfort related to the duration, immobility, prone position or noise was experienced by more than 20% of women. In multivariate analyses, 'MRI' was associated with more favorable examination psychological experience (p≤.001), especially in women younger than 50; baseline STAI-State anxiety was associated with lower MGQ scores (p≤.001) and higher MRI discomfort (p≤.001).

CONCLUSION

In spite of the discomfort experienced with MRI, perception of care and experience with this surveillance procedure was more positive than with standard imaging.

PRACTICE IMPLICATIONS

Information and support may assuage some of the adverse effects of an uncomfortable examination technique.

Abstract A15: Establishment and characterization of a new patient-derived non-small cell lung cancer xenograft panel for pharmacological assessment

Background: Development of targeted therapies in non-small cell lung carcinoma (NSCLC) is rapidly growing and offers promising treatment perspectives for cancer patients. However, the assessment of new therapeutic compounds requires preclinical models defined by precise tumor molecular features that could impact their antitumor efficacy. The aim of this study was then to develop and characterize a new reliable panel of human NSCLC xenografts.

Material and methods: From 28 samples of NSCLC specimens obtained from patient's surgery and grafted into Swiss nude mice, 18 transplantable xenografts were established (64%). Molecular characterization included histological features, gene mutation status (EGFR, KRAS, and BRAF), and research of ALK translocation in both xenografts and their corresponding patient's tumors. For determination of the predictive value of the models, a standard pharmacological assessment was then performed in 6 adenocarcinoma (ADK) models using the EGFR inhibitor erlotinib (50 mg/kg/day, 5 days/week, 4 weeks, orally). Tumor Growth Inhibition (TGI) was calculated to measure the efficiency of erlotinib. Finally, to evaluate responses to erlotinib according to individual mouse variability, we decided to consider each mouse as one tumor-bearing entity. In all in vivo experiments, a relative tumor volume variation (RTVV) of each erlotinib-treated mouse was calculated from the following formula: Vt/Vc, where Vt is the volume of the treated mouse and Vc the median volume of the corresponding control group at a time corresponding to the end of treatment. An overall response rate (ORR) was then calculated for both EGFR-mutated and -non mutated tumors.

Results: Among the 18 established models, we have diagnosed 9 ADK, 6 epidermoid carcinomas, and 3 undifferientiated large cell cancers, with a high degree of similarity with the originated patient's tumors in regard to histological characteristics (Morphology and IHC), and a complete concordance for gene mutation status. Among the 18 NSCLC xenografts, 3 were EGFR mutated (exon 18 G719A, exon 19 del18b, and exon 21 L858R) and 3 others were KRAS mutated (G12C). No BRAF mutation nor ALK translocation were found. Erlotinib induced a TGI of 30%, 62%, and 93% for the 3 EGFR-mutated xenografts, and 0% (preliminary result), 37%, and 52% (KRAS-mutated model) for the 3 wild type EGFR tumors. Moreover, the individual mouse ORR ORR ≥ 90% was 26% in the first group and 4% in the second one, respectively (p &lt; 0,05).

Conclusions: We have developed and characterized a new panel of primary human NSCLC xenografts that is highly representative of the heterogeneity of the disease and responses to the anti-EGFR targeted therapy, and provides precious tools to assess innovative therapeutic approaches.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr A15.

Survival of breast cancer patients with meningeal carcinomatosis

BACKGROUND

Breast cancer is the leading nonhematologic cause of meningeal carcinomatosis (MC). The aim of this study was to report the outcome of patients diagnosed with breast cancer MC and treated in single institution by a high-dose intrathecal methotrexate (MTX) regimen.

METHODS

Ninety-one patients were diagnosed with breast cancer MC from 2000 to 2007. Intrathecal treatment was MTX 15 mg/day (days 1-5), hydrocortisone acetate (day 1) and oral folinic acid (days 1-5), repeated every 2 weeks. Patients and tumor characteristics were associated with the early clinical and biological outcome and with the overall survival (OS).

RESULTS

The median survival was 4.5 months (range 0-53). In multivariate analysis, adverse prognostic factors at diagnosis were performance status >2 [P = 0.006, response rate (RR) = 0.33 (0.15-0.71)], more than three chemotherapy regimens before MC diagnosis [P = 0.03, RR = 0.40 (0.19-0.93)], negative hormone receptor status [P = 0.02, RR = 0.4 (0.19-0.90)] and high Cyfra 21-1 level [P = 0.048, RR = (0.09-0.99)]. Clinical progression after one cycle and biological response after two cycles were independently associated with OS [P < 0.001, RR = 0.09 (0.02-0.37) and P = 0.003, RR = 3.6 (1.5-8.5), respectively]. We propose a prognostic score in order to define three distinct groups of prognosis.

CONCLUSIONS

MC presents a poor prognosis, but 1-year survival rate was 25%. This score may become a useful tool for treatment decision and clinical trials.

Outcome of HER2-Positive (HER2+) Metastatic Breast Cancer Patients (MBC) Treated with Trastuzumab (T): An Institutional Based Review

Background: HER2+ status is associated with poor prognosis, high incidence of visceral and brain metastasis. However the addition of trastuzumab to chemotherapy (CT) significantly improves survival in early and advanced breast cancer. The purpose of this retrospective study was to explore the pattern of outcome in a cohort of MBC patients treated with T-based chemotherapy in a single institution. T was approved in Europe in 2000 and in 2001 all pts had access to T according HER2+ status. Methods: Women with de novo or recurrent breast cancer treated with trastuzumab at Institut Curie between 2001 and 2006 with HER2+ status (IHC 3+ or FISH +) were identified from the Institut Curie database. Disease was classified in two groups: patients who received T upfront and those who received T after one or several CT regimens. Overall survival (OS) was defined as the time from the date of the first metastasis to the date of death or last follow-up and was estimated using the Kaplan-Meier product method. Results: The final analysis included 244 patients. Median age was 53.4 yrs (29-80). Median time from primary and first metastasis was 22 mths (0-238). Visceral metastasis were present in 153 pts (63%) and 125 pts (51%) presented multiple sites. One hundred pts (42%) developed brain metastasis during the course of disease. One hundred and sixty five pts (68%) received T as first line, 79 pts (32%) after a median of one line of CT (median 1, range 1-5). One hundred and twenty four pts (52%) received more than 3 regimens. The median overall survival was 53 mths (4-113), similar in both groups. However there is a major bias: pts with very aggressive disease not treated upfront with T not have not been offered delayed T and don't appear in the analyzed population. Patients who developed brain metastasis had a median survival of 41 mths (11-90). Complete characteristics of pts will be presented. Conclusions: The introduction of T has altered the natural history of HER2+disease. Even outside a clinical trial, our results show that the addition of T to CT improves the prognosis of MBC patients with HER2+ disease. Prolongation of T after progression with other CT appears beneficial, even in pts with a high disease burden. The high incidence of brain metastases remains an issue in such a population.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5107.

Automatic acquisition of synonym resources and assessment of their impact on the enhanced search in EHRs

OBJECTIVE

Currently, the use of natural language processing (NLP) approaches in order to improve search and exploration of electronic health records (EHRs) within healthcare information systems is not a common practice. One reason for this is the lack of suitable lexical resources. Indeed, in order to support such tasks, various types of such resources need to be collected or acquired (i.e., morphological, orthographic, synonymous).

METHODS

We propose a novel method for the acquisition of synonymy resources. This method is language-independent and relies on existence of structured terminologies. It enables to decipher hidden synonymy relations between simple words and terms on the basis of their syntactic analysis and exploitation of their compositionality.

RESULTS

Applied to series of synonym terms from the French subset of the UMLS , the method shows 99% precision. The overlap between thus inferred terms and the existing sparse resources of synonyms is very low. In order to better integrate these resources in an EHR search system, we analyzed a sample of clinical queries submitted by healthcare professionals.

CONCLUSIONS

Observation of clinical queries shows that they make a very little use of the query expansion function, and, whenever they do, synonymy relations are rarely involved.

Vacuum-assisted large-core needle biopsy (VLNB) improves the management of patients with breast microcalcifications – Analysis of 1009 cases

AIMS

To evaluate the surgical management of patients who underwent VLNB for breast microcalcifications.

METHODS

This retrospective study compared the histological results and the surgical procedures in two groups of patients, group 1: large-core needle biopsy n=1009, and group 2: surgical biopsy n=270.

RESULTS

After VLNB, 54% patients were not operated on after stereotactic large-core needle biopsy, 42% underwent one operation, 4% underwent two operations and 0.2% underwent three operations. No surgery was performed for 95% of benign lesions. Multiples operations were necessary in 12% of patients with malignant lesions of VLNB group compared to 45% in the surgical biopsy group. The rate of underdiagnosis of borderline lesions and ductal carcinomas in situ was 16% by the large-core biopsy technique.

CONCLUSION

VLNB constitutes an alternative to surgical biopsy. This procedure avoids surgery for most benign lesions and reduces the number of surgical procedures in malignant lesions.

[Using a pleural implantable access system for the management of malignant pleural effusions. Experience of Institut Curie]

PURPOSE

Malignant pleural effusion has a very poor prognosis, raises problems of medical management and impairs quality of life. The authors report the first experience of a pleural implantable access system for the treatment of recurrent symptomatic malignant pleural effusion.

DESCRIPTION

Prospective follow-up of 26 patients between 20/8/2005 and 2/11/2006 in a single center. Thirty pleural implantable access systems were placed in 26 patients (22 patients with breast cancers, 3 bilateral placements and one case of replacement) under sedation following the decision of a multidisciplinary meeting.

EVALUATION

Twenty-five patients obtained partial or complete relief of their dyspnea. Four patients underwent spontaneous pleurodesis after a maximum of 2 months. Twelve patients were receiving chemotherapy at the time of placement. The number of aspirations performed varied between 1 and 28 over a period of 11 to 330 days. Eight patients died within 1 month after placement of the system and 6 survived more than 6 months. Seven patients died at Institut Curie or in a palliative care unit without returning home. The other 16 patients presented a total of 198 days of hospitalization for 2,305 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pleuro-pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient developed loculation of the pleural cavity after 16 thoracenteses making further thoracentesis ineffective.

CONCLUSIONS

The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It shows a number of advantages in terms of comfort and infectious risk compared to tunneled pleural catheters.

Automatic acquisition of synonyms from French UMLS for enhanced search of EHRs

Currently, the use of Natural Language Processing (NLP) approaches in order to improve search and exploration of electronic health records (EHRs) within healthcare information systems is not a common practice. One reason for this is the lack of suitable lexical resources: various types of such resources need to be collected or acquired. In this work, we propose a novel method for the acquisition of synonymous resources. This method is language-independent and relies on existence of structured terminologies. It enables to decipher hidden synonymous relations between simple words and terms on the basis of their syntactic analysis and exploitation of their compositionality. Applied to series of synonym terms from the French subset of the UMLS, the method shows 99% precision. The overlap between thus inferred terms and the existing sparse resources of synonyms is very low.

Use of a Pleural Implantable Access System for the Management of Malignant Pleural Effusion: The Institut Curie Experience

PURPOSE

Malignant pleural effusion has a very poor prognosis, raises problems of medical management, and impairs quality of life. The authors report the first experience of a pleural implantable access system for the treatment of recurrent symptomatic malignant pleural effusion.

DESCRIPTION

Prospective follow-up of 29 patients between August 20, 2005 and August 1, 2007 in a single center. Thirty-four pleural implantable access systems were placed in 29 patients (23 patients with breast cancers, 4 patients with bilateral placements, and 1 patient with a replacement) under sedation after the decision of a multidisciplinary meeting.

EVALUATION

Twenty-eight patients obtained partial or complete relief of their dyspnea. Six patients underwent pleurodesis after a maximum of 2 months. Fifteen patients were receiving chemotherapy at the time of placement. Seven patients died at the Institut Curie or in a palliative care unit without returning home. The other 22 patients presented a total of 280 days of hospitalization for 2,717 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient had loculation of the pleural cavity develop after 16 thoracenteses making further thoracentesis ineffective.

CONCLUSIONS

The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It presents a number of advantages in terms of comfort and infectious risk compared with tunnelled pleural catheters.

[Reflexion on innovation diffusion factors: the case of Herceptin]

New innovating cancer therapies are becoming available on the market. Because medical innovations put a serious financial burden on healthcare system, it is important to understand their diffusion. To analyze this process of diffusion, the molecule trastuzumab (Herceptin) provided by Roche Laboratories was chosen. Because Herceptin is commercialized since 1999 few data are available for this analysis. The objective of this study is to identify factors and brakes associated with the diffusion of the innovation Herceptin. By identifying these factors and brakes, one can notice that Herceptin is the perfect case to illustrate a successful diffusion. All factors mentioned in E. M. Rogers theory are verified with Herceptin: benefit, simplicity, triability, observability and compatibility. The tolerance is excellent and side effects minimized except for cardiac toxicity for patients previously treated with anthracyclines. The weakness concerning financing has been overcome since France changed the payment system to a prospective payment based on the hospital activity. The only problem left is that the fluorescence in situ hybridisation (FISH) test is still not reimbursed by the social security.

Brachytherapy versus prostatectomy in localized prostate cancer: Results of a French multicenter prospective medico-economic study

PURPOSE

To prospectively compare health-related quality of life (HRQOL), patient-reported treatment-related symptoms, and costs of iodine-125 permanent implant interstitial brachytherapy (IB) with those of radical prostatectomy (RP) during the first 2 years after these treatments for localized prostate cancer.

METHODS AND MATERIALS

A total of 435 men with localized low-risk prostate cancer, from 11 French hospitals, treated with IB (308) or RP (127), were offered to complete the European Organization for Research and Treatment of Cancer core Quality of Life Questionnaire QLQ-C30 version 3 (EORTC QLQ-C30) and the prostate cancer specific EORTC QLQ-PR25 module before and at the end of treatment, 2, 6, 12, 18, and 24 months after treatment. Repeated measures analysis of variance and analysis of covariance were conducted on HRQOL changes. Comparative cost analysis covered initial treatment, hospital follow-up, outpatient and production loss costs.

RESULTS

Just after treatment, the decrease of global HRQOL was less pronounced in the IB than in the RP group, with a 13.5 points difference (p < 0.0001). A difference slightly in favor of RP was observed 6 months after treatment (-7.5 points, p = 0.0164) and was maintained at 24 months (-8.2 points, p = 0.0379). Impotence and urinary incontinence were more pronounced after RP, whereas urinary frequency, urgency, and urination pain were more frequent after IB. Mean societal costs did not differ between IB (8,019 euros at T24) and RP (8,715 euros at T24, p = 0.0843) regardless of the period.

CONCLUSIONS

This study suggests a similar cost profile in France for IB and RP but with different HRQOL and side effect profiles. Those findings may be used to tailor localized prostate cancer treatments to suit individual patients' needs.

Gefitinib and chemotherapy combination studies in five novel human non small cell lung cancer xenografts. Evidence linking EGFR signaling to gefitinib antitumor response

The epidermal growth factor receptor (EGFR) signaling pathway is often activated in NSCLC, and thus represents a promising therapeutic target. We studied the antitumor activity of gefitinib (Iressa), an orally active EGFR-tyrosine kinase inhibitor, alone and in combination with standard chemotherapy in 5 recently established human NSCLC xenografts with wild-type EGFR. Mice were treated with 2 protocols of chemotherapy based on cisplatin (CDDP) combined with either gemcitabine (GEM) or vinorelbine (VNR). Gefitinib alone significantly inhibited tumor growth (TGI) in 4 of the 5 tumor xenografts (mean TGI of 58%, range: 25-70%). CDDP+VNR alone failed to achieve any significant responses, while CDDP+GEM achieved significant responses in 2 xenografts (TGI of 93 and 47%). Addition of gefitinib to CDDP+GEM potentialized chemotherapy in the 3 CDDP+GEM-resistant xenografts, but did not potentialize the CDDP+VNR combination. The effect of gefitinib treatment on the activity of extra cellular-regulated kinase (Erk), Akt, JNK and p38 kinases was assessed in IC9LC11 and IC1LC131, two NSCLC xenografts selected for their sensitivity and resistance to gefitinib, respectively. In IC9LC11, gefitinib strongly inhibited Erk, Akt and Jnk phosphorylation, but P38 remained active. Inversely, in IC1LC131, Erk and Akt pathways remained active, while Jnk and P38 pathways were inhibited by gefitinib. The data indicate that the antitumor activity of gefitinib in NSCLC, alone or in combination with chemotherapy, is tumor-dependent and is influenced by downstream signaling events independent of EGFR status.

The financial impact of trastuzumab in metastatic breast cancer: The experience of the Institut Curie

663

Purpose: To estimate, in term of public health on the scale of a region, the cost of trastuzumab and to point out the financial impact of this new targeted therapy in the adjuvant setting. Methods: To understand the consequences of the spending on of trastuzumab at a macroeconomic level in the French hospital financing system, we decided to focus on an establishment in particular, and to analyze the increasing spending of trastuzumab at a micro-economic level, to provide a cost analysis of patients treated with trastuzumab for HER2-overexpressing metastatic breast cancer. We retrospectively reviewed 137 medical reports of patients who received trastuzumab either in combination with chemotherapy or as a single agent and in maintenance therapy. Median age of the patients was 52 years (range 32- to 79+). Eighty five percent had 3+ HER2 overexpression and fifteen percent had 2+ HER2 (FISH amplified). Results: Median survival from first treatment with trastuzumab was 38.5 months (range 0,04–53,06+). The cost of the first year treatment is in average €43,435.58 per patient, for the second year €36,419.01 and for the third year €37,198.94. Drugs cost represents 78% of the hospital stays cost for a patient and 2.9% of the budget of Institut Curie. Conclusions: This retrospective analysis showed the very high level of expenses of trastuzumab to treat metastatic breast cancers. With the adjuvant use of trastuzumab, it is expected that these expenses are going to increase exponentially.

No significant financial relationships to disclose.

[New radiotherapy techniques for non-small-cell lung cancer]

Lung cancer is one of the most difficult challenges for radiotherapy. Problems include ballistic targeting compromised by respiratory movements, poor tolerance of neighboring healthy tissues and difficult dosimetry due to the heterogeneous nature of the thoracic tIssues. New perspectives are offered by recent developments allowing a more comprehensive approach to thoracic radiotherapy integrating new advances in imaging techniques, contention, dosimetry, and treatment devices. Two techniques are particularly promising: conformal radiotherapy and respiration-gated radiotherapy. Conformal radiotherapy, a three-dimensional conformal mode of irradiation with or without intensity modulation, is designed to achieve high-precision dose delivery by integrating advanced imaging techniques into the irradiation protocol. These tools are used to optimize irradiation of target Volumes and avoid recurrence while sparing as much as possible healthy tissues. If healthy tissue can be correctly protected, increased doses can be delivered to the target tumor. Respiration-gated techniques offer promising prospects for the treatment of tumors which are displaced by respiratory movements. These techniques allow better adaptation of the irradiation fields to the target tumor and better protection of healthy tissues (lung, heart...). These new approaches are now routine practices in many centers. Early results have been very promising. We describe here the currently available techniques for thoracic radiotherapy.