Recommendations for Post-Operative Radiotherapy after complete resection of Thymoma - a French DELPHI consensus initiative

BACKGROUND

Thymomas are rare intrathoracic malignancies that can relapse after surgery. Whether or not Post-Operative Radiotherapy (PORT) should be delivered after surgery remains a major issue. RADIORYTHMIC is an ongoing, multicenter, randomized phase 3 trial addressing this question in patients with completely R0 resected Masaoka-Koga stage IIb/III thymoma. Experts in the field met to develop recommendations for PORT.

METHODS

A scientific committee from the RYTHMIC network identified key issues regarding the modalities of PORT in completely resected thymoma. A DELPHI-method was used to question 24 national experts, with 115 questions regarding: 1/ Imaging techniques, 2/ Clinical Target Volume (CTV) and margins, 3/ Dose constraints to Organs At Risk, 4/ Dose and fractionation, 5/ Follow-up and records. Consensus was defined when opinions reached ≥ 80% agreement.

RESULTS

We established the following recommendations: pre-operative contrast-enhanced CT-scan is recommended (94% agreement); optimization of radiation delivery includes either a 4D-CT based planning (82% agreement), a breath-holding inspiration breath-hold-based planning, or daily control CT-imaging (81% agreement); imaging fusion based on cardiovascular structures of pre-operative and planning CT-scan is recommended (82% agreement); right coronary and left anterior descending coronary arteries should be delineated as cardiac substructures (88% agreement); rotational RCMI/VMAT is recommended (88% agreement); total dose is 50Gy (81% agreement) with 1.8-2Gy per fraction (94% agreement); cardiac evaluation, and follow-up for patients with history of cardiovascular disease is recommended (88% agreement) with EKG and evaluation of LVEF at 5 years and 10 years.

CONCLUSION

This is the first consensus for PORT in thymoma. Implementation will help to harmonize practices.

[Interest of focal radiotherapy in case of oligoprogression under immunotherapy in the treatment of metastatic non-small cell lung cancer]

INTRODUCTION

The prognosis of metastatic non-small cell lung cancer (NSCLC) has been improved by the use of immune checkpoint inhibitors (ICI). Unfortunately, in some cases, cancer cells will develop resistance mechanisms. In case of progression in a limited number of lesions (oligoprogression), focal treatment with radiotherapy is proposed while continuing the ICI therapy.

METHODS

A cohort of 37 patients with metastatic NSCLC treated with nivolumab (anti-PD-1) in second or subsequent line and who received focal radiotherapy for oligoprogression with continuation of nivolumab was compared with a control cohort of 87 patients no oligoprogressor treated par immunotherapy.

RESULTS

After a median follow-up of 37 months [18; 62], the median progression free survival (PFS) in the radiotherapy-treated cohort was 15.04 versus 5.04 months in the control cohort, with a statistically significant difference (P=0.048). The median PFS following focal radiotherapy in the oligoprogressor group was 7.5 months. In univariate analysis, the presence of lung metastasis was associated with increased PFS, in contrast to the presence of brain metastases, which were associated with decreased PFS in the radiotherapy group. The median overall survival was not reached in both groups, with no significant difference between the two cohorts.

CONCLUSION

The combination of focal radiotherapy in case of oligoprogression and continued treatment with nivolumab in the treatment of metastatic NSCLC in the second or subsequent line of treatment seems to be with an increase in PFS.

Combined treatment modalities in Pancoast tumor: results of a monocentric retrospective study

BACKGROUND

A retrospective monocentric study of consecutive patients with superior sulcus tumor non-small cell lung cancer (SS-NSCLC), treated by induction concurrent chemoradiotherapy (CRT), article management.

METHODS

From 1994 to 2005, 36 patients (15 T3, 21 T4 tumors, including N2-N3 node involvement) received induction CRT with cisplatin/vinorelbine/fluorouracil combined with 44 Gy radiotherapy (5 daily 2 Gy fractions/week). After CRT completion, RECIST evaluation and operability were assessed. In resectable patients, surgery was performed one month after CRT. Patients with unresectable disease followed CRT up to 66 Gy. The median of follow-up period was 38.6 months [2-206].

RESULTS

Induction CRT was completed for 94.4% with 71% radiological objective response (OR). Sixteen patients (44%) underwent surgical resection, and pathologic complete resection was performed in 93.8%. There were 7 patients (44%) with pathologic complete response. The median disease-free survival (DFS) time was 12.9 months with DFS rates at 1 and 2 years 53.6% and 39.1% respectively. The median overall survival (OS) was 46.4 months. The OS rates at 2 and 5 years were 68.8% and 37.5% respectively with no difference between T3 and T4 tumors. In unresectable disease, the median DFS time was 8.1 months. The DFS rate at 1 year was 25.2%. The median OS was 9.1 months. The OS rates at 1 and 2 years were 45% and 16.9% respectively. Recurrences were found in 72% of patients. Brain metastasis was the most common site of recurrence. Prognostic factors for OS were the response to induction treatment, the possibility of surgery, and pathologic complete response.

CONCLUSIONS

This trimodality treatment regimen confers a survival outcome in agreement with previous studies. Patients with pretreatment N3 lymph node should be included in trimodality treatment.

Adherence with oral oncologic treatment in cancer patients: interest of an adherence score of all dosing errors

PURPOSE

Patient nonadherence to oral antineoplastic therapy is a well-recognized barrier to effective treatment. In order to identify patients who may need additional support to become adherent, it is important to have a useful tool that takes into account all the parameters of adherence to prescription. The aim of this prospective study was to evaluate adherence of oral antineoplastic agents and to investigate two calculation methods of adherence score.

PATIENTS AND METHODS

Twenty-nine cancer patients were enrolled in this study. Fourteen were treated by capecitabine and 15 patients by aromatase inhibitors. Adherence was measured using a medication event monitoring system and adherence score was calculated by a usual method and a composite adherence score that takes into account missed doses and also intake interval errors (between 2 doses and between meals).

RESULTS

Across the 6-month evaluation period, average adherence was 95% with the standard calculation (capecitabine group: 89%; aromatase inhibitor group: 99%) versus 83% with the composite index (capecitabine group: 62%; aromatase inhibitor group: 99%) (p = 0.030). The composite calculation permits to highlight more nonadherent patients (29.6 vs. 7.4%), particularly in the capecitabine group (73 vs. 18%, p = 0.001). We report 2 cases identified as nonadherent with composite adherence rate.

CONCLUSION

The composite adherence score permits to better evaluate adherence to prescription and to identify barriers to adherence and persistence.

[Brachytherapy in carcinomas of anal canal and rectum: techniques and results]

Conservative treatment of small anal canal and low rectal cancers is a valid alternative to radical surgery through combinated strategies including external beam and/or intracavitary irradiation, concomitant chemotherapy and 192 iridium implantation as a booster dose. Feasibility, tolerance and results are effective. Local control of the disease and the quality of the anal functions are good. The treatment requires great care in patient selection and follow-up.