Stereotactic body radiation therapy for liver metastases in oligometastatic disease

Oligometastatic cancers designate cancers in which the number of metastases is less than five, corresponding to a particular biological entity whose prognosis is situated between a localized and metastatic disease. The liver is one of the main sites of metastases. When patients are not suitable for surgery, stereotactic body radiotherapy provides high local control rate, although these data come mainly from retrospective studies, with no phase III study results. The need for a high therapeutic dose (biologically effective dose greater than 100Gy) while respecting the constraints on the organs at risk, and the management of respiratory movements require expertise and sufficient technical prerequisites. The emergence of new techniques such as MRI-guided radiotherapy could further increase the effectiveness of stereotactic radiotherapy of liver metastases, and thus improve the prognosis of these oligometastatic cancers.

Prevention of radiation enteritis by interposition of an intra-abdominal spacer before irradiation of an appendiceal tumour abscess drainage route

The initial presentation of a mucinous adenocarcinoma of the appendix can be a peri-appendicular abscess. The abdominal wall muscles can be invaded during radiological or surgical drainage. The management of such a tumour is complex. The resection of a drainage route can be uncertain and R1. In this case, further treatment with adjuvant radiotherapy may be necessary. One possible deleterious side effect of radiotherapy on the abdominal wall is radiation injury to the bowel. As a preventive measure, a spacer (here a breast prosthesis) can be interposed.

Rectal cancer radiotherapy

We present the updated recommendations of the French society of oncological radiotherapy for rectal cancer radiotherapy. The standard treatment for locally advanced rectal cancer consists in chemoradiotherapy followed by radical surgery with total mesorectal resection and adjuvant chemotherapy according to nodal status. Although this strategy efficiently reduced local recurrences rates below 5% in expert centres, functional sequelae could not be avoided resulting in 20 to 30% morbidity rates. The early introduction of neoadjuvant chemotherapy has proven beneficial in recent trials, in terms of recurrence free and metastasis free survivals. Complete pathological responses were obtained in 15% of tumours treated by chemoradiation, even reaching up to 30% of tumours when neoadjuvant chemotherapy is associated to chemoradiotherapy. These good results question the relevance of systematic radical surgery in good responders. Personalized therapeutic strategies are now possible by improved imaging modalities with circumferential margin assessed by magnetic resonance imaging, by intensity modulated radiotherapy and by refining surgical techniques, and contribute to morbidity reduction. Keeping the same objectives, ongoing trials are now evaluating therapeutic de-escalation strategies, in particular rectal preservation for good responders after neoadjuvant treatment, or radiotherapy omission in selected cases (Greccar 12, Opera, Norad).

Implementation of image-guided brachytherapy as part of non-surgical treatment in inoperable endometrial cancer patients

OBJECTIVE

This study assessed outcomes of inoperable endometrial cancer (IEC) patients treated with definitive external beam radiation therapy (EBRT) followed by a 3D image-guided brachytherapy boost.

METHODS

All consecutive patients treated with EBRT followed by 3D image-guided brachytherapy for IEC were retrospectively included. EBRT delivered a dose of 45Gy. Then, patients had an uterovaginal brachytherapy guided by 3D imaging. Clinical target volume (CTV_BT) included the whole uterus and the initial disease extent. Gross tumour volume (GTV_res) included the residual disease at time of brachytherapy.

RESULTS

Twenty-seven patients were identified. Causes of inoperability were comorbidities (37%) or tumour loco regional extent (63%). Including EBRT and brachytherapy, the median D₉₀ (minimal dose delivered to 90% of the volume) was 60.7 Gy_EQD2 (IQR = 56.4-64.2) for the CTV_BT, and was 73.6 Gy_EQD2 (IQR = 64.1-83.7) for the GTV_res. The median overall treatment time was 50 days (IQR = 46-54). The mean follow-up was 36.5 months (SD = 30.2). The cumulative incidence of local, pelvic and distant failures was 19% (n = 5), 7% (n = 2) and 26% (n = 7), respectively. Five-year overall survival was 63% (95% CI = 43-91). Late urinary and gastro intestinal toxicities ≥ grade 2 were reported in four (15%) and two patients (7%) respectively. No vaginal toxicity ≥ grade 2 was reported.

CONCLUSIONS

EBRT followed by intracavitary brachytherapy seems to be an effective option for IEC. The implementation of 3D concepts at time of brachytherapy may contribute to high local control probability and low toxicity profile. Large scale retrospective or prospective data are needed to confirm these early data.

[Follow-up after radiotherapy of anal canal carcinoma]

Anal canal carcinoma is a rare and curable disease for which the standard of care is radiation therapy with concurrent 5-fluoro-uracil and mitomycine-based chemotherapy. Post-treatment follow-up however is rather poorly defined. This article offers a review of the various post-treatment surveillance options both for early diagnosis of relapse and care for late treatment effects. While follow-up remains mostly clinical, we will discuss morphologic (endorectal echoendoscopy, pelvic magnetic resonance imaging, tomodensitometry and positron emission tomography) and biologic (squamous cell carcinoma antigen and pathology) follow-up so as to determine their diagnostic and prognostic value.