[en] Endometrial adenocarcinomas rank third as tumoral sites en France. The tumors are confined to the uterus in 80% of the cases. Brachytherapy has a large place in the therapeutic strategy. The gold standard treatment remains extra-fascial hysterectomy with bilateral annexiectomy and bilateral internal iliac lymph node dissection. However, after surgery alone, the rate of locoregional relapses reaches 4-20%, which is reduced to 0-5% after postoperative brachytherapy of the vaginal cuff. This postoperative brachytherapy is delivered as outpatients treatment, by 3 or 4 fractions, at high dose rate. The utero-vaginal preoperative brachytherapy remains well adapted to the tumors which involve the uterine cervix. Patients presenting a localized tumor but not operable for general reasons (< 10%) can be treated with success by exclusive irradiation, which associates a pelvic irradiation followed by an utero-vaginal brachytherapy. A high local control of about 80-90% is obtained, a little lower than surgery, with a higher risk of late complications. Last but not least, local relapses in the vaginal cuff, or in the perimeatic area, can be treated by interstitial salvage brachytherapy, associated if possible with external beam irradiation. The local control is reached in half of the patients, but metastatic dissemination is frequent. We conclude that brachytherapy has a major role in the treatment of endometrial adenocarcinomas, in combination with surgery, or with external beam irradiation for not operable patients or in case of local relapses. It should use new technologies now available including computerized after-loaders and 3D dose calculation. (authors)

[en] The authors report the dosimetric comparison of two techniques used for the treatment of cervical cancers: the intensity-modulated conformational radiotherapy (IMRT) with static beams and modulated arc-therapy with RapidArc. The treatment plans of 15 patients have been compared. The clinical target volume (CTV) comprises the gross target volume, the cervix, the upper third of the vagina, and ganglionary areas. The previsional target volume comprises the clinical target volume and a one centimetre margin. Organs at risk are rectum, bladder, intestine and bone marrow. Arc-therapy seems to provide a better sparing of intestine that IMRT, while maintaining a good coverage of the previsional target volume and decreasing treatment duration. Short communication

No abstract available

[en] Purpose To evaluate two dosimetric supports used in pulse dose rate brachytherapy (P.D.R.): coverage of target volumes, dose to organs at risk, residual tumor after surgery, survival. Patients and methods Twenty patients treated for uterine cervix tumor first by brachytherapy P.D.R. had a dosimetric CT-scan after implantation. For 9 patients, the treatment was planned from standard radiographies and then reported on CT-scan images. For 11 patients, it was directly planned from CT-scan. Six weeks after, 18 patients underwent surgery. Results With a median follow-up of 22 months, 2 year actuarial survival was 89%. Six patients developed grade II urinary or gynecological complications (LENT SOMA scale). No residual tumor was found for 12 patients (7 with a 3D treatment and 5 a 2 D treatment). Ninety-five percent of C.T.V.H.R. received 53 Gy (2D treatment) or 63 Gy (3D treatment). Two cm³ of bladder wall received 63 Gy (2D) or 74 Gy (3D) although 2 cm³ of rectal wall received 37 Gy (2D) and 35 Gy (3D). Conclusion Using CT-scan made us improve the coverage of the uterine cervix but increase the dose received by the bladder, without increasing the rate of histological remission after surgery. We should be prudent before changing our practice. (authors)

[en] Purpose. - To retrospectively assess the efficacy of post-mastectomy re-irradiation for local relapse of breast cancer. Patients and methods. - Twenty patients, initially treated by conservative surgery and radiotherapy (50 Gy in 25 fractions over 5 weeks) were treated from 1998 to 2001 for a local relapse by salvage mastectomy and re-irradiation (either electron or photon beams). Mean age was 53 years (31-71). Reasons for re-irradiation were that the local relapses were inflammatory (4 pts), multifocal (5 pts), cutaneous (5 pts), involved the nipple (3 pts) or because the surgical margins (either muscle or skin) were involved (3 pts). The median dose of re-irradiation was 45 Gy (33-65) in 15 fractions over 33 days. Mean follow-up was 48 months (5-97). Results. - Fifteen patients remained free of a second local recurrence and 10 were still alive, without metastasis. Neither the dose of re-irradiation nor the irradiated surfaces were prognostic factors of local control (P = 0.877 and P = 0.424). Five patients developed radiation-induced pneumonitis without functional respiratory impairment. The incidence of pneumonitis seemed to be related to the biological dose of re-irradiation (P = 0.037). Other late complications occurred such as pigmentation changes (12 pts), telangiectasia (8 pts), chondritis (2 pts), parietal fibrosis (7 pts), rib fractures (4 pts), severe pain (11 pts) and lymphedema (2 pts). The increase in biological equivalent dose was highly statistically linked with the occurrence of disabling pain (P = 0.0123). Conclusion. - Parietal re-irradiation achieves good and lasting local control with an acceptable rate of acute complications but with a risk of disabling late sequelae such as severe pain. (author)

[en] The use of three-dimensional breast radiotherapy after a conservative treatment allowed cardiotoxicity as well as the dose delivered to lungs to be significantly reduced. However several bibliographic references give different dose constraints. Based on the constraints given by the Oncological radiotherapy French Society (SFRO), the authors analysed whether these recommendations could be actually respected within a daily practice. Based on a sample of 91 patients, the authors collected the following data: mammary gland volumes receiving respectively 95 and 107% of the dose before the boost calculation, heart and pulmonary volumes receiving different dose levels. Coverage constraints are indicated. It appears that the present technique does not allow the constraints to be respected in a majority of cases. Short communication

[en] Acute mucositis is common after radiotherapy for head and neck cancers. During the past 3 decades, there was a gradual evolution in the treatment modalities for locally advanced carcinomas (concomitant radio-chemotherapy, accelerated radiotherapy). These new strategies are accompanied by an increase in early mucosal reactions. At the present time, there is no widely accepted prophylaxis or effective treatment. Many traditional remedies or new agents seem ineffective (Sucralfate, Chlorhexidine, GM-CSF, Silver nitrate, Prostaglandin, anti-oxidants, Benzydamine hydrochloride), while others seem promising (Povidone-iodine, nonabsorbable antibiotic lozenges and anti-fungal, local GM-CSF, Glutamide, Low-energy laser, corticosteroids). Radioprotectors are controversial and should be only used in experimental protocols and not in routine practice. However, some recommendations can be proposed: general prevention and global care before cancer therapy should be systematic (oral hygiene, dental and periodontal treatment, advice to avoid the use of tobacco and alcohol); frequent oral rinsing with a bland mouthwash (Povidone-iodine or others) should be used at the start of treatment because there are significant modifications of the oral microflora increased by a disturbed salivary flow; these mouthwashes could be associated with nonabsorbable antibiotic lozenges or anti-fungal topical (bicarbonates, Amphotericine B); Systematic percutaneous fluoroscopic gastrostomy should be decided before any aggressive treatments (concomitant radio-chemotherapy, accelerated radiotherapy); pain should be controlled; finally, the radiation technique should be optimized (mucosal sparing block, conformal radiotherapy and intensity modulated radiation therapy). (authors)

[en] Fractionated radiotherapy and chemotherapy in the cancer of the uterine cervix carcinomas, brachytherapy with pulse rate, three dimensional calculations to determine volume to irradiate and then to optimize the dosimetry are the different points tackled in this part devoted to the cervix uterine cancer. (N.C.)

[en] Two articles are devoted to chemoradiotherapy in the uterine cervix carcinomas. The first one makes the evaluation of efficiency and tolerance of preoperative chemoradiotherapy. The second one underlines a relationship between the volume of brachytherapy and the rate of delayed complications. Recent works have shown an increase of the local control when the dose of brachytherapy increases, the brachy-therapies should be realised in the future with an optimization of the dose distribution. (N.C.)

[en] Purpose: Our study aims at evaluating the cost of pulsed dose-rate (P.D.R.) brachytherapy with optimized dose distribution versus traditional treatments (iridium wires, cesium, non-optimized P.D.R.). Issues surrounding reimbursement were also explored. Materials and methods: This prospective, multi-centre, non-randomized study conducted in the framework of a project entitled 'Support Program for Costly Diagnostic and Therapeutic Innovations' involved 21 hospitals. Patients with cervix carcinoma received either classical brachytherapy or the innovation. The direct medical costs of staff and equipment, as well as the costs of radioactive sources, consumables and building renovation were evaluated from a hospital point of view using a micro costing approach. Subsequent costs per brachytherapy were compared between the four strategies. Results: The economic study included 463 patients over two years. The main resources categories associated with P.D.R. brachytherapy (whether optimized or not) were radioactive sources (1053 Euros) and source projectors (735 Euros). Optimized P.D.R. induced higher cost of imagery and dosimetry (respectively 130 Euros and 367 Euros) than non-optimized P.D.R. (47 Euros and 75 Euros). Extra costs of innovation over the less costly strategy (iridium wires) reached more than 2100 Euros per treatment, but could be reduced by half in the hypothesis of 40 patients treated per year (instead of 24 in the study). Conclusion: Aside from staff, imaging and dosimetry, the current hospital reimbursements largely underestimated the cost of innovation related to equipment and sources. (authors)