The "Gating 2006" trial was conducted to evaluate the real impact of respiratory-gated conformal radiation therapy on acute radiation pneumonitis (ARP) incidence. A prospective analysis of predictive factors of ARP is proposed. Between 07/2006 and 07/2011, 242 patients (pts) entered the trial. All pts had proven non-metastatic NSCLC, mainly stage III (87%), and treated with curative RT intent (66Gy, 2Gy/fr). ARP prospective evaluation included clinical, thoracic scans (all reviewed by an independent panel of experts) and management evaluations 6-8 and 10-12 weeks after RT. ARP was scored according to RTOG acute classification, identifying 4 groups (Gr) of patients. Two hundred nine pts were evaluable for ARP and classified as:-Gr 1: no ARP (clinic or CT): n=45 (21.5%)-Gr 2: asymptomatic ARP: n=54 (25.8%),-Gr 3: moderate ARP: n=96 (45.9%)-Gr 4: severe ARP: n=14 (6.7%). Considering predictive factors for moderate/severe ARP (Gr 1-2 vs 3-4), the age and the percentage of the lungs irradiated over 25, 30 and 40 Gy (V25, V30, V40) were associated with ARP (p<.05). Surprisingly, the concomitant chemo-radiation was associated with less toxicity as well as a low baseline diffusion capacity (p<.05). In multivariate analysis, the age and V40 were significantly associated with ARP (p=0.008 and p=0.005). Regarding only the severe ARP (Gr 4), the age, the surgery before RT, V5, V20, V25, V30, V40, the mean lung dose and the clinical target volume (CTV) were associated with Gr4 ARP in univariate analysis. In multivariate analysis, only the age and V5 were significantly associated with Gr 4 ARP (p=0.01 and P=0.003). Nor the other clinical parameters, the baseline lung function nor the other dosimetric parameters were predictive of ARP. With a median follow-up of 25.2 months, the 1y-DFS was 38% (CI95%[31 - 45]). The 2y-DFS as well as the analysis of predictive factor of survival will be presented at the congress with mature data. ARP is quite frequent in this large prospective study. The older age is significantly associated with both moderate and severe ARP. V5 is also significantly and independently associated with severe ARP.

La radiothérapie stéréotaxique (RST) prend une place de plus en plus importante dans le traitement des patients inopérables atteints de carcinomes pulmonaires de stade précoce (T1-T2 N0M0). L’évaluation de la réponse reste dans certains cas difficiles et il peut être difficile de différencier une réponse d’une progression. Le but de cet article est d’exposer ces différents changements et de conclure sur un protocole de surveillance optimal. En confrontant notre expérience clinique et les données de la littérature, les principaux aspects scannographiques sont exposés et illustrés pour chaque situation clinique : pneumopathie radique, fibrose radique, réponse thérapeutique et progression. Une revue de la littérature a été réalisée en interrogeant les principales bases de données et en sélectionnant les articles traitant de la RST pulmonaire et des aspects radiologiques post-thérapeutiques. Les aspects scannographiques induits par la RST diffèrent significativement des images retrouvées après radiothérapie conformationnelle classique sur les plans morphologiques et chronologiques. En particulier, les modifications induites par la RST sont limitées à un volume restreint, entourant le volume traité. La connaissance des critères radiologiques nécessaires pour différencier une réponse thérapeutique d’une récidive est un enjeu majeur dans le contexte actuel de développement de cette technique.

The purpose of this study is to evaluate the feasibility, efficacy, and toxicity of SBRT for treatment of unresectable hepatic or lung metastases regardless of their primary tumor site for patients with a history of aggressive systemic chemotherapy. Between July 2007 and June 2010, 90 patients were prospectively enrolled in this observational study and treated with the SBRT system for hepatic or pulmonary metastatic lesions. The endpoints of this study were local control, overall survival (OS), disease-free survival (DFS), relapse free-survival, and treatment toxicity. A total of 113 liver and 26 lung metastatic lesions in 52 men (58%) and 38 women (42%) were treated. Median follow-up was 17 months. Median age was 65 years (range, 23-84 years). Primary cancers were 63 GI, three lung, eight breast, four melanoma, three neuro-endocrine tumors, three sarcomas and six other cancers. Median diameter of the lesions was 28 mm (range, 7-110) for liver and 12.5 mm (range, 5-63.5) for lung. Local control rates at 1 and 2 years were 84.5% and 66.1%, respectively. Two-year OS rate was 70% (95% CI: 55-81%). The 1 and 2-year DFS rates were 27% (95% CI: 18-37%) and 10% (95% CI: 4-20%), respectively. Median duration of DFS was 6.7 months (95% CI: 5.1-9.5 months). Two grade 3 toxicities were observed: gastritis in a patient with a hepatic lesion and epidermitis in a patient treated for two different hepatic lesions. No grade 4 toxicity was reported. High-dose SBRT for metastatic lesions is both feasible and effective with high local control rates. Overall survival is comparable with other available techniques. Treatment is well tolerated with very low toxicity. SBRT could represent an interesting treatment option for oligometastatic patients not amenable to surgery, even for patients heavily pre-treated with chemotherapy.

Stereotactic radiation therapy (SRT) is becoming more and more important in the treatment of inoperable patients with early stages of pulmonary carcinomas (T1-T2 N0M0). In certain cases, evaluation of the response is still problematical and it can be difficult to differentiate response from progression. The aim of this paper is to set out these various changes and to produce a protocol for optimal monitoring. By comparing our clinical experience with data from the literature, the main visual aspects on a CT scan are set out and illustrated for each clinical situation: radiation pneumonitis, radiation fibrosis, therapeutic response and progression. The literature was reviewed by querying the main databases and selecting papers concerning pulmonary SRT and post-therapeutic radiological appearance. CT appearance induced by SRT differs significantly from images after classic conformal radiation therapy, both morphologically and chronologically. In particular, the modifications induced by stereotactic radiation therapy are only seen in a limited volume surrounding the volume treated. Knowledge of the radiological criteria necessary to differentiate between a therapeutic response and recurrence is of major importance in the present context of increase in use of this technique.

Malignant mesotheliomas are aggressive and rapidly fatal neoplasms arising from the mesothelial cells. The most common sites of origin are the pleural and peritoneal cavities; the pericardium and the tunica vaginalis are infrequently involved, and malignant mesothelioma in the spinal canal is extremely rare. Here we report a case of primary spinal malignant mesothelioma. We also report the results of a literature search conducted in PubMed with specific key terms, inclusion criteria, and exclusion criteria, with a comparison of elected case studies and case series, and statistical analysis as appropriate.A 35-year-old man presented with a 3-month history of swelling and pain in the left lower extremity. Neurologic examination revealed a loss of sensation below the L5 dermatome. Magnetic resonance imaging (MRI) showed a mass at the L4-5 level. A diagnosis of schwannoma was suspected, and surgical resection was performed. Histopathological findings were consistent with sarcomatoid malignant mesothelioma. Thoracic and whole-abdomen computed tomography yielded normal results. The patient refused adjuvant radiotherapy or chemotherapy. Positron emission tomography–computed tomography performed at 3 months postoperatively showed no abnormality. At 8 months postoperatively, the patient developed back pain and difficulty with defecation; MRI demonstrated tumor recurrence. During a second operation, invasion of the vertebra and cauda equina was noted. A subtotal resection was achieved, and the pain was partially alleviated. Two months later, the patient succumbed to a traffic accident.Spinal malignant mesothelioma is an extremely rare but highly aggressive entity. Preoperative identification is challenging, and definitive diagnosis depends on histopathological evidence. Surgical resection can help relieve the symptoms, but the overall prognosis is poor.

7050 Background: Stereotactic radiation therapy is a promising treatment for early stage lung cancer occurring in medically inoperable patients (pts). Robotic radiosurgery with the CyberKnife allows for real-time tumor tracking under free breathing conditions. It could reduce toxicity while maintaining the same efficacy. We report our initial experience with 51 pts treated with the fiducial-less Xsight Lung Tracking System.METHODSPatients were accrued after evaluation by thoracic surgeons and oncologists. Selection criteria were: single T1 or T2 pulmonary tumor, tumor size between 15 and 60 mm, N0 and M0. Initial staging included CT-Scan with contrast agent and FDG-PET. If an anatomopathological proof could not be obtained, treatment was proposed for evolutive lesions: increase in size on two consecutive CT-Scans and single FDG uptake of the tumor on PET. No chemotherapy was used until disease progression. Response was evaluated with the modified RECIST criteria every 3 months and toxicity with the CTCAE v4.0 grading scale.RESULTS43 men (84%) and 8 women (16%) were treated for 25 T1 (49%) and 21 T2 (41%) lung cancer. 5 pts (10%) were treated for a relapse after prior surgery (4%) or radiation therapy (6%). Median follow-up was 15 months (5-30). Median age was 69 (50-85). All pts were smokers. Median tumor size was 24 mm (15-70). Histology was known for 19 pts (37%): 4% adenocarcinoma, 19% squamous, 8% large cell and 6% not otherwise specified. Median delivered dose was 60 Gy (36-60 Gy) in 3 fractions. Median growth tumor volume (GTV) was 11 cm3 (1.6-115). Local control rate was 86%, including 16 complete responses, 16 partial responses and 12 stable diseases. 7 progressions were observed. 1 pt relapsed with mediastinal lymph nodes and 6 pts with distant metastases and subsequently received chemotherapy. Disease-specific survival rate was 98% at 15 months. 7 grade 1 (14%) and two grade 2 (4%) radiation pneumonitis were found on CT-Scan at 3 months and disappeared on later controls.CONCLUSIONSLocal control rate was similar to what is reported in other studies using fiducials for tumor tracking. Toxicity seems lower. This method could represent a completely non-invasive curative treatment for pts not amenable to surgery.

L’objectif de cet article est de rapporter l’expérience acquise au centre de lutte contre le cancer Nantes-Atlantique de la radiothérapie guidée par l’image à travers l’utilisation de trois dispositifs d’imagerie de repositionnement, l’ExacTrac® (BrainLAB™), l’OBI-CBCT (Varian™) et le MVCT (Tomotherapy Inc™), dans le cadre de la prise en charge de patients traités par irradiation externe pour un cancer de la prostate.Pour chacun des systèmes présentés, la technique d’irradiation a été décrite, ainsi que le protocole d’imagerie associé. Une étude sur les décalages effectués à chaque session d’imagerie a été menée. Avec le système ExacTrac®, une comparaison a été faite selon que les décalages réalisés quotidiennement étaient calculés sur les structures anatomiques ou sur les positions d’implants radio-opaques intraprostatiques pour huit patients. De plus, en considérant les décalages moyens sur toute la durée d’un traitement, l’impact dosimétrique des décalages a été estimé. Pour le système OBI-CBCT, deux modalités d’imagerie ont été utilisées, soit deux images orthogonales de basse énergie (kV–kV), soit une tomographie conique (CBCT). Jusqu’à présent, quelle que soit la modalité, le recalage a toujours été effectué sur les repères osseux. Les décalages appliqués ont été comparés pour 26 patients. Enfin, pour la tomographie conique de haute énergie (MVCT), une imagerie quotidienne a été systématiquement réalisée pour tous les patients. La valeur moyenne des décalages relevés après cinq séances a été calculée. Pour le reste des séances, pour 12 patients, l’écart à cette valeur a été calculé pour montrer la pertinence ou non d’une imagerie quotidienne.Ce travail a permis de rapporter l’intégration des dispositifs de repositionnement dans le service de radiothérapie. Il montre également les perspectives offertes par ces différents systèmes. Ils autorisent au minimum d’assurer un repositionnement quotidien, et ils laissent entrevoir la future possibilité de réaliser des radiothérapies guidées par la dose.The aim of this work was to report the experience of image-guided radiotherapy at the CLCC Nantes-Atlantique using three repositioning imaging devices, the ExacTrac® (BrainLAB™), the OBI®-CBCT (Varian™) and the MVCT (Tomotherapy Inc™), in the case of prostate external radiotherapy.For each linac and its imaging device, a treatment plan was described. Moreover, studies concerning calculated shifts after imaging sessions were achieved. Using ExacTrac®, for eight patients, a study compared daily shifts based on bony anatomy or on implanted markers. Considering mean values of displacements over a course of radiotherapy, dosimetric impact was evaluated. With the OBI®-CBCT, two imaging modalities were used, kV–kV (0° and 270°) and CBCT. Up to now, whatever the images, displacements were calculated using the bony anatomy. For both modalities and for 26 patients, shifts were compared. Since the beginning of the Tomotherapy HiArt® use, MVCT was performed for each session of each patient. For 12 patients, mean displacements were calculated after five fractions. Then the deviations to those values were calculated. This was done to show the relevance of daily MVCT.This work allows us to report the use of three repositioning imaging devices in the radiotherapy department. At least they provide an efficient positioning tool. And they let us see the future radiotherapy which would probably be the dose-guided radiotherapy.

The relatively recent introduction of CyberKnife® in the field of radiotherapy has prompted the question of accessibility and usefulness of this technique for seniors. From June 2007 to June 2009, we treated 345 patients of all ages with CyberKnife as part of a single-center study. Median age was 61 years (range, 8–86 years). Ninety-eight patients were over 70 and 17 were older than 80. The treatment could not be completed with 2% (2/98) patients over 70 vs. 3.6% (9/247) among the younger (ns). Physiologic or psychologic problems in maintaining position for a long time were not more frequent among those over 70. The same was true with those over 80. Patients over 70 years old are able to tolerate CyberKnife treatment as efficiently as their younger counterparts. Elderly patients should not be restricted from access to CyberKnife radiosurgery with curative intent.

La radiothérapie stéréotaxique par CyberKnife® a été introduite en France en 2006. Deux modes de traitement sont actuellement disponibles : l’un (Synchrony®) nécessite l’implantation d’un ou de plusieurs fiduciels afin que la lésion puisse être suivie en temps réel, l’autre (Xsight Lung Tracking System®) s’affranchit totalement de cette contrainte et permet de planifier et de réaliser des traitements sans fiduciels. Soixante huit patients ont été pris en charge pour une tumeur pulmonaire entre juin 2007 et novembre 2009. À partir d’août 2008, 26 patients ont été traités avec l’Xsight Lung Tracking System®. Nous décrivons les conditions nécessaires à la réalisation de ce traitement (position, taille, latéralité de la lésion), la toxicité et les résultats de ce traitement. L’analyse a porté sur 22 patients. Le suivi était en médiane de six mois (3–16). Le taux de contrôle local était de 100 %. Le principal effet secondaire rencontré était une pneumonie radique de grade 1 (27 %). Aucune toxicité de grade 3 ou 4 n’a été rapportée. Le taux de contrôle local élevé et la très faible toxicité obtenue par le CyberKnife® en mode Xsight Lung® indiquent le potentiel de cette technique dans la prise en charge thérapeutique des patients inopérables. Stereotactic radiation therapy using the CyberKnife® has been introduced in France in 2006. Two treatment modalities are currently available: the first one (Synchrony®) is a real-time fiducial-based target tracking system, while the other (Xsight Lung Tracking [XLT] System®) is completely fiducial-free. Sixty-eight patients were treated for a pulmonary tumor between June 2007 and November 2009. Since august 2008, the XLT System® was used for 26 patients. We report the necessary conditions for the XLT System (position, laterality and size of the tumor), the toxicity and outcome of this treatment. Twenty-two patients were analyzed. Median follow-up was 6 months (min = 3; max = 16). Local control rate was 100%. The main toxicity was grade grade 1 pulmonary alveolitis (27%). No grade 3 or 4 toxicities were reported. The high local control rate and low toxicity obtained with the CyberKnife® XLT System® suggest that such treatment is an alternative for inoperable patients.

TPS289 Background: Stereotactic radiation therapy (SBRT) for non-small cell lung cancer (NSCLC) T1-2 N0 M0 is considered as a good therapeutic option for patients noneligible for surgery. This study is a prospective French multicentric nonrandomized medico-economic study. Methods: 120 patients (pts) are to be included within 3 groups of treatment (approximately 80 pts treated in SBRT with Linac, 20 pts treated using Cyberknife and 20 pts treated in conformal conditions [RC3D] without SBRT), coming from 15 institutions. The type of treatment depends on the choice of the physician, according to the local availabilities. Main inclusion criteria are pts with good performans status, treated for nonoperated proven peripheral CBNPC or non proven CBNPC with strict criteria (positive PET scan, progression on 2 successive scans, …), ≤ 5 cm, N0, M0. Written informed consent is collected. Primary objective of the study is the local control rate at 2 years. Secondary objectives are (1) economic study of the different modalities of RT (CK vs. SBRT on Linac vs. RCTD), (2) acute and late toxicity study, (3) overall survival and disease free survival as well as (4) quality of life study. Sixteen patients have been included till now (6 months of inclusion) and about 30 patient's data should be available at the time of the congress. First results concerning local control, cost of treatment, acute and subacute toxicity as well as quality of life in the three groups will be given and open to discussion. No significant financial relationships to disclose.

Purpose. - Stereotactic radiation therapy using the CyberKnife (R) has been introduced in France in 2006. Two treatment modalities are currently available: the first one (Synchrony (R)) is a real-time fiducial-based target tracking system, while the other (Xsight Lung Tracking [XLT] System (R)) is completely fiducial-free.Patients and methods. - Sixty-eight patients were treated for a pulmonary tumor between June 2007 and November 2009. Since august 2008, the XLT System (R) was used for 26 patients. We report the necessary conditions for the XLT System (position, laterality and size of the tumor), the toxicity and outcome of this treatment.Results. - Twenty-two patients were analyzed. Median follow-up was 6 months (min = 3; max = 6). Local control rate was 100%. The main toxicity was grade grade 1 pulmonary alveolitis (27%). No grade 3 or 4 toxicities were reported.Conclusion. - The high local control rate and low toxicity obtained with the CyberKnife (R) XLT System (R) suggest that such treatment is an alternative for inoperable patients. () 2010 Societe francaise de radiotherapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.

Congenital penile curvature (CPC) is caused by a disorder in the embryonic development of the urethra and corpora cavernosa. The condition causes difficulty for penetration, requiring surgical correction when it prevents intercourse.We present the cases of 2 men in their 40s who had ventral curvature greater than 60° of 2 years of evolution, with maintained erections. The patients underwent surgery for rotation of the corpora cavernosa. After the complete denudation of the penis, athermal release of the neurovascular bundle of the penis from the ventral side to the dorsal was performed. Once the curvature was verified using artificial erection, an incision was performed in the tunica albuginea of both corpora cavernosa, continuously suturing both internal and external margins with resorbable monofilament. The rectification of the curvature was then checked, and the mucocutaneous plane was reconstructed.The surgical time was 120 min and there were no intraoperative complications. Both patients were discharged 24 h after the surgery. At 1 week, the patients experienced spontaneous night-time erections and were able to maintain sexual relations 1 month after the surgery. At 6 months, the residual curvature was less than 20°, the penile shortening was less than 1 cm and the International Index of Erectile Function-5 was 25 for both cases.Surgery for rotation of the corpora cavernosa helps correct CPC without significant penile shortening or erectile dysfunction. In our opinion, the procedure is an appropriate treatment for patients with CPC but requires studies with long-term follow-up in order to consider it the technique of choice.La incurvación peneana congénita (IPC) está originada por una alteración en el desarrollo embrionario de la uretra y los cuerpos cavernosos. Condiciona dificultad para la penetración, precisando corrección quirúrgica cuando imposibilita el coito.Presentamos 2 varones en la 4.ª década de la vida que presentan incurvación ventral superior a 60° de 2 años de evolución con erecciones mantenidas. Los pacientes fueron sometidos a cirugía de rotación de los cuerpos cavernosos. Tras la denudación completa del pene se realiza la liberación atérmica del paquete vasculonorvioso del pene desde la cara ventral hasta la dorsal. Una vez evidenciada la incurvación mediante una erección artificial se realiza una incisión en la albugínea de ambos cuerpos cavernosos, suturando de forma continua con monofilamento reabsorbible ambos bordes internos y externos. Posteriormente se comprueba la rectificación de la incurvación y se reconstruye el plano mucocutáneo.El tiempo quirúrgico fue de 120 min, no existiendo complicaciones intraoperatorias. Ambos pacientes fueron dados de alta a las 24 h de la intervención. A la semana presentaban erecciones nocturnas espontáneas, pudiendo mantener relaciones sexuales al mes de la intervención. A los 6 meses la incurvación residual era inferior a 20°, el acortamiento peneano inferior al centímetro y el IIEF-5 de 25 en ambos casos.La cirugía de rotación de los cuerpos cavernosos permite corregir la IPC sin acortamiento peneano significativo ni disfunción eréctil. En nuestra opinión constituye un tratamiento adecuado en pacientes con IPC, necesitándose estudios con seguimientos a largo plazo para considerarla la técnica de elección.