Le but de ce travail était l'évaluation du rapport bénéfice/risque de la radiothérapie seule ou associée à une hormonothérapie chez des patients âgés. Il s'agit d'une étude monocentrique rétrospective des dossiers de 95 patients consécutifs, âgés d'au moins 80 ans, pris en charge à visée curative pour un adénocarcinome prostatique non opéré par radiothérapie externe ou curiethérapie, avec ou sans hormonothérapie associée, entre janvier 2003 et décembre 2013. Les scores G8 et de Balducci ont été établis à partir des données du dossier médical. L'âge médian des patients était de 82 ans [80–91 ans], l'indice de performance de 0 ou 1, 83,2 % « fit elderly » selon la classification de Balducci, le score G8 supérieur à 14 dans 56,8 % des cas. Selon la classification de D'Amico/Zumsteg, le cancer était de risque : faible (quatre patients), intermédiaire favorable (dix patients), intermédiaire défavorable (28 patients) ou élevé (53 patients). Quatre-vingt-onze patients ont reçu une radiothérapie, 36 une hormonothérapie concomitante, quatre une curiethérapiee exclusive, 21 ont préalablement reçus une hormonothérapie à visée palliative, avant un changement de stratégie. La radiothérapie externe était conformationnelle « standard » pour les 50 premiers patients, avec modulation d'intensité pour les patients ultérieurs. La dose médiane était de 74 Gy dans la prostate (en fractionnement classique pour tous les patients). Les aires ganglionnaires pelviennes ont été irradiées chez 15 patients. Le suivi médian était de 5,1 ans. La radiothérapie externe a dû être arrêtée prématurément chez huit patients pour une toxicité aiguë de grade 3 ou plus (urinaire : n = 4 ; diarrhée : n = 1), une chute accidentelle (n = 2) et une dépression (n = 1). Seuls trois patients ont souffert d'une toxicité tardive de grade 3 (aucune de grade 4), vésicale (n = 2) et rectale (n = 1). Les probabilités de survie médiane globale et sans évènement (décès ou récidive) étaient respectivement de 9,9 et 8 ans, avec une différence significative (p = 0,023) selon les groupes pronostiques pour la survie sans événement (différence non significative pour la survie globale, p = 0,19). Une radiothérapie à visée curative pour un adénocarcinome de la prostate peut être proposée chez des patients sélectionnés de 80 ans et plus.

Introduction: Cancer treatment decision making represents a crucial step in the management of older cancer patients, especially the decision between palliative or curative intent.

BACKGROUND:The conditions of use and access to medical records have become an important source of interest in the last decade. In this context, our main objective was to assess the impact of a paper patient-held records, shared with healthcare professionals.METHODS:In the particular case of breast cancer management, we identified the expectations of practitioners and patients. Secondly and according to a Delphi method, we defined the content and size of a medical record, which could be held by the patient. Following these preliminary studies, we conducted a randomized controlled trial, comparing patients with usual follow-up to others holding the new record containing essential information for coordination of care.RESULTS:The patient-held record favoured membership and satisfaction of both patients and health professionals. It was used as a communication tool between physicians and patients, but could also cause anxiety to some patients. Patient quality of life, data confidentiality and costs of care remained identical in the two arms. With its benefits for both patients and healthcare professionals, a new concept of medical records was revealed by this study.CONCLUSION:New models for healthcare organization deeply modify the roles and relationships of all the actors in the healthcare system. Further research on patient-held records is needed to evaluate the full range of its benefits and limits.

Background. - The conditions of use and access to medical records have become an important source of interest in the last decade. In this context, our main objective was to assess the impact of a paper patient-held records, shared with healthcare professionals.Methods. - In the particular case of breast cancer management, we identified the expectations of practitioners and patients. Secondly and according to a Delphi method, we defined the content and size of a medical record, which Could be held by the patient. Following these preliminary studies, we conducted a randomized controlled trial, comparing patients with usual follow-up to others holding the new record containing essential information for coordination of care.Results. - The patient-held record favoured membership and satisfaction of both patients and health professionals. It was used as a communication tool between physicians and patients, but could also cause anxiety to some patients. Patient quality of life, data confidentiality and costs of care remained identical in the two arms. With its benefits for both patients and healthcare professionals, a new concept of medical records was revealed by this study.Conclusion. - New models for healthcare organization deeply modify the roles and relationships of all the actors in the healthcare system. Further research on patient-held records is needed to evaluate the full range of its benefits and limits. (C) 2008 Elsevier Masson SAS. Tous droits reserves.

Fluorescence imaging techniques can ac- curately monitor a variety of gas-phase parameters in- cluding species concentrations, temperature and veloc- ity. However, in using such techniques in free-piston shock tunnels, a number of problems are encountered. For example, emission from metallic impurities present in the flow imposes a severe limitation, especially at the very high specic flow enthalpies. In spite of this and other diculties encountered, it has been possible to successfully apply such methods to many impor- tant flow studies in free-piston shock tunnels, some of which are described in this paper.

The multidisciplinary dimension which imposes the follow up of patients suffering from breast cancer raises difficulties of communication between community and hospital practitioners. The aim of this study was to assess information needs and expectations when the general practitioners and private gynecologists on one hand, and the hospital practitioners on the other hand, exchange medical information in the follow up of patients suffering from breast cancer. This descriptive study included a sample of 225 general practitioners and 216 gynecologists in private practice, and 233 hospital practitioners in the Rhone-Alps French region. Response rate was respectively 68 % (153), 64 % (139) and 42 % (99). This study showed different perceptions on the frequency of shared documents (reports, letters) or phone calls according to the speciality. In spite of a strongly felt partnership, an expectation of change was found with notably the wish of a stronger implication in the follow up and the wish to receive numerous information concerning the patients. The community practitioners expected to be more aware of the stage of the cancer, the prognosis and the level of information given to the patients. The hospital specialists expected to be informed about psychological problems or comorbidity. Pending the generalization of an electronic shared medical records, the experiment of a patient-held records may help to fulfil these expectations.

OBJECTIVES:To describe the role of gynecologists in the care of women with breast cancer, their relationship with hospital specialists and with patients, and their expectations in terms of the quality of this relationship. MATERIALS AND METHODS:A descriptive cross-sectional study was performed in 2002. Two hundred and fifty gynecologists from Rhone Alpes region were randomly selected and received a questionnaire. RESULTS:Sixty-four percent of the polled practitioners answered. Forty-two percent of gynecologists had about 25-50 patients with breast cancer. Their participation in the care principally concerned the phases of diagnosis (99%) and remission (98.5%). Eight percent took part in therapeutic decision making. Ninety-two percent of the gynecologists wanted to receive systematically feedback concerning any consultation or hospitalization and 98% wanted to know the name and address details of the care coordinator. CONCLUSION:Gynecologists are willing to participate in the care of breast cancer patients. This for, they want to have more details about therapy, follow-up and the level of information given to the patients.

Décrire le rôle des médecins gynécologues dans la prise en charge des femmes atteintes de cancer du sein, les échanges mis en place avec leurs confrères hospitaliers spécialisés et avec les patientes, et leurs attentes dans la qualité de cet échange. Une étude descriptive transversale a été menée en 2002, portant sur 250 médecins gynécologues libéraux de la région Rhône-Alpes tirés au sort. Il s’agissait d’une enquête postale par questionnaire. Le taux de participation est de 64 %. Quarante-deux pour cent des gynécologues libéraux estiment suivre entre 25 et 50 patientes atteintes de cancer du sein. Leur participation dans la prise en charge se fait principalement lors du diagnostic (99 %) et en phase de rémission (98,5 %). Huit pour cent disent participer aux décisions thérapeutiques. À 92 %, les gynécologues souhaitent recevoir de façon systématique un compte rendu de consultation et d’hospitalisation et à 88 % connaître les coordonnées d’un médecin coordinateur de la prise en charge. Les médecins gynécologues de ville sont très désireux d’être partie prenante dans la prise en charge des femmes atteintes de cancer du sein. Pour ce faire, ils souhaitent obtenir plus facilement des données sur les traitements en cours, le suivi prévu et l’information dispensée à la patiente. To describe the role of gynecologists in the care of women with breast cancer, their relationship with hospital specialists and with patients, and their expectations in terms of the quality of this relationship. A descriptive cross-sectional study was performed in 2002. Two hundred and fifty gynecologists from Rhone Alpes region were randomly selected and received a questionnaire. Sixty-four percent of the polled practitioners answered. Forty-two percent of gynecologists had about 25-50 patients with breast cancer. Their participation in the care principally concerned the phases of diagnosis (99%) and remission (98.5%). Eight percent took part in therapeutic decision making. Ninety-two percent of the gynecologists wanted to receive systematically feedback concerning any consultation or hospitalization and 98% wanted to know the name and address details of the care coordinator. Gynecologists are willing to participate in the care of breast cancer patients. This for, they want to have more details about therapy, follow-up and the level of information given to the patients.

Planar laser-induced fluorescence of nitric oxide is used to measure a component of the velocity field for the Mach 7 flow around a 30-deg half-angle, 50-mm-diam cone mounted to a long, 38-mm-diam shaft, or sting. Transverse velocities are measured in the freestream, the shock layer, and the separated region at the junction between the cone and the sting. For most of the flowfield, the uncertainty of the measurements is between ±50 and ±100 m/s for velocities ranging from -300 to 1300 m/s, corresponding to a minimum uncertainty of ±5%. The measurements are compared with the commercial computational fluid dynamics (CFD) code CFD-FASTRAN . The agreement between the theoretical model and the experiment is reasonably good. CFD accurately predicts the size and shape of the shock layer and separated region behind the cone as well as the magnitude of the gas velocity near the reattachment shock. However, the magnitude of the velocity in the shock layer and gas expansion differ somewhat from that predicted by CFD. The discrepancies are attributed to a small systematic error associated with laser-beam attenuation and also to inexact modeling of the flowfield by CFD

Planar laser-induced fluorescence (PLIF) of nitric oxide is used to measure a component of the velocity field for the Mach 7 flow around a cone. Velocities are measured in the freestream, shock layer, and the separated region behind the cone. The measurements are compared with computational fluid dynamics (CFD) codes. The comparison indicates that the CFD correctly predicts the flow over the forebody and in the expansion around the cone shoulder, but incorrectly predicts the location of the re-attachment shock.

Radiation is often necessary after pneumonectomy, either immediately or due to local cancer recurrence. High radiation doses represent a challenge due to the limited tolerance of the lung and the necessity of preserving and protecting the remaining lung parenchyma. The use of CT scan based-treatment planning allows delivery of high radiation doses. To evaluate the radiation tolerance of the lung after high radiation dose, we compared pulmonary function tests performed before surgery and after radiation therapy. Ten male patients (mean age, 56 years old; age range, 45-73) were irradiated after pneumonectomy for lung cancer. All patients had a CT scan-based treatment planning. The mean radiation dose was 56 Gy (45-66 Gy) delivered with a linear accelerator and multiple complex fields. Two or more sets of pulmonary function tests were available (before surgery and 2 to 6 months after radiation). No patient developed clinical radiation pneumonitis and most of the patients had a minimal paramediastinal fibrosis at CT scan. Postirradiation pulmonary lung tests were compared to the theoretical values of the estimated defect observed after pneumonectomy. No significant decrease in forced expiratory volume in 1 s/inspiratory vital capacity (FEV1/IVC) was observed in ten evaluable patients; the observed values were comparable to those expected after pneumonectomy without irradiation (FEV1/IVC: 61 to 100%), showing that irradiation did not alter pulmonary function. Computerized tomography-based treatment planning and the use of complex beam positioning allowed optimal lung parenchymal preservation. Through this procedure, high doses of radiation can be delivered to the mediastinum and bed tumor. Comparison of pulmonary function tests performed before surgery and after radiation showed no alteration of lung function, even after high doses. Optimal tools required for the evaluation of radiation on lung parenchyma are still to be defined.

BACKGROUND AND PURPOSE:Symptoms of acute radiation enteritis (ARE), dominated by diarrhea, occur in more than 70% of patients receiving pelvic irradiation. Eicosanoids and free radicals release have been implicated in the pathogenesis. Mesalazine (5-ASA) is a potent inhibitor of their synthesis in the mucosa and could therefore be of some interest in preventing ARE. PATIENTS AND METHODS:The study was performed in six radiotherapy units in France who agreed on standardized irradiation procedures. One hundred and fifty-three patients planned for external beam radiotherapy to the pelvis > or = 45 Gy for prostate (n = 97) or uterus (n = 54) cancer were randomized on a double blind basis to receive prophylactic 5-ASA (4 g/day Pentasa) or placebo. Patients with concomitant chemotherapy were excluded. Prostate and uterus cancers were chosen since these centropelvic tumors require a similar radiotherapy protocol during the first step of treatment and involve a comparable volume of small intestine. The symptoms of ARE and their severity were assessed every week during irradiation, and 1 and 3 months after its end. All patients followed a low fiber and low lactose diet. End points were diarrhea, use of antidiarrheal agents, abdominal pain, and body weight. Effficacy was evaluated using intention to treat. RESULTS:(means +/- SD) Groups did not differ for age (mean 64 +/- 9 years), sex, tumor site, or irradiation procedure. During irradiation, diarrhea occurred in 69% and 66% of the 5-ASA and placebo groups, respectively (chi2, P = 0.22). Curves of survival without diarrhea did not differ between groups (logrank P = 0.09). Severity of diarrhea did not differ between groups except at d15 where it was significantly more severe in the 5-ASA group (ANOVA P = 0.006). Duration of diarrhea did not differ (22 +/- 15 days in both groups, P = 0.88). Abdominal pain was less frequently reported in the 5-ASA group at d28 (34% vs. 51%, P = 0.048). Use of antidiarrheal agents and body weight did not differ between groups. CONCLUSION:Mesalazine 4 g/day did not decrease the symptoms of ARE.

La radiothérapie est souvent nécessaire après pneumonectomie, soit d'emblée, soit pour une récidive locale. Il est cependant difficile de délivrer une dose élevée au poumon restant en raison de la tolérance limitée du parenchyme et de la nécessité de préserver un volume pulmonaire suffisant. L'utilisation d'une dosimétrie assistée par ordinateur à partir d'images tomodensitométriques permet d'augmenter la dose totale. Pour évaluer la tolérance pulmonaire à cette irradiation à haute dose, des épreuves fonctionnelles respiratoires ont été demandées avant la chirurgie, puis après la radiothérapie. Dix hommes ayant un cancer bronchique ont été irradiés après pneumonectomie (âge médian, 56 ans; extrêmes: 4573 ans). La radiothérapie était délivrée à partir d'images tomodensitométriques après dosimétrie par ordinateur. Une dose totale moyenne de 56 Gy (45–66 Gy) était délivrée, à l'aide d'un accélérateur linéaire, par de multiples faisceaux. Les fonctions pulmonaires ont été évaluées avant la pneumonectomie et 2 à 6 mois après radiothérapie. Aucune pneumopathie cliniquement détectable n'a été observée après radiothérapie, mais la tomodensitométrie a montré dans la plupart des cas une fibrose paramédiastinale minime. La comparaison des tests effectués avant et après radiothérapie n'a pas montré de diminution significative du coefficient de Tiffeneau (VEMS/CV) après la radiothérapie (61 à 100%). La dosimétrie assistée par ordinateur et l'utilisation de multiples portes d'entrée ont permis une protection optimale du parenchyme pulmonaire restant. Il a été ainsi possible d'augmenter la dose totale délivrée au médiastin et au lit tumoral. Grâce à cette technique, les tests effectués après la radiothérapie se sont révélés comparables à ceux réalisés avant pneumonectomie.

L'amélioration des résultats de la radiothérapie passe, entre autres, par une adaptation des modalités d'irradiation (dose totale, fractionnement, étalement, traitements associés…) aux caractéristiques biologiques de la tumeur et des tissus sains qui l'environnent. Un test prédictif de la réponse à la radiothérapie se distingue d'un facteur pronostique par sa vocation à permettre une irradiation ≪sur mesure≫. De nombreuses investigations semblent susceptibles d'apporter l'information biologique nécessaire, mais aucune n'a encore fait la preuve de son intérêt en routine clinique. Les principales difficultés proviennent de la lourdeur technique des procédures, de la caractérisation insuffisante des cellules étudiées, et surtout de la complexité de la biologie des tissus sains et tumoraux. Cet article fait le point sur les connaissances acquises concernant la détermination de la radiosensibilité, de la cinétique de prolifération et de l'oxygénation des cellules tumorales. La recherche de tests prédictifs de la réponse à l'irradiation reste cependant un domaine extrêmement actif en raison de l'importance des enjeux et du progrès des connaissances. Des perspectives encourageantes se dessinent du fait des développements technologiques, de la (re-)découverte de l'apoptose et des travaux portant sur la tolérance des tissus sains.The potential tailoring of radiotherapy modalities to the biological characteristics of individual tumours and normal tissues appears to be an exciting way to improve the therapeutic ratio in radiation therapy patients. Numerous assays have been proposed to provide the clinician with the biological information necessary to predict the outcome after irradiation and to guide the treatment prescription, but none of them has made its way to daily practice. Major difficulties are due to the technical burden of the procedures, the poor characterization of the assayed cells, and, moreover, the high complexity of tumour and normal tissues biology. The present paper reviews the present status of the assessment of tumour cells radiosensitivity, proliferation and oxygenation. Research remains extremely active in the field of biological predictors of response to irradiation. Future steps forwards are expected from progress in the available technologies, (re-)discovery of apoptosis and investigation of normal tissue tolerance.

Although cancer of the penis is a rare disease, we have collected 506 cases through a multicentric study. In the present study we analyse the results obtained from 259 patients treated by interstitial brachytherapy from 1959 to 1989. Among the 259 patients, 184 males had exclusive brachytherapy (group A) while 75 received a combination of surgery and brachytherapy and/or external beam irradiation (EBI) (group B). Five- and 10-year survival rates are, respectively: overall survival, 66 and 52%; cause-specific survival, 88 and 88%; disease-free survival, 78 and 67%. One hundred and forty-three patients in group A (78%) and 48 (64%) in group B avoided mutilation of the penis while late side effects occurred in 137259 patients (53%). Survival depends on the volume of the tumor and the presence of involved nodes; systematic groin dissection does not however seem advisable.