Crossover of the Patient Satisfaction Surveys, Adverse Events and Patient Complaints for Continuous Improvement in Radiotherapy Department

BACKGROUND

The patient's needs and expectations can be assessed through satisfaction surveys, adverse event declarations and records of complaints. However, by crossing individual complaints, satisfaction surveys in combination with adverse events received we could get valuable information. The objective is to identify common elements of work between these different sources to improve care.

METHODS

A retrospective analysis of patient's complaints, surveys and adverse events was carried out in order to highlight common improvement items between these 3 sources of information.

RESULTS

A satisfaction survey was given to the patients at the end of their treatment, who filled it out and left it in the "ad hoc" letterbox. At the end of December 2019, 4695 questionnaires had been collected (response rate 37%). In addition, since 2014, 1369 patients (approximately 20 patients per month) have been interviewed "face to face" by the research nurse who assesses their satisfaction using open questions. At the same time, a collection of complaints and adverse events was carried out. All this data has been analysed and cross-checked in order to highlight areas for improvement, in order to strengthen the safety and quality of care in our department.

CONCLUSIONS

Collecting and analysing satisfactions surveys, unexpected events and complaints constitute in our opinion, an effective tool to achieve patient empowerment. We aim for the patients to become a real player in their safety, involved in the overall effort to improve quality of their radiotherapy treatment by reporting what does not meet their expectations.

[Mental illnesses: the playground for new technologies]

The current health care crisis, induced by the coronavirus pandemic, is at the origin of significant global changes within our societies and profoundly modifies the health care sector as well, especially in the field of mental health. Nowadays, this latter is particularly poorly equipped in financial and human resources. Without major and immediate changes, the mental health sector will not be able to cope with the expected exponential rise of care needs, exacerbated by the rapid deterioration of mental health in the general population and among health care providers. We intend to illustrate the potential role and benefit of new technologies, able to solve the imbalance. Without any possible doubt, the health care crisis has provided a formidable momentum for their arousal, but we still have to determine their accessibility, feasibility, efficacy and efficiency by running controlled clinical trials.

[Radiomics and automation in radiotherapy]

Cancer incidence is steadily progressing worldwide, in parallel with the aging of the population. Workload is increasing constantly, especially in the fields of oncology and radiotherapy. This is particularly worrysome, as there is a general shortage of skilled professionals in the field (for example in medical physics). Moreover, every single patient does represent an enormous amount of data issued from a wide range of sources. This is especially true as far a medical imaging is concerned. Extraction of morphological data (anatomical location and extent of the tumour) and functional data (tumour biology and metabolism in general) becomes laborious. Moreover, images contain information which cannot be discerned by the human eye. Therefore, to handle shortage of human resources and transform this enormous amount of data automatically, artificial intelligence becomes a «must have». We intend to highlight the growing importance of radiomics as a cornerstone in automation of processes in radiotherapy, especially for treatment planification and a more personalized individualized treatment approach.

[Palliation by radiation is also our business !]

Radiotherapy (RT), both with a curative and a palliative intent, is one of the cornerstones of oncological treatments. A variety of symptoms linked to cancer can be relieved with RT (such as pain, bleeding, compression exerted by a tumour lesion…). Very often, palliative RT is proposed when other medical treatments (painkillers, morphine…) are no longer efficient, or the patient does not tolerate them anymore. Palliative RT is an integral part of the global supportive oncological care. Indeed, patients' wishes and prognosis are taken into account in each and every step of the treatment pathway. Every treatment deserves an individualized approach and benefits from the best available techniques.

[Dental management of head and neck irradiated patients]

The oncological management of head and neck tumours is well known and standardized. Radiotherapy is one of the effective tools. However, it induces major changes in healthy tissues: teeth, gums, mucous membranes, salivary glands and bones. Some, like mucositis, are immediate and often reversible; others, like hyposialia or fibrosis, are late effects and often irremediable. These changes greatly affect oral health and make its management more complex. Dental management also becomes a capital element of the care path but, unfortunately, often remains neglected by the patient but also by some practitioners. It concerns all the stages of the clinical course: initial assessment, cancer treatment itself and long-term follow-up. If neglected, the patient's quality of life will be affected and complications, sometimes serious, such as osteoradionecrosis, may occur. Specific care recommendations for maintaining oral health are mentioned, especially for those patients requiring oral cavity irradiation.

[How to improve radiotherapy ? Technological developments and radiotherapy of tomorrow]

Radiotherapy established itself in the 20th century as an essential modality in the fight against cancer. The major technological advances of the last decades have allowed a considerable improvement in the therapeutic window. They have also paved the way for stereotactic radiotherapy and new indications. The aim of this article is to enable readers to understand external radiotherapy in 2021 and to understand the challenges of tomorrow. Three areas of improvement in the discipline will be described, the optimization of the prescribed therapeutic dose, the improvement of the distribution of this dose and, finally, the better understanding of radiobiology. For each of these axes, the current implications will be described as well as those which could/should have a major impact on the radiotherapy. FLASH radiotherapy will also be discussed.

[Precision medicine in oncology : where do we stand ?]

The «one size fits all» approach is seriously challenged by rapid progression of medical knowledge, especially in the field of individual genome expression. It is currently known that the anti-tumour effect of a given treatment and possible side effects at the level of healthy tissues, can at least partly be predicted and explained by individual variations of gene expression. However, most of us realize that these differences in response are also linked to a variety of other individual characteristics, such as for example the environment and socio-economic factors. Without any possible doubt, there are multiple problems (technical, administrative, financial, cultural and ethical) to be solved, before we witness the real irruption of precision medicine and its holistic individualized approach in our daily oncological practice. It has to start with an international effort, disregarding borders of individual countries, in order to obtain very large amounts of data (with a high degree of variability to avoid bias). This holistic approach, at both societal and individual levels, is the entrance door for a personalized approach in care, whether this is curative, predictive or preventive.

[Pharma industry reinvents itself in the turmoil. Part 2. Opportunities]

In the first article we described how pharmaceutical industry is facing major challenges in general. In this second part, we intend to focus on new concepts and developments, which might sound «futuristic» for most of us. However, this seems definitely «work in rapid progress», especially concerning, for example, the use of the pharmacogenome (prerequisite for treatment personalization), «clever» medication, 3D printing and labelling with QR code. The future is bright but we cannot omit to quote the ever growing role of incumbent actors, both in the fields of medication production as well as distribution.

[Pharma industry reinvents itself in the turmoil. Part 1. Challenges]

The pharmaceutical industry faces, as many other public and private sectors, a significant deficit in trust (medication considered too expensive, not always readily available, even if it is deemed essential, lack of financial transparency). Moreover, we are more than very surprised by the lack of efficiency (colossal investments, compared to the modest final output). Not a single human activity sector can afford the luxury of such a situation. In these moments of doubts, industrial leaders are pushed to reinvent the whole sector, starting from research and development, through production and commercialization, to finish with retail. They are massively investing in new disruptive technologies (artificial intelligence, connected health, big data), redesigning the way clinical trials are elaborated and performed.

[The COVID-19 pandemic : a real opportunity for digital health]

Nowadays, we are facing a global health crisis. The infectious agent, the virus SARS-CoV-2, has some clinical and pathological characteristics which have been described extensively throughout published medical literature. The pandemic outbreak arises in a very particular period. Never before, our political disorganization and lack of collaboration has been highlighted as it was during the present health care crisis. Our health care system is shaking because of the lack of sufficient human and financial resources. However, technological changes, and especially remote health (teleconsultations and remote monitoring) are disrupting the whole ecosystem. We intend to illustrate that the COVID outbreak offers a unique opportunity to accelerate acceptance of these rapid technological changes, which are anyway unavoidable. Teleconsultations and remote monitoring, which both appeared as a devil out of the box from nowhere, at least for some care providers in the health care landscape, are there to stay.

[Thinking differently about health care after COVID-19]

The health crisis linked to the coronavirus pandemic (COVID-19) has forced society and hospitals in particular to adapt and reform. Teamwork between hospitals, even beyond the networks, helped them to deal with the crisis. The medical and nursing staff had to learn to work differently and differentiate urgent from non-urgent care. But the patient also had to change his/her behaviour. Access to hospitals has been divided between a separate COVID and non-COVID route in order to avoid contamination. Telemedicine has become a daily way of communicating between doctors and patients. Telephone consultations have been set up with reimbursement by social security. However, these actions and innovations should not end with the crisis but, on the contrary, be a lever to rethink the role of hospitals, and our health care system more generally.

[Medical imaging professionals and related specialties : a questioning is essential!]

Nowadays, we are facing an overwhelming amount of public announcements concerning the rise of artificial intelligence (AI) in the world of medical imaging (including radiology, nuclear medicine and radiotherapy). While most of the applications are still limited to specific niches, there is a general trend to build real transversal platforms. Multiple industrial players, in collaboration with the clinicians in the field, are striving to build those platforms in order to offer plenty of use cases of AI for several purposes and needs (screening/detection, diagnosis and prediction). It is already undeniable that AI far exceeds human capabilities in terms of resolution, speed of image analysis and efficiency. Negative attitudes and skepticism from concerned professionals should be banned. Colla¬boration with data scientists and engineers for the large scale development and implementation should be pushed forward for the benefit of both patients and payers.

[Cybersecurity in the health care sector]

Cybersecurity is a real threat in almost all human activity domains. The health sector is a particular vulnerable target for cybercriminals. The first reason is obviously the financial incentive: the value of the content of a personal electronic health record, sold on the darknet, easily exceeds 1000 US dollars. The second reason is the aging Information Technology (IT) infrastructure we are dealing with, both in the hospital sector as well as in the vast majority of private medical practices. There is also an astonishing lack of environmental consciousness and an absence of a real safety culture in the medical profession. Very often there is neither an institutional basic training, nor a continuous and mandatory education in institutional cybersecurity. There is no single magic bullet to solve the problem, but various mechanisms can be put in place to mitigate the risks and limit the hazards as much as possible.

[Are you able to smell a diagnosis ?]

Since centuries, the human clinical observation skills include our capacity to smell. However, it is well known that this particular capacity is largely outraced by our lovely dogs. Some centers around the world are actively training these dogs in order to provide a correct diagnosis for particular diseases. This clinical observation has given rise to intensive development of digital tools which are able to recognize patterns of volatile organic compounds (VOC's) in the exhaled air, but not only. It is not a single VOC which is important but an association - a specific pattern - which at the end represents the signature of a disease. This widely opens the door to applications both in the diagnostic field, as well as for follow-up of treated patients.

[Laennec versus Forbes : tied for the score ! How technology helps us interpret auscultation]

For at least two centuries, the stethoscope has served as an essential cornerstone in clinical semiology. The sounds of heart and lung have been used for the differential diagnosis by multiple generations of physicians. One can argue today that our hearing and cognitive capacities are largely outraced by the development of new techniques with embarked artificial intelligence. This latter is able to recognize and differentiate with high precision cardiac and pulmonary sounds.

[Additive manufacturing in health care (part 2) : printing organs of vital importance]

In a previous article, we highlighted the technical characteristics and economical advantages of additive manufacturing, especially for medical material as well as "hard" body structures without vital function (bone, cartilage and teeth). In the present paper we illustrate the technological advances in the field of printing vital organs. From a simple idea to a proof of concept, steps will be taken rapidly in order to introduce these techniques for functional replacement in the clinics in order to solve the ever-growing gap between supply and demand in the field of organ transplantation.

[Additive manufacturing in health care (part 1) : printing of non vital structures]

Additive manufacturing is creating a real revolution in every sector of human activity, including health care. The main reasons are a reduction of manufacturing cost, of waste production, and of energy consumption. In the health care sector, it offers unique production opportunities for medical material, especially in low-income and emerging countries. However, as the 3D (bio-)printing techniques evolve, there are more and more viable alternatives for total or partial organ replacement in order to restore function. In this first article, we will focus on medical materials and on "hard" tissues such as bone, cartilage and teeth. In a second article, we will highlight the potential of 3D bio-printing to produce tissues of vital importance.

[The necessary face-lifting for the electronic health record]

A revised Electronic Health Record (HER) is one of the most important keystones for the building of a new ecosystem. The latter is characterized by keywords such as big data, artificial intelligence, and cloud technology. The HER, which is used nowadays, does not fit within this purpose and - by the way - is considered as one of the most important reasons for frustration and burnout in the medical profession. Very often, the HER is mainly designed to collect data useful for billing purposes. However, it has to evolve rapidly to a tool which allows both storage of controlled and validated data, and analysis resulting in useful information. This information can help the professional both in diagnosis and prevention, at an individual level as well as at the level of population health. It should also be of potential use for organization and management of the health care sector as a whole. This deep facelift is an absolute requirement, if we want to cope with the major challenges of our exhausted health care sector.

[The urgent need for a new ecosystem in healthcare]

The key performance indicators in healthcare illustrate that the system we run nowadays is no longer sustainable. There is an urgent need for fundamental changes within the current ecosystem, if we want to maintain or improve the levels of quality, security and equity in healthcare. Disruptive technologies profoundly modify all domains of our society. Those changes, driven by technical convergence, are particularly rapid and extensive in the fields such as big data and analysis, artificial intelligence, cloud and blockchain. These continuously evolving technologies could potentially offer opportunities to efficient problem solving in the health care sector. The culture of our organizations needs major changes and especially adaptability and fast speed integration to a process which is inevitable.

[Could we consider that radiotherapy is effective outside the irradiation area ? The abscopal effect]

Radiotherapy is known for its action on local tumoral control. However, it is also able to induce immunomodulatory effects at a systemic level. The abscopal effect (from latin ab scopus which means «away from the target») is an illustration of this phenomenon. It is defined as a tumor regression observed outside and at a distance of the irradiation fields. The potential application of this effect of treatment in disseminated cancers is a fast-growing field of research. The optimal therapeutic strategy to achieve this effect remains unknown.

[Multiple vertebral hemangiomas treated simultaneously with CyberKnife® Technology]

Haemangioma are benign, vasoformative lesions of endothelial origin. A minority of patients with a vertebral location are symptomatic with neck or back pain. Neurological deficits due to spinal cord compression are rare and mostly observed at the thoracic and upper lumbar spine. Treatment is indicated in case of relevant symptomatology. Several invasive treatment modalities exist such as surgery and intralesional injections, but radiotherapy is the most common treatment for painful lesions. We report a case of a patient with symptomatic bifocal vertebral haemangioma (d9, l3) associated with dorsal and lumbar pain treated simultaneously using a cyberknife® vsi system, with a significant reduction of pain and a limited toxicity.

Clinical Outcomes of 130 Patients with Primary and Secondary Lung Tumors treated with Cyberknife Robotic Stereotactic Body Radiotherapy

Background

Authors report clinical outcomes of patients treated with robotic stereotactic body radiotherapy (SBRT) for primary, recurrent and metastatic lung lesions.

Patients and methods

130 patients with 160 lesions were treated with Cyberknife SBRT, including T1-3 primary lung cancers (54%), recurrent tumors (22%) and pulmonary metastases (24%). The mean biologically equivalent dose (BED_10Gy) was 151 Gy (72–180 Gy). Median prescribed dose for peripheral and central lesions was 3×20 Gy and 3×15 Gy, respectively. Local control (LC), overall survival (OS), and cause-specific survival (CSS) rates, early and late toxicities are reported. Statistical analysis was performed to identify factors influencing local tumor control.

Results

Median follow-up time was 21 months. In univariate analysis, higher dose was associated with better LC and a cut-off value was detected at BED_10Gy ≤ 112.5 Gy, resulting in 1-, 2-, and 3-year actuarial LC rates of 93%, vs 73%, 80% vs 61%, and 63% vs 54%, for the high and low dose groups, respectively (p = 0.0061, HR = 0.384). In multivariate analysis, metastatic origin, histological confirmation and larger Planning Target Volume (PTV) were associated with higher risk of local failure. Actuarial OS and CSS rates at 1, 2, and 3 years were 85%, 74% and 62%, and 93%, 89% and 80%, respectively. Acute and late toxicities ≥ Gr 3 were observed in 3 (2%) and 6 patients (5%), respectively.

Conclusions

Our favorable LC and survival rates after robotic SBRT, with low rates of severe toxicities, are coherent with the literature data in this mixed, non-selected study population.

[Comprehensive therapeutic strategy for localized esophageal cancer. Second part : interest of multimodal approaches with or without surgery]

In recent years, the treatment of esophagus cancer has been completely changed, thus competing the dogma of surgery as the cornerstone treatment. Multimodality treatments as radio-chemotherapy directly followed by surgery, or delayed surgery, significantly improve patient survival compared to surgery alone. Neoadjuvant radiochemotherapy is associated with a higher complete pathologic response rate and improved survival compared to chemotherapy alone. Immediate surgery after radio-chemotherapy is challenged for patients who present a complete clinical response, especially in case of squamous cell carcinoma. Indeed, systematic resection is associated with a significant postoperative mortality rate and has not proven any survival advantage in complete clinical responders as opposed to delayed resection in case of locally persistent or recurrent disease. In squamous cell carcinoma, this could lead to organ preservation, thus avoiding the mortality and durable functional impairment of esophagectomy. This review will discuss the positioning of the multimodality treatment strategy with neoadjuvant radiochemotherapy and chemotherapy and also the strategy of organ preservation.

Stereotactic Robotic Body Radiotherapy for Patients With Unresectable Hepatic Oligorecurrence

BACKGROUND

The purpose of this study was to analyze local control (LC), liver progression-free survival (PFS), and distant PFS (DFS), overall survival (OS), and toxicity in a cohort of patients treated with stereotactic body radiotherapy (SBRT) with fiducial tracking for oligorecurrent liver lesions; and to evaluate the potential influence of lesion size, systemic treatment, physical and biologically effective dose (BED), treatment calculation algorithms and other parameters on the obtained results.

PATIENTS AND METHODS

Unoperable patients with sufficient liver function had [18F]-fluorodeoxyglucose-positron emission tomography-computed tomography and liver magnetic resonance imaging to confirm the oligorecurrent nature of the disease and to further delineate the gross tumor volume (GTV). An intended dose of 45 Gy in 3 fractions was prescribed on the 80% isodose and adapted if risk-related. Treatment was executed with the CyberKnife system (Accuray Inc) platform using fiducials tracking. Initial plans were recalculated using the Monte Carlo algorithm. Patient and treatment data were processed using the Kaplan-Meier method and log rank test for survival analysis.

RESULTS

Between 2010 and 2015, 42 patients (55 lesions) were irradiated. The mean GTV and planning target volume (PTV) were 30.5 cc and 96.8 cc, respectively. Treatments were delivered 3 times per week in a median of 3 fractions to a PTV median dose of 54.6 Gy. The mean GTV and PTV D98% were 51.6 Gy and 51.2 Gy, respectively. Heterogeneity corrections did not influence dose parameters. After a median follow-up of 18.9 months, the 1- and 2-year LC/liver PFS/DFS/OS were 81.3%/55%/62.4%/86.9%, and 76.3%/42.3%/52%/78.3%, respectively. Performance status and histology had a significant effect on LC, whereas age (older than 65 years) marginally influenced liver PFS. Clinical target volume physical dose V45 Gy > 95%, generalized equivalent uniform dose (a = -30) > 45 Gy and a BED (α/β = 10) V105 Gy > 96% showed statistically significant effect on the LC. Acute Grade 3 gastrointestinal (GI) and late Grade 2 GI and fatigue toxicity were found in 5% and 11% patients, respectively.

CONCLUSION

Favorable survival and toxicity results support the potential paradigm shift in which the use of SBRT in oligorecurrent liver disease could benefit patients with unresectable or resectable liver metastases.

[Comprehensive therapeutic strategy for localized esophageal cancer]

Esophageal cancers represent a highly heterogeneous entity mixing two different tumour types : AdenoCarcinoma (ADC) and Squamous Cell Carcinoma (SSC). Developing in the same organ, they are very often considered as a unique pathology and, consequently, the same therapeutic strategy is indiscriminately applied. Esophageal cancer treatments are particularly complex and require a multidisciplinary approach. Despite impressive advances in the tumour statidifaction, surgery, radiotherapy and chemotherapy, the overall prognosis remains grim even at an early stage of the disease. In order to improve the treatment of esophageal cancers and the patient’s survival, we need to consider that ADC and SCC represent two different pathologies requiring specific therapeutic strategies. This review in two parts will present recent data from clinical trials under the scope of tumour histology to set up dedicated therapeutic strategies. In this first part, we explain the restricted role of surgical resection, the prognostic factors and the results of exclusive combined chemotherapy and radiation in localized esophageal cancer.

FDG PET/CT for rectal carcinoma radiotherapy treatment planning: comparison of functional volume delineation algorithms and clinical challenges

PET/CT imaging could improve delineation of rectal carcinoma gross tumor volume (GTV) and reduce interobserver variability. The objective of this work was to compare various functional volume delineation algorithms. We enrolled 31 consecutive patients with locally advanced rectal carcinoma. The FDG PET/CT and the high dose CT (CTRT) were performed in the radiation treatment position. For each patient, the anatomical GTVRT was delineated based on the CTRT and compared to six different functional/metabolic GTVPET derived from two automatic segmentation approaches (FLAB and a gradient-based method); a relative threshold (45% of the SUVmax) and an absolute threshold (SUV > 2.5), using two different commercially available software (Philips EBW4 and Segami OASIS). The spatial sizes and shapes of all volumes were compared using the conformity index (CI). All the delineated metabolic tumor volumes (MTVs) were significantly different. The MTVs were as follows (mean ± SD): GTVRT (40.6 ± 31.28ml); FLAB (21.36± 16.34 ml); the gradient-based method (18.97± 16.83ml); OASIS 45% (15.89 ± 12.68 ml); Philips 45% (14.52 ± 10.91 ml); OASIS 2.5 (41.6 2 ± 33.26 ml); Philips 2.5 (40 ± 31.27 ml). CI between these various volumes ranged from 0.40 to 0.90. The mean CI between the different MTVs and the GTVCT was < 0.4. Finally, the DICOM transfer of MTVs led to additional volume variations. In conclusion, we observed large and statistically significant variations in tumor volume delineation according to the segmentation algorithms and the software products. The manipulation of PET/CT images and MTVs, such as the DICOM transfer to the Radiation Oncology Department, induced additional volume variations.

[Impact of the use of Luminette® on well-being at work in a radiotherapy department]

PURPOSE

Studies showed beneficial effect of light therapy on well-being at work. Our randomized cross-over study aimed at analyzing the effects of light exposition with the use of Luminette® in a hospital department without access to natural light.

MATERIALS AND METHODS

The study design proposed an alternation between two periods of four weeks of use of Luminette® and two periods of four weeks without Luminette®. After every period, participants completed questionnaires (sociodemographic data, seasonal and general depression, anxiety, quality of sleep, slumber and general health).

RESULTS

Twenty-five persons participated in the study (average age=36.5, SD=7.7). The sample showed several benefits after one month of Luminette®: diurnal slumber (P=0.046), general health perception (P=0.026), physical functioning (P=0.042), pains (P=0.023) and role limitations due to emotional problems (P=0.013). One month later, certain benefits remained without light therapy: diurnal slumber (P=0.028), pains (P=0.044) and emotional problems (P=0.042).

CONCLUSION

This study has showed that the use of Luminette® could lead to similar positive results to those obtained with light therapy in other studies. This study has confirmed that Luminette® could have a positive effect on well-being at work.

[Does Radiotherapy have a role in end-of-life care?]

Up to 50% of cancer patients will receive radiation therapy as a part of their treatment. Radiation may be delivered with curative or palliative intent, according to the extent of disease, the patient's performance status and his wishes. The aim of palliative radiotherapy is to locally control primary tumor or metastasis and, thus, to slow down the disease. Another purpose is to decrease symptoms as part of the supportive care in the end of life. The total dose, the dose per fraction and the technique of irradiation used vary with the treatment aim. Indications of radiotherapy in the end of life are reviewed in this paper

[Radiotherapy and urogenital Paget disease]

Urogenital Paget disease is usually treated by surgery. However, in case of recurrence or if multilating surgery is foreseen, radiotherapy seems to open a reasonable alternative. We report a successful treatment with radiotherapy in a patient with urogenital Paget's disease.

[Vascular perfusion as the origin of neoplasm resistance to radio- and chemotherapy]

Angiogenesis is a hallmark of tumours. The newly formed tumour vessels are structurally and functionally abnormal leading to tumour perfusion heterogeneities and subsequently to the development of hypoxic areas. Generally, tumour hypoxia refers to an increasing distance between vasculature and tumour cells (i.e. chronic hypoxia). Chronic hypoxia promotes tumour resistance to treatments and metastasis. The temporal aspect of hypoxia is completely neglected in chronic hypoxia. Intermittent hypoxia (HI) takes the transient and temporal aspect of hypoxia into account. HI is defined as pO2 fluctuations in tumour vessels secondary to transient arrest of tumour blood flow. IH extends the concept of tumour hypoxia to tumour vessels and vascular cells. Transient arrest of tumour blood flow promotes tumour resistance to radio- and chemotherapy treatments and favours metastasis. Moreover, IH protects tumour vessels and endothelial cells against pro-apoptotic stresses and promotes angiogenesis. A comprehensive dissection of the mechanisms leading to IH allows the development and establishment of new therapeutic approaches.

["Triple negative" breast cancer]

In western countries, every woman out of eight will develop breast cancer. Over the last two decades, the incidence has considerably increased, but mortality has remained stable and begins to decrease in Europe and the United-States, probably because of new therapy, changes in the use of hormone replacement therapy in postmenopausal women and early diagnosis. Breast cancer is still the first cause of death by cancer in woman under 65. "Triple negative" a breast cancer, a subtype representing 10% of all breast cancers, is characterised by the absence of receptors to oestrogen, progesterone and no histochemical expression of HER-2 growth factor. This subtype carries a poor prognosis and a high incidence of early metastatic recurrence. Furthermore, no target therapy can be defined up to now in this subtype. Thus, identification of new target therapy and prediction of tumoral response to various treatments could help in the global understanding of patients affected by this particularly aggressive type of breast cancer.

[Image guided stereotactic treatment with CyberKnife yields surgical precision]

The field of radiation oncology is rapidly evolving especially thanks to the tremendous progress in robotics and computer sciences. One of the consequences is the implementation of a technique like the CyberKnife. This particular radiation therapy modality allows the use of "ablative" radiation doses, a concept which is not even conceivable with conventional approaches. This has been made possible by major changes in the ways target and margins around are defined and the way radiation therapy is fractionated. The result of these changes is for some tumours a doubling of the radiobiological effect of the ionizing irradiation. In order to cover the target with the highest possible conformality, without harming surrounding healthy tissues, optimized definition of the target is key. It is not only important to get information on the extent of the target with the highest possible resolution, but it is also important to assess the content, i.e., metabolic heterogeneity. The developments made in the field of diagnostic and functional radiology and nuclear medicine do allow to take advantage of the numerical information to individualize and adapt treatment prescription, even consider modification throughout the course of irradiation.

[Hypofractionated postoperative radiotherapy for breast cancer]

Postoperative adjuvant radiotherapy for breast cancer is usually applied in twenty five fractions of 2 Gy on the whole breast followed by a boost dose on the initial tumour site. Facing a continuous rise of the workload in radiotherapy departments, investigators have tried to reduce the burden of such a treatment approach both for the patients and the departments as available resources are not unlimited. These hypo-fractionated treatment schedules have been tested and validated in randomized controlled trials. Based on this evidence a new treatment algorithm has been built up as it has been shown that those schedules do provide similar levels of local control with comparable or an even lower risk of toxicity.

[Head and neck tumors: standards of care and new approaches]

We intend to review the general value of radiotherapy in the management of head and neck cancer. Our aim is to define a treatment protocol which is evidence-based and therefore of use in daily clinical practice. There is general agreement on the efficacy of the concomitant schedules combining radiotherapy and chemotherapy, both in the adjuvant setting as well as in the exclusive non-surgical approach. This however does not preclude further research aiming at optimizing the therapeutic index. As far as neoadjuvant chemotherapy is concerned, applied prior to radical local treatment, there are no conclusive data available which allows us to implement this treatment option in routine clinical practice. This approach deserves further investigations and patients should be entered in well designed prospective randomized trials.

[Ductal carcinoma in situ (DCIS): can radiotherapy be avoided?]

There is a never ending discussion on the need for radiotherapy after conservative breast surgery for DCIS (Ductal Carcinoma In Situ). It is true that adjuvant irradiation does not yield any difference in overall survival in the published randomized trials. However, postoperative irradiation after breast conserving surgery (BCS) has been shown to significantly reduce ipsilateral breast event (IBE), whether this is a DCIS recurrence or a recurrence with an invasive component. The real question is to define if there is a subgroup of patients for whom radiotherapy can be withheld without taking any significant local risk. Nowadays, we are not able to define such a subgroup as the possible selection criteria to avoid radiotherapy have never been validated within a well designed prospective randomized trial. Therefore, we think that there is no available evidence to avoid radiotherapy after BCS for DCIS. However, radiotherapy is not indicated after mastectomy.

Simultaneous alteration of de novo and salvage pathway to the deoxynucleoside triphosphate pool by (E)-2'-deoxy-(fluoromethylene)cytidine (FMdC) and zidovudine (AZT) results in increased radiosensitivity in vitro

To test whether a thymidine analog zidovudine (=AZT), is able to modify the radiosensitizing effects of (E)-2'-Deoxy-(fluoromethylene)cytidine (FMdC). A human colon cancer cell line Widr was exposed for 48 hours prior to irradiation to FMdC. Zidovudine was added at various concentrations immediately before irradiation. We measured cell survival and the effect of FMdC, AZT and FMdC + AZT on deoxynucleotide triphosphate pool. FMdC results in a significant increase of radiosensitivity. The enhancement ratios (ER =surviving fraction irradiated cells/surviving fraction drug treated and irradiated cells), obtained by FMdC or AZT alone are significantly increased by the combination of both compounds. Adding FMdC to AZT yields enhancement ratios ranging from 1.25 to 2.26. FMdC reduces dATP significantly, with a corresponding increase of TTP, dCTP and dGTP. This increase of TTP, dCTP and dGTP is abolished with the addition of AZT. Adding AZT to FMdC results in a significant increase of the radiosensitizing effect of FMdC. This combination appears to reduce the reactive enhancement of TTP, dCTP and dGTP induced by FMdC while it does not affect the inhibitory effect on dATP.

[Innovative technologies in radiation oncology]

At present, radiation oncology is again flourishing thanks to the development of highly accurate techniques as intensity modulated radiation therapy, stereotactic radiation therapy and hadrontherapy. These therapeutic modalities are made possible by the advent of image guided radiation therapy and respiratory gating that allows a better patient repositioning during the irradiation and between fractions. Nowadays, thanks to these recent technological advances, one can more easily conceive dose escalation, hypofractionation and combined treatment of radiation with sensitizing drugs and this together with a better protection of normal tissue aiming at, simultaneously, improved tumour control and better quality of life. This article describes these innovative technologies that, when integrated to other anti-tumoral therapeutic modalities, seem to be very promising.

Effect of timing of surgery on survival after preoperative hyperfractionated accelerated radiotherapy (HART) for locally advanced rectal cancer (LARC): is it a matter of days?

We intend to analyse retrospectively whether the time interval ("gap duration" = GD) between preoperative radiotherapy and surgery in locally advanced rectal cancer (LARC) has an impact on overall survival (OS), cancer specific survival (CSS), disease free survival (DFS) and local control (LC). Two hundred seventy nine patients with LARC were entered in Trial 93-01 (hyperfractionated accelerated radiotherapy 41.6 Gy/26 Fx BID) shortly followed by surgery. From these 250 patients are fully assessable. The median GD of 5 days was used as a discriminator. The median follow-up for all patients was 39 months. GD > 5 days was a significant discriminator for actuarial 5-years OS (69% vs 47%, p = 0.002), CSS (82% vs 57%, p = 0.0007), DFS (62% vs 41%, p = 0.0003) but not for LC (93% vs 90%, p = non-significant). In multivariate analysis, the following factors independently predict outcome; for OS: age, GD, circumferential margin (CM) and nodal stage (ypN); for CSS: GD, ypN and vascular invasion (VI); for DFS: CEA, distance to anal verge, GD, ypN and VI; for LC: CM only. Gap duration predicts survival outcome but not local control. The patients submitted to surgery after a median delay of more than 5 days had a significantly better outcome.

Preoperative hyper-fractionated accelerated radiotherapy (HART) in locally advanced rectal cancer (LARC) immediately followed by surgery. A prospective phase II trial

BACKGROUND AND PURPOSE

We aim to report on local control in a phase II trial on preoperative hyper-fractionated and accelerated radiotherapy schedule (HART) in locally advanced resectable rectal cancer (LARC). This fractionation schedule was designed to keep the overall treatment time (OTT) as short as possible.

PATIENTS AND METHODS

This is a prospective trial on patients with UICC stages II and III rectal cancer. The patients were submitted to a total dose of 41.6 Gy, delivered in 2.5 weeks at 1.6 Gy per fraction twice a day with a 6-h interfraction interval. Surgery was performed within 1 week after the end of irradiation. Adjuvant chemotherapy was delivered in a subset of patients.

RESULTS

Two hundred and seventy nine patients were entered and 250 are fully assessable, with a median follow-up of 39 months. The 5-years actuarial local control (LC) rate is 91.7%. The overall survival (OS) is 59.6%. The freedom from disease relapse (FDR) is 71.5%. Downstaging was observed in 38% of the tumors.

CONCLUSION

The actuarial LC at 5 years is 91.7%, although we are dealing with stages II-III LARC, mainly located in the lower rectum (median distance = 5 cm). The pattern of failure is dominated by distant metastases and treatment intensification will obviously require a systemic approach.

[Prevention of heterotopic ossification following prosthetic total hip replacement]

Heterotopic ossification, mostly of the hip, is a frequent complication after reconstructive surgery. Most common prophylactic therapies are non-steroidal anti-inflammatory medication (AINS) applied post-operatively and external radiotherapy (RT) administered in the pre- or post-operative setting. Both treatments proved to be efficient in several randomised clinical trials. Prevailing trend regarding RT is a treatment prior to surgery. It is appreciated by both physician and the patient because it is simple and comfortable. In this article, we present the literature linked to the subject together with the benefit and the inconvenience of both therapeutic methods.

Positive interactive radiosensitisation in vitro with the combination of two nucleoside analogues, (E)-2′-deoxy- 2′-(fluoromethylene) cytidine and iododeoxyuridine

(E)-2'-Deoxy-2'-(fluoromethylene) cytidine (FMdC), an inhibitor of ribonucleotide diphosphate reductase (RR), is a potent radiation-sensitiser acting through alterations in the deoxyribonucleoside triphosphate (dNTP) pool in the de novo pathway to DNA synthesis. The activity of thymidine kinase (TK), a key enzyme in the 'salvage pathway', is known to increase in response to a lowering of dATP induced by FMdC. Nucleoside analogues such as iododeoxyuridine (IdUrd) are incorporated into DNA after phosphorylation by TK. Radiation sensitisation by IdUrd depends on IdUrd incorporation. Therefore, we have investigated the radiosensitising effect of the combination of FMdC and IdUrd on WiDr (a human colon cancer cell-line) and compared it to the effect of either drug alone. We analysed the effects of FMdC and IdUrd on the dNTP pools by high-performance liquid chromatography, and measured whether the incorporation of IdUrd was increased by FMdC using a [(125)I]-IdUrd incorporation assay. The combination in vitro yielded radiation-sensitiser enhancement ratios of >2, significantly higher than those observed with FMdC or IdUrd alone. Isobologram analysis of the combination indicated a supra-additive effect. This significant increase in radiation sensitivity with the combination of FMdC and IdUrd could not be explained by changes in the dNTP pattern since the addition of IdUrd to FMdC did not further reduce the dATP. However, the increase in the radiation sensitivity of WiDr cells might be due to increased incorporation of IdUrd after FMdC treatment. Indeed, a specific and significant incorporation of IdUrd into DNA could be observed with the [(125)I]-IdUrd incorporation assay in the presence of 1 microM unlabelled IdUrd when combined with FMdC treatment.

[Prospective study of accelerated postoperative radiation therapy in patients with squamous-cell carcinoma of the head and neck]

PURPOSE

To assess the feasibility and efficacy of accelerated postoperative radiation therapy (RT) in patients with squamous-cell carcinoma of the head and neck (SCCHN).

PATIENTS AND METHODS

Between December 1997 and July 2001, 68 patients (male to female ratio: 52/16; median age: 60-years (range: 43-81) with pT1-pT4 and/or pN0-pN3 SCCHN (24 oropharynx, 19 oral cavity, 13 hypopharynx, 5 larynx, 3 unknown primary, 2 maxillary sinus, and 2 salivary gland) were included in this prospective study. Postoperative RT was indicated because extracapsular infiltration (ECI) was observed in 20 (29%), positive surgical margins (PSM) in 20 (29%) or both in 23 patients (34%). Treatment consisted of external beam RT 66 Gy in 5 weeks and 3 days. Median follow-up was 15 months.

RESULTS

According to CTC 2.0, acute morbidity was acceptable: grade 3 mucositis was observed in 15 (22%) patients, grade 3 dysphagia in 19 (28%) patients, grade 3 skin erythema in 21 (31%) patients with a median weight loss of 3.1 kg (range: 0-16). No grade 4 toxicity was observed. Median time to relapse was 13 months; we observed only three (4%) local and four (6%) regional relapses, whereas eight (12%) patients developed distant metastases without any evidence of locoregional recurrence. The 2 years overall-, disease-free survival, and actuarial locoregional control rates were 85, 73 and 83% respectively.

CONCLUSION

The reduction of the overall treatment time using postoperative accelerated RT with weekly concomitant boost (six fractions per week) is feasible with local control rates comparable to that of published data. Acute RT-related morbidity is acceptable.

[Endoluminal, cardiovascular radiotherapy: a new standard]

The treatment for cardiovascular disease, especially the treatment of coronary stenosis, has been continuously improving during the last decades. Routine use of angioplasty was improved by the use of coronary stenting further reducing cardiac morbidity. However, the incidence of restenosis after cardiovascular angioplasty remains high. The restenosis process is mainly explained by neointimal proliferation. Therefore, the utility of ionizing radiation has been systematically investigated in order to reduce proliferation of the neointimal tissue. Radiation therapy turns out to be a very efficient approach in reducing the rate of both de novo lesions as well as of instant restenosis. Recent clinical data from randomized trials confirm the utility of intracoronary radiation therapy and change the treatment standards in interventional cardiology.

Radiation therapy alone or combined surgery and radiation therapy in squamous-cell carcinoma of the penis?

To assess the prognostic factors and the outcome in patients with squamous-cell carcinoma of the penis, a retrospective review of 41 consecutive patients with non-metastatic invasive carcinoma of the penis, treated between 1962 and 1994, was performed. The median age was 59 years (range: 35-76 years). According to the International Union Against Cancer (UICC) 1997 classification, there were 12 (29%) T1, 24 (59%) T2, 4 (10%) T3 and 1 TX (2%) tumours. The N-classification was distributed as follows: 29 (71%) patients with N0, 8 (20%) with N1, 3 (7%) with N2 and 1 (2%) with N3. Forty-four per cent (n=18) of the patients underwent surgery: partial penectomy with (n=4) or without (n=12) lymph node dissection, or total penectomy with (n=1) or without (n=1) lymph node dissection. 23 patients were treated with radiation therapy alone, and all but 4 of the patients who were operated upon received postoperative radiation therapy (n=14). The median follow-up period was 70 months (range 20-331 months). In a median period of 12 months (range 5-139 months), 63% (n=26) of the patients relapsed (local in 18, locoregional in 2, regional in 3 and distant in 3). Local failure (stump in the operated patients, and the tumour bed in those treated with primary radiation therapy) was observed in 4 out of 16 (25%) patients treated with partial penectomy +/-postoperative radiotherapy versus 14 out of 23 (61%) treated with primary radiotherapy (P=0.06). 15 (83%) out of 18 local failures were successfully salvaged with surgery. In all patients, 5- and 10-year survival rates were 57% (95% confidence interval (CI), 41-73%) and 38% (95% CI, 21-55%), respectively. The 5-year local and locoregional rates were 57% (95% CI, 41-73%) and 48% (95% CI, 32-64%), respectively. In patients treated with primary radiotherapy, 5- and 10-year probabilities of surviving with penis preservation were 36% (95% CI, 22-50%) and 18% (95% CI, 2-34%), respectively. In multivariate analyses, survival was significantly influenced by the N-classification, and surgery was the only independent factor predicting the locoregional control. We conclude that, in patients with squamous-cell carcinoma of the penis, local control is better in patients treated with surgery. However, there seems to be no difference in terms of survival between patients treated by surgery and those treated by primary radiotherapy +/-salvage surgery, with 39% having organ preservation.

Fractionated irradiation combined with carbogen breathing and nicotinamide of two human glioblastomas grafted in nude mice

This study addressed the potential radiosensitizing effect of nicotinamide and/or carbogen on human glioblastoma xenografts in nude mice. U-87MG and LN-Z308 tumors were irradiated with either 20 fractions over 12 days or 5 fractions over 5 days in air-breathing mice, mice injected with nicotinamide, mice breathing carbogen, or mice receiving nicotinamide plus carbogen. The responses to treatment were assessed using local control and moist desquamation. In U-87MG tumors, the enhancement ratios (ERs) at the radiation dose required to produce local tumor control in 50% of the treated mice (TCD(50)) with nicotinamide and/or carbogen ranged from 1.13 to 1.24 for irradiation in 20 fractions over 12 days. In LN-Z308 tumors, the ERs at the TCD(50) with nicotinamide and/or carbogen ranged from 1.22 to 1.40 for irradiation in 5 fractions over 5 days and from 1.11 to 1.30 in 20 fractions over 12 days, respectively. Skin injury was slightly enhanced, with ERs ranged from 1.06 to 1.15 when radiation was combined with carbogen and/or nicotinamide. Thus carbogen and nicotinamide can slightly improve the radiation response of human glioblastoma xenografts.

A survey on staging and treatment in uterine cervical carcinoma in the Radiotherapy Cooperative Group of the European Organization for Research and Treatment of Cancer

BACKGROUND

The treatment outcome of advanced stage uterine cervical carcinoma remains unsatisfactory. In order to elaborate a novel trial within The Radiotherapy Cooperative Group (RCG) of the European Organization for Research and Treatment of Cancer (EORTC), we conducted a survey in 1997-1998 to determine the variability of pre-treatment assessment and treatment options. The variability of choosing surgery, defined radiation therapy techniques and chemotherapy are investigated, as well as the center's choices of future treatment strategies.

METHODS

Fifty two of 81 RCG centers from the RCG have participated in the survey. As one would expect, there is a large variation in the techniques used for pretreatment evaluation and treatment options. There is no 'standard' for reporting acute and late side effects. Chemotherapy is used neither systematically nor uniformly, and some centers continue to use neadjuvant chemotherapy modalities.

RESULTS

Furthermore, the survey reveals that there is a strong demand for the reduction of overall treatment-time, for clinical investigation of novel combined modality treatment strategies, especially chemo-radiation therapy, and also for the use of new radiation sensitizers.

CONCLUSION

We conclude that a more homogeneous approach to the pretreatment evaluation as well as treatment techniques is required in order to allow adequate quality control in any future trial of the RCG in the EORTC.

Effect of grade on disease-free survival and overall survival in FIGO stage I adenocarcinoma of the endometrium

OBJECTIVE

To analyse the effect of differentiation on disease-free survival (DFS) and overall survival (OS) in patients with stage I adenocarcinoma of the endometrium.

PATIENTS AND METHODS

From 1979 to 1995, 350 patients with FIGO stage IA-IC with well (G1), moderately (G2) or poorly (G3) differentiated tumors were treated with surgery and high dose-rate brachytherapy with or without external radiation. Median age was 65 years (39-86 years).

RESULTS

The 5-year DFS was 88+/-3% for the G1 tumors, 77+/-4% for the G2 tumors, and 67+/-7% for the G3 tumors (P=0.0049). With regard to the events contributing to DFS, the 5-year cumulative percentage of local relapse was 4.6% for the G1 tumors, 9.0% for the G2 tumors, and 4.6% (P=0.027) for the G3 tumors. Cumulative percentage of metastasis was 1.4, 6.3 and 7.2% (P<0.001), respectively, whereas percentages of death were 6.0, 7.9 and 20.7% (P<0.001). The 5-year OS was 91+/-3, 83+/-4 and 76+/-7%, respectively (P=0.0018). In terms of multivariate hazard ratios (HR), the relative differences between the three differentiation groups correspond to an increase of 77% of the risk of occurrence of either of the three events considered for the DFS (HR=1.77, 95% CI [0.94-3.33]), (P=0.078) for the G2 tumors and of 163% (HR=2.63, 95% CI [1.27-5.43]), (P=0.009) for the G3 tumors with respect to the G1 tumors. The estimated relative hazards for OS are, respectively, in line with those for DFS: HR=1.51 (P=0.282) for the G2 tumors; and HR=3.37 (P=0.003) for the G3 tumors.

CONCLUSION

Patients with grade 1 tumors are those least exposed to either local relapse, metastasis, or death. In contrast patients with grade 2 tumors seem to be at higher risk of metastasis, whereas patients with grade 3 tumors appear at higher risk of death. Since we have looked at the first of three competing events (local relapse, metastasis and death), this suggests that patients with grade 3 tumors probably progress to death so fast that local relapse, if any, cannot be observed.

Sensitizing human cervical cancer cells In vitro to ionizing radiation with interferon beta or gamma

Human cervical cancer is often associated with human papilloma virus (HPV). HPV products, such as the oncoproteins E6 and E7, are known to disrupt the function of TP53 (formerly known as p53). The protein encoded by the TP53 gene plays a central role in managing cellular damage. Interferons are known to down-regulate E6/E7 and may therefore restore TP53 function and influence radiation sensitivity. We investigated whether IFNB or IFNG, at various concentrations (2- 300 IU/ml) and for a range of durations of exposure (from 48 h before to 8 h after irradiation), were able to modify the radiation response of HeLa, C4-1, Me-180, C33-A and SiHa cells. In parallel to the clonogenic assays, we analyzed the effect on the mRNA that encodes IFNB and E6 by Northern blotting in the same experimental conditions. A significant change in the initial slope of the dose-response curve was observed more consistently with IFNB than with IFNG. No changes in the mRNA or protein level of TP53 and E6 could be detected. Thus other mechanisms of action need to be investigated to explain radiosensitization with recombinant IFNB in cells of human cervical cancer cell lines.

The ribonucleoside diphosphate reductase inhibitor (E)-2'-deoxy-(fluoromethylene)cytidine as a cytotoxic radiosensitizer in vitro

(E)-2'-Deoxy-(fluoromethylene)cytidine (FMdC) is known as an inhibitor of ribonucleoside diphosphate reductase, a key enzyme in the de novo pathway of DNA synthesis. FMdC was tested as a modifier of radiation response in vitro on a human colon carcinoma cell line (WiDr), and the observed radiosensitization was confirmed on two human cervix cancer cell lines (C33-A and SiHa). Using the clonogenic assay, the effect ratio (ER) at a clinically relevant dose level of 2 Gy was 2.10 (50 nM FMdC), 1.70 (30 nM FMdC), and 1.71 (40 nM FMdC) for the three cell lines WiDr, C33-A, and SiHa, respectively. A more detailed analysis of the importance of timing and concentration of FMdC was done on the WiDr cell line alone, yielding an increased ER(2Gy) with increasing concentration and duration of exposure to the drug, ranging from 1.0 (6 h) to 1.8 (72 h) at 30 nM FMdC and from 1.2 (6 h) to 3.5 (24 h) at 300 nM. We investigated the effect of FMdC on the cellular deoxynucleotide triphosphate pool in WiDr cells and demonstrated a marked depletion of dATP and a significant rise of TTP levels. Cell cycle analysis showed early S-phase accumulation induced by FMdC alone, G2-M block induced by irradiation alone, and an increased accumulation of cells in G2-M if both modalities are used. Our data suggest that FMdC is a radiation response modifier in vitro on different cancer cell lines. The observed radiosensitization may in part be explained by alteration of the deoxynucleotide triphosphate pool, which is consistent with the effect of FMdC on ribonucleoside diphosphate reductase.