RESUMEN
PURPOSE: The standard treatment of T2-T3 rectal adenocarcinoma is radical proctectomy by total mesorectal excision often combined with some neoadjuvant treatment. To reduce morbidity of this surgery, organ preservation strategy using various combination of radiotherapy, chemotherapy and local excision is gaining interest. Some randomized trials have proven the feasibility of such approaches. The OPERA trial demonstrated, for T2 T3<5cm diameter low-middle rectum, that a contact X-ray brachytherapy boost of 90Gy in three fractions over 4 weeks was able to achieve a planned organ preservation in 81% of patients at 3years with 97% success for tumour smaller than 3cm treated with contact X-ray brachytherapy boost first. To try to expand organ preservation to larger tumours we set up a feasibility trial in T2-T3 tumours using total neoadjuvant treatment and a contact X-ray brachytherapy boost. MATERIAL AND METHOD: The trial was approved by the institutional review board of Nice. Inclusion criteria were operable patients, 75years or less, adenocarcinoma of the low-middle rectum staged T2c-T3N0 larger than 3.5cm and less than 6cm in diameter or T2-T3N1 less than 6cm in diameter. Treatment started in all cases with neoadjuvant chemotherapy associating 5-fluoro-uracile, irinotecan and oxaliplatin ('folfirinox' regimen, four to six cycles). In case of good tumour response after four cycles, a contact X-ray brachytherapy boost (delivering 90Gy in three fractions) was given followed by chemoradiotherapy (external beam radiotherapy delivering 50Gy, with concurrent capecitabine). After six cycles if only a partial response (tumour still larger than 3cm) was seen, chemoradiotherapy was given and contact X-ray brachytherapy boost was delivered after that. At the end of this total neoadjuvant treatment a watch and wait strategy was decided in case of clinical complete response or radical proctectomy by total mesorectal excision for partial response. RESULTS: Between July 2019 and October 2022, 14 patients were included; median age was 66years (range: 51-77years), there were nine male and five female, two T2 N1 tumours, seven T3N0, and five T3N1, all were M0. Median tumour diameter was 40mm (range: 11-50mm); three tumours had a circumferential extension greater than 50%. Seven patients received four folfirinox cycles and seven had six cycles. Contact X-ray brachytherapy boost was given during folfirinox chemotherapy before chemoradiotherapy in 11 patients (and after in three). The tolerance was good, with no grade 4-5 toxicity. The main grade 3 early toxicity was in relation with the folfirinox regimen. A clinical complete response was seen in 12 patients at the end of the total neoadjuvant treatment (85%). All these patients are alive and have preserved their rectum with a mean follow-up time of 17.8months (range: 6-48months) and a good bowel function (low anterior rectal resection syndrome score below 30). The main contact X-ray brachytherapy boost toxicity was radiation ulceration in three patients that usually healed within 6 months, sometimes necessitating hyperbaric oxygen. CONCLUSION: The preliminary results of this feasibility study show that early tolerance of these intensive total neoadjuvant treatment is compatible with an acceptable toxicity. The high rate of organ preservation in this intermediate group of T2-T3 tumours is encouraging and is a good argument to start the next randomized TRESOR trial that will aim at achieving a 65% of 3-year survival with organ preservation in this intermediate tumour group.
Asunto(s)
Adenocarcinoma , Protocolos de Quimioterapia Combinada Antineoplásica , Braquiterapia , Capecitabina , Quimioradioterapia , Estudios de Factibilidad , Fluorouracilo , Irinotecán , Terapia Neoadyuvante , Oxaliplatino , Neoplasias del Recto , Humanos , Neoplasias del Recto/terapia , Neoplasias del Recto/radioterapia , Neoplasias del Recto/patología , Braquiterapia/métodos , Fluorouracilo/uso terapéutico , Quimioradioterapia/métodos , Adenocarcinoma/terapia , Adenocarcinoma/radioterapia , Adenocarcinoma/patología , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Oxaliplatino/uso terapéutico , Capecitabina/uso terapéutico , Femenino , Masculino , Irinotecán/uso terapéutico , Leucovorina/uso terapéutico , Tratamientos Conservadores del Órgano/métodos , Estadificación de NeoplasiasRESUMEN
PURPOSE: Evaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35Gy in 5 fractions. MATERIAL AND METHODS: From June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35Gy in 5 fractions of 7Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT. RESULTS: A total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient. CONCLUSIONS: HSRT delivering 35Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.
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Adenoma , Neoplasias Encefálicas , Neoplasias Hipofisarias , Radiocirugia , Adenoma/diagnóstico por imagen , Adenoma/radioterapia , Adenoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Encefálicas/radioterapia , Humanos , Persona de Mediana Edad , Neoplasias Hipofisarias/diagnóstico por imagen , Neoplasias Hipofisarias/radioterapia , Neoplasias Hipofisarias/cirugía , Hipofraccionamiento de la Dosis de Radiación , Radiocirugia/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenAsunto(s)
Proteínas Bacterianas/biosíntesis , Brotes de Enfermedades/prevención & control , Departamentos de Hospitales , Control de Infecciones/métodos , Infecciones por Klebsiella/epidemiología , Infecciones por Klebsiella/prevención & control , Klebsiella pneumoniae/enzimología , Medicina Física y Rehabilitación , beta-Lactamasas/biosíntesis , Portador Sano/microbiología , Femenino , Francia/epidemiología , Humanos , MasculinoRESUMEN
INTRODUCTION: Possible admission to a PRM unit of a hemiplegic patient equipped with a left ventricular assistance device (LVAD) may constitute a cause for concern. We are reporting our observation on the subject. OBSERVATION: A 30-year-old hemiplegic patient presented with left hemiparesis secondary to a right middle cerebral artery (MCA) ischemic stroke having occurred during cardiopulmonary arrest. Persistence of major left ventricle dysfunction necessitated installation on 8 November 2011 of a mono-ventricular HEART-MATE II assistive device. Possible later recourse to cardiac transplantation would depend on clinical development. When admitted to a PRM unit on 18 January 2012, the patient presented with left hemiparesis and cognitive disorders. Virtually all members of the attendant medical and paramedical team were given instruction on the functioning of electrical power assistance systems. In spite of the complexity of the logistics, and notwithstanding the difficulty of managing potentially worrisome medical problems, multidisciplinary rehabilitation efforts were successful. The patient's improved condition led to the decision to undertake heart transplantation, which was carried out on 27 October 2012. DISCUSSION AND CONCLUSION: This observation illustrates the undeniable role of PRM in decision-making and, more generally, in the opportunities that may arise in sensitive and challenging situations.
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Corazón Auxiliar , Hemiplejía/rehabilitación , Disfunción Ventricular Izquierda/rehabilitación , Adulto , Trasplante de Corazón , Hemiplejía/complicaciones , Humanos , Infarto de la Arteria Cerebral Media/complicaciones , Masculino , Grupo de Atención al Paciente , Disfunción Ventricular Izquierda/complicaciones , Disfunción Ventricular Izquierda/terapiaRESUMEN
An investigation of x-ray spectral reconstruction from transmission data by direct resolution of the matrix system A*F = T (using spectral algebra formalism) has been previously presented. The resolution has been done with simulated spectrum. In this paper, the method on a real case of a 12 MV photon beam was tested. A special study of the setup has been made to estimate and reduce the experimental errors that could alter the results. In order to convert F(E) (a fraction of the signal due to a photon of energy E) into photon fluence phi (E), the chamber energy response R(E) has been studied and an approximated analytical function for its representation was proposed. Spectra reconstructed from different transmission data using different attenuators, buildup caps, and ionization chambers have been compared to verify the uniqueness of the reconstructed spectra. To test the validity of the results, dosimetric values, such as Depth Dose Data have been calculated, from our spectrum, using a specific code developed by Kosunen et al. The results show a good agreement between the measured and calculated data.
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Aceleradores de Partículas , Radiometría/métodos , Modelos Estructurales , Dosis de Radiación , Dispersión de Radiación , AguaRESUMEN
X-ray spectral reconstruction from transmission data was investigated by direct resolution of the matrix system A*F = T using spectral algebra. Theoretical, numerical, and physical conditions were studied to obtain the physical solution of the problem. It is shown why the least-square-fitting methods may not give good results for high energy photon spectra above several MeV. The proposed method does not need a preshaped starting spectrum. Simulation studies have been made with arbitrary but realistic spectra of different shapes and maximum energies simulating the reality and using different materials as attenuator like carbon, aluminum, and even water. Conditions on the attenuator choice to obtain the physical solution of the system are given. The reconstruction method provides good results in the radiotherapy energy range despite measurement errors. The computation is quick and implementable on a personal computer with a mathematical coprocessor.