[IMRT combined to IGRT: increase of the irradiated volume. Consequences?]

Image-guided radiotherapy (IGRT) combined or not with intensity-modulated radiation therapy (IMRT) are new and very useful techniques. However, these new techniques are responsible of irradiation at low dose in large volumes. The control of alignment, realignment of the patient and target positioning in external beam radiotherapy are increasingly performed by radiological imaging devices. The management of this medical imaging depends on the practice of each radiotherapy centre. The physical doses due to the IGRT are however quantifiable and traceable. In one hand, these doses appear justified for a better targeting and could be considered negligible in the context of radiotherapy. On the other hand, the potential impact of these low doses should deserve the consideration of professionals. It appears important therefore to report and consider not only doses in target volumes and in "standard" organs at risk, but also the volume of all tissue receiving low doses of radiation. The recent development of IMRT launches the same issue concerning the effects of low doses of radiation. Indeed, IMRT increases the volume of healthy tissue exposed to radiation. At low dose (<100mGy), many parameters have to be considered for health risk estimations: the induction of genes and activation of proteins, bystander effect, radio-adaptation, the specific low-dose radio-hypersensitivity and individual radiation sensitivity. With the exception of the latter, the contribution of these parameters is generally protective in terms of carcinogenesis. An analysis of secondary cancers arising out of field appears to confirm such notion. The risk of secondary tumours is not well known in these conditions of treatment associating IMRT and IGRT. It is therefore recommended that the dose due to imaging during therapeutic irradiation be reported.