Résultats du traitement du médulloblastome à Casablanca de 2000 à 2012

PurposeTo describe the therapeutic results, with the aim to contribute to improving the care of patients with medulloblastoma.Patients and methodsA retrospective study of 69 cases of medulloblastoma collected in the university hospital Ibn Rochd of Casablanca between 2000 and 2012.ResultsFifty-three children with an average age of 9 years and 16 adults with an average age of 32.4 years were included in the study. Thirty-seven children and eight adults suffered from a high-risk tumour. The radiotherapy was received by all patients with a mean dose of 36 Gy to the whole brain and 54 Gy in the posterior fossa. All patients in the paediatric group and 10 patients in the adult group received concomitant chemotherapy, 44 children and four adults received adjuvant chemotherapy. Tumour recurrence was observed in 17 children after a mean follow-up period of 38 months. These recurrences were observed in five adults after a mean follow-up period of 42 months. The posterior fossa was the main site of relapses. Overall survival was 77.7% for the children and 61% for the adults. Overall survival was better (70% versus 25%) when the interval between radiotherapy and surgery was less than 40 days in the paediatric group. The recurrence rate was significantly higher for the high-risk group: 41% versus 13% for the standard risk. In the adult group, overall survival differences according to the risk group were significant (100% for the standard risk versus 37.5% for the high risk).ConclusionThe overall survival and recurrences rate obtained are encouraging. The risk group and time between surgery and radiotherapy were prognostic factors with significant impact on survival depending on the age group. We recommend reducing these times to improve therapeutic results.     

Résultats thérapeutiques du cancer du cavum : y a-t-il une différence entre enfants et adultes ?

PurposeTo compare therapeutic results of nasopharyngeal carcinoma between adults and children.Patients and methodsThree hundred and seventy seven patients with nasopharyngeal carcinoma received a radiotherapy between 1993 and 2007. Sixty-nine of them were 20 years old or less. Two hundred and sixty eight patients received a chemotherapy (neoadjuvant or concomitant).ResultsOverall survival and disease-free survival at 5 years were 67 % and 59.4 % in all patients, respectively. Overall survival rates at 5 years in children and adults were 66 % and 64 %, respectively (P = 0.17), disease-free survival rates at 5 years were 66 % and 57 %, respectively (P = 0.17). Local failures occurred more frequently in adults than in children (1.4 % versus 14 %). However, metastatic events were frequently seen in children. Late toxicities were important in children, xerostomia was the most common one.ConclusionDespite locally advanced disease in children, therapeutic results were better than in adults but not statistically significant. The use of treatment combination (chemotherapy and radiotherapy) in juvenile nasopharyngeal carcinoma may explain our findings.     

Association du double blocage de HER2 et radiothérapie dans la prise en charge du cancer du sein exprimant HER2

PurposeThe tolerance of the concurrent use of radiotherapy, pertuzumab and trastuzumab is unknown. The purpose of this study was to evaluate the toxicity of this association in patients treated for HER2 positive metastatic and/or locally recurrent unrespectable breast cancer.Material and methodsA retrospective study was performed in our institution for all consecutive patients treated with concurrent irradiation, pertuzumab and trastuzumab. The radiotherapy was performed while pertuzumab and trastuzumab were administrated as a maintenance treatment at the dose of 420 mg (total dose) and 6 mg/kg respectively every 3 weeks without chemotherapy. Toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Left ventricular ejection fraction (LVEF) was measured at baseline and then every 3–4 months.ResultsWe studied 77 patients. treated in between 2013 and 2019 with median follow-up of 38 months (range 0–264 months). Median age was 53 years (33–86). There were 50 patients (64.9%) with metastatic and 27 patients (35.1%) with recurrent disease. All patients received docetaxel followed by P–T as first line treatment and they received 34 cycles (10–85) of pertuzumab and trastuzumab. All patients experienced partial or complete response according to RECIST criteria. Irradiation volumes were whole breast (41 patients, 53.2%) and chest wall (29 patients, 37.7%) at a dose of 50 Gy with a median duration of 39 days. Radiotherapy of lymph nodes was performed in 53 patients (68.8%) as following: supraclavicular–infraclavicular and axillary lymph nodes in 52 patients (67.5%), and internal mammary nodes in 31 patients (40.3%). For 20 patients. (26.0%) radiotherapy was palliative: bone irradiation (12 patients, 15.6%), whole-brain radiotherapy (2 patients, 2.6%), cerebral metastasis irradiation (6 patients). As early toxicity we observed: radio dermatitis as following: 36 patients (46.8%) presented grade I, 17 patients (22.1%) presented grade II, and 3 patients (3.9%) presented grade III. One patient (1.3%) presented grade II esophagitis. One patient (1.3%) presented asymptomatic decrease of LVEF during treatment and 6 patients (7.7%) presented a decrease of LVEF. There was no radiation-induced pneumonitis. As late toxicity, we observed 1 (1.3%) case of grade I and 1 (1.3%) with grade II telangiectasia. There was 1 case (1.3%) of grade III cardiac toxicity, 8 months after the concurrent treatment.ConclusionThe concurrent use of radiotherapy, pertuzumab and trastuzumab is feasible with good tolerance. Larger prospective data with longer follow-up is needed to confirm these results.     

État des lieux du traitement multidisciplinaire du cancer du rectum

In the last 10 years, a number of important European randomized published studies investigated the optimal management of rectal cancer. In order to define an evidence-based approach of the clinical practice based, an international consensus conference was organized in Italy under the endorsement of European Society of Medical Oncology (ESMO), European Society of Surgical Oncology (ESSO) and European Society of Therapeutic Radiation Oncology (ESTRO). The aim of this article is to present highlights of multidisciplinary rectal cancer management and to compare the conclusions of the international conference on ‘Multidisciplinary Rectal Cancer Treatment: looking for an European Consensus’ (EURECA-CC2) with the new National Comprehensive Cancer Network (NCCN) guidelines.     

Curiethérapie du cancer prostatique : haut débit ou bas débit de dose ?

Low-dose brachytherapy for prostate cancer was actually proposed in the first years of the XXth century. Its modern version (iodin 125 or palladium 103 permanent implants) now benefits from some 15 years of experience in a few pioneer centers, with very satisfactory results in term of efficacy/toxicity ratio. More recently, a high-dose rate (HDR) prostate brachytherapy technique has been introduced. Initially utilized essentially as a "boost" irradiation combined with external radiotherapy, it is now being proposed by some authors as a monotherapy for selected localized prostate cancers. Although sophisticated radiobiological models have been proposed to compare those two dose-rates, they are not considered to be valid and reliable enough to compare such different irradiation schemes (A low-dose rate irradiation lasting several months vs a few high-dose fractions given in a few days). When it comes to the implantation techniques, it seems that most of the technical problems which arose for both schemes have been solved, and that the experience of a given team is now much more important than the technique itself. Clinical results cannot be reliably compared so far, the follow-up of the patients treated by HDR brachytherapy being usually shorter, and the patients treated with HDR usually presenting with more advanced lesions. Radioprotection features are very different, with no accident reported for low-dose rate implants. For HDR no irradiation is given at all to the staff and family during a normal application, but one has to face the threat of manipulating high activity sources, with a few accidents or incidents reported in the literature. Financial studies show that for more than 20-30 patients treated in a year, HDR is more economical, although a decrease in the cost of the seeds could change the picture. In conclusion, for low-risk localized prostate cancer, it does not appear reasonable to give up using a low-dose rate technique, which proved to be both efficient and poorly toxic. This actually corresponds to the recent GEC-ESTRO recommendations. For the other patients, a dose escalation is appealing: this could be performed using brachytherapy (LDR or HDR), with or without hormonotherapy. Several trials are ongoing or will be activated very soon to try and answer.     

Chimioradiothérapie préopératoire du cancer du rectum : expérience d’un centre

PurposeIn recent decades, the management of rectal cancer has been significantly improved by optimizing the surgical treatment with the total mesorectal excision and the development of neoadjuvant radiotherapy with or without chemotherapy. In this study, we investigated the impact of changes in practice over a period of 15 years in an expert centre.Patients and methodsA monocentric study was conducted retrospectively on cT3-resectable T4 patients who received chemoradiotherapy for a locally advanced rectal adenocarcinoma between 1993 and 2008. We studied sphincter preservation, pathological complete response (ypT0), survival, and toxicities by different concomitant chemotherapy and treatment period.ResultsAmong the 179 patients who had a chemoradiotherapy, 56.4% were received concomitant 5-fluoro-uracil-leucovorin, 28.5% with concomitant capecitabine, and 15.1% with concomitant oxaliplatin and capecitabine. The average dose of radiotherapy was 45 Gy (25 × 1.8 Gy). Five-year disease-free survival was 74.3% and overall survival 68.8%. The rate of local recurrence and distant metastases were 6.1 and 23.6%. In multivariate analysis, concomitant chemotherapy oxaliplatin and capecitabine improved the pathological complete response rate (ypT0; capecitabine: 6%, 5-fluoro-uracil-leucovorin: 10.3%, capecitabine-oxaliplatin: 22.2%), but not significantly (P = 0.12) and with more toxicities, and treatment interruptions. Sphincter preservation rate was not improved significantly during the study period (1993–2004 vs. 2005–2008), but disease-free survival improved from 72.2% up to 87.5% (P = 0.03).ConclusionOur results are consistent with those published in the literature. Concomitant chemotherapy with 5-fluoro-uracil or capecitabine remains the standard scheme. Upfront chemotherapy, before chemoradiotherapy, should be investigated with regard to the predominance of metastasis.     

Carcinome mucineux du sein : profil clinique,biologique et évolutif

PurposeMucinous carcinoma of the breast accounts for 1 to 4% of all breast cancer. There are two histological subtypes: mixed mucinous carcinoma, where the ductal carcinoma is associated with the colloid component, and pure mucinous carcinoma, with a favorable prognosis, where the mucus surrounds the tumour tissue and constitutes a mechanical barrier limiting cell invasion and making this form less aggressive. Our study aimed to determine retrospectively the main epidemiological, clinical, biological, and therapeutic features, as well as the prognosis of this rare form of breast carcinoma.Materials and methodsThe authors report 32 cases of mucinous carcinoma of the breast diagnosed in Mohammed-VI centre for cancer treatment in Casablanca.ResultsThe average tumour size was 4.5 cm (0.5–7 cm). We found ten positive lymph node dissections, seven of them were of mixed mucinous carcinoma with a tumour size ranging between 4 and 7 cm. Mucinous carcinoma was pure in 16 cases, mixed in 14 and a neuroendocrine differentiation was found in two cases. Most tumours were of an intermediate histological grade (n = 19) with positive hormonal receptors (68%). After a mean follow-up of 30 months, complete remission was maintained in 92% of evaluable patients.ConclusionMucinous carcinoma is a rare type of breast cancer, with a favourable prognosis for the pure form.     

Profil moléculaire du carcinome micropapillaire invasif du sein

Background

Invasive micropapillary carcinoma of the breast is a rare and aggressive histological variant of breast carcinoma. The new molecular classification of breast cancers distinguishing five subtypes, which are characterized by distinct molecular and immunohistochemical features as well as the histological one.

Aims of study

Define the molecular characteristics of invasive micropapillary carcinoma of the breast.

Methods

This is a retrospective review, from 2002 to 2008, included 7 cases of invasive micropapillary carcinoma of the breast diagnosed at the Department of Pathology, Farhat Hached hospital, Sousse, Tunisia. The clinico-pathological features, treatment modalities as well as immunohistochemical features patient??s outcome were recorded.

Results

The mean age of patients was 43.7 years (30?C63 years). Nodular tumefaction was the most common presenting symptom (6 cases) and inflammatory breast in one case. We found visceral metastases (liver) in one case. Five patients underwent surgery, in association with neoadjuvant chemotherapy in 3 cases and adjuvant chemotherapy in 2 cases. These patients underwent post-operative radiotherapy. Tumor size ranged from 10 to 160 millimeters. We found three tumors with histologic grade II, two tumors with grade III and one tumor with grade I. Lymphatic invasion and lymph node metastases were seen respectively in 3 and 4 cases. Estrogen receptors were expressed in 4/7 cases and progesterone receptors were expressed in 5/7 cases. Her 2 was expressed in 2/7 cases, CK5/6 and EGFR were negative in all cases. The Ki-67 was positive in 3 cases. Four cases have a luminal A profile, one case a luminal B profile, one case Her 2 profile and one case ??normal-breast-like?? profile.

Conclusion

Invasive micropapillary carcinoma of the breast is a rare and aggressive histological variant of breast carcinoma which has a heterogeneous molecular profile; further study is required to confirm these constatations.     

Actualité sur la chirurgie robotique du cancer du rectum

The use of robotics in rectal cancer surgery is relatively new. Several teams have reported on their experience with favorable early outcomes. We have reviewed the main publications on this topic and reported our own preliminary experience.     

Quelle RCMI ? Du « step and shoot » au VMAT : point de vue du physicien

Intensity-modulated radiation therapy (IMRT) is essential to have a dose distribution matching with the planning target volume (PTV) in case of concave-shape target. Today IMRT delivery techniques with linear accelerator can be divided into two classes: techniques with fixed gantry, called “step and shoot” (S&S) and “sliding window” (SW), and rotational techniques, called intensity modulated arc therapy (IMAT) and volumetric modulated arc therapy (VMAT). We discuss about constraints for IMRT implementation from dosimetric planning to treatment delivery. We compare S&S and VMAT performances concerning dose distribution quality, efficiency and delivery time. We describe quality controls that must be implemented and the methods for analysis and follow-up performances. VMAT tends to yield similar dose distribution to MRT with fixed gantry. VMAT also decreases monitor units as well as treatment delivery time to less than 5 minutes. However, VMAT is an IMRT technique more difficult to master than S&S technique because there are more variable parameters.     

Fonction rénale et chirurgie du cancer du rein

Although radical nephrectomy is still practiced in many patients with large renal tumors, oncology and nephrology arguments for kidney-sparing approach for small renal masses has taken over this first. Indeed, partial nephrectomy provides equivalent oncologic results while preserving renal function and thereby limit morbidity and cardiovascular mortality related to chronic kidney disease. In addition, patients who develop kidney cancer often have medical comorbidities that may affect renal function, such as diabetes and hypertension. Histological examination of renal tissue adjacent to the tumor showed significant pathological changes in the majority of patients. For elderly patients or patients with comorbidities, active surveillance allows kidney-sparing approach with extremely low rates of progression and metastasis of cancer disease. Despite these significant advances in understanding for the treatment of small renal masses, partial nephrectomy remains underused. Better management must take into account the preservation of renal function in order to increase overall survival. A strategy for the systematic evaluation of renal function in patients with CR, with multidisciplinary staff (nephrologist urologist and oncologist), is therefore highly desirable.     

Personnalisation de la dose,du volume et du fractionnement de la radiothérapie du sein

Randomized trials demonstrated similar overall survival between mastectomy and breast-conservative surgery followed by adjuvant radiation therapy. Breast-conservative surgery, with adjuvant radiation therapy, with or without neoadjuvant systemic therapy has become the standard of care for women with early or locally advanced breast cancer. Nevertheless, certain cardiac, lung or cutaneous toxicities may alter the long-term body image and the quality of life of a limited number of patients who consider having had “overtreatment” or treatment outside the best knowledge of science. In case of low-risk breast cancer, several trials have evaluated the carcinologic outcome in absence of radiation therapy after breast-conservative surgery. Local recurrences increased in case of breast-conservative surgery alone but without impact on overall survival. Multiple debates have emerged in order to select the most appropriate evaluation criteria. Finally, a large consensus has considered that reducing local recurrences is important but with modern technologies and after identifying patients of individual radiosensitivity. Indeed, in case of a low absolute risk of local recurrence, radiation therapy techniques have been developed to allow a focal treatment especially for patients with high risk of developing late effects. This kind of compromise takes into account the reduction risk of local recurrences but also the probability of developing radiation-induced cutaneous sequelae. In the same way, for patients considered at high risk of recurrence, the huge volumes need specific techniques to better cover the targets while protecting the surrounding critic organs such as heart and lung. Intensity-modulated radiation therapy and the local high boost may help to decrease local recurrences of these more extended and aggressive diseases while considering the individual radiosensitivity that paves the way of long-term sequelae. In this article, we detail a personalized approach of breast radiation therapy considering the absolute risk of local recurrences and the probability of radiation-induced toxicity appearance.     

Implications radiobiologiques de la classification moléculaire des cancers du sein : présent ou avenir ?

Breast cancer treatment guidelines are based on usual prognostic factors such as size, histological grade, axillar lymph node involvement, expression of hormonal receptors. The intrinsic molecular classification is giving additional information over clinical and pathological features. Predictive models for systemic relapse have been established and are currently under clinical investigation to determine precisely when chemotherapy is needed. This review will look after the implications of this classification in terms of radiobiology: on one hand, we will look if this classification helps for loco-regional relapse prediction and on the other hand, if it is able to change the radiotherapy schedule within the molecular classification.     

Carcinome colloïde pur du sein : étude anatomoclinique de sept cas

PurposeBreast mucinous carcinoma is a particular histological form characterized by the extracellular production of mucus. The pure form is rarely reported and its prognostic is better than the other types of the breast cancer. The aim of the present study was to discuss the various anatomoclinical, therapeutic aspects and the prognostic factors of the pure mucinous carcinoma of the breast.Patients and methodsWe report seven cases diagnosed over a period of 11 years (1993-2003) in the laboratory of anatomy and pathological cytology of the university hospital of Sfax. A review of the clinical files with immunohistochemistry study (hormonal receptor, synaptophysine, chromogranine, Bcl2, Ki67, P53 and Her-2/neu (C-erbB-2)) were carried out for all the cases.Resultspure colloid carcinoma of the breast accounted for 0,5% of the whole of the breast cancers. The average age of patients was 69 years. At the time of the diagnosis, four tumours were classified T4, one T3, two T2, two N1 and one N3; no patient had presented metastasis (M0) according to pTNM classification. The echomammography showed regular contours mass in four cases. The anatomopathological study showed that the neuroendocrine differentiation was found in two cases, all the tumours had presented positivity for the hormonal receptors (oestrogen and progesterone) and negativity for the other antibodies, two cases exhibited the Bcl2 positivity and negativity for the other antibodies. An adjuvant radiotherapy was carried out for all the patients. The average duration of follow-up was of 33 months; the evolution was marked by the occurrence of metastases in two cases.ConclusionThe pure colloid carcinoma of the breast constitutes a particular morphological entity which deserves to be individualized; neuroendocrine differentiation of these tumours must be required. Their forecast is relatively favourable.