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.     

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.     

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.     

Prise en charge des récidives locales du cancer du rectum

Aim

Treatment of locally recurrent rectal cancer remains a difficult and controversial issue. The aim of this study was to retrospectively assess the efficiency of various treatment methods and to define the most accurate management of those recurrences.

Patients and methods

From January 2000 to December 2009, 113 patients were treated for rectal cancer, out of which 14 (8 men and 6 women) presented local recurrences. Five patients received preoperative radiotherapy.

Result

More than 50% of local recurrences occur in the first postoperative year, and symptoms were present in 86% of cases. Operability was 71%, and resectability was 60%. Six patients underwent a curative resection, and four patients underwent palliative treatment: laparotomy with biopsy in two cases and colostomy in other two cases. The resection was R0 in three cases (30%); it consisted of an anterior resection extended to small bowel with colorectal anastomosis, a posterior exenteration and an abdominoperineal resection. The resection was palliative in three cases: R1 in two cases and R2 in one case. Operative mortality was zero, and morbidity was 50%. The global survival was 12 months.

Conclusion

The results of this study suggest that management of resection of local recurrences remains a challenge. Long-term results may possibly be improved by using adjuvant treatment.     

Impact de l’alimentation sur le pronostic du cancer du sein

It is generally recognised that overweight and obesity at the time of diagnosis are risk factors for breast cancer recurrence and mortality. This effect is likely to be observed whatever the age at the time of diagnosis, except that for women aged 85 and over, a low BMI might cause frailty. A large prospective study indicated that an increase in weight after diagnosis is also a risk factor for recurrence and breast cancer mortality. Such an observation awaits confirmation. Adipose tissue is a source of estrogen synthesis through the activity of aromatase on steroids. However, high levels of insulin, as found in metabolic syndrome, can stimulate tumour cell proliferation and might therefore be a target for lifestyle intervention. Currently, calorific restriction with weight loss has been shown to be the most successful nutritional intervention in overweight or obese women and can be further improved by physical activity.     

Adénocarcinomes du bas œsophage. Adénocarcinomes du cardia

Adenocarcinomas of the distal esophagus and the gastric cardia have many similar characteristics and common risk factors. Gastric cardia tumors are more closely related to esophageal adenocarcinomas than to distal gastric carcinomas. Adenocarcinomas of the distal esophagus and gastric cardia should be regarded as one clinical entity. However the two types of tumor differed in prevalence of molecular characteristics that are interesting to analyze, to identify the risk factors specially associated with each entities.     

Cancer du pancréas

About 7200 new cases of pancreatic adenocarcinomas are diagnosed each year in France. At the time of diagnosis, an efficient carcinologic surgery will not be possible for nearly 80 % of patients, in relation to loco-regional extension or metastatic dissemination. After surgical resection, the median survival of resected patients ranges from 12 to 20 months, with a high rate of relapses. Currently, the use of radiotherapy for patients with pancreatic cancer is controversial. In adjuvant setting, the standard treatment is six months of chemotherapy with FUFOL or gemcitabine. Chemoradiation (CRT) may improve the survival of patients with incompletely resected tumors (R1). This must be validated in a prospective trial. Neoadjuvant CRT is a promising treatment but always under evaluation. For the treatment of patients with locally advanced tumors, there is not a standart treatment. A strategy of initial chemotherapy followed by CRT for non progressive patients is under evaluation. Whereas in the first trials of CRT large fields were used, the current trend is to reduce the treated volumes to improve tolerance. The delineation of target volumes has been improved by the use of simulation CT. The aims of this work are to precise the radio-anatomical particularities, the pattern of spread of pancreatic cancer and the principles of 3D conformal radiotherapy illustrated with a clinical case.     

Cellules souches du cancer du sein : prendre le cancer à la racine

In cancer stem cell (CSC) hypothesis, tumors are organized in a hierarchical model with CSC at the top of the hierarchy. CSCs display both stem cell properties (self-renewal and differentiation) and specific tumoral properties (tumorigenicity, metastatic capacity, resistance to conventional therapies). Recent works on breast cancer allow CSCs isolation and help deciphering CSC biology and targeting with specific therapies. In clinical trials, CSC biology has to be taken into account and the criteria to judge therapeutic efficiency have to change.     

Expérience guinéenne de la chirurgie conservatrice du cancer du sein

Objective

To evaluate the first results of conservative breast cancer surgery in surgical oncology unit of Donka University Hospital, Conakry, Guinea.

Patients and methods

Between 2007 and 2012, 140 surgical interventions for breast cancer were performed. In the present study, we report the case of 12 patients who underwent conserving breast surgery for breast cancer stages I (4), IIA (2) and IIB (6). The indication was based on the stage and the initial diagnostic procedure. In case of correlation between clinical examination, mammography and pathological review, quadrantectomy axillary dissection (QAD) were performed. If the tripod was discordant, a QAD was indicated in the case of lymphadenopathy or a quadrantectomy in the absence of axillary lymphadenopathy. Depending on the result of the histological examination of the surgical specimen, adjuvant chemotherapy and radiotherapy were recommended. Neoadjuvant chemotherapy was administrated for tumours whose size was greater than 3 cm. Thus, the following treatments were performed: QAD (8 cases), quadrantectomy (4 cases), neoadjuvant chemotherapy (3 cases), adjuvant chemotherapy (7 cases) and radiotherapy (6 cases). Post-operative complications, local control and survival of patients were studied.

Results

Postoperative complications observed for 3 cases were as follows: seroma (3 cases), breast lymphedema (2 cases), dysesthesia in the inner face of arm (1 case) and cosmetic sequelae of breast surgery (1 case). The magnetic resonance imaging of the remaining breast showed a residual suspected tumour in only 1 out of 6 cases. This patient underwent a radical mastectomy secondarily. After a median follow up of 32.0 months, all patients were alive without recurrence.

Conclusion

The newly introduced conserving breast surgery in Guinea is an effective alternative for the treatment for early diagnosed breast cancer. It must obey the respect resection margins and consider aesthetic imperatives.     

Curiethérapie du canal anal

Low dose-rate brachytherapy as a boost after concomitant chemoradiation therapy is a standard of care for locally advanced anal carcinoma, providing a rigorous selection taking into account the initial staging and tumor response to external beam radiotherapy. Local control is likely to be superior when the boost is performed with brachytherapy than with external beam radiotherapy. The several steps of the brachytherapy procedure are described. The standard treatment scheme is a concomitant chemoradiation therapy, including 45 Gy (1,8 Gy × 5) pelvic external beam radiotherapy and two courses of 5-fluorouracil and mitomycin-C, followed by a 15 Gy brachytherapy boost with a gap limited to 2 to 3 weeks. Higher irradiation dose for the most advanced cases has not yet demonstrated a therapeutic gain in terms of colostomy free survival. Exclusive brachytherapy for in-situ carcinoma or invasive carcinoma less than 10 mm is not recommended due to a high risk of local recurrence. Pulsed dose rate brachytherapy is an alternative to low dose rate brachytherapy (iridium wires) providing the respect of the recommended dose rate (0.5 to 1 Gy/hour). High dose rate brachytherapy is still under evaluation.     

L’épreuve du corps

A philosophical approach to the body sheds light on how certain aspects of modern medicine can contribute to destabilizing our relationship with our body and our bodily relation to the world and to others. We consider this destabilization, as well as some concrete remedial measures, in light of the concept of “buoyancy” [portance]. Buoyancy includes the structuring supports that we can find in other bodies, in an enduring relationship to matter and nature, and in communal action.