Cancer du rectum : volumes cibles de la radiothérapie préopératoire

Preoperative radiotherapy is the standard treatment for locally advanced resectable rectal adenocarcinoma. The total mesorectal excision leads to a dramatic increase of local control rate. Thus, the mesorectal space is the usual field for the spread of rectal cancers cells. It could therefore be considered as the clinical target volume (CTV) in the preoperative conformational radiotherapy. From the anatomical basis and radiological contributions, we propose several CTVs for different locations of rectal carinoma.     

Tolérance et efficacité de la radiothérapie préopératoire chez les patients âgés atteints d’un cancer du rectum

PurposeTo retrospectively assess the impact of age on tolerance and oncologic outcomes treated by neoadjuvant treatment for patients of 70 years old or above with locally advanced rectal cancer.Patients and methodsNinety-one consecutive patients were divided into three groups: group 1 from 70 to 75 years (n = 31); group 2: 76 to 79 years (n = 31) and group 3, patients aged 80 years or above (n = 29). Radiation therapy was delivered according two schemes: 25 Gy in five fractions (short scheme) or 45 to 50 Gy with a classical fractionation (long scheme). Long scheme patients received a concomitant chemotherapy with 5-fluoro-uracile alone or associated with oxaliplatin.ResultsThe three groups were comparable for performance status, Charlson's score and T staging. Long scheme radiation therapy and chemotherapy were performed in 77.5, 74.5 and 48.3% of patients (P = 0.03) and 77.4, 71 and 41.4% (P = 0.006) in the groups 1, 2 and 3, respectively. All patients treated with the short scheme irradiation received the treatment without any acute toxicity. In the long scheme group, 65% of patients received the treatment on time and grade 3 or above toxicity was observed in 12% of patients who did not receive oxaliplatin and in 48% of patients who received oxaliplatin. The overall survival rate at 3 and 5 years was 66.9% and 60.8% in the group 1, 90.5% and 75.9% in the group 2 and 80.5% and 73.8% in the group 3 (P = 0.15).ConclusionNeoadjuvant treatment is feasible with encouraging survival rates for patients aged 70 years and older. Short scheme radiation therapy seems to be an interesting option in this population.     

Logothérapie,groupe de paroles et analyse existentielle en cours de radiothérapie : expérience pilote d’un centre parisien de radiothérapie

Objective

A pilot study has been carried out to assess the benefit of a pilot support group based on existential analysis and logotherapy (therapy centred on the sense of existentialism), alongside the medical treatment of breast cancer.

Materials and Methods

A group of women under the care of the Hartmann Oncology Institute in the final phase of treatment for breast cancer were selected to take part in the support group during this very specific transition period between being ill and resuming a “normal” life.

Results

Between December 2015 and June 2016, eight women participated in the support group. Results taken from an assessment session and a satisfaction survey completed by all participants demonstrate the importance of talking, the relationships created session after session within the group and the support provided by the synergy between the group and its leaders in order to assert a new lifestyle dynamic — a noodynamic according to the terminology of Viktor Frankl (1905–1997), the psychiatrist who created logotherapy — and to give a new purpose to their life.

Conclusions

The results from the support groups on the quality of life of patients treated for breast cancer are encouraging, and establishing these groups alongside logotherapy would be advantageous for a larger number of patients.

     

Chimioradiothérapie postopératoire des cancers des voies aérodigestives : vers un nouveau standard ?

Head and neck squamous cell carcinomas are frequently diagnosed at an advanced stage. Their treatment remains controversial, and has to be multidisciplinary. External beam radiotherapy is a recognized treatment option after radical curative surgery in order to improve local control. Different adjuvant treatment options have been studied in order to improve the outcome of these patients. We review in this paper the different prognostic factors indicating an adjuvant treatment and the interest of treatment intensification in bad prognostic patients.     

Radiothérapie avec modulation d’intensité préopératoire des cancers rectaux : intérêt et application

Preoperative radiotherapy boosted by chemotherapy is a recommended treatment in locally advanced rectal cancers. This treatment is delivered by three dimensional conformal irradiation, which is usually well tolerated but can induce potential toxicity such as rectitis, cystitis and hematologic adverse effects. Intensity-modulated radiotherapy, widely available nowadays, allows optimization of volume covering and sparing of organs at risk such as bladder and bone marrow. This review presents relevant clinical situations and requirements for a beneficial and safe preoperative irradiation of rectal cancers by intensity-modulated technique. This technique is compared to three-dimensional conformal radiotherapy.     

Résultats préliminaires d’une tomothérapie hélicoïdale adjuvante avec boost intégré dans le cadre d’un traitement conservateur d’un cancer du sein

PurposeTo evaluate the dosimetry and acute toxicity of helical tomotherapy for locoregional irradiation of patients after breast-conserving surgery.Patients and methodsTwenty breast cancer patients with breast-conserving surgery treated by helical tomotherapy have been studied. The median age was 49 (min: 25, max: 69). The whole breast, tumour bed and lymph nodes were prescribed 52.2 Gy, 63.8 Gy and 50.4 Gy, all in 29 fractions. The dose per fraction was 2.2 Gy to the boost, 1.8 Gy to the breast and 1.74 Gy to the lymph node volumes. The reproducibility was analysed by recording the daily shifts in x, y and z directions and roll rotation. All toxicities were described using the Common Terminology Criteria for Adverse Effects v3.0.ResultsTwenty-two tumours were irradiated. Six-eight percent were located in the inner quadrant. In 90 % of patients supraclavicular and internal mammary nodes were treated. The coverage of planning target volumes (PTV) was as follows: PTV boost: V₁₀₇ = 0.3 % ± 0.5 SD, V₉₅ = 98.4 % ± 1.9 SD; PTV breast: −V₁₀₇ = 7.8 % ± 17.3 SD, V₉₅ = 96.8 % ± 2.2 SD; PTV LN: V₁₀₇ = 2.5 % ± 4.2 SD, V₉₅ = 92.7 % ± 13.2 SD. The mean V20 of the homolateral lung was 18.9 % ± 3.5 SD. For left side lesion, the mean V30 of the heart was 0.9 % ± 0.8 SD. The mean V5 was: V5 homolateral lung: 73.1 % ± 11.8 ET, controlateral lung: 38.9 % ± 21, heart (left side breast): 57.3 % ± 21, controlateral breast: 15.5 % ± 9.6. Median shifts were as follow: x-axis –0.04 mm (IC 95: –0.4 +0.38), y-axis –0.37 mm ± 5.51 (IC 95: –0.88 +0.14), z-axis 2.90 mm ± 5.42 (IC 95: + 2.4 + 3.4) and roll rotation 0.22 ± 1.10 (IC 95: –0.1 + 0.32). The treatment tolerance was acceptable with 1 definitive interruption couple of fractions before the end and 3 temporal interruptions for skin toxicity. No grade 3 or 4 toxicity. Ninety-five percent of patients experienced skin toxicity: 45 % grade 2. There were 3 cases of oesophagitis. The median follow-up of presented series is 9.7 months and all of the patients are free of disease without any residual early or late toxicity.ConclusionsHelical tomotherapy can achieve full target coverage while protected to the heart and ipsilateral lung. This treatment was well tolerated and reproducible. However, the low doses to normal tissue volumes need to be reduced in future studies.     

Cancer de l’œsophage : radio-chimiothérapie exclusive ou préopératoire ?

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50 Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.     

Modalités actuelles du bilan d’un cancer bronchique

Résumé  Le bilan initial en cas de suspicion de cancer bronchique doit répondre à quatre impératifs: apprécier l’état clinique, obtenir une preuve cyto- ou histologique, définir le cTNM, et en cas de résécabilité, l’opérabilité du patient. En quelques années, les modalités de ce bilan ont connu une révolution. Aujourd’hui, la TEP-TDM devrait être réalisée systématiquement lorsque le patient est traité dans une perspective curative. Les dernières recommandations internationales soulignent la nécessité de documenter l’envahissement médiastinal. Les progrès des techniques dites à l’aiguille (TBNA, EUS et EBUS-TBNA) sont très excitants, mais en cas de résultat négatif l’abord chirurgical reste la référence. L’évaluation fonctionnelle avant résection pulmonaire est aussi abordée.      

Patients sous palbociclib et hormonothérapie pour un cancer du sein métastatique : peut-on prédire la survenue d’une hématotoxicité précoce et sévère ?

IntroductionThe addition of palbociclib to endocrine therapy has been shown to improve progression free survival in hormone receptor positive metastatic breast cancer patients. This cyclin CDK4/6 inhibitor could expose patients to a grade 3–4 hematological toxicity, leading to treatment discontinuation or treatment interruption that is potentially associated with a lack of efficiency. The aim of this study was to identify predictive factors of severe early hematotoxicity (ESHT).MethodsThis retrospective cohort study included patients who started palbociclib in the Institut Sainte Catherine between December 1, 2016 and January 1, 2019 for the treatment of metastatic breast cancer. Individual data and hematological toxicity were collected from electronic medical records. ESHT was defined as the occurrence, during the first 3 cycles, of grade 4 or grade 3 hematological toxicity requiring palbociclib dose reduction.ResultsIn total, 181 patients (180 females) were included; median age was 67 years. Forty-six patients (25.4%) experienced an ESHT. Predictive factors of ESHT in multivariate analysis were a performance status (PS) of 2 or more (P = 0.024) and an history of radiotherapy of bone metastasis in the previous year (P = 0.003). Before palbociclib initiation, a neutrophil count below 3.37 g/L was predictive of ESHT with a sensibility of 76% and a specificity of 71%.ConclusionsECOG PS, bone radiotherapy within the year and low baseline neutrophils count are associated with ESHT in palbociclib-treated metastatic breast cancer patients. These elements could be useful for a careful monitoring leading to adapted therapy.     

Radiothérapie postopératoire avec cétuximab pour les carcinomes épidermoïdes de la tête et du cou à haut risque de récidive non éligibles au cisplatine : expérience d’un centre et revue de la littérature

PurposeThe use of concurrent cetuximab with postoperative radiotherapy for patients with head and neck cancer has been scarcely discussed in the literature. The main aim of this study was to report clinical outcomes of high-risk head and neck cancer patients treated by postoperative radiotherapy with cetuximab.Patients and methodsBetween January 2013 and December 2016, all medical records of patients operated for head and neck cancer who underwent postoperative radiochemotherapy were retrospectively analyzed. Patients who received cisplatin were excluded; only patients who received cetuximab were included in the analysis.ResultsAmong 52 patients with head and neck cancer treated with postoperative radiochemotherapy, 18 patients received cetuximab potentiation due to ineligibility for cisplatin. Median overall survival (OS) and progression-free survival (PFS) were 23 and 19,5 months and 3-year OS and PFS were 30,5% and 25,9%, respectively. There was a 22% treatment discontinuation rate.ConclusionIn our single-center retrospective analysis, postoperative radiotherapy with cetuximab for patients with high-risk head and neck cancer ineligible for cisplatin showed similar outcomes to the literature data for exclusive postoperative radiotherapy, with a high discontinuation rate. These low-power data support the lack of indication for cetuximab in combination with postoperative radiotherapy.     

Lymphome de MALT du rectum : à propos d’un cas traité par irradiation

The mucosa-associated lymphoid tissue (MALT) lymphoma is a distinct clinical pathologic entity that develops in diverse anatomic locations such as the stomach, salivary gland, thyroid, lung, skin and breast. However, colorectal involvement is extremely rare. To our knowledge, only ten cases of primary rectal MALT lymphoma have been reported in the literature. We report a 46-year-old woman with rectal MALT lymphoma, which regressed after radiotherapy. The patient had rectal bleeding. Colonoscopy showed a pseudonodular and ulcerated big fold in the rectum. Microscopic and immunohistologic studies of the biopsy specimen showed typical features of low grade MALT lymphoma. Upper endoscopy showed chronic gastritis with lymphoid follicles but without any infiltration of lymphoma cells. Helicobacter pylori infection was confirmed by histology. No extra-intestinal involvement was found on the staging evaluation, which included computed tomography (CT) of the abdomen, chest, pelvis and a bone marrow biopsy. We attempted to eradicate H. pylori with a 7-day course of omeprazole, amoxycillin, and metronidazole. Eradication was proved successful by endoscopy. Repeated colonoscopy 4 months after the end of treatment showed that the rectal tumor had not regressed. Biopsy specimens confirmed the persistent infiltration of lymphoma cells. The patient was considered to be a non-responder to eradication therapy and was indicated for radiotherapy. He underwent a total of 34 Gy. Complete regression was confirmed by colonoscopic and histologic examination at 2 months after the end of treatment. He was followed up closely with colonoscopy, but no relapse of these lesions was detected after 12 months.