Bulletin de synthèse de veille 2006

Context

The validity of clinical practice guidelines is based on their regular update as well as the quality of the initial guideline development process. The Standards, options and recommendations (SOR) of the French National Federation of Comprehensive Cancer Centres (FNCLCC), therefore, has implemented a literature monitoring process.

Objectives

To identify new data that will likely modify the recommendations set forth in Standards, Options and Recommendations in the Management of Patients with Carcinoma of Unknown Primary Site (2002), evaluate the data’s impact and inform potential users of its validity.

Methods

The monitoring process consists of 3 main steps taken in collaboration with experts: data collection; data selection and classification; and data analysis.

Results

Using this monitoring process, we identified the need for an update of the recommendations for treating the cervical metastases of an epidermoid carcinoma. All other recommendations in the initial document remain valid (explicit and transparent expert determination).     

Une maladie de Hodgkin compliquant l’évolution de la maladie de Castleman

Introduction

Castleman disease (CD) is rare and is characterized by the existence of a localized form and a multicentric form. The evolution can be marked by the emergence of malignant disease.

Case report

A 57-year-old man, followed for CD for 20 years, was hospitalized for anemia syndrome, lymphadenopathy of the axillary and sus clavicular lymph nodes and a biological inflammatory syndrome. Histology of the lymph node revealed Hodgkin disease (HD) rich in lymphocytes.

Discussion

The prevalence of hematologic malignancies in CD is difficult to establish because of the small number of cases reported. The pathomecanism involves cytokines especially IL-6 where the rate was found high in both the CD and the HD.     

Place de la radiothérapie externe dans les cancers de la thyroïde

Anaplastic thyroid cancers represent 1–2% of all thyroid tumours and are of very poor prognosis even with multimodality treatment including external beam radiation therapy. Conversely, differentiated thyroid carcinomas (at least 80% of thyroid cancers) hamper good prognosis with surgery with or without radioiodine and there is hardly any room for external beam radiation therapy. Insular and medullar carcinomas have intermediary prognosis and are rarely irradiated. We aimed to update recommendations for external beam irradiation in these different clinical situations and put in light the benefits of new irradiations techniques. A search of the French and English literature was performed using the following keywords: thyroid carcinoma, anaplastic, chemoradiation, radiation therapy, surgery, histology and prognostic. Non-mutilating surgery (often limited to debulking) followed by systematic external beam radiation therapy is the standard of care in anaplastic thyroid cancers (hyperfractionated-accelerated radiation therapy with low-dose weekly doxorubicin with or without cisplatin if possible). Given anaplastic thyroid cancers’ median survival of 10 months or less, neoadjuvant and adjuvant chemotherapy may also be discussed. Ten-year survival rates for patients with papillary, follicular and Hürthle-cell carcinomas are 93%, 85%, and 76%, respectively. Massive primary incompletely resected iodine-negative disease indicates external beam radiation therapy. Older age (45 or 60-year-old), poor-prognosis histological variants (including tall cell cancers) and insular cancers are increasingly reported as criteria for external beam radiation therapy. Massive extracapsular incompletely resected nodal medullary disease suggests external beam radiation therapy. Radiation therapy morbidity has been an important limitation. However, intensity modulated radiation therapy (IMRT) offers clear dosimetric advantages on tumour coverage and organ sparing, reducing late toxicities to less than 5%. The role of radiation therapy is evolving for anaplastic thyroid cancers using multimodal strategies and new chemotherapy molecules, and for differentiated cancers using minor criteria, such as histological variants, with IMRT becoming a standard of care.     

Calcul de dose de radiothérapie à partir de tomographies coniques : état de l’art

In external beam radiotherapy, the dose planning is currently based on computed tomography (CT) images. A relation between Hounsfield numbers and electron densities (or mass densities) is necessary for dose calculation taking heterogeneities into account. In image-guided radiotherapy process, the cone beam CT is classically used for tissue visualization and registration. Cone beam CT for dose calculation is also attractive in dose reporting/monitoring perspectives and particularly in a context of dose-guided adaptive radiotherapy. The accuracy of cone beam CT-based dose calculation is limited by image characteristics such as quality, Hounsfield numbers consistency and restrictive sizes of volume acquisition. The analysis of the literature identifies three kinds of strategies for cone beam CT-based dose calculation: establishment of Hounsfield numbers versus densities curves, density override to regions of interest, and deformable registration between CT and cone beam CT images. Literature results show that discrepancies between the reference CT-based dose calculation and the cone beam CT-based dose calculation are often lower than 3%, regardless of the method. However, they can also reach 10% with unsuitable method. Even if the accuracy of the cone beam CT-based dose calculation is independent of the method, some strategies are promising but need improvements in the automating process for a routine implementation.     

Évaluation monocentrique de la tolérance de l’association concomitante de trastuzumab et de radiothérapie

PurposeProspective monocentric study of the skin and heart tolerance of a concurrent administration of trastuzumab (T) and radiotherapy (RT) for breast cancer (BC).Patients and methodsFrom February 2004 to January 2007, 57 patients (pts), were treated by a concomitant administration of T and normo-fractionated RT of either whole breast (± boost) or chest. The perfusion of T started either with or after chemotherapy (CT). Left ventricular ejection fractions (LEVF), assessed at baseline, before start of RT, after completion of RT and then every four to six months with either echocardiography or multiple gated acquisition scanning, were considered normal if greater or equal to 50% or stated so by the cardiologist. Inclusion criteria included a normal LVEF at baseline. Skin toxicity was evaluated using CTCAEV3. Median age was 49 years (25–80). CT with anthracycline was administered in 84% (total dose 300 mg/m²). All but one patient (treated weekly) received T every three weeks (8 mg/kg followed by 6 mg/kg) for a median duration of 12 months (6–33). The internal mammary chain was irradiated in 88% of cases. Median follow-up for LVEF assessment was 13 months (2–33).ResultsLVEF at pre-RT were normal in 54 pts (100%, three Missing Data [MD]), at post-RT in 56 pts (98%, no MD) and at last follow-up in 53 pts (95%, one MD). There were two grade 0, 44 grade I and 11 grade II skin reactions. For the 27 patients with a skin toxicity assessment after six months, late skin toxicity was grade 0 in 22 pts, grade 1 in four, grade 2 in one.ConclusionProvided that the technique is adapted, the acute skin and heart toxicities of the concomitant administration of T-RT appeared satisfactory. More patients and longer follow-up are still mandatory.     

死亡de智慧

在这个世界上,生命无处不在,无论是花草树木还是飞禽走兽,生命的活力无处不光彩。所有这些光彩来自生命的接力和自然的交替,而这种现象早已被人类理解和接受。其实,人类也是自然界的一个成员,我们在接受其他生物生与死的变化时,往往很难接受自己生与死的变化,殊不知两者的变化完全一样。不同的是,其它生物缺乏人类这种对生与死的意识,也就没有对生与死的深刻思考和被强烈冲击。     

Les tumeurs de la granulosa de l’ovaire

Ovarian granulosa cell tumors (TGO) are rare neoplasms. They arise from sex cord stromal cells of the ovaries. They are characterized by their slow natural history, and their tendency to relapse long time after the initial diagnosis. Complete staging surgery of the disease is the cornerstone of treatment. Chemotherapy is indicated for localized tumors with a high risk of recurrence, and for recurrent or advanced tumors. Prolonged follow-up is recommended.     

Aplicación del método de Gail de cálculo de riesgo de cáncer de mama a la población valenciana

Background

The objective of this study was to verify whether the method defined by Gail is applicable and predictive in a population of women in Valencia (Spain).

Population and methods

Of the 685 patients diagnosed with breast cancer and attended-to in 2000–2001, 186 incident cases were identified. The variables studied were obtained from a specific questionnaire which included characteristics of reproductive history, number of biopsies and contraceptive pill consumption prior to the diagnosis. Using the model of the National Surgical Adjuvant Breast and Bowel Project (NSABP), an adaptation of the Gail model, the risk of developing breast cancer at 5 years was estimated.

Results

Only 40% of those women diagnosed as having breast cancer would have been identified as a high-risk patient by the Gail method. With our population group, the method detected the elderly women with a medical history of breast cancer who developed advanced stage disease.

Conclusions

The Gail method does not adapt well to the study population of Valencia. It would be necessary to add other risk-factors to the Gail method so as to identify more patients in our area.     

Estudio computarizado de la influencia de la proliferación y de la variación de la radiosensibilidad en un programa de radioterapia fraccionada. Efecto del tiempo total de tratamiento sobre el control tumoral

Propósito

Estudiar, para la radioterapia fraccionada, la influencia que tienen las variaciones de radiosensibilidad y cinética de proliferación a lo largo del tratamiento, así como el efecto del tiempo total de tratamiento, sobre la probabilidad de control tumoral.

Métodos

Partiendo de los datos de la cinética de crecimiento y de la radiosensibilidad de los esferoides multicelulares (MTS) de la línea celular MCF-7 de cáncer de marna, se efectÚa la simulación computarizada de un tratamiento fraccionado de radiosterapia.

Resultados

Cuando se progresa en la terapia, aumenta la tasa de proliferación, lo que explica el fenómeno de repoblación acelerada. Sólo si aumenta la radiosensibilidad a lo largo del tratamiento, un agregado celular con las características proliferativas de los MTS puede ser esterilizado. Una demora en el inicio del tratamiento o una interrupción del mismo producen un empeoramiento de la probabilidad de control tumoral, que es más acusado en el caso de una interrupción y cuanto más tarde se produce ésta. El aumento de la dosis para el control del 50% de los tumores cuando se prolonga el tiempo total de tratamiento alcanza valores de 0,5–1,14 Gy por día de aumento en el tiempo total.

Conclusiones

En otros trabajos, cuando se analizan datos clínicos mediante modelos de probabilidad de control, los valores obtenidos para los parámetros puede que ajusten los datos, pero quizás no muestren las verdaderas características histológicas de los tumores correspondientes. En la situación aquí presentada, al igual que para otros tipos de tumores como los de cabeza y cuello, el aumento del tiempo total de tratamiento hace necesario corregir la dosis total para mantener los nivelés de control previstos.     

Évaluation de la qualité de vie en oncologie

Sans résumé     

Utilidad diagnóstica de la tomografía de emisión de positrones en la evaluación de los gliomas

La tomografía de emisión de positrones (PET) proporciona imágenes de la distribución de algunos isótopos radiactivos de vida corta que representan procesos bioquímicosin vivo. Esta revisión considera las ventajas y limitaciones de la PET en la evaluación de los tumores cerebrales, en concreto de los gliomas. Las principales aplicaciones son:a) aproximación al grado tumoral de las neoplasias cerebrales;b) diferenciar la recurrencia de la radionecrosis;c) valoración de la extensión para el manejo terapéutico, yd) seleccionar el sitio óptimo para la biopsia. La F-18-fluorodesoxiglucosa (F-18-FDG) es el trazador más utilizado. En general, los tumores de alto grado presentan una captación elevada de F-18-FDG. De forma similar, una captación de F-18-FDG elevada se asocia con un tumor de alto grado y peor pronóstico, aunque existe un considerable solapamiento de hallazgos. Una dificultad inherente se refiere a la elevada captación de las sustancia gris normal. La PET-FDG presenta dificultades en la detección de los gliomas de bajo grado porque su captación puede ser relativamente baja en relación con el córtex normal. Por esta razón los tumores de bajo grado pueden pasar desapercibidos para la PET-FDG; sin embargo, la PET con C-11 metionina (C-11-MET) y otros trazadores y la imagen estructural correlativa generalmente ofrecen el diagnóstico correcto. La PET-MET permite delinear la extensión del tumor, sin tener en cuenta el grado de malignidad. La imagen metabólica con FDG puede ser Útil en la detección precoz de la recurrencia de los tumores cerebrales, diferenciándola de la radionecrosis tardía. Esto solamente es cierto si el tumor ya era visualizado con PET-FDG antes del tratamiento, así que la PET-MET podría proporcionar menos estudios falsos negativos. Se discuten también algunas causas no malignas de captación anormal y los efectos del tratamiento. En conclusión, la PET ha demostrado utilidad clínica en la evaluación de los tumores cerebrales de origen glial, ofreciendo información adicional a la imagen anatómica. F-18-FDG y C-11-MET pueden desempeñar papeles complementarios.     

Diseño de un programa de base de datos para el seguimiento de pacientes, aplicando el Real Decreto 1566/1998 sobre control de calidad en radioterapia

Introduction

In July of 1999, following the Royal (State) Decree # 1566/1998 and the ISO 9002 guidelines, a computer program was designed to analyze, annually, the parameters of toxicity, control of disease and survival.

Material and methods

A total of 2.192 patients were studied in Radiation Oncology until may 2005. Of the patients, 51,8% had initial stage disease and the 46.4% had advanced stages. The initial-advanced tumor index was of 1.1. Treatment intent was palliative in 23.8% and curative in 60.3% of cases.

Results

The 3-year disease free survival (DFS) in curative-intent cases was 78.5% in the initial-stage and 55.2% in the advanced-stage patients (p<0.00001). Follow-up was 95.8% of the patients. Loco-regional failure rate was 9.7% and tumor persistence following radiotherapy was 9.4%. The overall rate of late-onset complications was 4.2% (RTOG scoring).

Conclusions

The initial-to-advanced tumor index, the rates of loco-regional filure, of survival and of complications provide an evaluation of the quality of treatment in an Oncology-Radiotherapy departiment.     

Carcinome épidermoïde pur de la vésicule

Squamous cell carcinoma accounts for less than 2% of gallbladder carcinomas, and is characterised by an invasive growth, a reduced tendency for lymph node metastasis, an increased tendency for hepatic infiltration or liver metastasis and a poorer prognosis than adenocarcinoma. Because of diagnostic delays, this tumour is generally diagnosed in advanced stages. We describe 4 cases of pure squamous cell carcinoma; the authors discuss diagnosis and therapeutic difficulties of these tumours. In both histological types of gallbladder carcinoma, treatment depends on the grade of local and regional invasion and tumour spread at diagnosis.