Cancer de l’œsophage

Esophageal cancers are highly malignant tumours with often a poor pronostic, except for minimal lesions treated with surgery. Radiation therapy, or combined radiation and chemotherapy is the most used therapeutic modality, alone or before ?sophagectomy. The delineation of target volumes is now more accurate owing the possibility to use routinely the new imaging techniques (mainly PET). The aim of this work is to precise the radio-anatomical particularities, the pattern of spread of esophageal cancer and the principles of 3D conformal radiotherapy illustrated with a clinical case.     

Chimioradiothérapie des cancers de l’œsophage : revue critique de la littérature

Locally advanced oesophageal cancer treatment requires a multidisciplinary approach with the combination of chemotherapy and radiotherapy for preoperative and definitive strategy. Preoperative chemoradiation improves the locoregional control and overall survival after surgery for locally advanced oesophageal cancer. Definitive chemoradiation can also be proposed for non-resectable tumours or medically inoperable patients. Besides, definitive chemoradiation is considered as an alternative option to surgery for locally advanced squamous cell carcinomas. Chemotherapy regimen associated to radiotherapy consists of a combination of platinum derived drugs (cisplatinum or oxaliplatin) and 5-fluorouracil or a weekly scheme combination of carboplatin and paclitaxel according to CROSS protocol in a neoadjuvant strategy. Radiation doses vary from 41.4 Gy to 45 Gy for a preoperative strategy or 50 to 50.4 Gy for a definitive treatment. The high risk of lymphatic spread due to anatomical features could justify the use of an elective nodal irradiation when the estimated risk of microscopic involvement is higher than 15% to 20%. An appropriate delineation of the gross tumour volume requires an exhaustive and up-to-date evaluation of the disease. Intensity-modulated radiation therapy represents a promising approach to spare organs-at-risk. This critical review of the literature underlines the roles of radiotherapy for locally advanced oesophageal cancers and describes doses, volumes of treatment, technical aspects and dose constraints to organs-at-risk.     

Prise en charge des adénocarcinomes de la jonction œsogastrique résécables : quel traitement périopératoire ?

Adenocarcinoma of the oesophagogastric junction has an ominous prognosis. Until now, oesophageal adenocarcima care was close to the squamous cell cancer one whereas adenocarcinoma of the cardia was mixed with gastric cancers. Results from randomised studies mixed them without making distinctions. Nevertheless, context, natural history and clinical outcome differ. Five-year survival rate is around 40 %, all stages included. Results from several phase-III studies or meta-analysis allowed to define three therapeutic strategies applicable to adenocarcinoma of the oesophagus and the oesophagogastric junction. In Europe, in the case of a resectable tumour, preoperative chemotherapy became a standard treatment since results from the Magic trial. In the United States, post-operative radiochemotherapy according to the "Macdonald" scheme is used in case of a resected tumour with a R0 surgery. Actually, modern techniques of irradiation could reduce the rate of gastro-intestinal toxicities. The survival benefit from preoperative radiochemotherapy is still very controversial with high rates of postoperative morbidity and mortality. We have performed a review of the litterature with a methodological analysis of data with a high level of evidence in order to advise perioperative treatment guidelines for patients with a resectable adenocarcinoma of the lower oesophagus or gastro-oesophageal junction. Results from pre- or postoperative strategies and the role of radiotherapy will need to be analysed in the future through a randomised study.     

Chimioradiothérapie exclusive pour cancer de l’œsophage : comparaison entre 66 Gy et 50 Gy,une étude rétrospective

PurposeTo compare the influence of radiation dose, high dose versus standard dose, on survival for patients with esophageal carcinomas treated with definitive radiochemotherapy.Patients and methodsBetween 2003 and 2006, 143 consecutive patients with squamous-cell carcinoma and adenocarcinoma, clinical stage I to IVA, treated in two different institutions were retrospectively reviewed, 83 patients had received more than 50.4 Gy, median dose 66 Gy (50.7–72 Gy) and 60 less than or equal to 50.4 Gy, median dose 50 Gy (38–50.4 Gy).ResultsMedian age was higher in high dose group (67.6 versus 61.7 years). Nutritional status and stage were better in high dose group with a lower weight loss (5.1 versus 7.9%), a higher body mass index (25.7 versus 22.9), more N0 patients (60.2 versus 31.7%) and less stage III (27.7 versus 63.3%). Median follow up was 20.8 months (2.8–92.4 months), and 64.9 months (4.2–92.4 months) for the 33 surviving patients. No statistically significant difference was shown for local/locoregional control, disease-free survival. Overall survival at 2-, 3- and 5-year and median survival was respectively 44.7%, 36.8%, 19.1% and 21.2 months in high dose group and 50.8%, 31.6%, 20.7% and 24.6 months in standard dose group (P = 0.9).ConclusionNo difference was found between the two groups in terms of local/distant control and overall survival. A prospective randomised study is needed.     

L’apprentissage de la relation et de l’examen cliniques en cancérologie

Résumé: Malgré la multiplication des examens complémentaires, lexamen et la relation cliniques restent au cur de la pratique médicale. Ils justifient donc un enseignement structuré et attentif. Cet enseignement fait désormais lobjet dune disposition législative fondée sur le respect des patients. Il tient compte dune approche globale, biopsychosociale. Ses objectifs méritent dêtre précisés en vue dune relation de qualité avec des malades en situation difficile. En pratique on insistera sur la dédramatisation dun diagnostic de cancer, sur la façon dapporter de mauvaises nouvelles (diagnostic initial de cancer ou évolution terminale) et sur la pratique des touchers pelviens. Toute cette formation en cancérologie doit sinscrire en cohérence avec une formation clinique générale.