Place de la chimiothérapie hyperthermique intrapéritonéale (CHIP) dans la prise en charge du cancer de l’ovaire : expérience monocentrique institutionnelle

The peritoneal carcinomatosis of ovarian cancer led to the development of optimal cytoreduction surgery completed by hyperthermic intraperitoneal chemotherapy (HIPEC). The main goal of this study is to evaluate the feasibility, tolerance and efficacy of this technique in patients with ovarian cancer. A retrospective monocentric study has evaluated 43 patients with HIPEC procedures from 1995 to 2009. After a complete cytoreduction surgery, a HIPEC procedure with cisplatin is performed. Data on complications and survival parameters were collected. Prognostic factors were also analyzed. Post-surgery complications included one death due to a septic shock (2.3%) and six patients have presented major complications (13.9%). The median of overall survival and progression free survival were 53.6 and 39 months, respectively. Patients with a primary complete surgical cytoreduction of the peritoneal carcinomatosis presented overall survival length of 131 months versus 84 months without initial complete resection (P < 0.0001). Surgical cytoreduction combined with HIPEC is a feasible procedure with acceptable morbid-mortality rates. The initial complete resection of the peritoneal carcinomatosis significantly increases survival and represents a strong prognostic factor.     

Étude prospective de la qualité de vie après une CHIP par oxaliplatine pour carcinose péritonéale

BackgroundCytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is now the reference technique for limited peritoneal carcinomatosis (PC). Operative mortality is actually at 3 or 4%, and decrease as morbidity. Together, they did not limit acceptation of HIPEC. However, one of the major limitation of this aggressive treatment is that patient can be afraid to impair overall quality of life (QoL). The aim of this article was to assess QoL in patients at least 12 months after HIPEC using Oxaliplatin.MethodPatients completed a questionnaire before and after surgery at 1, 3, 6 and 12 months. QoL was assessed with the EORTC QLQ-C30 questionnaire.ResultatsBetween September 2006 and October 2008, 32 of 35 patients who had undergone HIPEC were interviewed. PC originated in primary lesions of the colon/rectum (N = 17), ovary (N = 3), stomach (N = 3), appendix (N = 2), mesothelium (N = 2), pseudomyxoma peritonei (N = 3) and primary carcinoma of peritoneum (N = 2). The percentage of patients completing the questionnaire at each time point was: baseline = 87% (N = 28); 1 and 3 months = 46% (N = 15); 6 months = 62% (N = 20); and 12 months = 59% (N = 19). Morbidity and mortality were respectively 35 and 5%. Median hospital stay was 19 days. QoL score had decreased considerably in 60% of patients in the early postoperative assessment period after HIPEC (1 month), as compared with baseline score. Forty five per cent had reported significant pain and limitations on physical functioning. QoL score had returned to baseline at 3 months in 53,3% of patients: 20% reported lack of energy and fatigue. Fifty-five and 73% of patients had recovered their overall QoL at 6 and 12 months, respectively. Also, psychosocial problems, diarrhea and constipation, and peripheral neuropathy of oxaliplatin were reported in 20% of survivors over the course of the first year after HIPEC.ConclusionShort-term QoL with physical and functional well-being are impaired in the first few months after surgery plus HIPEC using oxaliplatin. Long-term QoL returns to baseline at 3 months; however 20% of patients still report psychosocial problems, gastrointestinal symptoms and oxaliplatin-induced neuropathy. It is useful and important for patients to see this HIPEC QoL data at the time of consultation before treatment.     

Cancers des voies aérodigestives supérieures : le retour de la chimiothérapie néoadjuvante ?

Chemotherapy is a part of the combined multimodality treatment for locally advanced head and neck cancers. Concomitant administration with radiation therapy is the standard treatment for these patients. The efficacy of the docetaxel–cisplatinum–5-fluoro-uracil (TPF) regimen compared to the platinum–5-fluoro-uracil (PF) regimen raised the question of whether this treatment could improve the therapeutic results for locally advanced tumours. For larynx preservation, induction chemotherapy using TPF, followed by radiation therapy for good responders is a valid option. However, clinical studies have to be performed to compare this approach to the concomitant radiation therapy–chemotherapy approach using functional endpoints. For locally advanced tumors, despite the superiority of the TPF regimen over the PF, there is no evidence in the literature to support the use of induction chemotherapy prior to concomitant radiation therapy–chemotherapy. Two recent studies (DECIDE, PARADIGM) failed to demonstrate any benefit, but both trials were stopped early because of slow enrollment. Other studies are on going, or with recently finished accrual, will help to shed light on the role of this treatment     

Impact de la chimiothérapie adjuvante sur les fonctions cognitives dans le cancer du sein: revue de la littérature

Understanding the neuropsychological consequences of chemotherapy is a major challenge. Studies have shown that treatment with adjuvant chemotherapy for breast cancer may be associated with mild cognitive deficits. These disorders have a negative impact on the quality of life of patients. Few studies have been conducted with elderly patients, although the age factor is the biggest risk for this cancer. This article offers an overview of the literature and discusses the impact of such impairments in the elderly.     

Controverse: utilité des agonistes de la GnRH en protection ovarienne en cours de chimiothérapie pour cancer du sein

Techniques for fertility preservation can be offered in women of reproductive age receiving chemotherapy. The use of a GnRH agonist during chemotherapy is one of the first techniques that has been proposed. Underlying mechanisms remain controversial, but the results of nonrandomized trials in breast cancer and other diseases were encouraging. Randomized trials in breast cancer show conflicting results, and are difficult to interpret. There are also some concerns about a possible interaction with the effectiveness of cancer treatment that remain to be evaluated, even if the data available seem to be reassuring. Thus, currently, the use of this method of fertility preservation is controversial, but should probably be mentioned and explained to patients, and eventually proposed, rather in trials. Other methods for fertility preservation currently available, that have a promising efficiency and are compatible with the use of agonists, should be preferred in these patients.     

Cancers de prostate : quelle place pour la radiothérapie à visée curative chez les patients âgés ?

PurposeDiscuss the place of radiotherapy given in a curative intent in elderly patients with localised prostate cancer according to complications, local control, survival observed in a specific and a review of the literature.Patients and methodsThe cohort consisted of 65 males aged 80 or more with localised prostate cancer who choose radiotherapy as a curative modality. Twelve radiotherapy centres affiliated to the Rare Cancer Network participated to the study. The retrospective analysis was carried out on immediate and late side-effects, biological free of relapse survival and global survival. Multivariate analysis took into account the comorbidities, the initial prostatic specific antigen (PSA) value, the Gleason score and the therapeutic modalities.ResultsFrom January 1990 to December 2000, 65 patients were included into the cohort. Mean age was 81 years. The specific series consisted of 10 T1, 40 T2 and 15 T3 N0M0. Median follow up was 65 months. Immediate and late complications were comparable to those described in younger patients who received a similar irradiation. There were no negative impact of the treatment on disease free survival and global survival. Recent literature did suggest analogous results.ConclusionsRadiation therapy with a curative intent should not be systematically withheld in elderly patients with localised prostate cancer.     

Prédiction de la résistance à la chimiothérapie des tumeurs trophoblastiques gestationnelles (TTG) de bas risque par l’analyse de la cinétique des hCG

Early determination of the resistance risk to firstline chemotherapy in patients with low-risk gestational trophoblastic disease would be helpful. The strategies based on one hCG time point measured during the 1st or the 7th week of treatment are not reproducible enough. Model-based approaches that enable calculation of the mathematical equations of hCG individual kinetics are promising. The reproducibility of the early predictive value of modelled kinetic parameters was shown in three large international studies. It should be possible to define for any patient her risk of resistance by integrating the hCG values measured during the first 50 treatment days in a program. An international validation of this concept is planned.     

La recherche en cancérologie réalisée par les chirurgiens envahit le domaine de la biologie – de la dormance à la métastase

Cancer research program was analyzed. This research was identified using the “master of science in surgery” performed by the majority of surgical resident and fellow. It was analyzed as three axes studying: (i) how to improve the technical practice; (ii) the contribution of surgical skills in basic research, in particular via orthotopic animal models as microenvironment; and (iii) the research in basic biology, testing hypotheses and strategies not confined to surgery but totally multidisciplinary. This research is active with more than half of the fellowships grant in urology sponsored via the French Urologist Association, for projects studying cancer and more than a third of subjects pertaining to the master oncology.     

Calcifications intraprostatiques : marqueurs fiduciels naturels dans la radiothérapie guidée par l’image du cancer de la prostate

PurposeTo establish whether intraprostatic calcifications can serve as natural fiducials for image-guided radiotherapy (IGRT), replacing the implantation of intraprostatic fiducial markers.Patients and methodsPatients with prostate cancer, having intraprostatic calcifications visible on CT scan were selected and underwent intensity-modulated radiotherapy/3D conformal radiotherapy with IGRT in the department of radiotherapy of Henri-Mondor Hospital. All cone-beam computed tomographies (CBCT) were repositioned on intraprostatic calcifications. For each acquired image, displacements of intraprostatic calcifications were calculated with reference to position on planning CT in three directions: lateral, longitudinal and vertical.ResultsBetween 2011 and 2013, nine patients had 183 CBCT. For each image, three displacements and space coordinates were calculated using a single reference (intraprostatic calcification). Mean lateral, longitudinal and vertical movements were 0.26 ± 5.7 mm, −1 ± 4.6 mm and 0.42 ± 3.5 mm, respectively.ConclusionStudies exploring prostatic movements with fiducial markers as reference and ours with natural fiducials yield similar results. Our data confirm previous studies that have suggested that intraprostatic calcifications can be used as natural fiducials with potential reduction of iatrogenic risks and costs associated with the implantation of fiducial markers.     

Arcthérapie volumétrique modulée : ultime évolution de la radiothérapie conformationnelle ?

Technology development in radiotherapy has improved significantly during the last decade. The rapid evolution of 3D radiotherapy to intensity-modulated radiotherapy was possible thanks to inverse planning systems. Intensity modulated radiotherapy improved in its turn by possibilities of volumetric irradiation during a single rotation, reducing therefore the overall treatment. This article presents the technical parameters of this volumetric irradiation technique and a review of miscellaneous clinical indications.     

Cancers gastriques et pancréatiques : la (chimio)radiothérapie néoadjuvante remplacera-t-elle la chimioradiothérapie adjuvante ?

For many years, adjuvant chemoradiotherapy remained essential in the therapeutic management of gastric and pancreatic adenocarcinomas. For these tumours, surgical excision, the only hope of offering the patient prolonged survival, is only possible in 20% of cases. The median survival of operated patients is only 12 to 20 months due to the frequency of locoregional and/or metastatic recurrences. For stomach cancers, adjuvant chemoradiotherapy is justified by the results of the phase III trial Intergroup 0116 published by MacDonald et al. The gain in survival was at the cost of significant toxicity. This treatment was supplanted in the early 2000s by perioperative chemotherapy. Currently, neoadjuvant chemoradiotherapy clinical studies are ongoing with the aim of improving treatments observance and tolerance. For pancreatic cancers, the role of adjuvant chemoradiotherapy has long been discussed because of trials with contradictory results. Neoadjuvant radiotherapy has many advantages in terms of efficacy and tolerance. It increases the chances of subsequent complete tumour resection. Several prospective trials are currently ongoing to clarify its place in the therapeutic arsenal.     

La radiothérapie stéréotaxique peut-elle remplacer la curiethérapie pour les cancers du col utérin localement évolués ? Positionnement de la Société française de radiothérapie oncologique

Brachytherapy is part of the treatment of locally advanced cervical cancers, accounting for about half of the total delivered dose. The benefit of dose escalation is the most important in advanced cases or if the tumor has responded poorly. The use of interstitial implantations makes it possible to reach doses of the order of 85 to 90 Gy (including external beam radiotherapy contribution) in most patients, through image-guided approaches. Brachytherapy delivery is one of the quality criteria for patient care. To date, no data allow us to consider as an alternative the use of external boost through intensity-modulated or stereotactic body radiotherapy. Indeed, the doses delivered to the tumor and the capacity to spare normal tissues remains lower, as compared to what is permitted by brachytherapy. It is therefore appropriate for centers that do not have access to the technique to establish networks with centers where brachytherapy is performed, to allow each patient to have access to the technique. It is also necessary to promote brachytherapy teaching. The issue of reimbursement will be crucial in the coming years to maintain expertise that is today insufficiently valued in its financial aspects, but has a very high added value for patients.