Chimioradiothérapie concomitante des cancers infiltrants de la vessie

Until now, radical cystectomy has been considered the most effective treatment for invasive bladder cancer. However it fails to cure more than 50% of patients and can result in a mediocre quality of life. In an effort to improve cure rates, combined modality regimens have been investigated. Despite the preliminary results of early clinical trials, randomized trials have most often failed to show any benefit from neoadjuvant or adjuvant chemotherapy or radiotherapy. One of the major progress brought by radiotherapy has been the wide use of conservative treatment in several cancer, and in the recent years promising results have been published with concomitant radio-chemotherapy. The use of conservative approach in bladder cancer now appears to be a tangible reality for selected patients, but this combined modality have not yet been tested in randomized trials.     

Chimioradiothérapie concomitante du cancer de l''œsophage

Radiation therapy with concomitant chemotherapy is the standard treatment for non resectable esophageal carcinoma. For patients with operable tumors, surgery is the traditional treatment. However several data have suggested that preoperative chemo- and radiotherapy could improve therapeutic results. At the present time, no randomized trial has demonstrated, except for adenocarcinoma of the cardia, the benefit of preoperative treatment. Other randomized trials are needed to determine the role and the optimal modalities of these treatments. This is a review of the literature data in concomitant chemotherapy and radiation in the management of esophagus.     

Places respectives de la radiothérapie et de la chimiothérapie dans le traitement adjuvant du cancer du sein : intérêt théorique et faisabilité de la chimioradiothérapie

Concomitant radiochemotherapy is of potential interest in the treatment of early stage breast cancer. Radiotherapy improves local control after both conservative surgery and mastectomy and in this last case also improves overall survival. Some questions however still exist concerning the role of the delay between surgery and radiotherapy on the efficacy of this treatment. Over 6 months, the benefit due to radiotherapy could be reduced. Adjuvant chemotherapy leads to improved survival in all categories of patients with breast cancer, either with or without axillary-node involvement. Anthracyclin-containing regimens seem to be the most efficient, but their superiority on “historical” standard regimens such as cyclophosphamide-methotrexate-5-fluorouracil has never been fully established. Chemotherapy and radiotherapy have synergistic effects. Used simultaneously, their effect on residual disease after surgery could be increased. Moreover, this therapeutic modality enables reduction of treatment duration as well as the delay between surgery and radiotherapy. Some studies have demonstrated the good tolerance of concomitant radiotherapy and FNC (5-fluoro-uracil, mitoxantrone and cyclophosphamide) or CMF. Three French randomized trials testing the value of concomitant vs sequential radiotherapy + chemotherapy are ongoing. However, careful and critical interpretation of survival data will be required to consider concomitant chemoradiotherapy as a standard adjuvant treatment of early stage breast cancer.     

Intérêt des traitements adjuvants dans les sarcomes utérins : expérience de l’institut CurieRole of adjuvant treatments in uterine sarcoma: experience of Curie Institute.

Purpose. – Uterine sarcoma is a rare disease and survival is poor. From 1975 to 1995, 73 uterine sarcomas were treated at the Curie Institute, and we analysed prognostics factors of survival.Patients and methods. – Seventy-one patients underwent primary surgery, in most cases a radical non conservative surgery and a lymphadenectomy. Every patient had an irradiation (external beam irradiation and/or brachytherapy), and 24 patients received adjuvant chemotherapy. We observed that youngest patients had more leiomyosarcomas and low histologic grade tumours. Median survival was 42 months, and 5-years survival and local control were 36 and 68 % respectively. Pelvic recurrences were most often before 2 years. This series demonstrates the impact of adjuvant irradiation on local control. This impact was stronger if the tumour had a high histologic grade (p<0.01). However, irradiation, as well as chemotherapy, had no impact on the survival.Conclusion. – The study confirmed that irradiation enable a better local control. However modalities of radiation therapy (brachytherapy and/or external beam radiotherapy, dose, volume), are still controversed.     

Chimioradiothérapie: rappel historique et état des lieux

The idea of combining radiotherapy and chemotherapy goes back to the very beginning of the antimitotic drugs era. At that time, this association was mainly based on a simple concept: spatial cooperation. The first period was one of so-called “adjuvant” (post-irradiation) chemotherapy, soon followed by the once-fashionable “neo-adjuvant” chemotherapy era. Today, concomitant administration of both therapies, mainly based on radiosensitization, appears promising, although the previous schemes were clearly efficient for some specific indications. In 1998, radiochemotherapy combinations represent an unavoidable part of the anticancer strategy. A number of them have been recognized as the standard treatment for some localizations, and there is little risk to imagine that this number will increase within the next decade.     

L''évaluation du coût des complications peut-elle contribuer à la poursuite du développement de la radiothérapie ?

At the present time, the current improvement of technical and dosimetric aspects of radiation oncology has to be evaluated in terms of potential benefit for the patient and the society. For this last point of view, specially designed economic analyses must be performed in order to justify the number of resources involved by these technical improvements. If the question is how the current technical procedures could reduce the risk of undesirable side-effects, the response cannot be immediately drawn from the literature. This paper emphasizes the possibility to evaluate the role of side-effects as endpoints of economic analyses when using special models in medical decision making such as Markov's. Only few oncologic situations are reliable to properly analyze the relationship between sophisticated radiation techniques and the incidence of post-radiation complications. These situations should be selected when prospective economic analyses are planned in the field of radiation therapy.     

Pancréatectomie après chimioradiothérapie néoadjuvante pour adénocarcinome exocrine du pancréas potentiellement résécable

The last of the therapeutic modalities proposed for exocrine adenocarcinoma of the pancreas which appears to be potentially resectable, neoadjuvant chemoradiotherapy has many prerequisites: validation of the diagnosis, determination of resectability with a high degree of confidence and palliation of biliary obstruction when present. This rather complex strategy does not seem to have major deleterious effects on the operative procedure or the postoperative course. Only multicentric protocols will, in the near future, give an answer to the question of secondary toxic effects and improvement of survival of this new therapeutic strategy.     

Chimioradiothérapie des carcinomes des voies aérodigestives supérieures

The objective of this study was to review randomized trials which evaluated the effect of the radio-chemotherapy in head and neck carcinoma, and which compared radiotherapy alone vs the same local treatment plus chemotherapy. Over 40 such randomized trials have been performed, which generally showed no statistical difference between both arms. However few trials showed a benefit which is almost always in favor of the CT arm. Indeed, some trials of concomitant chemoradiotherapy have shown a statistically significant benefit in favor of the combined treatment. On the contrary, neoadjuvant chemotherapy generally leads to no detectable benefit compared to radiotherapy alone. These results have been reinforced by those of four randomized trials comparing neoadjuvant chemoradiotherapy and the same chemotherapy but given concomitantly with radiotherapy. The global effect of chemotherapy on survival of patients with head & neck sqamous cell carcinoma has been recently evaluated by a meta-analysis based on individual patient data which included more than 10,000 patients from 63 randomized trials. The absolute survival rate benefit at 5 years is 4%, but is more pronounced in the concomitant combinations (8% at 5 years). In tumors classified as “T3” of the pharyngo-larynx, neoadjuvant chemotherapy followed by radiotherapy in good responders can avoid a total laryngectomy without significantly compromised survival. In the nasopharynx carcinoma, a few randomized studies have been performed, suggesting a benefit in favor of chemoradiotherapy. Finally, future randomized trials will determine what are the optimal chemoradiotherapy schedules, as well as determining what is the best radiotherapy (accelerated, hyperfractionated) to use in combination with chemotherapy.     

La chimioradiothérapie dans le traitement du cancer du canal anal

In the treatment of anal canal carcinoma, since the work of Nigro, the 5-fluorouracil-mitomycin C regimen is considered standard when applied concomitently with radiotherapy. Surgery is used mainly to salvage the failures after irradiation. Two randomized European trials (EORTC, UKCCCR) have shown that the 5-fluorouracil-mitomycin C combination improves local control but not overall survival. The RTOC-ECOG trial has shown that mitomycin C improves local control when compared to 5-fluorouracil alone. This chemotherapy is responsible for a toxic death in 2% of cases. The 5-fluorouracil-cisplatin regimen will posibly represent an alternative to the 5-fluorouracil-mitomycin C. Ongoing trials will help to answer this question.     

Effets tardifs de la radiothérapie sur le muscle strié

There are few data regarding the adverse effects of radiotherapy on skeletal muscle. This tissue is considered to be radioresistant. Muscle toxicity of radiation is unfrequent and does not represent a limiting factor for dose escalation.     

Effets tardifs des radiations ionisantes sur les tissus de la sphère otorhinolaryngologique

Numerous structures are included in the irradiated volume of patients presenting with head and neck cancer: skin, mucosa, bone, teeth, cartilage, muscles, salivary glands, etc. Curative intent treatment of such tumours requires aggressive approach which can lead to severe sequellae. These sequellae are in most cases dose-dependent and volume-dependent. However, an appropriate technique might decrease the severity of such sequellae. Details of these late changes are presented, including their pathophysiology, clinical syndromes, potential treatment, and prevention.     

Effets tardifs de la radiothérapie chez l'enfant

Although most pediatrie tumors can be cured with lower doses of radiation than their adult counterparts, long-term radiation-induced complications and sequelae remain a major concern both in terms of frequency and intensity. Most of them have been extensively documented in the pre-chemotherapeutic era like those affecting bone, cartilage and soft tissue growth or CMS and endocrine glands. More recently the emphasis has been put on the apparent increasing incidence of reported second malignancies. This could have been favored by the chemo-radiation combinations used in most children but also has been made possible mainly by the extensive follow-up of the increasing cohort of cured children.     

Prise en charge des sarcomes des tissus mous des membres par radiothérapie externe

Soft tissue sarcomas are rare tumours. Conservative surgery followed by postoperative radiation therapy represents the gold standard in the majority of cases. Postoperative radiotherapy improves local control without affecting survival. Besides the quality of surgical excision, which remains the major prognostic factor, the importance of the irradiation volume and particularly margins used in external beam radiotherapy were also found to influence local control of the disease. In this study, we propose to conduct a literature review on the present state of our knowledge on this subject in the form of an articulated controversy: in favour or opposed to large margins in external radiotherapy.