Personnalisation de la dose,du volume et du fractionnement de la radiothérapie du sein

Randomized trials demonstrated similar overall survival between mastectomy and breast-conservative surgery followed by adjuvant radiation therapy. Breast-conservative surgery, with adjuvant radiation therapy, with or without neoadjuvant systemic therapy has become the standard of care for women with early or locally advanced breast cancer. Nevertheless, certain cardiac, lung or cutaneous toxicities may alter the long-term body image and the quality of life of a limited number of patients who consider having had “overtreatment” or treatment outside the best knowledge of science. In case of low-risk breast cancer, several trials have evaluated the carcinologic outcome in absence of radiation therapy after breast-conservative surgery. Local recurrences increased in case of breast-conservative surgery alone but without impact on overall survival. Multiple debates have emerged in order to select the most appropriate evaluation criteria. Finally, a large consensus has considered that reducing local recurrences is important but with modern technologies and after identifying patients of individual radiosensitivity. Indeed, in case of a low absolute risk of local recurrence, radiation therapy techniques have been developed to allow a focal treatment especially for patients with high risk of developing late effects. This kind of compromise takes into account the reduction risk of local recurrences but also the probability of developing radiation-induced cutaneous sequelae. In the same way, for patients considered at high risk of recurrence, the huge volumes need specific techniques to better cover the targets while protecting the surrounding critic organs such as heart and lung. Intensity-modulated radiation therapy and the local high boost may help to decrease local recurrences of these more extended and aggressive diseases while considering the individual radiosensitivity that paves the way of long-term sequelae. In this article, we detail a personalized approach of breast radiation therapy considering the absolute risk of local recurrences and the probability of radiation-induced toxicity appearance.     

Personnalisation de la dose et du fractionnement de la radiothérapie des cancers de la tête et du cou

Head and neck cancers comprise a variety of tumours depending on the sub-site, for which target volumes and the prescribed doses need to be individualized according to each patient's history and presentation. This article aims at describing the main factors involved in decision-making regarding dose and volume, as well as ongoing research. Contouring and treatment guidelines, use of altered fractionation, major prognostic factors, the role of Human papillomavirus and of functional imaging will be presented and discussed.     

Les carcinomes du nasopharynx Les modalités de la radiothérapie et les associations de la radiothérapie et de la chimiothérapie: état actuel et perspectives

Nasopharyngeal carcinoma (NPC) is a highly radiosensitive and chemosensitive. In the patient with locally advanced Humours, the results of conventional radiotherapy are unsatisfactory with significant rates of both local recurrences and distant metastases. The aim of this review is to report the innovative strategies for treatment of the nasopharyngeal carcinoma. Altered fractionation techniques can improve local control. The impact of the innovative techniques, including conformai radiation, stereotactic radiation and IMRT, on survival, must be evaluated in randomised trials. The encouraging early results obtained with concurrent (more than sequential) chemotherapy and radiotherapy must be confirmed in prospective randomized trial in endemic areas.     

Déterminants moléculaires et génétiques d’efficacité et de toxicité du 5-fluoro-uracile

At the present time, 5-FU remains the standard molecule in the treatment of a large number of solid tumours and is the first choice when it comes to gastrointestinal cancers. A large number of markers, indicators of response and safety, have been described for this molecule and its oral form, capecitabine. Although the number of markers with clinically validated relevance remains low, combining both genetic and molecular research at the patient’s bedside with these markers will provide personalised oncological medicine and aims to improve the efficacy/safety balance for these medicinal products. To this end, and at a time where multicentre studies presenting strong evidence are available, 5-Fluorouracil and other fluoropyrimidines should be seen as the molecules of choice, fully benefiting from the progress being made in the area of biomarker-based medicine.     

Bévacizumab et taxanes dans le traitement de première ligne du cancer du sein métastatique: survie globale et analyse de sous-groupes de l’étude ATHENA France

The international phase IIIb study, ATHENA assessed the combination of bevacizumab/taxane-based chemotherapy in the first-line treatment of HER2negative metastatic breast cancer (mBC) in real-life setting. Among the 365patients included in France, median overall survival (OS) is 28.4months (CI95% 24.8-33.0), with a median time from treatment start to end of study of 36,5months (25,1-45,4). Exploratory analyses in three sub-groups show that the median OS in long responder patients (not progressing for at least one year; n = 116) is not reached. In responder patients (n = 308), median OS is 33.0 months (CI95% 28.6-37.4) and 12.4months (CI95% 11.2-17.4) in non-responders (n = 41). In patients with mBC expressing hormone receptors (HR+), treated with first-line hormone therapy before inclusion (n = 87) median OS in is 23.2months (CI95% 19.6-28.6), and 35.3months (CI95% 32.2-not reached); P = 0.004in patients treated first with chemotherapy + bevacizumab (n = 179). The safety analysis in the various sub-groups of grade 3-5adverse events of particular interest to bevacizumab of this study was comparable to the safety data of randomized phase III studies.     

Carcinomes du nasopharynx Aspects cliniques,indications et résultats de la radiothérapie transcutanée et de la curiethérapie État de la question en 2001

Nasopharynx carcinomas (NPC) are a very special head and neck cancer, in term of epidemiology, clinic and pathology. Endemic disease in South East Asia, undifferentiated nasopharynx carcinoma are very frequent CT scan and NMR allow a better knowledge of the modalities of the clinical presentation. Prognostic factors include local and regional extension, NPC is a wellknown radiosensitive disease with a dose-response curve well established. Modern imaging modalities and modification of the ballistic explain the amelioration of the local control and the diminution of therapeutic sequellae. Brachytherapy is an interesting modalities for the boost and the treatment of recurrent disease. The exact place of 3 D CRT and IMRT is not yet known as modifications of fractionation. Local control for T1T2 tumor is excellent but is related to clinical extension (cranial and neurologic involvement) and nodal extension (supra clavicular N3) and show the interest of combined chemo-radiotherapy protocols.     

Fonction rénale et chirurgie du cancer du rein

Although radical nephrectomy is still practiced in many patients with large renal tumors, oncology and nephrology arguments for kidney-sparing approach for small renal masses has taken over this first. Indeed, partial nephrectomy provides equivalent oncologic results while preserving renal function and thereby limit morbidity and cardiovascular mortality related to chronic kidney disease. In addition, patients who develop kidney cancer often have medical comorbidities that may affect renal function, such as diabetes and hypertension. Histological examination of renal tissue adjacent to the tumor showed significant pathological changes in the majority of patients. For elderly patients or patients with comorbidities, active surveillance allows kidney-sparing approach with extremely low rates of progression and metastasis of cancer disease. Despite these significant advances in understanding for the treatment of small renal masses, partial nephrectomy remains underused. Better management must take into account the preservation of renal function in order to increase overall survival. A strategy for the systematic evaluation of renal function in patients with CR, with multidisciplinary staff (nephrologist urologist and oncologist), is therefore highly desirable.     

Immunothérapie et cancer du sein

Immunotherapy development is increasing in several types of tumor, including breast cancer. A large number of studies have focused on the evaluation of tumor-infiltrating lymphocytes, or TILS, as a prognostic and predictive factor, and it seems that a breast cancer sub-type with high rates of TILS has a better prognosis. It can be assumed that these tumors would be good candidates for immunotherapy. Concerning immune checkpoint inhibitors, preliminary results from anti-PD1 administration for breast cancer are less impressive than in other types of cancer, but there are signs of activity in a small proportion of patients who may benefit from treatment over an extended period. At the same time, vaccines targeting various tumor antigens (HER2, Tn, etc.) were developed, and have shown ability to induce an anti-tumor immune response. The future is therefore to a combination of these vaccines with immunotherapy. Nevertheless, the presence of a biomarker to predict response is lacking and we need to identify which patients would benefit from these new and expansive therapies.     

Peur de la récidive et/ou progression du cancer et prévention en santé mentale

Patients often mention the return of the cancer and express their anxiety about a possible invasion of their body by the cancer or the spread of the disease in other organs. Particularly, post-treatment, they describe the fear of cancer recurrence (FCR) as a sword of Damocles hanging over their head and threatening their future peace by spreading the notion of uncertainty. Some authors refer to the FCR as a central dimension in many patients, and others point out the problem of pervasive fear of return and/or progression of the disease being one of the most often reported difficulties by cancer survivors. The objective of our work is to present a literature review and propose terms of psychological interventions focused on FCR.     

Dent et irradiation : denture et conséquences sur la denture de la radiothérapie des cancers de la tête et du cou

Pre-irradiation dental care depends on teeth health, fields and dose of irradiation, compliance to fluorides, cessation of tobacco and psychosocial cofactors. Dental care aims at preventing complications and preserving the quality of life (eating, speech and aesthetics). Approximately 11% of patients do not require any pre-irradiation dental care. Dental complications vary from slight colorations of the teeth to major complication such as osteoradionecrosis. Osteoradionecrosis rates vary from 1 to 9%, and may be decreased by using a 21-day delay between extractions and irradiation, provided that it does not postpone cancer treatment, with a dose-dependent risk (<6% if <40 Gy; 14% between 40 et 60 Gy; ≥20% if >60 Gy). Osteoradionecrosis occurs spontaneously (35%), mostly involves the mandibula (85%).     

Les lymphangiomes kystiques du mésentère et du rétropéritoine

Study aim

Study of clinical, diagnostic and therapeutic aspects of mesenteric and retroperitoineal cystic lymphangiomas.

Material and methods

This is a retrospective study relating to four patients: two men and two women. The average age at the time of the diagnosis was 33.5 years with extremes of 19 and 48 years. The clinical presentation at the time of the diagnosis was the following: abdominal pains, and a mass or voussure of the abdominal wall. Imagery was in favour of a cystic image. Surgical exploration showed the existence of a mesenteric and retroperitoneal cystic mass. The anatomopathological examination concluded cystic lymphangioma.

Conclusion

Mesenteric and mesocolic cystic lymphangiomas are congenital benign tumours. Complete resection should be performed whenever possible. Intracystic sclerotherapy is possible for unresectable lymphangiomas.     

Retard diagnostique et thérapeutique du cancer du testicule au Sénégal

Introduction

Testicular cancer is a rare disease in black subjects, by disregarding the diagnosis in some cases. We report three cases diagnosed at a metastatic stage.

Patients and methods

We conducted a retrospective study of three cases of testicular cancer. We collected patient age at diagnosis, circumstances of diagnosis, the rate of tumor markers, pathologic results after resection of the tumor and complementary therapies, and morbidity and mortality. Patients have been described based on the summary of their observations.

Results

The average age of our patients was 28 years. All our patients presented at least once without a testicular cancer diagnosis has been discussed. At the histological level, it was in the three cases of non seminomatous germ cell tumors. There were lymph node metastases in our three patients and visceral involvement in two patients. Two patients out of three died during chemotherapy. The third patient had six cycles of chemotherapy with the protocol bleiomycine, etoposide, cisplatin has. Four months after the end of six treatments, he is in complete remission, thoracic and abdomino-pelvic CT scan and tumor markers were normal.

Conclusion

The rarity of testicular cancer in black subjects should not be a reason to disregard them. Late diagnosis often leads to advanced stages with poor prognosis and the need the to use more frequently adjuvant chemotherapy whose cost is not always within reach of patients in our country.