Cancer de l’endomètre

Endometrial cancers are frequent and affect mainly postmenopausal women. They are mostly diagnosed at an early stage with an excellent prognosis. Surgery is the reference for a precise FIGO staging who guide adjuvant treatment. Tumor extension, grade, myometrium invasion and involved lymph nodes will be discriminating in therapeutic strategy. The management of stages I and II has been recently amended by ESMO, who proposed surveillance, brachytherapy, and radiation therapy followed by brachytherapy for respectively low, intermediate and high risk groups. These recommendations are controversial and must be confirmed. Locally advanced stages represent a heterogeneous population in which surgery should be proposed if it is feasible then followed by radiotherapy and/or chemotherapy. Based on an illustrated clinical case, indications, delineation, dosimetry and complications expected with radiotherapy are demonstrated.     

Surveillance du cancer de l’endomètre

Available data on appropriate follow-up in endometrial cancer highlight the need of well-conducted studies. Most recurrences tend to occur within three years and involve symptoms. Routine tests are not advocated without symptoms. In case of suspicious recurrence, TEP/CT seems to be the most sensitive and specific method. There is limited evidence to decide whether follow-up schedules with multiple visits result in survival benefits. An appropriate follow-up should be discussed based upon the risk of recurrence. Counselling on the potential symptoms of recurrence should be a major aim.     

Curiethérapie dans les cancers de l’endomètre

Surgery remains the cornerstone of the treatment for endometrial cancer, but brachytherapy plays a major role in the care of patients. In postoperative situations, brachytherapy is frequently indicated to prevent recurrences of the vaginal cuff. In case of medically inoperable patient, it can be, with or without external irradiation, an alternative treatment. In these two situations, techniques are radically different.     

Voies d’abord chirurgicales pour le cancer de l’endomètre ?

The recommendations of the Institut national du cancer and of the Société francaise d’oncologie gynécologique in endometrial carcinoma (2010) reported that laparoscopy is the standard surgical approach for patients with apparent stage FIGO I in preoperative outcomes including MRI (www.e-cancer.fr). For patients with stage FIGO greater than I, laparotomy is the standard surgical approach. In case of lymph nodes or peritoneal restaging, the laparoscopy could be a good option especially by extraperitoneal route in patients with recent first surgery.     

Aspects histoépidémiologiques du cancer de l’endomètre à Ouagadougou

We conducted a retrospective study over a period of 23 years from 1 January 1986 to 31 December 2008 in the department of pathology of CHU YO and a private laboratory in the city of Ouagadougou. The purpose of this study was to determine histo-epidemiological aspects of endometrial cancer in Ouagadougou. We collected 43 cancers of the endometrium, which represented 0.87%of all cancers, and 2.7%of the breast and gynecological cancers. The average age on the onset of endometrial cancer was 56.7 years (range 4–79 years). The most affected age group was 51-60 years. We also noted that 89.5% of women were postmenopausal. Most samples came from Ouagadougou (83.3%). The laboratory of pathology of CHU YO diagnosed almost 57% of the cases. The indication of the pathological examination was dominated by menorrhagia (87.4%). On histopathology, we found a predominance of adenocarcinoma (67%), followed by squamous cell carcinoma (12%), sarcoma of the chorion cytogenic (12%), undifferentiated carcinoma (7%) [Au: Please check]and embryonal rhabdomyosarcoma (2%). In total, carcinomas accounted for 86% and sarcomas 14%. Through this study, we encourage the establishment of a national screening program for women at high risk, so that all cases are diagnosed and treated early.     

Les cancers primitifs de l’urètre

Urethral carcinoma is a rare cancer. The published data on this topic are limited. Evidence-based information are of grade B and C. Sparing surgery can be an option for localized anterior tumors. For localized, advanced, and posterior tumors the treatment must be discussed by a multidisciplinary team, but the optimal treatment remains to be defined.     

Cancer du col de l’utérus : état des lieux après lancement d’un programme de lutte

Cervical cancer is the first gynecological cancer among African women in terms of frequency and mortality. This cancer is easily accessible to prevention by human papillomavirus (HPV) vaccination and screening by pap smears combined or not with HPV test. In Fianarantsoa, Madagascar, screening methods have been available since 2010. Objectives of this study are to assess medical and paramedical knowledge about cervical cancer history, emphasize reality of this disease in the region, and update prevention and management of precancerous lesions. We found a lack of knowledge concerning cervical cancer history by doctors, nurses, and midwives. Twenty-two invasive cervical cancers have been observed in oncology and gynecology services. None of those women had undergone a planned screening. Screening rate by visual inspection after acetate application was 0.47% and by sporadic pap smears was 1.86%. Positive test was observed in 10% and 8.5%, respectively. Fifty-three women have undergone cryotherapy for precancerous lesions within four years. This study shows that real incidence of cervical cancer must be very high in the community, here in the region and probably in Madagascar, contrasting with misunderstanding of medical and paramedical staff. Screening policy should be put in place and efforts need to be done to increase the level of screening rate and improve prognosis and mortality by cancer.     

Référentiels et techniques d’irradiation de haute précision : cancer de l’endomètre

Radiation oncology is a field in which many technologic improvements have been made over the past decades. External beam radiotherapy has evolved from treatment fields planned on X-rays to 3-dimensional planning with fusion with MRI's and PET images. Recently, intensity-modulated radiotherapy has been tested for many cancer localizations, and its role in the treatment of gynecologic cancers is still under evaluation. Potential benefits are well known: decrease of treatment toxicity, improvement of efficacy through better dose delivery. But the implementation of this technique requires a careful target and organs at risk delineation. The goal of this review is to evaluate the use of intensity-modulated radiotherapy in endometrial cancers with respect of dosimetric and clinical studies to date. In addition, challenges and perspectives of intensity-modulated radiotherapy integration are discussed.     

Cancers de l’endomètre de stades avancés : chirurgie première ou chimiothérapie néoadjuvante ?

Endometrial cancers with peritoneal spread are stage IVB of FIGO classification. Their pattern is similar to that of ovarian cancer. Optimal debulking surgery and chemotherapy are predictor of better overall and disease free survival. Despite the poor outcome, there is a need for new treatment options. Recommended management for this group of patients should consist of surgical cytoreduction followed by chemotherapy. There may be a role for neoadjuvant chemotherapy followed by interval surgery in selected subgroups of patients.     

Cancer de l’estomac

Radiochemotherapy Gatrointestinal intergroup study have demonstrated a convincing local control and overall survival benefit. Oncologists and GI workshops have in the present not had a major interest in the radiotherapy treatment of gastric cancer due to a number of factors. Primary because toxicities may be severe, second physicians may have low experience in definition of clinical target volume and in third perioperative chemotherapy is widely used in this indication. In Summary this issue should be used as guides for defining appropriate radiation planning treatment for the adjuvant postoperative therapy of gastric cancer.     

Cancer: de l’engagement éthique à la responsabilité politique

Today, ethical awareness is not able to comply with general considerations or academic resolutions. It must meet a commitment requirement, even sometimes leaning towards dissent and supporting certain necessary resistances. The cancer story is not particularly meaningful from an ethical values point of view that it could move on from. This, in a context where representations of the disease and its tragic realities trigger positions and practices that are questionable in many respects. In the 1980s, AIDS patients were able to promote other principles and impose the image of a person who was clearly ill, but recognized for their words, their own knowledge, their rights and their choices. With this outlook, the up until then little known aspects of medical and care ethics could be identified. These aspects concern the follow-up the person receives along the course of the disease, but are just as much about access to innovative care and treatments, new research practices and the daily issues in life during and after the disease. It is certainly not ethics specific to cancer, although this disease which penetrates our collective consciousness with such intensity is likely to trigger a more global thinking, that now specifically applies to chronic disease, its human and societal issues.     

Cancer de l’oropharynx

Cancers of the oropharynx are common lesions. Their treatment often includes radiation therapy either exclusively or in combination with chemotherapy or after surgery. The definition of target volumes is made difficult by the complex anatomy of this area. The aim of this work is to clarify the principles of 3D conformal radiation illustrated by a case report.     

Cancer de l’oropharynx

Oropharyngeal carcinomas, contrary to other head and neck carcinomas are of increasing frequency, mostly due to a frequent association with human papillomavirus infection. Pluridisciplinary management is necessary. New techniques as transoral surgery or intensity-modulated radiation therapy have the potential to reduce toxicities and morbidity while offering equivalent local control rates. Early stages may be treated with single modality treatment (surgery or radiotherapy) with five-year overall survival rate exceeding 80%. Advanced stages need therapeutic associations and five-years survival rates are inferior to 40%.     

Valeur juridique des recommandations de bonne pratique : cas de l’hormonothérapie des cancers du sein

On April 27th 2011, the French Supreme Administrative Court (Conseil d’État) granted the Recommendations for Good Practice set out by the French National Authority for Health (Haute Autorité de santé - [HAS]) a legal status, considering that they “must be regarded as (…) decisions which may be subject to an action for annulment”. The judge came to this conclusion through a quasi-syllogistic reasoning. Firstly, the French Code of Medical Ethics requires physicians to care for their patients in accordance with established scientific knowledge. Secondly, the HAS recommendations recall in particular this established scientific knowledge. Treating patients according to established scientific knowledge requires then that physicians follow the HAS recommendations. While the case at bar does not directly involve liability for medical malpractice – since the applicant only sought to have an HAS recommendation declared void – it is nonetheless necessary to examine the impact of this ruling for health professionals. Indeed, this decision raises a number of concerns for everyday medical practice. Guidelines concerning the endocrine treatment of hormonodependant breast cancers are plentiful. In January 2010, the HAS and the French National Institute for Cancer (Institut national du cancer) issued a “Guide for long-term illnesses – Breast cancer” (Guide ALD - Cancer du sein). In addition to these nation-wide guidelines, the Regional Networks for Cancer (réseaux régionaux de cancérologie) issued their own recommendations. Other guidelines are also set out in the framework of consensus conferences, such as the Nice Saint-Paul-de-Vence (France) and St. Gallen (Switzerland) conferences. In the United States, the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO), and in Europe, the European Society of Medical Oncology (ESMO) make recommendations as well. Therefore, the HAS recommendations are hardly the sole source of information for physicians and these documents sometimes contradict each other. Besides, these can quickly become obsolete, what still limits their relevance. Nevertheless, in the judge's mind, there is no place for conflicting interpretations; scientific knowledge must be consistent, homogeneous and objective. However, the reality is quite the opposite. This simplistic vision shared by judges does not seem to grasp the complexity of everyday medical practice. After a critical reading of the Conseil d’État judgment, we shall consider the potential issues and concerns raised by this ruling in medical practice using the example of hormone therapy for breast cancer patients.