Association métachrone d’un adénocarcinome rectal et d’une GIST: à propos d’un cas

Background

Gastointestinal stromal tumors (GISTs) are rare neoplasms. They represent less than 1% of all gastrointestinal tumors. Little is known about their association with other tumors of different histogenesis. Coexistence of GISTs, especially with metachronous or synchronous colorectal cancer, is a phenomenon with increasing number of relative reports in the last five years.

Case report

We report a 64-year-old man, with no history of disease, presenting with colorectal adenocarcinoma, treated with concomitant chemoradiotherapy, anterior resection of rectum, and adjuvant chemotherapy. After 9 months, he developed a locally advanced recurrent tumor. The patient received a second-line chemotherapy. Radiology estimate after six cycles discovered incidentally an antral gastric mass, which measured 5/4 cm in tomodensitometry imaging. Histological examination of mass’s biopsy revealed a GIST, and immunohistochemistry proved positive CD117. The patient continued to receive chemotherapy because of both malignant progress of colorectal adenocarcinoma and poor prognosis. Surgery of GISTs will be considered if complete or partial responses to chemotherapy of colorectal cancer are achieved.

Discussion

The coexistence of GISTs and other primary tumors is usually discovered incidentally during GI surgery for carcinoma, or during work-up for radiological or endoscopy exploration. The known genetic pathways of tumorigenesis are different for the two neoplasms: c-kit appears to be occasionally overexpressed in colorectal cancer, and it is not clear if the protein is indeed a key player in the carcinogenetic process, as it is in GISTs. Other studies are necessary to assess if tyrosine-kinase inhibitors could be used in a multimodality regimen in colorectal cancer.     

Présentation d’un outil d’évaluation du déroulement d’un projet de prise en charge en soins palliatifs et en soins de support

Résumé:  Pour répondre aux besoins complexes et multiples d’une population particulière de ?patients lourds?, la mise à disposition et la coordination de professionnels de santé complémentaires s’organisent à domicile ou dans les services d’hospitalisation. Analyser cette prise en charge recouvre aussi bien sa planification au stade de projet, son repérage et son identification au moment de sa mise en œuvre. Son évaluation qualitative et quantitative d’une part, sa déclaration dans le PMSI et sa valorisation par la T2A en hospitalisation d’autre part, permettent d’espérer et/ou d’adapter au mieux les moyens aux objectifs. Cet article présente un outil de recueil de données, élaboré à partir de travaux préexistants et spécifiquement créés pour évaluer le dé roulement d’un projet de prise en charge en soins palliatifs ou de support. Les informations collectées concernent le projet de chaque personne prise en charge (population concernée, sympt?mes et besoins, objectifs de la structure, projets de vie et de soins, moyens mis en œuvre, activités réalisées) et le projet de la structure. Cet outil, une fois testé et validé, pourrait être adapté par les professionnels de santé impliqués dans ce type de prise en charge.      

Immunothérapies et thérapies ciblées en oncologie médicale : rationnel d’essai d’association et perspectives

New immunotherapies, also called “immune checkpoints”, are promising and showed interesting antitumoral activities in particular in advanced setting of melanoma, clear cell renal cancer or non-small cell lung carcinoma. These treatments include ipilimumab, anti-PD-1 and anti-PD-L1. There is a strong rational for combination of immunotherapies and targeted therapies. This review is dedicated to expose the theorical issues and preclinical data of such combinations. This review examined the impact of immunotherapies on transduction pathways and modification of immunity related to targeted therapies. First clinical data form early drug development studies showed the difficulties observed with such combination and limitating toxicities. Finally, potential interesting combinations are overviewed with an emphasis on sequential treatments.     

Métastase splénique isolée d’un cancer de l’ovaire

Isolated splenic metastasis from a solid cancer is rare. Total splenectomy is a good option for diagnosis and treatment of splenic metastases. It offers, perhaps, a further chance of prolonged survival. We report a case of isolated splenic metastasis of epithelial ovarian cancer. Thirteen months after the splenectomy and chemotherapy, the patient remains in complete remission.     

Résultats préliminaires d’une tomothérapie hélicoïdale adjuvante avec boost intégré dans le cadre d’un traitement conservateur d’un cancer du sein

PurposeTo evaluate the dosimetry and acute toxicity of helical tomotherapy for locoregional irradiation of patients after breast-conserving surgery.Patients and methodsTwenty breast cancer patients with breast-conserving surgery treated by helical tomotherapy have been studied. The median age was 49 (min: 25, max: 69). The whole breast, tumour bed and lymph nodes were prescribed 52.2 Gy, 63.8 Gy and 50.4 Gy, all in 29 fractions. The dose per fraction was 2.2 Gy to the boost, 1.8 Gy to the breast and 1.74 Gy to the lymph node volumes. The reproducibility was analysed by recording the daily shifts in x, y and z directions and roll rotation. All toxicities were described using the Common Terminology Criteria for Adverse Effects v3.0.ResultsTwenty-two tumours were irradiated. Six-eight percent were located in the inner quadrant. In 90 % of patients supraclavicular and internal mammary nodes were treated. The coverage of planning target volumes (PTV) was as follows: PTV boost: V₁₀₇ = 0.3 % ± 0.5 SD, V₉₅ = 98.4 % ± 1.9 SD; PTV breast: −V₁₀₇ = 7.8 % ± 17.3 SD, V₉₅ = 96.8 % ± 2.2 SD; PTV LN: V₁₀₇ = 2.5 % ± 4.2 SD, V₉₅ = 92.7 % ± 13.2 SD. The mean V20 of the homolateral lung was 18.9 % ± 3.5 SD. For left side lesion, the mean V30 of the heart was 0.9 % ± 0.8 SD. The mean V5 was: V5 homolateral lung: 73.1 % ± 11.8 ET, controlateral lung: 38.9 % ± 21, heart (left side breast): 57.3 % ± 21, controlateral breast: 15.5 % ± 9.6. Median shifts were as follow: x-axis –0.04 mm (IC 95: –0.4 +0.38), y-axis –0.37 mm ± 5.51 (IC 95: –0.88 +0.14), z-axis 2.90 mm ± 5.42 (IC 95: + 2.4 + 3.4) and roll rotation 0.22 ± 1.10 (IC 95: –0.1 + 0.32). The treatment tolerance was acceptable with 1 definitive interruption couple of fractions before the end and 3 temporal interruptions for skin toxicity. No grade 3 or 4 toxicity. Ninety-five percent of patients experienced skin toxicity: 45 % grade 2. There were 3 cases of oesophagitis. The median follow-up of presented series is 9.7 months and all of the patients are free of disease without any residual early or late toxicity.ConclusionsHelical tomotherapy can achieve full target coverage while protected to the heart and ipsilateral lung. This treatment was well tolerated and reproducible. However, the low doses to normal tissue volumes need to be reduced in future studies.     

Immunologie et cancer: mécanismes d’échappement tumoraux

Résumé: Au cours de son développement, la tumeur met en place des mécanismes déchappement lui permettant de croître à linsu du système immunitaire. Les cellules tumorales sous-expriment certaines de leur protéine de surface, impliquées dans la reconnaissance par le système immunitaire. Elles peuvent également réguler négativement la prolifération des lymphocytes T, notamment en favorisant la croissance dune population de lymphocytes T régulateurs. Cette revue détaille certains des processus impliqués dans les mécanismes déchappement tumoraux avant de se focaliser sur le développement et le rôle des lymphocytes T régulateurs.     

Schwannome présacré: à propos d’un cas

Introduction

Presacral schwannomas are rare benign tumors, representing 1% to 5% of all schwannomas. We report a case diagnosed by imaging modalities (CT-MRI) and treated by complete surgical resection.

Case report

A 55-year-old female has had a history of abdominal pain since one year without compressive signs. A pelvic retrorectal mass has been discovered clinically. CT and MRI were very suggestive of a presacral schwannoma. Histological examination after complete surgical removal of the mass confirmed the diagnosis of a benign schwannoma.

Discussion

Giant presacral schwannomas are rare pelvic tumors. Often asymptomatic, they are diagnosed lately. CT and MRI are very useful in assessing the diagnosis and evaluating the extent of the tumor. Surgery is the therapeutic modality of first choice. Prognosis is good if the tumor is benign but recurrence is frequent.

Conclusion

Presacral schwannoma can cause pelvic pain. Imaging modalities (MRI++) often guide surgical resection.     

Stratégies d’immunothérapie dans les cancers colorectaux

Recent studies have underlined the close link between immune response and prognosis of patients with colorectal cancer (CRC). Immune response understanding combined with biotechnology progress of the last years has allowed development of immunotherapy strategies in CRC. Immunotherapy strategies are divided in “active” or “passive” strategies (patients immune system stimulation or not) and considering the activation of antigen specific immune response or not. These immunotherapy strategies are well tolerated and induced cellular and humoral response correlated with clinical response. Many monoclonal antibodies targeting signalisation pathways or angiogenic growth factors have demonstrated their efficacy in CRC. Multiple vaccine strategies, using different tumour associated antigens, have demonstrated a biological efficacy but with poor clinical results. Results are more promising in adjuvant setting but need to be confirmed by randomized trials. Adoptive immunotherapy with transfer of tumour associated antigen specific T cell is probably the most promising strategy. Actually, except monoclonal antibodies, immunotherapy is not used in clinical practice in CRC due to the lack of results and absence of standardisation.     

Métastases choroïdiennes d’un adénocarcinome pulmonaire traité par injections intravitréennes d’anti-VEGF et irradiation externe : à propos d’un cas

Choroidal metastases of lung cancer are very uncommon. This localization should be suspected on blurred vision and confirmed with an ophthalmological examination. Its treatment is not entirely codified. We report a case of blurred vision secondary to bilateral choroidal metastasis in a patient with choroidal metastases from a lung adenocarcinoma, treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and external beam radiotherapy. According to a literature review, we analyzed the place of the targeted treatments used alone or combined with the radiotherapy.     

Réflexions sur les critères d’évaluation des traitements anticancéreux lors des procédures d’autorisation de mise sur le marché

Although clear and validated recommendations exist concerning the evaluation of cancer treatments at the international level, the criteria retained to obtain the marketing authorization (MA) are multiple and heterogeneous. This qualitative survey explores the opinion related to the assessment of cancer treatment among the several concerned population. By the way of semi-structured interviews, our aim was to elicit perceptions toward the criteria which should be retained during the process of MA, by patients, oncologists, members of the pharmaceutical industry, health decision-makers and general population. Our survey emphasizes the variability of the significations associated with the criteria of efficiency of cancer treatments according to the characteristics of the respondents. We also have observed some common expectations from patients and oncologists toward the economic and political aspect, but also from the whole respondents toward the importance of the comfort of the patients. Lastly, the necessity to define specific criteria related to clinical cases emerges.     

Métastase pinéale d’un carcinome mammaire : à propos d’un cas et revue de la littérature

Pineal metastases of solid tumors are rare. Primary cancer is generally absent at the diagnosis, for which a cerebral MRI is important. We report a case of pineal metastasis occurring in a 76-year-old woman treated for breast carcinoma in our department.     

Les adénopathies métastatiques d’un carcinome épidermoïde sans porte d’entrée. Quelle est l’attitude actuelle ?

The diagnosis of carcinoma of unknown primary (CUP) is made after exclusion of the presence of a mucosal primary. There are two mains options for the primary treatment of CUP, either a neck node dissection followed by postoperative radiotherapy or chemo-radiotherapy, or a primary radiotherapy or chemo-radiotherapy depending on the nodal stage followed in case of residual neck disease by a selective neck dissection. There is no data to suggest the superiority of one over the other. For radiotherapy, unilateral neck or bilateral neck, including the upper aerodigestive tract mucosa are possible options. There is no definite data to demonstrate the superiority of one over the other, but owing the reduced toxicity of unilateral irradiation, and the possibility of salvage treatment in case of emergence of a mucosal primary and/or a contralateral neck node development, the former may be the preferred option. Advances in radiotherapy such as intensity modulated radiation therapy have the potential to spare organs at risk and reduce late toxicity rates. A selective irradiation approach customized on “major” criteria, such as nodal stage and level, HPV and EBV status and accessory criteria, such as histological variants, is under investigation.