Association du double blocage de HER2 et radiothérapie dans la prise en charge du cancer du sein exprimant HER2

PurposeThe tolerance of the concurrent use of radiotherapy, pertuzumab and trastuzumab is unknown. The purpose of this study was to evaluate the toxicity of this association in patients treated for HER2 positive metastatic and/or locally recurrent unrespectable breast cancer.Material and methodsA retrospective study was performed in our institution for all consecutive patients treated with concurrent irradiation, pertuzumab and trastuzumab. The radiotherapy was performed while pertuzumab and trastuzumab were administrated as a maintenance treatment at the dose of 420 mg (total dose) and 6 mg/kg respectively every 3 weeks without chemotherapy. Toxicity was assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Left ventricular ejection fraction (LVEF) was measured at baseline and then every 3–4 months.ResultsWe studied 77 patients. treated in between 2013 and 2019 with median follow-up of 38 months (range 0–264 months). Median age was 53 years (33–86). There were 50 patients (64.9%) with metastatic and 27 patients (35.1%) with recurrent disease. All patients received docetaxel followed by P–T as first line treatment and they received 34 cycles (10–85) of pertuzumab and trastuzumab. All patients experienced partial or complete response according to RECIST criteria. Irradiation volumes were whole breast (41 patients, 53.2%) and chest wall (29 patients, 37.7%) at a dose of 50 Gy with a median duration of 39 days. Radiotherapy of lymph nodes was performed in 53 patients (68.8%) as following: supraclavicular–infraclavicular and axillary lymph nodes in 52 patients (67.5%), and internal mammary nodes in 31 patients (40.3%). For 20 patients. (26.0%) radiotherapy was palliative: bone irradiation (12 patients, 15.6%), whole-brain radiotherapy (2 patients, 2.6%), cerebral metastasis irradiation (6 patients). As early toxicity we observed: radio dermatitis as following: 36 patients (46.8%) presented grade I, 17 patients (22.1%) presented grade II, and 3 patients (3.9%) presented grade III. One patient (1.3%) presented grade II esophagitis. One patient (1.3%) presented asymptomatic decrease of LVEF during treatment and 6 patients (7.7%) presented a decrease of LVEF. There was no radiation-induced pneumonitis. As late toxicity, we observed 1 (1.3%) case of grade I and 1 (1.3%) with grade II telangiectasia. There was 1 case (1.3%) of grade III cardiac toxicity, 8 months after the concurrent treatment.ConclusionThe concurrent use of radiotherapy, pertuzumab and trastuzumab is feasible with good tolerance. Larger prospective data with longer follow-up is needed to confirm these results.     

Cancer du sein négligé et localement évolué : quelle réalité ? Réflexion à propos de deux cas sur l’optimisation de la prise en charge multidisciplinaire

The standard treatment for breast cancer patients with untreated locally advanced breast cancer is neo-adjuvant chemotherapy or hormonal treatment. In some cases, this treatment is followed by surgery and/or radiotherapy when the multidisciplinary approach is present. In some cases of patients presenting metastatic diseases, the radiotherapy is forgotten or proposed late when the local disease is extremely advanced with symptoms and decreased quality of life. Two cases of extremely advanced non operable T4 stage breast cancer are reported and the importance of multidisciplinary approach is discussed. The place and the right time of radiotherapy in this multidisciplinary strategy is reported.     

Adénocarcinome du bas œsophage et du cardia: prise en charge chirurgicale

Adenocarcinoma of the esogastric junction is increasing more rapidly than any other cancer in western country. Patients with carcinoma of the cardia often présent at an advanced stage of disease. Accurate preoperative staging of cancer of the cardia need computed tomography, endoscopic ultrasound: laparoscopy is useful for advanced cancer to detect liver and peritoneal metastatis, preventing an unnecessary laparotomy in up to 20% of patients. The Siewert's classification of the cancer of the esogastric junction is accepted internationally: type I: tumor center within the late 5 cm of the distal esophagus, treated with subtotal esophagectomy; type II: located at the esogastric junction, treated with distal esophagectomy and, either proximal or total gastrectomy; and type III: subcardial cancer, treated by extended total gastrectomy. The dominating independent prognostic factors are a complete resection (RO) and the lymph node status (pNO) Expected S year survival rate is 30% in patients undergoing surgery with curative intent (RO) and less than 1% in patients undergoing palliative surgery.     

Critères de prise en charge en médecine physique et de réadaptation et pathologies cancéreuses

Introduction

Physical medicine and rehabilitation (PMR) cares are limited in practice in France. The complexity of treatments and their potential effects on disability, life expectancy, constitute some chronic factors of the cancer diseases. This chronic evolution is more and more indication of PMR interventions to limit deficiency or disability.

Objectives

To present the PMR modalities at different situations of the cancer diseases evolutions.

Methodology

This paper reports the orientation in our outpatient unit, the modalities for cares in PMR, the role of PMR doctors and the different technological or competent needs for cancer patients with deficiency or disability.

Discussion

A new and important reflexion with information, studies and acquired experiences are necessary. Organization of cares, institutions and cooperation must be developed in this specific domain of the rehabilitation for cancer patients with disability.     

Cancers du col utérin : nouveautés dans la prise en charge en oncologie radiothérapie

During the recent past years, the therapeutic management of locally advanced cervical cancer patients has consistently improved, with the integration of image guided brachytherapy and dose escalation strategies leading to an improvement of local control rates. In parallel, the evolution of external beam radiotherapy techniques and the better control of organs at risk doses in brachytherapy have contributed to decrease the probability of severe normal tissue complication. In case of advanced disease, patients prognosis remains however marked by a high risk of distant failure, and this finding has encouraged the assessment of various research pathways in order to better predict and/or prevent tumor relapse. Major studies are being conducted or have been published, and the place of chemoradiation and brachytherapy has been confirmed as first intent treatment in case of locally advanced disease. Numerous prospective or retrospective data, few of which are reviewed there, have been integrated as part of a strategy aimed at being more and more personalized. Next steps of therapeutic optimization will include the assessment of multiparameters radiological tools, but will also rely on a better understanding of radiobiological pathways involved in local or systemic response to irradiation, and the most promising of those is probably the anti-tumor immune response.     

Métastases cérébrales : quelle prise en charge en 2012 ?

During the last French radiation oncology society annual congress, the therapeutic options for the management of brain metastases were presented. The indications and limits of surgery, stereotactic radiotherapy and whole brain radiotherapy, as well as their benefit in terms of overall survival, local control and improvement of the functional and neurocognitive status were discussed. The prognosis significance of the different phenotypes of breast cancer on the risk for BM as well as their roles in the treatment of brain metastases were also described. Surgery improves overall survival for patients with a single brain metastase and should be considered in the case of symptomatic lesions. The overall survival of patients treated with stereotactic radiotherapy do not differ from that of patients treated with surgery. These treatments should be mainly considered for patients with good performance status, one to three small brain metastases (< 3 cm) and limited extracranial disease. Whole brain radiotherapy is more and more discussed in adjuvant setting due to potential late neurocognitive toxicity. This toxicity could be improved with the development of techniques sparing the hippocampus. HER2+ and triple-negative breast cancer patients are at increased risk for brain metastases. Prognosis of these patients differs as the overall survival of HER2+ patients has improved with anti-HER2 therapies. The optimal combination of local and systemic therapies remain to be determined.     

Perspective socio-anthropologique de la prise en charge de la dénutrition du malade cancéreux

The diet of the cancer patient is a major focus of prevention and treatment strategy of the recent plans that fight against cancer. It is sometimes reduced to a rapid series of more or less general advice, often interfered by other sources of information, more or less conventional. In this pathological situation where the nutritional status of the patient is paramount, it seems crucial to understand the different modalities of how the food behavior is implemented. This article describes the construction modalities of the cancer eater decisions. The goal of the socio-anthropological analysis proposed in this article is to initiate a reflection on the under nutrition problem by focusing on the approach of the eater diagnosed with cancer. The aim is to help identify ways of action to fight against under nutrition and improve the quality of life of the patient.     

Trouble bipolaire et cancer : particularités de la prise en charge

Bipolar disorder is a common psychiatric disorder characterized by mood fluctuations. Bipolar disorder is not a risk factor of cancer but bipolar patients often have lifestyle and daily habits that can increase the risk for cancer. When bipolar patients have been diagnosed with cancer, they need a sustained psychiatric follow-up and support because of the distress due to the diagnosis of cancer or to the side effects of some treatments used in oncology (corticotherapy, chemotherapy, interferon...), which can lead to a destabilization of mood and alter the treatment of cancer. Most people with bipolar disorder are prescribed psychoregulators, but these treatments have to be used with caution in the case of cancer comorbidity, keeping in mind their interferences and the cumulative effects with current cancer treatments. Consultation-Liaison psychiatrists play a major role in the follow-up and the surveillance of these patients, in collaboration with oncologists, general practitioners, and also patient’s families.     

Évaluation et prise en charge de la toxicité cutanée en cours de radiothérapie

Acute radiation dermatitis remains one of the most commonly observed side effect during radiation therapy leading to complication such as superinfection or treatment disruption. Its management is characterized by a great heterogeneity. Few strategies have demonstrated a benefit in preventing radiation dermatitis, which relies mostly on decreasing dose delivered to the skin and skin care practices. Simple emollients and use of topical steroids can be useful in early stages. The singularity of the skin toxicity seen with cetuximab and radiotherapy warrants a specific grading system and distinctive clinical treatment with use of antibiotics.     

Adénocarcinome du bas œsophage et du cardia: prise en charge non chirurgicale

Dedicated studies to esophageal carcinomas are few. Surgical excision remains the treatment of choice for localised tumours. External beam radiation therapy could be used alone to obtain a quick palliation and to allow the recovery of normal eating. Currently, combined modality treatment demonstrated better results when compared to radiation alone. Efficiency of combined modality treatment of adenocarcinoma seems equivalent to epidermoid. Numerous phase II studies demonstrated the feasibility of combined radio-chemotherapy in a preoperative setting. However, phases III trials are criticised and actually no definitive conclusion can be drawn. Inclusion of patients with such a tumour should be encouraged.     

Résultats et enseignements d’une stratégie innovante de prise en charge des nausées et vomissements chimio-induits

Current chemotherapy-induced nausea and vomiting management guidelines recommend taking into account the emetogenic potential of the chemotherapy employed as well as individual risk factors to such effects. We performed an interventional prospective study to assess the impact of an innovating therapeutic optimization strategy. The latter combines current guidelines application to a specific consultation in order to individualize the treatment. This study included 170 patients and covered a total of 1,746 days of various chemotherapies. Among these patients, 86.5% never vomited and 53.8% never had any nausea or vomiting. These results seem generally better than the ones found in the literature with all kinds of chemotherapies. Regarding them, we have attempted to highlight the determining criteria for a successful antiemetic treatment.     

Nouvelles techniques de radiothérapie externe : exemple de prise en charge dans les cancers du sein

The purpose of new radiotherapy techniques is to better deliver dose conformation in the tumour volume while diminishing organs at risk exposition. Their development is soaring in the breast cancer field in the adjuvant setting with intensity-modulated radiation therapy but also in cerebral and extracerebral oligometastastic presentation. Their usage is still being debated for breast cancer care. The objective of this narrative review is to list and discuss clinical data at our disposal for these news technologies.     

Radiothérapie et thérapie ciblée pour la prise en charge du cancer du sein : mise au point

The purpose of this study was to review the current knowledge regarding combinations of the most commonly used targeted therapies or those under development for the management of breast cancer with radiation therapy. Several studies have shown that the combination of radiation therapy and tamoxifen increased the risk of radiation-induced lung toxicity; therefore, the two modalities are generally not given concurrently. The combination of HER2 inhibitors (trastuzumab, pertuzumab) and radiation therapy appeared to be safe. However, trastuzumab emtansine (T-DM1) should not be given concomitantly with brain radiation therapy because this combination may increase the risk of brain radionecrosis. The combination of radiation therapy with other new targeted therapies such as new selective estrogen receptor modulators (SERDs), lapatinib, cell cycle inhibitors, immune checkpoint inhibitors, or molecules acting on DNA damage repair seems feasible but has been mainly evaluated on retrospective or prospective studies with small numbers of patients. Moreover, there is a great heterogeneity between these studies regarding the dose and fractionation used in radiotherapy, the dosage of systemic treatments and the sequence of treatments used. Therefore, the combination of these new molecules with radiotherapy should be proposed sparingly, under close monitoring, pending the ongoing prospective studies cited in this review.     

Carcinosarcomes gynécologiques : revue générale et principes de prise en charge

Carcinosarcoma, also known as mixed mesodermal tumor or malignant mixed Mullerian tumor (MMMT) is a pathological entity combining a sarcomatous and a carcinomatous component. Found in thoracic, digestive, genitourinary, liver or skin locations, the most common location is the female genital tract. In gynecological tumors, carcinosarcoma accounts for about 2-5% of endometrial cancers, and 1% of ovarian cancers. To date, there is no consensus on the therapeutic strategy. It relies mostly on maximum cytoreductive surgery. Adjuvant therapy remains controversial, and few prospective studies investigating its interest. Retrospective studies show the benefits of adjuvant chemotherapy based on platinum in most cases. Radiation therapy has a place in the adjuvant situations of endometrial and cervical carcinosarcoma. A more detailed pathological knowledge, and the use of targeted therapies may be promising in this histological subtype whose prognosis remains very poor. The objective of this study is to present the main principles of carcinosarcoma management in female genital tracts, describing pathological and prognostic features at the same time.