Radiotherapy in the management of rare gastrointestinal cancers: A systematic review

The aim of this analysis is to assess radiotherapy's role and technical aspects in an array of rare gastrointestinal (GI) cancers for adult patients. Collection data pertaining to radiotherapy and digestive rare cancers were sourced from Medline, EMBASE, and Cochrane Library. Preoperative chemoradiotherapy improved outcomes for patients with esophageal undifferentiated carcinoma compared with esophageal salivary gland types of carcinomas. For rare gastric epithelial carcinoma, perioperative chemotherapy is the common treatment. Adjuvant chemoradiotherapy showed no benefice compared with adjuvant chemotherapy for duodenal adenocarcinoma. Small bowel sarcomas respond well to radiotherapy. By analogy to anal squamous cell carcinoma, exclusive chemoradiotherapy provided better outcomes for patients with rectal squamous cell carcinoma. For anal adenocarcinoma, neoadjuvant chemoradiotherapy, followed by radical surgery, was the most effective regimen. For pancreatic neuroendocrine tumors, chemoradiotherapy can be a suitable option as postoperative or exclusive for unresectable/borderline disease. The stereotactic body radiotherapy (SBRT) is a promising approach for hepatobiliary malignancy. Radiotherapy is a valuable option in gastrointestinal stromal tumors (GIST) for palliative intent, tyrosine kinase inhibitors (TKIs) resistant disease, and unresectable or residual disease. Involved field (IF) radiotherapy for digestive lymphoma provides good results, especially for gastric extranodal marginal zone lymphoma (MALT). In conclusion, radiotherapy is not an uncommon indication in this context. A multidisciplinary approach is needed for better management of digestive rare cancers.

Primary neuroendocrine tumors of the breast: About a case and of the review of the literature

primary neuroendocrine carcinomas of the breast represent a minority and are currently included in the latest WHO classification of breast tumors. Their morphological and immunohistochemical features (chromogranin and synaptophysin expression) allow the retain the diagnosis.

we report a case of primary neuroendocrine carcinoma of the breast in 50 years old Moroccan women who presented nodule 4,2 cm palpable and mobile of the left breast. Lumpectomy axillary lymph node resection was performed. a histopathological examination disclosed the diagnosis of primary breast neuroendocrine tumors with negative surgical margins and positive lymph nodes (13 N+/19 N). The tumor cells were positive for neuroendocrine markers, a highKi67 proliferation index and the membrane expression of the invasive tumor cells to the anti-HER2 antibody was 2, a FISH done which was equivocal. Our patient received 6 courses of chemotherapythen radiotherapy; currently she received adjuvant hormonal treatment with Tamoxifene.

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The morphological and immunohistochemical features (Chromogranin and Synaptophysin expression) allow to retain the diagnosis.

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Studies, including larger series, are needed in order to understand the biological behavior of these tumors.

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Surgical treatment (mastectomy with axillary dissection and metastasectomy), remains the first line treatment in primary neuroendocrine tumors

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The chemotherapy protocol is not standardized: Primary neuroendocrine tumors of the breast are treated by some as adenocarcinoma of the breast and by others as neuroendocrine carcinoma

Lynch syndrome or hereditary non polyposis colorectal cancer (HNPCC) in a moroccan family: Case report

Introduction and importance

Colorectal cancer is a major global health problem. In 5% of cases, a genetic predisposition to cancer's syndrome is the etiology, such as Lynch syndrome. The population prevalence of Lynch syndrome has been estimated at 1/440. The objectives of this study are to show the interest of the oncogenetic consultation in the management of patients with suspicion of Lynch syndrome.

Case presentation

It is a 70-year-old patient with a family history of different neoplasms. The patient has also been followed for an adenocarcinoma of the colon. An oncogenetic consultation was indicated, which led to the diagnosis of Lynch syndrome, according to the Amsterdam II criteria. A study of the MisMatch Repair genes was requested, to allow a pre-symptomatic diagnosis of apparented subjects at risk, and thus to also allow monitoring and early diagnosis of neoplasms or prophylactic measures.

Discussion

Lynch syndrome is one of the most common cancer susceptibility syndromes. A constitutional deleterious mutation in one of the DNA MisMatch Repair genes, is responsible for nearly 70% of cases of this syndrome. The oncogenetic consultation and the identification of the genetics cause, makes it possible to set up specific monitoring and to offer a pre-symptomatic test to all major relatives of the index case.

Conclusion

This medical observation shows the benefit of the oncogenetic consultation, if a genetic predisposition to cancer's syndrome is suspected. The diagnostic of this predisposition and monitoring of the propositus and his exposed, like in Lynch syndrome will help in the early management of cancers, specially colorectal cancer and endometrial adenocarcinoma.

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Lynch syndrome in a moroccan family: A case report:

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It shows the interest of a oncogenetic consultation if we suspect a hereditary predisposition to cancers.

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And the necessity of the surveillance of the propositus and his exposed relatives, to make possible an early management of cancers.

[Small cell neuroendocrine carcinoma of the bladder: Report of five cases and a review of the literature]

Neuroendocrine small cell carcinoma of the bladder is a rare and aggressive tumour, accounting for less than 1% of all bladder tumours. Given its rarity and the absence of randomized trials, the therapeutic management of these tumours remains difficult. By analogy with small cell lung cancer, multimodal treatment is often proposed. Radical cystectomy plus chemotherapy and chemoradiation therapy are associated with better survival compared to monotherapy. We report our experience in the management of these tumours with literature review.

[Radiotherapy of primary breast sarcomas: Retrospective study]

PURPOSE

Primary breast sarcomas are heterogeneous tumours derived from non-epithelial mammary gland structures. Although they represent a rare entity, their incidence may increase in the coming years owing to conservative approach considered in the treatment of breast cancer. The aim of this work was to highlight the effect of postoperative irradiation in the treatment of these tumours.

MATERIALS AND METHODS

This is a retrospective study conducted at the Mohammed-VI centre for cancer treatment between 2004 and 2011. Survival rates were calculated by the Kaplan-Meier method.

RESULTS

Fifteen cases were collected. The median age was 41.9years. Phyllode sarcoma accounted for 66% of this series. Surgical treatment was performed in 93% of the patients with negative margins in 33.33% of the cases. Neoadjuvant chemotherapy was indicated in 46% of the patients with locally advanced tumours and 66% of the patients received postoperative radiotherapy for positive or close margins. Five years overall survival and relapse free survival was not significantly different with the use of adjuvant radiotherapy.

CONCLUSION

Due to the rarity of this entity and the absence of randomized trials, evidence based management is still lacking. However, a multidisciplinary approach is to be required including surgical excision followed by radiotherapy, depending on the tumour characteristics.

Lung adenocarcinoma with thyroid metastasis: a case report

BACKGROUND

The metastases of a primary lung cancer over the thyroid gland are extremely rare. We report on an unusual presentation of thyroid metastasis of lung cancer in order to improve the management of similar cases.

CASE PRESENTATION

Three years ago, a Moroccan male 59-year-old was admitted for dyspnea, dry cough, and chest pain. He had smoked about 30 cigarette packs a year. Clinical examination revealed a right thyroid nodule. Chest and neck computed tomography (CT) scan showed a proximal left tumor in contact with the pulmonary artery and revealed a suspected nodule in the right lobe of the thyroid with homolateral neck node. Transbronchial biopsy was performed and pathological examination revealed adenocarcinoma of the lung and positive for thyroid transcription factor. Other explorations carried out, such as brain CT, bone scan and abdominal ultrasound were normal. After a repeated negative fine needle aspiration biopsy of the suspected nodule of the right lobe of the thyroid, we performed total thyroidectomy with neck dissection. An anatomopathologic exam revealed a tubulopapillary adenocarcinoma poorly differentiated. An Immunohistochemistry showed positive tumor cells with TTF1 and cytokeratin (CK) 7 but negative cells with thyroglobulin and CK20. Thus, the pulmonary tumor was classified stage IV. Chemotherapy based on the combination of cisplatin and etoposide was conducted along with supportive care. The tumor grew up with brain metastases after three cycles of chemotherapy. Unfortunately, the patient died 2 months after despite brain radiotherapy.

CONCLUSION

We presented a medical case of a patient with thyroid metastasis resulting from a pulmonary adenocarcinoma which has rapidly evolved to brain metastases. The prognosis was pejorative in our clinical case (5 months after admission).

[Orbital metastasis from mucinous adenocarcinoma of the rectum]

Orbital metastasis from colorectal cancer are extremely rare. Only six cases are described in the literature. The discrepancy between the frequency of colorectal cancer and the rarity of metastasis to the eye and orbit remains paradoxical and enigmatic. We report the case of an 18-year-old young woman with orbital metastasis as the presenting sign of rectal cancer. Proptosis is the most frequent presenting clinical sign. Once the diagnosis is made, the prognosis is poor and treatment is palliative.

[Intracranial ependymomas: retrospective study of 16 cases]

PURPOSE

To report the epidemiological, clinical aspects and therapeutic results of intracranial ependymomas in Morocco.

PATIENTS AND METHODS

Our retrospective study concerned 16 cases of intracranial ependymomas, treated from January 1995 to December 2002 at the radiotherapy department of Ibn Rochd Hospital of Casablanca, Morocco.

RESULTS

The average age was 15 years and complete surgery was possible in two cases. All the patients received cranial radiotherapy, combined with chemotherapy in six cases. Overall survival and progression-free survival at 5 years were respectively 50% and 31%. Eleven patients had local recurrence after an average period of 21 months. Progression-free survival at 5 years was better if complete resection: 100% vs. 28.6% in cases of incomplete resection, and depending on the histological type with 50% for classic ependymomas and 16.6% for anaplastic.

CONCLUSION

Ependymomas are rare tumors and complete resection is the standard treatment followed by postoperative radiotherapy. The place of chemotherapy remains to be defined.

Cancer du sein: l’homme est aussi concerné. Étude de 21 cas

Introduction

Le cancer du sein, première pathologie maligne chez la femme, reste une maladie rare chez l’homme. Il représente environ 1 % des cancers du sein et moins de 1 % de l’ensemble des néoplasies masculines. L’objectif de cette étude est d’analyser les caractéristiques cliniques, histologiques et thérapeutiques du cancer du sein chez l’homme.

Patients et méthodes

Les auteurs présentent une étude descriptive menée de manière rétrospective au service de radiothérapie-oncologie du CHU Ibn-Rochd de Casablanca, entre janvier 2006 et décembre 2007, concernant une série de 21 patients de sexe masculin présentant un cancer du sein.

Résultats

L’âge médian était de 70 ans (extrêmes: 39–84). Le délai médian de consultation était de huit mois (extrêmes: 2–24). Il s’agissait, dans 16 cas, d’une tumeur rétroaréolaire dont la taille médiane était de 35 mm (extrêmes: 15–80). Les tumeurs étaient classées T2 dans 12 cas et T4 dans sept cas. Le type histologique le plus représenté était le carcinome canalaire infiltrant (CCI) [18 cas]. Le grade SBR II a été retrouvé dans 13 cas. Le taux d’envahissement ganglionnaire axillaire prouvé histologiquement était de 38 % (huit patients) et dans 14 % des cas plus de trois ganglions étaient envahis. L’effraction capsulaire n’a été retrouvée que dans quatre cas. Les récepteurs hormonaux étaient positifs dans 19 cas. La prise en charge thérapeutique a consisté en une chirurgie radicale dans 14 cas avec une chimiothérapie associée à une radiothérapie dans cinq cas, 66 % des patients ont reçu une hormonothérapie. Après un suivi moyen de 23 mois, trois malades ont développé des métastases et six malades sont encore vivants sans maladie.

Conclusion

Le cancer du sein chez l’homme est rare. Son diagnostic se fait souvent à un stade tardif. Son traitement est similaire à celui de la femme avec un retard diagnostique retentissant sur le pronostic.

Identification of G2607A mutation in EGFR gene with a significative rate in Moroccan patients with nasopharyngeal carcinoma

The epidermal growth factor receptor (EGFR) is involved in the regulation of several cellular processes and in the development of many human cancers. Somatic mutations of EGFR at tyrosine kinase domain have been associated with clinical response to tyrosine kinase inhibitors (TKIs) in lung cancer patients. In this study, we evaluated the frequency of point mutations in EGFR for future use of TKI in clinical treatment of nasopharyngeal carcinoma (NPC). Sixty Moroccan patient specimens of NPC were analysed for EGFR mutations in the region delimiting exons 18 and 21 by direct sequencing. Our results showed the absence of mutations in the EGFR kinase domain in these exons in all 60 analysed specimens. Sequence analysis of the EGFR—TK domain, revealed the presence of (G2607A) polymorphism at exon 20. The genotypes AA and GA were found respectively in 39 (65%) and 16 (26.6%) cases. Statistical analysis showed no difference between the polymorphism and either gender or age of patients. Mutations in EGFR kinase domain are rare events in NPC biopsies, suggesting, that treatment of NPC patients with TKI may not be effective. However, EGFR G2607A polymorphism at exon 20 is frequent in NPC cases and could be associated to clinical response to TKI therapy.

[A rare tumor of the infratemporal fossa]

INTRODUCTION

Giant cell tumors of bone (GCT) are usually benign and relatively rare. They have an aggressive behavior and an unpredictable prognosis. They occur mainly in the young adult, with a preferential localization in long bones. We report a giant cell infratemporal fossa tumor.

OBSERVATION

A 55-year-old female patient consulted for swelling in the right cheek. Surgical excision was incomplete because of the subtemporal tumor localization. Histological assessment proved a GCT. Forty-five grays postoperative external radiotherapy was applied to the surgical site. The patient had local control at the 12-month follow-up.

DISCUSSION

GCTs are seldom observed in the facial skeleton (2%). The recommended treatment is surgery. Radiotherapy can be indicated in case of incomplete or impossible surgical excision, or when surgery would be responsible for a major functional deficit.

[Ocular metastasis heralding gastric adenocarcinoma]

Ocular metastasis is a rare presenting feature of gastric adenocarcinoma. We report a 48-year-old woman who presented with a decrease in visual acuity of the right eye leading to the discovery of an ocular metastasis. Diagnostic work-up identified a gastric adenocarcinoma with pulmonary metastases. She received four cycles of chemotherapy combining epirubicin, cisplatin and fluorouracil. The patient died 6 months after the diagnosis of respiratory failure.

[Neuroendocrine carcinoma with large cells of the breast: case report and review of the literature]

Neuroendocrine carcinoma with large cells is a slightly different tumor from the high rank of malignity. We report a case of breast localization in a 28-year-old patient. It is a locally advanced classified T4dN1M0 tumor that required neoadjuvant chemotherapy. The clinical answer was 75% of the level of the tumor. A standard surgery mastectomy with axillary lymph node dissection was realized, followed by external radiotherapy. The anatomopathologic and the immuno-histochemical study of the operational part confirmed the diagnosis of neuroendocrine carcinoma with large cells expressing the progesterone receptor. The patient is subjected to adjuvant hormonal treatment. After a 12 months retreat, a complete remission is maintained. Considering the scarcity of neuroendocrine carcinoma with large cells of the breast, the therapeutic standard is not yet available and the forecast remains difficult to determine.

[Giant-cell bone tumors of the spine: report of two cases and literature review]

Giant cell tumours (GCT) are relatively rare neoplasms, most often benign. They are characterized by their local aggression. We report two observations of GCT, the spine in a 51-year-old woman and a 14-year-old boy. They were revealed by spinal pain and cord compression for the second observation. Computed tomography and magnetic resonance imaging showed osteolysis of the body and vertebral arch of L5 for the first and a process affecting the vertebral body and medullary canal of T6-T7 with spinal cord compression for the second case. The diagnosis was confirmed by histological examination in two cases. An external radiation at a dose of 45 Gy on L4, L5 and the sacrum was made in the first case and the dose of 40 Gy on the vertebrae of T4 to T9 and an additional 6 Gy on T5-T8 in the second case. The patients are alive without progress with five years and 18 months follow-up, respectively. Radiation could be proposed as a standard treatment for patients with incomplete excision or where surgery would induces functional deficits.

[Osteosarcoma of the skull base: a case report]

Osteosarcoma, usually observed in long bones, is the second most frequent primitive malignant bone tumor after myeloma. The skull base is an exceptional localization. We report a case of skull base osteosarcoma managed in our department. A 23-year-old female was admitted for bilateral epistaxis, headache, decreasing visual acuity then blindness. Physical examination revealed bilateral blindness and exophthalmia. Cranial magnetic resonance imaging showed a voluminous mass in the skull base extending to the nasosinusal area. A rhinoseptal surgical approach was used but the tumor was so huge that excision was impossible. The biopsy identified at an osteoblastic osteosarcoma. Search for extension (chest computed tomography and abdominal ultrasonography) was negative. Chemotherapy was to be delivered before combination chemoradiotherapy but the patient died before any treatment could be started. Osteosarcoma of the skull base is very rare. The treatment is based on surgery which should be as complete as possible followed by chemoradiotherapy. Prognosis is poor. Median survival is around six months.

[Small-cell carcinoma of the vulva]

Small-cell carcinoma is a rare and aggressive malignancy; this tumor is lethal due to the propensity to metastasize early in the course of the disease. It occurs most frequently in the lung. Small-cell cancer also rarely may occur in the female genital tract, usually in the cervix. This article concerns the fifth reported case of small-cell carcinoma of the vulva in a 34-year-old women who had developed a vulvar mass3 months earlier. The physical examination revealed bilateral inguinal lymph nodes. The mass was excised and the histological finding was a small-cell carcinoma. Postoperative search for metastasis included computed tomography scan of the abdomen, pelvis, chest and brain that showed right iliac lymph nodes. The osteo medullar biopsy was positive. The patient was treated with 6 cycles of chemotherapy including cisplatinum (80mg/m2 d1) and etoposide (100mg/m2 d1 d2 d3). Adjuvant radiotherapy (50Gy) was administered but the disease progressed and the patient died after 7 months. Small-cell carcinoma of the vulva is a very rare tumor. Similarly to small-cell cancers arising in other sites, it appears that regional therapy is not a sufficient treatment for this tumor. Chemotherapy should be used to improve outcome.