Treatment adherence in retinoblastoma: A retro-prospective cohort study in Ivory Coast and the Democratic Republic of Congo

BACKGROUND

In high-income countries, retinoblastoma is curable in more than 95% of cases, whereas in low-income countries, mortality remains high, especially when the diagnosis is made late or the treatment is discontinued.

AIMS

To determine the factors associated with adherence to the treatment of retinoblastoma in the Ivory Coast and the Democratic Republic of Congo (DRC).

METHODS AND RESULTS

A retro-prospective cohort study was carried out. Data were collected from patient folders and follow-up records of parents.

RESULTS

A total of 175 children with retinoblastoma were registered from January 2013 to December 2015. Seventy-six children (43%) were 5 years old and above. Care costs were covered by families in 86.9% of cases. Chemotherapy refusal was recorded in 39 cases (22.3%), and enucleation refusal was recorded in 79 cases (45.1%). After 36 months of follow-up, we recorded 16.6% deaths, 27.4% treatment dropouts, and 18.3% loss to follow-up after treatment. The commonest cause for enucleation refusal was fear of infirmity, while chemotherapy refusal and absconding treatment were due to financial constraints.

CONCLUSION

Poor adherence to retinoblastoma management was due to financial constraints, and a lack of knowledge of the disease and its treatment. Family psychosocial support is needed to improve this condition.

Finding Adequate Information: A Major Challenge for Policy-Makers in the Field of Cancer

Background and context: A global cancer epidemic is developing (GLOBOCAN 2012). In the case of low- and-middle-income countries, difficulties are cumulative: inadequate health systems, lack of training for professionals. Drastic decisions have to be taken in a very complex field. Good decision needs good information. What about information dedicated to policy-makers: to decide a question, they need specific information, marked by these features: synthetic, clear, scientifically validated. Actually, this is not easy to find. Moreover policy-makers can't really benefit from: 1. Information for health professionals which is complex and overabundant (the request “cancer” on PubMed “out” nearly 1.5 millions references). 2. Documents or testimonials for patients. Written by scientific societies or patients' associations, they mostly focus on 2 topics “understand your disease” and “how to cope with”. 3. Information from the Web, not always reliable in terms of quality. Strategy/Tactics: While policy advisors and international organizations provide appropriate studies and reports, mostly focused on “what should be done”, we believe that knowledge of basic cancer data are necessary to understand the proposals. We talk about issues like “what is cancer”, “what exactly cover radiotherapy, oncological surgery…”. Regarding French speaking Africa, Alliance Ligues Africaines and Méditérranéennes (ALIAM) and The French League have produced targeted information for decision-makers. The document was presented in Brazzaville in June 2017. Access to this book is free: www.livre-cancer.aliam.org . The editorial method was discussed and we made the choice to write short sheets, to quickly understand the useful definitions and problems. Rather than comprehensiveness, a pedagogical will and a desire for clarity guided the writing. Diagrams and photos had to be abundant to facilitate understanding. Moreover, this format allows a permanent update of the subjects and the introduction of new topics as needed. What was learned: On the basis of this experience, ALIAM and the league are convinced that a pedagogic document with an international vocation would be useful for all policy makers. Proposal for action: UICC would be the perfect organizer of a working group to produce such a document. The goal would be to develop a consensus text which resume essential data on all common themes of cancer. About 25 themes could be identified, e.g., definition and mechanisms of development of cancers, risk factors, screening and early diagnosis, anatomic pathology and telepathology, molecular biology, imaging and interventional radiology, surgery, radiotherapy, chemotherapy and innovative therapies, palliative care etc. Moreover, focus on specific location of cancer (breast, cervix, lung…) and pediatric cancers should be developed. Then, it would be easier for any world regions to supplement this validated information with additional specific data describing the local situation. Hierarchizing action priorities would be facilitated.

Retinoblastoma in Sub-Saharan Africa: Case Studies of the Republic of Côte d'Ivoire and the Democratic Republic of the Congo

PURPOSE

In most low-income countries, the diagnosis of retinoblastoma is delayed, resulting in a severe prognosis. The objectives of this study were to describe the access to diagnosis and care of children diagnosed with retinoblastoma and the challenges in two sub-Saharan African countries: the Republic of Côte d'Ivoire and the Democratic Republic of the Congo.

PATIENTS AND METHODS

A descriptive cross-sectional study was conducted. Data were collected from the medical records of patients admitted during the period of January 1, 2013 to December 31, 2014. Data were entered and analyzed using Epi Info7.1 software and SAS 9.3.

RESULTS

One hundred sixteen cases of retinoblastoma were collected, including 60 boys and 56 girls. The median diagnosis age was 3 years for both countries. Ninety-eight patients (84%) had unilateral retinoblastoma. Most of the patients presented with advanced disease (76% had extraocular retinoblastoma). Median time between initial symptoms and diagnosis was 8.5 months (range, 0.4 to 116.7 months). Median time between diagnosis and treatment initiation was 31 days (range, 0 to 751 days). The median cost for the treatment of the disease was estimated at $1,954 per patient.

CONCLUSION

Late diagnosis of retinoblastoma, with extraocular disease, occurs frequently in both African countries. It is associated with delay in initiating treatment, and the cost of the treatment remains unaffordable for most of the families. Support groups for parents of affected children and the support of the Franco-African Pediatric Oncology Group remain important in improving early diagnosis and providing treatment in sub-Saharan African countries.

Treatment of retinoblastoma in Sub-Saharan Africa: Experience of the paediatric oncology unit at Gabriel Toure Teaching Hospital and the Institute of African Tropical Ophthalmology, Bamako, Mali

BACKGROUND

Retinoblastoma (Rb) is the most common intraocular primary malignancy in children. In industrialised countries, the cure rate is about 95%. We present the results of a prospective study on the management of Rb in the paediatric oncology unit of Gabriel Touré Teaching Hospital and African Institute of Tropical Ophthalmology, from November 1, 2011 to December 31, 2015.

PROCEDURE

The aims of this prospective study were to evaluate the treatment of localised Rb, ocular prosthesis after enucleation, conservative management for bilateral Rb as well as survival rates in all patients. Patients with early stage Rb at diagnosis were included. The treatment was performed according to the retinoblastoma treatment guidelines of the French-African Paediatric Oncology Group.

RESULTS

Eighty-eight patients were included in the study. Sex ratio was 1:1 (M = 44, F = 44). Median age at diagnosis was 3 years (range: 2 months-5 years). Unilateral intraocular Rb was predominant (n = 50; 56.8%). Conservative treatments were performed on nine eyes in nine patients. Overall survival and event-free survival of the entire cohort at the end of 4 years were 73% (95% CI 60.8-81.2%) and 59% (95% CI 47.9-69.5%), respectively, with a median follow-up of 3.7 years (0.1-5.6 years). In conclusion, early enucleation in early stage of Rb can improve outcomes in resource-limited countries. Delayed enucleation and refusal of adherence to treatment are still major concerns and remain a barrier to improving overall patient survival.

Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP)

Pediatric radiotherapy is a critical part of pediatric oncology protocols and the quality of the radiotherapy may determine the future quality of life for long-term survivors. Multidisciplinary team decision making provides the basis for high-quality care. However, delivery of high-quality radiotherapy is dependent on resources. This article provides guidelines for delivery of good quality radiation therapy in resource-limited countries based on rational procurement and maintenance planning, protocol development, three-dimensional planning, quality assurance, and adequate staff numbers and training.

First-in-human phase I study of the DNA-repair inhibitor DT01 in combination with radiotherapy in patients with skin metastases from melanoma

BACKGROUND

DT01 is a DNA-repair inhibitor preventing recruitment of DNA-repair enzymes at damage sites. Safety, pharmacokinetics and preliminary efficacy through intratumoural and peritumoural injections of DT01 were evaluated in combination with radiotherapy in a first-in-human phase I trial in patients with unresectable skin metastases from melanoma.

METHODS

Twenty-three patients were included and received radiotherapy (30 Gy in 10 sessions) on all selected tumour lesions, comprising of two lesions injected with DT01 three times a week during the 2 weeks of radiotherapy. DT01 dose levels of 16, 32, 48, 64 and 96 mg were used, in a 3+3 dose escalation design, with an expansion cohort at 96 mg.

RESULTS

The median follow-up was 180 days. All patients were evaluable for safety and pharmacokinetics. No dose-limiting toxicity was observed and the maximum-tolerated dose was not reached. Most frequent adverse events were reversible grades 1 and 2 injection site reactions. Pharmacokinetic analyses demonstrated a systemic passage of DT01. Twenty-one patients were evaluable for efficacy on 76 lesions. Objective response was observed in 45 lesions (59%), including 23 complete responses (30%).

CONCLUSIONS

Intratumoural and peritumoural DT01 in combination with radiotherapy is safe and pharmacokinetic analyses suggest a systemic passage of DT01.

[Risks related to radiation therapy]

Radiotherapy is used for about 60% of cancer patients, in 2/3rd of the cases with a curative intent. If the frequent early secondary effects are transitory and with a limited impact, some late effects, even rare as cardiac troubles and secondary tumors, are now more important due to the increase of cure rate and due to the improvement of life expectancy of cured patients. Technologic improvements of the last decades reduced some of these risks, as the strengthening of human resources and the development of quality assurance procedures have contributed to reduce the risk of major accidents.

70 Gy versus 80 Gy in localized prostate cancer: 5-year results of GETUG 06 randomized trial

PURPOSE

To perform a randomized trial comparing 70 and 80 Gy radiotherapy for prostate cancer.

PATIENTS AND METHODS

A total of 306 patients with localized prostate cancer were randomized. No androgen deprivation was allowed. The primary endpoint was biochemical relapse according to the modified 1997-American Society for Therapeutic Radiology and Oncology and Phoenix definitions. Toxicity was graded using the Radiation Therapy Oncology Group 1991 criteria and the late effects on normal tissues-subjective, objective, management, analytic scales (LENT-SOMA) scales. The patients' quality of life was scored using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire 30-item cancer-specific and 25-item prostate-specific modules.

RESULTS

The median follow-up was 61 months. According to the 1997-American Society for Therapeutic Radiology and Oncology definition, the 5-year biochemical relapse rate was 39% and 28% in the 70- and 80-Gy arms, respectively (p = .036). Using the Phoenix definition, the 5-year biochemical relapse rate was 32% and 23.5%, respectively (p = .09). The subgroup analysis showed a better biochemical outcome for the higher dose group with an initial prostate-specific antigen level >15 ng/mL. At the last follow-up date, 26 patients had died, 10 of their disease and none of toxicity, with no differences between the two arms. According to the Radiation Therapy Oncology Group scale, the Grade 2 or greater rectal toxicity rate was 14% and 19.5% for the 70- and 80-Gy arms (p = .22), respectively. The Grade 2 or greater urinary toxicity was 10% at 70 Gy and 17.5% at 80 Gy (p = .046). Similar results were observed using the LENT-SOMA scale. Bladder toxicity was more frequent at 80 Gy than at 70 Gy (p = .039). The quality-of-life questionnaire results before and 5 years after treatment were available for 103 patients with no differences found between the 70- and 80-Gy arms.

CONCLUSION

High-dose radiotherapy provided a better 5-year biochemical outcome with slightly greater toxicity.

[Is proton beam therapy the future of radiotherapy? Part I: clinical aspects]

Proton beam therapy uses positively charged particles, protons, whose physical properties improve dose-distribution (Bragg peak characterized by a sharp distal and lateral penumbra) compared with conventional photon-based radiation therapy (X-ray). These ballistic advantages apply to the treatment of deep-sited tumours located close to critical structures and requiring high-dose levels. [60-250 MeV] proton-beam therapy is now widely accepted as the "gold standard" in specific indications in adults--ocular melanoma, chordoma and chondrosarcoma of the base of skull --and is regarded as a highly promising treatment modality in the treatment of paediatric malignancies (brain tumours, sarcomas…). This includes the relative sparing of surrounding normal organs from low and mid-doses that can cause deleterious side-effects such as radiation-induced secondary malignancies. Other clinical studies are currently testing proton beam in dose-escalation evaluations, in prostate, lung, hepatocellular cancers, etc. Clinical validation of these new indications appears necessary. To date, over 60,000 patients worldwide have received part or all of their radiation therapy program by proton beams, in approximately 30 treatment facilities.

Conformity index: a review

We present a critical analysis of the conformity indices described in the literature and an evaluation of their field of application. Three-dimensional conformal radiotherapy, with or without intensity modulation, is based on medical imaging techniques, three-dimensional dosimetry software, compression accessories, and verification procedures. It consists of delineating target volumes and critical healthy tissues to select the best combination of beams. This approach allows better adaptation of the isodose to the tumor volume, while limiting irradiation of healthy tissues. Tools must be developed to evaluate the quality of proposed treatment plans. Dosimetry software provides the dose distribution in each CT section and dose-volume histograms without really indicating the degree of conformity. The conformity index is a complementary tool that attributes a score to a treatment plan or that can compare several treatment plans for the same patient. The future of conformal index in everyday practice therefore remains unclear.

Conformity index: a review

We present a critical analysis of the conformity indices described in the literature and an evaluation of their field of application. Three-dimensional conformal radiotherapy, with or without intensity modulation, is based on medical imaging techniques, three-dimensional dosimetry software, compression accessories, and verification procedures. It consists of delineating target volumes and critical healthy tissues to select the best combination of beams. This approach allows better adaptation of the isodose to the tumor volume, while limiting irradiation of healthy tissues. Tools must be developed to evaluate the quality of proposed treatment plans. Dosimetry software provides the dose distribution in each CT section and dose-volume histograms without really indicating the degree of conformity. The conformity index is a complementary tool that attributes a score to a treatment plan or that can compare several treatment plans for the same patient. The future of conformal index in everyday practice therefore remains unclear.

[Oncolor: a comprehensive cancer network in the Lorraine Region of France]

Legislation governing patients' rights and health care quality (March 2002) provided for the creation of healthcare networks intended to improve the management of patients with complex and/or chronic diseases. As defined in the Cancer Plan, activated in March 2003, an oncological healthcare network covers a particular French region, with the aim of offering patients equal access to the best available care and accompaniment, based on caregiver coordination, shared multidisciplinary tools, and communication. ONCOLOR, the regional cancer network launched in the Lorraine region in 1993, complies with these objectives. Nevertheless, its future development depends on continued dynamism, durable financial support, and regular evaluation of the benefits for patients and caregivers. The key words are professionalism and consensus.

[Rectal cancer Information dedicated to cancer patients and relatives]

In response to the evolution of the information-seeking behaviour of patients and concerns from health professionals regarding cancer patient information, the French National Federation of Comprehensive Cancer Centres (FNCLCC) introduced, in 1998, an information and education program dedicated to patients and relatives, the SOR SAVOIR PATIENT program. The methodology of this program adheres to established quality criteria regarding the elaboration of patient information. Cancer patient information, developed in this program, is based on clinical practice guidelines produced by the FNCLCC and the twenty French regional cancer centres, the National League against Cancer, The National Cancer Institute, the French Hospital Federation, the National Oncology Federation of Regional and University Hospitals, the French Oncology Federation of General Hospitals, many learned societies, as well as an active participation of patients, former patients and caregivers. The handbook SOR SAVOIR PATIENT Understanding rectal cancer is an adapted version of the clinical practice guidelines (CPG) Standards, Options and Recommendations for rectal cancer. It is meant to provide a basis for the explanation of the disease and treatments and to facilitate discussions with the healthcare team. It is available from the FNCLCC (101, rue de Tolbiac, 75013 Paris, Tel. (0033) 1 44 23 04 68, www.fnclcc.fr). This document has been validated at the end of 2004 and published in 2005. SOR SAVOIR PATIENT guides are systematically updated when new research becomes available. Information leaflets, extracted from the handbook SOR SAVOIR PATIENT Understanding rectal cancer and published in this edition of the Bulletin du cancer, allow patients to better understand colonoscopy and colostomy, which represent an important patient information need. These articles are meant to inform patients and relatives about the disease and its treatments. It also offers health professionals a synthetic evidence-based patient information source which facilitates discussions with the patient.

Use of a decision analysis model to assess the cost-effectiveness of 18F-FDG PET in the management of metachronous liver metastases of colorectal cancer

Few data exist on the medicoeconomic usefulness of PET in the management of metachronous liver metastases from colorectal cancer. This study was designed to assess the cost-effectiveness of PET in the diagnosis and staging of patients with metachronous liver metastases of colorectal cancer using a decision analysis model.

METHODS

Two alternatives were compared: CT and CT associated with PET (CT+PET). Transition probabilities were estimated from published data and consultations with experts. Survival data were provided by the Burgundy Digestive Cancer Registry (France). Costs of imaging techniques and treatments were assessed using reimbursements from the French health care insurance for the year 2004. Evaluation criteria included incremental cost-effectiveness ratios and the proportion of unnecessary operations avoided in patients without metachronous liver metastases.

RESULTS

CT+PET was the most cost-effective strategy, presenting an expected incremental cost saving of 2,671 (approximately $3,213) per patient, for the same level of expected effectiveness as CT alone (1.88-y life expectancy per patient). Sensitivity analyses performed on epidemiologic and economic parameters showed that this model was robust. The model also suggested that CT+PET could avoid exploratory surgery for 6.1% of patients-that is, 88.4% risk reduction compared with CT alone.

CONCLUSION

PET for diagnosis and staging does not generate additional survival effectiveness compared with CT alone. However cost savings associated with its use and the improvement of therapeutic management therefore justify its generalization in clinical practice.

[Radiation oncology training in France: demography, analysis of motivations of the young specialists, evaluation of the training]

During the 5 past national courses organised by the French society of radiation oncology (SFRO), three different types of survey were performed to analyse demography, motivations and quality of training of the young specialists. During the 5 past years, 50 radiation oncologists were training for the whole country (about 15 per year were graduated). A recent increase the number of young specialists is observed with a total number of 50 in 2000 to 75 in 2005. Nevertheless, the number of young specialists is dramatically insufficient and exposes for the future to an important demographic crisis. Analysis of motivations of choice for radiation oncology confirms the influence of a practical stage of oncology during the second cycle of the medical studies for 60% of the young specialists. Analysis of practical and theoretical training was performed according to the point of view and living experiences of the students. On the other hand, informations from teachers were less complete. Some needs are emphased as: 1) the quality of the follow during the training (importance of the recent implementation of a logbook); 2) importance of theoretical and practical training at the radiotherapy department; 3) help and incentive for research and scientific publication.

The GETUG 70 Gy vs. 80 Gy randomized trial for localized prostate cancer: feasibility and acute toxicity

PURPOSE

To describe treatments and acute tolerance in a randomized trial comparing 70 Gy and 80 Gy to the prostate in patients with localized prostate cancer.

METHODS AND MATERIALS

Between September 1999 and February 2002, 306 patients were randomized to receive 70 Gy (153 patients) or 80 Gy (153 patients) in 17 institutions. Patients exhibited intermediate-prognosis tumors. If the risk of node involvement was greater than 10%, surgical staging was required. Previous prostatectomy was excluded, and androgen deprivation was not admitted. The treatment was delivered in two steps. PTV1-including seminal vesicles, prostate, and a 1-0.5-cm margin-received 46 Gy given with a 4-field conformal technique. PTV2, reduced to prostate with the same margins, irradiated with at least 5 fields. Dose was prescribed according to ICRU recommendations in the 70 Gy group, but adapted at the 80 Gy level.

RESULTS

All patients but one in the 80 Gy arm completed the treatment. In the 70 Gy arm, the mean dose to the PTV2 was 69.5 Gy. In the 80 Gy arm, the mean dose in the PTV2 was 78.5 Gy. Acute toxicity according to Radiation Therapy Oncology Group scale during treatment was reported in 306 patients. There was no statistically significant difference between the two arms: 12% had no toxicity, 80% complained of bladder toxicity, and 70% complained of rectal symptoms. Two months after the end of treatment, 43% of the 70 Gy level and 48% of the 80 Gy level complained of side effects, including 24% and 20% of sexual disorders. There was 6% and 2% of Grade 3 urinary and rectal toxicity. Five patients required a 10-29-day suspension of the treatment. Acute Grade 2 and 3 side effects were related to PTV and CTV1 size, which was the only independent predictive factor in multivariate analysis. Toxicity was not related to the center, age, arm of treatment, or selected data from dose-volume histogram of organ at risk.

CONCLUSION

Treatments were completed in respect to constraints. Acute toxicity was acceptable. Intensity of toxicity depended on target volumes.

[Oncolor is ten years old: the age of discretion for the Lorraine network in oncology]

Oncolor, network in oncology in Lorraine, was born ten years ago, from a group of professionals in the field of oncology who worked closed together with regional administrative authorities. Oncolor was created with respect of equilibrium between the different regional partners avoiding struggle for power. Oncolor was conducting different actions: recognition of hospital sites according to three levels based on technical and humans means at disposal (highly specialised sites, specialised sites, and associated sites); the definition of good practice for hospital pharmacies leading to the generalization of centralized preparation of chemotherapy under responsibility of a pharmacist; the organization of multidisciplinary practice through the written and implementation of clinical guidelines accessible on the web site of the network (www.oncolor.org) even by the patients (86 guidelines on line today); creation and access to a software to help physicians for decision called Kasimir; the formalization of multidisciplinary meetings with a common process. All these tools help physicians in their relationship with the patient. The web site was opened to professionals but also to patients in December 2001. Oncolor was also implicated in different training programs for physicians, pharmacists, nurses and other professionals. The annual budget increased from 47,000 euros in 1998 up to more than 700,000 euros in 2002. To conclude, to build a network in oncology is an exciting task. It must become more professional, keeping in mind the original objective: every patient, whatever his place of consultation is, have to benefit of the best treatment adapted to his personal situation.

[Preoperative brachytherapy for clinical stage I and II endometrial carcinoma: results from a series of 780 patients with a 10-year follow-up]

AIMS OF THE STUDY

Retrospective analysis of patients treated by preoperative brachytherapy for endometrial carcinoma.

PATIENTS AND METHODS

From 1973 to 1994, 780 consecutive patients with a clinical stage I-II endometrial carcinoma were treated with brachytherapy followed by surgery and pelvic irradiation if necessary. Tumour was staged according to 1979 UICC classification. There were 462 T1a, 257 T1b, and 61 T2, 62% were well differentiated. Brachytherapy consisted in one low dose rate endocavitary application. Sixty grays were delivered on the reference isodose. Surgery consisted in a TAH/BSO (Piver II) and was performed 6 weeks later. Nodal pelvic irradiation was indicated in case of unfavourable pathological prognostic factors.

RESULTS

Median follow up was 122 months. Five year survival rates were: 84% for overall survival, 86% for survival without recurrence, 92.8% for local control, and 3.8% for late complications. Pronostic factors were age, stage, differentiation, grade and postoperative extension. Multivariate analysis showed only age, differentiation and postoperative extension to be independent prognostic factors.

CONCLUSION

If for stage 1, initial surgery has now replaced preoperative brachytherapy in most cases because it allows to identify initial prognostic factors, preoperative brachytherapy remains the most interesting option for stage 2 endometrial carcinomas.

Efficacy and morbidity of arc-therapy radiosurgery for cerebral arteriovenous malformations: a comparison with the natural history

PURPOSE

To report the results of arc-therapy radiosurgery for cerebral arteriovenous malformation (AVM) and to compare the adverse event rate with the rate expected from the natural history.

METHODS AND MATERIALS

We performed a retrospective study of our 118 first patients with a mean follow-up of 46 months (range, 5-105 months). The AVMs had features indicating a poor prognosis at initial presentation and had already been treated by previous embolizations in 88% of patients. The mean volume of the targets was 7.4 cm3 (range, 0.3-28.3 cm3). The mean minimal and maximal dose was 17.7 Gy (range, 10-25 Gy) and 24.5 Gy (range, 17-36 Gy), respectively.

RESULTS

The crude and 5-year actuarial rate of cure (total obstruction of the AVM shunt at angiography) was 54% (60 of 112) and 77%, respectively. The only independent prognostic factor of cure was the AVM volume (crude cure rate 67% for <7 cm3 vs. 35% for > or =7 cm3; p = 0.001). No patient died. Transient and permanent complications and hemorrhage occurred in 5%, 1.7%, and 6% of patients, respectively. The annual risk of an adverse event (hemorrhage or complication) was 3.9%.

CONCLUSION

The results of our series showed that radiosurgery, performed alone or after prior shrinkage of the AVM by embolization, is both effective and well tolerated, with a rate of adverse events comparable to that expected from the natural history.

Ré-irradiation pariétale après mastectomie de rattrapage pour récidive d’un cancer du sein après traitement conservateur : étude rétrospective sur 20 patientes (Nancy : 1988–2001)

PURPOSE

To retrospectively assess the efficacy of post-mastectomy re-irradiation for local relapse of breast cancer.

PATIENTS AND METHODS

Twenty patients, initially treated by conservative surgery and radiotherapy (50 Gy in 25 fractions over 5 weeks) were treated from 1998 to 2001 for a local relapse by salvage mastectomy and re-irradiation (either electron or photon beams). Mean age was 53 years (31-71). Reasons for re-irradiation were that the local relapses were inflammatory (4 pts), multifocal (5 pts), cutaneous (5 pts), involved the nipple (3 pts) or because the surgical margins (either muscle or skin) were involved (3 pts). The median dose of re-irradiation was 45 Gy (33-65) in 15 fractions over 33 days. Mean follow-up was 48 months (5-97).

RESULTS

Fifteen patients remained free of a second local recurrence and 10 were still alive, without metastasis. Neither the dose of re-irradiation nor the irradiated surfaces were prognostic factors of local control (P = 0.877 and P = 0.424). Five patients developed radiation-induced pneumonitis without functional respiratory impairment. The incidence of pneumonitis seemed to be related to the biological dose of re-irradiation (P = 0.037). Other late complications occurred such as pigmentation changes (12 pts), telangiectasia (8 pts), chondritis (2 pts), parietal fibrosis (7 pts), rib fractures (4 pts), severe pain (11 pts) and lymphedema (2 pts). The increase in biological equivalent dose was highly statistically linked with the occurrence of disabling pain (P = 0.0123).

CONCLUSION

Parietal re-irradiation achieves good and lasting local control with an acceptable rate of acute complications but with a risk of disabling late sequelae such as severe pain.

[Training of pharmacy personnel in the management of a centralized unit: the Oncolor network experience]

The network of cancer care units in Lorraine area (Oncolor) developed management training for people working in chemotherapy units, and cytotoxic drug preparation. The programme was framed both for staff of executives (pharmacists), and technicians. Firstly, comparison between practices and theoretical recommendations lead to the elaboration of standardized operating procedures. Secondly, we elaborated a specific handbook for this education programme. A series of four-days independent sessions were organized for pharmacists and technicians. Each session combined theoretical and technical teaching for preparing antineoplastic drugs. Participants passing a successful final examination received a certificate from the Oncolor's network attesting their capacity to manage a chemotherapy unit. Four sessions were performed, with 35 participants. Only 31 passed at final examination. This preliminary experience will be enlarged to all members of the network and regularly brought up to date.

[Clinical practice guidelines in cancerology: comparative study of three decision support-systems for breast and prostate cancer in Lorraine french region]

Oncolor, the French regional cancer network of Lorraine, proposes clinical guidelines for the diagnosis, the treatment and the follow-up of cancers. In addition to paper documents, two computerized supports, a web site and the Kasimir software have been developed to make the use of these guidelines and their updating easier. This study aims at evaluating these three tools in breast and prostate cancer and to determine if computerized supports provide an additional help and an added value. From May to July 2001, 25 physicians of the Oncolor network have analysed, by consulting the guidelines on each of the 3 supports, 23 clinical cases of breast cancer and 22 cases of prostate cancer, i.e. in total 1,293 cases. We observe for breast cancer a response rate consistent with the guideline significantly higher with the Kasimir software compared to paper (87.1% versus 77.8%) or to Internet (87.1% versus 75.8%), an optimisation of the recourse to a specialised physician or a pluridisciplinary committee and globally a good satisfaction of the users. These results induce us to continue with the Kasimir experiment, to develop it for other cancers, especially those with a complex management and to evaluate its impact on medical practices.

[How to improve the initial management of adult patients with tumors of bone and soft tissues: the experience of a multidisciplinary committee from the Oncolor network before the distribution of regional guidelines]

Tumors of bone and soft tissues in adults are rare accounting in France for 2000 to 2500 new cases per year. These tumors are heterogenous and their diagnosis is made after first surgery. Therefore, an early pluridisciplinary approach, by physicians who have acquired an expertise in this field, is advised before any biopsy or surgical resection and at all the further step in the subfrequent management. This paper describes the experience of a pluridisciplinary committee, specialized in malignant tumors of bone and soft tissues in adults, with a highly specialized team which is part of a network in the treatment of cancer in Lorraine, the Oncolor network, before the distribution of regional guidelines. After a description of the organisation of this committee, we made a retrospective analysis of all the cases submitted to these experts advice for the first time, between January and December 2000. This study reveals an insufficient pluridisciplinary coordination at the initial management, which has been done by making regional referentials available, and therefore some errors which lead in some cases to inadapted treatment. It underlines therefore the necessity to implement more actively the present data of science, and to develop the management in multidisciplinary committees. Oncolor aims to harmonize this pluridisciplinary approach as well as to diffuse standard recommendations.

[Target-volume and critical-organ delineation for conformal radiotherapy of prostate cancer: experience of French dose-escalation trials]

The delineation of target volume and organs at risk depends on the organs definition, and on the modalities for the CT-scan acquisition. Inter-observer variability in the delineation may be large, especially when patient's anatomy is unusual. During the two french multicentric studies of conformal radiotherapy for localized prostate cancer, it was made an effort to harmonize the delineation of the target volumes and organs at risk. Two cases were proposed for delineation during two workshops. In the first case, the mean prostate volume was 46.5 mL (extreme: 31.7-61.3), the mean prostate and seminal vesicles volume was 74.7 mL (extreme: 59.6-80.3), the rectal and bladder walls varied respectively in proportion from 1 to 1.45 and from 1 to 1.16; in the second case, the mean prostate volume was 53.1 mL (extreme: 40.8-73.1), the volume of prostate plus seminal vesicles was 65.1 mL (extreme: 53.2-89), the rectal wall varied proportionally from 1 to 1, 24 and the vesical wall varied from 1 to 1.67. For participating centers to the french studies of dose escalation, a quality control of contours was performed to decrease the inter-observer variability. The ways to reduce the discrepancies of volumes delineation, between different observers, are discussed. A better quality of the CT images, use of urethral opacification, and consensual definition of clinical target volumes and organs at risk may contribute to that improvement.

The obligatory action of protein tyrosine phosphatases in ACTH-stimulated steroidogenesis is exerted at the level of StAR protein

A key regulatory step in the steroidogenic hormones signaling pathway is the synthesis of steroidogenic acute regulatory protein (StAR). This protein facilitates the delivery of cholesterol to the inner mitochondrial membrane, the rate-limiting step in steroidogenesis. ACTH and LH pathway also includes tyrosine dephosphorylation processes. Indeed, our previous studies have demonstrated that both hormones increase protein tyrosine phosphatase (PTP) activity by a PKA-dependent mechanism and that the action of PTPs is required for the stimulation of steroid biosynthesis in adrenal and Leydig cells. In order to test the putative relationship between PTP activity and StAR protein induction in adrenocortical cells, in the present study we evaluated steroid production and StAR protein level in Y1 adrenocortical cells under PTP inhibition. Phenylarsine oxide (PAO), a powerful cell permeable PTP inhibitor, reduced ACTH-stimulated steroidogenesis in a concentration-dependent fashion. A concentration of 2.5 microM of this compound inhibited steroid synthesis in a 56% (ACTH = 318 +/- 30, ACTH + PAO = 145 +/- 18 ng progesterone/mL, P < 0.001) and also abrogated StAR protein induction. Phenylarsine oxide reduced the protein level after 60 min and this effect still remained at 120 min. A second PTP inhibitor, benzyl phosphonic acid, acting by a different mechanism, reproduced PAO effects on both steroidogenesis and StAR protein. Taken together, these results indicate that PTP activity participates in StAR protein induction and led us to attribute to the PKA-mediated PTP activation in steroidogenic systems a functional role, as mediator of StAR protein induction.

[Conformal radiotherapy in prostate cancer: for whom and how?]

External radiotherapy is one of the modalities used to cure localized prostate carcinoma. Most of localized prostate carcinomas, specially those of the intermediate prognostic group, may benefit from escalated dose above 70 Gy at least as regard biochemical and clinical relapse free survival. 3D-CRT allows a reduction of the dose received by organs at risk and an increase of prostate dose over 70 Gy. It is on the way to become a standard. Intensity modulated radiation therapy increases dose homogeneity and reduces rectal dose. These methods necessitate rigorous procedures in reproducibility, delineation of volumes, dosimetry, daily treatment. They need also technological and human means. It is clear that localized prostate cancer is a good example for evaluation of these new radiotherapy modalities.

[Acute urinary complications after prostate iodine-125 brachytherapy: evaluation and risk factors]

PURPOSE

Evaluation of acute urinary toxicity following prostate Iodine-125 brachytherapy and determination of risk factors.

PATIENTS AND METHODS

Between September 2000 and July 2001, 50 men were entered into the study. A clinical follow-up accompanied by an objective measurement of urinary morbidity, including uroflowmetry and post-void residue, enabled the evaluation of acute toxicity before and then at one, three and six months of the implantation. Predictors were also searched for.

RESULTS

38 (76%) patients developed urinary disorders but those remained minor or moderate. The IPSS, as well as uroflowmetry deteriorated significantly at the first and third month post-implant, before improving during the sixth month. Besides, the variations of the post-void residue were less significant. Concerning the factors of risk, an initial IPSS superior to eight and a prior alpha-blocker treatment were the preoperative identified risk factors. Regarding dosimetric parameters, preoperative U30 and postoperative D90, D95, V100, V150 and V200 were identified.

CONCLUSION

Though remaining minor or moderate, the great frequency of acute urinary toxicity following prostate brachytherapy requires frank and open dialogue with the patient in conjunction with an evaluation of the urinary status before implantation Patients with higher initial IPSS or having required a prior alpha-blocker treatment are more exposed to these disorders and their correlated postoperative dosimetric factors.

[Cancer networks]

The complexity of legislation and the obstacle race run by all promoters in search of approval and funding for their projects could have greatly hindered the development of healthcare networks in France, or at least discouraged many promoter. Yet social and health professionals, along with certain healthcare service staff, considered these networks highly useful for decompartmentalising the French healthcare system. They would favour patient-oriented projects. It is not a surprise that the number of networks in the field of oncology is expanding rapidly, with more than 60 projects registered by public authorities by the end of 1999. Cancers are chronic diseases which often bring into play the patient's vital prognosis, as well as psychological and social consequences - sometimes dreadful - for patients and their relatives. Cancer patient management calls for a multidisciplinary approach in elaborating the therapeutic project and providing psychological support. Continuity and consistency of care require a partnership between different care providers from different specialities, with different medical practice and environments - hospital or home care, public or private practice. Though so much information has become available in the medical literature, quality of care demands that each healthcare professional keeps fully aware of the latest diagnostic or therapeutic findings and techniques in his/her field. Certain cancer networks have become a place where care providers and establishments can share methods and medical practice. Network promoters and members have thus been able to regain control over the functioning and the future of their profession. Patients have also obtained a place in decisions concerning their own health. Setting up healthcare networks will certainly shake up the tranquil system which the WHO has reported as the world's best health care system at the dawn of this century. However, this will also probably contribute to maintaining this excellence.

Cervical lymph node relapses of head-and-neck squamous cell carcinoma: is brachytherapy a therapeutic option?

PURPOSE

To report the results of interstitial brachytherapy (IBT) without salvage surgery for isolated cervical lymph node relapses.

PATIENT AND METHODS

From 1970 to 1989, 84 patients were treated; 76 patients had relapsed in sites of previous external beam radiation. In 72 patients, IBT was sole salvage treatment (mean, 56.5 Gy). In 12 patients IBT (mean, 38 Gy) was combined with further external beam radiotherapy (mean, 41 Gy).

RESULTS

Local control in the neck was 49% at 1 year, 31% at 2 years, and 0% at 5 years. Overall survival was 33% at 1 year, 13% at 2 years, and 1% at 5 years. Significant toxicity occurred in 35% (7% fatal). Multivariate analysis shows survival after salvage was better for patients who had achieved initial control for > or =18 months before relapse (0% vs. 13% at 3 years, p < 0.0002). Lymph node control was better for patients who received total salvage dose > or =60 Gy (0% vs. 56% at 3 years, p = 0.0004).

CONCLUSION

Given its poor efficiency and its toxicity, IBT must be considered only when surgery is contraindicated and if lymph node relapse occurs after a minimal interval of 18 months.