F. Huguet

Cancer du pancréas

Resume On estime qu’environ 7 200 nouveaux cancers du pancreas exocrine ont ete diagnostiques en France en 2005. Au moment du diagnostic, 20 % des patients sont atteints d’une tumeur jugee operable, 30 % d’une tumeur localement evoluee inoperable, et 50 % d’une maladie metastatique. Apres exerese chirurgicale, la duree mediane de survie des patients operes n’est que de 12 a 20 mois en raison de la frequence des recidives. La place de la radiotherapie chez les patients atteints de cancer du pancreas operable ou localement evolue est actuellement controversee. En situation adjuvante, le traitement standard est une chimiotherapie par acide folinique et 5-fluoro-uracile ou gemcitabine pendant six mois. En association avec une chimiotherapie concomitante, la radiotherapie postoperatoire permettrait d’ameliorer la probabilite de survie des patients en situation de resection tumorale incomplete. Ceci reste a demontrer dans un essai prospectif. La chimioradiotherapie neo-adjuvante est une approche prometteuse mais non validee a ce jour. Pour les tumeurs localement evoluees, il n’existe pas de standard therapeutique. Une chimiotherapie premiere par gemcitabine suivie chez les patients en situation de non-progression d’une chimioradiotherapie represente une strategie therapeutique seduisante qui est en cours de validation. Alors que dans les premiers essais de radiotherapie pancreatique etaient utilises de grands faisceaux d’irradiation, la tendance actuelle est a la reduction des volumes traites afin d’ameliorer la tolerance. La definition des volumes cibles a ete amelioree par l’utilisation de la scanographie de simulation. L’objectif de ce travail etait de preciser les particularites radio-anatomiques, les modes d’extension des cancers du pancreas et les principes de l’irradiation conformationnelle tridimensionnelle illustres par un cas clinique.

Apport de la TEP au diagnostic, évaluation thérapeutique et suivi du cancer de l’œsophage

FDG-(18F) PET can now be usually included in the treatment strategy of esophageal cancers for the pretreatment staging in operable tumours or for the diagnosis of recurrence. PET is also a good tool in conformal radiation therapy for improving the target coverage to treat the metabolic target volume or the biological target volume. Furthermore, PET seems to be interesting for evaluation of tumour response and could modify the treatment strategy after neoadjuvant chemotherapy or concurrent chemotherapy and radiation therapy. New radiotracers could allow advances in biological and molecular tumour delineation and contribute to change in treatment strategy based on functional and biological imaging.

La formation des internes en radiothérapie-oncologie

RésuméUn dialogue continu entre les médecins en formation (internes et chefs de clinique) organisés en association, la SFjRO et les enseignants de la SFRO et du collège CNEC a permis de créer une dynamique de formation des internes en oncologie radiothérapie.Les cours nationaux des internes organisés en séminaires résidentiels depuis 2001 ont couvert les besoins d’un enseignement théorique national de thèmes plus difficiles à enseigner en région tels que la radioanatomie, la radiobiologie, la radiophysique et la curiethérapie. Ces cours nationaux ont indiscutablement eu un effet dynamisant et ont aussi permis, grâce à un dialogue direct des internes avec les enseignants et les représentants professionnels: de suivre l’évolution du nombre de médecins en formation en temps réel et signaler les besoins d’augmenter le nombre de postes d’internes et surtout de postes de chefs de cliniques assistantsd’analyser les motivations des internes pour le choix des spécialités oncologiquesde confirmer annuellement les besoins d’évolution de la maquettede discuter précocement avec les professionnels publics et privés sur les modes d’installation. L’implication croissante des médecins en formation lors du congrès annuel national de radiothérapie, l’introduction d’une session des jeunes radiothérapeutes, la création d’un cours d’été contribue à des étapes supplémentaires renforçant un « effet d’école ». Malgré un regain d’intérêt évident depuis cinq ans en oncologie radiothérapie (de 52 à 89 internes en formation sur les cinq années du cursus) la démographie reste inquiétante et couvre incomplètement les besoins d’une discipline en pleine évolution et renouvellement. Les besoins à venir concernent principalement: un accès élargi au clinicat pour permettre aux futurs oncologues radiothérapeutes de compléter leur formation en cancérologie en postinternatde plus grandes facilités aux activités de recherche, avec un accès aux différents mastersune mobilité accrue en France, en Europe et en internationalune ouverture aux autres disciplines en cancérologie avec la mise en place de cours communs aux autres options d’oncologie.AbstractIn France, national courses covering the theoretical aspects of radiotherapy (such as radiological anatomy, radiobiology, radiophysics and brachytherapy) contributed to an increase in interest in radiation oncology among interns. In 2001, the number of trainees amounted to 52, increasing to 89 in 2006. We describe other activities, such as active participation in the national meeting, thematic courses, and evaluation policies. An analysis of motivations demonstrated an equal interest in general oncology and the technical aspects of the discipline. Even with such encouraging results, the number of young specialists is inadequate, covering less than half the future needs of this speciality.

Radiothérapie des cancers épidermoïdes de la tête et du cou localement évolués : état de l’art, actualités et directions futures

Therapeutic principles of radiation therapy in head and neck carcinomas will be discussed in this review. Intensity-modulated radiotherapy with concomitant cisplatin should be standard. In case of contraindication to chemotherapy, cetuximab is an option, while hyperfractionation should be considered in patients unfit for concomitant treatment. Concomitant chemotherapy should be administered in the presence of extracapsular extensions and positive margins in the postoperative setting. Current research areas such as desescalation in human papillomavirus-positive tumours, adaptive radiotherapy, radiomics and immunotherapy will also be addressed.

La radiothérapie a-t-elle encore une place dans le traitement des cancers du pancréas ?

About 7,200 new cases of pancreatic adenocarcinoma are diagnosed each year in France. At the time of diagnosis, only 20% of patients have an operable tumor; 30% have local or regional extensions and 50% metastatic dissemination. Median survival of patients after surgical resection ranges from 12 to 20 months, because of the high relapse rate. Currently, the use of radiotherapy is controversial for patients with operable or locally advanced pancreatic cancer. The standard treatment is six months of chemotherapy with FUFOL or gemcitabine. Combining it with radiation therapy as an adjuvant (CRT) may improve the survival of patients with incompletely resected tumors. This must still be demonstrated in a prospective trial. Neoadjuvant CRT is a promising treatment but still under evaluation. There is no standard treatment for patients with locally advanced tumors. A strategy of initial chemotherapy (gemcitabine) followed by CRT for patients with non-progressive tumors is under evaluation in the LAP07randomized trial.

Cancers du col utérin de stade IB2, IIA et IIB sans extension ganglionnaire traités par chimioradiothérapie préopératoire

PURPOSE To evaluate the results of preoperative chemoradiation for resectable bulky cervical carcinoma without lymph node involvement after surgical lymph node staging. PATIENTS AND METHODS Between 2000 and 2010, 45 patients with cervical carcinoma stage IB2 (11 patients), IIA2 (3 patients) and IIB with proximal parametrial invasion (31 patients) were treated with pelvic radiation therapy at a dose of 40.5Gy and concurrent platin (44 patients) or mitomycin (one patient). Forty-two patients had low-dose-rate preoperative uterovaginal brachytherapy at a dose of 20Gy. All patients underwent hysterectomy. Three patients had postoperative low-dose-rate vaginal brachytherapy at a dose of 20Gy. The median follow-up was 34 months. RESULTS A pathologic cervical residual tumor was observed in 16 patients (35.6%). Six patients presented a relapse (13.3%) with a median delay of 8 months. The 5-year overall survival and disease free survival rates were 88.4% and 84.7%, respectively. In univariable analysis, a cervical residual tumor was the only predictive factor of overall survival (P=0.03). Late toxicity was observed in seven patients. CONCLUSION Chemoradiation followed by surgery for resectable bulky stage I-II cervical carcinoma without lymph node involvement on pretreatment surgical staging can be used with a good local control and a high rate of 5-year overall survival.

Nouvelles techniques de radiothérapie des tumeurs de la face et du cou : état des lieux et perspectives

RésuméLors des 20 dernières années, des progrès majeurs ont été faits dans la prise en charge par radiothérapie des cancers des voies aérodigestives supérieures (VADS) avec trois axes d’optimisation technique: une meilleure définition de la cible tumorale, une optimisation de la distribution de la dose délivrée au volume tumoral et une diminution de la dose délivrée aux organes sains. Ces nouvelles techniques d’irradiation permettent d’améliorer la qualité de vie des patients sans diminution du contrôle local et de la survie.AbstractDuring the last twenty years, major advances have been made in treating head and neck cancer using radiation therapy with three axis of technical optimization, namely, a better definition of target volumes, an optimization of dose distribution to the tumor, and a decrease of dose to healthy organs. These new radiation therapy techniques can improve the patient’s quality of life without decreasing local control and survival.During the last twenty years, major advances have been made in treating head and neck cancer using radiation therapy with three axis of technical optimization, namely, a better definition of target volumes, an optimization of dose distribution to the tumor, and a decrease of dose to healthy organs. These new radiation therapy techniques can improve the patient’s quality of life without decreasing local control and survival.

Carcinoma of the salivary glands: guidelines and case report of sustained remission with docetaxel

Salivary glands tumours are rare neoplasms for which there are few clinical trials. The most common malignant parotid tumour is the mucoepidermoid carcinoma. High‐grade mucoepidermoid carcinomas are highly aggressive tumours. The initial therapy of localized disease is known, but when there is a recurrence, several options are possible and chemotherapy is generally reserved for palliative treatment. We comment on published guidelines and report a case of sustained remission with docetaxel.

Article originalChimioradiothérapie de rattrapage à visée curative de rechutes pelviennes isolées de cancers du col utérinIsolated pelvic recurrences of cervical carcinoma treated with salvage chemoradiotherapy

PURPOSE Evaluation of the results of salvage radiation therapy with curative intent in the treatment of recurrent cervical carcinoma. PATIENTS AND METHODS Fourteen patients with a recurrence of a cervical cancer were treated in our department between 1982 and 2009. Five patients had a pelvic relapse, four a vaginal relapse and five a pelvic lymph node relapse. Four patients had first a surgical resection of the relapse, which was incomplete in two patients. All patients had pelvic radiotherapy with a median dose of 55Gy in conventional fractionation. Concurrent chemotherapy was administered to 12 patients. A vaginal brachytherapy with a median dose of 20Gy was performed in addition in 3 patients. The median follow-up was 39months. RESULTS Safety of radiation therapy was correct with 29% of grade 3 acute or intestinal toxicity. Tumor control was observed in 10 patients (71%). Four patients presented a locoregional tumor progression. At the time of analysis, three patients had died from their cancer. From the date of relapse, the rate of overall survival at 2 and 5year was respectively 84% and 74%. Three patients (21%) had severe late effects. CONCLUSION In our experience, chemoradiotherapy can achieve a high rate of remission in patients with isolated pelvic recurrence of cervical cancer. This treatment is feasible only if the patient had not received radiation therapy before or if the relapse is out of the previously irradiated volume.

Chimioradiothérapie de rattrapage à visée curative de rechutes pelviennes isolées de cancers du col utérin

PURPOSE Evaluation of the results of salvage radiation therapy with curative intent in the treatment of recurrent cervical carcinoma. PATIENTS AND METHODS Fourteen patients with a recurrence of a cervical cancer were treated in our department between 1982 and 2009. Five patients had a pelvic relapse, four a vaginal relapse and five a pelvic lymph node relapse. Four patients had first a surgical resection of the relapse, which was incomplete in two patients. All patients had pelvic radiotherapy with a median dose of 55Gy in conventional fractionation. Concurrent chemotherapy was administered to 12 patients. A vaginal brachytherapy with a median dose of 20Gy was performed in addition in 3 patients. The median follow-up was 39months. RESULTS Safety of radiation therapy was correct with 29% of grade 3 acute or intestinal toxicity. Tumor control was observed in 10 patients (71%). Four patients presented a locoregional tumor progression. At the time of analysis, three patients had died from their cancer. From the date of relapse, the rate of overall survival at 2 and 5year was respectively 84% and 74%. Three patients (21%) had severe late effects. CONCLUSION In our experience, chemoradiotherapy can achieve a high rate of remission in patients with isolated pelvic recurrence of cervical cancer. This treatment is feasible only if the patient had not received radiation therapy before or if the relapse is out of the previously irradiated volume.