R. de Crevoisier

The postchemotherapy PSA surge syndrome

BACKGROUND Chemotherapy has emerged as a standard treatment in patients with castration-refractory prostate cancer (CRPC). Consensus criteria are available to define response in CRPC as at least a 50% decline in serum prostate-specific antigen (PSA) confirmed 4 weeks later. The objective of this work was to study early serum PSA changes in patients under chemotherapy and to correlate these changes with subsequent response assessment. PATIENTS AND METHODS Serum PSA levels were monitored every 3 weeks in 79 patients with CRPC treated with chemotherapy and a time course of serum PSA levels was obtained. Correlation with response was studied. RESULTS According to consensus criteria, 21 (40%) and 20 (38%) patients achieved a PSA response and stabilization, respectively, after first-line chemotherapy. Among patients who achieved either a response or a stabilization, 8 of 41 (20%) had a serum PSA rise during the first 8 weeks of chemotherapy, followed by a subsequent decline in serum PSA. The same observation was made in patients receiving second-line chemotherapy: 6 of 20 patients achieving a response or stabilization had an initial serum PSA rise. The postchemotherapy increase in serum PSA could reach more than twice the baseline value. The duration of the PSA surge ranged from 1 to 8 weeks. When considering responders only, 6 of 30 (20%) had a postchemotherapy serum PSA surge, followed by a drop. CONCLUSION Postchemotherapy PSA surges occur not infrequently in patients with CRPC who respond to chemotherapy. Physicians should be aware of this effect to avoid inadequate early discontinuation of chemotherapy.

Radiothérapie guidée par l’image

The IGRT is described in its various equipment and implementation. IGRT can be based either on ionizing radiation generating 2D imaging (MV or kV) or 3D imaging (CBCT or MV-CT) or on non-ionizing radiation (ultrasound, optical imaging, MRI or radiofrequency). Adaptive radiation therapy is then presented in its principles of implementation. The function of the technicians for IGRT is then presented and the possible dose delivered by the on-board imaging is discussed. The quality control of IGRT devices is finally described.

Radiotherapy in head and neck cancer in the elderly: a challenge

Elderly patients represent the most rapidly growing subgroup of the patient population in France and in the majority of industrialized countries. The effect of age in terms of the prognosis and response to treatment remains unclear. The management strategy (curative versus palliative) for head and neck cancer in the elderly has given vent to divergent opinions and controversies in several respects (the type and quality of treatment, quality of life and economic consequences). This review only focuses on the radiotherapy schedule and head and neck cancers. We compare aged patients with head and neck cancer to younger patients in terms of clinical features, tumor biology, type of treatment, side effects and response. We conclude that if the patient is in a good general condition following a complete evaluation of the cancer, physicians should propose curative treatment with radiotherapy because retrospective trials demonstrate that response in older patients when treated aggressively is comparable to that of younger patients. However, specific trials concerning aged patients with head and neck cancer, quality of life and radiotherapy are warranted.

Recommandations pour le contrôle de qualité en curiethérapie

Brachytherapy consists of sealed radioactive source implantation. The diversity in the nature of radioelements, in their energy and activity requires strict implantation and utilization rules. These rules include radioactive source physical parameters check, after-loading machine and treatment planning system quality assurance and safe and reproducible dosimetric systems. Patient and medical workers information guarantee radioprotection and prevention of accidental exposures.

Tumeur urothéliale de vessie chez le patient « fragile »

Resume Pour les tumeurs urotheliales de vessie, l’indication du traitement adjuvant est basee sur le risque de recidive et sur les comorbidites (fonction renale alteree). Le facteur pronostique principal est le statut ganglionnaire (N+ = mauvais facteur pronostic). Il existe un faible niveau de preuve pour la chimiotherapie postoperatoire. Deux protocoles adjuvants sont utilises (MVAC ou GC). Chez les patients dits « unfit » (contre indication au cisplatine du fait de l’alteration de leur etat general et/ou de leur fonction renale), on peut proposer l’association gemcitabine-taxanes mais cela reste encore en evaluation. Concernant la radiotherapie adjuvante pour marges chirurgicales positives, l’indication depend du risque metastatique. L’association RT-CT concomitante peut etre consideree comme une alternative a la chirurgie d’exerese pour les patients demandeurs, refusant la cystectomie apres une information pertinente ou inoperables pour des raisons medicales. Cependant, les criteres d’inclusion sont tres selectifs.Adjuvant therapies in bladder cancer are based on risk of recurrence and associated comorbidities (renal failure). Lymph node involvement is the most important prognostic factor for decision. Two adjuvant chemotherapies exist: MVAC or GC. In unfit patients, association (Gemcitabine and Taxanes) could be proposed. Indication of adjuvant radiotherapy depends on metastatic risk and resection margins. Concomitant chemotherapy and radiotherapy should be proposed to selected patients who refuse or are not candidate for radical cystectomy.