[Management of metastatic hormone-naive prostate cancer at diagnosis]. / Prise en charge d'un cancer de la prostate métastatique au diagnostic.

In Belgium, 12 % of patients present with upfront metastatic hormone-naive prostate cancer. Surgical or medical castration has been the only approved treatment for decades. Since 2014, several randomized trials have demonstrated that survival could be significantly improved in patients who are deemed fit enough to cope with the potential added side-effects. Docetaxel chemotherapy and androgen receptor axis-targeted next generation hormonal agents such as abiraterone, enzalutamide and apalutamide have been shown to improve overall survival when given within 12 weeks after castration initiation. Similarly, prostate radiotherapy, in the absence of urological contraindications, might also improve overall survival in patients presenting with less than 5 bone metastases. How these strategies can be combined remains a matter of debate and is currently under investigation.

En Belgique, le cancer de la prostate se présente sous une forme métastatique d'emblée chez 12 % des patients. Depuis des décennies, le traitement repose sur la castration, chirurgicale ou médicamenteuse. Depuis 2014, plusieurs études randomisées ont démontré le bénéfice de compléter cette castration chez les patients aptes à tolérer les effets secondaires éventuels des traitements complémentaires proposés. La chimiothérapie par docétaxel et les hormonothérapies de nouvelle génération visant l'axe androgènes/récepteurs aux androgènes, telles que l'abiratérone, l'enzalutamide et l'apalutamide, permettent d'augmenter significativement la survie des patients lorsqu'elles sont instaurées dans les 3 mois qui suivent la mise en oeuvre de la castration. De même, l'irradiation de la prostate, lorsque la situation urologique le permet, pourrait augmenter la survie des patients ayant moins de 5 métastases osseuses. Le bénéfice éventuel de combiner ces stratégies reste débattu et en cours d'investigation.

[Locally-advanced cervix cancer : multidisciplinary management]. / Cancer du col utérin localement avancé : approche multidisciplinaire.

Cervical cancer is the fourth most common cancer in women and is linked in over 95 % of cases to papillomavirus infection, the incidence of which has fallen in recent years due to screening and vaccination. Almost half of these cancers are diagnosed at a locally advanced stage with an overall 5-year survival of around 65 %. In recent decades, the management strategy of these locally advanced cancers has changed considerably and has allowed the improvement of survival but above all of local control as well as the reduction of toxicity, due to the implementation of imaging. Standard treatment consists of external beam radiation therapy combined with concomitant chemotherapy followed by intrauterine brachytherapy. The role of neo-adjuvant and adjuvant chemotherapy is still being evaluated. New therapeutic approaches (particularly immunotherapy) in addition to standard treatment are also being studied.

Le cancer du col de l'utérus est le quatrième cancer le plus fréquent chez la femme et est lié, dans sup�rieur a 95 % des cas, à une infection par le papillomavirus, dont l'incidence a chuté ces dernières années grâce au dépistage et à la vaccination. Près de la moitié de ces cancers sont diagnostiqués à un stade localement avancé avec une survie globale à 5 ans de l'ordre de 65 %. Ces dernières décennies, la stratégie de prise en charge de ces cancers localement avancés a considérablement changé. Elle a permis l'amélioration de la survie, mais surtout du contrôle local, ainsi que la réduction de la toxicité, grâce notamment à l'implémentation de l'imagerie. Le traitement standard consiste en une radiothérapie externe associée à une chimiothérapie concomitante, suivie d'une curiethérapie intra-utérine. La place de la chimiothérapie néo-adjuvante et adjuvante est toujours en cours d'évaluation. De nouvelles approches thérapeutiques (immunothérapie), en complément du traitement standard, sont aussi à l'étude.

[Role of local radiotherapy after prostatectomy]. / Indications d'un traitement de radiothérapie locale après prostatectomie radicale.

Different risk factors of biochemical relapse after prostatectomy have been identified: extra-capsular extension, seminal vesicle invasion and/or involved surgical margin. There is enough evidence in the literature that post-operative adjuvant radiation therapy can improve five and ten years local control rate, disease free survival and metastasis-free survival. Nevertheless, radiotherapy treatment is linked to a low risk of low grade toxicity and only 20-40% of biochemical relapse are observed after prostatectomy even if there is one involved surgical margin. So, it could be reasonable to propose a close monitoring of the PSA ("Prostate Specific Antigen") and adjuvant radiotherapy once the PSA is superior to 0 ng/ml. Rising PSA superior to 0.2 ng/ml after radical prostatectomy, corresponding to biochemical recurrence, is defined as a local relapse when the biochemical relapse is late and the PSA doubling time is superior to 6 months. Then, salvage radiotherapy is effective and has to be proposed taking the age of the patient, his comorbidities and his desires in consideration.

[Permanent iodine-125 implants brachytherapy: results after 10 years of experience in Liège University Hospital]. / La curiethérapie prostatique par implants permanents d'iode 125: résultats après 10 ans d'expérience au CHU de Liège.

Permanent implant iodine-125 brachytherapy is an attractive treatment option for men with localized prostate cancer and is an alternative approach to radical prostatectomy. Overall survival and biochemical relapse free survival are similar with both treatments but the toxicity is different. More potency preservation, less incontinence and one day hospitalisation are attractive for the patient with brachytherapy. On the other side, pre-existing obstructive or irritative urinary symptoms at baseline have to guide the patient to a surgical approach. A patient has to be able to select one of these two therapeutic opportunities through a complete transparent information. In this paper, we related our permanent implant iodine-125 brachytherapy experience. Overall survival, biochemical relapse free survival and registred toxicity are similar to those published in the literature.

[Clinical case of the month. The role of radiotherapy for the treatment of advanced squamous cell carcinoma of the vulva. Case report and review of the literature]. / Place de la radiothérapie dans le traitement des carcinomes épidermoïdes vulvaires. A propos d'un cas et revue de la littérature.

Locally advanced squamous cell carcinoma of the vulva is treated with concomitant chemoradiotherapy if surgery is too mutilating and/or implies the use of stomy. We report in this paper, the unusual case of a young patient treated successfully with this non-surgical approach.

[Radiotherapy and urogenital Paget disease]. / Le cas clinique du mois: Radiothérapie dans le cadre d'une maladie de Paget touchant la région génitale.

Urogenital Paget disease is usually treated by surgery. However, in case of recurrence or if multilating surgery is foreseen, radiotherapy seems to open a reasonable alternative. We report a successful treatment with radiotherapy in a patient with urogenital Paget's disease.

Hospital financing in Belgium: recent changes and future options.

A new mode of financing hospital operating costs has been gradually introduced in Belgium since 1982. It is a 'prospective pricing' system. Each hospital is assigned a budget envelope at the beginning of the fiscal year. This budget is calculated on a per diem basis. A portion of the budget is variable in function of the number of patient days. The annual budget of each hospital is determined by comparing its performance with the one of a reference group of similar hospitals. Since the introduction of the new mode of financing the financial situation of the Belgian hospitals has improved markedly. Moreover, the hospital expenditures of the health insurance scheme are under control: in 1984 and 1985 these expenditures increased at a lower rate than inflation. The continued increase of other medical expenditures, however, indicates that the principles of this new financing system should be extended to the medico-technical departments.