Effective delivery of palliative radiotherapy: A prospective study.

PURPOSE: The main goal of palliative radiotherapy is to reduce patient's discomfort. But sometimes patients do not receive any benefits from this treatment because of rapid worsening of their general condition. This prospective monocentric study assessed the effective delivery of palliative radiotherapy. MATERIALS AND METHODS: From 1st December 2015 to 29th February 2016, all consecutive patients receiving palliative radiotherapy in our hospital were included. The primary endpoint was the effective delivery of palliative radiotherapy according to the initial prescription (total dose, overall treatment time and fractionation). The secondary endpoints were the number of treatment breaks, the clinical benefit, the number of deaths and the delays for admission in the palliative care unit. RESULTS: Fifty-nine patients were included and 64 treatments were analysed. The treatment sites were: bone (70.3%) and brain (21.9%). The treatment goals were: pain control only (43.8%), decompression only (21.9%), pain control and decompression (32.8%), haemostatic aim (1.6%). Palliative treatment was achieved in 57 cases (89%). Temporary interruption of the radiotherapy treatment was necessary in six cases (9.4%; three for medical reason, three for logistic reason). The main reason of permanent interruption was worsening of performance status (seven cases). Palliation of symptoms (complete or partial responses) was obtained in 44 cases (68.8%). Seven patients (11.9%) died during the month after the end of the treatment. No delay or cancellation for admission in the palliative care unit were observed. CONCLUSION: Palliative radiotherapy was completed as originally planned in 51 cases (79.9%) with a clinical benefit for 44 cases (68.8%). Radiation therapy must not be neglected as a palliative treatment at the end-of-life.

[Overall treatment time assessment of radiotherapy delivered in a curative intent: A prospective study]. / Respect de l'étalement de la radiothérapie à visée curative : étude prospective.

PURPOSE: To assess the overall treatment time of radiotherapy delivered with curative intent in a cohort of 185 consecutive patients and the causes of this possible delay. If delay, to propose corrective actions. MATERIALS AND METHODS: We report a single-center prospective study including all consecutive patients receiving a radiation therapy with curative intent, from 1st December 2013 to 28th February 2014, on the three linear accelerators of the radiotherapy department. For each fraction missed, the causes of non-completion were prospectively collected. This analysis took into account the following parameters: age, sex, occupation, transport type and duration, tumour localization, radiation dose, concomitant chemotherapy, hospitalization, type of linear accelerator. RESULTS: One hundred and fifty-five patients were included in the study (183 evaluable, two did not complete treatment). The overall treatment time was respected for 31 patients (17%). It was lengthened on 4.6 days (d) (0-29 d; median: 3d). The mean number of delayed fractions was 3.4 (0-17; median: 2). The reasons of delay were: breakdown 32.2%; maintenance 29.3%; holiday 11%; treatment toxicity 9.4%; inadequate planning 8.6%; other disease 3.9%; treatment refusal 2.1%; unspecified personal reasons 1.5%; refusal to wait 0.8%; transportation 0.3%; error of communication 0.3%; other 0.6%. Two parameters had a significant impact on the overall treatment time: the type of linear accelerator in relation to breakdown occurrence (P<0.001) and transportation duration (more or less than 40 min, P=0.022). One hundred and thirty-eight patients (75%) and 79 patients (43%) were treated on one or more than two Saturdays. Treatment on Saturday significantly reduced the overall treatment time (median, 1.9 d; P<0.001). CONCLUSION: The overall treatment time was globally respected excluding break down and maintenance. Their impact on the overall treatment time is minimized by the systematic opening of the department on Saturdays.

Histological grade concordance between diagnostic core biopsy and corresponding surgical specimen in HR-positive/HER2-negative breast carcinoma.

BACKGROUND: The identification and validation of suitable predictive and prognostic factors are a challenge to improve the treatment scheme selection. Discordances in histological grade can be established between core biopsy and surgical specimens. This is important in HR-positive/HER2-negative subgroup where histological grade identifies patients at high risk and is a strong determinant for treatment scheme. METHODS: A total of 350 consecutive invasive breast carcinoma biopsies were assessed and compared with surgical specimens in Institut Curie, Paris, France. Clinical, radiological and pathological data were recorded. RESULTS: Histological grade concordance rate in the HR+/HER2- group was 75%. A grade underestimation was mainly due to mitotic index misgrading (23%). Large tumours (P<0.05), premenopausal patients (P=0.005) and non-ultrasound-guided biopsies (P=0.04) were risk factors for misgrading. The highest discordance was found in tumours that required chemotherapy (39%, P<0.05), and it was related to an underestimation of histological grade on core biopsies (94%). CONCLUSIONS: Histological grade in HR+/HER2- group is important to identify patients with poor prognosis and start a systemic therapy. Histological grade discordance was correlated with an underestimation of mitotic index and factors probably associated with intratumor heterogeneity (premenopausal status, tumour size and the type of core biopsy performed). But such discordance did not appear to modify the therapeutic decision, because systemic treatment decision-making also integrates other variables. Determining histological grade in core biopsy can be especially important in HR-positive/HER2-negative subgroup where it identifies patients at high risk and is a strong determinant of the treatment scheme.

Synovial sarcoma of the lateral pharyngeal wall.

OBJECTIVE: The present study describes the clinical, radiological and histological features of pharyngeal synovial sarcoma, on the basis of one clinical case, and discusses management. CASE STUDY: A male patient, aged 27 years, presented with synovial sarcoma of the lateral pharyngeal wall, revealed by pharyngeal discomfort and bloody sputum. CT and MRI showed a partially necrotic tumoral process centered on the upper half of the piriform sinus. Pathologic analysis found a malignant biphasic tumor, suggestive of synovial sarcoma. Partial pharyngolaryngectomy was performed on a lateral approach, with associated radiotherapy. DISCUSSION: Synovial sarcoma raises diagnostic and therapeutic issues. Prognostic factors are not clearly established. CONCLUSION: Pharyngeal synovial sarcoma is a rare tumor. Treatment is essentially surgical, requiring wide margins; radiotherapy is usually associated. The value of chemotherapy has yet to be assessed.

[Dosimetric and clinical benefits of respiratory-gated radiotherapy for lung and breast cancers: results of the STIC 2003]. / Intérêts dosimétriques et cliniques de la radiothérapie asservie à la respiration des cancers du poumon et du sein : résultats du Stic 2003.

PURPOSE: To compare respiratory-gated conformal radiotherapy versus conventional conformal radiotherapy for the irradiation of non-small cells lung cancer and breast cancer. PATIENTS AND METHODS: The STIC 2003 project was a comparative, non-randomized, multicenter and prospective study that included in 20 French centers between April 2004 and June 2008, 634 evaluable patients, 401 non-small cells lung cancer and 233 breast cancers. RESULTS: The final results confirmed the feasibility and good reproducibility of the various respiratory-gated conformal radiotherapy systems regardless of tumour location. The results of this study demonstrated a marked reduction of dosimetric parameters predictive of pulmonary, cardiac and esophageal toxicity, especially for non-small cells lung cancer, as a result of the various respiratory gating techniques. These dosimetric benefits were mainly observed with deep inspiration breath-hold techniques (ABC and SDX), which markedly increased the total lung volume compared to the inspiration-synchronized system based on tidal volume (RPM). For non-small cells lung cancer, these theoretical dosimetric benefits were correlated with a significant reduction in clinically acute and late toxicities, especially the pulmonary. For breast cancer, although less clear due to the lower total dose, there was a decrease in the dose delivered to the heart, potentially reducing the risk of cardiac toxicity in the long-term, especially during the irradiation of the left breast, and a reduction in dose to the contra lateral breast. CONCLUSION: Respiratory-gated radiotherapy appears to be essential to reduce the risk of acute and late toxicities, especially for lungs and heart, during irradiation of non-small cells lung cancer and breast cancers.

[Role of locoregional radiation therapy in breast cancer patients with negative lymph nodes after preoperative chemotherapy and mastectomy. The Institut Curie-Hôpital René-Huguenin experience]. / Rôle de l'irradiation locorégionale adjuvante en l'absence d'envahissement ganglionnaire après chimiothérapie néoadjuvante, mastectomie totale et lymphadénectomie axillaire pour un cancer du sein. Expérience de l'hôpital René-Huguenin-institut Curie.

PURPOSE: Neoadjuvant chemotherapy generally induces significant changes in the pathological extent of disease and challenges the standard indications of adjuvant postmastectomy radiation therapy. We retrospectively evaluated the impact of postmastectomy radiation therapy in breast cancer patients with negative lymph nodes (pN0) after neoadjuvant chemotherapy. PATIENTS AND MATERIALS: Among 1054 breast cancer patients treated with neoadjuvant chemotherapy in our institution between 1990 and 2004, 134 patients had pN0 status after neoadjuvant chemotherapy and mastectomy. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of postmastectomy radiation therapy on locoregional recurrence-free survival and overall survival was evaluated by multivariate analysis including known prognostic factors. RESULTS: Among 134 eligible patients, 78 patients (58.2%) received postmastectomy radiation therapy, and 56 patients (41.8%) did not. With a median follow-up time of 91.4 months, the 10-year locoregional recurrence-free survival and overall survival rates were 96.2% and 77.2% with postmastectomy radiation therapy and 86.8% and 87.7% without radiation therapy, respectively (no significant difference). In multivariate analysis, there was a trend towards poorer overall survival among patients who did not have a pathologically complete primary tumour response after neoadjuvant chemotherapy (hazard ratio [HR], 6.65; 95% CI, 0.82-54.12; P=0.076). Postmastectomy radiation therapy had no effect on either locoregional recurrence-free survival (HR, 0.37; 95% CI, 0.09-1.61; P=0.18) or overall survival (HR, 2.06; 95% CI, 0.71-6; P=0.18). There was a trend towards poorer overall survival among patients who did not have pathologically complete in-breast tumour response after neoadjuvant chemotherapy (HR, 6.65; 95% CI, 0.82-54.12; P=0.076). CONCLUSIONS: This retrospective study showed no increase in the risk of distant metastasis, locoregional recurrence or death when postmastectomy radiation therapy was omitted in breast cancer patients with pN0 status after neoadjuvant chemotherapy and mastectomy. Whether the omission of postmastectomy radiation therapy is acceptable for these patients should be addressed prospectively.

[Management of inflammatory breast cancer after neo-adjuvant chemotherapy]. / Traitement locorégional du cancer du sein inflammatoire après chimiothérapie néoadjuvante.

PURPOSE: To assess the benefit of breast surgery for inflammatory breast cancer. PATIENTS AND METHODS: This retrospective series was based on 232 patients treated for inflammatory breast cancer. All patients received primary chemotherapy followed by either exclusive radiotherapy (118 patients, 51%) or surgery with or without radiotherapy (114 patients, 49%). The median follow-up was 11 years. RESULTS: The two groups were comparable apart from fewer tumors smaller than 70 mm (43% vs 33%, P=0.003), a higher rate of clinical stage N2 (15% vs 5%, P=0.04) and fewer histopathological grade 3 tumors (46% vs 61%, P<0.05) in the no-surgery group. The addition of surgery was associated with a significant improvement in locoregional disease control (P=0.04) but with no significant difference in overall survival rates or disease-free intervals. Late toxicities were not significantly different between the two treatment groups except for a higher rate of fibrosis in the no-surgery group (P<0.0001), and more lymphedema in the surgery group (P=0.002). CONCLUSION: Our data suggest an improvement in locoregional control in patients treated by surgery, in conjunction with chemotherapy and radiotherapy, for inflammatory breast cancer.

[Early stage breast cancer: is exclusive radiotherapy an option for early breast cancers with complete clinical response after neoadjuvant chemotherapy?]. / Cancers du sein de stade II-IIIA: la radiothérapie exclusive est-elle une option en cas de réponse clinique complète à la chimiothérapie néoadjuvante?

PURPOSE: To determine whether exclusive radiotherapy could be a therapeutic option after complete clinical response (cCR) to neoadjuvant chemotherapy (NCT) for early breast cancers (EBC). PATIENTS AND METHODS: Between 1985 and 1999, 1477 patients received néoadjuvante chemotherapy for early breast cancer considered to be too large for primary conservative surgery. Of 165 patients with complete clinical response, 65 were treated by breast surgery (with radiotherapy) and 100 by exclusive radiotherapy. RESULTS: The two groups were comparable in terms of baseline characteristics, except for larger initial tumor sizes in the exclusive radiotherapy group. There were no significant differences in overall, disease-free and metastasis-free survivals. Five-year and 10-year overall survivals were 91 and 77% in the no surgery group and 82 and 79% in the surgery group, respectively (P = 0.9). However, a non-significant trend towards higher locoregional recurrence rates (LRR) was observed in the no surgery group (31 vs. 17% at 10 years; P = 0.06). In patients with complete responses on mammography and/or ultrasound, LRR were not significantly different (P=0.45, 10-year LRR: 21 in surgery vs. 26% in exclusive radiotherapy). No significant differences were observed in terms of the rate of cutaneous, cardiac or pulmonary toxicities. CONCLUSION: Surgery is a key component of locoregional treatment for breast cancers that achieved complete clinical response to neoadjuvant chemotherapy.

[Role of lymph node irradiation in breast cancer patients with negative pathologic node status after neoadjuvant chemotherapy: the René-Huguenin Cancer Center experience]. / Rôle de l'irradiation ganglionnaire chez les patientes indemnes d'envahissement ganglionnaire après chimiothérapie néoadjuvante pour un cancer du sein: expérience du centre René-Huguenin.

PURPOSE: Neoadjuvant chemotherapy generally induces significant changes in the pathological extent of disease. This potential down-staging challenges the standard indications of adjuvant radiation therapy. We assessed the utility of lymph node irradiation in breast cancer patients with pathological N0 status (pN0) after neoadjuvant chemotherapy and breast-conserving surgery. PATIENTS AND MATERIALS: Among 1054 breast cancer patients treated with neoadjuvant chemotherapy in our institution between 1990 and 2004, 248 patients with clinical N0 or N1-N2 lymph node status at diagnosis had pN0 status after neoadjuvant chemotherapy and breast-conserving surgery. Cox regression analysis was used to identify factors influencing locoregional recurrence-free survival, disease-free survival and overall survival. RESULTS: All 248 patients received breast irradiation, and 158 patients (63.7%) also received lymph node irradiation. With a median follow-up of 88 months, the 5-year locoregional recurrence-free survival and overall survival rates were respectively 89.4% and 88.7% with lymph node irradiation and 86.2% and 92% without lymph node irradiation (no significant difference). Survival was poorer among patients who did not have a pathological complete primary tumor response (pCR) (hazards ratio [HR]=3.05; 95% CI, 1.17 to 7.99) and in patients with N1-N2 clinical status at diagnosis ([HR]=2.24; 95% CI, 1.15 to 4.36). Lymph node irradiation did not significantly affect survival. CONCLUSIONS: Relative to combined breast and local lymph node irradiation, isolated breast irradiation does not appear to be associated with a higher risk of locoregional relapse or death among breast cancer patients with pN0 status after neoadjuvant chemotherapy. These results need to be confirmed in a prospective study.

The differential response to chemotherapy of ovarian metastases from colorectal carcinoma.

PATIENTS AND METHODS: All patients with metastatic (ovarian and extraovarian) CRC who underwent resection of ovarian metastases in our institution from April 1988 to August 2006 were analyzed and the response to preoperative chemotherapy was evaluated according to the RECIST criteria, and analyzed with respect to the sites of metastases (ovarian and extraovarian). RESULTS: The studied population consisted of 23 women. At presentation, 20 patients had symptoms. Preoperative chemotherapy resulted in tumor control of measurable extraovarian metastases in 65% of cases. In contrast, no objective tumor response of ovarian metastases was observed, disease stabilization was obtained in only 3 patients (13%), and progression or occurrence of new ovarian metastases were observed in 20 patients (87%) (p=0.0005). With a median follow-up of 54 months [15-229], median overall survival was 30 months, and 3-year overall survival was 18%. CONCLUSION: Ovarian metastases are less responsive to chemotherapy compared to other sites. As these "metastatic sanctuaries" often cause symptoms, surgical resection should always be considered for ovarian metastases, even in the case of associated extraovarian metastases.

[The role of radiotherapy in the management of patients with small cell lung cancer]. / Place de la radiothérapie dans la prise en charge des carcinomes bronchiques à petites cellules localisés.

Small cell lung carcinomas are aggressive on account of their high and early risk of dissemination. They represent less than 20% of all lung cancers and only a third of these present with limited stage disease at diagnosis. Currently, treatment is based on synchronous thoracic irradiation and chemotherapy combining platinum salts and etoposide with or without other drugs. Because of the high risk of brain metastases, prophylactic cranial irradiation (PCI) is indicated in patients with a complete response and should be part of the standard management of these patients on the basis of a meta-analysis showing a 5% increase in survival at three years. In limited stage disease 5 year survival rates can reach 25% but the majority of patients will relapse. This progress is the consequence of a better combination of thoracic and cerebral irradiation and polychemotherapy. Even in extensive disease PCI reduces the risk of brain metastases and significantly improves overall survival. Many issues are subject to further clinical research concerning modalities of combination radio-chemotherapy, radiotherapy target volumes, optimum dosage, and the use of drugs in association with irradiation.

[Serodiagnosis of human fasciolasis by micro-ELISA with reference to homologous somatic or excretory-secretory antigens. Comparison with an indirect immunofluorescent technic]. / Séro-diagnostic de la fasciolase humaine par micro-ELISA face à des antigènes homologues somatiques ou excrétés-sécrétés. Comparaison à l'immuno-fluorescence indirecte.

A new type of antigen constituted by excretory-secretory products (ES antigens) of adult Fasciola hepatica cyst alive in vitro is studied by the micro-ELISA method and compared with somatic antigens obtained from adult liver flukes. The results are practically the same (especially the sensitivity and the specificity of the test) but ES antigens seem to have more antigenicity. The results given by the ELISA method and by the IFAT (immunofluorescence antibody test) do not show any connection between the two tests, as the antigens employed are distinct, but IFAT gives a lightly inferior percentage of positivity to that obtained by ELISA.

[Serodiagnosis of onchocerciasis using micro-ELISA. Study of 450 sera and comparison with indirect immunofluorescence]. / Séro-diagnostic de l'onchocercose par micro-Elisa. Etude de 450 sérums et comparaison avec l'immuno-fluorescence indirecte.

The microtest ELISA has been used for human Onchocerciasis serological study. The antigens employed were adult Onchocerca volvulus extracts, collected from dissected nodules, delipidized and cleared from human proteins by affinity Chromatography. Under the circumstances, the positivity limit of the test seems excellent (maximum )D: 0,23) defined with 171 negative sera, 66 of them taken from Africans. Specificity controls were studied with 56 heterologous sera; cross-reactions occurred with hydatidosis and especially wit various nematode infections, in particular loasis. With reagents and technical conditions used, the specificity limit of the test corresponds to an OD of 0,4 (measured with a 3 mm optical course). The diagnosis value of the test was verified by studying sera from 90 individuals wit a positive skin biopsy and with sera from 233 adults living in endemic areas. For all the infected people, the global percentage of positivity with ELISA is not greater than that with indirect immunofluorescent antibody test (85%). On the other hand, the micro-test ELISA seems slightly more sensitive in detection of high serological positivities. We did not find any statistically relationship presence and quantity of microfilarial worms in skin biopsy and positivity with the microtest ELISA. Likewise, in some polyinfested patients (with Onchocerca volvulus and Dipetalonema perstans or Wuchereria bancrofti), we did not observe any correlation between the results given the microtest ELISA and the quantity of microfilariae in the blood stream.