Tunisian adult's Hodgkin lymphoma Study Group.

The Tunisian adult's Hodgkin lymphoma (HL) Study Group was created in 1999. It aimed to improve the management of this curable hematologic malignancy by standardizing the diagnosis, assessment of disease, treatment management and therapeutic evaluation in different Tunisian centers (Hematology, oncology and radiotherapy).Since 1998, four versions of the prospective national protocol for treating adult Hodgkin lymphoma have succeeded (MDH99, MDH2002, MDH2008, MDH2015). Each version was based on the results of the previous version and analyzed according to new data from the literature. Due to this national study group, the number of patients lost to follow decreased significantly (30% before the creation of the group and only 3% for patients treated with MDH2008), the complete and uncertain response rates have improved (75% before the creation of the group and 92% in patients treated with MDH2008) with dramatically improved rates of overall survival from 57% to 90%. On the other hand there was an improvement of toxic death rate (13% of toxic deaths in MDH2002 to 4.37% in the MDH2008) with a decrease of the respective rate of primary failure and relapse by 17% and 12.5% in MDH2002 against the 11.4% and 7.8% in the MDH2008. This resulted in an improvement in overall survival (90%) and event-free survival at 5 years (75%). Now with the introduction of positron emission tomography in Tunisia, we hope yet to finalize the assessment of response and thus better adapt the treatment of this disease. Our objective remains the improvement of event-free survival rate to reach 80%.

Tourniquet on the low segment of the uterus reduces blood loss in postpartum hemorrhage during hysterectomy for placenta accreta: Old but gold.

Objectives: To investigate the feasibility, safety, and efficiency after application of a cervical tourniquet during caesarian hysterectomy owing to placenta accreta. Study design: It was a monocentric prospective observational study for 3 years. Patients were allocated into two group: Group Tourniquet: (TG) in which a cervical tourniquet was systematically applied during hysterectomy, control group (CG) when the caesarian hysterectomy was performed without. Results: 20 patients in the TG and 23 patients in the CG. Tourniquet application significantly reduced per operative estimated blood loss volume (TG: 530 ± 135 vs 940 ± 120 ml in the CG, p = 0.0074), ΔHB (0.6 [0.3-1.9] vs 2.5[2.5-3.6] g/dl in the CG, p = 0.006) RBC transfusion requirements' (TG: 2 ± 1.7 vs 4.3 ± 2.1 units in the CG, p = 0.046) procedure duration (TG: 98 ± 21 vs 137 ± 33 min in the CG, p = 0.015), clotting disorders (TG: 1 (5%) vs 6 (26,1%) in the CG, p = 0.013) and the incidence of bladder wounds (TG: 1 (5%) vs 5 (21,7%) in the CG, p = 0.048). There was no significant difference regarding ICU transfer rate (TG: 16 (80%) vs 20 (86.9%) in the CG, p = 0.53) or length of stay (TG: 1.4 [2,3] vs 2.3 [1-4] days in the CG, p = 0.615) and digestive wound (TG: 0 vs 2 (8,7%) in the CG, p = 0.641). Conclusion: In case of a radical management of placenta accreta. A strategy that involves the application of a cervical Tourniquet should be considered as a feasible, safe and above all efficient alternative to prevent blood spoliation.

Prophylactic occlusion balloons of both internal iliac arteries in caesarean hysterectomy for placenta accreta spectrum disorder reduces blood loss: A retrospective comparative study.

Background: The placenta accreta spectrum is a complex disorder characterized by abnormal invasion of the placenta into the uterine wall, posing a significant risk of life-threatening haemorrhage for patients. Its incidence is on the rise, largely attributed to the increasing rates of caesarean sections. Management of this spectrum involves a multidisciplinary approach, although standardized protocols are not yet established. While caesarean hysterectomy remains the standard Gold, several adjunctive treatments have emerged in recent years to mitigate bleeding risk and associated morbidity. Among these, prophylactic occlusion balloons placed in the internal iliac arteries have shown promise. The aim of our study is to demonstrate the effect of prophylactic occlusion balloons in both uterine iliac arteries in the management of placental accreta spectrum disorders. Methods: A retrospective monocentric cohort study was conducted in the Department "C" of Gynaecology and Obstetrics at the Maternity Center of Tunis. The study spanned three years, from January 2nd, 2020, to December 31st, 2022. The study population consisted of two groups: Control Group (CG) comprised patients who underwent caesarean hysterectomy without internal-iliac prophylactic occlusion balloons, and Occlusion balloons of both internal iliac arteries Group (OBIIAG) included patients who underwent caesarean hysterectomy with internal-iliac prophylactic occlusion balloons. Results: A total of 38 patients were included in the study, all of whom exhibited similar epidemiological characteristics and comparable personal and obstetric histories. The most prevalent risk factor among the patients was a history of caesarean section (92%). On average, patients were diagnosed at 30 weeks of gestation, with third-trimester bleeding being the most common presentation (71% of cases). The median gestational age at delivery was between 36 and 37 weeks. We observed a significant difference in blood loss between the two groups (2888 ml in the control group and 1828 ml in the group with internal-iliac prophylactic occlusion balloons, p < 0.05). Implementation of this technique resulted in a reduced need for massive transfusions (p < 0.01) and shorter operating times (126 min for the control group and 92 min for the group with internal-iliac prophylactic occlusion balloons; p = 0.04). There were no significant differences in morbidity between the two groups. Conclusion: The intra-iliac prophylactic occlusion balloons can help reduce the risk of hemorrhage and the morbidities that come with the placenta accreta spectrum disorder.

[Tumors of the pineal region: retrospective study of 40 cases]. / Les tumeurs de la région pinéale: étude rétrospective à propos de 40 cas.

BACKGROUND: the tumours of the pineal region are rare brain tumours, most common in children and characterized by a large clinical and histologic polymorphism. AIM: to assess the outcome and prognostic factors of 40 patients with primitive pineal region tumours treated at the department of radiotherapy of Salah Azaiz institute. METHODS: between January 1977 and December 2000, 40 patients received radiotherapy. There were 22 adults and 18 children (age < 16 years). The mean age was 20.4 years and sex ratio was 2.07. Histologic diagnosis was confirmed in 11 cases; 16 patients had a CT evaluation after 20 Gy radiotherapy and in 13 cases diagnosis was performed with CT aspects ± germinal tumour markers. Target volume varied; 10 had craniospinal irradiation, 16 had local irradiation and 14 had whole brain irradiation with a boost at the tumour bed. Chemotherapy was proposed for metastases and recurrent diseases. RESULTS: survival rates were 87% at 2 years and 74, 5% at 5 years. For children, survival rates were 88% at 2 and 4 years. Eight patients (20%) failed locally and 5 patients (12.5%) had metastasis. Age, performance status and large fields of radiotherapy seem to be associated with prognosis and survival. CONCLUSION: Pineal tumours and especially germinal tumours are chemosensitive and radiosensitive, care of these tumours is multidisciplinary involving surgery, chemotherapy and radiotherapy. From our study and a review of the literature, we tried to find a therapeutic strategy for tumours of the pineal region.

[Prognostic value of parapharyngeal extension in nasopharyngeal carcinoma]. / Valeur pronostique de l'extension parapharyngéee dans les carcinomes nasopharyngés.

AIM: This study evaluated the prognostic value of the Para pharyngeal space involvement in nasopharyngeal carcinoma T 2 disease (UICC 1997 classification). METHODS: From January 1997 and December2001; 32 patients with nasopharyngeal carcinoma were examined by CT scan and according to the 1997 International Union Against Cancer (UICC) staging system, 15 had stage T2a M0 (G1) and 17 T2bM0(G2). The median age was 47 years. The male to female ratio was 1.81 (G1); 4.3 (G2). All patients were pathologically confirmed by biopsy from the nasopharynx as having UCNT in 100% (G1) and 94% (G2). The node involvement was 52% for the G1 (N2: 26%, N3: 26%) and 80% for the G2 (N2: 47%, N3: 41%). Both neoadjuvant chemotherapy and radiotherapy were performed for advanced N disease and only radiotherapy for NO. RESULTS: Examination and CT scan were performed for the evaluation of the treatement. The completely clinical remission after chemotherapy was 12.5% (G1) and 53% (G2), partial remission was 25% (G1) and 35% (G2). The CT scan control wasn't performed for all patients. The complete response was 69% (G1) and 53% (G2); partial response was 6% for both two groups. The median follow up was 79 months. Disease free survival rates were 70% for G1 (T2a) and 48% for G2 (T2b). Distant metastasis rates were 26% (G1) vs 6% (G2) and more likely in the presence of advanced N disease. Five years overall survival was 78% (G1) T2a vs. 55% (G2) T2b.The N disease was correlated to metastasis as overall survival was 66.7% for N3 disease vs 85.7% for N0. CONCLUSION: Parapharyngeal tumor involvement affects local and regional tumor failure. Subclassification of T2 disease into T2a/T2b should have an impact on treatment strategies.

[Internal mammary lymph node invasion in breast cancer: myth or reality?]. / L'atteinte de la chaîne mammaire interne dans le cancer du sein: mythe ou réalite?

The internal mammary nodes are often underestimated as breast cancer lymphatic pathway spread. It is yet the first site of lymphatic invasion in central or internal tumors and the second site in external tumors. The intra-thoracic situation of internal mammary nodes explains partly, the difficulty of its exploration. To evaluate the risk of internal mammary node invasion, some predictive factors are established (tumor size, internal or central tumor location, axillary node invasion and young age). Prognostic and therapeutic impact of invasion justifies its systematic research. Without exploring internal mammary nodes status, TNM classification remains, incomplete. CT scanner, magnetic resonnance imaging, positron emission tomography scanner and sentinel node exploration technique are helpful to explore this region and to adapt its irradiation.

[Estimated cost of managing invasive cervical cancer in Tunisia]. / Estimation du coût de la prise en charge du cancer invasif du col de l'utérus en Tunisie.

In Tunisia, cervical cancer incidence is about 4.8 per 100,000, but the diagnosis is often made too late, with 5-year survival rates of 35% or less. Given the budgetary constraints facing the health system, and taking into account the low incidence of cervical cancer in Tunisia, the comparative cost effectiveness analysis of screening programs must be strongly considered by policy and decision-makers. A retrospective study to estimate the average direct cost of managing cervical cancer during the first year after diagnosis was conducted among patients with cervical cancer diagnosed in 2003 at the Salah Azaiez Cancer Institute in Tunis. The study included 64 patients with cervical cancer. The direct medical cost is equal to the sum of the respective consumable costs related to hospitalization, ambulatory care, diagnostic tests, surgical procedures, chemotherapy and radiation. Regarding the in-patient hospital stay, the overall cost of a hospital day is a macro-cost including the accommodation expenses themselves, as well as staff costs and non-specific drugs. An extrapolation of the cost of care has been done at the national level; the method used consisted in multiplying the mean of the direct medical costs according to the FIGO stage by the number of incident cases at national level, for the corresponding stage. The distribution by FIGO stage was derived from the Cancer Registry of the northern region of the country. This extrapolation is an estimate, It assumes that the costs of care are similar in other health facilities, and secondly, it assumes that the distribution by FIGO stage according to that of the northern region's registrar is approximately the same at the national level. The results showed that the direct medical care cost of cervical cancer ranged from 777 to 7458 DT (431 to 4143 euro) with an average of 3180 +/- 1390 DT (1766 +/- 772 euro). The national cost was estimated at 877,680 DT (486,847 euro). Although, the cost of care for cervical cancer in Tunisia does not represent a considerable burden for health system, cervical cancer screening remains the best intervention to improve cancer survival rates.

[Tunisian National Protocol for Adult Hodgkin's Lymphoma Treatment: Results of a therapeutic regimen adapted to the 2-cycle CT response, about 444 patients]. / Protocole national Tunisien prospectif de traitement du Lymphome de Hodgkin de l'adulte : résultats d'un schéma thérapeutique adapté à la réponse par tomodensitométrie à 2 cycles, à propos de 444 patients.

OBJECTIVE: In Tunisia, the management of Adult Hodgkin's Lymphoma (HL) has been standardized since 1999. We propose in this study to report the therapeutic results of the national protocol of adult HL treatment (MDH2008). PATIENTS AND METHODS: Our study is prospective multicenter interesting 444 patients followed for HL between July 2008 and June 2013 and treated according to the MDH2008 protocol. The median age of our patients was 30 years. B symptoms were present in 62.8 % of our patients. According to the Ann Arbor classification, our patients were in stages I, II, III and IV in 3 %, 42 %, 26 % and 29 %, respectively. The MDH2008 protocol is based on a strategy adapted to the therapeutic response to 2 cycles of chemotherapy. RESULTS: Response≥75 % to 2 courses of chemotherapy was achieved in 43 % of patients and the response rate at the end of treatment was 92.1 %. Forty-eight patients (11.4 %) had primary failure. In the multi-variant study, bulky mediastinal mass (IMT≥0.35) was an independent predictive factor of primary failure (P: 0.000). Nineteen toxic deaths (4.35 %) were reported. The relapse rate was 7.8 %. Event free survival, relapse-free survival and overall survival at 5years were 75 %, 89 % and 90 %, respectively. Adaptation of the treatment to the 2 cycles response was effective in unfavorable early stages and advanced stages. CONCLUSION: Compared to MDH2002 (second version of Tunisian prospective protocol), the MDH2008 reduced the primary failure rate, the rate of toxic deaths with escalated BEACOPP and the rate of relapse in Tunisian patients.

[Total body irradiation: techniques and main indications]. / Irradiation corporelle totale: techniques et indications.

The radiotherapy department at Salah Azaïz institute had started, in March 2000, a new sophisticated technique of irradiation consisting in total body irradiation (TBI). TBI is used in many preparative regimens before bone marrow transplantation in the treatment of haematological malignancies. TBI aims to destroy immunocompetent tissues in order to avoid graft rejection and to eradicate residual tumor cells. In this article, we review different TBI techniques and its main indications. We also describe the acute and late effects of TBI.

Radio-induced malignancies of the scalp about 98 patients with 150 lesions and literature review.

INTRODUCTION: - The induction of malignant diseases is one of the most concerning late effects of ionizing radiation. The topic of this study deals with skin tumors developed in the irradiated areas in children given X-ray therapy for tinea capitis. MATERIAL AND METHODS: - All patients with malignant tumors of the scalp referred to Salah Azaiz Institute between 1970 and 2001 have been questioned in order to determine if there had been a prior X-ray irradiation for tinea capitis, its modality, and its consequences. The first scalp irradiation goes back to 1922 and the last was performed in 1963. RESULTS: - Ninety-eight patients with 150 radio-induced cancers of the scalp following irradiation for tinea capitis are reported (1.5 lesion per patient). The patients were irradiated in various hospitals and dispensaries throughout the country. Eighty-one patients (82%) had only one session of radiation. The average age at irradiation was 12 (+/-6) years, the latent period for radiation-induced skin cancers was 36 (+/-14) years. In 61 patients (62%), the scalp appeared normal and in 38% radiodermatitis was noted. Patient age at diagnosis of malignancy varied from 20 to 83 years with an average of 47 years. Basal cell carcinomas (125 cases) and spinocellular carcinomas (16 cases) were the most common, three other cases of annexial tumors, two malignant non-Hodgkin's lymphomas and four melanoma lesions are also present. Radiotherapy was used for the treatment of 74 patients (alone in 42 and associated with surgery in 32 patients); 14 patients had exclusive surgical excision. CONCLUSIONS: - Basal cell carcinomas are the most frequent tumors arising on chronic radiodermatitis. In spite of the long latency period, patients' young age at irradiation explained the occurrence of these cancers at a relatively young age. Literature review is suggesting recessive mutation of tumor-suppressor genes as the characteristic abnormality in radio-induced cancer.

Computed tomography after breast conserving carcinoma treatment: recognition of surgically induced lesions prior to radiation therapy.

To introduce computed tomography for the detection of post-surgical intramammarian lesions, exposing risk factors for subsequent radiation therapy. 104 patients with breast cancer were treated. They previously underwent breast conserving carcinoma treatment and were subsequently irradiated. The techniques were planned individually based on a CTdata set. All the acquired slices were evaluated with regard to seromas, larger tissue defects or organized hematomas. Seromas and tissue defects are raising the rate of byeffects during radiation therapy and deteriorating the cosmetic results. Pretherapeutical CT allows the puncture of hidden seromas and the individual adaptation of the irradiation technique in order to avoid overdosage due to tissue defects. Therefore CT is valuable for all patients prior to radiation therapy.