[Meningioma under progestin treatment : what attitude to adopt ?] / Méningiome sous traitement progestatif : quelle attitude adopter ?

The risks of meningioma associated with the use of cyproterone acetate at high doses (25 to 100 mg/day) have been known since 2007. Recently, two additional molecules have been incriminated: nomegestrol acetate and chlormadinone acetate. The higher the cumulative dose and the longer the treatment duration, the bigger the risk of meningioma (12-fold after 5 years of treatment for nomegestrol acetate, and 7-fold after 3.5 years of treatment for chlormadinone acetate). Nevertheless, these medications have many indications that demonstrate their importance in the daily practice of the general practitioner, of the gynecologist and of the reproductive endocrinologist. Therefore, caution is required when introducing a powerful progestin that is incriminated in the long term at high doses. If the benefit/risk balance favours the initiation of progestin therapy, it is recommended to use the minimal effective dose and to limit the duration of use. Clinical and brain imaging monitoring should also be performed. Finally, if a meningioma develops on progestin, it is recommended that any medication containing a progesterone agonist be suspended.

Les risques de méningiome liés à la consommation de l'acétate de cyprotérone à de fortes doses (25 à 100 mg/jour) sont connus depuis 2007. Récemment, deux molécules supplémentaires ont été incriminées : l'acétate de nomégestrol et l'acétate de chlormadinone. Le risque de développer un méningiome est d'autant plus important que la dose cumulée est grande et que la prescription se prolonge dans le temps (risque multiplié par 12 à partir de 5 ans de traitement pour l'acétate de nomégestrol, et multiplié par 7 à partir de 3,5 ans de traitement par acétate de chlormadinone). Néanmoins, ces médications possèdent de nombreuses indications témoignant de leur importance dans la pratique quotidienne du médecin généraliste, du gynécologue et de l'endocrinologue de la reproduction. Dès lors, la vigilance est de mise lors de l'introduction d'un progestatif puissant incriminé à long terme et à haute dose. Si la balance bénéfices/risques plaide en faveur de l'instauration d'un traitement par progestatif, il est recommandé d'utiliser la dose minimale efficace et d'en limiter la durée d'utilisation. Une surveillance clinique et par imagerie cérébrale systématique est vivement recommandée. Enfin, en cas de détection d'un méningiome, il est recommandé de suspendre toute médication contenant un agoniste de la progestérone.

Acute toxicity and patient-reported outcomes in anal canal cancer: results of a pilot study.

INTRODUCTION: Anal canal cancer (ACC) is uncommon. The gold standard of care is chemoradiotherapy treatment. However, this treatment is associated with considerable acute and late side effects. The aim of this pilot study was to evaluate acute toxicity and patient-reported outcomes (PRO) in these patients from planning to 3 months after treatment. METHODS: Sixteen patients were recruited to this prospective observational study from March 2015 to December 2017. All patients received volumetric modulated arc therapy (VMAT) in 30#. Toxicity data were graded by a Radiation Oncologist using the Common Terminology Criteria for Adverse Effects (CTCAE) version 4 at planning, weekly during treatment, 6-week and 3-month post-treatment. PRO data were collected using the EORTC QLQ C30 and CR29 questionnaires completed by patients at planning, mid and end treatment and 3-month post-treatment. RESULTS: The majority of toxicity and PRO items peaked in severity at the end of treatment (week 6). Skin was the only item where >50% of patients had ≥ grade 2 toxicity at any point with 75% having ≥ grade 2 at week 6. Patient-reported embarrassment significantly increased over time (P < 0.001). No meaningful relationships were found between PRO and CTCAE results. CONCLUSION: After reaching their maximum severity at the end of treatment, the majority of toxicity and PRO items approached baseline levels by 3-month post-treatment. The results of this study suggest that PROs are an important complementary tool to CTCAE and provide greater understanding of patients' perception of treatment side effects.

Stereotactic radiosurgery for melanoma brain metastases: Concurrent immune checkpoint inhibitor therapy associated with superior clinicoradiological response outcomes.

INTRODUCTION/PURPOSE: This study assessed long-term clinical and radiological outcomes following treatment with combination stereotactic radiosurgery (SRS) and immunotherapy (IT) for melanoma brain metastases (BM). METHODS: A retrospective review was performed in a contemporary cohort of patients with melanoma BM at a single tertiary institution receiving Gamma Knife® SRS for melanoma BM. Multivariate Cox proportional-hazards modelling was performed with a P <0.05 for significance. RESULTS: 101 patients (435 melanoma BM) were treated with SRS between January-2015 and June-2019. 68.3% of patients received IT within 4 weeks of SRS (concurrent) and 31.7% received SRS alone or non-concurrently with IT. Overall, BM local control rate was 87.1% after SRS. Median progression free survival was 8.7 months. Median follow-up was 29.2 months. On multivariate analysis (MVA), patients receiving concurrent SRS-IT maintained a higher chance of achieving a complete (CR) or partial response (PR) [HR 2.6 (95% CI: 1.2-5.5, P = 0.012)] and a reduced likelihood of progression of disease (PD) [HR 0.52 (95% CI: 0.16-0.60), P = 0.048]. Any increase in BM volume on the initial MRI 3 months after SRS predicted a lower likelihood of achieving long-term CR or PR on MVA accounting for concurrent IT, BRAF status and dexamethasone use [HR = 0.048 (95% CI: 0.007-0.345, P = 0.0026)]. Stratified volumetric change demonstrated a sequential relationship with outcomes on Kaplan-Meier analysis. CONCLUSION: Concurrent SRS-IT has favourable clinical and radiological outcomes with respect to CR, PR and a reduced likelihood of PD. Changes in BM volume on the initial MRI 3 months after SRS were predictive of long-term outcomes for treatment response.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

INTRODUCTION: Advancements in technology and processes are designed to bring improvement. However, this is often achieved in parallel with increases in complexity, simultaneously presenting opportunities for new types of errors. This study aims to contextualise the impact of internal departmental changes upon radiation incidents and near misses recorded. METHODS: A timeline of events and a comprehensive incident categorisation system were applied to all radiation incidents and near misses recorded at the Princess Alexandra Hospital Radiation Oncology department from 2003 to 2019, inclusive. Descriptive statistics were performed to identify the type and number of incidents reported during the time period in relation to potential changes within the department, with a focus on the implementation of an electronic environment. RESULTS: Over the seventeen-year period, 157 incidents and 76 near misses were reported. The majority of incidents were classified as 'procedural' (78%), with 'treatment' being both the highest point of error and point of detection (49% and 85%, respectively). The largest number of incidents and near misses were reported in 2018 (n = 39) which was also a year that experienced the largest number of departmental changes (n = 16), including the move to a completely electronic planning process. CONCLUSIONS: Changes within the department were followed by an increasing number of reported incidents. Proactive measures should be undertaken prior to the implementation of major changes within the department to aid in the minimisation of incident occurrence.