Effects of combined resistance and aerobic training program on myoelectric activity of Vastus Lateralis in patients with breast cancer during adjuvant chemotherapy period.

OBJECTIVE: Chemotherapy and/or radiation are normally the predominant therapies administered to cancer patients. Commonly, patients express complaints of fatigue during adjuvant treatment. Furthermore, regular practice of physical exercise during adjuvant treatment seems to have positive effects. The aim of this study was to investigate the effects of combined muscle strength, and a supervised aerobic training program on myoelectric activity of Vastus Lateralis during isometric test in patients with breast cancer undergoing adjuvant chemotherapy. PATIENTS AND METHODS: Thirty-two women with breast cancer (20 patients in the training group and 12 patients as controls) undergoing adjuvant chemotherapy participated in the study. They took part in a 6-week training period. A muscle-strength program included isometric contraction and electrical muscle stimulation (EMS). Aerobic training program consisted of supervised intermittent cycling exercise and home-based walking exercise. The outcome measures were Root Mean Square (RMS), Mean Power Frequency (MPF), Maximal Voluntary isometric Contraction (MViC), and Endurance Time (ET) of Vastus Lateralis, before and after the training period in the two groups. RESULTS: Compared to controls, a significant increase in MViC (p=0.001) and ET (p=0.005) in quadriceps accompanied by a significant decrease in RMS (p=0.007) and a significant increase in MPF (p=0.002) has been obtained in the training group. CONCLUSIONS: Supervised muscle strength and supervised aerobic training programs enhanced muscle activity and muscular performance in women with breast cancer during adjuvant chemotherapy treatment and optimized the decrease of muscular fatigue.

Neoadjuvant endocrine therapy with or without palbociclib in low-risk patients: a phase III randomized double-blind SAFIA trial.

BACKGROUND: The most prevalent subtype of breast cancer (BC) is luminal hormonal-positive breast cancer. The neoadjuvant chemotherapy regimens have side effects, emphasizing the need to identify new startegies. OBJECTIVE: Analyze the complete pathologic response (pCR) rate and overall response in a low-risk hormone-positive subset of patients receiving neoadjuvant hormone treatment (NAHT) with or without Palbociclib (a CDK4/CDK6 inhibitor) to boost NAHT effectiveness. MATERIALS AND METHODS: Based on the upfront 21-gene Oncotype DX or low-risk Breast Recurrence Score assay (RS™), the SAFIA trial is designed as a prospective multicenter international, double-blind neoadjuvant phase-III trial that selects operable with luminal BC patients that are HER2-negative for the induction hormonal therapy with Fulvestrant 500 mg ± Goserelin (F/G) followed by randomization of responding patients to palbociclib versus placebo. The pCR rate served as the study's main outcome, while the secondary endpoint was a clinical benefit. RESULTS: Of the 354 patients enrolled, 253 initially responded and were randomized to either F/G fulvestrant with palbociclib or placebo. Two hundred twenty-nine were eligible for the evaluation of the pathologic response. No statistically significant changes were observed in the pCR rates for the patients treated with the F/G therapy with placebo or palbociclib (7% versus 2%, respectively) per the Chevallier classification (Class1 + Class2) (p = 0.1464) and 3% versus 10% assessed per Sataloff Classification (TA, NA/NB) (p = 0.3108). Palbociclib did not increase the rate of complete pathological response. CONCLUSION: Neoadjuvant hormonal therapy is feasible in a selected population with a low RS score of < 31 CLINICAL TRIAL: NCT03447132.

Testicular metastasis of colorectal carcinoma: A new observation.

Testicular metastases in colorectal cancer are rare, and pathogenesis still remains unclear. It tends to occur in late stage of disease and has a poor prognosis. We present a 37-year-old patient complained from abdominal pain with deterioration of performance status and weight loss. Body scan showed a recto sigmoid tumor associated with metastasis in the left liver with pelvic lymphadenopathy and hetero nodular testis. Colonoscopy showed a stenosing upper rectum tumor. Histology concluded to an adenocarcinoma. The patient had a transverse colon resection and a right orchiectomy. Histology concluded to an invasive adenocarcinoma with carcinosis, secondary testicular and hepatic metastasis.

Adolescents and young adults with classical Hodgkin lymphoma in northern Tunisia: insights from an adult single-institutional study.

PURPOSE: The aim of this study was to extensively describe the epidemiological, clinical and therapeutic outcomes of adolescents and young adults (AYA) population with classical Hodgkin Lymphoma (cHL). Then, a comparison between AYAs and adults and between the subgroups of AYAs treated with the same adult protocol was accomplished to further inform on optimal therapy approach of choice for adolescent patients. MATERIAL AND METHODS: In this mono-centric, retrospective study, we reviewed the medical records. We analyzed 112 consecutive North Tunisian patients, including 66 AYAs (15 to 39 years) and 46 adults (≥40years) affected by cHL treated from 2000 to 2015 at Salah Azaiez Institute. Then, we performed a comparative analysis between AYA and 46 adult patients and a subgroup analysis between adolescents and young adults. All patients were treated according to the national protocol for HL, edited by the Tunisian Society of Hematology. The treatment included chemotherapy and involved-field radiotherapy (RT) at a dose of 20 or 30 Grays (Gy) for responders and 36Gy for non-responders. RESULTS: AYA patients presented with adverse features with nodular sclerosis subtype (p=3.88×10-02) and mediastinal mass involvement (p=9.40×10-04). At a median follow-up of 51 and 32 months for AYAs and adults, respectively, no statistical difference in terms of 3 and 5-years overall survival (OS) and event-free survival (EFS) was shown. Using the Kaplan-Meier method, in AYAs, the ABVD regimen has an impact on 3-years EFS (p=4.63×10-02). The 36Gy RT was associated with the best 3-years EFS (p=9.24×10-03). Besides, AYA patients with advanced-stage had the worst 3-years OS (76%) (p=2.41×10-02). Although the adolescents and young adults shared similar clinical presentation, we noted that the adolescent group had the worst 3-years EFS (48%), but the best 3-years OS (91%). We identified 15% of primary refractory patients and a rate of toxicity of 5.3% in AYA. CONCLUSION: The treatment approach used is well tolerated by adult patients. However, the AYA patients and particularly adolescent subgroup had more advanced disease at diagnosis and should be treated more intensively in dedicated units. RT dose<36Gy and ABVD chemotherapy were associated with lower EFS in this population.

Inflammatory breast cancer in Tunisia in the era of multimodality therapy.

BACKGROUND: This study aimed to identify prognostic factors for outcome in Tunisian patients with nonmetastatic inflammatory breast cancer (IBC) receiving multimodality therapy. PATIENTS AND METHODS: From 1994 to 2000, 100 patients with nonmetastatic IBC were reviewed. Patients underwent neo-adjuvant chemotherapy including anthracyclines (99%), then mastectomy (93%) when feasible, radiotherapy (83%) and adjuvant chemotherapy (84%). Sixty patients (60%) had hormone therapy. RESULTS: Median age at diagnosis was 44 years (range 23-71). Seventy patients had premenopausal status (70%). Ten cases occurred during pregnancy (10%). Body mass index indicated overweight or obesity in 76 patients (76%). After neo-adjuvant chemotherapy, pathologic complete response (pCR) rate was 20%. Median time of follow-up for surviving patients was 44 months. Median progression-free survival (PFS) was 19 months and overall survival (OS) 30 months. Factors associated with improved survival were no pregnancy (P = 0.0095), estrogen receptor positivity (P = 0.028), tumor size <5 cm (P = 0.021), clinical complete response (cCR) (P = 0.022), pCR (P = 0.011), negative nodes (P = 0.053) and hormone therapy (P < 0.001). In multivariate analysis, cCR, negative nodes and hormone therapy were independently associated with better OS and PFS. Factors predictive to pCR were age >45 years, negative nodes and cCR. CONCLUSIONS: Tunisian patients with IBC have particular epidemiologic characteristics, with earlier disease and context of overweight and obesity, but prognostic factors are similar to those reported in the literature. Hormone therapy seems to improve patient outcome.

[Recurrence of a glassy cell carcinoma of the vagina: An exceptional situation]. / Récidive d'un glassy cell carcinoma du vagin : une situation exceptionnelle.

Glassy cell carcinoma is a rare neoplasm that occurs most frequently in the uterine cervix. We describe the second reported case of glassy cell carcinoma arising in the vagina. We present a case of a 24-year-old woman with a history of post-coïtal bleeding associated with menometrorrhagia. Different explorations have concluded in a glassy cell carcinoma arising in the vagina, with clinical staging III according to the International Federation of Obstetrics and Gynecology. The patient received three cycles of neoadjuvant chemotherapy with a good response. Then she had a para-aortic lymphadenectomy and ovarian transposition. Following the surgery, she had radiotherapy. The gynecological examination showed no budding lesion and the biopsy was negative. Six months later, the patient complained of a pelvic pain. The examination revealed a locoregional recurrence. Surgical revision was not possible and the patient was a candidate for a palliative chemotherapy. Although, glassy cell carcinoma runs an aggressive clinical course, an early diagnosis may help in a more effective management and offer a better prognosis.

Two years survival of primary cardiac leiomyosarcoma managed by surgical and adjuvant therapy.

BACKGROUND: Cardiac tumors are a very rare entity. Leiomyosarcoma represents less than 1% of cases. CASE PRESENTATION: a 51-year-old woman diagnosed with primary left atrium leiomyosarcoma. She was treated by optimal surgery and adjuvant chemotherapy. She is still alive after a follow-up of 24 months without evidence of local or distant recurrence. CONCLUSIONS: Cardiac leiomyosarcoma is a rare tumor with a dismal prognosis. Surgery is the mainstay of treatment. Adjuvant treatment is still controversial.

Round cell sarcoma of the colon with CIC rearrangement.

BACKGROUND: The CIC-rearranged sarcoma is a very rare highly aggressive malignant soft tissue group of tumors. It has recently been described as highly aggressive soft tissue tumors of children and young adults sharing similar morphological features with the Ewing sarcoma. The digestive localization is exceptional. CASE PRESENTATION: A 14-year-old male presented with a history of abdominal pain for 1 year, which increased in intensity over the last 2 months. Imaging findings showed a large heterogeneous mesenteric mass on the left flank of the abdomen. Exploratory laparotomy was performed and revealed a large cystic hypervascularized mass depending on the transverse colon and mesocolon. A wide excision of the lesion was performed with segmental colectomy. No postoperative complications were noted. The microscopic examination revealed a vaguely nodular growth of undifferentiated small round cells, arranged in solid sheets separated by thin fibrous septa with a scarce stroma. After an uncomplicated post-operative course, the patient was referred for chemotherapy. The patient died 2 months later with a peritoneal and pleural progression. CONCLUSIONS: The CIC-rearranged sarcoma is an aggressive tumor. There is no standard therapy for this rare disease. Their treatment includes surgery and chemotherapy. Resistance to chemotherapy is common. Further publications and studies will help to determine a standard therapy for this rare disease.

Alternating radiotherapy and chemotherapy in non-metastatic inflammatory breast cancer.

Ninety-nine patients presenting with non-metastatic inflammatory breast cancer were treated with an alternating protocol of radiotherapy and chemotherapy. The alternating schedule consisted of 8 courses of combined chemotherapy, including doxorubicin, vincristine, cyclophosphamide, methotrexate and 5-Fluorouracil, and 3 series of loco-regional radiotherapy delivering a total dose of 65 to 75 Gy to the breast tumor, 65 Gy to the axilla, and 50 Gy to the supraclavicular and internal mammary chain lymph nodes. Radiotherapy was started after the third course of chemotherapy. A 1-week gap was respected between each course of chemotherapy and each series of radiotherapy. Seventy-five percent of patients were in complete remission at the end of this induction treatment. The 3-year local control was 72% and the 3-year overall survival rate was 70%. An isolated local recurrence was observed in only 4% of patients. Approximately one-half of patients developed distant metastases. These results show that alternating radiotherapy and chemotherapy schedules deserve further investigation in locally advanced breast cancer.

[Primary chemotherapy with the Rosen T10 protocol before conservative surgery in limb primitive osteosarcomas: results about 56 cases]. / Chimiothérapie première par le protocole T10 de Rosen avant chirurgie conservatrice dans les ostéosarcomes primitifs des mebres: résultats à propos de 56 cas.

We report the results of a prospective Tunisian study using primary chemotherapy followed by conservative surgery in primitive limb osteosarcoma. From January 1988 to January 1998, 56 patients affected by limb osteosarcoma entered in a prospective study of neoadjuvant chemotherapy with the T10 protocol before surgery with a conservative intent. Initial work-up include: clinical exam with tumor measurements, chest and limb X-rays, limb CT-scan or MRI, chest CT-scan, bone scintigraphy and hematological and renal biological exams. Patients receive pre- and post-operative chemotherapy according to the T10 modified protocol. Fifty-six patients (33 M/23 F) with a mean age of 19 years (8 to 28) are included. Mean clinical and radiological tumor size is around 14 cm. Main histologic type is classic osteosarcoma (50% of cases) and 10 patients (9%) presented with initial metastasis; 42 patients on 56 receive the whole pre-operative protocol. Treatment is well tolerated excluding 18 episodes of mucositis, 29 of leucopenia (< grade 3), 7 of thrombopenia (< grade 3), 4 of cutaneous toxicity, 2 of pulmonary toxicity and 3 of nausea-vomiting. We observe 36% of good histological responders and 64% of bad responders to primary chemotherapy, 27 patients on 49 operated (53%) have a conservative surgery and 18 (47%) a radical surgery. With a median follow-up of 51 months (8 to 128), 29 patients remain alive free of disease (15/17 GR and 14/30 BR), 2 are alive with disease, 2 died by toxicity, 14 died by progressive disease and 9 are lost to follow-up with evolutive disease. Five year disease-free survival is 55% for the 46 non metastatic patients. In univariate analysis, seric alkaline phosphatase level (p = 0.0014) and histological response to chemotherapy (p = 0.0218) are significant factors for prognosis.

[Dispensation of opioids by pharmacists in Tunisia]. / Dispensation des opioïdes par les pharmaciens en Tunisie.

This national survey aims to evaluate opioid availability and prescription by pharmacists in Tunisia and to examine pharmacists' attitude regarding Tunisian law. We surveyed a sample of 300 pharmacists randomly selected from the National Council of Pharmacists list and using the random table. This study started in September 1999 by sending to pharmacists a confidential questionnaire asking about the importance, the rate of sale and the availability of analgesics in their pharmacy. It also tried to determine pharmacists' opinions regarding Tunisian law. A total of 157 pharmacists out of 300 responded to the survey (52 per cent), 95 per cent were working in pharmacies and 15 per cent in hospitals. Analgesics were estimated to be important to very important in their work in 84 per cent and less important in 16 per cent of cases. They were given under advice with great importance in 85 per cent of cases and with less importance in 15 per cent of cases. Analgesic self-medication was frequent in 95 per cent of cases and rare in 4 per cent of cases. Analgesics of levels 1 and 2 were often to always available in 97 per cent of cases and rarely available in 1.5 per cent of cases. Some 84.7 per cent of pharmacists had opioid supplies and 8.9 per cent had no opioids in stock and 6.4 per cent hadn't given a response. 30 per cent of pharmacists think that the 7 days law for opioid prescription should be modified and 66 per cent think it should not, fearing illicit use, fraud and dependance. Pharmacists think that the minimal list of opioids to be stocked in a pharmacy is sufficient because of low demand.

[Choroid metastases]. / Les métastases choroïdiennes.

PURPOSE: The aim of the present study is to investigate the clinical features and the risk factors characteristic of choroidal metastasis, which is known as the most common malignant neoplasm of the adult eye. METHODS: A systematic ophthalmologic examination together with angiography and echography were performed in 106 patients with carcinoma. RESULTS: 10% of patients showed choroïdal metastasis. Breast and bronchogenic carcinoma were the most common primary tumor. 82% of cases died within a mean 6.5 months. Clinical, angiographic, echographic and histopathologic features of such metastasis were described. CONCLUSIONS: The importance of an early diagnosis of such metastasis are raised.

[Evaluation of implantable sites in medical oncology in Tunisia. Prospective study of 205 cases]. / Evaluation des sites implantables en cancérologie médicale en Tunisie. Etude prospective à propos de 205 cas.

OBJECTIVE: To evaluate the insertion and use of implantable central venous accesses in medical oncology at the Institute Salah Azaïz. METHODS: From January 1992 to June 2000, 205 patients including 179 adults (118F/61M) and 26 children aged 7 months to 72 years (mean 37 years) required the insertion of an implantable port (IP). Tumoral pathology was dominated by metastatic breast carcinoma (93/179), digestive cancer (42/179) and paediatric cancer (26 cases). RESULTS: Excluding 3 initial failures, we inserted 205 IP for 202 patients. The supraclavicular anatomic way (Yoffa) was used in 156/205 cases and the subclavicular (Aubaniac) for the resting 32 cases with a jugular conversion in 17 cases. Initial complications were represented by 6 arterial puncture (2.9%), 3 pneumothorax (1.5%) and 1 catheter migration in the right pulmonary artery. Median life duration of the material was 210 days (3 to 1460 days) for adults and 185 days (3 to 1460 ays) for children. Mean life duration for the 205 IP was 240 days +/- 239 (3 to 1460 days) with a total of 49,200 IP-days. We explanted 17 IP for infection (8 cases), cutaneous ulceration (8 cases) and actinomycin extravasation (1 case). We observed 6 cases (2.9%) of subclavian and jugular thrombosis treated by anticoagulants and conservation management of the port. Presently, 58 patients are alive with IP in place. CONCLUSION: Implantable ports represent a useful option in medical oncology for patients treated with prolonged chemotherapy and adjuvant treatments such as antibiotics, transfusion. This method allows a good comfort for the patients and also the treating team but requires a prealable training for the nursing team.

[Pediatric Hodgkin disease in North Tunisia: clinical and therapeutic study]. / La maladie de Hodgkin de l'enfant dans le Nord Tunisien : étude clinique et thérapeutique.

PURPOSE: To assess the epidemiological, clinical and therapeutic aspects of pediatric Hodgkin disease (HD) and to study prognosis factors. PATIENTS AND METHODS: We retrospectively reviewed the medical records of children (≤18 years) with HD treated between 1st January 1994 and 31st December 2004. Chemotherapy was undertaken in different departments of hematology and oncology in the North of the country and radiotherapy was centralized at the Salah-Azaïz National Cancer Institute. RESULTS: One hundred fourteen consecutively treated patients were collected. Median age was 12 years (4-18 years) and sex-ratio was 2.25. Peripheral lymphadenopathy was the predominant circumstance of HD detection (82.5%). The predominant histologic type was nodular sclerosing (56%). Treatment included chemotherapy and involved-field radiotherapy. With a mean follow-up of 23.5 months, relapse rate was 12.2%. Five-year overall survival (OS) and event-free survival (EFS) rates were 95% and 76%, respectively. Five-year OS was 98.2% and 90.8% for early and advanced stages respectively. In multivariate analysis, stage IV (P=0.029) and early response to initial treatment (P=0.003) retained statistical significance for EFS whereas the only prognostic factor for OS was stage IV (P=0.002). The long-term side effects were rare. No secondary tumor was noted. CONCLUSION: Combined-modality therapy using chemotherapy and involved-field radiotherapy was effective and well-tolerated in early stage pediatric HD. Stage IV patients should be referred to specialized units for intensive treatment. The short median follow-up in our study cannot allow considering long-term effects.

[Primary gastric MALT lymphoma in children. Report of 2 cases]. / Lymphome primitif gastrique de type malt de l'enfant. A propos de 2 cas.

Primary gastric MALT non-Hodgkin's lymphoma is rare in immunocompetent children. To our knowledge, only two cases have been previously described. We report two cases of gastric MALT lymphoma associated with Helicobacter pylori. Clinico-pathological features are similar to those observed in adults. The relationship between the microbial infection and non-Hodgkin's lymphoma development is discussed.