Assessment of an onco-sexology support and follow-up program in cervical or vaginal cancer patients undergoing brachytherapy.

PURPOSE: Women's sexual health and wellbeing with cervical or vaginal cancer may be largely affected by complications from external beam radiotherapy (EBRT) and utero-vaginal brachytherapy (BT), of which vaginal stenosis is the main complication. The objective of this study was to assess the impact of support by a nurse sexologist on sexuality, vaginal side-effects, and the quality of clinical follow-up in patients treated with brachytherapy for cervical or vaginal cancer. METHODS: We performed a retrospective study of the sexuality of women treated for cervical or vaginal cancer. Data from patients with cervical or vaginal cancer who underwent brachytherapy between 2013 and 2017 were collected at Institut Universitaire de Cancer de Toulouse-Oncopôle (IUCT-Oncopôle). Patients were divided into two groups: group A (intervention group) received support from a nurse sexologist and group B (control group) did not. The chi-square test and a logistic multivariate model were used for data analysis. RESULTS: A total of 156 patients were included in this study, including 57.7% who were followed by a nurse sexologist. We observed low compliance in using vaginal dilators after brachytherapy and/or radiotherapy over time regardless of the group, and patients' sexual activity was inadequately addressed. Information regarding the resumption of sexuality 2 months after treatment was missing in 1.1% of patients in group A and in 36.4% of patients in group B. Multivariate analysis showed that patients in group A had a lower risk of developing vaginal stenosis with OR crude = 0.5 (95% CI = 0.25-0.92) and OR adj. = 0.5 (95% CI = 0.26-1.09) compared with those in group B. CONCLUSION: This retrospective study highlights the lack of information collected by physicians during follow-up concerning the sexuality of patients with cervical or vaginal cancer treated by EBRT and BT. The support offered by nurse sexologists in improving patients' sexual activity and reducing their physical side-effects such as vaginal stenosis is likely to be beneficial. A prospective study is currently being conducted to validate the present findings.

Sexual Quality of Life and Needs for Sexology Care of Cancer Patients Admitted for Radiotherapy: A 3-Month Cross-Sectional Study in a Regional Comprehensive Reference Cancer Center.

BACKGROUND: Providing early and better care in onco-sexuality and a better understanding of the sexual health care needs of patients before they start treatment is required. OBJECTIVE: To assess sexual quality of life and need for sexology care of patients when they are starting radiotherapy. DESIGN: We performed a cross-sectional study of adult patients with cancer admitted for radiotherapy treatment in a regional comprehensive cancer center. METHODS: We selected all consecutive adult patients scheduled to start radiotherapy within a 3-month period and excluded patients who could not complete the questionnaires. Patients were asked to complete the Sexual Quality of Life Questionnaire (SQoL) and a needs-assessment questionnaire. OUTCOMES: Total score on the SQoL and willingness (yes or no) to get help for a sexual problem. RESULTS: The study sample was composed of 77 men and 123 women. The average SQoL scores were 68.4 ± 20.9 and 47.1 ± 13.0 for men and women, respectively (P < .001). Of sexually active patients, 58% had decreased frequency of intercourse or had completely stopped sexual activity after their cancer diagnosis. Half the participants wanted care for their sexual concerns. The proportion desiring specific types of care varied from 28.5% (couple counseling) to 54.5% (sexual physician) with variation by sex or type of cancer. Furthermore, 11.5% of participants declared their willingness to join support groups. CLINICAL IMPLICATIONS: Early interventions before radiotherapy could improve sexual quality of life, particularly in women. STRENGTHS AND LIMITATIONS: Strengths are the SQoL validated in men and women, the original window for assessment, and the study location. Limitations are the monocentric design, the potential recall bias for data before cancer diagnosis, and the fact that some patients had treatments before radiotherapy. CONCLUSION: Our data suggest the need to examine the sexual health trajectory in a prospective fashion from diagnosis to survivorship. Almont T, Delannes M, Ducasson A, et al. Sexual Quality of Life and Needs for Sexology Care of Cancer Patients Admitted for Radiotherapy: A 3-Month Cross-Sectional Study in a Regional Comprehensive Reference Cancer Center. J Sex Med 2017;14:566-576.

Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series.

Vaginal reconstruction after pelvic exenteration (PE) represents a challenge for the oncologic surgeon. Since the introduction of perforator flaps, using pedicled vertical DIEP (deep inferior epigastric perforator) flap allows to reduce the donor site complication rate. From November 2012 to December 2014, 27 PEs were performed in our institution. 13 patients who underwent PE with vaginal reconstruction and programmed DIEP procedure for gynecologic malignancies were registered. Nine patients underwent PE for recurrent disease and four for primary treatment. Six of the 13 patients have a preoperative fistula. Anterior PE was performed in 10 patients, and total PE in 3 patients. A vertical DIEP flap was performed in 10 patients using one or two medial perforators. The reasons for abortion of vertical DIEP flap procedure were: failure to localizing perforator vessels in two cases, and unavailability of plastic surgeon in one case. A vertical fascia-sparring rectus abdominis myocutaneous flap was then harvested. Median length of surgery was 335min, and 60min for DIEP harvesting and vaginal reconstruction. No flap necrosis occurred. One patient in the VRAM (vertical rectus abdominis myocutaneous) group experienced a late incisional hernia and one patient in the DIEP flap group required revision for vaginal stenosis. In our experience, DIEP flap represents our preferred choice of flap for circumferential vaginal reconstruction after PE. To achieve a high reproducibility, the technically demanding pedicled vertical DIEP flap has to be harvested by a trained surgeon, after strict evaluation of the preoperative imaging with identification and localization of perforator vessels.

Adherence to guidelines in gynecologic cancer surgery.

The purpose of this study is to review the available evidence documenting the prognostic role of adherence to guidelines in gynecologic cancers. A systematic review of the PubMed database using "guideline," "adherence," and "cancer" was carried out on February 25, 2014. Two thousand one hundred twenty-three publications were identified. Only publications addressing the question of adherence to recommendations regarding surgical care and multidisciplinary management of gynecologic cancers were selected. Six studies were identified in endometrial cancer, 4 in ovarian cancer, and none in cervical cancer. Adoption of guidelines is an effective tool for disease control and must consequently be considered as a process measure of quality cancer care. It is urgent to develop reliable and reproducible tools to assess adherence to guidelines based on level 1 evidence in gynecologic cancer then to carry out investigations to document the prognostic impact of compliance with guidelines. The time has come to include adherence to guidelines in quality assurance programs.

Evaluation of the impact of the COVID-19 lockdown on the quality of life of patients monitored for cancer who practice an adapted physical activity: rugby for health.

PURPOSE: The benefits of regular physical exercise on the tolerability of cancer treatments, quality of life and survival rates post-diagnosis have been demonstrated but all supervised physical activities have been interrupted due to the global health crisis and the need for lockdown to halt the spread of SARS-CoV-2. To reintroduce activities post-lockdown, we wanted to assess the impact of the COVID-19 lockdown on the quality of life and the psychological status of patients who practice an adapted physical activity such as rugby for health. METHODS: The evaluation was conducted in two phases: an initial self-questionnaire comprised of 42 questions sent to all participants to assess the impact of lockdown and a second assessment phase in the presence of the participants. We assessed anthropometric data, functional fitness parameters, quality of life and the psychosocial status of the subjects. The data were compared to pre-lockdown data as part of a standardised follow-up procedure for patients enrolled in the programme. RESULTS: 105/120 (87.5%) individuals responded to the rapid post-lockdown survey analysis. In 20% of the cases, the patients reported anxiety, pain, a decline in fitness and a significant impact on the tolerability of cancer treatments. Twenty-seven patients agreed to participate in the individual analysis. Following lockdown, there was a significant decrease in the intensity of physical activity (p = 8.223e-05). No post-lockdown changes were noted in the assessments that focus on the quality of life and the level of psychological distress. Conversely, there was a significant correlation between the total of high energy expended during lockdown and the quality of life (p = 0.03; rho = 0.2248) and the level of psychological distress post-lockdown (p = 0.05; rho = - 0.3772). CONCLUSION: Lockdown and reduced physical activity, particularly leisure activities, did not impact the overall health of the patients. However, there was a significant correlation with the level of physical activity since the higher the level of physical activity, the better the quality of life and the lower the level of psychological distress.

Results of surgery after concurrent chemoradiotherapy in advanced cervical cancer: comparison of extended hysterectomy and extrafascial hysterectomy.

OBJECTIVES: The primary objective of this study was to compare disease-free survival (DFS) and overall survival (OS) of patients with and without completion surgery. The secondary objective was to compare DFS and OS of patients who had had systematic simple extrafascial hysterectomy or extended hysterectomy. The other objectives were to compare early and late complications with and without completion surgery and between the various surgical techniques. METHODS: One hundred seventy-one patients with advanced cervical cancer were included in a retrospective, multicenter series. RESULTS: The rate of pelvic control was 81.29% in our study after chemoradiotherapy, but histological residual cervical tumor persisted in nearly half of cases (49.71%). After a mean follow-up of 33 months, OS and DFS were not significantly higher in surgically treated patients, nor was the complication rate higher. Overall survival and DFS were not better after radical hysterectomy than after extrafascial hysterectomy. Statistically significant predictors of survival were clinical stage, tumor size, node extension, and residual tumor after chemoradiotherapy. CONCLUSION: There is no consensus regarding the maximal residual tumor volume after chemoradiotherapy suitable for surgery as there is no reliable imaging yet. Therefore, extrafascial hysterectomy with bilateral pelvic lymphadenectomy seems as a reasonable option if there are histological factors suggesting poor prognosis.

A comparative study of laparoscopic extraperitoneal lymphadenectomy [correction of laparoscopy] with the use of ultrasonically activated shears.

OBJECTIVE: We evaluated the use of the harmonic scalpel in reducing the occurrence of symptomatic lymphoceles and its related complications in paraaortic laparoscopic lymphadenectomies (PALLs). STUDY DESIGN: All PALL that were performed at the Institut Claudius Regaud between January 2003 and June 2007 were included. Since January 2006, the harmonic scalpel has been used systematically for all lymphostasis. Lymphoceles that required treatment were recorded as a complication. RESULTS: Ninety-eight patients were enrolled, 62 PALLs were performed with the standard technique (control group), and 36 PALLs were performed with the harmonic scalpel (study group). There were no differences regarding operating time, blood loss, median nodal yield, and duration of hospital stay. Seven patients of the control group vs none of the study group (P = .03) experienced a symptomatic lymphocele that required medical treatment; 4 patients had radiologic drainage, and 1 patient had surgical drainage. CONCLUSION: We demonstrate the efficacy of harmonic scalpel in reducing the occurrence of symptomatic lymphoceles in paraaortic extraperitoneal lymphadenectomy.

Pelvic lymph node dissection via a lateral extraperitoneal approach: description of a technique.

OBJECTIVE: Locally advanced cervical cancers are generally managed by radiation and chemotherapy. Pretherapeutic laparoscopic assessment of aortic nodes in patients with locally advanced cervical cancer offers valuable information for individualized treatment planning with minimal morbidity when the extraperitoneal approach is used. Although the pioneers of the technique proposed to sample only the aortic and common iliac nodes, there is growing evidence that concomitant radiation and chemotherapy does not control all the diseased pelvic nodes. As a result, diseased but not fixed pelvic nodes amenable to an attempt at laparoscopic removal should be debulked during the staging surgery. The objective of this paper is to describe a new development of the extraperitoneal endosurgical approach. METHODS: The left extraperitoneal approach routinely used for aortic and common iliac dissection has been extended to the pelvic area in eight patients. RESULTS: The left pelvic dissection, including the removal of obturator nodes, has been successfully completed in all cases, including two patients with macroscopically diseased nodes. The right pelvic dissection has been successful in three out of four attempts. CONCLUSION: The lateral extraperitoneal route used for the routine staging in our institution can be extended to the pelvic area without additional transumbilical transperitoneal laparoscopy, thus reducing the adhesion formation in patients candidates for definitive radiation therapy.

Experimental study of pelvic perioperative brachytherapy with iodine 125 seeds (I-125) in an animal model.

PURPOSE: The aim of this study is to investigate the feasibility of perioperative I-125 low-dose-rate brachytherapy mesh implantation in pelvic locations in an animal model, before applying it clinically. MATERIAL AND METHODS: The animal model was the Romanov adult ewe. Non-radioactive dummy I-125 seeds were implanted by laparotomy in the pelvic area. Forty-five dummy seeds were placed on a 10 cm² polyglactin mesh to obtain a dose of 160 Gy at 5 mm from the center of each seed. Three CT scans were performed at day 15, day 70, and day 180 after surgery to check the positioning of the mesh for eventual seed migration according to bony landmarks and to perform a 3D theoretical dosimetric study. The experimental study design was based on Simon's minimax plan with a preliminary analysis of 10 ewes to validate the protocol and a second series of 7 ewes. RESULTS: After the first step, 9 of 10 ewes were investigated. For 8 of 9 animals, the 160 Gy isodose line volume was within 10%, showing feasibility of the procedure and allowing 7 more to be added. At the end of the study, 16 of 17 animals were examined. No seeds loss was observed. The volume difference of the 160 Gy isodose line was within 10% in 13 of 16 ewes between the three CT scans. Twelve out of 16 had a coordinate deviation less than or equal to 10 mm on the three axes between the first and the third scans. CONCLUSIONS: These results show the technical feasibility of the pelvic mesh implantation in ewes. A phase I study for patients with locally advanced or recurrent pelvic tumors amenable to surgery, in combination with surgical resection should be possible.

Phase I trial of tipifarnib (R115777) concurrent with radiotherapy in patients with glioblastoma multiforme.

PURPOSE: To conduct a Phase I trial to determine the maximally tolerated dose (MTD) of tipifarnib in combination with conventional three-dimensional conformal radiotherapy (RT) for patients with glioblastoma multiforme. METHODS AND MATERIALS: After resection or biopsy, tipifarnib was given 1 week before and then continuously during RT (60 Gy), followed by adjuvant administration until progression. The tipifarnib dose during RT was escalated in cohorts of 3 starting at 200 mg/day. RESULTS: Thirteen patients were enrolled, and 12 were evaluable for MTD. Of these patients, 7 had undergone biopsy, 4 had partial resection, and 1 had gross total resection. No dose-limiting toxicity (DLT) was observed during the concomitant treatment at 200 mg. All 3 patients at 300 mg experienced DLT during the concomitant treatment: 1 with sudden death and 2 with acute pneumonitis. The MTD was reached at 300 mg. The adjuvant treatment was suppressed from the protocol after a case of pneumonitis during this treatment. Six additional patients were included at 200 mg/day of the new protocol, confirming the safety of this treatment. Of the 9 evaluable patients, 1 had partial response, 4 had stable disease, and 3 had rapid progression; the patient with gross total resection was relapse-free after 21 months. Median survival of the evaluable patients was 12 months (range, 5.2-21 months). CONCLUSION: Tipifarnib (200 mg/day) concurrent with standard radiotherapy is well tolerated in patients with glioblastoma. Preliminary efficacy results are encouraging.

Brachytherapy versus prostatectomy in localized prostate cancer: results of a French multicenter prospective medico-economic study.

PURPOSE: To prospectively compare health-related quality of life (HRQOL), patient-reported treatment-related symptoms, and costs of iodine-125 permanent implant interstitial brachytherapy (IB) with those of radical prostatectomy (RP) during the first 2 years after these treatments for localized prostate cancer. METHODS AND MATERIALS: A total of 435 men with localized low-risk prostate cancer, from 11 French hospitals, treated with IB (308) or RP (127), were offered to complete the European Organization for Research and Treatment of Cancer core Quality of Life Questionnaire QLQ-C30 version 3 (EORTC QLQ-C30) and the prostate cancer specific EORTC QLQ-PR25 module before and at the end of treatment, 2, 6, 12, 18, and 24 months after treatment. Repeated measures analysis of variance and analysis of covariance were conducted on HRQOL changes. Comparative cost analysis covered initial treatment, hospital follow-up, outpatient and production loss costs. RESULTS: Just after treatment, the decrease of global HRQOL was less pronounced in the IB than in the RP group, with a 13.5 points difference (p < 0.0001). A difference slightly in favor of RP was observed 6 months after treatment (-7.5 points, p = 0.0164) and was maintained at 24 months (-8.2 points, p = 0.0379). Impotence and urinary incontinence were more pronounced after RP, whereas urinary frequency, urgency, and urination pain were more frequent after IB. Mean societal costs did not differ between IB (8,019 euros at T24) and RP (8,715 euros at T24, p = 0.0843) regardless of the period. CONCLUSIONS: This study suggests a similar cost profile in France for IB and RP but with different HRQOL and side effect profiles. Those findings may be used to tailor localized prostate cancer treatments to suit individual patients' needs.

Concurrent radiotherapy for patients with metastatic melanoma and receiving anti-programmed-death 1 therapy: a safe and effective combination.

A combination of immune-checkpoint inhibitors and radiation therapy (RT) represents a promising therapeutic strategy in part mediated by the abscopal effect, but clinical experience related to this combination remains scarce. Clinical data and patterns of treatment were retrospectively collected from all consecutive patients with metastatic melanoma and receiving programmed-death 1 (PD-1) immune-checkpoint inhibitors. Survival data, best overall response, and acute and delayed toxicities (graded according to Common Terminology Criteria for Adverse Events, v 4.3) were compared between patients receiving concurrent RT (IR) or no irradiation (NIR). Fifty-nine patients received anti-PD-1 immunotherapy [pembrolizumab (n=28) or nivolumab (n=31)] between August 2014 and December 2015 at our institution. Among these, 29% (n=17) received palliative RT for a total of 21 sites, with a mean dose of 30 Gy delivered in 10 fractions. Acute and late toxicity profiles were similar in the two groups. After a 10-month median follow-up, the objective response rate (complete or partial response) was significantly higher in the IR group versus the NIR group (64.7 vs. 33.3%, P=0.02) and one complete responder after RT was compatible with an abscopal effect. The 6-month disease-free survival and overall survival rates for the NIR group versus the IR group were 49.7 versus 64.7% (P=0.32) and 58.8 versus 76.4% (P=0.42), respectively. We report here that the combination of RT and anti-PD-1 immunotherapy is well tolerated and leads to a significant higher tumor response rate within and outside the irradiated field, which is emphasized by the first reported case of an abscopal effect in solid tumors.

Low-dose intraoperative brachytherapy in soft tissue sarcomas involving neurovascular structure.

BACKGROUND AND PURPOSE: To evaluate intraoperative brachytherapy in the management of soft tissue sarcomas involving neurovascular structures, its impact on local control and complications. PATIENTS AND METHODS: Between 01/1989 and 12/2002, 98 patients received an intraoperative implant in conjunction with conservative surgery. Brachytherapy was part of the initial treatment (79 cases) or performed in recurrent disease (19 cases). We studied primary sarcomas involving neurovascular structures treated with conservative surgery and intraoperative brachytherapy (n = 6) or intraoperative brachytherapy and external irradiation (n = 73). Conservative surgery was performed as first treatment (51 cases), after chemotherapy (21 cases) and after primary external radiation (seven cases). Brachytherapy was performed according to Paris system rules. Patients were loaded with Iridium 192 (64 cases) or connected to a Microselectron PDR (15 cases). Mean dose given by brachytherapy was 20 Gy. Mean dose given of external radiotherapy was 46 Gy. RESULTS: With a median follow-up of 58 months, 5-year actuarial survival was 69% and local free disease at 5 years was 90%. Acute side-effects occurred in 22/79 requiring surgical repair in 10 patients. Late side-effects occurred in 35/79. No patient required amputation for complications. Prognostic factors were studied for the occurrence of acute and late side-effects and local control. CONCLUSIONS: Intraoperative brachytherapy is efficient with excellent local control rates in soft tissue sarcomas presenting with neurovascular involvement and offers an acceptable conservative option.

Management of soft tissue sarcomas (STS) in first isolated local recurrence: a retrospective study of 83 cases.

PURPOSE: To analyze the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcomas (trunk or extremities) and to identify prognosis factors. METHODS AND MATERIAL: Between 1980 and 1999, 83 adult patients were included in the study. Mean age was 61 years. Mean tumor size was 6 cm. Most sarcomas were located in extremities (n=74), were deep (n=60), and proximal (n=53); 30 involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (29 cases), marginal resection (43 cases), 5 patients requiring amputation. Final results were R0 (n=33), R1 (n=47) or R2 (n=3) resection. Besides surgery, 6 patients received neo-adjuvant and 7 others adjuvant chemotherapy. Twenty three patients received post-operative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial 192Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated. RESULTS: Mean follow up was 13 years. Thirty-seven (45%) patients relapsed, 62% of whom presenting an isolated local recurrence. Nineteen patients developed distant metastases. Multivariate analysis showed only tumor depth (P=0.05) and re-resection for primary R1 resection (P=0.018) being independent prognosis factors for tumor control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P=0.05). Overall survival rate was 73%, 54%, and 47% at, respectively, 3.5 and 10 years, and was 65%, 35% and 32% after a further local recurrence. Multivariate analysis showed trunk (P=0.0001) or inferior extremity locations (P=0.023), symptomatic (P=0.001), high grade (P=0.01), deep (P=0.01) tumors, and the occurrence of a further local failure (P=0.004) as unfavorable characteristics for overall survival. CONCLUSIONS: A first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, BCT being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumors, at best performed in centers that have expertise in this field.

Evaluation of sexual functions and sexual behaviors after penile brachytherapy in men treated for penile carcinoma.

PURPOSE: To assess sexual functions and behaviors of men treated by penile brachytherapy for a cancer of the penis. MATERIALS AND METHODS: Thirty eight men (19 patients treated by penile brachytherapy for a cancer of the penis and 19 age paired-matched controls) participated in a survey about sexuality. The mean age of patients and controls were 73.2 +/- 11.7 and 70.0 +/- 10.5 years, respectively (NS). Controls were men without penile pathology, without history of cancer and no evidence of cognitive impairment. All agreed to participate in the survey about sexuality using 2 questionnaires : the IIEF questionnaire, which explores 4 domains of sexual functions, namely erection, satisfaction, orgasm and desire, and a questionnaire created using the BASIC IDEA grid, which addresses nine domains: behavior, affect, sensation, self-image, cognition, interpersonal, drugs, expectation and attitude. RESULTS: Patients had better scores than controls in 3 domains of the IIEF: erection, desire and satisfaction. These results contrasted with the frequency of intercourse and the quality of erection (evaluated through the BASIC IDEA questionnaire) that were not significantly different between the two populations. Patients also had significantly higher frequency of masturbation (p <0.001) lower worry about sexual performance and higher expected satisfaction for future life (p: 0.021) than controls. CONCLUSION: Penile brachytherapy is a treatment of cancer of the penis that seems to have a moderated impact on sexual functions since most of sexual scores are not inferior in these patients than in age pair-matched controls.

OBJECTIFS: Évaluer les fonctions et comportements sexuels des hommes traités par curiethérapie pénienne pour un cancer du pénis. MATERIELS ET MÉTHODES: Trente huit hommes (19 patients traités par curiethérapie pénienne pour un cancer du pénis et de 19 témoins appariés sur l'âge) ont participé à une enquête sur la sexualité par questionnaire. L'âge moyen des patients et des témoins était de 73.2 +/- 11.7 ans et 70.0 +/- 10.5 ans, respectivement. Les témoins étaient des hommes sans pathologie pénienne, sans antécédent de cancer et aucune preuve de troubles cognitifs. Tous les patients ont accepté de participer à l'enquête sur la sexualité qui utilisait 2 questionnaires: le questionnaire IIEF, qui explore 4 domaines de fonctions sexuelles, à savoir érection, satisfaction, orgasme et désir, et un questionnaire créé en utilisant la grille BASIC IDEA, qui aborde 9 domaines: comportement, affect, sensation, image de soi, connaissances, rapports interpersonnels, médicaments, espérance et attitude. RÉSULTATS: les patients ont eu de meilleurs scores que les témoins dans 3 domaines de l'IIEF: érection, désir et satisfaction. Ces résultats contrastaient avec la fréquence des rapports et la qualité de l'érection (évaluée par le questionnaire BASIC IDEA) qui n'étaient pas différents entre les patients et les témoins. Les patients avaient également une fréquence significativement plus élevée de la masturbation (p <0.001) et de l'inquiétude des capacités sexuelles (p: 0.021) que les témoins, ce qui pourrait refléter un effet bénéfique de la masturbation dans cette population. CONCLUSION: La curiethérapie pénienne est un traitement du cancer du pénis qui semble avoir un impact modéré sur les fonctions sexuelles, puisque la plupart de scores sexuels chez les patients ne sont pas inférieurs à ceux des témoins appariés sur l'âge.

Determining the length of posttherapeutic follow-up for cancer patients using competing risks modeling.

BACKGROUND/OBJECTIVE: After a curative treatment for cancer, patients enter into a posttherapeutic surveillance phase. This phase aims to detect relapses as soon as possible to improve the outcome. Mould and others predicted with a simple formula, using a parametric mixture cure model, how long early-stage breast cancer patients should be followed after treatment. However, patients in posttherapeutic surveillance phase are at risk of different events types with different responses according to their prognostic factors and different probabilities to be cured. This paper presents an adaptation of the method proposed by Mould and others, taking into account competing risks. Our loss function estimates, when follow-up is stopped at a given time, the proportion of patients who will fail after this time and who could have been treated successfully. METHOD: We use the direct approach for cumulative incidence modeling in the presence of competing risks with an improper Gompertz probability distribution as proposed by Jeong and Fine. Prognostic factors can be taken into account, leading to a proportional hazards model. In a second step, the estimates of the Gompertz model are combined with the probability for a patient to be treated successfully in case of relapse for each event type. The method is applied to 2 examples, a numeric fictive example and a real data set on soft tissue sarcoma. RESULTS: and CONCLUSION: The model presented is a good tool for decision making to determine the total length of posttherapeutic surveillance. It can be applied to all cancers regardless of the localizations.

Brachytherapy for penile cancer: efficacy and impact on sexual function.

PURPOSE: Penis brachytherapy (PB) remains an alternative in the cancer treatment. The objective of this study was to assess the oncologic outcomes, sexual function, and the sexual behavior of men treated by PB for a cancer of the penis. METHODS AND MATERIALS: Between 1992 and 2009, 47 patients with a cancer of the penis were treated by PB ((192)Ir), in the Toulouse, Montpellier, and Barcelona cancer centers. The investigation into their sexuality was obtained by means of questionnaire. A total of 21 French patients were approached, of whom 19 (mean age=73.2 years) agreed to answer the questionnaire (participation rate=90.5%). RESULTS: Oncologic data: The specific survival and the disease-free survival at 5 years was 87.6% (95% confidence interval, 72.4-94.7%) and 84% (95% confidence interval, 57.6-94.7%), respectively. The rate of preservation of the penis was 66% (n=31). Sexual data: Among the 17 patients sexually active before brachytherapy, 10 patients remained sexually active after treatment (58.8%). Of the 18 patients who had erections before PB, 17 still had them after treatment (94.4%). Age was the main predictive factor. CONCLUSION: The PB seems to have a moderated impact on the sexual functions and the sexual behavior of the patients.

Impact of dosimetric parameters on local control for patients treated with three-dimensional pulsed dose-rate brachytherapy for cervical cancer.

PURPOSE: To investigate the impact of dose-volume histograms parameters on local control of three-dimensional (3D) image-based pulsed dose-rate brachytherapy (BT). METHODS AND MATERIALS: Within a French multicentric prospective study, the data of the 110 patients treated for cervical cancer with external beam radiotherapy followed by 3D image-based and optimized pulsed dose-rate BT were analyzed. Delineation procedures were performed on magnetic resonance imaging in a minority of cases and on CT for the majority of cases, adapted from the Gynaecological Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology recommendations. Optimization procedure was left to the discretion of the treating center. RESULTS: At 2 years, local control rate reached 78%. Dose to Point A, total reference air kerma, and intermediate-risk clinical target volume (IR-CTV) V60 were predictive factors for local control (p = 0.001, p = 0.001, and p = 0.013, respectively). Patients with IR-CTV V60 <75% had a relative risk of local recurrence of 3.8 (95% confidence interval, 1.4-11.1). There was no correlation found between the high-risk clinical target volume dosimetric parameters and local control. CONCLUSIONS: This multicentric study has shown that 3D image-based BT provides a high local control rate for cervical cancer patients. The V60 for IR-CTV was identified as an important predictive factor for local control.

A large retrospective multicenter study of vaginal melanomas: implications for new management.

The outcome of patients presenting with vaginal melanoma has been assessed in a large multicentric retrospective study. The databases of 12 French institutions were searched for primary vaginal melanomas managed between 1990 and 2007. Among the 54 patients recorded, 46 were managed with a curative intent and included in the study. The clinical characteristics, treatments, and detection of c-KIT protein expression have been studied. The median age of the patients was 63.5 years (42-88). Twenty-eight patients were classified as International Federation of Gynecology and Obstetrics (FIGO) stage I, five as stage II, six as stage III, and one as stage IVA. c-KIT protein was overexpressed in 80% of the patients. Forty-two patients underwent surgical resection of the tumor, nine patients received local adjuvant treatment, and 10 received systemic adjuvant therapy. The median relapse-free survival was 10.9 months. c-KIT-negative status (P=0.01) and stage I (P=0.02) were associated with locoregional recurrence. The rate of metastasis was increased for advanced FIGO stages (P<0.01). The median overall survival (OS) was 28.4 months. The finding of lymph node metastasis adversely affected OS (P<0.01). Conservative surgery and radiotherapy were associated with a decrease in metastasis-free and OS (P<0.01) compared with surgery alone, this group of patients presenting with advanced FIGO stages (P=0.02). Despite the use of limited data, conservative surgery combined with a sentinel lymph node procedure, followed by adjuvant radiotherapy could be proposed to patients with early FIGO stage in the absence of validated management. c-KIT negativity by immunochemistry appears to be a poor prognosis marker in terms of locoregional recurrences but not for metastatic spread nor survival. Further assessment of the role of c-KIT expression in this disease is thus mandatory to select patients for targeted therapy.

Erectile function after permanent 125I prostate brachytherapy for localized prostate cancer.

BACKGROUND AND PURPOSE: To analyze erectile function in men treated by prostate brachytherapy (PB) for localized prostate cancer. MATERIAL AND METHODS: Of a series of 270 sexually active men treated by PB, 241 (89%), mean age 65 yr (range, 43-80 yr), participated in a study on erectile function that was evaluated using the International Index of Erectile Function 5-item (IIEF-5) questionnaire before implantation and by postal survey after a mean follow-up of 36 months (range, 6-70 months). RESULTS: After PB, 27 patients (11%) had no erectile dysfunction (ED), 36 (15%) had mild ED, 58 (24%) had mild to moderate ED, 24 (10%) had moderate ED, 53 (22%) had severe ED and 43 (18%) were not sexually active. In patients with a preimplant IIEF score >12 (cut-off for intercourse with penetration), 73% had a deterioration of erectile function by at least one class after PB. Risk factors for ED after PB were age, preimplant IIEF score and prostate volume. Median time to ED onset was 16 months and was shorter with androgen deprivation (p = 0.007), diabetes (p = 0.03) and age over 55 (p = 0.01). CONCLUSIONS: Following PB, the majority of patients progressively develop or major ED after a free interval that may last several months. SUPPORT: Ligue Nationale contre le Cancer, France.

OBJET: Etude de la fonction érectile chez les hommes traités par curiethérapie pour un cancer localisé de la prostate. MATÉRIELS ET MÉTHODES: A partir de 270 hommes sexuellement actifs, traités par curiethérapie, 241 (89%), moyenne d'âge 65 ans (entre, 43­80 ans), acceptaient de participer à l'étude de la fonction érectile après curiethérapie. Cette étude menée par le questionnaire validé IIEF 5 (International Index of Erectile Function 5-item), évaluait la fonction érectile avant curiethérapie, et en moyenne 36 mois (entre 6-70mois) après la curiethérapie de prostate. L'enquête était faite par envoi postal. RÉSULTATS: Après la curiethérapie, 27 patients (11%) n'avaient pas de dysfonction érectile, 36 (15%) avaient une dysfonction très modérée, 58 (24%) entre très modérée et modérée, 24 (10%) modérée, 53 (22%) avaient une dysfonction érectile sévère et 43 (18%) n'étaient plus sexuellement actifs. Parmi les patients ayant un score IIEF avant curiethérapie >12 (score moyen permettant une pénétration pendant l'acte sexuelle), 73% avait une détérioration de leur fonction érectile d'au moins une classe IIEF. Les facteurs de risque de la dysfonction érectile après curiethérapie étaient: l'âge, le score IIEF avant curiethérapie et le volume de la prostate. La période moyenne pour déclencher une dysfonction érectile après curiethérapie était de 16 mois. Cette période se réduisait lorsque les patients étaient sous hormonothérapie (p = 0.007), avaient du diabète (p = 0.03) et étaient âgés de plus de 55 ans (p = 0.01). CONCLUSIONS: Après curiethérapie, la majorité des patients développaient progressivement une dysfonction érectile plusieurs mois après la curiethérapie. SOUTIEN: Ligue Nationale contre le Cancer, France.