[The role of general practitioners in the management of cancer patients from the central region of Tunisia: a retrospective study of 215 physicians]. / Quelle place pour les praticiens generalists dans la prise en charge des patients cancéreux de la region du centre Tunisien: Etude retrospective à propos de 215 médecins.

BACKGROUND: General practitioners have a major contribution in cancer prevention and screening. However, their contribution in the treatment plan management and in the post treatment follow-up of cancer patients needs to be clarified. OBJECTIVE: To evaluate the contribution of general practitioners of the public and private sectors in the management of cancer patients during and after the treatment protocol. To analyze the problems they encounter and find the possible solutions. METHOD: A retrospective declarative KAP (Knowledge, Attitudes and Practices) survey was conducted from first September 2010 to 28 February 2011 in the central region of Tunisia among 215 primary care physicians in the public and private sectors. The questionnaire focused on their effective involvement, the role during treatment, follow up and supportive care. RESULTS: Nearly 80% of physicians who participated in the survey were involved in the management of their patients, primarily by ensuring adherence to their treatment (42.9%), in the follow up care after treatment (42.3%) and in palliative care (29%), however the majority has never prescribed opioid drugs (66.5%). Only 46.6% of the physicians announced the diagnosis of cancer to their patients. The questioned doctors deplored the lack of training in oncology (22.8%) and the feeling of being excluded from the management of their patients once they have addressed them to their specialist peers (48.8%). The interviewed physicians expressed their wish to have a further medical training in oncology (79.5%) and to join a structured cancer network (55.8%). CONCLUSION: The majority of interviewed general practitioners of our region were engaged in cancer patients' care. However, gaps were identified especially in palliative care and in prescribing opioid drugs. Promoting continuing education in this field and the establishment of cancer networks will allow extend the scope of general practitioners' intervention in the cancer network.

[Li Fraumeni syndrome: a case with multiple primary cancers and presenting a germline p53 mutation]. / Le syndrome de Li Fraumeni: à propos d'un cas familial avec cancers multiples et présentant une mutation germinale du gène p53.

Li Fraumeni Syndrome (LFS) is a rare autosomal disorder characterized by a familial clustering of tumors. Analysis of several series of LFS families have shown that 70% of such families are attributable to germ-line mutations in TP53. We report the case of a patient who had a first degree family antecedent of cancer in young ages. At the age of 31 years, the patient was operated of bladder papillary superficial carcinoma; five years later, he was treated for a high grade pleomorphe sarcoma of the left thigh and treated by surgery, adjuvant chemotherapy and radiotherapy. At the age of 38 years, after abdominal pain, radiologic examination reveled pancreatic tumor with bone and lymphatic metastases. The patient died one month later from pulmonary embolism. Sequencing revealed a germiline mutation of this patient that was confirmed in a member of his family in codon 1009C>T, protein Arg337Cys, exon 10 of TP53 gene this mutation was revealed in his nephew (died at the age of 20 from bone sarcoma).

[Reasons of diagnostic delay of breast cancer in Tunisian women (160 patients in the central region of Tunisia)]. / Causes du Retard diagnostic du cancer du sein chez la femme Tunisienne: série de 160 patientes au centre Tunisien.

BACKGROUND: The diagnosis of breast cancer is, in Tunisia, still done at a late stage. AIM: To identify the principal obstacles against early diagnosis of breast cancer for patients consulting at advanced locally stage or with metastasis. METHODS: We have asked 160 patients with breast cancer showing local T3 or T4 evolution or metastasis at the time of diagnosis, about reasons for the late diagnosis of their breast cancer. RESULTS: The average delay in consultation was 11.6 months and the average size of the tumor was 6.3 cm. The cause of delays in diagnosis was, in 92.5% of cases linked to the patient, and in 24% of case to medical personnel. Two many causes found in patients were: a none-attribution of the symptoms as cancer (35%), and the absence of self-examination of the breasts (23.5%). A comparison of patients according to the cause of delay demonstrated that the distance from a medical centre is more frequent in the case of medical delays, the level of education is lower in patients who fail to carry out self-examination, the more frequent relevant family history of patients who have not attributed the symptoms to cancer, and the relative distance from a medical centre is more pronounced in women in difficult financial circumstances. CONCLUSION: Changing patient behaviour by public health education, besides professional educational programs could help to ovoid diagnosis delay of breast cancer in Tunisia and improve its outcome.

Malignant proliferating trichilemmal tumor of the scalp: a case report.

BACKGROUND: Malignant proliferating trichilemmal tumor is a rare skin tumor that affects mainly older women. It mimicks differential squamous cell carcinoma and its biological behavior is unpredictable. OBJECTIVE: To report on a new case of malignant proliferating trichilemmal tumor of the scalp and to describe the clinical and histopathologic findings. METHODS: A tumor measuring 2 cm was surgically excised with a 0.5 cm conservative margin of normal tissue RESULTS: Based on the histopathologic findings of tumor, this case was diagnosed as proliferating trichilemmal tumor of the scalp. Eleven months after tumor resection, the patient is free of disease. CONCLUSION: Malignant proliferating trichilemmal tumor is a rare malignant lesion with an unpredictable biological behavior. After wide excision, long term clinical follow up of the patient for early diagnosis of metastases is judicious.

[Quality of life in patients with colo-rectal cancers at a Tunisian hospital center. A case control study of a population unhurt by cancer]. / Qualite de vie des patients traites pour cancers colo-rectaux au Centre Tunisien. Etude cas témoin avec une population indemne de cancer.

UNLABELLED: The aim of our study is to value the quality of life (QOL) in patients with colo-rectal cancers in the region of tunisian center and to compare it to the QOL in a healthy population unhurt of cancer. METHODS: Our population is made by 80 patients treated for coloractal cancers. The population witness includes 80 healthy individuals unhurt of cancers. The assessment of the QOL in patients is achieved with the specific colo-rectal cancer questionnaire: the FACT-C. The comparison of the QOL in the 2 populations is made by the general questionnaire of quality of life of Spitzer. RESULTS: The QOL in patients is good in 55% of cases, average in 44% of cases and bad in 11% of cases. The QOL is better in case of favourable socioeconomic conditions (p < 0,05), colic localization (p < 0.015), absence of metastases (p< 0.05), not mutilating surgery (p < 0.01) especially the absence of stoma (p < 0.001) and the restoring of the continuity (p < 0.002), absence of pain (p < 0.0001), absence of current treatment (p < 0.01). The comparison of the different domains of QOL between the 2 groups (patients and healthy) finds a better QOL in healthy group, in all domains except for the relational ship domain witch turned to be comparable for the 2 samples.

[Knowledge, attitude and behavior about the inherited predisposition to cancer. A survery of a population without any history of cancer in central Tunisia]. / Connaissances, attitudes et comportements vis a vis de la predisposition hereditaire aux cancers. Enquete aupres d'une population indemne de cancers dans le centre Tunisien.

The genetic bases of inherited predisposition to cancer are now established. The aim of our study is to value the knowledge, attitude and behavior of the general population about the inherited predisposition to cancer. Our study involved a population of 200 individuals. Without any history of cancer. The mean age of our population was 37.5 years (18 to 74 years). The education level was low in 62.5% of cases (illiterate or primary education). About knowledge: heredity was considered a predisposing factor to cancer by 42.5% of the respondents. About attitude: we noted a cancerophobia in 82% of cases. 86.5% of our respondents trought that an early diagnosis increased the chance of recovery. About behavior: 72.5% of the studied population wishd to know if they were predisposed to develop cancer. In case of pregnancy, 79% wished to know if the foetus wasa cancer gene predisposition carrier. 28% would keep this foetus in case of positive genetic testing. These results are encouraging to develop oncogenetic counselling in Tunisia.

[Adult primary myelodysplastic syndromes. Report of 36 cases]. / Syndromes myelodysplasiques primitifs de l'adulte. A propos de 36 cas.

Between 1989 and 1999, 36 cases with primary myelodysplastic syndromes were diagnosed. They were 15 male and 21 females, the median age was 62 years (range: 22 to 90 years). Eighty one per cent of patients were presented symptoms of anemia. Lymphadenopathy, splenomegaly and skin manifestations were noted in 25% of cases. Hemogram showed anemia, leucopenia and thrombocytopenia respectively in 97%, 44% and 55% of cases. Refractory anemia with excess blasts (AREB) is the most frequent FAB subtypes of MDS (17 cases). Cytogenetic study concerned 24 patients. In 13 cases the karyotype was pathological with deletion 5 q in 64% of cases. Seventeen patients have received a chemotherapy. Survival rate to 36 months is 11%. At the time, the only curative treatment is the bone marrow transplantation, which is proposed to young patients with HLA identical donor.

[Epidemiologic, clinical and therapeutic aspects of chronic lymphoid leukemia: apropos of 120 cases]. / Aspects épidémiologiques, cliniques et thérapeutiques de la leucémie lymphoïde chronique: à propos de 120 cas.

We retrospectively studied 120 cases of chronic lymphocytic leukemia diagnosed between January 1988 and December 1998. The median age of our patients was of 66 years, 75% among them were male. The discovery of the illness was fortuitous in 20% of the cases, the peripheral adenopathy and the splenomegaly were noted respectively in 72 and 48% of the cases. The blood lymphocytosis was on average 51.109/1 with extremes of 5 and 818.109/1. Anemia was noted in 71% of the cases and a thrombopenia in 42%. Fifty patients were classified C stage of BINET and sixty elevated risk according to RAI. The therapeutic attitude was according to patient's age and the CLL stage. Thus, 94 patients received a chemotherapy and a complete or partial response was observed in 58 of the cases. The overall survival at 5 years were 47%. The retained prognostic factors were the stage according to the classifications of BINET and RAI, the thrombopenia and the lymphocytosis blood overhead 100.109/1.

[Diagnosis and treatment of primary germ cell tumors of the mediastinum. Report of six cases]. / Diagnostic et traitement des tumeurs germinales malignes primitives du mediastin. A propos de six cas.

Primary germ cell tumours of the mediastinum are rare. We report a retrospective study of six cases. Sex ratio was 2/1. The tumor site was the posterior mediastinum in two patients and anterior in the remaining cases. High level serum markers was noted in two patients. At histologic exam we found two cases of seminoma, one embryonal carcinoma, one case of yolk sac tumor and two cases of composite tumor. All patients had non metastatic but locally advanced disease at diagnosis. Three patients were treated with cisplatin based chemotherapy followed by radiotherapy or surgical resection of residual masses. Only one patient is still alive. As it is often reported in the literature, the prognosis of this disease is poor especially for non seminomatous tumours.

[Breast cancer in elderly women in Tunisia. Retrospective study of 106 patients older than 65 years]. / Le cancer du sein chez la femme âgée en Tunisie. Etude rétrospective à propos de 106 patientes de plus de 65 ans.

OBJECTIVE: To report the epidemiological profile, anatomo - clinic, prognostic and therapeutic of breast cancers in aged woman from the region of the Center of Tunisia. Our retrospective study concern 106 patients with mammary cancers treated between January 1990 and December 1997 at the Farhat Hached Hospital in Sousse (Tunisia). The mean age was 71 years (extremes 65-91), 66% of the patients had an age more than 75 years, the mean age at the menopause was of 50 years. The size middle clinic was of 50 mm, 45.3 % of tumors was classed T4, 39.6 % T3. 39.6% of patients have a clinical axillary adenopathis. 14.2% of patients have metastases at diagnostics. 62.5% of the cases have a high histo-pronostic grading. The prognostic factor analysis recovered in multivary survey two parameters significatifs for the survival: the size tumoral (p <0.005) and the presence of metastases at the time of the diagnosis (p <0.001). The biologic and evolutionary features of the cancer of the breast in the aged woman bring to consider the hormonal approach like the most logical, especially for the patients bearers of hormonosensibles tumors, of or the interest of the systematic dosage of the hormonal receptors.

[Perianal ulceration revealing Langerhans cell histiocytosis]. / Histiocytose langerhansienne révélée par une ulcération péri anale.

Langerhansian histiocytosis is a rare and heterogenous disease. Skin localisation is common but the lesion usually have typical aspect and topography. Peri anal localisation is rare. We report a case of isolated peri anal ulceration revealing a Langerhansian histiocytosis in a young patient.

Polymorphisms of glutathione-S-transferases M1, T1, P1 and susceptibility to colorectal cancer in a sample of the Tunisian population.

In this study, we investigated the associations of polymorphisms in glutathione-S-transferases (GSTs) genes that are GSTM1, GSTT1, and GSTP1, with sporadic colorectal cancer (CRC). Hundred and fifty patients with CRC and 128 healthy controls were genotyped. DNA was isolated from blood samples. Polymorphisms were assessed by polymerase chain reaction-restriction fragment length polymorphism-based methods and polymerase chain reaction multiplex. Logistic regression analyses showed significant risk for CRC associated with GSTP1 homozygotes for Val-105 (OR 4.82; 95 % CI 1.97-11.80) or for individuals who possessed at least one Val-105 allele (OR 2.54; 95 % CI 1.751-3.703). There were no statistically significant differences in the frequency of GSTM1- and GSTT1-null genotypes (p > 0.05). The GSTM1-null was found in 70.47 % of all cases and 70.07 % of controls (OR 0.61; 95 % CI 0.33-1.12). The GSTT1-null genotype was found in 38.77 % of cases and 49.22 % of controls (OR 1.53; 95 % CI 0.94-2.47). No effect of any genotype for GSTM1 and GSTT1 on CRC was detected. But then an association between the polymorphism of the GSTP1 and the CRC susceptibility was detected.

Impact of menstrual and reproductive factors on breast cancer risk in Tunisia: a case-control study.

This report examined the relationship between menstrual and reproductive factors and breast cancer risk. The case-control study was conducted on 400 women with histological confirmed breast cancer operated during the 2006-2009 period at Farhat Hached University Hospital, Sousse, Tunisia, and 400 cancer-free controls, aged 25-75 years. The menstrual and reproductive history was assessed using a structured questionnaire. Odds ratios (ORs), 95 % confidence intervals (CI) and a full confounding assessment, included in this analysis, were derived using logistic regression. A positive family history of breast cancer was associated with a significantly increased risk of breast cancer (OR = 5.15, 95 % CI 1.48-17.94). Significant risk reduction was found with later age at menarche (P = 0.02). There was an insignificant increase in risk with later age at menopause (≥ 51 years; OR = 1.87), later age at first live birth (≥ 26 years; OR = 1.76) and nulliparous women compared to parous women (OR = 2.35). An insignificant decrease in risk was observed with increasing parity number (≥ 3 delivery; OR = 0.86). A significantly reduced risk of breast cancer was found for those women whose lifetime duration of breastfeeding was 73-108 months and for those who breastfed for ≥ 109 months (P = 0.00). Our findings suggest that age at menarche and breastfeeding history have great effects on breast cancer risk among Tunisian women.

Clinicopathological study of primary gastric lymphomas in the central region of Tunisia, with survival analysis.

BACKGROUND: Primary gastric lymphomas (PGL) are rare and represent only 5% of gastric malignancies, but are apparently increasing in incidence worldwide. Optimal treatment of PGL remains controversial. The aim of this study was to evaluate clinicopathological characteristics, prognostic factors, survival rates, and treatment modalities in Tunisian patients with PGL. METHODS: We retrospectively analyzed data from patients treated for PGL in our hospital over an 18-year period (1994-2011). RESULTS: Data from 128 patients with PGL were retrospectively analyzed. Eighty-four were males and the median age was 57 years (range 5-89 years). The mean BMI was 22.9 (15-39). A total of 40 patients (31.2%) had a poor performance status (PS). The antrum was the most commonly involved site (52 cases, 40.6%). The most frequent pathological subtypes were diffuse large-cell lymphomas (46.4%) and mucosa-associated lymphoid tissues (32%). Disease was localized (stages IE and IIE) in 97 patients (75.8%). Ninety-six patients were evaluable. Chemotherapy alone was used in 73 (76%) patients, with 76.7% achieving complete remission. During chemotherapy, there were no severe complications requiring urgent surgery. Actuarial five-year overall and event-free survival were 60.2 and 54.3% respectively. We found no statistically significant difference in survival between patients treated with surgery and those treated by a conservative strategy. In the multivariate study, age greater than 60 years, poor PS, and BMI less than 20 were significant prognostic factors for overall survival (P=0.04, 0.009, and <0.001, respectively). CONCLUSION: Surgery provides no advantage for survival over conservative treatment. Age, PS, and BMI were effective prognostic factors.

[Study of sexuality among Tunisian women in remission from non-metastatic breast cancer, about 100 women]. / Étude de la sexualité chez les femmes Tunisiennes en rémission complète d'un cancer du sein non métastatique, à propos de 100 femmes.

The prognosis of breast cancer has significantly improved during the last years due to progress of the treatment options. It is a public health problem because of its frequency, severity, physical and psychological consequences. Quality of life appears increasingly as fundamental criteria in the assessment of treatment outcomes. This underlines the specific impact on sexuality. Aim. To evaluate the frequency and type of sexual dysfunction in 100 patients treated for non-metastatic breast cancer in post-treatment monitoring in external consultation of the Department of Oncological Medicine, CHU Farhat Hached, Sousse. Then, to identify predictive factors of these disorders. Procedure. Sexuality and body image were evaluated respectively using two scales: Relationship and Sexuality (RSS) and Body-Esteem Scale for Adolescents and Adults (BESAA). Results. Sexual desire has been affected by the disease and its treatment for 47 women. The capacity to achieve orgasm was reduced in 61 patients. Twenty felt less sexually attractive. Fifty-three women had reported a decrease in the frequency of sexual intercourse. Sixteen patients had reported a fear of sex. Dyspareunia and vaginal dryness were present in 45 women. The analytic study had found that sexual problems are related to the rural origin, the profession of the husband, the premenopausal period, lack of breast reconstruction, the CMF chemotherapy protocol (cyclophosphamide, methotrexate, 5-fluorouracil) and number of cycles of chemotherapy. Body image was significantly altered in patients with sexual dysfunction. In addition, psychosocial factors that best predicted sexual difficulties are the perception by the wife of an emotional distance in the relationship with her partner and fear of sex. Conclusion. The support for these sexual difficulties requires a joint and collaborative approach between oncologists, gynecologists, psychiatrists and sexologists.

Association between body mass index and risk of breast cancer in Tunisian women.

BACKGROUND AND OBJECTIVES: The number of breast cancer in women has increased dramatically in Tunisia. The cause is perceived to stem from adaptation to a westernized life style which increases body mass index (BMI). This study aimed to investigate the association between BMI and breast cancer among Tunisian women. DESIGN AND SETTING: Hospital-based case control study of breast cancer patients seen between November 2006 and April 2009 at the University College Hospital Farhat Hached in Sousse, Tunisia. PATIENTS AND METHODS: Standardized questionnaires concerning BMI and other anthropometric data were completed on 400 breast cancer cases and 400 controls. The controls were frequency-matched to the cases by age. RESULTS: BMI at diagnosis was positively correlated with the risk of breast cancer among postmenopausal women (P<.001 for trend). When compared with women with a low BMI (<19), women with a BMI of 23-27 and 27-31 had a 1.7-fold (95% CI, 1.1-2.9) and 2.1-fold (95% CI, 1.1-3.9) increased risk of breast cancer, respectively, after adjustment for non-anthropometric risk factors. BMI at diagnosis was not related to the risk of breast cancer among premenopausal women. The odds ratios for premenopausal women with a BMI of 23-27 and 27-31 were 1.5 (95% CI, 0.8-2.8) and 1.3 (95% CI, 0.4-4.5), respectively. Furthermore, present BMI was not associated with breast cancer risk in either pre- and postmenopausal women. CONCLUSIONS: Weight control in obese women may be an effective measure of breast cancer prevention in postmenopausal women.

Pure Small Cell Carcinoma of the Bladder: A Case Report.

Small cell carcinoma of the urinary bladder is an uncommon tumor that has been described in case reports or small series. We report a new case in a 67-year-old male who presented with gross hematuria and irritative symptoms. Cystoscopy revealed an extensive mass of the bladder and computed tomography scan showed an important thickening of the bladder wall. Diagnosis of small cell carcinoma was established after radical cystectomy and microscopic examination. The patient received pelvic hemostatic radiotherapy and platinium-based chemotherapy. Three months after the diagnosis, he developed bone, renal and adrenal metastases.