[((18)F)-fluorodeoxyglucose PET/CT in cervix cancer: lymph node assessment and prognostic/predictive value of primary tumour analysis]

PURPOSE

In cervix carcinoma: (a) to evaluate the ability of ((18)F)-fluorodeoxyglucose (FDG) positron emission tomography (PET) in the lymph node detection; (b) to investigate the prognostic and predictive value of the primary cervical PET parameters.

PATIENTS AND METHODS

Ninety patients treated for cervix carcinoma and evaluated initially by MRI and FGD PET were included. The performances of FDG-PET for lymph node detection (relatively to the lymph node dissection) have been described (sensitivity, specificity, positive predictive value and negative predictive value). PET tumour parameters analyzed were: maximum standard uptake value (SUVmax), the volume and the maximum diameter. The prognostic and predictive values of these parameters were investigated. The tumour response was evaluated on surgical specimens.

RESULTS

PET detected the cervical tumour with a sensitivity of 97% (mean values: SUVmax=15.8, volume=27 mm(3), maximum diameter=47). For the detection of the lymph nodes, the values of sensibility, specificity, positive predictive value and negative predictive value were: 86, 56, 69 and 78% in the pelvic, and 90, 67, 50 and 95% for the para-aortic area, respectively. The SUVmax was correlated with histologic response (P=0.04). The frequency of partial histological response was significantly higher for tumour SUVmax>10.9 (P=0.017). The maximum PET diameter and pathologic response had an impact on disease-free survival and overall survival in multivariate analysis (P<0.05).

CONCLUSION

PET has high sensitivity in detecting pelvic and para-aortic lymph nodes. Some primary cervical tumour PET parameters are useful as prognostic and predictive factors.

Chemoradiotherapy for cancer of the esophagus: contribution of the leucovorin, 5-fluorouracil bolus, and infusion-cisplatin-radiotherapy schedule starting with two neoadjuvant chemotherapy cycles: results from a pilot study

To assess feasibility and tolerance of a modification in the usual radiochemotherapy regimen for esophageal cancer by using a leucovorin, 5-fluorouracil bolus, and infusion-cisplatin regimen (six cycles), beginning with two cycles of chemotherapy before conventional radiotherapy (50 Gy), 33 patients, 30 were men, 62.8 +/- 9.5 years, were treated for an esophageal carcinoma (29 squamous cell), 27 of these were in stage III (based on computed tomography scan). Neoadjuvant chemotherapy was well tolerated; concomitant radiochemotherapy was associated with severe adverse events mostly hematological in 23 patients. Complete response was achieved in 70%; median overall survival was 14 months, and 2-year survival was 40 +/- 11%. More than one-third of cycles could be performed as outpatients. This regimen seems safe and efficient, and could be conducted in an outpatient basis.

Reducing radiotherapy delays after surgery for breast cancer in five radiotherapy departments

17011

Background: An interval superior to 8 weeks between surgery and radiotherapy increases the risk of recurrence for patients with early stage breast cancer treated with conservative surgery and breast irradiation and without chemotherapy. Five French radiotherapy departments launched simultaneously a quality improvement project aimed at reducing the delay to radiotherapy for all types of cancers concerned. Breast cancer radiotherapy delays were used as the principal proxy to evaluate overall progress. Methods: Teams focused their efforts on reducing the interval between the first appointment with the radio-oncologist and the start of the radiotherapy, interval on which they had control. Between May and December 2005, consultancy firms financed by the Ministry of Health, helped the teams (radio-oncologists, physicists, radiographers and nurses) to realize an organizational audit: identifying the processes of treatment, analysing the patient flow and the staff and equipment capacity. Concerning breast cancer, target intervals were set based on the 8 weeks standard. An action plan that included matching capacity and demand (better allocation of staff time during the week), standardising treatment processes and patient programming was implemented between January and December 2006. Results: The five radiotherapy departments reduced the delays to radiotherapy for breast cancers as well as for the majority of the other cancer types. Concerning breast cancer, the average of the five departments intervals between the first appointments and the start of the radiotherapy dropped from 4.9 weeks to 2.3 weeks, reducing in the same time the interval between surgery and radiotherapy. Furthermore, the teams’ cohesion, motivation and sense of responsibility increased, key elements for the sustainability of the improvements. These results were obtained without an increase of the departments resources. Conclusion: By redesigning their organisation with a patient centred goal, the five radiotherapy departments were able to meet the standards of practice. Following these results, ten new departments have joined the program financed by the Ministry of Health.

No significant financial relationships to disclose.

[Target-volume and critical-organ delineation for conformal radiotherapy of prostate cancer: experience of French dose-escalation trials]

The delineation of target volume and organs at risk depends on the organs definition, and on the modalities for the CT-scan acquisition. Inter-observer variability in the delineation may be large, especially when patient's anatomy is unusual. During the two french multicentric studies of conformal radiotherapy for localized prostate cancer, it was made an effort to harmonize the delineation of the target volumes and organs at risk. Two cases were proposed for delineation during two workshops. In the first case, the mean prostate volume was 46.5 mL (extreme: 31.7-61.3), the mean prostate and seminal vesicles volume was 74.7 mL (extreme: 59.6-80.3), the rectal and bladder walls varied respectively in proportion from 1 to 1.45 and from 1 to 1.16; in the second case, the mean prostate volume was 53.1 mL (extreme: 40.8-73.1), the volume of prostate plus seminal vesicles was 65.1 mL (extreme: 53.2-89), the rectal wall varied proportionally from 1 to 1, 24 and the vesical wall varied from 1 to 1.67. For participating centers to the french studies of dose escalation, a quality control of contours was performed to decrease the inter-observer variability. The ways to reduce the discrepancies of volumes delineation, between different observers, are discussed. A better quality of the CT images, use of urethral opacification, and consensual definition of clinical target volumes and organs at risk may contribute to that improvement.

[Severe interstitial pneumopathy due to herpes virus after radiochemotherapy for esophageal carcinoma]

The authors report two cases of severe bilateral interstitial pneumopathies occurring after a medical treatment for esophageal carcinoma. In both cases a broncho-alveolar lavage revealed the presence of herpes virus and a specific treatment rapidly cured the patients.

Salvage esophagectomy after unsuccessful curative chemoradiotherapy for squamous cell cancer of the esophagus

Surgery was performed on 6 patients after unsuccessful chemoradiotherapy for squamous cell cancer of the esophagus. The operation was very difficult due to post-irradiation sequelae in 5. The postoperative period was uneventful in 4 patients. Median intensive care unit stay and hospitalization were 5 and 47 days, respectively. Survival after surgery reached 44 months in 1 patient (59 months after diagnosis). Outcome was better in patients who had surgery after recurrence rather than after nonresponse to chemoradiotherapy. Salvage esophagectomy can be beneficial, in selected patients, after unsuccessful chemoradiotherapy for cancer of the esophagus by providing longer survival and better quality of life despite operative and postoperative morbidity.

Neoadjuvant chemotherapy and hyperfractionated radiotherapy with concurrent low-dose chemotherapy for squamous cell esophageal carcinoma

PURPOSE

We conducted a prospective study of neoadjuvant treatment for squamous cell carcinoma of the esophagus, modifying the chemotherapy protocol by adding l-folinic acid and giving bifractionated radiotherapy with a cis-diaminedichloroplatinum (CDDP) injection before each fraction.

METHODS AND MATERIALS

Thirty-two patients, 30 men, 2 women, mean age 56.2+/-8.9 years, with resectable squamous cell carcinoma of the esophagus (TNM stage I=4, IIA=4, IIB=13, III=11) were included. Chemotherapy, CDDP (80 mg/m2 D2), 5-fluorouracil (5-FU; 600 mg/m2, D1-4), and l-folinic acid (200 mg/m2, D1-4), was given in two sessions with a 3-week interval during which the patients received radiotherapy (45 Gy), two fractions per day (150 cGy/fraction). A 3-mg injection of CDDP was given prior to each fraction. Patients underwent surgery 4 to 7 weeks after neoadjuvant therapy.

RESULTS

No severe side effects were observed in 12 patients. Grade 3 effects (WBC, platelets, mucositis) occurred in 16 patients and grade 4 effects (platelets, mucositis) in four including 1 death due to septicemia with an infected catheter. Surgery was performed in 29 patients; 26 had resectable tumors (81%). Operative mortality was 10%. The 26 surgical specimens showed complete response (n=18), persistent microscopic residues (n=4), or not significant modification (n=4). Survival at 1, 2, and 3 years was 81, 61, and 51.6% and disease-free survival was 75, 59, and 54% respectively.

CONCLUSIONS

This new therapeutic combination is aggressive and associated with a high postoperative mortality but has a remarkable histological effect since complete response was achieved in 56% (95% CI: 39-73%) of the patients and 3-year survival reached 52%, a very high rate in our experience.

Combined radiochemotherapy for postoperative recurrence of oesophageal cancer

Postoperative recurrences are common after resection for oesophageal cancer. From January 1986 to September 1993 31 patients (30 males, one female, mean (SD) age: 57.5 (8.8) years) were treated for locoregional recurrence (n = 24), metastases (n = 6) or both (n = 1) occurring 15.0 (12.6) months after initial surgery. Radiotherapy and chemotherapy were combined in all cases. Symptomatic improvement was seen in 23 cases (74%) and lasted (excluding treatment period) for 6.3 (4) months. Objective tumoral response was seen in 20 patients (65%) including eight (26%) complete responses. Survival rates were at respectively six months, one, two, and three years: 70.7%, 47.1%, 17.1%, 4.3%. In conclusion, these results show that combined therapy could have a beneficial symptomatic effect and can be associated with prolonged survival in patients with postoperative recurrences of oesophageal cancer.

Bone metastasis revealing hepatocellular carcinoma: a report of three cases with a long clinical course

We report herein three cases of hepatocellular carcinoma revealed by bone metastases. The metastases were located in the skull, the iliac bone, and the femur. The metastases were treated by radiotherapy, and/or surgery. With regard to the liver malignancy itself, two patients were treated by tamoxifen and one by chemoembolizations. Two patients are alive 27 and 31 months after the first sign, and one died 31 months after the diagnosis. In conclusion, in patients with hepatocellular carcinoma revealed by bone metastases, long survival was obtainable in a few cases, and aggressive treatment could be of interest.

Three cases of sarcoma occurring after radiation therapy of breast cancers

We report 3 cases of sarcomas following irradiation for breast carcinoma. Median latent period ranged from 7 to 17 years. Histologic types were 1 malignant fibrous histiocytoma, 1 osteochondrosarcoma, 1 chondrosarcoma. Diagnosis was often delayed because of non-specific clinical features. The prognosis of these postirradiation sarcomas was poor with the median survival ranging from 10 to 70 months. One patient had a complete resection and is alive at 70 months. In the other 2 non-resectable patients, chemotherapy and/or radiotherapy did not induce an objective response. The poor prognosis when these tumors are diagnosed late emphasizes the need for increased awareness, which should lead to earlier diagnosis and, it is hoped, permit radical surgical treatment.