Robot-Assisted Surgery vs Robotic Stereotactic Body Radiotherapy in Prostate Cancer: A Cost-Utility Analysis.

Prostate cancer is the most common men cancer in France. Continuous progress in oncology led to develop robot-assisted Radical Prostatectomies (rRP) and robot-assisted stereotactic body radiotherapy (rSBRT). The present study aims at comparing economic and clinical impacts of prostate cancer treatments performed either with rSBRT or rRP in France. A Markov model using TreeAge Pro software was chosen to calculate annual costs; utilities and transition probabilities of localized prostate cancer treatments. Patients were eligible for radiotherapy or surgery and the therapeutic decision was a robot-assisted intervention. Over a 10-year period, rSBRT yielded a significantly higher number of quality-adjusted life years than rRP (8.37 vs 6.85). In France, rSBRT seemed more expensive than rRP (€19,475 vs €18,968, respectively). From a societal perspective, rRP was more cost-saving (incremental cost effectiveness ratio = €332/QALY). The model was sensitive to variations of costs of the initial and recurrence state in one-way sensitivity analyses. Robot-assisted stereotactic body radiotherapy seems more cost-effective than Radical Prostatectomy in terms of QALY despite the slightly higher initial cost due to the use of radiotherapy. It would be interesting to conduct comparative quality of life studies in France over longer periods of time.

How did we take care of our older cancer patients during the first COVID-19 wave? The French experience.

BACKGROUND: The management of older cancer patients has been highly challenging for clinicians in a health-care system operating at maximum capacity during the COVID-19 pandemic. PATIENTS AND METHODS: We analyzed data from 9 different institutions. The primary endpoint was to assess the prevalence of adapted patient care during the pandemic for elderly cancer patients. The secondary endpoint was to assess the incidence of hospitalization and mortality due to COVID-19. All patients were older than 65years of age. RESULTS: We analyzed data from 332 outpatients' case files between 9th of March and 30th of April 2020. The median age was 75years (range: 65-101) and 53% were male. Because of the COVID-19 pandemic, more than half of the outpatients received modified patient care, defined as postponement or cancellation of surgery, irradiation scheme adapted, systemic treatment or the use of telemedicine. Among patients with localized cancer, 60% had a change in management strategy due to the pandemic. Changes in management strategy were made for 53% of patients at the metastatic stage. GCSF was used , in 83% of patients, increasing considerably in the context of the pandemic. Sixty-nine percent of physicians used telemedicine. In the final analysis, only one patient was hospitalized for COVID-19 infection. No deaths due to COVID-19 were reported in elderly cancer patients during this time period. CONCLUSION: Our study is the first to assess modification of patient care in elderly cancer outpatients during an epidemic. With this unprecedented crisis, our objective is to protect our patients from infection via protective barrier measures and social distancing, but also to guarantee the continuity of cancer care without overexposing this fragile population. Physicians were able to adapt their practice and used new forms of management, like telemedicine.

Evaluation of medical practices in oncology in the context of the COVID-19 pandemic in France: Physicians' point of view: the PRATICOVID study.

The cancer population seems to be more susceptible to COVID-19 infection and have worse outcomes. We had to adapt our medical practice to protect our patients without compromising their cancer prognosis. The national PRATICOVID study aims to describe the adaptation of cancer patient care for this population. We analyzed data from nine different institutions. The primary endpoint was to assess the prevalence of adapted patient care during the pandemic. The secondary endpoints were to describe the point of view of clinicians and patients during and after the pandemic. We analyzed 435 medical procedures between 9th of March and 30th of April. Because of the COVID-19 pandemic, 47.6% of the outpatients received modified patient care. Twenty-four percent of scheduled surgeries were postponed, or were performed without perioperative chemotherapy, 18.4% followed a hypofractioned schedule, and 57% had an adaptive systemic protocol (stopped, oral protocol, and spacing between treatments). Seventy percent of physicians used telemedicine. During this period, 67% of the physicians did not feel distressed taking care of their patients. However, 70% of physicians are worried about the aftermath of the lockdown, as regards future patient care. The PRATICOVID study is the first to assess modification of patient care in cancer outpatients during an epidemic. With this unprecedented crisis, physicians were able to adapt their practice in order to protect their patients against the virus while ensuring continuity of patient care. But physicians are worried about the aftereffects of the lockdown specifically in regard to care pathway issues.

Safety and efficacy of fiducial marker implantation for robotic stereotactic body radiation therapy with fiducial tracking.

PURPOSE: The purpose of this study was to assess the feasibility, efficacy and toxicity of fiducial marker implantation and tracking in CyberKnife® stereotactic radiation therapy (SBRT) applied to extracranial locations. MATERIALS AND METHOD: This is a retrospective, single-centre, observational study to collect the data of all patients treated by stereotactic radiation therapy with fiducial marker tracking at extracranial locations, conducted between June 2014 and November 2017. Information regarding the implantation procedure, the types of toxicity related to marker implantation and the number of markers implanted/tracked during treatment were collected. Complication rates were evaluated using the CTCAE v4 [Common Terminology Criteria for Adverse Events] scale. The technical success rate was based on the ability to optimally track the tumor throughout all treatment fractions. RESULTS: Out of 2505 patients treated by stereotactic radiation therapy, 25% received treatment with fiducial marker tracking. The total number of implantation procedures was 616 and 1543 fiducial markers were implanted. The implantation-related complication rate was 3%, with 16 Grade 1 events and 4 Grade 2 events. The number of treated patients and the number of implanted markers has gradually increased since the technique was first implemented. The median treatment time was 27 min (range 10-76). 1295 fiducials were effectively tracked throughout all treatment fractions, corresponding to a technical success rate of 84%. The difference between the number of fiducials implanted and those tracked during treatment decreased significantly as the site's experience increased. CONCLUSION: Fiducial marker implantation and tracking is feasible, well-tolerated, and technically effective technique in SBRT for extracranial tumors.

Stereotactic prostate focal reirradiation therapy for local recurrence: preliminary results of Hartmann Oncology Radiotherapy Group.

OBJECTIVE: Our objective was to report our experience and to evaluate the feasibility and toxicity of focal salvage stereotactic body radiation therapy (SBRT) in patients with post-radiation local recurrence of prostate cancer. METHODS: We retrospectively reviewed medical records of patients treated with Cyberknife ® between October 2014 and April 2017 at our institution for a focal reirradiation delivered to the prostate/prostatic bed for local recurrence after radical or adjuvant radiotherapy. All patients underwent prostate biopsies at recurrence at the time of fiducial markers placement, had choline PET/CT and pelvic MRI. The treatment consisted in 36 Gy in six fractions delivered every other day. Post reirradiation toxicities were assessed according to the CTCAE v4 (Common Terminology Criteria for Adverse Events). RESULTS: 42 patients were treated with followed with a median follow-up of 21 months (range 3 - 31). 34 patients had biopsy proven recurrence. The initial treatment was radical prostatectomy and radiation therapy for 9 patients and radiation therapy alone for 33 patients. 23 patients from the group of prostate reirradiation had placement of rectal spacers. No Grade 4 or 5 toxicity were observed. 27 acute urinary events were recorded: 18 patients experienced Grade 1, 9 patients experienced Grade 2 toxicity and 1 patient experienced Grade 3 urinary toxicity, namely cystitis and/or dysuria. No Grade 2 or more digestive toxicity was observed. Rectal doses were significantly lower with rectal spacers. CONCLUSION: Salvage focal Cyberknife ® seems feasible and show promising results. ADVANCES IN KNOWLEDGE: SBRT for local prostate cancer recurrence after initial radiotherapy is well tolerated with short follow-up.

[Prospective: How will renal, prostatic and urothelial tumours be treated in 10 years?] / Prospective : comment traitera-t-on les tumeurs rénales et prostatiques et urothéliales dans 10 ans ?

Forward thinking does not seek to predict the future, to unveil it as if it were already in existence, rather, its aim is to help us to construct it. Although today's epidemiological and therapeutic situations for urogenital tumours can evolve over the next 10 years, diagnostic and therapeutic methods, as well as the treatment and implementation of innovations, are already rapidly changing. Rather than reducing our prospective thinking to the therapeutic treatment of cancer only, we will aim at proposing a global sanitary vision that includes diagnosis, therapies, prevention, routine utilisation of technomedicine, genomics and even nanomedicine. This journey into the near future of tomorrow's cancerology holds the promise of being better adapted to the evolution of the medical thinking process. Imagining the way we will be treating renal, prostatic and urothelial tumours in 10 years' time is as much an introspection into our present day treatment system as a projection into its hoped for future evolution.

[Single center experience with bevacizumab in a cohort of patients treated for a relapsing glioblastoma]. / Expérience monocentrique d'un traitement par bévacizumab dans la prise en charge des glioblastomes récidivant.

PURPOSE: Although there is no standard treatment for recurrent glioblastoma, prospective data in selected patients have suggested the usefulness of bevacizumab. We report our single center experience with bevacizumab in a cohort of patients treated for a relapsing glioblastoma. METHODS: We performed a retrospective analysis of consecutive patients treated with bevacizumab for a relapsed glioblastoma, between 2008 and 2013. Tumor responses, toxicities, time to progression and overall survival rates were analyzed. RESULTS: Thirty-five consecutive patients were identified. They were treated with bevacizumab 10mg/kg biweekly, associated with irinotecan (n=29; 84%), temozolomide (n=3; 9%) or as single agent (n=3; 9%) for a glioblastoma relapsing after chemoradiation (n=29) or after first line temozolomide only because of a poor general health status or because of multifocal tumor. Two (6%), 28 (80%) and five (14%) patients presented with Recursive Partitioning Analysis (RPA) III, IV and V-VI, respectively. After 2-3 months of treatment, median dose of prednisolone per patient was decreased three times. Clinical improvements or stability were reported in eight (23%) and 17 patients (49%). The best tumor response was partial response in 14 patients (40%), stable disease in nine patients (26%) and tumor progression in 11 patients (31%). Toxicities requiring treatment disruption were reported in five patients (14%). Median survival was 18.4 months (5-41 months). Median time interval between bevacizumab initiation and its disruption because of clinical/radiological progression and/or toxicity was 5.0 months (0.6-21.4 months). Median survival from bevacizumab initiation was 8.1 months (1.4-34 months). CONCLUSION: This single center retrospective experience suggests that bevacizumab is active for recurrent glioblastoma, in a series of poorly selected patients. Median survival times were in the range of those reported in therapeutic trials. This study questions the validity of usual predictive factors in the era of bevacizumab.

Safety of spinal radiotherapy in metastatic cancer patients receiving bevacizumab therapy: a bi-institutional case series.

We retrospectively assessed the outcome of patients receiving emergency spinal radiation therapy (RT) concurrently with bevacizumab. Clinical records of 18 consecutive patients receiving emergency spinal RT for symptomatic vertebral metastases during the course of bevacizumab-based therapy were examined. Patients were receiving biweekly bevacizumab combined with paclitaxel (n=17) or with docetaxel/carboplatin (n=1) or as a single agent (n=1) for advanced metastatic carcinoma. RT was delivered at doses of 30 Gy in 10 fractions (n=8), 20 Gy in five fractions (n=9) or 18 Gy in nine fractions (n=1). In 10 patients (56%), irradiation field encompassed the thoracic vertebrae. The median time interval between the bevacizumab infusion and the RT course was 1.5 days (0-8 days). The median follow-up was 8.3 months (2 days-42 months). A clinical benefit of RT was reported in 13 patients (72%), including four patients with complete pain relief. Two of the three patients with neurological impairment at the time of RT experienced a partial improvement in their symptoms. No pain recrudescence was reported within the irradiated field after RT completion. All toxicities were mild to moderate, with no acute toxicity reported in 13 patients (72%). No RT disruption was necessary because of acute toxicity. No delayed toxicity was reported within RT fields among 11 patients with at least 6 months of follow-up. Spinal RT during the course of bevacizumab-based therapy was not associated with the occurrence of unexpected adverse effects. This suggests that emergency RT should not be contraindicated in these patients, provided that doses and treatment volumes are defined carefully.

[Towards an integrated approach to cardiovascular toxicities related to the treatments of breast cancer]. / Vers une approche intégrée des toxicités cardiovasculaires liées aux traitements du cancer du sein.

There is an increasing number of therapeutic options in breast cancer management. While prognosis improves, the cardiac toxicity related to treatments remains a significant issue. This toxicity has several clinical presentations and can be explained by complex and diverse molecular mechanisms. Systemic treatments (anthracyclines, inhibitors of HER2 signaling pathway, hormone therapy, antiangiogenic agents) and radiotherapy have their own cardiac toxicity. However, the toxicities associated with these treatments may potentiate together and the existence of pre-existing cardiovascular risk factors should be taken into account. The assessment of cardiac hazard evolves toward a multifactorial approach. Several possibilities exist to minimize the incidence of cardiac complications. Those include pharmacological and technological innovations, but also a more accurate selection of patients and a growing involvement of practitioners in the field of cardiac toxicity, which is prerequisite for an early management of cardiac events.

Feasibility of radiation therapy in patients 90years of age and older: a French multicentre analysis.

BACKGROUND: There are only scarce data on the management of patients aged 90years or older with cancer, and more particularly on the place of radiation therapy (RT). We report the first large study on patients (pts) aged 90years or older receiving RT. METHODS AND MATERIALS: Records from RT departments from five institutions were reviewed to identify pts 90years of age and older who underwent RT for various malignant tumours treated between 2003 and 2012. Tumours' characteristics were examined, as well as treatment specificities and treatment intent. RESULTS: 308 pts receiving 318 RT courses were identified, mean age was 93.2years (standard deviation 2.8). Treatment was given with curative and palliative intent in 44% and 56%, respectively. Factors associated with a curative treatment were performance status (PS), place of life, previous surgery and tumour stage. Median total prescribed dose was 36Gy (4-76Gy). Hypofractionation and split course were used in 88% and 7.3%, respectively. Most toxicities were mild to moderate. RT could not be completed in 23 pts (7.5%). No long-term toxicity was reported. Median overall survival was 22.9months (95CI: 15.5-42.7months). Cancer was the cause of death in 8.7% and 46% of pts treated with curative and palliative intent, respectively. CONCLUSION: This study shows that RT is feasible for patients aged 90years or more. PS, place of life and tumour stage were factors of the therapeutic decision. There is no reason to withdraw pts with good general health condition from potentially curative RT, provided that careful attention is paid to factors of toxicity and to geriatric vulnerabilities.

First assessment of whole-brain radiation therapy combined with pemetrexed-based chemotherapy in non-small-cell lung carcinoma: data on safety and efficacy.

The folate antimetabolite pemetrexed was approved for the treatment of patients with metastatic nonsquamous non-small-cell lung carcinoma. Its activity on brain metastases makes pemetrexed attractive in combination with whole-brain radiation therapy (WBRT), but it could also potentially increase toxicity. We examined the medical records of 43 consecutive patients with brain metastases from non-small-cell lung carcinoma. Patients received pemetrexed-based chemotherapy at a dose of 500 mg/m. The median total number of pemetrexed-based chemotherapy cycles was 4 (range: 1-28). During the course of chemotherapy, patients received WBRT delivering 30 Gy in 10 fractions (n=34) or 20 Gy in five fractions (n=9). The median follow-up time was 30.5 weeks (range: 1-79 weeks). Intracranial progression was a cause of death in nine patients (20.9%). Clinical benefit of WBRT was reported in 30 patients (69.8%). The best radiological response was a complete response in eight patients (18.6%), a partial response in 16 patients (37.2%), stable disease in 11 patients (25.6%), and progression in four patients (9.3%). A stable intracranial disease until the last follow-up was observed in 26 patients (60.5%). The median estimated overall survival was 31 weeks (95% CI: 24-37 weeks). Most WBRT-related toxicities were low and 21 patients (48.9%) had no reported acute neurological toxicity. One patient developed unexplained encephalopathy 5 weeks after WBRT completion in the context of progressive diffuse brain metastases. The combination of pemetrexed with WBRT led to considerable clinical improvement and tumor responses in most patients. Overall neurological toxicity was rather low. A clinical trial is essential for better analysis of the potential synergistic effects of a drug with radiation and evaluation of neurological toxicity.

Treatment of elderly patients with glioblastoma: from clinical evidence to molecular highlights.

Elderly patients with glioblastoma are characterized by a high rate of associated morbidities, and a poor prognosis. Therefore, they have been excluded from most prospective clinical trials. However, the poorer outcome retrospectively reported in these patients might be also related to that those are less likely to receive the appropriate treatment than their younger counterparts. We reviewed the literature with regard to the optimal therapeutic management of this particular population, with focus on molecular perspectives for improving patients' selection. Clinical data have demonstrated that open craniotomy with resection of the tumor was superior to biopsy only in elderly patients with good Karnofsky Performance Status (KPS) score. Then, postoperative radiotherapy (RT) improves survival without impairing functional status or neurocognitive functions, compared with best supportive care only following resection. Despite promising preliminary data, the addition of concomitant temozolomide to RT has not been validated in patients more than 70-years old. In case of additional poor prognostic factors or after biopsy only, there is no definitive demonstration that RT, chemotherapy, or both could improve outcome. Incorporation of more sensitive predictive and/or prognostic molecular factors could help physicians in patients' selection. Further prospective trials should incorporate age-dependent molecular specificities in their design, and better focus on particular subgroup of patients exhibiting specific molecular alterations.

External beam radiotherapy in the management of spinal metastases: review of current strategies and perspectives for highly conformal irradiation modalities.

Bone metastases are frequent in advanced metastatic solid tumors. These secondary lesions are responsible for significant impairment of quality of life of patients with onset of pain, which is frequently resistant to standard analgesics. The therapeutic challenge for a patient with spinal metastasis is to maintain a quality of life as good as possible, commensurate with its life expectancy. Radiotherapy can provide efficient pain relief, but it should be integrated into a multidisciplinary approach. In the case of epidural spinal cord compression, it should be performed whenever possible after surgery. New highly conformal irradiation modalities have emerged for treatment of spinal metastases with therapeutic perspectives. Stereotactic radiosurgery could be provided for patients with single lesions or oligometastatic disease, a good general condition, absence of cord compression, and a life expectancy greater than 6 months. It is particularly promising for the treatment of classically radioresistant tumors or relapsing disease. Intensity-modulated radiotherapy, including Helical Tomotherapy, is a new perspective for treatment of multiple metastases. However, if these new techniques can provide efficient pain sedation, hindsight is currently low to judge their therapeutic benefit and these techniques are hardly available in most centers. Here, we offer a quick review of current strategies and new modalities of radiotherapy to put into perspective the place of these techniques in therapy of spinal metastases.

Pancreatic metastasis from prostate cancer.

The pancreas is an unusual location for metastases from other primary cancers. Rarely, pancreatic metastases from kidney or colorectal cancers have been reported. However, a variety of other cancers may also spread to the pancreas. We report an exceptional case of pancreatic metastasis from prostate cancer. Differences in management between primary and secondary pancreatic tumors make recognition of metastases to the pancreas an objective of first importance. Knowledge of unusual locations for metastatic spread will reduce diagnostic delay and lead to a timely delivery of an appropriate treatment.

[Craniopharyngiomas: role of radiotherapy]. / Craniopharyngiomes: place de la radiothérapie.

Craniopharyngiomas are benign tumors of the parasellar region, characterised by high relapsing rate. Aggressive attempt at total removal does result in prolonged progression-free survival in most patients. But for tumors that clearly involve the hypothalamus, complications associated with radical surgery have prompted to adopt a combined strategy of conservative surgery and radiation therapy to residual tumor with an as high rate of cure. This strategy seems to offer the best long-term control rates with acceptable morbidity. But optimal management of craniopharyngiomas remains controversial. Although it is generally recommended that radiotherapy is given following sub-total excision of a craniopharyngioma, it remains unclear as to whether all patients with residual tumour should receive immediate or differed at relapse radiotherapy.

[Testicular metastasis of prostatic adenocarcinoma: a case report]. / Métastase testiculaire d'un adénocarcinome prostatique: à propos d'un cas.

Metastasis of prostate adenocarcinoma to testis is an extremely rare occurrence. Orchiectomy is necessary to confirm histopathological diagnosis. Metastatic carcinoma of the prostate to the testis is a commonly accepted as a sign of disseminated disease. Systemic treatment are therefore required. We report a case of a 62-year-old patient who presented a prostatic carcinoma with a testicular metastasis.

[Spontaneous hematoma of the iliac psoas muscle in chronic myeloid leukemia. A case report]. / Hématome spontané du muscle psoas iliaque au cours de la leucémie myéloïde chronique. A propos d'un cas.

Spontaneous hematoma in the ilio-psoas muscle is an uncommon condition, usually observed as a complication of anticoagulation or hemophilia. Clinically, the onset is marked by violent pain in the territory of femoral nerve and/or psoitis. The diagnosis is confirmed by echography or CT-scan. The most serious complications are loss of self-sufficiency and neuro-muscular after-effect. Surgery is recommended in patients with neurological suffering, followed by early physiotherapy. We report the case of a 42-year-old man, with an ilio-psoas muscle hematoma, revealing chronic myeloid leukemia, without any hemostasis disorder.

[Advanced nonsmall cell lung cancer: importance of chemotherapy in the control of symptoms]. / Cancer bronchique non à petites cellules avancé: intérêt de la chimiothérapie dans le contrôle des symptômes.

Chemotherapy in advanced non-small-cell lung cancer may be a controversy because it is only palliative and costly. Benefit of chemotherapy is nevertheless clear in survival and particularly life quality. Beside this technical criteria, two other factors have an impact on the therapeutic decision: symptom control and patient's personal expectations. The aim of the strategy is to determine an acceptable compromise in each situation.