Radiation Therapy in Non-Melanoma Skin Cancers: An Italian Survey on Behalf of the Italian Association of Radiotherapy and Clinical Oncology.

AIMS: The National Palliative Care and Interventional Radiotherapy Study Groups of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) carried out a survey whose aim was to obtain a "snapshot" of the real-world practice of nonmelanoma skin cancer (NMSC) treatments in Italy. MATERIALS AND METHODS: The survey was conducted on SurveyMonkey's online interface and was sent via e-mail to our society Radiation Oncologists. RESULTS: Fifty-eight Italian radiation oncologists (ROs), representing 54 centers, answered the survey. Thirteen percent of the ROs declared they treat fewer than 10 NMSC lesions annually, 36% treat between 11 and 20, and 51% treat more than 20 lesions annually. Interventional radiotherapy (IRT) was offered by 25% of the ROs, and every case was reportedly discussed by a multidisciplinary team (71%). Electrons (74%), volumetric modulated arc therapy (V-MAT) (57%), three-dimensional conformal radiotherapy (3D-CRT) (43%), and IRT (26%) were the main treatment options. With external beam radiotherapy (EBRT), 46 and 53 different RT schedules were treated for curative and palliative intent, respectively; whereas for IRT, there were 21 and 7 for curative and palliative intent, respectively. The most popular EBRT curative options were 50-70.95/22-35 fractions (fx) and 50-70 Gy/16-20fx and for EBRT palliative settings, 30Gy/10fx, and 20-35Gy/5fx. For IRT, the most popular curative options were 32-50Gy/8-10fx and 30-54Gy/3-5fx, whereas 30Gy/6fz was the palliative option. Less than 10 re-RT cases were reported in one year in 42.5%, 11-20 cases in 42.5%, and >20 cases annually in 15%. Electrons (61%), VMAT (49%), and BRT (25%) were the most widely used approaches: 20-40Gy in 10fx and 20-25Gy in 5fx were the recommended fractionations. CONCLUSION: The survey shows a variegated reality. A national registry with more detailed data could help in undercover its causes.

Longitudinal analysis of heart and liver iron in thalassemia major patients according to chelation treatment.

Iron chelators and nuclear magnetic resonance imaging (MRI) techniques for assessing iron loading in liver and heart have greatly improved survival of thalassemic patients suffering iron overload-associated cardiomyopathy. However, the correlation between liver iron concentration and myocardial siderosis is ambiguous. Using an objective metric of time delay, scientists have demonstrated a lag in the loading and unloading of cardiac iron with respect to that of the liver. In the present study, we further tested this hypothesis with different chelation treatments. We analyzed the effect of three chelating treatment approaches on liver and cardiac iron content in 24 highly compliant patients who underwent 3 or more MRIs under each chelation treatment. Of the 84 MRIs considered, 32 were performed on deferoxamine (DFO - 8 patients), 24 on deferiprone (DFP - 7 patients), and 28 on combined therapy (DFO+DFP - 9 patients). In patients treated with DFO, changes in cardiac iron significantly lagged changes in liver iron but the opposite pattern was observed in patients treated with DFP (p=0.005), while combined therapy showed a pattern in-between DFO and DFP. We conclude that the temporality of changes of cardiac and liver iron is chelator-dependent, so that chelation therapy can be tailored to balance iron elimination from the liver and the heart.

[Umbilical cord prolapse: a case study over 23 years]. / La procidence du cordon : à propos d'une série sur 23 années d'activité

AIM: To determine the incidence of umbilical cord prolapse, the characteristics of the population, and to evaluate its management and the neonatal prognosis. MATERIAL AND METHODS: Ninety-three cases of cord prolapse that occurred between January 1986 and December 2009 at our level III labour ward were studied retrospectively. RESULTS: The incidence of cord prolapse was 0.18%. It occurred in 66.7% of cases in multiparous patients, in 19.4% of cases in twin pregnancies, and in 41.9% of cases in breech presentations. In 34.4% of cases, the gestational age was less than 37 weeks. Birth occurred vaginally in 33.3% of cases with a delivery time interval significantly less than for caesarean sections (P<0.001). At complete cervical dilation, more than three quarter of patients delivered vaginally. Vaginal birth was significantly more frequent in case of breech (P=0.009) and second twin (P=0.03). Parity did not influence birth route. Neonates with a birth weight less than 2500 g (30.1%) had significantly more frequently an Apgar score less than 7 at 5 min (P=0.02), a higher rate of transfer to intensive care (P<0.001) and a longer hospital stay (P=0.002). We report six neonatal deaths (6.5%). Neonatal status was not influenced by the time interval for delivery. CONCLUSION: Umbilical cord prolapse is still nowadays a serious complication of pregnancy, responsible for a significant rate of neonatal mortality. The aim in case of cord prolapse is to obtain fetal delivery the quickest way possible so as to improve the neonatal outcome. In some particular obstetrical situations such as breech presentations and second twin deliveries, birth occurs faster if performed vaginally as shown by our case study.

[Twin delivery with the first twin in breech position. A study of 137 continuous cases]. / L'accouchement gémellaire en cas de premier jumeau en présentation podalique. Étude d'une série continue de 137 cas.

AIM: The first twin (T1) in breech position is at risk of complications during vaginal delivery, making the choice of the appropriate delivery route highly important. Although British and American practice guidelines recommend the cesarean section, the French National College of Obstetricians and Gynecologists concluded that there was not enough data to choose one delivery route or the other. In this context, we set out to describe practices in our centre. MATERIAL AND METHODS: Our retrospective study was conducted at a level III labor ward between January 1st, 1995 and December 31st, 2006. One hundred and thirty-seven twin pregnancies at more than 26 gestational weeks (GW), with T1 in breech and T2 in any position, were included. RESULTS: A cesarean section was performed before labor in 60.6 % cases. Among the 54 (39.4 %) cases where a trial of labor was accepted, 29 patients (53.7 % success rate) delivered vaginally and 25 (46.3 %) had a cesarean section during labor. No statistical difference was observed between the neonatal outcomes after cesarean section as compared to vaginal birth. However, a significant relationship was found between delivery route and parity. Less than one-third of nulliparas versus two-third of patients with a history of at least one delivery, having trials of labor, ultimately gave birth vaginally. Thus, we observed a high rate of cesarean section during labor in nulliparas (68 % of the initially accepted trials of labor). CONCLUSION: Our study is the first one that clearly shows that the success rate of the trial of labor is closely related to a history of vaginal birth. Following these results and because of more than two-third of cesarean section during labor in nulliparas, we subsequently plan an elective cesarean section at the 38th GW for nulliparas with twin pregnancies and T1 in breech position. Nevertheless, if any of these patients go in labor before the cesearean section, a careful trial of labor is offered.

[Acute paracetamol overdose during pregnancy: a case report]. / Intoxication par le paracétamol chez la femme enceinte : à propos d'un cas.

Severe but regressive toxic liver damage was observed in a 30-week pregnant woman due to acetaminophen poisoning. A cesarean section was performed 1 week later for suspected chorioamniotitis and the patient gave birth to an infant who only experienced complications of preterm birth. The lack of fetal liver damage following acute maternal paracetamol poisoning seems to be the rule, as shown by a review of the literature.

[Operative delivery data in France for 2007: results of a national survey within teaching hospitals]. / Données 2007 de l'extraction instrumentale en France: résultats d'une enquête nationale auprès de l'ensemble des centres hospitalo-universitaires.

AIM: Clinical Practice Guidelines of the French College of Gynecologists and Obstetricians concerning operative deliveries were published in December 2008. That is why a national survey was performed for the year 2007 so as to obtain an inventory of obstetrical practices regarding the geographical distribution of the type of instrument used for operative deliveries following the level of each teaching hospital concerned. MATERIAL AND METHODS: We included in our study 49 teaching hospitals from metropolitan France and the overseas departments and territories. For the year 2007, we noted the number of operative deliveries, the type of instrument used, as well as the level of the maternity concerned with its total number of patients, births, cesarean sections, vaginal deliveries, and episiotomies. RESULTS: We obtained data from all 49 centres. The mean number of deliveries per year was 2203 for level I teaching hospitals, 2060 for level II and 2720 for level III, respectively. The rate of operative delivery was quite different from one centre to the other, ranging from 5.3 to 34.1% of all births. Similarly, for the type of instrument used, there existed clear geographical disparities although the notion of "School's instrument" was not as preeminent as before since most centres used at least two instruments. Moreover, the rate of cesarean varied from 9 to 29.5% (all levels concerned) with a national mean rate of 20.7% for teaching hospitals. Finally, mean rate of episiotomies ranged from 3.6 to 60%. DISCUSSION: This study showed that important differences existed between teaching hospitals in the use of instruments and that obstetrical practices are far from being uniform. However, in 2007, the routine use of more than one instrument in each centre was most usual, as opposed to the situation some decades ago. The use of obstetrical vacuum extractors has been largely disseminated. Each of the three types of instruments has specific indications and mastering at least two instruments seems more secure in the management of the numerous obstetrical situations. It is up to teaching hospitals to make sure that the use of at least two instruments is taught for operative deliveries. The recent publication of Clinical Practice Guidelines would probably help in standardizing operative deliveries in years to come.

[Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists]. / Evaluation d'une politique restrictive d'épisiotomie avant et après les recommandations du Collège national des gynécologues obstétriciens français.

AIM: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS: In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001). CONCLUSION: An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.

[Comparing fetal and maternal morbidities between operative deliveries by Teissier's spatulas and Minicup vacuum extractor]. / Morbidité materno-foetale liée à l'extraction instrumentale par spatules de Teissier. Etude comparative à la ventouse obstétricale de type Minicup.

OBJECTIVE: To compare fetal and maternal morbidities between operative deliveries by long Teissier's spatulas and Minicup vacuum extractor. MATERIAL AND METHODS: A retrospective study was conducted from January 2003 to July 2008 at the maternity ward, Besançon teaching hospital. Operative deliveries in term cephalic singleton pregnancies performed by Teissier's spatulas (case group) were compared to previous deliveries by vacuum extractor Minicup (control group). RESULTS: During the study period, 69 operative deliveries by Teissier's spatulas have been performed. No significant difference was found between the two groups in terms of maternal characteristics. Two third-degree perineal tears occurred following delivery by Teissier's spatulas with no third-degree tear in the vacuum extractor group (p = ns). The episiotomy rate in the Teissier's spatulas group was 15,9% compared to 11.6% in the vacuum extractor group (p = ns). Duration of operative delivery was significantly shorter in the Teissier's spatulas group (3.4 min vs 4.95 min; p = 0.007). Fetal morbidity was identical in the two groups. CONCLUSION: This study found no significant difference in terms of fetal and maternal morbidities between operative deliveries by Teissier's spatulas and vacuum extractor. Moreover, as opposed to Thierry's spatulas, the long Tessier spatulas can be adequately used in accordance with patient's wish and practice guidelines recommending a policy of restrictive episiotomy. However, a larger study is needed to confirm these preliminary results.

Radiation therapy in urinary cancer: state of the art and perspective.

Invasive urinary tumours are relatively rare, and their treatment may cause important changes in urinary, sexual and social functions. A systematic review of external radiation therapy studies in urinary cancers was performed. This synthesis of the literature is based on data from meta-analyses, randomised and prospective trials and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy with or without chemotherapy in cancer of the kidney, ureter and urethra. There are several reports on multimodality treatment in invasive bladder cancer: intravesical surgery and neoadjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial, and data on cancers of the urethra and ureter are few and inconclusive. Sufficient data now exist in the literature to demonstrate that conservative management with organ preservation is a valuable alternative to radical cystectomy, the traditional gold standard, in invasive bladder cancer.

[Assisted vaginal delivery using the vacuum extractor in frank breech presentation]. / Extraction par ventouse obstétricale sur présentation du siège décomplété

OBJECTIVES: When all the breech conditions for the acceptance of a vaginal breech birth are present, we occasionally practise a total breech extraction for non frank breech presentations. Similarly, for frank breech presentations, instead of using the fetal leg as tractor, we sometimes apply the vacuum extractor on the breech presentation in order to perform the first step of the total breech extraction. The vacuum extractor is not traumatic for the fetus and enable a quick extraction. This study was conducted to describe the technique we use in our ward. PATIENTS AND METHODS: A retrospective study including every singleton delivery with a breech presentation and a tried and assisted vaginal delivery using the vacuum extractor in our maternity ward from 1994 to 2004. A descriptive analysis of maternal, fetal and obstetrical elements has been carried out. RESULTS: Twenty-eight deliveries were indexed. In each case, a vaginal delivery was performed. Neonatal outcomes were satisfactory with a five minutes Apgar score always higher than 7. In all 96.5% of the extractions were realized under pelvic level +2. The main indication of extraction (78.5%) was a second stage of labour which was too long. CONCLUSION: Obstetricians should know several techniques to accept and to manage breech deliveries. Indications for assisted vaginal delivery using the vacuum extractor in frank breech presentation are unusual, concerning delay in the second stage with an engaged foetus. This technique may avoid some cesarean sections. Nevertheless vaginal breech delivery try should be happening with great caution and with a strict patient's eligibility.

Role of external radiation therapy in urinary cancers.

Invasive urinary tumors are relatively rare and their treatment may cause important changes in urinary, sexual, and social functions. A systematic review of external radiation therapy studies in urinary cancers has been carried out. This synthesis of the literature is based on data from meta-analysis, randomized and prospective trials, and retrospective studies. There are few controlled clinical trials using adjuvant or radical radiotherapy +/- chemotherapy in kidney, ureter, and urethra cancers; there are several reports of muscle-invasive bladder cancer using multimodality treatment: intravesical surgery and neo-adjuvant chemotherapy to radiotherapy or concomitant radiochemotherapy with organ preservation. The conclusions reached for renal cancer are controversial; urethra and ureter cancers data are few and inconclusive; sufficient data now exist in literature to demonstrate that conservative management with organ preservation, for muscle-invasive bladder cancer, is a valid alternative to radical cystectomy, viewed as the gold standard.