Evaluation of tumor response three months after concomitant chemoradiotherapy with high dose rate brachytherapy as a definitive treatment modality for locally advanced cervical cancer.

OBJECTIVE: Radiotherapy remains an essential part of the management of locally advanced cervical cancer. Post-treatment surveillance allows for tumor response assessment and early detection of progressive prosecutions or local recurrences that may benefit from salvage treatment. The objective of this work is to assess the effectiveness of this therapeutic modality. MATERIALS METHODS: This is a retrospective study of 69 patients treated with concomitant radiation chemotherapy followed by high dose rate intracavitary brachytherapy. The tumor response was assessed by gynecologic physical examination at three months after the end of treatment. RESULTS: Median age of patients is 54.9 years (33-78 years). The most common histological type is squamous cell carcinoma (89.9%). The average dose received during external radiotherapy is 52.2Gy (46-60Gy). The average dose received during brachytherapy is 27.5Gy (18-28Gy). Three months after completion of treatment, 95.6% of patients had complete tumor remission, and only 4.4% had a tumor residue of 1cm. CONCLUSION: Radiation chemotherapy with brachytherapy allows for improved short-term local control in cervical cancer.

COVID-19 and Gynecological Cancers: A Summary of International Recommendations.

Morocco and the rest of the world are experiencing a pandemic of a new coronavirus known as COVID-19 or SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). On August 24, 2020, the spread of the virus in Morocco had caused more than 52,000 cases and 880 deaths. Cancer patients are more susceptible to develop an infection than people without cancer because of their immunosuppression caused by the disease and treatments (surgery and chemotherapy). Therefore, these patients are at higher risk of infection with COVID-19 and a much higher risk of developing more serious forms. Given this epidemiological context, the establishment of guidelines for patients with gynecological cancers, requiring multidisciplinary management during the global COVID-19 pandemic, is crucial to limit their infection while maintaining their chances for a cure. In this paper, we summarize the international COVID-19 recommendations on the prioritization of surgical cases, the perioperative protective measures, the precautions to be taken in the brachytherapy unit, the COVID-19 screening, and finally the therapeutic indications of gynecological cancers by tumor location.

COVID-19, Brachytherapy, and Gynecologic Cancers: a Moroccan Experience.

The treatment of gynecological cancers is the main activity of brachytherapy units. However, during COVID-19 pandemic, precautions should be done in order to reduce the spread of the virus while maintaining all chances to recovery for all patients (Radiother Oncol 148, 227-228, 2020). Despite the extent of the pandemic in our country, limited data are available to establish recommendations with a sufficient level of evidence (Radiother Oncol 148, 227-228, 2020). More recently, the American Brachytherapy Society published some clarifications in this regard and international expert consensus recommendations of radiation therapy for gynecologic malignancies during the COVID-19 pandemic were published (https://www.americanbrachytherapy.org/about-abs/abs-news/abs-statement-on-coronavirus/, Gynecol Oncol 15, 2020). In this commentary, we sought to share the procedures adopted for the management of gynecological cancer patients during COVID-19 pandemic in our brachytherapy unit.

Merkel cell carcinoma occurring in a black woman: a case report.

BACKGROUND: Merkel cell carcinoma is a rare, very aggressive neuroectodermal tumor of the skin. It is typically located on sun-exposed skin and frequently found in white men aged between 70 and 80 years. CASE PRESENTATION: We report a case of a 58-year-old black woman diagnosed with Merkel cell carcinoma of the posterior face of the right elbow. She had biopsy excision and was lost to follow-up. Four months later, she presented with recurrent disease on the inferior third of the right arm with three ipsilateral axillary lymph node metastases. Amputation of the right arm and ipsilateral axillary lymph node dissection were performed, followed by adjuvant radiotherapy. Six months later, the patient died as a result of respiratory failure caused by lung metastasis. To the best of our knowledge, no specific studies have been done comparing the course and the characteristics of Merkel cell carcinoma in white and black populations, and no similar case has been reported in the literature. CONCLUSIONS: The Merkel cell carcinoma is very rare in black people. As described elsewhere in the literature, our patient had a poor outcome despite radical management. To date, to the best of our knowledge, there has been no comparison of the prognosis of this tumor in white and black populations.

Hypofractionated Regional Nodal Irradiation for Women With Node-Positive Breast Cancer.

PURPOSE: To evaluate the effect of hypofractionated radiation therapy (HFRT) of the breast/chest wall and regional nodes on overall survival (OS), disease-free survival (DFS), locoregional control and on treatment-related toxicity in patients with breast cancer and nodal involvement. METHODS AND MATERIALS: Two hundred fifty-seven patients treated between October 2009 and June 2011 with hypofractionated locoregional radiation therapy (42 Gy in 15 fractions) were retrospectively reviewed, 51 (19.8%) after breast-conserving surgery and 206 (80.2%) after radical surgery. Patients treated with breast-conserving surgery received a boost dose to the tumor bed (delivered by photons, electrons, or interstitial high-dose-rate brachytherapy). Two hundred fifty-six (99.6%) patients underwent chemotherapy, 209 (81.3%) had hormonal treatment, and 65 (25.3%) had anti-HER2 targeted therapy. RESULTS: The median follow-up time was 64 months (range, 11-88 months). The rates of 5-year OS, DFS, locoregional recurrence (LRR)-free survival, and distant metastasis (DM)-free survival were 86.6%, 84.4%, 93.9%, and 83.1%, respectively. In multivariate analysis (MVA), lymph node ratio >65%, lymphovascular invasion, and negative hormone receptor status predicted for OS, DSF, and DM. T3 to 4 stage was also associated with worse DFS and DM. Finally, for LRR the independent prognostic factors on MVA were N2 to 3 stage and grade 3. Hyperpigmentation was observed in 19.2% of patients, telangiectasia in 12.3%, and fibrosis in 30.7%. Grade ≥2 lymphedema was recorded in 5.8% of cases. During the study follow-up, no cardiac or symptomatic pneumonitis was observed, nor were plexopathy or rib fractures. CONCLUSION: According to the findings from this retrospective study, HFRT seems to be an acceptable alternative for patients with breast cancer who need regional nodal irradiation. However, prospective randomized trials are necessary to confirm these preliminary results.

Epidemiology and outcome of cervical cancer in national institute of Morocco.

BACKGROUND: On behalf of the medical staff of the National Institute of Oncology of Rabat, we conducted a retrospective study to report epidemiology and 5-year outcomes of cervical carcinoma in Moroccan women. METHODS: We reviewed all women diagnosed with invasive cervical carcinoma in our institute between January 2006 and December 2006. Outcomes and prognoses are analyzed in patients who received at least one treatment. RESULTS: The analysis included 646 women. Median age was 50 years (23-85 years). Bleeding was the most frequent symptom (95 %). The most predominant histology was squamous cell carcinoma (94 %). The majority of patients were diagnosed at locally advanced stages (88 %). Among patients who received treatment (n = 550), the management was based on concurrent chemoradiotherapy in 69.7 % of cases. The median duration of follow-up was 60 months (range 2-78 months). Overall survival, progression free survival, and locoregional recurrence free survival were 63.2, 60.7 and 79.1 % respectively. Significant poor prognostic factors in univariate analysis included stage, tumor size, lymph node involvement, anemia and absence of response to radiotherapy. The prognostic significance of response to radiotherapy and stage were retained in multivariate analysis. CONCLUSION: Cervical cancer in our Institute is diagnosed at locally advanced stages. Two third of patients were treated by concurrent chemoradiotherapy. Outcome of Moroccan patients are comparable to that of western countries. Significant prognostic factors were stage, tumor size, lymph node involvement, anemia, and response to radiotherapy. The way to reduce the global burden of cervical cancer in our country continues to be the development of vaccination and screening programs.

Skin metastases of cervical cancer: two case reports and review of the literature.

BACKGROUND: Although cervix carcinoma is one of the most common malignancies in women, hematogenous metastases are relatively not common. Cutaneous metastases, in particular, are unusual even at an advanced stage of disease. Their presence is a predictor of poor prognosis. CASE PRESENTATION: Case 1: A 63-year-old postmenopausal Moroccan woman was diagnosed as having cervical squamous cell carcinoma. She was treated with radical concurrent chemotherapy and radiation therapy followed by low-dose brachytherapy. Six months after finishing the therapy, multiple skin nodules appeared on her abdomen and chest wall. An excision biopsy was performed and showed metastatic squamous cell carcinoma. Her disease progressed and she died before completing her fourth course of palliative chemotherapy. Case 2: A 48-year-old Moroccan woman was diagnosed as having cervical squamous cell carcinoma; she was treated with concurrent chemoradiation. Before a planned high-dose brachytherapy, she noticed many nodular lesions on her arms, thighs, and chest wall. An excision biopsy was performed and showed metastatic squamous cell carcinoma. She then underwent a series of imaging examinations, including computed tomography of her chest, abdomen, and pelvis, and a whole body bone scan that showed disseminated disease involving her lungs and bones. She died after two courses of palliative chemotherapy, 2 months after the appearance of the skin lesions. CONCLUSION: We report two cases to illustrate a rare localization of metastasis from cervical carcinoma that is highly aggressive requiring early detection and aggressive management.

Primary Kaposi's sarcoma of the nasal cavity: a case report and review of the literature.

BACKGROUND: Kaposi sarcoma is a neoplastic vascular disorder. It usually present on the skin of the upper and lower extremities, rarely in the mucosa of the head and neck. The most common sites reported are within the oral cavity, particularly on the palate. Other mucosal sites are rare. We present an unusual case where the primary manifestation of the Kaposi's sarcoma was in the nasal mucosa. CASE PRESENTATION: A 56-year-old female of Mediterranean descent presented with a 1 year history of swelling on the left side of her nose, nasal obstruction and occasional minor epistaxes. Physical examination showed a firm and bulging polypoid mass which filled the left nasal cavity without cutaneous lesions. Computed tomography (CT) demonstrated a tumor, measuring 77 mm in diameter, occupying the left nasal cavity causing erosion of nasal septum and extending posteriorly to the left choana and nasopharynx. There was bilateral cervical lymphadenopathy. Patient treated with chemotherapy alone. She was in a complete response after the first cycle. The patient received no further treatment. She needs a regular medical checkups that include a review of a patient's medical history and a complete physical exam. She is in excellent local control over 12 months. CONCLUSIONS: A review of the literature revealed that only seven cases of primary Kaposi sarcoma of the nasal cavity have previously been published and only two of them presented in a patient not associated with the acquired immunodeficiency syndrome. Here, we report the third case where the primary manifestation of the Kaposi sarcoma was in the nasal cavity in a patient with an adequate immune system.

Oral verrucous carcinoma complicating a repetitive injury by the dental prosthesis: a case report.

Verrucous carcinoma (VC) is an unusual, well differentiated, and low-grade type of squamous cell carcinoma, characterized by benign histology and cytology but markedly invasive clinical behavior. They have a predilection for squamous mucosae, particularly those of the head and neck region. Many factors have been associated with its pathogenesis, including the presence of previous skin lesions; VC arising from a prosthesis injury is rare. Here we reported a case of VC of oral cavity a particularly very aggressive, arising from prosthesis injury. Regardless of the treatment modality, given new insights into the possible aggressivity of this tumor, radiotherapy associated to chemotherapy may be a more appropriate primary treatment compared with the significant local morbidity associated with surgery.

[Trastuzumab in early breast cancer]. / Le trastuzumab dans le traitement adjuvant du cancer du sein.

BACKGROUND: The HER2 gene or c-erb B2 or neu is amplified in 15-25% of breast cancers. This amplification is associated with an aggressive course of disease. The trastuzumab is a monoclonal antibody targeting the extracellular domain of HER2. This is the first targeted molecule designed to treat breast cancer. In the firstline metastatic disease, trastuzumab in combination with chemotherapy significantly improved survival of patients with HER2-positive disease. In the adjuvant setting, trastuzumab has been evaluated in several randomized trials. OBJECTIVE: The purpose of this literature review is to evaluate the efficacy and safety of Trastuzumab in the adjuvant treatment of HER2-positive breast cancer. METHODS: A search of articles published in English literature, between 1987 (date of establishment of prognostic value of HER2) and November 2012, was conducted on Medline and in the database of the main international congress using the following terms: "breast cancer", "HER2-positive", "adjuvant therapy" and "Trastuzumab". RESULTS: We identified seven randomized phase 3 trial evaluating trastuzumab in the adjuvant treatment of HER2-positive. The trastuzumab was administered weekly or every 3weeks. Its administration with concomitant taxane chemotherapy and with concurrent radiotherapy was preferred. Four randomized trials have clearly confirmed the benefit of trastuzumab, two positive in overall survival (OS) and progression free survival (PFS), and two positive in PFS. The duration of trastuzumab for 1year was the most effective. The trastuzumab was well tolerated. The most significant toxicity, associated with trastuzumab, was cardiac toxicity. However, it is found in only 5% or less of cases, and it is severe in only 2% or less of cases, and most patients recovered their cardiac function by medical treatment alone. CONCLUSION: In the contemporary medical literature, several strong arguments confirm the benefit in survival of trastuzumab administered concomitantly with a taxane-based chemotherapy and with concurrent radiotherapy, and for a period of 1year. Trastuzumab was well tolerated. Only 2% or less of patients experienced a serious cardiac toxicity, but it was reversible in most of the time.

[Urological cancers: ECCO/ESMO congress 2011]. / Cancers urologiques : congrès de l'ECCO/ESMO 2011.

In the Congress of European Cancer Organisation (ECCO)/European Society for Medical Oncology (ESMO), which took place in Stockholm between 23 and 27 September 2011, urological cancers were the subject of various oral presentations and posters. A selection of the more innovative researches, likely to change the patients' management was performed. In prostate cancer, abiraterone acetate should be indicated in patients previously treated with docetaxel and sipuleucel-T in patients with asymptomatic or minimally symptomatic castrate-resistant prostate cancer. Alpharadine should be indicated in patients with symptomatic bone metastases and denosumab in non-metastatic prostate cancer patients with a high risk of developing bone metastases. In metastatic renal clear cell carcinoma, the genetic polymorphisms are predictive for efficacy of anti-angiogenic agents. Targeting both vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) pathways is a very promising strategy. In urothelial cancer, two molecules are promising, the belinostat and the bortezomib. Other news on penile cancer and testicular seminoma are discussed.

Anthracycline and concurrent radiotherapy as adjuvant treatment of operable breast cancer: a retrospective cohort study in a single institution.

BACKGROUND: Concurrent chemoradiotherapy (CCRT) after breast surgery was investigated by few authors and remains controversial, because of concerns of toxicity with taxanes/anthracyclines and radiation. This treatment is not standard and is more commonly used for locally advanced breast cancer. The aim of our study was to evaluate the efficacy and safety of the concomitant use of anthracycline with radiotherapy (RT). FINDINGS: Four hundred women having operable breast cancer, treated by adjuvant chemotherapy (CT) and RT in concomitant way between January 2001 and December 2003, were included in this retrospective cohort study. The study compares 2 adjuvant treatments using CCRT, the first with anthracycline (group A) and the second with CMF (group B). The CT treatment was repeated every 21 days for 6 courses and the total delivered dose of RT was 50 Gy, divided as 2 Gy daily fractions. Locoregional recurrence free (LRFS), event free (EFS), and overall survivals (OS) were estimated by the Kaplan-Meier method. The log-rank test was used to compare survival events. Multivariate Cox-regression was used to evaluate the relationship between patient characteristics, treatment and survival.In the 2 groups (A+B) (n = 400; 249 in group A and 151 in group B), the median follow-up period was 74.5 months. At 5 years, the isolated LRFS was significantly higher in group A compared to group B (98.7% vs 95.3%; hazard ratio [HR] = 0.258; 95% CI, 0.067 to 0.997; log-rank P = .034). In addition, the use of anthracycline regimens was associated with a higher rate of 5 years EFS (80.4% vs 75.1%; HR = 0.665; 95% CI, 0.455 to 1.016; log-rank P = .057). The 5 years OS was 83.2% and 79.2% in the anthracycline and CMF groups, respectively (HR = 0.708; 95% CI, 0.455 to 1.128; log-rank P = .143). Multivariate analysis confirmed the positive effect of anthracycline regimens on LRFS (HR = 0.347; 95% CI, 0.114 to 1.053; log-rank P = .062), EFS (HR = 0.539; 95% CI, 0.344 to 0.846; P = 0.012), and OS (HR = 0.63; 95% CI, 0.401 to 0.991; P = .046). LRFS, EFS and OS were significantly higher in the anthracycline group where the patients (n = 288) received more than 1 cycle of concurrent CT (P = .038, P = .026 and P = .038, respectively). LRFS and EFS were significantly higher in the anthracycline group within the BCT subgroup (P = .049 and P = .04, respectively). There were more hematologic, and more grade 2/3/4 skin toxicity in the anthracycline group. CONCLUSIONS: After mastectomy or BCT, the adjuvant treatment based on anthracycline and concurrent RT reduced breast cancer relapse rate, and significantly improved LRFS, EFS and OS in the patients receiving more than 1 cycle of concurrent CT. There were more hematologic and non hematologic toxicities in the anthracycline group.

Primary Nasopharyngeal non-Hodgkin lymphomas: a retrospective review of 26 Moroccan patients.

BACKGROUND: Nasopharyngeal non-Hodgkin lymphomas (NNHL) are extremely rare. In this study, we will report the progress achieved in the management of this disease in our institute. METHODS: We retrospectively reviewed the records of 26 patients having primary NNHL who were managed between January 1997 and December 2008, to evaluate and compare their clinical characteristics and treatment outcome. Clinical variables, including age, sex, stage, and treatment modality, were assessed. Disease free survival and overall survival were measured. Survival curves were constructed using the KaplanMeier method. The log-rank test was used to compare them. RESULTS: Median age of our patients was 52.7 years. Nasal obstruction, nasal discharge and epistaxis were the frequent symptoms in NNHL patients. Histology of NNHL were mainly large B-cell and follicular lymphoma. Four patients (15.4%) were at stage I, 15 (57.6%) at stage II, and 7 (27%) were at stage III/IV. The patients were treated with chemotherapy alone (27%) or chemotherapy plus radiotherapy (73%). At early stage (stage I/II), the patients were managed with chemo-radiotherapy. When the whole treatment was completed, 18 patients (69.2%) achieved complete response and remained disease free. After 25.9 months median follow-up, overall survival at 1 year was 87% and disease free survival at 1 year was 71%. The difference in term of overall and disease free survival between stage I, II, III and IV was significant (Log rank test: p = 0.02 for overall survival and p = 0.01 for disease free survival). CONCLUSION: From our study, we conclude that histological characteristics, principle of treatment and outcome of primary NNHL patients are particular and more studies have to be directed.

Concurrent chemoradiotherapy in adjuvant treatment of breast cancer.

BACKGROUND: The optimal sequencing of chemotherapy and radiotherapy after breast surgery was largely studied but remains controversial. Concurrent chemo-radiotherapy is a valuable method for adjuvant treatment of breast cancer which is under ongoing research program in our hospital. We are evaluating the feasibility of the concomitant use of chemotherapy retrospectively. METHODS: Two hundred forty four women having breast cancer were investigated in a retrospective study. All patients were either treated by radical surgery or breast conservative surgery. The study compares two adjuvant treatments associating concomitant chemotherapy and radiotherapy. In the first group (group A) the patients were treated by chemotherapy and radiotherapy in concomitant way using anthracycline (n = 110). In the second group (group B) the patients were treated by chemotherapy and radiotherapy in concomitant way using CMF treatment (n = 134). Chemotherapy was administered in six cycles, one each 3 weeks. Radiotherapy delivered a radiation dose of 50 Gy on the whole breast (or on the external wall) and/or on the lymphatic region. The Kaplan-Meier method was used to estimate the rates of disease free survival, loco-regional recurrence-free survival and overall survival. The Pearson Khi2 test was used to analyse the homogeneity between the two groups. The log-rank test was used to evaluate the differences between the two groups A and B. RESULTS: After 76.4 months median follow-up (65.3 months mean follow up), only one patient relapsed to loco-regional breast cancer when the treatment was based on anthracycline. However, 8 patients relapsed to loco-regional breast cancer when the treatment was based on CMF. In the anthracycline group, the disease free survival after 5 years, was 80.4% compared to 76.4% in the CMF group (Log-rank test: p = 0.136). The overall survival after 5 years was 82.5% and 81.1% in the anthracycline and CMF groups respectively (Log-rank test: p = 0.428). The loco-regional free survival at 5 years was equal to 98.6% in group A and 94% in group B (Log-rank test: p = 0,033). The rate of grade II and grade III anaemia was 13.9% and 6.7% in anthracycline group and CMF group respectively (Khi2-test: p = 0.009). The rate of grade II and grade III skin dermatitis toxicity was 4.5% in the group A and 0% in the group B (Khi2-test: p = 0.013). CONCLUSION: From the 5 years retrospective investigation we showed similar disease free survival and overall survival in the two concurrent chemo-radiotherapy treatments based on anthracycline and CMF. However in the loco-regional breast cancer the treatment based on anthracycline was significantly better than that of the treatment based on CMF. There was more haematological and skin dermatitis toxicity in the anthracycline group.

A rare case of advanced testicular seminoma in a 78-year-old man managed successfully with carboplatin based chemotherapy: a case report.

BACKGROUND: Germ cell tumours are uncommon in aged man. We present a rare case of metastatic seminoma of the testis associated with liver and renal insufficiencies in a 78-years-old man managed successfully with carboplatin based chemotherapy. CASE PRESENTATION: A 78 years old man admitted with signs and symptoms suggestive of a testicular cancer with alteration of health. Computed tomography of the pelvis and abdomen showed a large retroperitoneal tumour. The diagnosis of seminoma was established from the histological study of the left orchidectomy. At admission, the liver and renal check-up showed liver and renal insufficiencies. CONCLUSION: The patient received 4 of carboplatin based chemotherapy with significant improvement in symptoms, and complete radiological response.

Primary lymphoma of the head and neck: two case reports and review of the literature.

BACKGROUND: The head and neck is the second most common region for the extra-nodal lymphomas after that of gastrointestinal tract. Approximately 2.5% of malignant lymphoma arises in the oral and para-oral region. In this paper we report two cases of early stage head and neck lymphoma which were managed successfully with chemotherapy and a review of the related literature. CASES PRESENTATION: The first case concerns a 48 years male patient having a diffuse large B-Cell lymphoma of the oropharynx at early bulky stage. This patient was managed successfully with 7 of Rituximab 375 mg/m2, Cyclophosphamide 750 mg/m2 d1, Doxorubicine 50 mg/m2 d1, Vincristine 1.4 mg/m2 d1, and prednisone 50 mg/m2 d1-5 (RCHOP) regimen. The second case concerns a 50 years female patient having the nasal natural killer (NK)/T-cell lymphoma of the left nasal pit at early stage. This case was managed successfully with 6 of Cyclophosphamide 750 mg/m2 d1, Doxorubicine 50 mg/m2 d1, Vincristine 1.4 mg/m2 d1, and prednisone 50 mg/m2 d1-5 (CHOP) regimen. CONCLUSION: These two cases highlight the important role of CHOP based chemotherapy for achieving successful treatment cure for patients having an early stage head and neck lymphoma.