Volumetric modulated arctherapy for locally advanced nasopharyngeal carcinoma: Clinical efficacy and late toxicity.

PURPOSE: We report our experience of 86 consecutive patients with locally advanced nasopharyngeal carcinoma who were treated with volumetric modulated arc therapy. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 86 patients with histologically proven primary nasopharyngeal carcinoma treated with volumetric modulated arctherapy technique radiotherapy. Primary endpoints were local, regional, distant control, and overall survival, second endpoint was late toxicity. RESULTS: The median age was 47.5 years (range: 13-79 years) with sex ratio 1.09. At diagnosis, rhinologic symptoms represented the most common clinical presentation, reported by 61 patients (70.9%). Almost 88.4% of patients presented non-keratinizing undifferentiated carcinoma histology (n=76). Most of the patients presented a locally advanced disease defined by stage III and IVa (95.3%). Therefore, 31 patients were treated by concurrent chemoradiation (36%), 52 patients received induction chemotherapy followed by concurrent chemoradiotherapy (57%), three patients received induction chemotherapy followed by exclusive radiotherapy (3.5%). and three patients treated with exclusive irradiation (3.5%). With a median follow up of 15.7 months (range: 4-33.3 months), nine patients died (10.4%), three presented local or locoregional relapse (3.4%), while nine patients presented distant recurrences (10.4%). The two years overall and disease-free survival rates were 88.7% and 83.1% respectively, locoregional control was 100% at 12 months and 96.2% at 24 months, and the two years distant failure-free survival was 86.7%. Time to relapse was the only prognostic factor in univariate analysis for overall survival in our study. The therapeutic tolerance was good with 61.7% of grade 3 and 2.3% grade 4 hyposialia respectively, 46.5% of otological disorders and no radionecrosis was noted. CONCLUSION: Volumetric modulated arctherapy technique with concurrent chemoradiotherapy is an effective treatment for nasopharyngeal carcinoma with excellent overall and locoregional control without severe toxicity. Distant metastasis is the major site of failure, so induction chemotherapy added to chemoradiotherapy must be discussed in multidisciplinary consultation meeting because it significantly improved recurrence-free survival and overall survival, as compared with chemoradiotherapy alone.

Lung cancer: Incidence and survival in Rabat, Morocco.

BACKGROUND: Lung cancer is the most common cancer worldwide, but epidemiologic data from developing countries are lacking. This article reports lung cancer incidence and survival in Rabat, the capital of Morocco. METHODS: All lung cancer cases diagnosed between 2005 and 2008 were analyzed using data provided by the Rabat Cancer Registry. The standardized rate was reported using age adjustment with respect to the world standard population, and the observed survival rates were calculated using the Kaplan-Meier method. RESULTS: Three hundred fifty-one cases were registered (314 males and 37 females), aged 27-90 years (median, 59 years). The most common pathological type was adenocarcinoma (40.2%) followed by squamous cell carcinoma (31.9%); the majority of cases were diagnosed at stage IV (52%). The age-standardized incidence rate was 25.1 and 2.7 per 100,000 for males and females, respectively, and the overall observed survival rates at 1 and 5 years were 31.7% and 3.4%, respectively. The clinical stage of disease was the only independent predictor of survival. CONCLUSION: The survival rate of lung cancer in Rabat is very poor. This finding explains the need for measures to reduce the prevalence of tobacco and to improve diagnostic and therapeutic facilities for lung cancer.

Unusual evolution of leiomyosarcoma of the rectum: a case report and review of the literature.

BACKGROUND: Leiomyosarcoma of the rectum is a rare entity that comprises less than 0.1 % of all rectal malignancies. Given the uncommon nature of this tumor and the controversy about its treatment we report one case and review the literature in an attempt to report a particular evolution and to discuss the most appropriate treatment. CASE PRESENTATION: This case report describes the presentation of leiomyosarcoma of the rectum. A 30-year-old man from the north of Morocco presented with rectorrhagia and constipation. On physical examination we found a mass in his rectum approximately 6 cm from his anal margin. Pelvic magnetic resonance imaging showed a rectal mass with a parietal attachment that invaded the fascia and his perirectal tissue. Before any treatment he defecated spontaneously the tumor. On histopathological examination a diagnosis of leiomyosarcoma was made. An anterior resection of his rectum was performed with adjuvant radiotherapy at a dose of 50 Gy. After 1 year of surveillance, he has not presented any clinical symptoms and pelvic magnetic resonance imaging was normal. Unfortunately, histological analysis of a superficial biopsy of a rectal leiomyosarcoma may not be reflective of the entire tumor mass, and a diagnosis is based essentially on postoperative pathological examination. The optimal treatment modality in patients with rectal leiomyosarcomas is controversial. Prognosis is also poor; tumor size, histological grade, mitotic index, and local staging are the most known prognosis factors. CONCLUSION: The prognosis of rectal leiomyosarcoma is poor; more investigations are necessary to understand the progression of these tumors and to define an optimal treatment modality.

Factors influencing diagnosis delay of advanced breast cancer in Moroccan women.

BACKGROUND: Delay in the diagnosis of breast cancer in symptomatic women of 3 months or more is associated with advanced stage and low survival. We conducted this study to learn more about the extent and reasons behind diagnosis delay of advanced breast cancer in Moroccan women. METHODS: A group of patients with advanced breast cancer were interviewed at the National Institute of Oncology in Rabat during the period from February to December 2014. Diagnosis delay was devised into patient delay and system delay. Patient delay was defined as time from first symptoms until first medical consultation. System delay was defined as time from first presentation to a health care provider until definite diagnosis or treatment. Prospective information and clinical data were collected on a form during an interview with each patient and from medical records. RESULTS: In all, 137 patients were interviewed. The mean age of women was 48.3 ± 10.4 years. The median of consultation time was 6[4,12] months and the median of diagnosis time was 1[1,3] months. Diagnosis delay was associated to a personal reason in 96 (70.1 %) patients and to a medical reason in 19 (13.9 %) patients. A number of factors predicted diagnosis delay: symptoms were not considered serious in 66 (55.9 %) patients; traditional therapy was applied in 15 (12.7 %) patients and fear of cancer diagnosis and/or treatment in 14 (11.9 %) patients. A use of traditional methods was significantly associated with rural residence and far away from basic health center (p = 0.000). Paradoxically, a family history of breast cancer was significantly higher in who report a fear of cancer diagnosis and/or treatment to diagnosis delay (p < 0.001). Also, a significantly higher risk of more than 6 months delay was found among rural women (P = 0.035) and women who live far away from specialized care center (P = 0.001). CONCLUSIONS: Diagnosis delay is very serious problem in Morocco. Diagnosis delay was associated with complex interactions between several factors and with advanced stages. There is a need for improving breast cancer information in our populations and training of general practitioners to reduce advanced breast cancer by promoting early detection.

Isolated thyroid metastasis revealed an unknown lung adenocarcinoma: a case report.

INTRODUCTION: Cancer metastasis to the thyroid is extremely rare. The most common sites that have been reported to metastasize to the thyroid gland are breast and kidney. As to primary lung cancer metastasizing to the thyroid gland, only a few cases have been described in the literature. CASE PRESENTATION: We report a case of a 37-year-old white Arabian woman who had never smoked tobacco products for whom a malignant thyroid mass revealed a primary lung tumor. She had a surgical excision for both the thyroid and the pulmonary tumors, and received adjuvant chemotherapy. At 1 year, she is still in remission. CONCLUSIONS: Our case is rare as it describes a case where the thyroid lesion was the revealing sign of an unknown lung carcinoma. Management of thyroid metastases should depend on the individual situation and surgical excision should be proposed whenever a patient's condition is favorable.

Prognostic factors affecting cervical adenocarcinoma: 10 years experience in a single institution.

OBJECTIVES: We performed a population-based study to determine the significance of adenocarcinoma and to evaluate its behavior over the last 10 years among patients treated in the National cancer institute of Morocco. STUDY DESIGN: This is a retrospective study that was conducted in the national cancer institute of Morocco. Over a period of 10 years, we retrieved 350 cases of cervical invasive adenocarcinoma. Survival was analyzed according to the Kaplan-Meier method. A univariate analysis of prognostic factors was performed using the test of log rank. Cox regression model was used for the multivariate analysis of prognostic factors. RESULTS: Mean age at presentation was 46 years. Sixty seven percent of the patients had locally advanced stage. Radiotherapy was prescribed in 73.3 % of the cases. The mean follow-up time for surviving patients was 51 months. The 5-year survival rates according to clinical stages were as follows, 76 and 62 % for stages I and II, respectively, 32 and 9 % for stages III and IV, respectively. Tumor stage, tumor grade, positive lymph nodes status, lymphovascular space involvement and patient's age were significant prognostic factors in a univariate analysis. While only stage and lymph node involvement remained significant independent predictors for survival in the multivariate analysis. CONCLUSION: Although in our country incidence of adenocarcinoma is lower than the ones reported in western countries, in general our results are consistent with those reported in the literature. Better outcomes are observed in both early stages and young patients. Also, we found that FIGO stage, grade and lymph node metastases to be significant prognostic factors for survival in cervical adenocarcinoma.

Five years' experience treating locally advanced cervical cancer with concurrent chemoradiotherapy: results from a single institution.

INTRODUCTION: Cervical cancer is the second most common cause of female cancer death. In Morocco it is the second most common cancer, our department recruits more than 500 patients each year and proximally half of the cases are diagnosed at an advanced stage. PATIENTS AND METHODS: Between January 2008 and December 2008, all patients with diagnosis of locally advanced cervical cancer referred to our department and treated with concurrent chemoradiotherapy were retrieved. We analyzed outcomes for this particular population; overall survival, local control, and toxicities, we also retrieved prognostic factors influencing outcomes for this population. RESULTS: The overall survival rate for the cohort was 68 % at 2 years, and reached 47 % at 5 years. The overall LC rate was 71 % at 2 years and 58 % at 5 years. The most important prognostic factors for OS and LC were the pretreatment hemoglobin, the tumor size, total duration of treatment, and the use of brachytherapy. For OS, the presence of enlarged lymph nodes was also important. For LC, the number of chemotherapy's courses was important. Of the included patients, 20 % experienced late grade 3 or 4 toxicity. CONCLUSION: The results of our study have shown that despite all the treatment strategies available, locally advanced cervical cancer is associated with bad outcomes. In this cohort, the most important prognostic factors were the pretreatment hemoglobin level and the tumor size.

Impact of cervical cancer on quality of life: beyond the short term (Results from a single institution): Quality of life in long-term cervical cancer survivors: results from a single institution.

BACKGROUND: Cervical cancer (CC) is one of the most widespread gynecological malignancies in women worldwide. Treatment strategies and screening modalities have largely evolved these past years resulting in an improvement of survival. However, treatment modalities are associated with long term side effects that significantly impacts quality of life (QOL) in cervical cancer survivors. The aim of this study is to evaluate QOL (General and sexual QOL) in cervical cancer survivors up to 10 years after the diagnosis. MATERIAL AND METHODS: In a cross-sectional descriptive study design, 110 cervical cancer survivors (CCS) and 80 healthy controls completed questionnaires assessing QOL. RESULTS: Participants were Arabic White, sexually active. The mean age at diagnosis was 34 years and was 43 years at the time of the interview. In our series long term CCS have generally a good global QOL comparable with healthy controls. However, issues concerning emotional functioning were over expressed by CCS. As to the sexual impact of cervical cancer; CCS experienced less sexual functioning and enjoyment and less satisfaction with their body image when compared to healthy controls. In a multivariate analysis, spiritual well-being and social support were the predictor factors that statistically affected QOL among the studied cohort, it accounted for 81 % of the variance in QOL scores. CONCLUSIONS: A better understanding of the complexity of the relationship between QOL and cervical cancer sequelae in one hand and socio-demographic factors in the other hand is necessary to improve QOL among cervical cancer survivors. More efforts should make to inform disease free patients about expected side effects and symptoms to face the physical changes that would affect their QOL and sexual activity.

[Superior vena cava syndrome with malignant causes]. / Syndrome cave supérieur d'origine maligne.

Superior vena cava syndrome comprises various symptoms and signs resulting from the obstruction of the superior vena cava and resulting in reduced blood flow. Superior vena cava may occur secondary to a variety of conditions, but malignant etiologies are the most common. Usually, the diagnosis is based on a quite clear clinical presentation. Patient with acute presentation can develop life-threatening complications such as cerebral or laryngeal edema. In the absence of these two conditions, a histologic diagnosis should be obtained before the initiation of any therapy. Management of superior vena cava syndrome requires a multidisciplinary team. Therapeutic approaches include radiotherapy, chemotherapy and endovascular approach, and the choice of therapy will depend on the severity of the symptoms, the type and the stage of the tumor, but also the patient's general condition.

[Concomitant chemoradiotherapy for muscle-invasive bladder cancer: current knowledge, controversies and future directions]. / Chimioradiothérapie concomitante des tumeurs infiltrantes de la vessie : acquis, controverses et perspectives.

Radical cystectomy with lymphadenectomy is currently the standard of care for muscle-invasive urothelial bladder cancer; however and because of its morbidity and its impact on quality of life, there is a growing tendency for bladder-sparing strategies. Initially reserved for elderly or unfit patients unable to undergo radical cystectomy, chemoradiotherapy became a true alternative to surgery for highly selected patients. Although there are no randomized trials comparing radical cystectomy with bladder preserving approaches, surgery remains the preferred treatment for many clinicians. Furthermore, comparison is even more difficult as modalities of radiotherapy are not consensual and differ between centers with a variability of protocols, volume of irradiation and type of chemotherapy. Several ongoing trials are attempting to optimize chemoradiotherapy and limit its toxicity, especially through techniques of adaptive radiotherapy or targeted therapies.

[Primary central nervous lymphoma: what is the role for radiotherapy?]. / Lymphome primitif du système nerveux central : quel rôle pour la radiothérapie ?

Primary central nervous system lymphoma is a rare extranodal form of non-Hodgkin lymphoma with an aggressive course and unsatisfactory outcome. Historically, whole-brain radiotherapy was the sole treatment for patients with primary central nervous system lymphoma, with high response rates but typically, this did not result in long-lasting remissions. The addition of high-dose methotrexate-based chemotherapy regimens to whole-brain radiotherapy has significantly improved patients' outcome, but has resulted in a higher incidence of late neurotoxicity, particularly in elderly patients. To date, the role of consolidation radiotherapy is controversial, and some investigators have developed alternative strategies aiming at avoiding immediate irradiation or using a reduced radiotherapy dose to the whole-brain with promising results.

[Small cell neuroendocrine carcinoma of the uterine cervix: Report of six cases and a review of the literature]. / Carcinome neuroendocrine à petites cellules du col utérin : à propos de six cas et revue de la littérature.

Neuroendocrine carcinoma is a rare and aggressive malignant tumour, mainly developing at the expense of the respiratory and of the digestive tract. Gynecological neuroendocrine tumours are rare and small cell neuroendocrine tumours of the uterine cervix represent 2% of cervical cancer. Given their rarity and the lack of randomized trials, the diagnostic and therapeutic management of these tumors is difficult and essentially based on that of pulmonary neuroendocrine tumours. Like the latter, and despite multimodality regimens, the prognosis of these tumours remains poor. Through this series, we report our experience in the management of these particular tumours while comparing our data with those of the literature.

[Efficacy of first-line radiation for non-resectable carotid paraganglioma]. / Efficacité de la radiothérapie en première intention d'un paragangliome carotidien non résécable.

BACKGROUND: Carotid paragangliomas are rare. Surgical resection is the primary treatment. However, when surgery is impossible, radiation therapy is an alternative potentially enabling local control with less morbidity. We report a case of good local control of an unresectable paraganglioma after external beam radiation. CASE REPORT: A 72-year-old-woman, had a 4-year history of right facial palsy associated with pulsatile tinnitus, episodic ear bleeding and ipsilateral hearing loss. Physical examination revealed a retro-mandibular and sub-mastoid pulsatile mass. Magnetic resonance imaging showed a large carotid paraganglioma involving the temporal bone. Since surgical resection was impossible, our patient was given external beam radiation therapy at a dose of 60 Gy. At 12 months follow-up, local control was good without significant toxicity. CONCLUSION: External beam radiation therapy seems to be a good alternative therapy for local control of carotid paragangliomas if surgical resection is impossible.

[Phyllodes tumors of the breast: analysis of 53 patients]. / Tumeurs phyllodes du sein à propos de 53 cas.

PURPOSE: Phyllode tumors of the breast are fibroepithelial tumors similar to fibroadenomas but with a predominant conjunctive tissue component. These are composed of a connective tissue stroma and epithelial elements. They are rare with an incidence of 0.3-0.9% of all breast neoplasms. The present study demonstrates the recent experiences in diagnosis, therapeutical management and clinical follow-up of this disease. PATIENTS AND METHODS: This is a retrospective study of the experience of the Institut National d'Oncologie (INO, Rabat) from 1998 to 2006. RESULTS: We included 53 patients. Median age was 37.2 years (15-67), tumor size was 1-30cm (median 10.25cm). The histological diagnosis was based on the biopsy in (7.8%) cases and extemporany in 22% cases, distant metastasis occurred in two patients; the treatment consisted of a surgery. The median follow-up was three years. Local recurrence occurred in ten patients. Distant metastasis occurred in two patients and five patients have died. CONCLUSION: The confrontation of our results to the data of the international literature shows that the diagnosis of the phyllodes tumours is histological. The basis of the treatment is surgery. The adjuvant radiotherapy is very important in patients at high risk for local recurrence; chemotherapy has a badly defined place. The prognostic is based on the histological characters of the tissue conjunctive component of these tumours.

Cerebellous metastases in patients with uterine cervical cancer. Two cases reports and review of the literature.

Brain metastases from cervical cancer are extremely rare. We report on two patients who developed cerebellous metastases following uterine cervical cancer. The interval between diagnosis of the primary cancer and diagnosis of brain metastasis was 8 months. The main complaint was symptoms of increased intracranial pressure and cerebellous syndrome. Surgical excision of the brain lesion followed by radiation therapy was performed in the first case. The second patient received palliative radiation therapy. The first patient died 8 months after diagnosis. The second patient is alive 2 months after diagnosis.

[Adenoid cystic carcinoma of the nasopharynx: a case report]. / Carcinome adénoïde kystique du nasopharynx: à propos d'un cas.

Nasopharyngeal adenoid cystic carcinoma is a rare tumor, few cases have been reported in the literature. The aim of this report is to present a new case of an adenoid cystic carcinoma of the nasopharynx. We report the case of a 50 years-old woman presenting with an adenoid cystic carcinoma of the nasopharynx with diffuse pulmonary metastasis. The treatment combined chemotherapy, based on cisplatin and adriamycin drugs, and palliative radiation therapy at the dose of 30 Gy. The patient died 6 months after diagnosis establishment. The best treatment of adenoid cystic carcinoma is complete surgical resection but extended resection can be difficult in some locations as nasopharynx. The adjuvant radiation therapy seems to improve local control.

[Primitive intracranial adenoid cystic carcinoma. A case report]. / Le carcinome adénoïde kystique primitif intracrânien. A propos d'une case.

We report the case of a 50-year-old woman presenting a primitive adenoid cystic carcinoma of the middle part of skull base diagnosed by transphenoidal biopsy. She was treated by exclusive radiation therapy with cobalt 60 1.25 MeV and the dose received was 66 Gy in 33 fractions. Our patient remains alive 50 months after the completion of treatment. Adenoid cystic carcinoma is a slow growing malignant tumor with perineural invasion which arises more frequently from salivary glands. The occurrence of primary intracranial adenoid cystic carcinoma is exceptional. The best treatment is radical surgery followed by radiotherapy. Chemotherapy is rarely used. Prognosis is worse than for salivary glands.

[Central nervous system germinoma: retrospective study of six cases]. / Les germinomes du système nerveux central: étude rétrospective de six cas.

PURPOSE: Retrospective analysis of six patients with intracranial germinoma treated in INO and a literature review. MATERIALS AND METHODS: Six patients were treated from 1993 to 1998, for histologically verified primary intracranial germinoma. Median age was 18 years (range: 14-26 years). All patients received chemo-radiotherapy (4FP + radiotherapy from 30 to 50 Gy). RESULTS: 4 tumours were in complete remission. Two patients have kept non-evolutive residual cyst. Five patients are alive with non-evolutive disease after 15-40 months of follow-up (average: 27 months). One patient was lost to follow-up, 14 months after treatment, without disease. CONCLUSION: The treatment of intracranial germinoma is currently first line chemotherapy followed by low-dose and limited irradiation.

[Intracranial Hodgkin disease: case report]. / Localisation intracrânienne de la maladie de Hodgkin: à propos d'un cas.

Hodgkin disease intracranial lesions are uncommon. We report the case of a 24-year-old man who presented with an intracranial relapse without other evidence of disease 24 months after multiple drug therapy and extended field radiation therapy for stage III Bb type 3 Hodgkin disease. The patient was treated by whole brain irradiation (40 Gy/20 fractions/4 weeks). Six months after completion of therapy, the patient had a second relapse, with bilateral inguinal metastatic nodes, which were treated by a second line polychemotherapy. The patient was free of disease 9 months later.