[French ccAFU guidelines - update 2020-2022: prostate cancer]. / Recommandations françaises du Comité de cancérologie de l'AFU ­ actualisation 2020­2022 : cancer de la prostate.

OBJECTIVE: - The purpose of the guidelines national committee ccAFU was to propose updated french guidelines for prostate cancer. METHODS: - A Medline search was achieved between 2018 and 2020, as regards diagnosis, options of treatment and follow-up of prostate cancer (PCA), and to evaluate the different references specifying their levels of evidence. RESULTS: - The guidelines outline the genetics, epidemiology and diagnosis of prostate cancer, as well as the concepts of screening and early detection. MRI, the gold standard imaging test for localized cancer, is indicated before prostate biopsies are performed. The therapeutic methods are detailed and indicated according to the clinical situation. Active surveillance is a reference therapeutic option for low-risk tumours with a low evolutionary risk. Early salvage radiotherapy is indicated in case of biological recurrence after radical prostatectomy. Androgen deprivation therapy (ADT) remains the backbone therapy in the metastatic stage. Docetaxel in combination with ADT improves overall first-line survival in synchronous metastatic prostate cancer. In this situation, the combination of ADT with abiraterone is also a standard of care regardless of tumor volume. Recent data indicate that ADT should be indicated with a new generation of hormone therapy (Apalutamide or Enzalutamide) in metastatic synchronous or metachronous patients, regardless of tumour volume. Local treatment of prostate cancer with radiotherapy improves survival in synchronous oligometastatic patients. Targeted treatment of metastases is being evaluated. In patients with castration-resistant prostate cancer (CRPC), new therapies that have emerged in recent years help to better control tumor progression and improve survival. CONCLUSION: - These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : cancer de la prostate French ccAFU guidelines ­ Update 2018­2020: Prostate cancer / Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : cancer de la prostate.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C'est cette nouvelle version qui doit être utilisée pour citer l'article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

[French ccAFU guidelines - Update 2018-2020: Prostate cancer]. / Recommandations françaises du Comité de Cancérologie de l'AFU ­ Actualisation 2018­2020 : cancer de la prostate.

OBJECTIVE: The purpose of the guidelines national committee ccAFU was to propose updated French guidelines for prostate cancer. METHODS: A Medline search was achieved between 2016 and 2018, as regards diagnosis, options of treatment and follow-up of prostate cancer, and to evaluate the different references specifying their levels of evidence. RESULTS: Epidemiology, classification, staging systems, diagnostic evaluation of prostate cancer are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of≥76Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high-risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a standard. In this situation, the combination of ADT and abiraterone acetate also becomes a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival. CONCLUSION: These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer.

[CCAFU french national guidelines 2016-2018 on prostate cancer]. / Recommandations en onco-urologie 2016-2018 du CCAFU : Cancer de la prostate.

OBJECTIVES: The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa). METHODS: A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence. RESULTS: Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of > 74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival. CONCLUSIONS: These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.

[Prostate cancer imaging: MRI and nuclear imaging]. / Imagerie du cancer de la prostate : IRM et imagerie nucléaire.

OBJECTIVES: Multiparametric magnetic resonance imaging (mp-MRI) and Tomography with Emission of Positons are increasingly used in prostate cancer. MATERIALS AND METHOD: A systematic review of the scientific literature was performed in the Medline database (PubMed), using different associations of the following keywords: MRI, PET MRI, prostate cancer. RESULTS: Accuracy in the detection of prostate cancer is improved by the combined use of standard T2-weighted MR imaging and advanced functional MR imaging techniques such as diffusion-weighted imaging and dynamic contrast-enhanced imaging. Multiparametric MR imaging provides the highest accuracy in detection, localization, and staging of prostate cancer. This accurate assessment is a prerequisite for optimal clinical management and therapy selection. Another recent advancement in the field is MR imaging guidance for targeted prostate biopsy, which is an alternative to the current standard of transrectal ultrasonography-guided systematic biopsy. Prostate MRI plays also an important role in tumor detection when there is clinical or biochemical suspicion of residual or recurrent disease after treatment. The emergence of new technologies such as Tomography with Emission of Positons (TEP) after injection of 18F-choline, allows to improve the staging of prostate cancer (nodes status, sentinel node and occult metastases) and thus to change the management, especially when relapse. CONCLUSION: The first results with modern imaging are already very promising, and numerous prospects are expected, either by improving technologies (parametric fusion of PET and MRI) or the appearance of new tracers more sensitive and more specific than the choline. Bone scan still retains an important place especially since its realization is now coupled with a tomographic study merged with a low dose scanner, thereby remarkably improving its diagnostic performance.

[Focus: Prostate cancer and PET-choline]. / Mise au point: TEP-choline et cancer de la prostate.

PET with (18)F-Fluorocholine has authorization for the diagnosis of bone metastases. There are no limitations to the realization of this exam but androgen deprivation treatment should not be initiated or modified before performing TEP-choline. Some studies have shown a good correlation between choline uptake within the prostate and the tumor, if the size is greater than 5 mm; this exam is interesting in case of negative biopsy. In the initial staging of high-risk prostate cancer, metastatic nodes could be detected if there are more than 5 mm, especially those localized outside the lymphadenectomy area. TEP-choline is the most efficient exam that could detect intra-medullary bone metastases. It could realize the staging N and M in one procedure, and it could replace conventional imaging exams to detect lesions at an early stage. In the evaluation of recurrent disease, TEP-choline is able to detect the site of relapse--local, pelvic nodal or bone metastases--from a threshold of 1 ng/mL, less if the velocity value is greater than 1 ng/mL per year or the doubling time less than 6 months. For low PSA value, (around 5 ng/mL), relapse is usually isolated, either be local or nodal or metastatic. TEP-choline could be carried out in a first intention to consider a local salvage treatment. Bladder accumulation of choline can hide local small volume recurrence: overcome this drawback by the administration of Furosemide. In case of high-level PSA, Standard examinations (scintigraphy, CT…) are sufficient to detect the site of relapse.

[The non-hormonal treatment of metastatic prostate cancer]. / Le traitement non hormonal de la maladie métastatique du cancer de la prostate.

AIM: To describe drugs used in the non-hormonal treatment of metastatic prostate cancer. MATERIAL: Bibliographical search was performed from the database Medline (National Library of Medicine, PubMed) and websites of the HAS and the ANSM. The search was focused on the characteristics, the mode of action, the efficiency and the side effects of the various drugs concerned. RESULTS: The metabolic radiotherapy although under-used for this indication, kept a place at the beginning of the disease. Radium-223 chloride seems to have to occupy an important place in the coming years. The chemotherapy, the only recourse until very recently in the castration-resistant prostate cancer, must redefine its place partially. The denosumab provide an interesting alternative to bisphosphonates. CONCLUSION: The non-hormonal treatment of the metastatic disease of the prostate cancer is changing rapidly with the emergence of new molecules. Urologist must know perfectly these new drugs.

[Positron emission tomography for volume delineation of pelvic nodal involvement]. / Place de la tomographie par émission de positons dans la délinéation des aires ganglionnaires pelviennes.

Radiotherapy planification has recently known important developments, with the rise of new technologies, such as conformational radiation therapy, intensity-modulated radiation therapy (IMRT) or stereotaxic radiation therapy. Delineation of target volumes has become primordial. Hybrid imaging by positron emission tomography associated to computed tomography scanner (PET-CT) gives an access to functional and morphological information. Radiotherapist and nuclear physicians working closely have the potential to allow a more optimal delineation, and a better preservation of organs at risk. During the past few years, this has been explored by many articles, and we propose a literature review organized by localization, about the use of PET-CT for pelvic nodes delineation.

Long-term follow-up of patients with papillary and follicular thyroid cancer: a prospective study on 715 patients.

PURPOSE: This prospective study evaluated the recurrence rate in 715 patients with differentiated thyroid cancer who had no evidence of persistent disease after total thyroidectomy and lymph node dissection in 94% of them followed up by radioiodine ablation (30-100 mCi) and assessed the predictive value of the initial thyroglobulin (Tg) levels for detecting recurrence, both during levothyroxine (LT4) treatment and after TSH stimulation. PATIENTS AND METHODS: Patients had Tg determinations performed at 3 months on LT4 treatment (Tg1) and at 9-12 months after stimulation by either thyroid hormone withdrawal or recombinant human TSH (Tg2); the Access kit was used (functional sensitivity of 0.11 ng/ml); they had undetectable anti-Tg antibodies. Patients were followed up annually. Predictive values were calculated by comparing Tg levels (Tg1 and Tg2) and the outcome in terms of recurrence. RESULTS: During the median follow-up of 6.2 yr, 32 patients had a recurrence. Assuming a cutoff level for Tg1 at 0.27 ng/ml, Tg1 sensitivity and specificity reached 72 and 86%, respectively, whereas predictive positive and negative values were 20 and 99%, respectively. With a cutoff level for Tg2 at 1.4 ng/ml, sensitivity and specificity reached 78 and 90%, respectively, whereas positive and negative predictive values were 26 and 99%, respectively. CONCLUSION: This large prospective cohort of patients presented a low rate of recurrence. Initial Tg measurements allow to predict long-term recurrence with an excellent specificity. Stimulated Tg determination presented a slightly higher sensitivity than Tg determination on LT4. TSH stimulation may be avoided when Tg measured 3 months after ablation is less than 0.27 ng/ml during LT4 treatment.

Accuracy of 18-fluoro-2-deoxy-D-glucose positron emission tomography in the pretherapeutic detection of occult para-aortic node involvement in patients with a locally advanced cervical carcinoma.

PURPOSE: Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node involvement at initial assessment. 18-Fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging. METHODS: Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement. RESULTS: A total of 125 LACC patients (stage IB2-IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (n = 117) or laparotomy (n = 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases. CONCLUSIONS: Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.

Sentinel lymphadenectomy for the staging of clinical axillary node-negative breast cancer before neoadjuvant chemotherapy.

BACKGROUND: Several authors reported sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NC). Nevertheless, the ideal time of SLNB is still a matter of debate. METHODS: We evaluated the feasibility and the accuracy of SLNB before NC using a combined procedure (blue dye and radio-labelled detection) before NC. Axillary lymph node dissection (ALND) was performed after completion of NC in a homogeneous cohort study with clinically axillary node-negative breast cancer. RESULTS: Among the 20 women who had metastatic SLNB (65%), 4 (20%) had additional metastatic node on ALND. By contrast, all the 11 women who had no metastatic SLNB had no involved nodes in the ALND. The SLN identification rate before NC was 100% with any false negative. CONCLUSIONS: SLNB before NC is a feasible and an accurate diagnostic tool to predict the pre-therapeutic axilla status. These findings suggest that ALND may be avoided in patients with a negative SLNB performed before NC.

Radioisotope guided sentinel lymph node dissection in patients with localized prostate cancer: results of the first 100 cases.

AIMS: The purpose of this prospective study was to assess the results and the relevance of radioisotope guided pelvic lymph node dissection (PLND) in loco-regional staging in patients with clinically localized prostate cancer. METHODS: A total of 100 patients with prostate cancer underwent radioisotope guided PLND. Eighty-seven patients were candidates for retropubic radical prostatectomy and 13 underwent radiotherapy. The 72 first patients received 2 x 0.3 ml of 30 MBq-nanocolloid-99mTc and the next 28 patients received 2 x 0.3 ml of 100 MBq. Sentinel lymph nodes (SLNs) were detected intraoperatively with a gamma probe. RESULTS: A median number of three SLNs was removed per patient. SLNs were located outside obturator fossa in more than two thirds of patients. Lymph node involvement was observed in 12% of patients. Fifty percent of the LNM were outside obturator fossa;41.6% of lymph node metastases (LNM) were lying at the first centimeters of the hypogastric artery. Eleven of the 13 LNM were detected in the SLN. The two non-SLN (NSLN) involved nodes were found in two patients who failed the sentinel lymph node procedure. Each of 12 patients had pre-operative PSA above 10 ng/ml and Gleason score > or = 7. CONCLUSIONS: Limited PLND to obturator fossa is clearly insufficient for accurate lymph node staging in patients with prostate cancer. SLN procedure could be an alternative for pelvic lymph node staging with an excellent sensitivity in patients with unfavorable prognostic factors (PSA >10 ng/ml; biopsy Gleason score >6).

[Role of FDG PET-CT in cutaneous melanoma]. / Place de la TEP-TDM au FDG dans le mélanome cutané

PURPOSE: The indications of FDG PET-CT are well established for some neoplasms, such as lung cancer and lymphoma. The role of FDG PET-CT for the management of cutaneous melanoma is less clear. METHODS: We successively describe the substances and machines used with PET-CT, and review the French recommendations and the latest scientific articles to determine which patients could benefit from this examination. RESULTS: PET-CT is not indicated for the diagnosis of the malignancy of a suspicious cutaneous lesion, or for initial regional node staging. PET-CT is not indicated for the initial staging of melanoma without node involvement. PET-CT could be proposed for the staging of thick melanoma with macroscopic involvement of the sentinel node. PET-CT is useful for distant staging. The sole curative treatment of melanoma being surgery, the most useful indications of PET-CT are preoperative staging of one (or more) nodal or distant metastases, whether histologically confirmed or not. Preoperative PET-CT can spare a patient with unknown metastases a useless surgery. PET-CT is not indicated for the staging of a patient with known inoperable metastatic disease. PET-CT is not indicated for assessing response to chemotherapy, except in clinical trials.

Comparison of seven serum thyroglobulin assays in the follow-up of papillary and follicular thyroid cancer patients.

BACKGROUND: Serum thyroglobulin (Tg) is the marker of differentiated thyroid cancer after initial treatment and TSH stimulation increases its sensitivity for the diagnosis of recurrent disease. AIM: The goal of the study is to compare the diagnostic values of seven methods for serum Tg measurement for detecting recurrent disease both during L-T4 treatment and after TSH stimulation. METHODS: Thyroid cancer patients who had no evidence of persistent disease after initial treatment (total thyroidectomy and radioiodine ablation) were studied at 3 months on L-T4 treatment (Tg1) and then at 9-12 months after withdrawal or recombinant human TSH stimulation (Tg2). Sera with anti-Tg antibodies or with an abnormal recovery test result were excluded from Tg analysis with the corresponding assay. The results of serum Tg determination were compared to the clinical status of the patient at the end of follow-up. RESULTS: Thirty recurrences were detected among 944 patients. A control 131I total body scan had a low sensitivity, a low specificity, and a low clinical impact. Assuming a common cutoff for all Tg assays at 0.9 ng/ml, sensitivity ranged from 19-40% and 68-76% and specificity ranged from 92-97% and 81-91% for Tg 1 and Tg2, respectively. Using assays with a functional sensitivity at 0.2-0.3 ng/ml, sensitivity was 54-63% and specificity was 89% for Tg1. Using the two methods with a lowest functional sensitivity at 0.02 and 0.11 ng/ml resulted in a higher sensitivity for Tg1 (81% and 78%), but at the expense of a loss of specificity (42% and 63%); finally, for these two methods, using an optimized functional sensitivity according to receiver operating characteristic curves at 0.22 and 0.27 ng/ml resulted in a sensitivity at 65% and specificity at 85-87% for Tg1. CONCLUSION: Using an assay with a lower functional sensitivity may give an earlier indication of the presence of Tg in the serum on L-T4 treatment and may be used to study the trend in serum Tg without performing any TSH stimulation. Serum Tg determination obtained after TSH stimulation still permits a more reliable assessment of cure and patient's reassurance.

Patients' and surgeons' perspectives on axillary surgery for breast cancer.

AIMS: The objectives of this study were to compare the postoperative morbidity of Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) and to compare the views of surgeons and patients regarding postoperative morbidity. METHODS: A prospective and comparative study was initiated to evaluate, 1 year after surgery, morbidity and sequelae after SLNB in 231 patients. Group I (n=141) underwent SLNB without ALND, group II (n=90) underwent SLNB followed by ALND when SLN where involved. Morbidity analysis was performed, respectively, by surgeons and patients. RESULTS: One hundred and eighty-five patients (80.5%) completed the questionnaire including 113 with SLNB alone, and 72 with ALND. One year after surgery, SLNB produced less morbidity than ALND for symptoms and function. There were significantly different assessments between surgeons and patients for pain, arm mobility and sensitiveness. CONCLUSIONS: One-year postoperative morbidity after SLNB is significantly lower than after ALND but views of surgeons and patients appears to be significantly different. Additional data are required to assess late consequences of axillary surgery.

Hodgkin's disease: prognostic role of gallium scintigraphy after chemotherapy.

Evaluation of the response to therapy is important for optimal selection of treatment strategy in patients with Hodgkin's disease (HD). Refractory disease requires intensive high-dose chemotherapy, whereas unnecessary treatment should be avoided in patients in complete remission. The purpose of this study was to evaluate the contribution of gallium-67 scintigraphy in predicting the clinical outcome in patients with HD and mediastinal involvement on the basis of scan results at the end of chemotherapy. Seventy-four patients with HD and mediastinal involvement were retrospectively investigated with 67Ga scintigraphy 72 h after injection of 220 MBq 67Ga citrate (planar and single-photon emission tomographic studies) following the completion of chemotherapy. At the same time, they all underwent computed tomography (CT). Patients were followed up for an average of 63 months (range 28-124 months). The disease status was newly diagnosed disease in 64 of the patients and relapse in 10. Systemic symptoms were absent (A) in 34 cases and present (B) in 40 cases. Forty-one patients had stage I or II disease and 33 patients had stage III or IV disease. Twenty-two patients had bulky disease on initial diagnosis. At the end of chemotherapy, all 74 patients showed regression of the mass by more than 50% (50%-100%) on CT. Patients were divided into two groups according to the positivity or negativity of the gallium scan after chemotherapy: 61 patients had negative and 13 patients had positive gallium scans. In the gallium-negative group, 19.7% of the patients relapsed and 91.8% were alive at the end of the follow-up. Relapse occurred in 20% of the patients with residual mass and in 19.6% of the patients without residual mass. In the gallium-positive group, 84.6% of the patients had recurrent disease and 61.5% were alive after intensive chemotherapy. There was a statistically significant difference in overall survival between patients with positive and patients with negative gallium results (P=0.0034). Disease-free survival differed significantly between patients with positive and patients with negative gallium scans at the end of chemotherapy (P<0.0001). The relative risk of death was 5.2 and the relative risk of relapse was 11.3 for patients with positive gallium scans, in comparison to those with negative gallium scans. The positive and negative predictive values for predicting relapse were 85% and 87%, respectively. It is concluded that even if gallium scan is performed at the end of chemotherapy, it can predict outcome. Alternative therapy may be required on the basis of gallium scan results obtained after treatment.

Thallium-201 perfusion scintigraphy in the evaluation of late myocardial damage in left-side breast cancer treated with adjuvant radiotherapy.

PURPOSE: To evaluate late myocardial damage after adjuvant radiotherapy using a mixed-beam (photons plus electrons) technique to treat the internal mammary lymph nodes in left-side breast cancer. METHODS AND MATERIALS: A bicycle ergometer stress test coupled with thallium-201 perfusion scintigraphy and analysis by single-photon computed tomography (CT) was performed on 19 patients treated with left-side breast/chest wall and internal mammary radiation for breast cancer between 1987 and 1993. To be sure that we would evaluate late toxicity caused by the irradiation, patients had to fulfill the following eligibility criteria: left-side breast cancer, treatment between 1987 and 1993 and no recurrence during follow-up, age < or = 75 years, no known risk for coronary artery disease, no previous chemotherapy, internal mammary field treated with an association of photons and electrons, and CT scan-based treatment planning. RESULTS: Median age at scintigraphy was 59 years. Two patients did not reach optimal exercise level and were not evaluable. Among the 17 evaluable patients representing 91.6 patient years of follow-up, there were no perfusion defects by visual or quantitative analysis. CONCLUSION: The mixed-beam technique seemed to spare the heart from harmful irradiation and to protect the myocardium. Results need to be confirmed on the long-term use of this technique.