Urinary system tumors
Urinary system cancers are principally prostate cancer, kidney cancer and bladder cancer.
PROSTATE CANCER
Overview
Prostate cancer is the commonest cancer in men. Its progress is generally slow, and symptoms sometimes remain hidden for several decades.
The risk of prostate cancer increases with age and with a family history. Dietary factors, such as a diet too rich in meat or fat, may also play a part. In Belgium, about 9,000 new cases occur each year.
The most suitable treatment for each patient therefore needs to be defined after considerable thought, involving specialists from many different fields. It is not always easy to predict how this cancer will develop.
Symptoms and screening
Prostate cancer does not generally produce any symptoms, except when advanced or if there are urinary manifestations (difficulty in urinating, frequent desire to urinate). Bone problems (pains in the bones or fractures) may occur.
As there are no symptoms in the early stages, early diagnosis of the disease requires screening.
Screening involves palpating the organ during a rectal examination, and measuring PSA (prostate specific antigen) concentrations in the blood. PSA is specific to the prostate but not to cancer. In other words, increased concentrations of this antigen can be caused by other prostate problems, such as infection.
For this reason, use of PSA is currently being called into serious question. Thankfully, new tests are being studied, such as searches for cancer cells in urine (PCA3 test), available at Cliniques Universitaires Saint Luc (Figure 1).
Treatment
If cancer is discovered during screening, initial treatment will not always be necessary. Some cases of the disease is not aggressive and will be of little or no consequence. In other cases, there is a greater likelihood of rapid development and treatment will be necessary immediately upon diagnosis.
The best approach therefore needs to be defined according to the characteristics of the cancer discovered, and to ensure that treatment best preserves the patient’s quality of life.
At a more advanced stage, anti-hormonal treatment is usually used. New drugs are being used as part of studies being conducted by our centre in association with other European and American centres. Investigations are concentrating on the importance of treatment combining hormone therapy and chemotherapy.
Preserving quality of life remains a major concern, whatever the treatment accepted, and it therefore needs to be reliably assessed. Removal of the prostate, the procedure in treatment of localised cancers, can lead to sexual problems and urinary incontinence. The multidisciplinary team dedicated to treatment of prostate cancer, has produced tools that help assess the risk of such complications, and, should they occur, define and reduce their impact on a patient’s well-being.
Effective hormone therapy, the main treatment given in advanced cases, carries a risk of side effects such as hot flushes or reduced sexual performance. Specialists in the multidisciplinary group have set up a national communication campaign aimed at informing doctors and some 22,000 patients on the effects of hormone therapy.
Finally, advanced cases of the disease often present bone metastases. It is important to diagnose these rapidly and to assess new treatments currently becoming available. The multidisciplinary team for urinary cancers has, with help from the Fondation Saint-Luc, developed a magnetic resonance imaging (MRI) tool that reveals bone metastases at a very early stage and monitors their size during treatment. Its technology produces three-dimensional images of bone marrow (Figure 3), and is now being used in numerous other reference centres in Europe.
KIDNEY, BLADDER AND TESTICULAR CANCER
Kidney cancer, an uncommon tumour, presents few symptoms and is often discovered by chance during an X-ray examination. It can be triggered by a genetic predisposition.
Surgery has long since been the only form of treatment and remains the procedure of choice if the cancer has not spread. It involves removal of the kidney (nephrectomy), which is usually partial, as the cancers discovered today are small. Partial nephrectomy is less drastic than total or radical nephrectomy, and as such is better tolerated.
The arrival of targeted therapies, drugs capable of targeting the finely balanced mechanisms behind kidney cancer, is a major step forward in treatment of advanced cases of the disease. These treatments are available at our centre.
This cancer, slightly commoner than kidney cancer, is treated locally either by removal of superficial lesions or by removal of the bladder (cystectomy). If metastases are involved, treatment will involve chemotherapy.
Testicular cancer is the commonest cancer in young adults. The condition can often be cured, but a multidisciplinary care approach is required.
Locomotive system or Sarcoma
Sarcomas are rare (1% of all cancers). Their treatment is complex and very specialised, requiring the experience of diagnosticians (radiologists, pathologists etc) and therapists (surgeons, radiotherapists and medical oncologists) who discuss the best treatment for patients on the basis of up-to-date scientific information, at multidisciplinary meetings.
About one hundred bone and supporting tissue tumours are treated at the Cliniques Universitaires Saint-Luc Cancer Centre each year. This accounts for about one fifth of all sarcomas treated in Belgium.
Diagnosis of sarcoma is complex, principally because of the wide variety of cancer locations and types. Sarcomas, in fact, are a highly varied group of cancers.
The variable nature and infrequent occurrence of sarcomas mean that there are still only a few teams with the experience necessary to care for them optimally.
Sarcomas are classified according to origin. Osteosarcoma indicates a sarcoma that develops from bone; liposarcoma indicates a sarcoma that develops from the fatty tissue that surrounds bone and muscles, and rhabdomyosarcoma, commoner in children, develops from the striated muscles.
SYMPTOMS AND DIAGNOSIS
Sarcoma most often appears as a mass, a “ball” that increases in volume. This mass is often located around the thigh or knee, but can occur anywhere in the body.
Osteosarcoma can cause persistent pain. Its presence is revealed through an X-ray taken to determine the cause of the pain. Less frequently, a fracture can also reveal bone sarcoma.
More rarely, pain is a warning sign of other types of sarcoma. In these cases, it can show itself in arching or other disabling deformities. Any unusual mass in soft tissue may appear in an ultrasound for superficial locations or in a magnetic resonance image for deep locations.
The cause of sarcoma is not well understood. There is a genetic influence in some cases.
Imaging, microscope examinations and genetic analysis guide the treatment strategy
The strategy to be followed during the treatment is finely balanced. Diagnosis must usually be confirmed through a biopsy, in which a sample of abnormal tissue is taken for microscope examination. This allows the type of sarcoma, and therefore the required treatment, to be determined. A very strict assessment of the extent of the tumour, using imaging techniques (conventional radiology, magnetic resonance imaging, scans etc) also allows helps identify the mass and locate it in relation to anatomical landmarks, thus avoiding drastic surgical procedures. This tumour mapping is essential for extended examination and planning of treatment.
Finally, identifying genetic characteristics of sarcoma is very useful. It defines the type of disease and determines the behaviour of the tumour more accurately, allowing adaptation of the treatment.
Genetic analysis is also useful in assessing the risk of cancer in a patient’s descendants.
Examining a tumour sample under the microscope, and extended examination through imaging, are essential to prevent insufficient or excessive surgery.
Identifying the genetic characteristics of certain sarcomas helps predict their development and adjust the treatment accordingly.
TREATMENT
Specific surgery
Surgery is the cornerstone of treatment. Operations to remove sarcomas are generally complex, involving removal of the cancer and sometimes reconstruction through bone transplants or artificial joints, or a combination of the two. This sophisticated approach helps preserve limb function as far as possible.
Modern imaging techniques allow a choice of transplant best suited for the reconstruction process to be made from the bone bank.
Progress in sarcoma treatment has considerably reduced the number of amputations; this is now only needed in less than 5% of all cases.
Radiotherapy and chemotherapy
Radiotherapy will be indicated according to type of surgery and size, location and grade of tumour.
For some tumours, radiotherapy is sometimes planned in addition to an operation. It makes the operation less drastic, while providing an equivalent rate of localised control.
Chemotherapy is also a treatment tool. Indeed, it is the basic treatment for childhood tumours.
In adults, chemotherapy is reserved for specific types of tumour or for more advanced stages.
In some cases, however, chemotherapy has to be administered before the operation to ease surgical removal of the tumour. Treatment with chemotherapy also reveals how sensitive the sarcoma is to chemotherapy; this can then be taken into account when determining the treatment to follow the surgery.
Epargner au maximum les tissus sains environnants
Much progress has therefore been made in treatment of sarcoma, on many sides. Diagnosis has been refined, tumour behaviour is better understood, more effective surgery can be given, and additional treatments, such as radiotherapy and chemotherapy, have been optimised.
Colo-rectal Tumours
TUMOURS OF THE COLON AND RECTUM: COLO-RECTAL CANCER STUDY CENTRE
The treatment of colon and rectal cancer requires a multidisciplinary approach in which sharing of knowledge by every specialist involved in diagnosing and treating cancer leads to true synergy and “tailor made” treatment for each patient.
For colon and rectal cancer, this multidisciplinary approach, effective for over 10 years now, has been applied successfully by the CPTCR or Cancer and Colo-Rectal Studies Centre.
EPIDEMIOLOGY
Over 7,000 cases of colon or rectal cancer are diagnosed in Belgium each year. This type of cancer is the third commonest in men, after lung and prostate cancer. In women, it is second behind breast cancer.
We treat almost 200 patients suffering from these tumours each year. Of this total, about fifty are cases of rectal cancer. Although the term “colo-rectal cancer” is often used in everyday language, it is more correct, especially when referring to treatment, to draw a distinction between colon cancer and rectal cancer.
If diagnosed and treated at an early stage, colon cancer can be cured in 95-100% of cases. Screening is therefore of utmost importance.
RISK FACTORS
Some colo-rectal cancer cases are “sporadic”, that is, they occur in isolation in patients not really predisposed to the condition. Others occur in families that show a clear genetic predisposition.
Sporadic cancers usually occur at age 65-70. Excessive consumption of red meat, not enough fibre in the diet, and lack of physical exercise, can favour it. Environmental factors are also implicated.
Finally, inflammatory intestinal conditions, such as Crohn’s Disease and haemorrhagic or ulcerative colitis, can also contribute.
Sporadic colo-rectal cancer develops slowly; several decades can pass between its inception and the onset of initial symptoms.
Familial adenomatous polyposis is a hereditary pre-cancerous condition in which a mutant gene is passed from one generation to the next. This disease accounts for 1% of colo-rectal cancer cases in Belgium. As the risk of malignant degeneration is 100%, preventive surgery, involving complete removal of colon and rectum and reconstruction of the intestinal tract, is necessary before the cancer appears.
The CPTCR members were among the first to research these mutations. They were therefore in on the beginning, in 1993, of the national polyposis register managed by FAPA (the Familial Adenomatous Polyposis Association).
Hereditary non-polyposis colo-rectal cancer, also known as Lynch’s syndrome, is another form of hereditary cancer, accounting for 5% of colo-rectal cancers.
Hereditary cancers occur at an earlier age than sporadic cancers. They are sometimes multiple and can affect other organs. This only stresses the importance of early detection in families at risk.
The genetic problem behind this cancer was discovered in 1998. Since then, it has been systematically looked for in all colonic tumours operated on at our centre. This process has enabled the diseases behind the problem to be identified and the necessary screening to be carried out within families affected, via genetic advice consultations.
Une partie de l'équipe de la Clinique des Pathologies Tumorales du Côlon et du Rectum
SCREENING
In families at risk, screening should begin before age 50, preferably at 40 or 10 years before the earliest cancer onset age within the family. In this case, screening should initially be carried out by means of coloscopy.
Colon polyps are lesions from which cancers develop. They very rarely present any symptoms. They can be removed during the coloscopy to prevent them from degenerating into cancer.
SYMPTOMS
A change in defecation patterns (unusual increase in frequency of stools, or alternating diarrhoea and constipation) is often a first sign of the disease. Bleeding through the anus can also indicate it. This loss can often be significant, but is frequently intermittent and wrongly dismissed as something trivial.
SURGICAL TREATMENT
Surgery is still the cornerstone for treatment of colo-rectal cancer. It is often combined with other treatments such as radiotherapy and chemotherapy.
The treatment programme is discussed during CPTCR meetings.
Surgical techniques have improved greatly. The laparoscopy has revolutionised surgical treatment of early-stage colon cancer, having been applied by the Colo-Rectal Surgery Unity since 1998. Its importance has now been clearly demonstrated.
During a laparoscopy, the surgeon views the operation site using a camera linked to an optical fibre, and handles instruments introduced into the interior of the body through small openings.
This approach helps preserve bodily integrity and removes tumours completely without excessive mutilation.
Post-operative complications are less frequent, as aesthetic consequences are very discreet. Recovery is much more rapid than with conventional surgery. Armed with its experience of the laparoscopy, our team has now produced the “fast track concept”, which reduces the impact of surgery on patients as far as possible, requiring a stay in hospital of only three days in most cases.
Surgical treatment of rectal cancer, like that of colon cancer, has some very specific aspects. Depending on the location and the extent of the tumour, three techniques are used.
Dissection intersphinctérienne partielle
Transanal endoscopic surgery allows small rectal tumours to be treated through natural channels. It is testimony to the efforts made to find a surgical technique that is both highly effective and much less invasive.
More advanced rectal cancer carries a higher risk of local recurrence. Its removal may lead to major changes in urinary function and sexual performance, in both men and women. It is therefore essential to choose a technique that helps prevent these complications. A technique known as “total mesorectal excision” completely removes the cancer while fully preserving both urinary function and sexual performance.
The CPTCR surgical team has been using this technique for over 10 years and is also involved in the “Procare” national teaching programme aimed at all surgeons wishing to learn the technique.
Previously, rectal surgery usually involved removal of the pelvic floor and anus, requiring insertion of a pocket or bag, also known as a stoma. Highly sophisticated sphincter protection procedures, pushed to the extreme and practised in reference centres, now mean that the anal sphincter can be preserved in some patients, thus sparing them the major inconvenience and discomfort of the stoma.
In cases of liver metastases, common in this type of cancer, each patient’s case is discussed jointly by specialists from the CPTCR and from the multidisciplinary Hepatic, Biliary and Pancreatic Cancer Group. To find out more about this multidisciplinary group, click here.
RADIO-CHEMOTHERAPY
Other treatments used in colo-rectal cancer cases are radiotherapy and chemotherapy. Radiotherapy is used only in cases of rectal cancer, not for colon cancer, and is not indicated in cases of advanced rectal cancer.
Chemotherapy can also be very useful after surgical treatment of certain rectal or colonic cancers.
Major steps have been made in pharmacological treatment of colo-rectal cancer. New “target” treatments have been introduced and are being used within huge international studies in which reference centres, such as our centre, take part. Most treatments are given intravenously in the outpatients’ department, meaning that patients do not have to be admitted to hospital. Some drugs are also administered orally.
Système de drains, capteurs de pression et de température en place pour la chimio-hyperthermie intra-péritonéale à ventre fermé
Finally, intraperitonal chemohyperthermia or “CHIP”, for generalised colo-rectal cancer within the abdomen, is another fruit of the multidisciplinary approach. Used in some cases of generalised colo-rectal cancer, it involves complete removal of all intraperitonal tumour tissue followed by localised heated chemotherapy aimed at destroying any cancer cells that may have escaped the surgery.
These approaches are now improving patient prognoses and providing cures, even in advanced cases of the disease.
RESEARCH
In addition to clinical research, our multidisciplinary group is also distinguished for its intensive basic research.
Two post-graduate students are working within the group, one on the basic mechanisms behind colo-rectal cancer and the other on the risk factors for recurrence of the cancer. They work closely with the National Cancer Register, within the framework of the Procare national project, in which all the CPTCR specialists are heavily involved.
Endocrine and thyroid tumours
EPIDEMIOLOGY
Thyroid cancer is rare, with an annual incidence of between 2.2 and 3.5 per 1,000 in the United States. It has tended to increase in frequency in recent years, probably because of improvements in diagnostic methods, which have allowed tumours previously missed to be detected.
Thyroid cancer is commoner in women. It can be triggered by accidental exposure to ionising radiation and by genetic factors.
The diagnostic procedure for thyroid cancer is not an easy one, and an operation is not decided upon until after reflection between all specialists concerned: endocrinologists, radiologists, nuclear specialists, pathologists and surgeons. This multidisciplinary approach allows the most suitable treatment to be decided upon for each case discussed.
Cancer of the thyroid develops slowly and carries a favourable prognosis. There is however a risk of recurrence, mainly within 5-10 years, and regular monitoring will therefore be necessary.
SYMPTOMS
Thyroid cancer is sometimes visible or palpable: it causes a slight swelling, like a “ball”, at the base of the neck. Although it can cause hoarseness or problems with swallowing, it is often discovered quite by chance, during an X-ray examination of the neck in connection with something else.
DIAGNOSTIC
Diagnosis is based on imaging techniques and on fine-needle nodule puncture.A thyroid ultrasound will provide important information on “nodules”, which are small tumours that develop in the thyroid but are not necessarily cancer. The ultrasound is therefore combined with a puncture of the nodule, using a fine needle, and a microscope analysis of cells obtained from the puncture.
These examinations must be conducted very carefully in order to guarantee their reliability.
In some cases, a scintigraph is conducted in addition to the examination. This involves intravenous injection of a very small amount of radioactive substance, which the thyroid captures. An instrument placed close to the neck detects radiation given off by the product. Scintigraphy can help better define the characteristics of nodules. The information provided in these various examinations dictates the treatment chosen.
Difficulties encountered in diagnosis and treatment of thyroid cancer have led the European scientific community to put together a series of recommendations. The specialists in the thyroid cancer multidisciplinary group have played an active role in compiling these consensus texts. They have also conducted considerable research into factors that influence the development of thyroid cancer. Identification of these markets helps refine the treatment further.
Thyroid ultrasound, nodule puncture, microscope examination of puncture samples and scintigraphy are the principal diagnostic examinations for cancer of the thyroid.
Cancer thyroïdien papillaire
TREATMENT
The prognosis for thyroid cancer is generally good. Effective treatment depends first of all on an efficient surgical approach. Thyroid surgery, which involves complete removal of the gland (thyroidectomy), is difficult because of the proximity of the vocal cords and parathyroid glands. The parathyroid glands are small, very close to the thyroid, and help regulate calcium and phosphorus in the blood. The surgeon’s skill will help overcome the potential risks of this operation.
Administration of radioactive iodine sometimes follows the operation. Iodine is essential for synthesis of thyroid hormones, and radioactive iodine destroys the few cancer cells in the thyroid that might have escaped the surgery.
Additional treatment with radioactive iodine requires radioactivity protection measures to protect the immediate and more distant environment. The patient must kept for two to three days in a shielded isolation room.
Surgery and radioactive iodine will generally cure the cancer. Surveillance, essential because of a risk of recurrence, is straightforward and involves a test that is very reliable if conducted properly. In this case, levels of thyroglobulin in the blood must be measured.
Thyroglobulin, produced specifically by the cells in the thyroid gland, is the storage protein for thyroid hormones.
Numerous international studies are concentrating on treatment of thyroid cancer. Participation in these studies has provided patients at the Cancer Centre with treatment based on the most recent progress.
Adult haematology
OVERVIEW
Blood or “haematological” cancers are divided into five major groups: leukaemia, lymphoma, myeloproliferative syndrome, multiple myeloma and myelodysplasia.
EPIDEMIOLOGY
About 1,200 cases of lymphoma occur each year in Belgium; there are about 300 cases of acute leukaemia and 400 cases of myeloma. Our haematology department is a specialist centre in Belgium.
RISK FACTORS
Blood cancers are commoner in patients with reduced immunity. They are also triggered by excessive exposure to certain products, or handling of these products in the absence of basic precautions. These products include pesticides, insecticides, certain types of radiation, benzene, various solvents, and petrol. Smoking can harm the blood as well as other organs. There is very little, if any, evidence of a familial or genetic pattern.
SYMPTOMS AND DIAGNOSIS
Excessive bleeding, persistent infections, paleness, an enlarged ganglion, bone pains, and a fracture following a minor injury, can all be alarm signals. These signs are however hardly specific, also being found in many non-cancerous diseases.
Diagnosis therefore requires additional examinations. Blood tests determine concentrations of red cells, white cells and platelets, and reveal the presence of abnormal cells in blood. If necessary, bone marrow or ganglia will also be examined under a microscope. These examinations will require a biopsy and can lead to a diagnosis.
Research is now being conducted with the aim of better understanding the finely balanced mechanisms that determine behaviour of malignant blood cancer cells, with the constant aim of improving standards of treatment.
Finally, a PET scan can also be useful in confirming a diagnosis. This modern imaging technique can use a marker to determine the location and activity levels of abnormal ganglia.
The decision on the best treatment to provide depends on regular exchange between specialists who carry out laboratory examinations and those who specialise in the treatments.
TREATMENT
Chemotherapy plays an important role in the treatment of leukaemia and lymphoma. Treatment is given partly in hospital and partly in the outpatients’ department.
The Cancer Centre specialists dedicated to treatment of blood cancer were the first in Belgium to suggest this arrangement, which spares patients an excessively long stay in hospital. Fifty to sixty patients are now treated daily in the “day hospital”.
A bone marrow transplant or stem blood-cell transplant is carried out when conventional treatment does not control the disease sufficiently. An “allogeneic” transplant involves taking healthy bone marrow or stem blood cells from a compatible donor (often a family member) and implanting them in the patient. In an autologous transplant, the patient’s marrow is taken and transfused back following intensive treatment.
The multidisciplinary team dedicated to blood cancers was one of the first to use and successfully complete bone marrow transplants. It remains at the forefront in its field.
Targeted therapies, such as antibody transfusions and new drugs used in the treatment of certain blood cancers, are specific. In other words, they act on cancer cells and preserve the rest of the body. These recent medical treatments are an important step forward, improving both efficacy and tolerance, and have been the subject of international studies in which reference centres such as ours have played an active part.
All these advances mean that blood cancer prognosis has improved markedly in recent decades. Current treatment now allows many cancers, long since seen as lethal, to be cured.
Some cancers, however, react much less readily to this treatment. Research conducted at our Centre aims to expose the mechanisms behind this resistance to treatment so that an optimum approach can be offered even in the most difficult cases. These complex studies require laboratory researchers and clinicians to work closely together.
Collaboration between laboratory researchers and clinicians involved in large international studies allows patients to benefit from the most up-to-date and effective treatments.
Paedratic haematology and oncology
OVERVIEW
Cancer in children is relatively rare, with only 325 new cases diagnosed in Belgium each year. One quarter of all childhood cancer cases in our country are treated at the Paediatric Haematology and Oncology Department in the Cliniques Universitaires Saint-Luc Cancer Centre. This level of activity makes it the leading reference institution in French-speaking Belgium.
Blood cancer, or leukaemia, accounts for some 30% of childhood cancer cases. It is followed by cancers of the central nervous system (brain tumours) and lymphatic ganglion cancers, or lymphomas.
Some types of cancer are found only in children. These are embryonic tumours or blastomas. Cells in embryos have great powers of multiplication, as there are few of them and their ultimate task is to build an adult body.
Once the body is complete, the cells stop multiplying, but in blastomas, the growth continues. There are therefore nephroblastomas, which develop from embryo kidney cells, hepatoblastomas, which develop from embryo liver cells, and retinoblastomas, which develop from embryo cells in the retina. Retinoblastomas are rare and every case observed in our country is treated at the Cancer Centre, which is a Europe-wide reference centre for this condition.
Finally, sarcomas, such as bone cancers, are commoner in teenagers. These tumours are treated through joint work with specialists in surgery and radiotherapy, who also deal with adult tumours.
Each young patient’s case is discussed in multidisciplinary meetings, in which every specialist doctor involved in the diagnosis and treatment of paediatric tumours participates. The specialists meet together and decide on the best treatment for each individual patient, on the basis of diagnosis, standards of care, and recent scientific discoveries.
SYMPTOMS
Symptoms of cancer develop rapidly, that is, in a few weeks, in children. In leukaemia, blood cells cease to function normally. Changes in red cells cause pallor and tiredness, changes in white cells cause repeated infections, changes in platelets cause frequent bleeding, which is difficult to control. In addition, cancer cells invade the bones, causing “migratory” pain, so called because its location constantly changes.
Les symptômes traduisent l’altération de l’organe dans lequel la tumeur se développe : sang dans les urines lorsque le rein est atteint, jaunisse lorsqu’il s’agit du foie, fractures en cas d’atteinte des os …La place occupée par la tumeur peut la rendre visible ou palpable : gonflement dans le cou, palpation d’une masse dans le ventre…La compression provoquée par cette masse peut à son tour générer des symptômes, tels les maux de tête ou les nausées survenant en cas de tumeur au cerveau.
The symptoms show changes in the organ in which the tumour is developing: blood in urine when the kidneys are affected, jaundice if the liver is affected, fractures if bones are affected. The location of the tumour can make it visible or palpable, by producing swelling in the neck or stomach, etc. Compression caused by the mass can in turn generate symptoms, such as headaches or nausea in the case of a brain tumour
The rapid development of cancer in children requires immediate referral to a reference centre, which will have the necessary experience of this condition and access to the most up-to-date diagnosis and treatment techniques.
RISK FACTORS
There are few contributory factors to cancer in children. Some genetic problems can sometimes play a part. Research currently being conducted within our institution is aimed specifically at better identifying the genetic factors that favour the onset of retinoblastoma.
TREATMENT
Highly efficient imaging techniques, such as the PET Scan, now allow tumours to be better defined. So-called functional imaging, for example, marks cells that multiply rapidly in various areas of the body. The boundaries of a tumour can now be pinpointed with great accuracy, thus ensuring complete removal during an operation.
Chemotherapy, used in most types of paediatric cancer, is now becoming more effective and less toxic, and can bring about a complete cure in most cases. Large-scale studies are ongoing at international level to improve the results of chemotherapy still further. Patients in the Cancer Centre’s paediatric haematology and oncology group are included in controlled studies that deal with the newest drugs, and have access to modern treatments without having to travel abroad. Regular contact with other world experts, which is a prerequisite of the studies, guarantees good quality care.
In some indications, depending on the type or severity of the tumour in question, a bone marrow transplant can be envisaged. The paediatric haematology and oncology group is very experienced in this field, having been a pioneer in the technique of transplantation for various blood diseases. Transplants are carried out in a dedicated children’s department and overseen by paediatric haematologists and oncologists. There is no need for transfer to an adult department or to another institution.
Side effects associated with chemotherapy are now better controlled. Effective drugs can combat nausea and vomiting, and reduce the risk of infection. Laser treatment, which aims to prevent or treat irritations of the mucous membrane such as mouth ulcers, has improved, reducing pain and speeding up the formation of scar tissue.
Finally, progress in treatment is also linked to refinement of reconstructive surgery and to the possibility of more targeted administration of radiotherapy, that is, destruction of cancer cells and preservation of healthy tissue.
ACCOMPANIMENT
Despite progress in treatment, the discovery of cancer in a child is often difficult to accept. The care must therefore relate not only to the medical aspects but offer both social and psychological support to children and their families. A school based in the hospital allows children to continue with their education during their stay in hospital. Thanks to a number of different associations, the paediatric haematology and oncology group now offers various programmes and organises holiday camps and other functions.
>> Kidscancer.be
Hepato-Bilio-Pancreatic Tumours
Outline
Hepato-bilio-pancreatic tumours comprise tumours of the liver, biliary ducts and the pancreas. Ranked by order of frequency, after cancer of the colon and of the stomach, cancers of the pancreas are in third place on the list of digestive system cancers. The number of new cases annually in Europe is 80,000.
Cancers of the liver are especially common in China, Japan, and in Africa. In Europe, their rate is low, yet it has doubled in 25 years, mainly due to the epidemic of hepatitis C. As for tumours of the biliary ducts, these are rarer still, yet their frequency is also increasing at the same rate.
Just over two hundred hepato-bilio-pancreatic tumours were treated in 2007 at the Saint-Luc University Cancer Centre Clinics, and this number is constantly increasing. They are distributed into:
- tumours of the pancreas: 40 % new cases
- tumours of the liver: 50% of cases, of which hepatic metastases, which stem most often from cancer of the colon, but also from other locations (breast, endocrine tumours…) constitute 30% and basic tumours 20%.
- tumours of the extrahepatic biliary ducts: 5 %
- endocrine tumours: 5% of cases. These tumours stem from the cells of the pancreas which secrete hormones (insulin, gastrin…).
Treatment of these tumours requires a pluridisciplinary approach in which surgeons, medical oncologists, gastro-enterologists, radiologists, nuclear physicians, radiotherapists, anatomical-pathologists, take part. This pluridisciplinary group meets every week, sharing knowledge is indispensable to provide each patient with a treatment which corresponds best to their illness.
Symptoms
Pancreatic and biliary tumours are generally characterised by pain in the upper part of the abdomen, loss of weight and a yellow complexion. Primary tumours of the liver are often discovered by chance, for example during an echography carried out on a patient suffering from cirrhosis.
Symptoms of endocrine tumours vary according to the hormones produced by the tumour.
Risk Factors
Cancer of the pancreas can be hereditary. It can also come about from chronic inflammation of the pancreas, caused by alcohol and tobacco.
Primary liver cancers are followed by cirrhosis in 80% of cases, cirrhosis is caused by the hepatitis B or C virus, or by alcohol, whereas not much is known about the risk factors for biliary tumours and endocrine tumours.
Diagnosis
In addition to traditional radiological examinations, two specific techniques are particularly useful in diagnosing this type of tumour: echo-endoscopy and octreoscan.
Echoendoscopy is an examination which combines an endoscopy and an echography. An echography probe is brought close to the organ to be studied using an endoscope. It is useful for researching or examining lesions and the surrounding organs. It enables tissue samples to be taken by puncture, so they can be studied in cytology. Saint-Luc University Clinics have developed the technique since its introduction in 1986 and are seen as a European leader in this area. Click here to learn more about this technique.
Scintigraphy in the marked octreotide “octréoscan®”, is used in the diagnosis and in the study of the spread of endocrine tumours. At the Saint-Luc University Clinics, the nuclear medicine service was the first to carry out this examination in Belgium.
Treatment
Cancers of the pancreas can only be operated on from the outset in 15 to 20 % of cases. When the tumour is present in a regionalised spread, the treatment consists of a combination of radiotherapy and chemotherapy, sometimes followed by surgery. In the event of the spread being more considerable and of metastases, we turn to classic chemotherapy and/or new medications which have resulted from research findings.
In cancer of the liver, hepatic transplant opens up perspectives of complete cure, with a survival rate equal to that of patients who have had transplants for reasons other than cancer, that is a 70-80% chance of survival after 5 years. Cancers of the liver currently make up 40% of the indications of hepatic transplant at Saint-Luc. When transplantation is not possible, we turn to other exeresis treatments. These are based on surgery when this is possible, or on radiological techniques known as “interventional” which either allow the active medication to be transported to the tumour site via the vessels which provide the blood supply, or enable the tumour to be cauterized through the skin via an alcohol injection or the emission of a thermo-electric current. The latter technique, known as radiofrequency, destroys tumours by causing hyperthermia.
The treatment of hepatic metastases requires that certain rules be adhered to. Their removal must be complete, yet should also preserve a sufficient quantity of healthy tissue so that the liver can continue to function normally.
It is nonetheless possible, by “portal vein embolization” technique, to increase the volume of the healthy part of the organ, which allows a wider resection of the metastases or the resection of metastases which were initially judged to be inoperable.
The latest chemotherapy medication has also proved to be equally useful in this situation: these reduce the size of the metastases before surgery. There may also be recourse to the radiofrequency technique.
Surgery is the treatment of choice for endocrine tumours and biliary duct tumours, yet it is not always possible to use in these cases. For endocrine tumours, metabolic radiotherapy provides promising results. Carried out in Nuclear Medicine, it consists of injecting radioactive particles against the tumour. However it is only carried out in some specialist centres such as the Erasmus University Hospital in Rotterdam, with which Saint-Luc University Clinics have a very close collaboration.
Surgical interventions intended for the treatment of hepato-bilio-pancreatic tumours can prove to be delicate. The experience which our surgical team has acquired in carrying out this type of intervention is decisive.
It enables transplants in the event of liver cancer, resection of hepatic metastases and complex surgery which endocrine tumours and biliary ducts require, to be successfully carried out.
Research
Hepato-bilio-pancreatic tumours are the subject of a lot of research. The intention is not only to optimise therapeutic approach, but also to make an early diagnosis, in turning to specific new tracers, which are used in Nuclear Medicine in our centre.
Research also leads to the discovery of new medication. These are used in the context of international studies in which our centre actively participates, so as to offer patients the most efficient medication.
Finally, in our research laboratories we are studying the mechanisms responsible for the development of primary cancers of the liver and the effects of chemotherapy on hepatic tissue.
Eye tumours
EPIDEMIOLOGY
The commonest eye cancer in adults is melanoma, occurring at a rate of about 7-8 new cases per million Belgian residents per year. This rate has not changed during the last twenty years. No trigger for ocular melanoma has yet been identified, although most cases develop from suspect nevi or “beauty spots”. The average age for onset of this disease is 60-65 years.
Each European country has an eye cancer reference centre. Our Ocular Oncology Unit has a wealth of experience in treating eye cancer, and is internationally recognised. Almost all ocular melanoma cases recorded in Belgium are referred to the Centre, as are most cases of retinoblastoma, the commonest eye cancer in children (1 case for every 20,000 births). The Ocular Oncology Unit currently welcomes patients from several neighbouring countries.
Treatment of ocular melanoma patients is determined during multidisciplinary meetings in which ophthalmologists, medical oncologists and anatomopathologists all take part. The optimal approach is thus decided upon, depending on the nature of the tumour, on the basis of up-to-date knowledge.
SYMPTOMS AND DIAGNOSIS
Intraocular melanoma is often discovered by accident. Starting in the choroid, the layer of vessels behind the retina, it leads to a detached retina, which causes visual problems. These however are not particular to cancer and are found in many other diseases also.
Intraocular melanoma is diagnosed during an examination of the ocular fundus, which shows the retina and choroid through a previously dilated pupil. This diagnosis requires considerable experience: it is not always easy to recognise a “suspect beauty spot”.
The image, called an ophthalmoscopy, is observed with the naked eye, and the imaging techniques, especially ultrasound and magnetic resonance, confirm a diagnosis in 99% of cases. A biopsy is not often required.
Needle biopsies are performed under local anaesthetic, sometimes as part of a research programme aimed at studying how the cancer behaves and at identifying certain genetic properties of tumours, which help with the prognosis.
Ocular melanoma must be diagnosed at an early stage: identifying the lesion early considerably increases the probability of successful treatment.
Ocular melanoma is a rare disease. Only a few centres in the world have sufficient experience to identify it early and provide optimal treatment using modern equipment.
TREATMENT
Treatment starts within a week of the diagnosis. New techniques have been perfected in recent years, saving the eye in most cases and avoiding the need for enucleation (surgical removal of the eye).
Transpupillar heat therapy involves subjecting the tissues to a temperature between 45°C and 60°C in order to kill the melanoma cells. A laser beam is passed through the pupil and focussed on the tumour. This technique is used in the outpatients’ clinic and does not require admission to hospital or surgery. Transpupillar heat therapy sessions can be repeated if necessary. The treatment provided by the Cancer Centre’s Ocular Oncology Unit has enjoyed a success rate of 94%.
Contact radiotherapy offers a comfortable alternative to enucleation when size and location of an ocular melanoma make transpupillar heat therapy impossible. Contact radiotherapy, also known as curie therapy, involves placing radioactive grains (iodine 125) attached to a support plate, in direct contact with the tumour for a period of 3-4 days. In Belgium, this very specialised, ultra-modern technique is only available at the Ocular Oncology Unit in the Cancer Centre.
Contact radiotherapy can control tumours in 97% of patients. However, in 5-10% of cases it causes complications, which lead to enucleation. Sometimes, contact radiotherapy can be combined with transpupillar heat therapy to make treatment more successful.
The chances of useful vision remaining at the end of treatment depend mainly on the size of a tumour and its location in relation to the optic nerve and the macula (the central part of the retina).
Enucleation is still the only available option when the tumour is too large to be treated by any other means.
Progress made in localised treatment of melanoma still does not prevent metastases from forming elsewhere, usually in the liver. If metastases occur, the prognosis is less favourable. Research conducted at the Ocular Oncology Unit is now concentrating on “ducting” treatments, which, administered together with local tumour treatment, are aimed at reducing the risk of metastases.
An anti-tumour vaccination could prove beneficial in this regard. This vaccination is currently being studied as part of a European study co-ordinated by our Ocular Oncology Unit.
RETINOBLASTOMA
Finally, the prognosis for retinoblastoma, the commonest eye tumour in children, has also improved. Until very recently, retinoblastoma required removal of the eye. Now, however, initial chemotherapy shrinks the tumour, allowing focal treatment to be given through transpupillar heat therapy or contact radiotherapy.
Oesogastric tumours
Frequency and risk factors
Cancers of the oesophagus and of the stomach are still relatively rare in comparison to those of the colon and the rectum. Two types can be distinguished for the oesophagus. The first, called epidermoid carcinoma, is linked to the consumption of alcohol and tobacco. The second, called adenocarcinoma, is a rare complication involving gastro-oesophageal reflux.
Distinguishing between the two types of cancers is carried out by identifying their location. Epidermoid carcinoma is more frequently situated in the upper and mid part of the oesophagus, while adenocarcinoma is always located in the lower third. Yet it is examination under the microscope of fragments taken during an endoscopy which provide a definitive answer.
Cancer of the stomach is found less frequently these days than it was in the past. This can perhaps be explained by the reduction in the frequency of persistent gastric ulcers, which constitute the main risk factor. There are now efficient treatments available which allow Helicobacter pylori bacteria to be eliminated, which is the main cause of ulcers. Removing these bacteria from the stomach means stomach ulcers do not become chronic, and do not degenerate into cancer. The presence of these bacteria is however very frequent, but that does not mean that a person who is a carrier will be affected by stomach cancer.
Symptoms
Diagnosis
In the event of cancer of the oesophagus or of the stomach being suspected, the first examination to be carried out is an endoscopy of the organs, known as a “gastroscopy” or an “oesophagogastroscopy”. This very precise technique is carried out under local anaesthetic or light sedation. It enables the oesophageal wall and the stomach to be looked at directly and if there is a tumour, to ascertain the extent of the localized spread. Click here to learn more about this examination (link to the “gastroscopy” fact sheet). This examination can be completed by an echoendoscopy which enables the localized spread of the tumour to be assessed. Click here to learn more about this examination (link to the “echoendoscopy” fact sheet).
Other imaging examinations are often carried out, such as a CT scan in conventional radiology and the PET scan in Nuclear Medicine, to study the extent of cancer of the oesophagus. Click here to learn more about the latter examination (link to the “PET Scan” fact sheet).
Treatment
Surgery is the main treatment for cancers of the oesophagus and the stomach. Some tumours which are very superficial to start with can now be treated in a completely satisfactory manner either by endoscopic resection, or by functional surgery according to the respective indications. This assumes, of course, expertise which can only be acquired in centres which have experienced specialists. On the other hand, for tumours which are more extensive, it is acknowledged that an operation should be carried out which will consist of partially or completely removing the affected organ, opening up the thorax and/or the abdomen. The essential element of the surgery is radical removal of all the neighbouring ganglions of the organ or seat of the tumour. Only practiced in exceptional centres in the Western world, such as ours, these interventions are often long and delicate. They require an expert surgical team, an experienced team of anaesthetists and also an intensive care service which is well-versed in following these patients who systematically spend the first post-operation days here. The close collaboration which exists between these three teams guarantees optimal patient care, minimizing all the risks linked to the operation.
For some patients for whom surgery would be too disfiguring, or who are too weak to benefit from an operation, and where the risks would become too great, a combination of radiotherapy and chemotherapy is proposed, with very satisfactory results. Both these treatments are administered in outpatient clinics, radiotherapy in 5 or 6 weeks and chemotherapy, at a rate of 4 cycles, of 3 or 4 weeks each.
Curietherapy, a radiotherapy method, is carried out on people who cannot be treated by classic external radiotherapy. This method uses a radioactive iridium wire which has an effect at short distance (2 to 3 cm), enabling the eradication of cancerous tumour in the oesophagus. This procedure is not as effective as external radiotherapy, but means treatment can be shorter, thus producing fewer secondary effects. It is often used when there is considerable difficulty swallowing (dysphagia) due to obstruction of the oesophagus by the tumour. An alternative in the event of obstruction is the placement of an oesophageal prosthesis (a tube slipped inside the oesophagus), which means oral feeding can still take place. Curietherapy and prosthetics are often associated with providing the patient with relief from the obstruction.
When cancer affects organs other than the oesophagus or the stomach, in other words if it metastasises, only chemotherapy can provide any sort of benefit.
Patient care requires collaboration amongst medical oncologists, radiotherapists, surgeons, anatomical pathologists and gastroenterologists, who meet up each week with the aim of taking the best decision for each particular patient.
Tumeurs de la peau - Clinique du mélanome
La Clinique du
mélanome du Centre du Cancer prend en charge les patients atteints de tumeurs pigmentées malignes aussi appelées des mélanomes. Il existe différentes formes de mélanome : la plus fréquente est le mélanome de la peau, les autres sont les mélanomes des muqueuses et ceux qui atteignent l’oeil.
Plus de 1500 nouveaux cas sont diagnostiqués chaque année en Belgique. La fréquence du mélanome de la peau est en constante augmentation; et jusqu’il y a peu elle doublait encore tous les 10 ans. Le mélanome cutané est particulièrement fréquent chez les jeunes adultes.
La pierre angulaire de l’approche diagnostique et thérapeutique optimale du mélanome est la pluridisciplinarité. Dans notre centre, dermatologues, chirurgiens, oncologues et anatomopathologistes se réunissent chaque semaine dans le cadre de réunions pluridisciplinaires. Cette organisation permet de définir, sur base des connaissances actuelles, l’attitude la plus opportune pour chaque patient.
FACTEURS DE RISQUE ET DEPISTAGE
Les principaux facteurs de risque du mélanome sont un grand nombre de « naevi » ou grains de beauté, surtout s’ils sont irréguliers, et l’exposition excessive au soleil, en particulier lors de la petite enfance.
Le risque de mélanome est plus élevé quand existent d’autres cas au sein de la famille. Plusieurs recherches en cours au Centre du Cancer visent d’ailleurs à mieux comprendre les facteurs génétiques impliqués dans l’apparition de certains mélanomes.
Le mélanome apparaît le plus souvent sur peau saine, mais il peut également se développer à partir d’un « naevus » ou grain de beauté. Pour dépister précocement le mélanome, il est donc conseillé de surveiller l’apparition éventuelle d’un grain de beauté d’aspect un peu inhabituel ou les éventuels changements d’aspect d’un grain de beauté existant. Il est conseillé aux patients à risque de se rendre au moins une fois par an chez le dermatologue afin que ce dernier puisse se livrer à un examen complet.
Notre Clinique du Mélanome organise un dépistage « ciblé », destiné aux familles dans lesquelles un cas est survenu et aux sujets à risque car présentant un grand nombre de grains de beauté ou des lésions pour lesquelles la probabilité d’évolution vers le mélanome est plus élevée.
Cette surveillance a lieu tous les 6 mois par dermoscopie digitalisée. Les photographies des grains de beauté à risque sont enregistrées et comparées au fil du temps.
CONFIRMATION DU DIAGNOSTIC ET TRAITEMENT
Le diagnostic de mélanome cutané est confirmé par l’examen au microscope de la lésion après son exérèse chirurgicale. Toute lésion suspecte requiert une exérèse rapide. La consultation de la Clinique du Mélanome est organisée de sorte que celle-ci puisse être réalisée immédiatement, sans devoir prendre un nouveau rendez-vous chez le chirurgien.
L’étendue de l’excision, effectuée par un chirurgien plasticien, dépend de l’épaisseur du mélanome. Le concours d’un expert en chirurgie plastique permet de réaliser l’exérèse du mélanome en préservant au mieux l’esthétique.
Le grain d beauté enlevé est ensuite analysé au laboratoire par l’anatomo-pathologiste. Cet examen détermine la nécessité ou non d’effectuer une chirurgie complémentaire pour retirer le premier relais de propagation des cellules tumorales, aussi appelé « ganglion sentinelle ».
Si l’analyse du ganglion sentinelle montre qu’il est envahi, tous les ganglions de la zone de drainage sont retirés dans un second temps opératoire.
Enfin, lorsque le mélanome, diagnostiqué trop tardivement, a entraîné des métastases, la participation à des études internationales permet de bénéficier des traitements les plus récents.
Les dépliants de la clinique du mélanome
- Qu'est-ce que le mélanome
- Dépistage
- Soins
- Informations pratiques
Pelvic Tumours
The pelvis is located in the lower part of the abdomen and contains several organs. In a woman, part of this anatomical region includes the uterus and the ovaries. The uterus is made up of two parts: the lower part, the cervix, and an upper part where pregnancy occurs, the body. The endometrium is the mucous membrane, or surface, situated in the cavity of the body of the uterus.
Cancer of the endometrium is more frequent than ovarian cancer, which is however more widespread than cancer of the cervix.
Symptoms, screening and diagnostics
Cancer of the cervix
There is an effective screening examination which means precancerous lesions can be detected: a cervical-vaginal smear test.
Smear tests consist of taking a sample of superficial cells from the cervix during a gynaecological examination. These cells are then examined under the microscope. Since cervical cancer develops slowly, regular gynaecological monitoring means that it can be detected at a very early stage.
Screening using smear tests begins at the age of 25. The test is repeated every three years.
Cervical cancer is caused by a virus called HPV or “human papillomavirus”, which is transmitted during sexual intercourse.
HPV is very widespread. It only causes cancer in a minority of cases. However the risk is not to be ignored and vaccination against HPV is therefore very important. This virus is transmitted during sexual intercourse, so it is important that young girls be vaccinated as early as possible, that is before they first start to have sexual intercourse.
At the moment this vaccine is funded for girls between the ages of 12 and 15 (public cost of 130 €, with contribution from INAMI: 10 € per injection). The vaccination requires three injections.
This vaccine can prevent 70 % of cases of cervical cancer. In the absence of 100 % protection, screening should be carried out or continued even after vaccination. For young female patients aged 16 and over, opinion with regard to vaccination is to be discussed with their doctor (family doctor, paediatrician, gynaecologist, …).
Cervical cancer does not reveal many symptoms, which is why regular monitoring is important. It is quite easy to diagnose by means of smear tests and a gynaecological examination.
Cancer of the endometrium
The occurrence of cancer of the endometrium is increased by obesity, arterial hypertension and diabetes. Cancer of the endometrium is indicated by abnormal losses of blood. If examinations are carried out prior to the initial symptoms, early diagnosis can be made in most cases and prognosis is good.
Cancer of the endometrium generally occurs beyond the age of 50.
The recurrence of blood loss at the menopause, or the occurrence of blood loss between menstruation in a woman who has not reached the menopause is sometimes significant. Such indications justify a medical consultation which will enable a diagnosis to be made quickly.
Diagnosis of cancer of the endometrium is made using a biopsy examination: a sample is taken of a small part of the suspected area and examined under the microscope. The sample is taken during an “endoscopy”, or to be more precise, a “hysteroscopy” - an examination which consists of inserting a guide, equipped with a small camera on the end, into the vagina.
Ovarian cancer
Strictly speaking, there is no such thing as a risk factor of ovarian cancer. Where genetic factors intervene, in the majority of cases it may occur in women who have no particular past history, at menopause or beyond.
Diagnosis of ovarian cancer at an early stage is not easy. The disease may manifest itself through abdominal pain. Confirmation of the diagnosis requires a biopsy taken during a “laparoscopy” or a “coelioscopy”. This minimally invasive technique allows the interior of the abdomen to be examined and samples or surgical treatments to be carried out, without opening the abdominal wall. This increases comfort for the patients and reduces the period of convalescence.
Treatment
Cancers of the endometrium can be diagnosed early in women who have regular gynaecological examinations, they do not generally require additional treatment. Radiotherapy focused on the lower pelvis is sometimes carried out when the tumour presents a risk of recurrence.
Cervical cancer is also treated by hysterectomy, which is generally more extensive since it is often accompanied by the removal of the neighbouring glands. Radiotherapy combined with chemotherapy supplements surgery in certain cases. Exact identification of the extent of the tumour, also enables better targeting of possible complementary radiotherapy.
Some women wish to protect their fertility. Partial removal of the uterus, when possible, aims to meet this requirement. Clarification, which rests to a large extent on the endoscopy, means the precise spread of the cancer can be determined and means there is a possibility of keeping a part of the uterus, without removing the entire organ.
Finally, treatment of ovarian cancer is generally based on a combination of surgery and chemotherapy.
New targeted therapies are used in the context of wide-ranging international studies, in which reference centres, like the Cancer Centre, play an active part.
Optimal treatment requires a pluridisciplinary approach
The frequent combination of different therapeutic weapons such as surgery, radiotherapy and chemotherapy, illustrates the need to correctly define the characteristics of cancer. This approach means a programme of care and the sequence of different treatments can be established. It requires the support of specialists in imaging or in microscopy who are capable of assessing the aggressiveness of the cancer and its spread.
Weekly multidisciplinary meetings organised at the Cancer Centre therefore include all specialists involved in the diagnosis and treatment of gynaecological tumours. They enable the therapeutic approach which is the most appropriate for each patient to be tailored , in accordance with current care standards.
Preserving fertility and anti-cancerous treatments
Anti-cancerous treatments, no matter where the tumour is located, at times prove to be deleterious to female fertility. Cryopreservation of ovarian tissue carried out at the Cancer Centre compensates for this disadvantage. It consists of taking a sample from a piece of the ovary and freezing it before anti-cancerous treatment, which is potentially deleterious to fertility. At the end of this treatment, the piece of the ovary is re-implanted by coelioscopy. Click here to learn more about this technique.
Breast tumours - The Breast Clinic
OVERVIEW
Breast cancer affects about one woman in ten in Europe. In Belgium, 8-9,000 new cases are diagnosed each year. Two thirds of these cancers strike after the menopause, one third before.
The diagnostic and therapeutic approach to breast cancer requires the help of numerous specialists, who together define the best strategy to be adopted for each individual case being treated.
RISKFACTORS
In 5-10% of cases, breast cancer is triggered by hereditary factors.
Breast cancer can also be triggered by hormonal factors. In these cases, early onset of menstruation or late menopause increases the duration of exposure to oestrogen. A late first pregnancy, no pregnancy at all, prolonged hormone therapy at the menopause, and obesity, can also favour the onset of the disease.
SYMPTOMS AND SCREENING
Initially, breast cancer does not display any symptoms. It is diagnosed at the screening stage. Later, it may take the form of a small nodule, or produce pain, colour change or nipple retraction…
The screening programme developed in Belgium is aimed at women aged 50-60 and based on a breast X-ray, known as a mammogram, conducted every two years. This is a basic examination, aimed at women who have no specific risk factors.
If risk factors are present, the screening strategy is slightly different. This means that women with a benign breast disorder are given a more comprehensive examination, including an ultrasound and possibly MRI in addition.
Our centre also offers women the opportunity to benefit directly from this comprehensive examination if their gynaecologist or GP requests it.
The checks are conducted annually between the ages of 40 and 50 years. After 60 years, they are conducted every two years.
As breast cancer is painless in the early stages, screening is very important.
TREATMENT
Treatment, which is discussed at multidisciplinary meetings, may include surgery, chemotherapy, hormone therapy or radiotherapy. These options are often combined and vary according to the type of cancer. All the specialists must therefore choose the most suitable approach, taking account of the characteristics and extent of the tumour.
If the surgical route is taken, the operation is as non-invasive as possible. It is sometimes preceded by chemotherapy. After the surgery, the multidisciplinary team meets again to discuss further treatment: radiotherapy, chemotherapy with or without radiotherapy, hormone treatment, etc…
A series of studies is currently aiming to identify more clearly the factors in the selection of women for whom chemotherapy would be most effective. Some factors, such as size and level of aggression of tumour, will be known to some extent. A large-scale European study aims to determine the role of genetic profiles. The multidisciplinary breast cancer team is involved in this study and in the international studies dealing with new treatments. These treatments include chemotherapy, hormone therapy and, more recently, treatments that specifically target tumour cells while sparing the neighbouring healthy cells. This is known as “targeted therapy”.
Treatment of breast cancer involves several different fields, including RESEARCH.
Chemotherapy can adversely affect fertility. This factor must be taken into consideration, especially when in cases of breast cancer affecting young women. A number of techniques, such as cryopreservation, now preserve ovarian function, and therefore the chances of pregnancy. These techniques were developed by the multidisciplinary sterility issues team at Cliniques Universitaires Saint-Luc, and are now offered to patients treated at our centre.
Finally, breast reconstruction after removal of a tumour is very important. It requires the help of plastic surgeons familiar with modern techniques that allow the successful completion of sometimes complex operations.
Vue de face et de profil après injection péritumorale.
THE NEED FOR EXCELLENCE: THE CLINICAL ROUTE
The diagnostic and therapeutic tools now available in breast cancer treatment are both efficient and complex. Also, their use requires quality control measures.
A schedule of various indicators will ensure that the treatment chosen is suitable. Data on the number and types of surgical procedures and the incidence of recurrence and complications linked to chemotherapy or radiotherapy are kept and regularly analysed.
Surgery is also assessed on the basis of several different criteria.
Examination of data obtained allows the multidisciplinary team’s activity to be compared with that of other international reference centres and ensures that the strategy being followed does not produce too many side effects, complications or recurrences.
Finally, European instructions have been defined for diagnosis and treatment of breast cancer. They deal with the clinical route that each patient has the right to follow. According to these instructions, any woman with breast cancer must be treated within one month of diagnosis. Deadlines are also set for various stages in refining and combining treatments. Compliance with these standards is important, as it can affect the progress of the disease; delay in setting up the treatment can be detrimental. Complying with European standards therefore helps optimise the clinical route followed by patients.
Checks are essential for guaranteeing quality of the care given
MULTIDISCIPLINARY CONSULTATION
Our Breast Clinic specialists (gynaecologists, medical oncologists, radiotherapists) all meet together in the same place once a week. Initially, each case is analysed and discussed during a weekly multidisciplinary discussion group meeting (radiology, anatomopathology, plastic and reconstructive surgery and the above specialities), held just before a joint consultation. A psychologist also attends this multidisciplinary meeting for patients who so wish. This process allows the treatment of this disease to be addressed comprehensively and properly understood.
The multidisciplinary breast cancer meeting is held on Wednesdays from 1830-2130 on Floor 1, Building B2. For an appointment or second opinion: (02) 764.18.18 (Chantal Parent, secretary) or (02) 764.42.14 (Nathalie Blondeel, oncology care co-ordinator). |
To find out more about multidisciplinary consultations, click here
Tumours in the central nervous system
OUTLINE
There is a difference between the central nervous system (CNS), which is composed of the brain, the cerebellum and the spinal cord and the peripheral nervous system, which is made up of all the nerves which run through the body and the structures which surround the nervous system. Tumours in the nervous system are rare: their incidence is not more than forty to sixty per hundred thousand. The majority of these, especially those of the central nervous system, are malignant. In Belgium, this type of tumour represents less than 2 % of all cancers. In a child, tumours of the CNS are the main cause of death from cancer. By and large, the causes which are responsible for the development of these tumours remain unknown. Ionising radiation comes first in the risk factors for cancerous tumours. The impact of radio waves emitted by mobile telephones on our brain is debated amongst the scientific community.
SYMPTOMS
There are four signs which might indicate a tumour in the brain: intracranial hypertension (headaches, nausea, vomiting and changes visible on examining the back of the eye), manifestations of epilepsy, motor deficits (weakness in a part of the body) and cognitive disturbances (disturbances in memory and confusion). There is however no need to panic: the vast majority of headaches for example have nothing to do with brain tumours. Tingling or loss of strength in one or several limbs, or in a segment of the body are alarm signals of a tumour of the peripheral nervous system, but these signs may also occur in many other complaints.
DIAGNOSIS
Apart from classical examinations using medical imaging and analysis of sample tissues under the microscope, the tool of choice for diagnosing SNC tumours is magnetic resonance imaging. This non invasive technique which has no secondary effects supplies high precision images in 2D and sometimes even in 3D. There are other additional imaging techniques, such as the PET Scan, and they help to draw up improved surgical intervention by targeted diagnosis and/or therapy.
TREATMENT
Patients suffering from cancer of the CNS are looked after by a multidisciplinary team where neurosurgeons, neuroradiologists, neuroendocrinologists, neurologists, medical oncologists, anatomical pathologists and radiotherapists approach each patient case together so as to ascertain a treatment which is best adapted to each situation.
The initial treatment for most initial brain tumours is surgery. More than 200 patients are operated on each year at Saint-Luc University Clinics, for malignant and benign tumours of the nervous system. In this institution a complex, ultra-modern surgery has been developed which is set to be a global leader for at least a few years yet. A very high-field MRI room is combined with a neurosurgery room. This allows the quality of the intervention to be monitored, even though it is not complete.
Surgical techniques have evolved very much in the last few years. Neuro-navigation, which has been used for 11 years, enables surgery to be carried out with computer assistance. The device shows the information in the microscope eyepieces, which the surgeon uses to operate. It is a little bit like GPS for a surgeon. Thus a lesion can be located with great precision and, using the computer screen, the neurosurgeon knows the exact position of the instruments in the patient’s brain and can therefore determine, with a great deal of precision, a path to the chosen target area. This technique is essentially used for pathologies which require millimetric precision, such as when operating on cerebral tumours. The benefits of this surgical method are key for the patient since comfort is markedly improved. Moreover, thanks to the millimetric precision of these interventions, the operating area can be better targeted for very small openings. The risks are thus limited; the patient wakes up faster and the length of stay in hospital is shorter.
The very high field MRI room has equipment which is the only one of its kind in the world and is connected to a neurosurgery room. Neuro-navigation has become a routine practice.
Often the tumour cannot be completely removed due to its infiltration, and there is a risk of considerable side effects in the patient. Post-operative radiotherapy is therefore often recommended. Thanks to developments in imaging and IT, the volume to be treated and the organs at risk are precisely defined, enabling the establishment (in 3 dimensions) of the radiation beams in such a way as to deliver a homogenous dose to the tumourous volume, while protecting the healthy adjoining tissues. In neuro-oncology, the technique of irradiation by TomoTherapy Hi-Art is mainly used to treat tumours at the base of the skull. This device on the one hand allows more targeted irradiation, and on the other very high precision treatment. Only some centres in Belgium, of which ours is one, have this device. Click here to learn more about Hi-Art.
The emergence of effective new chemotherapy agents in the treatment of cerebral tumours has radically changed the treatment of these cancers. These chemotherapies can be administered concomitantly with radiotherapy in the treatment of certain tumours, or as a supplement to them. Administration of these chemotherapies increases patient survival and also their quality of life.
Another revolution in the treatment of malignant tumours of the brain is the emergence of targeted therapies. Some medications specifically destroy tumourous cells by interacting with receptors shown on tumorous cells or their ligands (Anti-EGF). Other molecules specifically target the vessels which feed the tumours (Anti-VEGF).
Another development axis is the identification of genetic signature as factors in the prognosis and which are predictive of response to chemotherapy (MGMT methylation, chromosome loss: 1p19q).
RESEARCH
Research in oncology by the neuroradiological team in the medical imaging department applies mainly to two themes. The first is defining the best target for cerebral biopsy so as to guide the neurosurgeon’s movements and to be able to determine as precisely as possible the grade of tumour before treatment. The second theme is to clarify the therapeutic effects of surgery, radiotherapy and chemotherapy in the course of treatment, so as to adapt the treatment according to the results. In both these themes, perfusion images are at the centre of our research: magnetic resonance imaging of a thousand sections, gained in one minute to detect the degree of tumour neovascularisation.
Cancers of the head, neck and upper respiratory system
Neck, Jaw and Face Cancer Study Clinic
OVERVIEW
We recognise two distinct groups of “head and neck” cancer. The first and larger group covers cancers of the mouth cavity, pharynx and larynx. These cancers account for 90% of “head and neck” tumours and tobacco and alcohol play a part in their formation.
The remaining 10% are rarer tumours, located in the nasal cavities, sinuses or salivary glands. Finally, nasopharyngeal cancer, a very specific form of cancer located at the rear of the nasal cavity, is found mainly in Asian countries and in the Mediterranean basin. It is caused by the Epstein Barr virus, which infects patients during the first few weeks of life.
Head and neck cancers, rarer in women, account for approximately 7% of cancers observed in men. In Belgium there are 1,500-2,000 cases of this cancer per year.
Treatment is complex and depends on the type of tumour, which will dictate the choice between surgery, radiotherapy, chemotherapy and new drugs specifically aimed at the cancer. Defining the best strategy requires discussion between doctors specialising in different field and working together in a multidisciplinary team.
RISK FACTORS
Almost all head and neck cancers are linked to smoking and excessive alcohol consumption.
Although moderate alcohol consumption does not carry a real risk of cancer, the risk increases considerably if significant quantities are consumed (one bottle of wine, 10-15 units of beer a day).
Heavy smoking and excessive alcohol consumption, when combined, do not just have an additional effect; instead, the risk is multiplied by a factor of 5-10.
SYMPTOMS
Head and neck cancers tend to become evident at a late stage, depending on tumour location. Persistent hoarseness can indicate localised trouble in the larynx. A lesion at the back of the throat (pharynx) can produce difficulty or pain in swallowing.
Toothache, painful eating, or problems with speech, can indicate mouth cavity problems. Pharyngitis that does not respond to antibiotics must be checked carefully. Sometimes, cancer takes the form of a painless ganglion in the neck.
To sum up, symptoms of head and neck cancers are generally non-specific to start with, and can occur in diseases other than cancer. A consultation will determine their origin. Unfortunately, warning signs are often neglected, meaning that two thirds of cancers are diagnosed at an advanced stage.
TREATMENT
Small or medium tumours are treated with surgery or radiotherapy. There is more chance of a cure, and the consequences of treatment are not drastic: the voice is generally preserved and eating rapidly becomes easier after the surgery.
The choice of surgery or radiotherapy is taken after a multidisciplinary discussion, during which the surgeon, radiotherapy specialist and specialists determining the nature of the cancer (size, level of aggression etc) decide on the most suitable approach. The patient’s wishes are also taken into account: treatment methods, duration of treatment and hospital admission requirements can vary slightly, and this can affect the patient’s working life.
Regular monitoring is essential while the risk of another tumour appearing in the same area remains. Of course, if smoking and excessive alcohol consumption continue, the risk of lung cancer and cancer of the oesophagus remains.
More advanced cancers usually require combined treatment with surgery and radiotherapy. Frequently, however, the treatment offered combines radiotherapy and chemotherapy or the administration of drugs specifically aimed at the tumour. These combinations are aimed at making the radiotherapy more effective.
The choice of options takes account of both efficacy and functional consequences. In cases of advanced laryngeal tumours, it can be preferable to opt for accelerated or intensive radiotherapy, combined with chemotherapy or drugs, rather than a complete laryngectomy. Both options are equally effective, but the first, of course, will better preserve the voice.
For mouth cavity tumours, surgery followed by reconstruction is often a better indication, as radiotherapy within the mouth cavity can cause bone complications.
RESEARCH AND INNOVATION
Treatment of head and neck cancer is advancing on all fronts. Surgeons are developing innovative techniques not only in tumour removal but also in reconstruction of damaged organs. In radiotherapy, tomotherapy now allows tumours to be irradiated with great accuracy; the cancer can thus be treated with very high doses while the neighbouring healthy tissue is avoided.
Our specialists in the multidisciplinary “head and neck” group have published recommendations on determining the volume of tumour to be irradiated. These recommendations have been confirmed and are now used at international level.
Finally, medical treatment is not standing still. New molecules act specifically on cancer cells, increasing efficacy and reducing toxicity. New medical treatments, when combined with chemotherapy or radiotherapy, look very promising. They are used in the context of studies that our centre is conducting in association with other reference centres in Europe and the United States.
>> Neck, Jaw and Face Cancer Study Clinic
Chest and lung tumours: Oncology and chest surgery group
OVERVIEW
Lung cancer is one of the three commonest forms of cancer, causing the death of one man in every ten in Belgium. It is becoming more frequent in women and, in the vast majority of cases, it is caused by smoking.
In Belgium, about 6,000 new cases occur every year.
There are two principal types of lung cancer, namely non-small-cell cancer and small-cell cancer. They need to be distinguished, as their treatment and prognosis are very different.
The division is about 80% for non-small-cell cancer and 20% for small-cell cancer. Small-cell cancer, which is generally more aggressive, has become less common in the last twenty years.
All lung cancer cases treated at the Cancer Centre in Cliniques Universitaires Saint-Luc are discussed during weekly multidisciplinary meetings. This group includes pneumologists, medical oncologists, anatomopathologists, medical imaging specialists whose task is to determine the precise extent of the tumour, surgeons, radiotherapists, oncology care co-ordinators, etc. This skill-sharing approach allows each patient to be treated in the best possible way, in keeping with recent progress made in medicine.
Lung cancer is the commonest cause of cancer-related death.
RISK FACTORS
Smoking is undoubtedly the main risk factor in lung cancer, being implicated in 90% of cases. Environment also plays a role; some cancers are caused by exposure to asbestos.
SYMPTOMS
Symptoms of lung cancer often show late, and can be deceptive. Certain symptoms normally associated with smoking, such as coughing or difficulty in breathing, may become worse. The appearance of bloodstained sputum is often a worrying symptom. In the early stages, the patient’s general state sometimes remains unchanged. Lung cancer is often discovered by accident, during an X-ray examination.
Current studies assessing the importance of chest screening in subjects at risk (smokers aged over 40), but the benefit of this strategy has not, as yet, been clearly demonstrated. This stresses once more the importance of prevention.
The best way to minimise the risk of lung cancer is: don’t smoke.
DIAGNOSIS
Major progress has recently been made in approaches to diagnosing lung cancer. Modern imaging techniques are very efficient, allowing the extent of the tumour to be determined very precisely and thus leading to suitable treatment. The PET scan, one such technique, involves intravenous injection of a product that reveals cancer cells. At Cliniques Universitaires Saint Luc, it is carried out together with the CT scan (combined PET-CT), allowing a still more accurate diagnosis. Bronchial echo-endoscopy also determines the extent of a tumour, by performing an ultrasound with a mini-probe introduced into the bronchi. Carried out under local anaesthetic, it does not require admission to hospital.
Endobronchial endoscopy reduces the need for a mediastinoscopy, a surgical procedure involving examination of the region between the lungs using a camera introduced into the chest under a general anaesthetic.
Efficient and relatively non-invasive imaging techniques accurately determine the extent of the tumour and ease the choice of the most suitable treatment.
PET-CT combiné
TREATMENT
Treatment of lung cancer depends on its histological type and stage of advancement.
Some cancers limited to the lungs can be treated with surgery, which aims to remove the tumour completely. Early stages have a good prognosis, improved still further by post-operative chemotherapy. The operation usually involves removal of a lung or pulmonary lobe. In patients whose pulmonary function has been compromised by smoking, the extent of the operation can sometimes be limited, requiring complex and delicate procedures such as re-implantation of bronchi following removal of a central tumour.
When the disease is loco-regional in its extent but has not yet metastasised anywhere, treatment is multi-modal. In other words, includes both chemotherapy and radiotherapy. In some cases, this combined treatment can be further combined with surgical removal.
Finally, extended or metastatic cancers are treated with chemotherapy. A new class of drugs has recently appeared: targeted treatments, so called because they act directly on tumours without producing the side effects of conventional chemotherapy. Targeted treatments are currently used when chemotherapy fails, although current studies are assessing the importance of using them initially in some cases.
These studies are held in reference institutions. Our centre is involved in them, working with other hospitals in Europe and the United States.
Small-cell cancer is mainly treated with chemotherapy, sometimes in combination with radiotherapy. Surgery to treat this type of cancer is very rare.
All pathologies
