Bulletin du cancer
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Hyperthermic intraperitoneal chemotherapy (HIPEC) represents a new treatment strategy aimed to improve outcome of patients with advanced ovarian cancer. Based on theoretical and experimental basis, HIPEC should stand as an effective treatment for ovarian cancer. ⋯ Before this technique can be routinely used, some controversial aspects have to be defined: which drug is the best to deliver and at what temperature, is it necessary to use mono- or poly-chemotherapy regimens, which is the time-point for HIPEC in the natural history of ovarian cancer: at front-line therapy, at interval debulking following initial neo-adjuvant chemotherapy, at consolidation following front-line therapy, or at the time of recurrence. Nevertheless, we must not forget that the most important issue in ovarian cancer prognosis is maximal cytoreductive surgery, with no residual disease at completion of initial surgery.
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Intraperitoneal chemotherapy is a very attractive therapeutic alternative in the treatment of advanced ovarian carcinoma, due to its intraperitoneal spreading. Pharmacokinetic rational was described 30 years ago: a drug administered within the peritoneal cavity diffuse through the peritoneum towards the plasmatic compartment, depending on both its molecular weight and its lipid solubility. A slow output of the drug from the peritoneal cavity and a high plasma clearance are associated with a great pharmacokinetic advantage, illustrated by the area under the concentration time curve ratio. ⋯ The peripheral penetration being however limited to the first cellular layers, this way of delivery is interesting only for small residual disease. The most active drugs in the treatment of ovarian cancer, paclitaxel and platinum agents, are particularly convenient for this way of administration. The most optimal administration modality still remains to be defined and the development of the targeted therapies still opens new perspectives.
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For the past two decades, significant developments have been made in supportive care for the management of chemotherapy-induced nausea and vomiting (CINV). A better understanding of the pathophysiology of vomiting and the introduction of two new classes of antiemetic agents with a high therapeutic index (serotonin type 3 receptor antagonists [anti-5HT3 or setrons] in the 1990s and neurokinin type 1 receptor antagonists [anti-NK1] in 2000), possibly combined with corticosteroids, have helped to improve the management of this distressing side effect, constantly feared by patients. It is essential to distinguish between the anticipatory, acute (first 24 hours) and delayed phases of CINV, to take into account the emetogenic potential of the different chemotherapy protocols (very low, low, moderate and high) together with individual risk factors. The authors would like to propose methodological and therapeutic recommendations for the primary and secondary prophylaxis of the acute and delayed phases of CINV, based on recent publications by international learned societies.
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Neuropathic pain often occurs in the course of cancer evolution, but also as sequelae of surgical treatment, chemotherapy, or radiotherapy, when a nervous structure is impaired. Clinical features of neuropathic pain are specific, including spontaneous and evoked painful symptoms that are localized in an area of sensitive nerve distribution. Neuropathic pain may be concomitant to nociceptive pain, and its diagnosis can be easily performed in clinical practice using the DN4 questionnaire. Treatment of neuropathic pain is also specific, based on certain antidepressant or antiepileptic, often in combination with strong opioids.
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In medical practice, habits and ethics, on one hand, means, on the other hand, have evolved and induce the addition of autonomy to benevolence principle. In usual cases, traditional paternalism should be abandoned for allowing the patient to express his/her good and his/her choice for medical decision. This changes deeply doctor-patient relationship. Therefore, the physicians have to improve their practice in order to decrease inconveniences and increase advantages of this new relation, to finally better respect patients and their will.