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Résumé Cette deuxième partie est une mise au point qui s’intéresse aux manifestations auto-immunes satellites d’une pathologie tumorale, pouvant la révéler, en émailler le cours évolutif ou bien compliquer son traitement. La survenue de pathologies auto-immunes est classique au cours des syndromes lymphoprolifératifs. Les manifestations observées sont variées mais il s’agit surtout de cytopénies, notamment d’anémie hémolytique auto-immune, le plus souvent au cours d’une leucémie lymphoïde chronique. La relation entre cancers et myopathies inflammatoires n’est pas contestée. Le risque relatif de cancer au cours de la dermatomyosite est de 3,4 à 4,4. La stratégie optimale à adopter pour la recherche d’un cancer occulte n’est pas définie mais la recherche d’anticorps anti-p155 et la réalisation d’un TEP-scanner semblent être particulièrement intéressantes dans cette indication. Un tableau de vascularite cutanée ou systémique peut révéler une pathologie tumorale. Il s’agit le plus souvent d’une hémopathie (leucémie à tricholeucocytes) mais parfois d’un cancer solide (cancer pulmonaire ou digestif notamment). L’âge élevé et la corticorésistance doivent être des éléments d’alerte. Une polyarthrite cliniquement comparable à l’atteinte articulaire de la polyarthrite rhumatoïde peut révéler un cancer, le plus souvent bronchique. La polyarthrite est le plus souvent séronégative, chez un sujet masculin âgé et dans un contexte d’altération de l’état général. Les syndromes myélodysplasiques s’accompagnent de manifestations auto-immunes dans 10 à 30 % des cas. Il s’agit le plus souvent d’une vascularite ou d’une polychondrite atrophiante. Quant aux complications auto-immunes des traitements anti-tumoraux, il s’agit avant tout de cytopénies auto-immunes liées à la fludarabine et à l’alemtuzumab et aux thyroïdites liées à l’interféron alpha et à la radiothérapie cervicale. Autoimmune diseases may reveal or occur during the course of a neoplasia or its treatment. Autoimmune cytopenia, especially haemolytic anaemia, is common in lymphoproliferative disorders such as chronic lymphoid leukemia. The link between cancer and myositis is well established. Dermatomyositis is associated with an increased relative risk of cancer of 3.4 to 4.4. A combination of detection of antibodies against p155 and TEP-computed tomography may be the best approach to ascertain the presence of occult malignancy in patients with dermatomyositis. A cutaneous or a systemic vascularitis may reveal a cancer, most often a haematological malignancy such as hairy cell leukemia. Paraneoplastic polyarthritis have been described in particular with adenocardinoma of the lungs. Underlying neoplasia should be considered in male smokers patients with new onset polyarthritis and poor health status. The prevalence of autoimmune conditions in myelodysplastic syndromes is 10 to 30%. Vasculitis and relapsing polychondritis are the most commonly reported manifestations. Immune manifestations can also be related to treatment. The most common treatment complications are autoimmune haemolytic anaemia with fludarabine and thyroiditis related to interferon and cervical radiotherapy. [ABSTRACT FROM AUTHOR]

Résumé: Le lien entre maladie auto-immune et cancer n’est pas fortuit. Une pathologie auto-immune peut ainsi représenter le starter pour le développement ultérieur d’une pathologie lymphomateuse. Le chef de file de cette relation est le syndrome de Gougerot-Sjögren, avec un risque relatif de lymphome évalué jusqu’à 44. Il existe également un risque de lymphome au cours du lupus (risque relatif de 4,5) et de la polyarthrite rhumatoïde, mais qui apparaît moindre, avec un risque relatif d’environ de 2 à 3 dans les études les plus récentes. Il est actuellement bien démontré que c’est avant tout l’activité de la maladie et non les traitements immunosuppresseurs qui est l’élément déterminant de ce sur-risque. La survenue d’une tumeur solide au cours de l’évolution d’une maladie auto-immune est nettement moins documentée et concerne surtout la sclérodermie, associée notamment aux tumeurs bronchiques. Quant au risque de néoplasie induite par les immunosuppresseurs et les biothérapies, les données sont plutôt rassurantes. Il n’y a pas de risque avéré sous anti-TNFα hormis pour les carcinomes cutanés et peut-être les mélanomes, ni sous tocilizumab ou abatacept mais un recul évolutif plus important est nécessaire pour ces 2 molécules. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Relationships between granulomatosis and cancers have been suspected for a long time. Nevertheless, few evidence has been reported until recently. Here, we present a literature review about the association of granulomatosis and neoplasia. Current knowledge and key points: Aside from granulomatosis due to infectious disease, granulomas can be observed in cancer patients, mainly in two situations. Patients may rarely present with typical sarcoidosis occurring before, during or after the diagnosis of cancer. Recent studies have documented such a relationship particularly with lymphomas, testicular and lung cancers, melanomas and hepatocarcinomas. Secondly granulomas may be found as a sarcoid reaction in the vicinity of the tumour itself or more frequently in regional lymph nodes. Sarcoid reaction, reported in Hodgkin''s disease and gastric adenocarcinomas, may be associated with a better prognosis. Granulomatous reaction could play an important role in the host''s defences against metastatic extension. Immunotherapy such as interferon has been reported to induce systemic sarcoidosis probably by reproducing some physiopathological mechanisms involved in sarcoidosis. Future prospects and projects: Clinicians need novel non invasive diagnostic methods to differentiate neoplasia from benign sarcoid reactions. The 18-fluorodeoxyglucose (18-FDG) PET-scan has failed in this indication but the adjunction of a [3-(18)F]-alpha-methyltyrosine ((18)F-FMT) PET-scan could be useful. Biopsies is still necessary in most of cases. [Copyright &y& Elsevier]

Abstract: Objectives. – The risk of venous thrombosis during cancer is largely increased especially in case of chemotherapy, surgery, advanced stage disease, coagulation abnormalities. Survival of patients with cancer experiencing venous thrombosis seems to be worse. Although thrombosis may be a presenting feature of occult malignancy, there are insufficient data to support a more extensive screening than comprehensive medical history, physical examination, routine laboratory tests and chest radiography. Current knowledge and key points. – Pathophysiology of venous thrombosis during cancer is unspecific: venous stasis, vessel wall damage, hypercoagulability). Other factors like platelet abnormalities or the direct responsibility of chemotherapy or hormonotherapy have recently been though to play a causative role. Treatment of cancer-associated thrombosis usually requires at least 6 months of low-molecular-weight heparin therapy rather than oral anticoagulant. Inferior vena cava filters are not indicated. Primary prophylaxis of thrombosis during cancer could safely been achieved with low-molecular-weight heparin. Central venous catheters can be associated with thrombotic complications. Many risks factors have been identified: catheter''s type, modalities of catheter''s implantation, type of perfusion, bulky mediastinal mass… Prophylactic anticoagulation is not routinely recommended. Future prospects and projects. – Knew oral anticoagulants could facilitate the treatment of venous thrombosis occurring during cancer in the next years. [Copyright &y& Elsevier]

Abstract: Objectives: Increased incidence of cancers and the development of totally implanted venous access devices that contain their own port to deliver chemotherapy will lead to a greater than before numbers of central venous catheter related thrombosis (CVCT). Medical consequences include catheter dysfunction and pulmonary embolism. Compared with lower extremity deep venous thrombosis (DVT) (3 d) and with non CVC associated thrombosis (5 d), CVCT is associated with an increased duration of hospitalisation (9 d). CVCT oftentimes leads to the need to replace such ports at an average cost of 4500 euros. Current knowledge and key points: Vessel injury caused by the procedure of CVC insertion is the most important risk factor for development of CVCT. This event could cause the formation of a fresh thrombus, which is reversible in the large majority of patients. The incidence of CVC-related DVT assessed by venography has been reported to vary from 30 to 60% but catheter-related DVT in adult patients is symptomatic in only 5% of cases. The majority of patients with CVC-related DVT is asymptomatic or has non-specific symptoms: arm or neck swelling or pain, distal paresthesias, headache, congestion of subcutaneous collateral veins. In the case of clinical suspicion of CVC-related DVT, compressive ultrasonography (US), especially with Doppler and color imaging, currently is first used to confirm the diagnosis. The main criteria of color-Doppler US are visualization of mural thrombi or incompressibility of the veins. Consequently, contrast venography is reserved for clinical trials and difficult diagnostic situations. There is no consensus on the optimal management of patients with CVC-related DVT. Treatment of CVC-related VTE requires a 5- to 7-day course of adjusted-dose unfractionated heparin or LMWH followed by oral anticoagulants. Long-term LMWH that has been shown to be more effective than oral anticoagulant in cancer patients with lower limb DVT could be used in these patients. The optimal duration of oral anticoagulation treatment for CVC-related DVT is unknown, but patients with active cancer should be treated for at least 6 months or indefinitely. Future prospects and projects: The efficacy and safety of pharmacologic prophylaxis for CVC related thrombosis is not established. Additional studies performed in high risk populations are needed to define if LMWH or oral anticoagulation is indicated in this clinical setting. [Copyright &y& Elsevier]

Résumé L’activité physique est un déterminant majeur de santé publique, en contribuant à la baisse de la prévalence de plusieurs maladies. Le cancer se trouve au premier rang des causes de mortalité dans le monde. L’activité physique, accessible à toute la population, pourrait prévenir jusqu’à 25 % des cancers, en plus d’améliorer la survie et la qualité de vie des patients atteints de cancer. L’activité physique agit via divers mécanismes afin de ralentir ou diminuer la croissance tumorale, dont la production et la biodisponibilité des hormones sexuelles, l’insulino-résistance et l’insulino-sécrétion ainsi que l’inflammation. En prévention primaire, l’activité physique diminue le risque de cancer de 17 %, tous cancers confondus. Plus spécifiquement, l’activité physique réduit le risque de cancer du sein de 15–20 % et le risque de cancer colorectal de 24 %. La mortalité, toutes causes, est réduite de 33 % chez les survivants du cancer pratiquant l’entraînement physique. La qualité de vie relative à l’état de santé, la fatigue et la dépression sont améliorées par la pratique de l’activité physique dans la population de patients atteints de cancer. Dans la population générale, les recommandations mondiales sur l’activité physique pour la santé, publiées par l’Organisation mondiale de la santé, sont suggérées en prévention primaire du cancer. Chez les patients atteints d’un cancer, une activité physique adaptée est favorisée dès le début de prise en charge pour diminuer la fatigue, améliorer la tolérance et les bénéfices des traitements. Physical activity is a key determinant of public health and contributes to decreasing the prevalence of many diseases. Cancer is the leading cause of death worldwide. Physical activity, accessible to the entire population, could prevent up to 25% of cancers, in addition to improving survival rates and quality of life in cancer patients. Physical activity acts via various mechanisms to slow or decrease tumor growth, including the production and bioavailability of sex hormones, insulin resistance and insulin secretion, and inflammation. In primary prevention, physical activity reduces breast cancer risk by 15–20% and colorectal cancer risk by 24%. All-cause mortality is reduced by 33% in cancer survivors who exercise. Health-related quality of life, fatigue and depression are enhanced by the practice of physical activity in cancer patients. In the general population, the global recommendations on physical activity for health, published by the World Health Organisation, are suggested as a means of primary prevention of cancer. In cancer patients, an adapted physical activity routine is promoted from the very beginning of patient care to decrease fatigue as well as improve tolerance and benefits of treatments. [ABSTRACT FROM AUTHOR]

Abstract: Bisphosphonates are indicated for the treatment of bone lesions in patients with solid tumours or multiple myeloma. Bisphosphonates have proven their effectiveness in reducing the number of bone complications (hypercalcemia, pain, disease-related fractures, spinal cord compression) and delaying their occurrence in patients with bone tumours; they have also been shown to reduce the need for bone surgery and palliative or pain-relieving radiotherapy in these patients. International recommendations for the treatment of bone lesions related to malignant solid tumours and multiple myeloma have been established. We have elaborated clinical practice guidelines on the use of bisphosphonates to assist treatment decision-making in bone oncology. The guide contains decision trees and tables with information to guide pre-treatment evaluation and patient follow-up, as well as indications and conditions of use of bisphosphonates. In 2007, the regional cancer network of Rhône-Alpes, ONCORA, formed a working group (GIP ONCORA) to elaborate the guideline. The final version was then discussed and adopted at a plenary session in July 2009, during a collaborative workshop on supportive care recommendations organized by ONCORA and the regional cancer network of Lorraine. [Copyright &y& Elsevier]

Background: In view of the lack of recommendations on central venous catheter (CVC)-associated thrombosis in cancer patients, we established guidelines according to the well-standardized Standards, Options and Recommendations methodology. Material and methods: A literature review (1990-2007) on CVC-associated thrombosis was carried out. The guidelines were developed on the basis of the corresponding levels of evidence derived from analysis of the 36 of 175 publications selected. They were then peer reviewed by 65 independent experts. Results: For the prevention of CVC-associated thrombosis, the distal tip of the CVC should be placed at the junction between the superior cava vein and right atrium; anticoagulants are not recommended. Treatment of CVCassociated thrombosis should be based on the prolonged use of low-molecular weight heparins. Maintenance of the catheter is justified if it is mandatory, functional, in the right position, and not infected, with a favorable clinical evolution under close monitoring; anticoagulant treatment should then be continued as long as the catheter is present. Conclusions: Several rigorous studies do not support the use of anticoagulants for the prevention of CVCassociated thrombosis. Treatment of CVC-associated thrombosis relies on the same principles as those applied in the treatment of established thrombosis in cancer patients. [ABSTRACT FROM PUBLISHER]