Publication of october 2023

  • "Soins palliatifs pédiatriques
  • Otite moyenne aiguë en soins primaires
  • Vascularites
  • COVID long: l'importance d'informer
  • Agressions sexuelles sur les très jeunes enfants
  • Ama Contacts - 187e Promotion des Médecins de l’UCLouvain

 

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Month's articles

Radiothérapie

Radiotherapy innovations in 2023

The recent introduction of the artificial intelligence-powered linear accelerator Ethos® in our department now allows us to offer patients continuous and real-time adaptation of their radiation therapy treatment based on the patients’ daily anatomy.

In 2023, this adaptive radiotherapy was performed for the first time in the world in “breath-hold” to treat gastric lymphomas. This approach allows for a reduction of the irradiation margins while preserving adjacent organs.

Another area of innovation is stereotactic radiotherapy (SBRT) for liver tumors with mechanical ventilation assistance, which is an alternative to surgery for selected cases. Since 2018, non-invasive ventilation assistance, called MANIV, has been adopted, reducing irradiation margins and improving treatment quality. In October 2023, the Cliniques universitaires Saint-Luc became the first center to integrate MANIV into their routine clinical practice for treating liver tumors.

Stereotactic radiotherapy can also be offered for localized prostate cancer. It represents a faster and more precise alternative compared to traditional radiotherapy. Studies show comparable success rates with fewer side effects, highlighting the potential of SBRT for the treatment of prostate cancer.

Finally, an increasing number of patients are being treated with radiotherapy for bladder cancer. This conservative treatment is a new therapeutic alternative that can be offered under certain conditions. The application of adaptive radiotherapy in this indication is of maximum benefit due to the rapid and frequent variation in bladder volume during treatment. This makes it possible to avoid cystectomy and offer patients a better quality of life.

All these developments in radiotherapy align with our department's commitment to progress and improve patient care regarding oncological outcomes and quality of life.

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Oncologie médicale

Innovations in 2023 in Medical Oncology

The year 2023 witnessed a significant revolution in oncology, marked by the emergence of new anti-cancer molecules and innovative strategies.

Antibody conjugates have considerably improved patient survival in numerous cancer types. These treatments are likely to play a key role in advanced-stage disease of urothelial cancers and in several breast cancer types as well, including triple-negative, HER2-positive, and a new entity known as “HER2 weak”.

Considering renal cancer, targeting the HIF transcription factor by means of a targeted therapy that inhibits not only angiogenesis, but also various survival pathways, looks rather promising. This novel therapeutic strategy can be administered either as a single agent or in combination.

Uveal melanoma is the most common primary malignant intraocular tumor. Despite the efficacy of local treatments, half of all affected patients experience extra-ocular recurrence, with liver involvement observed in 90% of them. Median survival for patients with metastatic disease has been proven to range between 6 and 12 months. Targeted treatments, such as thermo-ablation or surgery, likely improve the prognosis of patients with single-site recurrences. Chemotherapy is not very effective. Treatment with immune checkpoint inhibitors, such as anti-PD-1 antibodies, only modestly increases overall survival in metastatic disease patients. Tebentafusp, a new form of immunotherapy, is the first molecule to demonstrate a real improvement in overall survival of metastatic patients. Tebentafusp is a T-cell receptor coupled with an anti-CD3 antibody, being able to transform all lymphocytes into anti-melanocyte lymphocytes. Nevertheless, only patients with an HLA-A*02:01 allele, meaning 50% of Caucasians, are likely to benefit from this therapeutic innovation.

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Nephrology

Innovations in 2023 in Nephrology

The year 2023 witnessed a number of significant advances in understanding and managing kidney disease. Among these figure the discoveries concerning the genetic variants in the gene encoding apolipoproteine L1 (APO-L1), shown to be closely associated with an increased risk of developing chronic kidney disease, particularly among populations of African or African-American descent. The precise mechanisms by which these APO-L1 variants contribute to the development of kidney disease have not been fully elucidated. Nevertheless, several studies have suggested that these variants may lead to an impaired podocyte function at the glomerular level. The discovery of the links between APO-L1 abnormalities and kidney disease has actually opened new perspectives for research pertaining to the development of targeted therapies. Understanding how these genetic variants influence the progression of kidney disease could similarly allow for the development of more effective prevention and treatment strategies, in addition to the identification of high-risk patient subgroups.

A new therapeutic approach to anemia in chronic kidney disease was made available last year. Roxadustat (EvrenzoR) belongs to a class of drugs known as hypoxia-inducible factor (HIF) prolyl hydroxylase inhibitors. These drugs act on the HIF-dependent erythropoiesis. Unlike the traditional treatment of kidney-disease-associated anemia consisting of subcutaneous or intravenous injections of recombinant erythropoietin (EPO), Evrenzo is administered orally. Consequently, this more convenient administration route could improve patient compliance and simplify the therapeutic process. In addition, in most patients, roxadustat was demonstrated to exhibit a safety and tolerability profile similar to that of recombinant EPO.

Another 2023 breakthrough was the approval of imlifidase in kidney transplantation. Imlifidase is a proteolytic enzyme that acts by selectively cleaving IgG antibodies. This agent can be employed to desensitize patients with high levels of pre-existing antibodies against human leukocyte antigen (HLA) antigens, meaning that transplantation could be considered even in the presence of immunological incompatibility with the donor. This approach may help improve access to transplantation for hyper-immunized patients.

These novelties developed in 2023 will gradually be implemented in clinical practice in 2024.

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Hematology/Oncology

Myelofibrosis, Multiple Myeloma, Anti-PF4 Antibodies, Acquired...

Myelofibrosis is a myeloproliferative neoplasm with a poor survival rate, primarily characterized by anemia, splenomegaly, constitutional symptoms, bone pain, and cachexia. The only curative treatment is allogeneic peripheral stem cell transplantation, although it is associated with a non-negligible mortality and morbidity risk. JAK2 inhibitors help reduce spleen size and alleviate symptoms in these patients. The two most recent JAK2 inhibitors (pacritinib and momelotinib) may also confer erythropoietic benefits.

Despite therapeutic advances in multiple myeloma management, the disease remains incurable, largely due to the emergence of resistant tumor clones. Immunotherapy has made significant progress in recent years. In front-line therapy, the inclusion of monoclonal antibodies alters the outcomes for transplant-eligible patients, providing potential long-term disease control. In relapse, bispecific antibodies and CAR-T cells demonstrated notable efficacy in terms of survival and residual disease control, offering real hope for patients resistant to conventional treatments. These two aspects will be addressed in this article.

In patients presenting with venous or arterial thrombosis associated with thrombocytopenia, the presence of anti-PF4 antibodies and their properties (heparin dependence and platelet activation capacity) should be investigated. Widely adopted in congenital hemophilia, emicizumab, a bispecific antibody mimicking the action of factor VIII, is poised to become a first-line hemostatic treatment for patients with acquired hemophilia. These patients will benefit from better protection against bleeding, delaying the onset of severe and often deleterious immunosuppression in fragile patients. Certain intravenous iron formulations may lead to hypophosphatemia, a neglected but avoidable complication. For refractory forms of autoimmune thrombocytopenia, complement, Bruton's tyrosine kinase, CD38, and the neonatal Fc receptor represent promising therapeutic targets.

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STOPP/START.v2

The tool STOPP / START.v2 allows evaluation of drug treatments prescribed to patients age 65 and older.

 

This tool, designed for all care settings, stimulates thinking and challenging medication taken by patients, especially drugs forcardiovascular and nervous system.

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