Digestive cancers

B. Buecher, P. Mariani, W. Cacheux
04/21/2017
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Digestive cancers can develop along the entire digestive tract (esophagus, stomach, small intestine, large intestine, anus) as well as in other organs, such as the liver, pancreas and biliary tracts.
Cindy Neuzillet
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What are digestive cancers?

With over 42,000 new cases diagnosed each year in France, colon and rectal cancers are by far the most common primary cancers of the digestive tract. This frequency justifies the introduction a few years ago of systematic screening for people aged 50 to 74 (as with breast cancer screening for women). If there are no particular risk factors, this screening involves a test every two years to search for a microscopic hemorrhage in the stool, which, if positive, is followed by a colonoscopy.

Pancreatic cancer has become much more common in recent decades. It is now the second most-common digestive cancer, ahead of stomach and esophageal cancer. Primary cancers of the small intestine are exceptional.

Primary cancers of the liver are rare and generally exacerbate the development of an underlying liver disease. Patients with cirrhosis, for which there are many causes, are the most at risk. In the liver, there can also be tumors known as liver metastases, since they come from another cancer that has spread to the liver. These are more frequent than primary cancers of the liver. They can be isolated or part of a spread to other organs (such as the lung) and/or the peritoneum (known as peritoneal carcinomatosis).

The symptoms that reveal digestive cancers depend on the organ affected.

A small number of these cancers occur due to genetic predisposition. These are known as hereditary forms of cancer. Hereditary forms of colon and rectal cancer are the most frequent. There are different types, the most common being Lynch syndrome (also known as HNPCC syndrome) and familial adenomatous polyposis. There are also hereditary forms of pancreatic and stomach cancer. In all cases, it is vital to identify individuals that have these genetic predispositions, given the impact for their own treatment (screening and sometimes specific therapy) and for that of their relatives.

Treatment at Institut Curie

Institut Curie can treat all primary cancers of the digestive tract, at both of its sites, in Paris and Saint Cloud. This helps to provide local treatment, to the extent possible. These are complex treatments, nearly always involving the intervention of various specialists, including surgeons, gastroenterologists, oncologists, radiotherapists, radiologists and pathologists. Sometimes geriatricians, nutritionists and doctors specializing in support-care pain management are also required. Psychological support is offered through psychologists and psychiatrists. Lastly, if a genetic predisposition to cancer is suspected, an oncogenetics consultation is offered to carry out constitutional diagnostic genetic analyses. Institut Curie is one of the main oncogenetics centers in the Paris region, and operates in a network with other public hospitals in Paris and the Gustave Roussy center.

The first contact takes place in consultation with one of the Institut’s specialists in digestive pathology. Additional radiobiological and biological tests essential to assessing the tumoral disease are then quickly carried out. Once all the required information is available, cases are then systematically presented and discussed at multidisciplinary consultation meetings in which all the specialists participate. The aim is to establish a therapeutic strategy and a personalized treatment plan, taking into account the characteristics of the patient and of the disease. It also involves ensuring the best possible coordination of the various skills. The cases can be discussed again periodically, if necessary, at each stage of the treatment. In all cases, treatment complies with the latest professional recommendations and the various references available. When possible and desirable, more innovative approaches or research options may be offered.

At the Saint Cloud site, Institut Curie (René Huguenin hospital) collaborates daily with Ambroise-Paré hospital (a public teaching hospital) in Boulogne (Hauts-de-Seine region), located less than 3 km away, in order to pool their skills and offer patients the best possible personalized care between these two institutions. At Ambroise Paré hospital, there is a Hepato-Gastroenterology department with an endoscopy unit that also has diagnostics (fibroscopy, colonoscopy and echoendoscopy with/without puncture), therapeutic activities (removal of tumors using minimally invasive techniques and placement of digestive prostheses) and screening. The Digestive Surgery department offers wide-ranging expertise in the treatment of digestive cancers and liver metastases. The Radiology department provides diagnostic imaging, interventional diagnostics (biopsy) and therapeutic (vascular and biliary) services. Lastly, there is an Anatomopathology department specializing, in particular, in diagnosis of digestive diseases, a multi-purpose medical surgical ICU and a 24/7 emergency department. At Institut Curie´s René Huguenin hospital , there is a Medical Oncology department, a Radiotherapy department offering latest-generation therapeutic services (conformal radiotherapy/IMRT/IGRT; high-dose brachytherapy; stereotaxy), an Oncogenetics unit, a Nuclear Medicine department, which recently hired an endocrine oncologist who specifically treats neuro-endocrine tumors, and a Functional Support Care and Palliative Care unit to support patients under treatment or monitoring. These entirely complementary areas of expertise allow us to offer patients a high level of proficiency. Digestive oncologists consult every day of the week, alternating between the two hospital sites, and on each side they coordinate a multidisciplinary consultation meeting with the various experts needed for the medical decision. The two care structures work actively in tandem to develop a therapeutic approach, allowing chemotherapy to be administered intra-arterially in the liver as part of the treatment for liver metastases in colorectal cancer. This treatment allows these metastases to be treated specifically and locally without exposing patients to general toxins.

At the Paris site, the entire treatment takes place on a single site, for the comfort of the patient. Lastly, at the Paris site, aside from a Medical Oncology department (conventional hospitalization and day hospital), a Digestive Surgery department with specialized surgeons, postoperative intensive care, a high-technicity Radiotherapy department (conformal radiotherapy/IMRT; tomotherapy; brachytherapy), a Diagnostic and Interventional Imaging unit (biopsy and percutaneous tumor destruction via radiofrequency) and a Nuclear Medicine department, all guaranteeing the best care. The Digestive Endoscopy unit has recently been developed and the equipment has been entirely replaced. It performs diagnosis and screening (for patients with medium, high or very high risk, meaning they have a hereditary form, identified at oncogenetics consultations). Echoendoscopy is also available. It is valuable for assessing the spread of localized cancers of the upper digestive tract, for certain screening activities (cancer of the pancreas in patients at risk), and for carrying out punctures. In terms of surgery, it may be “conventional” or minimally invasive (laparoscopy, and soon robot-assisted).

Liver surgery on metastases is frequent, since many patients treated at Institut Curie, regardless of their initial form of cancer, may require surgical removal of the metastases combined with chemotherapy. There is specific expertise in intraperitoneal chemo hyperthermia (IPCH), which enables microscopic residual disease to be treated in patients suffering from peritoneal carcinomatosis after it has been resected. Chemotherapy is delivered directly to the peritoneum at the end of the surgical procedure in a bath at a temperature of 42°C to 43°C. The cytotoxic action combined with chemotherapy and hyperthermia helps reduce the risk of recurrence. This complex procedure is intended mainly for carefully selected colorectal cancers complicated by peritoneal carcinomatosis.

Research at Institut Curie

The specialists at both Institut Curie sites play an active part in translational research and clinical research. Patients are offered a place in a clinical trial when they meet the specified requirements. Trials sometimes allow patients to be administered promising medications that are not yet on the market. The clinical trials available at Institut Curie cover all treatment methods, particularly early trials that assess immunotherapy and new targeted therapies in development.

The characterization of molecular alterations associated with cancer via the Somatic Genetics platform helps identify therapeutic targets and the development of new agents within the context of precision medicine.

Several teams from the research center, in collaboration with the clinicians from both of the Institut’s sites, are seeking to decipher the fundamental mechanisms involved in the development of digestive cancers. Another major aspect of the research conducted at Institut Curie is the detection of tumoral DNA in the blood, offering interesting perspectives for monitoring patients, monitoring specific anti-tumor treatments, assessing the prognosis, and screening for cancers and recurrences following treatment.

As a center specializing in the treatment of tumors of the anal canal and the rectum, Institut Curie has focused on research to discover and understand the biological and molecular function of these tumors. To date, the analysis of the largest cohort of tumors of the anal canal has been conducted in order to find new therapeutic options for the long term.

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