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Resume Introduction Le pemetrexed (Alimta®) est un nouvel agent anti-tumoral de la classe des anti-folates indique dans le traitement du mesotheliome pleural malin et du cancer bronchique non a petites cellules (CBNPC). Nous rapportons deux nouveaux cas de toxicite cutanee induite par le pemetrexed, a type de sclerose cutanee des jambes. Observations Cas no 1 : un homme de 66 ans presentait un adenocarcinome bronchique d�emblee metastatique, traite par six cures de cisplatine-pemetrexed, puis par pemetrexed seul en traitement d�entretien. Apres le quatrieme cycle de pemetrexed, il presentait une dermo-hypodermite douloureuse des membres inferieurs, non febrile, ressemblant cliniquement a un erysipele. Cas no 2 : une femme de 70 ans recevant du pemetrexed en traitement d�entretien pour un CBNPC presentait des le premier cycle un �deme erythemateux des jambes. Il s�agissait de placards erythemato-violaces �demateux, indures et douloureux, associes a une impotence fonctionnelle. Dans les deux cas, le pemetrexed a ete arrete et l�evolution locale a ete lentement favorable, avec persistance d�un �deme sclereux. Discussion Cet effet indesirable cutane est meconnu, entrainant un retard diagnostique. Les lesions sont initialement confondues avec un erysipele malgre la bilateralite et l�absence de syndrome febrile. Une supplementation par folates et vitamine B12 associee a de la dexamethasone pourrait faire diminuer l�incidence et la severite de cette toxicite. Nos deux patients n�ont pas presente de recidive ni d�aggravation de leur scler�deme sous taxanes, agents de chimiotherapie connus pour etre pourvoyeur de syndromes sclerodermiformes. Nous estimons que cette toxicite cutanee doit etre connue en raison de sa severite potentielle. Summary Background Pemetrexed (Alimta®) is a new-generation antifolate used to treat malignant pleural mesothelioma and non-small cell lung cancer (NSCLC). We report two cases of a new toxicity induced by pemetrexed: scleroderma-like induration of the lower extremities. Patients and methods The first case concerned a 66-year-old man diagnosed with pulmonary adenocarcinoma metastatic from the outset and in whom maintenance treatment comprised pemetrexed after first-line therapy comprising six courses of cisplatin-pemetrexed. After the fourth cycle of pemetrexed, he presented an erythematous oedema of the left leg, which was subsequently bilateral. Clinically, there was painful cellulitis associated with areas of bruising. The lesions had an appearance of erysipeloid-like infection, and there was no fever. The second case concerned a 70-year-old woman diagnosed with metastatic NSCLC. From the first course of pemetrexed, given as maintenance therapy, she presented erythematous oedema of both legs, without fever. After the second course, we observed the recurrence of the lesions consisting of erythemato-violaceous plaques on both legs, with severe bilateral indurated and painful oedema, associated with major functional disability. A diagnosis of bilateral erysipelas was made, and antibiotic treatment with cloxacillin was given. In both cases, pemetrexed was discontinued and the local outcome was very slowly favourable, with persistence of scleroderma. Discussion This cutaneous adverse effect is unrecognized, resulting in delayed diagnosis. It is often initially confused with bilateral erysipelas, despite absence of fever. According to some studies, the severity of the cutaneous toxicity may be connected with patients� folate status. Thus folate and vitamin B12 supplementation combined with dexamethasone could decrease the incidence of this side effect. There was no recurrence and no worsening with taxanes, chemotherapy agents known to induce scleroderma. We feel that this cutaneous toxicity must be recognised on account of its potential severity.

Background: We conducted an economic analysis of a phase III clinical trial comparing sequential radiochemotherapy (RT-CT) with concurrent RT-CT in patients with locally advanced non-small-cell lung cancer. Patients and methods: The trial was a randomized multicenter study comparing three cycles of chemotherapy (arm A) followed by radiotherapy against an RT-CT combination (two cycles of platinum etoposide) followed by two cycles of platinum-vinorelbine (arm B). The economic analysis adopted the payer's perspective and only included direct costs. Costs (€, 1996–2003) were recorded until the cut-off date. A cost minimization analysis and a sensitivity analysis were carried out. Results: Data from 173 patients were used in the economic study. Protocol costs tended to be higher in arm B, while relapse costs were significantly higher in arm A. The total number of hospital days was higher in arm B. The average total cost per patient was €16 074 in arm A and €15 245 in arm B (P = 0.15). The cost minimization analysis favored arm B. This advantage persisted in the sensitivity analysis. Conclusions: Concurrent RT-CT was not the more costly strategy in this phase III trial, despite lengthier hospitalization for toxicity. Other studies of similar design are needed to confirm these results in future randomized trials.

Pemetrexed (Alimta(®)) is a new-generation antifolate used to treat malignant pleural mesothelioma and non-small cell lung cancer (NSCLC). We report two cases of a new toxicity induced by pemetrexed: scleroderma-like induration of the lower extremities.The first case concerned a 66-year-old man diagnosed with pulmonary adenocarcinoma metastatic from the outset and in whom maintenance treatment comprised pemetrexed after first-line therapy comprising six courses of cisplatin-pemetrexed. After the fourth cycle of pemetrexed, he presented an erythematous oedema of the left leg, which was subsequently bilateral. Clinically, there was painful cellulitis associated with areas of bruising. The lesions had an appearance of erysipeloid-like infection, and there was no fever. The second case concerned a 70-year-old woman diagnosed with metastatic NSCLC. From the first course of pemetrexed, given as maintenance therapy, she presented erythematous oedema of both legs, without fever. After the second course, we observed the recurrence of the lesions consisting of erythemato-violaceous plaques on both legs, with severe bilateral indurated and painful oedema, associated with major functional disability. A diagnosis of bilateral erysipelas was made, and antibiotic treatment with cloxacillin was given. In both cases, pemetrexed was discontinued and the local outcome was very slowly favourable, with persistence of scleroderma.This cutaneous adverse effect is unrecognized, resulting in delayed diagnosis. It is often initially confused with bilateral erysipelas, despite absence of fever. According to some studies, the severity of the cutaneous toxicity may be connected with patients' folate status. Thus folate and vitamin B12 supplementation combined with dexamethasone could decrease the incidence of this side effect. There was no recurrence and no worsening with taxanes, chemotherapy agents known to induce scleroderma. We feel that this cutaneous toxicity must be recognised on account of its potential severity.

Background: Elderly cancer patients form a heterogeneous population in which therapeutic decision-making is often difficult. The aim of this randomised phase II trial was to evaluate the feasibility and activity of weekly docetaxel/gemcitabine (DG) followed by erlotinib after progression (arm A) vs erlotinib followed by DG after progression (arm B) in fit elderly patients with advanced non small-cell lung cancer (NSCLC). Methods: Elderly chemotherapy-naive patients with stage IIIB/IV NSCLC were selected after a comprehensive geriatric assessment (socioeconomic, cognitive, depression, ADL and IADL assessments). The primary endpoint was the time to second progression (TTP2). Overall survival (OS), the time to first progression (TTP1) and safety were secondary endpoints. Results: Between July 2006 and November 2008, 22 centres enrolled 100 patients. TTP2 was 7.5 and 5.8 months in arm A and arm B, respectively; TTP1 was 4.7 and 2.7 months; and the median OS time was 9.4 and 7.1 months; the respective 1-year survival rates were 36.2 and 31.4%. There was no major unexpected toxicity. Conclusion: These results suggest that weekly DG, followed by erlotinib, is a promising treatment for fit elderly patients with NSCLC; the efficacy of the reverse sequence was insufficient to recommend it for EGFR-non-selected patients.

Chondroid hamartomas disseminated in both lung fields were discovered in a 76 year old man presenting with recurrent haemoptysis. In view of this metastatic cannonball appearance and the negative investigations, exploratory thoracotomy was performed, revealing the correct diagnosis. Although classical, this form of hamartoma is rare and warrants a case report.

The authors report on a case of Wegener's syndrome diagnosed fortuitously by the discovery of a perforation of the nasal septum during a bronchial fibroscopy for monitoring of a pulmonary fibrosis. In addition to the late appearance of the nasal perforation, the clinical picture includes classic polyvisceral impairment with pulmonary fibrosis, polyarthralgias and renal insufficiency. After 21 months of treatment, a stabilization of the visceral lesions was recorded, with the all but total disappearance of the E.N.T. lesions.