[Atypical metastatic sites in rectal cancer]

We report the case of a 48-year-old woman operated on for rectal carcinoma and subsequently for metastasis located in three unusual sites (i.e., laryngeal, muscular and cutaneous). Three months after the last surgery, the patient was still alive, without any detectable metastasis.

Low-dose-rate intraoperative brachytherapy combined with external beam irradiation in the conservative treatment of soft tissue sarcoma

PURPOSE

Conservative treatment of soft tissue sarcomas most often implies combination of surgical resection and irradiation. The aim of this study was to evaluate low-dose-rate intraoperative brachytherapy, delivered as a boost, in the local control of primary tumors, with special concern about treatment complications.

METHODS AND MATERIALS

Between 1986 and 1995, 112 patients underwent intraoperative implant. This report focuses on the group of 58 patients with primary sarcomas treated by combination of conservative surgery, intraoperative brachytherapy, and external irradiation. Most of the tumors were located in the lower limbs (46/58-79%). Median size of the tumor was 10 cm, most of the lesions being T2-T3 (51/58-88%), Grade 2 or 3 (48/58-83%). The mean brachytherapy dose was 20 Gy and external beam irradiation dose 45 Gy. In 36/58 cases, iridium wires had to be placed on contact with neurovascular structures.

RESULTS

With a median follow-up of 54 months, the 5-year actuarial survival was 64.9%, with a 5-year actuarial local control of 89%. Of the 6 patients with local relapse, 3 were salvaged. Acute side effects, essentially wound healing problems, occurred in 20/58 patients, late side effects in 16/58 patients (7 neuropathies G2 to G4). No amputation was required. The only significant factor correlated with early side effects was the location of the tumor in the lower limb (p = 0.003), and with late side effects the vicinity of the tumor with neurovascular structures (p = 0.009).

CONCLUSION

Brachytherapy allows early delivery of a boost dose in a reduced volume of tissue, precisely mapped by the intraoperative procedure. Combined with external beam irradiation, it is a safe and efficient treatment technique leading to high local control rates and limited functional impairment.

[Cervical adenocarcinomas: diagnostic, prognostic and therapeutic aspects in a 49 case-control study]

OBJECTIVES

The aim of this study was to search for potential diagnostic, therapeutic and prognosis differences between a series of 49 adenocarcinomas of the cervix and a matched series of epidermoid carcinomas.

METHODS

Forty-nine adenocarcinomas were treated between 1978 and 1992 and retrospectively compared to a series of 98 paired epidermoid carcinomas.

RESULTS

The adenocarcinoma incidence is 5.4%. There was no significant difference for age distribution, parity, or hormonal status. There was also no significant difference for clinical features. Stage I appeared more frequently in the adenocarcinoma group (stage I: 69.4%, stage II: 14.3%, stage III: 14.3%, stage IV: 2%). Stage I are also more frequently found in the adenocarcinoma group (69.4% versus 42. 9%, p< 0,05). Combined radio-surgical treatment was proposed more often for the adenocarcinoma group (respectively radio-surgery combination 73%, radiotherapy alone 18%, surgery 9%); in the epidermoid carcinoma group, combined radio-surgical treatment and radiotherapy were the usual treatment (46%); surgery alone appeared in third rank place (8%). Adenocarcinoma pelvic recurrences appeared more frequently (28.6% for adenocarcinoma group versus 13.3% for epidermoid group p< 0.05), while distant recurrence was the same (12. 2% for adenocarcinoma group versus 11.2% for epidermoid group, p< 0. 05). Five years overall survival rate was worse for the adenocarcinoma group (52% versus 63.7%, p< 0.05) but the difference was not significant for the disease free survival rate. Only for stage Ib, there are also more pelvic recurrences (35.4% versus 13.1%, p< 0.05), more distant recurrences (9.6% versus 2.6%, p< 0.05), and lower overall survival for adenocarcinomas (58.7% versus 88.5%, p< 0. 01).

CONCLUSION

The incidence of adenocarcinomas is slightly increasing (absolute value in our experience) and the low stages seem to be more frequent in our experience probably by staging inaccuracy. Adenocarcinoma prognosis seems to be worse because of its poor radio-sensitivity. It seems necessary to optimize clinical staging and therapeutic protocols excluding radiotherapeutic approach, including surgical purposes or radio-surgical associations if unfavorable histological features or tumoral enlargement (T> 3 cm) are found.

Association of KM genotype with bullous pemphigoid

Association of kappa light chain immunoglobulin allotypes with bullous pemphigoid was examined in 101 Caucasian patients. Km alleles were determined by polymerase chain reaction amplification followed by restriction enzyme digestion. The frequency of Km(3)/Km(1,2)kappa light-chain genotype was found to be significantly associated with the disease, while that of the Km(3)homozygous genotype was significantly higher in patients with both anti-BPAG1 and anti-BPAG2 autoantibodies.

[Posterior rectopexy in total rectal prolapse-]

STUDY AIM

The aim of this retrospective study was to report the results of posterior Orr-Loygue rectopexy in 55 patients operated on for rectal prolapse.

PATIENTS AND METHOD

From 1986 to 1997, 114 patients were operated on for rectal prolapse and 55 had an Orr-Loygue operation. There were 47 women and 8 men (mean age: 55 years). Twenty-five patients (45%) had fecal incontinence, 26 (47%) described preoperative 'constipation'. The procedure was performed under general anesthesia, through laparotomy in 51 patients, through laparoscopy in 4 patients. Resection of sigmoid colon was associated to rectopexy in four patients.

RESULTS

Mortality rate was 0 and morbidity rate 12%. Mean hospital stay duration was 13.5 days. Mean follow-up was 63 months and at the end of the study, four patients (7%) had recurrence, 5/25 patients had still incontinence; 55% of the patients had unchanged postoperative bowel function, 22% described improvement (including the four patients with resection-rectopexy) but 38% (21/55) suffered from postoperative 'constipation'. The rate of 'constipation' induced or majored by rectopexy was 22% but the functional trouble described appeared often complex.

CONCLUSION

Posterior Orr-Loygue rectopexy is the operation recommended for patients in good general condition, especially if fecal incontinence is associated. In the course of the procedure, preservation of pelvic nerves and hypogastric plexus, and positioning of the strips not too tight between the anterolateral rectal walls and promontory must be emphasized. Posterior Orr-Loygue rectopexy is contraindicated when general anesthesis is too risky and when bowel dysfunction and/or rectal exoneration dysfunction are present.

Long-term functional results of colonic J pouch versus straight coloanal anastomosis

BACKGROUND

There are very few studies evaluating the long-term functional outcome of coloanal anastomoses. This retrospective study aimed to compare long-term functional results of straight and colonic J pouch anastomoses.

METHODS

Thirty-seven patients, 25 with a straight anastomosis and 12 with a J pouch anastomosis, responded to a standardized telephone questionnaire. The mean time since surgery was 10 (range 4-18) years.

RESULTS

The mean daily stool frequency was similar in both groups of patients (1.1 in patients with a reservoir, 1.5 in patients with a straight anastomosis). In both groups, two-thirds of patients had perfect continence or limited gas incontinence. Faecal incontinence was reported by two patients with a straight anastomosis and one patient with a pouch. Nocturnal stools and fragmentation were slightly more frequent in patients with a straight anastomosis. Half of the patients regularly used medication. Thirty-five of the 37 patients reported satisfaction with functional results.

CONCLUSION

Long-term functional results of coloanal anastomoses are satisfactory and, unlike early results, similar for both types of anastomosis. The functional benefit of a reservoir, seen in the first year after operation, is less evident with increasing time.

Effect of mitoxantrone liposomes on multidrug-resistant breast cancer cells

A major obstacle in efficacy of breast cancer chemotherapy is the emergence of multidrug resistance. We investigated modulation of multidrug resistance by liposome-encapsulated mitoxantrone in a drug resistant human breast MCF7R cell line and the influence of liposome composition. Neutral high phase-transition temperature and anionic low phase-transition temperature phospholipid liposomes, reduced the resistance factor from 142 to 15 and 38, respectively. The higher cytotoxicity obtained with mitoxantrone-encapsulation was not necessarily related to higher intracellular uptake. Our data suggest that liposomes, according to their lipid composition, may alter the P-glycoprotein function by plasma membrane stabilization and modulate multidrug resistance in human cancer.

Small intestine protection from radiation by means of a removable adapted prosthesis

BACKGROUND

A prosthesis has been designed to protect intestinal loops from radiation when postsurgical radiotherapy is necessary in cancer treatment. It is a silicone balloon that allows the small bowel to be pushed back away from the radiation field, and it is easily removed at the conclusion of radiotherapy.

METHODS

The device was used in 22 patients: 5 retroperitoneal tumors and 17 pelvic cancers. After surgical resection of the tumor, the device is placed either in the retroperitoneal area or in the pelvic cavity. A polyglactine 910 mesh is placed between the spacer and the bowel to prevent incarceration of the loops. The prosthesis can be filled or emptied between each radiation course and finally removed by means of a short incision under local or locoregional anesthesia.

RESULTS

The tolerance of the small intestine to radiation therapy has been satisfactory in each case, with a mean follow-up of 24.5 months (range 10 to 73). No modification of biological parameters was observed during the pelvic radiation therapy at 30, 45, and 65 Gy.

CONCLUSION

This device should appears to efficient for prevention of bowel injury during postsurgical radiation in successful treatment of abdominal, pelvic, or retroperitoneal tumors when indicated.

[Contribution of telemedicine applied to digestive cancer]

AIM OF THE STUDY

Telemedicine offers new possibilities for multidisciplinary care of cancer patients, allowing direct communications between different, complementary and geographically distant specialists. Thus, it is possible to form oncology committees in small hospitals where all specialties are not represented. The purpose of this study was to evaluate the medical and economic impact of visioconferences in the therapeutic management of cancer patients without access to oncology centers.

MATERIALS

A telemedicine network was created in Paris between the General Surgery and Gastroenterology services of Rothschild Hospital and the services of Oncology at Saint-Antoine Hospital and Radiotherapy at Tenon Hospital. The three hospitals were connected simultaneously (multipoint) by visioconference and thus constituted a pluridisciplinary oncology committee of radiotherapy, chemotherapy and surgery. Eighty seven cases were evaluated in 27 staff conferences. In 48 cases, this consisted of re-evaluating therapeutic decisions made in surgery or gastroenterology, and in 39 cases opinions were requested by surgery (18), gastroenterology (14) or oncology departments (7).

RESULTS

In only 34/87 cases therapeutic agreement was reached directly. The 53 other cases (60.9%) were debated. In fact, all 39 requests for opinion in difficult therapeutic decisions resulted in consensus. Among the 48 re-evaluations, disagreement persisted in one case between the surgeon in charge of the patient and the chemotherapist. Importantly, in 13 of 48 cases (27%), the discussion modified the therapeutic protocol initially proposed. The average cost was 118 French Francs per case and per center. Total initial investment was 334,762 French Francs, but the price of some equipment has already dropped from 30 to 60%.

CONCLUSION

In our study, the visioconference improved management of cancer patients for a weak working cost.

Monoterpenes inhibit cell growth, cell cycle progression, and cyclin D1 gene expression in human breast cancer cell lines

Monoterpenes are found in the essential oils of many commonly consumed fruits and vegetables. These compounds have been shown to exert chemopreventive and chemotherapeutic activities in mammary tumor models and represent a new class of breast cancer therapeutic agents. In this study, we investigated the effects of limonene and limonene-related monoterpenes, perillyl alcohol and perillic acid, on cell growth, cell cycle progression, and expression of cyclin D1 cell cycle-regulatory gene in T-47D, MCF-7, and MDA-MB-231 breast cancer cell lines. Our results revealed that limonene-related monoterpenes caused a dose-dependent inhibition of cell proliferation. Of the three monoterpenes tested, perillyl alcohol was the most potent and limonene was the least potent inhibitor of cell growth. The enantiomeric composition of limonene and perillyl alcohol did not interfere with their effect on cell growth. Sensitivity of breast cancer cell lines to monoterpenes was in the following order: T-47D > MCF-7 > MDA-MB-231. Growth inhibition induced by perillyl alcohol and perillic acid was associated with a fall in the proportion of cells in the S phase and an accumulation of cells in the G1 phase of the cell cycle. Finally, we showed that the effects of limonene-related monoterpenes on cell proliferation and cell cycle progression were preceded by a decrease in cyclin D1 mRNA levels.

Lipases and esterases: a review of their sequences, structure and evolution

This chapter aims to provide a brief review on the enzyme family of lipases and esterases. The sequences, 3D structures and pH dependent electrostatic signatures are presented and analyzed. Since the family comprises more than 100 sequences, we have tried to focus on the most interesting features from our perspective, which translates into finding similarities and differences between members of this family, in particular in and around the active sites, and to identify residues that are partially or totally conserved. Such residues we believe are either important for maintaining the structural scaf-fold of the protein or to maintain activity or specificity. The structure function relationship for these proteins is therefore of central interest. Can we uniquely identify a protein from this large family of sequences--and if so, what is the identifier? The protein family displays some highly complex features: many of the proteins are interfacially activated, i.e. they need to be in physical contact with the aggregated substrate. Access to the active site is blocked with either a loop fragment or an alpha-helical fragment in the absence of interfacial contact. Although the number of known, relevant protein 3D structures is growing steadily, we are nevertheless faced with a virtual explosion in the number of known or deduced amino acid sequences. It is therefore unrealistic to expect that all protein sequences within the foreseeable future will have their 3D structure determined by X-ray diffractional analysis or through other methods. When feasible the gene and/or the amino acid sequences will be analyzed from an evolutionary perspective. As the 3D folds are often remarkably similar, both among the triglyceride lipases as well as among the esterases, the functional diversities (e.g. specificity) must originate in differences in surface residue utilization, in particular of charged residues. The pH variations in the isopotential surfaces of some of the most interesting lipases are presented and a qualitative interpretation proposed. Finally we illustrate that NMR has potential for becoming an important tool in the study of lipases, esterases and their kinetics.

Repeated short-fasting modifies the macronutrient self-selection pattern in rats

The daily caloric intake and circadian pattern of macronutrient self-selection were examined in rats subjected to 3 h of food and water deprivation at the beginning or at the end of darkness. When one sole 3-h period of deprivation was applied, rats showed a compensatory response characterized by an unscheduled diurnal and nocturnal increase in the intake of the three macronutrients. However, repeated short restrictions during 15 days promoted a scheduled time-dependent feeding response, characterized by an exclusive increase in carbohydrate and fat intake and a decrease in protein intake. Repeated deprivation at the onset of dark produced a feeding response confined to the dark phase, while late dark deprivation produced both a diurnal and nocturnal increase in feeding. After 15 days of repeated restriction, rats showed no body weight variations with respect to control rats fed ad libitum. These results show that short fasting elicits a time- and macronutrient-dependent feeding response in rats, which involves reorganization of the macronutrient self-selection pattern to promote a total daily caloric compensation. These results suggest that animals principally respond to the energy deficit produced by restriction.

Mesenteric lengthening in ileoanal pouch anastomosis for ulcerative colitis: Is high division of the superior mesenteric pedicle a safe procedure?

PURPOSE

Lengthening of the mesentery is the technical key point of the ileoanal pouch procedure. Division of the superior mesenteric pedicle high in the mesentery is an original artifice that regularly provides sufficient descent of the pouch to reach the dentate line without any tension. A retrospective study compares two groups of patients with ulcerative colitis.

METHODS

Group 1 consisted of 21 patients with superior mesenteric pedicle division (mean lengthening, 6.1 cm), and Group 2 consisted of 44 patients without superior mesenteric pedicle division. Mortality and postoperative and late morbidity were studied along with functional outcome.

RESULTS

One patient died in Group 2 (postoperative pelvic sepsis); one patient died in Group 1 at six months from late liver transplant complications. Postoperative morbidity was insignificantly less important in Group 1 (P=0.02). Five patients in Group 2 had the pouch removed; none in Group 1 did. Pouchitis episodes developed in both groups, with no significant difference (P=0.5). Three patients in Group 1 developed anastomotic stenosis vs. 8 in Group 2 (P=0.5). Functional results at one-month, one-year, and two-year follow-ups are not significantly different, except that nighttime stool frequency increased in Group 2.

CONCLUSIONS

On the whole, morbidity and functional outcome appear similar. This suggests that high superior mesenteric pedicle division has no adverse effect and can be proposed routinely as an effective lengthening technique.

The polarized hepatic human/rat hybrid WIF 12-1 and WIF-B cells communicate efficiently in vitro via connexin 32-constituted gap junctions

Gap junction intercellular communication (GJIC) plays an essential role in the control of growth, differentiation, and functions of different tissues. The expression of connexins (Cxs), the structural proteins of gap junctions, is developmentally regulated and tissue-specific. In vivo hepatocytes express Cx32 and Cx26. Most currently available in vitro hepatic cell systems express Cx43 instead of the expected Cxs. This work analyzes the GJIC competence and Cx expression of the highly differentiated and polarized hepatoma-derived hybrid cell lines, WIF 12-1 and WIF-B. It shows (using two dye transfer assays) that both lines communicate efficiently and that the acquisition of GJIC competence precedes the formation of bile canaliculi. Interestingly, these cells communicate via Cx32 expression, whereas Cx26 and Cx43 are not expressed, as demonstrated by Western and Northern blotting, immunocytochemistry, and confocal microscopy. The human fibroblast W138 parent communicates via Cx43, whereas the rat hepatoma parent Fao and the subclone WIF 12-1 TGdelta, that has lost the human X chromosome, do not communicate, the expression of Cx32 being restricted to the mRNA in these two lines. The GJIC competence of WIF cells could thus result from the activation of the human X chromosome-linked Cx32 gene.

Group B streptococcal bacteraemia in the elderly

The aim of this retrospective study was to determine the clinical spectrum of group B streptococcal (GBS) bacteraemia in patients over 70 years old. Sixty-six adults with GBS bacteraemia were reviewed over a 5-year period. Disease characteristics, clinical diagnoses and underlying disease were compared in 33 older patients (mean age 82.4 years) and 33 younger patients (mean age 54.2 years). The older patients were also compared with a control group (mean age 81.3 years). Urinary tract infection (39%), skin infection (33%) and pneumonia (24%) were the most frequent clinical diagnoses in older patients. Urinary tract infection (39% versus 6%) was significantly more frequent in older than in younger patients. One underlying disease and one condition were more frequent in elderly patients: congestive heart failure (39% versus 6%) and being bedridden (36% versus 0%). A comparison with the older control group showed that being bedridden was highly associated with GBS bacteraemia and was an important mortality factor amongst older patients (10% versus 30%). In conclusion, GBS disease in the elderly was found to be a severe clinical problem with a high mortality despite appropriate treatment.

[Value of imaging in the management of advanced stage ovarian cancer "experience of 72 computed tomographic examinations"]

OBJECTIVE OF THE STUDY

To place computed tomography (CT) in the evaluation of advanced stages of ovarian tumors throughout two years experience (1991-1992) of a Cancer Medical Center.

MATERIALS AND METHODS

Study of 72 pelvic-abdominal CT examinations of 47 patients in stages III and IV, at the time of the initial diagnosis or during the treatment. The equipment used is a General Electric CE 10,000. The technique was conventional (digestive and intravenous opacification). These examinations were performed by practicing radiologists exclusively in cancerological units.

RESULTS

Carried out in immediate post-operative patients incompletely surgically examined, CT allows the quantification of residue and therefore a new staging in two-thirds of the cases. In the process of adjuvant chemotherapy, CT reveals the persistence of residue in 71% of the cases with therapy implications. At the time of follow-up, CT is revealing of abnormalities in 74% of the cases carried out to systematic content, in 60% of the cases with concomitant elevation of CA 125 level. Abnormalities are always present when CT is carried out from clinical symptoms and elevation of CA 125 level (3 cases in 3). Localized recurrence was only described in 7.6% of the cases.

CONCLUSION

CT is of relative usefulness for the assessment and surveillance of advanced stages of cancers. It contributes with accordance to the literature clarifying the criteria as "impossibility of resection" and according to our series, it contributes in redefining the stage; it participates, during the process of adjuvant therapy of avoiding the unuseful second-look procedures, without predicting "complete response"; finally it participates during the follow-up to the collection of the localized recurrence only situation susceptible to benefit from an efficient surgical treatment.

[Does laparoscopy increase the bacteriological risk of appendectomy? Results of a randomized prospective study]

OBJECTIVE

The authors compare the risk of bacteraemia in open and laparoscopic appendectomy in a prospective randomized study.

METHODS

35 patients with a presumptive diagnosis of acute appendicitis were randomized to have conventional open or laparoscopic surgical procedures. Before randomization, patients signed a consent form to participate in the study. Patients who were converted from laparoscopic to open appendectomy (3 cases), HIV+, allergic to Augmentin or who had contraindications to laparoscopic surgery were excluded from the study. A total of 32 patients were randomized: 17 to open (group I) and 15 to laparoscopic surgery (group II). There were no significant differences with regard to age, ASA score, symptoms or macroscopic aspect of the appendix. Two patients had a normal appendix, 12 had acute appendicitis, 14 gangrenous appendicitis and 4 ruptured or abscessed appendicitis. All patients received preoperative antibiotic prophylaxis (Augmentin) after blood cultures (H1) were drawn. Five other blood cultures were performed in standard medium and medium neutralizing Augmentin: at the time of opening the peritoneum (H2), after appendectomy (H3), after closure of the abdomen (H4), and at 6 (H5) and 12 hours (H6) after the operation. Bacterial cultures from the appendix site were performed before (P1) and after (P2) appendectomy.

RESULTS

The operative mortality rate after conventional or laparoscopic appendectomy was nil. The incidence of post-operative morbidity was 4 cases in group I and 2 cases in group II. No positive bacterial culture was obtained in 17 patients. The distribution of these patients was similar in groups I and II. Samples P1 and P2 were positive in 5 cases. Nine of 27 cases with negative P1 became positive in P2 (33%). There was no significant difference between the two groups with regard to the appearance of the appendix. Only two patients had positive blood cultures at H1. One of them had blood cultures at H3, H4 positive for a second germ.

CONCLUSION

A low risk of bacteraemia exists for both open and laparoscopic appendectomy. This risk did not appear to increase for laparoscopy. Conventional and laparoscopic surgical procedures led to positive peritoneal bacterial cultures after appendectomy in 33% of cases.