Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Prevalence and distribution of HPV genotypes and cervical-associated lesions in sexually active young French women following HPV vaccine

BACKGROUND

Despite the availability of safe and effective HPV vaccines in France, more than 80% of girls remain unvaccinated.

SETTING

A regional university hospital referral center in France.

OBJECTIVE

To estimate the overall prevalence and distribution of HPV in vaccinated, sexually active young French women who were screened for cervical cancer by cytology and HPV testing.

METHODS

High-risk HPV (HR-HPV) prevalence, genotype-specific prevalence and extent of multiple infections were assessed in 125 cervical samples from females with available vaccine data using hc2 assay and INNO-LiPA assay. HPV status was analyzed in accordance with cytological data.

RESULTS

In our series, mean age was 23 years, overall prevalence of HR-HPV was 52% and was correlated with the lesion grade. The diversity of HPV genotypes was broad. Single HR-HPV infections were identified in 11%, 21% and 47% of women with NILM, ASC-US/-H and LSIL respectively. Multiple infections with HR-HPV were detected in 28% of the specimens. Only 24.5% of women with NILM presented infections with 2 genotypes or more, vs 28% of women with ASC-US/-H and 35% of women with LSIL. The overall prevalence of genotypes covered by the quadrivalent vaccine was low (5.9%); with 4.2%, 0%, 0.8% and 0.8% for HPV 16, HPV 18, HPV 6 and HPV 11 respectively.

CONCLUSION

Among HPV-vaccinated young women, HR-HPV are detected at a high rate, and an association with the grade of cytological abnormalities was observed. However, HPV 16 and 18, both targeted by the vaccines, are remarkably rare among young French women since program implementation.

The influence of geographical access to health care and material deprivation on colorectal cancer survival: evidence from France and England

This article investigates the influence of distance to health care and material deprivation on cancer survival for patients diagnosed with a colorectal cancer between 1997 and 2004 in France and England. This population-based study included all cases of colorectal cancer diagnosed between 1997 and 2004 in 3 cancer registries in France and 1 cancer registry in England (N=40,613). After adjustment for material deprivation, travel times in England were no longer significantly associated with survival. In France patients living between 20 and 90min from the nearest cancer unit tended to have a poorer survival, although this was not statistically significant. In England, the better prognosis observed for remote patients can be explained by associations with material deprivation; distance to health services alone did not affect survival whilst material deprivation level had a major influence, with lower survival for patients living in deprived areas. Increases in travel times to health services in France were associated with poorer survival rates. The pattern of this influence seems to follow an inverse U distribution, i.e. maximal for average travel times.

Patterns of recurrence of obstructing colon cancers after surgery for cure: a population-based study

AIM

Little is known about patterns of recurrence in obstructing colon cancer (OCC) at a population level. The aim of this study was to determine the risk of recurrence following potentially curative surgery in OCC compared with that in uncomplicated colon cancer (CC).

METHOD

Data were obtained from the population-based digestive cancer registry of Burgundy (France). Local and distant failure rates were calculated using actuarial methods. A multivariate analysis was performed using a Cox model.

RESULTS

Obstructing colon cancer represented 8.5% of all colon cancers resected with curative intent (n = 3375). The 5-year cumulative local recurrence rate was 14.2% for OCC and 7.6% for nonobstructing CC (P = 0.003). In the multivariate analysis, obstruction was an independent risk factor for local recurrence [hazard ratio 1.53 (1.01-2.34), P = 0.047]. The risk of local recurrence increased with advanced stage and age at diagnosis. The 5-year cumulative rate for distant metastases was also higher in OCC than in nonobstructing CC (36.1 vs 23.1%; P < 0.001). The relative risk of distant metastasis was borderline significant in the multivariate analysis [hazard ratio 1.25 (0.99-1.59), P = 0.057]. Stage at diagnosis, macroscopic type of growth, period of diagnosis and sex were also significant prognostic factors. Age and subsite were not significant in the multivariate analysis.

CONCLUSION

It is possible to conduct special surveys in population-based registries to determine the recurrence rate of CC. Recurrence remains a substantial problem and is more frequent in OCC than in nonobstructing CC. Efforts must be made to diagnose CC earlier. Mass screening is a promising approach.

Improvement in survival of metastatic colorectal cancer: are the benefits of clinical trials reproduced in population-based studies?

AIM OF THE STUDY

To describe trends in survival of non-resectable metastatic colorectal cancer (MCRC) over a 34-year period in a French population-based registry taking into account major advances in medical therapy.

PATIENTS AND METHODS

3804 patients with non-resectable metastatic colorectal cancer diagnosed between 1976 and 2009 were included. Three periods (1976-96, 1997-2004 and 2005-09) were considered.

RESULTS

The proportion of patients receiving chemotherapy dramatically increased from 19% to 57% between the first two periods, then increased steadily thereafter reaching 59% during the last period (p<0.001). Median relative survival increased from 5.9 months during the 1976-96 period to 10.2 months during the 1997-2004 period but, despite the availability of targeted therapies, remained at 9.5 months during the 2005-09 period. During the last study period, less than 10% of elderly patients received targeted therapies compared to more than 40% for younger patients. Their median relative survival was 5.0 months compared to 15.6 months in younger patients.

CONCLUSION

There was an improvement in survival in relation with the increased use of more effective medical treatment. However, at a population-based level, patients are not all treated equally and most of them, especially the elderly, do not benefit from the most up-to-date treatment options.

Endocrine tumours: epidemiology of malignant digestive neuroendocrine tumours

Little is known about patients with malignant digestive neuroendocrine tumours (MD-NETs). Although their incidence is increasing, MD-NETs remain a rare cancer, representing 1% of digestive cancers. Most MD-NETs are well-differentiated. MD-NET poorly differentiated carcinomas account for 20% of cases on average. Anatomical localisation of MD-NETs varied according to geographic region. Stage at diagnosis and prognosis for patients with MD-NETs in the general population are considerably worse than often reported from small hospital case series. Prognosis varies with tumour differentiation, anatomic site and histological subtype. There are significant differences in survival from MD-NETs among European countries, independent of other prognostic factors. Early diagnosis is difficult; new therapeutic options appear to represent the best approach to improving prognosis.

European disparities in malignant digestive endocrine tumours survival

The aim of this study was to report on malignant digestive endocrine tumours (MDET) prognosis in several European countries. We analysed survival data from 19 cancer registries in 12 European countries on 3,715 MDET diagnosed between 1985 and 1994. The overall 5-year survival rate was 47.5%. It was 58.1% for differentiated MDET and 8.1% for small-cell MDET (p < 0.001), 55.9% for patients under 65 and 37.0% for older patients. Survival rates for small intestinal and colorectal were higher than for the other sites. The 5-year relative survival rates were 60.3% in Northern Europe, 53.6% in Western Continental Europe, 42.5% in the UK, 37.6% in Eastern Europe (p < 0.001). Among well-differentiated pancreatic tumours, 5-year relative survival was 55.6% for insulinoma, 48.4% for gastrinoma, 33.4% for glucagonoma, 28.8% for carcinoid tumours and 49.9% for non-functioning tumours. The relative excess risk of death was significantly lower in Western Continental Europe and Northern Europe and significantly higher in Easter European compared to the UK. MDET differentiation, site, geographic area, age and sex, were independent prognostic factors. Overall, in Europe approximately half of the patients with MDET survive 5 years after the initial diagnosis. Prognosis varies with tumour differentiation, anatomic site and histological type. There are significant differences in survival from MDET among European countries, independently of other prognostic factors.

Access to care, socioeconomic deprivation and colon cancer survival

BACKGROUND

The influence of socioeconomic environment on cancer survival has been established in numerous studies in the EU and the US, prognosis being constantly poorer for the most underprivileged patients.

AIM

To investigate the influence of distance to care centre and deprivation on colon cancer survival, using a multilevel Cox model and taking into account cancer stage at diagnosis and treatment modalities.

METHODS

The study population comprised all cases of colon cancer diagnosed between 1997 and 2000 in two French areas covered by specialized cancer registries (n = 2066).

RESULTS

Road distance to the nearest reference care centre was associated with poorer prognosis even after adjustment for stage at diagnosis (P for trend = 0.01). Subgroups analysis showed that this association was maximal for patients with advanced cancer [RR = 1.27 (1.04-1.51); P for trend = 0.015] for whom access to chemotherapy varying according to distance explained the major part of geographic inequalities in survival.

CONCLUSIONS

The major effect of distance from reference care centre on survival suggests that current regional health planning does not guarantee equity in cancer management. Improvement in access to adjuvant therapy, especially for patients with advanced cancers, seems crucial for reducing geographic disparities in colon cancer survival.

Clinical, molecular, and genotype-phenotype correlation studies from 25 cases of oral-facial-digital syndrome type 1: a French and Belgian collaborative study

Oral-facial-digital syndrome type 1 (OFD1) is characterised by an X linked dominant mode of inheritance with lethality in males. Clinical features include facial dysmorphism with oral, tooth, and distal abnormalities, polycystic kidney disease, and central nervous system malformations. Large interfamilial and intrafamilial clinical variability has been widely reported, and 18 distinct mutations have been previously reported within OFD1. A French and Belgian collaborative study collected 25 cases from 16 families. OFD1 was analysed using direct sequencing and phenotype-genotype correlation was performed using chi2 test. X inactivation studies were performed on blood lymphocytes. In 11 families, 11 novel mutations, including nine frameshift, one nonsense, and one missense mutation were identified, which spanned nine different exons. A combination of our results with previously reported cases showed that the majority of mutations (65.5%) was located in exons 3, 8, 9, 13, and 16. There was phenotype-genotype correlation between (a) polycystic kidney disease and splice mutations; (b) mental retardation and mutations located in exons 3, 8, 9, 13, and 16; and (c) tooth abnormalities and mutations located in coiled coil domains. Comparing the phenotype of the families with a pathogenic mutation to families with absence of OFD1 mutation, polycystic kidneys and short stature were significantly more frequent in the group with no OFD1 mutation, whereas lingual hamartomas were significantly more frequent in the group with OFD1 mutation. Finally, an X inactivation study showed non-random X inactivation in a third of the samples. Differential X inactivation between mothers and daughters in two families with high intrafamilial variability was of particular interest. Slight phenotype-genotype correlations were established, and X inactivation study showed that skewed X inactivation could be partially involved in the pathogenesis of intrafamilial clinical variability.

Survival of cancer patients in France: a population-based study from The Association of the French Cancer Registries (FRANCIM)

We present the main results of the first population-based cancers survival study gathering all French registry data. Survival data on 205,562 cancer cases diagnosed between 01/01/1989 and 31/12/1997 were analysed. Relative survival was estimated using an excess rate model. The evolution of the excess mortality rate over the follow-up period was graphed. The analysis emphasised the effect of age at diagnosis and its variation with time after diagnosis. For breast and prostate cancers, the age-standardised five-year relative survivals were 84% and 77%, respectively. The corresponding results in men and women were 56% versus 58% for colorectal cancer and 12% versus 16% for lung cancer. For some cancer sites, the excess mortality rate decreased to low values by five years after diagnosis. For most cancer sites, age at diagnosis was a negative prognostic factor but this effect was often limited to the first year after diagnosis.

Socioeconomic and geographic determinants of survival of patients with digestive cancer in France

Using a multilevel Cox model, the association between socioeconomic and geographical aggregate variables and survival was investigated in 81 268 patients with digestive tract cancer diagnosed in the years 1980-1997 and registered in 12 registries in the French Network of Cancer Registries. This association differed according to cancer site: it was clear for colon (relative risk (RR)=1.10 (1.04-1.16), 1.10 (1.04-1.16) and 1.14 (1.05-1.23), respectively, for distances to nearest reference cancer care centre between 10 and 30, 30 and 50 and more than 90 km, in comparison with distance of less than 10 km; P-trend=0.003) and rectal cancer (RR=1.09 (1.03-1.15), RR=1.08 (1.02-1.14) and RR=1.12 (1.05-1.19), respectively, for distances between 10 and 30 km, 30 and 50 km and 50 and 70 km, P-trend=0.024) (n=28 010 and n=18 080, respectively) but was not significant for gall bladder and biliary tract cancer (n=2893) or small intestine cancer (n=1038). Even though the influence of socioeconomic status on prognosis is modest compared to clinical prognostic factors such as histology or stage at diagnosis, socioeconomic deprivation and distance to nearest cancer centre need to be considered as potential survival predictors in digestive tract cancer.

Incidence and patterns of recurrence after resection for cure of colonic cancer in a well defined population

BACKGROUND

The aim of this study was to determine the incidence and patterns of failure following potentially curative surgery of colonic cancer.

METHODS

Data were obtained from the cancer registry of the Côte-d'Or (France). Data on 2657 patients who had resection for cure of colonic cancer between 1976 and 2000 were analysed. Local and distant failure rates were calculated using the actuarial method and multivariable analysis was performed using a Cox model.

RESULTS

The 5-year cumulative rate was 12.8 percent for local recurrence and 25.6 percent for distant metastases. Five-year cumulative local recurrence rates were 4.9 percent for stage I, 11.0 percent for stage II and 23.5 percent for stage III tumours (P<0.001). The corresponding rates for distant metastases were 6.4, 21.4 and 48.0 percent (P<0.001). The 5-year cumulative rates for distant metastases were 31.7 percent for the period 1976-1980 and 21.1 percent for 1996-2000, and the local recurrence rates were 17.6 and 9.0 percent respectively. The decreases in rates of local recurrence and distant metastases were significant in multivariable analysis. Cancer extension and presenting features were related to patterns of failure. Tumour location was significantly associated with risk of local recurrence, whereas age and gross features were associated with risk of distant metastasis.

CONCLUSION

Recurrence following resection of colonic cancer remains a substantial problem. Follow-up is of particular importance in the 3 years after surgery.

Management and prognosis of esophageal cancers: Has progress been made?

The aim of this study was to investigate time trends in treatment and prognosis of esophageal cancer in a well-defined French population. Data was obtained from the Burgundy Cancer Registry (France) and three time periods were defined: 1976-90, 1991-96 and 1997-2002. A logistic regression was used to identify factors associated with an R0 resection. A multivariate survival analysis was performed using a Cox model. From 1976 to 2002, 2267 patients were included. The R0 resection rate slightly increased from 20.9% to 25.8% (P=0.019) then remained stable. Operative mortality decreased from 11.7% to 6.7% (NS). Age and subsite significantly influenced the rate of resection for cure whereas period had no effect. Chemotherapy alone was seldom used and radiotherapy alone dramatically dropped over time. Chemoradiation used as adjuvant treatment increased from 16.3% (1976-90) to 30.6% (1997-02) (P<0.001) and as sole treatment from 16.0% to 48.5% (P<0.001). The 3-year survival rates were respectively 10.1% and 9.7% (NS). Age and stage at diagnosis influenced the prognosis of esophageal cancer whereas time period and histology had no influence. This study claims that esophageal cancer remains a serious cancer problem and no improvement has been seen in the study population in France in its management over time.

Trends in the management and survival of digestive tract cancers among patients aged over 80 years

BACKGROUND

Advances have occurred in the management of digestive tract cancers, but it is not known how much they have benefited the elderly.

AIMS

To determine trends in treatment, stage at diagnosis and prognosis of digestive tract cancers among patients aged > or =80 years in two well-defined French populations.

DESIGN

Time trends were studied in three age classes and in 5 four-year time intervals. A multivariate relative survival analysis was performed to estimate the independent effect of both age and period on prognosis.

RESULTS

Five-year relative survival rates were 1.9% for oesophageal cancer, 12% for stomach cancer, 41% for colon cancer and 37% for rectal cancer. The survival rates improved between the first and the fifth period for all cancer sites except for oesophageal cancer. This improvement remained significant after adjustment for age, sex, site and treatment. It was associated with an increase in the proportion of patients who underwent curative resection. Very few patients received adjuvant chemotherapy. The use of adjuvant radiotherapy for rectal and oesophageal cancers did not significantly increase over time.

CONCLUSIONS

Except for oesophageal cancers, substantial advances in the care of digestive tract cancers in the elderly have been achieved. Surgery should not be restricted on the basis of age alone. Further improvements can be made in particular to enhance adjuvant therapy whenever possible.

Are there regional differences in the management of colon cancer in France?

The purpose of this study was to assess possible regional disparities in the management of colon cancer in France. In 1995, 1605 patients with a colon cancer in eight areas covered by a population-based cancer registry were studied. Pre-therapeutic work-up, stage at diagnosis and therapeutic modalities were assessed. There were no differences between areas concerning the resection or the stage at diagnosis. The proportion of patients with a colonoscopy alone varied between 42.7 and 70.4% (P<0.001). The use of both colonoscopy and barium enema was even more heterogeneous (extremes from 11.7 to 40.2%, P<0.001). There were significant differences in the performance of abdominal computed tomography and tumour markers. The number of examined lymph nodes was lower than the recommendation in 47.3% of cases with extremes ranging from 36.9 to 60.9%. Adjuvant chemotherapy was performed on average in 49.4% of cases in stage II (in which it is not recommended) with extremes from 18.8 to 72.5% (P<0.001) and in 79.6% of the cases in stage III (in which it is recommended) with extremes from 63.6 to 94.4% (P=0.08). In conclusion, these results should alert practitioners and health care authorities in order to homogenize practices.

Cellular localisation of survivin: impact on the prognosis in colorectal cancer

PURPOSE

The present study was designed to determine whether the nuclear or cytoplasmic expression of survivin, was related to clinicopathological parameters and survival in sporadic colon carcinomas.

METHODS

Western blotting of cell fractions and immunocytochemical methodology were used in five human colon cancer cell lines. Immunohistochemical study was performed in formalin-fixed paraffin-embedded section from 46 patients with sporadic colorectal adenocarcinomas with a polyclonal antibody directed against survivin. Apoptotic index was evaluated by using the M30 antibody. Survival rates were estimated by the Kaplan-Meier method and compared using the log-rank test. Multivariate survival analysis was performed by the Cox proportional hazards model.

RESULTS

Western blotting and immunocytochemistry analyses confirmed that survivin could be detected both in the nucleus and the cytoplasm. Immunohistochemical analysis demonstrated that 39% of tumours expressed survivin in the nucleus and 41% in the cytoplasm. No relationship was observed between survivin expression and clinicopathological features. Unexpectedly, the apoptotic index appeared to be linked with high survivin nuclear expression. Overall, 3-year observed survival rate was 73% in patients with cytoplasmic survivin expression versus 48% for negative expression (P = 0.14). Survival was 72% versus 50% for positive nuclear survivin expression versus negative (P = 0.16). After adjustment for age and stage, cytoplasmic survivin expression was a significant prognostic factor. A high level of expression was associated to a better survival: RR = 0.35 [0.13-0.98], P = 0.045.

CONCLUSION

These results indicate that the analysis of the subcellular expression of survivin is a determining factor to define the prognostic value. Its evaluation, using a polyclonal antibody, might help clinicians in the stratification of patients with colorectal cancer.

Time trends in the treatment and survival of recurrences from colorectal cancer

BACKGROUND

Little is known about the management of recurrences from colorectal cancer at a population level.

MATERIALS AND METHODS

Data was obtained from the population-based cancer registry of Cote d'Or (Burgundy, France) over a 28-year period. Univariate and multivariate analyses were performed to analyse trends in treatment and survival for local recurrence and distant metastases.

RESULTS

The proportion of patients resected for cure increased from 6.7% (1976-1984) to 23.7% (1994-2003; P <0.001) for distant metastases and from 15.9% to 58.1% (P <0.001) for local recurrence. Age and period of diagnosis were independent factors associated with a resection for cure. Rectal cancer local recurrence was less often resected for cure than colon cancer local recurrence (P=0.05). Long-term survival was observed only after resection for cure: 5-year relative survival rates were 36.1% for local recurrence and 24.0% for distant metastases. In the multivariate analysis, survival decreased with age and increased over time but significantly only over the last study period. Surgical resection and palliative chemotherapy were other determinants of prognosis for distant metastases whereas surgical resection and palliative radiotherapy did influence the prognosis for local recurrence.

CONCLUSION

Substantial advances in the management of recurrences have been achieved over time. More effective treatments and mass screening represent promising approaches to decrease this problem.

What is the best way to assess microsatellite instability status in colorectal cancer? Study on a population base of 462 colorectal cancers

The assessment of the microsatellite instability (MSI) status in colorectal cancers is presently warranted for three reasons: 1) as a screening tool for hereditary nonpolyposis colorectal cancer, 2) as a prognostic marker, and 3) as a potential predictive factor of chemotherapy response. The aim of this study was to evaluate, on a large scale with tissue samples coming from a number of different sources, the difficulties met with routine use of immunohistochemistry (IHC) and to determine if it really does offer an accurate alternative to PCR genotyping. Colorectal carcinomas from 462 consecutive patients resected in public or private hospitals were assessed for MSI status by two methods: MSI testing (with BAT-26 microsatellite) and IHC detection of hMLH1, hMSH2, and hMSH6 proteins. Of the 398 cancers tested, immunohistochemistry was noncontributory in 42 (10.5%), focal in 9 (2.3%), and discordant with the PCR results in 36 (9%). For these 87 cases, complementary analyses were performed to explain discrepancy. After additional IHC assay with modified processing protocols, 8 cases remained noncontributory, 2 focal, and 28 discordant: 18 microsatellite stability IHC/MSI PCR and 10 MSI IHC/microsatellite stability PCR. For these discordant cases, we performed a multiplex PCR assay on DNA extracted from the frozen sample and BAT-26 was amplified from DNA extracted from the paraffin blocks used for IHC. Four discordant cases were reclassified after PCR multiplex assay (3 as MSI and 1 as microsatellite stability). Five other cases displayed intratumoral heterogeneity and 19 remained discordant. The discrepancy could be partly explained by variable technical protocols of fixation in the different laboratories, leading to variations in staining quality and difficulties in IHC interpretation. This population-based study is the first one to show that IHC is not sensitive and specific enough to be used routinely. Immunohistochemistry analysis of MMR proteins must be performed in standardized conditions and interpreted by confirmed pathologists. It cannot replace PCR as long as protocols are not optimized and harmonized.

Incidence and management of malignant digestive endocrine tumours in a well defined French population

BACKGROUND AND AIMS

Little is known about the epidemiology of malignant digestive endocrine tumours. The aim of this study was to report on their incidence and management in a well defined population.

METHODS

Data were obtained from the population based Digestive Cancer Registry of Burgundy (France) over a 24 year period. Incidence rates were calculated by sex, age groups, and period of diagnosis. Treatment and stage at diagnosis were also investigated. Prognosis was determined using crude and relative survival rates. A multivariate relative survival analysis was performed.

RESULTS

Between 1976 and 1999, 229 cases were recorded. Age standardised incidence rates were 0.76/100,000 for men and 0.50/100,000 for women. They increased over time in both sexes. The resectability rate was 74.1%. Among recorded cases, 26.6% did not extend beyond the organ, 20% had lymph node metastases, and 53.3% had visceral metastases or were unresectable. There was no improvement in the resection rate or in the stage at diagnosis over the study period. The overall relative survival rate was 66.9% at one year, 50.4% at five years, and 40.6% at 10 years. Stage at diagnosis, age at diagnosis, and subsite were independent significant prognostic factors.

CONCLUSIONS

Although their incidence is increasing, malignant digestive endocrine tumours remain a rare cancer, representing 1% of digestive cancers. Stage at diagnosis and prognosis at a population level are worse than those reported in hospital series. In the short term, new therapeutic possibilities represent the best way to improve their prognosis.

Sporadic colorectal cancers with defective mismatch repair display a number of specific morphological characteristics: relationship between the expression of hMLH1 and hMSH2 proteins and clinicopathological features of 273 adenocarcinomas

AIMS

The aim of this study was to assess the independent value of pathological criteria in the diagnosis of mismatch repair (MMR)-defective sporadic colorectal cancers.

METHODS AND RESULTS

Resected colorectal adenocarcinomas (n = 273) were reviewed in order to identify a number of specific morphological features of MMR-defective carcinomas. Of the 273 cases, 35.2% were right-sided and 5.9% were poorly differentiated. Focal extracellular mucin secretion was seen in 5.1% of cases and a stromal follicular reaction in 4.6%. The expression of the two major MMR proteins hMLH1 and hMSH2 was studied by immunohistochemistry. Carcinomas were considered deficient in the MMR system when a loss of nuclear signal in neoplastic cells was observed for one of the proteins. Such an extinction was seen in 37 of the cases (13.6%). The hMLH1 protein was the one most frequently altered (86.5%). After multivariate analysis, three independent factors were significantly associated with MMR deficiency: proximal location [odds ratio (OR) = 9.30; 95% confidence interval (CI) 2.79, 30.98], the presence of a true stromal follicular reaction (OR = 13.60; 95% CI 2.98, 62.00) and poor differentiation (OR = 8.33; 95% CI 1.63, 40.32).

CONCLUSIONS

These results confirm that sporadic colorectal MMR-defective adenocarcinomas display certain specific morphological characteristics. However, these pathological features are not sufficiently predictive and immunohistochemistry is needed to identify such tumours accurately.

[How to choose in practice a model to describe the geographic variation of cancer incidence? Example of gastrointestinal cancers from Côte-d'Or]

BACKGROUNDS

In epidemiology, standardized Incidence Ratio (SIR) can have large variance and it is then difficult to distinguish random fluctuations from real spatial variations when describing spatial variations in the rate of cancer. In this context, hierarchical model produce smoothed relative risks estimations helpful for solving this problem. The main advantage of these methods is to combine information of each geographical area with that obtained from prior assumption on the similarity between geographical sub-units. Nevertheless different assumptions produce different geographical maps of incidence of cancer, and the purpose of the present study was the development of a strategy to choose the most satisfactory description of the incidence of digestive cancer in a French department.

METHODS

The strategy to choose the most satisfactory geographical map depends on the following criteria: variability between geographical sub-units, auto-correlation, and variability within geographical sub-unit. These criteria have been estimated from observed data for each site of cancer.

RESULTS

This strategy was applied to digestive tract cancers diagnosed between 1976 and 1997 in the department of Côte-d'Or, France. High-risk areas were often detected in the urban zone of the department, but without autocorrelation in most cases.

CONCLUSION

This strategy permitted to describe cancers in very small areas, avoiding to a large extent the danger of focusing on falsely positive high-risk areas.

Microsatellite instability and intratumoural heterogeneity in 100 right-sided sporadic colon carcinomas

Microsatellite instability has been proposed as an alternative pathway of colorectal carcinogenesis. The aim of this study was to evaluate the interest of immunohistochemistry as a new tool for highlighting mismatch repair deficiency and to compare the results with a PCR-based microsatellite assay. A total of 100 sporadic proximal colon adenocarcinomas were analysed. The expression of hMLH1, hMSH2 and hMSH6 proteins evaluated by immunohistochemistry was altered in 39% of the cancers, whereas microsatellite instability assessed by PCR was detected in 43%. There was discordance between the two methods in eight cases. After further analyses performed on other tumoural areas for these eight cases, total concordance between the two techniques was observed (Kappa=100%). Our results demonstrate that immunohistochemistry may be as efficient as microsatellite amplification in the detection of unstable phenotype provided that at least two samples of each carcinoma are screened, because of intratumoural heterogeneity.

Prompting alcoholics to be referred to an alcohol clinic: the effectiveness of a simple letter

Many patients received in emergency units (EU) of hospitals present alcohol-related problems. Most are alcohol dependent or abusers and enter for drunkenness, stay a few hours and return home. To assess the effectiveness of a letter referring these patients to an outpatient alcoholism treatment clinic, we performed a randomized study. For 6 months, all the patients who had been diagnosed as alcoholic, who had an address and who had not consulted a physician for alcoholism in the 6 previous months were selected from the records of the EU of a French university hospital. At least 2 days after their stay in the EU, we sent a letter to 181 patients of an experimental group (group E) suggesting they make an appointment with a physician specializing in alcoholism. No letter was sent to 181 patients in a control group (group C). Six months later, 21 patients (11.2%) of group E had called the outpatient alcoholism treatment clinic to make an appointment and came to a consultation. Two of the 181 patients of group C came to the consultation. The effectiveness of this method for referring alcoholics to a clinic had been controlled by another prospective study. We concluded that sending a letter 2 days after the passage of an alcoholic to an EU for drunkenness is a useful method of referral to an outpatient alcoholism treatment clinic.

Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients

To determine the incidence rate of complications associated with vascular catheters in intensive care unit patients and to analyze risk factors for a positive vascular culture, we performed a multicenter study of intensive care unit patients at eight French hospitals. During the study period, 865 intravenous catheters were inserted in 566 patients; 362 (41.8%) were peripheral catheters, and 503 (58.2%) were central catheters. Local complications (i.e., infiltration) occurred significantly more often with peripheral than with central catheters (P less than 0.001); in contrast, fever and bacteremia were significantly more often associated with central than with peripheral catheters (P less than 0.01 and P less than 0.05, respectively). The culture of the vascular-catheter tip was positive for 24% of central catheters (32 of 1,000 catheters days) and for 9% of peripheral catheters (21 of 1,000 catheters days). Staphylococcus epidermidis was the most common microorganism isolated from both peripheral and central catheters, followed by Staphylococcus aureus and Pseudomonas aeruginosa. No significant risk factor associated with positive cultures for peripheral catheters was found by univariate analysis. In contrast, the purpose of the cannula (nutrition and monitoring of central venous pressure), the insertion site (jugular), the dressing type (semipermeable transparent dressing), the antiseptic used to prepare the insertion site (povidone iodine), and routine changing of the intravenous administration set were significantly associated with positive cultures of central catheters. Three factors, duration of catheterization, use of a semipermeable transparent dressing, and the jugular insertion site, were found to be independently associated with positive cultures of central catheters by multivariate analysis.

[Penicillin-induced encephalopathy]

Five cases of encephalopathy due to intravenous penicillin treatment (penicillin G sodium in 4 cases, oxacillin in 1) are reported in 5 uraemic patients. The first abnormalities noted were decreased consciousness and myoclonic jerks (3 cases), followed by seizures and coma (2 cases). Lumbar puncture and cerebral computed tomography gave normal results. Electroencephalograms showed diffuse sharp and slow activities over the brain areas. The diagnosis was confirmed by the high blood levels of the penicillins. Three patients recovered after discontinuation of the drugs; two patients died in status epilepticus and coma resistant to all treatments.

[Cutis verticis gyrata, hypertrophic gastritis, motrice diarhea, and horse's tall syndrome, a new association an apudoma (carcinoid or chemodectoma) (author's transl)]

The authors report the observation of a 70 years male with Cutis Verticis Gyrata (without hypertrophying osteopathy), Menetrier's hypertrophic gastritis, motrice diarrhea of the endocrine type, flush syndrom, liver angiomatosis and a large sacral water clear cells tumor with horse's tail syndrom. The initial tumor was on the posterior wall of rectum, but was necrosed : bone metastasing chemodectoma, or locally invading carcinoid ? This new complex paraneoplastic disease seems to be associated with APUD tumor.