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Marnat G, Bühlmann M, Eker OF, Gralla J, Machi P, Fischer U, Riquelme C, Arnold M, Bonafé A, Jung S, Costalat V, Mordasini P. Multicentric Experience in Distal-to-Proximal Revascularization of Tandem Occlusion Stroke Related to Internal Carotid Artery Dissection. AJNR Am J Neuroradiol 2018; 39:1093-1099. [PMID: 29700047 DOI: 10.3174/ajnr.a5640] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/07/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Internal carotid dissection is a frequent cause of ischemic stroke in young adults. It may cause tandem occlusions in which cervical carotid obstruction is associated with intracranial proximal vessel occlusion. To date, no consensus has emerged concerning endovascular treatment strategy. Our aim was to evaluate our endovascular "distal-to-proximal" strategy in the treatment of this stroke subtype in the first large multicentric cohort. MATERIALS AND METHODS Prospectively managed stroke data bases from 2 separate centers were retrospectively studied between 2009 and 2014 for records of tandem occlusions related to internal carotid dissection. Atheromatous tandem occlusions were excluded. The first step in the revascularization procedure was intracranial thrombectomy. Then, cervical carotid stent placement was performed depending on the functionality of the circle of Willis and the persistence of residual cervical ICA occlusion, severe stenosis, or thrombus apposition. Efficiency, complications, and radiologic and clinical outcomes were recorded. RESULTS Thirty-four patients presenting with tandem occlusion stroke secondary to internal carotid dissection were treated during the study period. The mean age was 52.5 years, the mean initial NIHSS score was 17.29 ± 6.23, and the mean delay between onset and groin puncture was 3.58 ± 1.1 hours. Recanalization TICI 2b/3 was obtained in 21 cases (62%). Fifteen patients underwent cervical carotid stent placement. There was no recurrence of ipsilateral stroke in the nonstented subgroup. Twenty-one patients (67.65%) had a favorable clinical outcome after 3 months. CONCLUSIONS Endovascular treatment of internal carotid dissection-related tandem occlusion stroke using the distal-to-proximal recanalization strategy appears to be feasible, with low complication rates and considerable rates of successful recanalization.
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Affiliation(s)
- G Marnat
- From the Interventional and Diagnostic Neuroradiology Department (G.M.), Bordeaux University Hospital, Bordeaux, France
| | - M Bühlmann
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - O F Eker
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - J Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - P Machi
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - U Fischer
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - C Riquelme
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - M Arnold
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - A Bonafé
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - S Jung
- University Institute of Diagnostic and Interventional Neuroradiology (J.G., P.M.)
| | - V Costalat
- Interventional and Diagnostic Neuroradiology Department (O.F.E., P.M., C.R., A.B., V.C.), Montpellier University Hospital, Montpellier, France
| | - P Mordasini
- From the Interventional and Diagnostic Neuroradiology Department (G.M.), Bordeaux University Hospital, Bordeaux, France
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Rochlitz C, Spirig C, Ruhstaller T, Suter T, Bühlmann M, Fehr M, Schönenberger A, Lerch S, Mayer M, Zaman K. Bevacizumab and pegylated liposomal doxorubicin as first-line therapy for locally recurrent or metastatic breast cancer: A multicenter, single-arm phase II trial of the Swiss Group for Clinical Cancer Research (SAKK). J Clin Oncol 2009. [DOI: 10.1200/jco.2009.27.15_suppl.1030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1030 Background: Bevacizumab in combination with taxanes has become a standard first-line treatment of advanced breast cancer in some countries, but there is no information on its use in combination with pegylated lipsomal doxorubicin in metastatic breast cancer. Therefore, we performed a multicenter, single-arm phase II trial to evaluate the toxicity and efficacy of pegylated liposomal doxorubicin (PLD) and bevacizumab (B) as first-line treatment in advanced breast cancer. Methods: PLD at a dose of 20 mg/m2 and B at 10 mg/kg were infused on days 1 and 15 of each 4-week cycle for a maximum of 6 cycles. Thereafter, B monotherapy was continued at the same dose until progression or toxicity. Primary endpoint was the occurrence of specific toxic events known to strongly interfere with quality of life, i.e., severe cardiac toxicity, any grade 4/5 toxicity, and selected grade 3 nonhematological toxicities (hand-foot-syndrome, cognitive disturbance, CNS hemorrhage, and mucositis/stomatitis). Secondary endpoints included overall response, progression free survival (PFS), time to treatment failure, and duration of response. Eligibility criteria included documentation of metastatic or inoperable breast cancer; measurable disease according to RECIST; erbB2-negativity; LVEF of ≥ 55%; WHO performance status 0 or 1. The study used a Herndon's two-stage design with 14 and 29 patients for stages 1 and 2, respectively. The promising rate of primary toxicity was <15% and the uninteresting rate >33%. The type I error probability was 5% and the power 80%. Results: The trial had to be stopped prematurely because of toxicity after the enrollment of 41 evaluable patients. Among these patients, 16 (39%) had grade 3 hand-foot syndrome, 1 grade 3 mucositis and 1 grade 4 cardiac toxicity. Thus, a total of 18/41 (44%, exact 95% c.i. 28–60%) of all patients had a primary toxicity. Best overall response rate was 23.3% (exact 95% c.i. 12–39%), median PFS was 7.5 months (95% c.i. 4.6–8.1 months). Conclusions: The combination of 2-weekly PLD and B in advanced breast cancer is surprisingly toxic and only modestly active and should not be further investigated. [Table: see text]
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Affiliation(s)
- C. Rochlitz
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - C. Spirig
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - T. Ruhstaller
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - T. Suter
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - M. Bühlmann
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - M. Fehr
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - A. Schönenberger
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - S. Lerch
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - M. Mayer
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
| | - K. Zaman
- University Hospital, Basel, Switzerland; Brustzentrum, St. Gallen, Switzerland; Inselspital, Bern, Switzerland; University Hospital, Zürich, Switzerland; Kantonsspital, Aarau, Switzerland; Swiss Group for Clinical Cancer Research, Bern, Switzerland; Centre Hospitalier Universitaire Vaudois Lausanne, Lausanne, Switzerland
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Abstract
DEFINITION Periampullary carcinomas are rare and constitute a special entity, as diagnosed earlier and having a better prognosis than other duodenal tumors. METHODS In the present study, we retrospectively reviewed the medical records of 16 patients with periampullary carcinomas over 10 years. RESULTS 16 patients, 10 men and 6 women (median age 66.7 years, range 42-80) had a malignant periampullary tumor. Initial symptoms were jaundice (88%), weight loss (69%), nausea and vomiting (50%) and abdominal pain (38%). Gastro-duodenoscopy, ERCP, ultrasound and CT scan were the most useful diagnostic tools. Histologically all the tumors were adenocarcinomas and solitary tumors. 91% were stage pT1 or pT2 tumors, localized in the duodenal wall without any infiltration of the pancreas. 36% of the tumors had metastasized either in lymph nodes or distant organs at diagnosis (18% pN1, 18% pM1). Resectability rate was 81%, curative resection was achieved in 62%. The operations performed were pancreatico-duodenectomy (n = 8), local tumor resection (n = 5) and palliative bypass (n = 3). Morbidity and reoperation rate were 37.5% and 18.8%, respectively; 30-day mortality was 0%. The 1- and 5-year survival rates were 58.3% and 33.3%, respectively. CONCLUSIONS Compared to carcinomas of the small bowel or the exocrine pancreas periampullary carcinomas have a far better 5-year survival rate of more than 30%. Aggressive diagnostic workup in case of the leading symptom jaundice and radical operative therapy are key factors to achieve this goal.
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Affiliation(s)
- M Naef
- Department of Visceral and Transplantation Surgery, University of Bern, Inselspital
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