[French ccAFU guidelines - update 2020-2022: upper urinary tract urothelial carcinoma]

INTRODUCTION

-The purpose was to propose an update of the French guidelines from the national committee ccAFU on upper tract urothelial carcinomas (UTUC).

METHODS

- A systematic Medline search was performed between 2018 and 2020, as regards diagnosis, options of treatment and follow-up of UTUC, to evaluate different references with levels of evidence.

RESULTS

- The diagnosis of this rare pathology is based on CT-scan acquisition during excretion and ureteroscopy with histological biopsies. Radical nephroureterectomy (RNU) remains the gold standard for surgical treatment, nevertheless a conservative endoscopic approach can be proposed for low risk lesion: unifocal tumor, possible complete resection and low grade and absence of invasion on CT-scan. Close monitoring with endoscopic follow-up (flexible ureteroscopy) in compliant patients is therefore necessary. After RNU, bladder instillation of chemotherapy is recommended to reduce risk of bladder recurrence. A systemic chemotherapy is recommended after RNU in pT2-T4 N0-3 M0 disease.

CONCLUSION

- These updated guidelines will contribute to increase the level of urological care for diagnosis and treatment for UTUC.

[French ccAFU guidelines - update 2020-2022: bladder cancer]

OBJECTIVE

- To update French guidelines for the management of bladder cancer specifically non-muscle invasive (NMIBC) and muscle-invasive bladder cancers (MIBC).

METHODS

- A Medline search was achieved between 2018 and 2020, notably regarding diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

RESULTS

- Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS <1) and renal function (creatinine clearance >60 mL/min) allow it (only in 50% of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

CONCLUSION

- These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment of patients diagnosed with NMIBC and MIBC.

French ccAFU guidelines – Update 2018–2020: Bladder cancer

Objective

To propose updated French guidelines for non-muscle invasive (NMIBC) and muscle-invasive (MIBC) bladder cancers.

Methods

A Medline search was achieved between 2015 and 2018, as regards diagnosis, options of treatment and follow-up of bladder cancer, to evaluate different references with levels of evidence.

Results

Diagnosis of NMIBC (Ta, T1, CIS) is based on a complete deep resection of the tumor. The use of fluorescence and a second-look indication are essential to improve initial diagnosis. Risks of both recurrence and progression can be estimated using the EORTC score. A stratification of patients into low, intermediate and high risk groups is pivotal for recommending adjuvant treatment: instillation of chemotherapy (immediate post-operative, standard schedule) or intravesical BCG (standard schedule and maintenance). Cystectomy is recommended in BCG-refractory patients. Extension evaluation of MIBC is based on contrast-enhanced pelvic-abdominal and thoracic CT-scan. Multiparametric MRI can be an alternative. Cystectomy associated with extended lymph nodes dissection is considered the gold standard for non-metastatic MIBC. It should be preceded by cisplatin-based neoadjuvant chemotherapy in eligible patients. An orthotopic bladder substitution should be proposed to both male and female patients with no contraindication and in cases of negative frozen urethral samples; otherwise transileal ureterostomy is recommended as urinary diversion. All patients should be included in an Early Recovery After Surgery (ERAS) protocol. For metastatic MIBC, first-line chemotherapy using platin is recommended (GC or MVAC), when performans status (PS < 1) and renal function (creatinine clearance > 60 mL/min) allow it (only in 50 % of cases). In second line treatment, immunotherapy with pembrolizumab demonstrated a significant improvement in overall survival.

Conclusion

These updated French guidelines will contribute to increase the level of urological care for the diagnosis and treatment for NMIBC and MIBC.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la vessie French ccAFU guidelines — Update 2018—2020: Bladder cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.006. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.006. That newer version of the text should be used when citing the article.

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU — Actualisation 2018—2020 : tumeurs de la voie excrétrice supérieure French ccAFU guidelines — Update 2018—2020: Upper tract urothelial carcinoma

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: doi:10.1016/j.purol.2019.01.005. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the doi:10.1016/j.purol.2019.01.005. That newer version of the text should be used when citing the article.

Abstract P4-13-23: Next-generation sequencing (NGS), array comparative genomic hybridization (aCGH) and patient-derived tumor xenograft (PDX) for precision medicine in advanced breast cancer: A single-center prospective study

Background

Genomic-based approaches in advanced breast cancer (ABC) were recently demonstrated as feasible in the clinical practice, but only a limited number of patients were actually treated with targeted therapies matching genomic alterations, with low antitumor activity. We conducted a pilot study to evaluate whether precision medicine using NGS and aCGH could be implemented prospectively at a single center in ABC patients. In addition, we examined whether PDX could be derived from ABC and thus could help inform therapeutic decision.

Methods

ABC patients accessible to tumor biopsy were prospectively enrolled at the Institut Paoli-Calmettes in the BC-BIO study (ClinicalTrials.gov, NCT01521676). Tumor tissue from locally recurrent or metastatic disease was immediately frozen after dedicated biopsy. Genomic profiling included high-resolution 4x180K aCGH (Agilent Technologies, Massy, France) and DNA sequencing, using a library of 365 cancer candidate genes (HaloPlex target enrichment kit, Agilent technologies, Santa Clara, CA, USA) and MiSeq analyzer (Illumina, San Diego, CA, USA) with 2x150-bp, paired-end at about 300x coverage. In a subset of patients, fresh tumor was implanted orthotopically in humanized cleared fat pads of NSG mice for establishing xenotransplants.

Results

A total of 34 ABC patients were included, with the following characteristics: median age 54 years (35-77); molecular subtypes: 11 triple-negative (32%), 12 luminal non-HER2 (35%), 4 luminal HER2 (12%), 3 HER2 non-luminal (9%), and 4 unknown (12%); 33 with previous chemotherapy (97%); 22 with previous endocrine treatment (35%); 7 with previous anti-HER2 (21%). Tumor biopsies were obtained from liver (15), skin (6), peritoneum (4), breast (3), node (3), lung (1), pleura (1), and ascitis (1), with a median tumor cellularity of 70% (range 10-90%). aCGH and NGS were available from 34 and 33 patients, respectively. An actionable target was found in 28 patients (82%), corresponding to 66 targets, including 37 mutations (8 in PIK3CA, 7 TP53, 4 ESR1, 2 AKT1, 2 BRCA2, 2 HER2), 22 amplifications (7 for CCND1, 2 CCNE1, 2 FGFR1, 2 IGF1R) and 7 homozygous deletions (3 for PTEN, 2 CDKN2A/B,1 BRCA2, 1 STK11). A targeted therapeutic proposal was possible, either in a clinical trial (N=18, 52%) or using already registered drugs (N=17, 50%). Ten patients actually received a targeted treatment, 1 of them experienced objective response and 1 showed stable disease for more than 6 months. Of 26 patients subjected to mouse implantation, 10 had successful xenografting (6 triple-negative, 2 HER2, 1 luminal non-HER2, 1 subtype non-attributed), with a median time to reach 10 mm of 148 days. These PDX will be used as models to understand the patient's therapeutic response.

Conclusion

Precision medicine using high-throughput DNA sequencing and aCGH can be implemented at a single center in the context of clinical practice and may allow direct therapeutic proposal in 1/3 of patients, but antitumor activity was minimal. PDX may be obtained in a significant fraction of patients, especially in triple-negative and HER2 subtypes, and could phenotypically complement genomic data.

Citation Format: Gonçalves A, Bertucci F, Chaffanet M, Guille A, Garnier S, Adelaide J, Carbuccia N, Brunelle S, Piana G, Cabaud O, Thomassin-Piana J, Paciencia-Gros M, Chereau-Ewald E, Lambaudie E, Sabatier R, Tarpin C, Provansal M, Jalaguier-Coudray A, Extra J-M, Sarran A, Pakradouni J, Viens P, Lopez M, Ginestier C, Charafe-Jauffret E, Birnbaum D. Next-generation sequencing (NGS), array comparative genomic hybridization (aCGH) and patient-derived tumor xenograft (PDX) for precision medicine in advanced breast cancer: A single-center prospective study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-13-23.

Buccodental side effects of sunitinib in patients with metastatic renal cell carcinoma

BACKGROUND

Sunitinib is a tyrosine kinase inhibitor approved for the treatment of renal cell carcinoma (RCC). Few data evaluated severe buccodental adverse events. The aim of this study was to evaluate sunitinib buccodental toxicity in patients with metastatic RCC and to compare it with that of standard chemotherapy in patients with other solid cancers.

METHODS

Patients with RCC treated with sunitinib and patients with other solid tumours treated with chemotherapy were followed for 3 months. Data on dental appliances, oral hygiene/care practices before and during treatment were collected.

RESULTS

A total of 116 patients were included (58 RCC treated by sunitinib: group S, and 58 treated by chemotherapy: group C). No differences in dental care habits were noted before treatment. In group S, patients reported significantly more frequent pain (P<0.01), teeth instability (P=0.01), gingival bleeding (P=0.01) and change in teeth colour (P=0.02). In all, 58% of patients in this group had to modify their diet (P<0.01). Frequency of dentist visits for teeth removal was increased (25% vs 8%, P=0.01).

CONCLUSION

Sunitinib seems to increase buccodental toxicity as compared with chemotherapy. This finding emphasises the need for optimal dental care and standardised dental follow-up in patients treated with sunitinib.

Aggressive angiomyxoma with diffusion-weighted magnetic resonance imaging and dynamic contrast enhancement: a case report and review of the literature

Introduction

Aggressive angiomyxoma (AA) is a rare benign soft tissue tumour usually affecting the pelvis and perineum of young women. Magnetic resonance imaging (MRI) is crucial in the management of AA patients for its diagnostic contribution and for the preoperative assessment of the actual tumour extension. Given the current development of less aggressive therapeutics associated with a higher risk of recurrence, close follow-up with MRI is fundamental after treatment. In this context, diffusion-weighted (DW) imaging has already shown high efficacy in the detection of early small relapses in prostate or rectal cancer.

Case Report

We report here a case of pelvic AA in a 51-year-old woman examined with dynamic contrast enhancement and DW-MRI, including apparent diffusion coefficient mapping and calculation.

Conclusion

To our knowledge, this is the first description of DW-MRI in AA reported in the literature. Here, knowledge about imaging features of AA will be reviewed and expanded.

Could thyroid dysfunction influence outcome in sunitinib-treated metastatic renal cell carcinoma?

BACKGROUND

Sunitinib is a standard of care for metastatic renal cell carcinoma (mRCC). Hypothyroidism is frequently observed under sunitinib therapy. This study was conducted to prospectively determine the correlation between thyroid function and progression-free survival (PFS) in this population.

PATIENTS AND METHODS

One hundred and eleven mRCC patients treated with sunitinib were evaluated for serum thyroid-stimulating hormone (TSH) and T4 levels before treatment and every 6 weeks during treatment. Survival was analysed according to a landmark method with a cut-off of 6 months, excluding early progressive or early-censored patients.

RESULTS

Out of the 102 patients with normal baseline thyroid function, 53% developed thyroid dysfunction, including 95% hypothyroidisms out of which 90.9% received L-thyroxine replacement. Median time to TSH alteration was 5.4 months. Median PFS was 11.7 months for the entire population. Median PFS was not different between the groups with abnormal or normal thyroid function after 6 months of treatment (18.9 and 15.9 months, respectively, log-rank P = 0.94, hazard ratio = 1.02, 95% confidence interval = 0.54-1.93). There was no difference even after adjustment for Memorial Sloan-Kettering Cancer Centre classification and therapy line.

CONCLUSIONS

Abnormal thyroid function with hormonal substitution did not increase survival in our population, independent of initial prognosis and previous treatments. Larger comparative studies are deserved to validate these conclusions.

Alterations of natural killer cells in metastatic prostate cancer

e16131

Background: Recently, prostate cancer (PCa) has been considered as a potential target for antitumoral immunotherapy and cells such as Natural Killer (NK) cells, with antitumoral activity are a promising candidate. NK cells activity is regulated by opposite signals delivered by inhibitory (NKRi) and activating receptors (NKRa). Primary human PCa express ligands for NKRa but the HLA class I (ligands for NKRi) expression is downregulated. Recently, our group have reported that patients with acute myeloid leukaemia have defective interactions receptor -ligand in NK cells due to a decreasing expression of Natural Cytotoxicity Receptors and it could be used as a evasion mechanism by leukaemia cells. The aim of this work was to evaluate the activating receptors expression to know if it could be used as evasion mechanism of the immune response in PCa. Methods: Activating and inhibitory receptors were analysed by flow cytometry in peripheral NK cells from 8 patients with metastatic androgen dependent prostate cancer (ADPC), 10 with metastatic androgen independent prostate cancer (AIPC), 7 patients with localized prostate cancer (LPC ) and 15 healthy donors. Results: The expression of NKp30, NKp46, and NKG2D (as determined by MFI) was significantly lower on NK cells from patients with ADPC and AIPC than in healthy donors. In ADPC patients, the ratio MFI (MFI receptor/MFI control isotype) of NKP30 (4.73 ± 1.07, p = 0.0003), of NKp46 (16.62 ± 3.42, p = 0.036) and of NKG2D (19.61 ± 6.44, p = 0.026) significantly differed from healthy donors (NKp30 26.65 ± 6.12; NKp46 39.73 ± 9.66 and NKG2D 37.97 ± 6.77). It was similar for AIPC NK cells(NKp30 6.28 ± 1.27, p = 0.0002; NKp46 16.24 ± 2.34, p = 0.014; NKG2D 13.61 ± 2.29, p = 0.0003). In ADPC and AIPC NK cells, the expression of NKRi and other NKRa did not differ from healthy donors. In LPC NK cells, the expression of NKRi and NKRa did not differ from healthy donors. Conclusions: We observed a decreased expression of principal activating receptors only in metastatic form of PCa. This could affect the interactions receptor-ligand in NK cells. Is it hormonal therapy or extension of the disease that is responsible of NK cells alterations? Moreover, this could constitute a potential mechanism for cancer cells immune escape and a possible target for therapies improving NK functions.

No significant financial relationships to disclose.

External validation of a nomogram predicting survival in men with metastatic hormone-refractory prostate cancer

e16066

Background: Armstrong et al. (Clin Cancer Res. 2007;13:6396–403) recently published a nomogram predicting the probability of survival in patients with hormone-refractory prostate cancer. The initial report showed a predictive accuracy of 0.69. So far, this nomogram was not yet externally validated. We validated this nomogram in a cohort of patients with hormone-refractory prostate cancer participating in five phase II trials. Methods: In our institution, 84 patients received chemotherapy for metastatic symptomatic hormone-refractory prostate cancer from September 1999 to November 2006. Follow-up was stopped in March 2008 and median follow up for all patients was 15.7 month. 75% of patients received docetaxel based chemotherapy. At the time of inclusion, median age was 69.0 years, median PSA was 40ng/ml, 93% had known bone metastases and 19% had visceral metastases. The area under the receiver operating characteristics curve was used to estimate the predictive accuracy of the nomogram and calibration plots were used for comparison between predicted and observed probabilities. Results: Of all patients, median survival was 15.5 month. The nomogram predicted median survival was 19.9 month, overestimating the true survival by roughly 30%. The predictive accuracy of the predictions at 1 year, 2 years and 5 years was 0.76, 0.69 and 0.64, respectively. The calibration plots showed departures from ideal predictions at 1 year (up to 20% of over estimation of true survival) and 5 years ( up to 19% of under estimation of true survival), whereas the predictions at 2 years showed almost perfect calibrations. Conclusions: The Armstrong et al1 nomogram provides accurate survival predictions in patients with hormone-refractory prostate cancer. The current external validation of this nomogram provides evidence that the nomogram might generally be applied to those patients in daily practice.

No significant financial relationships to disclose.

Computed tomography in suspected local breast cancer recurrence

PURPOSE

The purpose of this prospective study was to test computed tomography (CT) in the evaluation of local breast cancer recurrence.

MATERIALS AND METHODS

Our study population included 103 women referred for mamma CT examination for reasons of suspicious findings in a conservatively treated breast. In these patients, both clinical and conventional imaging studies (mammography, ultrasonography) features of local recurrences were non specific or suspicious. The patients underwent breast CT before and 90 s after intra-venous contrast medium administration. Criterion for cancer recurrence was detection of a lesion with an enhancement of 20 UH or more. The final diagnosis was based on operative histopathological findings or follow-up for over two years.

RESULTS

Local recurrence was confirmed on histology in 52 patients. CT identified 47 breast recurrent cancers. False-positive contrast enhancement was seen in five patients. CT showed 90% sensitivity, 90% specificity and 90% accuracy.

CONCLUSION

Although mamma CT examination proved to have a high diagnostic efficacy in evaluating breast cancer recurrence, routine computed tomography is unnecessary for most patients.

"Mesorectum": the surgical value of an anatomical approach

The quality of total extirpation of the "mesorectum" nowadays determines the prognosis of rectal cancer but the planes of surgical dissection which have been proposed and the anatomical restrictions of this "mesorectum" are sometimes contradictory. The aim of this study was to clarify the relationships of the "mesorectum" with the fascias and nerves of the pelvic cavity to harmonize the plane of dissection in its total extirpation. Four pelvises (2 male, 2 female) harvested from embalmed cadavers were studied by dissection and anatomico-imaging correlation. Two pelvises (1 male, 1 female) were injected with copolymer via the internal iliac and inferior mesenteric arteries. They were then frozen and sectioned sagittally into two hemi-pelvises for the dissection. The two other pelvises were initially studied in 5 mm cuts with CT scanning and magnetic resonance scanning in the sagittal and "transverse oblique" planes. They were then frozen and then cut sagittally into two hemi-pelvises. Each hemi-pelvis was then cut into anatomical sections with an electric saw similar to the radiological cuts: sagittal cuts on the right hemi-pelvis, and "transverse oblique" cuts on the left hemi-pelvis. It was noted that the "mesorectum" was carpeted behind and laterally by a postero-lateral fibrous envelope belonging to the pelvic visceral fascia and in front by a recto-genital membrane of variable nature corresponding to the "Denonvilliers fascia". The postero-lateral fibrous envelope splits into two leaves (anterior and posterior) in front of the sacral concavity and constitutes, lateral to the rectum, the armature of the pelvic plexus. These two leaves delineated the avascular retro-rectal space. The results of the correlations were deceptive. Their use was limited by dilatation of the rectum, which flattened the perirectal fat onto the pelvic walls on all the sections. Nonetheless, the description of the "mesorectum" and the demonstration of its enveloping fascias by dissection allowed the development of a dissection plane for its total extirpation.

CT of small bowel obstruction in adults

The increasing use of computed tomography in evaluating patients with acute abdominal pain has revolutionized the diagnosis of small bowel obstruction in adults. Computed tomography is incontestably the most useful and powerful tool to make positive, topographic, and etiologic diagnoses of small bowel obstruction. Good knowledge of some key signs and rigorous analysis of computed tomographic images by radiologists should lead to improved diagnosis and appropriate treatment.

[Sigmoid volvulus: value of CT]

We report a case of sigmoid volvulus. CT findings are presented. The value of CT compared to abdominal plain radiographs and contrast enema is described.

Strangulated transomental hernia: CT findings

We report a case of surgically confirmed strangulation of small bowel through a defect in the greater omentum. Computed tomography demonstrated the presence and the location of this very unusual internal abdominal hernia. Those findings are presented.

Strangulated transomental hernia: CT findings

We report a case of surgically confirmed strangulation of small bowel through a defect in the greater omentum. Computed tomography demonstrated the presence and the location of this very unusual internal abdominal hernia. Those findings are presented.

Small bowel obstruction secondary to phytobezoar CT findings

A rare cause of small bowel obstruction due to a phytobezoar is reported. CT demonstrated an ovoid intraluminal mass with mottled gas pattern within the small bowel and intestinal obstruction signs. We believe that these CT findings are pathognomonic of this condition.

Two novel rat liver membrane proteins that bind advanced glycosylation endproducts: relationship to macrophage receptor for glucose-modified proteins

Advanced glycosylation endproducts (AGEs), the glucose-derived adducts that form nonenzymatically and accumulate on tissue proteins, are implicated in many chronic complications associated with diabetes and aging. We have previously described a monocyte/macrophage surface receptor system thought to coordinate AGE protein removal and tissue remodeling, and purified a corresponding 90-kD AGE-binding protein from the murine RAW 264.7 cell line. To identify AGE-binding proteins in normal animals, the tissue distribution of 125I-AGE rat serum albumin taken up from the blood was determined in rats in vivo. These uptake studies demonstrated that the liver was a major site of AGE protein sequestration. Using a solid-phase assay system involving the immobilization of solubilized membrane proteins onto nitrocellulose to monitor binding activity, and several purification steps including affinity chromatography over an AGE bovine serum albumin matrix, two rat liver membrane proteins were isolated that specifically bound AGEs, one migrating at 60 kD (p60) and the other at 90 kD (p90) on SDS-PAGE. NH2-terminal sequence analysis revealed no significant homology between these two proteins nor to any molecules available in sequence databases. Flow cytometric analyses using avian antibodies to purified rat p60 and p90 demonstrated that both proteins are present on rat monocytes and macrophages. Competition studies revealed no crossreactivity between the two antisera; anti-p60 and anti-p90 antisera prevented AGE-protein binding to rat macrophages when added alone or in combination. These results indicate that rat liver contains at least two novel and distinct proteins that recognize AGE-modified macromolecules, although p90 may be related to the previously described 90-kD AGE receptor isolated from RAW 264.7 cells. The constitutive expression of AGE-binding proteins on rat monocytes and macrophages, and the sequestration of circulating AGE-modified proteins by the liver, provides further evidence in support of a role for these molecules in the normal removal of proteins marked as senescent by accumulated glucose-derived covalent addition products, or AGEs.