Favorable safety profile of moderate hypofractionated over normofractionated radiotherapy in breast cancer patients: a multicentric prospective real-life data farming analysis

Background

Moderately hypofractionated whole-breast radiotherapy (HFRT) has proven to be as safe and efficient as normofractionated radiotherapy (NFRT) in randomized trials resulting in major changes in clinical practice. Toxicity rates observed in selected clinical trial patients may differ from those observed in unselected patients with possible comorbidities and frailty in real-life. This study aimed to examine the influence of HFRT versus NFRT on acute toxicity and identify risks factors of dermatitis in real-life patients.

Materials and methods

Prospective data from breast cancer patients, treated with locoregional radiotherapy were collected between November 2015 and February 2020 in 3 comprehensive cancer centers. Through a systematic data-farming strategy, acute toxicity evaluation forms (CTCAEv4.0) were prospectively completed and extracted electronically. The results from each center were then anonymously merged into a single database for analysis. A Chi-2 test was used to compare HFRT and NFRT. Furthermore, risk factors of dermatitis were identified in a sub-study (622 patients) by multivariate logistic regression analysis.

Results

In total, 3518 T0-4 N0-3 mostly M0 (85.8%) breast cancer patients with a median age of 60.7 (24–96 years old) were analyzed. Acute grade 2–3 dermatitis, grade 1–3 breast oedema, and grade 1–2 hyperpigmentation were less frequent with HFRT versus NFRT: respectively 8.9% versus 35.1% (Chi-2 = 373.7; p < 0.001), 29.0% versus 37.0% (Chi-2 = 23.1; p < 0.001) and 27.0% versus 55.8% (Chi-2 = 279.2; p < 0.001). Fewer patients experienced pain with HFRT versus NFRT: 33.4% versus 53.7% respectively (Chi-2 = 137.1; p < 0.001). Factors such as high BMI (OR = 2.30 [95% CI, 1.28–4.26], p < 0.01), large breast size (OR = 1.88 [95% CI, 1.07–3.28], p < 0.01) and lumpectomy over mastectomy (OR = 0.52 [95% CI, 0.27–0.97], p < 0.05) were associated with greater risk factors of grade 2–3 dermatitis in multivariate analysis regardless of NFRT or HFRT.

Conclusion

The results of this study suggests that breast HFRT may be a better option even for patients with a high BMI or large breast size. Acute toxicity was low to mild, and lower with HFRT compared to NFRT. Results from real-life data were robust, and support the use of HFRT beyond randomized study populations. Long-term real-life data awaits further investigation.

Prognostic Factors and Survival Score for Patients With Anaplastic Thyroid Carcinoma: A Retrospective Study from a Regional Registry

BACKGROUND/AIM

Anaplastic thyroid carcinoma (ATC) is the least common but most lethal of thyroid cancer, despite various therapeutic options, with limited efficacy. In order to help therapeutic decision-making, the purpose of this study was to develop a new prognostic score providing survival estimates in patients with ATC.

PATIENTS AND METHODS

Based on a multivariate analysis of 149 retrospectively analyzed patients diagnosed with ATC from 1968 to 2017 at a referral center, a propensity score was developed. A model was generated providing survival probability at 6 months and median overall survival estimates.

RESULTS

The median survival was 96 days. The overall survival rate was 35% at 6 months, 20% at 1 year and 13% at 2 years. Stepwise Cox regression revealed that the most appropriate death prediction model included metastatic spread, tumor size and age class as explanatory variables. This model made it possible to define three categories of patients with different survival profiles.

CONCLUSION

Distant metastasis, age and primary tumor size are strong independent factors that affect prognosis in patients with ATC. Using these significant pretreatment factors, we developed a score to predict survival in these patients with poor prognosis.

Primary gastric synovial sarcoma: A case report and literature review

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Primary synovial sarcoma (SS) of the stomach is a very rare disease.

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To date, only 39 gastric SS cases have been reported in the literature.

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Here is a report of a surgically resected primary gastric SS case and a review of the corresponding literature.

Introduction

Synovial sarcoma (SS) is a mesenchymal neoplasm that is characterized by its unique histological pattern and is most commonly found near the joints of the extremity. Stomach involvement is very rare. This work aimed to present the case of a patient with gastric SS. We also conducted a review of 39 gastric SS cases reported in the literature.

Presentation of case

Here we report a case of primary gastric synovial sarcoma in a 32-year-old male patient revealed by gastric reflux. Partial gastrectomy was performed showing a 35 mm lesion with a high spindle cell component. Immunohistochemistry revealed 18q11.2 translocation expression in most of the cells asserting a diagnosis of SS. No local or distant recurrence occurred at 8 months post-operative follow-up.

Discussion

The majority of SS occurs in the extremities and is most often associated with tendons in the large articulations of young adults. Gastric SS are very scarce and a molecular biology approach to detect the SYT-SSX fusion gene is required for conclusive diagnosis. We carried out a clinical review of the 40 cases of primary gastric SS, including our case. They all underwent an excisional surgery, most of them by partial gastectomy or wedge resection. Recurrences were rare and early when they occurred.

Conclusion

Gastric SS is a very uncommon neoplasia although it is henceforth a described entity. Immunohistochemical detection of a pathognomonic translocation is needed to make the diagnosis of SS. Best therapeutic approach for these tumors remains surgical resection with no specific excisional technique recommended.

Prognostic factors in patients with soft palate squamous cell carcinoma

BACKGROUND

To define the prognostic factors associated with outcome in patients with soft palate squamous cell carcinoma (SCC).

METHODS

Previously untreated patients with soft palate and uvula SCC treated in our institution between 1997 and 2012 were collected. The prognostic value of clinical, hematological, and treatment characteristics was examined.

RESULTS

We identified 156 patients, median age 58 years, with 71% drinkers, 91% smokers; 19% had synchronous cancer. Front-line treatment was chemoradiotherapy in 58 (37%), radiotherapy alone in 60 (39%), surgery in 17 (11%), and induction chemotherapy in 21 patients (14%). The 5-year actuarial overall survival (OS) and progression-free survival (PFS) were 41% and 37%, respectively. In univariate analysis, T3-T4 vs T1-T2 stage, N2-N3 vs N0-N1 stage, and neutrophil count >7 g/L were associated with worse OS and PFS (P < .05).

CONCLUSION

In patients with soft palate SCC, inflammation biomarkers were associated with OS.

[Hypofractionated radiotherapy in rectal cancer for elderly patients]

Rectal cancer is a common pathology in the elderly. The standard for advanced rectal tumors is a chemoradiotherapy regimen combined 50Gy with concomitant chemotherapy followed by a surgery. This treatment induces interruptions of chemoradiotherapy and toxicities G3-4 more important in people over 70 years of age. Hypofractionated radiotherapy 5×5Gy with surgery following week is an alternative. All retrospective studies on this fractionation report an excellent immediate and chronic tolerance. The randomized phase III NACRE trial, comparing these 2 radiotherapy, followed by surgery at 6-8 week, established a standard in the management of the elderly patients.

Hypofractionated Regional Nodal Irradiation for Women With Node-Positive Breast Cancer

PURPOSE

To evaluate the effect of hypofractionated radiation therapy (HFRT) of the breast/chest wall and regional nodes on overall survival (OS), disease-free survival (DFS), locoregional control and on treatment-related toxicity in patients with breast cancer and nodal involvement.

METHODS AND MATERIALS

Two hundred fifty-seven patients treated between October 2009 and June 2011 with hypofractionated locoregional radiation therapy (42 Gy in 15 fractions) were retrospectively reviewed, 51 (19.8%) after breast-conserving surgery and 206 (80.2%) after radical surgery. Patients treated with breast-conserving surgery received a boost dose to the tumor bed (delivered by photons, electrons, or interstitial high-dose-rate brachytherapy). Two hundred fifty-six (99.6%) patients underwent chemotherapy, 209 (81.3%) had hormonal treatment, and 65 (25.3%) had anti-HER2 targeted therapy.

RESULTS

The median follow-up time was 64 months (range, 11-88 months). The rates of 5-year OS, DFS, locoregional recurrence (LRR)-free survival, and distant metastasis (DM)-free survival were 86.6%, 84.4%, 93.9%, and 83.1%, respectively. In multivariate analysis (MVA), lymph node ratio >65%, lymphovascular invasion, and negative hormone receptor status predicted for OS, DSF, and DM. T3 to 4 stage was also associated with worse DFS and DM. Finally, for LRR the independent prognostic factors on MVA were N2 to 3 stage and grade 3. Hyperpigmentation was observed in 19.2% of patients, telangiectasia in 12.3%, and fibrosis in 30.7%. Grade ≥2 lymphedema was recorded in 5.8% of cases. During the study follow-up, no cardiac or symptomatic pneumonitis was observed, nor were plexopathy or rib fractures.

CONCLUSION

According to the findings from this retrospective study, HFRT seems to be an acceptable alternative for patients with breast cancer who need regional nodal irradiation. However, prospective randomized trials are necessary to confirm these preliminary results.

[Radiotherapy for endometrial cancer: experience of the national institute of oncology with 52 cases]

Le cancer de l'endomètre est le cancer gynécologique le plus fréquent en occident. Il concerne principalement les femmes ménopausées. L'objectif de notre travail est de rapporter l'expérience du service de radiothérapie à l'Institut National d'Oncologie (INO) dans la prise en charge du cancer de l'endomètre. Nous avons analysé rétrospectivement 52 cas de cancer de l'endomètre traités dans le service de radiothérapie de l'INO entre 2007 à 2009. Les données collectées à partir des dossiers médicaux de nos patientes concernaient les aspects épidémiologiques, cliniques, thérapeutiques et évolutifs de ce cancer. La médiane d’âge des patientes était de 57 ans, 87% étaient ménopausées. Le délai moyen de consultation était de six mois. Le maitre symptôme était des métrorragies chez 51 patientes. Le diagnostic histologique a été porté sur un curetage biopsique de l'endomètre dans 51% des cas. L'examen anatomopathologique a montré un adénocarcinome endométrioïde dans 92% des cas. Après le bilan, 27% des patientes étaient stade I, 30% stade II, 20% stade III et 1% stade IVA selon la classification de la Fédération Internationale de Gynécologie Obstétrique (FIGO). Après la chirurgie, 51% des patientes ont reçu une radiothérapie externe. La dose délivrée était de 46 Gray (Gy). Une curiethérapie du fond vaginal a été délivrée chez toutes les patientes. Sur le plan évolutif, 83% des patientes étaient toujours suivies en situation de bon contrôle de leur maladie, 8% ont eu une récidive locorégionale et 4% avaient des métastases à distance. Ainsi, le cancer de l'endomètre est un cancer dont le traitement repose sur la chirurgie. La radiothérapie est le traitement adjuvant principal.

Impact of cervical cancer on quality of life: beyond the short term (Results from a single institution): Quality of life in long-term cervical cancer survivors: results from a single institution

Background

Cervical cancer (CC) is one of the most widespread gynecological malignancies in women worldwide. Treatment strategies and screening modalities have largely evolved these past years resulting in an improvement of survival. However, treatment modalities are associated with long term side effects that significantly impacts quality of life (QOL) in cervical cancer survivors. The aim of this study is to evaluate QOL (General and sexual QOL) in cervical cancer survivors up to 10 years after the diagnosis.

Material and methods

In a cross-sectional descriptive study design, 110 cervical cancer survivors (CCS) and 80 healthy controls completed questionnaires assessing QOL.

Results

Participants were Arabic White, sexually active. The mean age at diagnosis was 34 years and was 43 years at the time of the interview. In our series long term CCS have generally a good global QOL comparable with healthy controls. However, issues concerning emotional functioning were over expressed by CCS. As to the sexual impact of cervical cancer; CCS experienced less sexual functioning and enjoyment and less satisfaction with their body image when compared to healthy controls.

In a multivariate analysis, spiritual well-being and social support were the predictor factors that statistically affected QOL among the studied cohort, it accounted for 81 % of the variance in QOL scores.

Conclusions

A better understanding of the complexity of the relationship between QOL and cervical cancer sequelae in one hand and socio-demographic factors in the other hand is necessary to improve QOL among cervical cancer survivors. More efforts should make to inform disease free patients about expected side effects and symptoms to face the physical changes that would affect their QOL and sexual activity.

[Primary central nervous lymphoma: what is the role for radiotherapy?]

Primary central nervous system lymphoma is a rare extranodal form of non-Hodgkin lymphoma with an aggressive course and unsatisfactory outcome. Historically, whole-brain radiotherapy was the sole treatment for patients with primary central nervous system lymphoma, with high response rates but typically, this did not result in long-lasting remissions. The addition of high-dose methotrexate-based chemotherapy regimens to whole-brain radiotherapy has significantly improved patients' outcome, but has resulted in a higher incidence of late neurotoxicity, particularly in elderly patients. To date, the role of consolidation radiotherapy is controversial, and some investigators have developed alternative strategies aiming at avoiding immediate irradiation or using a reduced radiotherapy dose to the whole-brain with promising results.

[Concomitant chemoradiotherapy for muscle-invasive bladder cancer: current knowledge, controversies and future directions]

Radical cystectomy with lymphadenectomy is currently the standard of care for muscle-invasive urothelial bladder cancer; however and because of its morbidity and its impact on quality of life, there is a growing tendency for bladder-sparing strategies. Initially reserved for elderly or unfit patients unable to undergo radical cystectomy, chemoradiotherapy became a true alternative to surgery for highly selected patients. Although there are no randomized trials comparing radical cystectomy with bladder preserving approaches, surgery remains the preferred treatment for many clinicians. Furthermore, comparison is even more difficult as modalities of radiotherapy are not consensual and differ between centers with a variability of protocols, volume of irradiation and type of chemotherapy. Several ongoing trials are attempting to optimize chemoradiotherapy and limit its toxicity, especially through techniques of adaptive radiotherapy or targeted therapies.

[Superior vena cava syndrome with malignant causes]

Superior vena cava syndrome comprises various symptoms and signs resulting from the obstruction of the superior vena cava and resulting in reduced blood flow. Superior vena cava may occur secondary to a variety of conditions, but malignant etiologies are the most common. Usually, the diagnosis is based on a quite clear clinical presentation. Patient with acute presentation can develop life-threatening complications such as cerebral or laryngeal edema. In the absence of these two conditions, a histologic diagnosis should be obtained before the initiation of any therapy. Management of superior vena cava syndrome requires a multidisciplinary team. Therapeutic approaches include radiotherapy, chemotherapy and endovascular approach, and the choice of therapy will depend on the severity of the symptoms, the type and the stage of the tumor, but also the patient's general condition.

[Muscle metastasis of an epidermoid carcinoma of the cervix: report of a case and review of the literature]

Les métastases musculaires sont rares, leur nombre est probablement sous estimé. Nous rapportons le cas d'une patiente âgée de 65 ans, ayant présenté une métastase musculaire d'un carcinome épidermoïde du col utérin 6 mois après le diagnostic de la tumeur primitive. Le diagnostic a été obtenu à partir de la biopsie et du scanner abdomino-pelvien. Le traitement a consisté en une irradiation palliative à la dose de 30Gy. L’évolution a été marquée par le décès de la patiente. A travers ce cas clinique on a démontré que le muscle peut être touché par les métastases d'un carcinome épidermoïde du col utérin et que leur pronostic reste en général péjoratif.

[Lost to follow-up in radiotherapy: experience of the National Institute of Oncology in Morocco]

Les perdus de vue (PDV) sont toute personne incluse dans un programme et dont on est sans nouvelles depuis six mois. L'objectif de cette étude est de fournir une description objective du problème des malades PDV au service de radiothérapie à l'Institut National d'Oncologie (INO), elle permet d’étudier l'impact des facteurs socio-économiques, démographiques et ceux liés à la maladie entraînant l'abandon du traitement par le patient. Nous avons réalisé une étude rétrospective de 77 patients PDV parmi 2254 patient admis à l'INO du premier janvier au 31 décembre 2011 pour traitement par radiothérapie. La présente analyse a mis en évidence que les taux d'abandon sont associés à des facteurs liés à la maladie et qu’à la fois le patient et le médecin doivent être formés et être conscients de la façon dont les stades avancés de la maladie, le mauvais statut de performance ainsi que la combinaison des autres problèmes de santé peuvent suffisamment conduire le patient à l'abandon du traitement.

[Meningioma of the maxillary sinus: report of a case with review of the literature]

Les méningiomes extracrâniens sont rares, leur localisation au niveau du sinus maxillaire est exceptionnelle. Nous rapportons le cas d'une patiente âgée de 41 ans, ayant présenté une exophtalmie avec des céphalées intermittentes évoluant depuis 8 ans. Le diagnostic a été retenu à partir de la biopsie et du scanner cérébral et du massif facial. Le traitement a consisté en une irradiation exclusive à la dose de 54 Gray (Gy). La patiente est restée en bon contrôle locorégional, après un recul de 18 mois. A travers ce cas clinique on a démontré que le sinus maxillaire peut être touché par le méningiome, et qu'il doit être inclus dans le diagnostic différentiel des tumeurs des tissus mous.

[Small cell neuroendocrine carcinoma of the uterine cervix: Report of six cases and a review of the literature]

Neuroendocrine carcinoma is a rare and aggressive malignant tumour, mainly developing at the expense of the respiratory and of the digestive tract. Gynecological neuroendocrine tumours are rare and small cell neuroendocrine tumours of the uterine cervix represent 2% of cervical cancer. Given their rarity and the lack of randomized trials, the diagnostic and therapeutic management of these tumors is difficult and essentially based on that of pulmonary neuroendocrine tumours. Like the latter, and despite multimodality regimens, the prognosis of these tumours remains poor. Through this series, we report our experience in the management of these particular tumours while comparing our data with those of the literature.

Plasmocytome solitaire osseux : expérience de l’institut national d’oncologie de Rabat (INO)

Nous évaluerons les aspects diagnostiques, thérapeutiques et évolutifs du plasmocytome solitaire osseux dans notre structure. Il s'agit d'une revue rétrospective portant sur 11 patients suivis et traités dans le Service de Radiothérapie de l'Institut National d'Oncologie de Rabat pour un plasmocytome solitaire osseux entre janvier 1999 et décembre 2009. L’âge moyen de nos patients était de 53 ans (19-79 ans). La douleur était le signe révélateur le plus fréquent. Le siège des lésions était rachidien dans 4cas, nasosinusien dans 2cas, orbitaire dans 1 cas, costal dans 1 cas, presternal dans 1 cas, sellaire dans 1 cas et sacré dans 1 cas. Tous les malades ont reçu une radiothérapie. Cette irradiation était délivrée seule dans 8 cas (73%) ou associée à la chirurgie (laminectomie) dans 3 cas (27%). La dose moyenne de la radiothérapie était de 44 Gy (30 à 60 Gy) et celle-ci a été délivrée par un appareil de télécobalthérapie ou un accélérateur linéaire. La durée moyenne de suivi était de 78 mois (38-118 mois). Le contrôle local, défini par une stabilité radiologique, a été obtenu chez 7 des 11 malades (87%). Un patient a évolué vers un myélome multiple après un délai de 8 mois. La radiothérapie constitue un traitement efficace du plasmocytome osseux solitaire. Le pronostic est affecté par l’évolution vers le myélome multiple, ce qui justifie une surveillance rigoureuse après traitement et suggère une réflexion sur la place exacte de la chimiothérapie.

Study of the localization of iron, ferritin, and hemosiderin in Alzheimer’s disease hippocampus by analytical microscopy at the subcellular level

Previous studies of the structure of core nanocrystals of ferritin (Ft) in the brains of patients with Alzheimer's disease (AD) have shown differences in the mineral compound in comparison with physiological Ft. Both Ft cores have a polyphasic composition but whereas the major phase in physiological Ft is hexagonal ferric iron oxide (ferrihydrite), the major phases in brain AD Ft are two cubic mixed ferric-ferrous iron oxides (magnetite and wüstite). One of these (wüstite) is similar to what is detected in hemosiderin (Hm) cores in primary hemochromatosis (Quintana, C., Cowley, J.M, Marhic, C., 2004. Electron nanodiffraction and high resolution electron microscopy studies of the structure and composition of physiological and pathological ferritin. J. Struct. Biol. 147, 166-178). We have studied, herein, the distribution of iron, Ft, and Hm in sections of AD hippocampus using analytical microscopy. Iron present in Ft cores was directly mapped in a nanoSIMS microscope and the iron distribution has been correlated with the constituent elements N, P, and S. Ft and Hm cores were visualized at an ultrastructural level in an analytical transmission electron microscope. In senile plaques, Ft was observed in the coronal region associated with a non-beta-amyloid component and in the periphery of plaques, together with Hm, in sulfur-rich dense bodies of dystrophic neurites. Hm was also found in lysosomes and siderosomes of glial cells. Ft was observed in the cytoplasm and nucleus of oligodendrocytes. Ft was particularly abundant in myelinated axons in association with oligodendrocyte processes. These findings provide new arguments to support the hypothesis of a dysfunction of Ft (with eventual degradation to Hm) in AD resulting in an increase of toxic brain ferrous ions that may contribute to the production of free radicals that induce both cellular oxidative stress and aged-related myelin breakdown associated with cognitive decline and AD (Bartzokis, G., 2004. Age-related myelin breakdown: a developmental model of cognitive decline and Alzheimer's disease. Neurobiol. Aging 25, 5-18).

[Isolated ptosis in a 58-year-old woman]

A 60-year-old woman who had experienced isolated ptosis for two years was seen when it had been fixed for one year. She had a personal and familial history of stromal corneal dystrophy. The diagnosis of mitochondrial cytopathy was made on the basis of clinical, electrophysiological, biological and histological findings. Surgical repair of the ptosis allowed visual recovery. The relationship between ptosis, corneal dystrophy and mitochondrial cytopathy is discussed.

[Contribution of intravitreal infracyanine green to macular hole and epimacular membrane surgery: preliminary study]

PURPOSE

To evaluate the contribution of intravitreal infracyanine green to macular hole and epimacular membrane surgery.

PATIENTS AND METHODS

Twenty-five consecutive patients were operated on for macular hole (seven cases) or epiretinal membrane (18 cases) using intravitreal infracyanine. In most cases, 25mg of infracyanine powder was diluted in 5ml of solvent, then in 5ml of BSS and used within 1 hour. The solution was injected at the end of the vitrectomy and aspirated after 1-2 minutes. The internal limiting membrane was removed in both diseases. All specimens were studied using confocal microscopy or an immunocytochemical preparation.

RESULTS

In cases of macular hole, the internal limiting membrane was bright green colored. Opening and peeling were greatly facilitated. In cases of epiretinal membrane, staining was variable: the most frequent aspect was an uncolored central area similar to a geographic map surrounded by a green stained zone. Sometimes the coloration appeared as sparse spots on the posterior pole. Occasionally the staining was homogeneous as in the macular hole cases. After the removal of the membrane, a second injection made it possible to check for the persistence of the internal limiting membrane and proceed to its ablation when necessary. A good correlation was found between surgical and histopathological aspects.

CONCLUSION

Intravitreal infracyanine green is very helpful for the removal of internal limiting membrane in macular holes and epiretinal membrane surgery.

Neoadjuvant chemotherapy in locally advanced gastric carcinoma--a phase II trial with combined continuous intravenous 5-fluorouracil and bolus cisplatinum

Locally advanced gastric adenocarcinomas (LAGC) have a poor prognosis, particularly when tumours are bulky, located in the cardia or in the event of locoregional lymph node involvement. Patients bearing these tumours were entered in a phase II trial of neoadjuvant chemotherapy, combining continuous intravenous 5-fluorouracil (5FU) (1000 mg/m2 for 5 days) and cisplatinum (CDDP) (100 mg/m2 on day 2) repeated every 4 weeks, for one to six cycles according to response and tolerance. 30 patients have been entered, 26 after clinical evaluation (CAT scan and upper gastrointestinal endoscopy) and 4 with unresectable tumours at prior laparotomy. Median age was 60 years, 15/30 patients had a tumour of the cardia, 15/30 had enlarged lymph nodes and 7/30 had linitis plastica (diffuse type). A mean number of three cycles was administered (range 1-6). 27 of the 30 patients were evaluable for response. One patient achieved a complete response (CR) and 14 a partial response (56%; 95% confidence interval 38-74%). No patient had tumour progression, and only 1/6 with linitis plastica responded. 28 patients underwent surgery, and 23 had a macroscopically complete resection (77% of the 30 entered patients); RO resections were performed in 60% of the cases, mainly after an objective response (13/15 versus 4/12 in nonresponders). No pathological CR were seen. Grade 4 neutropenia was observed in eight cycles (5 patients), with five septic complications and one death due to toxicity. Four postoperative complications were observed: 2 cases of severe pneumonia and 2 subphrenic abscesses. One postoperative death, due to intravascular disseminated coagulation, was observed at day 30. Median survival was 16 months and the 1-, 2- and 3-year survival was 67, 42 and 38%, respectively. Patients with linitis plastica had a significantly shorter survival (P < 0.002). We conclude that neodjuvant chemotherapy is feasible in LAGC, although randomised trials are warranted to demonstrate its efficacy on survival and resection rates.

Efficacy of combined 5-fluorouracil and cisplatinum in advanced gastric carcinomas. A phase II trial with prognostic factor analysis

Combined chemotherapy has demonstrated a degree of efficacy in gastric carcinoma. As 5-fluorouracil (5FU) and cisplatinum are two of the most active drugs, we have tested the efficacy of combined 5FU and cisplatinum in a prospective phase II trial. Cycles were administered every 4 weeks and consisted of 5FU 1000 mg/m2/day 5 days continuous intravenous (i.v.) infusion and cisplatinum 100 mg/m2 on day 2. Cycles were repeated according to tolerance and efficacy. 87 patients entered the study, 57 with metastatic or recurrent tumour (M) and 30 with locally advanced gastric cancer (LAGC). The response rate for the 83 evaluable patients was 43% [95% confidence interval (CI) 30-56%]. There were four complete responses (5%), 32 partial responses (39%), 34 cases of stable disease and 13 cases of progressive disease. Responses were more frequent in patients with a good performance status (P = 0.02), with their primary located in the cardia (P = 0.003), with a non-linitis plastica tumour form (P = 0.003) or a tumour containing less than 50% of independent cells (P = 0.016). Median survival was 9 months for the total population. It was better in patients with a good performance status (P = 0.01), and those who did not have linitis plastica (P = 0.005). Toxicity was acceptable, although grade 3-4 neutropenia was reported in 22% of the cycles, mucositis in 14% and 3 patients died of septic complications. The combination of 5FU and cisplatinum is effective in terms of tumour response in advanced gastric cancer and warrants testing with the other active regimens.

Conjunctival biopsy in Sjögren's syndrome: correlations between histological and immunohistochemical features

We have examined conjunctival biopsies from nine primary and two secondary cases of Sjögren's syndrome. In all cases histopathological examination revealed metaplasia of the conjunctival epithelium associated with a reduced number of goblet cells and a polymorphic inflammatory cell infiltrate of the stroma. Using monoclonal antibodies with texture analysis of stained preparations we have shown that in all cases the lymphocytic infiltrate was predominantly T-cell but with substantial numbers of IgA and IgG secretory B-cells in three cases. The number of Langerhans cells present was reduced in biopsies showing the most marked degree of epithelial metaplasia.