Impact of Post-Mastectomy Radiotherapy on Cosmesis and Quality of Life after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Single Institution Experience

PURPOSE/OBJECTIVE(S)

Immediate breast reconstruction (IBR) yields better cosmetic results and reduce psychological distress than delayed (DBR). Literature data showed better local cosmesis after reconstruction autologous flaps than prothesis. Our aim is to compare cosmetic results and quality of life (QoL) after PMRT delivered either after IBR or DBR with DIEP flap.

MATERIALS/METHODS

We reviewed files of 99 patients (100 DIEPs) treated in our department from January 2000 to December 2019. Patients were divided into 2 groups depending on the treatment sequence: IBR (n = 22) versus DBR (n = 78) followed by PMRT. All the patients had their DIEP flap by the same surgical team. All patients had cosmetic evaluation using Harvard/RTOG cosmesis grading scale. Fifty percent (32 in IBR and 14 in DBR group) of the patients responded to the QoL evaluation using auto questionnaires and BREAST-Q to evaluate breast specific HRQoL and satisfaction. The analysis of cosmetic scores was carried out with a Chi2 test and the analysis of QoL scores with a student test. Kaplan Meier (log-rank test) is used for recurrence-free and overall survival.

RESULTS

Median follow-up was 56 months. Median age of the patients was 48 (28-71). In terms of disease stage: T1-2 (52%), N0 (38%). 86% of the patients had chemotherapy either in neo-adjuvant (26%) or adjuvant (60%) settings. Radiation therapy (RT) delivered a total dose ranged between 45 Gy and 50 Gy using 1.8-2.5 Gy/per fraction. Supra-clavicular and internal mammary chain irradiation was performed in 67% and 33% of the patients respectively. After surgery, 15% had post-operative complications such as DIEP necrosis (n = 8) that delayed RT delivery. Among the 99 patients, 3 died from metastatic evolution and were not included in the cosmetic and QoL analyses. Local recurrence rate was slightly higher after DBR (12.5%) as compared to IBR (3.8%). Loco-regional and metastatic recurrence rates were 4.5% and 4.5% after IBR versus 1.3% and 9% after DBR (p = NS). Disease free and overall survival were 88% and 98% at 5y and 66% and 96% at 10y.Good-to-excellent results were observed in 57% in the IBR vs 67% in the DBR (p = 0.92). There was no impact of previous chemotherapy (p = 0.21), tobacco use at diagnosis (p = 0.27), diabetes (p = 0.86), RT timing (p = 0.53) and endocrine therapy administration (p = 0.67). QoL was evaluated with the BREAST-Q self-evaluation for 5 post operative items: psycho-social, physical, sexual well-being and satisfaction with breast and global cosmetic results. Out of the 99 patients, 46% had responded to the QoL evaluation. We found no statistical difference between the two groups for all the BREAST-Q evaluation items.

CONCLUSION

Our center is considered expert for DIEP reconstructions since its development in end of the nineties. Our data showed no impact PMRT using conventional fractionation (with mainly 1.8 Gy/fraction) on cosmetic results, QoL, and patients' satisfaction regardless of the timing of the breast reconstruction. Additional studies are in progress with updates.

Attenuated cell-cycle division protein 2 and elevated mitotic roles of polo-like kinase 1 characterize deficient myoblast fusion in peripheral arterial disease

INTRODUCTION

We propose that MuSC-derived myoblasts in PAD have transcriptomic differences that can highlight underlying causes of ischemia-induced myopathy.

METHODS

Differentiation capacity among perfused and ischemic human myoblasts was compared. Following next generation sequencing of mRNA, Ingenuity Pathway Analysis (IPA) was performed for canonical pathway enrichment. Live cell imaging and immunofluorescence were performed to determine myocyte fusion index and protein expression based on insights from IPA, specifically concerning cell cycle regulators including cell-division cycle protein 2 (CDC2) and polo-like kinase 1 (PLK1).

RESULTS

Ischemic myoblasts formed attenuated myotubes indicative of reduced fusion. Additionally, myoblasts from ischemic segments showed significant differences in canonical pathways associated with PLK1 (upregulated) and G2/M DNA damage checkpoint regulation (downregulated). PLK1 inhibition with BI2536 did not affect cell viability in any group over 24 h but deterred fusion more significantly in PAD myoblasts. Furthermore, PLK1 inhibition reduced the expression of checkpoint protein CDC2 in perfused but not ischemic cells.

CONCLUSION

Differentiating myoblasts derived from ischemic muscle have significant differences in gene expression including those essential to DNA-damage checkpoint regulation and cell cycle progress. DNA-damage checkpoint dysregulation may contribute to myopathy in PAD.

Understanding the Relationship Between Official and Social Information About Infectious Disease: Experimental Analysis

BACKGROUND

Communicating official public health information about infectious diseases is complicated by the fact that individuals receive much of their information from their social contacts, either via interpersonal interaction or social media, which can be prone to bias and misconception.

OBJECTIVE

This study aims to evaluate the effect of public health campaigns and the effect of socially communicated health information on learning about diseases simultaneously. Although extant literature addresses the effect of one source of information (official or social) or the other, it has not addressed the simultaneous interaction of official information (OI) and social information (SI) in an experimental setting.

METHODS

We used a series of experiments that exposed participants to both OI and structured SI about the symptoms and spread of hepatitis C over a series of 10 rounds of computer-based interactions. Participants were randomly assigned to receive a high, low, or control intensity of OI and to receive accurate or inaccurate SI about the disease.

RESULTS

A total of 195 participants consented to participate in the study. Of these respondents, 186 had complete responses across all ten experimental rounds, which corresponds to a 4.6% (9/195) nonresponse rate. The OI high intensity treatment increases learning over the control condition for all symptom and contagion questions when individuals have lower levels of baseline knowledge (all P values ≤.04). The accurate SI condition increased learning across experimental rounds over the inaccurate condition (all P values ≤.01). We find limited evidence of an interaction between official and SI about infectious diseases.

CONCLUSIONS

This project demonstrates that exposure to official public health information increases individuals' knowledge of the spread and symptoms of a disease. Socially shared information also facilitates the learning of accurate and inaccurate information, though to a lesser extent than exposure to OI. Although the effect of OI persists, preliminary results suggest that it can be degraded by persistent contradictory SI over time.

Exploring the direct and indirect effects of elite influence on public opinion

Political elites both respond to public opinion and influence it. Elite policy messages can shape individual policy attitudes, but the extent to which they do is difficult to measure in a dynamic information environment. Furthermore, policy messages are not absorbed in isolation, but spread through the social networks in which individuals are embedded, and their effects must be evaluated in light of how they spread across social environments. Using a sample of 358 participants across thirty student organizations at a large Midwestern research university, we experimentally investigate how real social groups consume and share elite information when evaluating a relatively unfamiliar policy area. We find a significant, direct effect of elite policy messages on individuals' policy attitudes. However, we find no evidence that policy attitudes are impacted indirectly by elite messages filtered through individuals' social networks. Results illustrate the power of elite influence over public opinion.

[Periprosthetic fractures of the acetabulum: revision endoprosthetics]

BACKGROUND

Periprosthetic acetabular fractures are an increasing severe complication in revision arthroplasty. A differentiation is made between periprosthetic acetabular fractures (acute/traumatic fractures) and insufficiency fractures (chronic fractures).

OBJECTIVE

This article introduces a novel treatment algorithm that provides assistance in therapeutic decision making for implant selection and the anchoring philosophy based on diagnostic decision criteria and the relevant load-bearing osseous structures, taking the defect situation into account.

MATERIAL AND METHODS

The article provides an overview of original and review articles.

RESULTS

The essential criteria for decisions in treatment planning are based on the stability of the primary cup, the load-bearing ability of the main anatomical structures and the resulting defect situation. For insufficiency fractures the reason for the revision and therefore the exclusion of periprosthetic joint infections (PJI) must additionally be considered. In the case of proven PJI a two-stage or multistage prosthesis exchange must be carried out. Based on the extent of apparent bony defects and pelvic discontinuity, the spectrum of treatment options ranges up to implantation of individual patient custom-made acetabular components.

DISCUSSION/CONCLUSION

This overview introduces a new treatment algorithm that provides assistance in decision making for traumatic periprosthetic acetabular fractures and insufficiency fractures. It also provides decision criteria for selection of implants and the surgical approach. Due to the complexity of revision arthroplasty often requiring specialized expertise in trauma and orthopedic surgery and experienced revision surgeons, the operative treatment of periprosthetic acetabular fractures should only be carried out in specialized orthopedic and trauma surgery centers with appropriate experience.

Preferences for surrogate designation and decision-making process in older versus younger adults with cancer: A comparative cross-sectional study

OBJECTIVE

To compare the preferences of older (≥70 years old) versus younger (<70 years old) cancer patients regarding surrogate designation and decision making.

METHODS

A cross-sectional survey. Patient characteristics and information about surrogacy and involvement in decision making were collected. Associations between patient characteristics and preferences were examined.

RESULTS

The study included 130 patients aged ≥70 years (mean age 80 years) and 102 patients aged <70 years (mean age 55) and. Factors independently associated with surrogate knowledge (66%): younger age, more children living nearby, high income; factors associated with having already designated a surrogate (62%): younger age, decreased number of daily medications; factors associated with designating a surrogate after questionnaire administration (40%): low education, metastasis. Patients requiring an informed consent for any intervention was associated with older age (adjusted OR [aOR]_{per year} = 1.04[95% confidence interval 1.00-1.08]), not living alone (aOR = 2.52[1.00-6.36]), and having children (aOR = 4.49[1.13-17.81]).

CONCLUSION

All cancer patients, wanted to be fully informed and 72% wanted to be involved in medical decisions. Preferences for decision control vary between age groups, depending on family members' presence and living alone.

PRACTICE IMPLICATIONS

Sharing complete and clear information should be an important key in the process of cancer patients' care, regardless of patient age.

Results of the GETUG-AFU 19 trial: A randomized phase II study of dose dense methotrexate, vinblastine, doxorubicin, and cisplatin (dd-MVAC) with or without anti-epidermal growth factor receptor (EGF-R) monoclonal antibody panitumumab (PANI) in advanced transitional cell carcinoma (ATCC)

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Background: Frequent overexpression and correlation with stage and survival has been reported with the EGF-R pathway in ATCC. Methods: 93 patients (pts) with locally advanced or metastatic bladder or upper urinary tract (UUT) transitional cell carcinoma were planned with a 1:2 randomisation ratio. Patients with K-Ras or H-Ras mutations were excluded. dd-MVAC included M 30 mg/m2d1, V 3 mg/m2d2, D 30 mg/m2d2 and cisplatin 70 mg/m2d2 (d1 = d14) with G-CSF support. PANI 6 mg/kg was given on d2. The number of pts was determined from the 9-month median progression-free survival (PFS) rate reported with dd-MVAC. Using a one stage Fleming design, the dd-MVAC+PANI combination will be considered to be active if at least 37 patients among 70 do not show tumor progression at 9 months (p0 = 0.50, p1 = 0.70, alpha = 0.08 and beta = 0.03). As basal-like subtype might be related to Anti-EGFR treatment response, the phenotype was determined using a Keratin 5/6 and GATA3 double immunostaining (8 basal like among 58 cases tested). Results: From September 2010 to November 2015, 96 patients (bladder 68, UUT 21, both 8) received dd-MVAC (33) or dd-MVAC+PANI (63). No significant difference was observed among baseline characteristics and prognostic factors. The median number of cycles was 6 (1-6) in both arms. At least one grade > 2 toxicity was observed in 79% and 76% of patients in the dd-MVAC and PANI arms, respectively. More dermatological adverse events were observed in the PANI arm. Objective responses were reported in 23 (70%) pts in the dd-MVAC arm and 30 pts (48%) in the PANI arm. With a median follow-up of 27 months, PFS was 6.8 months and 5.7 months in the dd-MVAC and PANI arms respectively; OS was 20.2 months and 12.5 months in the dd-MVAC and PANI arms, respectively. No association was observed between PFS and basal-like feature for patients treated by MVAC+PANI. Molecular subtyping is in progress to confirm this observation at mRNA level. Conclusions: When combined with dd-MVAC, PANI does not seem to improve efficacy in pts with ATCC. Clinical trial information: NCT02818725.

Ipsilateral breast cancer recurrence after Deep Inferior Epigastric Perforator (DIEP) flap reconstruction: Incidence and radiological presentation

PURPOSE

To assess the incidence and presentation of ipsilateral cancer recurrences (ICR) after deep inferior epigastric perforator (DIEP) flap reconstruction for breast cancer.

PATIENTS AND METHODS

Data of 247 consecutive women with DIEP flap reconstruction after breast cancer in our institution between 1997 and 2009 were retrospectively reviewed.

RESULTS

Mean follow-up time was 4.1years±3.2 (SD) (median: 3years; range: 1month - 14years). Thirty-one patients (12.5%, 95%CI: =8.7-17.3) presented 34 relapses, in average 4.1years±2.6 after mastectomy: 14 (41%) were ipsilateral, 6 (18%) contralateral and 14 (41%) metastatic. ICRs occurred earlier (3.9 vs. 5.8years; P<0.05) than non-ICRs. Most ICRs (10/14, 71%) involved the periphery of the flap and presented as palpable nodules. The remaining (4/14, 29%) involved the axilla and 3/4 (75%) were palpable. Imaging procedures detected infra-clinical ICRs in 3 of 10 imaged patients (30%).

CONCLUSION

ICRs after DIEP flap reconstruction are more frequent than contralateral recurrences suggesting the need for imaging follow-up of the reconstructed breast.

Abstract P1-15-08: Tangential fields (TgF) breast radiotherapy (RT): Prospective evaluation of the dose distribution in the sentinel lymph node area (SLNa) as determined intra operatively by clip placement

Purpose:

The coverage of axilla contents by radiation therapy (RT) is an important issue in the new era of minimal axillary surgery based on sentinel lymph node biopsy (SLNB). Data from recent trials demonstrated equivalent survival in breast cancer (BC) patients with 1-2 positive SLNs with or without axillary lymph node dissection (ALND). In a similar context, AMAROS trial showed that complete RT coverage of the axilla is a better option than ALND regarding the risk of arm lymphedema. Our recent data showed that axillary levels are underdosed when only tangential fields (TgFs) are used (Belkacemi et al, Ann Oncol 2013). We aimed to evaluate the dose distribution in the SLNa defined intra operatively by clips placement. This could be a important for patients with SLN involvement who have neither ALND nor RT to the axilla.

Materials/Methods:

Twenty-five patients have been prospectively included in this study. They had clips placement in the SLNa during the SLNB procedure. Breast dose was ranged between 40 to 50Gy in 15 to 25 fractions. Additional boost to the tumor bed of 10 or 16Gy was delivered in 21 patients. Level I-III and organs at risk were contoured using the RTOG contouring atlas. The SLNa was defined as 1.5 cm in diameter around the clips. Dose-volume-histograms were analyzed regarding the volumes receiving 95% or 50% of the prescribed dose. Percentages overlap between TgFs and SLNa volume were analyzed to define 3 groups: 100% overlap ("suitable group" with SNLa completely included in the TgF), &gt; 50% overlap ("partially suitable group" with SLNa partially included in the TgF) and 0-49% overlap or completely outside the TgFs ("unsuitable group").

Results:

The mean dose delivered to levels I, II, III and SLN area were 25, 5, 2 and 33Gy respectively. The volume covered by the 95%-isodose were respectively 2%, 0%, 0% and 4%. The average dose delivered to level I, II, III and SLN area were higher using High TgFs vs STgFs (38 vs 22Gy, p=0.004; 11 vs 3Gy, p=0.019; 5 vs 2Gy, p=0.003; 43 vs 31Gy,p=0.02), respectively. HTgFs covered better 50% of all axilla levels. Boost delivery and initial tumor site did not influence axilla coverage by the TgFs.

The SNLa was totally or partially covered in 48% and 28% of patients, respectively. The mean dose delivered to 95% of the SNLa was only 22Gy using STgFs and 33Gy with the HTgFs. Using the STgFs, the SNLa was either totally (n=8/20) or partially (n=6/20) covered by &gt; 50% of dose. Average dose was 46, 34 and 8Gy, respectively in the 3 groups. HTgFs allowed a complete coverage of the SLNa in all patients.

Conclusion:

In patients undergoing breast conservative therapy, TgFs provide a limited coverage of the SLNa. STgFs allowed total coverage of this area in less than half of the patients. Thus, SLNa should be delineated in patients who have only SLNB procedure. Some of these patients with nodal involvement without additional ALND could benefit from HTgFs irradiation or a better-personalized nodal RT using a dedicated nodal RT technique such that reported in AMAROS trial. The last allow better coverage of the axilla contents than TgFs.

Citation Format: Yazid Belkacemi, Veronique Bigorie, Quiong Pan, Romain Bosc, Ryan Bouaita, Frederic Pigneur, Elias Assaf, Hakima Badaoui, Emmanuel Itti, Elie Calitchi. Tangential fields (TgF) breast radiotherapy (RT): Prospective evaluation of the dose distribution in the sentinel lymph node area (SLNa) as determined intra operatively by clip placement [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-15-08.

Tunable properties of GO-doped CoFe2O4 nanofibers elaborated by electrospinning

We report on the synthesis of cobalt ferrite (CoFe₂O₄) nanofibers doped with graphene oxide (GO) via the electrospinning technique and the study of their chemical, structural and magnetic properties.

Breast radiotherapy (RT) using tangential fields (TgF): a prospective evaluation of the dose distribution in the sentinel lymph node (SLN) area as determined intraoperatively by clip placement

BACKGROUND

Randomized trials have established that patients with limited involvement of sentinel lymph node (SLN) do not require axillary lymph node dissection (ALND). The similar outcome in patients with ≤2 positive SLN with or without additional ALND is attributed, in part, to tangential fields (TgF) RT. We evaluated the dose distribution in the SLN biopsy area (SLNBa) as determined intraoperatively by clips placement for radiotherapy (RT) optimization.

METHODS

This prospective study included 25 patients who had breast conservation. Titanium clips were used intraoperatively to mark the SLNBa. All patients had 3D-conformal RT using standard (STgF) or high tangential fields (HTgF). Axillary levels, SLNBa, and organs at risk were contoured on a CT scan. Dose distribution and overlap between TgF and target volumes were analyzed.

RESULTS

The average doses delivered to axilla levels I-III and SLNBa were 25, 5, 2, and 33 Gy, respectively. The average dose delivered to SLNBa was higher using HTgF with better coverage of the axilla. Only 12 of 25 patients (48 %) had their SLNBa completely covered by the TgF. There was no impact of TgF size on ipsilateral lung dose. The mean heart dose delivered using STgF was lower than HTgF.

CONCLUSIONS

In the era of SLNB, axilla and SNLBa RT technique has to be standardized to deliver adequate dose. We recommend the use of HTgF or direct axillary RT techniques (such as in AMAROS trial) in patients with metastases in SLN without ALND completion, when only TgF are expected to cure potential residual disease in the axilla.

Abstract P4-16-10: Positive sentinel lymph nodes (SLNs) without axillary dissection in breast cancer: the tangent fields of irradiation may not allow optimal coverage and dose distribution in level I and II of the axilla

Purpose: The recent Z0011 trial demonstrated equivalent survival in patients (pts) with breast cancer (BC) and 1 to 2 positive SLNs who were randomly assigned to SLN biopsy (SLNB) alone or followed by axillary lymph node dissection (ALND). More importantly, regional recurrence with SLNB alone was less than 1%, despite the fact that an estimated 27% of patients had additional metastases in the undissected axillary nodes. Currently, many teams do not recommend anymore ALND when the pts receive systemic therapy and whole breast irradiation (WBI). However, the optimal design of radiation fields for patients with positive SLNs who do not undergo ALND is uncertain. This prospective study was designed to define the dose distribution and coverage of level I and II of the axilla using only tangent fields after conservative surgery (CS) or total mastectomy (TM).

Methods and Materials: Thirty four pts were included in this analysis. 5 (14.7%) had TM and 29 (85.3%) had CS. Median age was 54 (30–90) years. All pts had 3D conformal RT. The level I/II/III axillary volumes were contoured using the RTOG contouring atlas. The total dose delivered was 50Gy in 25 fractions (n = 11) or the same dose (D) followed by a boost of 10 to 16Gy (n = 23). Pts were analyzed according to the total dose delivered in these 2 groups: group 1 (50Gy; n=11), group 2 (60 to 66Gy; n=23). A subgroup analysis was also performed in the group 2 regarding the initial tumor site and delivered dose: 66Gy to the upper quadrant (n = 14 group 2a) vs the lower quadrant (n = 4; group 2b) vs 60Gy to the upper quadrant (n = 5, group 2c). All dose-volume-histograms were analyzed. Mean, median values derived from level I and level II volumes were compared using t-test. Level of significance was set at p-value = 0.05.

Results: In the whole population, the median D delivered to level I and II was 16.2 and 1.7 Gy, respectively. The mean D at these levels were 21.2 Gy (rang: 1.0–48.1) and 5.0 Gy (0.1–40.9), respectively. The volume of 95% and 50%–isodose coverage were 0 cm3 and 17.2 cm3 for level I and 0 cm3 for level II. The mean values for level I and II volumes were 1.4 cm3 and 21.9 cm3, respectively.

According to the total D delivered (with or without boost), no difference was found between group 1 and group 2 in terms mean, median, and minimal D delivered to axilla levels (p = 0.5 and 0.9). Conversely, the difference was statistically significant for maximal D (p = 0.01). Furthermore, there was no difference according to tumor site and total dose between group 2a and 2b and group 2c (p = 0.07 and 0.7). In addition, no difference was observed between irradiation of whole breast or chest wall at 50Gy (p = 0.3 and 0.7).

Conclusion: In patients undergoing conservative surgery or post-mastectomy radiotherapy, tangent fields provide a limited coverage of level I and II of the axilla as defined by the RTOG contouring atlas. In addition, these regions were mainly underdosed with au total dose &lt; 30Gy even for pts who received 66Gy at the upper quadrant. These data should be considered when only tangent fields are planed to target the axilla in patients with metastases in SLNB positive without axillary dissection.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-16-10.

Combining paclitaxel and lapatinib as second-line treatment for patients with metastatic transitional cell carcinoma: a case series

BACKGROUND

Current first-line cisplatin-based combination chemotherapy regimens provide interesting response rates but limited impact on survival for patients with metastatic transitional cell carcinoma of the urothelium. Such results leave a significant patient population in need of salvage therapy.

PATIENTS AND METHODS

As the epidermal growth factor receptors 1 and 2 (EGFR and HER2) are frequently overexpressed in urothelial carcinoma, we explored the feasibility of a combination of paclitaxel (80 mg/m(2)/week) and lapatinib (1,500 mg orally daily) for six patients who were treated after failure of first-line platinum-based chemotherapy.

RESULTS

Only one out of six patients was able to receive the full doses during the first six weeks of treatment, while grade 2 or 3 diarrhea events required lapatinib dose reduction (one patient) or discontinuation (five patients), despite loperamide support.

CONCLUSION

This combination is not recommended for this population of patients.

5-fluorouracil/leucovorin combined with irinotecan and oxaliplatin (FOLFIRINOX) as second-line chemotherapy in patients with metastatic pancreatic adenocarcinoma

BACKGROUND

To evaluate the efficacy and toxicity of irinotecan and oxaliplatin plus 5-fluorouracil (FU) and leucovorin (FOLFIRINOX) as second-line therapy in metastatic pancreatic adenocarcinoma (MPA).

PATIENTS AND METHODS

We retrospectively analyzed the medical records of 27 patients with MPA treated with FOLFIRINOX as second-line therapy between January 2003 and November 2009 in our hospital. The recommended schedule was oxaliplatin 85 mg/m(2) on day 1 + irinotecan 180 mg/m(2) on day 1 + leucovorin 400 mg/m(2) on day 1 followed by FU 400 mg/m(2) as a bolus on day 1 and 2,400 mg/m(2) as 46-hour continuous infusion biweekly.

RESULTS

The median age of the 27 patients (13 males and 14 females) was 63 years (45-83). All patients had progressive disease after first-line chemotherapy by gemcitabine. A total of 167 cycles were administered, with a median number of 6 cycles (1-29) per patient. One toxic death occurred (sepsis). Tolerance of treatment was acceptable, and the relative dose density delivered per patient was 92.8% for oxaliplatin, 89.1% for irinotecan and 96.4% for FU. Grade 3-4 neutropenia occurred in 55.6% of the patients, including 1 febrile neutropenia. The other toxicities were manageable. Regarding efficacy, 22 of the 27 patients were evaluable (WHO and RECIST criteria). Five patients had partial responses and 12 stable disease, resulting in an overall disease control rate of 63%. Median time to progression was 5.4 months (0.7-25.48), and median event-free survival was 3 months (0.5-24.9). Median overall survival was 8.5 months (0-26). A clinical benefit was reported for 55% of the patients.

CONCLUSIONS

These results confirmed the good safety profile and the efficacy of the FOLFIRINOX regimen as second-line treatment of MPA.

Telomere Shortening and Associated Chromosomal Instability in Peripheral Blood Lymphocytes of Patients With Hodgkin’s Lymphoma Prior to Any Treatment Are Predictive of Second Cancers

PURPOSE

To investigate a potential link between telomere length, chromosomal instability, and the advent of a second cancer (SC) in patients with Hodgkin's lymphoma (HL), who are known to be at risk for SCs. This study was premised on the finding that telomere dysfunction and DNA repair pathways were related to many pathologic conditions.

METHODS AND MATERIALS

Three cohorts of patients with HL were studied: 73 who were prospectively followed >5 years after diagnosis (prospective HL cohort), 28 who developed a SC (SC HL cohort), and 18 long-term survivors with no evidence of disease or complication since their initial treatment (NED HL cohort). Telomere length was analyzed by a telomeric restriction fragment assay in peripheral blood lymphocytes. Thirty healthy donors and 70 patients with a newly diagnosed solid tumor were the control population.

RESULTS

Compared with controls, patients from the prospective HL cohort, before any treatment, showed age-independent shorter telomeres (mean, 8.3 vs. 11.7 kb in healthy donors; <6 kb in 18% in HL patients), increased spontaneous chromosomal abnormalities, and increased in vitro radiation sensitivity (p < 10(-4) each). After treatment, telomere shortening was associated with cytogenetic profiles characterized by the persistence of complex chromosomal rearrangement and clonal aberrations. Moreover, the two cases of SC in the prospective HL patients had short telomeres and CCR initially. In addition, the SC HL cohort was characterized by markedly short telomeres (6.6 vs. 9.7 kb in the NED HL cohort), the presence of complex chromosome rearrangements, and increased in vitro radiation sensitivity.

CONCLUSIONS

An intimate relationship between pre-treatment telomere shortening, chromosomal instability, radiation sensitivity and occurrence of SC was found in HL patients.

JC human polyomavirus (JCV) and Epstein-Barr virus (EBV) replicative activities are detected in Hodgkin/Reed Sternberg cells (HRS) and circulating lymphocytes (PBL) of Hodgkin lymphoma (HL) and associated with relapse, especially in younger patients

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Background: The HRS derive from germinal-center B-cells, potential sites for latency and reactivation of JCV in immunosuppressed individuals. Replication of human polyomaviruses (JC, BK, SV40) and EBV was assessed in Hodgkin (HL) and B cell non-Hodgkin (B-NHL) lymphomas. Methods: FISH, immunohistochemistry for oncogenic proteins, PCR and DNA sequencing to identify polyomaviruses and EBV on involved nodes and in PBL before, during and after treatment (N = 73 HL, 91 B-NHL). Controls were 30 healthy donors, 70 solid tumors and 14 acute leukemia patients. Results: using FISH, JCV and EBV DNA were detected in all lymphoma nodes. High genome copy number of JCV and EBV were present in 60% and 63%, respectively, in HL patients versus 11% and 14% in B-NHL patients (P < 10−6; P < 10−5). Using nest-PCR, JCV DNA sequencing after laser capture microdissection identified the presence and specificity of JCV sequences in HRS. T antigen and LMP1 co-expression, in 34% of HRS, was associated with early HL relapse (P < 10−4), particularly in young patients (P < 10−5). Only in HL patients PBL, genome copy number of JCV increased significantly during treatment (42%). Rogue cells (cultured lymphocytes with multiple complex chromosomal aberrations indicative of genomic instability) appeared in 40% of patients, and correlated with relapse (p < 10−4). The same JCV sequences were found in tumor cells and PBL of HL patients. Co-genomic replication of EBV and JCV was highly correlated in lymph nodes and in PBL in HL. Conclusions: JCV genomic replication was detected for the first time in HRS, and associated to rogue cell emergence in PBL. Co-detections of JCV and EBV genomic replication in HRS and PBL are associated with relapse, especially in young patients. HRS and PBL JCV/EBV infections are linked and worth further studies.

No significant financial relationships to disclose.

Primary diffuse large B-cell non-Hodgkin lymphoma of the paranasal sinuses: a report of 14 cases

Sinonasal lymphoma (SL) is a rare form of extranodal lymphoma. Of 33 SL cases, 14 consecutive diffuse large B-cell lymphomas were treated with CHOP (adriamycin, cyclophosphamide, vincristine and prednisone) or CHOP-like chemotherapy regimen. Ten achieved complete remission (CR) and three achieved a partial remission. With a median follow-up period of 80 months, seven patients relapsed or progressed [one case including central nervous system (CNS) progression]. Four of the relapses involved the CNS. Eight patients were alive, including seven in CR and six patients had died of their lymphoma. This observation strongly suggests that CNS prophylaxis should be used in SL.

[Pellet guns: a persistent threat to eyes]

Following a recent case of bilateral perforating ocular trauma by multiple pellets, the authors reviewed pellet traumatisms treated in the Emergency Department and operated on in the Ophthalmology Department of the Villeneuve-St-Georges Hospital over the past 15 years. At close range, pellet weapon shootings can generate lid, conjunctiva, and powder cornea tattoos; in these cases, the lesions are often unilateral. Shooting at longer range does not result in corneodermic tattoos, but because pellets scatter, binocular lesions frequently occur. The different lesions caused by these nonmagnetic foreign bodies are often very serious. An early, even very early, traumatic cataract is sometimes very difficult to treat in these polytraumatized eyes. The visual prognosis is more reserved, as the impact zones often involve the posterior pole and the macular area. The best recovered visual acuity is 30-35/20, with visual field alterations, but the injury to the eyeball by multiple pellets can generate globe atrophy. The authors stress the gravity of these ocular traumas, fortunately rarer but not completely eradicated since the law of May 6, 1995, which restricted the possession of these pellet guns.

[Air bags and eye injuries: chemical burns and major traumatic ocular lesions--a case study]

The authors report a case of bilateral eye lesions with extended visual sequelae after the inflation of a driver's airbag during a head-on collision. The superficial facial lesions were accompanied by bilateral eye lesions, reaching both the anterior and posterior segments. Bilateral periorbital palpebral hematomas; voluminous bipalpebral edema combined with severe -conjunctival edema, corneal erosions, and edema; bilateral hyphema; pupillary changes with multiple iris sphincter breaks and weak pupillary light reflex only on the right eye; retrocession of the iridocorneal angle; and on fundus examination both retinas had posterior and peripheral hemorrhages and Berlin retinal edema. Five years after the trauma and 4 years after posttraumatic surgery for cataract that had progressively appeared on the left eye, the visual acuity is 25/20 in both eyes notwithstanding a small paracentral scotoma related to a break in the Bruch membrane. A review of the literature shows several types of ophthalmological lesions related to the airbag mechanism, which after combustion of an alkaline powder inflates at a very high speed, resulting in a risk of corneal-conjunctive-palpebral alkaline burns added to an eye contusion, which may be responsible for severe lesions. The American studies distinguish three factors affecting the seriousness of these airbag accidents: (a) wearing glasses, (b) position and size of the driver, and (c) inflation force of the airbag. Wearing a seatbelt is mandatory to minimize the violence of the oculofacial impact. After facial trauma from an airbag, an ophthalmological examination is necessary to assess of the chemical burns of the tissues exposed to the alkaline powder and possible major ocular lesions.

[Mesothelioma--asbestos in Lebanon: a problem to be considered]

To estimate the incidence of pleural mesothelioma and its relationship with the occupational and environmental exposure to asbestos in Chekka region. Between 1991 and 2000, 22 cases of malignant mesothelioma were diagnosed at Hôtel-Dieu de France Hospital. Eighteen cases were epidemiologically investigated. Fifteen among these 18 patients (83%) had a positive exposure history: exposure was occupational in 11 cases and environmental in 4 cases. The tumor was attributable to Eternit Company in 12 cases among the exposed 15 (80%). These 12 cases were secondary to occupational exposures in 8 and to environmental exposure in 4 cases. Mean latency period between exposition and diagnosis was 29 years. Fifteen patients died from the progression of their disease after a median survival of 8 months. The relationship between pleural mesothelioma and Eternit Company with the related occupational and environmental risk in Chekka region is obvious. The assessment of the incidence needs a national cancer registry. Despite the protective measures taken by the government since 1996, an increase in the incidence is suspected in the coming ten years because of the long latency period of the disease.

[Endoscopic evaluation of chronic human immunodeficiency virus-related diarrhea]

Chronic diarrhea is an important clinical problem in patients infected with HIV. Data assessing the diagnostic yield of upper and lower endoscopy are limited. We reported 10 cases of HIV-infected patient referred to our hospital for chronic diarrhea from March 1995 to June 1999. 60% of the pathogens were identified obviously by stool studies. Cryptosporidium and Mycobacterium avium intracellulare (MAI) were the most common organisms. In this study, endoscopy identified 2 additional cases of MAI and one of 5 cryptosporidia detected in stool. Immunologic test identified a CMV infection in one case. Stool tests and endoscopy identified obviously 80% of the pathogens. Most investigators and us agree that stool studies should be the first diagnostic test. In patients with negative stool studies, lower endoscopy is more cost-effective than upper endoscopy and indicated as an initial exam.