Endovascular treatment of wide-neck anterior communicating artery aneurysms using WEB-DL and WEB-SL: short-term results in a multicenter study

BACKGROUND AND PURPOSE

Endovascular treatment of wide-neck anterior communicating artery aneurysms can often be challenging. The Woven EndoBridge (WEB) device is a recently developed intrasaccular flow disrupter dedicated to endovascular treatment of intracranial aneurysms. The aim of this study was to investigate the feasibility, safety, and efficacy of the WEB Dual-Layer and WEB Single-Layer devices for the treatment of wide-neck anterior communicating artery aneurysms.

MATERIALS AND METHODS

Patients with anterior communicating artery aneurysms treated with the WEB device between June 2013 and March 2014 in 5 French centers were analyzed. Procedural success, technical complications, clinical outcome at 1 month, and immediate and 3- to 6-month angiographic follow-up results were analyzed.

RESULTS

Ten patients with unruptured anterior communicating artery aneurysms with a mean neck diameter of 5.4 mm were treated with the WEB. Treatment failed in 3 of the 10 aneurysms without further clinical complications. One patient developed a procedural thromboembolic event, and the other 6 had normal neurologic examination findings at 1-month follow-up. Immediate anatomic outcome evaluation showed adequate occlusion (total occlusion or neck remnant) in 6 of 7 patients. Angiographic control was obtained in all patients, including 6 adequate aneurysm occlusions (3 complete occlusions and 3 neck remnants) at short-term follow-up.

CONCLUSIONS

In our small series, treatment of wide-neck anterior communicating artery aneurysms with the WEB device was feasible and safe. However, patient selection based on the aneurysm and initial angiographic findings in the parent artery is important due to the limitations of the WEB device navigation.

Use of an angiographic catheter in place of the Racz epidural catheter in the lysis of epidural space adhesions. A technical note

This technical note describes lysis of adhesions in the epidural space with the use of a 5F vascular catheter inserted on a 0.35-inch guide passed through the sacral foramen. Commonly employed in the administration of anesthetics, a vascular catheter can be advantageously used in place of the Racz epidural catheter, with a potential reduction in damage to the nerve structures of the sacral canal.

Treatment of a Symptomatic Epidural Gas Cyst Using an Angiographic 5F Catheter in the Epidural Space of the Spinal Cord through the Sacral Hiatus. A Case Report

An 85-year-old woman arrived at our institution because of left lumbar sciatica of about two years duration unrelieved by conventional oral pain therapy. A computed tomography scan obtained at the second visit showed an epidural gas cyst, with compression and dislocation of the left spinal nerve root L5. The common treatment of an epidural gas cyst is either a direct surgical approach or a CT-guided needle aspiration. We describe an alternative method to mechanical lysis of epidural gas cysts with the use of an 5F angiographic catheter inserted on a 0.035-inch guidewire. This procedure is less invasive than a surgical approach and safer than a CT-guided needle aspiration. Remission of symptoms was maintained at control visits at three and five months.

Rupture of a Left Internal Jugular Vein

A 60-year-old woman with neurofibromatosis type 1 presented with a nonpainful swelling in the left laterocervical region that had suddenly arisen after mild exertion the previous evening. Computed tomography with and without contrast enhancement revealed a rupture of the wall of the left internal jugular vein, with a diffuse subcutaneous hematoma. Postoperative histopathologic examination reported diffuse proliferation of plexiform neurofibromatous tissue within the vessel wall.

Qualitative comparison of MR TSE T2 and HASTE in temporomandibular disorders. Clinical observations

AIM

The aim of the study is to evaluate the quality of the temporal mandibular joint (TMJ) imaging in patients with lack of condyle-disk coordination with the Half-Fourier Acquisition Single Shot Turbo Spin Echo (HASTE), and compare it with the quality of TSE T2-weighted images.

METHODS

Twenty-seven patients were selected (12 men and 15 women; age range 17-69 years) with medical history negative for facial trauma or surgery. The instrument used was a Siemens 1.5 Tesla with bilateral coil dedicated for studying both TMJs. TSE T2-weighted and HASTE images in the parasagittal axis with open and closed mouth were obtained for both joints.

RESULTS

The quality of the TSE T2-weighted images was better for all parameters considered (both at open and at closed mouth) than the HASTE images; however, the latter method is considerably quicker.

CONCLUSIONS

HASTE was found to be a valid method for use as rapid screening to study the TMJ and for use in patients who are unable to maintain an immobile position. Time and cost required for the examination are drastically reduced.

Response to thyrotropin of normal thyroid follicular cell strain FRTL5 in hypergravity

Thyroid hormones control every cell in the organisms and, as indicated by many hormonal changes in astronauts during and shortly after space missions, its complex regulation may be influenced by gravity. To test in vitro the effects of gravity environment on thyroid, we selected a unique cultured cell system: the FRTL5, a normal follicular thyroid cell strain in continuous culture, originally derived from adult rat thyroids. To establish if modifications of the gravitational environment may interfere with post-receptorial signal transduction mechanisms in normal mammalian cultured cells, following our previous microgravity experiments, we exposed thyrotropin-stimulated and unstimulated FRTL5 cells to hypergravity (5 g and 9 g) in a special low-speed centrifuge. At all thyrotropin doses tested, we found significant increases in terms of cyclic AMP production in FRTL5 thyroid cells. The data here reported correlate well with our previous microgravity data, showing that the FRTL5 cells functionally respond to the variable gravity force in a dose-dependent manner in terms of cAMP production following TSH-stimulation.

Combined modality therapy of resectable high risk rectal cancer

Aim of this phase I-II study was to evaluate the efficacy of preoperative concomitant radiochemotherapy in resectable high risk (TNM stage: II and III) rectal tumors, 64 patients entered the study: 37 had low rectal cancer, 27 mid-rectal cancer. 50 patients were clinically staged as stage III (Dukes C) and 14 as stage II (Dukes B). Treatment protocol included bolus mitomycin C at the dose of 10 mg/m2 on day 1 and 5FU continuous infusion at the daily dose of 1000 mg/m2 on day 1, 2, 3, 4. Concomitant external radiotherapy up to a dose of 3780 cGy was delivered at the daily dose of 180 cGy. Surgery was performed 4 to 5 weeks after radiation therapy (RT). Before surgery all patients were clinically restaged to evaluate the response to concomitant radiochemotherapy. Treatment compliance was 97%. Toxicity was 27% prevalently shown as bone marrow depletion and radiodermatitis. In 37 patients (61%) there was 50% reduction (partial response) of neoplastic volume. In 5 patients (8%) no neoplastic cells were evidenced in the surgical specimen on histology (complete response). The distance between the lower margin of the tumor and the internal anal orifice increased in 72% of cases. Postoperative morbidity was 28%. The incidence of anastomotic dehiscences was 8.7% over 46 anterior resections. Postoperative mortality was nil. Definitive staging evidenced 24 patients (39%) stage I or with no evidence of tumor. The incidence of local recurrence was 5% and that of distant metastasis 8%.

A randomized phase II study comparing sequential versus simultaneous chemo-radiotherapy in patients with unresectable locally advanced squamous cell cancer of the head and neck

BACKGROUND

Single-modality radiotherapy is still considered standard treatment for patients with locally advanced unresectable cancer of the head and neck. As treatment outcome is poor, attempts to integrate chemotherapy into the overall management of these patients are ongoing.

PATIENTS AND METHODS

A randomized study was undertaken to compare a sequential with a simultaneous chemoradiotherapy program. Between February 1986 and February 1991, 93 eligible patients with locally advanced unresectable cancer of the head and neck were stratified by WHO PS, T and N class and primary site and then randomized to receive either three courses of neoadjuvant chemotherapy with cisplatin (100 mg/m2 i.v. d 1) and 5-fluorouracil 1000 mg/m2/days 1-5 by continuous i.v. infusion every 3 weeks prior to definitive conventional radiotherapy of 65-70 Gy (sequential treatment), or cisplatin 100 mg/m2 on days 1, 22, 43 given simultaneously for the duration of the same conventional radiotherapy (simultaneous treatment).

RESULTS

At the end of the entire treatment 18 complete responses (47%) in the sequential-treatment arm and 18 (41%) in the simultaneous treatment arm were obtained. No statistically significant differences in the 5-yr progression-free survival, in the median time to loco-regional and distant progression and in the 5-yr overall survival were observed. Leukopenia was more frequent in the simultaneous than in the sequential arm (p = 0.03), whereas alopecia (p = 0.008) and phlebitis (p < 0.0001) were more frequent in the sequential-treatment arm. A better compliance was associated with the concomitant treatment, with 87% of the patients completing the entire radiotherapy program versus 63% of those in the sequential arm (p = 0.01).

CONCLUSIONS

In the present study, the two treatment arms showed similar activity (complete response, progression-free and overall survival rates). Compliance to treatment was better in the concomitant arm. These data suggest that concomitant chemo-radiation therapy might be considered an option in unresectable locally advanced cancer of the head and neck. Phase III studies are needed in order to establish the superiority of this combination of cisplatin and radiotherapy versus radiotherapy alone.

Improved local control and survival with the "sandwich" technique of pelvic radiotherapy for resectable rectal cancer. A retrospective, multivariate analysis

PURPOSE

The following study was done to evaluate the therapeutic value of radiotherapy as an adjunct to surgery for rectal cancer patients.

METHODS

One-hundred twenty-four patients underwent curative resection by one surgeon (RC) from 1982 to 1991. Forty patients received combined preoperative and postoperative (sandwich) radiotherapy, 30 patients received postoperative radiotherapy, and 54 patients were treated by surgery alone. During the study period sandwich radiotherapy was primarily offered as a free treatment option for patients with tumors which were believed to be transmurally invasive, whereas postoperative radiotherapy was an alternative therapeutic option offered to patients with tumor classified as Dukes B and C at histopathologic examination.

RESULTS

Operative mortality was 2 percent in the sandwich radiotherapy group vs. 7 percent in the surgery alone group. After a median follow-up of 60 months, the actuarial locoregional recurrence rate at five years was 3 percent for the sandwich radiotherapy group compared with 18 and 30 percent for the postoperative radiotherapy and surgery alone groups, respectively (P = 0.019). A multivariate analysis using the Cox model confirmed the favorable independent influence of sandwich radiotherapy on local tumor control, especially in distal tumors. The therapeutic benefit of sandwich radiotherapy translated into increased survival in the low-rectum Dukes B subgroup of patients. The actuarial five-year survival rates were 86 percent, 50 percent, and 28 percent in the sandwich radiotherapy, postoperative radiotherapy and surgery alone groups, respectively (P = 0.05).

CONCLUSIONS

Preoperative radiotherapy has a significant effect on the prognosis of rectal cancer patients.

Prognostic factors for chemotherapy response and survival using combination chemotherapy as initial treatment of advanced head and neck squamous cell cancer

Between May 1981 and December 1987, 152 consecutive patients with locally advanced and previously untreated head and neck squamous cell cancer (HNSCC) received two or three courses of neoadjuvant chemotherapy (NAC) prior to surgery and/or radiotherapy. Eighteen percent of patients achieved a complete response and 45% a partial response (PR), for an overall response rate of 63%. A variety of pretreatment patient and tumor characteristics were analyzed for both the tumor response to NAC and survival rate. Significantly higher CR rates were found in patients with a World Health Organization (WHO) performance status (PS) of 0 to 1 than in those patients with a PS of 2 (P = .03). Patients with stage III disease were significantly more likely to respond than those with stage IV (P = .006). Evaluation of all parameters through multivariate analysis identifies the tumor classification (P = .001) and the primary site (P = .006) as the most significant in predicting CR. The overall 5-year survival rate of the entire group of patients was 18% (median survival, 14.3 months). Analysis by PS (P = .001), stage (P = .002), and tumor (P = .001), and node (P = .01) classes showed significant differences. Patients achieving a CR after NAC had a significantly improved survival rate as compared with those with residual disease at assessment (P = .0003). With the multistep regression analysis, the tumor (P = .005) and node (P = .007) classifications, and the sex (P = .03) were significant factors, but CR (P = .0004) remained the most important and independent predictive factor. Randomized prospective trials are requested to clearly establish the role of NAC on survival rates.

Chemotherapy/radiation therapy plus/minus lonidamine in the treatment of non-small cell lung cancer (limited disease): preliminary results

One hundred sixteen patients with unresectable locally advanced non-small cell lung cancer (NSCLC) were accrued in a prospective randomized trial comparing (A), chemotherapy (cisplatin and etoposide [VP-16]) for two courses plus radiation therapy (30 + 20 Gy split course), followed by an additional two courses to (B), the same regimen plus the addition of lonidamine (LND). There were 93 patients evaluable for response (46 in the chemotherapy/radiation arm and 47 in the chemotherapy/radiation/LND arm). One hundred fifteen patients were evaluable for toxicity. The overall response rates, median time to progression, and median survival time were similar in both arms. For the group of patients with squamous cell histology, time to progression was 27 weeks on arm A and 38 weeks on arm B (P = 0.01). Two-year survival in the squamous cell group in arm A was 9%, in arm B, 39%. LND does not give rise to additional toxicity, although myalgia and testicular pain are characteristic side effects.

Neoadjuvant chemotherapy in previously untreated patients with advanced head and neck squamous cell cancer

Between May 1981 and January 1986, 130 consecutive patients with advanced untreated head and neck squamous cell cancer (HNSCC) received neoadjuvant chemotherapy (NAC) with two or three courses of the CABO combination (methotrexate 40 mg/m2 intravenously (IV) on days 1 and 15; CDDP 50 mg/m2 IV on day 4; bleomycin 10 mg IV on days 1, 8, and 15; and vincristine 2 mg IV on days 1, 8, and 15 every 3 weeks) prior to surgery and/or radiotherapy. Of the 123 patients evaluable for response to chemotherapy, 19 (15.4%) had a complete remission and 59 (48%) a partial response, yielding a 63.4% overall response rate. Response rate was significantly correlated with the performance status (PS) (P = 0.001), the stage (P = 0.005), and the T class (P = 0.02); 107 patients completed subsequent local treatment (87 with radiotherapy and 20 with surgery +/- radiotherapy). The median survival of the 124 patients evaluable for survival was 14.7 months and the overall survival rate at 3 years was 24%. The median survival and the overall survival at 3 years for the surgical subgroup were 24.7 months and 38% and for the radiotherapy subgroup were 14.3 months and 22%. These results were compared with those obtained in a historical control group of 79 patients treated in our institute with short courses of chemotherapy regimens, which did not include cisplatin, followed by radiotherapy (29 patients) or local treatments alone (26 patients with radiotherapy and 24 patients with surgery +/- radiotherapy) between January 1976 and December 1980. Most of the patient characteristics were evenly distributed (age, sex, and primary sites) except that more advanced lesions were included in the NAC group (Stage IV: 85% versus 62%; T4: 65% versus 42%; N2-3: 48% versus 29%). The overall survival was significantly higher in patients receiving NAC than in the historical control group, comparing both the groups taken as a whole (P less than 0.05) and the surgery +/- radiotherapy (P less than 0.05) and the radiotherapy (P less than 0.02) subgroups. This experience suggests a positive role of NAC on survival. However, this improvement in outcome compared with a historical control group cannot be regarded as definitive evidence for benefit to patients. Randomized studies using active regimens are required to confirm these data.