[Stereotactic hypofractionated radiation therapy as a bridge to transplantation for hepatocellular carcinoma: Case report of a complete pathological response and review of the literature]

Patients with hepatocellular carcinoma who are on liver transplant waiting list usually require local treatment to limit any risk of tumour growth. Historically percutaneous radiofrequency ablation or transarterial chemoembolization represented the major therapeutic alternatives. Depending on the size, or the topography of the lesion these two techniques may not be feasible. Radiation therapy under stereotactic conditions has recently emerged in the management of localized hepatocellular carcinoma as an alternative to the focused therapies performed to date. We herein report the case of a 43-year-old patient harbouring a complete histological response on explant after liver stereotactic irradiation and discuss its role in the management of hepatocellular carcinoma before liver transplantation.

[Current Nomina Anatomica for oral and maxillofacial surgery]

Using the international organonymy is mandatory as well for daily clinical practice as for research and teaching our students. The international organonymy, Nomina Anatomica, is in Latin. A rather unsuccessful attempt at using a French version of the international organonymy in clinical practice has been made in France. Eponyms have been systematically contraindicated; the definitions of general anatomy are applied, as well as a systematic Gallicization of the Latin terminology. Despite a stringent observance of these rules, some terms remain inappropriate because they are misleading or inaccurate. Furthermore, using this language used worldwide remains uneasy in daily clinical practice. We had for objective to focus on the main anatomical terms used routinely in oral and maxillofacial surgery, and to justify their use in clinical practice, research, and education.

First case report of an acute genotype 3 hepatitis E infected pregnant woman living in South-Eastern France

In European countries, epidemiology of hepatitis E virus (HEV) infection is not well known. Although, seroprevalence of HEV Immunoglobulin G reached a few percent in European women, no acute hepatitis E during pregnancy has been described so far. Here, we report a case of an autochthonous HEV genotype 3 infection in a 41-years-old pregnant woman living in a non-endemic country. The acute hepatitis had a spontaneous good outcome for the mother and the child. In non-endemic areas where Hepatitis E infections are emerging, unexplained cytolysis, whatever its level, in a pregnant woman could be investigated for HEV, using biological molecular and serology tools.

A national survey of acute hepatitis E in France

BACKGROUND

Few data are available on the incidence, risk factors and contamination pathways involved in acute indigenous hepatitis E in developed countries.

AIMS

To draw up an overall picture of hepatitis E cases, to confirm whether or not the majority of the cases were indigenous and to attempt to identify the risk factors and contamination pathways involved in hepatitis E.

METHODS

This study was performed in the framework of a national network (ANGH) including 96 participating centres. The 19 centres with at least one case of acute HEV reported a total number of 53 cases.

RESULTS

A decreasing South-to-North geographic gradient was observed. A nonspecific clinical profile was observed in many cases. Acute hepatitis E was of indigenous origin in 90% of the patients. The most relevant and/or frequent possible risk factors among the 47 indigenous metropolitan cases were water consumption from a personal water supply, uncooked shellfish consumption and the recent acquisition of a pet pig.

CONCLUSIONS

This national survey confirmed that acute indigenous hepatitis E is an emerging disease in developed countries such as France, and suggests that various risk factors are responsible for acute indigenous hepatitis E contamination in non-endemic countries.

[Temporal cellulitis of odontogenic origin complicated by temporomandibular osteoarthritis]

INTRODUCTION

Temporal cellulitis complicated by temporomandibular osteoarthritis and mandibular osteomyelitis is rare with the availability of antibiotics and the prevention of dental infections.

CASE REPORT

A 56 year-old woman developed a jaw abscess during hospitalization in an intensive care unit following medical drug overdose. Repeatedly surgical drainage was performed guided by CT scans and multiple antibiotherapies. CT scan follow-up revealed temporomandibular arthritis with decrease of the joint space, synovitis, and subchondral cysts. Slow improvement was noted but limited mouth opening was persistent.

DISCUSSION

This case illustrates the insidious evolution of an uncommon infection. It requires both expert clinical evaluation and an early MRI or CT scan investigation to determine the extension of the infection. Treatment is urgent because of the prognosis and is achieved by surgical drainage and adequate long-term antibiotherapy.

Expression of the transcription factor Klf6 in cirrhosis, macronodules, and hepatocellular carcinoma

BACKGROUND AND AIMS

Macronodules (MN) occurring in cirrhosis are considered to be precursor lesions for hepatocellular carcinoma (HCC). However, early molecular events in hepatocellular carcinogenesis are poorly understood. The aim of this study was to compare gene expression profiling between cirrhotic tissues, MN, and HCC, to identify genes early involved in liver carcinogenesis.

METHODS

Tissues were obtained from explanted livers: nine cirrhosis, 10 MN, and seven HCC. Total RNAs were extracted by RNeasy and reverse transcribed with labelled [(33)P]-alpha ATP. Hybridations were performed on Atlas Human Cancer 1.2 membranes (1176 genes).

RESULTS

A two-way hierarchical clustering algorithm successfully isolated specific gene expression profiles when comparing MN, cirrhosis, and HCC. A total of 16 and 14 genes were up- and down-expressed, respectively, in HCC as compared to cirrhotic tissues. The molecular signature of MN was characterized by the down-expression of 23 and 42 genes as compared to cirrhosis and HCC, respectively. Among them, Klf6 was down-expressed in all MN samples whereas it was over-expressed in cirrhosis and HCC. This result was confirmed at RNA level by quantitative real time-polymerase chain reaction and at protein level by Western blotting. However, no mutation in the exon 2 of Klf6 was detected.

CONCLUSION

We identified a molecular signature of MN characterized by a down-expression of several genes. One of them, Klf6 was found to be down-expressed in all MN without evidence of somatic mutations in the exon 2. This gene could be involved at an early stage of hepatocarcinogenesis.

Fulminant liver failure from acute autochthonous hepatitis E in France: description of seven patients with acute hepatitis E and encephalopathy

Fulminant hepatitis E has not been well characterized in industrialized countries. The aim of this study was to prospectively describe patients with acute hepatitis E presenting as fulminant hepatic failure, i.e. with encephalopathy and prothrombin index <50%. Between February 1997 and April 2005, seven patients with encephalopathy were diagnosed with acute hepatitis E using viral RNA detection. These patients were compared with 33 patients diagnosed with a mild form (absence of encephalopathy) of acute hepatitis E during the same time period. Patients were 65 +/- 11 years old. Five were active drinkers and six had chronic liver disease. All hepatitis E virus sequences evaluated (5/7) were of genotype 3. All patients but two died (71%). Four patients had no travel history. When compared with patients with a mild form of acute hepatitis E, active alcohol abuse and chronic liver disease were more frequent in patients with the severe form. Duration of hospitalization was longer. Aspartate transferase and bilirubin levels were significantly higher. Prothrombin index and accelerin levels were lower and death was more frequent. Acute nontravel-associated hepatitis E can appear as fulminant hepatitis with encephalopathy and coagulation disorders. Prognosis is severe and this may be due to the age at which it occurs and frequent underlying chronic liver disease.

KLF6 transcription factor protects hepatocellular carcinoma-derived cells from apoptosis

Hepatocellular carcinoma (HCC) is a major public health concern because of the absence of early diagnosis and effective treatments. Efficient diagnosis modalities and therapies to treat HCC are needed. Kruppel-like factor (KLF) family members, such as KLF6, are involved in cell proliferation and differentiation. KLF6 is inactivated in solid tumors, which may contribute to pathogenesis. However, KLF6 status in HCC is controversial. Thus, we undertook the characterization of KLF6 expression and function in HCC and HCC-derived cell lines. We found that HCC, HepG2 and HuH7 cells expressed KLF6 messenger ribonucleic acid and protein. Next, using RNA interference, we demonstrated that inhibiting KLF6 expression in vitro strongly impaired cell proliferation-induced G1-phase arrest, inhibited cyclin-dependent kinase 4 and cyclin D1 expression, and subsequent retinoblastoma phosphorylation. Finally, KLF6 silencing caused p53 upregulation and inhibited Bcl-xL expression, to induce cell death by apoptosis. Taken together, these data demonstrated that KLF6 is essential for HCC-derived cells to evade apoptosis.

Treatment of experimental murine pancreatic peritoneal carcinomatosis with fibroblasts genetically modified to express IL12: a role for peritoneal innate immunity

BACKGROUND

Peritoneal carcinomatosis from pancreatic cancer has a poor prognosis with a median survival of 3.1 months. This is mainly due to lack of effective treatment. Interleukin 12 (IL12) is a proinflammatory cytokine that has a potent antitumoral effect by stimulating innate and adoptive immunity.

AIM

To examine the antitumoral effect and toxicity of intraperitoneal delivery of IL12 using an ex vivo gene therapy approach in a murine model of pancreatic peritoneal carcinomatosis.

METHODS

Peritoneal carcinomatosis was generated by direct intraperitoneal inoculation of the pancreatic cancer cell line Capan-1 in athymic mice. Syngenic fibroblasts were genetically modified in vitro to secrete IL12 using a polycistronic TFG murine IL12 retroviral vector coding for both p35 and p40 murine IL12 subunits. Ex vivo gene therapy involved injection of the genetically modified fibroblasts intraperitoneally twice a week for 4 weeks.

RESULTS

Treatment of pre-established peritoneal carcinomatosis with fibroblasts genetically modified to express IL12 induced a marked inhibition of tumour growth as measured by comparison of the weights of the intraperitoneal tumour nodules in the treated and control animals (3.52 (SD 0.47) v 0.93 (SD 0.21) g, p<0.05) and improved survival. This effect was associated with infiltration of the peritoneal tumour nodules with macrophages. Peritoneal lavage confirmed enhancement of the innate peritoneal inflammatory activity, with an increased number of activated macrophages and natural killer cells. Moreover, macrophages harvested from animals with peritoneal carcinomatosis and treated with IL12-expressing fibroblasts expressed an activated proinflammatory antitumoral M1 phenotype that included strongly enhanced reactive oxygen species and nitric oxide production. There was no treatment-related toxicity.

CONCLUSION

Multiple injections of genetically modified fibroblasts to express IL12 is an effective and well-tolerated treatment for experimental murine pancreatic peritoneal carcinomatosis via activated innate immunity and in particular activated M1 macrophages.

[Platelet aggregation inhibitors and vitamin K antagonists in stomatology and maxillo-facial surgery]

Anti-thrombin, anti-platelet and anti-vitamin K agents are common treatments given for the prevention of thrombotic or embolic events. In oral or maxillofacial surgery, the question is whether oral anticoagulants or anti-platelets should be discontinued or not: temporary interruption could limit the risk of bleeding, but would increase the risk of thrombosis, and inversely. The best risk/benefit ratio must be achieved, but in many cases anti-platelet agents or even anti-vitamin K agents can be continued. In case of "potentially hemorrhagic" oral surgery, anti-platelet agents should be interrupted about ten days before the intervention. Anti-vitamin K agents should be interrupted four days before surgery and if required, replaced by low-molecular weight heparin at preventive or curative doses. In the very large majority of patients however, surgery (avulsion for example) can be performed without interrupting anticoagulation. Data in the literature have demonstrated that despite the theoretical risk of hemorrhage, bleeding is minimal and can be easily controlled by local treatments; the risk of thrombotic or thromboembolic events after discontinuing anticoagulation is much greater. A close collaboration between the dentist, the stomatologist, and the clinician is required to determine whether anti-thrombosis prevention should be continued and whether the anticoagulation level is adapted to the thrombotic risk. Good surgical technique and local anti-hemorrhagic treatment are essential in oral surgery, particularly in patients taking anti-platelets or oral anticoagulants.

[Chronic recurrent multifocal osteomyelitis of the mandible. A case report]

Chronic recurrent multifocal osteomyelitis (CRMO) is a disorder rarely localized to the lower jaw.

CASE REPORT

A fourteen-year-old boy complained of a swollen of his lower jaw. After a CT Scan, a bone biopsy was performed and yielded S. oralis against which an adapted intravenous antibiotherapy was administered without efficacy. The absence of malignant process and the revelation of an other focus of fixation at the Tc bone scan localized on humerus called to mind the diagnosis of CRMO.

CONCLUSION

The diagnosis of this disease is difficult and based on a number of concording arguments:clinical and radiological signs of osteomyelitis, multifocal presentation, recurrent relapses and remissions, inaction of antibiotics, elimination of the other differential diagnosis, in particular the infectious osteitis.

[Difficult diagnosis for a lingual ulceration. Wegener granulamotosis]

Making the correct diagnosis for a lingual ulceration can be difficult. We present the case of a 55-year-old man, alcoholic and smoker who presented with a single lingual ulceration. The initial diagnosis suggested a cell-squamed carcinoma but histological examination revealed a Wegener Granulomatosis. Wegener Granulomatosis in the oral cavity is found in 6-13% of cases but rarely primary sign of the disease. The authors review differential diagnosis that should be taken into consideration when presented with similar lesion.

[Evaluation of mandibular propulsion appliances in children. A study of 18 cases]

PURPOSE

Mandibular propulsion appliances are used currently in the treatment of class II malocclusion. The purpose of this study was to evaluate their effects on facial development to formulate specific indications.

PATIENTS AND METHODS

Eighteen children (mean age 9-12) treated with a propulsion device for a class II division 1 malocclusion with a minimum of 4 mm overjet were included in a retrospective study over a 4 year period. We compared maxillomandibular and dentoalveolar position before and after treatment using Delaire computer software cephalometric analysis and superpositions.

RESULTS

Statistically significant effects on molar discrepancy (p = 0.0002), overjet (p = 0.0003), sagittal mandibular position (p = 0.0040 for FM-Me/theoretical and p = 0.0010 for NP-FM-Me), mandibular length (p = 0.004 for FM-Me/theoretical), mandibular corpus length (p = 0.0286 for Go-Me/theoretical), upper incisors palatal version (p = 0.0002), and on lower incisors lip version (p = 0.0436) were assessed. No action on maxillary growth (p = 0.7274 for FM-NP/theoretical), ramus length (p = 0.9651 for Cp-Go/theoritecal), lower facial height (p = 0.7045 for ENA-Me/theoretical) or translation of the alveolar arches (p = 0.9571 for A-Pti'/ENA-Pti and p = 0.1564 for B-Pa'/B-Pa) could be confirmed.

CONCLUSIONS

An increase in mandibular corpus development and no effect on alveolar arches suggests a basal mandibular action for this device. This concludes that retromandibular position and brachycorpus with upper incisor lip version, without lower incisors lip version are the best indications for mandibular propulsion appliances. Prospective studies should be carried out to confirm this hypothesis.

[Semi-rigid bracket splinting of teeth after traumatic luxation]

We describe a non-rigid procedure using brackets for splinting teeth after traumatic avulsion. This type of appliance preserves alveolodental ligament physiology and enables immediate mastication without occlusal obstruction. Installation is easy, except when severe bleeding or alveolar fracture occurs.

Transjugular intrahepatic portosystemic shunts in the treatment of refractory ascites: results in 48 consecutive patients

PURPOSE

To assess the efficacy, morbidity, and mortality involved in the creation of transjugular intrahepatic portosystemic shunts (TIPS) in the treatment of patients with refractory ascites in Child-Pugh classes B and C.

MATERIALS AND METHODS

Forty-eight consecutive patients with refractory ascites were treated with TIPS creation in a tertiary care institution. They were followed for a median of 337 days (range, 3-1376 d).

RESULTS

TIPS significantly decreased the portohepatic pressure gradient (20.7 +/- 5.9 mm Hg vs. 6.8 +/- 4.1 mm Hg; P < .0001). Seventy-three percent of patients had complete or partial response. One year after TIPS creation, survival was 73% in Child class B patients and 56% in Child class C patients. Thirteen patients experienced procedural complications (portal vein thrombosis, peritoneal bleeding, acute renal failure, pneumothorax, hemoptysis, spontaneous bacterial peritonitis, and heart failure) and TIPS creation was considered the cause of death in five patients (10.4%). Primary patency was 65% at 3 months and 23% at 1 year, but shunt obstruction was accessible for a second intervention. Ten patients (21%) had de novo encephalopathy after TIPS creation.

CONCLUSIONS

This series suggests that TIPS is an effective treatment for refractory ascites; however, it is a challenging procedure and serious complications--usually renal and heart failure--can be seen. A careful selection of patients is mandatory.

Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices

The optimal management of ruptured gastric varices in patients with cirrhosis has not been codified yet. The present study reports the use of transjugular intrahepatic portosystemic shunt (TIPS) in patients with refractory gastric variceal bleeding. Thirty-two consecutive patients were included. All had been unresponsive to vasoactive agents infusion, sclerotherapy, and/or tamponade and were considered poor surgical candidates. They were followed-up until death, transplantation, or at least 1 year (median: 509 days; range 4 to 2,230). Hemostasis was achieved in 18 out of 20 patients actively bleeding at the time of the procedure. In the whole sample of 32 patients, rebleeding rates were 14%, 26%, and 31%, respectively at 1 month, 6 months, and 1 year. De novo encephalopathy was observed in 5 (16%) patients. Seven patients experienced complications and consequently 4 of these patients died. TIPS primary patency rates were 84%, 74%, and 51%, respectively, at 1 month, 6 months, and 1 year. For the same periods of time, survival rates were 75%, 62%, and 59%. These results suggest that TIPS can be used in cirrhotic patients with refractory gastric variceal bleeding and are effective in achieving hemostasis as well as in preventing rebleeding.

[Spheno-mandibular ankylosis. A case]

A rare case of spheno-mandibular ankylosis is reported in a 12 year-old child. The patient only complained of a restricted mouth opening; no particular etiologic factors were found to explain what was perhaps a myositis ossificans of the pterygoid muscles. However, neither the anatomic presentation at surgery, nor the histologic findings could confirm this diagnosis. An intra-oral route was chosen for the ankylosis resection, and the reconstruction of the resected upper part of the ramus was performed by a costo-chondral graft. The patient was free of recurrence 3 years after follow up.

FLT3-ligand administration inhibits liver metastases: role of NK cells

FLT3-ligand (FL) is a recently described cytokine that stimulates the proliferation and differentiation of hematopoietic progenitors both in vivo and in vitro and, when administered to mice, induces an accumulation of dendritic cells (DC) in different lymphoid and nonlymphoid organs and tissues, including the liver. We have studied the antitumor effect of FL administered alone or in combination with IL-12 in a day 3 murine liver metastasis model. FL significantly reduced the number of hepatic metastases (36.00 +/- 11.00 vs 92.00 +/- 10.19 in control group, p < 0.05). Histologic evaluation of the livers revealed that FL induced a significant infiltration of the tumor border by lymphocytes and DC associated with increased number of apoptotic figures. Immunohistochemical analysis demonstrated that FL significantly enhanced the number of DC in the liver parenchyma and within the liver metastases, as well as the number of CD4+ and CD8+ T lymphocytes. These data support the suggestion that DC may be directly involved in the antitumor effect of FL. Interestingly, the antitumor effect of FL was greatly reduced by the NK depletion. Combination of FL and IL-12 resulted in greater antitumor efficacy than these cytokines alone. In summary, we have shown that FL has significant antitumor effect on preexisting murine C3 liver tumors that is mediated by NK cells. We have also demonstrated that the FL/IL-12 combination has an enhanced antitumor activity in the same murine tumor model.

Computed tomography of superior mesenteric vein thrombosis following appendectomy

During a 5-year period, superior mesenteric vein (SMV) thrombosis was detected with computed tomography (CT) in six patients shortly after an appendectomy. No sign of SMV was present at appendectomy, and a period of more than 2 weeks free of clinical symptoms had elapsed between the appendectomy and the onset of the SMV thrombosis. In four cases, the appendicitis was complicated. These patients had nonspecific signs and symptoms, although two of them had elevation of blood hepatic enzyme levels. In all cases, postcontrast CT demonstrated enlargement of the SMV, with well-defined enhancement of the vascular wall and an intraluminal clot. In one case, CT showed extension of the thrombus to the portal vein with the presence of low-attenuation areas in the liver, consistent with hepatic infarcts. Two patients had predisposing diseases: idiopathic hypersplenism in one case and chronic hepatic disease in the other. SMV thrombosis is a possible complication of appendicitis, and early appendectomy in appendicitis can prevent this complication. Moreover, as in any abdominal surgery, early appendectomy may be complicated by thrombosis of the SMV, thus creating problems of postoperative diagnosis. The complication is more frequent when the initial operation is performed under difficult conditions (peritonitis), or when the patient presents with a coagulopathy. CT is useful in the diagnosis of SMV thrombosis, thus leading to early management with anticoagulant therapy, with a view to avoiding complications such as intestinal ischemia, portal vein thrombosis, and hepatic infarction.

IFN-gamma-inducing factor/IL-18 administration mediates IFN-gamma- and IL-12-independent antitumor effects

We evaluated the mechanism of the antitumor effects of mouse rIFN-gamma-inducing factor/IL-18 protein on the growth of mouse tumor cell lines in vivo. Mice received IL-18 before or after challenge with CL8-1, a mouse melanoma cell line. Both regimens significantly suppressed tumor growth and reduced the number of mice with growth of tumor from 60% (3/5) to 20% (1/5). Furthermore, IL-18 administered before and after tumor inoculation completely abrogated the establishment of CL8-1 in all animals. IL-18 administration also significantly suppressed the growth of MCA205, a sarcoma cell line, even when treatment was delayed to 7 days following tumor inoculation. Although IL-18/IL-12 combination therapy had the most significant and immediate antitumor effects, many mice so treated succumbed with markedly elevated serum IFN-gamma levels. The antitumor effects of IL-18 were abrogated almost completely when NK cells were eliminated using anti-asialo GM1 Ab administration, but only marginally impaired in IFN-gamma or IL-12 gene-disrupted mice. Immunohistochemical staining revealed that the number of the CD8+ T cells, but not CD4+ T cells, found at the tumor site was reduced in animals treated with IL-18. These results indicate that IL-18 has potent antitumor effects mediated by CD4+ T cells and NK cells, but in IFN-gamma- and IL-12-independent pathways.