Impact of mismatch repair deficiency on tumour regression grade after neoadjuvant chemotherapy in localized gastroesophageal adenocarcinoma

BACKGROUND

The use of neoadjuvant chemotherapy (NAC) in patients with mismatch repair (MMR) deficient (dMMR) localized gastric and oeso-gastric junction (OGJ) adenocarcinoma is subject of debate. Histological response assessment might help to better evaluate the impact of dMMR on response to NAC.

METHODS

Patients with localized gastric/OGJ adenocarcinoma resected after NAC were retrospectively identified. MMR protein expression status was assessed by immunohistochemistry. The primary objective was the frequency of histological responders to NAC defined by tumour regression grade (TRG) using Mandard's (TRG1-2) and Becker's (TRG1) classifications, according to the MMR status.

RESULTS

In total, 247 patients with 43 dMMR and 204 pMMR gastric/OGJ adenocarcinoma were identified. Among dMMR tumours, 18 (42%) arose from the OGJ. Histological response (Becker TRG1-2) was observed for 28% and 35% of dMMR and pMMR tumours, respectively (p = 0.35). Similar results were observed with Mandard classification. With a median follow-up of 37.5 months, median disease-free and overall survival were not reached for the dMMR group.

CONCLUSION

Histological response after NAC in patients with localized dMMR gastric/OGJ adenocarcinoma is not statistically different to those with pMMR tumours. This study provides additional data for the discussion about avoiding NAC in patients with dMMR gastric/OGJ adenocarcinomas.

Spatial Positioning and Matrix Programs of Cancer-Associated Fibroblasts Promote T-cell Exclusion in Human Lung Tumors

It is currently accepted that cancer-associated fibroblasts (CAF) participate in T-cell exclusion from tumor nests. To unbiasedly test this, we used single-cell RNA sequencing coupled with multiplex imaging on a large cohort of lung tumors. We identified four main CAF populations, two of which are associated with T-cell exclusion: (i) MYH11+αSMA+ CAF, which are present in early-stage tumors and form a single cell layer lining cancer aggregates, and (ii) FAP+αSMA+ CAF, which appear in more advanced tumors and organize in patches within the stroma or in multiple layers around tumor nests. Both populations orchestrate a particular structural tissue organization through dense and aligned fiber deposition compared with T cell-permissive CAF. Yet they produce distinct matrix molecules, including collagen IV (MYH11+αSMA+ CAF) and collagen XI/XII (FAP+αSMA+ CAF). Hereby, we uncovered unique molecular programs of CAF driving T-cell marginalization, whose targeting should increase immunotherapy efficacy in patients bearing T cell-excluded tumors.

SIGNIFICANCE

The cellular and molecular programs driving T-cell marginalization in solid tumors remain unclear. Here, we describe two CAF populations associated with T-cell exclusion in human lung tumors. We demonstrate the importance of pairing molecular and spatial analysis of the tumor microenvironment, a prerequisite to developing new strategies targeting T cell-excluding CAF. See related commentary by Sherman, p. 2501. This article is highlighted in the In This Issue feature, p. 2483.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Tertiary Lymphoid Structure-B Cells Narrow Regulatory T Cells Impact in Lung Cancer Patients

The presence of tertiary lymphoid structures (TLS) in the tumor microenvironment is associated with better clinical outcome in many cancers. In non-small cell lung cancer (NSCLC), we have previously showed that a high density of B cells within TLS (TLS-B cells) is positively correlated with tumor antigen-specific antibody responses and increased intratumor CD4⁺ T cell clonality. Here, we investigated the relationship between the presence of TLS-B cells and CD4⁺ T cell profile in NSCLC patients. The expression of immune-related genes and proteins on B cells and CD4⁺ T cells was analyzed according to their relationship to TLS-B density in a prospective cohort of 56 NSCLC patients. We observed that tumor-infiltrating T cells showed marked differences according to TLS-B cell presence, with higher percentages of naïve, central-memory, and activated CD4⁺ T cells and lower percentages of both immune checkpoint (ICP)-expressing CD4⁺ T cells and regulatory T cells (Tregs) in the TLS-B^high tumors. A retrospective study of 538 untreated NSCLC patients showed that high TLS-B cell density was even able to counterbalance the deleterious impact of high Treg density on patient survival, and that TLS-B^high Treg^low patients had the best clinical outcomes. Overall, the correlation between the density of TLS-B^high tumors with early differentiated, activated and non-regulatory CD4⁺ T cell cells suggest that B cells may play a central role in determining protective T cell responses in NSCLC patients.

Management of incidental discovery of microscopic squamous cell carcinoma in zones of osteoradionecrosis of the mandible

OBJECTIVES

Osteoradionecrosis (ORN) of the mandible is a common complication of head and neck radiotherapy and often requires surgical treatment. Squamous cell carcinoma (SCC) can be exceptionally discovered within zones of ORN on histological examination of the operative specimen. The authors discuss the management of these lesions based on a short patient series.

MATERIALS AND METHODS

This single-centre retrospective study was based on patients managed between 2012 and 2014 for ORN with incidental discovery of microscopic SCC.

RESULTS

Five patients with incidental discovery of microscopic SCC in a zone of ORN of the mandible were included in this study. The mean time to onset of ORN after the end of radiotherapy for locally advanced SCC of the oral cavity or oropharynx was 42 months. Surgical treatment consisted of marginal or segmental mandibulectomy with free flap reconstruction. No recurrence was observed with a mean follow-up of 35 months [24-46].

CONCLUSION

The incidental discovery of microscopic SCC in a zone of ORN of the mandible is a rare event and has not been reported in the literature. Optimal management cannot be reliably defined due to the lack of data in the literature, but the present study supports careful histological examination of ORN specimens. Treatment must be as conservative as possible to avoid excessively invasive surgery.

Salivary duct carcinoma: Prospective multicenter study of 61 cases of the Réseau d'Expertise Français des Cancers ORL Rares

BACKGROUND

The purposes of this study were to describe the characteristics of a prospective multicenter series of patients with salivary duct carcinoma and to investigate prognostic factors.

METHODS

Patients included for salivary duct carcinoma between 2009 and 2016 in the Réseau d'Expertise Français des Cancers ORL Rares (REFCOR) database were selected. Immunohistochemical analyses were performed.

RESULTS

Sixty-one patients were included in this study. The primary site was the parotid gland in 90% of the cases. Fifty-seven percent of the tumors were stage IV, 65% of patients had lymph node involvement, and 10% had metastases. Tumors showed androgen receptor (89%) and human epidermal growth factor receptor 2 (HER2)/neu (36%). Ninety-four percent of patients underwent surgery and 86% had postoperative radiotherapy. Six patients were treated with targeted therapies. The 3-year overall survival (OS) was 74% and the 3-year disease-free survival (DFS) was 44%. Tumor stages III to IV reduced DFS (hazard ratio [HR] 4.3; P = .04). The N2/3 class reduced distant metastasis-free survival (HR 7.3; P = .007).

CONCLUSION

Salivary duct carcinoma prognosis is poor and is correlated with tumor stage and lymph node classification. Androgen receptor and HER2/neu should be tested as they offer the possibility of targeted therapies.

[Appendicovesicostomy (Mitrofanoff procedure) in children: Long-term follow-up and specific complications]

OBJECTIVE

In children, intermittent catheterization by appendicovesicostomy according to Mitrofanoff is an interesting alternative to the urethral approach. Objective of the study was to evaluate the rate of appendicovesicostomy's specific complications.

METHOD

From 1997 to 2017, data on children treated and followed for an appendicovesicostomy in an academic institution were collected retrospectively. Rates of surgical complications specifically encountered on appendicovesicostomy, time of onset, frequency, and necessity of surgical reinterventions have been reported.

RESULTS

Thirty-four patients were operated on and followed for a median of 6.2 years [0.3-24]. Fifty percent had a complication, occurring after a median of 8 months [2-90], and 38% required at least one surgical revision. If complication occurred, adjustment of medical treatment and intermittent catheterization was effective in 12% of patients, endoscopic or over-fascial surgery was necessary in 17% of cases, and under-fascial revision in 21% of cases. Median time to complication was 4 months [1-90] after creation or revision of appendicovesicostomy. Thirty-height percent of difficult channel catheterization were reported, of which 46% were over or under-fascial stenosis. Inaugural urinary incontinence was 18%, and only 9% if using the appendix. At the end, 97% of appendicovesicostomy were continent.

CONCLUSIONS

Appendicovesicostomy is a high risk of complications and postoperative revisions surgery, in order to have a functional continent channel.

LEVEL OF EVIDENCE

4.

Reappraisal of metastatic lymph node topography in head and neck squamous cell carcinomas

Objective

To analyze the lymphatic distribution of metastatic carcinomatous cells in cervical lymph nodes in head and neck squamous cell carcinoma (HNSCC).

Study Design and Setting

We retrospectively reviewed 119 patients treated in our hospital for HNSCC (1999-2004). Topography of the neck dissection specimens was prospectively classified according to the classification of Robbins. The 4000 lymph nodes were analyzed by optical microscopy using hematoxylin-eosin-safran (HES) staining. In cases of negative results in level II, cytokeratin (AE1/AE3) immunodetection was performed.

Results

Metastases were visualized using HES in 6.4% of lymph nodes for oral cavity, and 4.7% of oropharyngeal, 4.4% of hypopharyngeal, and 1.3% of endolaryngeal cancers. The highest incidence of nodal metastasis was observed in level IIa ( P < 0.01). In eight patients (6.7%) with lymph node metastases, level II was spared. In these patients, all 134 nodes histologically negative on HES were confirmed to be negative by IHC.

Conclusions

Level IIa is the main level involved in regional metastases of HNSCC, regardless of the primary site of cancer. However, in eight (6.7%) patients, level II was spared, as confirmed by IHC. In these cases, level II did not represent the first step of drainage from the tumor. The sentinel lymph node technique in HNSCC is discussed in light of these results.

Comparative analysis of micro-RNAs in human papillomavirus-positive versus -negative oropharyngeal cancers

BACKGROUND

Oncogenic mechanisms of human papillomavirus (HPV)-positive oropharyngeal cancer are still poorly characterized. Analysis of their microRNA expression profile might provide valuable information.

METHODS

The microRNA expression profiles were analyzed by micro-arrays in 26 oropharyngeal cancers. A microRNA signature specific to HPV-status was identified by analyzing a learning/training set consisting of 16 oropharyngeal cancers. The robustness of this signature was further confirmed by blind case-by-case classification of a validation set composed of 10 independent tumors. Putative targeted molecular pathways were proposed using DIANA miRPath online software (http://microrna.gr/mirpath).

RESULTS

We have identified 25 miRNA signatures, which discriminates HPV16-positive oropharyngeal cancer from their HPV-negative counterparts. These 25 microRNAs play a potential role in Wnt and PI3K-pathways, cell-adhesion/cell-polarity, and the cytoskeleton regulation.

CONCLUSION

Our study contributes to a better understanding of pathogenic mechanisms involved in the development of HPV-positive oropharyngeal cancer and in the identification of potential therapeutic molecular targets. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

A Pilot Comparison of 18F-fluorocholine PET/CT, Ultrasonography and 123I/99mTc-sestaMIBI Dual-Phase Dual-Isotope Scintigraphy in the Preoperative Localization of Hyperfunctioning Parathyroid Glands in Primary or Secondary Hyperparathyroidism: Influence of Thyroid Anomalies

We compared (18)F-fluorocholine hybrid positron emission tomography/X-ray computed tomography (FCH-PET/CT) with ultrasonography (US) and scintigraphy in patients with hyperparathyroidism and discordant, or equivocal results of US and (123)I/(99m)Tc-sesta-methoxyisobutylisonitrile (sestaMIBI) dual-phase parathyroid scintigraphy. FCH-PET/CT was performed in 17 patients with primary (n = 11) lithium induced (n = 1) or secondary hyperparathyroidism (1 dialyzed, 4 renal-transplanted).The reference standard was based on results of surgical exploration and histopathological examination. The results of imaging modalities were evaluated, on site and by masked reading, on per-patient and per-lesion bases.In a first approach, equivocal images/foci were considered as negative. On a per-patient level, the sensitivity was for US 38%, for scintigraphy 69% by open and 94% by masked reading, and for FCH-PET/CT 88% by open and 94% by masked reading. On a per-lesion level, sensitivity was for US 42%, for scintigraphy 58% by open and 83% by masked reading, and for FCH-PET/CT 88% by open and 96% by masked reading. One ectopic adenoma was missed by the 3 imaging modalities. Considering equivocal images/foci as positive increased the accuracy of the open reading of scintigraphy or of FCH-PET/CT, but not of US. FCH-PET/CT was significantly superior to US in all approaches, whereas it was more sensitive than scintigraphy only for open reading considering equivocal images/foci as negative (P = 0.04). FCH uptake was more intense in adenomas than in hyperplastic parathyroid glands. Thyroid lesions were suspected in 9 patients. They may induce false-positive results as in one case of oncocytic thyroid adenoma, or false-negative results as in one case of intrathyroidal parathyroid adenoma. Thyroid cancer (4 cases) can be visualized with FCH as with (99m)Tc-sestaMIBI, but the intensity of uptake was moderate, similar to that of parathyroid hyperplasia.This pilot study confirmed that FCH-PET/CT is an adequate imaging tool in patients with primary or secondary hyperparathyroidism, since both adenomas and hyperplastic parathyroid glands can be detected. The sensitivity of FCH-PET/CT was better than that of US and was not inferior to that of dual-phase dual-isotope (123)I/(99m)Tc-scintigraphy. Further studies should evaluate whether FCH could replace (99m)Tc-sestaMIBI as the functional agent for parathyroid imaging, but US would still be useful to identify thyroid lesions.

Is 18F-fluorocholine-positron emission tomography/computerized tomography a new imaging tool for detecting hyperfunctioning parathyroid glands in primary or secondary hyperparathyroidism?

CONTEXT

Preoperative ultrasonography and scintigraphy using (99m)Tc-sestamibi are commonly used to localize abnormal parathyroid glands. In cases of discrepant results between scintigraphy and ultrasonography, it is important to rely on another diagnostic imaging modality. (18)F-fluorodeoxyglucose (FDG) and (11)C-methionine positron emission tomography (PET) have been studied, but are imperfect to detect abnormal parathyroid glands. Recently, first cases of abnormal parathyroid glands taking-up radiolabelled choline were discovered incidentally in men referred to (11)C-choline or (18)F-fluorocholine (FCH)-PET/CT for prostate cancer. We checked if FCH uptake was a general feature of adenomatous or hyperplastic parathyroid glands.

METHODS

FCH-PET/CT was performed in 12 patients with primary (n = 8) or secondary hyperparathyroidism (1 dialyzed, 3 grafted) and with discordant or equivocal results on preoperative ultrasonography (US) and/or (123)I/(99m)Tc-sestamibi dual-phase scintigraphy. The results of the FCH-PET/CT were evaluated, with surgical exploration and histopathologic examination as the standard of truth.

RESULTS

On a per-patient level, the detection rate of FCH-PET/CT (at least one FCH focus corresponding to an abnormal parathyroid gland in a given patient) was 11/12 = 92%. FCH-PET/CT detected 18 foci interpreted as parathyroid glands and correctly localized 17 abnormal parathyroid glands (7 adenomas and 10 hyperplasias). On a per-lesion level, FCH-PET/CT results were 17 TP, 2 false negative ie, a lesion-based sensitivity of 89%, and 1 false positive.

CONCLUSION

As the main result of this pilot study, we show that in patients with hyperparathyroidism and with discordant or equivocal results on scintigraphy or on ultrasonography, adenomatous or hyperplastic parathyroid glands can be localized by FCH-PET/CT with good accuracy. Furthermore, FCH-PET/CT can solve discrepant results between preoperative ultrasonography and scintigraphy and has thus a potential as a functional imaging modality in the detection of abnormal parathyroid glands. Our preliminary results are encouraging and prompt us to further evaluate FCH-PET/CT as a functional imaging agent in patients with biochemical hyperparathyroidism.

Carcinoma of the salivary glands: guidelines and case report of sustained remission with docetaxel

WHAT IS KNOWN AND OBJECTIVE

Salivary glands tumours are rare neoplasms for which there are few clinical trials. The most common malignant parotid tumour is the mucoepidermoid carcinoma. High-grade mucoepidermoid carcinomas are highly aggressive tumours. The initial therapy of localized disease is known, but when there is a recurrence, several options are possible and chemotherapy is generally reserved for palliative treatment. We comment on published guidelines and report a case of sustained remission with docetaxel.

CASE SUMMARY

Our case concerns a 64-year-old woman with a high-grade mucoepidermoid carcinoma of the parotid gland with local recurrence treated with docetaxel 50 mg/m² every 15 days. After the sixth cycle, a complete remission was observed on CT-scan. The tolerability was excellent. After 2 years of docetaxel, the patient was still in complete remission.

WHAT IS NEW AND CONCLUSION

Docetaxel is an active drug for the treatment of mucoepidermoid carcinoma of salivary glands. A prospective study should confirm these data.

A predictive transcriptomic signature of oropharyngeal cancer according to HPV16 status exclusively

OBJECTIVE

Human-papillomaviruses (HPV) type 16 is a causative agent in an increasing subset of oropharyngeal squamous cell carcinomas (OPSCCs). These tumors have distinct oncogenic mechanisms and a more favorable prognosis than tobacco-induced OPSCCs. Although these differences emphasize the need for a specific therapeutic approach, HPV status is still not used to guide treatment. A better characterization of the molecular profile related to HPV16-induced OPSCC might help to develop personalized treatments.

PATIENTS AND METHODS

Using a human whole-genome DNA-microarray, we have examined the gene expression profiles in 15 HPV-negative and 15 transcriptionally-active HPV-positive OPSCCs. The study was conducted in two steps. Firstly, a learning/training-set consisting of 8 HPV16-positive and 8 HPV16-negative OPSCCs was analyzed to identify a specific signature. Potentially confounding factors (stage, sex and tobacco) were equally distributed in both groups. Subsequently the robustness of this signature was confirmed by blind case-by-case classification of a validation-set composed of the 14 remaining tumors.

RESULTS

We have identified a signature composed of 224 genes, which discriminates HPV16-induced OPSCC from their HPV-negative counterparts. After the blind classification of the 14 tumours, the viral status was revealed: 13 out of 14 tumors were correctly classified according to tumor etiology, 1/14 was not determined and none were misclassified. Several of the differentially expressed genes were involved in cell-cycle regulation, DNA replication and repair, transcription regulation, immune response and apoptosis.

CONCLUSION

Our study contributes to a better understanding of pathogenic mechanisms involved in the development of HPV-positive OPSCCs and in the identification of potential therapeutic targets.

Haemorrhagic shock, therapeutic management

The management of a patient in post-traumatic haemorrhagic shock will meet different logics that will apply from the prehospital setting. This implies that the patient has beneficiated from a "Play and Run" prehospital strategy and was sent to a centre adapted to his clinical condition capable of treating all haemorrhagic lesions. The therapeutic goals will be to control the bleeding by early use of tourniquet, pelvic girdle, haemostatic dressing, and after admission to the hospital, the implementation of surgical and/or radiological techniques, but also to address all the factors that will exacerbate bleeding. These factors include hypothermia, acidosis and coagulopathy. The treatment of these contributing factors will be associated to concepts of low-volume resuscitation and permissive hypotension into a strategy called "Damage Control Resuscitation". Thus, the objective in situation of haemorrhagic shock will be to not exceed a systolic blood pressure of 90 mmHg (in the absence of severe head trauma) until haemostasis is achieved.

Oropharyngeal cancers: significance of HPV16 detection in neck lymph nodes

BACKGROUND

An increasing proportion of oropharyngeal squamous cell carcinomas (OPSCCs) is associated with human papillomavirus (HPV) type 16 infection. Several authors have suggested that HR-HPV DNA could be used as a marker of metastases in cervical cancers. Although HPV16 DNA has been detected in neck lymph node (LN) metastases of HPV16-positive OPSCC, its significance remains controversial. Does this presence correlate to metastatic involvement or is it just the consequence of LN filter function?

OBJECTIVES

This study aims to analyse the relationship between HPV16 detection in neck LNs of HPV16-positive OPSCC and their pathological status.

STUDY DESIGN

HP16-viral load (VL) was quantified by real-time-polymerase-chain reaction in primary tumours and neck LNs, in 11 patients with HPV16-positive OPSCC and in three patients with HPV16-negative OPSCC. HPV16 in situ hybridisation and p16 immunohistochemistry were performed in all LNs.

RESULTS

A total of 45 LN levels were assessed. HPV16 DNA was not identified in HPV16-negative OPSCC LNs. All metastatic LNs from HPV16-positive OPSCC had a high VL and the viral DNA was located within tumoural cells. Among 27 pathologically tumour-free LN (PTFLN) levels 16/27 had no detectable VL, whereas the VL was low or medium (<10(5)copies/million cells) in 8/27 and high (>10(5)copies/million cells) in 3/27 PTFLN. In the latter group, no metastatic cell was identified and the viral DNA was located in immune cells.

CONCLUSION

HPV16 detection in LN is explained by its presence within either metastatic cells or immune cells. HPV16 detection in PTFLN is not necessarily correlated to occult LN metastases.

Human papillomavirus type 16 oropharyngeal cancers in lymph nodes as a marker of metastases

BACKGROUND

Oropharyngeal squamous cell carcinomas (OSCCs) are associated with high-grade human papillomavirus (HPV) infection in 20% to 30% of cases. HPV-16 DNA has been detected in cervical lymph node metastases of HPV-16(+) OSCC. However, the meaning of HPV-16 DNA detection in lymph nodes remains controversial. Does the presence of HPV-16 DNA in lymph nodes correlate with their metastatic involvement, or is it just a consequence of the filter function of lymph nodes?

METHODS

Viral load quantification using reverse transcriptase-polymerase chain reaction was retrospectively performed in primary tumors and in cervical lymph nodes, originating from levels IIa, IIb, and III, in 11 patients with HPV-16(+) OSCC and in 3 control patients with HPV-16(-) OSCC.

RESULTS

A total of 45 lymph node levels were analyzed. HPV-16 DNA was not detected in HPV-16(-) OSCC lymph nodes. No statistically significant difference was found between primary tumors and metastatic lymph nodes viral load (P > .01). The viral load value was significantly higher in metastatic lymph nodes than in tumor-free lymph nodes (P < .01). Among 27 tumor-free lymph node levels, the viral load value was undetectable in 16, low or medium (<10(5) copies per million cells) in 8, and high (>10(5) copies per million cells) in 3.

CONCLUSIONS

HPV-16 DNA detection in lymph nodes of patients affected with HPV-16(+) oropharyngeal cancer is indicative of metastatic involvement. Tumor-free lymph nodes with a high viral load value would suggest the presence of occult lymph nodes metastasis and the opportunity to use HPV-16 DNA as a metastatic marker. Further investigations are needed.

Study of the MLB parameterisation for change in surface solar irradiance with sun zenith angle in clear sky

Abstract. The MLB parameterisation (Modified Lambert-Beer, Mueller et al., 2004) describes the change in SSI with sun zenith angle (SZA) in clear-sky conditions. It applies to the direct and global SSI as well as their spectral distribution. We assess its performances by comparing its results to the outputs of the radiative transfer model libRadtran and standard interpolation procedures. The standard two-point fitting MLB function performs very well at SZA between 0° and 60° and fairly bad from 60° to 89.9°. A parameterisation made of four MLBs for four intervals (0°, 60°), (60°, 75°), (75°, 85°) and (85°, 89.9°) is also tested. This piecewise MLB parameterisation exhibits satisfactory performances at any SZA and outperforms standard linear interpolation techniques. 95 % of errors in global SSI are less than 1 W m−2 for each band and less than 5 W m−2 for total irradiance.

[Undifferentiated malignant round cell tumors of the sinonasal tract and nasopharynx]

Undifferentiated malignant round cell tumors of the sinonasal tract and nasopharynx comprise of aggressive malignant neoplasms with overlapping morphologic features, which yet are very different and can be identified as carcinoma, lymphoma, sarcoma, melanoma or olfactory neuroblastoma. Differentiating these tumors is important because their treatment and prognosis are quite different. Because of the limited initial biopsy tissue materials, major differential diagnostic difficulties may arise. The use of a panel of immunohistochemical markers and the identification, in some cases, of specific chromosomal translocations are most often required. We describe clinical, morphological, immunohistochemical and molecular features as well as therapeutic management and prognosis of rhabdomyosarcoma (RMS), Ewing sarcoma/primitive neuroectodermic tumor (EWS/PNET), nonkeratinizing nasopharyngeal carcinoma, undifferentiated subtype (UCNT), olfactory neuroblastoma (ONB), small cell carcinoma, neuroendocrine type (SCCNET), sinonasal undifferentiated carcinoma (SNUC) and mucosal melanoma. Mesenchymal chondrosarcoma, small round cell synovialosarcoma, lymphomas and plasmocytoma are not introduced. The most important features of diagnosis will be summarized in two tables.

Clinical significance of micrometastases detection in lymph nodes from head and neck squamous cell carcinoma

OBJECTIVE: Study the clinical relevance of micrometastases in head and neck squamous cell carcinoma (HNSCC).

METHODS: We reviewed the outcome of 31 patients who underwent neck dissection for HNSCC with lymph node analysis by cytokeratin 19 real-time Taqman polymerase chain reaction (CK19RT-PCR) for detection of micrometastasis. Fifteen patients were N+ on histopathology (group 1) and 16 were N-; nine of these 16 patients were CK19RT-PCR positive (group 2), whereas seven were negative (group 3). Local and neck recurrences, metastases, and other tumour sites were recorded during follow-up.

RESULTS: Five patients in group 1, eight patients in group 2, and one patient in group 3 experienced a tumor-related event. N-patients in groups 2 and 3 had a different outcome ( P < 0.01).

CONCLUSION: It is suggested that CK19RTPCR detection of micrometastasis in lymph nodes could be of significant prognostic value in HNSCC, because more aggressive treatment could be indicated in these patients.

[What is the most relevant definition of orthostatic hypotension: systolic blood pressure drop, diastolic blood pressure drop, or both?]

The agreed definition of orthostatic hypotension (OH) is a drop of 20 mmHg systolic and/or 10 mmHg diastolic blood pressure (BP) within the first 3 min of erect posture. For elderly people, a question can be raised about diastolic BP relevance in OH's definition.

OBJECTIVE

To determinate HO's prevalence and risks factors considering systolic blood pressure (SBP)'s drop, or diastolic blood pressure (DBP)'s drop, or either.

METHODS

We assessed OH for 554 consecutive, ambulatory, elderly subjects, attending a geriatric outpatient clinic. OH was defined as a SBP drop>20mmHg (SBP-OH), or a DBP drop>10 mmHg (DBP-OH), or a drop in either (SBP. DBP-OH). OH's prevalence and risks factors were determined.

RESULTS

In this population, 76 +/- 6 years of age, (70% hypertension), SBP-OH's prevalence was 17%, DBP-OH's prevalence was 12% and SBP. DBP-OH's prevalence was 25%. OH's risks factors varied considering OH's definition. After adjusting for significant determinants, SBP-OH's risk factors were: Antihypertensive therapy (OR=2.95; IC 95%: 1.21-4.04), age>75years (OR=2.11; IC 95%: 1.22-3.66), anti-hypertensive poly therapy (OR=2.01; IC 95%: 1.39-2.92) and SBP level (OR=1.16; IC 95%: 1.01-1.33). Considering DBP-OH, the only significant risk factor was DBP's level (OR=2.64; IC 95%: 1.89-3.68). SBP. DBP-OH was only determined by anti-hypertensive poly therapy (OR=1.61; IC 95%: 1.13-2.29) and DPB level (OR=1.32; IC 95%: 1.08-1.60).

CONCLUSION

For elderly people, OH's prevalence and risks factors vary considering OH's definition. SBP's drop seems to be more relevant than DBP's drop. A long term follow up is necessary to determine if SBP-OH is correlated with HO' s side effects and to establish the dangerous level of SBP' s drop.

Detection of occult carcinomatous diffusion in lymph nodes from head and neck squamous cell carcinoma using real-time RT-PCR detection of cytokeratin 19 mRNA

The aim of the present study was to evaluate the occult lymph node carcinomatous diffusion in head and neck squamous cell carcinoma (HNSCC). A total of 1328 lymph nodes from 31 patients treated between 2004 and 2005 were prospectively evaluated by routine haematoxylin–eosin–safran (HES) staining, immunohistochemistry (IHC) and real-time Taqman reverse–transcriptase polymerase chain reaction (real-time RT–PCR) assay. Amplification of cytokeratin 19 (CK19) mRNA transcripts using real-time RT–PCR was used to quantify cervical micrometastatic burden. The cervical lymph node metastatic rates determined by routine HES staining and real-time RT–PCR assay were 16.3 and 36.0%, respectively (P<0.0001). A potential change in the nodal status was observed in 13 (42.0%) of the 31 patients and an atypical pattern of lymphatic spread was identified in four patients (12.9%). Moreover, CK19 mRNA expression values in histologically positive lymph nodes were significantly higher than those observed in histologically negative lymph nodes (P<0.0001). These results indicate that real-time RT–PCR assay for the detection of CK19 mRNA is a sensitive and reliable method for the detection of carcinomatous cells in lymph nodes. This type of method could be used to reassess lymph node status according to occult lymphatic spread in patients with HNSCC.

Adult Papillary Renal Tumor With Oncocytic Cells

We report a series of 10 oncocytic renal papillary tumors, with the aim of determining their clinicopathologic features. All patients were male (median age, 71 years), treated by radical nephrectomy and free of recurrence or metastasis (median follow-up, 62 months). Tumors (median size, 3.3 cm) were intrarenal and well limited, with no extrarenal extension. They consisted of thin, nonfibrotic papillae lined by a single layer of oncocytic cells, with finely granular eosinophilic cytoplasm and round regular nucleus exhibiting central nucleolus (Fuhrman grade II, except for one grade III). Foci of necrosis were present in most cases. All tumors were immunoreactive for alpha-methylacyl-coenzyme A racemase, vimentin, and CD10; 4 expressed renal cell carcinoma antigen and 3 cytokeratin 7. There were a low number of cytogenetic changes in the 5 analyzed cases (median, 4; range, 1-7), with no trisomy 7 or 17. Papillary architecture, necrosis, and immunohistochemical profiles argued against the diagnosis of oncocytoma and suggested our cases to be part of the papillary renal cell carcinoma group. However, the cases were atypical for type 1 papillary carcinoma (due to oncocytic cells and absence of trisomy 17) and for type 2 (due to a good outcome). These results suggest that adult papillary renal tumors with oncocytic cells might be a distinct variant in the papillary renal cell carcinoma group.

Molecular Oxygen Reduction in PEM Fuel Cell Conditions: ToF-SIMS Analysis of Co-Based Electrocatalysts

A series of Co-based electrocatalysts for oxygen reduction in acid media has been prepared using two different Co precursors: cobalt acetate (CoAc) and a cobalt porphyrin (CoTMPP). These catalysts have been analyzed by ToF-SIMS to obtain information on the number and the structure of catalytic active sites in these materials. The results are compared with the results of a similar analysis already performed on a series of Fe-based electrocatalysts (J. Phys. Chem. B 2002, 106, 8705) also prepared with two different Fe precursors: iron acetate (FeAc) and an iron porphyrin (ClFeTMPP). The interpretation of ToF-SIMS data for Fe-based catalysts allowed us to conclude that whatever the Fe precursor was, the same catalytic sites (FeN2/C and FeN4/C, with their respective dominant ToF-SIMS signatures: FeN2C4+ and FeN4C8+ ions) were found. The comparison of the ToF-SIMS data with the activity of those catalysts led to the conclusion that the FeN2C catalytic site was more active than FeN4/C. When the same procedure is applied to ToF-SIMS data measured for Co-based catalysts, the following conclusions are drawn: (i) as for Fe precursors, both Co precursors also give similar results; (ii) as for Fe-based catalysts, the same four families of MetalNxCy+ ions, with 1, 2, 3, and 4 nitrogen atoms, are also found in the spectra of Co-based catalysts, but there is no dominant CoNxCy+ ion signature; (iii) only CoN4/C can be ascertained on the basis of ToF-SIMS measurements. There is no strong support from ToF-SIMS measurements for (or against) the existence of CoN2/C in Co-based catalysts as there is for FeN2/C in Fe-based catalysts; (iv) contrary to Fe-based catalysts, all catalytic sites (if there are any besides CoN4/C) are about equally active in Co-based electrocatalysts.

[Non-compaction of the myocardium in childhood]

Non compaction of the ventricular myocardium is a rare and severe myocardiopathy with numerous trabeculations and deep intertrabecular recesses directly connected with the ventricular cavity. Many complications may occur: heart failure, arrythmia, thrombotic events. However, phenotypic and genotypic presentations vary. Non compaction affects infants in almost half of the cases. A pediatric national cohort study (directed by the filiale de cardiologie pédiatrique de la société française de cardiologie) should allow to analyse the clinical and epidemiological characteristics of the patients as well as to accurate both non compaction's diagnosis and prognosis. Inclusion criteria of this retrospective multicenter study were: age lesser than 18, echographic and/or histologic criteria of non compaction, no congenital heart disease such as pulmonary atresia. This population included 38 patients: 21 were asymptomatic at diagnosis. Ten familial forms were detected. The ECG was abnormal in 77% of the cases, the chest-X ray in 80%. Echocardiography remains the usual technique for diagnosis. However, previously reported quantitative criteria are not easy to use in a retrospective study. Treatment was symptomatic as the etiology of non compaction is unknown. The prognosis is severe: 31.5% of the patients died or had a cardiac transplantation. Only 30% of the patients were free of cardiac events for a 2-year period. Inclusion of new patients must go on to set up a prospective study and biomolecular analysis in informative families.

Facteurs de risque de mortalité après chirurgie pour dissection aortique de type A : impact des traitements antithrombotiques préopératoires

OBJECTIVE

The purpose of this investigation was to study the incidence and consequences of anticoagulant therapy in the surgical management of acute aortic dissections.

STUDY DESIGN

Retrospective study.

PATIENTS AND METHODS

We reviewed all acute type A aortic dissections that were surgically managed in our institution from 1 January 1990 to 31 December 2000. Survival outcome and characteristics potentially associated with survival were abstracted from patient records. We screened preoperative electrocardiograms (ECG) and anticoagulant therapy.

RESULTS

ST segment elevation incidence was 14% and preoperative anticoagulant therapy occurred in 63 (20%) cases as follow: aspirin 12%, aspirin + heparin 6%, thrombolysis 1%. Overall mortality was 22%. Time between pain and surgery was not statistically different between anticoagulant therapy and standard group. Administration of antithrombotic agents before admission in -hospital increased significantly mortality (Odds ratio (OR) = 2.02; IC [1.1-3.71]; p = 0.023). Other risk factors for death were preoperative circulatory failure (OR = 8.28 [4.23-16.24], p < 0.0001), preoperative cardiac arrest (OR = 21.92 [7.16-67.14], p < 0.0001), preoperative circulatory arrest (OR = 2.79 [1.60-4.88], p = 0.0003), preoperative cerebral perfusion (OR = 2.45 [1.18-5.05], p = 0.016), postoperative circulatory failure (OR = 3.37 [1.85-6.17], p < 0.0001), postoperative cardiac arrest (OR = 9.92 [3.49-28.21], p < 0.0001), postoperative serum creatinine >150 micromol/l (OR = 4.55 [2.43-8.50], p < 0.0001), postoperative dialysis (OR = 5.63 [2.44-13.20], p < 0.0001), more than 7 days of post-operative ventilation (OR = 23.44 [12.0-45.7], p < 0.0001).

DISCUSSION

In our experience, 20% of acute type A aortic dissections had received a preoperative anticoagulant therapy. This event is an independent risk factor of in-hospital death and is more frequent in case of ischaemic ECG abnormalities.

[Endocarditis and congenital heart disease in the adult]

The prevalence of congenital cardiopathy is approximately 8% of live births, and 80 to 85% of patients reach adulthood thanks to the progress in the management of even complex malformations. Congenital cardiopathies represent 10 to 18% of adulthood cardiopathies complicated by infectious endocarditis, and in the specialist units for adolescent and adult congenital cardiac patients, 5% of admissions are provoked by endocarditis. The majority of malformations have a risk of infected graft, but patients who have a complex cyanogenic cardiopathy or an operated cardiopathy requiring insertion of prosthetic material, and those who have already had previous episodes of endocarditis are at a very high risk. Longitudinal studies show evolution of the responsible microbes, with an increase of the HACEK group; nevertheless, the streptococci and staphylococci remain uppermost. Diagnosis relies on the classic Duke University criteria but Doppler echocardiography is sometimes difficult to interpret in complex malformations or extra-cardiac sites of infection, and in 6 to 11% of cases the microbe is not identified. Infectious endocarditis remains a particularly serious complication: 50% of patients have aggravation of their cardiopathy and 20 to 30% require surgery; however the mortality has fallen by 20% to a little less than 5% in the most recent series. It is vital that patient education should be pursued even if, in certain circumstances, prophylaxis is not always either possible or effective....