Management after local excision of small rectal cancers. Indications for completion total mesorectal excision and possible alternatives

The treatment of superficial rectal cancers (local excision, or proctectomy with total mesorectal excision (TME) remains controversial. Endoscopy and endorectal ultrasonography are essential for the precise initial definition of these small cancers. During endoscopy, the depth of the lesion can be estimated using virtual chromoendoscopy with magnification, thereby aiding the assessment of the possibilities of local excision. Current international recommendations indicate completion proctectomy after wide local excision for cases where the pathologic examination reveals poorly-differentiated lesions, lymphovascular invasion, grade 2 or 3 tumor budding, and incomplete resection. But debate persists regarding whether the depth of submucosal invasion can accurately predict the risk of lymph node spread. Recent data from the literature suggest that the depth of submucosal invasion should no longer, by itself, be an indication for additional oncological surgery. Adjuvant radio-chemotherapy could be an alternative to completion proctectomy in patients with pT1 rectal cancer and unfavorable histopathological criteria. A Dutch randomized controlled trial is underway to validate this strategy.

Risk factors for severe morbidity and definitive stoma after elective surgery for sigmoid diverticulitis: a multicenter national cohort study

BACKGROUND

In the decision to perform elective surgery, it is of great interest to have data about the outcomes of surgery to individualize patients who could safely undergo sigmoid resection. The aim of this study was to provide information on the outcomes of elective sigmoid resection for sigmoid diverticular disease (SDD) at a national level.

METHODS

All consecutive patients who had elective surgery for SDD (2010-2021) were included in this retrospective, multicenter, cohort study. Patients were identified from institutional review board-approved databases in French member centers of the French Surgical Association. The endpoints of the study were the early and the long-term postoperative outcomes and an evaluation of the risk factors for 90-day severe postoperative morbidity and a definitive stoma after an elective sigmoidectomy for SDD.

RESULTS

In total, 4617 patients were included. The median [IQR] age was 61 [18.0;100] years, the mean ± SD body mass index (BMI) was 26.8 ± 4 kg/m2, and 2310 (50%) were men. The indications for surgery were complicated diverticulitis in 50% and smoldering diverticulitis in 47.4%. The procedures were performed laparoscopically for 88% and with an anastomosis for 83.8%. The severe complication rate on postoperative day 90 was 11.7%, with a risk of anastomotic leakage of 4.7%. The independent risk factors in multivariate analysis were an American Society of Anesthesiologists (ASA) score ≥ 3, an open approach, and perioperative blood transfusion. Age, perioperative blood transfusion, and Hartmann's procedure were the three independent risk factors for a permanent stoma.

CONCLUSIONS

This series provides a real-life picture of elective sigmoidectomy for SDD at a national level.

TRIAL REGISTRATION

Comité National Information et Liberté (CNIL) (n°920361).

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

International Validation of the Immunoscore Biopsy in Patients With Rectal Cancer Managed by a Watch-and-Wait Strategy

PURPOSE

No biomarker capable of improving selection and monitoring of patients with rectal cancer managed by watch-and-wait (W&W) strategy is currently available. Prognostic performance of the Immunoscore biopsy (ISB) was recently suggested in a preliminary study.

METHODS

This international validation study included 249 patients with clinical complete response (cCR) managed by W&W strategy. Intratumoral CD3+ and CD8+ T cells were quantified on pretreatment rectal biopsies by digital pathology and converted to ISB. The primary end point was time to recurrence (TTR; the time from the end of neoadjuvant treatment to the date of local regrowth or distant metastasis). Associations between ISB and outcomes were analyzed by stratified Cox regression adjusted for confounders. Immune status of tumor-draining lymph nodes (n = 161) of 17 additional patients treated by neoadjuvant chemoradiotherapy and surgery was investigated by 3'RNA-Seq and immunofluorescence.

RESULTS

Recurrence-free rates at 5 years were 91.3% (82.4%-100.0%), 62.5% (53.2%-73.3%), and 53.1% (42.4%-66.5%) with ISB High, ISB Intermediate, and ISB Low, respectively (hazard ratio [HR; Low v High], 6.51; 95% CI, 1.99 to 21.28; log-rank P = .0004). ISB was also significantly associated with disease-free survival (log-rank P = .0002), and predicted both local regrowth and distant metastasis. In multivariate analysis, ISB was independent of patient age, sex, tumor location, cT stage (T, primary tumor; c, clinical), cN stage (N, regional lymph node; c, clinical), and was the strongest predictor for TTR (HR [ISB High v Low], 6.93; 95% CI, 2.08 to 23.15; P = .0017). The addition of ISB to a clinical-based model significantly improved the prediction of recurrence. Finally, B-cell proliferation and memory in draining lymph nodes was evidenced in the draining lymph nodes of patients with cCR.

CONCLUSION

The ISB is validated as a biomarker to predict both local regrowth and distant metastasis, with a gradual scaling of the risk of pejorative outcome.

Risk factors of anastomosis-related difficult endoscopic retrograde cholangiopancreatography following endoscopic ultrasound-guided gastro-gastrostomy using a standardized protocol (with video)

OBJECTIVES

Little is known about how to perform the endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP; EDGE) in patients with gastric bypass using lumen-apposing metal stents (LAMS). The aim was to assess the risk factors of anastomosis-related difficult ERCP.

METHODS

Observational single-center study. All patients who underwent an EDGE procedure in 2020-2022 following a standardized protocol were included. Risk factors for difficult ERCP, defined as the need of >5 min LAMS dilation or failure to pass a duodenoscope in the second duodenum, were assessed.

RESULTS

Forty-five ERCPs were performed in 31 patients (57.4 ± 8.2 years old, 38.7% male). The EUS procedure was done using a wire-guided technique (n = 28, 90.3%) for biliary stones (n = 22, 71%) in most cases. The location of the anastomosis was gastro-gastric (n = 24, 77.4%) and mainly in the middle-excluded stomach (n = 21, 67.7%) with an oblique axis (n = 22, 71%). The ERCP technical success was 96.8%. There were 10 difficult ERCPs (32.3%) due to timing (n = 8), anastomotic dilation (n = 8), or failure to pass (n = 3). By multivariable analysis adjusted by two-stage procedures, the risk factors for a difficult ERCP were the jejuno-gastric route (85.7% vs. 16.7%; odds ratio [ORa ] 31.875; 95% confidence interval [CI] 1.649-616.155; P = 0.022), and the anastomosis to the proximal/distal excluded stomach (70% vs. 14.3%; ORa 22.667; 95% CI 1.676-306.570; P = 0.019). There was only one complication (3.2%) and one persistent gastro-gastric fistula (3.2%) in a median follow-up of 4 months (2-18 months), with no weight regain (P = 0.465).

CONCLUSIONS

The jejunogastric route and the anastomosis with the proximal/distal excluded stomach during the EDGE procedure increase the difficulty of ERCP.

Two-stage free latissimus dorsi flap for the management of a voluminous enterocutaneous fistula in a patient with Ehlers-Danlos syndrome: a case report

Background

Ehlers-Danlos syndrome (EDS) is a rare genetic disorder that causes abnormal collagen structure and production, seriously impacting the quality of connective tissues. Reconstructive surgery can be challenging in affected patients, and additional precautions should be taken for microsurgical transfers.

Case Description

This case aimed to describe the management of a 27-year-old man with vascular EDS and a history of heavy smoking who developed a voluminous enterocutaneous fistula after multiple abdominal surgeries. Due to the high surgical risk of flap failure resulting from the patient's condition, the large full-thickness abdominal defect, and the lack of locoregional reconstructive options, a two-stage free latissimus dorsi flap reconstruction was performed. A left myocutaneous free latissimus dorsi flap (sized 10 cm × 25 cm) was transferred and anastomosed to the left superficial femoral artery and the proximal part of the rerouted greater saphenous vein. The flap was folded, sutured to itself, and left in place for 8 days. Once the flap's viability was confirmed, complete small bowel liberation with resection of the enterocutaneous fistula and end-to-end primary anastomosis were performed by the visceral surgeons. The latissimus dorsi flap was unfolded and moved cephalically to cover the defect. No complications were reported on the flap. A fistula recurrence occurred on postoperative day 9 but was successfully addressed within 6 weeks using a combination of nasogastric tube aspiration, somatostatin, antibiotics, and negative pressure therapy. Follow-up at 6 months showed complete wound healing with no further complications.

Conclusions

This report suggests the two-stage free flap transfer strategy to manage a voluminous full-thickness abdominal wall defect in a patient with vascular EDS. This approach allowed for optimal tissue coverage and full abdominal restoration while minimizing the risk of complications.

Cognitive and psychiatric signs revealing Sneddon syndrome: A case report

Key Clinical Message

The diagnosis of Sneddon Syndrome should be considered in adults with young-onset dementia accompanied by neuropsychiatric signs and livedo racemosa. Magnetic resonance imaging and cerebral angiography are essential. A cutaneous biopsy may help in the diagnosis.

Abstract

Sneddon syndrome (SS) is a clinical entity corresponding to a noninflammatory thrombotic vasculopathy that typically includes livedo racemosa and cerebrovascular ischemia. Psychiatric symptoms with cognitive impairment often occur but are rarely the inaugural symptoms. We present a case of secondary SS in a 45-year-old man in whom dementia and psychosis revealed the disease.

A systematic review of minimal length of lroximal margin in gastric adenocarcinoma resection

For early distal gastric cancers, a proximal margin (PM) > 2-3 cm might probably be sufficient. For advanced tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

INTRODUCTION

In gastric cancer surgery, microscopic positive margin is a poor prognostic factor whereas complete resection with tumor-free margins remains a challenging issue. European guidelines recommended a macroscopic margin of 5 or even 8 cm for diffuse-type cancers to achieve R0 resection. However, it is unclear if the length of negative proximal margin (PM) could have a prognostic impact on survival. We aimed to perform a systematic review of the literature analyzing PM length and its prognostic impact in gastric adenocarcinoma.

MATERIAL AND METHODS

Pubmed and Embase databases were searched for "gastric cancer" or "gastric adenocarcinoma," combined with "proximal margin," between January 1990 and June 2021. English-written studies that specified PM length were included. Survival data, in relation to PM, were extracted.

RESULTS

Twelve retrospective studies, with a total number of 10,067 patients, met inclusion criteria and were analyzed. Mean length of proximal margin on the whole population varied from 2.6 to 5.29 cm. Three studies found minimal PM cut-off to improve overall survival in univariate analysis. Concerning recurrence-free survival analysis, only 2 series showed better results with PM > 2 or > 3 cm, using Kaplan-Meier method. Multivariate analysis demonstrated an independent impact of PM on overall survival in 2 studies.

CONCLUSION

For early distal gastric cancers, a PM > 2-3 cm might probably be sufficient. For advanced or proximal tumors, many confounding factors have a prognostic impact on survival and recurrence and negative margin involvement may be more relevant than negative margin length.

FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty

Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.

Multiple Laparoscopic Liver Resection for Colorectal Liver Metastases

Over the past decades, liver cancer's minimally invasive approach has primarily become as a new standard of oncological care. Colorectal liver metastases (CRLM) are one of the most developed indications of laparoscopic liver resection (LLR). CRLM resection is still the best treatment known in terms of survival. As multiple CRLM are found in up to 80% of cases at diagnosis (Manfredi S. and al, Annals of Surgery 2006), a lot of possible technical management approaches are described. With the development of the parenchymal-sparing strategy, multiple concomitant laparoscopic liver resections (LLR) are gaining acceptance. However, no recommendation is available regarding its indications and feasibility. Also, laparoscopic two-stage hepatectomy is developing for bilobar CRLM, and this also does not have established recommendation. The purpose of this paper was to highlight novelty and updates in the field of multiple minimally invasive liver resections. A review of the international literature was performed. The feasibility of laparoscopic concomitant multiple LLR and two-stage hepatectomy for CRLM as well as their outcomes were discussed. These clarifications could further guide the implementation of minimal resection in multiple colorectal liver metastases therapies.

MSI colorectal cancer, all you need to know

Colorectal cancer management has been dramatically impacted by molecular profiling these last years. Among these molecular subgroups, patients with microsatellite instability (MSI) are of particular interest, owing to the prognostic and predictive value of this tumor biomarker. This review article explains the molecular abnormalities underlying MSI phenotype and the consequences of such molecular abnormalities on carcinogenesis, genetic instability and immune infiltration. It details the diagnostic methods for identifying MSI colorectal cancer patients and describes how the prognostic and theranostic values of this marker are impacting treatment decision-making for these patients in 2022.

Translation and validation of the Arabic version of the "Suicide Behavioral Attitude Questionnaire"

INTRODUCTION

Attitudes and knowledge of health professionals are critical dimensions in the management of suicidal behavior. The "Suicide Behavioral Attitude Questionnaire" (SBAQ) was designed in Brazil to measure these variables in paramedical personnel.

AIM

To translate and validate the SBAQ in literary Arabic.

METHODS

After author-approved translation and back-translation, the Arabic version of the SBAQ was distributed to 125 Tunisian caregivers working in psychiatric departments. Factor analysis and internal consistency were calculated. The stability was measured overtime using the paired Student's T-test.

RESULTS

Cronbach's alpha value was 0.741. The adequacy index of the factorization factor Kaiser-Meyer-Olkin (KMO) of our sample was 0.74. This value was higher than 0.5 which indicates that our data was suited for factor analysis. Bartlett's sphericity test result was significant, rejecting the null hypothesis. Three factors were extracted explaining 50.7% of the overall variance. Cronbach's alpha value for the three subscales was 0.735, 0.713 and 0.798. The instrument had good stability over time.

CONCLUSIONS

The Arabic version of the SBAQ showed good reliability and validity allowing its use in Arabic speaking paramedical personnel.

Adult mild encephalitis with reversible splenial lesion and catatonia: A case report

The relationship between corpus callosum and schizophrenia is elusive. Neuropsychiatric symptoms in Mild encephalitis with reversible splenial lesion (MERS) such as delirium, and negativism, suggest a link between corpus callosum and psychiatric disturbances.

Here in, we report catatonia as an initial symptom of MERS in a schizophrenic patient.

The aim of this study is to discuss the likely causal relationship between catatonic syndrome and MERS.

To the best of our knowledge, the catatonia was not reported before as a prodromal symptom of MERS. We therefore report this case in order to enlarge the spectrum of MERS symptoms in psychiatric patients and discuss the relationship between catatonia and splenium lesions.

Management of Pathogenic CDH1 Variant Carriers within the FREGAT Network: A multicentric Retrospective Study

OBJECTIVE

To describe the management of pathogenic CDH1 variant carriers (pCDH1vc) within the FREGAT (FRench Eso-GAsTric tumor) network. Primary objective focused on clinical outcomes and pathological findings, Secondary objective was to identify risk factor predicting postoperative morbidity (POM).

SUMMARY BACKGROUND DATA

Prophylactic Total Gastrectomy (PTG) remains the recommended option for gastric cancer risk management in pCDH1vc with however endoscopic surveillance as an alternative.

METHODS

A retrospective observational multicenter study was carried out between 2003 and 2021. Data were reported as median [interquartile range] or as counts (proportion). Usual tests were used for univariate analysis. Risk factors of overall and severe POM (i.e. Clavien-Dindo grade 3 or more) were identified with a binary logistic regression.

RESULTS

99 patients including 14 index cases were reported from 11 centers. Median survival among index cases was 12.0[7.6-16.4] months with most of them having peritoneal carcinomatosis at diagnosis (71.4%). Among the remaining 85 patients, 77 underwent a PTG (median age 34.6 [23.7 - 46.2], ASA score 1: 75%) mostly via a minimally-invasive approach (51.9%). POM rate was 37.7% including 20.8% of severe POM, with age≥ 40 years and low volume centers as predictors (P=0.030 and P=0.038). After PTG, the cancer rate on specimen was 54.5% (n=42, all pT1a) of which 59.5% had no cancer detected on preoperative endoscopy (n=25).

CONCLUSION

Among pCDH1vc, index cases carry a dismal prognosis. The risk of cancer among patients undergoing PTG remained high and unpredictable and has to be balanced with the morbidity and functional consequence of PTG.

Hepatic Arterial Infusion Chemotherapy With Folfirinox or Oxaliplatin Alone in Metastatic Colorectal Cancer

Background

Hepatic arterial infusion (HAI) of chemotherapy is an option for the treatment of patients with liver metastases from colorectal cancer (LMCRC). Though HAI with oxaliplatin (HAI-Ox) is generally used, intravenous (IV) 5-fluoro-uracil (5FU)-oxaliplatin-irinotecan HAI (HAI-Folfirinox) is feasible and leads to curative-intent surgery in 30% of pretreated patients. We compared the efficacy and safety of HAI-Ox and HAI-Folfirinox.

Methods

Patients who underwent HAI chemotherapy for LMCRC were retrospectively included from 2008 to 2019 from six French expert centers.

Results

Data were collected from 273 previously treated patients with LMCRC. Patients received HAI-Folfirinox (n = 52) or HAI-Ox (n = 221) combined with IV chemotherapy. The objective response rate (ORR) was 43.2% in patients with HAI-Folfirinox and 45.9% (ns) in patients with HAI-Ox. Median overall survival (OS) was 17 months (95% CI: 15–32.3) with HAI-Folfirinox and 26.2 months (95% CI: 19.4–34.4; p = 0.1) with HAI-Ox. Median progression-free survival (PFS) was 7.9 months (95% CI: 4.9–10.3) with HAI-Folfirinox and 6.4 months (95% CI: 6.0–7.7; p = 0.6) with HAI-Ox. The secondary liver resection rate was 35.6% with HAI-Folfirinox and 16.7% with HAI-Ox (p = 0.007). Grade 2 and above toxicities were significantly more frequent with HAI-Folfirinox. In the global population, only 2 factors were prognostic for OS in multivariable analyses: liver-only disease [hazard ratio (HR): 0.4; 95% CI 0.20–0.83; p = 0.013] and local complications of the catheter (HR: 3.8; 95% CI 1.6–9.0; p = 0.002).

Conclusion

Hepatic arterial infusion results in high response rates, secondary resections, and long survival in pretreated patients with LMCRC.

Marfan syndrome and schizophrenia : a case report and literature review

Introduction

Marfan syndrome is an autosomal dominant systemic disorder with connective tissue defects in multiple organ systems. Cardinal manifestations of this syndrome involve the cardiovascular, the skeletal and the ocular system. Interestingly, many cases of patients with Marfan syndrome and schizophrenia have been reported.

Objectives

Discuss the etiological link between Marfan syndrome and schizophrenia

Methods

Presentation of a clinical case illustrating the comorbidity between schizophrenia and marfan syndrome. A search was conducted in PubMed database using the terms : schizophrenia AND Marfan syndrome.

Results

Ms JW a 36-year- old single women, she had schizophrenia since the age of 20 years, she was hospitalized in our service for psychotic relapse in a context of treatment discontinuation. She had a personal history of persistence of the ductus arteriosus for which she had been operated during her childhood, a scoliosis operated and multiple pathological fractures. On mental status examination, she was distressed and hallucinated, She had disorganized thought processes and a paranoid delirium. On physical examination, she had features suggestive of Marfan syndrome such as crowded teeth, a high arched palate, arachnodactyly , hyperlaxity and a high myopia. We don’t dispose genetic evaluation for marfan syndrom because of the nonavaibility of facilities to perform genetic analysis. Several studies have indicated that psychiatric symptoms might be part of the clinical profiles of marfan syndrom. However, their relationship and underlying pathogenesis are not easily clarified.

Conclusions

Co-occurrence of marfan syndrom and schizophrenia might be explained by some shared etiological pathways between both disorders.

Disclosure

No significant relationships.

Anxiety among frontline healthcare professionals during the coronavirus pandemic

Introduction

Anxiety has become a topical issue since the arrival of the coronavirus pandemic, especially for frontline healthcare professionals as they deal with patients affected by the Covid-19.

Objectives

Objectify anxiety in frontline medical and paramedical staff and study its associated factors.

Methods

We conducted a national descriptive and analytical cross-sectional study via a survey over a 2-month period from September to October 2020. We used “Beck Anxiety Inventory” to screen anxiety as well as “Brief Cope Scale” to detect probable correlations between anxiety and coping mechanisms.

Results

We collected 78 persons. The mean age was 29.86 years. 35.9% moved out of home. 39.7% worked in Covid units. 7.7% had personal psychiatric history. 76.9% provided direct care to patients with Coronavirus. The frontline staff reported that only 29.5% of patients were stables. Only 48.4% received adequate training of protection against Covid-19. 64.1% of professionals did PCR test and only 16.7% of them tested positive. We objectified an increase of 6.4% in the anxiolytics use. Stigma affected 57.7% of professionals. We highlighted a link between anxiety and social support strategy (p=0.048). 92.3 % of the staff suffered from anxiety according to Beck Anxiety Inventory.

Conclusions

Screening anxiety among frontline medical and paramedical staff might enhance their productivty and thus provide patients with the best care.

Disclosure

No significant relationships.

Anxiety, depression and tinnitus: a cross-sectional study about 60 cases

Introduction

Tinnitus is an auditory perception of a “phantom” nature with highly changing features. There is an established correlation between anxiety, depression, sleep disorders and tinnitus.

Objectives

To evaluate the prevalence of sleep disorders and emotional disorders during tinnitus and their correlation to the severity of the symptomatology

Methods

A descriptive cross-sectional study of 60 patients consulting for subjective tinnitus. For each patient we collected epidemiological data and performed an ENT and general examination, an audiometric and psychoacoustic evaluation and a psychometric evaluation. To evaluate the severity of the tinnitus we used the visual analog scale VAS and the subjective tinnitus severity test (STSS). Disability was assessed by the Tinnitus Handicap Inventory (THI). Anxiety and depression were assessed by: the Hamilton anxiety Rating scale and the Beck depression inventory.

Results

The prevalence of emotional disorders was: 21.7% for depression, 48.33% for generalized anxiety disorder, 11.67% for dysthymia, 5% for agoraphobia 16.67% for panic disorder and 1.67% for social phobia. The intensity of tinnitus was correlated with more panic disorder (p=0.008). Subjective severity of tinnitus was correlated with disability (p=0.0001), awareness of tinnitus in relation to sleep duration (p=0.006) and disturbed sleep (p=0.047). Disability was correlated with subjective tinnitus severity (p=0.0001), panic disorder (p=0.0007), generalized anxiety disorder (p=0.033), and poor sleep quality (p=0.005).

Conclusions

Our results emphasize the importance of emotional disorders as well as sleep disorders in chronic “tinnitus”. These disorders should be systematically investigated and eventually treated in order to optimize the management of the patients.

Disclosure

No significant relationships.

Therapeutic characteristics of patients followed for bipolar disorder with rapid cycles: Study on a Tunisian population

Introduction

Bipolar disorder is a frequent and particularly severe psychiatric pathology that causes significant morbidity and mortality. The rapid cycling forms are more severe in terms of their expression, evolutionary course, therapeutic responses and associated comorbidities.

Objectives

The aim of this study is to conduct a descriptive assessment of therapeutic characteristics in patients with rapid cycling bipolar disorder.

Methods

Our work involved a population of 97 patients followed for bipolar disorder diagnosed according to DSM5 criteria, including 37 patients meeting the specification “with rapid cycles”. The patients were divided into two groups: - Group of patients with bipolar disorder with rapid cycles (TBCR) - Group of patients with bipolar disorder without rapid cycling (TBNCR). We compared the therapeutic features among these two groups.

Results

The dominant polarity was depressive in patients with rapid cycles. They required more mood stabilizers. A greater proportion of them had received treatment with serotonin reuptake inhibitor antidepressants. They were more likely to use hypnotics such as antihistamines and zolpidem.

Conclusions

Rapid cycling TB is a relatively common clinical modality that should be investigated and identified.The use of antidepressants is associated with this course of the disease. Their utilization in the treatment of bipolar depression must be thoughtful and well studied

Disclosure

No significant relationships.

Coping strategies among mothers of children with leukemia in Tunisia

Introduction

The diagnosis of leukemia in a child is traumatic life experience that negatively affects parents and especialy the mother which is the “caregiver” who assists and coordinates all stages of treatment.

Objectives

To determine the prevalence of psychological distress among mothers of tunisian children with leukemia and to investigate their coping strategies.

Methods

A cross-sectional study was conducted at Aziza Othmana hospital department of pedo-oncology in Tunisia between June and July 2021. HADS scale was used to estimate the prevalence of anxiety and depression and coping strategies were measured via arabic version of the brief cope scale.

Results

We included 31 mothers, their middle age was 41 years old. In this study we didn’t include mothers with psychiatric history. Acute lymphoblastic leukemia was the most frequent type of cancer in our sample (94%). The middle age of the children was 10 years old and all of them were under chemotherapy. Clinically significant levels of anxiety and depression were reported by 58% and 49% of mothers, respectively. In our study, 81% of the participants practiced prayer and all mothers turned to religion as a coping strategy. Approach coping styles (especially acceptance and planning) were more frequently used than avoidant coping styles (especially substance use and denial).

Conclusions

Mothers are profoundly affected by a child’s cancer diagnosis, they should have early assessment of their mental health needs to have access to appropriate interventions.

Disclosure

No significant relationships.

Antisocial personality disorder in women: a cross-sectional study about 20 cases

Introduction

Antisocial personality disorder (ASPD) is characterized by a long term pattern of disregard for, or violation of the rights of others that occurs in childhood or early adolescence and continues into adulthood. This disorder remains unknown in women.

Objectives

The aim of this study was to describe socio-demographic, clinical, psychometric and therapeutic characteristics of women with ASPD hospitalized in psychiatric ward.

Methods

A cross-sectional and descriptive study was conducted in G psychiatry department, in Razi hospital. It included 20 women with ASPD and hospitalized in psychiatric ward. Socio-demographic, clinical and therapeutic characteristics were assessed. A psychometric evaluation was carried out by the application of six scales: BIS 11, HCR 20, VRAG, PCL-R, ENFP and PID5-BF.

Results

The mean age of the patients was 34 ± 9 years. Patients with a personal history of suicide attempt accounted for 45% of the study population. Patients with a criminal history accounted for 67.5% of the study population. A substance-related disorder was found in 85% of the patients. Adjustment Disorder was retained in 42.5% of the patients and Psychotic Disorder was diagnosed in 32.5% of the population. The average score at VRAG was 6.18 ± 5.8. The mean score at PCL R was 24 ± 4.2. High impulsivity scores were found.

Conclusions

ASPD represents a major concern for clinicians in psychiatric wards. A better knowledge of the characteristics of this trouble in women could improve their quality of care.

Disclosure

No significant relationships.

Coping strategies among medical and paramedic frontline healthcare workers during the coronavirus pandemic

Introduction

The epidemic of COVID-19 has affected the psychological health of people, especially frontline medical and paramedical staff. Several coping strategies have been used to combat the impact of this virus on their lives.

Objectives

Describe the impact of coronavirus on mental health and identify coping strategies

Methods

We carried out a cross-sectional, descriptive and analytical study, conducted over a period of two months ( september and october 2020), in 22 hospitals in Tunisia, including frontline medical and paramedical staff. To evaluate anxiety and depression, we used the Beck Inventory. To identify coping strategies, we used the Brief COPE.

Results

We collected 78 professionals. The mean age was 29.86+-5.4. The majority were medical residents (67.9%) working in covid units in 39.7% of cases. The rythm of work was daily in almost half of the cases, giving direct care to the patients tested positive in 76.9%. More than half had not received adequate training, and protective equipment was available in only 50% of cases. We found 35.9% of the staff who had to move for fear of infecting their families. More than half of the frontline staff were victims of stigma (57.7%). Depression and anxiety were tested minor in 40%. The most used coping strategy in the face of this distressing virus was social support (64.1%) followed by emotion-focused mechanisms (53,8%). Social support strategy was significantly correlated with prevention of anxiety (p=0.048)

Conclusions

Participants practiced and recommended various coping strategies to deal with stress, depression and anxiety emerging from COVID-19 pandemic.

Disclosure

No significant relationships.

Depression among frontline medical and paramedical staff during the coronavirus pandemic

Introduction

The current coronavirus pandemic is a unique and unusual situation. It is putting the general population under severe strain. However, frontline medical and paramedical staff remain particularly vulnerable to depression because of its close contact with patients.

Objectives

The aim of this work was to screen and evaluate depression in the frontline professionals during the pandemic and to study their associated factors .

Methods

In this study , we conducted a national descriptive and analytical cross-sectional study over a 2-month period from September to October 2020. We used “Beck Depression Inventory” to assess depression and “Brief Cope Scale” to detect a possible correlation between depression and coping mechanisms.

Results

We collected 78 professionals. The mean age was 29.86 years. 2/3 of workers were women. 67.9% of the staff were residents. 39.7% worked in Covid units. 7.7% had personal psychiatric history. 56.4% of the staff worked daily and 76.9% of them provided direct care to patients with Coronavirus. 52.6% of workers did not receive adequate training of protection against Covid-19.The staff reported 66.7% of death among their patients. 42.3% suffered from minor depression and only 2.3% suffered from severe depression. During this period we objectified an increase of 14.1% in the psychoactive substances use. Stigma affected 57.7% of professionals. We didn’t objectify a significant correlation between Depression and coping mechanisms .

Conclusions

Screening depression among healthcare professionals should be considered in order to prevent it, ensure continuity of care and avoid sick leaves.

Disclosure

No significant relationships.

First episode psychosis related to COVID-19 infection

Introduction

During the course of COVID-19 pandemic, The respiratory system is the most commonly affected while many neuropsychiatric manifestations of the disease have been observed.

Objectives

Emphasize the importance of eliminating the diagnosis of covid 19 infection in a pandemic context face to first episode psychosis.

Methods

Presentation of case report

Results

A 29-year-old woman unemployed married with no personal medical history and with psychiatric family history. She wasn’t exposed to subject with covid 19 in her family circle. She was admitted in psychiatric care for acute behavioural disorders during five days. On physical examination: she was afebrile, eupneic and tachycardiac. Oxygen saturation was 96% and blood pressure was 100/50 mmHg. Specialized neurological examination was normal and cerebral CT scan was without abnormalities. At the psychiatric interview she was extremely agitated. She was distressed her speech was incoherent. She had auditory and visual hallucinations and a multi-thematic delirium. One day after her admission she died suddenly, the autopsy found positive RT PCR covid test and bilateral basal pneumonia.

Conclusions

In individuals presenting with new-onset psychosis in areas endemic to COVID-19, consideration should be made for neuropsychiatric manifestations of Covid 19 from where the importance to push the explorations and to test the patients.

Disclosure

No significant relationships.

The "Immunoscore" in rectal cancer: could we search quality beyond quantity of life?

Because of the function and anatomical environment of the rectum, therapeutic strategies for local advanced rectal cancer (LARC) must deal with two challenging stressors that are a high-risk of local and distal recurrences and a high-risk of poor quality of life (QoL). Over the last three decades, advances in screening tests, therapies, and combined-modality treatment options and strategies have improved the prognosis of patients with LARC. However, owing to the heterogeneous nature of LARC and genetic status, the patient may not respond to a specific therapy and may be at increased risk of side-effects without the life-prolonging benefit. Indeed, each therapy can cause its own side-effects, which may worsen by a combination of treatments resulting in long-term poor QoL. In LARC, QoL has become even more essential with the increasing incidence of rectal cancer in young individuals. Herein, we analyzed the value of the Immunoscore-Biopsy (performed on tumor biopsy at diagnosis) in predicting outcomes, alone or in association with clinical and imaging data, for each therapy used in LARC.

Facteurs associés à la symptomatologie anxiodépressive chez des femmes tunisiennes atteintes d’un cancer du sein

Objectifs : L’étude avait pour objectif d’estimer la prévalence de la dépression et de l’anxiété dans une population de femmes tunisiennes suivies pour un cancer du sein et de relever les données sociodémographiques, cliniques et de vie de couple qui leur sont associées.

Matériels et méthodes : Une étude transversale auprès de 100 patientes suivies pour un cancer du sein a été réalisée. Un questionnaire portant sur les caractéristiques sociodémographiques, cliniques, thérapeutiques, sur la vie conjugale et sur la sexualité du couple a été administré. L’échelle HADS (Hospital Anxiety and Depression Scale) a été utilisée pour le dépistage des symptômes anxieux et dépressifs.

Résultats : Un score clinique a été retrouvé dans 48 % des cas pour l’anxiété et 37 % des cas pour la dépression. Les patientes qui ont vécu une réaction négative de leur conjoint face à leur maladie et dont la relation de couple et la relation sexuelle ont été altérées présentaient des scores significativement plus élevés de symptomatologie anxieuse et dépressive. Une relation sexuelle non altérée était retrouvée comme facteur protecteur de l’anxiété et de la dépression.

Conclusion : Les résultats de cette étude mettent en évidence l’importance de développer des mesures spécifiques pour améliorer la communication et promouvoir la santé sexuelle au sein du couple en Tunisie.

What Is the Optimal Elective Colectomy for Splenic Flexure Cancer: End of the Debate? A Multicenter Study From the GRECCAR Group With a Propensity Score Analysis

BACKGROUND

The optimal elective colectomy in patients with splenic flexure tumor is debated.

OBJECTIVE

This study aimed to compare splenic flexure colectomy, left hemicolectomy, and subtotal colectomy for perioperative, histological, and survival outcomes in this setting.

DESIGN

This is a multicenter retrospective cohort study.

SETTING

Patients diagnosed with nonmetastatic splenic flexure tumor who underwent elective colectomy were included.

PATIENTS

Between 2006 and 2014, 313 consecutive patients were operated on in 15 French Research Group of Rectal Cancer Surgery centers.

INTERVENTIONS

Propensity score weighting was performed to compare short- and long-term outcomes.

MAIN OUTCOME MEASURES

The primary end point was disease-free survival. Secondary end points included overall survival, quality of surgical resection, overall postoperative morbidity, surgical postoperative morbidity, and rate of anastomotic leakage.

RESULTS

The most performed surgery was splenic flexure colectomy (59%), followed by subtotal colectomy (23%) and left hemicolectomy (18%). Subtotal colectomy was more often performed by laparotomy compared with splenic flexure colectomy and left hemicolectomy (93% vs 61% vs 56%, p < 0.0001), and was associated with a longer operative time (260 minutes (120-460) vs 180 minutes (68-440) vs 217 minutes (149-480), p < 0.0001). Postoperative morbidity was similar between the 3 groups, but the median length of hospital stay was significantly longer after subtotal colectomy (13 days (5-56) vs 10 (4-175) vs 9 (4-55), p = 0.0007). The median number of harvested lymph nodes was significantly higher after subtotal colectomy compared with splenic flexure colectomy and left hemicolectomy (24 (8-90) vs 15 (1-81) vs 16 (3-52), p < 0.0001). The rate of stage III disease and the number of patients treated by adjuvant chemotherapy were similar between the 3 groups. There was no difference in terms of disease-free survival and overall survival between the 3 procedures.

LIMITATIONS

The study was limited by its retrospective design.

CONCLUSIONS

In the elective setting, splenic flexure colectomy is safe and oncologically adequate for patients with nonmetastatic splenic flexure tumor. However, given the oncological clearance after splenic flexure colectomy, it seems that the debate is not completely closed. See Video Abstract at http://links.lww.com/DCR/B703.

CUL ES LA COLECTOMA ELECTIVA PTIMA PARA EL CNCER DE NGULO ESPLNICO FIN DEL DEBATE UN ESTUDIO MULTICNTRICO DEL GRUPO GRECCAR CON UN ANLISIS DE PUNTAJE DE PROPENSIN

ANTECEDENTES:La colectomía electiva óptima en pacientes con tumores del ángulo esplénico continua en debate.OBJETIVO:Comparar la colectomía de ángulo esplénico, hemicolectomía izquierda y colectomía subtotal para los resultados perioperatorios, histológicos y de supervivencia en este escenario.DISEÑO:Estudio de cohorte retrospectivo multicéntrico.ESCENARIO:Se incluyeron pacientes diagnosticados de tumores del ángulo esplénico no metastásicos que se sometieron a colectomía electiva.PACIENTES:Entre 2006 y 2014, 313 pacientes consecutivos fueron intervenidos en 15 centros GRECCAR.INTERVENCIONES:Se realizó una ponderación del puntaje de propensión para comparar los resultados a corto y largo plazo.PRINCIPALES MEDIDAS DE RESULTADO:El criterio de valoración principal fue la supervivencia libre de enfermedad. Los criterios de valoración secundarios incluyeron la supervivencia general, la calidad de la resección quirúrgica, la morbilidad posoperatoria general, la morbilidad posoperatoria quirúrgica y la tasa de fuga anastomótica.RESULTADOS:La cirugía más realizada fue la colectomía del ángulo esplénico (59%), seguida de la colectomía subtotal (23%) y la hemicolectomía izquierda (18%). La colectomía subtotal se realizó con mayor frecuencia mediante laparotomía en comparación con la colectomía de ángulo esplénico y la hemicolectomía izquierda (93% frente a 61% frente a 56%, p <0.0001), y se asoció con un tiempo quirúrgico más prolongado (260 min [120-460] frente a 180 min [68-440] frente a 217 min [149-480], p <0.0001). La morbilidad posoperatoria fue similar entre los tres grupos, pero la duración media de la estancia hospitalaria fue significativamente más prolongada después de la colectomía subtotal (13 días [5-56] frente a 10 [4-175] frente a 9 [4-55], p = 0.0007). La mediana del número de ganglios linfáticos extraídos fue significativamente mayor después de la colectomía subtotal en comparación con la colectomía del ángulo esplénico y la hemicolectomía izquierda (24 [8-90] frente a 15 [1-81] frente a 16 [3-52], p <0.0001). La tasa de enfermedad en estadio III y el número de pacientes tratados con quimioterapia adyuvante fueron similares entre los 3 grupos. No hubo diferencias en términos de supervivencia libre de enfermedad y supervivencia general entre los 3 procedimientos.LIMITACIONES:El estudio estuvo limitado por su diseño retrospectivo.CONCLUSIONES:En un escenario electivo, la colectomía del ángulo esplénico es segura y oncológicamente adecuada para pacientes con tumores del ángulo esplénico no metastásicos. Sin embargo, dado el aclaramiento oncológico tras la colectomía del ángulo esplénico, parece que el debate no está completamente cerrado. Consulte Video Resumen en http://links.lww.com/DCR/B703.

Case report: Schizophrenia and hypertrophic osteoarthropathy, a rare syndrome hiding a life-threatening condition

Schizophrenia is associated to somatic disorders especially cardio-vascular and auto-immune. Through this case report, we describe an association with hypertrophic osteoarthropathy (HPO). For this patient, it was a paraneoplastic syndrome secondary to lung cancer. This syndrome is rare but important to recognize since it could hide a life-threatening condition.

Is Adjuvant Chemotherapy Necessary for Obstructing Stage II Colon Cancer? Results From a Propensity Score Analysis of the French Surgical Association Database

OBJECTIVE

The aim of this study was to compare the survival of patients with stage II obstructing colon cancer (OCC) who had adjuvant chemotherapy with those who did not.

SUMMARY BACKGROUND DATA

The need for adjuvant chemotherapy in stage II colon cancer is still debated.

METHODS

All consecutive patients treated for a stage II OCC in a curative intent (with primary tumor resection) between January 2000 and December 2015 were included in this retrospective, multicenter cohort study which included a propensity score analysis using an odds of treatment weighting (Average Treatment effect on the Treated, ATT). The endpoint was the comparison between the 2 groups for overall survival (OS) and disease-free survival (DFS) according to whether or not patients received adjuvant chemotherapy.

RESULTS

During the study period, 504 patients underwent a curative colectomy for a stage II OCC. Among these patients, 179 (35.5%) had adjuvant chemotherapy and 325 (64.5%) had no adjuvant treatment. Among the 179 patients who received adjuvant chemotherapy, 108 patients (60%) received oxaliplatin based regimen and 99 patients (55%) completed all scheduled cycles. At multivariate analysis, after weighting by the odds (ATT analysis) and adjustment, adjuvant chemotherapy after resection of a stage II OCC was associated with improvements in OS [hazard ratio (HR) = 0.42 (0.17-0.99), P = 0.0498] and DFS [HR = 0.57 (0.37-0.88), P = 0.0116].

CONCLUSION

This study suggests that adjuvant chemotherapy after curative resection of stage II OCC may improve oncological outcomes.

Emergency surgery for obstructive splenic flexure colon cancer: results of a multicentric study of the French Surgical Association (AFC)

Management of malignant left-sided colonic obstruction remains challenging and requires a stoma in 40-65% of patients. In those with obstructive splenic flexure colon cancer (OSFCC), a debate still exists regarding the most appropriate surgery. The aim of this muticenter study was to report and compare the different surgical procedures in OSFCC patients with a special focus on operative and histological characteristics and survival outcomes including 12-month stoma-free survival. Between 2000 and 2015, 2325 patients were treated for obstructive colon cancer in centers members of the French National Surgical Association (AFC). Among them, 198 underwent surgery for OSFCC and were retrospectively analyzed. Patients with OSFCC and proximal colonic ischemia or perforation were excluded. Four procedures were performed: decompressing stoma (DS, 39%), splenic flexure colectomy (SFC, 39%), subtotal colectomy (STC, 17%,) and left hemicolectomy (LHC, 5%). All patients treated with LHC underwent a Hartmann's procedure. There was no significant difference between groups for postoperative mortality and morbidity. Hospital stay was significantly longer after DS. The length of the specimen, longitudinal resection margins and number of harvested lymph nodes were significantly higher in the STC group. There was no difference for overall and disease-free survival. Stoma-free survival was significantly lower after LHC (62%) in comparison with the other groups (p < 0.0001). At the end of follow-up, 50% of patients who underwent LHC had a permanent stoma. In OSFCC patients without proximal colonic ischemia or peritonitis, LHC should no longer be recommended due to a high risk of permanent stoma.

Upfront progression under pembrolizumab followed by a complete response after encorafenib and cetuximab treatment in BRAF V600E-mutated and microsatellite unstable metastatic colorectal cancer patient: A case report

Two new treatments have recently become standard care for patients with metastatic colorectal cancer (mCRC): encorafenib (BRAF inhibitor) associated with cetuximab (anti-EGFR) in the second or third line of chemotherapy for BRAF V600E tumors, and pembrolizumab (an anti PD-1 immune checkpoint inhibitor) for tumors harboring microsatellite instability (MSI)-high and/or deficient mismatch repair (dMMR). Furthermore, 30% of BRAF V600E mutated mCRC are MSI/dMMR through a sporadic hypermethylation of the promoter of hMLH1. We report here, for the first time, the case of a patient with BRAF V600E, PIK3CA, and SMAD4 mutated and dMMR/MSI mCRC, in whom we observed an atypical response pattern under the sequence of pembrolizumab followed by the doublet encorafenib and cetuximab treatment. The patient was progressive after a single cycle of pembrolizumab followed by a rapid complete response after only 2 months of treatment with encorafenib and cetuximab, discovered during R0 cytoreduction surgery for peritoneal carcinomatosis.

Imaging of postoperative complications following Ivor-Lewis esophagectomy

Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.

Couples religion et cancer : vignettes cliniques

Dans ce travail, nous allons illustrer l’effet des croyances religieuses relatives au cancer au sein du couple sur l’acceptation ou le refus du cancer à travers deux vignettes cliniquesMme M. etMme A.MmeM. semble s’orienter vers une approche d’acceptation, de résilience face à sa maladie. Mme M. considère que son cancer pourrait être une punition, une épreuve ou un test et que la meilleure attitude à avoir c’est de s’accrocher à ses croyances religieuses comme un moyen de survie. À l’opposé, Mme A. semble s’orienter vers une attitude de défi, de révolte. Elle aussi aborde la maladie en considérant la récidive comme une épreuve, une punition (bien que non méritée) ; par contre, elle conteste cette sentence. L’interprétation que fera un patient de sa propre condition influencera son attitude vis-à-vis de lui-même, de son couple et des traitements qu’il recevra.

Impact of laparoscopy on oncological outcomes after colectomy for stage III colon cancer: A post-hoc multivariate analysis from PETACC8 European randomized clinical trial

BACKGROUND

In colon cancer (CC), surgery remains the mainstay of treatment with curative intent. Despite several clinical trials comparing open and laparoscopic approaches, data on long-term outcomes for stage III CC are lacking.

METHODS

This post-hoc analysis of the European PETACC8 randomized phase 3 trial included patients from 340 sites between December 2005 and November 2009, with long follow-up (median 7.56 years). Patients were randomly assigned to FOLFOX or FOLFOX+cetuximab after colonic resection. The surgical approach was left to the referring surgeon's discretion.

RESULTS

Among 2555 patients included, 1796 (70.29%) were operated on by open surgery and 759 (29.71%) by laparoscopy. The 5-year OS rate was better after laparoscopic resection (85.4%, 95%CI 82.5-87.7) than after open surgery (80.2%, 95%CI 78.2-82.0; p = 0.002). The 5-year DFS rate was also better after laparoscopy (p = 0.016). However, in multivariate analysis using a propensity matching, the surgical approach was not found to be an independent prognostic factor for OS or DFS. OS (p = 0.0243) and DFS (p = 0.035) were increased after laparoscopic surgery in KRAS/BRAF WT sub-group CONCLUSION: We showed that laparoscopic resection has comparable long-term outcomes to open surgery in patients with stage III CC. For those with RAS and BRAF WT CC, laparoscopic colectomy may favorably impact survival.

How I treat stage II colon cancer patients

Stage II colon cancer (CC) is probably one of the best prognosis gastrointestinal tumors seen in our consultations, but often takes a lot of time for physicians to determine appropriate treatment because of the limited benefit of adjuvant chemotherapy (CT) in these patients, together with the limited evidence in this situation. How to choose the best treatment for each individual patient is thus dependent on molecular (microsatellite instability/microsatellite stability status) and clinico-pathological features relevant enough to classify these tumors into low-, intermediate- and high-risk stage II disease and to choose an appropriate attitude for each of these subgroups. In practice, the first step in treatment decision making must be to assess the patient's status and comorbidities to see if the patient is eligible for an adjuvant treatment. Then, as fluoropyrimidines (FPs) are the corner stone of CC adjuvant treatment, screening for dihydropyrimidine dehydrogenase deficiency is mandatory in western countries. Finally, depending on the patient's characteristics and tumor risk stage, the strategy may be surveillance, adjuvant FP alone or oxaliplatin-based adjuvant CT. In the near future, new tools such as Immunoscore® (HalioDx; Luminy Biotech Enterprises, Marseille Cedex, France) and circulating tumor DNA may help to identify more precisely patients with minimal residual disease for more personalized adjuvant treatment approaches.

•

Stage II CC is a heterogeneous disease with a complex management due to the limited data and benefit of adjuvant CT.

•

Risk stratification through prognostic parameters is crucial to aid clinicians in determining the appropriate therapy.

•

Lymph node sampling <12 and pT4 are currently recognized as the major prognostic features associated with worse survival.

•

Adjuvant CT should be considered by incorporating prognostic features and balanced against patient's age and comorbidities.

Does neoadjuvant FOLFOX chemotherapy improve the prognosis of high-risk Stage II and III colon cancers? Three years' follow-up results of the PRODIGE 22 phase II randomized multicentre trial

AIM

Neoadjuvant chemotherapy has proven valuable in locally advanced resectable colon cancer (CC) but its effect on oncological outcomes is uncertain. The aim of the present paper was to report 3-year oncological outcomes, representing the secondary endpoints of the PRODIGE 22 trial.

METHOD

PRODIGE 22 was a randomized multicentre phase II trial in high-risk T3, T4 and/or N2 CC patients on CT scan. Patients were randomized between 6 months of adjuvant FOLFOX (upfront surgery) or perioperative FOLFOX (four cycles before surgery and eight cycles after; FOLFOX perioperative). In wild-type RAS patients, a third arm testing perioperative FOLFOX-cetuximab was added. The primary endpoint was the tumour regression grade. Secondary endpoints were 3-year overall survival (OS), disease-free survival (DFS), recurrence-free survival (RFS) and time to recurrence (TTR).

RESULTS

Overall, 120 patients were enrolled. At interim analysis, the FOLFOX-cetuximab arm was stopped for futility. The remaining 104 patients represented our intention-to-treat population. In the perioperative group, 96% received the scheduled four neoadjuvant cycles and all but one had adjuvant FOLFOX for eight cycles. In the control arm, 38 (73%) patients received adjuvant FOLFOX. The median follow-up was 54.3 months. Three-year OS was 90.4% in both arms [hazard ratio (HR) = 0.85], 3-year DFS, RFS and TTR were, respectively, 76.8% and 69.2% (HR=0.94), 73% and 69.2% (HR = 0.86) and 82% and 72% (HR = 0.67) in the perioperative and control arms, respectively. Forest plots did not show any subgroup with significant difference for survival outcomes. No benefit from adding cetuximab was observed.

CONCLUSION

Perioperative FOLFOX has no detrimental effect on long-term oncological outcomes and may be an option for some patients with locally advanced CC.

Use of antipsychotics with tamoxifen

Introduction

Bipolar disorder is a frequent and serious psychiatric disease. Antipsychotics are habitually required for its management especially during an acute manic episode. The association of cancer with bipolar disorder may impact psychiatric management. The choice of the adequate antipsychotic drug remains a challenge in this case. The clinical benefit of tamoxifen is obtained after the hepatic metabolism with cytochrome P450 2D6 which generates endoxifen, the potent metabolite of tamoxifen. Evidence has emerged that antipsychotics may potentially inhibit the CYP2D6. Study data supporting this interaction are rare.

Objectives

In this work, we aimed to illustrate the modalities of care of bipolar disorder in a patient receiving tamoxifen.

Methods

Presentation of a clinical case of a patient treated by Tamoxifen for her breast cancer and who was admitted in our department for acute mania with psychotics features, followed by a literature review.

Results

A 53-year-old woman with past history of breast cancer diagnosed in 2018, treated with lumpectomy and radiation, followed by tamoxifen. She has been admitted in 2019 in our department for an acute mania with psychotics features. Olanzapine was prescribed with good clinical evolution. The psychiatric and oncologic status of the patient was stable after one year under tamoxifen and olanzapine.

Conclusions

Psychiatrists must be aware that some of the prescribed medications co-administered with tamoxifen interfere with the CYP2D6 function, which may potentially increase the risk of breast cancer recurrence. A close collaboration between psychiatrists and oncologists is required to adapt therapeutic protocols.

Acute mania in patient under tamoxifen

Introduction

Tamoxifen is an antioestrogen agent used in breast cancer treatment. According to some guidelines, this molecular was also proposed for the treatment of acute mania. In fact, Tamoxifen inhibits the intracellular action of the protein kinase C (PKC), which is the direct target in the treatment of mania episodes. Lithium and valproate have also the same action.

Objectives

We aimed to show the case of an acute mania under an inhibitor PKC treatment and insisted that other studies are recommended.

Methods

Case report description and research on medline, pubmed with the keywords: Tamoxifen, Bipolar disorder, protein kinase C,mania.

Results

We reported a case of a 53-year-old woman with past history of unipolar depression. In 2018 when she was diagnosed with breast cancer. She received antidepressant drugs but she interrupted the treatment after a few months. She was treated for her breast cancer with mastectomy, radiotherapy, and 20 mg per day of Tamoxifen prescribed since Mars 2018. She had been admitted in June 2019 in our department for acute mania. The patient received Tamoxifen as it was prescribed. She was not taking any concomitant medications. No history of drug abuse was reported. Medical examination, laboratory, and radiological investigations did not indicate any medical pathology.

Conclusions

In our case, Tamoxifen had not ovoid the acute mania in spite of its Known anti-manic properties as reported in the literature. Possible neurobiological effect of tamoxifen on the nervous system should be studied to evaluate the safety of this treatment mainly in patients with bipolar disorder.

Mental disorders during pregnancy and postpartum period

Introduction

Mental disorders of pregnancy or postpartum correspond to all the psychopathological states linked to the period of the pregnancy-puerperium. They are the subject of prevention and screening and are currently a public health priority

Objectives

Describe the socio-demographic characteristics of the patients who presented mental disorders during pregnancy and/or postpartum. Identify the various risk factors predisposing to these disorders

Methods

We carried out a retrospective descriptive analytical study including patients who presented mental disorders during their pregnancy or postpartum and who were hospitalized during the period from January to October 2020.We collected 20 patients.

Results

The average age was 39.84 years. Mental disorders were present in 73.7% during the postpartum period. The patients had a personality disorder in 47.7%. They were smokers in 57% of cases. Pregnancy was desired in 73.7% with regular follow-up in 84.2%. Pregnancy was complicated by toxemia in 22% of cases and gestational diabetes in 27% of cases. Delivery was by caesarean section in 68.4% with primiparity in 50%. According to the DSM5, the psychic disorder most often found during pregnancy was the characterized depressive disorder 43%, and during the postpartum we found the brief psychotic episode 42.1%. The treatment was in half of the cases association between antidepressants and antipsychotics. Mental disorders were significantly correlated with the presence of stressful life events during pregnancy (p =0.02)

Conclusions

Mental disorders during pregnancy and postpartum are frequent and important to detect. Early diagnosis and adequate care are the two essential elements that should allow these women to fully experience their motherhood