Sandostatin LAR (long-acting octreotide acetate) for malignant carcinoid syndrome: a 3-year experience

BACKGROUND

Somatostatin analogues are the best therapy for controlling the symptoms of malignant carcinoid syndrome. Octreotide acetate given as subcutaneous injection up to three times daily, intramuscular Lanreotide injection given once per 1-2 weeks and monthly intramuscular Sandostatin LAR have demonstrated similar efficacy in short-term studies.

AIM

To assess the long-term effect of Sandostatin LAR on the management of patients with malignant carcinoid syndrome.

METHODS

This was a 3-year retrospective study. Twenty-seven patients were assessed with a median follow-up of 23 months. Thirteen patients were switched from subcutaneous octreotide and 14 patients were octreotide naive. All patients showed avid uptake on indium-111 octreotide imaging.

RESULTS

Ten of the 13 patients previously on subcutaneous octreotide and 13 of the 14 patients who were octreotide naive had good symptom control on Sandostatin LAR. Over the period of follow-up, many patients showed progression of their tumour and required additional therapies. Patients expressed a preference for monthly intramuscular Sandostatin LAR as opposed to daily subcutaneous injections of octreotide. Although Sandostatin LAR was difficult to administer in certain instances, overall it was well tolerated.

CONCLUSIONS

Sandostatin LAR provides good long-term symptomatic control in patients with malignant carcinoid syndrome; it is well tolerated and patients expressed improved satisfaction in their management.

[Lipoblastoma of the buttock]

Lipoblastoma is an uncommon benign soft tissue tumor arising from embryonal mesenchymal cells. It occurs mostly during early childhood with a predilection for the extremities, trunk, head and neck. This tumor tends to spread locally and no metastatic potential has been reported. Complete surgical resection is mandatory to prevent local recurrence. MRI provides excellent presurgical delineation of the tumor and confirms its fatty nature. Histology demonstrates the presence of lipoblasts in different stages of maturation; cytogenetic evaluation often discloses chromosomal anomalies of tumoral cells. A case of lipoblastoma of the buttock in a 10 month infant associated with anomalies of chromosome 8 is reported.

[Pollution of the groundwater in the city of Niamey, Niger]

We conducted a study on chemical and bacteriological groundwater pollution in Niamey, a Sahelian city of some 700,000 inhabitants. A total of 22 wells and 24 bore-holes were selected on a geological and socio-economic basis. The superficial aquifers, located on each bank of the River Niger and connected to the wells, presented high levels of oxidizable nitrogen and bacteriological pollution (coliform and faecal Streptococcus) which make the water unfit for human consumption. The deep aquifer, which supplies pumps, was also polluted but to a lesser degree. Faecal pollution increased after the rainy season. The lack of sanitation in Niamey and the seepage of polluted matters from the superficial layers could explain this pollution. Eventually, the use of the groundwater could increase and constitute a major health risk for the majority of the inhabitants of Niamey.

Congenital disseminated malignant rhabdoid tumor and cerebellar tumor mimicking medulloblastoma in monozygotic twins: pathologic and molecular diagnosis

Malignant rhabdoid tumors are highly aggressive childhood tumors. Recently, all of the malignant rhabdoid tumors, whatever their location, have been related to the inactivation of the hSNF5/INI1 gene. A subset of cerebral tumors, associated with malignant rhabdoid tumors or isolated ones arising in siblings, showed similar molecular alterations. We report for the first time in monozygotic twins a congenital disseminated malignant rhabdoid tumor in one twin and a cerebellar tumor mimicking a medulloblastoma in the other. Molecular analysis revealed similar alterations for both tumors: a deletion of exon 7 of the hSNF5/INI1 gene in one allele, and a point mutation in the same exon in the other, suggesting a common genetic pathway. Analysis of constitutional DNA revealed a germline mutation. These findings are in favor of a common etiology for rhabdoid tumor and a subset of brain tumors developing in infancy.

[Metastatic meningioma to the first thoracic vertebral body. A case report and review of the literature]

This report describes a case of metastatic meningioma involving the first thoracic vertebral body in a 63-year-old woman. The patient was treated surgically 10 years earlier for a benign meningioma of the right parietal vault. Local recurrence was diagnosed in 1992. Despite the gamma-knife radiosurgery, recurrence required surgical treatment in 1999. Histological findings were compatible with atypical meningioma (grade II WHO). One year later, the patient presented left C8 cervicobrachial neuralgia. Investigation led to discovery of a D1 tumor that was a metastasis of the atypical intracranial meningioma. A resection of the vertebral T1 body with C7-T2 osteosynthesis was performed with an excellent recovery and no postoperative complication.

[The pectoralis myofascial flap in oropharyngeal and pharyngolaryngeal reconstruction in salvage surgery]

BACKGROUND

The pectoralis major myofascial (PMMF) flap is rapidly mobilized, reliable in a number of clinical situations calling for vascularized soft tissue coverage in the head and neck. Salvage surgery after radiation failures produce salivary fistula, skin flap necrosis, vascular rupture. Use of PMMF improves healing in such cases.

METHODS

A retrospective review performed at the university hospital, Marseille, between August 1987 and August 1999, was undertaken in two groups of salvage surgery. Groupe 1: protection of great vessels and fistula prevention after total laryngectomy (TL) and pharyngolaryngectomy (PL). Groupe 2: intra oral and pharyngeal defects reconstruction. Outcomes were classified in three types: type 1 - no complications; type 2 - delayed healing; type 3 - complicated healing. In groupe 2, in six cases the amount of flap contraction was analysed by C.T. scan.

RESULTS

83 PMMF was performed. Groupe 1, 57 cases (TL 28 cases, PL 26 cases); groupe 2, oral cavity défect 9 cases; oropharyngeal défects; 17 cases. There was no flap necrosis or vascular rupture. The donor site complications rate was 9.2%. The overall complications follow up was; groupe 1; type 1: 66%; type 2: 32%; type 3: 2%. In the groupe 2, type 1: 81%; type 2: 19%; type 3: 0%. The flap contracture was 30%. The use of PMMF in salvage surgery must be indicated in all cases after TL or PL, and is an excellent alternative from soft tissue coverage of oropharyngeal defects.

Chronic hepatitis C virus infection associated with a generalized granuloma annulare

We report the first case of generalized granuloma annulare occurring in a 65-year-old woman who was chronically infected with hepatitis C virus. Granuloma annulare totally regressed during alpha-interferon treatment. As chronic hepatitis C virus infection is frequent, a serodiagnosis would be of interest in patients who have generalized granuloma annulare. A link between these 2 diseases may be strongly suspected.

Clinicopathologic growth factors in vestibular schwannomas: a morphological and immunohistochemical study of 69 tumours

Tumour growth of vestibular schwannomas is still difficult to predict. The aim of our study was to determine whether any defined histopathological feature was correlated with the clinical course. We did a retrospective study with 69 paraffin-embedded tumours to establish whether the number of vessels, blood cells extravasation or degree of inflammation, all semi-quantitatively assessed, could be indicative of potential of growth. An immunohistochemical study was also performed with an endothelial marker CD34, the leukocyte common antigen CD45 and the estrogen and progesterone hormone receptors. All these parameters were correlated with patient's age, duration of symptoms (d), with a clinical growth index (CLI = tumour size/d). No clinical parameters proved to be predictive of tumour growth. Tumour size was significantly (p = 0.01) related to the number of vessels and we found a significant relationship between the clinical growth index (CLI) and total number of vessels, especially when duration of symptoms lasted less than 1 year (p < 0.001). However, we found no relationship between duration of symptoms or CLI and CD34 index. The degree of inflammation was significantly correlated (p = 0.007) with duration of symptoms when it lasted more than 1 year. The CD45 index and the semi-quantitative evaluation of the inflammation were well correlated (p = 0.001). No estrogen receptors antigenic site was detected and only seven tumours expressed progesterone receptor in a few cells without any significant clinical value. These results suggest that vessel density is determinant for sporadic acoustic neuroma growth especially for a short clinical course.

New purification protocol for actinide measurement in excreta based on calixarene chemistry

The determination of actinides concentration level in excreta, mainly urine is currently carried out to monitor people potentially exposed to alpha emitters. To measure actinides in such samples, specific analytical protocols have been set up. The chemical purification uses different chromatographic columns to selectively separate the actinides and each fraction, after electroplating, is measured by alpha spectrometry. To reach 1 mBq l(-1) of U, Pu or Am using these protocols, 6 days equally distributed between the chemical purification and the measurement are necessary. The protocol proposed here is based on a single extractant, the 1,3,5-trimethoxy-2,4,6-tricarboxy-p-tert-butylcalix[6]arene, used to selectively separate U, Pu and Am from the urinary matrix prior to be measured. Using this analytical protocol, U and Pu are quantitatively and selectively recovered in two different acidic backextraction solutions whereas Am is quantitatively and selectively recovered in the organic phase. Furthermore, the purification stage is considerably shortened. The uranium and plutonium amounts are measured in aqueous phases using alpha spectrometry or inductively coupled plasma-mass spectrometry, whereas Am is measured in the organic phase using alpha liquid scintillation (photon/electron-rejecting alpha liquid scintillation).

Adult mesoblastic nephroma

We report a case of asymptomatic mesoblastic nephroma in a 54-year-old woman. The tumor showed immunohistochemical reactions similar to developing nephrons. Electron microscopy showed immature tubules with numerous intracytoplasmic intermediate filaments. Recent studies support the concept of pathogenesis of the mesoblastic nephroma originating from collecting ducts. However, this case exhibited a complex pattern of antigenic expression not restricted to the collecting ducts, but including the glycoprotein CD24 and the neural cell adhesion molecule (NCAM). The following differential diagnoses will be discussed: benign mixed epithelial and stromal tumor, metanephric adenoma, and nephrogenic adenofibroma.

Tubular lesions determine prognosis of IgA nephropathy

To assess the prognostic value of histological classification for renal outcome, we did a multivariate analysis of 194 patients with immunoglobulin A (IgA) nephropathy between 1985 and 1995. We also evaluated semiquantitative scales of tubular lesions and vessel lesions. At the time of the biopsy, 65 patients (33.5%) had chronic renal failure. At the end of the follow-up, 33 patients (17%) required hemodialysis. The mean age of the patients was 37.8 +/-18.9 years with predominance of men (sex-ratio: 3.12). Patients were followed-up for a mean of 43.2 +/- 37.2 months. Univariate analysis showed that hypertension (P < 10(-4)), nephrotic syndrome (P = 0.01), and crescents (P = 0.02) were significant in predicting renal failure, unlike subendothelial topography of IgA deposits (P = 0.05) and proteinuria (P = 0.05). Hematuria was a protective factor (P = 0.03). Multivariate analysis showed that tubular grade 2 (relative risk [RR], 5.5) and tubular grade 3 (RR = 28.8) were the best factors to predict chronic renal failure. The histological classification of Haas was significant in the univariate analysis, but not in the multivariate analysis. Tubular grading predicted renal outcome better than did the other histological parameters.

[Extensive rhinectomy. Apropos of 7 cases]

We report our experience in reconstructive surgery after total rhinectomy. Reconstructive surgery is performed after large excision and negative marginal biopsy results. The three layers of the nose (mucosal, osteocartilagineous and cutaneous) are restored by mucosal and cutaneous flaps and osteocartilaginous grafts. Carcinologic and cosmetic results are satisfactory but functional results may yet be improved.

Cerebellar papillary meningioma in a 3-year-old boy: the usefulness of electron microscopy for diagnosis

We report one case of papillary meningioma located in the posterior fossa in a 3-year-old boy. Despite a gross total resection, a major recurrence occurred 6 months later that was operated on. Eight months later, another recurrence was observed with intracranial metastases and dissemination throughout the cerebrospinal fluid. The tumor had a papillary architecture more obvious in the recurrence. Areas of necrosis were numerous. Tumor cells had large clear atypical nuclei. Many mitotic figures were seen and Ki-67 labeling index was high. The tumor cells were immunoreactive for vimentin and polysialylated neural cell adhesion molecule only, ruling out a diagnosis of ependymoma or medulloblastoma. Diagnosis of meningioma was done by electron microscopy, which showed interdigitating cytoplasmic processes and cell junctions. Cytogenetic study revealed unusual karyotypic abnormalities.

[Lumbar canal stenosis caused by amyloidosis of the yellow ligament]

Symptomatic lumbar canal stenosis without bony stenosis has previously been described. We describe the pathological modifications of ligamentum flavum among such operated patients. Ten patients were prospectively included in this study. Their mean age was 74, ranges: from 52-90. Clinical manifestation was a radicular claudication (sciatic or crural). Neuroradiology confirmed in all cases the ligamentum flavum thickness as the main cause of the symptomatology. This feature was also confirmed operatively and complete resection of the ligamentum flavum was performed. Resolution of the radicular pain was obtained in all cases at last follow-up. Pathological examination of the ligamentum flavum displayed characteristic features of degenerative modifications and elastic fibers fragmentation caused by numerous amorphous deposits. The deposits were studied using red Congo staining, polarized light and immunostaining methods. Such technique showed evidence of amyloid origin of the deposits. Immunodetection was positive for the P component in the amyloid deposits and for beta-2-microglobulin in one case (chronic renal failure and hemodialysis). The deposits did not express antitransthyretin antibodies. In parallel, control ligamentum flavum were obtained from 10 operated patients affected by bony lumbar stenosis. Moderate degenerative features were observed but small amounts of amyloid deposits were found in only 3 of those cases, without thickening of the ligamentous structure. This study correlates the presence of thickened ligamentum flavum caused by amyloid deposition, with symptomatic non-osseous lumbar canal stenosis. Association with degenerative modifications of the spine in the studied cases is suggestive of a microtraumatic origin.

[The use of calvarial bone in nasal reconstruction]

Twenty-seven nasal reconstructions with parietal bone graft performed between January 1989 and January 1995 were analyzed retrospectively. No complications involving parietal bone were observed. After a 2-year follow-up there have been no cases of shifting, extrusion or resorption of the rhinoplasty. Our experience shows that calvarial bone is an ideal material for nasal reconstruction bone grafts.

Catecholaminergic CATH.a cells express predominantly delta-opioid receptors

CATH.a cells are a catecholaminergic cell line of neuronal origin. The opioid receptor complement expressed by CATH.a cells was defined pharmacologically and by reverse transcription-polymerase chain reaction (RT-PCR). CATH.a cells were found to express mRNA encoding all three of the major subtypes of opioid receptors. The relative abundance of CATH.a cell opioid receptor transcripts was delta > kappa> mu. Pharmacological and functional data were in agreement with the results of RT-PCR inasmuch as delta-opioid receptor was identified as the most abundant opioid receptor subtype expressed by CATH.a cells. In addition, at least one of the opioid signalling pathways, inhibition of adenylyl cyclase activity, was found to be operant in this cell line. CATH.a cells should be of general utility for the study of opioid receptor signalling mechanisms in the context of catecholaminergic neurons.

Automated and quantitative immunocytochemical assays of Nm23/NDPK protein in breast carcinomas

A series for Nm23-protein immunodetection was investigated in human breast carcinomas. Frozen sections were processed by automated immunoperoxidase procedure, and immunoprecipitates in positive tumors were quantified by processing digitized microscopic images. Nm23 immunohistochemical expression in tumors was correlated with clinicopathological data and with intra-tumoral proteins also detected by automated and quantitative immunohistochemistry. A positive Nm23 immunoreaction was observed in 58% of tumors, within cell cytoplasm. Nm23 expression was independent of the patient's age, and of tumor size, type and grade, but an inverse relationship was observed between Nm23 expression and axillary-lymph-node metastasis. An inverse relationship was also observed between Nm23 and P-53, CD-31, cathepsin D, tenascin and P-gp immunohistochemical expressions. But Nm23 expression was independent of c-erb-B product, growth fraction (MIB1/Ki67), and immunohistochemical expression of hormone receptors/P-S2. The results suggest that the anti-metastatic nm23 gene may partly act upon the regulation of tumor-cell proliferation (correlation with P-53) and may have some effects on epithelial-cell/stroma interactions (regulation of extracellular-matrix protease and of angiogenesis) independently of hormone sensitivity.

Cathepsin D detected by automated and quantitative immunohistochemistry in breast carcinomas: correlation with overall and disease free survival

AIM

To determine the prognostic significance and clinical relevance of cathepsin D detected by immunocytochemical assays (ICAs) in breast carcinomas.

METHODS

151 patients presenting with palpable or impalpable breast carcinomas and who had not received any kind of adjuvant chemotherapy or endocrine therapy who were operated from January 1986 to May 1987 were studied. ICAs of tumour specimens were performed in optimal technical conditions (frozen sections, automated immunoperoxidase technique (Ventana), and computer assisted analysis of digitised coloured microscopic images (SAMBA)) to determine cathepsin D immunocytochemical expression. Results of quantitative ICAs were correlated with overall and disease free survival over 8.4 years of follow up in axillary lymph node positive and negative patients.

RESULTS

Cathepsin D immunocytochemical expression in tumours of 15% or more was significantly associated with poor overall survival in the whole group and in node positive patients (Kaplan Meier, log rank test p = 0.003 and p = 0.007); however, it was not correlated with survival in node negative patients. Cathepsin D immunocytochemical expression (> 15%) correlated with short disease free (p = 0.015) and short recurrence free survival (p = 0.021) in the group as a whole but not when node positive and negative patients were evaluated separately.

CONCLUSIONS

In optimal conditions (automated and quantitative ICAs on frozen sections) cathepsin D immunohistochemical expression is a significant prognostic indicator in terms of overall, disease free, and recurrence free survival; however, there is no correlation when node negative patients are considered separately.

CD31/PECAM automated and quantitative immunocytochemical assays in breast carcinomas: correlation with patient follow-up

The purpose of this study was to determine the prognostic significance of quantitative CD31 immunohistochemical assays. CD31 assays were performed on a series of 167 breast carcinoma specimens under optimal technical conditions that involved frozen sections, an automated immunoperoxidase technique, and computer-assisted analysis of digitized colored microscopic images. Results of automated quantitative immunohistochemical assays were correlated with patient follow-up (9.6 years). Patients were divided into two subgroups: those who had axillary lymph node-positive (N+) disease and those who had lymph node-negative (N-) disease. The marked immunocytochemical expression of CD31 in tumors (cutoff point, 20%) was significantly (P = .033) associated with a poor overall survival rate (Kaplan-Meier, log rank test); however, a significant association was not observed in the N+ and N- subgroups. CD31-immunostained tumor cell surfaces larger than 20% correlated with the metastasis-free survival rate (P = .004) in all patients and in the N+ subgroup (P = .005) but not in the N- subgroup. In addition, marked immunocytochemical expression of CD31 correlated with the short-term disease-free survival rate (P = .04) in the N+ subgroup but not in the N- subgroup. In multivariate analysis (proportional hazards regression, Cox model) the prognostic significance of CD31 was independent of tumor size and histologic type but not of grade. The results suggest that, under optimal technical conditions (automated and quantitative immunohistochemical assays on frozen sections), immunohistochemical expression of CD31 is a significant prognostic indicator of overall and metastasis-free survival rates. CD31 has limited prognostic value, however, and is not a completely independent prognostic indicator because it is related to nodal status.

Automated and quantitative immunocytochemical assays of CD44v6 in breast carcinomas

CD44 variants carrying sequences encoded by exon v6 are preferentially expressed in metastatic animal cancer cell lines. CD44v6 overexpression correlates tumor dedifferentiation and progression in some human carcinomas, but the relationship of CD44v6 overexpression with metastatic behavior of tumor observed in animal models is controversial, particularly in breast carcinomas. The discrepancies probably result from analytical bias. We investigated CD44v6 and CD44s expression in 218 frozen samples of primary breast carcinomas. Immunocytochemical procedure was performed under optimal technical conditions using commercially available 2F-10 monoclonal antibody (MAb), a microprocessor-controlled automated device (Ventana Medical Systems, Tucson, AZ), and quantitative evaluation of results by processing digitized-colored microscopic images (SAMBA, Grenoble, France). CD44v6 expression in tissue sections was shown to be independent of the patient age, tumor size, histological types and grades, and the lymph node status. CD44v6 expression was also independent of the expression of molecules endowed with poor prognostic significance detected by MAbs (anti-p53, anti-c-erb B-2 protein, MIB1) on consecutive sections. No significant relationship could be evidenced either between CD44v6 expression, and CD31 involved stromal angiogenesis and cathepsin D. Finally, CD44v6 was independent of markers of hormone dependence (estrogen and progesterone receptors, pS2) and of multidrug resistance (P-glycoprotein). Similar results were observed with anti-CD44s. We conclude that the true prognostic significance of CD44v6 overexpression still remains to be shown under rigorous technical conditions (frozen samples, well-documented MAbs, and optimal standardization of procedure using automation and quantitative analysis) providing data appropriate for further correlation with long-term patient follow-up.