Neoadjuvant treatment of borderline resectable and non-resectable pancreatic cancer

Neoadjuvant therapy is increasingly becoming a valid treatment option for patients with locally advanced pancreatic cancer (LAPC). In borderline resectable disease, neoadjuvant therapy is employed to improve the probability of margin-clear resections. In non-metastatic, non-resectable pancreatic cancer, treatment primarily aims to induce disease control, but may achieve conversion to surgical resectability in some patients. Several treatment modalities including chemotherapy, chemoradiotherapy (CRT) or the sequential use of both have been investigated in numerous, mostly small and non-randomized studies. Nevertheless, there is a consistent finding that neoadjuvant therapy can induce resectability in up to 30%-40% of LAPC patients. Once resection has been achieved, overall survival appears to be comparable to that observed for primarily resectable patients. Thus, patient selection evolves as an important aspect of neoadjuvant therapy; retrospective analyses identified induction chemotherapy as an appropriate tool to define LAPC patients who may benefit most from subsequent treatment with CRT. The clinical importance of induction chemotherapy may further increase once highly active protocols such as the FOLFIRINOX or the gemcitabine plus nab-paclitaxel regimen are introduced into novel multimodality treatment concepts.

Cytokeratin 19-fragments (CYFRA 21-1) as a novel serum biomarker for response and survival in patients with advanced pancreatic cancer

Background:

CYFRA 21-1 serves as biomarker in several epithelial malignancies. However, its role in pancreatic cancer (PC) has not yet been investigated.

Methods:

Within a prospective single-centre study serial blood samples were collected from patients with confirmed advanced PC. Pre-treatment values and weekly measurements of CYFRA 21-1, carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (assessed by Elecsys 2010, Roche Diagnostics) during palliative first-line chemotherapy were obtained. Biomarker data were correlated with objective response (determined by RECIST) as well as time to progression (TTP) and overall survival (OS) using uni- and multivariate analyses.

Results:

Seventy-eight patients were included, 45% of these received treatment in prospective clinical trials. Median TTP was 3.9 months, median OS 7.7 months. Pre-treatment CYFRA 21-1 levels were significantly associated with performance status (P=0.0399) and stage of disease (P=0.0001). Marker values before chemotherapy and at the 2-month staging of all three markers were considered significant predictors for objective treatment response. Pre-treatment CYFRA 21-1 levels, as well as CA 19-9 values, could be applied to define subgroups (categorised by tertiles) with a different OS outcome (CYFRA: 14.8 vs 7.1 vs 4.8 months, CA 19-9: 14.2 vs 7.1 vs 5.2 months; P<0.0001). CYFRA 21-1 and CA 19-9 (both as categorised and as continuous variables) showed a highly significant correlation with TTP and OS at nearly all-time points assessed in univariate analysis. In multivariate analysis, only CYFRA 21-1 and performance status were independent predictors for OS.

Conclusions:

CYFRA 21-1 may serve as a valuable tool for monitoring treatment response and assessing prognosis in advanced PC.

The interpolation nasolabial flap: the advantageous solution for nasal tip reconstruction in elderly and polymorbid patients

BACKGROUND

Nasal tip is one of the most frequent areas affected by basocellular carcinoma. The treatment must avoid any postsurgical deformity, as the nasal tip is the main part of the facial triangle. Most of these patients are elderly and polymorbid. The surgeon must find a compromise between the cosmetic effect and an acceptable stress for the patient.

METHODS

There were five methods of nasal tip reconstruction used on a group of fifty elderly patients with various medical comorbidities: skin graft, bilobed flap, dorsal nasal flap, forehead flap and interpolation nasolabial flap. The resulting cosmetic effect was objectivized by a standardized questionnaire and the advantages and disadvantages of each method were discussed.

RESULTS

According to the characteristics that were considered (good vascular supply, matching skin color and texture, sufficient amount of material, possibility to cover exposed cartilage or to combine it with cartilaginous graft; scars of minimal visibility, perfect aesthetic outcome, use of local anesthesia, short surgical time, and technical simplicity) was the interpolation nasolabial flap found as the most appropriate.

CONCLUSION

Interpolation nasolabial flap is an easy and effective method for treatment of smaller and middle-sized defects of the nasal tip with minimal stress for the patient.

LEVEL OF EVIDENCE

Level III.

PexLoc-Parallel excitation using local encoding magnetic fields with nonlinear and nonbijective spatial profiles

With the recent proposal of using magnetic fields that are nonlinear by design for spatial encoding, new flexibility has been introduced to MR imaging. The new degrees of freedom in shaping the spatially encoding magnetic fields (SEMs) can be used to locally adapt the imaging resolution to features of the imaged object, e.g., anatomical structures, to reduce peripheral nerve stimulation during in vivo experiments or to increase the gradient switching speed by reducing the inductance of the coils producing the SEMs and thus accelerate the imaging process. In this work, the potential of nonlinear and nonbijective SEMs for spatial encoding during transmission in multidimensional spatially selective excitation is explored. Methods for multidimensional spatially selective excitation radiofrequency pulse design based on nonlinear encoding fields are introduced, and it is shown how encoding ambiguities can be resolved using parallel transmission. In simulations and phantom experiments, the feasibility of selective excitation using nonlinear, nonbijective SEMs is demonstrated, and it is shown that the spatial resolution with which the target distribution of the transverse magnetization can be realized varies locally. Thus, the resolution of the target pattern can be increased in some regions compared with conventional linear encoding. Furthermore, experimental proof of principle of accelerated two-dimensional spatially selective excitation using nonlinear SEMs is provided in this study.

Banff 2011 Meeting report: new concepts in antibody-mediated rejection

The 11th Banff meeting was held in Paris, France, from June 5 to 10, 2011, with a focus on refining diagnostic criteria for antibody-mediated rejection (ABMR). The major outcome was the acknowledgment of C4d-negative ABMR in kidney transplants. Diagnostic criteria for ABMR have also been revisited in other types of transplants. It was recognized that ABMR is associated with heterogeneous phenotypes even within the same type of transplant. This highlights the necessity of further refining the respective diagnostic criteria, and is of particular significance for the design of randomized clinical trials. A reliable phenotyping will allow for definition of robust end-points. To address this unmet need and to allow for an evidence-based refinement of the Banff classification, Banff Working Groups presented multicenter data regarding the reproducibility of features relevant to the diagnosis of ABMR. However, the consensus was that more data are necessary and further Banff Working Group activities were initiated. A new Banff working group was created to define diagnostic criteria for ABMR in kidneys independent of C4d. Results are expected to be presented at the 12th Banff meeting to be held in 2013 in Brazil. No change to the Banff classification occurred in 2011.

Early ultrastructural changes in renal allografts: correlation with antibody-mediated rejection and transplant glomerulopathy

Transplant glomerulopathy (TG) is associated with antibody-mediated renal allograft rejection (AMR) and reduced graft survival. Histologically, TG is typically seen >1 year posttransplantation. However, ultrastructural changes including glomerular endothelial swelling, subendothelial widening and early glomerular basement membrane duplication are associated with development of TG but appear much earlier. We examined the specificity of these changes for AMR, and whether these are inevitably associated with development of TG. Of 98 for cause renal allograft biopsies carried out within 3 months of transplantation with available serologic data, 17 showed C4d-positive AMR and 16 had histologic changes of AMR and donor-specific antibodies (DSA), but no C4d. All three ultrastructural changes were seen in 11 of 17 biopsies with C4d-positive AMR, 8 of 16 with histologic changes of AMR and DSA but no C4d, and 0 of 65 without histologic changes of AMR and/or DSA (p < 0.0001 for both of the former groups vs. the latter). Twenty patients with positive DSA (18 with histologic changes of AMR and 11 C4d-positive) had ≥1 follow-up biopsy; eight developed overt TG 3.5-30 months posttransplantation. Among the 18 patients with DSA and histologic changes of AMR, 11 C4d-positive and 7 C4d-negative, treatment for AMR after the early biopsy significantly reduced subsequent development of overt TG.

[Submucous lipoma as a cause of invagination in adulthood]

The casuistry describes the invagination that occurred to a 67-years old patient due to the small intestine lipom. The patient with the three-day abdominal pain and vomiting was admitted to the department of surgery. On the basis of the CT examination the patient underwent an operation for the invagination of the small inkotine. The resection of the invaginated loop, the anastomosis end to end were performed. Histologicaly the submucosus lipom was found.

Defective Bacteriophage PBSH in Bacillus subtilis: III. Properties of Adenine-16 Marker in Purified Bacteriophage Deoxyribonucleic Acid

The adenine-16 (ade-16) marker (the marker nearest the chromosomal origin of Bacillus subtilis) in purified PBSH deoxyribonucleic acid (DNA) renatured more rapidly and to a greater extent than any other marker in the phage DNA, and more rapidly and to a greater extent than all markers, including ade-16, in bacterial DNA. The renaturation of the phage DNA ade-16 marker followed a first-order reaction, whereas renaturation of bacterial markers was initially a second-order reaction. No cross-linkages were detected in DNA molecules containing the ade-16 marker. Buoyant density measurements and inactivation by heat and micrococcal deoxyribonuclease of the ade-16 marker did not reveal large segments of clusters of the individual bases in these molecules. Alternative mechanisms for the unique renaturation behavior of the ade-16 marker are discussed.

ABO antibody titer and risk of antibody-mediated rejection in ABO-incompatible renal transplantation

Therapeutic plasma exchange (TPE) preconditioning with immunosuppressive therapy reduces ABO antibody titers, permitting engraftment of ABO-incompatible (ABO-I) kidney transplants. The posttransplant predictive role of ABO antibody titers for antibody-mediated rejection (AMR) is unknown. This retrospective study evaluated 46 individuals who received TPE to permit ABO-I kidney transplantation. ABO antibody titers were performed using donor-type indicator red cells. Seven individuals (15.2%) experienced clinical or subclinical AMR. There was no significant difference between recipient blood group, number of pretransplant TPE and baseline titer between those with and without AMR. At 1-2 weeks posttransplant the median titer was 64 (range 4 - 512) among individuals with AMR and 16 (range 2 - 256) among individuals without AMR. Total agglutination reactivity score was significantly higher among individuals with AMR (p = 0.046). The risk of AMR was significantly higher among individuals with an elevated posttransplant titer of >or=64 (p = 0.006). The sensitivity of an elevated posttransplant titer was 57.1% with a specificity of 79.5%. The positive predictive value was 33.3% and the negative predictive value was 91.2%. Most individuals with AMR have an elevated titer, however, the positive predictive value of a high titer for AMR is poor.

Banff '09 meeting report: antibody mediated graft deterioration and implementation of Banff working groups

The 10th Banff Conference on Allograft Pathology was held in Banff, Canada from August 9 to 14, 2009. A total of 263 transplant clinicians, pathologists, surgeons, immunologists and researchers discussed several aspects of solid organ transplants with a special focus on antibody mediated graft injury. The willingness of the Banff process to adapt continuously in response to new research and improve potential weaknesses, led to the implementation of six working groups on the following areas: isolated v-lesion, fibrosis scoring, glomerular lesions, molecular pathology, polyomavirus nephropathy and quality assurance. Banff working groups will conduct multicenter trials to evaluate the clinical relevance, practical feasibility and reproducibility of potential changes to the Banff classification. There were also sessions on quality improvement in biopsy reading and utilization of virtual microscopy for maintaining competence in transplant biopsy interpretation. In addition, compelling molecular research data led to the discussion of incorporation of omics-technologies and discovery of new tissue markers with the goal of combining histopathology and molecular parameters within the Banff working classification in the near future.

Diagnostic dilemmas of infantile sarcoma of the forearm

The authors present an interesting case of a suckling baby treated for forearm tumour. All the preoperative examinations including the imaging methods are documented, as are the surgical procedures and the final results. The case report is interesting not only because such surgery is infrequent but also due to the unpredictable progress of the final diagnosis statement. Before surgery the tumour was diagnosed as an organising haematoma; based on clinical and radiological signs the diagnosis subsequently rose to rapidly growing haemangioma or vascular malformation causing arm paresis and vascular supply disorder. The diagnosis was changed to angiolipoma during surgery. The final histopathological statement was: infantile fibrosarcoma. Despite the virtue of imaging methods and meticulous clinical examination, the surgical and histopathological findings are not necessarily absolutely identical. Having presented this particular case the authors would like to share their experience.

Nasal reconstruction in children with the combination of nasolabial and island flaps

BACKGROUND

The reconstruction of the nose is one of the most complicated aesthetic-reconstructive procedures. The difficulty of the procedure lies is in the necessity for reconstruction not only to capture the very complicated, various shapes of the nose but also to preserve the function of the nose: to allow the patient to breathe through the nose.

MATERIALS AND METHODS

12-year-old girl had loss injury of the part of left wing of the nostril. We used the compound nasolabial flap with a small excess to resolve the mucosal and skin defect. One year after the first operation relief of natural transition of the new wing of the nostril and cheek was created with small island flap.

RESULTS AND CONCLUSIONS

The reconstruction of a wing of the nostril in multistage procedures with combined nasolabial flap and island flap allowed us to perform precise modelation of the nostril wing with the natural transition to the cheek. An island flap with its scars creates the required contour of a nostril wing and prevents the collapse and flattening of the nostril wing externally.