Treatment of distal aneurysms of the cerebellar arteries by intraaneurysmal injection of glue

Distal aneurysms of the cerebellar arteries are associated with a poor prognosis, as surgery or embolization with GDCs is very difficult. We report our experience with a new therapeutic method involving intraaneurysmal injection of glue. Three aneurysms were catheterized with a flow-guided microcatheter, and glue was slowly injected into the aneurysms. In two cases, treatment resulted in total occlusion of the aneurysm with preservation of the parent artery. In one case, the aim was to occlude both the aneurysm and parent artery.

Interest of pelvic and paraaortic lymphadenectomy in patients with stage IB and II cervical carcinoma

OBJECTIVES

The objectives of this study were to evaluate the interest and the potential therapeutic value of systematic pelvic and paraaortic lymphadenectomy in patients with stage Ib and II cervical carcinoma.

METHODS

This was a prospective study including 421 patients with cervical cancer treated, from 1985 to 1994, by combined radiation therapy and surgery with systematic pelvic and paraaortic lymphadenectomy.

RESULTS

The overall rate of pelvic lymph-node involvement was 26% (106 patients), and the rate of paraaortic metastases was 8% (32 patients). Pelvic nodal involvement was unilateral in 14% (59 patients) and bilateral in 11% (47 patients). Macroscopic positive nodes were found in 12% (52 patients). In a univariate analysis, a young age (<30 years), a tumor size >/=4 cm, stage II disease, and nodal involvement were associated with significantly decreased survival. The nodal status and the characteristics of positive nodes (number and location) were the most significant prognostic factors. In the multivariate analysis, age, the tumor size, and the site of nodal involvement (pelvic or paraaortic) were prognostic factors. Three-year survival was 94% for patients with negative nodes compared to 64% for patients with positive pelvic nodes and 35% for patients with positive paraaortic nodes (P < 0.0001).

CONCLUSION

These results confirm the diagnostic and prognostic value of systematic complete lymphadenectomy when planning adjuvant treatment and the therapeutic value of complete removal of bulky positive nodes.

Apoptosis in carcinoma of the bladder: relation with radiation treatment results

PURPOSE

Radiotherapy is widely used in the treatment of bladder cancer. The search for biological parameters that could select patients who will respond to radiation treatment has become essential. The aim of this study is to assess whether the pretreatment apoptotic index is useful in predicting local control and survival in a group of bladder cancer patients treated by radiotherapy.

METHODS AND MATERIALS

Fifty-five patients with invasive bladder carcinoma treated between 1983 and 1996 were included in this study. Radiotherapy was given to a median dose of 66 Gy, mean 63.28 Gy, in 1.8-2 Gy daily fractions. Apoptotic cells were studied in hematoxylin-eosin slides. Clinicopathological tumor characteristics were studied in relation to the apoptotic index, and as prognostic factors for local control and survival in both univariate and multivariate analysis.

RESULTS

Pretreatment apoptotic indexes were related to tumor stage, mitotic index, and Ki67 proliferation index. Five-year actuarial local control for the whole group was 45%. Patients with tumors showing low pretreatment apoptotic indexes had better local control (p < 0.037) and survival (p < 0.01) than highly apoptotic tumors. Tumor stage (T2 vs. T3-4) and the pretreatment apoptotic index were significant predictive factors for local control and survival in multivariate analysis.

CONCLUSIONS

The pretreatment apoptotic index is useful in predicting the clinical outcome of bladder cancer patients treated by radiotherapy. Assessment of biological tumor characteristics could allow the selection of patients for different treatment strategies.

[Assessment of risks associated with multiple events]

Our aim, when evaluating many events, is to assess overall survival S(t) but also event free survival EFS(t). In addition, we often wish to estimate the respective contribution of each event involved in event free survival and to describe the distribution of the time of occurrence of each event by breaking down EFS into its different components. However, these different events are often dependent and/or exclusive. Appropriate statistic tools, named competing risk analyses are then required. The aim of this article is to define situations necessitating competing risk analyses as opposed to more simple alternatives which, although often used, are not always appropriate. First two examples are presented to illustrate the problems we face when studying many events. Statistical methods used to compute competing risks are then developed, as is the type of interpretation that can be given to these results.

Serum cholecystokinin and neurotensin during follow-up of pancreas, prostate and medullary thyroid tumors

BACKGROUND

Growth of pancreatic carcinoma cells is stimulated by cholecystokinin (CCK) and neurotensin (NT). Prostatic carcinoma cells can secrete neurotensin. The CCK gene has been described in thyroid medullary carcinomas (MCT).

METHODS

Serum CCK and NT were measured by RIAs during monitoring of 19 pancreas tumours, 10 prostate adenocarcinomas and 10 thyroid medullary cancers (MCT).

RESULTS

No correlations were found between CCK and NT in the three tumour types, nor with CA 19.9, PSA, CEA or calcitonin. In pancreas adenocarcinomas (n = 12), initial median CCK was > 8pg/ml (non significant differences between stages T, N or M). Median NT was > 80 pg/ml in all but M0 and stage I-II cases, and significantly higher in M1 and stages IV (P = 0.002). Non significant differences were found for CCK and NT according to clinical stages. In prostate cancers, median CCK was significantly more elevated after relapse (P = 0.040). Median NT was significantly more elevated in disease-free patients (P = 0.04). In MCT, CCK and NT were not related to clinical stages.

CONCLUSION

In pancreas and prostate cancers serum CCK may follow tumour load and disease progression. NT was lower in progressive disease. The contribution of these peptides in human tumour growth, since they may have therapeutic implication, warrants further investigation.

Prognostic factors for survival in patients with brain metastases from renal cell carcinoma

BACKGROUND

Patients presenting with brain metastases from renal cell carcinoma portend a poor prognosis, with a reported median survival of 4-6 months. Given their short life expectancy, these patients generally have been excluded from clinical trials that assess the efficacy of medical treatments. However, clinical impression suggests that some patients may achieve long term palliation.

METHODS

The clinical features of 68 patients who were treated at the Institut Gustave Roussy for brain metastases from renal cell carcinoma were collected retrospectively. Using univariate and multivariate analyses, a prognostic model based on independent prognostic factors was established. An external data set of 57 patients was used to validate the model.

RESULTS

The median survival was 7 months. On univariate analysis survival was related significantly to the following adverse prognostic factors: no initial nephrectomy, left side and temporal location of brain metastases, presence of fever or weight loss, erythrocyte sedimentation rate > 50 mm/h, and time from initial diagnosis to brain metastases < or = 18 months. Multivariate analyses identified the previous variable as well as the presence of other visceral metastases as independent prognostic factors. Forty-four patients (65%) with no or 1 adverse prognostic factor (average risk group) had a median survival of 8 months and a 26% 1-year survival rate. Twenty-four patients (35%) with 2 adverse prognostic factors (poor risk group) had a median survival of 3 months and a 1-year survival rate of 9%. This model proved to be discriminant in an external data set; the median survival of patients assigned to the average risk group was 11 months (46% 1-year survival rate) compared with 4 months (9% 1-year survival rate) for patients assigned to the poor risk group.

CONCLUSIONS

Patients presenting with brain metastases from renal cell carcinoma and poor risk prognostic factors are highly unlikely to benefit from medical treatments except symptomatic procedures. Conversely, the enrollment of patients with average risk prognostic factors into clinical trials dealing with chemotherapy or immunotherapy may be considered.

[Management of intracanalicular acoustic neurinoma]

Between 1991 and 1996, 35 patients had an intracanalicular tumor: 26 patients were operated via middle cranial fossa approach (MFA: 23 cases) or translabyrinthine approach (TL: 3 cases), 9 cases were supervised by audiovestibular testing and MRI. For the operated patients through MFA the functional hearing (pure tone loss < 50 dB and 100% vocal discrimination) was preserved in 47.8% of cases, facial function was grade I and II in 83% of cases and grade III in 17% of cases. One recurrence was noted and reoperated by TL. For the TL operated patients, the postoperative facial function was normal (grade I) in all cases. Among the 9 supervised cases for reasons of age (more than 60 years), or the tumoral size (< than 5 mm): the tumor in 3 cases did not increase in size, 5 cases increased by 1 mm/year and 1 case increased 1 cm/year (and must be operated). These results show the importance of the middle cranial fossa approach for excision of intracanalicular neuromas and supervising patients with the same tumor according to age, and tumoral size.

The role of Ki67 proliferation assessment in predicting local control in bladder cancer patients treated by radical radiation therapy

PURPOSE

To assess whether tumour proliferation as measured by Ki67 immunostaining has any predictive value for local control in bladder cancer patients treated by radiotherapy.

PATIENTS AND METHODS

Fifty-five patients suffering from infiltrating bladder carcinoma recommended for radical radiotherapy (66 Gy/6-7 weeks) were included in this study. Paraffin-embedded pre-treatment tumour sections were stained with the Ki67 antibody. The percentage of Ki67-positive nuclei was correlated with established prognostic factors, local control and survival.

RESULTS

The Ki67 index was not related to local control in our patients when the median was selected as the cut-off value. Patients with tumours with a very low (<27%) Ki67 index had better local control at 5 years (69%) than patients with tumours with greater (>27%) Ki67 expression indices (31.5%) (P<0.05; log-rank test).

CONCLUSIONS

Ki67 immunostaining was a feasible method to estimate tumour proliferation. Patients with very low proliferating tumours seemed to achieve better local control after fractionated radiotherapy compared to other patients. Further studies are needed with a greater number of patients to accurately define the role of Ki67 expression in predicting tumour repopulation during fractionated radiotherapy.

A phoneme effect in visual word recognition

In alphabetic writing systems like English or French, many words are composed of more letters than phonemes (e.g. BEACH is composed of five letters and three phonemes, i.e./biJ/). This is due to the presence of higher order graphemes, that is, groups of letters that map into a single phoneme (e.g. EA and CH in BEACH map into the single phonemes /i/ and /J/, respectively). The present study investigated the potential role of these subsyllabic components for the visual recognition of words in a perceptual identification task. In Experiment 1, we manipulated the number of phonemes in monosyllabic, low frequency, five-letter, English words, and found that identification times were longer for words with a small number of phonemes than for words with a large number of phonemes. In Experiment 2, this 'phoneme effect' was replicated in French for low frequency, but not for high frequency, monosyllabic words. These results suggest that subsyllabic components, also referred to as functional orthographic units, play a crucial role as elementary building blocks of visual word recognition.

Hearing restoration in posterior fossa tumors

OBJECTIVE

This study aimed to assess the results of hearing restoration with a cochlear or a brainstem implant in posterior fossa tumors.

PATIENTS

Six patients were selected. Two patients with an acoustic neuroma in the only-hearing ear (cases 1 and 2), one patient with a posterior fossa meningioma (case 3), one patient with bilateral facial neuroma (case 4), and two patients with bilateral acoustic neuroma (cases 5 and 6) participated.

INTERVENTION

In cases 1 and 2, the patients had a cochlear implant inserted on the only-hearing ear opposite the acoustic neuroma. In case 3, the patient presented with total deafness on the left side and a 10-mm meningioma on the right side. A cochlear implantation was performed after removal of the meningioma on the right side. In case 4, the patient was operated on on both sides with bilateral postoperative deafness. A cochlear implantation was performed on the better hearing ear. In cases 5 and 6, patients underwent an auditory brainstem implantation after the exeresis of the second tumor.

RESULTS

Promontory test results were positive for patients 1, 2, 3, and 4. After implantation, patients 1, 2, 3, and 4 scored 98%, 13%, 70%, and 30%, respectively, in open-set sentence recognition tests, whereas patients 5 and 6 scored 0% and 20%, respectively.

CONCLUSIONS

In case of nonfunctional cochlear nerve, in acoustic neuroma, either bilateral and in the only-hearing ear, promontory test should be performed. If positive results, a cochlear implantation should be performed, because successful results could be expected. Overall results of cochlear implantation on speech discrimination are better than those obtained with a brainstem implant.

IL-13 increases the cPLA2 gene and protein expression and the mobilization of arachidonic acid during an inflammatory process in mouse peritoneal macrophages

Pretreatment of mouse peritoneal macrophages with interleukin-13 (IL-13) potentiates the mobilization of arachidonic acid (AA) and the production of HETEs but does not affect the production of cyclooxygenase metabolites triggered by the suboptimal concentration of an inflammatory agonist (opsonized-zymosan). Cycloheximide suppresses these effects of IL-13 suggesting that de novo protein synthesis is involved. Indeed, IL-13 induces a time-dependent increase in the levels of cytosolic PLA2 (cPLA2) protein and mRNA. This study demonstrates a new pathway for IL-13 to modulate the inflammatory process in macrophages via modifications of cPLA2 expression and subsequent AA mobilization.

[Trans-petrous surgery in acoustic neuroma. Value of preoperative audiovestibular and facial investigation in the risk evaluation of facial nerve function]

Between 1987 and february 1994, 162 consecutive patients with acoustic neuroma were operated on by an otoneurosurgery team, using transpetrous approaches (89% translabyrinthine, 8% middle fossa and 3% retrosigmoid). The relationship between the clinical, audiometric and vestibulographic characteristics and the post-operative facial nerve function were evaluated. In acoustic neuromas with cerebello-pontine component inferior to 3 cm without central neurologic signs (ic: central controlateral auditory and/or ipsilateral vestibular pathway alteration), good post-operative facial nerve function was achieved in 80% of cases. In acoustic neuromas superior to 3 cm with alteration of the central vestibular and auditory pathways, a good result was obtained in only 30% of cases which correlated negatively with preoperative facial dysfunction. These results underline the value of preoperative facial and audiovestibular examinations in predicting the postoperative facial nerve function following surgery for acoustic neuroma.

Long-term photosynthetic acclimation to increased atmospheric CO(2) concentration in young birch (Betula pendula) trees

To study the long-term response of photosynthesis to elevated atmospheric CO(2) concentration in silver birch (Betula pendula Roth.), 18 trees were grown in the field in open-top chambers supplied with 350 or 700 &mgr;mol mol(-1) CO(2) for four consecutive growing seasons. Maximum photosynthetic rates, stomatal conductance and CO(2) response curves were measured over the fourth growing season with a portable photosynthesis system. The photosynthesis model developed by Farquhar et al. (1980) was fitted to the CO(2) response curves. Chlorophyll, soluble proteins, total nonstructural carbohydrates, nitrogen and Rubisco activity were determined monthly. Elevated CO(2) concentration stimulated photosynthesis by 33% on average over the fourth growing season. However, comparison of maximum photosynthetic rates at the same CO(2) concentration (350 or 700 &mgr;mol mol(-1)) revealed that the photosynthetic capacity of trees grown in an elevated CO(2) concentration was reduced. Analysis of the response curves showed that acclimation to elevated CO(2) concentration involved decreases in carboxylation efficiency and RuBP regeneration capacity. No clear evidence for a redistribution of nitrogen within the leaf was observed. Down-regulation of photosynthesis increased as the growing season progressed and appeared to be related to the source-sink balance of the trees. Analysis of the main leaf components revealed that the reduction in photosynthetic capacity was accompanied by an accumulation of starch in leaves (100%), which was probably responsible for the reduction in Rubisco activity (27%) and to a lesser extent for reductions in other photosynthetic components: chlorophyll (10%), soluble protein (9%), and N concentrations (12%) expressed on an area basis. Despite a 21% reduction in stomatal conductance in response to the elevated CO(2) treatment, stomatal limitation was significantly less in the elevated, than in the ambient, CO(2) treatment. Thus, after four growing seasons exposed to an elevated CO(2) concentration in the field, the trees maintained increased photosynthetic rates, although their photosynthetic capacity was reduced compared with trees grown in ambient CO(2).

Treatment of non-metastatic rhabdomyosarcomas in childhood and adolescence. Results of the second study of the International Society of Paediatric Oncology: MMT84

The second International Society of Paediatric Oncology (SIOP) study for rhabdomyosarcoma (MMT84) had several goals. The two principal aims were: (1) to improve the survival of children with rhabdomyosarcoma; and (2) to reduce the late effects from therapy by restricting the indications for surgery and/or radiotherapy after good response to initial chemotherapy. A further aim was to investigate the role of high-dose chemotherapy in young patients with parameningeal primary tumours. 186 previously untreated eligible patients entered the study. Patients with completely resected primary tumour received three courses of IVA (ifosfamide, vincristine and actinomycin D). Patients with incompletely resected tumour received six to 10 courses of IVA according to stage. Patients achieving complete remission with chemotherapy alone did not usually receive radiotherapy or undergo extensive surgery, but patients remaining in partial remission received local therapy with surgery and/or radiotherapy. Only patients over 5 years of age with parameningeal disease and patients over 12 years with tumours at any site were given systematic irradiation. Complete remission was achieved in 91% (170/186) of all patients. With a median follow-up of 8 years, the 5-year overall survival was 68% (+/- 3% standard error of the mean (SEM) and the 5-year event-free survival 53% (+/- 4% SEM). These results show an improvement over previous SIOP study (RMS75) in which survival was 52% and event-free survival was 47%. Among the 54 patients who exhibited isolated local relapse, 35% (19/54) survived in further remission longer than 2 years after retreatment, including local therapy (surgery +/- radiotherapy). Analysis of the overall burden of therapy received by all surviving children (including primary treatment and treatment for relapse if required) showed that 24% (28/116) were treated by limited surgery followed by three courses of IVA, 29% (34/116) were treated by chemotherapy alone (after initial biopsy) and 13% (15/116) received chemotherapy plus conservative local treatment (limited surgery or radiotherapy for residual disease). Only 34% (39/116) received intensive local therapy defined as radical wide field radiotherapy or radical surgery or both. Compared with the results obtained in the previous SIOP study, treatment in MMT84 was based on response to initial chemotherapy and, despite an overall reduction of the use of local therapy, significantly improved survival for patients with non-metastatic disease. This trial, also for the first time, provides evidence that retreatment after local relapse can achieve long-term second remissions.

Tirapazamine-cisplatin: the synergy

Tirapazamine is a novel bioreductive agent with selective cytotoxicity against hypoxic tumour cells. Synergy with cisplatin and other chemotherapeutic agents has been shown in preclinical trials. Pharmacokinetic studies of tirapazamine have revealed that exposure increases with dose over the range of 18-450 mg m(-2) for a single dose and of 9-390 mg m(-2) for multiple doses. Plasma clearance is high. Tirapazamine has been clinically tested in combination with cisplatin at escalating doses in a phase I trial and at therapeutic doses in three separate phase II trials in patients with advanced non-small-cell lung cancer (NSCLC) in 11 study centres. Limiting toxicity for tirapazamine at an intravenous dose of 390 mg m(-2) was acute, reversible hearing loss. Other frequently observed side-effects included muscle cramping and gastrointestinal symptoms. Tirapazamine did not cause myelosuppression, and no toxic deaths were reported in these trials. The anti-tumour efficacy against previously untreated, advanced NSCLC was evaluated by cumulative intent-to-treat analysis of 132 patients. The objective response rate (confirmed by two independent measurements) was 25% [confidence interval (CI) 17.8-33.33], with a median survival of 38.9 weeks (CI 29.4-49.9). The efficacy of tirapazamine plus cisplatin shown in these trials was better than that of historical controls with cisplatin monotherapy. Two large-scale international trials have been conducted, involving more than 70 centres, to confirm these results. The CATAPULT I trial compares tirapazamine plus cisplatin with cisplatin and has finished accrual with 446 patients. The CATAPULT II trial, which is comparing tirapazamine plus cisplatin with etoposide plus cisplatin, had enrolled 550 patients by June 1997. Follow-up is ongoing. Tirapazamine is the promising first drug from a new class of cytotoxic agents with a novel mechanism of action. It can be effectively combined with cisplatin, and possibly with other agents, because of its safety profile and lack of overlapping dose-limiting toxicity, such as myelosuppression. The combination of tirapazamine and cisplatin appears to be safe and effective in the treatment of NSCLC.

Simulating individual word identification thresholds and errors in the fragmentation task

This article presents a large-scale study that collected word identification thresholds and errors in the fragmentation task for all four-letter French words. In the first part of this article, we identify some of the variables (e.g., word frequency, neighborhood size, letter confusability) that affect performance in the fragmentation task. In the second part, we analyze individual response performance and identify different response strategies. We demonstrate that the interactive activation model can account for individual response strategies by adapting two of its original parameters: word-letter feedback and letter-word inhibition. In the third part, we demonstrate that the adaptation of the interactive activation model to the fragmentation task makes it possible to successfully simulate a facilitatory frequency effect on identification thresholds, an inhibitory neighborhood size effect on error rates, and an inhibitory letter confusability effect on identification thresholds. When the task-specific processes of the fragmentation task are specified and individual response strategies are considered, the interactive activation model provides a parsimonious architecture for modeling the task-independent processes involved in word perception.

Opiate agonist-induced changes in behavioral sensitivity to clonidine are observed in perinatally malnourished rats exposed to chronic stress

Sensitivity of alpha2-adrenoceptors following repeated immobilization sessions plus morphine (MOR) or beta-endorphin (BETA) was assayed by examining clonidine (CLO)-induced hypoactivity in adult malnourished rats at perinatal age. As previously described, chronic restraint did not attenuate the hypoactivity elicited by CLO in malnourished rats, although chronic restraint did have such an effect on motor activity in control animals. MOR and BETA administration prior to each restraint session induced subsensitivity of alpha2-adrenoceptors in malnourished rats as determined by a blunted response to clonidine challenge. An injection of naloxone (NAL) prior to BETA before each stress session fully antagonized the subsensitivity to clonidine observed in malnourished animals. A possible deficiency in the functional role of the opiate system in the process of adaptation to chronic stress in perinatal malnourished rats is suggested.

Expression of heat shock protein 70 and c-myc in cervical carcinoma

Heat shock protein 70 (hsp70), is a molecular chaperone that binds to c-myc and regulates its accumulation and localisation. In an attempt to confirm this association and to find out its prognostic significance in cervical carcinoma, paraffin embedded sections from 15 chronic cervicitis, 31 squamous cell carcinomas (scc) and 7 adenocarcinomas of the uterine cervix were immunohistochemically (IHC) stained for hsp70 and c-myc. hsp70 was faintly expressed cytoplasmically in non neoplastic squamous and endocervical epithelium, while mainly nuclear staining with variable intensities was seen in all scc and in squamous intraepithelial lesions (SIL) overlying 8 tumors. Both cytoplasmic and nuclear staining was noted in adenocarcinoma. c-myc was moderately expressed in the cytoplasm of all non neoplastic endocervical glands, while very mild cytoplasmic staining was noted in squamous epithelium. In SIL and in scc the staining intensity increased and was mainly nuclear. For adenocarcinoma, nuclear and cytoplasmic staining with different intensities was noted. There were significant positive correlations between the IHC expression of hsp70 and c-myc (p = 0.0001). In conclusion, our results confirm the co-association of c-myc and hsp70. This co-association might be a mechanism of tumor escape by preventing hsp70 binding to one of its normal target, the MHC class I, and preventing its subsequent expression on the surface of the cancerous cells. Lastly, the nuclear expression of hsp70 might be considered as an indicator of malignant transformation.

KI67 proliferation index in tumors of the upper urinary tract as related to established prognostic factors and long-term survival

OBJECTIVE

Nephroureterectomy is the standard treatment for tumors of the renal pelvis and ureter. Conservative management or indication of adjuvant treatment in these neoplasms is based mainly in histological grade and stage. The aim of this study is to assess the relation of Ki67 index with other established prognostic factors and to define its predictive value for long term survival, which could be useful in selecting the best treatment for each individual case.

METHODS

81 patients with urothelial tumors of the renal pelvis and ureter, diagnosed and treated between 1975 and 1993, comprised the present study. Ki67 immunostaining was performed in paraffin-embedded tissue. A cut-off limit of 20% was chosen. Tumor location, histological grade, histological pattern, local (T), nodal (N), vascular and perineural invasion and stage (TNM) were assessed in relation to the proliferation index and as prognostic criteria for survival in both univariate and multivariate analysis.

RESULTS

The Ki67 proliferation index was found to be related to grade (p < 0.001), T (T0 vs T1-4; p < 0.01), N (p < 0.038), TNM categories (stage 0 vs I-IV; p < 0.048) and perineural invasion (p < 0.01). There was a marginal relation to vascular invasion (p < 0.11). Survival was better for the patients with low proliferating tumors (90%) than for high proliferating ones (67%) (p < 0.02). In the multivariate analysis only T stage was statistically significant (p < 0.01) but a highly suggestive trend was found for the Ki67 index (p < 0.07).

CONCLUSIONS

Tumor proliferation assessed by Ki67 immunostaining is related to the progression of the disease and proved to be of predictive value for long-term survival in tumors of the renal pelvis and ureter. The Ki67 index is able to detect high-risk patients that could not be cured by radical surgery alone, raising the need for some type of aduvant treatment in these cases. The treatment predictive effect observed in low grade-low stage cases suggests its possible utility in patients managed conservatively.

Lymphatic spread in stage Ib and II cervical carcinoma: anatomy and surgical implications

OBJECTIVE

To determine the frequency and topography of pelvic and para-aortic node involvement in cervical carcinoma and to identify the appropriate level for resection of the lymphatic chains.

METHODS

Between 1985 and 1994, 421 women with stage Ib or II cervical carcinoma were treated by surgery in combination with irradiation. Each underwent a radical hysterectomy with systematic pelvic and para-aortic lymphadenectomy.

RESULTS

A median of 34 lymph nodes were removed per patient. The overall frequency of lymph node involvement was 26%, and the frequency of para-aortic metastases was 8%. The frequency of lymph node metastasis was associated significantly with stage (chi(2) = 7.8; P < .02), tumor size (chi(2) = 14.8; P < .001), and patient age (chi(2) = 5.9; P < .05). The frequency of para-aortic involvement was below 3% in patients with small tumors (under 2 cm). When pelvic nodes were involved, the obturator group was concerned in 76 cases (18%) and the external iliac group in 48 patients (11%). When para-aortic nodes were involved, the left para-aortic chain was the most frequently concerned (23 patients [5%]). In eight of these patients, nodal involvement was found only above the level of the inferior mesenteric artery. Among 106 patients with pelvic positive nodes, 28 (26%) also had para-aortic metastatic nodes.

CONCLUSION

Para-aortic lymphadenectomy should remove all of the left para-aortic chain (inframesenteric and supramesenteric) and so should be performed up to the level of the left renal vein. According to the low frequency of para-aortic involvement when tumor size is below 2 cm, such a procedure could be avoided in patients with small tumors.

Intracranial berry aneurysms: angiographic and clinical results after endovascular treatment

PURPOSE

To determine the types of aneurysm that may be treated endovascularly with platinum detachable coils.

MATERIALS AND METHODS

Two hundred eight patients with 236 intracranial berry aneurysms underwent endovascular coil embolization; 150 patients had subarachnoid hemorrhage at the time of presentation.

RESULTS

Treatment was performed in 182 patients with 203 (86%) aneurysms (86%). Follow-up angiograms were obtained at 3 months in 160 cases of aneurysm. A second procedure was performed in 18 (11%) of these cases, and a third was performed in one case. Final follow-up results in 152 aneurysms demonstrated total occlusion in 123 (81%) cases, subtotal occlusion in 26 (17%) cases, and incomplete occlusion in three (2%) cases. All patients with subtotally occluded aneurysm were scheduled for later angiographic follow-up and any indicated repeat treatment. Technique-related morbidity rate was 4% (seven patients with permanent neurologic deficits due to clotting). Technique-related mortality rate was 2% (perioperative rupture in two, hematoma due to urokinase perfusion in one, rebleeding of the initial hematoma after excessive uncontrolled anticoagulation in one). Rebleeding occurred in one patient after incomplete occlusion.

CONCLUSION

Endovascular coil embolization seems to be a reliable technique, with good anatomic and clinical results, that provides protection against rebleeding of ruptured aneurysms.

[Intra-labyrinthine schwannomas: a report of two cases]

Intralabyrinthine schwannomas are rare tumors of vestibule, cochlea, semicircular canals, or some combination of these three. In the past, they have been found at autopsy or as incidental finding at surgery. Since the advent of magnetic resonance imaging (MRI) with intravenous gadolinium contrast, the preoperative diagnosis is possible. We report two cases of intralabyrinthine schwannoma: one case of intralabyrinthine schwannoma extended into the internal auditory canal (IAC), a second case of tumor restricted to the vestibule. No characteristic clinical presentation of this tumor is reported in the literature. In patients with vestibular weakness (vertigo and no response of caloric testing), MRI with gadolinium contrast can make the diagnosis of intravestibular tumor. In patients with the more common IAC acoustic neuromas, MRI can demonstrate extension of tumor into the labyrinth; diagnosing this extension preoperatively is important to plan surgical treatment.