A population-based study of the usefulness of screening for neuroblastoma

BACKGROUND

Neuroblastoma has many characteristics which suggest that preclinical detection might improve outcome. The Quebec Neuroblastoma Screening Project was initiated to determine whether mass screening could reduce mortality in a large cohort of infants. As an early endpoint, we report whether screening could reduce the incidence of poor-prognosis neuroblastoma in children with advanced-stage disease over 1 year of age.

METHODS

All 476,603 children born in the province of Quebec during the 5-year period of May 1, 1989, to April 30, 1994, were eligible for urinary assay of homovanillic acid and vanillylmandelic acid at 3 weeks and 6 months of age. Children with a positive screen were referred to one of four paediatric cancer centres in the province for uniform evaluation and treatment if necessary. Standardised incidence ratios (SIRs) were calculated for neuroblastoma in the province and two similar population-based controls, the state of Minnesota and the province of Ontario, during the same period of time and with similar ascertainment procedures.

FINDINGS

Compliance with screening in Quebec province was 91% at 3 weeks (n = 425,816) and 74% at 6 months (n = 349,706). Through July 31, 1995, with a follow-up of the birth cohort of 15-75 months, 118 cases of neuroblastoma were diagnosed, 43 detected preclinically by screening, 20 detected clinically before screening at 3 weeks of age, and 55 detected clinically after 3 weeks of age having normal screens (52) or never screened (3). Retrospective analysis of stored samples confirmed that 49 of 52 patients missed by screening had levels of catecholamine metabolites that were too low to be detected at 6 months or earlier. Based on US Surveillance, Epidemiology and End Results data, 54.5 cases of neuroblastoma would have been expected in Quebec province during the study period, for an SIR of 2.17 (95% CI 1.79-2.57, p < 0.0001). For the two control groups, 43 and 80 cases of neuroblastoma were detected, respectively, compared with 37.9 and 85.4 expected, overall SIR 1.00 (not significant). SIRs for Quebec province by age at diagnosis in yearly intervals show a marked increased incidence under 1 year of age (SIR 2.85, 2.26-3.50), with no reduction in incidence in subsequent years. Limiting analysis to only patients diagnosed over 1 year of age with advanced-stage disease, 22 cases were detected in Quebec province versus 14.4 expected (SIR 1.52, 0.95-2.23). Data in the two control groups show no significant increase or decrease in any-stage disease in children under or over the age of 1 year, except for an increase in early-stage disease in Minnesota children over 1 year: 10 versus 3.8 expected (SIR 2.67, 1.27-4.58).

INTERPRETATION

Screening for neuroblastoma increases the incidence in infants without decreasing the incidence of unfavourable advanced-stage disease in older children. It is unlikely that screening for neuroblastoma in infants will reduce mortality for this disease.

Current treatment of cerebral metastasis

Brain metastasis from systemic cancer remains a significant source of morbidity and mortality. Current treatment modalities include surgery, whole brain radiation, radiosurgery, brachytherapy, chemotherapy, and other experimental methods such as hyperthermia, hormonal therapy, and the use of biological modifiers. In this article we review and evaluate recent developments in these treatment modalities for the management of cerebral metastasis.

Receptor-mediated calcium signalling in glial cells from mouse corpus callosum slices

We addressed the question of whether glial cells in intact white matter tracts express neurotransmitter receptors and we used Ca+2 signalling as a probe to detect the receptor activation. Corpus callosum slices from postnatal mice were bulk-loaded with the Ca+2-sensitive fluorescent dye fluo-3, and confocal microscopy was used to measure Ca+2 transients in response to neuroligands. Glial cell bodies were intensely dye-loaded and could be discriminated from the diffuse fluorescence of axons. Subpopulations of glial cells from slices obtained at postnatal days 3 to 7 responded with Ca+2 signals to ATP, glutamate, histamine, GABA, norepinephrine, serotonin, angiotensin II, bradykinin, and substance P. These subpopulations showed a distinct overlap; cells which were responsive to substance P always showed Ca+2 signalling in response to histamine, ATP, GABA and high K+ (membrane depolarization). GABA-responsive cells almost always showed a [Ca+2]i increase after membrane depolarization. In brain slices from postnatal day 11 to 18 animals, the Ca+2 responses were evident for glutamate, ATP, and norepinephrine, while GABA, substance P, serotonin, histamine, or angiotensin II rarely elicited a response. This study demonstrates that white matter glial cells in slices exhibit a large repertoire of neurotransmitter responses linked to Ca+2 signalling and that these receptor systems are differentially distributed on sub-populations of glial cells.

Reproductive characteristics of a population of urban Swiss women

OBJECTIVE

To describe the variability of reproductive life, from menarche to menopause, in the Geneva female population.

DESIGN

Women's Health Survey, 1992-1993.

SETTING

Mobile epidemiology unit of a University Hospital.

SUBJECTS

One thousand and thirty-two women aged 30 to 74 years, resident in Geneva, Switzerland.

MAIN OUTCOME MEASURE

Menstrual and reproductive history.

RESULTS

A 'typical' woman of Geneva has her menarche at 13 years, regular 28 day cycles with 5 days of menstrual flow. She is 26 years old when she first gives birth and has her last baby (which is typically the second) at age 31. She has 37 years of potential fecundity and a natural menopause at age 50. In addition, 11% of the women have tried to be pregnant during two years without success, 67% have ever used oral contraceptives, 20% had a first birth at age 30 or more and 23% were nulliparous. Younger women reported earlier ages at menarche. Women with lower education tended to be a younger age at the birth of her first child.

CONCLUSIONS

In this first study of the reproductive characteristics of women in Geneva, nulliparity and a late first birth appeared unusually frequent, especially when compared with American or Chinese women. The observed distributions of reproductive history are compatible with the very high incidence rate of breast cancer in the Geneva population.

Passive smoking, active smoking, and education: their relationship to weight history in women in Geneva

OBJECTIVES

This study was undertaken to determine the relationship of education and tobacco smoke to lifetime weight history in women.

METHODS

Information on passive smoking, active smoking, and weight history was collected from 928 women aged 29 to 74 years selected from the general population of Geneva, Switzerland. Multivariate analysis of variance was performed for weight, weight at age 20, and weight changes since age 20.

RESULTS

Education was inversely related to weight at age 20, current weight, and weight gain since age 20. The least educated group had a current weight of 4 kg more than the most educated group. Differences across smoking categories were small: passive smokers had the highest current weight (63.4 kg) and former active smokers had the lowest (60.4 kg). Weight gain since age 20 tended to be smaller in former and current active smokers (5.5 to 7.2 kg) than in passive smokers (8.3 to 10.4 kg) and those never exposed (9.1 kg).

CONCLUSIONS

In this sample, education was an important predictor of women's current weight and weight history. Passive and active smoking had little long-term effect on weight.

Antithrombotic therapy for patients with stroke symptoms. Guidelines for family physicians

Anticoagulant therapy to halt or limit a potentially devastating stroke carries both risk and an unproven benefit. Two case reports highlight potential pitfalls. Antiplatelet agents are indicated for ischemia secondary to artery-to-artery embolism. Anticoagulation should be undertaken only when a demonstrated cardiac embolic source places a patient at ongoing risk of repeated embolic stroke. This article reviews rational approaches to anticoagulation for neurologic patients.

The association between tumour necrosis factor-alpha, interleukin-6 and microbiological findings in the synovial fluid of aborted and neonatal calves

Tumour necrosis factor-alpha (TNF alpha) and interleukin-6 (IL-6) were detected in the intra-carpal synovial fluids collected from aborted and recently dead young calves. Five out of seven TNF-alpha positive joint fluids were bacteriologically positive and two were sterile. Only one out of 20 TNF-alpha negative joint aspirates was infected (P = 0.0014). Sixteen of the synovial fluid samples were examined for the presence of IL-6. In 12 samples IL-6 was detected, six of which were bacteriologically contaminated. Four out of the 16 samples were IL-6 negative. These findings indicated the possible association between TNF-alpha and the intra-articular inflammatory processes in young calves, which in the present study were either found in combination with or without IL-6.

Relation of breast cancer with passive and active exposure to tobacco smoke

Studies on passive smoking have consistently shown a tendency toward an increased risk of breast cancer, while studies an active smoking have failed to demonstrate an association. This apparent contradiction may stem from not separating passive smokers from the unexposed when assessing the effect of active smoking. a population based case-control study was conducted in Geneva, Switzerland, between January 1992 and October 1993 to determine the relation of passive and active smoking to breast cancer when the referent unexposed category consisted of women unexposed to active and passive smoke. The 244 patients with breast cancer (cases) were compared with 1.032 women free of breast cancer (controls). The lifetime history of active and passive smoking was recorded year by year, between the age of 10 and the date of the interview. The adjusted odds of breast cancer for ever active smokers, compared with women unexposed to either passive or active smoke, were 2.2 (95% confidence interval (CI) 1.0-4.4) for an average lifetime consumption of 1-9 cigarettes per day, 2.7% (95% CI 1.4-5.4) for 10-19 cigarettes per day, and 4.6 (95% CI 2.2-9.7) for 30 or more cigarettes per day. Among passive smokers, the adjusted odds ratio was 3.2 (95% CI 1.6-6.3) for being exposed for the equivalent of 2 hours per day for 25 years. The odds ratios were adjusted for known or postulated risk factors of breast cancer, including alcohol and saturated fat intake. There was no evidence of strong selection, detection, or recall biases. Active and passive exposure to tobacco smoke may increase the risk of breast cancer. Additional studies are needed to decide whether the association is causal. Further elucidation of this relation would benefit not only the prevention of breast cancer but also the the prevention of other smoking-related diseases in women.

Tirilazad does not protect rat brain from brachytherapy-induced injury

BACKGROUND

Acute and chronic brain injury are common sequelae of high-dose focused radiation, as in radiosurgery and brachytherapy. Development of protectors of radiation injury, which would work in brain but not in tumor, would help enhance the therapeutic ratio of focused-radiation therapy.

METHODS

Radiation protection by a clinically available 21-aminosteroid, Tirilazad, was studied in a rat brain brachytherapy model, both in tumor and non-tumor bearing animals. For the tumor model, 9L Glioma/SF line cells were implanted stereotactically into the right frontal lobe of F-344 rats and grew to a sphere of 5.0-mm diameter after 12 days. Animals received a standard brachytherapy dose of 80 Gy to a 5.5-mm radius volume administered by a high-activity removable iodine-125 seed. Radiation damage was evaluated 24 hours after removal of the seeds in all animals and again at 3 months in non-tumor-bearing animals, by T1-weighted gadolinium-enhanced and T2-weighted magnetic resonance imaging (MRI) on a 1.5-T unit. Treated animals received Tirilazad 5 mg/kg intravenously 15 minutes prior to implant, 1 hour after implant, every 6 hours for the duration of the implant, and for 24 hours after removal of the seed. Control animals were administered vehicle only.

RESULTS

In both non-tumor-bearing and tumor-bearing rats, no difference in the volume of lesions on enhanced T1 or T2 MRI was seen between the Tirilazad-treated and control groups. In the non-tumor-bearing rats, volume of both T1 enhanced and T2 MRI lesions was significantly reduced at 3 months compared to the values at 24 hours.

CONCLUSIONS

In the present model, Tirilazad failed to reduce the volume of radiation brain injury from brachytherapy as seen on MRI, studied acutely in tumor-bearing and non-tumor-bearing animals and also at 3 months in non-tumor-bearing rats.

Brain tumour surgery in the elderly: a brief reappraisal

Brain tumour surgery in the elderly has a relatively poor outcome and a high complication rate. In spite of this, well-selected patients can benefit substantially from aggressive intervention, and the health care team must individualize treatment in every case. Using two case reports and a review of the relevant literature, the author presents a neurosurgical approach to selected elderly patients with brain tumours.

Chromosome 12-linked autosomal dominant scapuloperoneal muscular dystrophy

Scapuloperoneal syndromes are characterized by their distribution of muscle weakness and wasting. The reported pattern of inheritance has been variable. Both neurogenic and myopathic forms of autosomally dominantly inherited scapuloperoneal syndrome have been described. It has been suggested that these are variants of other neuromuscular diseases. We examined 44 members from a family with 14 members affected with a scapuloperoneal syndrome. Physiological and histological analysis implied that this condition is predominantly myopathic. Linkage analysis was done to confirm the genetic etiology of the disease in this family and to evaluate the possibility that it is a allelic variant of other neuromuscular diseases. Genetic analysis demonstrated linkage of the disease to chromosome 12, which makes it genetically distinct from other loci known to cause neuromuscular disease. Muscle fibers with hyaline desmin-containing cytoplasmic inclusions in combination with focal myopathic changes may be a disease-specific morphological marker of the disease.

Neuron-like physiological properties of cells from human oligodendroglial tumors

One of the most common symptoms of patients with oligodendrogliomas is the high frequency of epileptic seizures. We thus studied the physiological properties of cells in six human oligodendrogliomas and two oligoastrocytomas obtained from surgical material. The majority of tumor cells in living brain slices can generate action potentials as recorded with the patch-clamp technique indicating that this tissue is dominated by electrically excitable cells. In cultures from the same material, the action potential generating cells prevail within the first days and are subsequently replaced by electrically inexcitable cells. From histopathological and immunohistochemical data, the histogenesis of human oligodendroglial tumor is still uncertain. Our physiological study has not settled the debate on the origin of these tumors but revealed important findings with regard to this question. Since action potential generating glial cells have not been described in situ so far their occurrence in oligodendroglial tumors implies that oligodendroglial tumor cells may belong to the neuronal cell lineage.

Laparoscopic colorectal surgery: analysis of 140 cases

BACKGROUND

This study was performed to prospectively assess the results of our first 140 consecutive patients who underwent laparoscopic or laparoscopic-assisted colorectal operations.

METHODS

The parameters studied included the type and length of procedure, intra- and postoperative complications, conversion to open surgery, and length of ileus and hospitalization.

RESULTS

140 laparoscopic and laparoscopic-assisted procedures were performed between May 1991 and January 1995. The mean patient age was 48 (range 12-88) years; there were 78 males and 62 females. Indications for surgery included inflammatory bowel disease in 47, colorectal carcinoma in 19, diverticular disease in 17, polyps in 16, familial polyposis in 7, colonic inertia in 7, fecal incontinence in 11, sigmoidocele in 3, irradiation proctitis in 3, rectal prolapse in 2, intestinal lymphoma in 2, and miscellaneous conditions in 6. The procedures included 38 total abdominal colectomies (TAC) (ileoanal reservoir 28, ileorectal anastomosis 8 and end ileostomy 2); 70 segmental resections of the colon, small bowel, and rectum; 18 diverting stoma creations; 10 reversal of Hartmann's procedures; and 4 other procedures. In 15 cases, the laparoscopic procedure was converted to a laparotomy (11%); 31 patients (22%) sustained 37 complications, which included: enterotomies(7), hemorrhage(10), intraabdominal abscess(4), prolonged ileus(6), wound infection(4), intestinal obstruction(2), anastomotic leak(1), aspiration(1), cardiac arrhythmia(1), and upper intestinal bleeding(1); there was no mortality. The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 17%, others 9%), P < 0.05. The mean length of operating time was 4 (range 2.5-6.5) h for TAC, 2.6 (range 1.5-5.5) h for segmental colonic resections, and 1.7 (range 0.7-4) for all other procedures. The length of ileus was 3.5 (range 2-7) days after TAC, 3 (range 2-7) after the segmental resections and 2 (range 1-4) after the other procedures. The mean length of hospital stay was 6.8 (2-40) days (8.4, 6.5, and 6.3 days for the TAC, segmental resections, and other procedures, respectively).

CONCLUSION

The feasibility of laparoscopic colorectal surgery has been well established. TAC is associated with a higher complication rate compared to other laparoscopic colorectal procedures.

Stereotactic management of bacterial brain abscesses

BACKGROUND

CT and MR guided stereotactic techniques have provided promising results in the management of brain abscesses. We reviewed our results of stereotactic management of brain abscesses in 20 consecutive patients with 28 abscesses from 1986 to 1993.

METHODS

13 abscesses were in the cerebral hemispheres, 12 in the cerebellum, 2 in the pons and 1 in the thalamus. The bacterial organism was isolated in 12 of the 20 cases. All patients, except one who had a tuberculous abscess, were on antibiotics for less than 7 weeks.

RESULTS

Although there were 3 patients in coma before surgery, the mortality rate was zero and 17 patients had an excellent recovery with 3 patients having a persistent mild neurologic disability. Stereotactic aspiration of the largest lesion in the patients with multiple brain abscesses combined with intravenous antibiotic therapy was sufficient for the resolution of all lesions. Two of our patients treated with antibiotics alone showed abscess progression with neurologic worsening.

CONCLUSION

Stereotactic aspiration is safe, accurate, and when combined with the appropriate antibiotics, should be considered the procedure of choice in the management of brain abscesses.

[Dietary differences between restaurants and home in a representative sample of the adult population residing in Geneva]

Differences in dietary intakes between those who eat at home and those who eat at the restaurant have not been documented previously. In the present study, three registered dietitians interviewed 626 adult residents of Geneva on the telephone about their diet the day before. Interviews were distributed over the seven days of the week. Participation rate was 80%. Results show that men go more often to the restaurant than women, that young people have lunch at the restaurant more often than older people but that age is not related to having dinner at the restaurant. When a resident of Geneva goes to the restaurant to have dinner, he eats and drinks more than those who eat at home, but the relative content of proteins, lipids and carbohydrates of the diet is not different. In conclusion, in Geneva the diet at the restaurant is very similar to the diet at home. This suggest that the meals in a restaurant tend to adapt to the customer's expectations rather then the opposite. The potential implication for public health is that the priority is to inform the customer about what is a healthy diet, the restaurant owner will follow his client's need.

Screening for neuroblastoma in North America. Preliminary results of a pathology review from the Quebec Project

BACKGROUND

The Quebec Neuroblastoma Screening Project was initiated to assess clinical and biologic aspects of neuroblastomas detected by screening infants born in the province of Quebec from May 1, 1989, to April 30, 1994.

METHODS

Infants were screened for preclinical detection of neuroblastoma by determination of catecholamine metabolites, vanillylmandelic acid (VMA), and homovanillic acid (HVA). Patients with tumors discovered through this screening as well as patients in the same birth cohort with clinically detected tumors were referred to Quebec Oncology Centers for further investigation, diagnosis, and treatment. Pathology specimens were submitted to Childrens Hospital Los Angeles for central review. Tumors were histopathologically classified according to the Shimada system.

RESULTS

As of August, 1993, 340,000 infants were screened at 3 weeks and 245,000 of them were retested at 6 months of age. Thirty-one tumors were detected through this screening and removed. Histologic material was available for 27 cases: 14 were detected at 3 weeks of age and 13 at 6 months of age. Twenty-six patients had tumors with favorable histology (FH), and one patient had a Stage I tumor with unfavorable histology (UH). At the time of this writing, all mass screening patients are alive, including one child with relapsed disease. During this period, 48 tumors were detected clinically in the same birth cohort, 40 of which were evaluated histologically. Of these 40 cases, 28 of 29 tumors diagnosed in patients up to age 12 months indicated an FH, whereas 9 of 11 tumors diagnosed in patients older than age 12 months indicated a UH. All patients with FH tumors are alive including a child with relapsed disease. The single patient with UH diagnosed before age 12 months died of disease. Of the nine patients with UH diagnosed after age 12 months, four died of disease, one relapsed, and four are alive (including one treated with bone marrow transplantation) after variable follow-up periods.

CONCLUSIONS

The tumors detected by mass screening, similar to those tumors detected through clinical examination before age 12 months, were predominantly FH with good prognosis. However, those tumors that were missed by screening and were detected clinically after the patient was 12 months of age were predominantly UH, with serious clinical problems. This subgroup of patients not detectable by the current screening system presents an immediate and important clinical challenge that should be addressed in future studies.

Low-grade gliomas

Supratentorial low-grade gliomas comprise a group of primary central nervous system neoplasms with characteristics of neuroglial cells (i.e., astrocytes and oligodendrocytes) and relatively low anaplastic potential, although through time they tend to behave more aggressively. Immediate surgical intervention and subsequent radiation therapy are advocated by some workers; at present, however, it remains unclear whether early intervention prolongs survival or changes the natural history of the disease, especially in those patients who present with a seizure and a normal interictal examination.

The changing clinical presentation of complete molar pregnancy

OBJECTIVE

To determine if the clinical presentation of complete hydatidiform mole has changed in recent years compared with historic controls (1965-1975).

METHODS

Chart review of all 74 patients referred to the New England Trophoblastic Disease Center for the primary management of complete hydatidiform mole during 1988-1993 was performed and comparison made to historic controls (1965-1975).

RESULTS

Vaginal bleeding remained the most common presenting symptom, occurring in 62 of 74 (84%) current patients, compared with 297 of 306 (97%) controls (P = .001). However, anemia was present in only four of 74 (5%) current patients, compared with 165 of 306 (54%) controls (P = .001). Excessive uterine size, preeclampsia, and hyperemesis occurred in only 21 of 74 (28%), one of 74 (1.3%), and six of 74 (8%) current patients, respectively, compared with 156 of 306 (51%), 83 of 306 (27%), and 80 of 306 (26%), respectively, of historic controls (P = .001). No cases of clinical hyperthyroidism or respiratory distress were found in recent years. Ultrasound diagnosed complete hydatidiform mole before the onset of clinical symptoms in seven of 69 (10%) current patients. Among patients not receiving chemoprophylaxis, persistent gestational trophoblastic tumor developed in 23% of current patients and 18.6% of historic controls.

CONCLUSION

Fewer current patients with complete hydatidiform mole present with the traditional symptoms of complete hydatidiform mole (excessive uterine size, anemia, preeclampsia, hyperthyroidism, or hyperemesis) when compared with historic controls. However, there has been no statistically significant change in the development of persistent gestational trophoblastic tumor in current patients compared with historic controls.

C1-C2 posterior cervical fusion: long-term evaluation of results and efficacy

Posterior wiring techniques are the most commonly used methods of achieving C1-C2 arthrodesis. Recently, transarticular screw fixation and interlaminar clamping have been advocated to achieve more secure fixation. A retrospective review of patients undergoing C1-C2 fusion for nonneoplastic disease was undertaken at the University of Toronto Hospital, with the aim of determining the long-term outcome of the selected procedures. Thirty-two patients underwent 36 procedures from 1986 to 1992, with a mean follow-up of 4.7 +/- 2.2 years (range, 2.0-8.0 yr). The most common disease processes were odontoid fracture (18 patients), transverse atlantal ligament injury (5 patients), os odontoideum (5 patients), and rheumatoid C1-C2 instability (3 patients). Thirty-one Gallie fusions, one Brooks-Jenkins fusion, two transarticular screw fusions, and two Halifax clamp applications were performed. Six (19%) of Gallie/Brooks-Jenkins fusions failed. These occurred with os odontoideum (three patients), Type II odontoid fracture (two patients), and transverse atlantal ligament injury (one patient). All transarticular screw and Halifax clamp procedures resulted in successful fusions. Two procedures (6%) resulted in new neurological deficit; both of these patients underwent posterior wiring for os odontoideum. This study suggests that Type II odontoid fractures may be successfully managed by a posterior wiring technique alone. Rheumatoid C1-C2 instability may be managed by posterior wiring supplemented with halo immobilization. Transarticular screw fixation has several potential advantages as a technique for C1-C2 arthrodesis and, in particular, may be appropriate for os odontoideum that had a high failure rate (75%) with conventional posterior wiring, even when this was supplemented with halo bracing.

Port site fascia closure in laparoscopic assisted colectomy: a simple technique

The importance of port site fascia closure after laparoscopic procedures has been recently recognized as an increasing number of port site hernias have been reported. We present a simple technique of port site closure after laparoscopic-assisted colon resections.