[Proposal for the delineation of postoperative primary clinical target volumes in maxillary sinus and nasal cavity cancers]

In this article, we propose a consensus delineation of postoperative clinical target volumes for the primary tumour in maxillary sinus and nasal cavity cancers. These guidelines are developed based on radioanatomy and the natural history of those cancers. They require the fusion of the planning CT with preoperative imaging for accurate positioning of the initial GTV and the combined use of the geometric and anatomical concepts for the delineation of clinical target volume for the primary tumour. This article does not discuss the indications of external radiotherapy (nor concurrent systemic treatment) but focuses on target volumes when there is an indication for radiotherapy.

Radiation therapy of the primary tumour and/or metastases of digestive metastatic cancers

Metastatic gastrointestinal cancer is not an uncommon situation, especially for pancreatic, gastric, and colorectal cancers. In this setting, few data are available on the impact of the treatment of the primary tumour. Oligometastatic disease is associated with longer survival in comparison with more advanced disease. Metastasis-directed therapy, such as stereotactic body radiotherapy, seems related to better outcomes, but the level of evidence is low. In most tumour locations, prospective data are very scarce and inclusion in ongoing trials is strongly recommended.

Stereotactic body radiation therapy for liver metastases in oligometastatic disease

Oligometastatic cancers designate cancers in which the number of metastases is less than five, corresponding to a particular biological entity whose prognosis is situated between a localized and metastatic disease. The liver is one of the main sites of metastases. When patients are not suitable for surgery, stereotactic body radiotherapy provides high local control rate, although these data come mainly from retrospective studies, with no phase III study results. The need for a high therapeutic dose (biologically effective dose greater than 100Gy) while respecting the constraints on the organs at risk, and the management of respiratory movements require expertise and sufficient technical prerequisites. The emergence of new techniques such as MRI-guided radiotherapy could further increase the effectiveness of stereotactic radiotherapy of liver metastases, and thus improve the prognosis of these oligometastatic cancers.

Pembrolizumab versus cetuximab concurrent with radiotherapy in patients with locally advanced squamous cell carcinoma of head and neck unfit for cisplatin (GORTEC 2015-01 PembroRad): a multicenter, randomized, phase II trial

BACKGROUND

To evaluate potential synergistic effect of pembrolizumab with radiotherapy (RT) compared with a standard-of-care (SOC) cetuximab-RT in patients with locally advanced-squamous cell carcinoma of head and neck (LA-SCCHN).

PATIENTS AND METHODS

Patients with nonoperated stage III-IV SCC of oral cavity, oropharynx, hypopharynx, and larynx and unfit for receiving high-dose cisplatin were enrolled. Patients received once-daily RT up to 69.96 Gy in 33 fractions with weekly cetuximab (cetuximab-RT arm) or 200 mg Q3W pembrolizumab during RT (pembrolizumab-RT arm). The primary endpoint was locoregional control (LRC) rate 15 months after RT. To detect a difference between arms of 60%-80% in 15-month LRC, inclusion of 66 patients per arm was required to achieve a power of at least 0.85 at two-sided significance level of 0.20.

RESULTS

Between May 2016 and October 2017, 133 patients were randomized to cetuximab-RT (n = 66) and pembrolizumab-RT (n = 67). Two patients (one in each arm) were not included in the analysis (a consent withdrawal and a progression before treatment start). The median age was 65 years (interquartile range 60-70 years), 92% were smokers, 60% were oropharynx (46% of oropharynx with p16+) and 75% were stage IV. Median follow-up was 25 months in both arms. The 15-month LRC rate was 59% with cetuximab-RT and 60% with pembrolizumab-RT ]odds ratio 1.05, 95% confidence interval (CI) 0.43-2.59; P = 0.91]. There was no significant difference between arms for progression-free survival (hazard ratio 0.85, 95% CI 0.55-1.32; P = 0.47) and for overall survival (hazard ratio 0.83, 95% CI 0.49-1.40; P = 0.49). Toxicity was lower in the pembrolizumab-RT arm than in the cetuximab-RT arm: 74% versus 92% patients with at least one grade ≥3 adverse events (P = 0.006), mainly due to mucositis, radiodermatitis, and rash.

CONCLUSION

Compared with the SOC cetuximab-RT, pembrolizumab concomitant with RT did not improve the tumor control and survival but appeared less toxic in unfit patients with LA-SCCHN.

[Challenges and limits of therapeutic de-escalation for papillomavirus-related oropharyngeal cancer]

The incidence of HPV-related oropharyngeal cancers has been increasing in Western countries for several decades. If they are individualized within the latest TNM classification, the current standards of management do not authorize the management of these patients to be singled out. However, their distinct oncogenesis and their excellent prognosis compared to other patients has allowed the development of several clinical trials based on the question of therapeutic de-escalation. This review of the literature aims to take stock of the elements provided by clinical research in recent years.

Radiation therapy and antiangiogenic therapy: Opportunities and challenges

The importance of tumoral vascularization as a therapeutic target was first described in 1971 by Folkman. Anarchic vascularization in response to tumour hypoxia, especially mediated by vascular endothelial growth factor, represents a major target in the management of many cancers. The contribution of systemic anti-angiogenic treatments including humanized anti-VEGF monoclonal antibodies (bevacizumab) and tyrosine kinase inhibitors, whose effect on vascular normalization and correction of tumour hypoxia has been shown in preclinical studies to be enhancing the effect of radiotherapy. Early trials combining radiotherapy and antiangiogenics with a small number of patients have contradictory results and tend to put into perspective the opportunity that this synergistic association represents. The efficiency found must be tempered by some toxicity described, especially in association with high doses per fraction. The aim of this article is to present the main studies reporting the efficiency and safety of the combination of antiangiogenic drugs and radiotherapy, as well as the expected opportunities.

Radiotherapy for cancers of the oesophagus, cardia and stomach

We present the updated recommendations of the French society for radiation oncology on radiotherapy of oesophageal cancer. Oesophageal cancer still remains a malignant tumour with a poor prognosis. Surgery remains the standard treatment for localized cancers, regardless of histology. For locally advanced stages, surgery remains a standard for adenocarcinomas after neoadjuvant treatment with chemotherapy or chemoradiotherapy. However, it is a therapeutic option after initial chemoradiotherapy for stage III squamous cell carcinomas, given the increased morbidity and mortality with a multimodal treatment, which results in an equivalent overall survival with or without surgery. Preoperative or exclusive chemoradiotherapy should be delivered according to validated regimens with an effective total dose (50Gy), if surgery is not planned or if the tumour is deemed resectable before chemoradiotherapy. Intensity-modulated radiotherapy significantly reduces irradiation of the lungs and heart and may reduce the morbidity of this treatment, especially in combination with surgery. In case of exclusive chemoradiotherapy, dose escalation beyond 50Gy is not currently recommended. Some technical considerations still remain questionable, such as the place of prophylactic lymph node irradiation, adaptive radiotherapy, evaluation of response during and after chemoradiotherapy and the value of proton therapy.

Rectal cancer radiotherapy

We present the updated recommendations of the French society of oncological radiotherapy for rectal cancer radiotherapy. The standard treatment for locally advanced rectal cancer consists in chemoradiotherapy followed by radical surgery with total mesorectal resection and adjuvant chemotherapy according to nodal status. Although this strategy efficiently reduced local recurrences rates below 5% in expert centres, functional sequelae could not be avoided resulting in 20 to 30% morbidity rates. The early introduction of neoadjuvant chemotherapy has proven beneficial in recent trials, in terms of recurrence free and metastasis free survivals. Complete pathological responses were obtained in 15% of tumours treated by chemoradiation, even reaching up to 30% of tumours when neoadjuvant chemotherapy is associated to chemoradiotherapy. These good results question the relevance of systematic radical surgery in good responders. Personalized therapeutic strategies are now possible by improved imaging modalities with circumferential margin assessed by magnetic resonance imaging, by intensity modulated radiotherapy and by refining surgical techniques, and contribute to morbidity reduction. Keeping the same objectives, ongoing trials are now evaluating therapeutic de-escalation strategies, in particular rectal preservation for good responders after neoadjuvant treatment, or radiotherapy omission in selected cases (Greccar 12, Opera, Norad).

COMT rs4818, pain sensitivity and duration, and alveolar bone grafting of oral clefts

PURPOSE

Verifying whether the mutation in COMT rs4818 could be involved in pain modulation.

METHODS

Thirty-two individuals born with cleft lip and palate that underwent bone graft from the iliac crest bone were assessed at 12, 24, 48, 72 h, and 7 days regarding their pain experience using a visual analogic scale. DNA from each participant was collected from saliva samples, and genotyping of rs4818 was performed using TaqMan chemistry. Overrepresentation of rs4818 alleles was tested using chi-square or Fisher's exact tests with an alpha of 0.05.

RESULTS

Of the 32 individuals, eighteen reported long pain duration, nine reported high pain intensity, and fourteen low pain intensity up to 48 h. No differences were found in the distribution of individuals depending on the reported pain by sex (p = 0.12), age (p = 0.42), or cleft type (p = 0.5). The distribution of COMT r4818 alleles was different depending on the intensity and duration of pain. Carriers of the C wild-type allele were four times more likely to show high pain intensity and duration (odds ratio = 4.29, 95% confidence interval 1.13-16.18), meaning that the G variant allele is protective.

CONCLUSION

COMT rs4818 is associated with postoperative pain after alveolar bone grafting.

Tolerance and efficacy of dose escalation using IMRT combined with chemotherapy for unresectable esophageal carcinoma: Long-term results of 51 patients

PURPOSE

The optimal dose in esophageal cancer patients treated with definitive chemoradiation (CRT) remains debated. We herein report on the dosimetric results, treatment-related toxicities and long-term outcomes of escalated dose up to 60Gy delivered with intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

All consecutive patients that received a definitive CRT>50Gy for an unresectable esophageal carcinoma between 2010 and 2015 were retrospectively evaluated for this study. Methodology included data base search, delayed toxicity grading, statistical testing including frequency analysis and survival analysis.

RESULTS

A total of 51 patients were irradiated for a squamous cell carcinoma (86.3%) or an adenocarcinoma (13.7%). The median age at diagnosis was 62 years. Seven patients were simultaneously irradiated for another synchronous primary tumor. Forty-six patients (90.2%) received concurrent platin-based chemotherapy. The median prescribed doses were 60Gy (54-66) and 48Gy (44.8-56) delivered in 30 (27-35) fractions to the high and the low risks PTV respectively. The mean dose delivered to the lungs was 11.4Gy (IC 95%: 4.8-19.8), the median volumes receiving up to 20Gy (V20) and 30Gy (V30) were 13.5% (3.0-46.0) and 4.6% (0.7-19.8) respectively. The mean dose delivered to the heart was 13.9Gy (IC 95%:0.3-31.3) with a median V40 of 3.3% (0.0-25.0). One treatment-related death occurred within days after RT completion (neutropenic aplasia). After a median follow-up of 2.7 years (95% CI: 1.9-4.3), the 2-year overall survival, disease free survival and loco-regional control rates were 53.6%, 42.0% and 72.8% respectively. Delayed treatment related-toxicities ≤grade 3 occurred among 25 patients (62.5%) mostly esophageal stricture (79.2%).

CONCLUSION

We demonstrated in this study that dose escalation using IMRT in combination with platin-based chemotherapy as a definitive treatment for esophageal carcinoma is safe and results in higher loco-regional and control survival when compared to previously reported data.

[Definitive or neo-adjuvant chemoradiation in esophageal carcinoma?]

Management of resectable esophageal carcinoma is based on a multimodal treatment associating neo-adjuvant chemoradiation before surgery. This therapeutic sequence allows a disease-free survival rate at 2 years around 45% but remains associated with a high post-operative morbidity. In case of definitive chemoradiotherapy, the dose delivered to the macroscopic disease is a controversial topic since decades and the prognosis of patients treated in this setting at the dose of 50Gy remains poor. This article proposes a review of the main published data and the ongoing studies related to the management of these patients.

[Stereotactic hypofractionated radiation therapy as a bridge to transplantation for hepatocellular carcinoma: Case report of a complete pathological response and review of the literature]

Patients with hepatocellular carcinoma who are on liver transplant waiting list usually require local treatment to limit any risk of tumour growth. Historically percutaneous radiofrequency ablation or transarterial chemoembolization represented the major therapeutic alternatives. Depending on the size, or the topography of the lesion these two techniques may not be feasible. Radiation therapy under stereotactic conditions has recently emerged in the management of localized hepatocellular carcinoma as an alternative to the focused therapies performed to date. We herein report the case of a 43-year-old patient harbouring a complete histological response on explant after liver stereotactic irradiation and discuss its role in the management of hepatocellular carcinoma before liver transplantation.

[Uncommon dermatologic disorders triggered by radiation therapy of breast cancer: A case-series]

Radiotherapy's main skin toxicities are now well-separated, acute (acute radiation dermatitis) or chronic complications (chronic radiation dermatitis, induced cutaneous carcinoma, aesthetic sequelae). Exceptionally, radiotherapy may induce, by isomorphic reaction or Koebner's phenomenon, some specific dermatosis. In this article, we report five new observations of these unusual complications of radiation therapy, occurring in very variable time after breast irradiation and remaining strictly localized in the irradiated field (cutaneous mastocytosis, Sweet syndrome, lichen planus, vitiligo). These cases emphasize the need to realize a systematic histological exam if any atypical skin lesion appears after radiotherapy, even long after.

[Breast ductal carcinoma in situ with microinvasion: pathological review and clinical implications]

PURPOSE

Recent improvements in the detection of breast cancer at an early stage have resulted in a rising incidence of breast ductal carcinoma in situ with microinvasion. So far, there is no consensus regarding its optimal management. We hereby report on our 10-year single institutional experience in breast ductal carcinoma in situ with microinvasion including pathological reviewing.

PATIENTS AND METHODS

All consecutive patients treated for a ductal carcinoma in situ with microinvasion at the Institut Claudius-Regaud (Toulouse, France) over a 10-year period were included in this study. We reviewed all available histological materials.

RESULTS

Sixty-three patients were eligible for this study. Two patients presented with a lymph node invasion at diagnosis. Each patient benefited from initial surgical management, which consisted either in mastectomy (n=25) or conservative resection (n=37). Axillary exploration was performed in 52 patients (82%). After a median follow-up of 61.3 months [46.9;69], the 5-year overall survival and disease free survival were 98.2 (95% CI=[88.2;99.7]) and 89.5% (95% CI=[76.3;95.6]) respectively. Two delayed invasive relapses occurred leading to one specific death. The pathological review highlighted a trend towards a loss of HR and HER2 expression (9%) in the microinvasive component in comparison with its surrounded in situ carcinoma.

CONCLUSION

The risk of initial lymph node involvement and delayed invasive local relapse deserve an optimal locoregional management including lymph node evaluation. The non-negligible discrepancy's rate between in situ and microinvasive components justifies HR status and HER2 expression assessment on the microinvasive component.

Role of radiation therapy in the conservative management of sarcoma within an irradiated field

PURPOSE

To report on clinical outcome and toxicity profile after combined treatment that included radiation therapy (RT) in patients with localized sarcoma within an irradiated field.

PATIENTS AND METHODS

Individual clinical data from all consecutive patients diagnosed and treated for a localized SIF between January 2000 and October 2011 at the Institut Claudius Regaud, Toulouse, France, were retrospectively reviewed. Outcomes of patients with SIF who underwent adjuvant or definitive radiotherapy were compared with patients who did not receive further RT.

RESULTS

Of the 27 patients eligible for this study: surgery alone (S), surgery followed by RT (S + RT) or definitive RT (RT) was performed in 16, 8 and 2 cases respectively. The rate of unresectable, gross or microscopically positive margin disease among the 10 re-irradiated patients was significantly higher than the non re-irradiated group (90% vs. 12% p < 0.001). After a median follow-up of 3.8 years, there was a trend toward longer survival and better local control in the subgroup of patients who received adjuvant or definitive RT compared to the rest of the cohort with an acceptable toxicity profile. The 4-year relapse free survival rates of patients treated with and without RT were 53% and 27% respectively (p = 0.09).

CONCLUSION

SIF complete surgical resection is often difficult to achieve, enhancing the risk of relapse. RT should be discussed in case of unresectable tumor or after suboptimal surgery as part of intensified local management that has a curative intent.

[Evaluation and management of acute radiation dermatitis]

Acute radiation dermatitis remains one of the most commonly observed side effect during radiation therapy leading to complication such as superinfection or treatment disruption. Its management is characterized by a great heterogeneity. Few strategies have demonstrated a benefit in preventing radiation dermatitis, which relies mostly on decreasing dose delivered to the skin and skin care practices. Simple emollients and use of topical steroids can be useful in early stages. The singularity of the skin toxicity seen with cetuximab and radiotherapy warrants a specific grading system and distinctive clinical treatment with use of antibiotics.

Summary of the IADR Cariology Research Group Symposium, Barcelona, Spain, July 2010: new directions in cariology research

Caries remains the most prevalent noncontagious biofilm-mediated disease in humans. It is clear that the current approaches to decrease the prevalence of caries in human populations, including water fluoridation and school-based programs, are not enough to protect everyone. The scientific community has suggested the need for innovative work in a number of areas in cariology, encompassing disease etiology, epidemiology, definition, prevention, and treatment. In this symposium, two of these areas, dealing specifically with etiological aspects of caries were discussed: (1) systematic research on caries risk assessment using population-based cohort techniques, and (2) genetic studies to identify genes and genetic markers of diagnostic, prognostic, and therapeutic value. This paper summarizes these presentations.

Axis inhibition protein 2 (AXIN2) polymorphisms and tooth agenesis

Tooth agenesis is a common congenital disorder that affects almost 20% of the world's population. A number of different genes have been shown to be associated with cases of tooth agenesis including AXIN2, IRF6, FGFR1, MSX1, PAX9, and TGFA. Of particular interest is AXIN2, which was linked to two families segregating oligodontia and colorectal cancer. We studied two collections of families affected with tooth agenesis and tested them for association with AXIN2. Significant association between tooth agenesis and AXIN2 was found (p=0.02) in cases with at least one missing incisor. Our work further supports a role of AXIN2 in human tooth agenesis and for the first time suggests AXIN2 is involved in sporadic forms of common incisor agenesis. Future studies should identify which specific tooth agenesis sub-phenotypes are consequence of AXIN2 genetic variations. A sub-set of these cases could have an increased susceptibility for colon cancer or other types of tumours and this knowledge would have significant clinical implications.

An unusual cause of acute renal failure in a kidney transplant recipient: Salmonella enteritidis post-infectious glomerulonephritis

BACKGROUND

Salmonella enteritidis-associated acute renal failure has often been described and is usually a result of dehydration or of rhabdomyolysis. A few cases of acute renal failure with glomerular syndrome, caused by S. enteritidis infection, have been reported in the literature, but none have been proven by histological findings.

METHODS

Herein, we report on a case of S. enteritidis-related glomerulonephritis that occurred in a 42-year-old male transplant recipient. He was admitted with fever, signs of urinary infection, diarrhea, and nephritic syndrome, i.e. edema, hypertension, increase in serum creatinine, microscopic hematuria, proteinuria. His urine culture tested positive for S. enteritidis.

RESULTS

Under light microscopy, the graft biopsy showed proliferative and exudative endocapillary glomerulonephritis. In addition, there was polymorphonuclear infiltration of the interstitium, and extra-capillary proliferation in one glomerulus. Immunofluorescence showed granular deposits of C3 in the mesangium. Electron microscopy showed electron-dense deposits typical of humps. He fully recovered on a double antibiotic therapy that included ofloxacin and amikacin.

CONCLUSION

Although acute renal failure related to non-typhoidal Salmonella infections are often related to dehydration or rhabdomyolysis, this case report shows that it might also be related to immune complex-mediated glomerulonephritis manifesting as nephritic syndrome.

Thrombotic microangiopathy in a sirolimus-treated renal transplant patient receiving gemcitabine for lung cancer

BACKGROUND

Many etiologies lead to thrombotic microangiopathy (TMA), amongst which are antineoplastic chemotherapies. Gemcitabine, a nucleoside analogue, has been approved for the treatment ofbladder and advanced non-small cell lung carcinomas (NSCLC). The reported incidence of gemcitabine-associated TMA in the literature is low, ranging from 0.015-0.31%.

METHODS

Herein, we describe the first reported case of gemcitabine-induced TMA in a renal transplant patient. This occurred in a 54-year-old male transplant recipient undergoing sirolimus-based immunosuppression. In February 2005, he was diagnosed to have NSCLC, for which he received dual chemotherapy, including carboplatin and gemcitabine. After the third cycle he developed TMA.

RESULTS

On admission, he presented with weakness, edema, normal blood pressure, leucopenia (2440/mm3), thrombopenia (11,000/mm3), hemolytic anemia with hemoglobin at 8 g/dl, schistocytes between 18-33% per hundred, increase in lactate dehydrogenase at 600 IU/l (N <380), and decreased haptoglobin at 0.29 g/l. Renal function was stable: serum creatinine was 1.3 mg/dl, albuminemia 30 g/l, proteinuria was present at 3 g/l in association with microscopic hematuria, and sirolimus trough level was 6.4 ng/ml. Treatment included infusions of fresh frozen plasma, withdrawal of sirolimus, which was replaced by mycophenolate mofetil, and suspension of chemotherapy. He fully recovered from TMA within 4 weeks. The concomitant use of sirolimus, which inhibits vascular endothelial growth factor, plus gemcitabine may have resulted in TMA.

MSX1 and orofacial clefting with and without tooth agenesis

MSX1 has been considered a strong candidate for orofacial clefting, based on mouse expression studies and knockout models, as well as association and linkage studies in humans. MSX1 mutations are also causal for hereditary tooth agenesis. We tested the hypothesis that individuals with orofacial clefting with or without tooth agenesis have MSX1 coding mutations by screening 33 individuals with cleft lip with or without cleft palate (CL/P) and 19 individuals with both orofacial clefting and tooth agenesis. Although no MSX1 coding mutations were identified, the known 101C > G variant occurred more often in subjects with both CL/P and tooth agenesis (p = 0.0008), while the *6C-T variant was found more often in CL/P subjects (p = 0.001). Coding mutations in MSX1 are not the cause of orofacial clefting with or without tooth agenesis in this study population. However, the significant association of MSX1 with both phenotypes implies that MSX1 regulatory elements may be mutated.

Gastrointestinal stromal tumour: spiral computed tomography features and pathologic correlation

PURPOSE

Our purpose was to define the diagnostic accuracy of helical computed tomography (CT) in the identification, characterisation and evaluation of extension of gastrointestinal stromal tumours (GIST) through correlation with some pathological findings.

MATERIALS AND METHODS

Between August 2000 and September 2004, we conducted a retrospective study of the abdominal CT of 15 patients with histological diagnosis of GIST - that is, the immunopositivity for c-kit (CD117) - on a surgical specimen of the primary disease. We used a helical CT single-slice (Toshiba, Asteion; rotation time 0.75 s) in ten cases and helical CT multislice (Toshiba, Aquilion; 4 slices/rotation; rotation time 0.5 s) in five cases. In all cases, we used an organ-iodate nonionic contrast agent intravenously at a concentration of 350-400 mgI/ml. All cases studied the entire abdomen. Site, morphology and tumour size (smaller than 5 cm, 5-10 cm and larger than 10 cm) were considered parameters for tumour identification. Size, partial or total extraluminal tumour growth, homogeneous or inhomogeneous lesion enhancement and the eventual presence of calcifications were assumed to be criteria for characterisation of a GIST. Hepatic, peritoneal and/or lymph node metastases were considered parameters of intermediate or high malignancy. We correlated the results with some pathological features derived from the analysis of surgical tissue: site, morphology and tumour size, tissue components and risk of malignancy of GIST (on the basis of the 2002 Fletcher classification).

RESULTS

We demonstrated one substantial concordance between radiological and pathological valuation of site, morphology, tumour size and absence of intralesional calcifications of GIST. Nine of ten GIST smaller than 5 cm, the two 5-10 cm and the three larger than 10 cm presented extraluminal growth. Enhancement was inhomogeneous in five of ten lesions smaller than 5 cm and in all cases larger than 5 cm. At pathological analysis, in all cases of inhomogeneous enhancement, solid, hemorrhagic, necrotic and cystic areas were found. Of seven tumours of intermediate malignancy, six were smaller than 5 cm and only one larger than 10 cm; the two 5-10 cm were of high malignancy and all tumours superior of 10 cm were at intermediate or high malignancy. Of the two cases with metastases, one was of intermediate and one of high malignancy. In the other cases of intermediate or high malignancy, metastases were absent.

CONCLUSIONS

The immunopositivity for c-kit is requisite for definitive diagnosis of GIST, but imaging, and particularly helical CT, has a primary role. In this study, CT is was reliable for tumour identification. All tumours larger than 5 cm presented extraluminal growth, inhomogeneous enhancement, absence of calcifications and lymph node metastases. Furthermore, the tumour larger than 5 cm showed extraluminal growth and inhomogeneous enhancement. Tumour size established with CT was not sufficient to determine the degree of malignancy. Metastases at the time of diagnosis were indicative of intermediate or high malignancy, but the absence of metastases did not allow classification of GIST in the group of low and very low risk of malignancy.

MSX1, PAX9, and TGFA contribute to tooth agenesis in humans

In this study, we sought to determine the association between tooth agenesis and DNA sequence variation in the genes MSX1 and PAX9 in an ethnically diverse human population. Since cleft lip/palate is also associated with both tooth agenesis and the gene TGFA, we included TGFA in the analysis as well. Cheek swab samples were obtained for DNA analysis from 116 case/parent trios. Probands had at least one developmentally missing tooth, excluding third molars. Genotyping was performed by single-strand conformational polymorphism or kinetic polymerase chain-reaction assays. Transmission distortion of the marker alleles and DNA sequence analysis was performed. Results showed that tooth agenesis is associated with markers of the genes MSX1 and TGFA. No mutations were found in MSX1 or PAX9 coding regions. There were statistically significant data suggesting that MSX1 interacts with PAX9. These findings suggest that MSX1, PAX9, and TGFA play a role in isolated dental agenesis.

Multislice CT: technical principles and clinical applications

The aim of this article is to describe the main technical differences between multi-slice Computed Tomography (CT) and spiral CT. We also briefly discuss the diagnostic benefits of this new technology which consolidates and expands on the results achieved with spiral CT in the 90s. More specifically, gantry speed and improved spatial resolution in the z axis considerably expand angiographic and cardiac applications, allow high-quality multiplanar and 3D reconstructions, and introduce CT in organ perfusion studies (particularly those of heart and brain).

Formation of alkali-soluble fluoride on the surface of human dental enamel after treatment with fluoridated gels: influence of the pH variation and of the treatment time

The aim of this study was to quantify, in vitro, the formation of CaF2 after the application of three fluoridated gels: one neutral, one acidulated and another highly acidulated, on a bovine enamel dental surface treated with a Dijkman's demineralizing solution (1990). 145 sections were utilized, obtained from 145 sound teeth and divided into seven groups: C (enamel without treatment); FN1 (enamel demineralized and treated with neutral gel for 1 minute); FN4 (enamel demineralized and treated with neutral gel for 4 minutes); FFA1 (enamel demineralized and treated with acidulated gel for 1 minute); FFA4 (enamel demineralized and treated with acidulated gel for 4 minutes); FAA1 (enamel demineralized and treated with highly acidulated gel for 1 minute) and FAA4 (enamel demineralized and treated with highly acidulated gel for 4 minutes). The formation of CaF2 was analyzed by SEM and chemically by Caslavska's method (1975). The average and standard deviations from the groups studied were respectively: C-0.63; 0.38; FN1-23.06; 16.52; FFA1-54.11; 49.00; FAA1-43.87; 32.66; FN4-34.92; 23.00; FFA4-67.91; 42.36; FAA4-56.03; 38.96. (Mann-Whitney non-parametric test). The time of application did not interfere in the CaF2 formation from the acidulated and highly-acidulated gels. A minor concentration of fluoride and amount of pH from highly-acidulated gel did not affect the higher formation from the CaF2 in relation to the acidulated gel in both cases when the application was evaluated.

Pacifier-sucking associated with a bizarre habit: a case report

A case of a child, who used the pacifier with an uncommon habit is presented. She pulled out the hair on the right side of her head after rolling it round the base of the pacifier. She then sucked it and swallowed it. Based on this report the authors are emphasizing the importance of accompanying the orofacial development of the child as from its first year of life.

Effects of three different infant dentifrices on biofilms and oral microorganisms

The purpose of this work was to evaluate the effects of infant dentifrices: A--with lactoperoxidase, glucose oxidase and lactoferrin; B--with 1100 ppm of NaF and sodium lauryl sulfate; C--with extract of calendula. The dentifrices were test on biofilms formed in vitro from saliva and dental plaque of infants, using reference strains A. viscosus (ATCC 43146); C. albicans (ATCC 51501); L. casei (ATCC 4646); S. mitis (ATCC 49456); S. mutans (ATCC 25175); S. oralis (ATCC 35037); S. sanguis (ATCC 10586); S. sobrinus (ATCC 27609) and isolated clinically microorganisms C. albicans, S. mitis, S. mutans, S. oralis, S. sanguis, S. sobrinus and Lactobacillus sp. Twenty infants were chosen, who were beginning treatment at the Infants Clinic of the Pediatric Dentistry Department, Federal University of Rio de Janeiro. A pool of unstimulated saliva and a pool of dental plaque were collected from which biofilms were produced. Supernatants from each dentifrice were prepared and concentrated and diluted solutions of the dentifrices and a control sterile diluent were tested against the biofilms produced, for 1 and 3 minutes, and against the microorganisms. The results were statistically analyzed by the ANOVA and Tukey Test. After the exposure of the biofilms produced both from saliva and from dental plaque, to the dentifrice B concentrated and 1/2, for 1 and 3 minutes, the viable microorganisms count (CFU/ml), compared to the controls, was significantly reduced (p < 0.05). However, exposure to the dentifrices A and C concentrated and dentifrice B 1/4 and 1/8, for 1 and 3 minutes, was not significantly lethal to the biofilms. The dentifrices A and C, either concentrated or diluted (1/2 to 1/128) and the dentifrice B in the dilutions 1/16 to 1/128 did not have an antimicrobial effect on any microorganism evaluated. For all the microorganisms evaluated, the dentifrice B concentrated and in the 1/2 dilution showed a significant antimicrobial effect, when compared with the control (p < 0.05).

Craniometaphyseal dysplasia: case report

Craniometaphyseal dysplasia is a rare genetic bone remodeling disorder characterized by undertubulation of the long bones, especially in the lower extremities, causing deformities of the metaphyses of the long bones, and sclerosis of the skull base or cranial bone hyperostosis. The authors report a case of craniometaphyseal dysplasia in an 8-year-old Brazilian child, emphasizing the importance of precocious diagnosis of this rare genetic disorder.