Transrectal high-intensity focused ultrasound (HIFU) for management of rectosigmoid deep infiltrating endometriosis: results of Phase-I clinical trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) of the rectosigmoid is associated with painful symptoms. When medical treatment is ineffective, surgical resection remains the standard treatment, despite significant risk of adverse events. High-intensity focused ultrasound (HIFU) is a minimally invasive ablative procedure. Focal One® is a transrectal HIFU (TR-HIFU) device used in prostate cancer treatment. The primary objective of this study was to confirm the feasibility of treatment with TR-HIFU in patients presenting with posterior DIE with rectosigmoid involvement. We also assessed its safety and clinical efficacy in this context.

METHODS

This was a non-controlled, prospective, Phase-I clinical trial in a French University Hospital which is a multidisciplinary center for management of endometriosis. Included were patients older than 25 years, without plans to conceive within 6 months, who presented with a single lesion of posterior DIE, with rectosigmoid invasion, after failure of hormonal therapy. All lesions were assessed preoperatively using transvaginal sonography and magnetic resonance imaging. Patients completed questionnaires on gynecological and intestinal symptoms (similar to a visual analog scale (VAS)), and on quality of life (Medical Outcomes Study 36-item short-form survey (SF-36) and, for the second half of patients recruited, symptom scoring system for constipation (KESS), female sexual function index (FSFI) and endometriosis health profile short-version score (EHP-5)), before, and at 1, 3 and 6 months after, TR-HIFU treatment with a Focal One real-time ultrasound-guided HIFU device.

RESULTS

Twenty-three consecutive patients were included in the study between September 2015 and October 2019. All 23 lesions were visualized, giving a detection rate of 100%. Twenty lesions were treated ('feasibility rate', 87.0%): in 13 the whole lesion was treated and in seven the lesion was treated partially. The mean duration of the TR-HIFU procedure was 55.6 min. We observed a significant improvement in VAS score at 6 months, with differences relative to preoperative scores as follows, for: dysmenorrhea (-3.6, P = 0.004), dyspareunia (-2.4, P = 0.006), diarrhea (-3.0, P = 0.006), constipation (-3.0, P = 0.002), dyschezia (-3.2, P = 0.003), false urge to defecate (-3.3, P = 0.007), posterior pelvic pain (-3.8, P = 0.002) and asthenia (-3.8, P = 0.002). There was also a significant improvement in the SF-36 score, with an increase at 6 months relative to the preoperative score in both the physical component summary (+ 9.3%, P = 0.002) and mental component summary (+ 10.9%, P = 0.017). No major complications occurred during or after any procedure.

CONCLUSIONS

TR-HIFU therapy for posterior DIE is feasible. If its efficacy and safety are confirmed, it could be a minimally invasive alternative to surgery for the treatment of rectosigmoid endometriosis. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Hyperosmolar hyperglycemic non ketotic coma and rhabdomyolysis; an uncommon clinical encounter

Rhabdomyolysis is usually attributed to trauma. However there is an association of rhabdomyolysis with hyperosmolar states. Recognition of this association will enable better management of the patient and reduce the burden on the care taker by preventing the onset of complications that can prove fatal. It is also important to realise that hyperosmolar coma can be the presenting complaint of a diabetic seeking medical attention for the first time.

Perforated choledochal cyst in a Jehovah's Witness patient

Perforation is a rare presentation of a choledochal cyst. The case reported is a 9-month-old female baby with a perforated choledochal cyst. Being a Jehovah's Witness, blood tranfusion was refused. Apart from highlighting this social dilemma, the suitability of a cystojejunostomy as a temporary measure in the above scenario is evaluated and discussed.

Involution of the sheep mammary gland

Changes in the ovine mammary gland epithelium during initiated involution were studied by light and electron microscopy. Apoptosis of the duct and alveolar epithelial cells was first identified at 2 d after weaning, reached a peak at 4 d and then progressed gradually thereafter. Apoptotic cells were phagocytosed by intraepithelial macrophages and alveolar epithelial cells. Occasional apoptotic epithelial cells were observed in the alveolar and duct lumina. The highly vacuolated cells in the alveolar and duct lumina were confirmed to be macrophages as they were CD45+, MHC class II+. Changes in myoepithelial cells involved shrinkage and extension of cytoplasmic processes into the underlying stroma and no apoptosis was observed. Regression of the blood capillaries was also by apoptosis. The resulting apoptotic bodies were either taken up by adjacent endothelial cells or were shed into the capillary lumen to be phagocytosed later by mural endothelial cells or blood monocytes. The mammary glands were completely involuted by 30 d after weaning. It was concluded that the mammary gland involutes by apoptosis, a process which allows deletion of cells without the loss of the basic architecture and the integrity of the epithelial lining of the gland.

Orthodontic management of the congenital cleft palate patient

Patients with cleft anomalies require extensive and prolonged treatment from birth to adulthood. These patients are subject to the scrutiny of many health disciplines during this comprehensive rehabilitation process. The orthodontist, who is intimately involved from the beginning, must achieve tooth alignment, arch symmetry, and establish a suitable functional occlusion that will provide allied disciplines with the appropriate foundation to optimize their treatment objectives. Each completed treatment phase should be sequential in manner, so as to facilitate and expedite the treatment goals of the other team member. To ensure the continuity of treatment and to satisfy the aesthetic, functional, and socio/psychologic requirements of each case, treatment must be coordinated and closely monitored by periodic team evaluations.

Liver, spleen, and vessels: preliminary clinical results of CT with perfluorooctylbromide

This phase 1-2 trial investigated the use of a 100% wt/vol emulsion of perfluorooctylbromide (PFOB) in computed tomography (CT) of 30 patients with metastatic cancer. Injection of 3 g/kg (maximum dose administered to these patients) provided an average liver enhancement of +31 HU on CT scans obtained after 48 hours. Maximum splenic opacification occurred immediately after injection; 1 g/kg, which allowed an immediate enhancement of +35 HU, appeared sufficient for the diagnosis of splenic conditions. Vascular opacification was insufficient for diagnostic purposes. In four patients with metastases, more lesions were seen with the use of PFOB with CT than with conventional CT. Adverse effects included five cases of low back pain that were reversible when the infusion rate was reduced. Fever and trembling were also noted 6 hours after injection in five patients. In all patients, symptoms regressed spontaneously within several hours. Clinically inapparent and dose-independent splenomegaly (volume increase of at least 20% on CT examinations) was noted in eight patients.

Relationship between systemic 5-FU passage and response in colorectal cancer patients treated with intrahepatic chemotherapy

The study described herein was conducted to analyze the relationship between tumor exposure to 5-FU and clinical response. Six patients were placed on continuous 5-day intrahepatic 5-FU chemotherapy for colorectal cancer metastasized to the liver. The starting dose was 600-800 mg/m2 per day; cycles were repeated at 4-week intervals. The 5-FU dose was increased by 250 mg/day at each cycle. All six patients received 3 or more cycles, for a total of 37 cycles. Response was evaluated after each cycle by ultrasonography or computed tomography (CT). Pharmacokinetic data revealed a high individual cycle-to-cycle variability for all six patients in the 5-FU area under the curve (AUC day 1 to day 5) corrected for the dose. These variations in drug biodisposition, reflecting hepatic 5-FU uptake, were significantly related to measurable modifications in the tumor mass in 71% of cycles. The correlation between the reduction in local drug exposure and tumor regrowth was better than that between the increase in local drug exposure and tumor reduction. These findings constitute an original illustration in humans of the experimental concept of the drug exposure/tumor response relationship for 5-FU.

Continuous 5-day regional chemotherapy by 5-fluorouracil in colon carcinoma: pharmacokinetic evaluation

Eighteen patients with liver metastasis or locoregional recurrence of colon carcinoma received locoregional treatment by continuous 5-day infusions of 5-FU. 5-FU blood levels were measured by HPLC every day of the cycle at 8 am and 5 pm for a total of 87 cycles. Twelve patients were given the drug by an intra-arterial hepatic (i.a.h.) route, 3 by the portal vein (i.p.v.) and 3 by an intra-arterial pelvic (i.a.p.) route. These three routes were compared in respect of their relative pre-systemic drug uptake and the effect of dose escalation. Both the i.a.h. and i.p.v. routes, but not the i.a.p. route, resulted in a significant reduction in AUC 0-105 h compared to the i.v. route at the same dose range. Increasing the dose led to a modification in circulating 5-FU levels proportional to the dose for the i.v. and i.a.p. routes. By contrast, for the i.a.h. and i.p.v. routes, systemic drug delivery was significantly elevated, out of proportion with the dose, indicating a saturable process. For the i.a.h. route, increasing the 5-FU dose from 780 to 1000 mg m-2 day-1 caused a drop in hepatic extraction from 0.93 (0.90-0.95) to 0.44 (0.21-0.66). Liver saturation mechanisms were also evidenced by a mean increase of 2.6 times for the circulating drug level during the second part of the cycle as compared to the first part (P less than 0.001). The evolution of 5-FU AUC 0-105 h as a function of the dose was exponential (r = 0.75, P less than 0.001). Local extraction consecutive to i.a.p. was non-existent, implying that this route of drug administration has no potential advantage over classical i.v. infusion.

The quadrilateral analysis: a differential diagnosis for surgical orthodontics

The integration of the diagnostic and treatment skills of both the orthodontist and the maxillofacial surgeon has become a standard procedure in the treatment of severe dentofacial dysplasias. Orthognathic surgery, surgery without prior tooth movement, is being replaced by an interdisciplinary approach as the treatment of choice. When a proper tooth-to-denture-base relationship is obtained, an ideal maxillomandibular relationship can be achieved surgically. The quadrilateral analysis enables the practitioner to obtain an individualized skeletal, dental, and soft-tissue assessment of each patient requiring treatment. It determines the direction and extent of the skeletal dysplasia in millimeter measurements and allows the clinician to outline the appropriate surgical orthodontic procedures. The quadrilateral analysis indicates that in a balanced facial pattern a 1:1 ratio exists between the maxillary bony base length (Max.Lth.) and the mandibular bony base length (Mand.Lth.); also that the average of the anterior lower facial height (ALFH) and the posterior lower facial height (PLFH) equals these bony base lengths. Simply stated, the Max.Lth. = Mand.Lth. = (formula; see text) An accurate diagnosis locates the area and quantifies the magnitude of skeletal dysplasia. Then the correct placement of a dentition within the denture bases and the appropriate surgery in the area of dysplasia can produce an individualized, balanced facial pattern.

The quadrilateral analysis: an individualized skeletal assessment

There must be a change in our approach to orthodontic diagnosis, especially in those cases involving skeletal dysplasias. The orthodontic practice of today requires a more in-depth diagnostic approach before a realistic treatment plan can be developed. An understanding of the problem that exists is emerging as the essential ingredient before appliance therapy can begin. Diagnosis should dictate the direction of treatment for both the orthodontist and the surgeon. A cephalometric analysis should be able not only to detect but to locate the area of the skeletal dysplasia. Surgery, if at all possible, should be performed where the problem exists. In many cases, it becomes rather confusing to determine whether or not surgical orthodontic treatment is indicated, because most of the cephalometric measurements that are used do not reveal whether a skeletal problem exists, its location, or its magnitude. We believe that current cephalometric analyses do not completely recognize the extent of the dysplasia or where it is located within the jaws. Because of this, surgery is performed by repositioning bones to mask the defect rather than to restore a normal balance between the bones of the face. The only recourse the surgeon has is to achieve an acceptable facial profile by relying on cephalometric norms or to make the necessary correction on what appears visually to be an acceptable profile. The quadrilateral analysis offers an individualized cephalometric diagnosis on patients with or without skeletal dysplasias. We believe that it is a reliable and accurate method of assessing whether orthodontic treatment, surgical treatment, or a combination of both is required to achieve a satisfactory result.

Tandem concept in the nonextraction treatment of class II malocclusion

1. A systematic controlled nonextraction approach in the treatment of certain Class II malocclusions exhibiting arch-length deficiencies has been presented. 2. Clinical cases, diagnostic criteria for case selection, the biomechanics of this tandem force system, time sequence in tooth movement, and ways to avoid untoward sequelae have also been offered. 3. The major advantages in utilizing the basic extraoral appliance and auxiliary mechanisms are as follows: A. various groups of tooth movements are initiated in one or more areas of both dental arches simultaneously. B. Orthodontic pressures are within physiologic limits. C. A minimum number of bands is required. D. Positive control of anchorage is ensured. E. Class II mechanics is not necessary. 4. In each of the four cases presented, the anteroposterior and mediolateral changes that occurred resulted in an increase in the linear length and width of the maxillary and mandibular dental arches. A sufficient increase in the maxillary apical base was also noted and may prove to be a significant yardstick in measuring the stability index of each case. 5. Photographic and cephalometric evaluation revealed that the facial contour and the relative position of the mandibular incisors were not adversely affected.