Evaluating health perceptions of soft-tissue sarcoma patients using the Wilson-Cleary Model to identify key targets for improving outcomes and quality of care

INTRODUCTION

Soft-tissue sarcoma (STS) is a rare cancer of the connective tissues requiring invasive treatment. Due to the complexity of treatment, STS patients experience more functional impairment and disability than other oncologic populations. Given that extant literature is unclear and exclusively focused on physical function, the objectives of this study were to use the Wilson-Cleary Model of HRQL to evaluate the extent to which biological function (tumor site, depth and size), symptoms (fatigue, pain, anxiety/depression), and functional status are associated with the health perceptions of soft-tissue sarcoma patients 12 months post-op.

METHODS

Data were drawn from an inception cohort study at the McGill University Health Centre. Inclusion criteria included 18 years of age and a biopsy-confirmed diagnosis of STS. Those with evidence of metastasis at diagnosis or less than 12 months of follow-up were excluded. Statistical analyses included T-tests, Pearson correlations, and multiple linear regression.

RESULTS

331 patients were included (185 males, 146 females) with mean (SD) ages of 56 (17). Significantly more females reported pain and anxiety/depression. Self-reported function was significantly higher in males. Overall, the regression model explained 53 % of the variance in health perceptions in males, and 48 % in females. Only self-reported function was significantly associated with health perceptions in males (B = 0.34) and females (B = 0.48). Further, compared to females without pain, females with pain perceived their health as significantly worse.

CONCLUSION

Evaluating health perceptions with a multidimensional lens revealed new information about the STS patient experience. Findings suggest that key targets include routine psychosocial distress monitoring and addressing rectifiable disability-related barriers promptly.

Finding a needle in a haystack: The identification of clinical practice guidelines for psychosocial oncology through an environmental scan of the academic and gray literature

OBJECTIVE

Clinical practice guidelines (CPGs) are evidence-based tools well-suited to translate the latest research evidence into recommendations for routine clinical care. Given the rapid expansion of psychosocial oncology research, they represent a key opportunity for informing the treatment decisions of overburdened clinicians, standardizing service delivery, and improving patient-reported outcomes. Yet, there is little consensus on how clinicians can most effectively access these tools and little to no information on the current availability and scope of CPGs for the range of psychosocial symptoms and concerns experienced by patients with cancer.

METHOD

Our environmental scan consisted of an academic and gray literature designed to identify currently available CPGs addressing a range of cancer-related psychosocial symptoms.

RESULTS

Findings revealed a total of 23 existing psychosocial oncology CPGs that met full eligibility criteria. The gray literature search was found to be more effective at identifying CPGs (n = 22) compared to the academic search (n = 9).

CONCLUSION

Several concerns arose from the systematic search. The limited publication of CPGs in peer-reviewed journals may make clinicians and stakeholders more hesitant to implement CPGs due to uncertainties about the methodological rigor of the development process. Further, many existing CPGs are outdated or failed to be updated according to guideline recommendations, meaning that the recommendations may fall short of their purpose to translate up-to-date research findings.

FUTURE DIRECTIONS

Future research should seek to systematically assess the quality of existing psychosocial oncology CPGs and shed light on the current state of implementation and adherence in clinical practice in order to better inform guideline developers on the current needs of the psychosocial oncology community.

Measurement of Lower Uterine Segment Thickness to Detect Uterine Scar Defect: Comparison of Transabdominal and Transvaginal Ultrasound

OBJECTIVES

Lower uterine segment (LUS) thickness measurement using transabdominal ultrasound (TA-US), transvaginal ultrasound (TV-US), or the combination of both methods can detect scar defect in women with prior cesarean. We aimed to compare the sensitivity of three approaches.

METHODS

Women with prior cesarean underwent LUS thickness measurement at 34-38 weeks' gestation. Among those who underwent repeat cesarean before labor, we compared the accuracy of TA-US, TV-US, and the thinner of the two measurements (the "combined measurement") for uterine scar dehiscence using the area under the curve (AUC) of receiver operating curves with their 95% confidence intervals (CI). We calculated the sensitivity and specificity of the three approaches using a cut-off of 2.3 mm based on prior literature.

RESULTS

We included 747 participants. The mean LUS thickness was greater with TA-US (3.8 ± 1.6 mm) compared with TV-US (3.5 ± 1.9 mm) or the combined measurement (3.2 ± 1.5 mm; P < .001). The AUC was 78% (95% CI: 69%-87%), 85% (95% CI: 79%-91%), and 88% (95% CI: 82%-93%), respectively (all with P < .001). The AUC difference between TA-US and the combined measurement was not significant (P = .057). A LUS below 2.3 mm would have predicted 9 (45%) of the 20 cases of uterine scar dehiscence using TA-US, 17 (85%) using TV-US, and 18 (90%) using the combined measurement (P < .01).

CONCLUSION

The choice of ultrasound approach influences the measurement of the LUS thickness. The combination of the TA-US and TV-US seems to be superior for the detection of uterine dehiscence.

Predictive factors for morcellation during total laparoscopic hysterectomy: a cohort study

OBJECTIVE

Our objective was to identify predictors of morcellation during total laparoscopic hysterectomy (TLH) DESIGN: Retrospective cohort study (Canadian Task Force classification II-2) SETTING: University Hospital Center in XXX PARTICIPANTS: Women undergoing a TLH for a benign gynecologic pathology form January 1st 2017 to January 31st 2019 INTERVENTION: All women underwent a TLH. If the uterus was to voluminous to be removed vaginally, surgeons favored in-bag morcellation by laparoscopy. Uterine weight and characteristics were assessed prior to surgery by ultrasound or MRI in order to predict morcellation.

MAIN RESULTS

A total of 252 women underwent a TLH and the mean age was 46±7 (30-71) years old. The main indications for surgery were abnormal uterine bleeding (77%), chronic pelvic pain (36%) and bulk symptoms (25%). Mean uterine weight was 325 (17-1572)±272 grams, with 11/252 (4%) uterus being >1000 grams and 71% of women had at least one leiomyoma. Among women with a uterine weight <250 grams, 120 (95%) did not require morcellation. On the opposite, among women with a uterine weight >500 grams, 49 (100%) required morcellation. In addition to the estimated uterine weight (≥250 versus <250 grams; OR 3.7 (CI 1.8-7.7, P < 0.01), having ≥ 1 leiomyoma (OR 4.1, CI 1.0-16.0, P = 0.01) and a leiomyoma of ≥5 cm (OR 8.6, CI 4.1-17.9, P < 0.01) were other significant predictors morcellation in multivariate logistic regression analysis.

CONCLUSION

Uterine weight estimated by preoperative imaging as well as the size and number of leiomyomas are useful predictors of the need for morcellation.

Squaramide Tethered Clindamycin, Chloroquine, and Mortiamide Hybrids: Design, Synthesis, and Antimalarial Activity

Malaria remains one of the major health problems in the world. In this work, a series of squaramide tethered chloroquine, clindamycin, and mortiamide D hybrids have been synthesized to assess their in vitro antiplasmodial activity against 3D7 (chloroquine-sensitive) and Dd2 strains of Plasmodium falciparum. The most active compound, a simple chloroquine analogue, displayed low nanomolar IC50 value against both strains (3 nM for 3D7 strain and 18 nM for Dd2 strain). Moreover, all molecular hybrids incorporating the hydroxychloroquine scaffold showed the most potent activities, exemplified with a chloroquine dimer, IC50 = 31 nM and 81 nM against 3D7 and Dd2 strains, respectively. These results highlight the first time use of clindamycin and mortiamide D as antimalarial molecular hybrids and establish these valuable hits for future optimization.

The impact of physician support on skin self-examination among melanoma patients: A serial mediation model with self-efficacy and intentions to perform skin exams

OBJECTIVE

Melanoma is the most lethal of skin cancers; however, survival rates are excellent if the tumor is detected early. Clinical practice guidelines for melanoma follow-up care recommend regular skin self-examination (SSE) for individuals at high risk for melanoma. The current analyses tested whether self-efficacy for SSE and intention to perform SSE mediate the relationship between physician support for SSE and SSE behavior among a sample of melanoma patients.

METHODS

We ran a serial mediation model on a cross-sectional sample of melanoma patients (n = 154) drawn from an observational study with longitudinal follow-up.

RESULTS

Self-efficacy and intention to perform SSE sequentially mediated the relationship between physician support and SSE behaviors (β = .31, t(152) = 3.61, p < .001 without mediators versus β = .11, t(150) = 1.50, p = .14 with mediators), as supported by a significant total indirect effect (β = .21, [95 % CI = .08-.35]).

CONCLUSION

Self-efficacy for SSE and intention to perform SSE together explain the link between perceived physician support for SSE and the practice of SSE.

PRACTICE IMPLICATIONS

Physician communication about the importance of SSE plays an important role in encouraging patient adherence to SSE recommendations and, thus, supporting early detection efforts.

Patient-identified early clinical warning signs of nodular melanoma: a qualitative study

BACKGROUND

Nodular (NM) and superficial spreading melanoma (SSM) show different disease trajectories, with more rapid development in NM and fewer opportunities for early detection often resulting in worse outcomes. Our study described the patient-identified early signs of thin NM via comparisons to thin (≤ 2 mm) SSM and thick (> 2 mm) NM.

METHODS

We conducted semi-structured interviews with NM and SSM patients and analyzed the data using thematic analysis.

RESULTS

We enrolled 34 NM and 32 SSM patients. Melanoma early signs uniquely identified by patients with thin NM included white, blue or black coloration, "dot-like" size, fast changes in shape and color observed over 2 weeks, elevation and texture or "puffiness" over 6-12 months, and the sensation that the mole "did not feel right". Early signs reported by both thin NM and thin SSM patients included round or oblong shape, "jagged" border, pink/red, brown/reddish or dark coloration, "elevated like a pimple" or "tiny bump", fast color darkening, diameter growth, and border irregularity, and mole feeling "really itchy".

CONCLUSIONS

We found evidence that early signs of NM can be self-identified, which has important implications for the earlier detection of this most aggressive type of melanoma by both health professionals and patients.

Endometrial ablation or resection versus levonorgestrel intra-uterine system for the treatment of women with heavy menstrual bleeding and a normal uterine cavity: a systematic review with meta-analysis

BACKGROUND

Endometrial ablation/resection and the levonorgestrel intra-uterine system (LNG-IUS) are well-established treatment options for heavy menstrual bleeding to avoid more invasive alternatives, such as hysterectomy.

OBJECTIVE

The aim was to compare the efficacy and safety of endometrial ablation or resection with the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and to investigate sources of heterogeneity between studies.

SEARCH METHODS

We searched the databases MEDLINE, EMBASE, CENTRAL, Web of Science, Biosis and Google Scholar as well as citations and reference lists published up to August 2019. Two authors independently screened 3701 citations for eligibility. We included randomized controlled trials published in any language, comparing endometrial ablation or resection to the LNG-IUS in the treatment of premenopausal women with heavy menstrual bleeding and a normal uterine cavity.

OUTCOMES

Thirteen studies (N = 884) were eligible. Two independent authors extracted data and assessed the quality of included studies. Random effect models were used to compare the modalities and evaluate sources of heterogeneity. No significant differences were observed between endometrial ablation/resection and the LNG-IUS in terms of subsequent hysterectomy (primary outcome, risk ratio (RR) = 1.13, 95% CI 0.60 to 2.11, P = 0.71, I2 = 14%, 12 studies, 726 women), satisfaction, quality of life, amenorrhea and treatment failure. However, side effects were less common in women treated with endometrial ablation/resection compared to the LNG-IUS (RR = 0.52, 95% CI 0.37 to 0.71, P < 0.001, I2 = 0%, 10 studies, 580 women). Three complications were reported in the endometrial ablation/resection group and none in the LNG-IUS group (P = 0.25). Mean age of the studied populations was identified as a significant source of heterogeneity between studies in subgroup analysis (P = 0.01). In fact, endometrial ablation/resection was associated with a higher risk of subsequent hysterectomy compared to the LNG-IUS in younger populations (mean age ≤ 42 years old, RR = 5.26, 95% CI 1.21 to 22.91, P = 0.03, I2 = 0%, 3 studies, 189 women). On the contrary, subsequent hysterectomy seemed to be less likely with endometrial ablation/resection compared to the LNG-IUS in older populations (mean age > 42 years old), although the reduction did not reach statistical significance (RR = 0.51, 95% CI 0.21 to 1.24, P = 0.14, I2 = 0%, 5 studies, 297 women). Finally, sensitivity analysis taking into account the risk of bias of included studies and type of surgical devices (first and second generation) did not modify the results. Most of the included studies reported outcomes at up to 3 years, and the relative performance of endometrial ablation/resection and LNG-IUS remains unknown in the longer term.

WIDER IMPLICATIONS

Endometrial ablation/resection and the LNG-IUS are two excellent treatment options for heavy menstrual bleeding, although women treated with the LNG-IUS are at higher risk of experiencing side effects compared to endometrial ablation/resection. Otherwise, younger women seem to present a lower risk of eventually requiring hysterectomy when treated with the LNG-IUS compared to endometrial ablation/resection.

Low expression of ANT1 confers oncogenic properties to rhabdomyosarcoma tumor cells by modulating metabolism and death pathways

Rhabdomyosarcoma (RMS) is the most frequent form of pediatric soft-tissue sarcoma. It is divided into two main subtypes: ERMS (embryonal) and ARMS (alveolar). Current treatments are based on chemotherapy, surgery, and radiotherapy. The 5-year survival rate has plateaued at 70% since 2000, despite several clinical trials. RMS cells are thought to derive from the muscle lineage. During development, myogenesis includes the expansion of muscle precursors, the elimination of those in excess by cell death and the differentiation of the remaining ones into myofibers. The notion that these processes may be hijacked by tumor cells to sustain their oncogenic transformation has emerged, with RMS being considered as the dark side of myogenesis. Thus, dissecting myogenic developmental programs could improve our understanding of RMS molecular etiology. We focused herein on ANT1, which is involved in myogenesis and is responsible for genetic disorders associated with muscle degeneration. ANT1 is a mitochondrial protein, which has a dual functionality, as it is involved both in metabolism via the regulation of ATP/ADP release from mitochondria and in regulated cell death as part of the mitochondrial permeability transition pore. Bioinformatics analyses of transcriptomic datasets revealed that ANT1 is expressed at low levels in RMS. Using the CRISPR-Cas9 technology, we showed that reduced ANT1 expression confers selective advantages to RMS cells in terms of proliferation and resistance to stress-induced death. These effects arise notably from an abnormal metabolic switch induced by ANT1 downregulation. Restoration of ANT1 expression using a Tet-On system is sufficient to prime tumor cells to death and to increase their sensitivity to chemotherapy. Based on our results, modulation of ANT1 expression and/or activity appears as an appealing therapeutic approach in RMS management.

Operationalization of skin self-examination in randomized controlled trials with individuals at increased risk for melanoma: A systematic review

OBJECTIVE

To investigate how skin self-examination was operationalized and the psychometric properties of the scales used to assess this behavior in randomized controlled trials (RCTs) testing interventions that promote SSE among individuals at increased risk for melanoma.

METHOD

Eight scientific databases (e.g., Medline, EMBASE, CINAHL, PsycINFO) and four trial registries (e.g., Clinicaltrials.gov, UK Clinical Trails Gateway) were searched from inception through April 2, 2019. Three reviewers carried out the selection of relevant trials and conducted data extraction.

RESULTS

The review identified 13 unique RCT's. The definition of skin self-exams, extrapolated from instructions provided to participants during the trials and reported in only 6/13 trials, included periodically checking the skin of the entire body, individually or with partners/mirrors, with or without tracking or monitoring tools, and using the ABCDE criteria to identify early signs of melanoma. There was variability in how skin self-examination behavior was measured with respect to item content, number of items, response format, and type of outcome variable used: continuous or binary). No validity evidence and minimal reliability evidence for the measures were identified.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Future studies are needed to establish the psychometric properties of measures assessing skin self-examination.

Short and long-term barriers and facilitators of skin self-examination among individuals diagnosed with melanoma

Background

Melanoma can be lethal if not detected early and treated. Early detection can be facilitated via skin self-examination (SSE) and as such, SSE is part of melanoma follow-up care for individuals with a prior history, who face a life-long risk of reoccurrence. The objective of the current study was to identify short- and long-term predictors of SSE among melanoma survivors to inform future prevention interventions in high-risk groups.

Method

This is an observational study with longitudinal assessments conducted with adult melanoma patients in active follow-up care.

Primary outcome measures

Behavioral outcomes, comprehensive SSE (checking up to 5 body areas in the last 3 months) and optimal SSE (checking the entire body at least monthly in the last 3 months) were assessed at 3, 12, and 24 months post a dermatological educational session on skin cancer prevention. T tests and chi square analyses were used to examine changes in outcomes from 3 to 12 and 24 months. Linear and logistic regression models were used to examine the association between predictors and the primary outcomes.

Results

Comprehensive SSE did not decrease significantly from 3 (M = 2.7, SD = 1.1) to 12 (M = 2.6, SD = 1.2) and 24 months (M = 2.4, SD = 1.2) post the education session, with the stronger predictor at all timepoints being intentions to perform SSE. Optimal SSE was higher at 3 months (59%) compared to 12 (46%) and 24 months (34%), with key predictors including self-efficacy and intentions to perform SSE and male sex at 3 months post; self-efficacy and reliance on medical advice at 12 months; and (lower) education and self-efficacy at 24 months.

Conclusions

The key findings of this study are that 1) survivors maintain SSE behaviour over time, but rates of SSE performed in agreement with medical recommendations are higher immediately post standard dermatological education (i.e. usual care) and decrease somewhat over a 24-month period; and 2) the strongest psycho-social predictors of SSE are intentions and self-efficacy to perform the behavior, which are highly modifiable, for example via motivational interviewing and goal setting health interventions.

Retraction Note: Aluminum in Neurological and Neurodegenerative Disease

The Editor-in Chief of Molecular Neurobiology has retracted this article [1] at the request of the corresponding author. This is because it significantly overlaps with their previous publication [2]. Both articles report the same results and as such this article is redundant.Walter J. Lukiw, Maire E. Percy, and Zhide Fang agree to this retraction.William J.Walsh and Yuhai Zhao do not agree to this retraction. Aileen I. Pogue, Nathan M. Sharfman, Vivian Jaber, and Wenhong Li have not responded to any correspondence from the editor/publisher about this retraction. Donald R. C. McLachlan, Catherine Bergeron, Peter N. Alexandrov, and Theodore P. A. Kruck are deceased.[1] McLachlan, D.R.C., Bergeron, C., Alexandrov, P.N. et al. Mol Neurobiol (2019) 56: 1531. https://doi.org/10.1007/s12035-018-1441-x[2] McLachlan, D.R.C., Alexandrov, P.N., Walsh, W.J. et al. J Alzheimers Dis Parkinsonism (2018) 8(6): 457. https://doi.org/10.4172/2161-0460.1000457.

Prognostic significance of age in 5631 patients with Wilms tumour prospectively registered in International Society of Paediatric Oncology (SIOP) 93-01 and 2001

BACKGROUND

To enhance risk stratification for Wilms tumour (WT) in a pre-operative chemotherapy setting, we explored the prognostic significance and optimal age cutoffs in patients treated according to International Society of Paediatric Oncology Renal Tumour Study Group (SIOP-RTSG) protocols.

METHODS

Patients(6 months-18 years) with unilateral WT were selected from prospective SIOP 93-01 and 2001 studies(1993-2016). Martingale residual analysis was used to explore optimal age cutoffs. Outcome according to age was analyzed by uni- and multivariable analysis, adjusted for sex, biopsy(yes/no), stage, histology and tumour volume at surgery.

RESULTS

5631 patients were included; median age was 3.4 years(IQR: 2-5.1). Estimated 5-year event-free survival (EFS) and overall survival (OS) were 85%(95%CI 83.5-85.5) and 93%(95%CI 92.0-93.4). Martingale residual plots detected no optimal age cutoffs. Multivariable analysis showed lower EFS with increasing age(linear trend P<0.001). Using previously described age categories, EFS was lower for patients aged 2-4(HR 1.34, P = 0.02), 4-10(HR 1.83, P<0.0001) and 10-18 years(HR 1.74, P = 0.01) as compared to patients aged 6 months-2 years. OS was lower for patients 4-10 years(HR 1.67, P = 0.01) and 10-18 years(HR 1.87, P = 0.04), but not for 2-4 years(HR 1.29, P = 0.23). Higher stage, histological risk group and tumour volume were independent adverse prognostic factors.

CONCLUSION

Although optimal age cutoffs could not be identified, we demonstrated the prognostic significance of age as well as previously described cutoffs for EFS (2 and 4 years) and OS (4 years) in children with WT treated with pre-operative chemotherapy. These findings encourage the consideration of age in the design of future SIOP-RTSG protocols.

Development and initial validation of the Self-Efficacy for Skin Self-Examination Scale in a Canadian sample of patients with melanoma

PURPOSE

Melanoma is the deadliest type of skin cancer, although survival rates are high if detected early. Skin self-examination (SSE) is a health behaviour that can lead to early detection of melanoma and more positive health outcomes. Self-efficacy for SSE is a potential predictor of engaging in skin self-exams. However, no standardized measures of self-efficacy for SSE are currently available. The present study reports on the development and initial validation of a measure assessing self-efficacy for SSE.

METHOD

Based on a literature review, including previous studies assessing this construct, the research team developed 9 items capturing confidence in one's ability to conduct SSE. Items were subsequently revised by the research team and two dermatologists, resulting in the elimination of 4 items and modifications to the response options. The final 5-item Self-Efficacy for SSE scale was administered to a sample of 242 melanoma patients recruited from local hospitals. We assessed the scale's factor structure through exploratory factor analysis and the internal consistency with Cronbach's alpha. Scale scores were correlated with intentions to perform SSE, physician support for SSE, skin cancer-specific distress, general distress, and sociodemographic variables to assess convergent and divergent validity.

RESULTS

The scale was found to be unifactorial with adequate model fit, have acceptable internal consistency (Cronbach alpha = 0.74), and initial evidence of convergent and divergent validity, as indicated by the scale correlating with physicians' support for SSE (r = 0.30, p < 0.01), intention to perform SSE (r_s = 0.21, p < 0.01) and a weak correlation with general distress (r = 0.15, p < 0.05).

CONCLUSIONS

Pending future research corroborating these findings, this measure has potential for use by nurses and other health professionals in follow-up care to identify individuals at risk for low self-efficacy for SSE requiring more targeted educational SSE interventions.

Don't take down the monkey bars: Rapid systematic review of playground-related injuries

OBJECTIVE

To synthesize the available evidence on playground-related injuries and to determine the prevalence of these injuries in pediatric populations.

DATA SOURCES

A rapid systematic review was conducted using PubMed, EMBASE, and the Cochrane Library, as well as the gray literature.

STUDY SELECTION

The search was limited to studies published between 2012 and 2016 and identified a total of 858 articles, of which 22 met our inclusion criteria: original quantitative studies published in peer-reviewed journals in the past 5 years, concerning unintentional injuries in playgrounds in children aged 0 to 18 years.

SYNTHESIS

Information was collected on study and injury characteristics, and the proportion of pediatric injuries related to playground activity was determined. Studies were performed in various countries and most were retrospective cohort studies. The prevalence of playground-related injury ranged from 2% to 34% (median 10%). Studies varied in the types of injuries investigated, including head injuries, genitourinary injuries, ocular and dental trauma, and various types of fractures. Most injuries were low severity.

CONCLUSION

Although playgrounds are a common location where pediatric injuries occur, these injuries are relatively low in frequency and severity.

LI-RADS for CT diagnosis of hepatocellular carcinoma: performance of major and ancillary features

PURPOSE

To evaluate the diagnostic performance of Liver Imaging Reporting and Data System (LI-RADS) v2017 major features, the impact of ancillary features, and categories on contrast-enhanced computed tomography (CECT) for the diagnosis of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This retrospective study included 59 patients (104 observations including 72 HCCs) with clinical suspicion of HCC undergoing CECT between 2013 and 2016. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category based on major features only and in combination with ancillary features. The composite reference standard included pathology or imaging. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by generalized estimating equation models.

RESULTS

Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) respectively had a sensitivity of 86.1%, 81.6%, 20.7%, and 26.1% and specificity of 39.3%, 67.9%, 89.9%, and 85.0% for HCC. Ancillary features (ultrasound visibility as discrete nodule, subthreshold growth, and fat in mass more than adjacent liver) respectively had a sensitivity of 42.6%, 50.8%, and 15.1% and a specificity of 79.2%, 66.9%, and 96.4% for HCC. Ancillary features modified the final category in 4 of 104 observations. For HCC diagnosis, categories LR-3, LR-4, LR-5, and LR-TIV (tumor in vein) had a sensitivity of 5.3%, 29.0%, 53.7%, and 10.7%; and a specificity of 49.1%, 84.4%, 97.3%, and 96.4%, respectively.

CONCLUSION

On CT, LR-5 category has near-perfect specificity for the diagnosis of HCC and ancillary features modifies the final category in few observations.

Aluminum in Neurological and Neurodegenerative Disease

With continuing cooperation from 18 domestic and international brain banks over the last 36 years, we have analyzed the aluminum content of the temporal lobe neocortex of 511 high-quality human female brain samples from 16 diverse neurological and neurodegenerative disorders, including 2 groups of age-matched controls. Temporal lobes (Brodmann areas A20-A22) were selected for analysis because of their availability and their central role in massive information-processing operations including efferent-signal integration, cognition, and memory formation. We used the analytical technique of (i) Zeeman-type electrothermal atomic absorption spectrophotometry (ETAAS) combined with (ii) preliminary analysis from the advanced photon source (APS) hard X-ray beam (7 GeV) fluorescence raster-scanning (XRFR) spectroscopy device (undulator beam line 2-ID-E) at the Argonne National Laboratory, US Department of Energy, University of Chicago IL, USA. Neurological diseases examined were Alzheimer's disease (AD; N = 186), ataxia Friedreich's type (AFT; N = 6), amyotrophic lateral sclerosis (ALS; N = 16), autism spectrum disorder (ASD; N = 26), dialysis dementia syndrome (DDS; N = 27), Down's syndrome (DS; trisomy, 21; N = 24), Huntington's chorea (HC; N = 15), multiple infarct dementia (MID; N = 19), multiple sclerosis (MS; N = 23), Parkinson's disease (PD; N = 27), and prion disease (PrD; N = 11) that included bovine spongiform encephalopathy (BSE; "mad cow disease"), Creutzfeldt-Jakob disease (CJD) and Gerstmann-Straussler-Sheinker syndrome (GSS), progressive multifocal leukoencephalopathy (PML; N = 11), progressive supranuclear palsy (PSP; N = 24), schizophrenia (SCZ; N = 21), a young control group (YCG; N = 22; mean age, 10.2 ± 6.1 year), and an aged control group (ACG; N = 53; mean age, 71.4 ± 9.3 year). Using ETAAS, all measurements were performed in triplicate on each tissue sample. Among these 17 common neurological conditions, we found a statistically significant trend for aluminum to be increased only in AD, DS, and DDS compared to age- and gender-matched brains from the same anatomical region. This is the largest study of aluminum concentration in the brains of human neurological and neurodegenerative disease ever undertaken. The results continue to suggest that aluminum's association with AD, DDS, and DS brain tissues may contribute to the neuropathology of those neurological diseases but appear not to be a significant factor in other common disorders of the human brain and/or CNS.

Hysterosalpingosonography Is Not as Effective as Hysterosalpingography to Increase Chances of Pregnancy

OBJECTIVE

This study sought to examine whether hysterosalpingosonography (sono-HSG) is as effective as hysterosalpingography (HSG) in facilitating conception by comparing pregnancy rates in the 6 months following the procedures.

METHODS

This retrospective noninferiority study (Canadian Task Force classification II-2) was conducted at a tertiary university centre. The investigators studied 440 consecutive eligible infertile women. Bilateral tubal occlusion, severe male infertility, and having undergone both procedures were exclusion criteria. Tubal testing, as part of the infertility workup, was performed by either sono-HSG or HSG. The primary outcome was pregnancy, defined as a positive fetal heartbeat on ultrasonographic examination, in the 6 months following the procedure.

RESULTS

A total of 57 pregnancies (26%) were observed in the HSG group and 33 (15%) in the sono-HSG group. Adjusted and non-adjusted relative risks of pregnancy in the 6 months following sono-HSG compared with HSG were 0.61 (95% CI 0.42-0.89) and 0.58 (95% CI 0.39-0.85). Adverse events were infrequent with both procedures (sono-HSG, 1%; HSG, 4%; P = 0.16).

CONCLUSION

This study suggests that uterine flushing as performed during sono-HSG is not as effective as when performed during HSG to increase the chances of pregnancy, but further studies will be required because of bias related to the retrospective study design.

Aluminum in neurological disease - a 36 year multicenter study

Aluminum is a ubiquitous neurotoxin highly enriched in our biosphere, and has been implicated in the etiology and pathology of multiple neurological diseases that involve inflammatory neural degeneration, behavioral impairment and cognitive decline. Over the last 36 years our group has analyzed the aluminum content of the temporal lobe neocortex of 511 high quality coded human brain samples from 18 diverse neurological and neurodegenerative disorders, including 2 groups of age-matched controls. Brodmann anatomical areas including the inferior, medial and superior temporal gyrus (A20-A22) were selected for analysis: (i) because of their essential functions in massive neural information processing operations including cognition and memory formation; and (ii) because subareas of these anatomical regions are unique to humans and are amongst the earliest areas affected by progressive neurodegenerative disorders such as Alzheimer's disease (AD). Coded brain tissue samples were analyzed using the analytical technique of: (i) Zeeman-type electrothermal atomic absorption spectrophotometry (ETAAS) combined with (ii) an experimental multi-elemental analysis using the advanced photon source (APS) ultra-bright storage ring-generated hard X-ray beam (7 GeV) and fluorescence raster scanning (XRFR) spectroscopy device at the Argonne National Laboratory, US Department of Energy, University of Chicago IL, USA. These data represent the largest study of aluminum concentration in the brains of human neurological and neurodegenerative disease ever undertaken. Neurological diseases examined were AD (N=186), ataxia Friedreich's type (AFT; N=6), amyotrophic lateral sclerosis (ALS; N=16), autism spectrum disorder (ASD; N=26), dialysis dementia syndrome (DDS; N=27), Down's syndrome (DS; trisomy21; N=24), Huntington's chorea (HC; N=15), multiple infarct dementia (MID; N=19), multiple sclerosis (MS; N=23), Parkinson's disease (PD; N=27), prion disease (PrD; N=11) including bovine spongiform encephalopathy (BSE; 'mad cow disease'), Creutzfeldt-Jakob disease (CJD) and Gerstmann-Straussler-Sheinker syndrome (GSS), progressive multifocal leukoencephalopathy (PML; N=11), progressive supranuclear palsy (PSP; N=24), schizophrenia (SCZ; N=21), a young control group (YCG; N=22) and an aged control group (ACG; N=53). Amongst these 18 common neurological conditions and controls we report a statistically significant trend for aluminum to be increased only in AD, DS and DDS compared to age- and gender-matched brains from the same anatomical region. The results continue to suggest that aluminum's association with AD, DDS and DS brain tissues may contribute to the neuropathology of these neurological diseases but appear not to be a significant factor in other common disorders of the human central nervous system (CNS).

LI-RADS for MR Imaging Diagnosis of Hepatocellular Carcinoma: Performance of Major and Ancillary Features

Purpose To evaluate the performance of major features, ancillary features, and categories of Liver Imaging Reporting and Data System (LI-RADS) version 2014 at magnetic resonance (MR) imaging for the diagnosis of hepatocellular carcinoma (HCC). Materials and Methods This retrospective institutional review board-approved study included patients with liver MR imaging and at least one pathologically proved lesion. Between 2004 and 2016, 102 patients (275 observations including 113 HCCs) met inclusion criteria. Two radiologists independently assessed major and ancillary imaging features for each liver observation and assigned a LI-RADS category. Per-lesion estimates of diagnostic performance of major features, ancillary features, and LI-RADS categories were assessed by using generalized estimating equation models. Results Major features (arterial phase hyperenhancement, washout, capsule, and threshold growth) had a sensitivity of 88.5%, 60.6%, 32.9%, and 41.6%, and a specificity of 18.6%, 84.8%, 98.8%, and 83.2% for HCC, respectively. Ancillary features (mild-moderate T2 hyperintensity, restricted diffusion, mosaic architecture, intralesional fat, lesional fat sparing, blood products, and subthreshold growth) had a sensitivity of 62.2%, 54.8%, 9.9%, 30.9%, 23.1%, 2.8%, and 48.3%, and a specificity of 79.4%, 90.6%, 99.4%, 94.2%, 83.1%, 99.3%, and 91.4% for HCC, respectively. The LR-5 or LR-5 V categories had a per-lesion sensitivity of 50.8% and a specificity of 95.8% for HCC, respectively. The LR-4, LR-5, or LR-5 V categories (determined by using major features only vs combination of major and ancillary features) had a per-lesion sensitivity of 75.9% and 87.9% and a per-lesion specificity of 87.5% and 86.2%, respectively. Conclusion The use of ancillary features in combination with major features increases the sensitivity while preserving a high specificity for the diagnosis of HCC.

Lack of CT scanner in a rural emergency department increases inter-facility transfers: a pilot study

OBJECTIVE

Rural emergency departments (EDs) are an important gateway to care for the 20% of Canadians who reside in rural areas. Less than 15% of Canadian rural EDs have access to a computed tomography (CT) scanner. We hypothesized that a significant proportion of inter-facility transfers from rural hospitals without CT scanners are for CT imaging. Our objective was to assess inter-facility transfers for CT imaging in a rural ED without a CT scanner.

RESULTS

We selected a rural ED that offers 24/7 medical care with admission beds but no CT scanner. Descriptive statistics were collected from 2010 to 2015 on total ED visits and inter-facility transfers. Data was accessible through hospital and government databases. Between 2010 and 2014, there were respectively 13,531, 13,524, 13,827, 12,883, and 12,942 ED visits, with an average of 444 inter-facility transfers. An average of 33% (148/444) of inter-facility transfers were to a rural referral centre with a CT scan, with 84% being for CT scan. Inter-facility transfers incur costs and potential delays in patient diagnosis and management, yet current databases could not capture transfer times. Acquiring a CT scan may represent a reasonable opportunity for the selected rural hospital considering the number of required transfers.

Second malignant neoplasm following childhood cancer: A nested case-control study of a recent cohort (1987-2004) from the Childhood Cancer Registry of the Rhône-Alpes region in France

From a population-based cohort of cases of first cancers diagnosed between 1987 and 2004, before the patient's age of 15 years, the authors conducted a nested case-control study, matching 64 patients who experienced a second malignant neoplasm (SMN) with 190 controls. SMNs comprised 10 leukemia or myelodysplastic syndromes, 5 lymphomas induced by Epstein-Barr virus after allograft, and 49 solid tumors, including mainly 25 carcinomas (17 of the thyroid), 9 bone sarcomas, and 7 central nervous system (CNS) tumors. The median latency occurrence was 6.5 years, and that of thyroid carcinomas induced by 12 Gy fractioned total body irradiation (TBI) was 7.6 years. The relative risk (RR) of an SMN was increased by genetic and family factors and increased 17 to 69 times according to the dose of radiotherapy administered in the region for the first cancer. Age younger than 4 years at the time of radiotherapy increased the risk of SMN. Chemotherapy adjusted according to the dose of radiotherapy administered in the field yielded a greater RR of an SMN only for cumulative doses exceeding 2 g/m² of epipodophyllotoxin but not for alkylating agents or platinum compounds. The RR of secondary leukemia increased 10-fold following high doses of epipodophyllotoxin >2 g/m² but was not affected by alkylating agents or anthracyclines. The crude RR of a solid SMN developing after radiotherapy was very high at 18 and reached 90.7 for thyroid carcinoma after TBI, whereas the authors observed no increased risk associated with chemotherapy. These results confirm the risk of secondary leukemia after epipodophyllotoxin and of solid tumor after radiotherapy.

Should busulfan therapeutic range be narrowed in pediatrics? Experience from a large cohort of hematopoietic stem cell transplant children

Busulfan, the corner stone of hematopoietic stem cell transplantation regimens, has a narrow therapeutic window. Therapeutic drug monitoring (TDM)-guided dosing to reach the conventional area under the concentration-time curve (AUC) target range of 900-1500 μmol min/L is associated with better outcomes. We report our experience with busulfan TDM in a large cohort of children. The aims were to investigate the relevance of using a more restricted therapeutic range and investigate the association between busulfan therapeutic range and clinical outcome. This study includes 138 children receiving 16 doses of intravenous busulfan, with the first dose assigned based on weight and doses adjusted to a local AUC target range of 980-1250 μmol min/L. Busulfan TDM combined with model-based dose adjustment was associated with an increased probability of AUC target attainment, for both target range: 90.8% versus 74.8% for the conventional target range and 66.2% versus 43.9% for the local target range (P<0.001). The median follow-up was 56.2 months. Event-free survival was 88.5%, overall survival was 91.5% and veno-occlusive disease occurred in 18.3% of patients. No difference was observed for clinical outcomes depending on the selected target range. Pharmacokinetic monitoring and individualization of busulfan dosage regimen are useful in improving target attainment, but using a restricted target range has no impact on clinical outcomes.

Treatment of relapsed Wilms tumour (WT) patients: experience with topotecan. A report from the SIOP Renal Tumour Study Group (RTSG)

BACKGROUND

Topotecan has been variably incorporated in the treatment of patients with relapsed Wilms tumour (WT) who failed initial treatment with three or more effective drugs. Our objective was to describe outcome and to retrospectively investigate the potential role of topotecan in relapsed WT patients.

METHODS

Children who were treated with topotecan as part of their chemotherapeutic regimens for relapsed WT were identified and included in our retrospective study. Patient charts were reviewed for general patient characteristics, histology and stage at initial diagnosis, number and type of relapse, salvage treatment schedules, toxicity, response to treatment and outcome.

RESULTS

From 2000 to 2012, 30 children (median age at relapse 5.5 years, range 1.6-14.5 years) were identified to have received topotecan as part of their salvage regimens (primary progressive disease n = 3, first, second and third relapse n = 13, 9 and 2 respectively, partial response n = 3). Topotecan was administered as a single agent (12 patients) or in combination with other drugs (18 patients). Sixteen patients had high-risk histology according to the SIOP classification, 15 died within 12 months because of progressive disease. Fourteen patients had SIOP intermediate-risk histology of which four patients displayed objective responses to topotecan. Overall, 6 out of 14 intermediate-risk patients survived (median follow up of 6 years), however, three of whom (stage V) had bilateral nephrectomy after topotecan treatment.

CONCLUSIONS

Topotecan does not seem to show effectiveness in the treatment of relapsed WT patients with initial high-risk histology. In patients with intermediate-risk histology, the role of topotecan might deserve further attention, to prove its efficacy.

Outcome of localised blastemal-type Wilms tumour patients treated according to intensified treatment in the SIOP WT 2001 protocol, a report of the SIOP Renal Tumour Study Group (SIOP-RTSG)

Blastemal-type Wilms tumour (BT-WT) has been identified as a high risk histological subgroup in WT assessed after pre-nephrectomy chemotherapy in trials of the International Society of Paediatric Oncology (SIOP) Renal Tumour Study Group. Therefore, in SIOPWT2001, post-operative chemotherapy for BT-WT was intensified aiming to improve survival. Survival analysis of all unilateral BT-WT patients (SIOPWT2001) (n=238), was compared with historical BT-WT controls (SIOP93-01) (n=113). 351/4061 (8.6%) unilateral non-metastatic BT-WT patients (SIOP93-01/SIOPWT2001) were studied. Median age at diagnosis was 43 months (Inter Quartile Range (IQR) 24-68 months), stages: I (n=140, 40%), II (n=106, 30%), III (n=105, 30%). BT-WTs were higher staged, showed greater volume decrease after pre-operative chemotherapy and were diagnosed at an older median age compared to other WT patients. Patient characteristics did not differ substantially between SIOP93-01 and SIOPWT2001. Univariate analysis showed a 5-year event-free survival (EFS) of 80% (95% confidence interval (CI): 75-86%) (SIOPWT2001) compared to 67% in SIOP93-01 (95% CI: 59-76%; p=0.006) and overall survival (OS) of 88% (95% CI: 83-93%) (SIOPWT2001) compared to 84% (95% CI: 77-91%; p=0.4) in SIOP93-01. 95% of relapses were distant metastases (SIOP93-01/SIOPWT2001). Treatment protocol, age at diagnosis, tumour stage (III versus I/II) and volume (at surgery), were prognostic variables for EFS (uni- and multivariate Cox regression analysis). Independent prognosticators for OS were age at diagnosis, tumour stage and volume (at surgery). The most significant survival benefit of intensified treatment, was observed in Stage I (EFS 96% in SIOPWT2001 (OS 100%), 71% in SIOP93-01 (OS 90%)). BT-WT derived benefits from more intensive chemotherapy as reflected by a reduction in relapse risk. However, the benefit of the more intensive chemotherapy to improve OS was only observed in stage I BT-WTs, by adding doxorubicin.

Synovial sarcoma in children and adolescents: the European Pediatric Soft Tissue Sarcoma Study Group prospective trial (EpSSG NRSTS 2005)

BACKGROUND

To report the results of the first European prospective nonrandomized trial dedicated to pediatric synovial sarcoma.

PATIENTS AND METHODS

From August 2005 to August 2012, 138 patients <21 years old with nonmetastatic synovial sarcoma were registered in 9 different countries (and 60 centers). Patients were treated with a multimodal therapy including ifosfamide-doxorubicin chemotherapy and radiotherapy, according to a risk stratification based on surgical stage, tumor size and site, and nodal involvement.

RESULTS

With a median follow-up of 52.1 months (range 13.8-104.4 months), event-free survival (EFS) was 81.9% and 80.7%, and overall survival (OS) was 97.2% and 90.7%, at 3 and 5 years, respectively. The only significant prognostic variable at univariate analysis was the risk group: 3-year EFS was 91.7% for low-risk, 91.2% for intermediate-risk, and 74.4% for high-risk cases. In 24 low-risk patients (completely resected tumor ≤5 cm in size) treated with surgery alone, there were two local relapses and no metastatic recurrences. Among 67 high-risk patients (unresected, or axial tumor or nodal involvement), 66 underwent surgery after neoadjuvant chemotherapy. Response to chemotherapy was 55.2%, including 22.4% cases with complete or major partial remissions, and 32.8% with minor partial remissions.

CONCLUSION

This study demonstrates that collaborative prospective studies on rare pediatric sarcomas are feasible even on a European scale, with excellent treatment compliance. The overall results of treatment were satisfactory, with higher survival rates than those previously published by pediatric groups. Nonetheless, larger, international projects are needed, based on a cooperative effort of pediatric and adult oncologists.

CLINICAL TRIALS NUMBER

European Union Drug Regulating Authorities Clinical Trials No. 2005-001139-31.

A Case of Familial Creutzfeldt-Jakob Disease Presenting with Dry Cough

Background:

Clinical diagnosis of Creutzfeldt-Jakob disease (CJD) is based on the classical triad of rapidly progressive dementia, myoclonus and abnormal EEG. The 200k mutation within the gene encoding PrP, located on the short arm of chromosome 20, accounts for more than 70% of families with CJD worldwide.

Case Report:

Herein, we report a patient who developed persistent dry cough and classical signs of CJD, including severe cognitive decline, cerebellar signs, and myoclonic jerks, leading to death a few weeks after disease onset. Mutation screening showed that he had the 200k point mutation in the PRNP gene. His mother had died twenty years earlier with neuropathologically confirmed CJD. She had presented a rapidly progressive ataxia with myoclonus, dementia, visual hallucinations, and the same persistent dry cough.

Conclusions:

The clinical presentation of this familial CJD case with persistent dry cough is quite unusual. Therefore, a neurological etiology should be sought when confronted with an unexplained persistent cough.

Interobserver variability of cervical cytology in HIV-infected women

OBJECTIVES

Our objectives were to determine the reproducibility of cytological specimen interpretation between two pathologists in human immunodeficiency virus (HIV)-infected women (from the VIHGY, ANRS CO17 study of human papillomavirus genital pathology among HIV-positive women) and to analyse the improvement, if any, between conventional and liquid-based cytology (LBC) interpretations.

MATERIALS AND METHODS

A sample of all abnormal and 40% of randomly selected normal Papanicolaou (Pap) tests was randomly ordered and read blindly by a second pathologist using the revised Bethesda terminology 2001. For both conventional and liquid-based preparations, unweighted and Cicchetti-Allison-weighted kappa and their 95% confidence intervals (CIs) were calculated. Kappa values were then compared using the Altman rule to classify the reproducibility of cytological specimen interpretation.

RESULTS

Two hundred and seventy-seven conventional Pap tests were reviewed, including 79 abnormal and 10 unsatisfactory results. Overall agreement between the two observers was 78%, with an estimated Cicchetti-Allison-weighted kappa of 0.69 (95%CI, 0.61-0.77). The corresponding values for the 268 LBCs, including 123 abnormal and two unsatisfactory results, were 84% and 0.82 (95%CI, 0.76-0.87), respectively. The reproducibility of LBC interpretations was significantly higher than that of conventional preparations (P = 0.009) and, for both laboratories, the percentages of unsatisfactory results were significantly lower for LBC.

CONCLUSION

In HIV-infected women in the combination antiretroviral therapy era, the strength of agreement was better for LBCs than for conventional preparations, with a lower percentage of unsatisfactory results. When available, LBC should be preferred because of its higher reproducibility.

Parameningeal rhabdomyosarcoma in pediatric age: results of a pooled analysis from North American and European cooperative groups

BACKGROUND

Parameningeal (PM) site is a well-known adverse prognostic factor in children with localized rhabdomyosarcoma (RMS). To identify risk factors associated with outcome at this site, we pooled data from 1105 patients treated in 10 studies conducted by European and North American cooperative groups between 1984 and 2004.

PATIENTS AND METHODS

Clinical factors including age, histology, size, invasiveness, nodal involvement, Intergroup Rhabdomyosarcoma Study (IRS) clinical group, site, risk factors for meningeal involvement (MI), study group, and application of radiotherapy (RT) were studied for their impact on event-free and overall survival (EFS and OS).

RESULTS

Ten-year EFS and OS were 62.6 and 66.1% for the whole group. Patients without initial RT showed worse survival (10-year OS 40.8% versus 68.5% for RT treated patients). Multivariate analysis focusing on 862 patients who received RT as part of their initial treatment revealed four unfavorable prognostic factors: age <3 or >10 years, signs of MI, unfavorable site, and tumor size. Utilizing these prognostic factors, patients could be classified into different risk groups with 10-year OS ranging between 51.1 and 80.9%.

CONCLUSIONS

While, in general, PM localization is regarded as an adverse prognostic factor, the current analysis differentiates those with good prognosis (36% patients with 0-1 risk factor: 10-year OS 80.9%) from high-risk PM patients (28% with 3-4 factors: 10-year OS 51.1%). Furthermore, this analysis reinforces the necessity for RT in PM RMS.

Treatment and outcome of patients with relapsed clear cell sarcoma of the kidney: a combined SIOP and AIEOP study

Background:

Clear cell sarcoma of the kidney (CCSK) is an uncommon paediatric renal tumour. Relapses occur in about 15% of the patients. Since detailed clinical information on relapsed CCSK is scarce, the current study aims to describe outcome of patients with relapsed CCSK treated according to recent European protocols.

Patients and methods:

We analysed prospectively collected data of all CCSK patients who developed a relapse after complete remission at the end of primary treatment, entered onto SIOP and AIEOP trials between 1992 and 2012.

Results:

Thirty-seven of 237 CCSK patients (16%) treated according to SIOP and AIEOP protocols developed a relapse. Median time from initial diagnosis to relapse was 17 months (range, 5.5 months - 6.6 years). Thirt-five out of thirty-seven relapses (95%) were metastatic; the most common sites of relapse were the brain (n=13), lungs (n=7) and bone (n=5). Relapse treatment consisted of chemotherapy (n=30), surgery (n=19) and/or radiotherapy (n=18), followed by high-dose chemotherapy and autologous bone marrow transplantation (ABMT) in 14 patients. Twenty-two out of thirty-seven patients (59%) achieved a second complete remission (CR); 15 of whom (68%) developed a second relapse. Five-year event-free survival (EFS) after relapse was 18% (95% CI: 4%–32%), and 5-year overall survival (OS) was 26% (95% CI: 10%–42%).

Conclusions:

In this largest series of relapsed CCSK patients ever described, overall outcome is poor. Most relapses are metastatic and brain relapses are more common than previously recognised. Intensive treatment aiming for local control, followed by high dose chemotherapy and ABMT, seems to be of benefit to enhance survival. Novel development of targeted therapy is urgently required.

Paediatric and adolescent alveolar soft part sarcoma: A joint series from European cooperative groups

BACKGROUND

Alveolar soft part sarcomas (ASPS) are generally chemo- and radio-resistant mesenchymal tumours, with no standardized treatment guidelines. We describe the clinical behaviour of paediatric ASPS and compare these features to previously reported adult series.

PATIENTS AND METHODS

The clinical data of 51 children and adolescents with ASPS, prospectively enrolled in or treated according to seven European Paediatric trials were analysed.

RESULTS

Median age was 13 years [range: 2-21]. Primary sites included mostly limbs (63%). IRS post-surgical staging was: IRS-I (complete resection) 35%, II (microscopic residual disease) 20%, III (gross residual disease) 18% and IV (metastases) 27%. Only 3 of the 18 evaluable patients (17%) obtained a response to conventional chemotherapy. After a median follow-up of 126 months (range: 9-240), 14/18 patients with IRS-I tumour, 10/10 IRS-II, 7/9 IRS-III and 2/14 IRS-IV were alive in remission. Sunitinib treatment achieved two very good partial responses in four patients. Ten-year overall survival (OS) and event free survival (EFS) was 78.0 ± 7% and 62.8 ± 7% respectively. Stage IV, size >5 cm and T2 tumours had a poorer outcome, but only IRS staging was an independent prognostic factor.

CONCLUSIONS

ASPS is a very rare tumour frequently arising in adolescents and in the extremities, and chemo resistant. Local surgical control is critical. ASPS is a poorly chemo sensitive tumour. For IRS-III/IV tumours, delayed radical local therapies including surgery are essential. Metastatic patients had a poor prognosis but targeted therapies showed promising results.