Applications of Viscoelastic Testing in Breast Cancer Patients: A Systematic Review Focusing on Hypercoagulability and Free Flap Thrombosis

Viscoelastic testing is a clinically available method to assess hypercoagulability. This systematic review aims to provide a comprehensive overview of the existing literature and the potential use of such testing in patients with breast cancer. A systematic literature search for studies investigating the application of viscoelastic testing for patients with breast cancer was conducted. Studies were included as long as they were original, peer-reviewed, and in the English language. Studies were excluded if they were review articles, did not include breast cancer patients, or if the full text was unavailable. This review identified 10 articles that met the inclusion criteria. Two of the studies utilized rotational thromboelastometry, and an additional four studies used thromboelastography, to assess hypercoagulability in patients with breast cancer. Three of the identified articles discussed the use of thromboelastometry in free flap breast reconstruction for patients with breast cancer. One study was a retrospective chart review looking at thromboelastography and microsurgical breast reconstruction. Current literature regarding the application of viscoelastic testing in breast cancer and free flap breast reconstruction is limited, with no randomized trials thus far. However, some studies suggest that there may be potential utility in viscoelastic testing to assess risk for thromboembolism in breast cancer patients, and future research in this area is warranted.

Systematic Review on Gender-Affirming Testosterone Therapy and the Risk of Breast Cancer: A Challenge for Physicians Treating Patients from Transgender and Gender-Diverse Populations

Conflicting evidence exists about the risk of breast cancer in transgender and gender-diverse (TGD) patients treated with testosterone. This review aimed to summarize current knowledge regarding the risk of breast cancer associated with gender-affirming testosterone treatment (GATT). A systematic literature search using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist was conducted in January 2023 through Ovid, Scopus, and Web of Science databases. English-language, peer-reviewed articles evaluating breast cancer in TGD patients after GATT that met the inclusion criteria were included. This review included 22 articles, with 14 case reports, 4 case series, and 4 retrospective cohort studies. The review identified 26 TGD patients who developed breast cancer post-GATT therapy, with inconclusive evidence on the relationship between testosterone and the risk of breast cancer in TGD patients. This uncertainty in part arises from the mechanisms governing testosterone's effects within breast tissue, with contrasting theories proposing both proliferative and antiproliferative impacts. Considering this ambiguity, it is imperative for healthcare providers to engage in informed discussions with patients prior to initiating hormone therapy to discuss potential adverse effects, including the possibility of breast cancer development in TGD individuals. Patient education and shared decision-making are essential components of responsible care in this context.

Frequent Upregulation Of HER2 Protein In Hormone Receptor-Positive HER2-Negative Breast Cancer After Short-Term Neoadjuvant Endocrine Therapy

Background. Endocrine resistant metastatic disease develops in ~20-25% of hormone-receptor positive (HR+) breast cancer (BC) patients despite endocrine therapy (ET) use. Upregulation of HER family receptor tyrosine kinases (RTKs) represent escape mechanisms in response to ET in some HR+ tumors. Short-term neoadjuvant ET (NET) offers the opportunity to identify early endocrine escape mechanisms initiated in individual tumors. Methods. This was a single arm, interventional phase II clinical trial evaluating 4 weeks (+/-1 week) of NET in patients with early-stage HR+/HER2-negative (HER2-) BC. The primary objective was to assess NET-induced changes in HER1-4 proteins by immunohistochemistry (IHC) score. Protein upregulation was defined as an increase of ≥1 in IHC score following NET. Results. Thirty-seven patients with cT1-T3, cN0, HR+/HER2- BC were enrolled. In 35 patients with evaluable tumor HER protein after NET, HER2 was upregulated in 48.6% (17/35; p=0.025), with HER2-positive status (IHC 3+ or FISH-amplified) detected in three patients at surgery, who were recommended adjuvant trastuzumab-based therapy. Downregulation of HER3 and/or HER4 protein was detected in 54.2% of tumors, whereas HER1 protein remained low and unchanged in all cases. While no significant volumetric reduction was detected radiographically after short-term NET, significant reduction in tumor proliferation rates were observed. No significant associations were identified between any clinicopathologic covariates and changes in HER1-4 protein expression on multivariable analysis. Conclusion . Short-term NET frequently and preferentially upregulates HER2 over other HER-family RTKs in early-stage HR+/HER2- BC and may be a promising strategy to identify tumors that utilize HER2 as an early endocrine escape pathway. Trial registration number: NCT03219476 Date of registration for prospectively registered trials: July 17, 2017.

Abstract P4-02-03: HER1-4 protein up-regulation following short-term neoadjuvant endocrine therapy in patients with hormone receptor-positive HER2-negative breast cancer

Background: Patients with hormone receptor-positive (HR+) breast cancer (BC) experience significant improvement in long-term outcomes with endocrine therapy (ET). However, metastatic recurrences of endocrine resistant disease develop in about 20-25% of patients and remain a major cause of BC mortality. Up-regulation of HER family growth factor receptor tyrosine kinases (RTKs) represent early escape mechanisms in tumors treated with ET. Neoadjuvant endocrine therapy (NET) offers a unique opportunity to identify responsiveness of HR+ BCs and detect tumors that display up-regulation of HER RTKs. Methods: A single arm, interventional, exploratory clinical trial evaluating four weeks of NET in early stage HR+/HER2-negative BC patients was conducted at our institution (NCT03219476). The primary objective was to assess changes in HER protein expression (HER1-4) from diagnostic core biopsies to surgically resected tumors treated with NET. Secondary objectives included assessment of other molecular markers, tumor proliferation and volumetric responses. Optimized protocols for immunohistochemistry (IHC) were used for HER1-4, and HER2 status was further assessed by fluorescence in situ hybridization (FISH) if IHC (2+) equivocal. Up-regulation was defined as an increase of ≥ 1 in IHC scores (ordinal 0,1,2,3) or gene amplification by FISH. Chi-square tests of independence and one sample difference in proportion tests were performed. Linear regression was used to evaluate association of variables of interest with the primary outcome. A significance level of 0.05 was used throughout. Results: Thirty-seven patients with cT1-T3, cN0 HR+/HER2-negative BC were enrolled. One patient had multifocal disease resulting in 38 tumors. Patient and tumor characteristics are shown in Table 1. There was no significant change in ER-positivity between pre- and post-treatment specimens. However, a trend towards decrease in PR-positivity was seen in post-treatment tumors consistent with functional ER pathway disruption (p=0.08). HER1-4 proteins were significantly up-regulated in 44.7% tumors (17/38) with HER2 being the most frequently up-regulated HER RTK (p=0.035). HER3 and HER4 were down-regulated in 50% tumors (19/38). Three patients converted to HER2-positive status (IHC 3+ or FISH amplified) at surgery and received adjuvant trastuzumab-based treatment. Ki67 decreased in 71% tumors [median 3.35 (range 0.06-25.5)] and increased in 26.3% tumors [median 1 (range 0.08-3.78)]. No significant associations were identified between any clinic-pathologic covariates and change in HER1-4 protein expression on multivariate analysis. Conclusions: HER1-4 proteins were significantly up-regulated in 44.7% of tumors after short-term NET in patients with early stage HR+/HER2-negative BC, with HER2 up-regulation being the most predominant and statistically significant. Down-regulation in HER3 and HER4 were seen in 50% of tumors, however the biological and clinical significance of this finding is unclear. Short-term NET is a promising strategy to identify HR+ tumors that up-regulate HER2 as an early escape pathway and endocrine resistance mechanism. Patients with such HER2 up-regulated tumors after NET may benefit from HER2-directed therapies upon disease recurrence or as adjuvant combination therapy. These findings need to be further explored in larger randomized clinical trials.

Table 1.Median Age (range)64yrs (42-81)Median BMI (range)28.3 (19.3-55.1)Post-menopausal, N (%)31 (83.8)Median clinical tumor size (range)1.3cm (0.5-7.7)Invasive ductal, N (%)26 (70)Grade, N (%)Low16 (43.2)Intermediate18 (47.4)High4 (10.5)Median tumor size at surgery (range)1.2cm (0.09-4)pN stage at surgery, N (%)N030 (81)N17 (19)NET, N (%)Aromatase inhibitors28 (75.6)Tamoxifen9 (24.4)

Citation Format: Lubna Naaz Chaudhary, Julie M Jorns, Yee Chung Cheng, Sailaja Kamaraju, John Burfeind, Mary Beth Gonyo, Amanda Kong, Caitlin Patten, Tina Yen, Chandler Cortina, Ebony Carson, Nedra Johnson, Carmen Bergom, Anjishnu Banerjee, Yu Wang, Yunguang Sun, Christopher R Chitambar, Hallgeir Rui. HER1-4 protein up-regulation following short-term neoadjuvant endocrine therapy in patients with hormone receptor-positive HER2-negative breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-02-03.

Abstract PD7-07: Neoadjuvant endocrine therapy helps identify HER2 up-regulation in patients with hormone receptor-positive HER2-negative breast cancer

Background: Endocrine therapy provides significant improvement in the long-term outcomes of patients with hormone receptor-positive (HR+) breast cancer (BC). However, metastatic recurrences of endocrine resistant disease develop in about 20-25% of patients and remain a major cause of BC mortality. Up-regulation of the HER2 growth factor receptor represents a common escape strategy used by cancer cells to survive and continue to proliferate in an ER-independent manner. Neoadjuvant endocrine therapy (NET) offers a unique opportunity to identify responsiveness of HR+ BCs and detect tumors that display up-regulation of HER2, an early endocrine resistance mechanism. Methods: A single arm, interventional, exploratory clinical trial evaluating four weeks of NET in early stage HR+/HER2-negative BC patients was conducted at our institution (NCT03219476). The primary objective was to assess changes in HER protein expression (HER1-4) from diagnostic core biopsies to surgically resected tumors treated with NET. Secondary objectives included assessment of other molecular markers, tumor proliferation and volumetric responses. Optimized protocols for immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) were used to assess HER2 status in the pre- and post-treatment tumor specimens. Chi-square and t-tests were performed. Linear regression multivariate analysis was performed to evaluate association of covariates with the primary outcome with 80% power at a significance level of 0.05. Here we present the changes in HER2 protein expression with NET in this study. Up-regulation was defined as an increase of ≥ 1 in IHC scores (ordinal 0,1,2,3) or gene amplification by FISH. Results: Thirty-seven patients with cT1-T3, cN0 HR+/HER2-negative BC were enrolled. Median age at diagnosis was 64 yrs (42-81) and median BMI was 28.3 (19.3-55.1). Most patients were post-menopausal (83.8%). Median tumor size clinically was 1.3 cm (0.5-7.7). Most tumors were low (42.1%) or intermediate (47.4%) grade and invasive ductal histology was seen in 70%. Median tumor size at surgery was 1.2 cm (0.09-4). One patient had a complete pathologic response (pCR) at surgery. Seven patients had pN1 disease at surgery (six with 1 lymph node involved, one with pN1mi). There was no significant change in ER-positivity between pre and post-treatment specimens. However, a trend towards decrease in PR-positivity was seen in post-treatment tumors consistent with functional ER pathway disruption (p=0.08). On HER2 protein assessment by IHC, most patients had IHC 0 (37.8%) or IHC 1+ (54%) at diagnosis. Significant up-regulation in HER2 protein was seen in 46% (17/37) of patients (p=0.0004), whereas down-regulation was detected in only 5% (2/37) and no change in the remaining 49% (18/37). Three patients converted to HER2-positive status (IHC 3+ or FISH amplified) at surgery and received adjuvant trastuzumab-based treatment. No significant associations were identified between any clinicopathologic covariates and change in HER2 protein expression. Conclusions: HER2 was up regulated in 46% of tumors after short-term NET in patients diagnosed with early stage HR+/HER2-negative BC. Short-term NET is a promising strategy to identify HR+ tumors that up-regulate HER2 as an early escape pathway and endocrine resistance mechanism. Patients with such HER2 up-regulated tumors after NET may benefit from HER2-directed therapies upon disease recurrence or as adjuvant combination therapy. These findings need to be further explored in larger randomized clinical trials.

Citation Format: Lubna N Chaudhary, Julie M Jorns, Yee Chung Cheng, Sailaja Kamaraju, Mary Beth Gonyo, Amanda Kong, Caitlin Patten, Tina Yen, Chandler Cortina, Ebony Carson, Nedra Johnson, Carmen Bergom, Anjishnu Banerjee, Yu Wang, Christopher R Chitambar, Hallgeir Rui. Neoadjuvant endocrine therapy helps identify HER2 up-regulation in patients with hormone receptor-positive HER2-negative breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD7-07.

Do we need cardiopulmonary exercise to determine the optimal time for intervention in valvular heart disease?

Introduction

Cardiopulmonary exercise testing (CPET) is underused in many clinical conditions other than HF. In valvular heart disease (VHD), CEPT can aid in choosing the right timing for surgery. The goals of this study were to compare the assessment of functional capacity (FC) by CEPT and NYHA scale, and to analyze the relationship between ventilatory efficiency (VE) parameters and time to surgery.

Methods

197 CPET were performed in 163 patients with moderate or severe VHD (51% female). Real METS (RM) were calculated as indexed peak VO2/3.5 (1 MET = 3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the exercise duration. An agreement analysis between RM, EM and NYHA was performed. The association among VE/VCO2 slope, pet CO2 at anaerobic threshold (AT), OUES and time to surgical indication was also studied using Cox logistic regression analysis.

Results

See Table. The RM and EM were 4,7±1,7and 6,2±2,9, respectively (p<0.01), and the correlation was low (ICC=0,7, p<0.001). The agreement between NYHA class and % of peak predicted V02 was very low (kappa index = 0.1, p<0.001). VE parameters were predictive of an earlier surgical indication: petCO2 AT (p=0.02), VE/VCO2 slope (p=0.069), OUES (p=0.014).

Conclusions

In asymptomatic VHD patients, the surgical indication should not rely solely in their FC assessed by either NYHA scale or EM derived by duration of exercise. In our series, these parameters clearly overestimated the FC of the population. Also, the ventilatory inefficiency may be a surrogate marker of advanced disease and lead to a closer surveillance for an earlier intervention.

Real and estimated METS by type of VHD

Funding Acknowledgement

Type of funding source: None

P4344An example that big data analysis is ready for the prime time

Introduction

Data about the epidemiology of valvular heart disease (VHD) is scarce. The increasing aging of the population may cause an augmented prevalence of VHD, with a great number of comorbidities that conveys a higher surgical risk. The aim of this study was to describe the prevalence of VHD in the patients attended at our institution from 2007 until 2017 and to describe the main characteristics of this population.

Methods

We used a new tool based on EHRead Technology to extract clinical relevant information from Electronic Health Records, designed for descriptive and predictive big data analysis. All medical reports generated at the outpatient clinic, ER or hospitalization ward were examined. Patients with a diagnosis of moderate or severe VHD were selected. The prevalence of VHD was also estimated in 2 quintiles, from 2008 until Feb 2013 and from March 2013 until Dec 2017.

Results

The total prevalence of VHD in our population was 1.04% (n=3431). Mitral regurgitation was the most frequent valvular lesion (0.4%, n=1318), followed by aortic stenosis (0.3%, n=967) and aortic regurgitation (0.28%, n=938). There was a clear female predominance (63%), and the median age was 76.4. In the 1st quintile the prevalence of VHD was 0.25%, and increased to 0.79% in the 2nd. This trend was consistent in all type of valvular lesions. The prevalence of comorbidities was higher than in other epidemiological studies (Table).

Prevalence of comorbidities Severe MR Severe AS Severe AR Euro Heart Valve Survey Hypertension 54,5% 69,1% 47,9% 49% Dyslipidemia 32,2% 40,6% 27,4% 35% Diabetes Mellitus 28,0% 31,5% 16,4% 15% Smoking (current) 5,6% 5,4% 13,7% 39% Coronary heart disease 12,0% 17,0% 12,3% 13% Stroke 7,0% 8,9% 5,5% 7% Chronic kidney disease 18,9% 16,9% 20,5% 15% Chronic obstructive pulmonary disease 11,2% 9,9% 11,0% 15% MR: Mitral regurgitation, AS: aortic stenosis, AR: aortic regurgitation, MS: mitral stenosis.

Sex Distribution

Conclusions

The older age and greater number of comorbidities seen in our series over the past ten years, compared to the Euroheart Valve Survey reinforce the idea that the percutaneous valvular therapies should play a major role in the treatment of patients with VHD. Although, the prevalence of VHD may be underestimated in our population, due to the methodology, it reflects an ever-growing pathology in an older and sicker population.

P2750Why should cardiopulmonary exercise testing be routinely used for assessing patients with valvular heart disease?

Introduction

The role of cardiopulmonary exercise testing (CPET) is unquestionable to assess prognosis in heart failure. In patients with valvular heart disease (VHD), the functional capacity (FC) is crucial to aid in the right timing of surgery. The aim of this study was to compare the assessment of the FC by CPET and NYHA and the correlation between ventilatory efficiency parameters and resting systolic pulmonary artery pressure (SPAP).

Methods

We studied 100 VHD patients (57% female) who underwent a CPET. We calculated the real METS (RM) as indexed peak VO2/3.5 (1 MET=3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the time of exercise. An agreement analysis between RM, EM and NYHA was calculated. The correlation among VE/Vslope CO2, EqCO2at anaerobic threshold (AT), PETCO2, partial pressure end-tidal CO2 at AT and SPAP was analyzed.

Results

The results are shown in Table and Figure. The RM and the EM were 4.7±1.7 and 5.5±3, respectively (p<0.01) with a low agreement (ICC=0.6, p<0.01). The agreement between NYHA and the classification obtained from peak % of predicted peak VO2 was very low (weighted kappa =0.06, p=0.28). In patients with severe mitral VHD, the ventilatory efficiency parameters were correlated with SPAP (PETCO2 (AT), r=−0.7, p=0.002; EqCO2 (AT), r=0.5, p=0.04:VE/Vslope CO2, r=0.3, p 0.2), whereas in those with severe aortic VHD, these correlations were much lower (PETCO2 (AT), r=−0.3, p=0.13; EqCO2 (AT), r=0.2, p=0.15; VE/Vslope CO2, r=0.18, p 0.31).

Total (n=100) Mitral regurgitation (n=35) Aortic regurgitation (n=23) Age 65 (29–86) 66 (30–84) 65 (11–87) LVEF (%) 62±6 63±6 61±7 SPAP (mmHg) 40±11 39±11 36±8 NYHA I (60%), II (33%), III (7%) I (63%), II (29%), III (9%) I (63%), II (33%), III (4%) Indexed peak VO2 (ml/min/kg) 16±6 17±6 19±8 Peak % predicted VO2 73±18 74±17 79±18 Predicted VO2 AT (%) 58±19 54±19 61±22 Eq CO2 AT 33±6 32±7 32±5 VE/VSlope CO2 33±6 32±7 33±8 PetCO2 AT 34±4 36±4 36±5

Type and degree of VHD

Conclusions

NYHA scale and estimation of METS derived from the time of exercise clearly overestimated the FC of our population. In our series, the ventilatory inefficiency in patients with mitral VHD could be a surrogate marker of advanced disease and could lead to an earlier intervention.

Simultaneous acute appendicitis and pseudomembranous colitis in a pediatric patient

Acute appendicitis is a common cause for pediatric surgery, with an increasing incidence as this population ages. Pseudomembranous colitis (PMC) from Clostridum difficle is being seen more frequently in pediatric patients, especially after treatment with antibiotics and in those with Hirschsprung's disease. Only three prior cases of appendicitis associated with PMC have been described in the literature, and all of them occurred in adult patients. Here, we describe the first documented pediatric case: a 16-year-old female who developed acute appendicitis while concomitantly being treated for suspected pseudomembranous colitis. We concur with previous authors that there may be an association between these two pathologies; furthermore, this association may not always be clinically apparent and may be both under-diagnosed and under-reported.

Support vector analysis of color-Doppler images: a new approach for estimating indices of left ventricular function

Reliable noninvasive estimators of global left ventricular (LV) chamber function remain unavailable. We have previously demonstrated a potential relationship between color-Doppler M-mode (CDMM) images and two basic indices of LV function: peak-systolic elastance (Emax) and the time-constant of LV relaxation (tau). Thus, we hypothesized that these two indices could be estimated noninvasively by adequate postprocessing of CDMM recordings. A semiparametric regression (SR) version of support vector machine (SVM) is here proposed for building a blind model, capable of analyzing CDMM images automatically, as well as complementary clinical information. Simultaneous invasive and Doppler tracings were obtained in nine mini-pigs in a high-fidelity experimental setup. The model was developed using a test and validation leave-one-out design. Reasonably acceptable prediction accuracy was obtained for both Emax (intraclass correlation coefficient Ric, = 0.81) and tau (Ric, = 0.61). For the first time, a quantitative, noninvasive estimation of cardiovascular indices is addressed by processing Doppler-echocardiography recordings using a learning-from-samples method.

Effects of angiotensin converting enzyme inhibitors in hypertensive patients with aortic valve stenosis: a drug withdrawal study

OBJECTIVE

To determine the effects of angiotensin converting enzyme (ACE) inhibitors in hypertensive patients with aortic valve stenosis (AS).

DESIGN

Observational, drug withdrawal, single blinded study, with randomisation of the order of tests.

SETTING

Hypertension and asymptomatic AS.

PATIENTS AND INTERVENTIONS

20 patients (aged 73 (9) years, valve area 0.7 (0.3) cm2, left ventricular ejection fraction > or = 45%) were enrolled. Each patient underwent two sets of tests (with and without taking the drug), each of which included clinical evaluation, Doppler echocardiogram, and symptom limited exercise echocardiography.

MAIN OUTCOME MEASURES

Functional and haemodynamic variables while taking and not taking ACE inhibitors.

RESULTS

Drug intervention induced no change in patients' subjective functional class. While taking ACE inhibitors, patients had a lower systolic blood pressure (140 (18) mm Hg with ACE inhibitors v 159 (12) mm Hg without ACE inhibitors, p = 0.02), a higher mean pressure gradient (34 (15) mm Hg v 28 (18) mm Hg, p = 0.037), and a higher left ventricular stroke work loss (19 (6)% v 14 (10)%, p = 0.009). Other baseline functional and haemodynamic parameters were unmodified. Five patients had an abnormal blood pressure response during one of the exercise tests (two patients while taking the drug and three patients while not taking the drug). When taking ACE inhibitors, patients had a higher stroke volume at peak stress (59 (11) ml v 54 (25) ml, p = 0.046). All other stress variables remained constant.

CONCLUSIONS

In AS, the afterload relief caused by ACE inhibitors is blunted by a parallel increase in the pressure gradient. However, ACE inhibitors favourably affect stress haemodynamic function in most hypertensive patients with AS and should not be discontinued.

[Importance of the clinical-radiological complementarity in superficial cerebral siderosis]

We report two cases of superficial siderosis of central nervous system. In one case it was idiopathic and in the other secondary to an unidentified subarachnoid hemorrhage. The symptoms that characterized the clinical picture of both were gait disturbance and hypoacusis. The MRI study showed a superficial rim of hypointensity that covered the cerebellum and brainstem, and extended along the cranial nerves and the brain surface. The findings were clearer in the T2 spin echo series. Due to the high sensitivity for hemosiderin deposits, MRI made it possible to make the final diagnosis of this rare disease.

[Dementia with frontal lobe atrophy: clinical study from 18 patients with cognitive impairment and frontal lobe involvement detected by structural and functional neuroimaging]

OBJECTIVE

To characterize clinically patients with cognitive impairment and frontal lobe degeneration at neuroimaging.

PATIENTS AND METHODS

Patients diagnosed of dementia or mild neurocognitive impairment by DSM IV criteria and neuropsychological tests with frontal lobe atrophy and hipoperfusion detected by computed tomography and single photon emission computed tomography.

RESULTS

18 patients, 5:1 on behalf of women; mean age at onset, 74 years; hereditary for dementia, 38%; mean duration of illness at first testing, 2 years; the most common initial symptoms, memory loss. At initial examination, psychotic or behavioral impairment was found in 61% and parkinsonism in 38%, the commonest cognitive troubles at this moment was the executive function, language and anterograde memory dysfunctions at the same rate. Frontal lobe atrophy and hypoperfusion was found in 100%, temporal in 88% and parietal in 38%. Electroencephalogram was pathological in 33%. The course of the disease was progressive but with fluctuation in 27%. Frontotemporal dementia clinical criteria in 13 patients, 4 of them clinical criteria of dementia with Lewy bodies too, and clinical criteria of Alzheimer s disease in 5.

[Non tumoural cerebral biopsies: an analysis of 50 cases]

OBJECTIVE

Cerebral biopsy is an invasive technique with limited, specific indications in view of the potential risk of complications.

PATIENTS AND METHODS

We reviewed a series of 50 cases of biopsies via craniotomy done over a period of 10 years to investigate suspected non tumoural disorders.

RESULTS

There was a predominance of space occupying lesions and treatable infections (36%) and of non diagnostic biopsies (40%). There was poor correlation between the initial clinical diagnosis and the histological findings (50 71%). There were no complications.

CONCLUSIONS

We conclude that the indications should be better defined and, in view of the satisfactory tolerance of this procedure, the study group should be increased by using other less invasive procedures (stereotaxia).

[Symptomatic paroxysmal dystonia (non-kinesigenic forms): two new cases]

We report two new cases of symptomatic paroxysmal non-kinesigenic dystonia. The first is a 68-year-old woman with paroxysmal spontaneous dystonic spasms in her right arm lasting 1 minute. They occurred 1-2/day, a few months after a cerebral infarction (left internal capsule and left lenticular nucleus) which occurred 6 years ago. The second is a 30-year-old woman with a 7-year-history of spontaneous dystonic postures (flexion spasms) in her left arm lasting 15 minutes and occurring monthly. In this case an Arnold-Chiari malformation with cervical syringomyelia was discovered.

[Idiopathic cervical plexopathy]

We describe a 26 year-old woman with cervical plexopathy with damage of left superficial or cutaneous branches, and left cervical sensory dorsal rami. Picture began acutely and vanished few days later. We ruled out known etiologies like traumatisms, tumours and surgical and anaesthetic complicated procedures, therefore the patient suffered an idiopathic cervical plexopathy. We hypothesize two possibilities for this clinical picture: an autoimmune reaction or a muscular entrapment.

Mitochondrial functions in chronic spinal muscular atrophy

We determined the respiration rate, respiratory control and ADP/O ratios, with different substrates in mitochondria isolated from seven patients with chronic spinal muscular atrophy and compared them with normal human muscle. In all cases studied, a severe alteration of the respiratory control with variable derangement of oxidative phosphorylation was found. Similar findings have been described in other neuromuscular disorders including the so-called "mitochondrial myopathy". We believe that this disturbance of mitochondrial function is non specific and only the hypermetabolic syndrome of Luft could be considered biochemically as a "mitochondrial myopathy", a disorder selectively involving mitochondria of skeletal muscle.