Systemic relapses of primary CNS lymphomas (PCNSL): a LOC network study

Primary central nervous system lymphomas (PCNSLs) classically remain confined within the CNS throughout their evolution for unknown reasons. Our objective was to analyse the rare extracerebral relapses of PCNSL in a nationwide population-based study. We retrospectively selected PCNSL patients who experienced extracerebral relapse during their follow-up from the French LOC database. Of the 1968 PCNSL included in the database from 2011, 30 (1.5%, median age 71 years, median KPS 70) presented an extracerebral relapse, either pure (n = 20) or mixed (both extracerebral and in the CNS) (n = 10), with a histological confirmation in 20 cases. The median delay between initial diagnosis and systemic relapse was 15.5 months [2-121 months]. We found visceral (n = 23, 77%), including testis in 5 (28%) men and breast in 3 (27%) women, lymph node (n = 12, 40%), and peripheral nervous system (PNS) (n = 7, 23%) involvement. Twenty-seven patients were treated with chemotherapy, either with only systemic targets (n = 7) or mixed systemic and CNS targets (n = 20), 4 were consolidated by HCT-ASCT. After systemic relapse, the median progression-free survival and overall survival (OS) were 7 and 12 months, respectively. KPS > 70 and pure systemic relapses were significantly associated with higher OS. Extracerebral PCNSL relapses are rare, mainly extranodal, and frequently involve the testis, breast, and PNS. The prognosis was worse in mixed relapses. Early relapses raise the question of misdiagnosed occult extracerebral lymphoma at diagnostic workup that should systematically include a PET-CT. Paired tumour analysis at diagnosis/relapse would provide a better understanding of the underlying molecular mechanisms.

A219 AMINOTRANSFERASE IMPROVEMENTS IN PATIENTS WITH NON-ALCOHOLIC STEATOHEPATITIS ARE ASSOCIATED WITH FIBROSIS REGRESSION IN THE REGENERATE STUDY

Background

The interim analysis of the REGENERATE study showed obeticholic acid (OCA) 25 mg treatment significantly improved liver histology in patients with nonalcoholic steatohepatitis (NASH) and fibrosis. Elevations in aminotransferases are associated with adverse liver-related outcomes in NASH.

Aims

Here, we evaluate the utility of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) as markers of treatment response to OCA in patients with NASH.

Methods

Changes in ALT (upper limit of normal [ULN] = 55 U/L) and AST (ULN = 34 U/L) were assessed systematically at 1, 3, 6, 12, and 18 months in 931 NASH patients with stage 2 or 3 fibrosis randomized 1:1:1 to placebo (PBO), OCA 10 mg, or OCA 25 mg in REGENERATE (intent-to-treat population). Least-square mean (LSM) and 95% confidence intervals (CIs) of percentage change from baseline in ALT and AST were analyzed using a mixed-effect repeated-measures model.

Results

Baseline characteristics were well-balanced across treatment arms: ALT 79±53 U/L; AST 58±36 U/L; 44% F2, 56% F3. Aminotransferase values were > ULN for ALT in 60% (7% > 3xULN), and for AST in 74% (9% > 3xULN) of patients. Rapid, progressive, and dose-dependent improvement in ALT and AST was seen across PBO, OCA 10 mg, and OCA 25 mg arms, which at Month 18 was: ALT LSM change (95% CI), respectively, -4.9% (-10.7–0.9), -23.2% (-28.9– -17.4) and -31.9% (-37.7– -26.1) and in AST, -8.7% (-12.1– -5.2), -13.4% (-16.8– -9.9), and -19.4 (-22.8– -15.9). ALT and AST LSM reductions in OCA arms vs PBO were seen regardless of patient ULN status at baseline. In all patients, ALT/AST reduction was associated with probability of fibrosis regression at Month 18, ranging from approximately 20%, 95% CI (14–27) to 45% (37–54) with any reduction in ALT (> 0%–100%) and between approximately 20%, 95% CI (25–38) to 43% (35–57) with any reduction in AST (> 0%–100%). Interestingly, even with increases of ≤ 40% in AST or ALT there was still a small probability of fibrosis regression (< 20%). Analysis of changes in ALT and AST in individual patients showed that more patients had improvements on OCA than PBO at Month 18 (FIG 1).

Conclusions

OCA resulted in consistent dose-dependent improvement of ALT and AST. Patients with reductions in ALT or AST were up to twice as likely to have fibrosis improvement than those whose ALT or AST increased. The REGENERATE study is ongoing and will continue through clinical outcomes for verification and description of clinical benefits of OCA in treatment of NASH.

Funding Agencies

None

P14.48 Extracerebral relapses of primary CNS lymphoma (PCNSL): a LOC network retrospective study

BACKGROUND

Classically PCNSL remain confined within the CNS throughout their evolution for reasons still unknown (> 80% cerebral relapses). The aim of this study was to describe the characteristics and outcomes of the rare extracerebral relapses of PCNSL.

MATERIAL AND METHODS

This is a multicenter, retrospective study. We included all immunocompetent patients newly diagnosed with diffuse large B-cell PCNSL registered in the national LOC network database since 2010 and followed prospectively, who presented an extracerebral relapse, pure (extracerebral only site) or associated with concomitant CNS relapse (mixed). All had body scan and/or TEP -CT at diagnosis work up.

RESULTS

Of the 1968 PCNSL included in the database, 29 (1.5%) patients presented a systemic relapse [median age 71 years, median KPS 70% at relapse], either pure (n=19) or mixed (n=10), with a histological confirmation in 19 cases (66%). The median delay between initial diagnosis and systemic relapse was 15 months [2–49 months], with 5 very early relapses (<8 months) and 10 late relapses (>21 months). 27 patients had symptoms, 21 related to the location of relapse and 6 with only general symptoms. The localization was thoracic (n=11), abdominal/pelvic (n=14), head/neck (n=6) and limbs (n=9). We found visceral (n=24, 83%), including testis in 5 (28%) men and breast in 3 (27%) women, lymph node (n=12, 41%) and peripheral nervous system (PNS) (n=8, 28%; 4 plexus and 4 extradural roots) involvement. 27 patients were treated with chemotherapy, either with only systemic target (n=8) (R-CHOP alone) or mixed systemic and CNS target (n=19) (R-CHOP-MTX, R-ICE, GEMOX, RDHAC) and consolidated by high-dose chemotherapy with autologous stem cell transplantation (HCT-ASCT) in 4 cases [median age 55 years, median KPS 80%], with 34% of complete response. After systemic relapse, median progression-free survival was 8 months and overall survival (OS) was 9 months, 15 months for pure systemic and 4.5 months for mixed relapses. KPS>70%, pure systemic relapses and complete response were significantly associated with higher OS in univariate analysis.

CONCLUSION

Extracerebral PCNSL relapses are very rare, mainly extranodal and involve a large spectrum of anatomical sites, the most frequent being testis, breast and PNS. Prognosis was worse in case of mixed relapse than in pure systemic relapse that was similar to non PCNSL lymphomas. Very early relapses raise the question of misdiagnosed occult extracerebral lymphoma at diagnostic work up that should include systematically a FDG PET-CT. More studies are needed to refine their treatment and to specify the role of HCT-ASCT. Paired tumor tissues at diagnosis (CNS)/relapse (extracerebral) analysis would provide a better understanding of underlying molecular mechanisms.

A217 NONINVASIVE ASSESSMENTS TO IDENTIFY PATIENTS WITH ADVANCED FIBROSIS DUE TO NASH: SCREENED POPULATION FROM THE REGENERATE TRIAL

Aims

We explored the ability of noninvasive tests (NITs) to identify patients (pts) with advanced fibrosis due to NASH.

Methods

All screened pts from the ongoing phase 3 REGENERATE with available histology data were included. Five NITs were evaluated using established literature cutoffs to identify or exclude advanced fibrosis (values between upper and lower thresholds were considered indeterminate): Aspartate Transaminase-to-Platelet Ratio Index (APRI; ≥0.57, ≤0.84), Enhanced Liver Fibrosis (ELF; ≥7.7, <9.8), Fibrosis-4 (FIB-4; ≥1.30, <2.67), NAFLD fibrosis score (NFS; ≥−1.455, <0.676), and Transient Elastography (TE; ≥7.9 kPa, <9.6 kPa). Three testing methods applied were single NIT, 2 simultaneous NITs weighted equally (NFS+ELF, FIB-4+ELF, NFS+TE, FIB-4+TE), and 2 sequential NITs with the second test performed only if the first test was indeterminate (NFS→ELF, FIB-4→ELF, NFS→TE, FIB-4→TE).

Results

4133 pts in the REGENERATE screened population had an available biopsy (baseline liver biopsy: F0, 15.5%; F1, 27.2%; F2, 21.2%; F3, 29.6%; F4, 6.5%). Of these, 96% had FIB-4, NFS, and APRI, 41% had TE, and 28% had ELF. Single NITs with upper thresholds demonstrating strong specificity for identification of advanced fibrosis were FIB-4 (97%), NFS (94%), and APRI (86%); NITs with lower thresholds demonstrating good sensitivity for identification of early fibrosis were ELF (100%) and TE (88%). Evaluation of 2 simultaneous NITs resulted in a greater percentage of pts in the indeterminate zone. Application of 2 sequential tests improved the accuracy of identification and reduced misclassification vs 2 simultaneous tests.

Conclusions

Sequential NIT strategies may decrease liver biopsy rates while maintaining the accuracy of noninvasive diagnosis in pts with advanced fibrosis due to NASH.

Funding Agencies

Intercept Pharmaceuticals

Elaboration and Formalization of Current Scientific Knowledge of Risks and Preventive Measures Illustrated by Colorectal Cancer

Objectives: Present the method used to elaborate and formalize current scientific knowledge to provide physicians with tools available on the Internet, that enable them to evaluate individual patient risk, give personalized preventive recommendations or early screening measures.

Methods: The approach suggested in this article is in line with medical procedures based on levels of evidence (Evidence-based Medicine). A cyclical process for developing recommendations allows us to quickly incorporate current scientific information. At each phase, the analysis is reevaluated by experts in the field collaborating on the project. The information is formalized through the use of levels of evidence and grades of recommendations. GLIF model is used to implement recommendations for clinical practice guidelines.

Results: The most current scientific evidence incorporated in a cyclical process includes several steps: critical analysis according to the Evidence-based Medicine method; identification of predictive factors; setting-up of risk levels; identification of prevention measures; elaboration of personalized recommendation. The information technology implementation of the clinical practice guideline enables physicians to quickly obtain personalized information for their patients. Cases of colorectal prevention illustrate our approach.

Conclusions: Integration of current scientific knowledge is an important process. The delay between the moment new information arrives and the moment the practitioner applies it, is thus reduced.

Diagnostic performance of FibroTest, SteatoTest and ActiTest in patients with NAFLD using the SAF score as histological reference

BACKGROUND

Blood tests of liver injury are less well validated in non-alcoholic fatty liver disease (NAFLD) than in patients with chronic viral hepatitis.

AIMS

To improve the validation of three blood tests used in NAFLD patients, FibroTest for fibrosis staging, SteatoTest for steatosis grading and ActiTest for inflammation activity grading.

METHODS

We pre-included new NAFLD patients with biopsy and blood tests from a single-centre cohort (FibroFrance) and from the multicentre FLIP consortium. Contemporaneous biopsies were blindly assessed using the new steatosis, activity and fibrosis (SAF) score, which provides a reliable and reproducible diagnosis and grading/staging of the three elementary features of NAFLD (steatosis, inflammatory activity) and fibrosis with reduced interobserver variability. We used nonbinary-ROC (NonBinAUROC) as the main endpoint to prevent spectrum effect and multiple testing.

RESULTS

A total of 600 patients with reliable tests and biopsies were included. The mean NonBinAUROCs (95% CI) of tests were all significant (P < 0.0001): 0.878 (0.864-0.892) for FibroTest and fibrosis stages, 0.846 (0.830-0.862) for ActiTest and activity grades, and 0.822 (0.804-0.840) for SteatoTest and steatosis grades. FibroTest had a higher NonBinAUROC than BARD (0.836; 0.820-0.852; P = 0.0001), FIB4 (0.845; 0.829-0.861; P = 0.007) but not significantly different than the NAFLD score (0.866; 0.850-0.882; P = 0.26). FibroTest had a significant difference in median values between adjacent stage F2 and stage F1 contrarily to BARD, FIB4 and NAFLD scores (Bonferroni test P < 0.05).

CONCLUSIONS

In patients with NAFLD, SteatoTest, ActiTest and FibroTest are non-invasive tests that offer an alternative to biopsy, and they correlate with the simple grading/staging of the SAF scoring system across the three elementary features of NAFLD: steatosis, inflammatory activity and fibrosis.

[Paracoccidioidomycosis of the external ear]

BACKGROUND

Paracoccidioidomycosis is a systemic fungal infection common in Latin America. Cutaneous involvement is frequent and usually affects multiple sites, being most frequently associated with lesions of the oropharyngeal mucosa. The cutaneous form on its own is rare.

PATIENTS AND METHODS

We report a case of paracoccidioidomycosis isolated from the ear of a 43-year-old immunocompetent man. The lesion consisted of a partially ulcerated plaque on the auricle of the left ear. Direct examination, histopathological examination and PCR revealed the presence in the skin lesion of yeasts identified as Paracoccidioides brasiliensis.

DISCUSSION

The sites of paracoccidioidomycosis on the ear can be confused with other tropical diseases frequently found in the Amazon region such as leishmaniasis, leprosy and lobomycosis. The absence of any other cutaneous sites in this case raised the question of whether the lesion was of primary or secondary origin.

Differential patterns of morphological and molecular hybridization between Fraxinus excelsior L. and Fraxinus angustifolia Vahl (Oleaceae) in eastern and western France

We examined large-scale patterns of morphology, genetic structure and ecological correlates of Fraxinus excelsior and the closely related species Fraxinus angustifolia in France, in order to determine the degree of hybridization between them. We sampled 24 populations in two putative hybrid zones (Loire and Saône), and five control populations of each species. We measured foliar characteristics of adult trees and used five nuclear microsatellites as molecular markers. Canonical discriminant analysis indicated that the two species differ in morphology, but that intermediate types are common in the Loire region but less frequent in the Saône region. Bayesian population assignment identified one F. angustifolia and two F. excelsior gene pools. Most Loire individuals clustered genetically with the F. angustifolia gene pool. In contrast, the Saône region presented individuals belonging mostly to F. excelsior pools, although the F. angustifolia type was frequent in certain populations. The lowest F(ST) values were found between the Loire and F. angustifolia controls that also exhibited no significant isolation by distance. The proportion of the F. angustifolia gene pool in each locality was negatively correlated with winter temperatures, suggesting that a cold climate may be limiting. Hybridization is probably favoured by the intermediate climatic conditions in the Loire region that allow both species to occur, but is somewhat hampered by the harsher winters in the Saône area where morphological introgression has apparently not yet occurred.

Cyclic changes in the vaginal epithelium of normal rhesus macaques

Studies in nonhuman primates indicate that changes in the thickness and integrity of the vaginal epithelium affect the transmission rates of HIV-1, but few studies have examined the normal variations that may occur in the vagina of normal macaques as a result of aging or changes in the menstrual cycle. This study was conducted to determine if differences occur in the thickness of the vaginal mucosa with age or menses. Vaginal mucosal thickness was compared in 46 rhesus macaques grouped as juvenile (1-3 years old), mature cycling (3-21 years old), and geriatric (> 21 years old). Epithelia of mature cycling macaques were also compared at different stages of the menstrual cycle. Older females (> 21 years) had the thinnest and least keratinized epithelium of all groups, followed by the youngest females (< 3 years). The vaginal epithelium was also thinner in cycling macaques during menses compared to the follicular stage. In addition, young, geriatric, or cycling macaques during menses had minimal keratinization. We hypothesize that normal physiologic changes in the vaginal epithelium of women occur with age and menses, which may affect a woman's susceptibility to HIV-1 transmission and other sexually transmitted diseases. Also, age and menstrual cycle should be considered when designing vaginal transmission experiments in rhesus macaques.

CpG-C ISS-ODN activation of blood-derived B cells from healthy and chronic immunodeficiency virus-infected macaques

Cytosine-phosphate-guanine class C (CpG-C) immunostimulatory sequence oligodeoxynucleotides (ISS-ODNs) activate human B cells and dendritic cells (DCs), properties that suggest potential use as a novel adjuvant to enhance vaccine efficacy. After demonstrating that the CpG-C ISS-ODN C274 activates macaque DCs, we examined in vitro activation of macaque B cells by C274 as a prelude to evaluation of this molecule as an adjuvant in the testing of candidate human immunodeficiency virus vaccines in the rhesus macaque-simian immunodeficiency virus (SIV) model. C274 induced macaque CD20(+) B cells to proliferate more strongly than CD40 ligand or CpG-B ISS-ODN. C274 enhanced B cell survival; increased viability was most evident after 3-7 days of culture. Increased expression of CD40, CD80, and CD86 by B cells was apparent within 24 h of exposure to C274 and persisted for up to 1 week. C274-stimulated, B cell-enriched and peripheral blood mononuclear cell suspensions from naïve and immunodeficiency virus-infected monkeys secreted several cytokines [e.g., interleukin (IL)-3, IL-6, IL-12, interferon-alpha] and chemokines [e.g., monocyte chemoattractant protein-1/CC chemokine ligand 2 (CCL2), macrophage-inflammatory protein-1alpha/CCL3, IL-8/CXC chemokine ligand 8]. In comparison, exposure of macaque B cells to SIV had minimal impact on surface phenotype, despite inducing cytokine and chemokine production in cells from infected and uninfected animals. These observations emphasize the need to identify strategies to optimally boost immune function, as immunodeficiency viruses themselves only partially activate B cells and DCs. The ability of C274 to stimulate B cells and DCs in healthy and infected monkeys suggests its possible use as a broad-acting adjuvant to be applied in the rhesus macaque model for the development of preventative and therapeutic vaccines.

Immune responses induced by intranasal imiquimod and implications for therapeutics in rhinovirus infections

Notwithstanding the progress recently made in immunology and virology, there is yet no effective, specific treatment for the common cold. Symptomatic treatment is minimally effective. An anecdotal report of rapid clearing of the common cold of recent onset after intranasal application of imiquimod in several subjects by one of the authors, made us test the hypothesis that this treatment works through the secretion of interferon by the nasal mucosa. We decided to do an animal study in primates (Indian Macaca Mulata): 5 treatment and 3 control animals were used. Imiquimod or placebo was massaged into the nares of the animals and periodic samples of post-nasal fluid were taken and measurements for Interferon alpha (IFNalpha) and Tumor Necrosis Factor alpha (TNFalpha) were made by ELISA methods, and kinetic studies. mRNA IFNalpha was also isolated and analyzed by quantitative competitive RT-PCR. The internal standard was constructed to be complementary to and compete with oligonucleotide primers and for amplification of target sequences. One intranasal application of imiquimod rapidly (1-4 Hours) induced high levels of mRNA for IFNalpha, and minimal levels in the control animals. Rapid induction of INFalpha, and proportional increase of TNFalpha sustained for 4 and 6 hours respectively were noted. No adverse reactions to treatment were found in macaques during this short period of intranasal imiquimod usage (except in one macaque with a short period of lacrimation). No animal had cytotoxic effects when examined at 6 hr, 12 hr, 24 hr or 48 hr, except one animal, which had an episode of lacrimation for 6 hr post treatment. Thus both safety and efficacy of short treatment with imiquimod is proven in this animal model. Proof of principle for intranasal treatment of the common cold with imiquimod is shown. We think that this work will encourage a number of double blind clinical trials to confirm the effectiveness of the intranasal treatment of the common cold with imiquimod.

A generalized heterozygote deficiency assessed with microsatellites in French common ash populations

Common ash is a temperate forest tree with a colonizing behaviour, a discontinuous spatial distribution and a peculiar and poorly known mating system. Microsatellite markers were used to study the genetic structure in natural populations of common ash. Twelve populations located in northeastern France were analysed at five loci. Levels of genetic variability within and among stands were estimated for the seedling and adult stages. As expected for a forest tree, our results reveal high levels of intrapopulation diversity and a low genetic differentiation between stands. However, a general and significant heterozygote deficiency was found, with a mean F(IS) of 0.163 for the seedlings and of 0.292 for the adult trees. The different explanations for such an excess homozygosity are discussed: a nonMendelian inheritance of alleles, the presence of null alleles, a Wahlund effect and assortative mating.

Elaboration and formalization of current scientific knowledge of risks and preventive measures illustrated by colorectal cancer

OBJECTIVES

Present the method used to elaborate and formalize current scientific knowledge to provide physicians with tools available on the Internet, that enable them to evaluate individual patient risk, give personalized preventive recommendations or early screening measures.

METHODS

The approach suggested in this article is in line with medical procedures based on levels of evidence (Evidence-based Medicine). A cyclical process for developing recommendations allows us to quickly incorporate current scientific information. At each phase, the analysis is reevaluated by experts in the field collaborating on the project. The information is formalized through the use of levels of evidence and grades of recommendations. GLIF model is used to implement recommendations for clinical practice guidelines.

RESULTS

The most current scientific evidence incorporated in a cyclical process includes several steps: critical analysis according to the Evidence-based Medicine method; identification of predictive factors; setting-up risk levels; identification of prevention measures; elaboration of personalized recommendation. The information technology implementation of the clinical practice guideline enables physicians to quickly obtain personalized information for their patients. Cases of colorectal prevention illustrate our approach.

CONCLUSIONS

Integration of current scientific knowledge is an important process. The delay between the moment new information arrives and the moment the practitioner applies it, is thus reduced.

Optimization of 4A zeolite synthesis as recovery of wastes from aluminum finishing

A model representing the synthesis process of 4A zeolite from wastes of aluminum finishing plants was obtained and validated through statistical tests. From this model, the optimum values for the molar ratios SiO2/ Al2O3, Na2O/SiO2 and H2O/Na2O, which define the type and quality of the synthesized zeolite, were estimated for the use of these wastes as raw material. The obtained zeolites could be used as water softeners in the formulation of detergents. The resulting liquors could be reused in the cleaning of the extrusion matrices used for aluminum profiles or recycled for new zeolites synthesis.

A meiotically reproducible chromosome length polymorphism in the ascomycete fungus Ophiostoma ulmi (sensu lato)

We have followed the transmission of Ophiostoma ulmi s.l. chromosome length polymorphisms (CLPs) into the F2 generation to determine the reproducibility of a genome rearrangement culminating in the conversion of a 1.0 Mb chromosome into a 800 kb chromosome. The 1.0 Mb chromosome in strain CESS16K is thus far unique among O ulmi s.l. wild-type strains, as no other wild-type strains have been observed with chromosomes smaller than 2.3 Mb. It has been previously shown that the 1.0 Mb chromosome is mitotically stable, carries at least one normally expressed gene, and is transmitted through meiosis. In this study, a series of crosses were performed to further elucidate the pattern of inheritance of the 1.0 Mb chromosome and the process of conversion of the 1.0 Mb species to 800 kb. In crosses where the 1.0 Mb chromosome was allowed to pair with itself or with the 800 kb chromosome, all progeny inherited a copy of the 1.0 Mb or 800 kb form, further demonstrating the A-type nature of these small chromosomes. When a cross was repeated between the strains CESS16K (1.0 Mb chromosome) and FG245Br-O (no 1.0 Mb or 800 kb chromosome), the occurrence of a 800 kb chromosome was observed in 9% of the progeny. A reciprocal cross between an 800 kb strain and a strain with no 800 kb or 1.0 Mb chromosome was conducted, and a progeny strain containing a 1.0 Mb chromosome was recovered. The reproducibility and reciprocality of the 1.0 Mb to 800 kb chromosome conversion demonstrates that meiotic processes are responsible for this CLP, and that O. ulmi s.l. strains with various divergent genome architectures can remain sexually compatible.

Combined interstitial hyperthermia and brachytherapy: Institute Gustave Roussy technique and preliminary results

In 1981, a protocol was developed at the Institute Gustave-Roussy, utilizing combined interstitial hyperthermia and brachytherapy, to treat recurrent tumors in previously irradiated areas. This protocol consisted of interstitial hyperthermia, 44 degrees C for 45 minutes, followed immediately by iridium 192 curietherapy, delivering 30 Gy in 2 or 3 days to the tumor volume. Fourteen implantations have been performed in 11 patients. Complete eradication of tumor has been achieved thus far in 10 cases. Two patients were not evaluable because of rapid death resulting from diffuse metastases, and two patients demonstrated a partial response (greater than 50% tumor reduction). Treatment has been generally well tolerated despite prior high dose irradiation. There has been only one serious complication-a large area of painful necrosis following retreatment of a recurrent floor of mouth carcinoma. Special "metallic-plastic" tubes were developed to improve tissue tolerance. We were able to document that a high and homogeneous temperature could be delivered throughout the tumor volume. The technical innovations, and the techniques of implantation and temperature documentation are described below.

[Spontaneous rupture of the spleen during chronic pancreatitis. A report on two new cases (author's transl)]

Spontaneous spleen rupture during chronic pancreatitis is scarcely seen. About 2 personal cases, the authors study 15 published cases. The spleen break can occur in patients with a known chronic pancreatitis, or with pancreatic signs, or without any symptomatology. Diagnosis is hard: spontaneous spleen break often looks like an acute pancreatitis. The high frequency of associated left pleural effusion is significant. Arteriography is helpful when it is done. Splenectomy, often too late, is the right treatment.

[Treatment of hydatid cyst of the liver. Our present attitude (author's transl)]

From 1968 to 1978 the authors treated 60 hydatid cysts of the liver. Echotomography and computerised axial tomography showed the topography of the cyst. However, coelio-mesenteric arteriography and cavography are essential before any kystectomy. In spite of its simplicity, resection of the salient dome of the diaphragm is less often used, owing to the risk of bile leakage and recurrence. Pericystectomy fulfils better our therapeutic objectives. It is more difficult to carry out for there is a risk of hemorrhage. Marsupialisation and hepatectomy are exceptional. Since 1974, 13 pericystectomies out of 15 patients have been carried out, whereas resection of the salient dome was previously the most commonly used procedure (40 out of 45 cases). Only regular immunological follow up is a reliable test of lasting cure.