Combined therapy with ibrutinib and bortezomib followed by ibrutinib maintenance in relapsed or refractory mantle cell lymphoma and high-risk features: a phase 1/2 trial of the European MCL network (SAKK 36/13)

Background

The Bruton's tyrosine kinase inhibitor ibrutinib and the proteasome inhibitor bortezomib have single-agent activity, non-overlapping toxicities, and regulatory approval in mantle cell lymphoma (MCL). In vitro, their combination provides synergistic cytotoxicity. In this investigator-initiated phase 1/2 trial, we established the recommended phase 2 dose of ibrutinib in combination with bortezomib, and assessed its efficacy in patients with relapsed or refractory MCL.

Methods

In this phase 1/2 study open in 15 sites in Switzerland, Germany and Italy, patients with relapsed or refractory MCL after ≤2 lines of chemotherapy and both ibrutinib-naïve and bortezomib-naïve received six cycles of ibrutinibb and bortezomib, followed by ibrutinib maintenance. For the phase 1 study, a standard 3 + 3 dose escalation design was used to determine the recommended phase 2 dose of ibrutinib in combination with bortezomib. The primary endpoint in phase 1 was the dose limiting toxicities in cycle 1. The phase 2 study was an open-label, single-arm trial with a Simon's two-stage min-max design, with a primary endpoint of overall response rate (ORR) assessed by CT/MRI. This study was registered with ClinicalTrials.gov, NCT02356458.

Findings

Between August 2015 and September 2016, nine patients were treated in the phase 1 study, and 49 patients were treated between November 2016 and March 2020 in the phase 2 of the trial. The ORR was 81.8% (90% CI 71.1, 89.8%, CR(u) 21.8%) which increased with continued ibrutinib (median 10.6 months) to 87.3%, (CR(u) 41.8%). 75.6% of patients had at least one high-risk feature (Ki-67 > 30%, blastoid or pleomorphic variant, p53 overexpression, TP53 mutations and/or deletions). In these patients, ibrutinib and bortezomib were also effective with an ORR of 74%, increasing to 82% during maintenance. With a median follow-up of 25.4 months, the median duration of response was 22.7, and the median PFS was 18.6 months. PFS reached 30.8 and 32.9 months for patients with a CR or Cru, respectively.

Interpretation

The combination of ibrutinib and bortezomib shows durable efficacy in patients with relapsed or refractory MCL, also in the presence of high-risk features.

Funding

SAKK (Hubacher Fund), Swiss State Secretariat for Education, Research and Innovation, Swiss Cancer Research Foundation, and Janssen.

Age and sex associate with outcome in older AML and high risk MDS patients treated with 10-day decitabine

Treatment choice according to the individual conditions remains challenging, particularly in older patients with acute myeloid leukemia (AML) and high risk myelodysplastic syndrome (MDS). The impact of performance status, comorbidities, and physical functioning on survival is not well defined for patients treated with hypomethylating agents. Here we describe the impact of performance status (14% ECOG performance status 2), comorbidity (40% HCT-comorbidity index ≥ 2), and physical functioning (41% short physical performance battery < 9 and 17% ADL index < 6) on overall survival (OS) in 115 older patients (age ≥ 66 years) treated on a clinical trial with a 10-day decitabine schedule. None of the patient-related variables showed a significant association with OS. Multivariable analysis revealed that age > 76 years was significantly associated with reduced OS (HR 1.58; p = 0.043) and female sex was associated with superior OS (HR 0.62; p = 0.06). We further compared the genetic profiles of these subgroups. This revealed comparable mutational profiles in patients younger and older than 76 years, but, interestingly, revealed significantly more prevalent mutated ASXL1, STAG2, and U2AF1 in male compared to female patients. In this cohort of older patients treated with decitabine age and sex, but not comorbidities, physical functioning or cytogenetic risk were associated with overall survival.

The B-type natriuretic peptide of the Congo and Timneh grey parrot

In captivity, cardiovascular diseases are common in grey parrots. The diagnosis of these diseases in living birds is difficult, and new diagnostic possibilities would be desirable. The heart is an important endocrine organ in which cardiomyocytes synthetise B-type natriuretic peptide (BNP) and release it into the bloodstream. This hormone has a significant role in cardiovascular and body fluid regulation. The blood concentration of BNP is used in human medicine and small animal medicine as a diagnostic tool in the identification of heart diseases and as a prognostic marker for the risk of mortality. The nucleotide and amino acid sequence of BNP was described in Congo (n = 4) and Timneh (n = 3) grey parrots by PCR after RNA isolation from the atria and ventricles. The results showed a high similarity between the nucleotide sequences of the grey parrots’ BNP and the already known sequence of this hormone in chickens. The amino acid sequence of the mature peptide region is consistent in these three species. BNP plasma concentration could be a possible blood parameter for identifying clinically manifest cardiovascular diseases in grey parrots as it is in other species.

Clinical characteristics and outcome of patients over 60 years with Hodgkin lymphoma treated in Switzerland

Hodgkin lymphoma (HL) in older patients appears to be a different disease compared with younger patients with historically lower survival rates. This is related to a variety of factors, including increased treatment-related toxicity, the presence of comorbidities, and biologic differences. In order to better assess the clinical characteristics, treatment strategies, and outcome of this particular population, we conducted a population-based, retrospective analysis including 269 patients with HL older than 60 years (median age 71 years, range 60-94), treated between 2000 and 2017 in 15 referral centers across Switzerland. Primary endpoints were overall survival (OS), progression-free survival (PFS), and cause-specific survival (CSS). The vast majority of patients were treated with curative intent, either with a combined modality approach (chemotherapy followed by radiation therapy) or with systemic therapy. At a median follow-up of 6.6 years (95% confidence interval [CI], 6.0-7.6), 5-year PFS was 52.2% (95% CI, 46.0-59.2), 5-year OS was 62.5% (95% CI, 56.4-69.2), and 5-year CSS was 85.1.8% (95% CI, 80.3-90.1) for the entire cohort. A significant difference in terms of CSS was observed for patients older than 71 years in comparison to patients aged 60-70 years (hazard ratio 2.6, 1.3-5.0, p = 0.005). Bleomycin-induced lung toxicity (BLT) was documented in 26 patients (17.7%) out of the 147 patients exposed to this compound and was more frequent in patients older than 71 years (15/60, 25%). Outcome of HL pts older than 71 years appeared to decrease substantially in comparison to the younger counterpart. Treatment-related toxicities appeared to be relevant, in particular, BLT. New, potentially less toxic strategies need to be investigated in prospective clinical trials in this particular frail population.

Ibrutinib added to 10-day decitabine for older patients with AML and higher risk MDS

The treatment of older, unfit patients with acute myeloid leukemia (AML) is challenging. Based on preclinical data of Bruton tyrosine kinase expression/phosphorylation and ibrutinib cytotoxicity in AML blasts, we conducted a randomized phase 2 multicenter study to assess the tolerability and efficacy of the addition of ibrutinib to 10-day decitabine in unfit (ie, Hematopoietic Cell Transplantation Comorbidity Index ≥3) AML patients and higher risk myelodysplasia patients (HOVON135/SAKK30/15 trial). In total, 144 eligible patients were randomly (1:1) assigned to either 10-day decitabine combined with ibrutinib (560 mg; sequentially given, starting the day after the last dose of decitabine) (n = 72) or to 10-day decitabine (n = 72). The addition of ibrutinib was well tolerated, and the number of adverse events was comparable for both arms. In the decitabine plus ibrutinib arm, 41% reached complete remission/complete remission with incomplete hematologic recovery (CR/CRi), the median overall survival (OS) was 11 months, and 2-year OS was 27%; these findings compared with 50% CR/CRi, median OS of 11.5 months, and 2-year OS of 21% for the decitabine group (not significant). Extensive molecular profiling at diagnosis revealed that patients with STAG2, IDH2, and ASXL1 mutations had significantly lower CR/CRi rates, whereas patients with mutations in TP53 had significantly higher CR/CRi rates. Furthermore, multicolor flow cytometry revealed that after 3 cycles of treatment, 28 (49%) of 57 patients with available bone marrow samples had no measurable residual disease. In this limited number of cases, measurable residual disease revealed no apparent impact on event-free survival and OS. In conclusion, the addition of ibrutinib does not improve the therapeutic efficacy of decitabine. This trial was registered at the Netherlands Trial Register (NL5751 [NTR6017]) and has EudraCT number 2015-002855-85.

High thromboembolic event rate in patients with locally advanced oesophageal cancer during neoadjuvant therapy. An exploratory analysis of the prospective, randomised intergroup phase III trial SAKK 75/08

Background

High rates of venous thromboembolic events (VTEs), mainly in advanced disease, are reported for patients with cancer of the upper gastrointestinal tract (stomach, pancreas) and for treatment with cisplatin.

Methods

Exploratory analysis of VTEs reported as adverse events and serious adverse events in a prospective, randomised, multicentre, multimodal phase III trial according to VTEs reported as adverse events and severe adverse events. Patients with resectable oesophageal cancer (T2N1–3, T3-4aNx) were randomized to 2 cycles of chemotherapy with docetaxel 75 mg/m², cisplatin 75 mg/m² followed by chemo-radiotherapy (CRT) and subsequent surgery (control arm) or the same treatment with addition of cetuximab (investigational arm).

Results

VTEs occurred in 26 of 300 patients included in the trial, resulting in an incidence rate (IR) of 8.7% [95% CI 5.7–12.4%]. A total of 29 VTEs were reported:13 (45%) VTEs were grade 2, 13 (45%) grade 3 and three (10%) fatal grade 5 events. 72% (21/29) of all VTEs occurred preoperatively (IR 6.7%): 14% (4/29) during chemotherapy and 59% (17/29) during CRT. In multivariable logistic regression only adenocarcinoma (IR 11.1%, 21/189 patients) compared to squamous cell cancer (IR 4.5%, 5/111 patients) was significantly associated with VTE-risk during treatment, OR 2.9 [95%CI 1.0–8.4], p = 0.046. Baseline Khorana risk score was 0 in 73% (19/26), 1–2 in 23% (6/26) and 3 in only 4% (1/26) of patients with VTEs.

Conclusion

A high incidence of VTEs during preoperative therapy of resectable oesophageal cancer is observed in this analysis, especially in patients with adenocarcinoma. The role of prophylactic anticoagulation during neoadjuvant therapy in resectable esophageal cancer should be further evaluated in prospective clinical trials. According to our data, which are in line with other analysis of VTE-risk in patients with oesophageal cancer patients treated with neoadjuvant cisplatin-based chemotherapy and CRT, prophylactic anticoagluation could be considered balanced against individual bleeding risks, especially in patients with adenocarcinoma. In addition to the established risk factors, oesophageal adenocarcinoma treated with neoadjuvant cisplatin-based therapy may be regarded as a high-risk situation for VTEs.

Trial registration

Registered at clinicaltrials.gov,NCT01107639, on 21 April 2010,

Lenalidomide added to standard intensive treatment for older patients with AML and high-risk MDS

More effective treatment modalities are urgently needed in patients with acute myeloid leukemia (AML) of older age. We hypothesized that adding lenalidomide to intensive standard chemotherapy might improve their outcome. After establishing a safe lenalidomide, dose elderly patients with AML were randomly assigned in this randomized Phase 2 study (n = 222) to receive standard chemotherapy ("3 + 7") with or without lenalidomide at a dose of 20 mg/day 1-21. In the second cycle, patients received cytarabine 1000 mg/m² twice daily on days 1-6 with or without lenalidomide (20 mg/day 1-21). The CR/CRi rates in the two arms were not different (69 vs. 66%). Event-free survival (EFS) at 36 months was 19% for the standard arm versus 21% for the lenalidomide arm and overall survival (OS) 35% vs. 30%, respectively. The frequencies and grade of adverse events were not significantly different between the treatment arms. Cardiovascular toxicities were rare and equally distributed between the arms. The results of the present study show that the addition of lenalidomide to standard remission induction chemotherapy does not improve the therapeutic outcome of older AML patients. This trial is registered as number NTR2294 in The NederlandsTrial Register (www.trialregister.nl).

Multicenter Validation of the CamGFR Model for Estimated Glomerular Filtration Rate

Important oncological management decisions rely on kidney function assessed by serum creatinine-based estimated glomerular filtration rate (eGFR). However, no large-scale multicenter comparisons of methods to determine eGFR in patients with cancer are available. To compare the performance of formulas for eGFR based on routine clinical parameters and serum creatinine not calibrated with isotope dilution mass spectrometry, we studied 3620 patients with cancer and 166 without cancer who had their glomerular filtration rate (GFR) measured with an exogenous nuclear tracer at one of seven clinical centers. The mean measured GFR was 86 mL/min. Accuracy of all models was center dependent, reflecting intercenter variability of isotope dilution mass spectrometry-creatinine measurements. CamGFR was the most accurate model for eGFR (root-mean-squared error 17.3 mL/min) followed by the Chronic Kidney Disease Epidemiology Collaboration model (root-mean-squared error 18.2 mL/min).

Carboplatin dose based on actual renal function: no excess of acute haematotoxicity in adjuvant treatment in seminoma stage I

Introduction

The practice of carboplatin dosing is not concordant among different centres and oncologists. Some clinical guidelines recommend capping of the carboplatin dose at, for example, creatinine-clearance (Crea-Cl) of 125 mL/min because of concerns of excessive toxicity. Clinical data to support such recommendations are lacking, especially in patients with seminoma.

Methods

This is a retrospective analysis of acute haematotoxicity of patients with stage I seminoma treated with adjuvant carboplatin area under the curve (AUC) 7 in routine practice in two Swiss centres in 2005–2015, and a comparison of incidence and grade (according to Common Terminology Criteria for Adverse Events v4.0) of haematological adverse events (hAEs) in patients with Crea-Cl <125 mL/min vs >125 mL/min without dose capping.

Results

74 patients with 229 documented measurements were included (median 3/patient). A total of 151 hAEs occurred. Platelet nadir occurred earlier than median white cell/neutrophil count (median day 15 vs day 22; P<0.0001). The majority of hAEs were mild, with more than 80% being of grade 1. Only two (2.7%) clinically relevant hAEs necessitating subsequent interventions occurred (one patient received platelet transfusion, one patient with febrile neutropaenia). Haematological toxicities were not statistically different in patients dosed with Crea-Cl >125 mL/min versus those with Crea-Cl <125 mL/min. No hAEs other than grade 1 occurred before day 10 and after day 24.

Conclusions

Toxicity after single-dose carboplatin AUC 7 is generally mild. No excess of toxicity occurs in patients with high Crea-Cl above 125 mL/min, and therefore dose capping is not routinely necessary. In addition, this study provides a rationale for efficient use of healthcare services without compromising patients’ safety.

Arthrotomy versus arthroscopy in the treatment of the fragmented medial coronoid process of the ulna (FCP) in 421 dogs

In a retrospective trial over eight years 518 joints from 421 dogs with fragmented medial coronoid process of the ulna (FCP) were included. Seventy-five joints had an additional osteochondrosis dissecans of the medial aspect of the humeral condyle. Forty-six point eight percent of the dogs (197/421) were younger than one year. Two hundred and forty-seven joints were treated by conventional arthrotomy and 271 joints were treated by arthroscopy. Two hundred and thirty-eight cases (103 treated by arthrotomy and 135 by arthroscopy) were re-evaluated clinically and radiographically and 191 cases (88 treated by arthrotomy and 103 by arthroscopy) by means of a questionnaire at an average of 23 and 21 months after the operations, respectively. Forty-two point four percent (81/191) of the cases treated by arthrotomy did not show any lameness, 29.3% (56/191) showed temporary lameness after rest or heavy exercise, and 28.3% (54/191) showed constant lameness. The signs of which had, however, been reduced by surgery in 14 of these cases. Sixty point one percent (143/238) of the cases treated by arthroscopy did not show any lameness, 29.4% (70/238) showed temporary lameness after rest or heavy exercise and 10.5% (25/238) showed constant lameness, out of which four cases had improved after surgery. In the cases treated by arthroscopy, the period of convalescence was shorter. Differences between these methods were not observed with respect to the development of subsequent arthrosis. The results of the study show that arthroscopy, with its minimal invasive character, gives better functional results than conventional arthrotomy. However, the development of secondary arthrosis cannot be avoided by either method.

Bioartificial bone grafting:Tarsal joint fusion in a dog using a bioartificial composite bone graft consisting of β-tricalciumphosphate and platelet rich plasma – A case report

Grafting of large bone defects caused by trauma or tumor resection still remains a problem to solve. In experimental studies as well as in human dentistry, osteoconduction and biodegradation of the β-tricalciumphosphate Cerasorb® as well as osteoinductive capabilities of platelet rich plasma have been proven. In case of luxation of the right tarsal joint, including a compressive fracture of the forth tarsal bone, the recommended use of autologous cancellous bone to support osseous fusion was replaced by the use of a bioartificial bone graft. Biodegradation of the bone graft was proven clinically and radiographically. Complete osseous fusion of the intertarsal joint occurred. The use of the β-tricalciumphosphate Cerasorb in combination with platelet rich plasma to support a partial arthrodesis of the tarsal joint in a dog did not impede the healing process but led to full recovery of the patient, indicating that this concept of bioartificial bone grafting could support bone healing.

Incomplete ossification of the humeral condyle as the cause of lameness in dogs

In a retrospective and prospective trial over six years, 17 joints from 13 dogs presented with incomplete ossification of the humeral condyle (IOHC) were included. All dogs showed lameness of the forelimb but no humeral condylar fractures. One dog showed a fracture of the olecranon. Four of the bilaterally affected dogs showed only unilateral lameness. 53.8% of the dogs (7/13) were younger than one year. With regard to breed distribution, the German Wachtel was most frequently represented with three dogs. In 12 dogs the diagnosis was made by radiography in a craniocaudal view, and seven dogs could be further investigated by computed tomography. In one dog the diagnosis was only made during arthroscopy. Two joints showed an additional fragmented medial coronoid process of the ulna and another two an osteochondrosis dissecans of the medial humeral condyle. During arthroscopy, all joints showed a clearly visible fissure line in the joint cartilage between the humeral condyles. In ten joints the I0HC was treated with a transcondylar lag screw under arthroscopic control. Three of the four bilaterally affected dogs were treated only unilaterally because of a lack of lameness on the other side. In the dog with the olecranon fracture, only the fracture was treated. The patients were rechecked clinically and radiologically (n = 10) or by means of a questionnaire (n = 1) at an average of 26 months post operation. Seven cases, six of them treated by lag screw fixation, did not show any lameness. Three joints (one dog with olecranon fracture, two unilaterally affected dogs with lag screw fixation) showed some degree of lameness after heavy strain and one dog showed a continuous slight lameness. The four bilaterally affected and only unilaterally treated dogs showed no lameness on the untreated joint. With regard to development of arthrosis, six radiographically examined joints showed no increase in arthroses. In five joints the increase was mild and in two joints moderate. In six joints with lag screw fixation, the IOHC was radiographically unified and was confirmed by computed tomography in three cases.

Cervical myelopathy due to complex Atlanto-axial malformation including partial atlantal dorsal arch aplasia in a domestic rabbit

A 1-year-old dwarf rabbit was presented with sub-acute progressive tetraparesis. Radiography, CT and MRI revealed compressive cervical myelopathy secondary to a complex atlanto-axial malformation including partial aplasia of the atlantal dorsal arch, dens malformation, malarticulation and lateral atlanto-occipital displacement. Owners decided against surgical treatment and elected conservative treatment including analgesia with non-steroidal anti-inflammatory drugs, cage rest and physiotherapy. Within 2 months clinical signs deteriorated and the owner elected euthanasia. Subsequent necropsy confirmed imaging findings. Similar cases described in humans and dogs suggest that partial aplasia of the dorsal arch of the atlas might often be an asymptomatic radiologic finding in these species. In contrast, this first description of a similarly affected rabbit demonstrates that complex atlanto-axial malformations can cause severe clinical signs.

Lahmheits- und Osteoarthroseentwicklung nach Tibial Plateau Leveling Osteotomy (TPLO) und potenzielle prognostische Einflussfaktoren

Gegenstand: Untersuchung von Lahmheits- und Arthroseentwicklung nach Tibial Plateau Leveling Osteotomy (TPLO) bei Hunden und Evaluierung potenzieller prognostischer Einflussfaktoren. Material und Methoden: Es erfolgte eine retrospektive Auswertung der Patientenakten von 119 Hunden (135 Kniegelenken). Das Therapieergebnis, aktueller Lahmheitsstatus, Arthrosegrad und Arthroseentwicklung wurden anhand der klinischen und röntgenologischen Befunde einer Kontrolluntersuchung sowie durch einen Besitzerfragebogen ausgewertet. Ergebnisse: 58 Hunde (66 Gelenke) konnten klinisch und röntgenologisch, 61 Hunde (69 Gelenke) nur mittels Fragebogen kontrolliert werden. Bis zu 6,8 Jahre nach der TPLO war das Lahmheitsergebnis in 90,4% der Fälle “sehr gut” bis “gut”. Es kam zu einem moderaten Fortschreiten der Arthrose. Patienten mit Totalruptur des vorderen Kreuzbandes wiesen häufiger Meniskusschäden auf als Patienten mit Teilruptur. Patienten, bei denen eine mediale Teilmeniskektomie erfolgte, zeigten häufiger “sehr gute” Langzeitergebnisse und seltener ein Fortschreiten der Arthrose als Hunde, deren Meniskus belassen oder bei denen ein Release durchgeführt wurde. Die Komplikationsrate lag bei 22,2%. Schlussfolgerung und klinische Relevanz: Die klinischen Langzeitergebnisse nach TPLO sind sehr zufriedenstellend. Eine Teilmeniskektomie kann helfen, spätere Meniskusoperationen zu verhindern, ohne das langfristige Lahmheitsergebnis oder die Arthroseentwicklung negativ zu beeinflussen. Durch eine vorangegangene Operation oder postoperative Komplikationen verschlechtert sich weder das langfristige Lahmheitsergebnis noch beschleunigt sich das Fortschreiten der Arthrose.

Invasive histiocytic sarcoma of the lumbar spine in a ferret (Mustela putorius furo)

This report describes the history, clinical examination and histopathology of a histiocytic sarcoma in a domestic ferret. Clinical signs were acute paraplegia and dysuria. Physical examination revealed a firm, smooth, touch-sensitive mass in and around the lumbar vertebral column. Neurologic examination was consistent with a lesion between spinal cord segments T3 and L3. Magnetic resonance images revealed bone lesions of L2 and L3 combined with compression of the spinal cord due to a homogenous, isointense mass that was diagnosed as a malignant round cell tumour and the ferret was euthanased. Histopathology confirmed the diagnosis of an infiltrative histiocytic sarcoma.

Early Postoperative FDG-PET-CT Imaging Results in a Relevant Upstaging in the pN2 Subgroup of Stage III Colorectal Cancer Patients

INTRODUCTION

Clinical practice guidelines regarding follow-up in patients after curative resection of colorectal cancer (CRC) vary widely. Current follow-up recommendations do not include additional postoperative imaging before starting adjuvant treatment in any patients. We evaluated the potential benefit of our institutional approach, recommending ¹⁸fluor-deoxy-glucose (FDG)-positron emission tomography (PET)-computed tomography (CT) imaging in CRC stage III patients with ≥4 locoregional lymph node metastases (pN2).

PATIENTS AND METHODS

Our study included all patients from a single center with complete resection of a pT1-4, pN2, cM0 CRC. All patients were considered free of distant metastases on the basis of preoperative CT imaging of the chest, abdomen, and pelvis. The main objective of the present study was to assess the proportion of patients with changes of therapeutic management (defined as any other treatment than the preplanned adjuvant chemotherapy) because of the results of additional postoperative FDG-PET-CT imaging.

RESULTS

Fifty patients (22 female/28 male) were included; the median age was 64 years (range, 37-78 years). Previously undiagnosed metastatic disease resulting in a change of the therapeutic management was detected using postoperative FDG-PET-CT imaging in 7 patients (14.0%; 95% confidence interval, 5.8%-26.7%). The number needed to screen to detect new or previously occult metastases was 7 (7 of 50).

CONCLUSION

To our knowledge, this is the first study to evaluate the role of an additional postoperative FDG-PET-CT scan before adjuvant treatment in patients with completely resected CRC with ≥4 lymph node metastases (pT1-4, pN2) and without distant metastases on preoperative CT imaging (cM0). Postoperative FDG-PET-CT imaging represents a valuable tool for the detection of new macrometastases in the subgroup of pN2 cM0 CRC patients. The low number needed to screen for consequent therapeutic changes is clinically relevant and should be further evaluated.

Textile foreign body in a Green Iguana (Iguana iguana): Diagnostic imaging for localisation

INTRODUCTION

This case report includes different diagnostic imaging methods for localization of textile foreign bodies in reptiles and shows the limitations and advantages of these methods. A six-year-old, male, green iguana was presented to our clinic after ingesting a sock 5 days earlier. Ultrasound, contrast x-ray, computed tomography and endoscopy were used to locate the foreign body before surgery. Attempts to remove the sock endoscopically failed. The sock was surgically removed via celiotomy and enterotomy.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

Trends in incidence of oesophageal and gastric cancer according to morphology and anatomical location, in Switzerland 1982-2011

QUESTION UNDER STUDY/PRINCIPLES

This study aimed to evaluate trends in the incidence of oesophageal and gastric cancer by anatomical location and histology using nationally representative Swiss data.

METHODS

We included all oesophageal and gastric cancers recorded in 10 Swiss population-based cancer registries 1982-2011. We calculated age-standardised incidence rates (ASIRs) per 100 000 person-years (PY) (European standard) for both cancer sites stratified by sex, language region (German, French-Italian), morphology and anatomical location. To assess time trends, we estimated annual percentage changes (APCs) with 95% confidence intervals (95% CIs).

RESULTS

ASIR of oesophageal adenocarcinoma increased in both sexes and language regions (p <0.001). The steepest increase occurred in males of the German-speaking region (APC 6.8%, 95% CI 5.8-7.8) with ASIRs of 0.8 per 100,000 PY in 1982-1987 and 3.9 per 100.000 PY in 2007-2011. Incidence of oesophageal squamous cell carcinoma decreased significantly in males of both language regions by around -1.5% per year. In contrast, a slight but significant increase (APC 1.4%, 95% CI 0.3-2.4]) of oesophageal squamous cell carcinoma was observed in females of the German-speaking region. We observed stable rates for cancer of the gastric cardia. The incidence of noncardia gastric cancer decreased substantially in both sexes and language regions (p <0.001).

CONCLUSION

In Switzerland, the incidence of oesophageal adenocarcinoma has risen whereas incidence of noncardia gastric cancer has decreased substantially as observed in other developed countries.

CW and pulsed electrically detected magnetic resonance spectroscopy at 263GHz/12T on operating amorphous silicon solar cells

Here we describe a new high frequency/high field continuous wave and pulsed electrically detected magnetic resonance (CW EDMR and pEDMR) setup, operating at 263GHz and resonance fields between 0 and 12T. Spin dependent transport in illuminated hydrogenated amorphous silicon p-i-n solar cells at 5K and 90K was studied by in operando 263GHz CW and pEDMR alongside complementary X-band CW EDMR. Benefiting from the superior resolution at 263GHz, we were able to better resolve EDMR signals originating from spin dependent hopping and recombination processes. 5K EDMR spectra were found to be dominated by conduction and valence band tail states involved in spin dependent hopping, with additional contributions from triplet exciton states. 90K EDMR spectra could be assigned to spin pair recombination involving conduction band tail states and dangling bonds as the dominating spin dependent transport process, with additional contributions from valence band tail and triplet exciton states.

Contrast echocardiography for analysis of heart anatomy in tortoises

OBJECTIVE

The cardiac anatomy in tortoises depicted on B-mode and color-Doppler should be better differentiated by additional contrast-echocardiography.

MATERIAL AND METHODS

An intravenous contrast agent (INN-sulphur hexafluoride [SonoVue®]) was injected in four tortoises (three Testudo hermanni, one Agrionemys horsfieldii), via the coccygeal vein, with parallel B-mode echocardiographic examination. The results of the contrast-enhanced echocardiography were compared with the contrast-free B-mode recordings and color-Doppler ultrasound.

RESULTS

The use of SonoVue® enabled clearer distinction of the cardiac structures, differentiation of the arising major arteries, identification of wash-out-shunts, and visualization of blood flow patterns throughout the tortoise heart.

CONCLUSION AND CLINICAL RELEVANCE

This study enables the accurate depiction and differentiation of cardiac anatomy in tortoises through the use of a combination of B-mode, color-Doppler and contrast-echocardiography. Basic knowledge of blood flow in the reptile heart is essential to understand echocardiographic anatomy. Blood-flow-patterns and anatomy of the tortoise heart as found in this study will help to establish a basis for further echocardiographic examinations of these animals.

Mind the sump! - diagnostic challenge of a rare complication of choledochoduodenostomy

Sump syndrome is a rare long-term complication of side-to-side choledochoduodenostomy (CDD), a common surgical procedure in patients with biliary tract disease in the era before endoscopic retrograde cholangiopancreatography (ERCP). Frequently only pneumobilia, serving as sign for functioning biliary-enteric anastomosis, is reminiscent of the former surgery. We present the case of an 81-year-old patient with sump syndrome who presented with clinical signs of ascending cholangitis, decades after the initial CDD procedure. Finally the detailed medical history that was taken very thoroughly in combination with the presence of pneumobilia led to the suspicion of sump syndrome. Sump syndrome was diagnosed by ERCP, and after endoscopic debris extraction and antibiotic treatment the patient recovered quickly. In the ERCP era little is known about CDD and its long-term complications, especially by young colleagues and trainees. Therefore this report provides an excellent opportunity to refresh the knowledge and raise awareness for this syndrome.

The management challenge for household waste in emerging economies like Brazil: realistic source separation and activation of reverse logistics

Business opportunities in the household waste sector in emerging economies still evolve around the activities of bulk collection and tipping with an open material balance. This research, conducted in Brazil, pursued the objective of shifting opportunities from tipping to reverse logistics in order to close the balance. To do this, it illustrated how specific knowledge of sorted waste composition and reverse logistics operations can be used to determine realistic temporal and quantitative landfill diversion targets in an emerging economy context. Experimentation constructed and confirmed the recycling trilogy that consists of source separation, collection infrastructure and reverse logistics. The study on source separation demonstrated the vital difference between raw and sorted waste compositions. Raw waste contained 70% biodegradable and 30% inert matter. Source separation produced 47% biodegradable, 20% inert and 33% mixed material. The study on collection infrastructure developed the necessary receiving facilities. The study on reverse logistics identified private operators capable of collecting and processing all separated inert items. Recycling activities for biodegradable material were scarce and erratic. Only farmers would take the material as animal feed. No composting initiatives existed. The management challenge was identified as stimulating these activities in order to complete the trilogy and divert the 47% source-separated biodegradable discards from the landfills.

Metastable defect formation at microvoids identified as a source of light-induced degradation in a-Si:H

Light-induced degradation of hydrogenated amorphous silicon (a-Si:H), known as the Staebler-Wronski effect, has been studied by time-domain pulsed electron-paramagnetic resonance. Electron-spin echo relaxation measurements in the annealed and light-soaked state revealed two types of defects (termed type I and II), which can be discerned by their electron-spin echo relaxation. Type I exhibits a monoexponential decay related to indirect flip-flop processes between dipolar coupled electron spins in defect clusters, while the phase relaxation of type II is dominated by 1H nuclear spin dynamics and is indicative for isolated spins. We propose that defects are either located at internal surfaces of microvoids (type I) or are isolated and uniformly distributed in the bulk (type II). The concentration of both defect type I and II is significantly higher in the light-soaked state compared to the annealed state. Our results indicate that in addition to isolated defects, defects on internal surfaces of microvoids play a role in light-induced degradation of device-quality a-Si:H.

Morphometric parameters of peripheral nerves in calves correlated with conduction velocity

Background

Peripheral nerve injuries are the most frequent neurologic disorder in cattle. So far, no physiologic values have been established for the motor nerve conduction velocity (mNCV) in this precocial species.

Objectives

The electrophysiologic and morphometric reference values of peripheral nerves in calves were determined. It was hypothesized that these parameters would correlate to the high degree of maturity in the first days of life in this species compared to other species.

Animals

Twenty‐six healthy calves were used in this study.

Methods

The mNCV of the radial and the sciatic/common peroneal nerve was measured in all 26 calves. Nerve biopsies from a group of 6 calves were taken to correlate the obtained electrophysiologic data with morphological parameters.

Results

The mean mNCV of the radial nerve was 48.3 ± 10.6 m/s, whereas the mean mNCV of the sciatic/peroneal nerve was with 83.8 ± 5.9 m/s significantly faster (P < .0001). The average fiber diameter was 8.40 ± 2.80 μm (range, 1.98–17.90 μm) and the average g‐ratio was 0.61 ± 0.04 SD.

Conclusion and Clinical Importance

The established reference values for mNCV in calves correlate well with the evaluated morphometric parameters. Attributable to their comparably fast mNCV and high fiber diameters, juvenile calves appear to be much more mature individuals than other mammals. Electrophysiologic characterization of peripheral nerve injury now is feasible in this species.

Feline osteochondromatosis in a FELV-negative European shorthair cat

OBJECTIVE

To report palliative treatment in a case of multifocal feline osteochondromatosis in a feline leukaemia virus (FeLV) negative European shorthair cat.

CASE

A 6-year-old spayed female European shorthair cat was presented because of a right forelimb lameness caused by an osteochondromatous lesion which had trapped tendons, vessels and nerves of the antebrachium. Several other lesions were present which did not cause the animal discomfort. The cat was tested negative for FeLV. Palliative surgical removal of the mass was performed, resulting in a marked improvement of mobility with no local recurrence. The cat developed a non-regenerative anaemia after surgery, however the underlying cause was not identified upon request of the owner. Overall survival after surgery was only 2 months. The cat was then euthanised due to severe progression of the anaemia.

CONCLUSION

Palliative surgical removal of osteochondromas may result in local improvement. However, owners need to be aware that it does not increase overall survival and that the prognosis is poor. Infection with FeLV is not necessarily associated with such lesions.

Gender and strain-specific differences in the development of steatosis in rats

Non-alcoholic fatty liver disease (NAFLD) is a common problem with a wide variety of phenotypes. While its pathogenesis is still not fully understood, several risk factors for disease progression have been identified. Therefore, defining adequate animal models may serve to unreveal the pathogenesis in NAFLD. We studied Lewis and Sprague-Dawley rats of both genders (n = 6) fed standard (Std) or high-fat (HF) diet for three weeks. Disease stage was assessed by haematoxylin-eosin, Azan Heidenheim and Oil-Red staining, apoptosis by single-stranded DNA (ssDNA) detection and liver regeneration by Ki-67 staining. Serum markers of liver injury and lipid metabolism including adipocytokines were analysed. Livers of both strains and genders fed with HF diet demonstrated evidence of steatosis. Lewis rats developed microvesicular steatosis whereas Sprague-Dawley rats presented macrovesicular steatosis accompanied by pronounced fibrosis. Female gender of both strains was associated with lower steatosis grade and higher proliferation rate (P < 0.05). Gender-specific differences were most prominent in Lewis rats on a HF diet, where females showed lower alkaline phosphatase, cholesterol, triglyceride and leptin levels and a more favourable low-density lipoprotein/high-density lipoprotein ratio than males (P < 0.05). Reverse transcriptase-polymerase chain reaction analysis was performed to demonstrate changes in expression of various genes important for liver regeneration, fibrosis and steatosis. HF diet induced downregulation of proangiogenic genes such as vascular endothelial growth factor receptor 1 and 2 (P < 0.05) in males was not present in females. In conclusion, strain and gender served major roles in disease progression. These differences should be considered when designing studies and may offer new ways to advance therapeutic strategies.

Role of topoisomerase inhibition and DNA repair mechanisms in the genotoxicity of alternariol and altertoxin-II

Alternariol (AOH) and altertoxin-II (ALTX-II) have been demonstrated to possess genotoxic properties. However, the underlying mechanisms of action have not been fully elucidated yet. AOH has recently been shown to act as a topoisomerase I and II poison, contributing to its genotoxic properties. The topoisomerase-specific repair factor tyrosyl-DNA-phosphodiesterase-1 (TDP1) is involved in the respective repair processes of damaged DNA induced by topoisomerase II poison. In the present study, we investigated the role of DNA repair pathways for the extent of DNA damage by AOH and addressed the question whether interference with topoisomerase II might play a role in the genotoxicity of ALTX-II. Under cell-free conditions, AOH and ALTX-II suppressed the activity of topoisomerase II at a comparable concentration range. In HT29 cells, AOH enhanced the level of covalent DNA-topoisomerase II complexes, thus acting as a topoisomerase poison in DNA damaging concentrations. In contrast, ALTX-II in genotoxic concentrations did not show any effect on the stability of these complexes, indicating that interference with topoisomerases does not play a relevant role in genotoxicity. The differences in genotoxic mechanisms seem to be reflected in the activation of p53. AOH was found to increase p53 phosphorylation in HT29 cells in DNA damaging concentrations. In contrast, incubation with ALTX-II did not affect p53 phosphorylation despite substantial increase in tail intensity in the comet assay, suggesting that the DNA lesions formed by ALTX-II are not detected by the DNA-repair machinery of HT29 cells. These results are supported by differences in persistence of DNA damage, still maintained after 24 h for ALTX-II but nearly vanished already after 3 h for AOH. Furthermore, microarray and qPCR analysis did not indicate any substantial impact of AOH on the transcription of key elements of DNA repair pathways. However, siRNA-approaches indicate that, in addition to TDP1, the expression of other elements of the DNA repair machinery exemplified by the 70 kDa Ku autoantigen and the proliferating cell nuclear antigen are relevant for AOH-mediated DNA damage.

Atomic structure of interface states in silicon heterojunction solar cells

Combining orientation dependent electrically detected magnetic resonance and g tensor calculations based on density functional theory we assign microscopic structures to paramagnetic states involved in spin-dependent recombination at the interface of hydrogenated amorphous silicon crystalline silicon (a-Si:H/c-Si) heterojunction solar cells. We find that (i) the interface exhibits microscopic roughness, (ii) the electronic structure of the interface defects is mainly determined by c-Si, (iii) we identify the microscopic origin of the conduction band tail state in the a-Si:H layer, and (iv) present a detailed recombination mechanism.

[Myocardiosis in a 6-month-old Lawson's Dragon (Pogona henrylawsonii)]

In a 6-month-old, chronically inappetent Lawsons's Dragon (Pogona henrylawsonii) with stunted growth a hyperdense cardiac region was found using radiology and computed tomography. At necropsy a profound necrosis of the myocardium with dystrophic calcification was diagnosed. In contrast to the frequently seen metastatic mineralisation of soft tissues, mainly due to poor husbandry, primary tissue destruction is the cause for dystrophic calcification. In reptiles, this is a rarely described form of calcification. Possible causes are infectious processes, nutritional or metabolic insufficiencies, intoxications or genetic components. In the presented case the aetiology could not be determined. In conclusion, dystrophic calcifications should be considered as a differential diagnosis in reptiles with soft tissue mineralisation.

Frequency and risk factors of lower limb lymphedema following lymphadenectomy in patients with gynecological malignancies

OBJECTIVE

Lower limb lymphedema (LLL) is a major cause of morbidity in patients with gynecological malignancies after surgical treatment involving lymph node (LN) dissection. The aim of this study was to estimate the prevalence of LLL in such patients and detect risk factors for its occurrence.

MATERIALS AND METHODS

A retrospective analysis of all patients undergoing lymphadenectomy in newly-diagnosed gynecological malignancies at the University Hospital of Zurich between 2000 and 2007 was performed. Data from 313 patients were collected. Twenty patients with pre-existing edema or missing information were excluded before analysis. Time-to-LLL was estimated using the Kaplan-Meier estimate and potential risk factors were evaluated by a Cox regression model.

RESULTS

Estimated prevalence of LLL one year after surgery was 32%, increasing to 58% eight years after surgery. Median time to diagnosis of LLL was 5.2 years. The number of removed lymph nodes was significantly associated with time-to-LLL. Diagnosis of postoperative lymphocysts and local infections were accompanied by a significantly elevated risk for the development of LLL. Furthermore, time-to-LLL decreased with a higher body mass index (BMI) of the patient. In contrast, chemo- and radiotherapy, age, positive LNs, site of lymphadenectomy, and type of cancer were not observed to be associated with the occurrence of LLL.

CONCLUSIONS

LLL is a frequent postoperative complication in patients undergoing lymphadenectomy for gynecological malignancies. It is thus imperative to sufficiently educate patients about the risk and symptoms of LLL prior to surgery. The data clearly show an association between time-to-LLL and number of dissected LNs, stressing the need to prospectively analyze the prevalence of LLL and carefully plan LN sampling as increasing knowledge is gained regarding the therapeutic benefit of sentinel and systemic lymphadenectomy in patients with different stages of gynecological malignancies.