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Puyuelo O, Seguier D, Bommelaere T, Duquenne M, Lokmane EM, Pecoux F, Amara N, Lecornet E, Goasdoué H, Vermersch P, De Wachter S, Biardeau X. Real-life after sacral nerve modulation implantation: Rate, reasons, and risk factors for mid-term follow-up discontinuation. Prog Urol 2023; 33:1047-1061. [PMID: 37949799 DOI: 10.1016/j.purol.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/11/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVES To evaluate follow-up after implantation of a sacral nerve modulation implantable pulse generator (IPG) and to investigate the reasons and risk factors for follow-up discontinuation. MATERIALS AND METHODS All patients who underwent an IPG implantation to treat lower urinary tract symptoms between 2014-2019 within 6 hospital centers located in the district of "Hauts-de-France" (France) were systematically called during the year 2020 for a standardized (tele)consultation. Patients were divided into 3 distinct profiles according to the regularity of their 5-year postoperative follow-up: "Regular follow-up", "Irregular follow-up" and "Lost to follow-up". The primary outcome was the change in the annual proportion of the 3 follow-up profiles over the 5 years following IPG implantation. As secondary outcomes we described the reasons reported for follow-up discontinuation and looked for risk factors associated with. RESULTS Overall, 259 patients were included. At the time of data collection, after a mean follow-up of 28.4 (± 19.8) months, 139 patients (53.7%) had a "Regular follow-up", 54 (20.8%) had an "Irregular follow-up" and 66 (25.5%) were "Lost to follow-up". The proportion of patients with a "Regular follow-up" decreased year by year, representing only 46.2% of patients at five-years. 175 patients (67.6%) underwent a standardized (tele)consultation. In multivariate analysis, only "lack of knowledge of the follow-up protocol" was statistically associated with follow-up discontinuation (OR=5.16; 95% CI [2.12-13.57]). CONCLUSION The proportion of patients followed up after IPG implantation decreased steadily over the years, often related to a lack of therapeutic education. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- O Puyuelo
- Department of Urology, Claude-Huriez Hospital, CHU de Lille, University of Lille, 59000 Lille, France.
| | - D Seguier
- Department of Urology, Claude-Huriez Hospital, CHU de Lille, University of Lille, 59000 Lille, France
| | - T Bommelaere
- Department of Urology, Claude-Huriez Hospital, CHU de Lille, University of Lille, 59000 Lille, France
| | - M Duquenne
- Department of Urology, Claude-Huriez Hospital, CHU de Lille, University of Lille, 59000 Lille, France
| | - E M Lokmane
- Department of Urology, Valenciennes Hospital, Valenciennes, France
| | - F Pecoux
- Department of Urology, Victor Provo Hospital, Roubaix, France
| | - N Amara
- Department of Urology, Dunkerque Hospital, Dunkerque, France
| | - E Lecornet
- Department of Urology, Henin-Beaumont Polyclinic, Henin-Beaumont, France
| | - H Goasdoué
- Department of Urology, Abbeville Hospital, Abbeville, France
| | - P Vermersch
- University Lille, Inserm UMR-S1172 LilNCog, Lille Neuroscience and Cognition, CHU de Lille, FHU Precise, 59000 Lille, France
| | - S De Wachter
- Department of Urology, Antwerp University Hospital, Edegem, Belgium; Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Faculty of Medicine and Health Sciences, Wlrijk, Belgium
| | - X Biardeau
- Department of Urology, Claude-Huriez Hospital, CHU de Lille, University of Lille, 59000 Lille, France; University Lille, Inserm UMR-S1172 LilNCog, Lille Neuroscience and Cognition, CHU de Lille, FHU Precise, 59000 Lille, France
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Amara N, Al Youssef T, Massa J, Fidjel A, Khoury EE, Patel B, Flais M, Deswarte C. Intraoperative angiography of the neurovascular bundle using indocyanine green and near-infrared fluorescence improves anatomical dissection during robot-assisted radical prostatectomy: initial clinical experience. J Robot Surg 2023; 17:687-694. [PMID: 36308595 DOI: 10.1007/s11701-022-01483-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
Landmark artery identification in the neurovascular bundle (NVB) is important for nerve-sparing in radical prostatectomy. We aimed to investigate intraoperative angiography using indocyanine green and near-infrared fluorescence (ICG-NIRF) during robot-assisted radical prostatectomy (RARP) to identify the NVB, visualise vascularisation and haemostasis, and preserve erectile function. Our retrospective, unicentric study was performed in consecutive localised prostate cancer RARP patients (stage T1/T2, prostate-specific antigen < 10 ng/ml) who underwent ICG-NIRF angiography in France (2016-2021). When ready to dissect the NVB, the anaesthesiologist intravenously injected ICG (3 ml); the surgeon used alternating standard light or fluorescence to optimise NVB visualisation and facilitate microdissection. Primary outcomes: safety and feasibility of ICG-NIRF. Secondary outcomes: functional erectile dysfunction (Sexual Health Inventory for Men (SHIM) questionnaire) over 9 months, proportion of bilateral NVBs identified, ICG-related complications. Standard descriptive statistics were used; t test determined the significance of changes in SHIM scores versus baseline. Ninety-one patients received intraoperative angiography. The NVB was identified in all cases, without difficulties. No ICG-related complications or allergies were observed. There was no significant difference in the SHIM score at 9 months compared with baseline (p = 0.331), and erectile dysfunction returned to baseline levels in almost all patients. Intraoperative, real-time ICG-NIRF angiography is simple, non-invasive, and improves identification of key anatomical landmarks to optimise micropreservation of the NVB during RARP and preserve erectile function. Larger clinical studies should confirm preliminary results.
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Affiliation(s)
- Nordine Amara
- Oncology Urology Department, Centre Hospitalier de Dunkerque, 130 Avenue Louis Herbeax, 59240, Dunkirk, France.
| | - Tarek Al Youssef
- Oncology Urology Department, Centre Hospitalier de Dunkerque, 130 Avenue Louis Herbeax, 59240, Dunkirk, France
| | - Jordan Massa
- Oncology Urology Department, Centre Hospitalier de Dunkerque, 130 Avenue Louis Herbeax, 59240, Dunkirk, France
| | - Aouad Fidjel
- Oncology Urology Department, Centre Hospitalier de Dunkerque, 130 Avenue Louis Herbeax, 59240, Dunkirk, France
| | - Elias El Khoury
- Oncology Urology Department, Centre Hospitalier de Dunkerque, 130 Avenue Louis Herbeax, 59240, Dunkirk, France
| | - Belur Patel
- Urology Department, Baylor Scott & White Hospital, Temple, TX, USA
| | - Mathias Flais
- Anesthesiology and Pharmacology Department, Centre Hospitalier Dunkerque, Dunkirk, France
| | - Christophe Deswarte
- Anesthesiology and Pharmacology Department, Centre Hospitalier Dunkerque, Dunkirk, France
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Puyuelo O, Seguier D, Bommelaere T, Duquenne M, Lokmane E, Pecoux F, Amara N, Lecornet E, Goasdoué H, Vermersch P, De wachter S, Biardeau X. Suivi après implantation définitive d’un boitier de neuro-modulation sacrée. Prog Urol 2021. [DOI: 10.1016/j.purol.2021.08.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Amara N, Massa J, Al Youssef T, Carolus B, Delobel L, Dequirez P, Elkhouri E. Aquablation prostatique pour le traitement de l’hypertrophie bénigne de la prostate : résultats de l’expérience initiale. Prog Urol 2021. [DOI: 10.1016/j.purol.2021.08.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fakhfakh R, Zeglaoui H, El Amri N, Hamila S, Amara N, Baccouche K, Bouajina E. AB0288 GLUCOCORTICOID SPARING EFFECT OF THE BIOLOGIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS IN TUNISIAN REAL LIFE PRACTICE. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.6148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Glucocorticoids (GCs) are still widely prescribed in rheumatoid arthritis (RA). Despite their disease-modifying properties, they are associated with significant adverse effects. The international guidelines recommend the lowest effective dose and the lowest duration of GCs. Previous studies have shown that biologic disease modifying anti-rheumatic drugs (bDMARDs) can have a GC-sparing effect in RA.Objectives:The aim of the study was to assess the impact of the bDMARDs on glucocorticoids use in rheumatoid arthritis Tunisian patients, in real life practice.Methods:RA patients (according to the American College of Rheumatology criteria) who started their first bDMARDs (Tumour necrosis factor(TNF)α inhibitors, Tocilizumab and Rituximab) between January 2016 and august 2019, were recruited from the BINAR« Biologic National Registry», a prospective national Tunisian biologic registry. Oral prednisone intakewascompared at inclusion (M0), at 3 months (M3)and at 6 months(M6) after bDMARDs initiation.Results:175 patients were included (149 females / 26 males). The mean age was 54.1 years ± 12.6 and the mean disease duration was 6.7 years ± 3.5. The TNFαinhibitors, the Tocilizumab and the Rituximab were prescribed, respectively, in 79.4%, 17.7% and 8.6%. The mean DAS28 index activity was 4.9 ± 1.5 at M0, 4.5 ±1.5 at M3 and 4.2 ± 1.1 at M6 (p=0.78). At inclusion, 150 patients (85.7%) were taking oral prednisone and the mean dose was 8.2 ± 5.4 mg/day. Overall, a significant decrease of oral prednisone use was observed at M3 (78%) and M6 (67.6%). The mean daily dose of oral prednisone was 8.9 ± 4.3mg at M3 (p>0.05) and 8.1 ± 2.7 mg at M6 (P>0.05). At M3 and M6, 4% and 2% of patients (p>0.05) had lowered prednisone doses, respectively. Prednisone discontinuation was observed in 17.7% at M3 and 18.1% at M6. Increased prednisone doses were noted in 2.7% at M3 and 2.6% at M6. The bDMARDs use wasn’t associated with oral prednisone decrease at M3 (TNFi p=0.51; Tocilizumab p=0.54; Rituximab p=0, 77) and at M6 (TNFi p=0.61; Tocilizumab p=0.39; Rituximab p=0,64).Conclusion:This study showed a small glucocorticoids sparing-effect of bDMARDs at 3 months and 6 months in rheumatoid arthritis patients with a decrease of oral prednisone use of 18.1% at 6 months.References:[1]Fortunet c, Pers YP, Lambert J et al. Tocilizumab induces corticosteroid sparing in rheumatoid arthritis patients in clinical practice. Rheumatology 2015;54:672_677 doi:10.1093/rheumatology/keu339Disclosure of Interests:None declared
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Brousset P, Syrykh C, Abreu A, Amara N, Laurent C. DIAGNOSIS AND CLASSIFICATION ASSISTANCE FROM LYMPHOMA MICROSCOPIC IMAGES USING DEEP LEARNING. Hematol Oncol 2019. [DOI: 10.1002/hon.97_2629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- P. Brousset
- Pathology; IUCT-Toulouse Oncopole; Toulouse France
| | - C. Syrykh
- Pathology; IUCT-Toulouse Oncopole; Toulouse France
| | - A. Abreu
- Pathology; IUCT-Toulouse Oncopole; Toulouse France
| | - N. Amara
- Pathology; IUCT-Toulouse Oncopole; Toulouse France
| | - C. Laurent
- Pathology; IUCT-Toulouse Oncopole; Toulouse France
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Laurent C, Nicolae A, Laurent C, Le Bras F, Haioun C, Fataccioli V, Amara N, Adélaïde J, Guille A, Schiano De Colella J, Tesson B, Traverse-Glehen A, Chenard M, Mescam L, Moreau A, Chassagne-Clément C, Somja J, Escudié F, André M, Martin N, Hamy-Petit A, Reyal F, Croix M, Birnbaum D, Brousset P, Xerri L, Gaulard P. JAK-STAT PATHWAY AND EPIGENETIC REGULATORS ARE CRITICAL PLAYERS IN BI-ALCL PATHOGENESIS? Hematol Oncol 2019. [DOI: 10.1002/hon.16_2630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C. Laurent
- Pathology Department; Institut Universitaire du Cancer Oncopole CHU Toulouse INSERM U1037; Toulouse France
| | - A. Nicolae
- Pathology; Hôpital de Hautepierre; Strasbourg France
| | - C. Laurent
- CALYM - LYSARC; Institut Carnot; Pierre-Bénite France
| | - F. Le Bras
- Lymphoid Malignancies Unit; AP-HP, Groupe Hospitalier Henri Mondor - Albert Chenevier; Créteil France
| | - C. Haioun
- Lymphoid Malignancies Unit; AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, INSERM U955, Université Paris-Est; Créteil France
| | - V. Fataccioli
- Department of Pathology; AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, INSERM U955, Université Paris-Est; Créteil France
| | - N. Amara
- Pathology Department; Institut Universitaire du Cancer Oncopole CHU Toulouse INSERM U1037; Toulouse France
| | - J. Adélaïde
- Department of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm U1068, CNRS UMR7258, Aix-Marseille University, UM 105; Institut Paoli-Calmettes; Marseille France
| | - A. Guille
- Department of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm U1068, CNRS UMR7258, Aix-Marseille University, UM 105; Institut Paoli-Calmettes; Marseille France
| | | | - B. Tesson
- CALYM - LYSARC; Institut Carnot; Pierre-Bénite France
| | - A. Traverse-Glehen
- Pathology Department; Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud; Pierre-Bénite France
| | - M. Chenard
- Pathology; Hôpital de Hautepierre; Strasbourg France
| | - L. Mescam
- Department of Bio-Pathology; Institut Paoli-Calmettes; Marseille France
| | - A. Moreau
- Pathology; CHU Nantes; Nantes France
| | | | - J. Somja
- Pathology and Cytology Department; CHU de Liège; Liège Belgium
| | - F. Escudié
- Pathology Department; Institut Universitaire du Cancer Oncopole CHU Toulouse INSERM U1037; Toulouse France
| | - M. André
- Hematology; CHU UCL Namur; Yvoir Belgium
| | - N. Martin
- IMRB - Institut Mondor de Recherche Biomédicale; INSERM U955; Créteil France
| | - A. Hamy-Petit
- Residual Tumour & Response to Treatment Laboratory; RT2Lab, INSERM, U932, PSL Research University, Translational Research Department, Institut Curie; Paris France
| | - F. Reyal
- Department of Surgical Oncology; Institut Curie; Paris France
| | - M. Croix
- CALYM - LYSARC; Institut Carnot; Pierre-Bénite France
| | - D. Birnbaum
- Department of Predictive Oncology, Centre de Recherche en Cancérologie de Marseille (CRCM), Inserm U1068, CNRS UMR7258, Aix-Marseille University, UM 105; Institut Paoli-Calmettes; Marseille France
| | - P. Brousset
- Pathology Department; Institut Universitaire du Cancer Oncopole CHU Toulouse INSERM U1037; Toulouse France
| | - L. Xerri
- Department of Bio-Pathology and Tumor Immunology, Aix-Marseille University, Centre de Recherche en Cancérologie de Marseille (CRCM); Institut Paoli-Calmettes; Marseille France
| | - P. Gaulard
- Department of Pathology; AP-HP, Groupe Hospitalier Henri Mondor-Albert Chenevier, INSERM U955, Université Paris-Est; Créteil France
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Amara N, Hdiji O, Bouzidi N, Hadjkacem H, Dammak M, Mhiri C. Non-arteritic anterior ischemic optic neuropathy: Features and risk factors. J Neurol Sci 2017. [DOI: 10.1016/j.jns.2017.08.3557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sidhom Y, Kacem I, Ouerdiane A, Nasri A, Amara N, Gargouri A, Ben Djebara M, Gouider R. Antinuclear and antiphospholipid antibodies in patients with multiple sclerosis: Frequency and disease course in a Tunisian cohort. J Neurol Sci 2017. [DOI: 10.1016/j.jns.2017.08.2997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gourraud J, Morio F, Amara N, Sacher F, Mabo P, Babuty D, Mansourati J, Pasquie J, Maury P, Jesel L, Guyomarch B, Kyndt F, Barc J, Thollet A, Probst V. 98Risk stratification of arrhythmia and death in ARVC. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx501.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Amara N, Blouin-Bougie J, Bouthillier D, Simard J. On the readiness of physicians for pharmacogenomics testing: an empirical assessment. Pharmacogenomics J 2017; 18:308-318. [DOI: 10.1038/tpj.2017.22] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 03/02/2017] [Accepted: 04/14/2017] [Indexed: 01/24/2023]
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Gourraud J, Morio F, Amara N, Sacher F, Mabo P, Babuty D, Mansourati J, Pasquié J, Denis A, Maury P, Jesel L, Gilles L, Solnon A, Guyomarch B, Kyndt F, Barc J, Thollet A, Probst V. Risk stratification of arrhythmia and death in ARVC. Archives of Cardiovascular Diseases Supplements 2017. [DOI: 10.1016/s1878-6480(17)30499-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Laurent C, Delas A, Gaulard P, Haioun C, Moreau A, Xerri L, Traverse-Glehen A, Rousset T, Quintin-Roue I, Petrella T, Emile JF, Amara N, Rochaix P, Chenard-Neu MP, Tasei AM, Menet E, Chomarat H, Costes V, Andrac-Meyer L, Michiels JF, Chassagne-Clement C, de Leval L, Brousset P, Delsol G, Lamant L. Breast implant-associated anaplastic large cell lymphoma: two distinct clinicopathological variants with different outcomes. Ann Oncol 2015; 27:306-14. [PMID: 26598546 DOI: 10.1093/annonc/mdv575] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 11/11/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND ALK-negative anaplastic large cell lymphoma associated with breast implant (i-ALCL) has been recently recognized as a distinct entity. Among 43 830 lymphomas registered in the French Lymphopath network since 2010, 300 breast lymphomas comprising 25 peripheral T-cell lymphomas (PTCL) were reviewed. Among PTCL, ALK-negative ALCL was the most frequent and all of them were associated with breast implants. PATIENTS AND METHODS Since 2010, all i-ALCL cases were collected from different institutions through Lymphopath. Immuno-morphologic features, molecular data and clinical outcome of 19 i-ALCLs have been retrospectively analyzed. RESULTS The median age of the patients was 61 years and the median length between breast implant and i-ALCL was 9 years. Most implants were silicone-filled and textured. Implant removal was performed in 17 out of 19 patients with additional treatment based on mostly CHOP or CHOP-like chemotherapy regimens (n = 10/19) or irradiation (n = 1/19). CHOP alone or ABVD following radiation without implant removal have been given in two patients. The two clinical presentations, i.e. effusion and less frequently tumor mass correlated with distinct histopathologic features: in situ i-ALCL (anaplastic cell proliferation confined to the fibrous capsule) and infiltrative i-ALCL (pleomorphic cells massively infiltrating adjacent tissue with eosinophils and sometimes Reed-Sternberg-like cells mimicking Hodgkin lymphoma). Malignant cells were CD30-positive, showed a variable staining for EMA and were ALK negative. Most cases had a cytotoxic T-cell immunophenotype with variable T-cell antigen loss and pSTAT3 nuclear expression. T-cell receptor genes were clonally rearranged in 13 out of 13 tested cases. After 18 months of median follow-up, the 2-year overall survival for in situ and infiltrative i-ALCL was 100% and 52.5%, respectively. CONCLUSIONS In situ i-ALCLs have an indolent clinical course and generally remain free of disease after implant removal. However, infiltrative i-ALCLs could have a more aggressive clinical course that might require additional therapy to implant removal.
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Affiliation(s)
- C Laurent
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse INSERM, U.1037, Centre de recherche en cancérologie de Toulouse-Purpan, Toulouse
| | - A Delas
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse
| | - P Gaulard
- Department of Pathology, AP-HP, Groupe hospitalier Henri Mondor-Albert Chenevier, Créteil INSERM U955, Université Paris-Est, Créteil
| | - C Haioun
- INSERM U955, Université Paris-Est, Créteil Lymphoid Malignancies Unit, AP-HP, Groupe hospitalier Henri Mondor-Albert Chenevier, Créteil
| | - A Moreau
- Department of Pathology, Centre Hospitalier Hôtel Dieu, Nantes
| | - L Xerri
- Department of Pathology, Institut Paoli-Calmettes, Marseille
| | | | - T Rousset
- Department of Pathology, Hôpital Gui de Chauliac-Saint Eloi, Montpellier
| | - I Quintin-Roue
- Department of Pathology, Centre Hospitalier de Brest, Brest, France
| | - T Petrella
- Département de Pathologie, Montréal, Canada
| | - J F Emile
- Department of Pathology, Hôpital Ambroise Paré, Boulogne
| | - N Amara
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse
| | - P Rochaix
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse
| | | | - A M Tasei
- Department of Pathology, Centre Hospitalier Henri Duffaut, Avignon
| | - E Menet
- Department of Pathology, Hôpital René Huguenin, Saint Cloud
| | | | - V Costes
- Department of Pathology, Hôpital Gui de Chauliac-Saint Eloi, Montpellier
| | | | - J F Michiels
- Department of Pathology, Centre Hospitalier Pasteur L'Archet, Nice
| | | | - L de Leval
- Pathology institut of Lausanne, Centre Hospitalier Universitaire Vaudois, Suisse, Lausanne, Switzerland
| | - P Brousset
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse INSERM, U.1037, Centre de recherche en cancérologie de Toulouse-Purpan, Toulouse
| | - G Delsol
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse INSERM, U.1037, Centre de recherche en cancérologie de Toulouse-Purpan, Toulouse
| | - L Lamant
- Department of Pathology, Institut Universitaire du Cancer-Oncopole, Toulouse INSERM, U.1037, Centre de recherche en cancérologie de Toulouse-Purpan, Toulouse
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Baccouche K, Mani L, Belghali S, Alaya Z, Elamri N, Amara N, Zeglaoui H, Bouajina E. AB0281 Characteristics of the Rheumatoid Arthritis in a Five-Year Follow-Up of 300 Tunisian Patients. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-eular.5396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Alaya Z, El Amri N, Bellazreg F, Baccouche K, Belghali S, Zeglaoui H, Amara N, Hachfi W, Letaief A, Bouajina E. AB0854 Infectious Sacroiliitis: Clinical and Therapeutic Features (About 17 Cases). Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.5463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Zerraghi M, Benhacine Z, Amazit H, Ouboudinar L, Sebia H, Bouhabib M, Sellahi A, Amara N, Lahchili L, Djeghri H. P100 - À propos d’une observation : double arc aortique chez un nouveau né. Arch Pediatr 2010. [DOI: 10.1016/s0929-693x(10)70501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Goven D, Boutten A, Leçon-Malas V, Marchal-Sommé J, Amara N, Crestani B, Fournier M, Lesèche G, Soler P, Boczkowski J, Bonay M. Altered Nrf2/Keap1-Bach1 equilibrium in pulmonary emphysema. Thorax 2008; 63:916-24. [PMID: 18559366 DOI: 10.1136/thx.2007.091181] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Oxidative stress, resulting from the increased oxidative burden and decreased level of antioxidant proteins, plays a role in the pathophysiology of smoking-related pulmonary emphysema. Expression of several antioxidant proteins, such as heme oxygenase-1 (HO-1), glutathione peroxidase 2 (GPX2) and NAD(P)H:quinone oxidoreductase 1 (NQO1), results from an equilibrium created by positive or negative regulation by the transcription factors Nrf2, Keap1 and Bach1, respectively. However, whether the expression of these transcription factors is altered in emphysema and could account for decreased expression of antioxidant proteins is not known. A study was undertaken to investigate the expression and subcellular localisation of Nrf2, Keap1 and Bach1 as potential regulators of HO-1, GPX2 and NQO1 in alveolar macrophages, a key cell in oxidative stress, in lung surgical specimens from non-smokers without emphysema and smokers with and without emphysema. METHODS AND RESULTS Western blot, immunohistochemical and laser scanning confocal analysis revealed that the Nrf2 protein level decreased significantly in whole lung tissue and alveolar macrophages (cytosol and nucleus) in patients with emphysema compared with those without emphysema. Conversely, Bach1 and Keap1 levels were increased in patients with emphysema. These modifications were associated with a parallel decrease in the expression of HO-1, GPX2 and NQO1 at the cellular level, which was inversely correlated with airway obstruction and distension indexes, and increased macrophage expression of the lipid peroxidation product 4-hydroxy-2-nonenal. Silencing RNA experiments in vitro in THP-1 cells were performed to confirm the cause-effect relation between the loss of Nrf2 and the decrease in HO-1, NQO1 and GPX2 expression. Nrf2/Keap1-Bach1 equilibrium was altered in alveolar macrophages in pulmonary emphysema, which points to a decreased stress response phenotype. CONCLUSIONS This finding opens a new view of the pathophysiology of emphysema and could provide the basis for new therapeutic approaches based on preservation and/or restoration of such equilibrium.
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Affiliation(s)
- D Goven
- Inserm U700, Faculté de Médecine Paris 7, Site X Bichat, BP416, 75870 Paris Cedex 18, France
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Amara N, Lanone S, Desmard M, Ogier Denis E, Boczkowski J. Les particules diesel induisent l’expression de la métalloprotease de la matrice 1 (MMP-1) dans des cellules épitheliales alvéolaires via un mécanisme dépendant de la nad (P) h oxydase 4 (NOX-4). Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Almolki A, Bachoual R, Goven D, Amara N, Samb A, Boczkowski J. L’hème oxygénase 1 (HO-1) diminue l’expression de mucus induite par la fumée de cigarette dans les voies aériennes chez le rat. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)72119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zini L, Haulon S, Decoene C, Amara N, Villers A, Biserte J, Leroy X, Koussa M. Renal cell carcinoma associated with tumor thrombus in the inferior vena cava: surgical strategies. Ann Vasc Surg 2005; 19:522-8. [PMID: 15968492 DOI: 10.1007/s10016-005-5031-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to evaluate strategies used for surgical management of renal cell carcinoma with a tumoral thrombus extension in the inferior vena cava (IVC). From January 2000 to December 2001, urological and vascular surgeons jointly undertook surgical treatment on 10 patients with renal cell carcinoma and tumor thrombus in the IVC. There were five women and five men, with a mean age of 60.2 years. The limit of thrombus extension, classified according to the Neves and Zincke system, was level I (renal) in one patient, level II (infrahepatic) in one, level III (retrohepatic) in three, and level IV (atrial) in five. Exposure was achieved by chevron bilateral subcostal laparotomy associated with sternotomy in three patients, bilateral subcostal laparotomy in six, and median sternolaparotomy in one. Radical nephrectomy associated with caval thrombectomy was performed in all patients. Cardiopulmonary bypass was used in four of the five level IV patients. The fifth patient was contraindicated for cardiopulmonary bypass. Transesophageal echography (TEE)-guided endoluminal occlusion of the unobstructed infradiaphragmatic IVC was performed in patients with level III thrombus. Clamping of the IVC was performed in patients with levels I and II thrombus. All procedures were assisted by continuous TEE surveillance. No intraoperative gas or tumor emboli were detected by TEE. The mean number of red blood cell units transfused during the course of hospitalization was 9.7 (range 2-22, median 9). One patient died of multiple organ failure on the day 28 after the procedure. The mean duration of hospitalization was 16 days. The mean duration of follow-up was 9.7 months. During follow-up, two of the remaining nine patients died due to tumor recurrence. Tumor recurrence was also detected in one of the seven surviving patients. Surgery for renal cell carcinoma with tumor thrombus in the IVC must be carried out in a specialized facility with the assistance of TEE surveillance and, in some cases, cardiopulmonary bypass. Operative treatment improves the prognosis of renal cell carcinoma with tumor thrombus in the IVC. In patients with level III thrombus, TEE-guided endoluminal occlusion of the unobstructed infradiaphragmatic IVC simplifies surgical management by obviating the need for exposure of the retrohepatic and supradiaphragmatic IVC.
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Desmard M, Amara N, Lanone S, Motterlini R, Boczkowski J. Carbon monoxide reduces the expression and activity of matrix metalloproteinases 1 and 2 in alveolar epithelial cells. Cell Mol Biol (Noisy-le-grand) 2005; 51:403-8. [PMID: 16309591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Accepted: 05/12/2005] [Indexed: 05/05/2023]
Abstract
Matrix metalloproteinases (MMPs), particularly MMP-1 and MMP-2, are involved in the pathophysiology of emphysema. MMPs contain zinc in the catalytic site and its expression is regulated transcriptionally via mitogen activated protein kinases (MAPKs). Carbon monoxide (CO), one of the end products of heme oxygenase activity, has anti-inflammatory properties, which are mediated, at least in part, by activation of p38 MAPK. Furthermore, CO has the unique ability to bind to metal centers in proteins and can affect their specific activity. Therefore, we hypothesized that CO could inhibit MMPs expression and/or activity. Here we show that a recently identified carbon monoxide-releasing molecule, [Ru(CO)3Cl2]2 (or CORM-2) inhibits MMP-1 and MMP-2 mRNA expression in the human lung epithelial cell line A549. The MMPs mRNA expression was unaffected by the p38 MAPK inhibitor SB203580, but in the case of MMP-1 was reversed by the antioxidant N-acetylcysteine. In addition, CORM-2 inhibited both MMP-1 and MMP-2 activities. Interestingly, no effect was observed with (Ru(DMSO)4Cl2), a negative control that does not contain CO groups. To the best of our knowledge this is the first evidence on the effect of CO on MMPs expression and activity. This effect could have important implications in the pathophysiology of emphysema and other diseases involving proteases/antiproteases imbalance.
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Affiliation(s)
- M Desmard
- Institut National de la Santé et la Recherche Médicale (INSERM) Unité 700, and Institut Fédératif de Recherche 02, Faculté de Médecine Xavier Bichat, 75018 Paris, France
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22
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Cardine S, Chaze PA, Bourcier F, Amara N, Prevost G, Ruhomauly H, Garandeau C, Maisonneuve L, Benzacken L. Nécrose rétinienne aiguë bilatérale associée à une méningo-encéphalite à Herpes simplex virus 2. J Fr Ophtalmol 2004; 27:795-800. [PMID: 15499278 DOI: 10.1016/s0181-5512(04)96216-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Acute retinal necrosis syndrome (ARN syndrome) is a rare viral disease with a poor prognosis in most cases. It is characterized by substantial ocular inflammation with progressive retinal necrosis, occlusive vasculitis and sometimes extraocular features. CASE REPORT We report the case of a 62-year-old woman who was referred for a suspicion of a stroke. Ophthalmological examination revealed a profound bilateral visual loss due to extensive retinal necrosis. The patient was immediately treated with antiherpetic drugs. ARN syndrome with meningoencephalitis caused by herpes simplex virus type 2 was confirmed by PCR studies performed on aqueous humor and cerebrospinal fluid. Herpes simplex virus 2 (IgG+ , IgM-) was probably reactivated after intrathecal injection of steroids because of pain associated with narrowing of the lumbar vertebral canal. The patient was treated with intravenous Acyclovir for 3 weeks. After 4 months, both retinas were detached. DISCUSSION AND CONCLUSION ARN syndrome caused by herpes simplex virus 2 most often occurs after reactivation of the latent virus in patients with a neurological medical history or congenital infection. Antiviral treatment must begin early to decrease risks of bilateralization and complications.
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MESH Headings
- Acyclovir/therapeutic use
- Antiviral Agents/therapeutic use
- Aqueous Humor/virology
- Cerebrospinal Fluid/virology
- DNA, Viral/analysis
- Dexamethasone/administration & dosage
- Dexamethasone/therapeutic use
- Diagnostic Errors
- Drug Therapy, Combination
- Encephalitis, Herpes Simplex/complications
- Encephalitis, Herpes Simplex/drug therapy
- Encephalitis, Herpes Simplex/virology
- Female
- Ganciclovir/therapeutic use
- Hemiplegia/etiology
- Herpesvirus 2, Human/isolation & purification
- Humans
- Magnetic Resonance Imaging
- Middle Aged
- Polymerase Chain Reaction
- Retinal Detachment/etiology
- Retinal Necrosis Syndrome, Acute/diagnosis
- Retinal Necrosis Syndrome, Acute/drug therapy
- Retinal Necrosis Syndrome, Acute/etiology
- Retinal Necrosis Syndrome, Acute/virology
- Stroke/diagnosis
- Urinary Incontinence/etiology
- Virus Activation
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Affiliation(s)
- S Cardine
- Service d'Ophtalmologie, Centre hospitalier Robert Ballanger, Aulnay sous Bois
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Amara N, Ratsimba B, Wilhelm A, Delmas H. Growth rate of potash alum crystals: comparison of silent and ultrasonic conditions. Ultrason Sonochem 2004; 11:17-21. [PMID: 14624982 DOI: 10.1016/s1350-4177(03)00131-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The influence of power ultrasound on the growth rate of potash alum was investigated. The experiments on growth of potash alum crystals were carried out in a stirred double jacket tank in silent conditions as well as in the presence of power ultrasound (20 kHz) at 32 degrees C, with different initial crystal sizes. It was observed that the mass growth rate of potash alum was faster under ultrasound compared to that under silent conditions. The shape was not modified by ultrasound but the size of crystals, which are grown under ultrasound, are smaller and with higher density compared to those grown under silent conditions.
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Affiliation(s)
- N Amara
- Ecole Nationale Supérieure d'Ingénieurs des Arts Chimiques et Technologiques, 118 route de Narbonne, 31077 Toulouse, France
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Amara N, Leroy X, Nivet J, Biserte J, Mazeman E. [Schwannoma of the penis: a rare and unusual tumor of the external genital organs]. Prog Urol 2003; 13:324-5. [PMID: 12765077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
The authors report an isolated case of schwannoma of the penis in a 34-year-old man. The diagnosis was based on precise histological and immunohistochemical criteria and treatment consisted of simple surgical excision followed by clinical follow-up.
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Zini L, Amara N, Graziana JP, Villers A, Biserte J, Mazeman E. [Klippel-Trenaunay syndrome and multiple vesical hemangiomas: treatment with Neodymium:YAG laser]. Prog Urol 2001; 11:1282-4. [PMID: 11859666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
The authors report the case of a patient presenting with bladder haemangiomas in the context of Klippel-Trenaunay syndrome treated by Neodymium:YAG laser. Klippel-Trenaunay syndrome consists of a combination of hypertrophy of a limb, cutaneous angiomas and varicose veins. Bladder haemangioma is a benign congenital vascular tumour associated with Klippel-Trenaunay syndrome in 3 to 6% of cases, especially affecting children and young adults. Its most frequent clinical manifestation is haematuria. The diagnosis is based on endoscopy. Endoscopic treatment by Neodymium:YAG (Nd:YAG) laser photocoagulation appears to be a satisfactory treatment option.
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Affiliation(s)
- L Zini
- Service d'Urologie, CHRU de Lille, France.
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Abstract
The influence of power ultrasound on the crystallization of potash alum was investigated. Experiments have been carried out in a batch stirred vessel. It was found that ultrasonic waves decrease the supersaturation limits and modify the morphology of the crystals produced. The average crystal size decreases with an increase of ultrasonic power. To investigate also the action of ultrasound on already existing crystals, crystals produced in silent conditions were suspended in saturated potash alum solution at various ultrasonic powers. The results show that ultrasound has also an abrasive effect on potash alum crystals for high power inputs.
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Affiliation(s)
- N Amara
- Laboratoire de Génie Chimique (UMR CNRS 5503 INPT/UPS), Ecole Nationale Supérieure d'Ingénieurs de Génie Chimique (ENSIGC-INPT), 18 chemin de la Loge, 31078 Toulouse, France
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Amara N, Palapattu GS, Schrage M, Gu Z, Thomas GV, Dorey F, Said J, Reiter RE. Prostate stem cell antigen is overexpressed in human transitional cell carcinoma. Cancer Res 2001; 61:4660-5. [PMID: 11406532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
Prostate stem cell antigen (PSCA), a homologue of the Ly-6/Thy-1 family of cell surface antigens, is expressed by a majority of human prostate cancers and is a promising target for prostate cancer immunotherapy. In addition to its expression in normal and malignant prostate, we recently reported that PSCA is expressed at low levels in the transitional epithelium of normal bladder. In the present study, we compared the expression of PSCA in normal and malignant urothelial tissues to assess its potential as an immunotherapeutic target in transitional cell carcinoma (TCC). Immunohistochemical analysis of PSCA protein expression was performed on tissue sections from 32 normal bladder specimens, as well as 11 cases of low-grade transitional cell dysplasia, 21 cases of carcinoma in situ (CIS), 38 superficial transitional cell tumors (STCC, stages T(a)-T(1)), 65 muscle-invasive TCCs (ITCCs, stages T(2)-T(4)), and 7 bladder cancer metastases. The level of PSCA protein expression was scored semiquantitatively by assessing both the intensity and frequency (i.e., percentage of positive tumor cells) of staining. We also examined PSCA mRNA expression in a representative sample of normal and malignant human transitional cell tissues. In normal bladder, PSCA immunostaining was weak and confined almost exclusively to the superficial umbrella cell layer. Staining in CIS and STCC was more intense and uniform than that seen in normal bladder epithelium (P < 0.001), with staining detected in 21 (100%) of 21 cases of CIS and 37 (97%) of 38 superficial tumors. PSCA protein was also detected in 42 (65%) of 65 of muscle-invasive and 4 (57%) of 7 metastatic cancers, with the highest levels of PSCA expression (i.e., moderate-strong staining in >50% of tumor cells) seen in 32% of invasive and 43% of metastatic samples. Higher levels of PSCA expression correlated with increasing tumor grade for both STCCs and ITCCs (P < 0.001). Northern blot analysis confirmed the immunohistochemical data, showing a dramatic increase in PSCA mRNA expression in two of five muscle-invasive transitional cell tumors when compared with normal samples. Confocal microscopy demonstrated that PSCA expression in TCC is confined to the cell surface. These data demonstrate that PSCA is overexpressed in a majority of human TCCs, particularly CIS and superficial tumors, and may be a useful target for bladder cancer diagnosis and therapy.
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Affiliation(s)
- N Amara
- Department of Urology, Jonsson Cancer Center, University of California-Los Angeles School of Medicine, Los Angeles, California 90095, USA
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Bono W, Michon-Pasturel U, Amara N, Fauchais A, Hachulla E, Hatron P, Devulder B. Douleur lombaire aiguë révélant une malakoplakie. Rev Med Interne 2001. [DOI: 10.1016/s0248-8663(01)83513-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mauroy B, Goullet E, Stefaniak X, Bonnal JL, Amara N. Tendinous arch of the pelvic fascia: application to the technique of paravaginal colposuspension. Surg Radiol Anat 2001; 22:73-9. [PMID: 10959671 DOI: 10.1007/s00276-000-0073-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The authors give a description of the anatomy and topography of the tendinous arch of the pelvic fascia (TAPF), in order to facilitate its location during surgery. 35 TAPF in 25 female cadavers were dissected. The reproducibility of the landmarks was then verified at laparotomy. The TAPF can be easily identified and its resistance remains constant, even when the pelvic floor is hypotrophic. Its anterior extremity (d2) is at about 46 mm on a line perpendicular to the anterior edge of the pectineal ligament (35-55 mm), next to the pubovesical ligament. Its median part (dl) is perpendicular to the obturator foramen at a site located at an average of 30 mm below the obturator foramen (25-50 mm). Its posterior end is located at the ischial spine. These anterior landmarks, the only ones useful during surgery, allow its very easy location with the palmar surface of the finger. Testard and Delancey demonstrated the major role of the TAPF in stabilising the urethra submitted to strain. Richardson described a technique of paravaginal suspension for curing paravaginal fascial defect. The TAPF has never been well described, but his work allows its easy location during surgery. The suture of the vagina to the TAPF allows a more physiologic and stronger suspension of the bladder neck than other classical techniques.
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Affiliation(s)
- B Mauroy
- Institute of Anatomy, Faculty of Medicine, Lille, France
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Zakraoui L, Amara N, Hamza M, Mrabet A, Hamza M, Hila A, Haddad S. [Joint involvement in Wilson's disease]. Rev Rhum Mal Osteoartic 1986; 53:345-8. [PMID: 3738398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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