Paclitaxel plus bevacizumab or paclitaxel as first-line treatment for HER2-negative metastatic breast cancer in a multicenter national observational study

BACKGROUND

Bevacizumab combined with paclitaxel as first-line chemotherapy for patients with HER2-negative metastatic breast cancer (MBC) has led to mixed results in randomized trials, with an improvement in progression-free survival (PFS) but no statistically significant overall survival (OS) benefit. Real-life data could help in assessing the value of this combination.

PATIENTS AND METHODS

This study aimed to describe the outcome following first-line paclitaxel with or without bevacizumab in the French Epidemiological Strategy and Medical Economics (ESME) database of MBC patients, established in 2014 by Unicancer. The primary and secondary end points were OS and PFS, respectively.

RESULTS

From 2008 to 2013, 14 014 MBC patient files were identified, including 10 605 patients with a HER2-negative status. Of these, 3426 received paclitaxel and bevacizumab (2127) or paclitaxel (1299) as first-line chemotherapy. OS adjusted for major prognostic factors was significantly longer in the paclitaxel and bevacizumab group compared with paclitaxel [hazard ratio (HR) 0.672, 95% confidence interval (CI) 0.601-0.752; median survival time 27.7 versus 19.8 months]. Results were consistent in all supportive analyses (using a propensity score for adjustment and as a matching factor for nested case-control analyses) and sensitivity analyses. Similar results were observed for the adjusted PFS, favoring the combination (HR 0.739, 95% CI 0.672-0.813; 8.1 versus 6.4 months).

CONCLUSIONS

In this large-scale, real-life setting, patients with HER2-negative MBC who received paclitaxel plus bevacizumab as first-line chemotherapy had a significantly better OS and PFS than those receiving paclitaxel. Despite robust methodology, real-life data are exposed to important potential biases, and therefore, results need to be treated with caution. Our data cannot therefore support extension of current use of bevacizumab in MBC.

Cholesterol granuloma of the middle ear invading the cochlea

OBJECTIVES

To report a second case of cholesterol granuloma of the middle ear invading the cochlea.

MATERIAL AND METHODS

A 54-year-old woman, who had undergone right-side tympanoplasty with stapedectomy, complained of intermittent right-side otorrhea associated with cophosis. Otomicroscopy found anterior eardrum perforation with mucopurulent effusion. Computed tomography (CT) showed a lesion filling the tympanic cavity, exposing the tympanic facial nerve, with destruction of the ossicles; the vestibule and cochlea were ossified except for the basal turn. The petrous apex was normal. Magnetic resonance imaging (MRI) showed invasion of the cavity and basal turn of the cochlea by a mass in heterogeneous hypersignal on T-1 weighted images, non-enhanced by gadolinium injection, and hyperintensity on T2-weighted images. Cholesterol granuloma of the middle ear was suspected, with surgery indicated due to the facial nerve exposure and cochlear invasion.

RESULTS

A brownish-yellow compressive mass invading the basal turn of the cochlea, suggestive of cholesterol granuloma, was removed. Histologic examination confirmed diagnosis.

CONCLUSION

Direct invasion of the otic capsule by cholesterol granuloma is extremely unusual. Surgery is indicated in such cases, to avoid onset of neurologic complications.

[Computed tomography of the normal and pathologic temporal bone]

High-resolution computed tomography scanning (CT) allows depiction of microanatomic structures of the temporal bone. CT is useful for detecting several pathologic conditions of the temporal bone such as congenital malformations, particularly in young children with sensorineural hearing loss. Some external, middle and inner ear structures are difficult to evaluate. The objective of this study has been to provide the key planes in coronal and axial planes (five coronal planes and three axial planes) but also with oblique planes reconstruction (two planes) for normal temporal bones evaluation. These standardized planes help to improve visualization of the main congenital malformations. Identification of obvious morphogenetic malformations (Michel aplasia, Mondini deformity….) is not difficult. However, less severe dysplasia may be missed or normal micro anatomic structures in newborn misreaded.

[MR spectroscopy of the prostate with external surface coils: clinical feasibility]

PURPOSE

To determine the clinical feasibility of MR spectroscopy (MRS) of prostate cancer using external multi-channel surface coils at 1.5T. Materials and methods. Retrospective study of 31 patients with prostate cancer who underwent MRS as part of the staging work-up prior to radical prostatectomy. The ratio of the three main metabolites ([choline + creatine]/citrate) were measured along with spectral analysis of different regions of interest (ROI) placed in areas of normal tissue and cancer using the surgical specimen as the standard of reference.

RESULTS

One hundred and eighty-three voxels were analyzed. Qualitative visual analysis identified pathological spectra in 88.5% of cancer ROI, 11.7% of normal transitional zone ROI and 1.6% of normal peripheral zone ROI. The ratios of normal prostate tissue were significantly more elevated (p<0.0001) in the transition zone (0.41 +/- 0.24) than in the peripheral zone (0.22 +/- 0.36). Tumor containing voxels had significantly higher ratios (2.84 +/- 2.74) than normal tissue containing voxels of the transition zone (p<0.0001) and peripheral zone (p<0.0001).

CONCLUSION

Prostate MRS using external surface coils appears routinely feasible at 1.5T, even though it presents some limitations.

Risk Assessment in Node-Negative Breast Cancer by the Invasion Factors (Urokinase-Type Plasminogen Activator) and Its Inhibitor PAI-1. Correlation to the Tumor Characteristics in the Prospective NNBC 3-Europe Trial. On Behalf of the NNBC-3 Trial Group

Background:ASCO Tumor Marker Guidelines 2007 recommended clinical routine use of the invasion markers uPA and PAI-1 for risk assessment in N0 breast cancer patients (Harris et al. JCO 2007; 25:5287). We conducted the prospective NNBC 3-Europe trial addressing the direct comparison between risk-assessment by uPA/PAI-1 and clinico-pathological factors, and optimization of adjuvant chemotherapy for high-risk N0 pts: FEC*3-Doc*3 vs. standard FE100C*6.Study Design:Risk assessment was based on grade, and in G2 tumors either by uPA/PAI-1 status (UP) or by a St. Gallen adapted algorithm (CP). Type of assessment was decided by each centre prior to study participation. High-risk patients received adjuvant chemotherapy according to randomisation. Adjuvant endocrine therapy is given according to guidelines. Use of fresh tissue sampling was necessary for determination of uPA/PAI-1 by ELISA. All laboratories took part on the central quality assurance program. HER2 overexpression was confirmed centrally.Results:From Dec 2002 to Jan 2009, 153 centres recruited 4,150 pts (4,145 evaluable). In 2,497 pts., risk was assessed by UP, and in 1,648 by CP. By UP, 38.7% were assigned to the low-risk group, whilst 61.3% of the patients still had to receive adjuvant chemotherapy; by CP-assessment (n=1,648) the risk groups comprised 31.3%, and 68.7 %.Tab.1. Tumor characteristics.risk groupUP lowUP highCP lowCP hightotaln9671,5305161,1324,145age (median)54 (31-70)53 (21-70)57 (34-70)53 (21-70)54 (21-70)pT2178 (18.4%)544 (35.6%)24 (4.7%)603 (53.3%)1,349 (33%)Steroid hormone receptor status pos.951 (98.3%)1,116 (72.9%)513 (99.4%)739 (65.3%)3,331 (80.4%)HER2 overexpression45 (4.7%)284 (18.6%)6 (1.2%)247 (21.8%)582 (14.0%)triple negative (TNBC)15 (1.6%)319 (20.8%)2 (0.4%)295 (26.1%)631 (15.2%)Grading 1417 (43.1%)-164 (32.0%)15 (1.3%)596 (14.4%)Grading 2550 (56.9%)750 (48.9%)345 (67.4%)464 (40.7%)2,115 (51.0%)Grading 3-780 (50.9%)7 (1.4%)639 (56.1%)1,424 (34.4%)uPA value [ng/mg] median1.33.8--2.4PAI-1 value [ng/mg]median9.121.5--15.4 More pT2 tumors were listed as low risk by the UP method. Typical high risk groups (e.g. TNBC, HER2) were identified by UP. A substantial number of HER2 overexpressing tumors (4.7%) in UP were assigned to the low risk group, suggesting an independent effect of UP and HER2. In the QA programm, mean coefficients of variations were 12% for uPA and PAI-1 determination. In total 1,335 pts. were randomised to receive FEC-Doc, and 1.327 to receive FEC. The chemotherapy was well tolerated. However, we observed four therapy related deaths.Conclusions:Determination of uPA and PAI-1 in frozen tissue is feasible and reliable. Using UP for additional prognostic information may prevent chemotherapy from many patients. The effect of the taxane containing regimen will be evaluated with longer follow-up.Cooperation: EORTC Patho-Biology Group, AGO Breast Group, GBG, Unrestricted grants by Sanofi-Aventis, Pfizer, American Diagnostica, Martin-Luther-University Halle-Wittenberg.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4040.

Anastrozole and goserelin combination as first treatment for premenopausal receptor positive advanced or metastatic breast cancer: A phase II trial

1079

Background: Aromatase inhibitors (AIs) have shown high activity in postmenopausal women. However, as AIs do not suppress ovarian oestrogen synthesis, they are not effective in premenopausal women. The aim of this trial was to assess the efficacy of the combination of anastrozole and goserelin (LHRH agonist) in premenopausal women with advanced or metastatic hormonal receptor positive breast cancer. Methods: Premenopausal women with advanced estrogen receptor (ER) and/or progesterone receptor (PR) positive breast cancer were enrolled in this open, multicentre, non-comparative phase II trial and received anastrozole 1mg/day p.o. and gosereline 3.6 mg subcutaneously monthly until progression. The primary endpoint was objective response rate (ORR) assessed according to RECIST criteria. Results: Thirty-three patients (33), with a mean age of 44 (+ 5.9) years, PS 0–2, were enrolled from December 2001 to May 2005. All patients were ER positive and 75.8% PR positive and 6 patients (18.2%) received adjuvant treatment with anti estrogens. There were 4 (12.1%) complete responses (CR), 14 (42.4%) partial responses (PR), and 11 (33.3%) stable diseases (SD), giving an ORR of 54.6% (IC 95% [36.4; 71.9]). Twenty-one (63.6%) patients showed a clinical benefit (CR+PR+SD≥24 weeks) for a median duration of 13.7 (IC 95% [8.74; 22.97]) months. Median time to progression was 13 (6;33) months. The most commun AEs were hot flush in 29 (87.9%), arthralgia in 13 (39.4%) and nausea in 12 (36.4%) patients. Conclusions: The combination of anastrozole and gosereline is well tolerated and appears to be an effective treatment of premenopausal women with advanced breast cancer in this exploratory phase II trial.

No significant financial relationships to disclose.

ASCO-recommended prognostic factors uPA/PAI-1 in node-negative (N0) breast cancer patients (pts) compared to clinicopathological risk assessment within the NNBC 3-Europe trial

544

Background: ASCO Tumor Marker Guidelines 2007 recommended clinical routine use of the invasion markers uPA (urokinase-type plasminogen activator) and its inhibitor PAI-1 for risk assessment in N0 breast cancer pts (Harris et al, J Clin Oncol. 2007;25:5287). Ten-year follow-up data of the confirmatory prospective clinical uPA/PAI-1 trial (CHEMO-N0) will be presented at the ASCO 2009 Meeting (Harbeck et al.). We conducted a further prospective trial (NNBC 3-Europe) addressing the direct comparison between risk-assessment by uPA/PAI-1 (UP) and clinico-pathological factors (C), and optimization of adjuvant chemotherapy for high-risk N0 pts: FEC*3-Doc*3 vs. standard FEC*6. Methods: From December 2002 to January 2009, 4,040 pts were recruited by 151 centres. For uPA and PAI-1 ELISA, tumors samples were snap frozen und processed. Risk assessment was based on grade and in G2 tumors, either by UP or by a St. Gallen adapted C algorithm. High-risk pts were randomized for adjuvant chemotherapy. All laboratories took part in central quality assurance (QA) for uPA/PAI-1 determination. Results: Risk assessment was performed for 1,590 pts based on C and for 2,445 pts based on UP. End of accrual was planned when 2,572 high risk pts were randomised for chemotherapy and thus ends Jan 31, 2009. Current status shows 1,291 high-risk pts in the FEC-Doc and 1,294 in the FEC arm. In the low-risk arm, 1,450 pts have endocrine therapy, only. By both risk stratifications, 42% of the G2 tumors were assigned as low risk, but in total, more pts were classified as low-risk by UP (39%) than by C (31%). Median uPA level were at 2.40 ng/mg protein (below cutoff), median PAI-1 at 15.9 (above cutoff). In the QA programm, mean coefficients of variations are 12% for uPA and PAI-1 determination. Conclusions: The prospective biomarker trial using uPA/PAI-1 has just ended accrual with more than 4,000 patients. Routine uPA/PAI-1 determination is reliable and feasible even in core needle specimens. Using tumor grade and uPA/PAI-1, adjuvant chemotherapy may be avoided in about 39% of N0 breast cancer pts. Cooperation: EORTC Patho-Biology Group, AGO Breast Group, GBG, Unrestricted grants by Sanofi-Aventis, Pfizer, American Diagnostica, Martin-Luther-Universitaet Halle-Wittenberg.

[Table: see text]

Prognostic value of serum level of HER-2 extracellular domain (ECD) at diagnosis of HER-2 overexpressed primary breast cancer (BC)

e11508

Background: Serum level of HER2 ECD is an adverse prognostic factor in HER2 over-expressed metastatic BC. We analyzed the prognostic value of serum level of HER2 ECD at the diagnostic of HER2 over-expressed primary BC. Methods: Patients with HER2 over-expressed primary BC treated with adjuvant trastuzumab in 2005 and 2006 were retrospectively analyzed. Serum level of HER2 ECD was assessed on frozen sera collected for CA15–3 measurement before initial treatment. Serum level of HER2 ECD was measured with an Elisa commercial kit (Oncogene Science, Cambridge, MA). The cut-off was 15μg/l as recommended. Results: Pre-treatment serum was available for 65 patients treated for non metastatic HER2 over-expressed BC. Seven patients (11%) had initially an elevated serum level of HER2 ECD (mean 25μg/l, range 15.1–38.9). After an average follow-up of 30 months, 4 patients (57%) out of the 7 with initially elevated serum level of HER2 ECD had a metastatic relapse of BC. In contrast, only 3 patients (5%) out of 58 with initially low serum level of HER2 ECD experienced relapse (p=0.004). Median of serum level of HER2 ECD was 17μg/l in patients who experienced relapse during follow-up whereas it was 8.4μg/l in patients who remained relapse-free (p=0.03). Univariate analysis showed that only elevated serum level of HER2 ECD and absence of hormone receptors expression were linked with metastatic relapse (p=0.0004 and p=0.02, respectively). Multivariate analysis showed that elevated serum level of HER2 ECD and absence of hormone receptors expression were linked with metastatic relapse (p=0.02 and p=0.04, respectively). Survival curves showed also that elevated serum level of HER2 ECD was related with a worse disease-free survival (p=0.0004). Conclusions: In this small series, elevated serum level of HER2 ECD was an adverse prognostic factor for HER2 over- expressed non metastatic primary BC. It was also a predictive factor for early failure of adjuvant treatment with trastuzumab.

No significant financial relationships to disclose.

[Routine use of serial plasmatic CA 15-3 determinations during the follow-up of patients treated for breast cancer. Evaluation as factor of early diagnosis of recurrence]

PURPOSE

at our institution, CA 15-3 assays are routinely used for the early diagnosis of recurrence during the follow-up of patients treated for breast cancer, although published guidelines do not recommend this procedure. So, we decided to totally re-assess the usefulness of this policy.

PATIENTS AND METHODS

all records of patients presenting a first recurrence, local (50 cases) or metastatic (88 cases), of breast cancer during 2003 were re-examined. An increase in CA 15-3 concentration of more than 25% was considered significant.

RESULTS

an increase was observed in 18% of non metastatic recurrences. These increases had a prognostic value. CA 15-3 levels remained stable in 23% of metastasis cases and increased in 77%. In 14% of cases, the increase in CA 15-3 levels confirmed a clinically or radiologically suspected metastasis. Moreover, increased CA 15-3 levels in the absence of suggestive clinical or radiological signs led to the diagnosis in 18% of metastasis, 50% of which involved the bone.

CONCLUSION

our study demonstrates that CA 15-3 is useful for the early diagnosis of recurrence. Eighteen per cent of metastases were diagnosed by a marker increase alone. CA 15-3 assays could be useful in the early management of these metastases in patients treated for breast cancer.

[Parotid gland masses: diagnostic value of MR imaging with histopathologic correlations]

BACKGROUND AND PURPOSE

The purpose of our study has been to describe the pre-operatively MR Imaging appearance of masses in the parotid gland which may be sources of clinical and radiological confusion.

METHODS

Sixty-eight adults patients with a parotid mass (39 female, 29 male) has been prospectively investigated. T1-weighted, T2-weighted, diffusion-weighted and contrast-enhanced dynamic MR images were performed by using a 1.5 or 1 T MR Imaging unit (Philips Gyroscan Intera 1.5 T. Siemens Expert 1 T). All patients underwent a parotidectomy with histopathologic analysis.

RESULTS-CONCLUSIONS

In case of pleomorphic adenoma (N=30) MR imaging sensibility, specificity and accuracy were respectively 87.5, 80.5 and 83%. In case of Warthin tumors (N=13) the same values were respectively 45.5, 93 and 85%. In case of malignant tumors (N=13) theses values were respectively 71, 89 and 87%. Our routine MR Imaging study appears excellent not only for assessing the type and extent of benign salivary gland tumors and the relationship to adjacent structures, but also for determining whether the tumor is benign or malignant.

Urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 for improved management in node-negative (N0) breast cancer: Experiences from the ongoing multicenter trial NNBC 3-Europe

11081

Risk-assessment in N0 breast cancer is still controversial. In line with St. Gallen, only few patients (pts) are considered at such low risk of relapse, that adjuvant chemotherapy could be avoided. Various groups have started clinical trials aimed at improved risk-assessment by gene or protein analysis of the primary tumor. We launched the NNBC 3-Europe trial asking the following questions: Is the identification of low- risk pts by the invasion markers uPA and PAI-1 more effective than by St. Gallen criteria? Is adjuvant chemotherapy using an anthracycline- taxane sequence superior to standard FEC in N0 high-risk pts? The centres of the NNBC 3 trial had to choose their mode of risk- assessment (either St. Gallen criteria or uPA/PAI-1) prior to recruitment. High-risk pts receive chemotherapy randomly assigned to FEC-100*3 followed by Docetaxel-100*3 (FEC-Doc), or FEC-100*6. No adjuvant chemotherapy is given to low-risk pts. Pts with hormone receptor positive tumors receive standard endocrine therapy. To date, 1206 pts in 57 centres have been registered. Using fresh frozen tumor tissue, uPA and PAI-1 are tested in nine laboratories; inter-laboratory quality assurance is performed. In 141 of 1188 evaluable pts, St Gallen criteria were used. In the biological risk-assessment group, 150 of 1047 tumors (14.3%) were well differentiated, thus regarded as low-risk. Using both, tumor grade and uPA/PAI-1, 35.3% of the pts were considered low-risk, whereas the remaining 64.7% high-risk pts received adjuvant chemotherapy (FEC-Doc, n=334, or FEC, n=343). Multicenter prospective risk assessment based on testing of fresh frozen (or paraffin- embedded) tumor tissue is sophisticated. All trials with similar approach (MINDACT, TAILORx) had a long preparation phase including thorough assay validation. The ongoing NNBC-3 trial demonstrates that inclusion of pts based on testing of fresh frozen material is feasible in a routine setting. Risk-group distribution is as expected. The study is planned to recruit 5,700 pts and it is performed in cooperation with the EORTC Patho-Biology Group, the German AGO Breast Group, and the German Breast Group (GBG). Unrestricted grants by Sanofi-Aventis and Pfizer.

[Table: see text]

Efficacy and safety of trastuzumab plus vinorelbine as second-line treatment for women with HER2-positive metastatic breast cancer beyond disease progression

1094

Background: There is increasing evidence that women with HER2-positive metastatic breast cancer (MBC) benefit from continued trastuzumab (H) therapy beyond disease progression (PD). In a Phase II multicentre 2-step trial we evaluated women for their response to second-line treatment with H + vinorelbine (N) following PD after receiving first-line H + taxane for HER2-positive MBC. Methods: Women aged =18 years with HER2-positive MBC received H (8 mg/kg loading dose followed by 6 mg/kg q3w or 4 mg/kg loading dose followed by 2 mg/kg qw) + N (30 mg/m2 days 1 and 8 q3w) until PD. The primary end point was overall response rate (ORR); secondary end points included time to progression, time to treatment failure, overall survival and safety. Data from a planned interim analysis are presented. Results: Seventeen out of a planned 50 patients (pts) were enrolled between June 2003 and October 2006, with a mean age of 54 years (range 42–70). Nine pts had hormone receptor-positive disease at baseline and 17 pts had HER2-positive disease (16 pts IHC 3+; 1 pt IHC 2+ and CISH+). Pts had previously received H in combination with paclitaxel (9 pts) or docetaxel (8 pts) as first-line therapy for MBC. Pts received a median of 6 treatment cycles with H + N (range 2–14), with 2 pts receiving H q3w and 15 pts receiving H qw. ORR was 29%, with 2 pts showing a complete response, 3 pts experiencing a partial response and 4 pts achieving stable disease lasting 6 months. Eight pts experienced PD. Re-treatment with H + N was well tolerated beyond PD, with grade 3/4 haematological toxicities being the most common serious adverse events, leading to a delay and dose reduction of N. No relevant cardiac toxicities were reported, with only 2 grade 1 cardiac events. All pts withdrew, 14 due to PD. Conclusions: This interim analysis indicates that treatment with Herceptin plus chemotherapy beyond PD is active (ORR 29%) and well tolerated, and provides further evidence that re-treatment with H is a promising therapeutic option. Pt accrual is ongoing and updated results will be presented.

No significant financial relationships to disclose.

Epirubicin-vinorelbine vs FEC100 for node-positive, early breast cancer: French Adjuvant Study Group 09 trial

The aim of the study was to compare our reference adjuvant chemotherapy, FEC100 (fluorouracil 500 mg m⁻², epirubicin 100 mg m⁻² and cyclophosphamide 500 mg m⁻², six cycles every 21 days), to an epirubicin–vinorelbine (Epi-Vnr) combination for early, poor-prognosis breast cancer patients. Patients (482) were randomised to receive FEC100, or Epi-Vnr (epirubicin 50 mg m⁻² day 1 and vinorelbine 25 mg m⁻², days 1 and 8, six cycles every 21 days). The 7-year disease-free survival rates were 59.4 and 58.8%, respectively (P=0.47). The relative dose intensity of planned epirubicin doses was 89.1% with FEC100 and 88.9% with Epi-Vnr. There were significantly more grades 3–4 neutropenia (P=0.009) with Epi-Vnr, and significantly more nausea-vomiting (P<0.0001), stomatitis (P=0.0007) and alopecia (P<0.0001) with FEC100. No cases of congestive heart failure were reported, whereas four decreases in left ventricular ejection fraction occurred after FEC100 and five after Epi-Vnr. One case of acute myeloblastic leukaemia was registered in the FEC100 arm. After 7 years of follow-up, there was no difference between treatment arms. Epi-Vnr regimen provided a good efficacy in such poor-prognosis breast cancer patients, and could be an alternative to FEC100, taking into account respective safety profiles of both regimens.

Otospongiose cochléaire et pseudo-quatrième tour de cochlée

OBJECTIVE

To describe different sequences on magnetic resonance imaging (MRI) in otosclerosis with peri-cochlear involvement.

METHOD

MRI T1 and T2 sequences with T1 gadolinium injection and computed tomography (CT) scans with millimetric slices on axial and coronal views were obtained. The diagnosis of bilateral otosclerosis was confirmed by surgical exploration.

RESULTS

On the CT scan, there was a fourth turn of the cochlea which appeared on the MRI T1 sequence with an intermediate signal and on the T2 sequences with a high intensity signal. After gadolinium injection, there was signal enhancement, suggestive of active otospongiosis. On the CT scan, there was another lesion in front of the cochlea with endosteal involvement. This was no however visible on the MRI, even after gadolinium infusion, in accordance with inactive otospongiosis.

DISCUSSION

We reviewed the literature concerning MRI and results in otosclerosis.

CONCLUSION

MRI of the labyrinth with T1 sequences and gadolinium injection can be contributive to the diagnosis of otosclerosis to differentiate inactive from inactive otospongiosis. However, prospective studies must be conducted to confirm this hypothesis.

[Surgical and radiotherapeutic approaches according to postoperative margins analysis in breast cancer: survey realized in 20 French cancer centers]

Margin status is regarded as a major prognostic factor for local recurrence after breast conservative treatment. Margin definition in the literature is not always clear and precise. The impact on the therapeutic management may be quite different. This paper presents the radiotherapeutic attitude according to a survey realized in the twenty French cancer centers. The surgical practice in terms of margins status is appraised. The radiotherapist attitude in terms of boost's modulation is specified.

[Advantage of virtual endoscopy in the evaluation of the ossicular chain]

PURPOSE

Our study consists of a comparison of traditional computed tomography (CT) data sets with 2 views of virtual endoscopy in the preoperative evaluation of various diseases of the middle ear.

MATERIALS AND METHODS

We studied 59 patients, all sent for conductive hearing loss with normal eardrum who underwent a complete CT examination: axial helical acquisition and coronal incremental acquisition: virtual endoscopy with selection of two reproducible views: an external one of the auditory canal and a lower one of the hypotympanum. Reading was performed by 2 independent radiologists. All patients were subsequently operated by the same surgeon. Results were compared with surgical reports.

RESULT

Virtual endoscopy is valuable for the evaluation of ossicular and prosthesis dislocations, morphological anomalies of the malleus, incus, and stapes superstructure. Nevertheless, standard axial and coronal CT images remain necessary as confirmed by the poor results of virtual endoscopy in cases of attic obstruction, cholesteatomas and otospongiosis.

CONCLUSION

Virtual endoscopy is a valuable technique of the evaluation of some ossicular chain pathologies but it cannot be used alone.

[Contribution of pelvic floor MRI in the morphological and functional analysis of pre and postoperative levator muscle in patients with genital prolapse]

OBJECTIVES

This study was directed to evaluate the morphological and dynamic aspects of the pelvic floor muscles by the MRI in patients with gynecological prolapse before and after surgery.

MATERIALS AND METHOD

MRI had been made before surgical repair in 13 patients with gynecological prolapse, in 9 of this group MRI had been made after the surgery and the group of control was formed by 4 healthy women. We had used morphologic sequences T2 (TSE) and T1 (SE) and fast sequences T2 (TSE) in different positions: at rest, straining and retention for describe and evaluate the anatomic modification of the levator ani and the changes observed after surgery.

RESULTS

The MRI is able to identify the changes of the levator ani muscles: intrinsic degeneratives lesions, increase of the muscular laxity especially for the puborectalis muscle and the wider of the levator hiatus. After surgical repair, the levator hiatus width and the laxity of the puborectalis muscle are slightly modified during straining.

CONCLUSION

There are lesions in the muscular structure of the pelvic floor in patients with gynecological prolapse. The MRI was able to analyse these lesions very well especially after the use of fast sequences. The MRI is the future for exhaustive and non invasive study of the static pelvic disorders.

[Imaging of intraductal papillary mucinous tumor of the pancreas: literature review]

Intraductal papillary-mucinous tumor (IPMT) is defined as a syndrome consisting of dilatation of the main pancreatic duct and/or branch ducts associated with mucin overproduction. The purpose was to evaluate the usefulness of different imaging techniques (CT, EUS, ERCP) for determination of tumor invasion and pancreatic extension. Diagnosis often is delayed because it is confused with chronic pancreatitis or cystic neoplasms of the pancreas. It is difficult to rule out invasive malignancy. MRCP can be an essential imaging modality because it is a non-invasive technique. Intraductal ultrasound or pancreatoscopy could become in the future an additional useful preoperative procedure. A high frequency of invasive carcinoma in patients operated for pancreatic IPMT is observed. Surgical resection should be extended until a normal tissue margin is encountered.

Comparison of color duplex ultrasound and computed tomography scan for surveillance after aortic endografting

Endovascular repair of abdominal aortic aneurysms (AAA) requires regular surveillance for early detection of endograft failure. CT scanning is the gold standard surveillance procedure. The purpose of this study was to assess the reliability of color duplex ultrasound (CDU) in comparison to CT scanning for detection of endoleaks and changes in aneurysmal diameter. From November 1996 to September 1999, a total of 41 patients treated by aortic endografting underwent regular surveillance with both CT scanning and CDU. There were 39 men and 2 women with a mean age of 71 years (range, 50-83). Endovascular treatment involved deployment of a straight aorto-aortic stent in 6 cases, bifurcated stent in 33, and aorta-to-unilateral iliac artery stent in 2. Stent deployment failed in one case; the procedure was conversion to open surgery. Primary or secondary endoleaks were detected in 17 patients (42%). Our findings indicated that CDU is less reliable than the CT scan for detection of endoleaks, but that reliability of CDU for surveillance of aneurysmal diameter is fair.

Polyadenylic-polyuridylic acid plus locoregional radiotherapy versus chemotherapy with CMF in operable breast cancer: a 14 year follow-up analysis of a randomized trial of the Fédération Nationale des Centres de Lutte contre le Cancer (FNCLCC)

With a median follow-up of 14 years, the combination of polyadenylic-polyuridylic acid plus locoregional radiotherapy (257 patients) has significantly improved disease-free survival (p = 0.03) and significantly reduced the incidence of metastases (p = 0.04) when compared to CMF alone (260 patients), in women with operable breast cancer. The trial does not, however, permit an appreciation of the respective role of radiotherapy and PolyAU in these results.

[Right atrial angiosarcoma and MRI: a case report]

The authors report a case of right atrial angiosarcoma in a 29 year old man presenting with massive pericardial effusion. This case illustrates the value of MRI in the preoperative evaluation, providing accurate information about the site and extension of the tumor, and even about the malignant nature of the lesion. Multiplanar transesophageal echocardiography did not provide any additional information in this case.

Combined treatment with buserelin and tamoxifen in premenopausal metastatic breast cancer: a randomized study

BACKGROUND

Surgical or medical castration and antiestrogenic treatment with tamoxifen are common endocrine treatments for premenopausal women with breast cancer. However, tamoxifen therapy induces high levels of plasma estradiol, with unknown long-term effects. In this study, we investigated the effect of combining estrogen suppression with the luteinizing hormone-releasing hormone agonist buserelin and estradiol receptor blockade with tamoxifen to determine whether the high estradiol levels induced by tamoxifen could be reduced and whether the antitumor effects would be better.

METHODS

In a three-arm, randomized, prospective trial, from 1988 through 1995, a total of 161 premenopausal patients with advanced breast cancer were randomly assigned to treatment with buserelin, tamoxifen, or both. Patients with steroid receptor-negative tumors or with tumors of unknown receptor status who had a disease-free interval of less than 2 years were excluded. The median follow-up was 7.3 years, during which 76% of the patients died, all of breast cancer. Patient and tumor characteristics were well balanced among treatment groups. All P values are from two-sided tests.

RESULTS

Combined treatment with buserelin and tamoxifen was superior to treatment with buserelin or tamoxifen alone by objective response rate (48%, 34%, and 28% of patients who could be evaluated, respectively; P =.11 [chi(2) test]), median progression-free survival (9.7 months, 6.3 months, and 5.6 months; P =.03), and overall survival (3.7 years, 2.5 years, and 2.9 years; P =.01). Actuarial 5-year survival percentages were 34.2% (95% confidence interval [CI] = 20.4%-48.0%), 14.9% (95% CI = 3.9%-25.9%), and 18.4% (95% CI = 7.0%-29.8%), respectively. No differences in antitumor effects were observed between single-agent treatment groups. During combined treatment or treatment with buserelin alone, plasma estradiol levels were suppressed equally; in contrast, during treatment with tamoxifen alone, plasma estradiol levels increased threefold to fourfold over pretreatment levels.

CONCLUSION

Combined treatment with buserelin and tamoxifen was more effective and resulted in longer overall survival than treatment with either drug alone.

Delayed adjuvant tamoxifen: ten-year results of a collaborative randomized controlled trial in early breast cancer (TAM-02 trial)

AIM

Immediate adjuvant tamoxifen reduces disease recurrence and improves survival in patients with early breast cancer. However, is it too late to administer tamoxifen to patients who have already undergone treatment, but were unable to benefit from this adjuvant therapy? The French National Cancer Centers (FNCLCC) have investigated the efficacy of delayed tamoxifen administration in a randomized controlled trial.

PATIENTS AND METHODS

From September 1986 to October 1989, women with primary breast cancer, who had undergone surgery, radiotherapy, and/or received adjuvant chemotherapy but not hormone therapy more than two years earlier, were randomized to receive either 30 mg/day tamoxifen or no treatment. The 10-year disease-free and overall survival rates of the two groups of patients and of various subgroups were determined according to the Kaplan-Meyer method and compared by the log-rank test.

RESULTS

This intention-to-treat analysis comprised 250 Introduction women in the tamoxifen group and 244 in the control group. Patient characteristics (age, T stage, number of positive nodes, receptor status, and interval since tumor treatment) were comparable in both groups. Delayed adjuvant tamoxifen significantly improved overall survival only in node-positive patients and in patients with estrogen receptor-positive (ER+) or progesterone receptor-positive (PR+) tumors. Disease-free survival, however, was significantly improved in the global population and in several patient subgroups (node-positive, ER+, PR+). Patients in whom the interval between primary treatment and delayed adjuvant tamoxifen was greater than five years also had significantly improved disease-free survival.

CONCLUSIONS

Overall and disease-free survival results indicate that delayed adjuvant tamoxifen administration (30 mg/day) is justified in women with early breast cancer, even if this treatment is initiated two or more years after primary treatment.

A comparison of the efficacy and safety of ioxaglate and iobitridol in renal angioplasty

PURPOSE

To compare ioxaglate and iobitridol for percutaneous transluminal renal angioplasty (PTRA) as regards thromboembolic complications, the quality of diagnosis, and renal and general safety.

METHODS

One hundred and eighty-nine patients were prospectively studied, 98 of whom received ioxaglate, and 91, iobitridol. Twenty-two were secondarily excluded from the evaluation of thromboembolic complications as they did not undergo PTRA.

RESULTS

Two hundred and two PTRAs were performed. The total volumes of contrast medium administered and the procedure durations were the same for each patient. In the ioxaglate group, four dissections (3 stents), one occlusive dissection, and two spasms occurred; in the iobitridol group, there were three dissections (all stented), one occlusive dissection (stented), and two spasms. The final angiograms showed four renal infarctions with ioxaglate (2 of which were in patients who were not anticoagulated), two with iobitridol. No significant difference was seen in the incidence of thromboembolic complications when the PTRA was performed after anticoagulation (n = 150; 3.9% vs 4%, p = 0.78); in the whole population, thromboembolic complications were more frequent in the ioxaglate group but the difference was not significant (5.7% vs 3.7%, p = 0.74). The quality of the diagnosis and the general and renal safety were the same in the two groups.

CONCLUSION

Regarding the clotting phenomenon, we recorded as many thromboembolic complications with ioxaglate as with iobitridol.

Descriptive anatomy of the human auditory tube

The aim of this study was to correlate current morphologic data relating to the lumen of the auditory tube. Four methods were used: dissection under the operating microscope; microendoscopy of the tubal lumen; optical and electron microscope histology; and MR or CT imaging. The auditory tube consists of two unequal cones, a small posterior third, fixed and osseous (protympanum), and a mobile fibrocartilaginous anterior two-thirds, both joined by the tubal isthmus, a short constriction which is pseudosphincteric at endoscopy. The tensor veli palatini muscle (TVPM) and the levator veli palatini muscle (LVPM) are the chief muscles that vary the tubal lumen of the fibrocartilaginous portion, which is collapsed at rest. CT and especially MR imaging allows their observation in static conditions. Serial histologic sections reveal the continuity between the TVPM and the tensor tympani muscle. The main cartilage framing the lumen varies in shape according to the level surveyed. The tubal mucosa is lined with an epithelium combining ciliated and mucus cells, involved in mucociliary drainage and gas exchanges in the auditory tube. These morphologic elements represent a basis for study of tubal physiology and for planning treatment in dysfunctions of the auditory tube.

[Imaging and pathology of the ear and temporal bone (except for the skull base)]

Imaging occupies and increasing place in the investigation of pathological processes of the ear and temporal bone. For some of them (malformations, inflammatory conditions and tumours) the authors detail their indications and results. They conclude that imaging has become increasingly necessary in these conditions, and indispensable not only for choosing the method of treatment but also for medico-legal reasons.

Creutzfeldt-Jakob disease after extracranial dura mater embolization for a nasopharyngeal angiofibroma

We report a 25-year-old man with Creutzfeldt-Jakob disease (CJD) who had received dura mater embolization in the external carotid artery for a nasopharyngeal angiofibroma 90 months earlier. The patient was heterozygotous (Met/Val) at codon 129. This case suggests that dura mater embolization can be responsible for the CJD.