Characteristics of prescription in 29 Level 3 Neonatal Wards over a 2-year period (2017-2018). An inventory for future research

Objectives

The primary objective of this study is to determine the current level of patient medication exposure in Level 3 Neonatal Wards (L3NW). The secondary objective is to evaluate in the first month of life the rate of medication prescription not cited in the Summary of Product Characteristics (SmPC). A database containing all the medication prescriptions is collected as part of a prescription benchmarking program in the L3NW.

Material and methods

The research is a two-year observational cohort study (2017–2018) with retrospective analysis of medications prescribed in 29 French L3NW. Seventeen L3NW are present since the beginning of the study and 12 have been progressively included. All neonatal units used the same computerized system of prescription, and all prescription data were completely de-identified within each hospital before being stored in a common data warehouse.

Results

The study population includes 27,382 newborns. Two hundred and sixty-one different medications (International Nonproprietary Names, INN) were prescribed. Twelve INN (including paracetamol) were prescribed for at least 10% of patients, 55 for less than 10% but at least 1% and 194 to less than 1%. The lowest gestational ages (GA) were exposed to the greatest number of medications (18.0 below 28 weeks of gestation (WG) to 4.1 above 36 WG) (p<0.0001). In addition, 69.2% of the 351 different combinations of an medication INN and a route of administration have no indication for the first month of life according to the French SmPC. Ninety-five percent of premature infants with GA less than 32 weeks received at least one medication not cited in SmPC.

Conclusion

Neonates remain therapeutic orphans. The consequences of polypharmacy in L3NW should be quickly assessed, especially in the most immature infants.

How to assess hemodynamic status in very preterm newborns in the first week of life?

BACKGROUND

Assessing hemodynamic status in preterm newborns is an essential task, as many studies have shown increased morbidity when hemodynamic parameters are abnormal. Although oscillometric monitoring of arterial blood pressure (BP) is widely used due to its simplicity and lack of side effects, these values are not always correlated with microcirculation and oxygen delivery.

OBJECTIVES

This review focuses on different tools for the assessment of hemodynamic status in preterm newborns. These include the measurement of clinical (BP, capillary refill time and urinary output (UO)) or biological parameters (lactate analysis), functional echocardiography, and near-infrared spectroscopy (NIRS). We describe the concepts and techniques involved in these tools in detail, and examine the interest and limitations of each type of assessment.

CONCLUSIONS

This review highlights the complementarities between the different parameters used to assess hemodynamic status in preterm newborns during the first week of life. The analysis of arterial BP measured by oscillometric monitoring must take into account other clinical data, in particular capillary refill time and UO, and biological data such as lactate levels. Echocardiography improves noninvasive hemodynamic management in newborns but requires specific training. In contrast, NIRS may be useful in monitoring the clinical course of infants at risk of, or presenting with, hypotension. It holds the potential for early and noninvasive identification of silent hypoperfusion in critically ill preterm infants. However, more data are needed to confirm the usefulness of this promising tool in significantly changing the outcome of these infants.

Abstract P3-05-07: Poor prognosis early breast cancer: pathological characteristics of the Unicancer-PACS08 trial including patients treated with docetaxel or ixabepilone in adjuvant setting

Background: The PACS08 trial aimed to compare adjuvant FEC100-Docetaxel regimen to FEC100-Ixabepilone (Ixa) in poor prognosis early breast cancer (BC). The study population included BC patients presenting with triple-negative (TN) [i.e. estrogen receptor (ER)−/progesterone receptor (PR)−/HER2−] or ER+/PR−/HER2− tumor, which are subgroups significantly associated with worse prognosis. Central review was performed and detailed pathological characteristics of the cohort are reported herein.

Patients and method: Between 2007 and 2010, 762 patients with unilateral TNBC (n = 592, 78%) or ER+/PR−/HER2− BC (n = 170, 22%) were enrolled. Recruitment was interrupted due to BMS decision to stop Ixa development in adjuvant setting. As defined by inclusion criteria, TNBC were either node+ or node-, and ER+/PR−/HER2− BC only node+. Following the validation of ER, PR and HER2 status on whole sections prior to inclusion, paraffin blocks (n = 754) were sent for central pathology review, tissue microarray (TMA) construction and constitution of the trial collection for translational research studies. Review of the cases (n = 754) was performed by a board of expert breast pathologists on a one-week working session with discussion of the difficult cases under a multihead microscope. Tumor characteristics were assessed on whole tissue sections. Immunohistochemical detection of Ki67, EGFR, cytokeratins (CK)5/6 and 14, was performed on TMAs.

Results: TNBC were significantly associated with younger age at diagnosis (median age 51yr vs 57.5yr in the ER+/PR- subgroup, p &lt; 0.001). Most tumors were invasive ductal carcinomas (72%). Distribution of special histological subtypes was significantly different in the TNBC and ER+/PR−/HER2− subgroups, with the former comprising medullary (n = 16/17) and metaplastic (n = 34/34) subtypes while the latter was enriched in invasive lobular carcinomas (n = 27/35, p &lt; 0.0001). TNBC were significantly associated with higher histological grade as compared to ER+/PR−/HER2− subgroup (Table 1). Accordingly, TNBC displayed significantly higher proliferative activity as shown by mitotic count and Ki67 index (p &lt; 0.001). As compared to ER+/PR−/HER2− subgroup, TNBC showed distinct characteristics, and displayed a so-called basal-like phenotype in 80%. Among the ER+/PR−/HER2− subgroup, most tumors were classified as luminal B (64%). Interestingly, the presence of tumor lymphocytic infiltrate was more frequently observed in luminal B (59%) as compared to luminal A (30%) subtype (p &lt; 0.001).

Predictors of recurrence in high-grade cervical lesions and a plan of management

PRÉCIS: Positive endocervical margins are an important predictor of recurrence in high-grade cervical lesions, and though they do not always warrant retreatment, closer surveillance is recommended.

OBJECTIVE

To identify predictors of recurrence and persistence of high-grade cervical dysplasia and to determine appropriate follow-up.

DESIGN

prospective pilot study.

SETTING

Gynaecological surgical center.

POPULATION

Three hundred fifty-two patients were treated between 1999 and 2002 for high-grade lesions.

METHODS

According to the accessibility of the transformation zone and the degree of dysplasia, patients were treated either by conization or by loop electrosurgical excision procedure (LEEP). Follow-up comprised colposcopy and Pap-smear screening 4-6 months after treatment as well as high-risk human papillomavirus (HR-HPV) testing before and after treatment.

MAIN OUTCOME MEASURES

underscore predictors of recurrence and propose a treatment flowchart for both management and follow-up.

RESULTS

Of the 352 patients, 37 (10.5%) had true recurrence 6 months after initial surgical treatment and 6 patients (1.7%) had persistent lesions. Overall, 43 patients (12.2%) were considered as having recurrent disease. Patients were followed up for 5 years with a mean of 73 months. The most important predictor of recurrence was a positive HR-HPV test at 6 months postoperatively (odds ratio 38.8, 95% confidence interval 14.09, 107.05). The second significant predictor was positive endocervical margins and the third was positive pre-treatment HPV typing. A positive post-treatment HPV test had a more significant influence on risk than a positive test before treatment.

CONCLUSION

In agreement with recent findings, our study supports the usefulness of the HR-HPV test in the follow-up of treated high-grade lesions, especially when excision margins were positive.

Fluorescence in situ hybridization (FISH) technique by reference centers for HER2 status determination in metastatic breast cancer: quality assurance results of FISH 2002 study

Abstract #2069

Background: Concordance between IHC and FISH in local and regional centers was evaluated in the FISH 2002 Study. Primary metastatic breast cancer (MBC) tumor samples were tested by IHC for HER2 status according to in-house techniques at 18 regional (n=871) and 81 peripheral (n=670) centers in France between 2002 and 2006. All samples were tested by FISH at regional centers [Penault-Llorca et al. SABCS 2006]. This second part of the study comprises quality assurance evaluation of FISH techniques.&#x2028; Methods: 464 cases were selected according to the protocol and were either re-assessed using archived pictures or retested by 3 reference centers (Clermont-Ferrand, Strasbourg, Paris-Curie). 246 samples were re-assessed and 166 were retested.&#x2028; Results:Global discordance combining re-assessment and retesting results was 10.7% in the first half of the study and 5.1% in the second part (p=0.041).&#x2028; &#x2028; Discussion: Concordance was excellent for negative (100%) and IHC 2+ cases (97%). Among low amplification cases (≥6 and &lt;8 copies), 70% were concordant: discordant cases were mainly interpretation pitfalls of polysomic cases, emphasizing the importance of double-stained FISH analyses. These quality assurance results demonstrate that overall concordance and quality of HER2 status determined by FISH has improved significantly over time. This improvement is likely to be related to introduction of rigorous quality control procedures, training, and education, all of which should be continued.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2069.

Persistent and moderate hypercalcemia related to an ovarian clear cell adenocarcinoma: Pre- and postoperative parathyroid hormone related-peptide and 1,25-dihydroxyvitamin D3 levels

OBJECTIVE

To evaluate the role of PTH-related peptide (PTH-rP) and 1,25-dihyhydroxyvitamin D3 in a case of hypercalcemia related to an ovarian adenocarcinoma.

DESIGN

We report a case of humoral hypercalcemia in a patient aged 74 yr with a clear cell adenocarcinoma of the right ovary at an early stage of its development (stage T1aN0M0) revealed by moderate and persistent hypercalcemia (variable level between 2.7 and 3.2 mmol/l without any treatment) over six months.

METHODS

PTH-rP and 1,25-dihydroxyvitamin D3 were measured in blood samples taken before and after hysterectomy and bilateral salpingooophorectomy and in blood samples taken intraoperatively from the right ovarian vein and a peripheral vein.

RESULTS

High levels of plasma PTH-rP and 1,25-dihydroxyvitamin D3 concomitant with high serum calcium and low PTH levels were found before surgery, which was followed by normalisation of all parameters studied. A concentration gradient was found regarding plasma PTHrP (right ovarian vein 60.4 pmol/l, peripheral vein 4.5 pmol/l), not 1,25-dihydroxyvitamin D3.

CONCLUSION

1) moderate and persistent hypercalcemia can be observed at an early stage of an ovarian carcinoma; 2) the gradient of PTH-rP concentration between the samples taken from the right ovarian vein and a peripheral vein provides evidence for a direct secretion of PTH-rP by the ovarian tumor; 3) the increased 1,25-dihydroxyvitamin D3 level is not related to a direct ovarian production, but is a consequence of PTH-rP secretion.

Pubourethral ligaments in women: anatomical and clinical aspects

The anatomy and histological structure of the proximal (PPUL), distal (DPUL) and intermediate (IPUL) pubourethral ligaments in women was examined to improve the understanding of their roles in female urethral physiology. An anatomical study of the pelvis was carried out in 10 adult female cadavers (60-102 years), the pelvis being removed and frozen prior to dissection. The pubourethral ligaments (PUL) were dissected in sagittal sections in seven specimens and in a frontal section in one specimen; the remaining two pelves were dissected using a hypogastric approach. The location, insertion, direction and histological structure of the ligamentous structures were studied. The PUL were identified in all 10 dissections, being paired, symmetrical, pearly-white, fibrous and resistant to stretching. The bony (parietal) insertion was variable on the posterior surface of the pubis, while the visceral insertion was located on the dorsal aspect of the proximal third of the urethra and neck of the bladder for the PPUL and on the distal third of the urethra for the DPUL. Histologically, the ligaments were composed of dense collagen fibres and bundles of axially orientated smooth muscle fibres. The PPUL was closely associated with the sphincter urogenitalis muscle, whereas the DPUL appeared to reinforce the role of the compressor urethra. It is suggested that the PUL plays an effective role in passive and active suspension of the urethra. The pubourethral ligaments are a constant anatomical entity which should be spared in urethral surgery in women in order to ensure an intact urogenital sphincter.

[Local staging of prostate carcinoma with phased array MR imaging: prospective study over 5 years]

PURPOSE

To assess by MRI, using a pelvic phased array coil, the accuracy for staging prostate carcinoma and to correlate the results with the rate of positive surgical margins.

MATERIALS AND METHODS

Between January 1995 and December 1999, 176 patients with localized prostate carcinoma underwent a preoperative MRI examination using a pelvic phased-array coil (1 Tesla). MRI and histological results were compared in a prospective study.

RESULTS

131 were classified T2 and 45 were classified T3 at MRI. Pathologic findings showed 103 pT2 and 73 pT3. The accuracy of MRI (extra capsular or vesicle extension) was 75%. The risk for a patient labelled T2 or T3 at MRI to have a positive surgical margin was respectively 13.7% and 31%.

CONCLUSION

This study shows that the phased-array coil has a low sensitivity but a good specificity to distinguish between organ-confined cancer or not. It shows that the risk of positive surgical margins is higher for T3 lesions at MRI. The low sensitivity should be improved by using a multi coil phased array.

Impact of a modified apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins: a comparative study in 212 patients

OBJECTIVES

To assess the impact of a modified technique of apical dissection during radical retropubic prostatectomy on the occurrence of positive surgical margins (PSMs).

METHODS

Between 1992 and 1998, 212 nonconsecutive patients with localized prostate cancer (57 T1, 155 T2) underwent radical retropubic prostatectomy and were divided into two groups: group 1, 85 patients who underwent surgery before January 1994; and group 2, 127 patients who underwent surgery with the modification of the apical dissection after January 1994. The modified technique consisted of a wide excision of periprostatic soft tissue at the apex, including the bilateral neurovascular bundles. The clinical data (age, prostate-specific antigen, clinical staging) and pathologic findings (pathologic staging, Gleason score, PSM rate) of the two groups were compared.

RESULTS

No significant difference was found between the two groups regarding the median prostate-specific antigen level (10.8 ng/mL and 9.5 ng/mL), Gleason score, and pathologic staging. Overall, the PSM rate was 53% in group 1 and 20.5% in group 2 (P <0.001). The number of PSMs decreased 2.6-fold in group 2. The PSM rate was significantly reduced at the apex with the new technique (group 1, 33.3%; group 2, 7.7%; P = 0.008). The PSM rate expressed with the odds ratio was 4.4-fold lower for patients in group 2 than for those in group 1.

CONCLUSIONS

The modified apical dissection in radical retropubic prostatectomy significantly improves the PSM rate in patients with localized T1-T2 prostate cancer.

Assessment of the risk of positive surgical margins with pelvic phased-array magnetic resonance imaging in patients with clinically localized prostate cancer: a prospective study

OBJECTIVES

We assessed magnetic resonance imaging (MRI) performance in the prediction of positive surgical margins (PSMs) before radical prostatectomy in a prospective study correlating the MRI results and pathologic findings.

METHODS

Between January 1995 and December 1999, 176 patients (mean age 64.2 years, range 49 to 75), with localized prostate cancer (49 with Stage T1 and 127 with Stage T2) underwent preoperative MRI with a pelvic phased-array coil (Tesla-1, Siemens) at a mean interval of 35 days after randomized transrectal biopsies. The mean preoperative prostate-specific antigen level was 10.9 ng/mL (range 1.2 to 39). The MRI studies and specimen analysis were performed by one radiologist unaware of the clinical and biopsy findings and by one pathologist, respectively. Multivariate analysis was performed to compare the predictive value of MRI staging, prostate-specific antigen value, and preoperative Gleason score to identify the PSM rate.

RESULTS

Of the 176 patients, 131 (74%) had Stage T2 disease by MRI and 45 (26%) Stage T3 disease by MRI. Pathologic staging showed 103 with pT2 and 73 with pT3. Overall, the PSM rate of the series was 18%. The PSM rate was 13.7% and 31% for patients with T2 and T3 disease by MRI, respectively. For the T3 MRI cases, the PSM rate was 2.32-fold higher. MRI staging, like the prostate-specific antigen value, was a predictive factor of PSMs (P = 0.05).

CONCLUSIONS

The results of this study show that preoperative MRI staging with the phased-array coil may be helpful in predicting the PSM risk in radical prostatectomy candidates with clinically localized prostate cancer.

[Leiomyosarcoma of the renal vein]

The authors report a new case of leiomyosarcoma of the right renal vein, marked by a rapidly fatal course within 9 months, despite the initial absence of metastasis. This exceptional vascular tumour (only about thirty cases have been published) must be distinguished from primary renal leiomyosarcoma and retroperitoneal leiomyosarcomas involving adjacent structures. This difficult diagnosis was suggested by preoperative CT and angiography. Leiomyosarcomas of the renal vein generally have an unfavourable outcome in the medium term. The prognosis is related to the localized nature of the tumour and the risk of local and distant recurrence. Limited tumour resection is rarely sufficient and radical nephrectomy is usually necessary, possibly associated with a vascular procedure on the inferior vena cava in the case of contiguous extension.

[Primary carcinoid tumor and horseshoe kidney: potential association]

The authors present the ninth case of primary carcinoid tumour arising in a horseshoe kidney. The diagnosis and treatment were delayed due to the benign cystic appearance of the initial lesion. This exceptional association must be kept in mind, as horseshoe kidney is associated with an increased risk of malignant tumours, especially for carcinoid tumours. The minimally aggressive nature of these tumours generally allows limited surgical resection.

Retroperitoneal laparoscopic adrenalectomy: clinical experience in 52 procedures

OBJECTIVES

Laparoscopic adrenalectomy has become an effective option for removal of small adrenal tumors. The aim of this prospective study was to evaluate the retroperitoneal approach with regard to intraoperative complications, morbidity, and length of hospital stay.

METHODS

Between September 1996 and October 1999, we performed 52 laparoscopic adrenalectomies (31 left, 21 right) for benign lesions by a retroperitoneal approach in 44 patients (27 women, 17 men) with a mean age of 46.9 years (range 17 to 74). The average adrenal tumor size was 32 mm (range 10 to 63). All procedures required four trocars and a mean operative time of 135 minutes (range 75 to 240).

RESULTS

There was no mortality, conversion rate to open surgery was 1.9%, and estimated blood loss was 80 mL (range 30 to 200). With a mean follow-up of 16 months, morbidity was 17.2%, which included intraoperative complications (5. 7%) with two vascular injuries, and postoperative complications (11. 5%) with wound infections, deep hematoma, and parietal dehiscence. Average length of hospital stay was 5 days with a mean analgesic consumption of 2 days (range 1 to 5).

CONCLUSIONS

The retroperitoneal approach in laparoscopic adrenalectomy appears to be a minimally invasive and safe therapeutic option that may become the standard for unilateral or bilateral adrenal tumors not larger than 7 cm. However, a learning curve in laparoscopy is indispensable before starting this type of procedure.

[Large-cell calcifying Sertoli cell tumors: apropos of a case and review of the literature]

The authors report the case of a 22-year-old man presenting with a tumour of the lower pole of the left testis, present for 4 months, which proved to be a calcified Sertoli large cell tumour, an extremely rare group of sex cord tumours of the testis presenting specific clinical and histological features. These tumours are usually benign, occur during the first two decades of life and can be associated with dysplastic complexes or endocrinopathies (Carney's complex, Peutz-Jeghers syndrome). They present either in the form of bilateral, multifocal tumours in the context of a pathological association, or in the unilateral form, without association. Several malignant forms with metastases have been described. Conventional treatment is transinguinal radical orchidectomy.

Imaging features of uncommon adrenal masses with histopathologic correlation

Uncommon adrenal masses include cystic lesions (hydatid cyst, endothelial cyst), solid lesions (hemangioma, ganglioneuroma, angiosarcoma, primary malignant melanoma), and solid fatty lesions (myelolipoma, collision tumor). Most of these lesions do not have specific imaging features. The liquid content of adrenal cysts is clearly demonstrated on ultrasonographic scans, computed tomographic scans, and magnetic resonance images. Nevertheless, the histologic type cannot be predicted except at some stages of hydatid disease in which pathognomonic features are present. The most typical imaging features of hemangioma are phleboliths and enhancement of peripheral vascular lakes. Ganglioneuroma has nonspecific radiologic features, but this diagnosis should be considered in cases with early enhancement of fine septa and progressive filling. The radiologic features of angiosarcoma and primary malignant melanoma are nonspecific. A macroscopic lipid content within an adrenal mass is theoretically characteristic of myelolipoma. This diagnosis should be made with caution, especially when the lipid content is not predominant, because of the possible association with an adenoma.

[Value of free PSA/total PSA ratio in therapeutic decisions in the case of a single positive biopsy of the prostate]

OBJECTIVES

Study of the value of the free PSA/total PSA ratio in the therapeutic decision concerning prostatic adenocarcinoma, in the case of a single positive biopsy.

MATERIAL AND METHODS

The free PSA/total PAS ratio was calculated on serum samples derived from 37 patients with clinically localized prostatic carcinoma and only one positive biopsy, in whom radical prostatectomy was performed.

RESULTS

The free PSA/total PSA ratio appeared to be independent of pathological stage and histological prognostic criteria (grade and score, degree of capsular effraction).

CONCLUSION

In the case of a single positive biopsy, calculation of the free PSA/total PSA ratio does not appear to provide any decisional criteria in favour of radical prostatectomy.

[The use of MRI with a pelvic phased array antenna in the evaluation of the gland and tumor volume of clinically localized prostatic adenocarcinoma]

Prostate cancer is clinically understaged in 50% of cases. It was improved with the use of random biopsies, PSA analysis (balanced and unbalanced) and Gleason grade on biopsies. Traditional imaging techniques such as endorectal ultrasonography and CT Scan are known to be of no interest. MRI is a non-evasive technique which allows the three dimensional study of an organ with a high quality of tissue contrast. Moreover, the positioning of surface antennae or "phased array" allowed improvement in spatial resolution.

OBJECTIVE

To determine whether MRI allows an accurate staging of clinically localised adenocarcinoma by the direct estimation of capsular effraction, measure of glandular and tumor volumes and finally by obtaining reliable PSAd.

MATERIAL AND METHODS

A prospective study was done from March 1995 to November 1996 on 55 patients with a clinically localised adenocarcinoma. MRI 1 Tesla Imager (SIEMENS), pelvic phased array antennae. FSE sequences (T1 and T2), axial and frontal. Evaluation of volumes by on-screen. Standford protocol for histo-pathologic reading on the axial cuts. Direct planimetry on a millimetre paper.

RESULTS

Reliable estimation of glandular volume (average difference 0.7 cc). Sub-evaluation of tumoral volume (average difference 1.04 cc) with a 30% margin of error, accuracy 87%. Tumoral stage exact in almost 90% of the cases with a PPV of 94%.

CONCLUSION

Prostatic MRI, using surface antennae, allows to complete the conventional stage by stage development by correctly diagnosing 75% of locally evolved stages. Its limits are linked to the nature of the signal of the tumorous tissue as to the localisation of neoplasic lesions.

[Renal oncocytoma. Report of 13 cases]

We report 13 cases of renal oncocytoma. Urinary symptoms occurred in only 3 cases. The patient's age ranged from 41 to 74 years with an average of 62.3 years. The mean tumor diameter was 5.6 cm (range: 1.5-14). Diagnostic features of ultrasonography, CT scan and, in some instances, angiography were suggestive of renal oncocytoma in 2 patients, but never affirmative, 4 patients were treated by partial nephrectomy. No local or metastatic recurrence was observed with a mean follow-up of 30.8 months, ranging from 6 to 96 months. We assume that the term renal oncocytoma should be restricted to tumors exclusively composed of regular oncocytic cells with an eosinophilic granular mitochondria-rich cytoplasm and an absence of malignant potential. Diagnostic imaging characteristics may sometimes suggest the diagnosis of renal oncocytoma, but cannot eliminate the main differential diagnosis, i.e. granular renal cell adenocarcinoma. When the tumor is small and unifocal, nephron sparing surgery may be considered. Whether or not the diagnosis has been confirmed by fine needle aspiration, conservative surgery must be controlled by intraoperative frozen sections of the tumor and surgical margins.

Micrometastatic adrenal invasion by renal carcinoma in patients undergoing nephrectomy

OBJECTIVE

To examine adrenal invasion by renal cell carcinoma (RCC), particularly by adrenal micrometastasis, to determine whether adrenalectomy should be performed during radical nephrectomy.

PATIENTS AND METHODS

From 1987 to 1994, 129 patients with RCC (90 men and 39 women, mean age 61.4 years, range 22-81) underwent radical nephrectomy with associated adrenalectomy because they had risk factors for adrenal invasion (tumour size > 5 cm. or tumour of the superior pole). Pathological examinations were carried out systematically and records of these examinations reviewed. The tumour size was recorded and the frequency of invasion calculated.

RESULTS

There were 10 cases where the gland was invaded: one was a synchronous contralateral metastasis and nine (7%) were ipsilateral invasions of which two were tumours in the superior pole that invaded the gland by direct extension and the other seven invaded the gland by distant metastasis, six being micrometastatic (4.7%). A single micrometastasis was found in two cases (1.5%). There was no adrenal invasion by tumours of < 5 cm in diameter from the superior pole. When only tumours > 5 cm in diameter were considered, the ipsilateral invasion rate was 11% (9/80) and the micrometastatic rate was 7.5% (6/80).

CONCLUSION

Adrenalectomy need not be performed routinely in small tumours which are detected early, but the possibility of adrenal micrometastasis from larger tumours (> 5 cm) should be considered.

Renal oncocytoma in transplant patients: report of 2 cases

We report on 2 cases of renal oncocytoma occurring in a liver transplant patient and in a kidney allograft recipient, respectively, during the posttransplant period. This neoplasm has never been reported in transplant patients; its relationship with long-term immunosuppressive therapy is questioned.

[Primary bladder signet ring cell adenocarcinoma. Apropos of 1 case. Review of the literature]

The authors report a new case of signet ring cell carcinoma of bladder whose characteristic findings are the parietal infiltration and the rapidly fatal course. Based on a review of the literature, they define the histological features of this very rare tumour (less than 20 documented cases have been reported). The pluripotent behaviour of urothelial cells appears to be the essential element in the histogenesis of this tumour type, which is very similar to gastric linitis plastica.

Evolution of untreated mild rejection in heart transplant recipients

To elucidate whether mild rejection requires treatment, we retrospectively examined the spontaneous natural history of this histologic feature without an increase of immunosuppression. During a 4-year period, 55 heart transplantations were performed in 54 patients on whom 958 endomyocardial biopsies were performed. Among these biopsies, 162 specimens showed features of mild rejection. We studied the results of subsequent biopsies performed 7 to 10 days later, without any change in immunosuppression. These revealed regression of lesions to minimal rejection in 51 cases (31%), the same histologic feature in 82 cases (51%), or progression to moderate or severe rejection in 29 cases (18%). In 82% of these cases, therefore, no aggravation of histologic feature was observed. We separated the cases in which current-study biopsies showed mild rejection into three groups according to the result of the most recent biopsy, that is, minimal, mild, or moderate-severe rejection. The percentage of good outcome was not modified by the nature of the previous biopsy specimen: 84%, if minimal rejection was preceding the study biopsy; 82%, in the cases of mild rejection; and 77%, for moderate or severe rejection. We did not find significant differences in this evolution between patients with fewer or more than two moderate or severe acute rejections in the first 4-month period after heart transplantation (respectively, 15% or 24% progression to moderate or severe acute rejection after nontreated mild rejection).(ABSTRACT TRUNCATED AT 250 WORDS)

Phenotyping of 76 human bladder tumors with a panel of monoclonal antibodies: correlation between pathology, surface immunofluorescence and DNA content

Phenotyping of 76 bladder tumors (11 grade I, 33 grade II and 32 grade III) has been carried out by flow cytometry on cell suspensions with simultaneous determination of DNA content and surface immunofluorescence using G4 and 5 new monoclonal antibodies (10D1, 7C12, 6D1, 3C6 and 12F6) directed against bladder tumor cells. Ten normal bladder samples were used as control. Antibodies 6D1 and 12F6 were specific for tumor cells whereas the others also labelled umbrella cells. Cells from grade I tumors were labelled with 10D1, 6D1, 7C12 and 12F6 antibodies, and cells of grade II tumors with 7C12 and to a lesser degree with 12F6 but not with 10D1 and 6D1. Grade III tumor cells were specifically labelled with antibodies 3C6 and G4. Reactivity of antibodies with tissue sections was well correlated with cytometry results, except for the antibody 3C6. Finally, most of the cells stained by 3C6 and G4 were shown to have a DNA index greater than 1.0. In conclusion cells of low grade tumors can be identified with 10D1 and 6D1 antibodies, and antigens recognized by 3C6 and G4 antibodies are mostly expressed by aneuploid cells.

A monoclonal antibody (BL2-10D1) reacting with a bladder-cancer-associated antigen

A hybridoma cell line secreting an IgM monoclonal antibody (MAb) was produced after immunizing a mouse with RT4 cells and a crude suspension of human bladder carcinoma cells (WHO grades II and III TCC). This MAb reacted with RT4 target cells derived from a human transitional bladder cancer but failed to react with a majority of non-bladder cancer cell lines. Immunohistological studies indicate that this MAb reacts inconstantly with normal bladder: in positive cases only a few superficial cells (5% to 10% umbrella cells) are stained but not intermediate or basal cells of the urothelium. This MAb was evaluated on 118 tumors: it reacted with tumor tissue in a majority of grade I (79.5%) and grade II papillary TCC (77.3%), less with grade III papillary TCC (45%) and very rarely with invasive non-papillary TCC (14%). In cases of flat lesions a strong reactivity of superficial, intermediate and/or basal layer cells was observed in 50% of moderate and severe dysplasia and in all cell layers of carcinomas in situ (CIS)(9/9).

[Bilateral ureteral metastases, a 1st symptom of gastric cancer. Gastrectomy. Bilateral ureteral replacement]

Renal colic in a young adult led to the discovery of very extensive bilateral ureteral stenosis. Exploration and biopsy showed metastatic lesions of an asymptomatic gastric cancer. Gastrectomy and subtotal bilateral ureteral replacement by prosthesis gave excellent short term results.

Hypothesis on microangiopathy of cutaneous capillaries

Microangiopathy is a more or less pronounced PAS deposit-located exterior to the endothelial cells of the lymphatics and the basal membrane of the capillaries. This lesion, found in various normal and pathological states, has generated numerous pathogenic hypotheses. The presence of microangiopathy in 5 groups of 50 subjects representing five different clinical conditions, subjects over 60 years old or less than 40, diabetics, latent diabetics or patients with severe coronary heart disease, together with microscopic and/or ultrastructural lesions of the connective tissue (fibroblasts, collagen and elastic fibers, ground substance) has enabled us to propose a pathogenic hypothesis applicable to any microangiopathy. The initial change, hereditary or acquired, would be fibroblastic or interstitial. It would be characterized by the accumulation of glycoproteins, proteoglyacans and soluble collagen in the interstitium. Incomplete drainage of these macromolecules would occur around the blood and lymphatic capillaries and manifest itself by a PAS deposit, the hallmark of the microangiopathy.