Improved nationwide survival of sarcoma patients with a network of reference centers

BACKGROUND

We investigated the impact of the implementation of a network of reference centers for sarcomas (NETSARC) on the care and survival of sarcoma patients in France since 2010.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor boards (MDTBs), funded by the French National Cancer Institute (INCa) since 2010. Its aims are to improve the quality of diagnosis and care of sarcoma patients. Patients' characteristics, treatments, and outcomes are collected in a nationwide database. The objective of this analysis was to compare the survival of patients in three periods: 2010-2012 (non-exhaustive), 2013-2015, and 2016-2020.

RESULTS

A total of 43 975 patients with sarcomas, gastrointestinal stromal tumors (GISTs), or connective tissue tumors of intermediate malignancy were included in the NETSARC+ database since 2010 (n = 9266 before 2013, n = 12 274 between 2013 and 2015, n = 22 435 in 2016-2020). Median age was 56 years, 50.5% were women, and 13.2% had metastasis at diagnosis. Overall survival was significantly superior in the period 2016-2020 versus 2013-2015 versus 2010-2012 for the entire population, for patients >18 years of age, and for both metastatic and non-metastatic patients in univariate and multivariate analyses (P < 0.0001). Over the three periods, we observed a significantly improved compliance to clinical practice guidelines (CPGs) nationwide: the proportion of patients biopsied before surgery increased from 62.9% to 72.6%; the percentage of patients presented to NETSARC MDTBs before first surgery increased from 31.7% to 44.4% (P < 0.0001). The proportion of patients with R0 resection on first surgery increased (from 36.1% to 46.6%), while R2 resection rate decreased (from 10.9% to 7.9%), with a better compliance and improvement in NETSARC centers.

CONCLUSIONS

The implementation of the national reference network for sarcoma was associated with an improvement of overall survival and compliance to guidelines nationwide in sarcoma patients. Referral to expert networks for sarcoma patients should be encouraged, though a better compliance to CPGs can still be achieved.

Precision pain management in interventional radiology

Pain is a common manifestation of several benign and malignant conditions. Inadequate response to conservative therapies is often succeeded by incremental use of analgesics and opioids; however, such an approach is often ineffective, not well tolerated by patients, and carries the risk of addiction leading to the opioid crisis. Implementing minimally invasive percutaneous procedures, performed by interventional radiologists has proven to be successful in providing safe, effective, and patient-specific therapies across a wide range of painful conditions. In the present narrative review, we will review the repertoire of minimally invasive imaging guided interventions, which have been successfully used to treat common painful benign and malignant conditions. We briefly describe each technique, common indications, and expected results.

A propensity score-weighted study comparing a two- versus four-weekly pegylated liposomal doxorubicin regimen in metastatic breast cancer

PURPOSE

A 4-weekly schedule of pegylated liposomal doxorubicin (PLD) has been approved for the treatment of metastatic breast cancer (MBC). Phase II trials have suggested interest in a 2-weekly regimen. This study aimed to compare the efficacy and safety of these two schedules.

METHODS

Data from MBC patients treated with PLD between 2011 and 2021 were retrospectively collected. The objective was to demonstrate the noninferiority of the 2-weekly versus the 4-weekly schedule in terms of 6-month progression-free survival (PFS). The prespecified noninferiority margin was calculated as 1.20. A propensity score to receive either schedule was estimated using a gradient boosting algorithm. Survival analyses using Cox regression models weighted by the propensity score were performed to compare the schedules.

RESULTS

Among the 192 patients included, 96 (50%) underwent each schedule. The median number of previous systemic therapies was 4 (IQR, 3 to 6). Anthracyclines were previously given in early breast cancer in 63.9% of patients. The median follow-up was 10.0 months (IQR, 5.0 to 20.1). A comparable distribution of adverse events was observed. The median PFS was 3.2 months (95% CI, 2.9 to 3.9), and the median overall survival was 12.1 months (95% CI, 10.8 to 14.9). The weighted hazard ratio for PFS was 1.12 (90% CI, 0.82 to 1.54), including the noninferiority boundaries.

CONCLUSION

PLD appeared to be a well-tolerated drug in this heavily pretreated MBC population. The efficacy and safety of the 2-weekly schedule did not provide any advantage, suggesting no interest in changing the registered regimen.

Prise en charge médicale de la récidive du cancer épithélial de l'ovaire: Medical management of recurrent epithelial ovarian cancer

The panel of therapeutic options available for medical treatment of relapsed ovarian cancer increased over the last years. In late, platinum-sensitive relapse, standard treatment remains platinum-based polychemotherapy. The choice between bevacizumab added to chemotherapy followed by maintenance and inhibitors of poly-(ADP-riboses) polymerases (PARPi) after response to platinum-based therapy should be discussed, taking into account prior treatment, contraindications, and disease characteristics (biology, symptoms…). The addition of bevacizumab at first platinum-sensitive relapse can be considered if it has not been administered in first line, and it is optional (rechallenge) if previously administered (but without Marketing Authorization in this setting). PARPi are indicated for maintenance therapy after response to platinum-based chemotherapy (whatever the treatment line), regardless of BRCA mutational status, in case of no prior administration. Early relapses are associated with poor prognosis and therapeutic options are more limited. They are treated by monochemotherapy without platinum agents, associated with bevacizumab if not administered previously. Beyond first early relapse, there is no standard and inclusion in a clinical trial should be proposed if possible. Several clinical studies assessing associations of immunotherapy and chemotherapy and/or antiangiogenic drugs and/or targeted therapies (such as PARPi) are ongoing in early or late relapse.

Expression III: patients' expectations and preferences regarding physician-patient relationship and clinical management-results of the international NOGGO/ENGOT-ov4-GCIG study in 1830 ovarian cancer patients from European countries

Backround

The primary aim of this study was to investigate information needs and treatment preferences of patients with ovarian cancer, focusing especially on physician-patient relationship and treatment.

Patients and methods

A questionnaire was developed based on the experiences of the national German survey 'Expression II', and was provided to patients with ovarian cancer either at initial diagnosis or with recurrent disease via Internet (online-version) or as print-out-version.

Results

From December 2009 to October 2012, a total of 1830 patients with ovarian cancer from eight European countries (Austria, Belgium, France, Germany, Italy, Poland, Romania, Spain) participated, 902 (49.3%) after initial diagnosis and 731 (39.9%) with recurrent ovarian cancer. The median age was 58 years (range 17-89). Nearly all patients (96.2%) had experienced upfront surgery followed by first-line chemotherapy (91.8%). The majority of patients were satisfied with the completeness and comprehensibility of the explanation about the diagnosis and treatment options. The three most important aspects, identified by patients to improve the treatment for ovarian cancer included: 'the therapy should not induce alopecia' (42%), 'there must be more done to counter fatigue' (34.5%) and 'the therapy should be more effective' (29.7%). Out of 659 (36%) patients, who were offered participation in a clinical trial, 476 (26%) were included.

Conclusion

This study underlines the high need of patients with ovarian cancer for all details concerning treatment options irrespective of their cultural background, the stage of disease and the patient's age. Increased information requirements regarding potential side effects and treatment alternatives were recorded. Besides the need for more effective therapy, alopecia and fatigue are the most important side effects of concern to patients.

Successful treatment of primary cutaneous angiosarcoma of the nose with sequential chemo- and radiotherapy

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The optimal treatment of primary cutaneous angiosarcoma is considered to be surgical exision.

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Concurrent chemo-radiotherapy is efficient in the treatment of primary cutaneous angiosarcoma.

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The toxicity profile of this association is acceptable.

Long-term fatigue and quality of life among epithelial ovarian cancer survivors: a GINECO case/control VIVROVAIRE I study

BACKGROUND

Few data are available on long-term fatigue (LTF) and quality of life (QoL) among epithelial ovarian cancer survivors (EOCS). In this case-control study, we compared LTF, symptoms and several QoL domains in EOCS relapse-free ≥3 years after first-line treatment and age-matched healthy women.

PATIENTS AND METHODS

EOCS were recruited from 25 cooperative GINECO centers in France. Controls were randomly selected from the electoral rolls. All participants completed validated self-reported questionnaires: fatigue (FACIT-F), QoL (FACT-G/O), neurotoxicity (FACT-Ntx), anxiety/depression (HADS), sleep disturbance (ISI), and physical activity (IPAQ). Severe LTF (SLTF) was defined as a FACIT-F score <37/52. Univariate and multivariate logistic regressions were conducted to analyze SLTF and its influencing factors in EOCS.

RESULTS

A total of 318 EOCS and 318 controls were included. EOCS were 63-year-old on average, with FIGO stage I/II (50%), III/IV (48%); 99% had received platinum and taxane chemotherapy, with an average 6-year follow-up. There were no differences between the two groups in socio-demographic characteristics and global QoL. EOCS had poorer FACIT-F scores (40 versus 45, P < 0.0001), lower functional well-being scores (18 versus 20, P = 0.0002), poorer FACT-O scores (31 versus 34 P < 0.0001), and poorer FACT-Ntx scores (35 versus 39, P < 0.0001). They also reported more SLTF (26% versus 13%, P = 0.0004), poorer sleep quality (63% versus 47%, P = 0.0003), and more depression (22% versus 13%, P = 0.01). Fewer than 20% of EOCS and controls exercised regularly. In multivariate analyses, EOCS with high levels of depression, neurotoxicity, and sleep disturbance had an increased risk of developing SLTF (P < 0.01).

CONCLUSION

Compared with controls, EOCS presented similar QoL but persistent LTF, EOC-related symptoms, neurotoxicity, depression, and sleep disturbance. Depression, neuropathy, and sleep disturbance are the main conditions associated with severe LTF.

Vectorized gene therapy of liver tumors: proof-of-concept of TG4023 (MVA-FCU1) in combination with flucytosine

Background

TG4023 is a modified vaccinia virus Ankara (MVA) containing the yeast-originated transgene FCU1, expressing cytosine deaminase and uracil phosphoribosyltransferase enzymes that transform the prodrug flucytosine (5-FC) into cytotoxic 5-fluorouracil (5-FU) and 5-fluorouridine-5′-monophosphate, respectively. This first-in-human study aimed to assess the maximum tolerated dose (MTD) of intratumoral (IT) TG4023 and the safety, feasibility, and proof-of-concept (PoC) of TG4023/5-FC combination to deliver high 5-FU concentrations in tumors.

Patients and Methods

Cancer patients without further therapeutic option and with at least one injectable primary or metastatic liver tumor underwent on day 1 a percutaneous IT injection of TG4023 at doses of 107, 108, or 4.108 plaque forming units (p.f.u.) using ultrasound imaging guidance, after a dose-limiting toxicities (DLTs)-driven 3 + 3 dose-escalating design. On day 2, patients were given intravenous and/or oral 5-FC at a dose of 200 mg/kg/day for 14 days and were followed for safety through day 43. Tumor response was assessed at week 6, according to RECIST. Plasma and tumor 5-FU concentrations were measured to establish the PoC.

Results

In total, 16 patients completed treatment with TG4023 and 5-FC. One DLT/7 patients (ALT/aspartate aminotransferase transient increase) was observed at 4 × 108 p.f.u.; MTD was therefore not reached. The most frequent adverse events were pyrexia, asthenia, vomiting, and decreased appetite. Eight of 16 patients had stable disease. Mean 5-FU concentrations in plasma were 1.9 ± 2.6 ng/ml and 56 ± 30 ng/g in tumors. Seroconversion for anti-FCU1 antibodies was found for one patient from each cohort (16%, overall).

Conclusions

This phase I study demonstrated that IT injections of TG4023 were feasible and well tolerated; MTD was defined as 4 × 108 p.f.u. Therapeutic 5-FU concentrations in tumors established the virus-directed enzyme-prodrug therapy PoC.

Clinicaltrials.gov Number

NCT00978107.

Improved survival using specialized multidisciplinary board in sarcoma patients

BACKGROUND

Sarcomas are rare but aggressive diseases. Specialized multidisciplinary management is not implemented for all patients in most countries. We investigated the impact of a multidisciplinary tumor board (MDTB) presentation before treatment in a nationwide study over 5 years.

PATIENTS AND METHODS

NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized MDTB, funded by the French National Cancer Institute to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB and second pathological review are mandatory for sarcoma patients in France. Patients' characteristics and follow-up are collected in a database regularly monitored and updated. The management and survival of patients presented to these MDTB before versus after initial treatment were analyzed.

RESULTS

Out of the 12 528 patients aged ≥15 years, with a first diagnosis of soft tissue and visceral sarcoma obtained between 1 January 2010 and 31 December 2014, 5281 (42.2%) and 7247 (57.8%) were presented to the MDTB before and after the initiation of treatment, respectively. The former group had generally worse prognostic characteristics. Presentation to a MDTB before treatment was associated with a better compliance to clinical practice guidelines, for example, biopsy before surgery, imaging, quality of initial surgery, and less reoperations (all P < 0.001). Local relapse-free survival and relapse-free survival were significantly better in patients presented to a MDTB before initiation of treatment, both in univariate and multivariate analysis.

CONCLUSION

The compliance to clinical practice guidelines and relapse-free survival of sarcoma patients are significantly better when the initial treatment is guided by a pre-therapeutic specialized MDTB.

Baseline nutritional status is prognostic factor after definitive radiochemotherapy for esophageal cancer

Identify prognostic factors for survival and patterns of treatment failure after definitive radiochemotherapy for esophageal cancer. Between 2003 and 2006, 143 patients with squamous cell carcinoma and adenocarcinoma of the esophagus were retrospectively reviewed. Median age was 65 years (42-81). Median radiation dose was 62.5 Gy (38-72) with 1.8-2 Gy fraction. Median follow-up was 20.8 months (2.8-92.4). Three and 5-year local recurrence-free survival rates were 58.3% and 50.9%. In univariate analysis, traversable esophageal stricture was a prognostic factor. Three, 5-year locoregional recurrence-free survival rates were 42.4% and 34.9%. In multivariate analysis, traversable esophageal stricture and stage < IIB were independent prognostic factors. Three and 5-year disease-free survival rates were 30.5% and 25.9%. In multivariate analysis, Nutritional Risk Index (NRI) ≥ 97.5 and performance status (PS) = 0 were independent prognostic factors. Median, 3, and 5-year overall survival rates were 22.1 months, 34.4%, and 19.8%. In multivariate analysis, independent prognostic factors were NRI ≥ 97.5 and PS = 0. Median survival times for the NRI classes (no denutrition, moderate and severe denutrition) were 29.5, 19.7, and 12 months (P = 0.0004), respectively. A major impact of baseline NRI was found in terms of survival; it should be included in future prospective trials.

Advanced chondrosarcomas: role of chemotherapy and survival

BACKGROUND

There are limited data about the role of chemotherapy in patients with advanced chondrosarcomas.

METHODS

The medical charts of 180 patients with advanced chondrosarcomas having received chemotherapy in 15 participating institutions between 1988 and 2011 were reviewed.

RESULTS

Median age was 52 years. Sixty-three percent of patients had conventional chondrosarcoma and 88% had metastatic disease. Combination chemotherapy was delivered in 98 cases (54.5%). One hundred and thirty-one patients (73%) received an anthracycline-containing regimen. Using RECIST, the objective response rate was significantly different according to histological subtype, being 31% for mesenchymal chondrosarcoma, 20.5% for dedifferentiated chondrosarcoma, 11.5% for conventional chondrosarcoma and 0% for clear-cell chondrosarcoma (P = 0.04). Median progression-free survival (PFS) was 4.7 months [95% confidence interval (CI) 3-6.5]. Performance status (PS) ≥2, number of metastatic sites ≥1 and single-agent regimen were independently associated with poor PFS. Median overall survival (OS) was 18 months (95% CI 14.5-21.6). PS, number of metastatic sites and palliative surgery were independently associated with OS.

CONCLUSIONS

Conventional chemotherapy have very limited efficacy in patients with advanced chondrosarcoma, the highest benefit being observed in mesenchymal and dedifferentiated chondrosarcoma. These data should be used as a reference for response and outcome in the assessment of investigational drugs in advanced chondrosarcoma.

Combined oral topotecan plus carboplatin in relapsed or advanced cervical cancer: a GINECO phase I-II trial

AIM

Combined cisplatin-topotecan therapy is standard care for advanced cervical cancer, however it is associated with haematotoxicity and nephrotoxicity. This trial was designed to assess the combination of carboplatin which is less nephrotoxic, and oral topotecan.

PATIENTS AND METHODS

Patients with advanced/recurrent squamous cervical cancer received carboplatin (AUC5) on day 1, with escalating oral topotecan (3.0 mg/m(2) starting dose) on days 1, 8 and 15, every 4 weeks. Endpoints were the maximal tolerated dose for the phase I part and safety profiles and response rates for the phase II part of the study.

RESULTS

Two dose levels were evaluated. A total of 18 patients (6 phase I, 12 phase II) were treated. The maximal tolerated dose was 3.0 mg/m(2) topotecan with carboplatin AUC5. Phase II accrual was interrupted following unacceptable toxicity, with 10 therapy-related related serious events in 9 out of 12 patients: grade 3-4 pancytopenia (7), febrile neutropenia (1), grade 3 haemorrhage (1) and grade 3 vomiting (1).

CONCLUSION

Weekly oral topotecan combined with carboplatin is associated with unmanageable toxicity and is not recommended. Future studies are warranted to better understand the toxicity of such a combination and explore alternative combinations for advanced cervical cancer.

Phase I study of irinotecan and cisplatin in combination with pelvic radiotherapy in the treatment of locally advanced cervical cancer: A GINECO trial

PURPOSE

To define the recommended dose of the association of weekly irinotecan (Iri) and cisplatin (CP) with pelvic radiotherapy in Locally Advanced Cervical Cancer.

PATIENTS AND METHODS

Stage IB2-IV cervix cancer patients were treated with escalating doses of Iri starting from 30 mg/m(2) and a fixed dose of CP at 20 mg/m(2), both weekly concomitantly with a 45-Gy pelvic irradiation.

RESULTS

Fifteen patients entered the study, 6 at level 1 (Iri 30 mg/m(2)), 3 at level 2 (Iri 40 mg/m(2)) and 6 at intermediate dose (Iri 35 mg/m(2)). Median age was 47 years (34-72), FIGO stage IB (n=1), IIB (n=7), III (n=6), IVA (n=1). The recommended dose was weekly Iri 35 mg/m(2) and CP 20 mg/m(2). Dose limiting toxicities (grades 3-4) were diarrhea, abdominal pain, febrile neutropenia and fatigue.

CONCLUSION

In cervix cancer patients, radiosensitization with weekly cisplatin and irinotecan is feasible, and the recommended doses are cisplatin 20 mg/m(2)/week and irinotecan 35 mg/m(2)/week for future phase II studies.

[Primary myeloid sarcoma of uterine cervix and prevention of fertility. Report of a case]

The isolated myeloid sarcomas of the cervix are tumors whose forecast was dark for a long time. However, an effective but invasive treatment associating chemotherapy and radiotherapy allows for local remission. This treatment generally causes an ovarian failure and especially infertility. We report the case of a 29-year-old woman suffering from a myeloid sarcoma isolated from the uterine cervix and wishing a pregnancy. A prevention of the deficit ovarian was carried out. This patient presented normal menstrual cycles and a biochemical pregnancy three years after the beginning of the treatment.

Phase II trial of pegylated liposomal doxorubicin-cyclophosphamide combination as first-line chemotherapy in older metastatic breast cancer patients

OBJECTIVE

To evaluate the efficacy and toxicity of pegylated liposomal doxorubicin (PLD; Caelyx)-cyclophosphamide combination in older metastatic breast cancer patients.

METHODS

A multicenter phase II trial was conducted. Inclusion criteria were age 65-75 years, ECOG 0-1 and left ventricular ejection fraction > or =50%. First-line chemotherapy was given to metastatic breast cancer patients resistant to hormonal therapy. The treatment schedule was PLD 40 mg/m(2) and cyclophosphamide 500 mg/m(2) on day 1 every 4 weeks. Efficacy was the primary endpoint, while response duration and tolerance were the secondary endpoints.

RESULTS

Thirty-five patients (median age 71.3 years) were enrolled. No treatment-related death, no congestive heart failure or decrease in left ventricular ejection fraction and no febrile neutropenia were reported.

TOXICITY

grade 3 dyspnea was found in 1 patient, neutropenia in 11 patients (7 grade 3, 4 grade 4), grade 3 mucositis in 4 patients, grade 3 hand-foot syndrome in 1 patient and a generalized rash in 1 patient. An objective response (complete and partial response) was achieved in 10 (28.6%) patients and disease control in 24 (69%) with a progression-free survival of 8.8 months and a median overall survival of 20.3 months.

CONCLUSION

The PLD-cyclophosphamide combination is moderately active and safe in elderly metastatic breast cancer patients, but cannot be recommended routinely due to myelotoxicity and mucositis hazards.

[Late outcome of 89 patients with soft-tissue sarcomas treated by surgery and three different radiotherapy schedules]

PURPOSE

To evaluate the outcome of patients treated for soft tissue sarcoma using three different post-operative radiotherapy schedules.

METHODS AND MATERIALS

Between 1990 and 2003, 89 patients (median age 50.8 years) presenting with soft tissue sarcoma (located to the limbs for 66 of them) underwent post-conservative-surgery radiotherapy. Pathology was liposarcoma in 35 cases and 54 others tumors. Tumors grades (FNCLCC classification) were 1, 2, 3 or unknown in 29, 32, 19 and 9 cases, respectively. Surgery was considered as complete in 68 patients. Irradiation was normofractionated (NF) in 62 cases, hyperfractionated (BF) in 19 cases and hypofractionated (HF) in 8 cases. For all the patients, median delivered dose was 61 Gy [34-76 Gy].

RESULTS

Median follow-up of alive patients was 73,8 months [3-184]. Five-year local control (LC) and overall survival (OS) rates were 85.5 and 71.2% respectively. According to multifactorial analysis, favourable prognostic factors were for local control, complete surgery (P=0.0075) and for overall survival, complete surgery (P=0.0267), grade 1 tumor (P=0.012) and absence of distant recurrence (P=0.0488). There was no statistical evidence of difference for the five-year LC and OS rates between the patients who received NF, BF or HF. There were few complications and there were comparable in the three groups.

CONCLUSIONS

This retrospective serie showed similar results for all the schedules. There is no evidence to recommend bifractionation. Hypofractionation should be used only in selected patients with poor performans status.

Liver abscess due to clostridium septicum. A case report and review of the literature

The onset of liver abscess due to Clostridium septicum -an anaerobic gram-positive bacillus- is a rare condition, generally arising in cancer patients. The radiological picture is that of gas-containing pyogenic abscess, that predominates within preexisting liver metastases. We report a case of a 50-year-old patient with metastatic colon cancer who was referred with multiple Clostridium septicum liver abscesses. The patient underwent parenteral antibiotherapy as well as transcutaneous drainage of the largest liver abscess. However the outcome was unfavorable in a clinical picture of liver failure that was likely due to disease progression rather than sepsis. Clostridium septicum liver abscess is a life-threatening condition that occurs in fragile patients, mostly with metastatic cancers. A review of the reported cases is presented and treatment options are discussed.

Nonchemotherapy drug-induced agranulocytosis: experience of the Strasbourg teaching hospital (1985-2000) and review of the literature

Agranulocytosis is a life-threatening disorder that frequently occurs as an adverse reaction to drugs. The overall incidence of nonchemotherapy drug-induced agranulocytosis (DIA) ranges from 2.6 to 10 cases per million patients exposed to drugs per year. Although patients experiencing DIA may initially be asymptomatic, the severity of the neutropenia usually leads to severe sepsis, requiring intravenous broad-spectrum antibiotic therapy. In this setting, old age, septicaemia, shock, and the metabolic complications of infection, such as renal failure, are poor prognostic variables. The severity of neutropenia (< 0.1 x 10(9))/l) and its duration (> 10 days) may also impact negatively on the outcome. With appropriate management using pre-established procedures, the mortality rate is now around 5%. Haematopoietic growth factors have been shown to shorten the duration of neutropenia in DIA. However, it has yet to be determined whether their use translates into a better outcome in DIA patients experiencing sepsis. DIA still remains a rare event. However, given the increased life expectancy and subsequent longer exposure to drugs, as well as the development of new agents, physicians should be aware of this complication and its management.

Use of structured self-report assessment to diagnose borderline personality disorder during major depressive episodes

Diagnosis of borderline personality disorder (BPD) during episodes of major depression (MDE), although clinically important, is complicated in several respects when using self-report methods. Structured interview data were used to select a group of patients with comorbid BPD (n=21) from a sample of outpatients presenting with MDE. This group was compared with a group of MDE patients without BPD (n=24) and with a group of community controls (n=20) using self-report data from the Personality Assessment Inventory (PAI), the revised Personality Diagnostic Questionnaire (PDQ), and the Beck Depression Inventory (BDI). Analyses revealed that the BPD group obtained significantly higher scores on PAI and PDQ scales measuring features of BPD and on the PAI Negative Impression Management scale. The severity and type of MDE symptoms reported on the PAI and BDI did not differentiate the clinical groups. These data show that useful information for the diagnosis of BPD during depressive episodes can be gathered from self-report assessment instruments like the PAI.

Haematopoietic growth factor in antithyroid-drug-induced agranulocytosis

Drug-induced agranulocytosis (DIA) is often caused by antithyroid drugs. We retrospectively studied the use of granulocyte colony-stimulating factor (G-CSF) therapy in antithyroid-DIA. Data for 20 patients (10 treated with G-CSF) with antithyroid-DIA (neutrophil count <0.5x10(9)/l) were extracted from a cohort study of DIA patients (n=110). G-CSF (300 microg/day subcutaneously) was used where the neutrophil count was <0.1x10(9)/l, or the patient was aged >70 years, or there were severe features of infection or underlying disease. Mean patient age was 62 years (range 34-87); sex ratio (M/F) was 0.05. Carbimazole (n=19) and benzylthiouracile (n=1) were the causative drugs, at mean doses of 30 mg/day (range 20-60) and 100 mg/day (range 50-150), respectively, for a mean of 37 days (range 31-90). Antithyroid drugs were prescribed for Graves' disease (n=8), thyrotoxicosis related to amiodarone intake (n=6) and multinodular goitre (n=6). Clinical features included isolated fever (n=7), pneumonia (n=5), septicaemia or septic shock (n=5) and acute tonsillitis (n=3). Mean neutrophil count was 0.07+/-0.1x10(9)/l. No patient died. Mean durations of haematological recovery, antibiotic therapy and hospitalization were significantly reduced with G-CSF: 6.8+/-4 days vs. 11.6+/-5; 7.5+/-3.8 days vs. 12+/-4.5; and 7.3+/-4.8 days vs. 13+/-6.1, respectively (all p<0.05). G-CSF induced flu-like symptoms in 30% of patients, but reduced overall costs.

Oral cobalamin therapy for the treatment of patients with food-cobalamin malabsorption

BACKGROUND

The standard treatment for cobalamin (vitamin B(12)) deficiency involves regular intramuscular cobalamin injection. It has been suggested that oral cobalamin therapy may be effective for treating patients who have food-cobalamin malabsorption.

SUBJECTS AND METHODS

We prospectively studied 10 patients with cobalamin deficiency and well-established food-cobalamin malabsorption who received 3000 microg or 5000 microg of oral crystalline cyanocobalamin once a week for at least 3 months. Complete blood counts and serum cobalamin, homocysteine, and folate levels were determined at baseline and after 3 months of treatment. Patients were reexamined after 6 months.

RESULTS

After 3 months of treatment, all patients had increased hemoglobin levels (mean increase, 1.9 g/dL; 95% confidence interval: 0.9 to 3.9 g/dL;P <0.01 compared with baseline) and decreased erythrocyte cell volume (mean decrease, 7.8 fL; 95% confidence interval: 0.9 to 16.5 fL;P<0.001). However, 2 patients had only minor, if any, responses. Serum cobalamin levels were increased in all 8 patients in whom it was measured.

CONCLUSION

Our findings suggest that moderate doses of crystalline cyanocobalamin given orally may be an effective treatment for food-cobalamin malabsorption.

Pancreatic metastasis of alveolar soft-part sarcoma: a case report and review of the literature

Alveolar soft-part sarcoma is a rare tumour. Patients commonly present with distant metastases both at the time of diagnosis and late in the course of disease. We present a case of pancreatic metastasis, occurring more than six years after diagnosis. Treatment consisted in subtotal pancreatoduodenectomy with pylorus resection. Both specific patterns of relapse and treatment opportunities of this uncommon feature are discussed.

Semantic response consistency and protocol validity in structured personality assessment: the case of the NEO-PI-R

In this study we tested the hypothesis that groups of NEO Personality Inventory-Revised (NEO-PI-R; Costa & McCrae, 1992a) protocols identified as potentially invalid by an inconsistency scale (INC; Schinka, Kinder, & Kremer, 1997) would show reduced reliability and validity according to a series of psychometric tests. Data were obtained from 2 undergraduate student samples, a self-report group (n = 132) who provided NEO-PI-R self-ratings on 2 occasions separated by a 7- to 14-day interval and an informant group (n = 109) who provided ratings of well-known friends or relatives on 2 occasions separated by a 6 month interval. INC scores from the Time 1 protocols were used to divide these samples into low, moderate, and elevated inconsistency groups. In both samples, these 3 groups showed equivalent levels of reliability and validity as measured by: contingency coefficients for the 20 INC item responses across occasions; test-retest intraclass correlations of NEO-PI-R domain scores; convergent correlations with Goldberg's (1992) Bipolar Adjective Scale scores; and discriminant correlations between the 5 NEO-PI-R domain scores. The similarity of results across self-report and informant assessment contexts provides additional evidence that semantic consistency approaches to assessing protocol validity may overestimate the prevalence of random or careless response behavior in standard administration conditions. Several theories are discussed that accommodate the existence of valid inconsistency in structured personality assessment.

Otological manifestations of acute leukaemia: report of two cases and review of literature

Otological manifestations exceptionally reveal acute leukaemia, whereas leukaemic infiltration of any tissue is frequent at postmortem examination. We present two cases of acute myeloblastic leukaemia revealed by a loss of hearing due to a middle-ear leukaemic infiltration. The characteristics of such a clinical and radiological finding are emphasized. It is suggested that middle and inner ear can be a 'sanctuary' localization, which might sometimes require radiation therapy to achieve durable and complete remission.

[Failure of bone marrow autograft in metastatic malignant adrenalcortical carcinoma]

BACKGROUND

Despite different therapeutic modalities (surgery, hormones therapy, chemotherapy), 5-year survival in patients with malignant adrenocortical carcinoma remains only 10% to 20%. Bone marrow grafts may be proposed to intensify treatment.

CASE REPORT

In a 29-year-old patient with adrenocortical carcinoma with metastases to the lung and bone, an adjuvant bone marrow graft using peripheral stem cells was unsuccessful. Recurrence was observed at 3 months and overall survival was 2 years.

DISCUSSION

Our case illustrates the feasibility of this approach but also emphasizes the relatively poor results obtains with only 2 years survival (1 year after the bone marrow graft), comparable with other classical modalities reported in the literature.

Gemcitabine and protracted 5-FU for advanced pancreatic cancer. A phase II study

BACKGROUND/AIMS

Although chemotherapy in advanced pancreatic cancer procures dismal results, both 5-fluorouracil and gemcitabine have shown a modest activity. We report a phase II study of gemcitabine combined with protracted 5-fluorouracil.

METHODOLOGY

Gemcitabine was given at 1000 mg/m2/week intravenously, in combination with concomitant 5-fluorouracil 200 mg/m2/day as a protracted venous infusion, both 3 out of 4 weeks in patients with locally advanced or metastatic pancreatic adenocarcinoma. Twenty-nine patients were enrolled, among whom 27 were metastatic. Response rate, overall and progression-free survival were endpoints, as well as tolerance and clinical benefit.

RESULTS

We observed 3 (10%) partial responses, and 12 (42%) stabilizations within which the median disease control was 5.6 months. The median progression-free and overall survivals were 2.8 and 4 months, respectively. A clinical benefit was observed in 39% of patients. Myelosuppression was the main toxicity, but no grade 4 was observed. Other toxicities were mild.

CONCLUSIONS

This combination chemotherapy was well tolerated in advanced pancreatic cancer patients.

[Do hematopoietic growth factors have a role in the treatment of drug-induced agranulocytosis?]

PURPOSE

Our study was aimed at determining the role of hematopoietic growth factor in drug-induced agranulocytosis.

METHODS

Fifty-five cases of drug-induced agranulocytosis were reviewed and subdivided retrospectively into a G-CSF group (n = 15) and an untreated group (n = 40). Mortality and hematological recovery (number of days required for neutrophil counts to exceed 1.5 x 10(9)/L) were studied in the two groups.

RESULTS

The mean granulocyte count was 0.09 x 10(9)/L. All patients presented infection. In the G-CSF group, no mortality (0% versus 5%, P = 0.85) and a shorter recovery time (8.1 versus 9.5 days P = 0.39) were observed. No significant difference between the two groups was observed in either the duration of antibiotic therapy (9.3 days in the G-CSF group versus 10.1 days in the untreated group, P = 0.51) or duration of hospitalization (10 days in the treated group versus 11 days in the G-CSF group, P = 0.46).

CONCLUSION

Our results as well as a literature review indicate that G-CSF could decrease the time to hematological recovery and perhaps reduce mortality. However, the exact role of hematopoietic growth factors requires further investigations.

[Is there a place for interferon-alpha in the treatment strategy of multicentric Castleman's disease?]

INTRODUCTION

Castleman's disease is an unusual condition of unknown cause, consisting of massive proliferation of lymphoid tissue. Two forms (localized and multicentric) have been described. Interleukin-6 (IL-6) is at the core of the disease, being responsible for most of the clinical and biological signs that may be observed. Despite the benignancy of this pre-lymphoma condition, its course is usually aggressive and of poor prognosis in regard to the multicentric form. No consensus regarding treatment has been defined. Available data on the multicentric form of the disease are to scarce to allow any conclusion about the treatment timing and type of chemotherapy best suited to this condition. We report the case of a patient in whom interferon alpha (IFN-alpha) was used as first line treatment.

EXEGESIS

The case of a 52-year-old man with multicentric Castleman's disease combined with high IL-6, in whom, however, testing for human herpes virus-8 proved to be negative, is described. Interferon alpha (4.5 MU/m2 three times per week during 18 months) administered as first line treatment induced dramatic improvement in the patient's general condition and normalization of the tumoral syndrome. Moreover, biological parameters and IL-6 returned to normal. Two years after interferon disruption, complete remission is still present.

CONCLUSION

On the basis of the present data and those of two previous observations, anti-IL-6 and anti-infective properties of IFN-alpha are discussed. Treatment of multicentric Castleman's disease is based on corticosteroids and drugs derived from those pertaining to treatment of malignant lymphomas. Our results indicate that IFN-alpha is truly directed against Castleman's disease and has less toxicity than drugs usually prescribed. This argues for early use of IFN-alpha in Castleman's disease, in association or not with corticosteroids.

New insights into the pyrimidine salvage pathway of Saccharomyces cerevisiae: requirement of six genes for cytidine metabolism

Cytidine metabolism in the yeast Saccharomyces cerevisiae was analyzed by genetic and biochemical approaches. Disruption of a unique ORF (Genbank accession No. U 20865) bearing homology with eucaryotic or bacterial cytidine deaminases abolished cytidine deaminase activity and resulted in 5-fluorocytidine resistance. The gene encoding cytidine deaminase will be referred to as CDD1 (Genbank accession number AF080089). The ability to isolate mutants resistant to 5-fluorocytidine which mapped to five other loci demonstrated the existence of a complex cytidine metabolic network. Deciphering this network revealed several original features:(1) cytidine entry is mediated by the purine-cytosine transporter (Fcy2p),(2) cytidine is cleaved into cytosine by the uridine nucleosidase (Urh1p),(3) cytidine is phosphorylated into CMP by the uridine kinase (Urk1p),(4) a block in cytosine deaminase (Fcy1p), but not in cytidine deaminase (Cdd1p), constitutes a limiting step in cytidine utilisation as a UMP precursor.

Internal and temporal reliability estimates for informant ratings of personality using the NEO PI-R and IAS. NEO Personality Inventory. Interpersonal Adjective Scales

This study examines the internal consistency and temporal stability of informant ratings from two widely used instruments for normal personality assessment, the revised NEO Personality Inventory (NEO PI-R) and the Interpersonal Adjective Scales (IAS). Well-known adult targets were selected by 109 undergraduate students and rated on two occasions separated by a 6-month interval. With few exceptions, estimates of internal consistency are adequate to good for both instruments. NEO PI-R domain scores yield coefficient alphas ranging from .89 to .96, with a median of .80 for the 30 facet scales. IAS octant scales show coefficient alphas ranging from .83 to .92. Retest Pearson correlations are above .70 for each of the NEO PI-R domain scores and both IAS axis coordinates, and intraclass correlations are above .60 for all scales from both instruments. Score changes were small but statistically significant for three of the five NEO PI-R domains at retest. The retest stability of IAS type classifications varies as a function of the extremity of the associated octant scores.

Combined modality treatment for malignant transformation of a benign ovarian teratoma

Malignant transformation of a mature teratoma is a rare event. Patients often remain free of symptoms until the tumor burden makes the prognosis poor, due to pelvic and peritoneal metastases. We present a case of squamous cell carcinoma arising from a teratoma, with bowel and peritoneal invasion. The patient was treated by radical surgery followed by whole pelvic radiation and chemotherapy. This regimen, usually given for squamous cell tumors, such as cervical cancer, led to a 19-month persistent disease-free survival.

[Renal clear-cell adenocarcinoma and type B lymphomatous proliferation: a fortuitous association?]

PURPOSE

To discuss the potentially fortuitous occurrence of both renal carcinoma and B-cell malignant proliferation and its physiopathology.

METHODS

We describe a series of eight patients presenting with both diseases.

RESULTS

In these patients renal carcinoma was associated with either malignant non-Hodgkin lymphoma (seven cases) or multiple myeloma (one case). Of the eight patients three had both malignancies within the same renal tumor.

CONCLUSION

Though this association is unusual, it may not be fortuitous. Its physiopathology is discussed in regard to either growth factor synthesis within the renal tumor or mutations in tumor-suppressor genes.

[Compassionate use of gemcitabine in advanced pancreatic cancer: a French multicentric study]

Advanced-stage surgically unresectable adenocarcinoma of the pancreas is highly lethal. Attempts to improve this survival with chemotherapy were dismal, until gemcitabin was shown to be clinically beneficial and to modestly improve survival. We started an open multicentric compassionate study of gemcitabine in advanced adenocarcinoma of the pancreas to assess those benefits. Of 74 patients who were enrolled, 46 were assessable for tumoral response (2 partial response, 18 stable disease, 24 progressing disease). A clinical benefit was obtained in 48% of assessable patients. Myelotoxicity, nausea and vomiting were the major side effect. The median event-free and overall survivals from study inclusion were 2. 5 and 5 months respectively. This study confirms that gemcitabine can be effective even in patients with pretreated advanced adenocarcinoma of the pancreas.

Negativism in evaluative judgments of words among depressed outpatients with borderline personality disorder

This study contrasted the frequency of negativistic evaluative judgments to words of various emotional content between two groups of patients with Major Depressive Disorder (MDD) (20 patients with a comorbid diagnosis of Borderline Personality Disorder (BPD) and 20 patients without BPD) and a group of 20 community adult Controls. BPD patients made more "dislike" judgments with neutral words than MDD patients and Controls. The performances of the MDD patients were more similar to the Control group than to the BPD group, despite negligible differences between the two patient groups in the severity of depressive symptoms and overall psychopathology. As a whole, these data indicate that the presence of borderline features in patients with MDD can be an important qualifier in terms of patients attitudinal dispositions.

[Pseudo-acute surgical abdomen and acute leukemia]

The so-called pseudo-acute abdomen has been reported in acute leukemia, both at diagnosis or relapse. The clinical presentation may be misleading and life-threatening, due to the possible infiltration of any abdominal viscera. The authors present a series of eight patients and emphasize the management specificities of such patients and the possibility of long-term remissions, regardless of the severity of the initial presentation.

[Macrophage activation syndrome disclosing leukemic transformation of mycosis fungoides]

BACKGROUND

Mycosis fungoides can mimic pigmented purpuric dermatitis. We report such a case which progressed to peripheral T-cell lymphoma; progression was revealed by reactive hemophagocytic syndrome (RHS).

CASE REPORT

A 65-year old male patient was hospitalized for a pigmented and purpuric eruption. The skin lesions appeared 2 years earlier and at that time biopsy had shown pigmented and purpuric dermatitis. One month before hospitalization, general signs appeared. On admission, he had papular and purpuric rash, mainly on the trunk, hepatosplenomegaly, enlarged axillar and inguinal lymph nodes, and fever at 38.2 degrees. A skin biopsy showed histologic changes typical of mycosis fungoides. He also had bicytopenia, hepatitis, and increased triglyceride and ferritin levels suggesting RHS which was proved by means of bone marrow biopsy. These tests also evidenced peripheral T-cell lymphoma. The patient was treated with two courses of chemotherapy (CHOP) but the disease progressed and he deceased.

DISCUSSION

Mycosis fungoides can occasionally begin with an eruption very closely resembling pigmented purpuric dermatitis. Therefore, repeated biopsies should be done in case of widespread permanent pigmented purpuric dermatitis of no apparent origin. RHS is a life-threatening disease. The diagnosis should be suspected in any cytopenic patient with fever, increased triglyceride levels and abnormal liver tests. A search for an etiology must then be undertaken a prompt treatment is needed.

Paclitaxel-anthracycline combination chemotherapy in relapsing advanced ovarian cancer after platinum-based chemotherapy: a pilot study

Despite high response rates with platinum-based front-line chemotherapy, the prognosis for advanced ovarian carcinoma (AOC) is poor. Salvage chemotherapy for recurrent AOC was of little benefit before paclitaxel as single-agent therapy showed appreciable efficacy. Anthracyclines are effective, but are not often part of first-line therapy. In this pilot study, we investigated the feasibility of an anthracycline plus paclitaxel combination therapy for recurrent AOC. Twenty-four patients received 150 mg/m2 paclitaxel on day 1, with either 50 mg/m2 doxorubicin on day 1 or 75 mg/m2 epirubicin on day 1 every 3 weeks. A 27% overall response rate was obtained. Myelosuppression was the major toxicity, but was manageable. No myocardiac toxicity was observed. We conclude that paclitaxel-anthracyclines is a promising salvage combination therapy in AOC that should be investigated further.

Stability of normal personality traits after traumatic brain injury

OBJECTIVE

To test the hypothesis that changes in personality traits are evident after traumatic brain injury (TBI) using current models of normal adult personality variation.

DESIGN

Comparison of inception cohort and control group at two measurement occasions.

SETTING

A large urban academic medical center.

PARTICIPANTS

Retrospective personality assessments were obtained from significant others of 21 TBI patients within 30 days of injury and at 6-month follow-up and from a control group of significant others of 25 persons without neurological history twice over a 6-month interval.

MAIN OUTCOME MEASURES

Five scales-Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness-from the revised NEO Personality Inventory (NEO PI-R), Form R, and an observer rating scale for retrospective estimates of change (REC).

RESULTS

Significant score changes were found for only one of the five trait domains in the patient sample; controls showed minimal changes overall. Patients' Extraversion scores declined to average levels at 6-month follow-up, diminishing premorbid differences between patients and controls on this dimension. Subjective change estimates made by raters after follow-up reflected perceptions of increased neuroticism in patients that were inconsistent with the serial NEO PI-R data the raters provided.

CONCLUSIONS

The absence of systematic changes in personality trait scores among the patients cautions against presuming that such changes account for the behavior of TBI patients.