Cardiophrenic angle lymph node is an indicator of metastatic spread but not specifically peritoneal carcinomatosis in colorectal cancer patients: Results of a prospective validation study in 91 patients

BACKGROUND

The presence of cardiophrenic angle lymph node (CPALN) has been associated with the risk of peritoneal carcinomatosis (PC) in high risk colon cancer patients. Its accuracy to predict PC and its prognostic value in non-selected CRC patients has not been validated prospectively.

METHODS

From 2011 to 2013, all patients undergoing colectomy for colon cancer were included prospectively. Presence of CPALN was assessed on preoperative computed tomography scan by two radiologists. Surgical exploration was used as reference for the diagnosis of PC. Factors associated with presence of CPALN and progression-free survival were analyzed.

RESULTS

Ninety one patients fulfilled inclusion criteria. CPALN was detected in 36 patients (39.5%) on CT scan. At surgical exploration, PC was found in 6 patients (6.5%). Sensitivity, specificity, negative predictive value, positive predictive value and overall accuracy of CPALN on CT scan for predicting PC were 67%, 62%, 96%, 11% and 63% respectively. In multivariate analysis, the presence of distant metastases whatever the site was associated with the presence of CPALN (p = 0.03; hazard ratio HR = 3.8; confidence interval CI 95% = 1.1-13.3). In the multivariate analysis, only vascular involvement (p = 0.034, HR = 3.574, CI 95% = 1.10-11.60) was associated with progression-free survival whereas CPALN was not found to predict outcome (p = 0.893).

CONCLUSION

CPALN is a common finding in non-selected colon cancer patients. Although in the absence of CPALN, PC can almost be excluded, its value for the diagnosis of PC is limited. Our findings support that CPALN is mainly an indicator of metastatic spread of the tumor.

[Diagnostic value of multidisciplinary meetings on orbital inflammatory pathologies discussed in Nantes University Medical Center]

INTRODUCTION

Observational study of the diagnoses and the treatment modalities used for orbital inflammatory pathologies discussed in multidisciplinary meetings (MDM) in Nantes University Medical Center over 4 years.

MATERIAL AND METHOD

A multidisciplinary meeting to discuss eyelid and orbital pathologies (excluding cancer) has been held in Nantes three times per year since October 2008. This retrospective study focuses on the cases of orbital inflammatory pathologies discussed at this meeting from October 2008 to October 2012 (49 cases included).

RESULTS

Twenty-eight (57%) patients were diagnosed with orbital inflammation, 16 (33%) cases with isolated myositis and 5 (10%) with dacryoadenitis. In the diagnostic work-up, orbital biopsy was performed in 64% of orbital inflammation cases, 38% of myositis cases and 80% of dacryoadenitis cases. These specimens led to the diagnosis of 9 lymphomas, 2 histiocytoses and 1 metastasis. The internal medicine work-up allowed for the diagnosis of 3 granulomatoses with polyangiitis, one patient with sarcoidosis, and one patient with tuberculosis. Despite work-up, there remained 14 (29%) idiopathic orbital inflammatory syndromes (IOIS).

DISCUSSION

The MDM of orbital pathology allows for the collective approach to the most difficult cases of management and is not concerned with stable orbitopathies or those presenting no diagnostic dilemma. Despite a multidisciplinary, rational etiologic work-up (frequently involving a biopsy), we find a higher rate of IOIS than reported in the literature.

CONCLUSION

A multidisciplinary approach appears to be useful in improving management of orbital disease.

Familial deafness, congenital heart defects, and posterior embryotoxon caused by cysteine substitution in the first epidermal-growth-factor-like domain of jagged 1

In the present study, we report a kindred with hearing loss, congenital heart defects, and posterior embryotoxon, segregating as autosomal dominant traits. Six of seven available affected patients manifested mild-to-severe combined hearing loss, predominantly affecting middle frequencies. Two patients were diagnosed with vestibular pathology. All patients had congenital heart defects, including tetralogy of Fallot, ventricular septal defect, or isolated peripheral pulmonic stenosis. No individual in this family met diagnostic criteria for any previously described clinical syndrome. A candidate-gene approach was undertaken and culminated in the identification of a novel Jagged 1 (JAG1) missense mutation (C234Y) in the first cysteine of the first epidermal-growth-factor-like repeat domain of the protein. JAG1 is a cell-surface ligand in the Notch signaling pathway. Mutations in JAG1 have been identified in patients with Alagille syndrome. Our findings revealed a unique phenotype with highly penetrant deafness, posterior embryotoxon, and congenital heart defects but with variable expressivity in a large kindred, which demonstrates that mutation in JAG1 can cause hearing loss.

[Gross tumor volume and clinical target volume in radiotherapy. Tumors of the buccal cavity]

Radiation therapy, either alone or combined with surgery is a cornerstone in the treatment of oral cavity tumors. Target volumes to be treated with external beam radiation must take under consideration the initial tumor location, providing information on satellites lymph nodes to be irradiated as well. Modern imaging, with emphasis on CT scan with injection, is now mandatory for a better analysis of initial lesions including both tumor location and invaded lymph nodes. Tumor volumes based on clinical examination and CT scan analysis might be divided in two groups. First, volumes susceptible to receive a prophylactic irradiation for an hypothetical microscopic spread (CTV) to be treated with a prophylactic dose; second, volumes including lesions visible clinically or on CT scan that should receive a higher radiation dose (GTV). Clinical tolerance will largely be depending upon radiation-induced mucositis, impairing food intake. Radiation techniques aiming at normal tissues preservation should be used, including devices allowing keeping an open mouth during radiation delivery.

[5 conventional radiographic projections are necessary and sufficient for the study of the zygoma. Technics and results]

Though clinic examination gives us much information, radiology still is essential in head trauma. Many standard radiographic projections have been described in the past and yet since the eighties it appears that C.T. scanner (C.T.) has become absolutely necessary to a great number of us. In fact, C.T. is indispensable when there is a matter of vital urgency or when a functional problem appears (diplopia). But most of the time high quality standard radiographic projections are sufficient. We have selected five radiographic projections: the occipito-mental's such as Mahoney's or Blondeau or Louisette, the submento-vertical's, the rotated occipito-mental's. For each of these radiographic projections we have specified the angular definition, the realization techniques, the criterions of quality and the results. The use of conventional radiology gives us images of which the quality is high enough to allow a precise topographical diagnosis and is far cheaper than C.T. So we can assert that standard radiographic projections are necessary and sufficient and that the use of C.T. becomes indispensable only in the few cases of diplopia or enophthalmia or complicated maxillary fracture. In the case of a lateral head trauma, our strategy of radiographic exploration will be represented as indicated on picture n degrees 20.

[Post-traumatic cerebrospinal fluid rhinorrhea and otorrhea disclosing Mondini's syndrome]

A mild head injury could have played a role in the development of post-myringotomy cerebrospinal fluid rhinorrhea and otorrhea in an 18-month-old child with Mondini's syndrome. This notion of trauma may prevent exploration of the site of the fistula when these labyrinthic dysplasias are poorly understood. Once suspected, full radiological examination should precede closure of the gap using an otological approach.

[Value of the transpalatine approach for surgical access to nasopharyngeal fibromas (author's transl)]

Present special investigations offer the possibility of very good assessment of the extension and vascularisation of nasopharyngeal fibromas. It is no longer logical to seek to treat all tumours via wide surgical approaches since tumour size and spread vary from one case to another. Amongst the various surgical approaches available, the transpalatine technique is extremely valuable in the excision of small limited tumours limited to the cavum or to remove the sphenoidal prolongation of a large tumour. In such a case, a combined transpalatine and transantral approach facilitates the operation and ensures perfect control of the whole excision process, which considerably reduces the risk of recurrence.