Does adjuvant fluoropyrimidine-based chemotherapy provide a benefit for patients with resected rectal cancer who have already received neoadjuvant radiochemotherapy? A systematic review of randomised trials

BACKGROUND

The results of the recently published large European randomised study in rectal cancer (European Organisation for Research and Treatment of Cancer 22921 trial) do not support current guidelines recommending postoperative chemotherapy for patients who have previously undergone preoperative radiochemotherapy or radiotherapy [radio(chemo)therapy]. To evaluate this discrepancy further, a systematic review of relevant randomised trials was undertaken.

MATERIALS AND METHODS

A systematic literature search was carried out in order to identify randomised studies exploring adjuvant chemotherapy against observation in patients with rectal cancer previously treated with preoperative radio(chemo)therapy.

RESULTS

A statistically significant benefit of adjuvant chemotherapy was not found in any of the four relevant randomised trials. Non-protocolised subgroup analysis of one study indicated a beneficial effect of adjuvant chemotherapy for high rectal tumours and for patients downstaged to ypT0-2N0 but no effect for low-lying rectal tumours. However, the body of evidence indicates that patients downstaged after radio(chemo)therapy to ypT0-2N0 disease are not candidates for testing adjuvant chemotherapy in future trials due to the considerable over-treatment anticipated by this manoeuvre.

CONCLUSIONS

To resolve the issue in question, a meta-analysis of relevant studies is required, and new trials should be launched to explore new drug combinations against observation. Currently, delivery of adjuvant chemotherapy in patients undergoing preoperative radio(chemo)therapy is not evidence based.

Neoadjuvant treatment for unresectable rectal cancer: an interim analysis of a multicentre randomized study

PURPOSE

To present an interim analysis of the trial comparing two neoadjuvant therapies for unresectable rectal cancer.

METHODS

Patients with fixed cT3 or cT4 or locally recurrent rectal cancer without distant metastases were randomized to either 5 × 5 Gy and 3 courses of FOLFOX4 (schedule I) or 50.4 Gy delivered in 28 fractions given simultaneously with 5-Fu, leucovorin and oxaliplatin (schedule II). Surgery in both groups was performed 12 weeks after the beginning of radiation and 6 weeks after neoadjuvant treatment.

RESULTS

49 patients were treated according to schedule I and 48 according to schedule II. Grade III+ acute toxicity was observed in 26% of patients in group I and in 25% in group II. There were two toxic deaths, both in group II. The microscopically radical resection (primary endpoint) rate was 73% in group I and 71% in group II. Overall and severe postoperative complications were recorded in 27% and 9% of patients vs. 16% and 7%, respectively. Pathological complete response was observed in 21% of the patients in group I and in 9% in group II.

CONCLUSIONS

The interim analysis revealed no major differences in acute toxicity and local efficacy between the two evaluated strategies.

Point: short-course radiation therapy is preferable in the neoadjuvant treatment of rectal cancer

There are 2 types of neoadjuvant radiation regimens accepted as standard for resectable rectal cancer: short-course (5 × 5 Gy) radiation therapy alone with immediate surgery and long-course combined chemoradiation therapy with delayed surgery. A Polish randomized study (n = 312) and an Australian randomized study (n = 326) compared these 2 schedules. Both trials showed a lower rate of early adverse effects using a short-course radiation regimen and no differences in long-term oncologic outcomes and late toxicity rates between groups. The small number of fractions makes short-course radiation less expensive and more convenient than chemoradiation therapy. These facts indicate that short-course radiation is preferable to chemoradiation for resectable cancers. Additionally, short-course preoperative radiation with a long interval to surgery is a valuable option for patients unfit for chemotherapy, with unresectable cancer or with a small tumor that is amenable to local excision. Moreover, short-course radiation enables the intensification of both radiotherapy and chemotherapy in patients with metastatic rectal cancer with potentially resectable synchronous metastatic disease.

Intracranial aneurysms in autosomal dominant polycystic kidney disease

BACKGROUND AND PURPOSE

ADPKD correlates with an increased frequency of ICANs, but universal screening for ICANs in patients with ADPKD is not currently recommended. The aim of our study was to determine which groups might benefit from screening by determining the prevalence of ICANs in the Polish ADPKD population and identifying any subgroups with an increased risk for ICANs.

MATERIALS AND METHODS

Eighty-three adult, predialysis-phase patients with ADPKD underwent screening for ICANs with MRA of the brain.

RESULTS

The prevalence of ICANs in the studied population was 16.9%, with 6% of the screened group requiring neurosurgical intervention. We also found that the frequency of ICANs increases with age, reaching 22.4% in patients older than 45 years. All diagnosed ICANs were small (< 9 mm) and were localized in the anterior circulation. In addition, MR imaging revealed arachnoid cysts in 4.8% of patients with ADPKD.

CONCLUSIONS

We suggest that patients older than 45 years with ADPKD be considered as candidates for screening for ICANs, and we propose a clinical algorithm for this subgroup. However, we could not find risk factors for ICANs in younger patients with ADPKD.

Target volume for postoperative radiotherapy in non-small cell lung cancer: results from a prospective trial

BACKGROUND AND PURPOSE

A previous prospective trial reported that three-dimensional conformal postoperative radiotherapy (PORT) for pN2 NSCLC patients using a limited clinical target volume (CTV) had a late morbidity rate and pulmonary function that did not differ from those observed in pN1 patients treated with surgery without PORT. The aim of this study was to assess locoregional control and localization of failure in patients treated with PORT.

MATERIALS AND METHODS

The pattern of locoregional failure was evaluated retrospectively in 151 of 171 patients included in the PORT arm. The CTV included the involved lymph node stations and those with a risk of invasion >10%. Competing risk analysis was used to assess the incidence of locoregional failure and its location outside the CTV.

RESULTS

Overall survival at 5years was 27.1% with a median follow-up of 67months for 40 living patients. The 5-year cumulative incidence of locoregional failure was 19.4% (95% CI: 18.2-20.5%) including a failure rate of 2% (95% CI: 0-17%) in locations outside or at the border of the CTV.

CONCLUSIONS

The use of limited CTV was associated with acceptable risk of geographic miss. Overall locoregional control was similar to that reported by other studies using PORT for pN2 patients.

Herpes simplex virus infection in women with previous spontaneous abortion

We have carried out a retrospective clinical investigation of 45 women in the first and second trimester of pregnancy aiming to demonstrate the role of genital HSV infection in the genesis of spontaneous abortion (miscarriage). Latent HSV infection was diagnosed using the microneutralization test; asymptomatic HSV vaginal or cervical shedding was diagnosed with indirect immunofluorescence and cytological-Papanicolau staining. The results showed that the highest incidence of latent HSV type 2 infection (64%) occurred in women who had one or more spontaneous abortions, whereas this type of infection was found in only 5% of pregnant women of the control group. The incidence of asymptomatic cervical HSV type 2 infection was also considerably higher in patients with a history of spontaneous abortions. Our results indicate a possible aetiological connection between HSV and spontaneous abortion.

Recovery from herpes simplex virus type-1 hepatitis in a female adult

A study of one case of herpes simplex hepatitis in an adult woman is presented. The clinical feature and laboratory findings were typical for acute hepatitis in a febrile patient without herpetic mucocutaneous lesions. The evidence of high IgM antibody titer in serum against herpes simplex virus and confirmation of the herpes simplex virus hepatitis by immunofluorescent microscopy after liver biopsy helped us establish the diagnosis. After 3-months the patient recovered.

Aberrant DNA methylation of alternative promoter of DLC1 isoform 1 in meningiomas

DLC1 encodes GTPase-activating protein with a well-documented tumor suppressor activity. This gene is downregulated in various tumors through aberrant promoter hypermethylation. Five different DLC1 isoforms can be transcribed from alternative promoters. Tumor-related DNA methylation of the DLC1 isoform 1 alternative promoter was identified as being hypermethylated in meningiomas in genome-wide DNA methylation profiling. We determined the methylation pattern of this region in 50 meningioma FFPE samples and sections of 6 normal meninges, with targeted bisulfite sequencing. All histopathological subtypes of meningiomas showed similar and significant increase of DNA methylation levels. High DNA methylation was associated with lack of DLC1 protein expression in meningiomas as determined by immunohistochemistry. mRNA expression levels of 5 isoforms of DLC1 transcript were measured in an additional series of meningiomas and normal meninges. The DLC1 isoform 1 was found as the most expressed in normal control tissue and was significantly downregulated in meningiomas. Transfection of KT21 meningioma cell line with shRNA targeting DLC1 isoform 1 resulted in increased activation of RHO-GTPases assessed with pull-down assay, enhanced cell migration observed in scratch assay as well as slight increase of cell metabolism determind by MTT test. Results indicate that isoform 1 represents the main pool of DLC1 protein in meninges and its downregulation in meningiomas is associated with hypermethylation of CpG dinucleotides within the corresponding promoter region. This isoform is functional GAP protein and tumor suppressor and targeting of its expression results in the increase of DLC1 related cell processes: RHO activation and cell migration.

Herpesvirus hominis (HVH) infection in women with preterm labor

A possible etiologic relationship between maternal asymptomatic genital HVH infection and pre-term labor was discussed on the base of the results of the investigation performed in this study. Latent HVH infection was diagnosed by the test of microneutralization. Asymptomatic HVH vaginal and cervical shedding was investigated by indirect immunofluorescence and cytologically. The incidence of latent HVH type 2 infection was higher in women with previous pre-term labor than in the control group. The obtained difference appeared to be statistically significant. The comparison of HVH type 2 asymptomatic cervical infection of the examined and the control group shows that it lies on the boundary of statistical significance. It means that further research of the subject is needed including prospective virologic investigations with the aim of detecting active HVH infections at the time of pre-term labor. Concerning the increasing significance of genital HVH infections in our environment, it seems reasonable to aim diagnostic efforts at the determination of both latent and active HVH infections, in order to reduce the incidence of pre-term labor and the perinatal morbidity and mortality rates by use of the appropriate preventive and therapeutic measures.

[Bacterial vaginosis. Epidemiology and risk factors]

Bacterial vaginosis (BV) is a change in vaginal ecosystem where lactobacilli dominate, flora is absent or greatly reduced, and replaced with a mixed, predominantly anaerobic flora, consisting of Gardnerella vaginalis, Mycoplasma hominis, Mobiluncus spp, Bacteroides spp, Prevotela spp, Peptostreptococcus spp, Fusobacterium spp and Porphyromonas spp. The concentration of bacteria increases from 100 to 1000 fold in women with BV compared to healthy women. BV has been formerly known as nonspecific vaginitis, Haemophilus vaginitis, Corynebacterium vaginitis, Gardnerella vaginitis and anaerobic vaginintis. BV is the most prevalent form of vaginal disturbances in reproductive age women. The average incidence of BV varies: 10-35% in patients visiting gynaecological wards, 10-30% in patients visiting obstetric wards and 20-60% in patients visiting services of sexually transmitted diseases. A typical clinical symptom of BV is malodorous vaginal discharge. However, more than 50% of all women with BV are asymptomatic. BV has been associated with many gynaecological and obstetric complications such as cervicitis, salpingitis, endometritis, postoperative infections, urinary tract infections, pelvic inflammatory disease, mild abnormal Pap smear results and possible link with cervical intraepithelial neoplasia, preterm delivery, premature rupture of the membranes, chorioamnionitis and postpartum endometritis. Factors that increase the risk of BV are multiple partners, exposure to semen, prior trichomoniasis, intrauterine device usage, smoking, indigent population and frequent use of scented soap. Diagnosis of BV is established by Amsel's criteria of which three of four are the following: presence of homogeneous discharge, vaginal fluid pH > 4.5, positive amine test and microscopic analysis of Gram stained smear of vaginal discharge where "clue" cells (epithelial vaginal cells covered with mass of adherent bacteria, mostly coccobacilli) should be detected. The treatment of patients with BV consist of metronidazole or clindamycin, per os or intravaginally. The treatment of asymptomatic women and male sex partners of women with BV is controversial. The aim of the study was to establish the occurrence rate of BV in our women and potential factors increasing the risk of BV. We examined 166 women at the Institute of Microbiology and Immunology, University School of Medicine, Belgrade. Diagnosis of BV was established by Amsel's criteria. Each woman filled in a special questionnaire. Pregnant women were excluded. BV was diagnosed in 25% (33/166) of women. BV was more common among women with multiple partners. The most prevalent clinical symptom of BV was malodorous vaginal discharge. Vaginal symptoms became more evident after intercourse. Taking into consideration the occurrence rate of BV and its connection with numerous gynaecological and obstetric sequelae, and taking into account that the diagnosis of BV is quick, simple and inexpensive, we suggest that the examination of BV in women becomes a usual procedure.

How congenital cytomegalovirus infection changes insulin and glucose homeostasis in affected fetuses

Factors affecting the fetal glucose level can be of maternal, placental or fetal origin. The level of fetal insulin during gestation is regulated by the potential of the endogenous fetal production on one hand, and on the other, by the factors (primarily glycaemia) that stimulate or inhibit its production. The aim of this paper was to analyze in which way and to what extent congenital infection with the cytomegalovirus disturbs the metabolism of fetal glucose and insulin. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks gestation from 52 women referred to our clinic for fetal karyotyping and scatological analysis of fetal CMV infection. To determine the effect of cytomegalovirus (CMV) infection on insulin and glucose fetal homeostasis, cordocentesis was performed in 18 patients (group A) with proven congenital CMV fetal infection. The control group (B) consisted of 34 patients in whom blood samples were taken for fetal karyotyping. Maternal and fetal glucose levels were 3.95 mmol/l and 3.15 mmol/l in group A and 4.00 and 3.62 mmol/l in group B, respectively. Maternal average insulin level in group A was 14.45 mU/ml and in fetuses 10.64 mU/ml, while group B maternal and fetal insulin levels were 12.38 mU/ml and 15.35 mU/ml, respectively. Maternal/fetal (M/F) insulin ratio was 1.35 in group A and in group B, 0.84. Statistical analysis showed significantly lower glucose and insulin levels and also a higher maternal/fetal insulin ratio in fetuses affected by CMV infection (t = 1.4 p < 0.001). Consequences of congenital CMV infection were fetal hypoglycaemia and hypoinsulinemia.

[Cervical infection as a cause of female sterility]

The study covered 116 infertile women in whom other etiological factors were ruled out, while 55 fertile patients served as controls. In infertile women, within the ovulation term, microorganisms of intestinal origin were isolated in 42.24%. Banal flora was present in 24.13%, while the saprophytic flora was verified in 21.5%. Culture media remained sterile in 8.62%. In the control group the differences are self, evident: the pathogenic flora was present only in 12.18% and the culture media remained sterile in 38.18%. In spite of the findings in the endocervix, the cervix was macroscopically normal in 54.31% of infertile persons. In patients from the control group, with regard to deliveries, pathologic changes of the portion were present in a higher percentage. The number of spermagglutinins in the serum was somewhat higher in patients from the infertile group in whom the infection of the endocervix was observed.

[Prospective study of the incidence of HIV infection in the 1st trimester of pregnancy]

The article deals with the results of an anonymous testing of HIV infections in Yugoslavia. The presence of anti-HIV-antibodies was examined in the blood of pregnant patients, randomly selected, in a Ward where about 3000 artificial abortions were carried out in the first trimester of pregnancy in a six-month period. On the basis of the obtained results one patient of 177 tested women was infected by HIV virus. At the same time, it can be presumed that among 3000 pregnancies there were many anti-HIV positive persons. It should be emphasized that the staff was not aware of HIV infection in one patient, and that in Yugoslav epidemiological conditions a HIV infected person could unexpectedly be detected without preliminary findings and data.

[Importance of disposable medical materials and instruments in the prevention of intrahospital infections]

Possibility for transmission of infectious diseases from patients to medical staff or vice versa is significant. Protective measures for patients as well as physicians must be applied and controlled. The aim was to investigate the microbiological status of disposable and reusable instruments and materials in order to establish the difference between them in protection from microorganisms. From the 122 samples of wet swab from reusables, 70.5% were bacteriologically negative and 29.5% positive. Seventy percent of isolated bacteria were a pathogens, and 30% were pathogens. All 80 samples of wet swab from disposable products were sterile. The frequency of bacteriologically negative samples among disposable products is highly significant (p < 0.01). These results confirm that the level of protection is higher if disposable products are used. Reusables should be replaced by disposable materials to decrease the incidence of nosocomial infections.

[Antenatal homeostasis of insulin and glucose in the fetus with cytomegalovirus infection]

Factors of effect on the fetal glucose level can be of maternal, placental or fetal origin. The level of fetal insulin during gestation is regulated by the potentials of the endogenous fetal production on one hand and on the other by the factors (primarily glucaemia) that stimulate or inhibit its production. The aim of this paper was to analyze in which way and to what extent the congenital infection with the Cytomegalovirus disturbs the metabolism of the fetal glucose and insulin. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks gestation from 52 women referred to our clinic for fetal karyotyping and scatological analysis of fetal CMV infection. To determine the effect of Cytomegalovirus (CMV) infection on insulin and glucose fetal homeostatis, we performed cordocentesis in 18 patients (group A) with proved congenital CMV fetal infection. Control group (B) consisted of 34 patients in whom blood samples were taken for fetal karyotyping. Maternal and fetal glucose levels were 3.95 mmol/l and 3.15 mmol/l in group A and 4.00 and 3.62 mmol/l in group B, respectively. Maternal average insulin level in group A was 14.45 mU/ml and in fetuses 10.64 mU/ml, while in group B maternal and fetal insulin levels were 12.85 mU/ml and 15.35 mU/ml, respectively. Maternal/fetal (M/F) insulin ratio was in group A 1.35, and in group B 0.84. Statistical analysis showed significantly lower glucose and insulin levels and also higher maternal/fetal insulin ratio in fetuses affected by CMV infection (t = 1.4, p < 0.001). Consequences of congenital CMV infection were fetal hypoglucaemia and hypoinsulinemia.

[HIV infection and human reproduction]

Problems connected with HIV infection, especially with its transmission, problems of HIV infection as an indicator of the termination of pregnancy, the role of pregnancy in the activation of latent HIV infection, and the possibility of the transmission of HIV infection by breast feeding are put forward and discussed. The authors present the results of their own studies of the presence of HIV antigen in the genital secretion, fetal tissue, and amniotic fluid in 4 anti-HIV positive pregnant women, in whom pregnancy was interrupted because of HIV infection. HIV antigen was positive in the cervical secretion and fetal tissue of one of the four pregnant women, whose diagnosis was ab. imminens. The presence of HIV virus, probably also of HIV antigen, in the cervical secretion appears significant for the transmission of infection from mother to child and for the occurrence of spontaneous abortion. When it is not possible to apply the method of HIV virus isolation, the determination of HIV antigen could have a prognostic importance of the effect of HIV on the course and outcome of pregnancy.

Essential and nonessential amino acids in appropriate and small for gestational age fetuses with congenital cytomegalovirus infection

The aim of the study was to evaluate the correlation between valine and glycine, representatives of essential and nonessential amino acids, in appropriate and small fetuses for gestational age with congenital cytomegalovirus (CMV) infection. Umbilical venous cord blood was obtained by cordocentesis at 22 to 29 weeks' gestation from 18 women (11 in appropriate for gestational age (AGA) -A, and 7 in small for gestational age (SGA) -B) fetuses with CMV infection. Plasma amino acids were measured with a Beckman M 121 amino acid analyzer. Maternal valine level was 136.0 mmol/l; fetal valine in AGA and SGA fetuses: 219 and 189 mmol/l, respectively. Fetomaternal valine ratio was significantly lower in the SGA group (1.39 mmol/l-SGA, 1.61 mmol/l AGA, t = 6.9 p < 0.001). The glycine level in maternal blood was 139.0 mmol/l; fetal in SGA and AGA fetuses 137 mmol/l, and 176 mmol/l, respectively. The fetomaternal glycine ratio was also significantly lower in the SGA group than in AGA. 1.01 and 1.27, respectively (t = -2.96, p < 0.001). Valine/glycine maternal and fetal ratio did not show any difference between groups. In the congenital CMV infected fetuses with intrauterine growth retardation there were decreased valine and glycine levels compared to the congenitally CMV infected fetuses with normal intrauterine growth. There was a lower fetal concentration of these amino acids compared to the maternal level in SGA fetuses. A decreased glycine level compared to the valine level has also been found in congenitally CMV infected fetuses with intrauterine growth retardation.

[T lymphocytes, non-malignant and premalignant changes in the planocellular epithelium of the uterine cervix]

T lymphocytes play an important role in the immune response to both neoplasia and viral infection. Normally, about 60% of T lymphocytes in the peripheral blood are T4 (helper) lymphocytes, while 20-30% are T8(suppressor) lymphocytes. When this ratio is inverted, most significant changes occur. The aim of the study was to examine the T4/T8 lymphocyte ratio in the peripheral blood of patients with nonmalignant and premalignant changes of the cervical epithelium and to compare it with that in patients without any cytological or colposcopical cervical abnormality. The results show a significant decrease of the T4/T8 lymphocyte ratio in the peripheral blood of patients with leukokeratosis (1.55) and especially of those with cervical intraepithelial neoplasia (1.19), compared with the results of the control group (2.31). These findings, as well as the knowledge of the importance of immune response in the control of the onset of malignancy, that the determination of T4/T8 lymphocyte ratio might be helpful in the prediction of the degree of premalignant cervical chance and indicate patient's follow-up.

[HIV infection and immunity disorders in patients with hemophilia]

The clinical, serological and immunological status of 23 haemophilia patients (21 with haemophilia 9 and 2 with haemophilia B) was investigated. In 12 of 23 haemophiliacs antibodies to HIV were detected. All seropositive patients were treated by imported clotting factor concentrates, and cryoprecipitates obtained by local donors. Six HIV positive haemophiliacs were in asymptomatic stage of HIV infection, and six others were in persistent generalized lymphadenopathy stage. HIV positive haemophiliacs showed a decreased number of CD4 and CD2 lymphocytes, inversed CD4/CD8 lymphocytes ratio, anergy to skin tests, decreased NK (natural killer), cell cytoxic activity, increased IgG and increased immune complexes. HIV negative haemophiliacs showed no different immunologic abnormality than healthy controls. Our results also showed differences in the degree and type of immunological abnormalities depending on different stages of HIV infection. Haemophiliacs in asymptomatic stage of HIV infection showed qualitative abnormalities of T cell immunity, manifested with decreased NK cells cytotoxic activity and anergy to skin tests, while haemophiliacs in persistent generalized lymphadenopathy stage, besides qualitative, showed quantitative abnormalities of T cell immunity, manifested with decreased lymphocyte subpopulations (CD2, CD3, CD4). Immunological disorders observed in our haemophilia patients were in direct correlation with the presence of anti HIV antibodies in peripheral blood, and we suppose that they may be attributed to HIV infection rather than to chronic antigenic stimulation with foreign proteins in blood products.