Randomized phase III study of docetaxel plus bavituximab in previously treated advanced non-squamous non-small-cell lung cancer

Background

Bavituximab is a monoclonal antibody that targets phosphatidylserine in the presence of β2 glycoprotein 1 (β2GP1) to exert an antitumor immune response. This phase III trial determined the efficacy of bavituximab combined with docetaxel in patients with previously treated advanced non-small-cell lung cancer (NSCLC).

Patients and methods

Key eligibility criteria included advanced non-squamous NSCLC with disease progression after treatment with platinum-based doublet chemotherapy, evidence of disease control after at least two cycles of first-line therapy, presence of measurable disease, ECOG performance status 0 or 1, adequate bone marrow and organ function, and no recent history of clinically significant bleeding. Eligible patients were randomized 1 : 1 to receive up to six 21-day cycles of docetaxel plus either weekly bavituximab 3 mg/kg or placebo until progression or toxicity. The primary end point was overall survival (OS).

Results

A total of 597 patients were enrolled. Median OS was 10.5 months in the docetaxel + bavituximab arm and was 10.9 months in the docetaxel + placebo arm (HR 1.06; 95% CI 0.88-1.29; P = 0.533). There was no difference in progression-free survival (HR 1.00; 95% CI 0.82-1.22; P = 0.990). Toxicities were manageable and similar between arms. In subset analysis, among patients with high baseline serum β2GP1 levels ≥200 µg/ml, a nonsignificant OS trend favored the bavituximab arm (HR 0.82; 95% CI 0.63-1.06; P = 0.134). Among patients who received post-study immune checkpoint inhibitor therapy, OS favored the bavituximab arm (HR 0.46; 95% CI 0.26-0.81; P = 0.006).

Conclusions

The combination of bavituximab plus docetaxel is not superior to docetaxel in patients with previously treated advanced NSCLC. The addition of bavituximab to docetaxel does not meaningfully increase toxicity. The potential benefit of bavituximab observed in patients with high β2GP1 levels and in patients subsequently treated with immune checkpoint inhibitors requires further investigation.

Clinical trial number

NCT01999673.

Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility

Background

To evaluate the effectiveness and feasibility of high-intensity focused ultrasound (HIFU) for the treatment of bone metastases.

Methods

A single-center prospective study was made involving 17 consecutive patients with symptomatic bone metastases. Patients were treated by Focused Ultrasound (FUs) performed with magnetic resonance (MR) guidance. Surgical treatment or radiotherapy treatment was not indicated for patients who underwent FUs. Lesions were located in the appendicular and axial skeleton and consisted of secondary symptomatic lesions. The clinical course of pain was evaluated using the Visual Analog Scale (VAS) before treatment, at 1 week, and at 1 month after treatment and the Oral Morphine Equivalent Daily Dose (OMEDD) was also recorded. We used Wilcoxon signed rank test to assess change in patient pain (R CRAN software V 3.1.1).

Results

We observed a significant decrease in the pain felt by patients between pre- procedure and 1 week post-procedure (p = 2.9.10-4), and pre-procedure and 1 month post-procedure (p = 3.10-4). The proportion of responders according to the International Bone Metastases Consensus Working Party was: Partial Response 50% (8/16) and Complete Response 37.5% (6/16).

Conclusions

HIFU under MR-guidance seems to be an effective and safe procedure in the treatment of symptomatic bone lesions for patients suffering from metastatic disease. A significant decrease of patient pain was observed.

Trial registration

NCT01091883. Registered 24 March 2010. Level of evidence: Level 3.

Biological determinants of spontaneous late preterm and early term birth: a retrospective cohort study

OBJECTIVE

Our aim was to examine the association between biological determinants of preterm birth (infection and inflammation, placental ischaemia and other hypoxia, diabetes mellitus, other) and spontaneous late preterm (34-36 weeks) and early term (37-38 weeks) birth.

DESIGN

Retrospective cohort study.

SETTING

City of London and Middlesex County, Canada.

SAMPLE

Singleton live births, delivered at 34-41 weeks to London-Middlesex mothers following spontaneous labour.

METHODS

Data were obtained from a city-wide perinatal database on births between 2002 and 2011 (n = 17,678). Multivariable analyses used multinomial logistic regression.

MAIN OUTCOME MEASURE

The outcome of interest was the occurrence of late preterm (34-36 weeks) and early term (37-38 weeks) birth, compared with full term birth (39-41 weeks).

RESULTS

After controlling for covariates, there were associations between infection and inflammation and late preterm birth (aOR = 2.07, 95% CI 1.65, 2.60); between placental ischaemia and other hypoxia and late preterm (aOR = 2.21, 95% CI 1.88, 2.61) and early term (aOR = 1.25, 95% CI 1.13, 1.39) birth; between diabetes mellitus and late preterm (aOR = 3.89, 95% CI 2.90, 5.21) and early term (aOR = 2.66, 95% CI 2.19, 3.23) birth; and between other biological determinants (polyhydramnios, oligohydramnios) and late preterm (aOR = 2.81, 95% CI 1.70, 4.64) and early term (aOR = 1.89, 95% CI 1.32, 2.70) birth.

CONCLUSIONS

Our findings show that delivery following spontaneous labour even close to full term may be a result of pathological processes. Because these biological determinants of preterm birth contribute to an adverse intrauterine environment, they have important implications for fetal and neonatal health.

Obstetric conditions and the placental weight ratio

INTRODUCTION

To elucidate how obstetric conditions are associated with atypical placental weight ratios (PWR)s in infants born: (a) ≥37 weeks gestation; (b) at ≥33 but <37 weeks gestation; and (c) <33 weeks gestation.

METHODS

The study included all in-hospital singleton births in London, Ontario between June 1, 2006 and March 31, 2011. PWR was assessed as <10th or >90th percentile by gestational age-specific local population standards. Multivariable analysis was carried out using multinomial logistic regression with blockwise variable entry in order of temporality.

RESULTS

Baseline factors and maternal obstetric conditions associated with PWR <10th percentile were: increasing maternal height, overweight and obese body mass indexes (BMI), large for gestational age infants, smoking, and gestational diabetes. Obstetric factors associated with PWR >90th percentile were: underweight, overweight and obese BMIs, smoking, preeclampsia, placenta previa, and placental abruption. In particular, indicators of hypoxia and altered placental function were generally associated with elevated PWR at all gestations.

DISCUSSION

An association between obstetric conditions associated with fetal hypoxia and PWR ≥90th percentile was illustrated.

CONCLUSIONS

The multivariable findings suggest that the PWR is similarly increased regardless of the etiology of the hypoxia.

Conservative multimodal management of a primitive neuroectodermal tumor of the thyroid

Abstract

Primitive neuroectodermal tumors (PNET) represent 1% of sarcomas. Head and neck peripheral PNETs have an intermediate prognosis between abdominopelvic disease and extremities. We here report the case of a 40-year old male who presented with primitive neuroectodermal tumor of the thyroid and was treated by multimodal treatment, including surgery, chemotherapy and intermediate dose radiotherapy. The patient is alive and fit with a functional larynx at 27 months. Multimodal treatments yield five-year survival rates of about 60%. Major drug regimens use vincristine, doxorubicin, ifosfamide or cyclophosphamide, dactinomycin and/or etoposide. Complete surgical excision is undertaken whenever possible to improve long-term survival. However, the relative radiosensitivity of tumors of the Ewing family, suggest multimodal treatment including adjuvant conformal radiotherapy in case of positive margins or poor response to chemotherapy rather than resection with 2-3 cm margins, which would imply laryngeal sacrifice for thyroid tumors. The role of expert rare tumor networks is crucial for optimal decision-making and management of such rare tumors on a case by case basis.

Differential expression of EGFR, HER2, P16, and high-risk (hr) HPV status in oropharyngeal (Or) and oral cavity (OC) squamous cell carcinoma (SCC)

5521

Background: We aimed to better characterize the expression of epidermal growth factor receptors family in Or and OC SCC and correlate it to hr HPV status and anatomoclinical features. Methods: In formalin fixed paraffin embedded tumor tissues, chromogenic in situ hybridization (CISH) was performed to detect hr HPV and immunohistochemistry to evaluate EGFR (positive score: 4 to 6), HER2 (0=negative, 1=positive) and P16 (positive score:≥70% labeled cells) expression. Baseline data were collected and analyze will be used. Results: Among 128 pts, 69 were tobacco users and 58 male. Median age at diagnosis was 61 y [23-95]. EGFR, Her2, P16 expression and hrHPV positivity were seen in 84 (65%), 12 (9%), 47 (37%) and 47 (37%) respectively. P16 signal was linked with absence of tobacco (31% vs. 72%, Pearson chi2 test: p<10-3), absence of alcohol (48% vs. 83%, p<10-3), Or site (53% vs. 76%, p=0.005), T1 (34% vs. 19%, p=0.06), N0 (52% vs. 23%, p=0.003), absence of nodal capsular rupture (85% vs. 68%, p=0.02), WHO grade 3 (37% vs. 68%, p=0.001), hr HPV detection (17% vs. 70%, p<10-3). Multivariate analysis confirmed the link between P16 expression and hr HPV CISH positivity (OR=0.05, CI 95% [0.01-0.21], p<10-3) , absence of tobacco (OR=9.2, CI 95% [2.1-40.7], p=0.03) and N0 (OR=0.2, CI 95% [0.04- 0.75], p=0.02). EGFR signal was linked with tobacco (31% vs 78%,p=10-3), alcohol (57% vs 81%, p=0.02), OC localization (77% vs 58%, p=0.03), well differentiated SCC (73% WHO grade 1-2 vs 56% grade 3, p=0.04), absence of hr HPV detection (74% vs 52%, p=0.01) and absence of P16 labeling (78% vs 44%, p<10-3). Multivariate analysis confirmed the link between EGFR positivity and tobacco (OR=0.32, CI 95% [0.1-0.9], p=0.03), alcohol (OR=9.5, CI 95% [1.2- 72.8], p=0.03) and OC localization (OR=0.3, CI 95% [0.1-1], p=0.05). HER2 signal was linked with alcohol (5% vs 18%, p=0.04), history of tobacco associated neoplasia (10% vs 0%, p=0.02), Or site (14% vs 2%, p=0.03) and who grade 3 (5% vs 14%, p=0.06). Her2 labeling was not associated with tobacco, sex, hr HPV detection, P16 positivity or EGFR one. Conclusions: Hr HPV associated SCC have a low expression of EGFR and are not associated with HER2 labeling.

The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies

Objective

To investigate whether initiating external cephalic version (ECV) earlier in pregnancy might increase the rate of successful ECV procedures, and be more effective in decreasing the rate of non-cephalic presentation at birth and of caesarean section.

Design

An unblinded multicentred randomised controlled trial.

Setting

A total of 1543 women were randomised from 68 centres in 21 countries.

Population

Women with a singleton breech fetus at a gestational age of 33^0/7 weeks (231 days) to 35^6/7 weeks (251 days) of gestation were included.

Methods

Participants were randomly assigned to having a first ECV procedure between the gestational ages of 34^0/7 (238 days) and 35^6/7 weeks of gestation (early ECV group) or at or after 37^0/7 (259 days) weeks of gestation (delayed ECV group).

Main outcome measures

The primary outcome was the rate of caesarean section; the secondary outcome was the rate of preterm birth.

Results

Fewer fetuses were in a non-cephalic presentation at birth in the early ECV group (314/765 [41.1%] versus 377/768 [49.1%] in the delayed ECV group; relative risk [RR] 0.84, 95% CI 0.75, 0.94, P = 0.002). There were no differences in rates of caesarean section (398/765 [52.0%] versus 430/768 [56.0%]; RR 0.93, 95% CI 0.85, 1.02, P = 0.12) or in risk of preterm birth (50/765 [6.5%] versus 34/768 [4.4%]; RR 1.48, 95% CI 0.97, 2.26, P = 0.07) between groups.

Conclusion

External cephalic version at 34–35 weeks versus 37 or more weeks of gestation increases the likelihood of cephalic presentation at birth but does not reduce the rate of caesarean section and may increase the rate of preterm birth.

Cisplatin + irinotecan versus cisplatin + etoposide in extensive stage small cell lung cancer (E-SCLC): Final “common arm”: Comparative outcomes analysis of JCOG 9511 and SWOG 0124

8027

Background: S0124 was a large North American phase III trial (n=651) that failed to confirm a survival benefit for cisplatin/irinotecan over cisplatin/etoposide in patients with E-SCLC, contrary to the results of J9511, a phase III trial exclusively in Japanese patients (n=154). As S0124 and J9511 protocols used identical treatment regimens and similar eligibility criteria, we compared demographics, toxicity, and outcomes using patient-level data and a “common arm” analysis to explore potential reasons for the divergent results. Methods: In both trials, patients with documented E-SCLC and adequate end-organ function were randomized to receive either cisplatin 60 mg/m2 day 1 + irinotecan 60 mg/m2 days 1, 8, & 15 Q 4 weeks or cisplatin 80 mg/m2 day 1 + etoposide 100 mg/m2 days 1–3 Q 3 weeks. Demographics and outcomes data were compared among 805 patients enrolled in J9511 and S0124 receiving identical treatment using a logistic model adjusted for age, sex, and performance status. Results: Of 671 patients in S0124, 651 were eligible. Patient characteristics (J9511 & S0124, respectively): Mean age - 61 & 62 years; Male sex - 132 (86%) & 370 (57%), p<0.001; Performance status 0 - 19 (12%) & 211 (32%), p<0.001. Efficacy and toxicity comparisons are summarized below. Conclusions: Significant differences in patient demographics, toxicity, and efficacy exist between J9511 and S0124 populations. These results, relevant in the current era of clinical trials globalization, warrant 1) consideration of differential patient characteristics and outcomes amongst populations receiving identical therapy; 2) utilization of the “common arm” model in prospective trials; and 3) inclusion of pharmacogenomic correlates in cancer trials where ethnic/racial differences in drug disposition are expected.

[Table: see text]

[Table: see text]

A phase II trial of IPI-504 (retaspimycin hydrochloride), a novel Hsp90 inhibitor, in patients with relapsed and/or refractory stage IIIb or stage IV non-small cell lung cancer (NSCLC) stratified by EGFR mutation status

8073

Background: IPI-504 (retaspimycin hydrochloride) is a potent, water-soluble heat shock protein 90 (Hsp90) inhibitor. IPI-504 causes the degradation of mutated epidermal growth factor receptor (mtEGFR) kinase and cMET in NSCLC cell lines. IPI-504 also significantly reduces tumor growth in murine xenograft models, including tumors resistant to tyrosine kinase inhibitors (TKIs). Methods: This phase II trial is investigating the safety and antitumor activity of intravenous (IV) 400 mg/m2 IPI-504 given twice weekly for 2 out of 3 weeks. Eligible patients (pts) had stage IIIb (w/ malignant effusion) or stage IV NSCLC that progressed after TKI treatment. EGFR mutation analysis was performed on all pts. Two cohorts (n=10 each) were initially enrolled and stratified by EGFR status (mtEGFR or wtEGFR). Planned cohort expansion to 29 pts occurred if ≥ 1 pt from that cohort had a best response of stable disease (SD) ≥12 wks or partial response (PR). Pts were evaluated for safety and RECIST response every 6 weeks. Central, independent radiology review was performed for all imaging studies. Results: 43 pts have been enrolled: 10 mtEGFR, 17 wtEGFR, 12 pending analysis, and 4 EGFR-failed samples. 19 pts are currently on study. Median age is 62 yrs (range 31–77). Median no. of prior therapies is 3. Common related adverse events are fatigue, nausea, and diarrhea. Anti-tumor activity has been observed, see table. Both cohorts have been expanded. Conclusions: IPI-504 monotherapy has been well tolerated, with evidence of anti-tumor activity, particularly and unexpectedly in the wtEGFR cohort. These data suggest that IPI-504 may have antitumor activity in heavily pretreated pts with advanced NSCLC. Further evaluation continues in the expansion phase of the trial.

[Table: see text]

[Table: see text]

Cisplatin (Cis)/etoposide (VP16) compared to cis/irinotecan (CPT11) in extensive-stage small cell lung cancer (E-SCLC): Pharmacogenomic (PG) and comparative toxicity analysis of JCOG 9511 and SWOG 0124

7524

Introduction: J9511 demonstrated a significant survival benefit for Cis/CPT11 over Cis/VP16 in Japanese patients (pts) with E-SCLC (Noda, et al. NEJM 2002). S0124 is the confirmatory North American phase III trial (accrual completed) using the identical J9511 protocol. We hypothesized that toxicities would differ between North American & Japanese pts due in part to differences in the distribution of genetic polymorphisms involved in chemotherapy metabolism. Methods: Toxicity data were compared among 706 pts enrolled in J9511 & S0124 receiving common treatment using a logistic model adjusted for age, sex, and performance status (PS). Select polymorphisms of the UGT1A1, ABCB1, & OATP genes in genomic DNA were evaluated in 142 pts in S0124 only (67 Cis/CPT11; 75 Cis/VP16). Associations between toxicity & genotype within each arm were assessed using logistic regression. Results: Pt demographics for J9511 & S0124 respectively: Mean age − 61 & 62 years; Male sex − 131 (86%) & 315 (57%); PS 0 − 19 (13%) & 173 (31%); PS>0 − 133 (87%) & 372 (68%). Comparative toxicities (≥ grade 3) are summarized ( table ). PG analysis in S0124 pts: ABCB1 (C3435T) T/T was associated with an increased risk of CPT11 grade 3+ diarrhea (p=0.04) versus C/C and C/T. UGT1A1 (G3156A) A/A was associated with increased risk of CPT11 neutropenia (p=0.009) & leukopenia (p=0.05). UGT1A1*28 TA7, typically associated with increased CPT11 toxicity, was seen in only 4 pts (2 Cis/CPT11; 2 Cis/VP16); thus no correlation was done. No gene tested was associated with VP16 toxicity. Conclusions: Significant differences in treatment-related myelosuppression exist between J9511 and S0124 pt populations. Certain polymorphisms in genes involved in CPT11 metabolism are significantly associated with CPT11 toxicities in S0124. Additional analyses are ongoing. These results support the hypothesis that toxicities may be associated with distribution of genetic polymorphisms.

No significant financial relationships to disclose.

[Table: see text]

A ten-year review of progress in the treatment of non-small-cell lung cancer with gemcitabine

During the past two decades, clinical research has focused on developing chemotherapeutic regimens that effectively prolong survival and provide palliation for patients with non-small-cell lung cancer (NSCLC). In the mid-to late-1990s, several new agents emerged from clinical development and demonstrated activity against this disease, including the novel antimetabolite gemcitabine. Gemcitabine is one of the most active agents for the treatment of NSCLC. When combined with a platinum analog, gemcitabine produces the best progression-free survival outcome of any platinum-based regimen in first-line advanced NSCLC treatment setting. On the basis of its excellent antitumor activity and favorable toxicity profile, gemcitabine has been approved for the first-line treatment of locally advanced or metastatic NSCLC.

Efficacy of gemcitabine plus platinum chemotherapy compared with other platinum containing regimens in advanced non-small-cell lung cancer: a meta-analysis of survival outcomes

PURPOSE

Gemcitabine-platinum combination activity has been clearly established in a number of phase II studies. It has also been compared against other combinations in many phase III trials. It is generally believed that all such regimens have an equivalent impact on survival. This meta-analysis aims to quantify the treatment effect of gemcitabine plus a platinum agent in the treatment of advanced NSCLC and compare the combination to other regimens used globally.

DESIGN

Data from a total of 4556 patients from 13 randomized trials investigating gemcitabine in combination with a platinum agent versus any other platinum-containing regimen were included in a meta-analysis of time-to-event outcomes.

RESULTS

A significant reduction in overall mortality in favor of gemcitabine-platinum regimens was observed, hazard ratio (HR) 0.90 (95% CI: 0.84-0.96) with an absolute benefit at 1 year of 3.9%. Median survival was 9.0 months for the gemcitabine-platinum regimens and 8.2 months for the comparator regimens. Sub-group analysis of the first- and second-generation platinum-based comparator regimens also indicated a significant benefit for gemcitabine-platinum regimens, HR 0.84 (CI: 0.71-0.9985). Analysis of third-generation agent plus platinum regimens showed a non-significant trend favoring gemcitabine-platinum regimens, HR 0.93 (CI: 0.86-1.01). There was a significant decrease in the risk of disease progression in favor of gemcitabine-platinum regimens, HR 0.88 (CI: 0.82-0.93). An absolute benefit of 4.2% at 1 year was estimated. Median progression-free survival was 5.1 months for gemcitabine-platinum regimens compared with 4.4 months for the comparator regimens. Sub-group analysis indicated a statistically significant progression-free survival benefit for patients assigned to gemcitabine-platinum treatment compared to first- and second-generation platinum regimens, HR 0.85 (CI: 0.77-0.94), and third-generation agent plus platinum regimens, HR 0.89 (CI: 0.82-0.96).

Does cervical length at 13-15 weeks' gestation predict preterm delivery in an unselected population?

OBJECTIVE

To assess the role of early mid-trimester cervical length measurement as a predictor of spontaneous preterm birth in an unselected population.

METHODS

In this prospective study, unselected, asymptomatic, Caucasian women with singleton pregnancies underwent standardized transvaginal ultrasonographic (TVS) cervical length measurement at 13-15 weeks' gestation as a screening test for preterm delivery (PTD). Women with multiple gestations, iatrogenic PTD, and previous cervical conization were excluded. The primary outcome measures were spontaneous PTD at < 37 and < 34 weeks. The correlation between cervical length and previous obstetric history was evaluated.

RESULTS

A total of 2469 patients met the inclusion criteria. The mean gestational age at cervical assessment was 14 + 2 weeks. The mean gestational age at delivery was 40 + 0 weeks. The rate of spontaneous deliveries before 37 weeks' gestation was 1.7%. In 0.2% the delivery occurred before 34 weeks' gestation. The mean +/- standard deviation cervical length for the entire population was 44.2 +/- 5.4 mm. No difference was observed between cervical length in women that delivered at term and those that delivered either before 37 or before 34 weeks' gestation. Previous obstetric history (prior preterm birth, previous miscarriages and terminations, and parity) did not affect cervical length at 14 weeks of gestation.

CONCLUSIONS

Performed at 14 weeks' gestation, TVS measurement of the cervical canal length to predict spontaneous PTD is not a reliable screening procedure.

Antepartal assessment of IUGR fetuses

Intrauterine growth restriction (IUGR) should be defined on the basis of a prenatally recognized defective growth compared to that expected for this fetus. This condition is encountered in 10-15% of the pregnancies and the perinatal outcome is impaired mainly as a consequence of fetal hypoxemia that is present in 30% of IUGR fetuses. In order to allow for proper management, the IUGR should be recognized prenatally and the method of choice for this purpose is ultrasound fetal biometry. After the identification of IUGR, 2nd level tests should be performed in order to assess the fetal oxygenation conditions. The validity of Doppler investigation on fetal and umbilical vessels is discussed, and the importance of using computer assisted cardiotocography instead of traditional eye ball evaluation of the non-stress test is emphasized.

Obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension

OBJECTIVE

The purpose of this study was to determine the obstetrical intervention rates and maternal and neonatal outcomes of women with gestational hypertension.

STUDY DESIGN

Induction and operative delivery rates and indices of maternal and neonatal morbidity were determined in women (37-41 completed weeks) with gestational hypertension (n = 979), preeclampsia (n = 165), chronic hypertension (n = 187), and control subjects (n = 11,434) in a retrospective review of St. Joseph's Health Care Perinatal Database from November 1, 1995, to October 31, 1999. Data were analyzed by chi-square test, analysis of variance, Dunnett's t -test, and pairwise chi-square tests with Bonferroni correction.

RESULTS

The induction and cesarean delivery rates in gestational hypertension were similar to preeclampsia and chronic hypertension groups and almost double of control subjects. The length of labor and postpartum stays and the incidence of operative vaginal delivery, postpartum hemorrhage, and neonatal intensive care involvement were greater in the gestational hypertension group than in the control subjects.

CONCLUSION

Women with gestational hypertension had obstetrical intervention rates much higher than control subjects and similar to those with preeclampsia and chronic hypertension.

Early screening for fetal cardiac anomalies by transvaginal echocardiography in an unselected population: the role of operator experience

OBJECTIVES

To examine the accuracy of early transvaginal fetal echocardiography performed in an unselected population by operators with different levels of experience and to compare the results with those obtained from a referral population.

DESIGN

Prospective study.

METHODS

A series of 4785 unselected fetuses and 221 referred fetuses were screened at 13-15 weeks' gestational age by transvaginal echocardiography. For each fetus, visualization of the four-chamber view plus the origin of the great arteries was attempted. Color Doppler imaging was only performed in cases of cardiac malformations already identified by two-dimensional echocardiography. The scans were performed by seven operators with different levels of experience. Reliability was assessed by conventional transabdominal echocardiography at 20-22 weeks, by postnatal follow-up in the first 3 months of life, and/or by autopsy in all cases of termination or fetal death.

RESULTS

The rate of complete visualization (four-chamber view plus great arteries) was 47.5% in the unselected population, and 76.9% in the referral population. There were four (0.08%) true positives among the unselected fetuses, and five (2.3%) among referrals, mostly with enlarged nuchal translucency or other malformations. Among the unselected fetuses, nine false negatives were detected by transabdominal echocardiography. Improvement in the operators' ability to recognize cardiac anomalies in unselected population was disappointing and was influenced more by individual approach than by the number of examinations performed.

CONCLUSIONS

Early screening for cardiac anomalies among unselected fetuses is ill-advisable. The usefulness of an early approach is confirmed in high risk fetuses or in the presence of enlarged nuchal translucency when performed by expert operators.

[Post-traumatic diaphragmatic hernia with late diagnosis. Report of a clinical case]

Starting from the observation of a case of late diagnosed left-side hernia after traumatic rupture of diaphragma, the authors consider the increasing incidence of this pathology during the years. The increased frequency of thoraco-abdominal traumas and the more sophisticated diagnostic tools, permit an earlier diagnosis nowadays. In our patient the diagnosis was made late on the basis of the standard x-ray of the thorax. The CT scan of the thorax and of the abdomen gave more informations. Left thoracotomy enabled a wide exposure of the herniated viscera; the breakthrough of the diaphragm was repaired by means of interrupted suture and it was necessary to apply two prostheses of synthetic material.

[Zenker's diverticulum. Apropos a case]

The authors report a case of Zenker's diverticulum in a patient 72 years old who underwent surgery. The pharyngoesophageal function was investigated before and after cricopharyngeal myotomy and diverticulopexy, with oesophageal manometry. Preoperative manometry showed an incomplete relaxation of the upper oesophageal sphincter and increased of pharyngeal pressure. This diverticulum has a pulsion pathogenesis and in this case is not associated with gastroesophageal reflux. It is important to check whether an associated oesophageal pathology exist once Zenker's diverticulum has been diagnosed: X-ray examination of oesophagus and stomach are capable of identifying the presence of diverticulum as well as other pathological association. In the case showed the clinical manifestation are represented by: cervical dysphagia, sensation of foreign body while eating due to the accumulation of ingested food in the diverticulum, and noisy deglutition. The surgical treatment in this case consist of diverticulopexy with cricopharyngeal myotomy. This case is treated with diverticulopexy for two reason: because is not very big and to reduce post-operative period. In conclusion the authors shows the importance of this surgery for not very large sized pouches, and emphasise the importance of manometric and radiographic control in pre and post-operative period. This kind of surgery reduce post-operative complication and the period to stay in bed.

Technical factors in early amniocentesis predict adverse outcome. Results of the Canadian Early (EA) versus Mid-trimester (MA) Amniocentesis Trial

The purpose of this study was to identify risk factors for fetal loss and other pregnancy complications associated with genetic amniocentesis. Data were acquired in the Canadian Early Amniocentesis Trial (CEMAT), a multicentered (12) prospective, randomized trial comparing continuous ultrasound-guided early amniocentesis (EA) and mid-trimester amniocentesis (MA) (CEMAT Group, 1998). Details of the procedure were recorded and analysed by allocation (EA versus MA), operator and centre, and correlated with pregnancy outcome. A total of 62 spontaneous pregnancy losses occurred between the procedure and 20 weeks' gestation among the 3691 patients who received their procedures within the allocated window (EA=53/1916, MA=9/1775). Technical factors correlating with these losses included procedures 'judged to be difficult' by the operator, and post-procedure amniotic fluid leakage or bleeding. Maternal risk factors included maternal hypertension (fetal loss 11. 1 per cent, compared with non-hypertensive women, 2.6 per cent) increased body mass index (BMI) and gravidity of three or greater. Allocation to EA was predictive of fetal loss, as well as failed procedure, multiple needle insertions, amniotic fluid leakage, failed culture and talipes equinovarus, in excess compared with MA. In conclusion, in this large prospective randomized trial evaluating amniocentesis, specific maternal, fetal and procedural variables were found to be predictive of fetal loss and adverse pregnancy outcome. Performing amniocentesis before 13 weeks' gestation (EA) was the major predictive factor for adverse outcome. These data suggest that first-trimester chorionic villus sampling (CVS) and MA will likely remain the invasive procedures of choice for evaluation of fetal karyotype.