International validation of the prognostic value of lymphovascular invasion in patients treated with radical cystectomy

Study Type – Prognosis (retrospective cohort)
Level of Evidence 2b

OBJECTIVE

To externally validate the prognostic value of lymphovascular invasion (LVI) in a large international cohort of patients treated with radical cystectomy (RC) for urothelial carcinoma of the bladder (UCB).

PATIENTS AND METHODS

We collected data from 4257 patients treated with RC and pelvic lymphadenectomy for UCB, without neoadjuvant chemotherapy, at 12 centres. LVI was defined as presence of nests of tumour cells within an endothelium‐lined space.

RESULTS

LVI was detected in 1407 patients (33.1%); the proportion of LVI increased with advancing stage, higher grade, soft‐tissue surgical margin involvement, and lymph node metastasis (P < 0.001 for all). In standard multivariate models, LVI was associated with both disease recurrence (hazard ratio 1.43, P < 0.001) and cancer‐specific mortality (1.45, P < 0.001). In the entire cohort, adding LVI to a base model that included standard features improved only minimally its predictive accuracy for both recurrence and cancer‐specific mortality (by 1.1% and 1.2%, respectively). In 3122 patients with negative lymph nodes, LVI remained independently associated with and improved the predictive accuracy of the standard predictors for recurrence (hazard ratio 1.68, P < 0.001; +2.3%) and cancer‐specific mortality (1.70, P < 0.001; +2.4%). By contrast, in 1071 node‐positive patients, LVI only marginally improved the prediction of cancer‐specific recurrence (hazard ratio 1.20, P < 0.001; +0.2%) and survival (1.23, P < 0.001; +0.5%).

CONCLUSIONS

LVI is strongly associated with clinical outcome in node‐negative patients treated with RC. The assessment of LVI might help to identify patients who could benefit from adjuvant therapy after RC. After confirmation in different populations, LVI should be included in the staging of UCB.     

Aortoenteric Fistula Development following Endovascular Abdominal Aortic Aneurysm Repair: A Case Report

Aortoenteric fistulae (AEF) are now known to occur following endovascular repair of abdominal aortic aneurysms (AAA), presumably because of mechanical forces of dislodged or migrating devices. We present an unusual case of fistula development between the ileum and an AAA presenting as a graft infection following endovascular AAA repair in the absence of direct mechanical strain. Continued pressurization of the aneurysm sac due to endoleak may predispose to this event, especially in large aneurysms. Aggressive surveillance and early interventions are necessary following all endovascular AAA repairs.     

Persistent Left Superior Vena Cava Identified During Central Line Placement: A Case Report

INTRODUCTION: A persistent left superior vena cava is found in 0.3-0.5% of the general population and in up to 10% of patients with a congenital cardiac anomaly. It is the most common thoracic venous anomaly and is usually asymptomatic. Being familiar with such anomaly could help clinicians avoid complications during placement of central lines, Swan-Ganz catheters, PICC lines, dialysis catheters, defibrillators, and pacemakers. CASE PRESENTATION: We describe a case of persistent left superior vena cava that was noted after placement of a central line. Mr JJ is a 41 year old African American man who was hospitalized for evaluation and management of alcoholic necrotizing pancreatitis. He required multiple central lines placements. He was noted to have a persistent left superior vena cava that was not recognized initially and thus lead to an unnecessary extra central line placement. DISCUSSION: This anatomic variant may pose iatrogenic risks if it is not recognized by the clinician. A central catheter that tracks down the left mediastinal border may also be in the descending aorta, internal thoracic vein, superior intercostal vein, pericardiophrenic vein, pleura, pericardium, or mediastinum. CONCLUSION: Our case is significant because the patient had two extra central venous catheter placements. This case strongly demonstrates the importance of knowing the thoracic venous anomalies.     

Congenital diaphragmatic hernias in the adult: report of six cases

The anterior hernia or the fissure of Larrey and Bochdalek hernia are exceptional in adult. We present 6 cases of congenital diaphragmatic hernia revealed in adult. Three hernia of the fissure of Larrey and three Bochdalek hernia. We discuss the different clinical, radiological, and therapeutic aspects of these hernia. We insist on the gravity of strangulated hernia and their surgical treatment.     

BAD and Bcl-2 regulation are early events linking neuronal endoplasmic reticulum stress to mitochondria-mediated apoptosis

The mechanism of endoplasmic reticulum (ER)-mediated apoptosis in neurons was examined. Using primary cortical neurons, we show that nordihydroguaiaretic acid (NDGA) and brefeldin A (BFA), two ER stressors, induce early ER stress as shown by Western blotting of the eukaryotic initiation factor-2alpha (eIF2alpha), an ER stress marker. This event was associated with an enhancement of neuronal apoptosis as demonstrated by the time-dependent increase in caspase-3 activity and by nuclear fragmentation. The study of the apoptotic signaling showed the translocation of cytochrome c from the mitochondrial matrix to the cytosol. Further evaluation of the apoptotic process revealed that NDGA and BFA induced a rapid dephosphorylation of BAD and decrease expression of Bcl-2. Altogether, our results indicate that neuronal ER stress is associated with an apoptotic cascade involving the mitochondria.     

Acute pancreatitis due to a metallic foreign body

We report a case of acute pancreatitis caused by a metallic foreign body located in the pancreatic head in a 38-Year-old woman. Only 15 cases of acute pancreatitis due to foreign bodies, metallic in five cases, have been published to date. In our case, diagnosis was established by the computed tomography scan. The patient declined surgery.