Chromogranin A,a Marker of the Therapeutic Success of Resection of Neuroendocrine Liver Metastases: Preliminary Report

Recent publications indicate that life may be prolonged by surgical debulking of neuroendocrine tumors. A minimum 90% reduction of liver metastases has been suggested to alleviate symptoms of the carcinoid. We have used the tumor marker chromogranin A (CgA) to assess hepatic resection in patients with neuroendocrine metastatic tumor disease. Since 1998, seven patients (3 men) of median age 73 years (range 64–84 years) with carcinoid primary tumors in the ileum who had solitary (n = 2) or multiple (n = 5) liver metastases underwent hepatic resections. Two patients had synchronous small intestinal and liver resections; the rest had deferred hepatic resections after intestinal resection. Hormonal manifestations in the form of loose stools or diarrhea or flushing were observed in five patients, and five had abdominal symptoms from partial obstruction of the small bowel. The resection was deemed radical in five patients. Two patients with non-radical resection needed postoperative octreotide treatment, and symptoms were alleviated or improved in the others. All seven patients are alive with an observation period from 6 to 64 months (median 36 months). Median CgA (normal < 30 ng/ml) was 292 ng/ml (range 79-14,000 ng/ml) before liver surgery. Postoperatively, CgA became normal in three of the radically resected patients, whereas in two others, it decreased to a lowest median level of 79 ng/ml (range 52–105 ng/ml). In two palliatively resected patients, one had a near normalization to 65 ng/ml, and the last patient had a reduction from 14,000 to 2400 ng/ml following debulking surgery. A similar postoperative reduction was noted for 24 hr urinary 5-HIAA excretion. Postoperative octreotide scintigraphy suggested residual hepatic or extrahepatic tumors in three of the patients thought radically resected, whereas two had no clear sign of disease corresponding to a normal CgA value. The CgA values, however, reflected the extent of positive scintigraphy findings. Serum CgA levels monitored the extent and short-term course of the disease and corresponded well with scintigraphy findings and 5-HIAA excretion, but prolonged follow-up in more patients may be necessary before decisive conclusions are allowed to be drawn.     

The nutrient artery canal of the femur: a radiological study in patients with primary total hip replacement

Objective Plain antero-posterior and lateral radiographs of the femur often show radiolucent lines, which may reflect the canal of a nutrient artery. In patients who have undergone total hip replacement these radiolucent lines must be differentiated from fractures caused by bursting of the shaft during the procedure.Design and patients In a retrospective radiological study 129 extremities of 95 patients with cementless primary hip prostheses were examined for radiolucent lines. Pre- and postoperative antero-posterior and lateral radiographs were analyzed.Results In 34 of 129 extremities (26.4%) radiolucent lines compatible with a nutrient artery canal were detected, 14 of which (10.9% overall) were seen on lateral radiographs. In 11 of 129 extremities (8.5%) a nutrient artery canal was detected only on the antero-posterior views, while in 9 of 129 extremities (7.0%) it was well defined in both projections. One patient (0.8%) presented with a fracture postoperatively, which was radiologically distinct from a nutrient artery canal. The distance between the tip of the greater trochanter and the proximal end of the nutrient artery canal was 170±25 mm; the canal length was 27±9 mm.Conclusion Nutrient artery canals are often seen radiologically on pre- and postoperative radiographs down to the mid-shaft level and should be routinely recorded.     

Combination of low and high resolution sequences in two orientations for dynamic contrast-enhanced MRI of the breast: more than a compromise

The purpose was to combine T1-weighted 3D gradient echo sequences at low and high spatial resolution (and short and longer acquisition time, respectively) in two orientations without compromising signal/time curve analysis and to evaluate the incremental value of assessing architectural features in high resolution images in dynamic contrast-enhanced MR mammography. T1-weighted 3D-FLASH sequences in a 1.5-T scanner (512×256 pixel matrix at high resolution; 256×128 pixels at low resolution sequences, 72 slices, 1.7-mm slice thickness, TR 8.8 ms, TE 4.5 ms, flip angle 25°) were acquired in a special order during a single investigation. Three observers evaluated architectural features of 36 histopathologically proven lesions using high or low resolution images independently. Architectural features of each lesion were assessed by rating on two three-point scales. Kappa statistics verified the decrease of inter-observer variability. All observers improved assessment of architectural features regarding high resolution images in transversal and coronal orientation (observer A: eight positive, three negative corrections; B: 12/5; C: 16/4). Most positive corrections resulted from improved detection of morphologic criteria of malignancy. Mean inter-observer agreement significantly (P<0.05) increased from slight to moderate (mean weighted increased from 0.185 to 0.422). This protocol at the charge of slightly enlarged time for measurement offers an elegant way to improve analysis of architectural features in MRM.     

Central nervous system control of the lower urinary tract: new pharmacological approaches to stress urinary incontinence in women

PURPOSE: Despite the prevalence of stress urinary incontinence in women there are no approved drugs for the disease. MATERIALS AND METHODS: Designing medical therapies requires a comprehensive understanding of how the internal and external sphincters are neurologically controlled. In this review recent advances in mapping storage and micturition reflexes, and the association of serotonergic and noradrenergic systems with these reflexes are discussed. RESULTS: Urine storage and micturition are controlled by a series of hard wired reflexes that are under the modulatory influence of serotonin and norepinephrine. Augmentation of the serotonergic and noradrenergic systems with duloxetine increases bladder capacity and urethral rhabdosphincter activity. The increase in sphincter activity is mediated by alpha1 adrenergic receptors and 5-hydroxytryptamine receptors. CONCLUSIONS: Increasing rhabdosphincter activity with duloxetine may offer a therapeutic benefit in women with stress urinary incontinence.     

Photodynamic therapy of prostate cancer by means of 5-aminolevulinic acid-induced protoporphyrin IX - in vivo experiments on the dunning rat tumor model

OBJECTIVE: In order to expand the use of photodynamic therapy (PDT) in the treatment of prostate carcinoma (PCA), the aim of this study was to evaluate PDT by means of 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PPIX) in an in vivo tumor model. METHODS: The model used was the Dunning R3327 tumor. First of all, the pharmacokinetics and the localization of PPIX were obtained using fluorescence measurement techniques. Thereafter, PDT using 150 mg 5-ALA/kg b.w. i.v. was performed by homogenous irradiation of the photosensitized tumor (diode laser lambda = 633 nm). The tumors were resected 2 days post-PDT and the extent of the necrosis was determined histopathologically. RESULTS: The kinetics of PPIX fluorescence revealed a maximum intensity in the tumor tissue within 3 and 4.5 h post-application of 5-ALA. At this time, specific PPIX fluorescence could be localized selectively in the tumor cells. The PDT-induced necrosis (n = 18) was determined to be 94 +/- 12% (range 60-100%), while the necrosis of the controls (n = 12) differs significantly (p < 0.01), being less than 10%. CONCLUSION: These first in vivo results demonstrate the effective potential of 5-ALA-mediated PDT on PCA in an animal model.     

Oblique screws at the plate ends increase the fixation strength in synthetic bone test medium

OBJECTIVE: To test the hypothesis that oblique screws at the ends of a plate provide increased strength of fixation as compared to standard screw insertion. DESIGN: Biomechanical laboratory study in synthetic bone test medium. METHODS: Narrow 4.5-mm stainless steel low-contoured dynamic compression plates were anchored with cortical screws to blocks of polyurethane foam. The fixation strength in cantilever bending (gap closing mode) and torsion was quantified using a material testing system. Different constructs were tested to investigate the effect of the screw orientation at the end of the plate (straight versus oblique at 30 degrees), the plate, and bridging length as well as the number of screws. RESULTS: An oblique screw at the plate end produced an increased strength of fixation in all tests; however, the difference was more significant in shorter plates and in constructs with no screw omission adjacent to the fracture site. Both longer plates and increased bridging length produced a significantly stronger construct able to withstand higher compression loads. Under torsional loading, the fixation strength was mainly dependent on the number of screws. CONCLUSIONS: The current data suggest that when using a conventional plating technique, plate length is the most important factor in withstanding forces in cantilever bending. With regard to resisting torsional load, the number of screws is the most important factor. Furthermore, oblique screws at the ends of a plate increase fixation strength.     

Current management of infants with fetal renal pelvis dilation: a survey by French-speaking pediatric nephrologists and urologists

To analyze the current management recommendations among French-speaking physicians treating infants with antenatal renal pelvis dilatation, we surveyed 83 pediatric nephrologists and 68 pediatric urologists by questionnaire. A total of 45 (54%) pediatric nephrologists and 38 (56%) pediatric urologists responded. The threshold for the diagnosis of abnormal fetal renal pelvis dilatation was significantly higher among pediatric urologists than nephrologists. All responders perform renal ultrasound examinations after birth. Postnatal renal pelvis dilatation was considered abnormal if the anteroposterior diameter was 11±1.9 mm by the pediatric urologists and 9±2.9 mm by the pediatric nephrologists (P=0.003). Pediatric urologists were more likely than nephrologists to recommend routine voiding cystourethrography [41% versus 20% (P=0.04)]. Mercaptoacetyl-triglycine renography was the most routinely used tool to achieve functional evaluation during follow-up among the responders. Pediatric urologists were more likely to recommend surgical treatment in dilated kidneys with initial function <40%. In conclusion, pediatric urologists had significantly higher thresholds for the detection of prenatal and neonatal renal pelvis dilatation. They also more frequently recommended routine voiding cystourethrography and surgical therapy of dilated kidneys with low function than pediatric nephrologists. The variability in attitudes is most probably due to the absence of clear guidelines based on prospective and controlled trials.The following workers contributed to this study. For the French-speaking Society of Pediatric Nephrology (SNP): J. Al Hosri (Hôpital Nord, Amiens, France), J.L. André (Hôpital dEnfants, Nancy, France), A. Bensman (Hôpital Trousseau, Paris, France), E. Berard (LArchet II, Nice, France), J.P. Bertheleme (Centre Hélio Marin, Roscoff, France), F. Bouissou (Hôpital des Enfants, Toulouse, France), G. Bourdat-Michel (CHU, Grenoble, France), G. Champion (CHU, Angers, France), S. Cloarec (Hôpital Clocheville, Tours, France), L. Collard (Hôpital E. Herriot, Lyon, France), J.C. Davin (Emma Childrens Hospital, Amsterdam, Holland), L. de Parscau (Hôpital Augustin Morvan, Brest, France), S. Decramer (Hôpital des Enfants, Toulouse, France), V. Desvignes (CH, Clermont Ferrand, France), R. Donckerwolcke (AZ, Maastricht, Holland), J. Ehrich (MHH, Hannover, Germany), M. Fischbach (Hôpital de Hautepierre, Strasbourg, France), M. Foulard (Hôpital Jeanne de Flandre, Lille, France), M.S. Ghuysen (CHU Sart Tilman, Liège, Belgium), J.B. Gouyon (Hôpital dEnfants, Dijon, France), J.P. Guignard (CHUV, Lausanne, Switzerland), C. Guyot (CHU, Nantes, France), P. Hansen (Hôpital Tivoli, La Louvière, Belgium), J.P. Hehunstre (Hôpital Pellegrin, Bordeaux, France), F. Janssen (Hôpital Universitaire des Enfants, Brussels, Belgium), M.J. Krier (Hôpital dEnfants, Nancy, France), A. Lahoche-Manucci (Hôpital Jeanne de Flandre, Lille, France), H. La Selve (Centre Hélio Marin, Roscoff, France), M.P. Lavocat (Hôpital Nord, Saint Etienne, France), C. Loirat (Hôpital Robert Debré, Paris, France), J. Lombet (CHR La Citadelle, Liège, Belgium), A. May (CH Sud Francilien, Evry, France), D. Morin (Hôpital Arnaud de Villeneuve, Montpellier, France), J.B. Palcoux (Hôtel Dieu, Clermont Ferrand, France), S. Palomera (CTMR, Bordeaux, France), C. Pietrement (American Memorial Hospital, Reims, France), S. Ploos van Amstel (Emma Childrens Hospital, Amsterdam, Holland), W. Proesmans (UZ Gasthuisberg, Leuven, Belgium), N. Ranguelov (CHU, Charleroi, Belgium), B. Roussel (American Memorial Hospital, Reims, France), M.H. Said (Hôpital E. Herriot, Lyon, France), A. Taque (Hôpital de Pontchaillou, Rennes, France), M. Tsimaratos (Hôpital La Timone, Marseille, France). R. Van Damme-Lombaerts (UZ Gasthuisberg, Leuven, Belgium)For the French-speaking Pediatric Urology Study Group (GEUP): T. Aivazoglou (Aglaia Kyriakou Hospital, Athens, Greece), J.L. Alain (CHU Dupuytren, Limoges, France), P. Alessandrini (Hôpital Nord, Marseille, France), G. Audry (Hôpital Trousseau, Paris, France), M. Avérous (Hôpital Lapeyronie, Montpellier, France), R. Besson (Hôpital Jeanne de Flandre, Lille, France), J. Biserte (Hôpital Huriez, Lille, France), B. Boillot (CHU Albert Michallon, Grenoble, France), J.M. Bondonny (Hôpital des Enfants, Bordeaux, France), J.P. Bonnet (Hôpital Simone Veil, Montmorency, France), P. Bugmann (Hôpital des Enfants, Geneva, Switzerland), F. Collier (Hôpital Universitaire des Enfants, Brussels, Belgium), J.F. Colombani (CHU, Fort-de-France, France), H. Dodat (Hôpital E. Herriot, Lyon, France), B. Dore (CHU, Poitiers, France), A. El Ghoneimi (Hôpital R. Debré, Paris, France), C. Esposito (Universitary Hospital, Naples, Italy), B. Fremond (Clinique Chirurgicale infantile, Rennes, France), P. Frey (CHUV, Lausanne, Switzerland), S. Geiss (Centre de la Mère et lEnfant, Colmar, France), I. Germouty (CHU, Brest, France), Y. Heloury (CHU, Nantes, France), A. Lacombe (Hôpital Clocheville, Tours, France), S. Lortat-Jacob (Hôpital Necker-Enfants Malades, Paris, France), T. Merrot (Hôpital Nord, Marseille, France), R. Moog (Hôpital de Hautepierre, Strasbourg, France), G. Morisson-Lacombe (Hôpital Saint Joseph, Marseille, France), J. Moscovici (Hôpital des Enfants, Toulouse, France), P. Mouriquand (Hôpital Debrousse, Lyon, France), E. Sapin (CHU, Dijon, France), A. Savanelli (Universitary Hospital, Catanzaro, Italy), M. Schmitt (Hôpital dEnfants, Nancy, France), H. Steyaert (Fondation Lenval, Nice, France), C. Tölg (CHU, Fort-de-France, France), J.S. Valla (Fondation Lenval, Nice, France), F. Varlet (Hôpital Nord, Saint Etienne, France), P. Wallon (Centre de Chirurgie de lEnfant, Bordeaux, France), D. Weil (Centre Hospitalier, Le Mans, France)     

Orbitofrontal epilepsy: electroclinical analysis of surgical cases and literature review

Clinical and electrographic data were reviewed on 2 of our patients with orbitofrontal epilepsy who were seizure free at 5-year follow-up, and on 2 similar patients from the literature. One of our patients was lesional, and the other was nonlesional. Interictal EEG discharges were lateralized to the side of invasively recorded orbitofrontal seizures in the nonlesional case. In this case, no clinical manifestations occurred until the orbitofrontal discharge had spread to the opposite orbitofrontal and both mesial temporal areas. Unresponsiveness or arrest of activity were the initial manifestations of complex partial seizures in both cases. The 2 cases from the literature with long-term seizure-free follow-up had little impairment of awareness and displayed vigorous motor automatisms. Interictal epileptiform activity was bifrontally synchronous in 1 case. Ipsilateral frontotemporal discharges were seen in both. Invasive ictal epileptiform activity appeared maximal in the ipsilateral orbitofrontal region in both patients. No consistent electrographic or clinical pattern characterized these 4 cases. Seizures of orbitofrontal origin may be characterized by either unresponsiveness associated with oroalimentary automatisms or limited alteration of awareness and associated with vigorous motor automatisms. Invasive monitoring of the orbitofrontal cortex should be considered in nonlesional cases with complex partial seizures that show nonlocalizing ictal patterns and interictal frontal or frontotemporal epileptiform discharges.