Concomitant cisplatin and radiotherapy in a conventional and modified fractionation schedule in locally advanced head and neck cancer: a randomised phase II EORTC trial

A randomised phase II trial was initiated to explore the feasibility of concomitant cisplatin and radiotherapy with conventional fractionation (CF) or multiple fractions per day (MFD) for patients with locally advanced head and neck malignancies. The MFD schedule was designed to achieve higher tumour concentrations of cisplatin at the time of irradiation by reducing the number of radiation treatment weeks from 7 to 3, allowing recovery from side-effects of both irradiation and cystostatic drugs during the rest periods, while keeping the same total dose and overall treatment time. Patients were randomised between a conventional fractionation scheme (CF) of 70 Gy in 7 weeks with 2 Gy per fraction with a daily dose of 6 mg/m(2) cisplatin and a modified fractionation scheme (MFD) delivering three fractions of 1.6 Gy per day, in weeks 1, 4 and 7, keeping the same overall treatment time and total dose. In the modified treatment regime, a daily dose of 10 mg/m(2) cisplatin was administered. 53 patients were entered in this trial and radiotherapy was given according to the schedule to all patients in both treatment arms. Cisplatin was given during the whole course of radiotherapy to only one quarter of the patients in the CF arm, stopping mostly after 5-6 weeks due to bone marrow depression and kidney toxicity, while patients in the MFD arm received it according to schedule. No difference was observed in acute and late toxicity in both treatment arms, while a similar or even better tumour response was obtained with MFD. A 67% higher daily dose of cisplatin concomitant with irradiation could be given in a 3-week multiple fractionation per day schedule, as opposed to the cisplatin given in the conventional daily fractionation schedule of 7 weeks with the same total radiation dose. Similar acute and late toxicities were seen in both treatment arms.     

Inhibition of O6-alkylguanine-DNA alkyltransferase by O6-benzyl-N2-acetylguanosine increases chloroethylnitrosourea-induced apoptosis in Mer+ human melanoma cells

The exposure of cells to -benzyl- 2-acetylguanosine (BNAG) and several guanine derivatives is known to reduce -alkylguanine-DNA alkyltransferase (AGAT) activity and to decrease the resistance of methyl enzyme repair positive (Mer ) cells to chloroethylnitrosoureas (CENUs) and. We evaluated the influence of AGAT activity inhibition by BNAG on the ability of two CENUs, 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) and 3-(2-chloroethyl)-1-(2-methylsulphonyl)ethyl-3-nitrosourea (cystemustine), to induce an apoptotic response in two melanoma cell lines, M3 Dau (Mer ) and IPC 227F (Mer ). The apoptotic morphology of cells was assessed by microscopy after Wright-Giemsa or Hoechst 33342 staining of cells, and DNA internucleosomal cleavage was demonstrated by the ladder-like pattern of DNA separated by agarose gel electrophoresis. The concentration-dependent number of apoptotic cells assessed using a terminal deoxynucleotidyl transferase-mediated dUTP-fluorescein nick-end labelling (TUNEL) assay 72 h after BCNU or cystemustine treatment (0-400 microM for 2 h) was increased by prior AGAT depletion with BNAG pretreatment (300 microM for 4 h) in Mer cells. These results suggest that the DNA lesions on the position of guanine are a key event in inducing an apoptotic response in melanoma cells. We also observed that cystemustine was a more potent inducer of apoptosis than BCNU, and that the synergism with BNAG was more potent with cystemustine than with BCNU. These results suggest that the nature of the CENUs associated with an AGAT inhibitor is a determinant factor in forecasting the clinical efficacy of the association, especially in melanoma.     

Long-term follow-up of a randomised trial designed to determine the need for irradiation following conservative surgery for the treatment of invasive breast cancer.

Four hundred consecutive patients aged under 70 years diagnosed with a clinical T1 or T2 breast cancer were randomised to receive post-operative radiotherapy (n = 208) or not (n = 192), and monitored to record all local recurrences, distant recurrences and deaths for up to 20 years (median 13.7 years). All patients were treated by wide local excision and adjuvant therapy [estrogen receptor (ER) positive: tamoxifen; ER negative: CMF chemotherapy]. Kaplan-Meier and log-rank test methods were used to estimate and compare survival and recurrence. The 20-year Kaplan-Meier rates for local breast recurrence were 28.6% [95% confidence interval (CI) 19.6% to 37.6%] for radiotherapy and 49.8% (95% CI 40.8% to 58.9%). There was no significant difference between the two groups with regard to disease-free or overall survival. The hazard ratio for death among women who received radiation, as compared with those that did not, was 0.91 (95% CI 0.64-1.28; P = 0.59). Therefore, post-operative radiotherapy produced a clear-cut reduction in locoregional recurrence 0.45 (0.31-0.64; P = 0.0001), but did not influence the incidence of distant metastases or time of death. However, of the 119 patients who had a local recurrence, 51 (42.8%) had a distant recurrence, whereas of the 281 without local recurrence only 59 (21%) ever had a distant recurrence. A Cox's regression analysis with local recurrence as a time-dependent variable showed a risk ratio of 5.28 (P < 0.0001). This strong relationship is dependent on the intensity of post-treatment follow-up and investigation.     

Assessing abnormal gene promoter methylation in paraffin-embedded sputum from patients with NSCLC

Aberrant methylation of CpG islands is an important pathway for regulation of gene expression. Recent data suggest that epigenetic abnormalities may occur very early in lung carcinogenesis. We studied the promoters of the four genes, HOX A9, p16(INK4a) (p16), MAGE A1 and MAGE B2 by methylation-specific PCR in matched normal tissue, tumour, and cytological negative sputum samples obtained from 22 patients with non-small cell lung cancer (NSCLC). We further report methylation abnormalities in sputum samples from 56 smokers with differential cytology readouts (negative, inflammatory changes, suspicious, and cancer). Our method was successfully performed on formalin-fixed and paraffin-embedded (FFPE) samples, and was fit to study only few cells obtained by a convenient non-invasive sputum collection and handling. The promoters of MAGE A1 and MAGE B2 had abnormal methylation patterns in, respectively, 50% and 41% of the cytologically negative sputum samples from NSCLC patients, whereas methylation abnormalities of p16 was observed in 27% of negative sputum samples. Interestingly, 95.5% (21 of 22) of the cytologically negative sputum samples from NSCLC patients had abnormal methylation in at least one of the four genes indicating a high sensitivity of this marker system. Moreover, a higher frequency of methylation abnormalities was observed in sputum samples from smokers with high cytological grade compared to low cytological grade. We conclude that the identification of abnormal gene methylation of a limited number of markers in FFPE sputum samples is feasible and may be investigated as a potential system for population-based screening of early stages of lung cancer.     

Human immune reconstitution with spleen cells in SCID/Beige mice

BACKGROUND: We developed an original experimental model to study chronic vascular rejection (CVR) consisting of a graft of human mesenteric artery followed by human immune reconstitution into CB.17 SCID/Beige mice. Human immune reconstitution achieved after human PBMC injection has often been variable and incomplete. The aim of this work was to develop an alternative method to achieve a complete, functional human immune reconstitution. METHOD: After institutional authorizations, spleen cells were recovered from cadaveric organ donors. Single intraperitoneal injections of various doses of spleen cells were made into 70 CB.17 SCID/Beige mice. Reconstitution of the human immune system was monitored by flow cytometry (circulating human cells) and ELISA (human IgG). Colonization of murine lymphoid organs by human cells was studied by immunohistochemistry and flow cytometry. Evaluation of the immune function consisted of examination of CVR lesions in human arterial grafts. The animals were humanely killed at day 28. RESULTS: After injection of 30 to 40 x 10(6) spleen cells, the mice showed significant human CD3(+), CD19(+), and CD56(+) populations in peripheral blood. The mean human cells levels were, respectively, 8.2% +/- 5.4%, 2.9% +/- 1.2%, and 5.3% +/- 5.1%. Murine spleen and mesenteric lymph nodes were colonized by human T and B cells, while the murine thymus was only colonized by human T cells. Human IgG was detected in murine serum (65.9 +/- 63.3 mg/L) and typical CVR lesions were observed within the allogeneic grafts. CONCLUSION: Intraperitoneal injection of 30 to 40 x 10(6) human spleen cells into CB.17 SCID/Beige mice induces complete and functional human immune reconstitution allowing the study of CVR under human allogeneic conditions.     

Salvage of amputated digits by temporary ectopic implantation

We present two clinical cases with complete amputation of multiple digits that were salvaged after having been successfully implanted on ectopic sites. The first case concerns a 73-year-old patient, who suffered a severe crush injury of his right hand that resulted in amputation of all four long fingers and an extensive tissue loss of the palm and the dorsum of the hand. Two of the amputated digits, that were considered to be replantable, were implanted on the dorsum of the left foot. The hand defect was covered with a pedicle groin flap. After six weeks, the two ectopically implanted fingers were transferred to their proper anatomical site. Several reconstructive procedures were performed later, in order to lengthen the first ray of the injured hand, and to deepen the first web space. Satisfactory functional results were recorded after eighteen months of follow-up. The second patient concerns a 45-year-old male patient, who had a gun shot accident of his right hand. The injury resulted in a composite tissue loss of the hand with complete amputation of his four long fingers. All fingers were implanted on the left forearm, while the hand defect was reconstructed using an osteocutaneous free flap of the iliac crest. Six weeks after the initial procedure, the ectopically implanted digits were transferred - as a single free flap - to the hand. We described with details the local conditions of the injured hands in both cases, and discuss the reasons we decided to perform this sophisticated method in order to preserve the viability and function of those totally amputated fingers. The recipient sites were selected in a distance from the injured area, always considering the availability and size of appropriate recipient vessels, and the safety of the surgical procedure. We agree that the whole concept of this procedure is very demanding, and requires several microsurgical operations with high risk of complications. However, it does deserve special consideration in reconstructive microsurgery, since it offers the possibility to salvage multiple amputated digits, by preserving the anatomy and restoring the function of severely injured hands.     

Urosepsis. Current therapy and diagnosis

Urosepsis is defined as sepsis caused by urinary tract infection. This occurs in 25% of all sepsis cases. Because of the increasing incidence of sepsis, this entity will be seen more frequently in medical practice and outpatient units. The immediate identification and treatment of the septic focus is crucial. Depending on severity, early reconstitution of adequate oxygen delivery has parallel priority, therefore necessitating intensive care unit treatment within the first hours. Therapy should consist of eliminating the infectious focus, antimicrobial treatment, supportive therapy, and special sepsis therapy.     

Successful extracorporeal resuscitation of a probable perioperative anaphylactic shock due to atracurium

We report the case of a 55-year-old woman ASA 2 scheduled for a cholecystectomy, who presented 25 minutes after the induction, a circulatory arrest probably due to a cardiac anaphylaxis attributed to atracurium. After 60 minutes of futile resuscitation without any spontaneous cardiac rhythm a percutaneous cardiopulmonary bypass (CPB) was initiated. Twenty minutes later and after three external electric shocks electric cardiac activity returned normal. The weaning was possible 120 minutes later with catecholamine support. She left the intensive care unit on postoperative day seven after a laparotomy secondary to splenic injury due to intensive cardiopulmonary resuscitation. She was discharged home without any neurologic or cardiac sequellae. Biological assessment done during the circulatory arrest and cutaneous tests performed ten weeks later confirmed an isolated allergy to atracurium. CPB is the most efficient support in case of reversible cardiac arrest but unfortunately the less accessible outside from cardiac surgery unit.     

Shoulder arthritis due to Haemophilus aphrophilus

We report a case of shoulder arthritis due to Haemophilus aphrophilus. The patient, a 56 year-old woman, was immunocompetent. She presented with a septic arthritis of the left shoulder without portal of entry. A synovial fluid sample was cultured and positive for a gram-negative bacillus after 8 days. It was identified as Haemophilus aphrophilus, in the HACCEK group, by PCR ARN 16S. We did not find any associated endocarditis. The patient recovered. As far as we know, this is only the 5th reported case of arthritis due to this microorganism.     

Recombinant canarypox vectored West Nile virus (WNV) vaccine protects dogs and cats against a mosquito WNV challenge

The safety and efficacy of a canarypox vector expressing PrM and E genes of West Nile virus (WNV) (ALVAC-WNV) was evaluated in dogs and cats. One group of 17 dogs (vaccinated with 10(5.6) TCID(50)) and two groups of cats (groups 1 [n=14] vaccinated with 10(7.5) TCID(50) and 2 [n=8] 10(5.6) TCID(50)) were vaccinated twice at 28-day intervals. Fifteen dogs and eleven cats served as negative controls. The cats and dogs were challenged 120 and 135 days after the second immunization, respectively via the bites of Aedes albopictus mosquitoes infected with WNV. The first dose of vaccine induced a detectable antibody response in four dogs and five cats (one immunized with low and four with high doses). After the second dose, all the vaccinated dogs and all of the cats, immunized with high dose had detectable antibody titers, whereas only four of eight cats in the low dose group were seropositive. None of the vaccinated dogs and one vaccinated cat developed viremia following the WNV mosquito-challenge. In contrast, 14 of the 15 control dogs and 9 of the 11 control cats developed viremia. The experimental vaccine described in this study may be of value in the prevention of WNV infection in dogs and cats.