Overview on the role of preoperative therapy in the management of kidney cancer.

The advent of molecular therapy through targeted kinase inhibitors (TKI) has revolutionized the management of renal cell carcinoma. Although surgical resection remains the cornerstone of any therapeutic plan, an increased risk of morbidity and mortality can be of concern in large and complex bulky tumors. Preoperative therapy with TKIs is hypothesized to facilitate resectability, reduce surgical morbidity and allow nephron-sparing surgery. Many concerns on the safety, efficacy and tolerability of these agents before surgery have halted the progress in this setting. In this paper, we will review the indications and safety of preoperative TKIs in RCC as well as the future approaches.

Transcatheter aortic valve implantation: a safe and efficient procedure to treat an aortic valve stenosis before lung cancer resection.

A 75 year old man presented with left upper lobe squamous cell carcinoma. Severe aortic stenosis has been discovered during preoperative assessment. In this situation, two therapeutic strategies are described: concomitant or two-staged procedures. The debate has not yet led to the conclusion on whether preferably performing one or the other. Furthermore, in an oncologic context, using cardiopulmonary bypass is still controversial. So, thoracic and cardiac surgeons jointly proposed to the patient a transcatheter aortic valve implantation followed, 72 h later, by lung cancer resection. This case report describes a way to treat both diseases avoiding cardiopulmonary bypass adverse effects and without delaying lung cancer treatment.

Water deprivation decreases strength in fast twitch muscle in contrast to slow twitch muscle in rat.

AIM: The effects of dehydration on muscle performance in human are still contradictory, notably regarding muscle force. The effect of water deprivation (WD) on mechanical properties of skeletal muscle, and more precisely its impact on slow and fast muscles, remains largely unknown. The aim of this study was to determine for the first time whether WD leads to changes in contractile properties of skeletal muscle and whether these changes were muscle-type-specific. METHODS: Sixteen-week-old male rats were assigned to either a control group (C) with water or a 96-hour WD group. At the end of the period, twitch and tetanus properties, as well as biochemical and structural analysis, were performed on soleus (SOL) and extensor digitorum longus (EDL) muscles. RESULTS: Absolute twitch (Pt) and tetanic (P0 ) tension were, respectively, 17% and 14% lower in EDL of WD rats as compared with C rats, whereas unexpected increases of 43% and 25% were observed in SOL. Tensions normalized with respect to muscle mass were not affected by WD in EDL, whereas they were increased by more than 40% in SOL. A 96-hour WD period leads to a decrease in fibre cross-sectional area and absolute myofibrillar content only in EDL. CONCLUSION: It is hypothesized that differences in the results between slow and fast muscles may come from (i) a muscle-type-specific effect of WD on protein balance, EDL showing a greater myofibrillar protein breakdown and (ii) a greater sensitivity to osmolality changes induced by WD in EDL than in SOL.

Combined life-threatening thromboses and hemorrhages in a patient with afibrinogenemia and antithrombin deficiency.

BACKGROUND: Patients with congenital afibrinogenemia suffer from spontaneous recurrent severe bleeding. While fibrinogen concentrates are known to effectively treat bleeding episodes, thrombotic complications often occur upon replacement therapy, rendering clinical management highly challenging. CASE PRESENTATION: We hereby report a case of combined afibrinogenemia and congenital antithrombin deficiency manifested by recurrent life-threatening bleeding, as well as spontaneous severe arterial occlusion, such as acute coronary syndrome and stroke, and venous thromboses like pulmonary embolism.Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia, yet the high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy combining fibrinogen concentrate with antithrombotic agent for optimal protection against the risk of both severe bleeding and thrombosis. For our patient, the thrombin generation assay objectively confirmed her prothrombotic tendency. CONCLUSION: This case may help us better understand the pathophysiology of arterial thrombosis in afibrinogenemia, while highlighting the difficulty of managing such complications.

Chemotherapy-induced differentiation to cure botryoid rhabdomyosarcoma: a case report and review of the literature.

Rhabdomyosarcoma (RMS) occurs rarely in adults and constitutes 2-6% of all uterine neoplasms. The authors report the case of a 26-year-old woman diagnosed with botryoid RMS that presented discordant progression results on follow up imaging and cytodifferentiation on pathologic control. This case showed that radiological evaluation could be misleading as the tumor demonstrated chemotherapy-induced differentiation without volume reduction. This case illustrates the limitations of using the imaging anatomical dimensions of sarcomas for treatment planning and highlights the potential role of functional imaging to assess the response to treatment.

[Ultrasound comparison of adjustable single-incision (Ajust) and transobturator tapes to assess post-operative fixation and function and clinical efficacy]. / Ultrazvuková studie porovnání kvality fixace pásky a lécebného efektu pásky zavádené z jedné incize (Ajust) a transobturatorní pásky TVT-O.

OBJECTIVE: The aim of this study was to compare fixation and mobility of adjustable single-incision (Ajust) and standard transobturator midurethral sling (TVT-O) tapes based on postoperative ultrasound monitoring of the position of the tape at rest and at maximal Valsava (tape descent). The hypothesis was that fixation of SIMS Ajust is comparable to that achieved by the standard transobturator midurethral sling. SETTING: Gynecology and Obstetrics Department, GUH and 1st Charles University Prague; Gynecology and Obstetrics Department Masarykova nemocnice Ústí nad Labem. DESIGN: Randomized trial, secondary analysis of ultrasound follow-up. METHODS: Between May 2010 and May 2012 100 women with proven urodynamic stress urinary incontinence were included in this randomized trial.All patients underwent a complete urogynecological investigation before the procedure (clinical examination, urodynamics, ultrasound examination), and they filled in the ICIQ and iQol questionnaires; after surgery, to evaluate their satisfaction with the procedure, VAS and Likert scales were added.Ultrasound examination as part of each post-operative check-up was performed the first day after surgery, two weeks, three months and one year after surgery. Ultrasound measurements were taken in a supine position at rest and during maximal Valsalva. Position of the bladder neck was assessed, and the position of the tape with respect to upper and lower tape margins. RESULTS: At one-year follow up no differences in subjective cure rates and objective cure rates were observed. In all checks after surgery there was no difference between the position of the tape at rest and at maximal Valsalva between the Ajust and TVT-O groups.The length of the upper and lower tape descent was similar. In TVT-O patients the mean length of upper tape margin descent increased from 8.8 mm on the first day after surgery to 10.0 mm three months after surgery; afterwards it remained stable. For Ajust patients there was virtually the same development - from 9.1 to 12 mm - and there was no further increase in the tape descent following the three-month measurement. CONCLUSIONS: The quality of the tape fixation after the Ajust procedure is as good as after standard transobturator midurethral sling. We did not observe any statistically significant differences in tape position and descent, indicating that the function is similar to obturator tape, which in turn suggests the same clinical efficacy. Ultrasound monitoring should be the part of post-operative monitoring whenever novel surgical techniques are introduced.

[Comparison of four formulas of adjusting QT interval for the heart rate in young elite athletes]. / Intervalle QT chez les athlètes : comparaison de quatre formules de correction dans une population de jeunes sportifs de haut niveau.

PURPOSE: Sudden cardiac death in young athlete is always tragic. Some international guidelines recommend the realization of an electrocardiogram before practicing competitive sports to carry out the risk of sudden cardiac death due to genetic cardiopathy like QT long syndrome. Unfortunately, the diagnosis can be difficult because intensive sport can increase the QT interval over normal recognized values for sedentary people. Using a QT correction formula free of heart rate appears essential. PATIENTS AND METHODS: Four hundred and forty-six young athletes (aged 10 to 18) had an electrocardiogram. QT intervals were measured and four methods were used to correct the QT interval for heart rate. RESULTS: The Bazett formula performed the worst in terms of rate adjustment success. Hodges and Fridericia formulas are the best both in males and females, independently of age. Female had longer QTc intervals than males. CONCLUSION: The most widely used Bazett formula should be surrendered whereas Hodges and Fridericia formulas should be preferred, particularly in young athletes.

Revealing a cancer diagnosis to patients: attitudes of patients, families, friends, nurses, and physicians in Lebanon-results of a cross-sectional study.

BACKGROUND: Disclosure of a cancer diagnosis to patients is a major problem for physicians in Lebanon. Our survey aimed to identify the attitudes of patients, families and friends, nurses, and physicians regarding disclosure of a cancer diagnosis. METHODS: Study participants included 343 physicians, nurses, cancer patients, families, and friends from clinics in two major hospitals in Lebanon. All completed a 29-item questionnaire that assessed, by demographic group, the information provided about cancer, opinions about the disclosure of the diagnosis to cancer patients, perceived consequences to patients, and the roles of family, friends, and religion. RESULTS: Overall, 7.8% of the patients were convinced that cancer is incurable. Nearly 82% preferred to be informed about their diagnosis. Similarly, 83% of physicians were in favour of disclosing a cancer diagnosis to their patients. However, only 14% of the physicians said that they revealed the truth to the patients themselves, with only 9% doing so immediately after confirmation of the diagnosis. Disclosure of a cancer diagnosis was preferred before the start of the treatment by 59% of the patients and immediately after confirmation of the diagnosis by 72% of the physicians. Overall, 86% of physicians, 51% of nurses, and 69% of patients and their families believed that religion helped with the acceptance of a cancer diagnosis. A role for family in accepting the diagnosis was reported by 74% of the patients, 56% of the nurses, and 88% of the physicians. All participants considered that fear was the most difficult feeling (63%) experienced by cancer patients, followed by pain (29%), pity (8%), and death (1%), with no statistically significant difference between the answers given by the participant groups. CONCLUSIONS: The social background in Lebanese society is the main obstacle to revealing the truth to cancer patients. Lebanese patients seem to prefer direct communication of the truth, but families take the opposite approach. Physicians also prefer to communicate the reality of the disease at the time of diagnosis, but in actuality, they instead disclose it progressively during treatment. Faith is helpful for acceptance of the diagnosis, and families play a key role in the support of the patients. An open discussion involving all members of society is necessary to attain a better understanding of this issue and to promote timely disclosure of a cancer diagnosis.

[Different outcome in two case reports of births showing symptoms of amniotic fluid embolism in the years 2002 and 2012 in the district hospital of Decin]. / Dve kazuistiky porodu s príznaky embolismu plodovou vodou v letech 2002-2012 s ruznými výsledky v Krajské zdravotní a. s., Nemocnice Decín, o.z.

This paper presents two case reports of amniotic fluid embolism quite identical in the onset of symptoms, 1,20 hr, respectively 1,40 hr after extraction of the fetus during delivery by caesarean section, both births were induced by prostaglandins. Both newborns were male. One patient died with autopsy providing evidence of massive pulmonary embolism, laboratory findings showed hemolysis. The second patient survived with neurological disorders, laboratory findings temporarily showed nonspecific antibodies. Both patients were subdued to hysterectomy, no trace of amniotic fluid components were found in the uterine vessels in either one of them.

[Fatal surgical extraction of cardiac resynchronisation therapy defibrillator leads in a context of endocarditis due to methicillin-resistant Staphylococcus epidermidis. A case report and review of literature]. / Extraction chirurgicale fatale de sondes de défibrillateur cardiaque triple chambre dans un contexte d'endocardite à Staphylococcus epidermidis méthicilline-résistant. À propos d'un cas et revue de la littérature.

A 82-year-old man equipped with a cardiac resynchronisation therapy defibrillator for dilated cardiomyopathy with normal coronary arteries, in complete atrioventricular block, develops six months after a change of the generator-pocket a severe endocarditis due to a methicillin-resistant Staphylococcus epidermidis with a large lead vegetation. After 4 days of adapted antimicrobial therapy, a surgical device removal is realised with unfortunately a fatal end during extraction. This observation points out the severity of cardiovascular device infections in old and weak population, as well as the difficulty of treatment choices because of both infectious and rhythmic constraints. The lead extraction is a strong recommendation but the modality and timing of extraction are not consensual, especially in cardioverter defibrillator-dependent patients. Surgical removal remains an alternative to percutaneous lead extraction but with a higher operative risk.

Dynamic properties of water in breast pathology depend on the histological compounds: distinguishing tissue malignancy by water diffusion coefficients.

BACKGROUND: The parameters that characterize the intricate water diffusion in tumors may also reveal their distinct pathology. Specifically, characterization of breast cancer could be aided by diffusion magnetic resonance.The present in vitro study aimed to discover connections between the NMR biexponential diffusion parameters [fast diffusion phase (D(FDP)), slow diffusion phase (D(SDP)), and spin population of fast diffusion phase (P1)] and the histological constituents of nonmalignant (control) and malignant human breast tissue. It also investigates whether the diffusion coefficients indicate tissue status. METHODS: Post-surgical specimens of control (mastopathy and peritumoral tissues) and malignant human breast tissue were placed in an NMR spectrometer and diffusion sequences were applied. The resulting decay curves were analyzed by a biexponential model, and slow and fast diffusion parameters as well as percentage signal were identified. The same samples were also histologically examined and their percentage composition of several tissue constituents were measured: parenchyma (P), stroma (St), adipose tissue (AT), vessels (V) , pericellular edema (PCE), and perivascular edema (PVE). Correlations between the biexponential model parameters and tissue types were evaluated for different specimens. The effects of tissue composition on the biexponential model parameters, and the effects of histological and model parameters on cancer probability, were determined by non-linear regression. RESULTS: Meaningful relationships were found among the in vitro data. The dynamic parameters of water in breast tissue are stipulated by the histological constituents of the tissues (P, St, AT, PCE, and V). High coefficients of determination (R2) were obtained in the non-linear regression analysis: D(FDP) (R2 = 0.92), D(SDP) (R2 = 0.81), and P1(R2 = 0.93).In the cancer probability analysis, the informative value (R2) of the obtained equations of cancer probability in distinguishing tissue malignancy depended on the parameters input to the model. In order of increasing value, these equations were: cancer probability (P, St, AT, PCE, V) (R2 = 0.66), cancer probability (D(FDP), D(SDP))(R2 = 0.69), cancer probability (D(FDP), D(SDP), P1) (R2 = 0.85). CONCLUSION: Histological tissue components are related to the diffusion biexponential model parameters. From these parameters, the relative probability of cancer in a given specimen can be determined with some certainty.

[Infectious thoracic aortic aneurysms: 7 cases and literature review]. / Anévrismes infectieux de l'aorte thoracique : présentation de 7 cas et revue de la littérature.

PURPOSE: Infectious aortic aneurysms are rare conditions, being responsible of 2% of aortic aneurysms. Most published results are surgical case series concerning infected abdominal aorta. In this retrospective study, we assessed clinical features and outcome of patients presenting infectious thoracic aortic aneurysms. PATIENTS AND METHODS: Diagnosis was based upon a combination of imaging evidence for thoracic aorta aneurysm and evidence for an infective aetiology including a culture of a causative pathogen, or a favourable outcome with anti-infective therapy. Retrospective case series. RESULTS: Six men and one woman were included, with a mean age of 66 years. All the patient presented at least one cardiovascular risk factor or atherosclerosis localisation. Fever (71%) and chest pain (42%) were the most common clinical presenting manifestations. The causative pathogens were: Staphylococcus aureus (N=1), Salmonella enteritidis (N=3) and Candida albicans (N=1). The contrast-enhanced computed-tomography disclosed an aneurysm whose diameter reached more than 50 mm (N=5), that increased rapidly in size (N=5), or presented an inflammatory aspect of the aortic wall (N=4). Management was both medical and interventional: surgery (N=3) or endoluminal repair (N=4). Outcome was favourable in six patients; one patient died from aneurysm-related complications. CONCLUSION: Clinical manifestations revealing an infectious thoracic aneurysm are variable. Diagnosis should be considered in patients presenting a rapidly-growing aneurysm, especially in the presence of elevated acute phase reactants. Endoluminal repair constitutes a treatment option. The role of FDG-PET for diagnosis and follow-up remains to be defined.

[Interhospital transport with extracorporeal life support: results and perspectives after 5 years experience]. / Transport interhospitalier sous extracorporeal life support : résultats et perspectives après cinq ans d'expérience.

OBJECTIVE: Describing the experience of a referral center for interhospital patients transport treated with extracorporeal circulatory or respiratory support (ECLS), the difficulties encountered and the results obtained. STUDY DESIGN: Retrospective and observational study. PATIENTS AND METHODS: All patients with respiratory or circulatory failure accepted for extracorporeal assistance for which routine medical transport was life threatening. STATISTICAL ANALYSIS: A descriptive analysis was performed (median and interquartile deviation). Comparison of biological data was performed using a non-parametric Wilcoxon test and 5 years overall survival was determined by a Kaplan-Meier analysis. RESULTS: Over a 55-month period, 29 patients were selected for transportation under ECMO or ECLS. Indication was respiratory failure in 38 % of cases, hemodynamic instability in 52 % of cases and combined symptoms in 10 % of cases. Average duration of transportation was 40 km (9-64 km). No complication related to transport was observed. Incidence of intrahospital death was 57 %. There was no correlation between death and indication of ECLS. Five-year survival was 55 % and 39 % for venovenous and arteriovenous ECLS, respectively. CONCLUSION: In our experience, interhospital transport of patients under ECMO is feasible in satisfactory conditions of safety with trained team and standard procedures.

Sequential FOLFOX-6 and gemcitabine for locally advanced and/or metastatic pancreatic cancer.

This prospective phase II trial aims to evaluate the sequential FOLFOX-6 and gemcitabine followed by adapted maintenance for advanced pancreatic cancer. Treatment included FOLFOX-6 for 4 cycles, followed sequentially by gemcitabine for 3 cycles. Patients, who show clinical benefit after both sequences, will receive maintenance treatment based on the investigator's discretion. From January 2005 to June 2008, 32 patients with median age of 63 were included; 75% of patients had metastatic disease, 81% had pure adenocarcinoma, while 19% had adenocarcinoma with a neuroendocrine component. There were 22% PR and 22% SD resulting in 44% tumor growth control. Under FOLFOX, grade 3/4 toxicities were neutropenia in 8 patients, thrombocytopenia and anemia in 3 patients each, and diarrhea in 2 patients. Under Gem, grade 3/4 neutropenia was observed in 4 patients, thrombocytopenia and anemia were observed in 2 patients, and hand-foot syndrome was observed in 3 patients. The median TTP and OS were 4 and 10 months, respectively. In APC, FOLFOX-6 regimen followed by gemcitabine achieved an interesting RR within a tolerable level of toxicity. This regimen seems to warrant further investigation to confirm its efficacy.

A phase II randomized study comparing navelbine and capecitabine (Navcap) followed either by Navcap or by weekly docetaxel in the first-line treatment of HER-2/neu negative metastatic breast cancer.

UNLABELLED: Following the proven efficacy and tolerability of Navcap and Navcap followed by docetaxel in the treatment of MBC, a phase II randomized study was initiated to assess the ORR of both arms in the first-line setting of MBC. Patients with no prior chemotherapy for MBC and HER-2/neu negative were eligible. All patients received Navcap (V 25 mg/m2 on d1 and d8 and C 825 mg/m2 bid D1-14 q3w) for a total of 4 cycles. Patients progressing under Navcap were withdrawn and received docetaxel as second-line treatment. Patients responding or stable were randomized to 2 arms: 4 cycles of Navcap (A) or 12 weekly docetaxel (25 mg/m²/week) (B). From July 2004 to July 2008, a total of 106 patients were enrolled. Ninety-four patients were evaluable before randomization, with a clinical benefit of 58%. Twenty-one patients (22%) had disease progression and were therefore not randomized. Forty-one patients were randomized to arm A and 29 patients to arm B. ORRs were 56 and 71% in arms A and B, respectively. The median time to progression and overall survival were 10 and 35 months in arm A and 12 and 37 months in arm B. Adverse events were mild. Arm A: grade 3-4 neutropenia (10%), grade 3 anemia (5%). Arm B: grade 3 neutropenia (6%), grade 3 anemia (6.2%), and grade 2 alopecia (12%). CONCLUSION: Both Navcap and Navcap followed by Docetaxel regimens were tolerated with manageable toxicity, offering consistent activities in terms of response rate for metastatic breast cancer patients.

Late respiratory effects of sulfur mustard: how is the early symptoms severity involved?

The association between severity of exposure to sulfur mustard (SM) and late respiratory complications is not clear. The aim of this study was to determine the presence of late pulmonary complications in patients with mild, moderate, and severe initial symptoms of sulfur mustard exposure. This was a retrospective cohort study on patients with mild, moderate, and severe initial symptoms of sulfur mustard exposure (during 1983-1988) in Baqyatallah University of medical sciences (2004-2005). The 'mild' group (n = 115) had no early symptom at the time of exposure. The 'moderate' group (n = 273) had early symptoms after exposure and were not hospitalized for that reason. The 'severe' group (n = 215) had early symptoms and had been hospitalized accordingly. Pulmonary function tests and high-resolution computed tomography of the chest were performed. The chi-square test was used for data analysis. The severe and moderate groups had a similar frequency of obstructive pattern (21%), whereas only one patient in the mild group showed this pattern. Air trapping did not significantly differ between groups. In the mild group, 74.8% (n = 86) showed significant air trapping, whereas it was 62.3% (n = 170) in moderate and 67.0% (n = 144) in severe groups (P = 0.057). Moderate and severe exposure to sulfur mustard causes an equal risk of late pulmonary complications, while mild exposure has lesser risk. Bronchiolitis obliterans is the main underlying respiratory consequence of sulfur mustard exposures and may relate to host factors rather than to severity of early symptoms.

A case of synchronous relapse of breast cancer and uterine müllerian adenosarcoma post tamoxifen in a premenopausal woman.

PURPOSE & METHODS: We report a case of a 42-year-old multigravida, premenopausal woman with breast carcinoma, who presented after four years of use of adjuvant tamoxifen with synchronous liver, bone, and lung metastasis of breast cancer with müllerian adenosarcoma. RESULTS: Immunohistochemical stains on the uterine tumor for estrogen and progesterone receptors showed positivity for both epithelial and stromal cells, actin, and desmin while the proliferative index (MIB-1) showed positivity for stromal cells only. The patient underwent a hysterectomy followed by palliative chemotherapy. She died 14 months after her relapse because of progressive disease (cerebral, bone, liver and lung metastases). CONCLUSION: Our case is the only one reported in the literature with synchronous relapse of breast adenocarcinoma and a Müllerian adenosarcoma. Moreover, it is one of the rare cases occurring in a premenopausal woman since all except two cases were postmenopausal.

Metachronous single lung transplantation after contralateral pneumonectomy. A ''big'' challenge?

Single lung transplantation for cystic fibrosis is an uncommon therapy. Contralateral pneumonectomy is, in these cases, rarely done before transplantation. Herein, we report the case of a single lung transplantation in a patient who had previously a contralateral pneumonectomy.