Long-term remission of locally recurrent oropharyngeal cancer after docetaxel-based chemotherapy plus cetuximab.

BACKGROUND: In recurrent head and neck squamous cell carcinoma ineligible for resection or irradiation, treatment aims primarily at symptom control and quality of life enhancement with an expected outcome of 6-12 months. METHODS: In 2005, a male patient, born in 1944, with a second local recurrence of human papillomavirus negative tonsil cancer was enrolled in the EXTREME trial, and randomized to platinum/5-fluorouracil/cetuximab arm resulting in partial remission with progression-free survival of 12 months. The second-line systemic therapy comprised 5 cycles of 3-weekly docetaxel/cisplatin/5-fluorouracil regimen plus weekly cetuximab. RESULTS: As confirmed on imaging and repeated biopsies, complete response was achieved with disease-free survival of 8 years and follow-up period of 12 years. Severe acute toxicities during the taxane-based chemotherapy plus cetuximab included grade 4 anorexia and grade 3 febrile neutropenia. CONCLUSIONS: Poor tumor differentiation, no weight loss, oropharyngeal location, white race, and particularly the induced complete response were most likely the key favorable prognostic factors in the reported patient. The possibility of a synergistic interaction between taxanes and cetuximab should be further explored.

The course of diaphragm atrophy in ventilated patients assessed with ultrasound: a longitudinal cohort study.

INTRODUCTION: Mechanical ventilation and the effect of respiratory muscle unloading on the diaphragm cause ventilator-induced diaphragmatic dysfunction (VIDD). Atrophy of the diaphragmatic muscle is a major part of VIDD, and has a rapid onset in most animal models. We wanted to assess the clinical evolution and risk factors for VIDD in an adult intensive care unit (ICU) by measuring diaphragm thickness using ultrasound. METHOD: We performed a single-centre observational cohort study, including 54 mechanically ventilated patients. The right hemidiaphragm was measured daily at the zone of apposition on the midaxillary line. RESULTS: Mean baseline thickness was 1.9 mm (SD ± 0.4 mm), and mean nadir was 1.3 mm (SD ± 0.4 mm), corresponding with a mean change in thickness of 32 % (95 % CI 27-37 %). Length of mechanical ventilation (MV) was associated with the degree of atrophy, whereas other known risk factors for muscle atrophy in an ICU were not. The largest decrease in thickness occurred during the first 72 hours of MV. CONCLUSIONS: Diaphragm atrophy occurs quickly in mechanically ventilated patients and can accurately be monitored using ultrasound. Length of MV, as opposed to other variables, is associated with the degree of atrophy. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov NCT02299986 . Registered 10/11/2014.

Correlation Between Apparent Diffusion Coefficient Value on MRI and Histopathologic WHO Grades of Neuroendocrine Tumors.

BACKGROUND: The correlation of diffusion-weighted MRI and tumor aggressiveness has been established for different tumor types, which leads to the question if it could also apply for neuroendocrine tumors (NET). PURPOSE: To investigate the possible correlation between apparent diffusion coefficient (ADC) value on magnetic resonance imaging (MRI) and histopathologic WHO-grades of NET. MATERIAL AND METHODS: Electronic patient records from patients presented at the multidisciplinary neuro-endocrine tumor board between November 2017 and April 2019 were retrospectively reviewed. Patients with both available MR imaging (primary tumor or metastasis) and known WHO tumor grade were included (n = 47). Average and minimum ADC values (avgADC; minADC) were measured by drawing a freehand ROI excluding only the outermost border of the lesion. The largest axial size (primary tumor) or most clearly delineated lesion (metastasis) was used. RESULTS: Forty seven patients met the inclusion criteria (mean age 59 ± 12 SD; 24F/23M). Twenty one patients (45%) were diagnosed with WHO G1 tumor, 17 seventeen with G2 (36%) and nine with G3 (19%) tumor. Twenty eight primary tumors and 19 metastases were measured. A significant difference was found between low-grade (G1+G2) and high-grade (G3) tumors (Mann-Whitney; avgADC: p < 0,001; minADC: p = 0,001). There was a moderate negative correlation between WHO-grade and avgADC/minADC (Spearman; avgADC: -0,606; 95% CI [-0,773; -0,384]; minADC: -0,581; 95% CI [-0.759; -0.353]). CONCLUSION: Our data show a significant difference in both average and minimum ADC values on MRI between low and high grade NET. A moderate negative correlation was found between histopathologic WHO grade and ADC value.

Is visceral adipose tissue a determinant of von Willebrand factor in overweight and obese premenopausal women?

Visceral obesity has been associated with an increased cardiovascular risk. However, the exact mechanisms are not completely clear. In this study we investigated the relationship between von Willebrand factor (vWF) and visceral adipose tissue (VAT) in a group of 181 overweight and obese premenopausal women visiting the weight management clinic of a university hospital. von Willebrand factor antigen (vWF:Ag), plasminogen activator inhibitor 1 (PAI-1) activity, VAT (computed tomography scan), insulin resistance (homeostasis model assessment of insulin resistance), and other anthropometric and metabolic parameters were measured. Subjects with VAT in the highest quintile had significantly higher levels of vWF:Ag (171+/-60 vs 129+/-40%; P=.001) and PAI-1 (24.7+/-8.5 vs 15.2+/-12.0 AU/mL; P<.001) compared with subjects in the lowest quintile. After correction for fat mass and homeostasis model assessment of insulin resistance the difference was still significant for vWF:Ag (P=.046), but not for PAI-1 (P>.05). Stepwise multiple regression analysis showed VAT and insulin resistance as independent determinants of vWF:Ag, whereas waist circumference, high-density lipoprotein cholesterol, and insulin resistance were independent determinants of PAI-1 activity. In a subgroup of 115 patients, we measured high-sensitivity C-reactive protein and found it to influence the relationship between VAT and vWF:Ag (r=0.16; P=.088), whereas the relationship with PAI-1 was still significant (r=0.21; P=.025). The results from this preliminary study suggest a plausible relation between visceral obesity and endothelial activation, possibly mediated by low-grade inflammation.

Protocol biopsy of the stable renal transplant: a multicenter study of methods and complication rates.

BACKGROUND: Clinical trials in renal transplantation must use surrogate markers of long-term graft survival if conclusions are to be drawn at acceptable speed and cost. Morphologic changes in transplant biopsies provide the earliest available evidence of damage, and "protocol" biopsies from stable grafts can be used to reduce the number of patients needed in clinical trials. This approach has been inhibited by concerns over safety, but the risk of biopsy of a stable kidney, with no active inflammation or acute functional impairment, has never been formally estimated. METHODS: In accordance with a predefined set of questions, a retrospective audit of a sequential series of protocol biopsies was performed in four major transplant centers. RESULTS: A total of 2,127 biopsy events were assessed for major complications, and 1,486 were assessed for minor ones. There were no deaths. One graft was lost, under circumstances indicating that the loss should have been prevented. Three episodes of hemorrhage required direct intervention. Three further patients required transfusion. There were two episodes of peritonitis, but one was arguably an unrelated event. All serious complications presented within 4 hr of biopsy. CONCLUSIONS: The incidence of clinically significant complications after protocol biopsy of a stable renal transplant is low. Direct benefits to the patients concerned (irrespective of the benefit that may accrue in clinical trials) were not formally assessed but seem likely to outweigh the risk of the procedure. We believe that it is ethically justifiable to ask renal transplant recipients to undergo protocol biopsies in clinical trials and routine care.

Posterior tracheal wall laceration after blunt neck trauma in children: a case report and review of the literature.

Adults seem to be more vulnerable than children to tracheal lacerations. Tracheal lacerations have been described particularly after surgical procedures and penetrating trauma, but they may also result from minor blunt trauma. We report the case of a 7-year-old boy who sustained a posterior tracheal wall laceration after a direct frontal fall on a wooden strut. We also review the literature on posterior wall tracheal laceration as an isolated feature after blunt cervical trauma in children, the diagnostic features and management options.

Acute respiratory distress after upper airway obstruction following palatoplasty.

We report a case of acute respiratory distress after upper airway obstruction following routine palatoplasty in an otherwise healthy 6-year-old boy. We believe that extreme variation of intrathoracal pressure was the basis of the development of the acute respiratory distress. We recommend after palatoplasty a more than careful postoperative clinical observation to detect and treat postoperative obstruction and hypoxemia.