[Treatment of exudative age-related macular degeneration: Consensus of French experts for first-line treatment selection and the importance of long-term risk/benefit ratio]. / Consensus d'experts français sur les critères de choix d'un traitement de 1re intention dans la DMLA néovasculaire et importance du ratio bénéfice/risque à long terme.

Choosing a first-line treatment to optimize long-term outcomes is a major challenge for treating patients with neovascular age-related macular degeneration (AMD). The development of several new molecules makes it critical to identify the relevant factors to consider so as to provide an optimal risk-benefit ratio when initiating a treatment in naïve patients with neovascular AMD. This paper proposes a consensus established with the Delphi method (which includes a gradation in a consensus based on an analysis of the convergence rate of answers) to provide criteria that guide the ophthalmologist's decision for treatment initiation and follow-up in neovascular AMD patients. Fourteen questions were submitted to 93 French retina experts. Thirteen (93%) of the questions reached a consensus (≥50% of answers consensual). The criteria recommended to take into account were both efficacy and onset of action of the molecules, their safety, and the ability to decrease injection frequency. The primary criterion of expected efficacy of a molecule is a combination of the gain in visual acuity and resorption of retinal fluid. With regard to safety, experts recommend tighter follow-up for molecules currently in development, and at every scheduled visit, patients should be screened to identify early any potential adverse effects such as intraocular inflammation, retinal vasculitis or vascular occlusion. Experts also emphasize the importance of the packaging of the biological, with a preference toward prefilled syringes. Injection frequency is a key factor, and the authors recommended aiming for a maximal injection interval of 12 to 16 weeks. The stability of that maximum interval is also an important factor to consider in treatment selection.

[Treat-and-extend anti-angiogenic protocol in clinical practice for patients with exudative age-related macular degeneration: Consensus of French experts]. / Consensus d'experts français sur la mise en œuvre pratique du régime Treat-and-Extend par anti-angiogéniques chez les patients atteints de DMLA exsudative.

Optimizing treatment regimens for anti-angiogenic drugs is now a major issue in the management of patients with exudative AMD. The evolution of these approaches has led retinologists to favor so-called proactive administration regimens, such as Treat-and-Extend (T&E), which make it possible to anticipate recurrence and to plan intravitreal injections of anti-angiogenic drugs in advance. Nevertheless, a real need to standardize the application of this regimen has been identified. This article proposes a consensus based on the Delphi methodology, which might provide a guide for ophthalmologists to manage patients with exudative AMD using the T&E protocol. While some aspects remain debated to date, this article provides elements to guide the implementation of T&E. The experts recommend that a loading dose of 3 monthly injections should be administered before starting T&E. They also recommend adjusting the reinjection intervals by±2 weeks in a standardized fashion. The intervals are then decreased in the presence of anatomical and/or functional deterioration, maintained when the interval of recurrence is identified, and increased when anatomical and/or functional improvement is observed. A maximum interval between 3 and 4 months is recommended by the experts, with maintenance of the maximum interval for 1 year before considering a possible exit from the T&E protocol. In the event of a significant decrease in visual acuity related to the disease along with significant anatomical degradation, it is recommended to restart monthly injections. In the case of bilateral disease, when synchronized timing of injections for both eyes is desired, the experts recommend using the shorter of the two intervals.

[Interest of optical coherence tomography performed immediately before intravitreal injection of anti-VEGF in exudative AMD]. / Intérêt de la tomographie à cohérence optique réalisée immédiatement avant injection intra-vitréenne d'anti-VEGF sur récidive exsudative dans la DMLA.

INTRODUCTION: Two or three systematic intravitreal injections (IVT) may be prescribed in a PRN approach to treat an exudative recurrence of neovascular age-related macular degeneration (AMD), according to the phenotype. Optical coherence tomography (OCT) may be performed immediately before the 2nd or the 3rd scheduled IVT, making it possible to cancel the procedure in the absence of exudation. The aim of the study was to evaluate the usefulness of this OCT examination and to assess the percentage of IVT cancelled, in order to evaluate a potential medico-economic benefit. METHODS: Monocentric retrospective study, in which were included 292 consecutive eyes with exudative recurrence of AMD, for which 2 or 3 IVT were scheduled between January 1st and April 30th, 2014. All patients received a first systematic IVT in the seven days following the diagnosis. Then, on the days of the 2nd and 3rd scheduled IVT, each patient had a visual acuity measurement and a Spectral domain-OCT (Spectralis, HRA Heidelberg Engineering). This measurement allowed for the IVT to be either performed as scheduled or cancelled. Both ranibizumab and aflibercept were used. A Chi(2) test was used to compare the qualitative variables and an adjusted Wilcoxon test for the quantitative values. RESULTS: Two hundred and ninety-two consecutive eyes were included; 172 in the "2 scheduled IVT" group (group A) and 120 in the "3 scheduled IVT" group (group B). At the first follow-up, 37.6% of scheduled IVT were cancelled after the OCT (44.1% in group A and 28.3% in group B). At the second follow-up, 33.3% of IVT were cancelled in group B. Overall, 150/412 (36.4%) IVT were avoided in this series. Presence of serous retinal detachment, retinal edema and increased central macular thickness were statistically correlated with confirmation of the scheduled IVT at the two follow-ups (P<0.001, P<0.001 and P=0.002, respectively). A savings of 429.80 € per patient was calculated during this short period of follow-up. CONCLUSION: An average non-injection rate of 36.4% of scheduled IVT was found in this protocol of management of recurrences with OCT performed the day of IVT. This protocol allowed to avoid unnecessary IVT one-third of the time and appeared highly cost-effective.

Number of examined lymph nodes and nodal status assessment in pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: The accuracy of the assessment of the nodal status in resected cephalic pancreatic adenocarcinoma (PA) depends on the number of examined lymph nodes (NELN). This study assesses the impact of the NELN on N staging and survival and propose a minimal number of examined lymph nodes (MNELN) ensuring reliability of the pN status determination. METHODS: 188 consecutive patients treated by pancreaticoduodenectomy (PD) for PA. Correlations between NELN and survivals of pN0 and pN1 groups and with the rate of pN1 patients were studied. A probability model based on the binomial law was built to estimate the MNELN able to detect pN1 patients with a sensitivity ≥ 95%. RESULTS: Overall and disease free 5-year survivals were 27.2% and 24.6% respectively. 135 patients (71.8%) were staged pN1. The median NELN was 17 (range 0-68). Overall and disease free survivals of pN1 patients were not related to NELN. The influence of NELN on survival in pN0 patients due to stage migration did not reach significance. The probability model showed that a MNELN of 16 nodes was required to detect pN1 patients with a sensitivity of 95%. CONCLUSION: A MNELN of 16 is required to assess pN status and should be considered as a quality criterion in future studies and trials on PD for PA.