Prediction of response to immune checkpoint blockade in patients with metastatic colorectal cancer with microsatellite instability.

BACKGROUND: Mismatch repair-deficient (dMMR) tumors displaying microsatellite instability (MSI) represent a paradigm for the success of immune checkpoint inhibitor (ICI)-based immunotherapy, particularly in patients with metastatic colorectal cancer (mCRC). However, a proportion of patients with dMMR/MSI mCRC exhibit resistance to ICI. Identification of tools predicting MSI mCRC patient response to ICI is required for the design of future strategies further improving this therapy. PATIENTS AND METHODS: We combined high-throughput DNA and RNA sequencing of tumors from 116 patients with MSI mCRC treated with anti-programmed cell death protein 1 ± anti-cytotoxic T-lymphocyte-associated protein 4 of the NIPICOL phase II trial (C1, NCT03350126, discovery set) and the ImmunoMSI prospective cohort (C2, validation set). The DNA/RNA predictors whose status was significantly associated with ICI status of response in C1 were subsequently validated in C2. Primary endpoint was progression-free survival by immune RECIST (iRECIST) (iPFS). RESULTS: Analyses showed no impact of previously suggested DNA/RNA indicators of resistance to ICI, e.g. MSIsensor score, tumor mutational burden, or specific cellular and molecular tumoral contingents. By contrast, iPFS under ICI was shown in C1 and C2 to depend both on a multiplex MSI signature involving the mutations of 19 microsatellites hazard ratio cohort C2 (HRC2) = 3.63; 95% confidence interval (CI) 1.65-7.99; P = 1.4 × 10-3] and the expression of a set of 182 RNA markers with a non-epithelial transforming growth factor beta (TGFB)-related desmoplastic orientation (HRC2 = 1.75; 95% CI 1.03-2.98; P = 0.035). Both DNA and RNA signatures were independently predictive of iPFS. CONCLUSIONS: iPFS in patients with MSI mCRC can be predicted by simply analyzing the mutational status of DNA microsatellite-containing genes in epithelial tumor cells together with non-epithelial TGFB-related desmoplastic RNA markers.

Seasonal variations of physiological responses, milk production, and fatty acid profile of local crossbred cows in Tunisia.

The study investigates the seasonal variations of physiological responses, milk yield, milk composition, and milk fatty acid profile of local crossbred cows (Friesian × Brown Atlas) in northwestern Tunisia. A total of 80 multiparous cows from smallholder farmers were sampled between 2018 and 2019. The cows were feed the same diet ad libitum and exposed to the same Mediterranean climatic conditions. Weekly rectal temperature (RT; °C), respiratory rate (RR; rpm), and heart rate (HR; bpm) were measured per cow in each season. Individual milk yield and samples were recorded bi-weekly and collected in duplicate for chemical analyses. Milk fatty acids (FAs) were analyzed using gas chromatography-mass spectrometry (GC-MS). Results showed an increase (P < 0.05) in RT (+ 1.3%), RR (+ 12.1%), and HR (+ 9.9%) when the temperature-humidity index (THI) increased from winter (53.6) to summer (74.4) in response to heat stress. Milk yield did not vary significantly between seasons (8.3 L/day on average). Summer milk contained more fat (+ 7.8%) and log SCC (+ 13.7%). The proportion of the monounsaturated (31.2 vs. 27.2%) and polyunsaturated (4.29 vs. 3.86%) FAs decreased (P < 0.05) between winter and summer. Saturated FAs (64.5 vs. 67.7%) were higher (P < 0.05) in summer than in winter. Winter milk fat contained higher levels of C18:2cis-9 trans-11 (CLA) (0.73 vs. 0.56%) and ω-3 FA (0.83 vs. 0.63%), but a lower ω-6/ω-3 ratio (4.07 vs. 6.17%) compared to summer. As the cows were fed the same diet throughout the two seasons, the performances obtained were mainly due to the resistance of the local crossbred cow to the hot conditions. It is concluded that the local crossbred cow maintains its productivity and tolerate the hot Mediterranean climate.

A transcriptomic signature to predict adjuvant gemcitabine sensitivity in pancreatic adenocarcinoma.

BACKGROUND: Chemotherapy is the only systemic treatment approved for pancreatic ductal adenocarcinoma (PDAC), with a selection of regimens based on patients' performance status and expected efficacy. The establishment of a potent stratification associated with chemotherapeutic efficacy could potentially improve prognosis by tailoring treatments. PATIENTS AND METHODS: Concomitant chemosensitivity and genome-wide RNA profiles were carried out on preclinical models (primary cell cultures and patient-derived xenografts) derived from patients with PDAC included in the PaCaOmics program (NCT01692873). The RNA-based stratification was tested in a monocentric cohort and validated in a multicentric cohort, both retrospectively collected from resected PDAC samples (67 and 368 patients, respectively). Forty-three (65%) and 203 (55%) patients received adjuvant gemcitabine in the monocentric and the multicentric cohorts, respectively. The relationships between predicted gemcitabine sensitivity and patients' overall survival (OS) and disease-free survival were investigated. RESULTS: The GemPred RNA signature was derived from preclinical models, defining gemcitabine sensitive PDAC as GemPred+. Among the patients who received gemcitabine in the test and validation cohorts, the GemPred+ patients had a higher OS than GemPred- (P = 0.046 and P = 0.00216). In both cohorts, the GemPred stratification was not associated with OS among patients who did not receive gemcitabine. Among gemcitabine-treated patients, GemPred+ patients had significantly higher OS than the GemPred-: 91.3 months [95% confidence interval (CI): 61.2-not reached] versus 33 months (95% CI: 24-35.2); hazard ratio 0.403 (95% CI: 0.221-0.735, P = 0.00216). The interaction test for gemcitabine and GemPred+ stratification was significant (P = 0.0245). Multivariate analysis in the gemcitabine-treated population retained an independent predictive value. CONCLUSION: The RNA-based GemPred stratification predicts the benefit of adjuvant gemcitabine in PDAC patients.

Ultra-broadband contactless imaging power meter.

Knowledge of the spatial and temporal distribution of heat flux is of great interest for the quantification of heat sources. In this work, we describe the development of a new ultra-broadband contactless imaging power meter based on electromagnetic to infrared technology. This new sensor and the mathematical processing of images enable the reconstruction of both spatial and amplitude distributions through a wide spectral range of sources. The full modeling of the thermoconverter based on 3D formalism of thermal quadrupoles is presented first before deriving a reduced model more suitable for quick and robust inverse processing. The inverse method makes it possible to simultaneously identify the heat losses and the spatial and temporal source distribution for the first time, to the best of our knowledge. Finally, measurements of multispectral sources are presented and discussed, with an emphasis on the spatial and temporal resolution, accuracy and capabilities of the power meter.

Early Impacts of the COVID-19 Pandemic on Telehealth Patterns in Primary Care, Mental Health, and Specialty Care Facilities in Texas.

OBJECTIVES: Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, many US clinics have shifted some or all of their practice from in-person to virtual visits. In this study, we assessed the use of telehealth among primary care and specialty clinics, by targeting healthcare administrators via multiple channels. METHODS: Using an online survey, we assessed the use of, barriers to, and reimbursement for telehealth. Respondents included clinic administrators (chief executive officers, vice presidents, directors, and senior-level managers). RESULTS: A total of 85 complete responses were recorded, 79% of which represented solo or group practices and 63% reported a daily patient census >50. The proportion of clinics that delivered ≥50% of their consults using telehealth increased from 16% in March to 42% in April, 35% in May, and 30% in June. Clinics identified problems with telehealth reimbursement; although 63% of clinics reported that ≥75% of their telehealth consults were reimbursed, only 51% indicated that ≥75% of their telehealth visits were reimbursed at par with in-person office visits. Sixty-five percent of clinics reported having basic or foundational telehealth services, whereas only 9% of clinics reported advanced telehealth maturity. Value-based care participating clinics were more likely to report advanced telehealth services (27%), compared with non-value-based care clinics (3%). CONCLUSIONS: These findings highlight the adaptability of clinics to quickly transition and adopt telehealth. Uncertainty about reimbursement and policy changes may make the shift temporal, however.

Comprehensive molecular classification of localized prostate adenocarcinoma reveals a tumour subtype predictive of non-aggressive disease.

Background: Management of localized prostate cancer (PCa) is a major clinical challenge since most of these cancers would not evolve but a majority of patients will still undergo a life-changing radical surgery. Molecular studies have shown that PCa can be classified according to their genomic alterations but none of the published PCa molecular classifications could identify a subtype corresponding to non-evolutive tumours. Materials and methods: Multi-omics molecular profiling was carried out on post-radical prostatectomy material from a cohort of 130 patients with localized PCa. We used unsupervised classification techniques to build a comprehensive classification of prostate tumours based on three molecular levels: DNA copy number, DNA methylation, and mRNA expression. Merged data from our cohort and The Cancer Genome Atlas cohort were used to characterize the resulting tumour subtypes. We measured subtype-associated risks of biochemical relapse using Cox regression models and survival data from five cohorts including the two aforementioned. Results: We describe three PCa molecular subtypes associated with specific molecular characteristics and different clinical outcomes. Particularly, one subtype was strongly associated with the absence of biochemical recurrence. We validated this finding on 746 samples from 5 distinct cohorts (P = 3.41 × 10-8, N = 746 tumour samples), and showed that our subtyping approach outperformed the most popular prognostic molecular signatures to accurately identify a subset of patients with a non-evolutive disease. We provide a set of 36 transcriptomic biomarkers to robustly identify this subtype of non-evolutive cases whose prevalence was estimated to 22% of all localized PCa tumours. Conclusion: At least 20% of patients with localized PCa can be accurately predicted to have a non-evolutive disease on the basis of their molecular subtype. Those patients should not undergo immediate surgery and rather be placed under active surveillance.

Antioxidant activities, anticancer activity and polyphenolics profile, of leaf, fruit and stem extracts of Pistacia lentiscus from Tunisia.

Plant derived compounds have played an important role in the development of several clinically useful anticancer drugs. The aim of the present study was 1) to evaluate for the first time the anti-proliferative activity of a polyphenol enriched extract obtained from leaf, fruit and stem of Tunisian variety of Pistacia lentiscus against two cultured cancer cells, and 2) to carry out a phytochemical analysis of vegetable extracts particularly by determining the chemical composition of phenolics (total polyphenols, flavonoids and condensed tannins content in solvents with varying polarities), 3) to  evaluate the antioxidant activity and identify the major compounds by RP-HPLC. Leaf extract using methanol/water (8:2) showed the highest polyphenol content (124.1 mg GAE/g DW). Moreover, total antioxidant capacity, reducing power and antiradical capacities against DPPH were maximal in leaf extracts with IC50 significantly lower than that standard (BHT). In MTT assay, methanol (8:2) extract exerted the most potent cytotoxic effect. The leaf extract exhibited an important antiproliferative activity (IC50: 135.67 ± 2.5 and 250.45 ± 1.96 µg/ml in CaCo2 and AGS cells respectively) but the infusion extracts of fruit stems and leaves were inactive. The RP-HPLC analysis revealed the presence of several phenolic compounds in P. lentiscus leaf, fruit and stem including tannic acid, gallic acid, digalloyl quinic acid derivative, quercetin and   p-coumaric acid as major phenolics. The high phenolic content and the important antioxidant activities of P. lentiscus extract could be a useful source of natural products and may be increasingly important for human consumption, prevention of damages caused by oxygen free as well as for the agro-food, cosmetic and pharmaceutical industries.

Antioxidant properties and phenolic profile characterization by LC-MS/MS of selected Tunisian pomegranate peels.

Antioxidant contents and activities of different extracts from four Tunisian pomegranate peels, locally called "Acide", "Gabsi", "Nebli" and "Tounsi", were studied. Peels samples were extracted with three solvents (water, ethanol and acetone). For each extract, the total phenol contents and antioxidant activity were evaluated. The highest values of polyphenol, tannins, flavonoids and anthocyanins were recorded in the acetone extract of Acide ecotype with 304.6 mg gallic acid equivalent/g; 292.23 mg gallic acid equivalent/g; 15.46 mg Quercetin/g and 54.51 mg cy-3-glu/100 g, respectively. The acetone extract of Acide ecotype also showed the highest free radical-scavenging and reducing power activity compared to other extracts. Besides, the phytochemical analysis by LC-MS/MS revealed a high content of ellagitannins with punicalagin and punicalagin derivatives as the major compounds that might be responsible for promising antioxidant activity of pomegranate peel extracts. Two compounds (Castalagin derivative and Galloyl-bis-HHDP-hex derivative) were detected only in "Acide" ecotype in important contents.

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach.

BACKGROUND: Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD: The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS: This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION: We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Cladodes from prickly pear as a functional ingredient: effect on fat retention, oxidative stability, nutritional and sensory properties of cookies.

The stems of Opuntia ficus-indica known as cladodes are rich source of bioactive and functional substances, which make them important candidate for the production of health-promoting food. Cladodes powder was incorporated at different levels of substitution (2.5%, 5% and 7.5%) in cookies (butter/wheat flour: 55/100 m/m). Substitution of wheat flour by cladodes powder improved dietary fiber, ash, potassium, magnesium and calcium contents of enriched cookies. The results also revealed that cladodes supplementation increased hardness; however, it decreased a* and b* values and reduced exudate loss of cookies during storage. Moreover, rising levels of cladodes powder contribute to the increase of antioxidant activity of cookies and decreased their oxidative degradation. Sensory evaluation showed that cladodes supplementation at 5% level remained acceptable at 5-point hedonic scale. The present study suggested that cladodes supplementation in high-fat cookies not only added nutritional value to food, but also improved its functional characteristics.

Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra-low rectal cancer.

AIMS: The only two procedures for surgical treatment of ultra-low rectal cancer without a permanent abdominal stoma are the intersphincteric resection (ISR) and the abdominoperineal resection (APR) plus a perineal pseudocontinent colostomy (PCC). This study compared functional results and quality of life following these two techniques. METHODS: Between January 1995 and December 2011, 36 patients had undergone an ISR (n = 14) or a PPC (n = 22) for very low rectal cancer. The Cleveland Clinica Florida (Wexner) fecal incontinence questionnaire and the EORTC Quality of Life questionnaire QLQ-C30 and CR38 had been administered. RESULTS: There were no differences in gender, age, the interval between surgery and questionnaire responses, preoperative TNM staging, perioperative treatment, the laparoscopic approach and circumferential margin involvement rate between the groups. The ISR and PPC led to no difference in quality of life (Qol) and continence with a median Wexner score of respectively 11 and 10 (P = 0.403) and a fecal incontinence rate of 58.2% and 41% (P = 0.221). The incontinent patients had experienced worse social functioning and tended to have worse overall health. The patients who had undergone ISR had more defecation problems and evacuation difficulties. CONCLUSION: Qol and continence are similar between ISR and PPC.

Respiratory motion management for external radiotherapy treatment.

We present the update of the recommendations of the French society of oncological radiotherapy on respiratory motion management for external radiotherapy treatment. Since twenty years and the report 62 of ICRU, motion management during the course of radiotherapy treatment has become an increasingly significant concern, particularly with the development of hypofractionated treatments under stereotactic conditions, using reduced safety margins. This article related orders of motion amplitudes for different organs as well as the definition of the margins in radiotherapy. An updated review of the various movement management strategies is presented as well as main technological solutions enabling them to be implemented: when acquiring anatomical data, during planning and when carrying out treatment. Finally, the management of these moving targets, such as it can be carried out in radiotherapy departments, will be detailed for a few concrete examples of localizations (abdominal, thoracic and hepatic).

Blue-green algae (Arthrospira platensis) as an ingredient in pasta: free radical scavenging activity, sensory and cooking characteristics evaluation.

The effects of semolina enrichment with blue-green algae (Arthrospira platensis) at three different levels (1, 2 and 3 g/100 g of semolina) on the colour, cooking properties, firmness, free radical scavenging activity and sensory characteristics of pasta are reported. Microalgae addition resulted in higher swelling index and lower cooking loss than the control sample. A significant increase in pasta firmness was evidenced with an increase of added microalgae due to structural reinforcement. In addition to colouring, the use of A. platensis (2 g/100 g of semolina) can enhance the sensory quality and nutraceutical potential as evaluated by free radical scavenging activity of pasta.

Volatile and lipid analyses by gas chromatography/mass spectrometry and nutraceutical potential of edible wild Malva aegyptiaca L. (Malvaceae).

Volatile and lipid chemical compositions, and nutritional and antioxidant properties of Malva aegyptiaca, an edible wild plant largely distributed in North Africa, were investigated. Forty-nine compounds of volatiles were identified showing large qualitative and quantitative differences during three phenological stages. The flowering stage was characterized by the presence of a high number of terpenic compounds, among them dillapiole was found to be the major one (55.15%). The nutrient composition of leaves and fruits was investigated in the present work. Fruits' lipidic fraction was characterized by its high level of linoleic acid (n-6) (36.17%). Interestingly, leaves' lipidic fraction was characterized by its very high content of camphor (43.69%) and by its relatively high content of linoleinic acid (n-3) (14.69%). Furthermore, our results showed that the phenolic contents varied from 352 to 404 mg gallic acid equivalent/g ethanolic and acetonic extracts, respectively. These extracts revealed interesting antioxidant activities including free radical scavenging activity (EC(50) = 0.38-0.57 mg/ml) and reducing power (EC(50) = 0.12-0.18 mg/ml).

Optimization of gluten-free sponge cake fortified with whey protein concentrate using mixture design methodology.

This study aimed to optimize mixtures of whey protein concentrate (WPC) and two flours of rice and maize flours for the production of gluten-free sponge cakes. This was obtained by using mixture design methodology. WPC incorporation had positive effects on specific volume and baking loss of cakes, whilst, their incorporation increased their hardness. Considering all cakes properties, two formulas F1 (78.5% Maize, 15% Rice and 6.5% WPC) and F2 (82.4% Maize, 12% Rice and 5.6% WPC) were optimized using a mixture design. The microstructure F1 was more organized and very well structured with smaller aggregates. According to the organoleptic evaluation, F1 was also most appreciated by the tasting panel. The findings of the present study indicated that maize and rice flours, and WPC could be used as a substitute for wheat flour in producing sponge cakes of high quality.

[Immature teratoma of the ovary and pregnancy]. / Tératome Immature De L'ovaire Et Grossesse.

BACKGROUND: Composing of less than 1% of all ovarian cancers, immature teratoma is a malignancy that mainly affects the young. Immature teratoma of the ovary together with pregnancy is rare. To our knowledge, this association was reported only in twelve cases. AIM: We Report two cases of immature teratoma of the ovary diagnosed during pregnancy and their respective issue. OBSERVATION: 1st case. A 28 years old woman gravida 1 with an immature teratoma of the ovary discovered during delivery by caesarean section. The treatment was conservative including salpingo-oophorectomy, omentectomy, aortic lymph node dissection and appendectomy. This patient had a second pregnancy with a good outcome. She delivered by caesarean section in order to perform radical treatment: hysterectomy and oophorectomy of the remaining ovary. 2nd case. A 22 years old woman gravida 1 with adnexal mass diagnosed during an ultrasonography exam at 15 weeks gestation. A conservative treatment was indicated, including salpingo-oophorectomy, omentectomy, aortic lymph node dissection, appendectomy and biopsy of the remaining ovary. The patient had a normal vaginal delivery. CONCLUSION: Immature teratoma is graded from 1 to 3. The management of this association is discussed, but it takes in consideration the surgical staging, the grade and the secretion of aFP. Conservative treatment without associating chemotherapy can be tempted in tumours with a stade AI and a low grade.

Antioxidant and antibacterial activities, interfacial and emulsifying properties of the apo and holo forms of purified camel and bovine α-lactalbumin.

The antioxidant and antibacterial activities of camel and bovine α-lactalbumin (α-La) in both calcium-loaded (holo) and calcium-depleted (apo) forms were investigated and compared. Antioxidant assay showed that camel and bovine α-La exhibited significant Ferric-reducing antioxidant power (FRAP), ferrous iron-chelating activity (FCA) and antiradical activities especially in their apo form. Camel apo α-La also exhibited attractive antibacterial activities against Gram-negative bacteria (Pseudomonas aeruginosa) and against fungal pathogens species (Penicillium bilaiae, Aspergillus tamari and Aspergillus sclerotiorum). Likewise, emulsifying properties (emulsification ability (EAI) and stability (ESI) indexes) and the surface characteristics (surface hydrophobicity, ζ-potential and interfacial tension) of the α-La were assessed. Maximum EAI were found at pH 7.0, with higher EAI values for the camel apo α-La (EAI ~19.5 m2/g). This behavior was explained by its relative high surface hydrophobicity and its greater efficiency to reduce the surface tension at the oil-water interface. Furthermore, emulsions were found to be more stable at pH 7.0 compared to pH 5.0 (ESI ~50%) due to the higher electrostatic repulsive forces between oil droplets at pH 7.0 in consistence with the ζ-potential results. This study concluded that the camel apo α-La has antibacterial, antioxidant, and emulsifying properties in agricultural and food industries.

Mid-position treatment strategy for locally advanced lung cancer: a dosimetric study.

OBJECTIVE: The internal target volume (ITV) strategy generates larger planning target volumes (PTVs) in locally advanced non-small cell lung cancer (LA-NSCLC) than the Mid-position (Mid-p) strategy. We investigated the benefit of the Mid-p strategy regarding PTV reduction and dose to the organs at risk (OARs). METHODS: 44 patients with LA-NSCLC were included in a randomized clinical study to compare ITV and Mid-p strategies. GTV were delineated by a physician on maximum intensity projection images and on Mid-p images from four-dimensional CTs. CTVs were obtained by adding 6 mm uniform margin for microscopic extension. CTV to PTV margins were calculated using the van Herk's recipe for setup and delineation errors. For the Mid-p strategy, the mean target motion amplitude was added as a random error. For both strategies, three-dimensional conformal plans delivering 60-66 Gy to PTV were performed. PTVs, dose-volume parameters for OARs (lung, esophagus, heart, spinal cord) were reported and compared. RESULTS: With the Mid-p strategy, the median of volume reduction was 23.5 cm3 (p = 0.012) and 8.8 cm3 (p = 0.0083) for PTVT and PTVN respectively; the median mean lung dose reduction was 0.51 Gy (p = 0.0057). For 37.1% of the patients, delineation errors led to smaller PTV with the ITV strategy than with the Mid-p strategy. CONCLUSION: PTV and mean lung dose were significantly reduced using the Mid-p strategy. Delineation uncertainty can unfavorably impact the advantage. ADVANCES IN KNOWLEDGE: To the best of our knowledge, this is the first dosimetric comparison study between ITV and Mid-p strategies for LA-NSCLC.

Cystic echinococcosis in Tunisia: analysis of hydatid cysts that have been surgically removed from patients.

Echinococcosis/hydatidosis caused by Echinococcus granulosus has a widespread distribution in the human population of Tunisia, particularly in the north-west and centre-west of the country. In a recent study, the morphological features, fertility and viability of hydatid cysts that had been excised from patients in Tunis were explored, and the E. granulosus strain or genotype involved in each case was identified from morphology of the protoscolex hooks and the results of molecular genotyping. The hepatic cysts investigated came from 41 patients [31 women and 10 men, with a mean (S.E.) age of 43.41 (14.25) years] who were treated for cystic echinococcosis, by surgery but rarely with chemotherapy, at the La Rabta Hospital in Tunis, in the 12 months ending in June 2008. Most (56%) of these patients originated from rural areas in endemic governorates. Of the 60 hepatic cysts that were studied, 38.3% were located in the right lobe of the liver and 35.0% each involved both hepatic lobes. Almost a third (31.7%) of the excised cysts were degenerating, with the rest considered viable and either multivesicular (38.3%) or univesicular (30.0%). Almost all (93.3%) of the cysts were categorized as fertile, with a mean protoscolex viability of 21.8%. Protoscolex viability was relatively high in the viable univesicular cysts with a visible cyst wall and in the multivesicular and multiseptate cysts with daughter cysts, and lowest in the cysts that appeared to be solid calcified masses. The observed variation in protoscolex viability with cyst type, in cysts excised from patients before any chemotherapy, supports the cyst classification recommended by the World Health Organization but could also be compatible with the imaging-based 'Gharbi' classification. The results of the molecular genotyping showed that all 23 cysts investigated (which came from 20 of the patients) were caused by E. granulosus of the G1 genotype (also known as the 'sheep' or 'sheep-dog' strain).