[What is new in 2012 for the specialist in hospital internal medicine?]. / L'année 2012 de la perspective de l'interniste hospitalier.

The knowledge in internal medicine is constantly and so rapidly evolving that practices have to be updated and adjusted to recent scientific rules, in order to improve quality and efficiency in the day to day activities. Residents in the Service of internal medicine of the Lausanne University present several relevant papers published in 2012, whose results are susceptible to change the daily hospital practices. From modest impacts to real revolution, a variety of subjects are discussed in the perspective of evidence based medicine.

Characterization of a new surface epitope specific for human epithelial cells defined by a monoclonal antibody and application to tumor diagnosis.

In an attempt to characterize the antigens attached to cells of a line established from a human squamous cell carcinoma of the tongue (CAL 27), BALB/c mice were immunized with whole CAL 27 cells; hybridomas were then produced using spleen cells of the animals and cells of an NS1 syngeneic myeloma. A hybridoma secreting a monoclonal antibody was obtained (CALAM 27); CALAM 27 was directed against an epitope attached to the CAL 27 cells. CALAM 27, IgG2a, reacted with a membrane antigen specific to all epithelial cells. After immunoprecipitation, this antigen corresponded to two bands (Mr 22,000 and 54,000). Reactivity disappeared when the tissue was embedded in paraffin but was conserved after fixation with acetone or methanol. This antigen was conserved for both benign and malignant epithelial cell pathologies. The action of CALAM 27 was tested on 80 samples of pleural effusions, ascites, and cerebrospinal fluid samples; after conventional cytological examinations, CALAM 27 failed to recognize either reactive mesothelial cells or meningothelial cells. In addition, the cell structure recognized by CALAM 27 is not found on certain lymphoid tissue cells. CALAM 27 also failed to react with small cell carcinoma of the lung. Its strictly epithelial specificity therefore permits its use for the diagnosis of micrometastases of carcinoma in ascites and cerebrospinal fluid, in pleural effusions, and in bone marrow. CALAM 27 may also prove useful in confirming diagnosis of pathologies suspected to be of epithelial origin.

Phenotypic heterogeneity studied by immunohistochemistry and aneuploidy in non-small cell lung cancers.

Non-small cell lung cancers (non-SCLC) differ from small cell lung cancers (SCLC) by many clinical features and prognosis. However, recent studies suggest that lung cancer heterogeneity frequently leads to the association of SCLC and non-SCLC in the same tumor. This phenotypic heterogeneity can be analyzed by immunohistochemistry using monoclonal antibodies (Mab) raised against differentiation related antigens. It may have clinical relevance inasmuch as the diversification of malignant cells is a well-known factor of tumor progression and may be due to chromosomal instability because inappropriate gene expression leads to the formation of antigens unrelated to cell lineage. Chromosomal instability in cancer leads to aneuploidy detectable by cell DNA content analysis. In a prospective study, we analyzed, in parallel, the expression of neuroendocrine related antigens by immunohistochemistry and the cell DNA content in frozen specimens from 40 patients who underwent complete surgical resection of primary non-SCLC in an attempt (a) to characterize the phenotypic heterogeneity and (b) to determine whether this heterogeneity is correlated with aneuploidy and clinical staging. Three Mabs were used in association as a marker of neuroendocrine antigen expression (S-L 11.14, MOC-1, and NE-25); reactivity of these Mabs in 9 SCLC and 3 lung carcinoid tissue sections was used as positive control. All SCLC and 2 of 3 lung carcinoids tested were homogeneously positive with Mabs S-L 11.14, MOC-1, and NE-25; 13 of 40 non-SCLC were homogeneously positive and 11 additional specimens focally positive with Mabs S-L 11.14, MOC-1, and NE-25. The frequency of this abnormal phenotype was significantly higher in poorly differentiated squamous cell carcinomas (chi 2 10.08; P less than 0.005), in clinical stage III non-SCLC (chi 2 5.93; P less than 0.02), and in tumors involving mediastinal lymph nodes (chi 2 5; P less than 0.03). The percentage of cells in the modal DNA of G0-G1 phase was significantly lower in non-SCLC homogeneously positive with Mabs S-L 11.14, MOC-1, and NE-25 [27.4 +/- 10.3% (SD)] in comparison with non-SCLC negative with these same Mabs [56.8 +/- 21.3%; P less than 0.01, Mann-Whitney U test]. We conclude that (a) mixed SCLC-non-SCLC differentiation is frequent and can be assessed by immunohistochemistry, (b) neuroendocrine differentiation in non-SCLC is mainly observed in poorly differentiated tumors and in advanced clinical stages, and that (c) this heterotopic phenotype is correlated with aneuploidy and has clinical implications.

Cytofluorometric detection of human endothelial cells in whole blood using S-Endo 1 monoclonal antibody.

It has long been debated whether endothelial cells are present at very low frequency in peripheral blood. Elevated concentrations of such circulating cells may represent a good marker of vascular injury. We have therefore designed an immunocytometric assay for the detection of rare endothelial cells in whole blood. This assay is based on a new monoclonal antibody (MAb) S-Endo 1, made against human umbilical vein endothelial cells (HUVEC) and specific for endothelial cells of various origins without detectable reactivity with blood cells. First, the sensitivity of the assay was established by using normal blood samples with admixed HUVEC as an in vitro model. A good correlation was obtained between added and counted endothelial cells; the recovery was greater than 90% and the minimum detectable concentration of HUVEC was about 0.2 cells/microliters whole blood. Using this rapid counting technique, no detectable levels of endothelial cells were found in the blood of normal individuals (CE less than or equal to 0.1 cells/microliters) while elevated concentrations (up to 8 cells/microliters) were detected in a human model of vascular injury corresponding to a traumatic venepuncture. Thus, this new whole blood immunocytometric assay using S-Endo 1 MAb may be useful in determining the levels of circulating endothelial cells in vascular disorders.

Rapid isolation of human endothelial cells from whole blood using S-Endo1 monoclonal antibody coupled to immuno-magnetic beads: demonstration of endothelial injury after angioplasty.

The presence in whole blood of circulating endothelial cells (EC) has been a subject of debate for many years. It could represent a good marker of vessel injury. We demonstrate here that human endothelial cells can be directly isolated and identified in circulating blood by means of an endothelial cell specific monoclonal antibody, S-Endo1, coupled to micromagnetic beads. The specificity and efficacy of the assay were established using normal blood samples with cultured EC added. Specific rosettes formed between EC and beads could subsequently be isolated with a magnet. The rosetted cells were recovered with a yield greater than 80%. Their endothelial origin was confirmed by the positive labelling of von Willebrand factor and thrombomodulin, as well as the presence of Weibel-Palade bodies. We applied this method to demonstrate significantly increased levels of EC in venous and arterial human blood samples in patients undergoing heart catheterization. This new whole blood immuno-separation method may be useful in determining endothelial cell injury in vascular disorders.

Intrapleural recombinant IL-2 in passive immunotherapy for malignant pleural effusion.

The purpose of this phase 1 study was to determine the toxicity and effectiveness of recombinant interleukin-2 (RU 49637 Roussel Uclaf-France) administered by continuous pleural infusion for 5 days to patients with different histologic subtypes of pleural cancer. Incremental doses of rIL-2 from 3 x 10(6) to 24 x 10(6) were given via a thin catheter inserted into the homolateral pleural cavity. Patients were evaluated before treatment and 36 days after treatment by computed tomography scan and thoracoscopy with biopsy. Twenty-two patients with malignant pleural effusion (15 malignant pleural mesotheliomas, 6 adenocarcinomas, 1 squamous cell carcinoma) were treated. The maximum tolerated dose (MTD) of rIL-2, defined as the dose that produced grade 3 or greater toxic reactions in 50 percent of the patients, was 24 x 10(6) IU/m2/d. Although some side effects were encountered at any dose, tolerance was acceptable. The main side effect was fluid retention (8 of 22) which never exceeded 10 percent of body weight. Responses were achieved in 10 out of 22 patients with 1 complete remission (mesothelioma) and 9 partial remissions (3 adenocarcinomas and 6 malignant pleural mesotheliomas). Based on these results, we recommend that phase 2 studies using rIL-2 at a dose of 21 x 10(6) IU/m2/d via the intrapleural route be undertaken.

S-L 11.14: a monoclonal antibody recognizing neuroectodermal tumors with possible value for bone marrow purging before autograft.

A new monoclonal antibody (S-L 11.14) raised against small cell lung cancer reacted with all but one neuroblastoma tumor cell sample tested and was relatively specific for such cells within the bone marrow. The ability of S-L 11.14 to eliminate neuroblastoma cells from the bone marrow with an immunomagnetic purging method was evaluated in an experimental model using the LAN.1 and SKNBE neuroblastoma cell lines as targets. Residual malignant cells after the purging procedure were quantified by the Hoechst staining method. The use of S-L 11.14 as a single reagent resulted in a 3-log elimination of malignant cells, a depletion equal to that obtained with a cocktail of five monoclonal antibodies currently used in clinical trials. The addition of the S-L 11.14 antibody to this cocktail did not enhance depletion.

Pre-clinical evaluation of anti-lacto-N-fucopentaose III (CD15) monoclonal antibodies for ex vivo bone marrow purging in acute myeloid leukemia.

In order to eliminate residual leukemic cells from the marrow of patients with acute myeloid leukemia (AML) prior to autologous bone marrow transplantation, the optimal conditions of utilization of three CD15 murine monoclonal antibodies (MoAb) were investigated. The VIM-D5 MoAb was used with rabbit complement (C'), whereas the 8.27 and SMY15A MoAbs were used in the presence of human C'. These antibodies were also tested after fixation on magnetic beads. In a culture assay in semi-solid medium with a mixture of normal marrow and 1% HL60 cells, a lysis of clonogenic cells greater than 99% was achieved with the three antibodies and two rounds of complement, or with antibody-coated magnetic beads. Cultures of leukemic clonogenic cells (CFU-L) were performed in 47 cases. An inhibition equal to or greater than 90% was achieved in seven cases with VIM-D5, 16 cases with 8.27 and 11 cases with SMY15A and C'. The correlation with cytotoxicity of fresh cells was low. Twenty cases were purged with antibody-coated beads. An inhibition equal to or greater than 90% was observed in 10 cases with VIM-D5, 11 cases with 8.27 and 12 cases with SMY15A. The mean recovery of normal CFU-GM was higher than 70% and that of BFU-E higher than 95% with any method of treatment. It is concluded that efficient marrow purging of clonogenic AML cells can be achieved in some cases without toxicity for normal progenitors. The addition of other MoAbs seems necessary to obtain a significant purge in a majority of cases.

Monoclonal antibodies to Coxiella burnetii for antigenic detection in cell cultures and in paraffin-embedded tissues.

The authors developed monoclonal antibodies to Coxiella burnetti, the agent of Q fever. The selected monoclonal antibody, Cox1D8, did not cross-react with other bacteria and was used for early detection of C burnetti in shell vial cell cultures and for staining C burnetii in paraffin embedded tissues. Formalin or Bouin fixation did not alter the reactivity of the antigen with the antibody. This monoclonal antibody could be useful in the pathologic diagnosis of Q fever hepatitis and endocarditis.

[Axillary lymphadenectomy prepared by fat aspiration versus functional axillary lymphadenectomy: preliminary results of a randomized prospective study]. / Lymphadénectomie axillaire préparée par lipoaspiration contre curage axillaire fonctionnel: résultats préliminaires d'un essai prospectif randomisé.

The objective of this study is to compare morbidity between 2 surgical procedures of axillary clearance: functional lymphadenectomy by classical dissection versus axillary dissection prepared by liposuction (Suzanne's procedure). Two hundred consecutive patients treated for breast cancer were included in a prospective randomized trial between 1st January, 1995 and 31st January, 1996 (Huriet's law). The assessment (number of nodes, postoperative stay, drainage duration, rate of seromas, number of complications, evaluation of mobility and sensitive disorders) was done on the first, fifth, tenth and thirty postoperative days. There is no significant difference between the 2 groups. The rate of seromas decreased significantly only for fat patients (8/25 versus 21/34, p < 0.05) and for the patients treated with radical mastectomy (17/37 versus 28/39, p < 0.05). In this preliminary study, liposuction does not change postoperative effects of axillary clearance, except for fat patients or after total mastectomy. The liposuction seems to facilitate a better anatomical dissection and a better preservation of the nervous and vascular elements.

[Immunotoxins]. / Les immunotoxines.

Immunotoxins are conjugates between antibodies especially directed against cancer cells and a subunit of a powerful toxin. We used the A-chain of ricin. These conjugates are specifically cytotoxic when used at very low concentrations in vitro and can destroy more than 99.99% of clonogenic cells. The efficacy of immunotoxins was also demonstrated in vivo but is inferior to its in vitro potency. For this reason the first use of immunotoxins in man can be the cleaning up of bone marrow from leukemic cells in the near future.

[Stromal luteoma of the ovary. Differential diagnosis of steroid cell tumors]. / Le lutéome du stroma ovarien. Diagnostic différentiel des tumeurs à cellules stéroïdes.

An observation of a stromal luteoma of the ovary is reported. It is a rare tumor (only about thirty cases of it have been published yet), occurring mostly in post menopausal women. Endocrine symptoms and sometimes virilizing signs may be observed. Abnormal vaginal bleeding is the most frequent clinical manifestation. This macroscopically observed tumor is surrounded by ovarian stroma and entirely composed of luteinized cells devoid of crystals of Reinke. Hyperthecosis of ovarian stroma is often observed. Its evolution is always benign. The authors recalled the place of stromal luteoma of the ovary among steroid (lipid) cell tumors and the elements of a differential diagnosis. These tumor might derive from ovarian stromal cells.

[Preoperative location of deep subclinical breast lesions using the harpoon technic. Apropos of 149 cases]. / Repérage pré-opératoire des lésions mammaires infra-cliniques profondes par la technique du "harpon". A propos de 149 observations.

Since April 1983, harpoon technique was used for limited excision of subclinical mammography-observed anomalies. The procedure involves the insertion of a harpoon-shaped metallic thread, after detection by mammography, to obtain guidance of surgical procedures. The results of 155 procedures in 149 patients included detection of 38 cancers (26%), confirming documented data in this field.

[Preoperative marking of non-palpable breast lesions by the stereotaxic tattooing and "harpoon" technique. 670 cases]. / Repérage pré-opératoire des lésions mammaires infracliniques par la technique du tatouage stéréotaxique et du "harpon". A propos de 670 observations.

OBJECTIVE: To compare the quality of pre-operative analysis of sub-clinical lesions of the breast using a wire and stereotaxic tattooing. METHODS: Between 1983 en 1990, 670 cases were analysed. At first needle or wire localisation techniques were used and then from 1988 onwards stereotaxic tattooing, first with the wire technique combined with it and later by itself from 1989 onwards. Place study carried out: Oscar-lambret Centre in the Department of Surgery and Radiodiagnosis 1, BP 307, Lille Cedex. RESULTS: 190 carcinomas were diagnosed (30.7%) of which 20 were micro-invasive and 46 carcinoma in situ. The efficiency of the analysis was evaluated according to the number of explorations that were necessary to remove healthy tissue around the lesion. The wire technique results were significantly different (15.43% = 339 cases), tattooing with wire (9.13% = 144 cases), and tattooing by itself (6.30% = 135 cases). CONCLUSION: It seems that pre-operative assessment using stereotaxic tattooing is the most reliable of methods because it allows limited excision of the lesion and a more aesthetic approach.

[Pregnancy following surgery for cancer of the breast]. / Grossesses après cancer du sein opéré.

Twenty-tree cases of pregnancy subsequent to mastectomy for carcinoma of the breast were observed. This association accounts for 8% of cases of breast carcinoma in potentially fertile women under 40. The overall prognosis is good, with a crude survival of 89% at 5 years and 70% at 10 and 15 years, superior to the figures observed in a control group matched for age, stage and date of treatment. Nevertheless, after elimination of the "selection effect" (pregnancy is more likely to occur in patients with a prolonged survival and no evidence of disease), no evidence of a biological effect of pregnancy was found: the prognosis in cases in which the delay from cancer to pregnancy is short is not different from the prognosis of the matched group. However, the disease free interval was longer in the pregnancy group.

[Breast cancer: can axillary dissection be restricted to Berg stages 1 and 2? Study of 895 cases]. / Cancer du sein: peut-on se limiter aux étages 1 et 2 de Berg, lors du curage axillaire? Etude à propos de 895 cas.

895 axillary clearances were carried out in 3 years between 1986 and 1988 on 878 patients with primary breast cancer. Two procedures were used: either direct total axillary clearance (in stages 1, 2 and 3 of Berg) or inferior axillary clearance (stages 1 and 2 of Berg). This was carried out in association with frozen section diagnosis of the lymph node followed by clearance in Berg stage 3 if the diagnosis on frozen section was positive. The authors found a higher frequency of late complications, particularly of arm lymphoedema in patients who had complete axillary clearance than in patients who only had an inferior axillary clearance. The survival rate actuarilly calculated was not significantly different in the two groups of patients. The carrying out of total axillary clearance was "beneficial" for only 3 patients who had negative inferior axillary clearance and positive sub-clavicular clearance. Finally the frozen section diagnosis of the state of the axillary nodes shown to be correct (specificity -99% and sensitivity -76%) but it was difficult to carry out routinely.

[Occult cancer of the breast]. / Les cancers infracliniques du sein.

21 cases of occult breast cancer were reviewed retrospectively. The patients were followed up from 1 to 9 years. Only one of these patients had partial axillary nodal disease and none had recurrence of mammary neoplastic disease. Thus, the prognosis of occult breast cancer is much better than that of clinical breast cancer and we think that all possible efforts must be made it order to detect breast cancer earlier. Mammography seems to be the best form of screening and in our opinion in every suspect disease surgical exploration must be performed.

[Treatment of intraductal carcinomas. 91 cases treated at Oscar-Lambret Center]. / Traitement des carcinomes intra-galactophoriques. A propos de 91 cas traités au Centre Oscar-Lambret.

During a period of 10 years, 91 ductal carcinomas in situ (DCIS) were operated. After a study of clinical and therapeutics characteristics, the evolution of the DCIS was studied. Eleven recurrences were seen in a period of 41 months. The actuarial risk of recurrence was 11% at 5 years and 17% at 8 years. About half of the recurrences were invasive and occurred 10 times out of 11 in the initial area or nearby. Among several factors studied, the association of radiotherapy with conservative surgery was the only one which reduced significantly the risk of recurrences.

[Conservative surgical treatment of retro-areolar breast tumors. Local control and esthetic results]. / Le traitement chirurgical conservateur des tumeurs rétro-aréolaires due sein. Contrôle local et résultats esthétiques.

OBJECTIVE: A retrospective study of local faiture and cosmetic results after conservative surgery for retroareolar breast cancer. PATIENTS AND RESULTS: Seventy-seven patients underwent a conservative surgical procedure between 1983 and 1994. Median follow-up was 37,5 months. Fourteen patients experienced a recurrence (5 local, 2 local and distant, 7 distant). Only two probably interrelated factors were associated with a risk of local recurrence: nipple-areola complex removed or not, and pathological margins. Cosmetic results were evaluated with patient's questionnaires: 40/47 patients (85%) stated they were satisfied. CONCLUSION: In spite of the short follow-up, conservative surgery is a safe procedure for local control only in cases with negative margins. Procedure for nipple areola complex is now questionable. Cosmetic results are achieved if indication of central lumpectomy are confined to small and limited tumors. For other tumors, plastic remodelling is necessary.

[Sarcoma of the uterine body]. / Sarcomes du corps utérin.

This work is a retrospective study of the sarcomas of the uterus which were treated at the Oscar Lambret centre in the last ten years. The difficulty in diagnosing sarcomas of the uterus by the histologist can be appreciated when it is realised that classification of uterine sarcoma is complex. It is not possible to give any statistical interpretation of what is found because of the relative rarity of the cases (about 3% of all cancers of the body of the uterus). The clinical, radiological and histological aspects have been studied. Prognosis is very bad. This means that the type of pathological anatomy that has been found determines the treatment.