Femoropopliteal In-stent Restenosis Repair: Midterm Outcomes After Paclitaxel Eluting Balloon Use (PLAISIR Trial).

OBJECTIVE: The aim was to assess 18 month outcomes of the paclitaxel eluting balloon (PEB) in patients with femoropopliteal (FP) in-stent restenosis (ISR). METHODS: In a national prospective and multicentre cohort study, symptomatic patients with femoropopliteal in-stent restenosis were included from January 2012 to June 2013. Patients were treated by paclitaxel eluting balloon angioplasty (In Pact Admiral, Medtronic, Santa Rosa, CA, USA). Clinical and duplex scan follow-up evaluations were performed at 1, 3, 6, 9, 12, and 18 months. The primary endpoint was freedom from target lesion revascularisation (TLR) at 12 months. Secondary endpoints were major adverse cardiovascular events (MACE), Target extremity revascularisation (TER), primary and secondary sustained clinical improvement, recurrent restenosis rate, primary and secondary patency, quality of life assessed by EQ-5D questionnaire, technical success, clinical success, and length of stay RESULTS: A total of 53 patients were enrolled. After a blinded review, 10 patients were defined as protocol violation because restenosis occurred more than 2 years after stent implantation. Procedures were performed in 55 limbs, 48 (87%) for claudication and 7 (13%) for critical limb ischaemia. The mean diameter and length of PEB were 6 ± 0.57 mm and 86 mm ± 32 mm, follow-up was 17 months (range 1-19). At 1 year, the survival rate was 96 ± 2.7% and freedom from TLR and TER were 90.2 ± 4.2% and 85 ± 5%, respectively. Sustained primary and secondary clinical improvements were 78.6 ± 5.7% and 92.0 ± 3.8%, respectively. At 1 year, the primary patency rate was 83.7 ± 5.0%. Prior to the procedure, the mean EQ-5D score was 66 ± 14 and 74 ± 16 at 1 year (p = .10). Two patients died during follow-up; one patient died 33 days after the procedure because of limb ischaemia. CONCLUSION: PEB for the treatment of FP ISR is associated with a low rate of re-interventions and restenosis. Clinical improvement is maintained at 18 months.

Neo/adjuvant chemotherapy does not improve outcome in resected primary synovial sarcoma: a study of the French Sarcoma Group.

BACKGROUND: There are only scarce data about the benefit of adjunctive chemotherapy in patients with localized synovial sarcoma (SS). PATIENTS AND METHODS: Data from 237 SS patients recorded in the database of the French Sarcoma Group were retrospectively analyzed. The respective impact of radiotherapy, neo-adjuvant chemotherapy and adjuvant chemotherapy on overall survival (OS), local recurrence-free survival (LRFS) and distant recurrence-free survival (DRFS) were assessed after adjustment to prognostic factors. RESULTS: The median follow-up was 58 months (range 1-321). Adjuvant, neo-adjuvant chemotherapy and postoperative radiotherapy were administered in 112, 45 and 181 cases, respectively. In all, 59% of patients treated with chemotherapy received an ifosfamide-containing regimen. The 5-year OS, LRFS and DRFS rates were 64.0%, 70% and 57%, respectively. On multivariate analysis, age >35 years old, grade 3 and not-R0 margins were highly significant independent predictors of worse OS. After adjustment to prognostic factors, radiotherapy significantly improved LRFS but not DRFS or OS. Neither neo-adjuvant nor adjuvant chemotherapy had significant impact on OS, LRFS or DRFS. CONCLUSION: As for other high-grade soft-tissue sarcomas, well-planned wide surgical excision with adjuvant radiotherapy remains the cornerstone of treatment for SS. Neo-adjuvant or adjuvant chemotherapy should not be delivered outside a clinical trial setting.

[Asplenia in the Hodgkin's patient]. / L'asplénisme du patient hodgkinien.

FEWER INDICATIONS AFTER SPLENECTOMY: Real therapeutic progress has been achieved over the last fifty years for patients with Hodgkin's disease known for their chronic immunodepression. Since the advent of effective chemotherapy protocols such as ABVD, and more recently intensive chemotherapy completed as needed with an autograft, splenectomy is no longer performed for therapeutic purposes but may be indicated for its contribution to diagnosis. STRATIFICATION OF RISK OF ASPLENISM: There remain however several questions concerning the infectious complications in these patients given chemotherapy and splenic radiotherapy. One of the objectives of this work was to propose a stratification of risk of asplenism as a function of treatments administered, the level of initial immunodepression, and the age of the patient.

[Standards, options, and recommendation for external radiotherapy of prostatic cancer: evaluation of the effect of dosage]. / Standards, Options et Recommandations pour la radiothérapie externe des patients atteints de cancer de la prostate: évaluation de l'effet dose.

CONTEXT: The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical speciality societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery. OBJECTIVES: Produce clinical practice guidelines for the radiotherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project. METHODS: The FNCLCC and the French Urology Association (AFU) designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers. RESULTS: The main recommendations are: 1/ a minimal dose of 70 Gy must be used, whatever the prognostic factors; 2/ it appeared that patients with favourable prognostic indicators (stage T1-2, PSA < or = 10 micrograms/L and Gleason score < or = 6) do not benefit from a dose escalation effect for doses over 70-74 Gy; 3/ patients with intermediate prognosis are the ones who benefit most from the dose escalation effect over 74 Gy, provided they receive exclusive radiation therapy; 4/ whenever possible, patients should be included in controlled trials designed to assess the effects of dose escalation and hormonotherapy.

[Standards, Options, and Recommendations for brachytherapy in patients with prostate cancer: efficacy and toxicity]. / Standards, Options et Recommandations pour la curiethérapie des patients atteints de cancer de la prostate: efficacité et toxicité.

CONTEXT: The "Standards, Options and Recommendations" (SOR) collaborative project was initiated in 1993 by the Federation of the French Cancer Centres (FNCLCC), with the 20 French Regional Cancer Centres, several French public university and general hospitals, as well as private clinics and medical specialty societies. Its main objective is the development of serviceable clinical practice guidelines in order to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review, followed by a critical appraisal by a multidisciplinary group of experts. Draft guidelines are produced, then validated by specialists in cancer care delivery. OBJECTIVES: Produce clinical practice guidelines for the brachytherapy of prostate cancer using the methodology developed by the Standards, Options and Recommendations project. METHODS: The FNCLCC and the French Urology Association (AFU) first designated the multidisciplinary group of experts. Available data were collected by a search of Medline and lists selected by experts in the group. A first draft of the guidelines was written, they validated by independent reviewers. RESULTS: The main recommendations are: 1/Brachytherapy with permanent seeds alone is a possible curative treatment for prostate cancer patients with the following prognosis factors: tumour stage T1 or T2a (TNM 1992), Gleason score < or = 6 and PSA < 10 micrograms/L. 2/Combined treatment with brachytherapy and hormonal therapy could be more efficient than brachytherapy alone for prostate cancer patients with Gleason score > 7 and/or PSA > 10.3/Combination of brachytherapy and external beam radiation therapy can be proposed to prostate cancer patients with intermediate prognosis. 4/Before and after seed implantation, risks of infection must be prevented by appropriate antibiotic therapy (recommendation). 5/Brachytherapy must not be performed within 2 months of transurethral prostate resection. 6/The height of the urethra receiving more than 200% of the prescribed dose must be reported. The portion of the rectum receiving 100 and 120% of the prescribed dose must be limited to 10 and 5 mm length, respectively.

Venous allografts preserved at 4 degrees C for infrainguinal bypass: long-term results from 170 procedures.

From April 21, 1982 to December 31, 1997, we performed 170 infrainguinal bypass procedures using isolated (n = 35) or composite (n = 135) venous allografts preserved at 4 degrees C as a substitute for saphenous autografts in 146 patients. The mean age of the patient population was 74 years. The indication was critical lower limb ischemia in 71% of cases. Seventy-five percent of procedures were below the knee and 26% were infrapopliteal. Mean length and diameter were 19.5 +/- 0.5 cm and 4.8 +/- 0.5 mm, respectively. After December 8, 1993, a reinforcement net was placed over the graft to prevent expansion in 71% of cases. Primary and secondary 5-year patency, calculated according to the Kaplan-Meier method, were 33 +/- 6% and 43 +/- 6%, respectively. Factors correlated with secondary patency were studied using the log-rank test. Previous ipsilateral infrainguinal revascularization was associated with a 40% decrease in secondary patency at 2 years (71% vs. 31%). Patency at 5 years was correlated with the level of anastomosis (47% for low popliteal anastomosis vs. 30% for infrapopliteal anastomosis). The likelihood of stenosis or dilatation of the allograft was 8% and 29.5%, respectively, at 5 years. The 5-year limb salvage and survival rates were 84% and 57%, respectively. The encouraging results of this series suggest that venous allografts provide a useful alternative for infrainguinal bypass when autologous grafts or other more reliable conduits are unavailable.

Impact of cerebrospinal fluid PCR on the management of HIV-infected patients with varicella-zoster virus infection of the central nervous system.

Over a 2 year period, we identified five HIV-infected patients who presented with central nervous system infection caused by varicella-zoster virus, three with myelitits, and two with meningoencephalitis. All five patients were profoundly immunocompromised. Clinical presentation of these patients overlapped to a significant extent with diseases caused by other viruses, e.g. CMV. Indeed, in one case, a dual infection with CMV was diagnosed, but the respective role of each virus was ascertained by in situ hybridisation. At the time of CNS involvement, only one patient had active VZV cutaneous lesions, which were instrumental in diagnosing her condition. In contrast, PCR for VZV DNA in the CSF was helpful in making a diagnosis in the four other cases, one of which was confirmed by a post mortem. Of these five patients, two patients developed VZV disease while receiving oral acyclovir and had foscarnet treatment initiated when MRI demonstrated widespread lesions. They did not respond to antiviral therapy. The three other patients had intravenous acyclovir initiated at a time when no or limited parenchymal lesions were observed by MRI. Two of these three patients had VZV infection diagnosed solely on the basis of PCR: all three responded to treatment. Our data show that reactivation of VZV involving the central nervous system occurs frequently in the absence of cutaneous lesions. PCR of cerebrospinal fluid may help in making an early diagnosis which is probably a prerequisite for successful treatment of VZV infection of the CNS.

Nine breast angiosarcomas after conservative treatment for breast carcinoma: a survey from French comprehensive Cancer Centers.

OBJECTIVES: To conduct a survey of the angiosarcomas developing after breast conservation for carcinoma in the French Cancer Centers, to study the evolution of these cases in detail, and to review literature in an attempt to propose an optimal treatment scheme. MATERIAL AND METHODS: Eleven of the 20 French Cancer Centers agreed to research and retrospectively analyze all angiosarcomas discovered in patients previously treated by conservative treatment. The majority of the patients were node negative, T1N0M0. The mean age of the patients at the time of primary breast cancer treatment was 62.5 years, and 69 years at the diagnosis of the angiosarcoma. RESULTS: During the last two decades, nearly 20,000 patients have been treated conservatively in these 11 centers, and only 9 cases of angiosarcoma were found. The median latency period between the treatment of the breast carcinoma and the diagnosis of the breast angiosarcoma was approximately 74 months, with a range of 57-108 months. Mastectomy was performed as the main treatment of this angiosarcoma. All recurrences after mastectomy for the angiosarcoma appeared within 16 months after the mastectomy. A median time of recurrence was found to be 7.5 months, regardless of the treatment. The angiosarcomas appeared to be very aggressive, and chemotherapy, radiotherapy, and sometimes hyperthermia could only palliate the condition for a short time. After the diagnosis of angiosarcoma, the median survival was 15.5 months, showing a particularly poor prognosis. Only 1 patient of 9 is alive without progressive disease at 32 months after salvage mastectomy for the recurrence of the angiosarcoma. Precise data obtained from 11 centers show that, of 18115 breast carcinomas treated conservatively, only 9 breast angiosarcomas are reported, which represents a prevalence of 5 cases of angiosarcoma per 10,000, which is the same prevalence for primary breast angiosarcomas occurring in healthy breasts. CONCLUSION: Angiosarcoma developing after breast conserving therapy for carcinoma is a rare event, and induction of it by treatment is controversial. However, early diagnosis is essential and it appears that radical mastectomy gives the highest chance of cure and the best long-term survival.

[Isolated peritoneal metastases from an lobular infiltrating breast carcinoma. Value of laparoscopy]. / Localisations péritonéales isolées d'un carcinome lobulaire infiltrant du sein. Place de la coelioscopie.

The authors report a case of peritoneal metastasis from an infiltrating lobular carcinoma of the breast. This case report enhances the frequency of this type of secondary location in the lobular carcinoma, with special attention to the diagnostic problems.

[Granulocytic sarcoma of the testis without hematological manifestations]. / Sarcome granulocytaire du testicule sans manifestation hématologique.

A 30-year-old man with a testicular tumor ressembling a "round cell sarcoma" was treated for rhabdomyosarcoma. Complete remission was achieved but the patient relapsed and died of the disease. A retrospective diagnosis of granulocytic sarcoma was established using an anti-myeloperoxidase antibody, unfortunately not available at the time of the initial diagnosis. No hematological disorders were observed during the course of the disease. Four cases of granulocytic sarcoma of the testis have been reported in the literature. All these cases where accompanied or followed by leukemia. The present case seems to be the first case of granulocytic sarcoma of the testis not accompanied by hematological disorders.

Long-term results with a Palmaz stent in the femoropopliteal arteries.

Highly contradictory results are achieved with stents in the superficial femoral and popliteal arteries. In order to compare our experience, we have reviewed a series of patients in whom a Palmaz stent was implanted at the femoropopliteal level. From January, 1991, to December, 1994, 35 patients were treated for claudication (63%) or for critical ischemia (37%), using endoluminal angioplasty and the implantation of a Palmaz stent. The stents were impianted in the superficial femoral artery in 26 cases (74%) and in the popliteal artery in 9 cases (26%). In case of restenosis (1 case), calcified stenosis (2 cases), complications of endoluminal angioplasty (32 cases), 44 stents were implanted in 35 stenoses (71.5%) and 10 short thromboses (28.5%). Follow-up was ensured periodically in all cases (D1, 2 months, 6 months, then every six months) using a clinical examination and a study with Doppler and duplex scanning. All stents were inserted without complications, with an initial success rate of 100%. During the follow-up period (32 +/- 4 months), two patients died (patent stent) and two were lost to follow-up. Acute thrombosis occurred in two cases (6%) and restenosis in five (14%) during the first six months after the operation. Restenosis occurred in all but one cases with a poor distal arterial runoff (p < 0.05). The popliteal artery was not more often affected by restenosis than the superficial femoral artery. Primary patency after one year is 80.4 +/- 7%, and 75.7 +/- 8% after two years. Assisted primary patency after 2 years is 83.3 +/- 7%. The implantation of a Palmaz stent is still a safe method, with low rates of acute thrombosis and a satisfactory long-term patency. Periodic and sonographic follow-up should allow improving the patency of restenosis by more than 50% under treatment.

-Emergency surgical treatment of acute carotid occlusion-. / Traitement chirurgical d'urgence des occlusions carotidiennes aiguës.

Conservative medical treatment of acute occlusion of the extracranial internal carotid artery usually gives mediocre results. When a major neurological deficit is involved, mortality can reach 16 to 55%, morbidity due to definitive deficit 40 to 69% and cure only 2 to 12%. It is thus logical to attempt revascularization as an emergency procedure. In situ intraarterial fibrinolysis is appropriate for acute occlusion in the intracranial territory of the internal carotid involving severe neurological deficits but surgery is more adapted and safer for acute occlusion of the extra-cranial internal carotid. In a personal series of 8 patients, we had 1 death, 1 aggravation, 1 improvement and 5 "cures" (62.5%). Based on data in the literature and our experience, we assessed the advantages of emergency surgery (immediate and definitive re-establishment of the carotid flow and vascularization of the hemisphere before installation of irreversible brain damage) and conditions suggesting chances of success: 1) diagnosis by noninvasive echo-Doppler of the cervical vessels and transcranial Dopler, without preoperative arteriography or CT-scan. 2) operation before 6 hours, 3) quality of the desobstruction, 4) no post-operative anti-coagulant treatment, 5) control of post-operative episodes of hypertension.

Peripheral primitive neuroectodermal tumour after allogeneic bone marrow transplantation.

We report a case of peripheral primitive neuroectodermal tumour (PNET) in a 36-year-old man who 10 years earlier received an allogeneic bone marrow transplantation (BMT) for a non-Hodgkin's lymphoma. Immunohistochemistry proved definitive elimination of a relapse of the original disease and confirmed the diagnosis of PNET. The role of total body irradiation pre-BMT in the genesis of this secondary tumour is discussed. The importance of registering secondary malignant solid tumours after BMT is emphasized. To our knowledge, an Ewing family tumour following BMT has not previously been reported.

The role of intraoperative transcranial Doppler monitoring in carotid artery surgery.

Of 135 carotid artery reconstructions performed under general anesthesia in 127 patients (mean age 68 years), 119 were performed with continuous intraoperative Doppler recording of the middle cerebral artery. This investigation was impossible in nine (6.7%) cases because of the absence of a visible temporal window, and results were deemed uninterpretable in six (4.5%) additional cases. The goals of this study were to test the feasibility and reliability of transcranial Doppler monitoring in the evaluation of intracranial perfusion and to determine the risk of cerebral ischemia during carotid artery clamping. The two outcome parameters measured were mean velocity and percentage of decreased flow in the middle cerebral artery during clamping. Patients were divided into four groups based on variations in these parameters. Groups I and IIA (low risk) represented 69.7% of cases, group IIB (significant risk) represented 21.9%, and group III (major risk) represented 8.4%. Transcranial Doppler monitoring appears to be a reliable means of observing middle cerebral artery flow during carotid surgery and in our opinion provides objective criteria for determining the need for an indwelling shunt. Accordingly, in this study no neurologic complications imputable to clamping were observed. Transcranial Doppler monitoring can also be used to ensure correct functioning of the shunt and to detect intraoperative embolic complications.

[Aneurysmal iliac lymphangiomyoma. Report of a case]. / Lymphangiomyome iliaque à forme anévrysmale. A propos d'un cas.

Single lymphangiomyoma, rarely encountered, is a form of lymphangiomyomatosis with characteristic proliferation of smooth muscle cells in lymph nodes and vessels. We observed a case in a 47-year-old woman with no past medical history. An echography performed for menorrhage revealed a single iliac localization in the right pelvis. The precise pre-operative diagnosis was difficult, but the pathology report formally identified the tumor as an isolated form without thoracic involvement. Unlike lymphangiomatosis itself which involves pulmonary lesions and which may require complementary treatment, total exeresis of a single tumour is the only treatment necessary, as was confirmed in this case.

[Small cell carcinoma of the prostate. Complete remission after chemoradiotherapy: apropos of a case]. / Carcinome de prostate à petites cellules. Rémission complète après chimio-radiothérapie: a propos d'un cas.

The authors report a case of pure small cell carcinoma of the prostate expressing neuroendocrine markers on immunohistochemistry. Treatment consisted of chemotherapy with cisplatin and etoposide combined with regional external beam radiotherapy. The result is encouraging with complete remission 15 months after the diagnosis.

[Inflammatory pseudo-tumor of the lung. Clinico-pathologic report of a case]. / Pseudo-tumeur inflammatoire du poumon. Etude anatomo-clinique d'une observation.

One case of a solitary pulmonary nodule occurring in a 54-year-old woman with history of breast carcinoma is presented. Histological examination of the surgical specimen excluded breast carcinoma metastasis and revealed an inflammatory pseudotumor. Principal clinico-pathological findings in previously reported cases are described. Inflammatory pseudotumors may exhibit, as in our case, some nuclear atypia making the diagnosis sometimes difficult with malignancy.

[Therapeutic modalities for germinal testicular tumors, excluding surgery. Radiotherapy--chemotherapy]. / Modalités thérapeutiques des tumeurs germinales testiculaires, chirurgie exclue. Radiothérapie--chimiothérapie.

There are two other treatments for germ cell tumours of the testis apart from surgery: radiotherapy and chemotherapy. Radiotherapy is ideally administered with a linear accelerator delivering photons and electrons. The dose is well established and smaller volumes are now irradiated. The precision is increased by CT and by the use of personalized shields. Radiotherapy is indicated in pure seminomas, with two exceptions: rare seminomas with a large tumour mass (2%), rare palliative indications for non-seminomatous germ cell tumours. Chemotherapy, following the progress due to the combination of vinblastine and bleomycin, has been based, for the last 10 years, on cisplatin, which must be administered at the correct dose. VP 16, ifosfamide and other drugs have also been introduced. In forms with a poor prognosis and depending on the clinical course, this chemotherapy should be administered at high doses with the protection of autologous bone marrow transplantation. This requires an appropriate infrastructure and a well trained team. The short-term and long-term effects of radiotherapy are more clearly defined than effects of chemotherapy.