Molecular detection of human papillomavirus and viral DNA load after radiotherapy for cervical carcinomas.

AIMS AND BACKGROUND: Infection with high-risk types of human papillomavirus (HPV) is a necessary cause for cervical carcinoma. Radiation therapy together with surgery is the most effective treatment. The purpose of this study was to investigate the molecular basis of the response to radiotherapy in cervical cancer cells. METHODS AND STUDY DESIGN: Tumor cells were obtained from biopsies of 44 cervical cancers, collected before and after radiotherapy. The presence of HPV was analyzed by polymerase chain reaction (PCR) using primers specific for the L1 region. RESULTS: The prevalence of HPV was 70.4%, with HPV16 being the most common (54.5%) and HPV18 the second (15.9%). Our analyses show that ionizing radiation does not influence HPV detection, as the percentage of HPV-positive biopsies was similar in patients before and after radiotherapy (HPV16 60% vs. 51.7% and HPV18 20% vs. 13.7%, respectively). However, the detection of HPV did vary by tumor stage, with the highest proportion observed in late-stage tumors (HPV16 and HPV18 in 80% and 60% of stage III tumors, respectively). We also found that HPV viral load is influenced by radiotherapy and tumor stage, with the highest viral loads in late-stage tumors (stage III) after 1 day since radiotherapy (p<0.05). According to Kaplan-Meier curves, higher HPV viral load was associated with significantly shortened progression-free survival (p = 0.04). CONCLUSIONS: Our data provide prospective evidence that ionizing radiation can affect the HPV viral load and this might offer the best strategies for assessment of therapeutic efficacy.

Sequence variation in the E2-binding domain of HPV16 and biological function evaluation in Tunisian cervical cancers.

HPV16 E2 variants have different effects on the transcriptional activity of the LCR. In this study, we examined the nucleotide and amino acid sequence variation within the HPV16 E2 gene and to correlate with disease progression. E2 gene disruption was detected by PCR amplification of the entire E2 gene using a single set of primers. Nucleotide variations were analyzed by bidirectional sequencing. mRNA expression patterns of E6 and E7 gene transcripts were evaluated by a reverse transcriptase-PCR method (RT-PCR). The detection of intact E2 genes was significantly higher among controls than cases (81.8% versus 37.5%, resp., P < 0.05). Among the E subgroup, variation at position 3684 C>A results in the amino acid substitution T310K and was more common among the E2 undisrupted cases (7/9; 77.7%), compared to controls (2/9; 22.2%). In addition, specific sequence variations identified in the E2 ORF at positions 3684 C>A were associated with increased viral oncogenes E6-E7 production. Besides HPV16 E2 disruption, the 3684 C>A variation within undisrupted E2 genes could be involved in an alternative mechanism for deregulating the expression of the HPV16 E6 and E7 oncogenes and appears to be a major factor contributing to the development of cervical cancer in Tunisian women.

Situation of HPV16 E2 gene status during radiotherapy treatment of cervical carcinoma.

BACKGROUND: Human papillomavirus (HPV) integration within the E2 gene has been proposed as a critical event in cervical carcinogenesis. This study concerned whether HPV16 status and E2 gene intactness are predictive of radiation response in patients with cervical cancer. MATERIALS AND METHODS: Biopsies of 44 patients with cervical cancer were collected before or after radiotherapy. The presence of HPV16 was assessed by polymerase chain reaction (PCR) using specific primers for the L1 region. E2 disruption was detected by amplifying the entire E2 gene. RESULTS: HPV16 DNA was found in 54.5% of the clinical samples. Overall, 62.5% of the HPV16 positive tumors had integrated viral genome and 37.5% had episomal genome. There was a tendency of increase of HPV16 E2 negative tumors compared with HPV16 L1 ones in advanced stages (75% versus 20% in stage III respectively). Detection of E2 gene appeared influenced by the radiotherapy treatment, as the percentage of samples containing an intact HPV16 E2 was more frequent in pretreated patients compared to radiotherapy treated patients (66.6% versus 20%). The radiation therapy caused an eight-fold [OR= 8; CI=1.22-52.25; p=0.03] increase in the risk of HPV16 genome disruption. The integration status is influenced by the irradiation modalities, interestingly E2 disruption being found widely after radiotherapy treatment (75%) with a total fractioned dose of 50 Gy. CONCLUSIONS: This study reveals that the status of the viral DNA may be used as a marker to optimize the radiation treatment.

HPV-16 E2 physical status and molecular evolution in vivo in cervical carcinomas.

A key event in the development of cervical carcinoma is the deregulated expression of high-risk human papillomavirus (HR-HPV) oncogenes, most commonly due to HPV integration into host DNA. Here we explored whether HPV-16 E2 gene integrity is a biomarker of progressive disease with oncogenes expression. HPV-16 genome disruption was assessed by amplification of the entire E2 gene, while mRNA expression patterns of the E1, E2, E6, and E7 genes were evaluated by reverse transcription PCR (RT-PCR). As expected, E2 disruption was significantly higher among patients with cervical cancers than subjects with benign lesions (p=0.02). The status of the E2 gene correlated with tumorogenesis, and seemed also to correlate with the stage of the carcinomas, since integrated HPV-16 DNA was frequently detected in patients with advanced cancer stages (75% of stage III vs 60% stages I and II). In bivariate analysis, the lesions’ grade was most significantly associated with HPV-16 DNA disruption (p<0.05). In cervical carcinoma the deletion pattern involved more frequently the E2 gene rather than the E1 gene (62.5% vs 45.8%). The prevalence of the E6/E7 HPV-16 transcripts in cervical carcinoma specimens and in benign cervical lesions were detected with frequencies of, respectively, 91.6% and 45.4%. The mRNA levels of the HPV-16 E6/E7 genes were expressed at approximately the same levels in each physical state. We consistently observed that E6/E7 were absent or weakly detectable in the presence of E2. However, in the absence of E2 the levels of E6/E7 markedly increased (p<0.05). This study underscores the significance of investigating alternative mechanisms of E2 expression and oncogenes E6/E7 transcripts in vivo as biomarkers for disease severity in cervical carcinomas.

Sternal or parasternal involvement from breast cancer: a misleading clinical sign.

BACKGROUND: Sternal arch is a nonspecific clinical signs wich may arise during following of breast cancer, this sign reveals an involvement of internal mammary nodes secondary to breast cancer. AIM: To report a rare event such as a loco-regional sternal or parasternal invasion secondary to locally advanced cases of breast cancer (BC) about a Tunisian series. METHODS: We collected retrospectively from 1988 to 2012, 11 cases of BC treated at the Institut Salah Azaiez (ISA) of Tunis, with presence during the disease evolution (initial or at relapse) of a sternal or parasternal swelling. We analyzed their clinical history, clinical and imaging data (CT-scan and/or MRI), stage, time of occurrence, treatment and evolution RESULTS: All patients were females and their mean age was 46 years varying from 24 to 75 years. The sternal or parasternal swelling was found at diagnosis in 5 cases and on recurrence in 6 patients after a mean free interval of 24 months, > 12 months in 5 cases. The mean clinical tumor size of the primitive BC was 38 mm (24-75 mm) and lesions located in external quadrants in 3 cases and internal or central in 6 cases. Sternal involvement related to large Intrammmary Chain (IMC) adenopathies was diagnosed by CT-scan. 7 patients had synchronous metastases. 9 out of the 11 patients received a locoregional RT and two received chemotherapy (CT). CONCLUSION: Sternal or parasternal swelling is a clinical apparent symptom of advanced internal mammary lymph nodes in breast cancer. The first etiologic diagnosis in this context is an advanced internal mammary chain (IMC) node involvement from breast cancer.

[Atypical presentations of internal mammary chain involvement in breast cancer]. / Les aspects trompeurs de l'atteinte de la chaîne mammaire interne dans les cancers du sein.

BACKGROUND: Breast cancer is the first cancer in women. Lymphatic involvement in breast cancer is common, especially in our patients because of the frequency of locally advanced forms. This contrast with a weak rate of diagnosed internal mammary chain invasion. METHODS: We present observations of patients presenting atypical forms of internal mammary chain involvement. AIM: To clarify the atypical presentations of internal mammary chain involvement in breast cancer. RESULTS: The invasion of internal mammary chain is often underestimated. Indeed, this site of lymphatic spread is not accessible to the clinical exam and its radiological exploration is not systematic. Otherwise, different clinical, pathological and radiological presentations have to attract our attention to a potential internal mammary chain invasion. CONCLUSION: Our misrecognition of this site of spread and its different presentations can partly explain the lack of diagnosis.

Correlation between ebv co-infection and HPV16 genome integrity in Tunisian cervical cancer patients

Infection with high risk Human papillomavirus (HR-HPV) is necessary but not sufficient to cause cervical carcinoma. This study explored whether multiple HR-HPV or coinfection with Epstein-Barr virus (EBV) influence the integration status of HPV16 genome. The presence and typing of HPV in a series of 125 cervical specimens were assessed by polymerase chain reaction (PCR) using the specific primers for the HPV L1 region. As for EBV infection, the viral EBNA1 gene was used for its detection through PCR amplification. Disruption of the HPV E2 gene was assessed by amplification of the entire E2 gene with single set of primers, while E2 transcripts were evaluated by a reverse transcription PCR method (RT-PCR). The overall prevalence of HPVDNA was of 81.8% in cervical cancers versus 26.9% in benign lesions. In HPV positive cases, HPV16 and HPV18 were the most prevalent types, followed by HPV types 33, 31. EBV EBNA1 prevalence was statistically more frequent in cervical carcinomas than in benign lesions (29.5%, vs 9.6%; P=0.01). No viral infection was detected in healthy control women. The uninterrupted E2 gene was correlated with the presence of E2 transcripts originating from the HPV episomal forms. It was observed that integration was more common in HPV18 and EBV coinfection. The presence of EBV caused a five-fold [OR= 5; CI= 1.15-21.8; P = 0.04] increase in the risk of HPV16 genome integration in the host genome. This study indicates that EBV infection is acting as a cofactor for induction of cervical cancer by favoring HPVDNA integration.

Correlation between ebv co-infection and HPV16 genome integrity in Tunisian cervical cancer patients.

Infection with high risk Human papillomavirus (HR-HPV) is necessary but not sufficient to cause cervical carcinoma. This study explored whether multiple HR-HPV or coinfection with Epstein-Barr virus (EBV) influence the integration status of HPV16 genome. The presence and typing of HPV in a series of 125 cervical specimens were assessed by polymerase chain reaction (PCR) using the specific primers for the HPV L1 region. As for EBV infection, the viral EBNA1 gene was used for its detection through PCR amplification. Disruption of the HPV E2 gene was assessed by amplification of the entire E2 gene with single set of primers, while E2 transcripts were evaluated by a reverse transcription PCR method (RT-PCR). The overall prevalence of HPVDNA was of 81.8% in cervical cancers versus 26.9% in benign lesions. In HPV positive cases, HPV16 and HPV18 were the most prevalent types, followed by HPV types 33, 31. EBV EBNA1 prevalence was statistically more frequent in cervical carcinomas than in benign lesions (29.5%, vs 9.6%; P=0.01). No viral infection was detected in healthy control women. The uninterrupted E2 gene was correlated with the presence of E2 transcripts originating from the HPV episomal forms. It was observed that integration was more common in HPV18 and EBV coinfection. The presence of EBV caused a five-fold [OR= 5; CI= 1.15-21.8; P = 0.04] increase in the risk of HPV16 genome integration in the host genome. This study indicates that EBV infection is acting as a cofactor for induction of cervical cancer by favoring HPVDNA integration.

[Radiation therapy in extra abdominal desmoid tumours]. / Radiothérapie des tumeurs desmoïdes extra abdominales.

BACKGROUND: Desmoid tumours are rare benign tumours that have local "malignity". They can be locally aggressive by infiltrating adjacent vascular, nervous and bony structures. AIM: To define the role of radiotherapy in the management of desmoid tumours. METHODS: Retrospective study of six extra-abdominal desmoid tumours treated with surgery and radiation therapy. RESULTS: Median age was 26.8 years (16-35 years). The tumor was located in the arm (1 case), in the legs (2 cases) and in the body (3 cases). Median tumoral sizes were 86.6 mm (60-100 mm). Five patients had local recurrence after surgical resection. Radiation therapy included Cobalt 60 in five cases and photons associated to linear acceleration in one case. Total dose was between 54 and 62 Gy. At the end of radiation therapy, tumoral control was obtained in five cases after a median follow-up of 26 months (1-83 months). CONCLUSION: Surgery is the main treatment of desmoids tumours but local recurrence rates remain high even after complete resection. The role of adjuvant radiation therapy is controversial.

[Superior vena cava syndrome and internal mammary nodes in breast cancer: two cases]. / Syndrome cave superieur avec atteinte de la chaine mammaire interne au cours d'un cancer du sein: a propos de deux observations.

BACKGROUND: The association of superior vena cava syndrome with involvement of the internal mammary lymph nodes in breast cancer has not been reported in the literature. AIM: To report two cases of association of superior vena cava with involvement of the internal mammary lymph nodes in breast cancer. CASES REPORT: We report two observations in two patients 45 and 52 years with breast cancer classified T4N2M0 and T3N2M0 treated. Both patients had clinical features compatible with the diagnosis of superior vena cava confirmed by the initial clinical appearance (observation 1) and after treatment (observation 2) to the CT scan. CONCLUSION: The combination of superior vena cava with the achievement of the internal mammary chain in breast cancer worse prognosis.

[Tumors of the pineal region: retrospective study of 40 cases]. / Les tumeurs de la région pinéale: étude rétrospective à propos de 40 cas.

BACKGROUND: the tumours of the pineal region are rare brain tumours, most common in children and characterized by a large clinical and histologic polymorphism. AIM: to assess the outcome and prognostic factors of 40 patients with primitive pineal region tumours treated at the department of radiotherapy of Salah Azaiz institute. METHODS: between January 1977 and December 2000, 40 patients received radiotherapy. There were 22 adults and 18 children (age < 16 years). The mean age was 20.4 years and sex ratio was 2.07. Histologic diagnosis was confirmed in 11 cases; 16 patients had a CT evaluation after 20 Gy radiotherapy and in 13 cases diagnosis was performed with CT aspects ± germinal tumour markers. Target volume varied; 10 had craniospinal irradiation, 16 had local irradiation and 14 had whole brain irradiation with a boost at the tumour bed. Chemotherapy was proposed for metastases and recurrent diseases. RESULTS: survival rates were 87% at 2 years and 74, 5% at 5 years. For children, survival rates were 88% at 2 and 4 years. Eight patients (20%) failed locally and 5 patients (12.5%) had metastasis. Age, performance status and large fields of radiotherapy seem to be associated with prognosis and survival. CONCLUSION: Pineal tumours and especially germinal tumours are chemosensitive and radiosensitive, care of these tumours is multidisciplinary involving surgery, chemotherapy and radiotherapy. From our study and a review of the literature, we tried to find a therapeutic strategy for tumours of the pineal region.

Clear cell carcinoma of the uterus.

AIM: The aim of this study was to determine the characteristics and outcome of patients presenting with clear cell carcinoma (CCC) of the endometrium treated in a single institution. METHODS: We reviewed the records of patients treated in the Salah-Azaiz institute for CCC of the endometrium. A histopathological stage was retrospectively assigned to these patients according to the FIGO classification and was compared to the clinical stage. Pathological features were studied in order to determine predictif factors of extrauterine disease extention and failure patterns. RESULTS: 12 patients were included in the study. The mean age at diagnosis was 64 years (50 to 84 yers). Upstaging after surgery was found in 9 patients. 9 patients had extrauterine extension. Deap myometrial invasion was not correlated with extrauterine extension. After a median follw up of 32 months, 4 patients presented with recurrences: one vaginal recurrence, two cases of pelvic and abdominal recurrence and abdominal recurrence in one patient. All recurrences occurred during the first year after surgery. Tumor recurrence was located within the radiation field in one case. Two patients with abdomino-pelvic recurrences progressed despite the association of surgery, radiation therapy and chemotherapy. CONCLUSION: Extrauterine extension is frequent at diagnosis and not correlated to classical risk factors observed in endometrioid carcinoma. A comptlete surgical staging is necessary for adjuvant treatment. Locoregional and distant recurrences are frequent and have a poor outcome.

[Internal mammary lymph node invasion in breast cancer: myth or reality?]. / L'atteinte de la chaîne mammaire interne dans le cancer du sein: mythe ou réalite?

The internal mammary nodes are often underestimated as breast cancer lymphatic pathway spread. It is yet the first site of lymphatic invasion in central or internal tumors and the second site in external tumors. The intra-thoracic situation of internal mammary nodes explains partly, the difficulty of its exploration. To evaluate the risk of internal mammary node invasion, some predictive factors are established (tumor size, internal or central tumor location, axillary node invasion and young age). Prognostic and therapeutic impact of invasion justifies its systematic research. Without exploring internal mammary nodes status, TNM classification remains, incomplete. CT scanner, magnetic resonnance imaging, positron emission tomography scanner and sentinel node exploration technique are helpful to explore this region and to adapt its irradiation.

[Prognostic value of parapharyngeal extension in nasopharyngeal carcinoma]. / Valeur pronostique de l'extension parapharyngéee dans les carcinomes nasopharyngés.

AIM: This study evaluated the prognostic value of the Para pharyngeal space involvement in nasopharyngeal carcinoma T 2 disease (UICC 1997 classification). METHODS: From January 1997 and December2001; 32 patients with nasopharyngeal carcinoma were examined by CT scan and according to the 1997 International Union Against Cancer (UICC) staging system, 15 had stage T2a M0 (G1) and 17 T2bM0(G2). The median age was 47 years. The male to female ratio was 1.81 (G1); 4.3 (G2). All patients were pathologically confirmed by biopsy from the nasopharynx as having UCNT in 100% (G1) and 94% (G2). The node involvement was 52% for the G1 (N2: 26%, N3: 26%) and 80% for the G2 (N2: 47%, N3: 41%). Both neoadjuvant chemotherapy and radiotherapy were performed for advanced N disease and only radiotherapy for NO. RESULTS: Examination and CT scan were performed for the evaluation of the treatement. The completely clinical remission after chemotherapy was 12.5% (G1) and 53% (G2), partial remission was 25% (G1) and 35% (G2). The CT scan control wasn't performed for all patients. The complete response was 69% (G1) and 53% (G2); partial response was 6% for both two groups. The median follow up was 79 months. Disease free survival rates were 70% for G1 (T2a) and 48% for G2 (T2b). Distant metastasis rates were 26% (G1) vs 6% (G2) and more likely in the presence of advanced N disease. Five years overall survival was 78% (G1) T2a vs. 55% (G2) T2b.The N disease was correlated to metastasis as overall survival was 66.7% for N3 disease vs 85.7% for N0. CONCLUSION: Parapharyngeal tumor involvement affects local and regional tumor failure. Subclassification of T2 disease into T2a/T2b should have an impact on treatment strategies.

Breast cancer in Tunisia in 2004: a comparative clinical and epidemiological study.

The aim of this study was to determine the epidemiological, clinical and anatomopathological aspects of breast cancer in Tunisia. We censored and analyzed all cases of breast cancer newly diagnosed in Tunisia during the year 2004. During that year, 1437 new cases of invasive breast cancer were diagnosed and 35 cases of non invasive breast cancer. There were 1408 women and 29 men. The accrual incidence was 27.1 and the standardized incidence was 28.5. The mean age for women was 51 years. The mean tumour size was 40.8 mm (32.3 mm and 42.5 mm for private and public sectors respectively). Tumour stage was T1 in 12.2% cases, T2 in 46.9% cases, T3 in 11.2% cases and T4 in 24.7% cases. Invasive ductal carcinoma was the most frequent (86,6%) with SBR II grade representing 54.5%. 27.7% of the patients had undergone conservative treatment. There was an unexpected increase of the incidence since 1994 where the standardized incidence was 16.9. We have noticed a moderate decrease of the tumour size of 8 mm during the last decade. This national epidemiological study on breast cancer showed an increase in the incidence of this cancer with a moderate decrease in the clinical tumour size. The relative young mean age of our patients may be explained by the age distribution in our population or by risk factors that may be particular to our country.

Effect of once-a-day fractionated total body irradiation on the risk of relapse after non-T-cell-depleted HLA-matched sibling transplantation.

PURPOSE: The aim of this study was to assess the impact of fractionated total body irradiation (F-TBI) on treatment-related mortality (TRM) and relapse in patients who received a non-T-cell-depleted allogeneic stem cell transplantation (ASCT) for hematological malignancies. MATERIALS AND METHODS: Between March 2003 and December 2004, a total of 24 patients with HLA-identical sibling donors entered this study and received three doses of 3.33 Gy F-TBI separated by 24 h and cyclophosphamide or etoposide. RESULTS: At a median follow-up of 37 months (range 29-47 months), 4 of the 24 patients (16.6%) died of TRM. Relapse occurred in 10 patients at a median of 9 months (range 2-18 months). Overall, 13 of 24 patients (54%) died. Relapse was the most common cause of death (9/13). The 2-year actuarial survival rate was 46% (+/-11%). CONCLUSION: In our experience, ASCT conditioned with F-TBI was associated with low TRM but a high early relapse rate in patients with hematological malignancies.

[Skin cancer in Tunisia: a retrospective study: 1379 cases and risk factors]. / Les cancers cutanés en Tunisie: une étude rétrospective de 1379 cas et facteurs de risques.

UNLABELLED: The aim of this study was to determine the clinical and epidemiological aspects of skin cancer in Tunisia. METHODS: we analysed the clinical files of all cases of skin cancer registrated at the ISA institute between 1975 and 1984. RESULTS: 1379 cases of skin cancer were referred to ISA, representing 9.02% of all cancer cases referred to the institute during the same period. Basal cell carcinoma (CBC) was the most frequent type (57.5%) followed by squamous cell carcinoma (CSC): 32.6% and melanomas: 4%. The sex ratio was 1.7 with a mean age of 61 years in men and 60 years in women. The face was the most frequent involved sites in CBC (92%). This region is usually exposed to the sun. The distribution of CSC in the body was different. The lesions were multiple in 11% of the cases. 13.7% of the CSC were developped on a burn scar. 21 cases were radio-induced and 45 patients had a xeroderma pigmentosum. CONCLUSION: skin cancer is relatively frequent in Tunisia. However, our incidence is inferior to other countries. Sun exposure is the main risk factor.

[Medulloblastoma with extracentral nervous system metastases: clinical presentation and risk factors]. / Medulloblastoma with extracentral nervous system metastases: clinical presentation and risk factors.

PURPOSE: Extra-central nervous system (extra-CNS) metastases are relatively unknown failure patterns in medulloblastoma. The aim of this study was to analyse epidemiological, clinical and aetiopathological aspects of these extra-CNS localisations. PATIENTS AND METHODS: Extra-CNS metastases were retrospectively identified in patients treated in the department of radiation therapy at Salah-Azaïz institute (ISA) for medulloblastoma. These metastases were diagnosed as extra-CNS for all secondary localisations not related to other tumour aetiology. Aetiopathological aspects are discussed with a literature review. RESULTS: Among 103 patients treated and followed-up in the department of radiation therapy of ISA from 1970 to 1992, 8 developed extra-CNS metastases (7.7%). Age at diagnosis of primitive tumour varied from 3 to 23 years. Sex ratio was 1. Primitive tumour treatment was: complete surgical resection in 4 patients with preoperative cerebrospinal fluid shunting in two, cerebrospinal axis irradiation in 7 patients and a cerebral-limited irradiation in 1. Two patients received chemotherapy for their initial treatment (systemic in one case and intrathecal in the other). The mean free-interval from diagnosis of primitive tumour to extra-CNS metastases was 23 months, varying from 8 to 53 months. These metastases were located in the liver (1 case), cervical lymph nodes (2 cases), bone marrow (1 case) and bone (2 cases). Two patients had multiple metastases: bone and bone marrow (in one), lung, pleura, cervical lymph node and bone localisations (in one). Treatment of these metastases was: chemotherapy in 5 cases, chemotherapy and radiation in one, radiation therapy in one and 2 patients were given only supportive care treatment. All patients died or are in progressive disease in less than one year from the diagnosis of extra-CNS metastases. CONCLUSION: Extra-CNS metastases are not rare and have a poor prognosis. The most commonly involved sites are bone, cervical lymph nodes and bone marrow. A complete work-up at initial diagnosis is recommended to screen early metastases. Literature review showed that histopathologic grading might help to identify groups at risk.