Randomized phase III trial in elderly patients comparing LV5FU2 with or without irinotecan for first-line treatment of metastatic colorectal cancer (FFCD 2001-02).

BACKGROUND: Metastatic colorectal cancer (mCRC) frequently occurs in elderly patients. However, data from a geriatric tailored randomized trial about tolerance to and the efficacy of doublet chemotherapy (CT) with irinotecan in the elderly are lacking. The benefit of first-line CT intensification remains an issue in elderly patients. PATIENTS AND METHODS: Elderly patients (75+) with previously untreated mCRC were randomly assigned in a 2 × 2 factorial design (four arms) to receive 5-FU (5-fluorouracil)-based CT, either alone (FU: LV5FU2 or simplified LV5FU2) or in combination with irinotecan [IRI: LV5FU2-irinotecan or simplified LV5FU2-irinotecan (FOLFIRI)]. The CLASSIC arm was defined as LV5FU2 or LV5FU2-irinotecan and the SIMPLIFIED arm as simplified LV5FU2 or FOLFIRI. The primary end point was progression-free survival (PFS). Secondary end points were overall survival (OS), safety and objective response rate (ORR). RESULTS: From June 2003 to May 2010, 71 patients were randomly assigned to LV5FU2, 71 to simplified LV5FU2, 70 to LV5FU2-irinotecan and 70 to FOLFIRI. The median age was 80 years (range 75-92 years). No significant difference was observed for the median PFS: FU 5.2 months versus IRI 7.3 months, hazard ratio (HR) = 0.84 (0.66-1.07), P = 0.15 and CLASSIC 6.5 months versus SIMPLIFIED 6.0 months, HR = 0.85 (0.67-1.09), P = 0.19. The ORR was superior in IRI (P = 0.0003): FU 21.1% versus IRI 41.7% and in CLASSIC (P = 0.04): CLASSIC 37.1% versus SIMPLIFIED 25.6%. Median OS was 14.2 months in FU versus 13.3 months in IRI, HR = 0.96 (0.75-1.24) and 15.2 months in CLASSIC versus 11.4 months in SIMPLIFIED, HR = 0.71 (0.55-0.92). More patients presented grade 3-4 toxicities in IRI (52.2% versus 76.3%). CONCLUSION: In this elderly population, adding irinotecan to an infusional 5-FU-based CT did not significantly increase either PFS or OS. Classic LV5FU2 was associated with an improved OS compared with simplified LV5FU2. CLINICALTRIALSGOV: NCT00303771.

[Imaging of acoustic neuroma (vestibular schwannoma). Breakthrough or dilemma?]. / Neuroradiologische Bildgebung des Akustikusneurinoms (Vestibularisschwannoms). Durchbruch oder Dilemma?

Magnetic resonance imaging (MRI) is the diagnostic gold standard in vestibular schwannoma. Sensitivity and specificity are both close to 100%. MRI detects the tumour and describes its extension, thereby giving the potential surgeon prognostic clues. Prediction of tumour growth, however, is not possible. Careful analysis of imaging findings almost always enables differentiation from various other disease entities. Follow-up of surgical as well as non-surgical patients is another important role of MRI. Computed tomography (CT) is restricted to pre-surgical workup and to the immediate postoperative period.

[Palmar fasciitis associated with polyarthralgia: rare paraneoplastic syndrome]. / Fasciite palmaire associée à des polyarthralgies: un syndrome paranéoplasique rare.

BACKGROUND: Palmar fasciitis associated with polyarthralgia is a rare paraneoplastic syndrome, frequently observed in women, and in most cases associated with ovarian carcinoma. CASE REPORT: A 51 year-old man complained of extensive palmar dermatological lesions associated with polyarthralgia of the legs. A few months earlier, cholangiocarcinoma had been diagnosed due to cholestatic icterus. The cutaneous biopsy confirmed the diagnosis of palmar fasciitis associated with polyarthralgia. DISCUSSION: This paraneoplastic syndrome is rarely described in digestive carcinoma and never in cholangiocarcinoma. The diagnosis is clinical, confirmed by certain laboratory exams. The evolution is similar to that of the carcinoma. Only curative treatment can achieve regression of the symptoms.

Evoked potentials in acute head injured patients with MRI-detected intracerebral lesions.

BACKGROUND: Magnetic resonance imaging (MRI) allows precise detection of intracranial lesions in head injured patients. We compared intracranial lesions detected in MRI to somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) concerning their prognostic value. METHODS: Thirty patients with traumatic brain injury and prolonged recovery were studied. Size, side and number of 474 intra- and extraparenchymal lesions as well as lesion localisation based on a specific anatomical classification were entered into a database (a total of 7080 data). In addition, we recorded median-nerve SEP (M-SEP), tibial nerve SEP (T-SEP) and BAEP in all of the patients. FINDINGS: M-SEP and Glasgow-Outcome-Score (GOS) one year after injury correlated significantly to patients with lesions in the brainstem (p<0.0001) and corpus callosum (p<0.001). Similar results were found for T-SEP (p<0.0001). All patients with bicortical loss of M-SEP had an unfavourable outcome (GOS 2). Among the analysis of lesion volume, only the volume of brainstem lesions correlated to GOS (p<0.001), but this was not found for callosal lesions. However, comparing the vegetative (GOS 2) to the non-vegetative group (GOS 3-5), for both callosal (p<0.02) and brainstem (p<0.005) lesions a significant correlation was found. INTERPRETATION: MRI does not improve the prognostic reliability of SEP in head injury but offers possibilities for clarifying electrophysiological and clinical pathologies. This explains that the volume of brainstem lesions, essentially influencing the clinical outcome, is strongly correlated to T-SEP and M-SEP. In contrast, callosal lesions did not show a clear relationship to outcome despite large callosal lesions (>4 ml) which tended to poor outcome. In conclusion, we suggest that MRI and SEP are supplementary to each other concerning prognostic evaluation.

[Cost of medical imaging practices in acute abdominal syndromes]. / Coût des pratiques d'imagerie médicale dans les syndromes abdominaux aigus.

OBJECTIVES: To describe the costs of medical imaging practices in the diagnosis management of acute abdominal pain (AAP). METHODS: Medical imaging techniques until decision for treatment were prospectively recorded in patients presenting with AAP. Direct costs used hospital analytic accountability. Time of human resources involved was also surveyed prospectively. RESULTS: In 122 adult patients (2.3 examinations on average) before treatment decision making, the more frequent practices were: initial plain abdomen x-ray followed by tomodensitometry (36.8%), by echography or endoscopy (17.2%), plain abdomen solely (19.6%) or initial abdominal tomodensitometry (12.3%). Direct costs ranged from 977 to 1073 FF for practices with initial plain abdomen x-ray, and from 996 to 1150 FF with initial tomodensitometry. It ranged from 808 to 880 FF when the treatment decision was surgery, and 300 FF higher when it was medical. CONCLUSION: Differences in costs assessed for practices were very narrow. Such information should be taken into account to determine cost-effective strategies, and to built up reference guidelines.

Effect of intracerebral lesions detected in early MRI on outcome after acute brain injury.

In the present study we classified intracerebral lesions likely to influence the outcome of head injured patients according to localization, lesion type, lesion number and lesion volume. A score of intracerebral lesions based on findings in early MRI is presented. Early MRI studies were performed in 30 patients (average 5-6 days after trauma) and outcome (GOS) was determined after 3 and 12 months. Lesions were classified and lesion volume V was calculated (V = pi abc/6). The applied intracerebral lesion score included lesions in the frontal cortex, basal ganglia, corpus callosum and brainstem. Patients in a persistent vegetative state (PVS) showed a higher number (p = 0.018) and volume (p = 0.013) of frontal lesions as compared to the non-vegetative group (NPVS). Lesion volume in basal ganglia differed significantly between PVS and NPVS (p = 0.01) and correlated to outcome (r = -0.65, p < 0.005). Volume difference in the corpus callosum between PVS and NPVS was significant (p = 0.02). The number (r = -0.61, p < 0.005) and volume (r = -0.62, p < 0.005) of brainstem lesions correlated to outcome and PVS differed in number (p = 0.012) and volume (p = 0.006). The intracerebral lesion score correlated to the GOS (r = -0.57, p = 0.001) and PVS and NPVS differed significantly. A lesion volume exceeding 40 ml in the frontal cortex, 3.5 ml in the basal ganglia, 4 ml in the corpus callosum or 1.5 ml in the brainstem is likely to lead to an unfavorable outcome. More than 4 lesions in the frontal cortex or 3 lesions in the brainstem appeared more frequent in patients with unfavorable outcome. Treatment strategies in the early phase after brain injury could be modified by the knowledge of certain lesions only visible on MRI.

Comparison of resection, liver transplantation and transcatheter oily chemoembolization in the treatment of hepatocellular carcinoma.

BACKGROUND/AIMS: Resection and liver transplantation are currently considered as the most useful treatments for hepatocellular carcinoma. However, transcatheter oily chemoembolization may be favourably compared with these two surgical treatments in patients with anatomically operable tumors. METHODS: Between 1985 and 1991, 122 patients with an Okuda stage I tumor were hospitalized in two French hospitals. Among these patients, 33 remained untreated, 42 were treated by transcatheter oily chemoembolization, 30 by resection and 17 by liver transplantation. The four groups were closely comparable except for age, the patients in the two surgical groups being significantly younger. Moreover, the frequency of pTNM II tumor was significantly higher in the resection group. RESULTS: The 5-year probability of survival was close to 45% in each of the three treated groups and was significantly higher than in the untreated group (0% at 4 years, p < 0.0001). The probability of cancer recurrence and/or metastatic dissemination was lower after transcatheter oily chemoembolization than after surgery. CONCLUSION: Thus, transcatheter oily chemoembolization seems comparable at 5 years with resection or transplantation for the treatment of resectable hepatocellular carcinoma.