PURPOSE: From October 1993 through July 1998, 48 assessable adult patients with non-resectable aggressive intracranial tumors were treated by a combination of high dose photon + proton therapy at the Centre de Protonthérapie d'Orsay. PATIENTS AND METHODS: Grade 1 and 4 gliomas were excluded. Patients benefited from a 3D dose calculation based on high-definition CT and MRI, a stereotactic positioning using implanted fiducial markers and a thermoplastic mask. Mean tumor dose ranged between 63 and 67 Gy delivered in five weekly sessions of 1.8 Gy in most patients, according to the histological types (doses in Co Gy Equivalent, with a mean proton-RBE of 1.1). RESULTS: With a median 18-month follow-up (range: four-58 months), local control in tumors located in the envelopes and in the skull base was 97% (33/34), and in parenchymal tumors, 43% (6/14) only. Two patients (5%) presented with a clinically severe radiation-induced necrosis (temporal lobe and chiasm). CONCLUSION: In our experience, high-dose radiation combining photons and protons is a safe and highly efficient procedure in selected malignancies of the skull base and envelopes.

Adult↗

PubMedDate not supplied

Adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy in localized uterine sarcomas: results of a case-control study with radiotherapy alone.

UNLABELLED: Uterine sarcoma is a poor prognosis disease, with a high risk of metastatic relapse. We conducted a study of adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy (n=18). The results were then compared in a matched case-controlled study to radiotherapy alone (n=16) or no therapy at all (n=2). Chemotherapy consisted in three cycles of adriamyein-platinum-ifosfamide (API) (doxorubicin 60 mg /m2 on day 1; cisplatin 100 mg /m2 on day 2; ifosfamide 5 g /m2 on day 1+mesna 5 g /m2 on day 1+granulocyte colony-stimulating factor; q 3 weeks). Drug doses were reduced (20% for ifosfamide and cisplatin) four times (four patients) due to hematologic toxicity. Compared to a case-control study of adjuvant radiotherapy alone, results were not decreased by the addition of a toxic chemotherapy. CONCLUSION: Adjuvant API chemotherapy followed by radiotherapy is a feasible protocol; a multicenter phase III study comparing radiotherapy alone versus API chemotherapy followed by radiotherapy just began in France.

Adult↗

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A pathophysiological approach to the altered CO 2 effect on cerebral blood flow in post-acute ischaemia in man.

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Blood Pressure↗

PubMedDate not supplied

Reversal of focal "misery-perfusion syndrome" by extra-intracranial arterial bypass in hemodynamic cerebral ischemia. A case study with 15O positron emission tomography.

Tomographic images of cerebral blood flow (CBF) and oxygen extraction fraction (OEF) using the 15O continuous inhalation technique, and positron emission tomography, were obtained from a patient with cerebral ischemia distal to an occluded left internal carotid artery. There was a focal mismatch between CBF and oxygen metabolism in the brain supplied by the middle cerebral artery where CBF was decreased and OEF increased ("misery-perfusion syndrome" as opposed to "luxury-perfusion syndrome"). These abnormalities were most marked in the parieto-occipital watershed area. After left superficial temporal to middle cerebral artery anastomosis, the clinical attacks ceased and a repeat study did not demonstrate the previous CBF and OEF abnormalities. This suggests that this pattern of abnormalities indicates potential viable tissue. The concept of "misery-perfusion" may be of some importance in the pathophysiological mechanisms of hemodynamic cerebral ischemia and serve as a rational basis for revascularization procedures.

Aged↗

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Effects of extra-intracranial arterial bypass on cerebral blood flow and oxygen metabolism in humans.

Twelve patients, eleven with a carotid obstruction and one with an occlusion of the middle cerebral artery, were studied before and after a successful unilateral extra-intracranial arterial by-pass, (EIAB) using PET and the 15-0 steady-state technique to measure regional cerebral blood flow (CBF), oxygen extraction fraction and oxygen metabolic rate (CMRO2). In the whole group of patients, both CBF and CMRO2 increased significantly on both cerebral hemispheres after EIAB, returning toward control levels defined in age-matched subjects. Mean oxygen extraction fraction, on the other hand, was not affected. Individually, three different effects of EIAB emerged: 1) Alleviation of a state of long standing unilateral "misery-perfusion", as reported earlier; 2) parallel increase of CBF and CMRO2 bilaterally, which appeared due to improvement of a hemodynamic depression of metabolism, the precise mechanism of which remains obscure; 3) Complex, unexpected changes in the CBF-CMRO2 couple again resulting in increases in CMRO2. This metabolic improvement afforded by EIAB in our patients has not been reported before; it suggests that long-standing hemodynamic failure may induce a metabolic depression that is still potentially reversible by surgical revascularization.

Adult↗

PubMedDate not supplied

Prevention of dexamethasone-induced lymphocytic apoptosis in the intestine and in Peyer patches by enteral nutrition.

BACKGROUND: Apoptosis is a programmed cell death, genetically controlled, that can be activated by physiological and pathophysiological events and by the administration of several drugs, including the exogenous administration of corticosteroids. The aim of this study was to develop a rat model of intestinal lymphocytic apoptosis induced by dexamethasone to determine if apoptosis could be prevented by enteral or parenteral nutrition. METHODS: Male Sprague-Dawley rats were used. On day 0, the right internal jugular vein was catheterized for parenteral nutrition, and a silicone tube was inserted into the duodenum for enteral feeding. Animals (n = 6/group) were randomly assigned to one of the following 3 feeding regimens: an immune-enhancing enteral diet; its placebo (the same formula without immunonutrients); and isocaloric isonitrogenous parenteral nutrition. On the seventh day, 200 microg of dexamethasone or vehicle were administered by i.v. bolus, and the diets were continued for 1 more day. Intestinal Peyer patches and thymic lymphocytic apoptosis were determined both by flow-cytometry and immunohistochemistry. RESULTS: A single dexamethasone dose (200 microg/rat) administered to surgically treated rats fasted for 18 hours, 24 hours later, caused massive intestinal and Peyer patches lymphocytic apoptosis (96 +/- 2% and 85 +/- 5%, respectively; p < .0001 versus vehicle in both kinds of tissue). Lymphocytic apoptosis was reduced to almost indetectable levels in intestinal and lamina propia lymphocytes (from 96 +/- 2% to <0.6%; p < .0001). Peyer patches lymphocytic apoptosis was reduced as well (from 85 +/- 5% to 15 +/- 7.1%; p < .001) in animals prefed the 2 enteral nutrition formulas. Those prefed parenteral nutrition only showed a partial decrease of lymphocytic apoptosis in the intestine (from 96 +/- 2% to 53 +/- 23%; p < .001). Nutrition had no effect on the dexamethasone-induced thymus involution. CONCLUSIONS: Enteral nutrition prevents intestinal intraepithelial and lamina propia lymphocytic apoptosis due to dexamethasone. These findings support the use of early enteral nutrition in critically ill patients treated with corticosteroids.

Animals↗

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[Our technique of hetero-lateral facio-facial anastomosis by means of nerve autografting in the treatment of permanent peripheral facial paralysis].

The authors describe the technique used in 12 surgical cases of heterolateral facio-facial anastomosis by nerve autograft in the treatment of permanent peripheral facial paralyses. Their main contention is that section of 50 p. 100 of the neurones of the peripheral branches of the facial nerve on the unaffected side does not impair motricity to any extent and that it therefore is possible to anastomose the proximal portion of some healthy branches to the corresponding distal portion of the affected side by placing between them a graft from the external saphenous nerve. The principles for fascicular suture as defined by Seddon and later by Millesi are followed. The technique differs from that made popular by Smith and later by Smii inasmuch as: --the bilateral, hidden face-lift incision makes possible a final passive musculotegumentary suspension of the paralysed side immediately improving the patient's appearance while the nerve re-establishes itself; --retrograde interfascicular dissection on the paralysed side allows precious centimetres to be gained; --pinpointing of the nerve suture area is possible by the placing of a silicone-coated ring with a clip some distance away.

Facial Nerve↗

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Serum cholecystokinin and neurotensin during follow-up of pancreas, prostate and medullary thyroid tumors.

BACKGROUND: Growth of pancreatic carcinoma cells is stimulated by cholecystokinin (CCK) and neurotensin (NT). Prostatic carcinoma cells can secrete neurotensin. The CCK gene has been described in thyroid medullary carcinomas (MCT). METHODS: Serum CCK and NT were measured by RIAs during monitoring of 19 pancreas tumours, 10 prostate adenocarcinomas and 10 thyroid medullary cancers (MCT). RESULTS: No correlations were found between CCK and NT in the three tumour types, nor with CA 19.9, PSA, CEA or calcitonin. In pancreas adenocarcinomas (n = 12), initial median CCK was > 8pg/ml (non significant differences between stages T, N or M). Median NT was > 80 pg/ml in all but M0 and stage I-II cases, and significantly higher in M1 and stages IV (P = 0.002). Non significant differences were found for CCK and NT according to clinical stages. In prostate cancers, median CCK was significantly more elevated after relapse (P = 0.040). Median NT was significantly more elevated in disease-free patients (P = 0.04). In MCT, CCK and NT were not related to clinical stages. CONCLUSION: In pancreas and prostate cancers serum CCK may follow tumour load and disease progression. NT was lower in progressive disease. The contribution of these peptides in human tumour growth, since they may have therapeutic implication, warrants further investigation.

Adenocarcinoma↗

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Nucleus 21-channel auditory brainstem implant in patients with previous tumour removal.

Three patients with neurofibromatosis type 2 who had undergone previous cochlear nerve tumour removal were implanted with the Nucleus 21-channel auditory brainstem implant (ABI). The time intervals between tumour removal and implantation were 4, 5, and 7 years, respectively. Total bilateral deafness was confirmed before implantation. One patient was also blind after acute intracranial hypertension. The translabyrinthine approach was used in all cases. The choice of side for implantation depended on pre-operative magnetic resonance imaging study, the facial nerve function, the presence of recurrent and/or other lesions, and the patient's preference. Although the scarring of prior surgical procedure largely changed the anatomical structures in the cerebello-pontine angle, various landmarks could be found to locate the foramen of Luschka, where the ABI electrode was inserted into the lateral recess of the fourth ventricle. During surgery, the electrically evoked auditory brainstem responses were recorded to confirm that the ABI stimulation activated the auditory system; the electromyogram of the 7th and 9th nerves was helpful in finding the landmarks and minimising the triggering of the cranial nerves with ABI stimulation. The number of active electrodes was 21, 7, and 4 in the three patients. All obtained meaningful pitch scaling and useful auditory sensations. One patient, with 21 activated electrodes, has achieved functional open-set speech understanding. The second patient, with 7 activated electrodes, has benefited from environmental sound awareness and improved lipreading. The last, blind, patient, with 4 electrodes activated, achieved only perception of environmental sounds.

Adult↗

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[Arteriography in pituitary tumors. Pseudotumoral aneurysm].

In the presence of any "expansive process" of the sellar region, one must recall that in I % of the instances there may be the possibility of a pseudo-tumoral aneurysm. In a number of cases, neither the clinical study, nor the roentgenologic and tomographic balance of the sellar region, will allow to differentiate an aneurysm and a pituitary tumor. Only the carotid arteriography makes possible a diagnosis of certainty under the condition to make a bilateral study (compression being insufficient). This kind of investigation will therefore be systematic, particularly in those cases in which a sphenoid route of access is considered for the management of the expansive process of the sellar region.

Carotid Arteries↗