Joelle Antoun

Anal cancer treatment: Current status and future perspectives

Anal cancers (AC) are relatively rare tumors. Their incidence is increasing, particularly among men who have sex with other men due to widespread infection by human papilloma virus. The majority of anal cancers are squamous cell carcinomas, and they are treated according to stage. In local and locally advanced AC, concomitant chemoradiation therapy based on mitomycin C and 5-Fluorouracil (5-FU) is the current best treatment, while metastatic AC, chemotherapy with 5-FU and cisplatin remains the gold standard. There are no indications for induction or maintenance therapies in locally advanced tumors. Many novel strategies, such as targeted therapies, vaccination, immunotherapy and photodynamic therapy are in clinical trials for the treatment of AC, with promising results in some indications.

Optimum chemotherapy in the management of metastatic pancreatic cancer

Pancreatic cancer is one of the most devastating solid tumors, and it remains one of the most difficult to treat. The treatment of metastatic pancreatic cancer (MPC) is systemic, based on chemotherapy or best supportive care, depending on the performance status of the patient. Two chemotherapeutical regimens have produced substantial benefits in the treatment of MPC: gemcitabine in 1997; and FOLFIRIONOX in 2011. FOLFIRINOX improved the natural history of MPC, with overall survival (OS) of 11.1 mo. Nab-paclitaxel associated with gemcitabine is a newly approved regimen for MPC, with a median OS of 8.6 mo. Despite multiple trials, this targeted therapy was not efficient in the treatment of MPC. Many new molecules targeting the proliferation and survival pathways, immune response, oncofetal signaling and the epigenetic changes are currently undergoing phase I and II trials for the treatment of MPC, with many promising results.

Long-term results of Ahmed glaucoma valve in association with intravitreal bevacizumab in neovascular glaucoma.

Purpose:Evaluate the long-term results of the Ahmed glaucoma valve (AGV) surgery in association with bevacizumab (Avastin) in neovascular glaucoma (NVG) patients. Design and Methods:This retrospective institutional study reviewed 39 eyes of 34 patients with NVG who underwent AGV implantation. The intravitreal bevacizumab (IVB) group included 19 eyes that received an injection of IVB 7 days preoperatively, whereas the no-IVB group included 20 eyes that did not receive any antivascular endothelial growth factor therapy. Findings such as intraocular pressure (IOP), number of antiglaucoma medications, best-corrected visual acuity (BCVA), and surgical outcomes were reviewed over a period of 5 years. Results:There were no significant differences in the preoperative characteristics between the 2 groups. At last follow-up visit, IOP was 16.37±5.72 mm Hg in the IVB group and 20.05±9.75 mm Hg in the no-IVB group (P=0.16). The number of postoperative antiglaucoma medications was significantly lower in the IVB group (P=0.02). Last visit’s mean BCVA was 2.34±1.00 logMAR in the IVB group and 2.66±1.04 logMAR in the control group (P=0.33). Hyphema was significantly less observed in the IVB group (P=0.02). The probability of success was 63.2% in the IVB group and 70.0% in the control group (P=0.37). Conclusions:Preoperative IVB before AGV was not associated with a better surgical success, IOP control, or BCVA. Its administration significantly decreased postoperative hyphema and number of last visit’s antiglaucoma medications.

Is metastatic pancreatic cancer an untargetable malignancy

Metastatic pancreatic cancer (MPC) is one of the most aggressive malignancies, known to be chemo-resistant and have been recently considered resistant to some targeted therapies (TT). Erlotinib combined to gemcitabine is the only targeted therapy that showed an overall survival benefit in MPC. New targets and therapeutic approaches, based on new-TT, are actually being evaluated in MPC going from immunotherapy, epigenetics, tumor suppressor gene and oncogenes to stromal matrix regulators. We aim in this paper to present the major causes rendering MPC an untargetable malignancy and to focus on the new therapeutic modalities based on TT in MPC.

VITREORETINAL SURGERY WITH SILICONE OIL TAMPONADE IN PRIMARY UNCOMPLICATED RHEGMATOGENOUS RETINAL DETACHMENT: Clinical Outcomes and Complications.

Background: To determine the anatomical and functional outcomes and possible complications after pars plana vitrectomy (PPV) with silicone oil (SO) tamponade in primary uncomplicated rhegmatogenous retinal detachments. Methods: This is a prospective observational study. Overall, 62 consecutive patients who underwent surgical repair by PPV and SO injection for primary uncomplicated rhegmatogenous retinal detachment between January 01, 2006 and April 30, 2012 were followed. In general, PPV was chosen over scleral buckling when a significant cataract or a vitreous hemorrhage prevented adequate fundus visualization. Silicone oil was chosen over gas tamponade in patients living at 1,000 meters above the sea level, where SF6 or C3F8 tamponade could not be performed because of the risk of acute increase of intraocular pressure (IOP). One thousand centistokes SO was used in all eyes. At all visits, patients had a detailed ocular history and thorough bilateral evaluation, including best-corrected visual acuity, anterior segment examination, and IOP measurements by aplanation and fundus examination. Outcomes were assessed at 1 day, 1 week, 1 month, 3 months, 6 months, and every 6 months thereafter. Increased IOP was defined as an IOP of more than 21 mmHg. Results: Anatomical success rate, final best-corrected visual acuity, IOP elevation, cataract formation, and other complications were the main outcome measures. This study included 62 eyes of 62 patients (41 men and 21 women) that underwent retinal detachment repair by PPV and SO injection. The age at the time of intervention was 57.6 ± 10.5 years (mean ± standard deviation; range, 34–79 years). All patients were whites. Mean follow-up was 24.5 ± 17.3 months (range, 6–70 months). Anatomical success rate defined as retinal reattachment 6 months after SO removal was 93.5%. Final BCVA was improved in 55 eyes (88.7%), with a mean of 4 Snellen lines, unchanged in 5 (8.1%), and worse in 2 eyes (3.2%), with a mean of 3 Snellen lines. Mean duration of SO tamponade was 5.12 ± 2.37 months (range, 2–12 months). From the 30 eyes that were still phakic after vitrectomy, 24 eyes (80.0%) underwent cataract surgery within a period of 7.37 ± 3.00 months (range, 2–13 months). Thirty-five eyes (56.5%) had an increase in IOP during the follow-up period. Thirty-one patients had transient ocular hypertension requiring topical treatment during the immediate postoperative period (one month). Only 1 eye (2.9%) required filtrating drainage surgery for IOP control. No eyes developed optic neuropathy secondary to IOP elevation. Conclusion: Pars plana vitrectomy with SO injection seems to be a safe and efficient surgical approach in the treatment of primary uncomplicated rhegmatogenous retinal detachment in patients living in high altitude (>1,000 m). Also, PPV and SO injection are associated with good anatomical and functional outcomes in our series. Reattachment rates are high, and rates of proliferative vitreoretinopathy are low. Cataract formation and elevated IOP represent frequent but successfully controlled complications.

Visian toric ICL implantation after intracorneal ring segments implantation and corneal collagen crosslinking in keratoconus.

Purpose To evaluate the safety and clinical outcome of Visian toric implantable collamer lens (TICL) implantation for the treatment of residual refractive errors 6 months after sequential intracorneal ring segments (ICRS) and corneal collagen UVA crosslinking (CXL) in stable keratoconus. Methods This retrospective study examined the results of a 3-step ICRS-CXL-TICL in 11 eyes of 7 patients with moderate to severe keratoconus. The 2 procedures (ICRS-CXL) were performed sequentially at an interval of 4 weeks and TICL implantation was performed at least 6 months after CXL. Data were collected preoperatively, at the 6-month follow-up visit after sequential ICRS-CXL, and at the 6-month follow-up visit after TICL implantation. Results The ICRS-CXL induced a significant decrease in keratometry, increase in visual acuity, and decrease in refraction. At 6-month follow-up after ICRS-CXL, mean Kflat was 45.19 ± 3.98 D vs 48.51 ± 4.26 D preoperatively (p = 0.022) and mean Ksteep was 50.41 ± 4.32 D vs 54.24 ± 4.96 D preoperatively (p = 0.032). Uncorrected distance visual acuity (UCVA) significantly improved from 1.47 ± 0.38 logMAR before ICRS-CXL to 0.27 ± 0.20 logMAR 6 months after (p = 0.002). Corrected distance visual acuity (CDVA) significantly improved from 0.50 ± 0.22 logMAR to 0.29 ± 0.23 logMAR (p = 0.001). At 6 months post TICL implantation, UCVA improved significantly to 0.27 ± 0.20 logMAR and the CDVA was 0.19 ± 0.11 logMAR. No intraoperative or postoperative complications occurred. Conclusions Toric ICL implantation after sequential ICRS implantation and CXL is an effective and safe option for correcting high residual refractive error and improving visual acuity in patients with moderate to severe keratoconus.

Rate of Corneal Collagen Crosslinking Redo in Private Practice: Risk Factors and Safety

Objective. To report the rate of progression of keratectasia after primary crosslinking (CXL) and evaluate the safety and efficiency of CXL redo. Materials and Methods. We conducted a retrospective analysis of the patients who underwent CXL between 2010 and 2013 at the Beirut Eye Specialist Hospital, Lebanon. Progression of keratectasia was based on the presence of an increase in maximum keratometry of 1.00 D, a change in the map difference between two consecutive topographies of 1.00 D, a deterioration of visual acuity, or any change in the refraction. Primary and redo CXL were done using the same protocol. Results. Among the 221 eyes of 130 patients who underwent CXL, 7 eyes (3.17%) of five patients met the criteria of progression. All patients reported a history of allergic conjunctivitis and eye rubbing and progressed within 9 to 48 months. No complications were noted and all patients were stable 1 year after CXL redo. Conclusion. Allergic conjunctivitis and eye rubbing were the only risk factors associated with keratoconus progression after CXL. A close followup is thus mandatory, even years after the procedure. CXL redo seems to be a safe and efficient technique to halt the progression after a primary CXL.

Intravitreal bevacizumab for retinal capillary hemangioblastoma: A case series and literature review

OBJECTIVE To evaluate the long-term outcomes of intravitreal bevacizumab for peripheral and juxtapapillary retinal capillary hemangioblastoma (RCH). DESIGN We conducted a retrospective noncomparative interventional case series. PARTICIPANTS There were 4 patients (5 eyes) presenting with RCH. METHODS Five eyes with RCH presented with exudative changes and visual loss. Three eyes of 2 patients with peripheral RCH were treated with cryotherapy and 2 intravitreal injections of bevacizumab (0.5 mg). Two eyes with juxtapapillary RCH were treated with 3 intravitreal injections of bevacizumab. The main outcome measures were changes in best-corrected visual acuity (BCVA), lesion size, exudation, and retinal thickness. RESULTS In peripheral RCH, improvement of BCVA from counting fingers to 20/400 was obtained in 1 eye. One patient with bilateral RCH maintained a vision of 20/20 in 1 eye with complete anatomic regression of the 3 small peripheral RCH lesions. The fellow eye with fibrotic bands from the RCH to the optic nerve head developed a tractional retinal detachment after the first injection and was treated with pars plana vitrectomy. In patients with juxtapapillary RCH, bevacizumab injections resulted in an improvement of BCVA from 20/80 to 20/20 in 1 eye, whereas the second eye did not show an improvement of BCVA despite a regression of the tumour. CONCLUSIONS Intravitreal anti-vascular endothelial growth factor agents, alone or in combination with other treatment modalities, may improve visual acuity. Further trials evaluating the dose, the number of injections, and the route of administration will be important in advancing antiangiogenic therapies for RCH.

Visian toric ICL implantation for residual refractive errors after ICRS implantation and corneal collagen cross-linking in keratoconus.

To the Editor: Some patients with keratoconus have poor corrected distance visual acuity (CDVA) associated with high refractive errors. According to our treatment protocol,1 the best approach for these cases is intracorneal ring segments (ICRS) implantation (usually one segment) to improve CDVA followed by corneal collagen cross-linking (CXL) treatment 4 weeks later to stabilize the cornea and phakic toric implantable collamer lens (TICL) (Visian Toric V4b ICL; STAAR Surgical, Monrovia, CA) implantation 4 to 6 months after CXL to correct the residual refractive errors. We conducted a retrospective analysis of 11 eyes of 7 patients with moderate to severe keratoconus (according to the Amsler–Krumeich classifi cation2, 4 eyes had stage II keratoconus and 7 eyes had stage III) and poor CDVA who underwent three-step ICRS implantationCXL-TICL implantation procedures at our eye hospital. The two procedures (ICRS implantation-CXL) were performed sequentially at an interval of 4 weeks and TICL implantation was performed at least 6 months after CXL. Data were collected preoperatively, at the 6-month follow-up visit after sequential ICRS implantation-CXL, and at the 6-month follow-up visit after TICL implantation. Mean age was 29.20 years (range: 22 to 46 years). Uncorrected distance visual acuity (UDVA) showed signifi cant improvement after three sequential procedures (mean UDVA improved from 1.47 ± 0.38 logMAR at baseline to 1.13 ± 0.50 logMAR after ICRS implantation-CXL procedures and to 0.27 ± 0.20 logMAR after ICL implantation). Overall, 63.7% of eyes (7 of 11) had UDVA greater than 20/40 by 6 months after ICL insertion. CDVA also showed signifi cant change 6 months after ICRS implantation-CXL (CDVA improved from 0.50 ± 0.22 logMAR at baseline to 0.29 ± 0.23 logMAR 6 months after ICRS implantation-CXL). However, CDVA did not show any signifi cant improvement after ICL insertion (0.19 ± 0.11 logMAR). Refraction signifi cantly improved after the three procedures. The spherical equivalent changed signifi cantly from -9.70 ± 3.1 diopters (D) at baseline to -7.65 ± 3.23 D 6 months after ICRS implantation-CXL and to -0.58 ± 1.01 D 6 months after TICL implantation. The cylindrical component also changed signifi cantly from 3.81 ± 1.15 D at baseline to 1.84 ± 0.35 D 6 months after ICL insertion. However, no signifi cant change was noted in cylindrical component 6 months after ICRS implantation-CXL (3.81 ± 1.15 D at baseline vs 4.06 ± 1.58 D 6 months after ICRS implantation-CXL). Keratometric readings (central corneal power obtained by topography) decreased after ICRS implantation-CXL: mean K (fl at) decreased from 48.51 ± 4.26 D at baseline to 45.19 ± 3.98 D 6 months after ICRS implantationCXL and mean K (steep) decreased from 54.24 ± 4.96 D at baseline to 50.41 ± 4.32 D 6 months after ICRS implantation-CXL. Mean K (max) decreased from 57.41 ± 6.32 D at baseline to 54.01 ± 4.75 D 6 months after ICRS implantation-CXL. In this retrospective study, all patients had poor CDVA and ICRS insertion (performed using femtosecond laser to create the tunnel) was effective in decreasing corneal distortion and improving CDVA; CXL treatment after ICRS insertion and before ICL implantation has the advantage of stabilizing the corneal topographic properties and providing greater stability of refraction without compromising safety and effi cacy of TICL implantation that decreased signifi cantly the refractive errors and improved signifi cantly the UDVA. No complications occurred during surgery or over the entire follow-up (6 months after the third procedure). Our results indicate that this three-step procedure is safe, effective, and predictable in the treatment of selected cases of keratoconus with poor CDVA and high refractive errors. However, a larger number of patients and a longer follow-up period are needed to further assess the safety and effi cacy of phakic TICLs in the management of keratoconus with high refractive errors and poor CDVA.

Osteonecrosis of the jaw during biyearly treatment with zoledronic acid for aromatase inhibitor associated bone loss in early breast cancer: A literature review

Osteonecrosis of the jaw (ONJ) is one of the most relevant and specific complication of biphosphonates. ONJ in patients receiving zoledronic acid every 3 to 4 weeks is frequently described, but the ONJ biyearly regimen used to reduce aromatase inhibitor associated bone loss (AIBL), is rarely reported. A literature review, focusing on the important trials using zoledronic acid to reduce AIBL, found that the mean risk of developing ONJ when zoledronic acid is used biyearly varies between 0.12% and 0.7%.