Salvage high-dose-rate brachytherapy and external beam radiotherapy for isolated vaginal recurrences of endometrial cancer with no prior adjuvant therapy

Publication date: Available online 10 August 2017
Source:Brachytherapy
Author(s): Christopher H. Chapman, Kaveh Maghsoudi, Ramey D. Littell, Lee-May Chen, I-Chow Hsu
PurposeTo evaluate clinical outcomes for isolated vaginal recurrence of endometrial cancer without adjuvant therapy treated with salvage external beam radiation therapy (EBRT) and high-dose-rate CT-based inverse-planned brachytherapy.Methods and MaterialsThirty women were included in this retrospective study. Median time to first recurrence was 16.7 months, and median age at recurrence was 73 years. Initial grade was 1 or 2 in 19 patients (63%), and 2009 FIGO stage IA in 19 patients. All patients received pelvic EBRT in 1.8 Gy daily fractions to a total of 45 or 50.4 Gy. Interstitial brachytherapy was used in 27 patients (90%). The median total EQD2 dose was 68.3 Gy. Kaplan-Meier estimates of overall survival (OS), cause-specific survival (CSS), progression free survival (PFS), locoregional failure-free survival, and distant failure–free survival (DFFS) were calculated.ResultsMedian follow-up was 76.4 months for vital status and 57.7 months for disease status after salvage therapy. The 5-year OS, CSS, PFS, locoregional failure-free survival, and DFFS after salvage therapy were 77%, 83%, 75%, 87%, and 86%. Initial high-grade disease was prognostic for OS, CSS, and DFFS (5-year OS 95% vs. 29%, p = 0.005). Initial stage beyond IA was prognostic for CSS, PFS, and DFFS (5-year CSS 93% vs. 74%, p = 0.025).ConclusionsSalvage EBRT and high-dose-rate brachytherapy resulted in a high rate of locoregional control. Initial high-grade and advanced stage disease were associated with greater distant failure and cancer-related mortality after salvage therapy.



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When increasing distraction helps learning: Distractor number and content interact in their effects on memory

Abstract

Previous work has demonstrated that increasing the number of distractors in a search array can reduce interference from distractor content during target processing. However, it is unclear how this reduced interference influences learning of target information. Here, we investigated how varying the amount and content of distraction present in a learning environment affects visual search and subsequent memory for target items. In two experiments, we demonstrate that the number and content of competing distractors interact in their influence on target selection and memory. Specifically, while increasing the number of distractors present in a search array made target detection more effortful, it did not impair learning and memory for target content. Instead, when the distractors contained category information that conflicted with the target, increasing the number of distractors from one to three actually benefitted learning and memory. These data suggest that increasing numbers of distractors may reduce interference from conflicting conceptual information during encoding.

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Risk adapted dose-intensified postoperative radiation therapy in prostate cancer patients using a simultaneous integrated boost technique applied with helical Tomotherapy

Postoperative adjuvant radiation therapy (ART) in T3 and R1 prostate cancer as well as salvage radiation therapy (SRT) in case of postoperative biochemical failure (BF) are established treatments. Dose-intensi...

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Relationship between radiation dose and microbleed formation in patients with malignant glioma

Cranial irradiation is associated with long-term cognitive changes. Cerebral microbleeds (CMBs) have been identified on susceptibility-weighted MRI (SWI) in patients who have received prior cranial radiation, ...

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Accuracy of 837 pedicle screw positions in degenerative lumbar spine with conventional open surgery evaluated by computed tomography

Abstract

Background

The spatial and directional accuracy of the positioning of pedicle screws in the lumbosacral spine with conventional open surgery assessed by computed tomography (CT) has been published in several studies, systematic reviews and meta-analyses with a short-term follow-up. Inaccurate pedicle screw insertion may cause neurologic symptoms and weakens the construct.

Methods

The data of 147 patients operated on with transpedicular screw fixation based on anatomical landmarks, supported by fluoroscopy, by a senior neurosurgeon in our clinic between 2000 and 2010 were analyzed retrospectively. The accuracy of the pedicle screw position was assessed by using postoperative CT images and graded in 2-mm increments up to 6 mm by two independent surgeons and partly by an independent radiologist.

Results

A total of 837 lumbosacral pedicle screws were inserted in 147 randomly selected patients by a senior neurosurgeon. A mean accuracy of 85.7% of the screws being inside the pedicles was identified by the surgeon observers, with 3.3% being perforated 4 mm or more outside the pedicles. Postoperative neurologic symptoms were observed on the side corresponding to the breach in an average of 25.9% of patients with pedicle perforations, and 89.2% of the misplaced screws were either medially or inferiorly inserted.

Conclusions

Screw application reached a mean accuracy of 85.7% based on anatomical landmarks supported by fluoroscopy, warranting computer-assisted navigation for increased accuracy. Our results of 24 patients (16.3%) with the breached screws indicate that the direction of the breach may be more important than the absolute deviation in causing new neurologic symptoms.

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Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study

Abstract

Background and study aims

The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment.

Methods

Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination.

Results

Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002).

Conclusions

After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

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Erratum to: SAGES University MASTERS Program: a structured curriculum for deliberate, lifelong learning

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Remnant gastropathy due to bile reflux after Roux-en-Y gastric bypass: a unique cause of abdominal pain and successful treatment with ursodiol

Abstract

Background

Chronic abdominal pain can occur after Roux-en-Y gastric bypass (RYGB), and can remain unexplained despite extensive investigation. Bile can pool in the gastric remnant and create a bile reflux gastropathy. The aim of this study was to assess gastric remnant findings in patients with RYGB and chronic abdominal pain of unclear etiology, and to determine the effectiveness of ursodiol therapy for patients with confirmed remnant gastropathy.

Methods

All consecutive patients with RYGB and a diagnosis of chronic abdominal pain, and a negative diagnostic workup (including physical examination, routine laboratory work, cross-sectional imaging, and standard upper endoscopy), who underwent device-assisted enteroscopy for evaluation of the gastric remnant, were included. Pathology reports, treatments, and clinical follow-up were recorded.

Results

28 post-RYGB patients (all female) with chronic abdominal pain and negative evaluation were included. Pooling of bile with gastric erythema was noted in 22/28 patients. All 22 patients with endoscopic erythema had pathology consistent with bile reflux chemical gastropathy. Of these patients, 12 were started on a proton pump inhibitor (PPI) alone, and 10 were started on ursodiol. Of the ursodiol group, 8/10 (80%) patients reported substantial improvement or resolution of abdominal pain at clinical follow-up. All three ursodiol patients with repeat endoscopic examination of the gastric remnant had endoscopic and histologic resolution of gastropathy. Of the PPI patients, 1/12 reported improvement in abdominal pain at clinical follow-up (p = 0.002), and both patients with repeat endoscopic examination of the gastric remnant had persistent remnant gastropathy.

Conclusions

Roux-en-Y gastric bypass patients with unexplained chronic pain, and biopsy-confirmed chemical gastropathy, had a significantly higher rate of abdominal pain resolution with ursodiol treatment compared to PPI. Remnant gastropathy due to bile reflux is a treatable cause of chronic abdominal pain in RYGB patients, and ursodiol should be considered for empiric treatment in RYGB patients with unexplained chronic abdominal pain.

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Trauma laparoscopy: when to start and when to convert?

Abstract

Background

The use of laparoscopy for stable patients with abdominal trauma is increasing and its accuracy is nearly 100%. However, indications for laparoscopy and for conversion differ among centers. The aim of this study was to investigate indications for trauma laparoscopy and for conversion to laparotomy.

Methods

All trauma patients managed with laparoscopy over a 4-year period were retrospectively analyzed. Indications for laparoscopy, morbidity, and reasons for conversion were investigated and predictors of morbidity and conversion were sought. The management algorithm of trauma patients was reviewed and updated.

Results

Laparoscopy was used in 318 stable trauma patients. Thirty-five patients presented with blunt and 283 with penetrating abdominal injuries. The conversion rate was 11.7% for penetrating and 22.9% for blunt abdominal trauma patients. The most common reason for conversion was continuous intraabdominal bleeding that could not be controlled quickly. It was followed by multiple complex injuries, hemodynamic instability, and intraoperative visualization problems. Diagnostic laparoscopy was performed in 45%, and therapeutic laparoscopy in 55% of cases. There were no missed injuries. Complications occurred in 21.2% in the converted group and in 9.6% in the laparoscopic group. Among initial systolic blood pressure, pulse, hemoglobin, lactate, and base deficit levels, only lower pH was associated with conversion.

Conclusion

The management of all stable trauma patients with laparoscopy appears to be a safe approach. The use of sound laparoscopic equipment by a well-coordinated trauma team with adequate expertise in laparoscopy, adherence to the algorithm, and strict compliance with predetermined procedural steps are fundamental to success. Continuous intraoperative bleeding, complexity of injuries, deterioration of the patient, poor visibility, and equipment failure are indications for conversion.

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Per-oral endoscopic myotomy (POEM): mid-term efficacy and safety

Abstract

Background and aims

Per-oral endoscopic myotomy (POEM) is becoming a standard treatment for achalasia. Long-term efficacy and the rate of post-POEM reflux should be further investigated. The main aim of this study was to analyze safety and mid-term (12 and 24 months) clinical outcomes of POEM.

Methods

Data on single tertiary center procedures were collected prospectively. The primary outcome was treatment success defined as an Eckardt score < 3 at 12 and 24 months. A total of 155 consecutive patients with achalasia underwent POEM; 133 patients were included into the analysis (22 patients will be analyzed separately as part of a multicenter randomized clinical trial).

Results

POEM was successfully completed in 132 (99.2%) patients, and the mean length of the procedure was 69.8 min (range 31–136). One patient underwent a drainage for pleural effusion; no other serious adverse events occurred. Treatment success at 3, 12, and 24 months was observed in 95.5% (CI 89.6–98.1), 93.4% (86.5–96.8), and 84.0% (71.4–91.4) of patients, respectively. A total of 11 patients (8.3%) reported initial treatment failure (n = 5) or later recurrence (n = 6). The majority of relapses occurred in patients with achalasia type I (16.7 vs. 1.1% achalasia type II vs. 0% achalasia type III; p<0.05). At 12 months, post-POEM reflux symptoms were present in 29.7% of patients. At 3 months, mild reflux esophagitis was diagnosed in 37.6% of patients, and pathological gastroesophageal reflux was detected in 41.5% of patients. A total of 37.8% of patients had been treated with a proton pump inhibitor.

Conclusion

POEM resulted in greater than 90% treatment success at 12 months which tends to decrease to 84% after 2 years. More than one-third of the patients had mild reflux symptoms and/or mild esophagitis.

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Photodynamic therapy is more effective than imiquimod for actinic keratosis in organ transplant recipients – a randomized intra-individual controlled trial

Abstract

Background

Actinic keratoses (AKs) in solid organ transplant recipients (OTRs) are difficult-to-treat pre-malignancies and comparison of topical therapies is therefore warranted.

Objectives

In an intra-individual study to compare efficacy and safety of field treatment with methyl aminolevulinate photodynamic therapy (MAL-PDT) and imiquimod (IMIQ) for AKs in OTRs.

Materials and methods

OTRs (n=35) with 572 AKs (grade I-III) in two similar areas in the face, scalp, dorsal hands or forearms were included. All patients received one MAL-PDT and one IMIQ session (3 weekly applications for 4 weeks) in each study area according to randomization. Treatments were repeated after 2 months (IMIQ) and 3 months (PDT) in skin with incomplete AK-response. Outcome measures were complete lesion response (CR), skin reactions, laboratory results and treatment preference.

Results

The majority of study areas received two treatment sessions (PDT n=25, IMIQ n=29 patients). At 3 months after two treatments, PDT-treated skin achieved higher CR (AK I-III, median 78%, range 50-100%) compared to IMIQ-treated skin areas (median 61%, range 33-100%, p <0.001). Fewer emergent AKs were seen in PDT- vs. IMIQ-treated skin (0.7 vs. 1.5 AK, p=0.04). Patients developed more intense inflammatory skin reactions following PDT (PDT 2.8, IMIQ 1.7, p<0.01) that resolved faster compared to IMIQ (median 10 vs. 18 days, p<0.01). Patient preference (p= 0.47) and cosmesis (p>0.30) were similar for PDT and IMIQ. No significant changes in laboratory results were observed.

Conclusion

Compared to IMIQ, PDT-treatment obtained higher AK clearance at 3-month follow-up and shorter-lasting, but more intense short-term skin reactions.

This article is protected by copyright. All rights reserved.

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Are vitiligo treatments cost-effective? A systematic review

Abstract

Vitiligo is characterised by well demarcated, cutaneous, macular depigmentation, with worldwide prevalence estimated to be between 0.2-1.8% [1]. Vitiligo treatments aim to encourage re-pigmentation and include topical corticosteroids, calcineurin inhibitors and NB-UVB phototherapy. Camouflage can also be prescribed to help mask the appearance of vitiligo, although this is frequently only prescribed for the face.

This article is protected by copyright. All rights reserved.

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Sirolimus effects on Kasabach-Merritt phenomenon coagulopathy

Abstract

Kasabach-Merritt phenomenon (KMP) is a very rare life-threatening condition that combines a vascular tumor belonging to the kaposiform hemangioendothelioma (KHE) spectrum lesions, and thrombocytopenia.^1,2 Thrombocytopenia results from platelet trapping within the tumor. Platelet activation leads to various degrees of decreased fibrinogen and elevated D-dimer levels. This coagulopathy is frequently protracted after thrombocytopenia resolution. Several treatments have been proposed with variable efficiency.

This article is protected by copyright. All rights reserved.

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Solar urticaria developing in patients with Erythropoietic Protoporphyria: a clue to the pathogenesis of Solar Urticaria?

Abstract

We describe three cases of solar urticaria (SU) developing in patients with a diagnosis of Erythropoietic Protoporphyria (EPP). We suggest that this may imply that the endothelium may be the location of a chromophore in SU.

Patient 1 was a 42-year-old female. She had EPP characterised lifelong by three day long bouts of burning pain and swelling on the backs of hands and face induced by 10 minutes of exposure to spring or summer sun, and an increased red cell free protoporphyrin IX concentration (36micromol/L (normal range <0.2micromol/L)).

This article is protected by copyright. All rights reserved.

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The Immune Reconstitution of the Skin Following Sex Mismatched Allogeneic Hematopoietic Stem Cell Transplant: A prospective case series utilizing fluorescent in situ hybridization and immunohistochemistry

Abstract

Graft versus host disease (GVHD) is a common, morbid, and potentially fatal complication of allogeneic hematopoietic stem cell transplantation (aHSCT).^1-3 The exact timing of the arrival of donor-derived immune cells and their profile in the skin have not been well described in humans.^4-6 Fluorescent in situ hybridization (FISH) is a technique that has been used to distinguish host versus donor-derived immune cells in patients who have undergone sex-mismatched aHSCT.⁷

This article is protected by copyright. All rights reserved.

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Acquired anhidrosis associated with systemic sarcoidosis: Quantification of nerve fibers around eccrine glands by confocal microscopy

Abstract

Neurological disorders can cause hypohidrosis and/or anhidrosis by disturbing either the central or the peripheral nervous systems.^1-3 Although a syringotropic variant of cutaneous sarcoidosis causes dysfunction of sweating, systemic sarcoidosis rarely causes hypohidrosis or anhidrosis.^4,5 Here we present a novel case of an acquired anhidrosis in a patient with systemic sarcoidosis. Furthermore, we developed a novel methodology to quantify nerve fibers around eccrine glands using confocal microscopy and found that nerve fibers around eccrine glands in anhidrotic areas are significantly decreased compared to hidrotic areas.

This article is protected by copyright. All rights reserved.

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Dermatofibrosarcoma Protuberans of the Breast—a Rare Entity

Abstract

Dermatofibrosarcoma protuberans (DFSP) represents about 1% of soft-tissue sarcomas with an estimated incidence of 0.8 to 5.0 cases per million per year. This lesion may occur anywhere in the body but more than 50% occur on the trunk, 20% on the head and neck and 30% on the extremities. DFSP of the breast is an extremely uncommon site of presentation. Data regarding DFSP of the breast is limited and mostly in the form of case reports. Clinical presentation is not uniform and may mimic benign skin lesions [1]. However, it typically presents as a nodular cutaneous mass in early or mid-adult life. We herein report a case of DFSP of the breast in a 33-year-old lady who was managed successfully in our institute and review the literature associated with it.

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Osteocondroma del seno maxilar, una localización infrecuente

Publication date: Available online 10 August 2017
Source:Acta Otorrinolaringológica Española
Author(s): Ana Belén Gil Guerra, Esther Gómez San Martín, María Isabel Jiménez Cuenca




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Early vs. standard unclamping technique in minimal access partial nephrectomy: a meta-analysis of observational cohort studies and the Lister cohort

Abstract

To evaluate if early unclamping (EUC) of the renal pedicle compromises perioperative outcomes in minimally invasive partial nephrectomy (PN). The cohort study includes all robot-assisted PN performed between September 2012 and September 2015 by a single surgeon at the Lister Hospital, Stevenage, UK. The systematic review and meta-analysis was performed according to the PRISMA guidelines identifying studies comparing EUC and standard unclamping (SUC) in either laparoscopic or robot-assisted PN. The Lister cohort prospectively reported 84 cases of robot-assisted PN (SUC = 22, EUC = 62) with a mean age of 58 years (SD = 11). The operative time (OT), estimated blood loss (EBL) and warm ischaemia time (WIT) were 186.5 min (SD = 33.8), 125.5 mls (SD = 188.91) and 16.7 min (SD = 5.6), respectively. The data from the Lister cohort were included in the meta-analysis. The systematic review identified four studies, encompassing 666 cases (313 SUC, 353 EUC), for inclusion in the final analysis. There was a statistically significant difference in WIT in favour of the EUC group [−10.59 min (95% CI −16.58, −4.60)]. Specifically, the reduction in WIT was more pronounced in laparoscopic PN (−15.43 min (95% CI −19.05, −11.81)), when compared with the robotic PN [−5.60 min (95% CI −5.70, −5.50)]. There was no statistical difference in OT [−3.97 min (95% CI −14.22, 6.28)]. EBL was found to be increased in the EUC group [71.39 ml (95% CI −0.78, 143.56)]. There was no statistically significant difference in transfusion rates or complications between the two groups. The EUC technique for robot-assisted PN appears to offer a safe limited period of WIT without compromising perioperative outcomes and morbidity.

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RE: Prosthetic Breast Implant Rupture: Imaging—Pictorial Essay

Abstract

Cooperation between plastic surgeons and radiologists is fundamental when breast prosthesis rupture is suspected. We describe our experience managing the case of suspected implant rupture in a patient that underwent CT scan imaging for thoracic pain. Poor clinical information given to radiologists leads to wrong diagnosis: during surgery, both prostheses were checked revealing no signs of rupture. Full communication among different specialists involved in the multidisciplinary approach is always recommended, and an easy-to-use national breast implant register would allow a better management of patients' follow-up and eventual preoperative planning.

Level of evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://ift.tt/18t7xNj.

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