Endoscopic DCR: How To Improve The Results

Since Toti described the initial dacryocystorhinostomy (DCR) operation in 1904 many technical modifications have evolved (Becker in Ophthalmic Surg 19:419–427, 1988). Overall, three groups of procedures are currently practised; external DCR, endoscopic DCR with contact laser, and surgical endoscopic DCR without laser (Woog et al. in Am J Ophthalmol 116:1–10, 1993; Jokinen and Karja in Arch Otolaryngol 100:41–44, 1974. Many factors influence the outcome of these different approaches. The purpose of this study was to improve the long term surgical outcome in endonasal DCR. A retrospective analysis of more than 1,500 patients, who underwent primary endoscopic DCR, was done and specific small modifications were identified and applied in the next 108 cases showing an improvement in the results.     

Endoscopic dacryocystorhinostomy vs KTP 532 laser-assisted endoscopic dacryocystorhinostomy

Objectives

Advances in endoscopy and lasers have improved surgical management of chronic nasolacrimal duct obstruction. This is a preliminary comparison between standard and laser assisted endoscopic dacryocystorhinostomy (DCR).

Study Design

Combined retrospective and prospective study.

Setting

Tertiary referral hospital.

Patients and Methods

Thirty-eight cases of chronic nasolacrimal duct obstruction underwent endoscopic DCR (26 standard and 12, laser-assisted) and were assessed at 3 and at 6 months postoperatively by nasal endoscopy.

Results

Three months postoperatively (n=38), total relief of epiphora among the nonlaser group was 80.76 vs 75% in the laser group (P=0.982). At 6 months (n=19), the laser group had recorded 100% symptomatic relief compared to 85.71% in the nonlaser group (P=0.964). The laser group suffered fewer complications (33.33 vs 46.15% for nonlaser group).

Conclusion

Lasers show promise in long-term management of duct obstruction and are associated with fewer complications. A larger study is required before and generalization is made.     

Endonasal endoscopic dacryocystorhinostomy: our experience

Objectives

To study the outcome of endonasal endoscopic dacryocystorhinostomy (DCR) with or without mucosal flap preservation, without mitomycin local application, silicon tube stenting or laser assistance. To determine the duration of the surgical procedure of DCR, influence of simultaneously performed endonasal endoscopic procedures for concomitant sinonasal diseases.

Methods

Combined retrospective and prospective study in our tertiary referral center. 24 patients with chronic dacryocystitis underwent 25 standard endonasal endoscopic DCR procedures, 10 with and 15 without mucosal flap preservation. 6 of these had concomitant sinonasal diseases for which they underwent septoplasty or functional endoscopic sinus surgery (FESS) or both, simultaneously or as staged procedures. Relief from epiphora and patency of the nasolacrimal fistula was assessed by nasal endoscopy and syringing of the lacrimal apparatus at 1 week, 3 weeks and 3 months postoperatively.

Results

Out of 18 patients who underwent only DCR, 17 patients (94.44%) had complete relief from epiphora. Out of 6 patients who underwent 7 DCRs with concomitant sinonasal surgery, 5 patients (85.71%) had complete relief from epiphora. Overall 23 out of 25 DCRs (92%) had complete relief. In 15 of the 25 procedures, mucosal flap was excised completely. In remaining 10 procedures, flap was trimmed, repositioned to cover exposed bone around the newly created nasolacrimal fistula. In either situation, only one patient each had partial block of the nasolacrimal fistula. Average duration of the surgical procedure of DCR was 18 min.

Conclusion

Endonasal endoscopic DCR is a viable alternative to external DCR, co-existing sinonasal diseases can be managed simultaneously, as may be required in 25% of cases. It can be performed under 20 min without mucosal flap preservation, mitomycin local application, silicon tube stenting or laser assistance and can still provide a good success rate (92%) with less complications.     

Endoscopic dacryocystorhinostomy with conventional instruments: results and advantages over external dacryocystorhinostomy

Background

The aim of study is to evaluate the Endoscopic dacryocystorhinostomy (DCR) with conventional instruments, its results and advantage over external dacryocystorhinostomy (DCR).

Methods

The study group comprised of 127 patients who underwent consecutive endoscopic dacryocystorhinostomy. The cases operated by one team were included in the study to make the uniform analysis and its result. There were 48 males and 79 female in this study and male female ratio was 1:1.6. The mean age of the patient was 37 years (range from 16 years to 58 years). There were wide variety of cases like epiphora, lacrimal sac abscess, lacrimal sac fistula, acute dacryocystitis and road vehicular accident. All the patients had undergone non-laser, non-powered conventional instruments surgery under local anesthesia. The lighted probe was not used in any case for sac identification. The free flow of saline through newly created stoma during sac syringing was considered as successful criteria. The stent was used in two cases of road vehicular accident and in remaining 125 cases no stent was used. There were 66 cases of epiphora, 30 cases of lacrimal sac abscess, 26 cases of acute dacryocystitis, 3 cases of lacrimal fistula and 2 case of road traffic accident with multiple fractures. The average follow up period was 17 months (maximum follow up 3 years and minimum 4 months.)

Results

The success rate was 96 %.

Conclusion

The endoscopic DCR with conventional instruments is safe with very high success rate without any complications. It can be done in acute cases and very much suited for lacrimal sac abscess and lacrimal sac fistula.     

Improving the Results of Endonasal Dacryocystorhinostomy with Mitomycin C Application: A Prospective Case–Control Study

Many surgical advancement paved to surgical success in endonasal endoscopic dacryocystorhinostomy. Mitomycin C is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. The objective of the study was to evaluate the advantage of mitomycin C in primary endoscopic endonasal dacryocystorhinostomy without stenting. Randomised case control design. Tertiary academic centre in central India. 112 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups with or without mitomycin C intraoperative application. 112 eyes underwent endoscopic-dacryocystorhinostomy. Additional surgeries were done according to necessity. Mitomycin C was applied in concentration of 0.4 mg/dl for 5 min. Patients were followed up on OPD-basis at the end of 1st week, 1st month, 3rd month and over phone call at end of 1 year. Symptomatic improvement assessed by verbal enquiry and clinically by syringing by ophthalmologist. 8 patients underwent septal surgery in case group and 4 in control group along with 1 concha bullosa correction in the case group (p?<?0.05). Nil intraoperative complications (p?<?0.05) and nil postoperative complication noted (p?<?0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96.5% at 3rd month in case group and 96.4% and 92.9% at 1 month and 3 month respectively in control group. Nasal endoscopy of all surgical failures showed restenosis in both case group and control group except 1 patient with granulation in control group. Eventhough intraoperative mitomycin C application is effective in increasing the success rate of endonasal DCR surgery in standard nasolacrimal duct obstruction, and with no significant complications from its use, the study did not show added benefit in the primary endoscopic endoscopic dacryocystorhinostomy without stenting.     

Prognostic value and interobserver agreement of endoscopic ultrasonography for superficial squamous cell carcinoma of the esophagus

Background and Aims. Submucosal invasion of superficial esophageal cancer (SEC) is related to the prognosis. We prospectively analyzed outcomes of SEC in patients staged by endoscopic ultrasonography (EUS). Patients and Methods. We staged 31 endoscopically diagnosed SEC cases using a 20/15-MHz thin probe. The EUS tumor stage was classified as EUSM (limited within mucosa), EUS-SM (with submucosal invasion), or EUS-MP over (invading the muscularis propria or deeper). Lymph node metastasis and 2-yr survival were analyzed according to the EUS tumor stage in 29 squamous cell carcinoma cases. Interobserver agreement of the EUS stage was tested between the examiner and a blind reviewer. Results. Lymph node metastasis was significantly frequent in the EUS-SM group (8 of 18 cases [44.4%]) compared with the EUS-M group (1 of 10 cases [10%]) (p=0.03). Patient survival at 2 yr after initial therapy was 72.2% in the EUS-SM group and 90% in the EUS-M group. Death from cancer was noted only in the EUS-SM group (three cases). The accuracy rates of EUS tumor staging were 74.1% by the examiner and 66.7% by the blind reviewer, with moderate interobserver agreement (κ=0.46). Conclusions. Thin-probe EUS can classify SEC into two groups: the EUS-M group with excellent outcome and the EUS-SM group with a significant risk of lymph node metastasis.     

Surgery for colorectal cancer in a low-volume unit

Background. The maintenance of modern therapeutic principles requires a proper case load to achieve acceptable surgical results. This may obligate administrative reorganization to overcome these problems and to provide an adequate level of cancer surgery. Aim. To assess the surgical results of patients coming for surgery for colorectal cancer in a low-volume non-academic unit during the past 15 yr. Methods. 458 consecutive patients referred for surgery between 1988 and 2001 in Kanta-Häme Central Hospital in Finland were analyzed regarding their disease, mode of surgery, and the immediate and long-term result. The data were collected from patient journals and from the National Centre of Statistics and analyzed in two successive periods. Results. The number of patients with a localized disease (Dukes A + Dukes B) decreased during the followup from 49% to 45%. A curative procedure was achieved in 68% in the first half and in 73% in the second half of the observation period. The immediate mortality was 5% and 2% in the two periods, respectively. The corrected 5-year survival according to the Dukes Classification was 92% (A), 69% (B), 41% (C), and 6% (D). In curative surgery for rectal cancer, the incidences of local recurrence decreased from 21% to 9% (NS) and the use of permanent colostomy from 59 to 42% (NS). Conclusions. Acceptable immediate and long-term results in curative surgery for colorectal cancer can be achieved in a low-volume surgical unit. Nevertheless, owing to the low volume, the improvement of the results obligates team-based institutional specialization and careful consideration about the extensiveness of the primary procedure in case of cancer obstruction.     

Comparison of sequential chemoradiation with radiation alone in the treatment of advanced head and neck cancers

Objectives: To compare locoregional control with alternating chemo radiation and radiation alone in patients with locally advanced head and neck carcinoma.Study Design: A prospective randomized study.Setting: Tertiary academic referral center.Patients: 50 patients of biopsy proven locally-advanced carcinoma of head and neck.Intervention: 25 patients were kept in Group I or study group (i.e. alternating chemo-radiation) and 25 patients in Group II or control group (i.e. radiation alone). In the study group, patients were given 3 cycles of chemotherapy (Cisplatin 20 mg/m^[2] and Inj. 5-FU 200mg/m^[2] from day 1–5 of each week) during weeks 1,5 and 9 alternated with radiation dose of 10Gy/week was given during weeks 2,3,4 and 6,7,8. In the control group, patients were given a total dose of 60Gy in 6 weeks.Outcome measures: The response rate at the primary site and nodal site was better in study group as compared to control group.Results: On comparing the response at the primary and nodal site together, 72% (18/25) patients of group I and 44% (11/25) patients of group II showed CR. PR was seen in 28% (7/25) and 36% (9/25) patients in group I and II respectively. No response was seen in 5/25 (20%) of patients in Group II.Conclusion: Our study has revealed that alternating/ sequential chemoradiation is a promising and feasible approach for patients in advanced head and neck cancer.     

Validation of virtual colonoscopy in the detection of colorectal polyps and masses

Background: Colorectal cancer, the second-leading cause of cancer-related mortality, is a preventable malignancy in many cases. Despite the availability of several screening modalities, compliance with screening recommendations remains unacceptably low. Virtual colonoscopy is a novel, minimally-invasive technique with the potential to increase colorectal cancer screening rates, but its effectiveness must first be validated. Published studies comparing virtual colonoscopy to conventional colonoscopy have reported varying results. These discrepancies may be attributed to differences in bowel preparation and scanning techniques, as well as errors in endoscopic lesion measurement, endoscopic colonic segmental localization, and the ability of conventional colonoscopy to actually detect lesions. These methodological issues can affect scientific results and ultimately affect the public’s perception of this emerging technique. Aim: The goal of this report is to expose existing methodological shortcomings and propose solutions incorporated in this study design. This article describes the rationale, study design, and outcome definitions of a single-center, blinded, direct comparative trial aiming at assessing the ability of virtual colonoscopy to detect colorectal polyps and masses relative to the criterion standard, conventional colonoscopy. Design Features: Bowel preparation was standardized using oral sodium phosphate lavage, orally administered iodinated contrast, and controlled colonic insufflation. Segmental unblinding allowed a second-look when results were discrepant and polyp matching was performed using an algorithm based on segmental localization and lesion size determination. Conclusions: This methodology could be applied to other studies assessing the accuracy of virtual colonoscopy in order to have uniformity of results.     

A comparative study of endoscope assisted myringoplasty and micrsoscope assisted myringoplasty

Objective

To determine the advantages and disadvantages of the endoscope as compared to the microscope in myringoplasty surgery and to compare the results of both groups.

Methods

Between January 2003 and September 2006, 100 patients underwent myringoplasty, 50 were endoscope assisted and 50 were microscope assisted. Results of surgery were compared at the end of six months post operation.

Results

In the endopscope group 82% of patients had a successful outcome and in the microscope group 86% of patients had a successful outcome.

Conclusion

In myringoplasty surgery the endoscope has several advantages and a few disadvantages. The surgical outcome of endoscope assisted myringoplasty was comparable to the conventional microscope assisted myringoplasty, but in terms of cosmesis and post operative recovery patients in the endoscope group had better results.     

Comparative study of percutaneous dilatational tracheostomy and conventional tracheostomy in the intensive care unit

Objective: Tracheostomy is a one of the earliest described surgical procedure dating back to 2000 B.C. Percutaneous tracheostomy is becoming increasingly popular as an alternative method for conventional tracheostomy in the intensive care unit. In this study we compare the results of the use of these 2 techniques in 32 patients who underwent elective tracheostomy in the intensive care unit.Study Design: Prospective randomized comparative study.Setting: Tertiary care hospital.Patients: Adult intubated patients selected randomly in the intensive care unit with normal cervical soft tissue, laryngeal framework, palpable cricoid cartilage and normal coagulation parameters.Results: 17 patients underwent conventional tracheostomy and 15 patients underwent percutaneous dilatational tracheostomy. Demographic data and duration of intubation comparable between two groups. The mean operative time, blood loss and complications were lower in percutaneous than in conventional tracheostomy.Conclusions: PDT is quicker to perform and has lower blood loss and complication rates compared to conventional tracheostomy. However percutaneous tracheostomy is not indicated in emergencies and in children. The cost of the percutaneous kit and use of bronchoscopy adds to the cost. It is a good alternative to conventional tracheostomy in properly selected patients.     

Long-term results after surgery for gastric cancer with or without jejunal reservoir

Background: Gastric cancer still has a disease-specific 5-yr survival less than 30% and an overall survival of about 15%. The quality of life of patients who undergo gastrectomy is poor owing both to the severity of the disease itself and to the mutilation of the upper gastrointestinal channel after the reconstruction. Therefore, the combination of a jejunal pouch with gastrectomy has been claimed to improve the life quality and nutritional status of these patients. Aim: To assess the clinical results after surgery for gastric cancer in two consecutive periods with or without jejunal-pouch reconstruction. Methods: 271 consecutive patients referred for surgery for gastric cancer in 1985–1991 (116 patients) and in 1992–1998 (155 patients) in Kanta-Häme central hospital were retrospectively analyzed regarding their disease, mode of surgery, and the immediate and long-term results. In the former observation period gastrectomy was performed with Roux-en-Y esophagojejunostomy without a reservoir, and in the latter period this procedure was combined with a jejunal reservoir. The data were collected from patient journals and from the death certificate obtained from the National Centre of Statistics in Finland. Results: During the study period the incidence of cancer in the cardia increased among the surgical patients from 13.1 to 26.7% (p <0.05). Despite this proximal migration, the cancer-specific 5-yr survival remained practically unchanged during the two study periods, 29.4% and 32.2% (NS). During the period of jejunal-pouch reconstruction there were non-significant increases of the incidences of local recurrence (from 18.9% to 26.5%), of immediate postoperative anastomotic fistulae (from 0.9% to 4.5%) as well as of the immediate mortality (from 2.6% to 3.7%) (NS for each). Conclusions: Despite proximal migration of gastric cancer and the application of a jejunal reservoir, the long-term as well as the immediate results after curative surgery (i.e., D2-gastrectomy) for gastric cancer have remained relatively unchanged. The jejunal-pouch reconstruction with the present technique after gastrectomy can therefore be safely applied.     

The role of cytoreductive surgery in the management of progressive glioblastoma

Question

Should patients with previously diagnosed malignant glioma who are suspected of experiencing progression of the neoplasm process undergo repeat open surgical resection?

Target population

These recommendations apply to adults with previously diagnosed malignant glioma who are suspected of experiencing progression of the neoplastic process and are amenable to surgical resection.

Recommendations

Level II

Repeat cytoreductive surgery is recommended in symptomatic patients with locally recurrent or progressive malignant glioma. The median survival in these patient diagnosed with glioblastoma is expected to range from 6 to 17 months following a second procedure. It is recommended that the following preoperative factors be considered when evaluating a patient for repeat operation: location of recurrence in eloquent/critical brain regions, Karnofsky Performance Status and tumor volume.     

Immunohistochemical evaluation of tissue-specific proteolytic enzymes in adenomas containing foci of early carcinoma

Background: Cathepsin D (CD) is an aspartyl lysosomal protease, and the prognostic value of CD expression has been studied in a variety of tumors, however, its role in early adenocarcinomas remains unclear. Aim of the Study: We evaluated the expression of CD in a series of colorectal adenomas with severe dysplasia containing foci of early carcinoma and compared the results to several histopathological and immunohistochemical features. Methods: Adenomas were obtained by endoscopic polypectomy from 33 patients. Twenty-four of the 33 adenomas contained well-differentiated adenocarcinomas and nine adenomas contained moderately differentiated adenocarcinomas. Results: Positive CD expressions were observed in 25% of well-differentiated adenocarcinomas and in 66.7% of moderately differentiated adenocarcinomas (p<0.05). Of the 12 adenocarcinomas with positive CD expression, four had positive CD expression in their adenomas (p<0.01), 6 showed positive Ki-67 expression in their adenomas (NS), and 10 had positive p53 expression in their adenomas (p<0.05). No significant association was seen between the level of CD expression and adenoma size. Conclusions: The expression of CD in adenocarcinoma correlated significantly with differentiation, and with the levels of CD and p53 expression in the adenomas of the polyp.     

Therapeutic targeting malignant mesothelioma with a novel 6-substituted pyrrolo[2,3-d]pyrimidine thienoyl antifolate via its selective uptake by the proton-coupled folate transporter

Purpose

We examined whether the novel 6-substituted pyrrolo[2,3-d]pyrimidine thienoyl antifolate, compound 2, might be an effective treatment for malignant pleural mesothelioma (MPM), reflecting its selective membrane transport by the proton-coupled folate transport (PCFT) over the reduced folate carrier (RFC).

Methods

HeLa sublines expressing exclusively PCFT (R1-11-PCFT4) or RFC (R1-11-RFC6) and H2452 MPM cells were assayed for transport with [³H]compound 2. [³H]Polyglutamate metabolites of compound 2 were measured in R1-11-PCFT4 and H2452 cells. In vitro cell proliferation assays and colony formation assays were performed. Inhibition of glycinamide ribonucleotide formyltransferase (GARFTase) was assayed by nucleoside protection assays and in situ GARFTase assays with [¹⁴C]glycine. In vivo efficacy was established with early- and advanced-stage H2452 xenografts in severe-combined immunodeficient (SCID) mice administered intravenous compound 2.

Results

[³H]Compound 2 was selectively transported by PCFT and was metabolized to polyglutamates. Compound 2 selectively inhibited proliferation of R1-11-PCFT4 cells over R1-11-RFC6 cells. H2452 human MPM cells were sensitive to the antiproliferative effects of compound 2. By colony-forming assays with H2452 cells, compound 2 was cytotoxic. Compound 2 inhibited GARFTase in de novo purine biosynthesis. In vivo efficacy was confirmed toward early- and advanced-stage H2452 xenografts in SCID mice administered compound 2.

Conclusions

Our results demonstrate potent antitumor efficacy of compound 2 toward H2452 MPM cells in vitro and in vivo, reflecting its efficient membrane transport by PCFT, synthesis of polyglutamates, and inhibition of GARFTase. Selectivity for non-RFC cellular uptake processes by tumor-targeted antifolates such as compound 2 presents an exciting new opportunity for treating solid tumors.     

Inhibition of HSP27 alone or in combination with pAKT inhibition as therapeutic approaches to target SPARC-induced glioma cell survival

Background

The current treatment regimen for glioma patients is surgery, followed by radiation therapy plus temozolomide (TMZ), followed by 6 months of adjuvant TMZ. Despite this aggressive treatment regimen, the overall survival of all surgically treated GBM patients remains dismal, and additional or different therapies are required. Depending on the cancer type, SPARC has been proposed both as a therapeutic target and as a therapeutic agent. In glioma, SPARC promotes invasion via upregulation of the p38 MAPK/MAPKAPK2/HSP27 signaling pathway, and promotes tumor cell survival by upregulating pAKT. As HSP27 and AKT interact to regulate the activity of each other, we determined whether inhibition of HSP27 was better than targeting SPARC as a therapeutic approach to inhibit both SPARC-induced glioma cell invasion and survival.

Results

Our studies found the following. 1) SPARC increases the expression of tumor cell pro-survival and pro-death protein signaling in balance, and, as a net result, tumor cell survival remains unchanged. 2) Suppressing SPARC increases tumor cell survival, indicating it is not a good therapeutic target. 3) Suppressing HSP27 decreases tumor cell survival in all gliomas, but is more effective in SPARC-expressing tumor cells due to the removal of HSP27 inhibition of SPARC-induced pro-apoptotic signaling. 4) Suppressing total AKT1/2 paradoxically enhanced tumor cell survival, indicating that AKT1 or 2 are poor therapeutic targets. 5) However, inhibiting pAKT suppresses tumor cell survival. 6) Inhibiting both HSP27 and pAKT synergistically decreases tumor cell survival. 7) There appears to be a complex feedback system between SPARC, HSP27, and AKT. 8) This interaction is likely influenced by PTEN status. With respect to chemosensitization, we found the following. 1) SPARC enhances pro-apoptotic signaling in cells exposed to TMZ. 2) Despite this enhanced signaling, SPARC protects cells against TMZ. 3) This protection can be reduced by inhibiting pAKT. 4) Combined inhibition of HSP27 and pAKT is more effective than TMZ treatment alone.

Conclusions

We conclude that inhibition of HSP27 alone, or in combination with pAKT inhibitor IV, may be an effective therapeutic approach to inhibit SPARC-induced glioma cell invasion and survival in SPARC-positive/PTEN-wildtype and SPARC-positive/PTEN-null tumors, respectively.     

Correlation between expression of orotate phosphoribosyl transferase and 5-fluorouracil sensitivity, as measured by apoptosis index in colorectal cancer tissue

Background. 5-Fluorouracil remains a key drug in the treatment of colorectal cancer, and the development of a simple and effective test for selecting patients likely to benefit from postoperative adjuvant chemotherapy is an important objective. Aim of the Study. This study aimed to clarify the feasibility of measuring apoptotic cell rate (AI%) in tumor after short-term oral 5-fluorouracil administration prior to surgery with the objective of establishing a simpler method to test for sensitivity. Methods. Forty-five colorectal cancer patients were allocated to two groups, and 21 patients were given oral 5-FU for 3 d prior to surgery. The AI% in surgical specimen, detected by TUNEL staining, was compared in the 5-FU-loaded and control groups. The correlation of AI% with 5-FU metabolic enzyme mRNA levels in tumor was also evaluated. Results. The AI% was significantly higher in the tumor tissue of patients receiving 5-FU than in the control group (p<0.0005). Although insignificant, thymidylate synthase mRNA level and orotate phosphoribosyl transferase mRNA demonstrated a weak positive correlation with AI%. Conclusions. The AI% measurement in tumor tissue following a 5-FU oral load for 3 d prior to surgery was feasible. It remains to be elucidated if this measurement as a new 5-FU sensitivity test reflects the prognosis with 5-FU-based postoperative adjuvant chemotherapy.     

The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline

Should whole brain radiation therapy (WBRT) be used as the sole therapy in patients with newly-diagnosed, surgically accessible, single brain metastases, compared with WBRT plus surgical resection, and in what clinical settings?

Target population This recommendation applies to adults with newly diagnosed single brain metastases amenable to surgical resection; however, the recommendation does not apply to relatively radiosensitive tumors histologies (i.e., small cell lung cancer, leukemia, lymphoma, germ cell tumors and multiple myeloma). Recommendation Surgical resection plus WBRT versus WBRT alone Level 1 Class I evidence supports the use of surgical resection plus post-operative WBRT, as compared to WBRT alone, in patients with good performance status (functionally independent and spending less than 50% of time in bed) and limited extra-cranial disease. There is insufficient evidence to make a recommendation for patients with poor performance scores, advanced systemic disease, or multiple brain metastases. If WBRT is used, is there an optimal dosing/fractionation schedule? Target population This recommendation applies to adults with newly diagnosed brain metastases. Recommendation Level 1 Class I evidence suggests that altered dose/fractionation schedules of WBRT do not result in significant differences in median survival, local control or neurocognitive outcomes when compared with “standard” WBRT dose/fractionation. (i.e., 30 Gy in 10 fractions or a biologically effective dose (BED) of 39 Gy10). If WBRT is used, what impact does tumor histopathology have on treatment outcomes? Target population This recommendation applies to adults with newly diagnosed brain metastases. Recommendation Given the extremely limited data available, there is insufficient evidence to support the choice of any particular dose/fractionation regimen based on histopathology. The following question is fully addressed in the surgery guideline paper within this series by Kalkanis et al. Given that the recommendation resulting from the systematic review of the literature on this topic is also highly relevant to the discussion of the role of WBRT in the management of brain metastases, this recommendation has been included below. Does the addition of WBRT after surgical resection improve outcomes when compared with surgical resection alone? Target population This recommendation applies to adults with newly diagnosed single brain metastases amenable to surgical resection. Recommendation Surgical resection plus WBRT versus surgical resection alone Level 1 Surgical resection followed by WBRT represents a superior treatment modality, in terms of improving tumor control at the original site of the metastasis and in the brain overall, when compared to surgical resection alone.     

Solitary true cyst of the pancreas in an adult

Background: Solitary true cyst of the pancreas is rare in adults, and the differential diagnosis of cystic lesions of the pancreas is challenging. Aim of the Study: To describe a solitary true cyst of the pancreas in an adult and discuss the differential diagnosis. Methods: A 50 yr old woman presented with a mass lesion in the right upper quadrant of the abdomen. Abdominal computed tomography showed a cystic lesion, with a maximum diameter of 12 cm, between the inferior surface of the liver and the ascending colon. The cyst was homogenous and had smooth edges. On magnetic resonance imaging, a unilocular cyst was seen that was low intensity on T1-weighted images and very high intensity on T2-weighted images. No connection between the cyst and the pancreatic ductal system was demonstrated on endoscopic retrograde cholangiopancreatography. Laparotmy was performed with a presumptive diagnosis of cystic tumor of the pancreas. Results: On pathologic examination, the cyst was serous and was lined with a single layer of normal cuboidal epithelium that was periodic acid Schiff stain negative. Meticulous examination failed to identify honeycomb-like microcysts characteristic of serous cystadenoma. The final diagnosis was a solitary true cyst of the pancreas. Conclusion: The differential diagnosis of solitary true cyst from other cystic lesion of the pancreas usually is based on histology. Particular care must be taken to distinguish this lesion from macrocystic serous cystadenoma.     

Chemoradiotherapy for advanced head and neck cancer — Analysis of a prospective, randomized trial

Objective: To study the efficacy of neo-adjuvant chemotherapy followed by radiotherapy in advanced head and neck cancer.Study design: Randomised, prospective study.Setting: Tertiary academic referral center.Patients: One hundred and eighty patients of advanced head and neck squamous cell carcinoma.Intervention: Patients were randomized into two arms. The study arm (CT-RT arm) received 3 cycles of anterior chemotherapy with Inj. Cisplatin 100 mg/m² on D₁ and Inj 5F.U. 700 mg/m² on D₁-D₄ at an interval of 21 days, followed by external radiation. The control arm (RT arm) received external radiotherapy only. The dose of Radiotherapy was 64 to 68 Gy in conventional fractionation.Results: Patients of CT-RT showed better tumour control locally than patients who received only RT. Toxicities were commoner in CT-RT arm but they were manageable. 5 year survival is higher in the CT-RT arm (21% vs 16%; p value> 0.05).Conclusion: Anterior chemotherapy with Cisplatin and 5F.U. is associated with good clinical response which is translated into increased survival along with acceptable toxicities.