Treatment of anal human papillomavirus-associated disease: a long term outcome study

Treatment for human papillomavirus (HPV)-associated anal canal disease has been unsatisfactory. The objective of our study was to determine the treatment outcome in our cohort with anal HPV disease. Overall, 181 patients were evaluated over a median period of 19.1 months (range = 2.8-125.5). Eighty-eight patients (48.6%) with high-grade anal intraepithelial neoplasia (AIN) and 82 patients (45.3%) with low-grade AIN underwent treatment. One hundred and forty-one patients (77.9%) received laser ablative treatment as an outpatient procedure. The treatment yielded cure, defined as a disease-free state at 12 months after treatment, in 63.0% (114/181). Median time to cure for the cohort was 31.5 months (95% confidence interval: 23.0-40.0). Treatment outcome showed no evidence of being affected by age, sexual preference, history of smoking or presence of high-grade disease. Median time to cure was significantly affected by a positive HIV status (P = 0.02) and the extent (volume) of the disease (P = 0.01). Contrary to the current view that treatment of HPV-related anal disease is difficult, unrewarding due to recurrences and may lead to substantial morbidity, we demonstrate that effective treatment is possible for both low- and high-grade AIN. These findings should help with the general desire to introduce screening for AIN for at-risk groups.     

Glioblastoma multiforme with epithelial differentiation: A potential diagnostic pitfall in cerebrospinal fluid cytology

Cerebrospinal fluid (CSF) cytology provides valuable diagnostic and prognostic information for diseases of the central nervous system (CNS) and remains the gold standard for the detection of neoplastic meningitis. Metastatic involvement of the CSF by non‐CNS neoplasms far surpasses that of primary brain tumors, although conventional glioblastoma multiforme (GBM) can occasionally be identified in the CSF. GBM with epithelial differentiation is an uncommon variant that may contain features such as adenoid structures, signet ring cells, or squamous metaplasia. Herein, we present a case of GBM with epithelial differentiation to highlight a potential diagnostic pitfall in CSF cytology. A 55‐year‐old man presented with neurological symptoms and a 6.4 cm left temporal lobe cystic mass. Primary resection revealed GBM with focal epithelial differentiation confirmed by cytokeratin, epithelial membrane antigen, and glial fibrillary acidic protein immunohistochemical studies. Four months following primary resection, the patient developed severe headache for which a lumbar puncture with CSF cytologic evaluation was performed. The cytospin preparation showed numerous malignant epithelioid cells with high nuclear–cytoplasmic ratio and prominent cytoplasmic vacuoles resembling metastatic carcinoma. However, the lesional cells were cytomorphologically identical to the epithelial component present in the patient's recently diagnosed GBM. This case illustrates the potential for GBM with epithelial differentiation to closely mimic metastatic carcinoma from a non‐CNS site in CSF cytology, which expands the differential diagnosis and emphasizes the necessity of clinical correlation. Diagn. Cytopathol. 2015;43:638–641. © 2015 Wiley Periodicals, Inc.     

A case of an atypically large proximal 15q deletion as cause for Prader–Willi syndrome arising from a de novo unbalanced translocation

We describe an 11 month old female with Prader–Willi syndrome (PWS) resulting from an atypically large deletion of proximal 15q due to a de novo 3;15 unbalanced translocation. The 10.6 Mb deletion extends from the chromosome 15 short arm and is not situated in a region previously reported as a common distal breakpoint for unbalanced translocations. There was no deletion of the reciprocal chromosome 3q subtelomeric region detected by either chromosomal microarray or FISH. The patient has hypotonia, failure to thrive, and typical dysmorphic facial features for PWS. The patient also has profound global developmental delay consistent with an expanded, more severe, phenotype.     

Lymphocytes from systemic lupus erythematosus patients display increased spreading on VCAM-1, an effect associated with active renal involvement

The mechanisms underlying leukocyte recruitment in systemic lupus erythematosus (SLE) are unclear. Leukocytes from SLE patients display increased integrin expression, but whether this results in an increased capacity to undergo adhesive interactions has not been investigated. Therefore, the aim of this study was to identify alterations in the capacity of leukocytes from SLE patients to undergo interactions with various substrates under flow conditions. Blood from SLE patients was examined in a flow chamber assay, and rolling, adhesion and post-adhesion spreading assessed on platelet monolayers or VCAM-1. P-selectin-dependent neutrophil rolling on platelet monolayers did not differ between SLE patients and healthy controls. Similarly, lymphocyte adhesion on VCAM-1 did not differ between patients and controls. However, post-adhesion spreading on VCAM-1 was significantly increased in lymphocytes from SLE patients. These parameters were unaffected by overall disease activity, presence of organ damage or prednisolone usage. However, leukocyte spreading on VCAM-1 was elevated in patients with evidence of active renal disease. These findings indicate that lymphocytes from SLE patients have an increased propensity to undergo post-adhesion spreading, a key preliminary step in leukocyte transmigration. This behavior may contribute to lymphocyte infiltration in SLE patients and may represent a novel biomarker of lupus nephritis.     

A review of inpatient urology consultations in an Irish tertiary referral centre

IntroductionOur institution is a 680-bed tertiary referral centre with broad medical and surgical subspecialty services. We retrospectively audited the pattern of inpatient consultations from all specialities within our institution to the urology department over a 1-year period.MethodsAll consultations to the urology service were identified from our computerised inpatient consultation system from July 2010 to June 2011. Follow up data on investigations, interventions and subsequent outpatient appointments were also identified by review of individual patient discharge letters.ResultsSeven hundred and twenty five inpatient consultations were received over the period. The male to female ratio was 7:3. Mean age of patients was 66 (15–96) years. Seventy three percent of referrals were from medical sub-specialities, most commonly nephrology (17%), gastroenterology (11%) and respiratory medicine (9%). The remainder were from general surgery (16%) and other surgical sub specialities (11%). Interns (66%) and senior house officers (SHO) (28%) communicated the majority of consults. Male lower urinary tract/benign prostate related issues resulted in 25% of all consultations. Less than half of consults (47%) resulted in interventions initiated by urology, most commonly of which were catheter insertions (48%) and endoscopic procedures (35%). Only 43% of consultations were followed up in the outpatients setting.ConclusionsInpatient consultations constitute a significant workload for urology services. The majority of these referrals did not require any urological intervention and could have been seen routinely in the outpatient setting. Providing structured referral guidelines and achieving better communication with referring teams may help to optimise this service.     

Agreement Between Chart Diagnoses and Standardized Instrument Ratings of Youth Psychopathology

Rating scales are useful for evidence-based assessment of youth psychopathology. However, it is not known whether these scales contribute information beyond that which clinicians gather without them. This study examined agreement between chart diagnoses and the Child Behavior Checklist (CBCL) for 82 community mental health clinic clients. Agreement was low, suggesting that the CBCL was not redundant with clinicians’ clinical impressions. These findings suggest that use of an instrument like the CBCL could potentially improve clinician diagnostic accuracy; future research should examine how best to utilize these scales in the diagnostic process and how to train clinicians in their use.     

Same-day <Superscript>90</Superscript>Y radioembolization: implementing a new treatment paradigm

Purpose

To assess the feasibility of conducting pretreatment mesenteric angiography, coil embolization, ^99mTc macroaggregated albumin (^99mTc-MAA) scintigraphy, and ⁹⁰Y radioembolization treatment in a single, same-day, combined outpatient encounter.

Methods

This was a retrospective study of 78 patients treated during the period 2008 – 2015 who were managed in a single outpatient encounter under the guidance of the Interventional Radiology Department and The Nuclear Medicine Department. Pretreatment planning was performed by reviewing baseline imaging and estimated perfused liver volume bearing the tumor. The region of interest was estimated using 3-D software; this value was used for dosimetry planning. Maximum lung shunting fractions of 10 % for hepatocellular carcinoma and 5 % for liver metastases were assumed. Subsequently, hepatic angiography and ^99mTc-MAA scintigraphy were performed followed by ⁹⁰Y treatment in one outpatient encounter. Total in-room procedure time was recorded.

Results

All patients underwent same-day angiography, ^99mTc-MAA scintigraphy and ⁹⁰Y radioembolization. Of the 78 patients, 16 received multiple segmental treatments to both lobes, 44 received treatment to the right lobe, and 18 received treatment to the left lobe. The median dose was 106 Gy. The median number of ⁹⁰Y vials needed was two (range one to six). The median in-room time was 160 min (75 – 250 min). The residential status of the patients was as follows, 18 % (14/78) were local residents, 55 % (43/78) traveled from outside the city limits, 18 % (14/78) were from out-of-state, and 9 % (7/78) were resident abroad. Of the 78 patients, 61 (77 %) had hepatocellular carcinoma, and 17 (22 %) had liver metastases. The median lung dose was 3.5 Gy.

Conclusion

This study demonstrated the feasibility of same-day ⁹⁰Y evaluation and treatment while maintaining the principles of safe and effective ⁹⁰Y infusion including tumoricidal dosimetry (lobar, segmentectomy), minimization of nontarget flow, and minimization of lung dose. This paradigm translates into expeditious cancer care and significant cost savings.