Stereotactic body radiation therapy for the treatment of early-stage minimally invasive adenocarcinoma or adenocarcnioma in situ (formerly bronchioloalveolar carcinoma): a patterns of failure analysis

Aims

Based on the hypothesis that first-line chemoradiation followed by chemotherapy was superior for primary tumor and non-inferior for distant lesions compared to chemotherapy alone in synchronous unresectable distant metastases rectal adenocarcinoma, this study was designed to assess the efficacy and safety of this strategy.

Materials and methods

Thirty two eligible patients received intensity modulated radiation therapy (45 Gy to the pelvis and a concomitant 10 Gy boost to the gross tumor), along with concurrent weekly capecitabine and oxaliplatin. Patients underwent radical surgery if all lesions were visually evaluated as resectable and received chemotherapy for a total of 6 months, whether pre- or post-operatively (definitive therapy group). The remaining patients received 6 months of consolidation chemotherapy followed by maintenance chemotherapy (non-definitive therapy group).

Results

The toxicities were acceptable, with radiation-induced dermatitis around the anal verge being the most common (18.8%). Fourteen patients underwent surgical resection of the rectal tumor, with 5 (35.7%) experiencing a pathological complete response. Nine out of 14 received definitive treatment, defined as R0 resections of all visible tumors. At a median follow-up of 12 months (range, 4–23 months), 2 cases were evaluated as local failure, and the median overall survival (OS) and progression free survival (PFS) for all 32 patients were 17.5 and 12 months, respectively. OS differed significantly in the definitive and non-definitive therapy groups (p=0.045), and PFS tended to differ (p=0.274).

Conclusion

It was demonstrated that the strategy of first-line chemoradiation followed by chemotherapy was effective and tolerable, especially for local control. OS and PFS were superior in patients who did than did not undergo curative therapy.     

Duct-to-mucosa versus invagination pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis

Background Postoperative pancreatic fistula remains one of the most common and troublesome complications following pancreaticoduodenectomy. No consensus exists regarding the optimal pancreaticojejunostomy reconstruction technique to reduce this complication. We aimed to perform a systematic review comparing two commonly used techniques of pancreaticojejunostomy reconstruction （duct-to-mucosa versus invagination）, by meta-analysis and assessment of evidence quality. Methods Databases searched including The Cochrane Library, Medline, PubMed, Embase, etc. Randomized controlled trials （RCTs） comparing duct-to-mucosa and invagination pancreaticojejunostomy were included. Outcomes of interest were pancreatic fistula rate, mortality, morbidity, reoperation and hospital stay. Pooled estimates were expressed as risk ratio （RR） or mean difference. Results From 321 identified abstracts, four RCTs （467 patients; duct-to-mucosa： 232; invagination： 235） were included. Pancreatic fistula rate （RR, 0.74; 95% confidence interval （C/）： 0.24-2.28; P=0.60）, mortality （RR, 1.18; 95% CI： 0.39- 3.54; P=0.77）, morbidity （RR, 0.91; 95% CI： 0.69-1.21; P=0.53）, reoperation （RR, 1.09; 95% CI： 0.54-2.22; P=-0.81） and hospital stay （mean difference, -1.78; 95% CI： -4.60-1.04; P=0.22） were similar between techniques. Conclusions Duct-to-mucosa and invagination pancreaticojejunostomy are comparable with regards to assessed parameters. High-quality, large-volume, multi-center RCTs with standard outcome definitions are required.     

Intraovarian expression of GnRH-1 and gonadotropin mRNA and protein levels in Siberian hamsters during the estrus cycle and photoperiod induced regression/recrudescence

The hypothalamic-pituitary-gonadal (HPG) axis is the key reproductive regulator in vertebrates. While gonadotropin releasing hormone (GnRH), follicle stimulating (FSH), and luteinizing (LH) hormones are primarily produced in the hypothalamus and pituitary, they can be synthesized in the gonads, suggesting an intraovarian GnRH-gonadotropin axis. Because these hormones are critical for follicle maturation and steroidogenesis, we hypothesized that this intraovarian axis may be important in photoperiod-induced ovarian regression/recrudescence in seasonal breeders. Thus, we investigated GnRH-1 and gonadotropin mRNA and protein expression in Siberian hamster ovaries during (1) the estrous cycle; where ovaries from cycling long day hamsters (LD;16L:8D) were collected at proestrus, estrus, diestrus I, and diestrus II and (2) during photoperiod induced regression/recrudescence; where ovaries were collected from hamsters exposed to 14 weeks of LD, short days (SD;8L:16D), or 8 weeks post-transfer to LD after 14 weeks SD (PT). GnRH-1, LHβ, FSHβ, and common α subunit mRNA expression was observed in cycling ovaries. GnRH-1 expression peaked at diestrus I compared to other stages (p < 0.05). FSHβ and LHβ mRNA levels peaked at proestrus and diestrus I (p < 0.05), with no change in the α subunit across the cycle (p > 0.05). SD exposure decreased ovarian mass and plasma estradiol concentrations (p < 0.05) and increased GnRH-1, LHβ, FSHβ, and α subunit mRNA expression as compared to LD and, except for LH, compared to PT (p < 0.05). GnRH and gonadotropin protein was also dynamically expressed across the estrous cycle and photoperiod exposure. The presence of cycling intraovarian GnRH-1 and gonadotropin mRNA suggests that these hormones may be locally involved in ovarian maintenance during SD regression and/or could potentially serve to prime ovaries for rapid recrudescence.     

Hodgkin's lymphoma: Diagnostic difficulties in fine‐needle aspiration cytology

It is commonly believed that cytodiagnosis of Hodgkin's lymphoma (HL) is much easier than that of non‐Hodgkin lymphoma (NHL). However, recognition of certain NHL subtypes with Reed‐Sternberg (R‐S)‐like cells and results of immunohistochemical studies point to the contrary. To study the limitations of cytology in diagnosis of HL, fine‐needle aspiration (FNA) smears of 130 lymphoma or suspected lymphoma cases were reviewed. Initial and reviewed cytodiagnoses were compared with histopathology in 89 cases. Immunocytochemical and immunohistochemical studies were performed in 56 and 59 cases, respectively. Among histologically diagnosed HL cases, definitive cytodiagnosis of HL (initial as well as reviewed) was significantly less frequent than cytodiagnosis of NHL among histologically diagnosed NHL cases (P = 0.0328 and = 0.0001, respectively). On the other hand, cytologically diagnosed HL/NHL cases were significantly more frequent in the former group (P = 0.0001 and = 0.0018, respectively). ALCL and TCRBCL were the two NHL subtypes which created confusion with HL in FNA smears. Twenty‐one cytohistological concordant HL cases and equal number of discordant cases were compared. When compared with discordant group, the patients in concordant group were significantly younger (P = 0.045). Hodgkin/Hodgkin‐like cells and typical R‐S cells were significantly more frequent in FNA smears of the concordant group (P = 0.0478 and = 0.0431, respectively). Immunocytochemical and immunohistochemical studies showed good correlation with histological diagnosis of HL. It is suggested that proper interpretation of cytologic features, together with use of immunocytochemical parameters can help in reducing the margin of error in cytodiagnois of HL. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

Initial experience with alcohol septal ablation using a novel magnetic navigation system

OBJECTIVES: We compared the use of magnetically assisted intervention (MAI) with conventional guidewire techniques to perform alcohol septal ablation (ASA) in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Treatment of symptomatic patients with HOCM using ASA has been established as an effective therapy. However, in many cases cannulaton of the septal artery can be technically challenging. Recently, a magnetically directed guidewire system has been developed to assist in navigation in difficult percutaneous interventions. By directing the guidewire to the septal branch, this system has potential to shorten the procedure time and increase success and safety of ASA in patients with HOCM. METHODS: From October 2004 through October 2006, 44 consecutive patients underwent ASA using MAI with the Niobe system (Stereotaxis, Inc., St. Louis, MO). We compared these patients to 29 age- and gradient-matched cases using conventional techniques performed by an operator with >100 prior cases. RESULTS: All procedures were successful. Both the MAI and conventional groups had improved symptoms, exercise times, and reduced gradients compared with baseline. One dissection occurred in the conventional group. Although there were no aggregate differences in acute or 3-month clinical outcomes, the time required for guidewire cannulation of the septal branch decreased progressively with increasing experience (third tertile vs first tertile (3 [1.25-4.75 vs 10.5 [6-17] minutes, P = 0.004) compared with the conventional group (6 [2-10.25] minutes, P = 0.075 vs third tertile), suggesting a learning curve for MAI. CONCLUSIONS: MAI has the potential to improve wiring time and outcomes of HOCM patients undergoing ASA.     

The effects of subthalamic nucleus deep brain stimulation on parkinsonian tremor

Deep brain stimulation (DBS) of the ventral intermediate (Vim) nucleus of the thalamus has been the target of choice for patients with disabling essential tremor or medication refractory parkinsonian tremor. Recently there is evidence that the subthalamic nucleus (STN) should be the targets for patients with tremor associated with Parkinson's disease (PD). To assess the effects of STN DBS on parkinsonian tremor, eight consecutive patients with PD and disabling tremor were videotaped using a standardized tremor protocol. Evaluations were performed at least 12 h after last dose of medication with the DBS turned off followed by optimal DBS on state. A rater blinded to DBS status evaluated randomized video segments with the tremor components of the Unified Parkinson Disease Rating Scale (UPDRS) and Tremor Rating Scale (TRS). Compared with DBS off state there were significant improvements in mean UPDRS tremor score 79.4% (p = 0.008), total TRS score 69.9% (p = 0.008) and upper extremity 92.5% (p = 0.008) TRS subscore. Functional improvement was noted with pouring liquids. Our findings provide support that STN DBS is an effective treatment of tremor associated with PD.     

T‐cell prolymphocytic leukemia (T‐PLL) with overlapping cytomorphological features with T‐CLL and T‐ALL: A Case Initially Diagnosed by Fine‐Needle Aspiration Cytology and Immunocytochemistry

T‐cell prolymphocytic leukemia (T‐PLL) is a very unusual form of chronic lymphoproliferative disorder, which has rarely been diagnosed by fine needle aspiration (FNA) cytology. We report one such case with some overlapping cytomorphological features with chronic lymphocytic leukemia and acute lymphoblastic leukemia. A 91‐year‐old man presented with generalized lymphadenopathy, pleural effusion, ascites, and an ulcerated growth in rectum. FNA smears from the left cervical lymph node showed a monotonous population of small lymphoid cells having small but distinct nucleoli that was initially diagnosed as chronic lymphocytic leukemia (CLL). Smears from the left axillary lymph node contained both small and medium‐sized lymphoid cells with frequent hand‐mirror cell appearance, which has been described in acute lymphoblatic leukemia (ALL). Immunocyto/histochemical stainings on smears and cell block preparations of the aspirate showed the following immunophenotype: CD3+, CD4+, CD5+, CD7+, CD8‐, CD20‐, CD23‐, and Tdt‐. Total peripheral blood leukocyte count was 26.4 × 10⁹/L and total lymphocyte count, 8.3 × 10⁹/L with predominance of small lymphocytes. T‐cell nature of the neoplasm was confirmed by biopsies from the cervical lymph node (T‐cell lymphoma), bone marrow (T‐cell lymphoid neoplasm/chronic lymphocytic leukemia), and the ulcerated rectal lesion (atypical T‐cell lymphoproliferative disorder). The patient developed deep vein thrombosis, heparin‐induced thrombocytopenia and bleeding from duodenal ulcer. By the time the reports of all the investigations were ready, the patient succumbed to bronchopneumonia. To the best of our knowledge, this T‐CLL/T‐PLL which was diagnosed initially by FNA cytology with immunocytochemical support is first of its kind to be reported. Diagn. Cytopathol. 2013;41:360–365. © 2011 Wiley Periodicals, Inc.     

Survival akin to injury, hospitalized patients with acute kidney injury based on the AKIN classification

Introduction: Acute kidney injury (AKI) is often associated with severe consequences. The aim of the study was to determine whether the acute kidney injury network classification predicts hospital stay, renal recovery and mortality. Methods: Hospitalized patients who were referred to the nephrology service over 6 months were studied retrospective with further 12 months prospective follow up. Statistical analysis was performed on their demography and outcome. Results: Among the 238 patients who were referred, 166 had AKI, median age 74 years and 32% were diabetics. 10% (n = 17) required acute renal replacement therapy. The overall all-cause mortality of AKI group (n = 166) compared to non-AKI group (n = 72) at 1 year was 55% as opposed to 27.8% (p < 0.001). There was a significant statistical difference in the composite outcome and survival between the AKI stages in terms of renal recovery (p = 0.018). The AKI group had a median 8 day increase in length of stay compared to the non-AKI group (20 vs. 12 days; p = 0.0175). However, there was no significant statistical difference between pre and post admission AKI (p value = 0.191). Conclusion: The AKIN staging of AKI predicts both early and late mortality. AKI has a major impact on inpatient and 1-year-survival, renal recovery and length of stay. AKI and renal recovery following the insult were independent prognosticators. Early identification and management of AKI cases can help to prevent progression of the severity of AKI and therefore, mandates timely referral to nephrology team to prevent progression of AKIN class and its consequences.