Multiple primary cancer: an increasing health problem. Strategies for prevention in cancer survivors

This study was set to look for associations between the sites of the first and subsequent tumours in patients with multiple primary cancer (MPC) diagnosed from 1975 to 2002 in the reference hospital of a Spanish northern region, and propose prevention strategies. Patient and tumour variables were measured. Crude and standardized incidence rates per 100 000 inhabitants were obtained, and the association between MPC incidence and time was analysed by means of lineal regression. Relative risks were calculated to analyse associations between tumour sites. A total of 2737 MPC cases were registered (male/female ratio = 2). The percentage of MPC with respect to the total cancer increased from 1.78% in the 1975–1979 period to 7.08% in the 2000–2002 period ( R ² = 0.92; P  = 0.003). Great increase of incidence by time was found ( R ² = 0.90; P  = 0.004). Breast, prostate and bladder cancers increase risk of second tumour in female genital organs [RR 4.78 (3.84–5.93)], urinary system [RR 3.69 (2.89–4.69)] and male genital organs [RR 3.76 (2.84–4.69)] respectively. The MPC incidence is increasing. Interventions for MPC prevention, according to the European Code against Cancer, should be implemented early after the first cancer principally if patients suffer breast, bladder, prostate, larynx and colon cancers.     

Adult Onset of Xanthelasmoid Mastocytosis: Report of a Rare Entity

Xanthelasmoid or pseudoxanthomatous mastocytosis is an extremely rare variant of diffuse cutaneous mastocytosis. Herein, we describe an adult male with cutaneous mastocytosis showing multiple widespread yellowish ovoid papules like eruptive xanthoma. A 60-year-old male visited our outpatient clinic with a 1-year history of generalized yellowish, ovoid, and skin color papular eruption located on the trunk, groin, extremities, with the modest pruritus. Vital signs were stable, and Darier''s sign was negative. No other subjective and objective signs were detected during the examination. No abnormality was detected in his diagnostic laboratory tests. Skin biopsy was taken, and histopathologic examination revealed proliferation of mast cells with ovoid and spindle nuclei with distinct cytoplasm borders around the capillaries, which was compatible with mastocytosis. Antihistamine was prescribed for pruritus control which was successful, but eruptions were persistent, and even 1-year phototherapy was not useful.     

Effects of voice therapy as objectively evaluated by digitized laryngeal stroboscopic imaging

Objective measurements derived from digitized laryngeal stroboscopic images were used to demonstrate changes in vocal fold vibration and in the size of benign lesions after 3 months of voice therapy. Forty chronically dysphonic patients were studied. By means of a rigid stroboscope, pretreatment and posttreatment recordings were made of the vocal folds at rest and under stroboscopic light during phonation. From each recording, images of the positions at rest and during vibration at maximal opening and at maximal closure were digitized. The surface areas of any lesions and of the glottal gap were independently measured in the digitized images by 2 experienced laryngologists. Referential distances were determined in order to compensate for discrepancies in magnification in the various recordings. After 3 months of voice therapy, significant improvement in lesion size and degree of maximal closure during vibration could be demonstrated in about 50% of the patients. The degree of maximal opening did not prove to be a significant parameter.     

Analyzing data from ordered categories

Clinical investigations often involve data in the form of ordered categories--e.g., "worse," "unchanged," "improved," "much improved." Comparison of two groups when the data are of this kind should not be done by the chi-square test, which wastes information and is insensitive in this context. The Wilcoxon-Mann-Whitney test provides a proper analysis. Alternatively, scores may be assigned to the categories in order, and the t-test applied. We demonstrate both approaches here. Sometimes data in ordered categories are reduced to a two-by-two table by the collapsing of the high categories into one category and the low categories into another. This practice is inefficient; moreover, it entails avoidable subjectivity in the choice of the cutting point that defines the two super-categories. The Wilcoxon-Mann-Whitney procedure (or the t-test with use of ordered scores) is preferable. A survey of research articles in Volume 306 of the New England Journal of Medicine shows many instances of ordered-category data (about 20 per cent of the articles had such data) and no instance of analysis by the preferred methods presented here. We suggest that investigators who are unfamiliar with these methods should seek the assistance of a professional statistician when they must deal with such data.     

Outcome of Kaposi's sarcoma and graft following discontinuation of immunosuppressive drugs in renal transplant recipients

PURPOSE: Owing to the use of immunosuppressive drugs, renal transplant recipients are at risk for malignancies including Kaposi's sarcoma (KS). Following the diagnosis, physicians tend to decrease the doses of immunosuppressive drugs to lower tumor progression rate. On the other hand, those who receive lower doses of immunosuppressive drugs are at a higher risk for acute rejection. In this study, we evaluated the outcome of KS on renal allografts following discontinuation or decrease in the doses of drugs. METHODS: Since 1984, 14 (nine men and five women) among 2000 cases of renal transplantation have been diagnosed as KS. In 11 patients, cyclosporine was completely discontinued, the dosage was decreased to half of the initial dose in other cases. Except one case, we discontinued either azathioprine or mycophenolate mofetil. RESULTS: During 57 months of follow-up on average, the serum creatinine level remained normal in 10 but increased in four cases. Kidney function deteriorated in two of these four patients at the beginning of study. Three patients died with normal serum creatinine levels. Discontinuation of immunosuppressive drugs caused complete remission of KS in all patients except one who received chemotherapy. CONCLUSION: Discontinuation of immunosuppressants following the diagnosis of KS caused complete remission of this cancer in almost all patients and seemed to be relatively safe for kidney graft function.     

Hydrocephalus and racemose cysticercosis: surgical alternative by endoscopic third ventriculostomy

BACKGROUND AND PURPOSE: Hydrocephalus is a frequent and potentially serious complication of neurocysticercosis. Its treatment often requires ventricular shunting. The complication rate is high due to obstruction or material infection, which may justify endoscopic third ventriculostomy (ETV). OBSERVATION: We report a case of obstructive hydrocephalus in a 46-year-old man in the context of racemose cysticercosis, presenting with headaches and transient disorders of consciousness. Imaging showed cystic lesions of the cisterna magna, responsible for hydrocephalus which was treated effectively by ETV. Treatment with albendazole decreased the volume of the cisterna magna cysts. RESULTS: The patient was followed for 6 years after ETV with no recurrence of hydrocephalus despite two more symptomatic episodes of the disease with extension of the cysts into the lumen of the fourth ventricle and into the perispinal subarachnoid spaces, effectively treated by albendazole each time. CONCLUSIONS: Treatment of obstructive hydrocephalus secondary to cerebral racemose cysticercosis by ETV seems to be an effective and safety technique. The role of ETV should be evaluated in this indication.     

Evolution of tuberculosis control and prospects for reducing tuberculosis incidence, prevalence, and deaths globally

Christopher Dye, DPhil; Catherine J. Watt, DPhil; Daniel M. Bleed, MD; S. Mehran Hosseini, MD; Mario C. Raviglione, MD

JAMA. 2005;293:2767-2775.

Context  The United Nations Millennium Development Goals (MDGs) are stimulating more rigorous evaluations of the impact of DOTS (the WHO-recommended approach to tuberculosis control based on 5 essential elements) and other possible strategies for tuberculosis (TB) control.

Objective  To evaluate the prospects for detecting 70% of new sputum smear–positive cases and successfully treating 85% of these by the end of 2005, for reducing TB incidence, and for halving TB prevalence and deaths globally between 1990 and 2015, as specified by the MDGs.

Data Sources  TB case notifications (1980-2003) from DOTS and non-DOTS programs and cohort treatment outcomes (1994-2002) reported annually to the World Health Organization (WHO) by up to 200 countries, TB death registrations, and prevalence surveys of infection and disease.

Study Selection  Case notification series that reflect trends in incidence, treatment outcomes from DOTS cohorts, death statistics from countries with WHO-validated vital registration systems, and national prevalence surveys of infection and disease.

Data Extraction  Case reports, treatment outcomes, prevalence surveys, and death registrations from WHO's global TB database covering 1990-2003 to estimate TB incidence, prevalence, and death rates through 2015 for 9 epidemiologically different world regions.

Data Synthesis  TB incidence increased globally in 2003, but incidence, prevalence, and death rates were approximately stable or decreased in 7 of 9 regions. The exceptions were regions of Africa with low (<4% in adults 15-49 years) and high rates (4%) of HIV infection. The global detection rate of new smear-positive cases by DOTS programs increased from 11% in 1995 to 45% in 2003 (with the lowest case-detection rates in Eastern Europe and the highest rates in the Western Pacific) and could reach 60% by 2005. More than 17 million patients were treated in DOTS programs between 1994 and 2003, with overall treatment success rates more than 80% since 1998. In 2003, overall reported treatment success was 82%, with much variation among regions. The highest rates were reported in the Western Pacific region (89%) and lowest rates in African countries with high and low HIV infection rates (71% and 74%, respectively), in established market economies (77%), and in Eastern Europe (75%). To halve the prevalence rate by 2015, TB control programs must reach global targets for detection (70%) and treatment success (85%) and also reduce the incidence rate by at least 2% annually. To halve the death rate, incidence must decrease more steeply, by at least 5% to 6% annually.

Conclusion  Reduction of TB incidence, prevalence, and deaths by 2015 could be achieved in most of the world, but the challenge will be greatest in Africa and Eastern Europe.

     

Eine vereinfachte Methode zur Therapie der Quadrizepssehnenruptur mittels transpatellarer PDS-Kordel

Quadriceps tendon ruptures are relatively unusual injuries caused by direct or more frequently indirect trauma. Since complete ruptures lead to loss of active extension of the knee joint, operative treatment is usually indicated. Several techniques are described in the literature. However, relatively little is known about the functional outcome after operative treatment of acute quadriceps tendon ruptures. We present a new operative technique using a 1.3-mm PDS cord passed through a transverse drill hole in the proximal pole of the patella. We operated ten consecutive cases of complete quadriceps tendon ruptures with the technique described between January 2000 and June 2003. Eight of ten patients were evaluated after a mean follow-up time of 38 months by physical examination, IKDC Subjective score, Lysholm and Tegner score as well as an isokinetic test of the quadriceps strength. No complications were noted in this period. The average postoperative scores were 87 (IKDC), 98 (Lysholm), and 4.5 (Tegner). Isokinetic testing showed an average of 25% quadriceps strength deficit. The operative treatment of complete quadriceps tendon ruptures using a PDS cord through a drill hole in the patella is a safe and effective technique permitting functional postoperative treatment.