Intralenticular changes in eyes with mature senile cataract on modified posterior segment optical coherence tomography

Purpose:To study the morphological changes within mature senile cataracts on modified posterior segment optical coherence tomography (OCT).Methods:A cross-sectional observational study recruiting patients of mature cataracts admitted for elective cataract surgery in tertiary eye care. A modified OCT imaging of the lens was done and lenticular findings were noted by a single observer. Corresponding slit-lamp biomicroscopic findings and intraoperative experiences were also noted by a second observer and respective surgeons.Results:Forty-four eyes of 44 patients were included. The mean age of patients was 65 ± 5.7 years. The intralenticular findings were uniform in groups of eyes, and they were characterized into three stages. First was a stage of early lamellar separation where small intralenticular clefts were noted superficially. Second was the stage of established lamellar separation where crescentic fluid clefts appeared interspersed between the lens fibers, and the depth increased as a function of severity. Both these stages did not show any distinct slit-lamp or intraoperative findings. A third stage of liquefaction identified as extensive lamellar separation with subcapsular fluid pockets. This was also reflected in slit-lamp biomicroscopy, showing the hydrated cortex with intraoperative challenges. Two cases showed peculiar changes, one of a hyperreflective subcapsular sheath and another of superficial nuclear lamellar separation.Conclusion:Mature cataracts may also show graded progression, which could be delineated on lenticular OCT. This could be of immense help in pre-operative planning and optimal management of these high-risk cases.     

Surgical Resection for Hepatoblastoma—Updated Survival Outcomes

Background

Hepatoblastoma is the most common liver malignancy in the pediatric age group. The management of hepatoblastoma involves multidisciplinary approach.

Methods

Patients with hepatoblastoma who underwent liver resection between 2000 and 2013 were analyzed and survival outcomes were studied.

Results

The crude incidence rate of hepatoblastoma at the Madras Metropolitan Tumor Registry (MMTR) is 0.4/1,00,000 population per year. Twelve patients underwent liver resection for hepatoblastoma during the study period; this included eight males and four females. The median age at presentation was 1.75 years (Range 5 months to 3 years). The median serum AFP in the study population was 20,000 ng/ml (Range 4.5 to 1,40,000 ng/ml). Three patients had stage I, one patient had stage II, and eight patients had stage III disease as per the PRETEXT staging system. Two patients were categorized as high risk and ten patients were categorized as standard risk. Seven of these patients received two to four cycles of neoadjuvant chemotherapy (PLADO regimen), and one patient received neoadjuvant radiation up to 84 Gy. Major liver resection was performed in nine patients. Nine patients received adjuvant chemotherapy. The most common histological subtype was embryonal type. Microscopic margin was positive in three cases. One patient recurred 7 months after surgery and the site of failure was the lung. The 5-year overall survival of the case series was 91%. The median survival was 120 months.

Conclusion

Liver resections can be safely performed in pediatric populations after neoadjuvant treatment. Patients undergoing surgery had good disease control and long-term survival.

     

A single institution series of cavernomas of the brainstem

We retrospectively analyzed a series of patients with brainstem cavernomas of the medulla, pons, or midbrain to attempt to define the natural history, indications for surgery, and outcome after surgical resection. Between 1993 and 2008, 52 patients with cavernomas of the brainstem presented to our institute and were managed either surgically or conservatively. Twenty-three patients underwent surgical excision using standard skull base approaches. Outcomes were correlated to the number of preoperative hemorrhages, location of the cavernoma, timing of surgery in relation to the hemorrhage and the preoperative neurological status. Nine patients improved after surgery, 12 deteriorated and two died. In the conservatively managed group, 15 patients had a good outcome, 11 deteriorated and one died. Multiple hemorrhages, poor preoperative neurological status and surgery during the acute phase were predictive of the surgical outcome. Excision of brainstem cavernomas should be considered in patients with symptomatic hemorrhages whose lesions approach the pial surface. Patients with minimal stable neurologic deficits without recurrent bleeds should be managed conservatively.     

Meningiomas in children and adolescents: a meta-analysis of individual patient data

Background

The epidemiological, prognostic, and therapeutic features of child and adolescent meningioma are poorly defined. Clinical knowledge has been drawn from small case series and extrapolation from adult studies. This study was done to pool and analyse the clinical evidence on child and adolescent meningioma.

Methods

Searches of PubMed, Medline, and Embase identified 35 case series of child and adolescent meningioma completed over the past 21 years. Individual patient data were obtained from 30 studies via direct communication with investigators. Primary outcomes were relapse-free survival (RFS) and overall survival. Prognostic variables were extent of initial surgery, use of upfront radiotherapy, age, sex, presence of neurofibromatosis, tumour location, and tumour grade. RFS and overall survival were analysed using Kaplan-Meier survival curves and multivariable Cox regression models.

Findings

From a total of 677 children and adolescents with meningioma, 518 were eligible for RFS analysis and 547 for overall survival analysis. Multivariable analysis showed that patients who underwent initial gross-total resection had better RFS (hazard ratio 0·16, 95% CI 0·10–0·25; p<0·0001) and overall survival (0·21, 0·11–0·39; p<0·0001) than those who had subtotal resection. No significant benefit was seen for upfront radiotherapy in terms of RFS (0·59, 0·30–1·16; p=0·128) or overall survival (1·10, 0·53–2·28; p=0·791). Patients with neurofibromatosis type 2 (NF2) had worse RFS than those without neurofibromatosis (2·36, 1·23–4·51; p=0·010). There was a significant change in overall survival with time between patients with NF2 compared with those without neurofibromatosis (1·45, 1·09–1·92; p=0·011); although overall survival was initially better for patients with NF2 than for those without neurofibromatosis, overall survival at 10 years was worse for patients with NF2. Patients with WHO grade III tumours had worse RFS than those with WHO grade I (3·90, 2·10–7·26; p<0·0001) and grade II tumours (2·49, 1·11–5·56; p=0·027).

Interpretation

Extent of initial surgical resection is the strongest independent prognostic factor for child and adolescent meningioma. No benefit for upfront radiotherapy was noted. Hence, aggressive surgical management, to achieve gross-total resection, is the initial treatment of choice. In the event of a subtotal resection, repeat resection is recommended to achieve maximum extirpation. Close observation is warranted for patients who have a subtotal resection or who have WHO grade III tumours. Patients without neurofibromatosis should have a minimum 10-year follow-up, whereas patients with NF2 should be considered a special risk category, necessitating life-long follow-up.

Funding

None.     

Myeloid and plasmacytoid dendritic cells transfer HIV-1 preferentially to antigen-specific CD4+ T cells

Dendritic cells (DCs) are essential antigen-presenting cells for the induction of T cell immunity against pathogens such as human immunodeficiency virus (HIV)-1. At the same time, HIV-1 replication is strongly enhanced in DC-T cell clusters, potentially undermining this process. We found that immature CD123(+) plasmacytoid DCs (PDCs) and CD11c(+) myeloid DCs (MDCs) were susceptible to both a CCR5- and a CXCR4-using HIV-1 isolate in vitro and were able to efficiently transfer that infection to autologous CD4(+) T cells. Soon after HIV-1 exposure, both PDCs and MDCs were able to transfer the virus to T cells in the absence of a productive infection. However, once a productive infection was established in the DCs, newly synthesized virus was predominantly spread to T cells. HIV-1 exposure of the MDCs and PDCs did not inhibit their ability to present cytomegalovirus (CMV) antigens and activate CMV-specific memory T cells. As a result, both PDCs and MDCs preferentially transmitted HIV-1 to the responding CMV antigen-specific CD4(+) T cells rather than to nonresponding T cells. This suggests that the induction of antigen-specific T cell responses by DCs, a process crucial to immune defense, can lead to preferential HIV-1 infection and the deletion of responding CD4(+) T cells.     

Signet ring cell histology and non-circumferential tumors predict pathological complete response following neoadjuvant chemoradiation in rectal cancers

Purpose  

Neoadjuvant chemoradiation followed by surgery is now the standard of care for patients with locally advanced rectal cancers. The aim of this study was to determine the rate of pathological complete response (pCR) following neoadjuvant treatment in patients with rectal cancers and identify the factors predicting the same.