Hypofractionated radiotherapy for T1N0M0 glottic cancer: retrospective analysis of two different cohorts of dose-fractionation schedules from a single institution

AIMS

To determine the influence of dose and fractionation on tumour characteristics, toxicity, disease control and survival outcomes in T1 glottic carcinoma.

MATERIALS AND METHODS

Between 1975 and 2000, treatment charts of 652 patients with T1 glottic carcinoma who received curative radiation with four hypofractionated schedules (50 Gy/15 fractions [3.3 Gy/fraction] or 55 Gy/16 fractions [3.43 Gy/fraction] or 60 Gy/24 fractions or 62.5 Gy/25 fractions [2.5 Gy/fraction]) were analysed. The patients were divided into two groups based on fraction size <3 Gy and >3 Gy. Local control and overall survival were calculated. Patient- and tumour-related factors affecting local control were analysed using univariate and multivariate analysis. Factors affecting late toxicity were also analysed.

RESULTS

The local control and overall survival at 10 years were 84 and 86.1%, respectively, for T1 glottic carcinoma. The response to radiation had a significant effect on local control with univariate analysis (P = 0.001). Other factors, such as beam energy, anterior commissure involvement and fractionation, did not affect local control. Persistent radiation oedema was seen in 123 patients (23.4%) and was significantly worse in patients who received radiation with a larger field size (>36 cm(2)) on a telecobalt machine (P < 0.001).

CONCLUSIONS

Radical radiotherapy schedules incorporating a higher dose per fraction yield acceptable local control rates and late toxicity. Telecobalt therapy for early glottic cancer is a safe alternative to treatment with 6 MV photons on a linear accelerator in terms of local control and late toxicity as long as field sizes smaller than 36 cm(2) are used.

Oral health status of a group of illicit drug users in Delhi, India

OBJECTIVES

To assess the oral health and related practices of a group of illicit drug users in Delhi, India; to compare with that of non-drug users; and to assess the impact of illicit drug use on oral health.

DESIGN

Cross-sectional study. Comparison was made with non-drug users to investigate any differences in oral health between illicit drug users and general population.

SETTING AND PARTICIPANTS

Illicit drug users attending a drug dependence treatment clinic in Delhi (n=126). Equal number of non-drug users attending other outpatient departments in the same setting.

OUTCOME MEASURES

Oral health practices assessed using structured questionnaire; dental caries, periodontal status and oral mucosa assessed using World Health Organization 2004 criteria; oral hygiene assessed using OHI-S.

RESULTS

Mean DMFT and OHI-S scores amongst the drug users were 3.48 and 3.80, respectively. Bleeding, shallow pockets and deep pockets were found as the highest CPI finding in 42%, 44% and 12% of drug users respectively. Premalignant states of leukoplakia and OSMF were diagnosed in 13% and 4% of drug users respectively. Significant differences were found between drug users and non-drug users with respect to oral hygiene practices; DMFT, OHI-S, CPI scores; and leukoplakia. In multivariate analysis, illicit drug use was significantly associated with CPI highest score (OR = 2.21, 95% CI 1.08-4.52).

CONCLUSION

The illicit drug users had significantly poorer oral hygiene practices, oral hygiene and periodontal health; higher caries experience; and higher prevalence of leukoplakia as compared to non-drug users. The findings of the study suggest that illicit drug use is independently associated with poor periodontal health.

Discoid lupus erythematosus of the periorbita: clinical dilemmas, diagnostic delays

PURPOSE

Untreated periocular discoid lupus erythematosus (DLE), though very rare, may lead to significant morbidity with lid deformities, trichiasis, and symblepharon formation. We present the largest reported cohort of patients with biopsy-proven DLE solely affecting the periorbital region.

METHODS

Observational case series of patients managed over a 7-year period (2004-10).

RESULTS

Seven patients (one male) presented to the Adnexal Service at Moorfields Eye Hospital at a median age of 47 years (range 23-71 years); median interval from symptom onset to biopsy-proven diagnosis was 38 months (range 6-86 months). Changes in peripheral skin were present in 1 patient (occurring after the initial eyelid presentation) and the presenting periocular features were dissimilar across the group, these included: chronic blepharo-conjunctivitis, madarosis, atypical chalazia, depigmentation of the eyelid margin, or marked, persistent periocular oedema with dacryoadenitis.Two cases settled spontaneously, but five required systemic hydroxychloroquine or intralesional corticosteroid injections.

CONCLUSION

Periorbital DLE is rare and very varied in its presentation, the protean manifestations often resulting in significant diagnostic delay. All patients with unusual periocular skin disease and those with a refractory inflammatory dermopathy, should undergo biopsy of involved tissue(s), thus leading to earlier diagnosis and prevention of permanent cicatricial periocular changes.

Assessment of compliance to treatment and efficacy of a resource-sparing hypofractionated radiotherapy regimen in patients with poor-prognosis high-grade gliomas

INTRODUCTION

The optimal radiotherapeutic management of poor-prognosis (elderly and/or poor performance status) high-grade gliomas (HGG) remains controversial. Hypofractionated radiotherapy (hypoRT) has been shown to be non-inferior to daily conventionally fractionated radiotherapy. This study aimed to assess the compliance to treatment and efficacy of a resource-sparing hypoRT regimen in this subset.

MATERIALS AND METHODS

The resource-sparing hypoRT regimen was delivered once weekly (5Gy/fraction) for seven fractions to a total dose of 35Gy in seven fractions over six weeks. Compliance to planned treatment and factors that could potentially influence it were analyzed.

RESULTS

Between January 2004 and October 2009, 63 patients with poor-prognosis HGG (age range 40-78 years; Karnofsky performance score ≤70) were offered resource-sparing hypoRT regimen. Twenty eight of 63 patients completed planned course of treatment giving a treatment compliance rate of 44%. Six (9.5%) patients did not receive even a single fraction of radiation after simulation/planning. Thirty eight patients (60%) received ≥3 fractions and were on treatment for at least two weeks. Performance status (P = 0.05) and grade (P = 0.04) significantly impacted upon compliance. Median overall survival for the cohort of 28 patients who completed planned course of treatment was 7.4 months (95% confidence interval: 4.4-10.5 months).

CONCLUSIONS

The treatment compliance to a resource-sparing once-weekly hypoRT regimen in poor-prognosis HGG has been somewhat suboptimal and discouraging, possibly due to the protracted scheduling over six weeks. Over 60% of patients were on treatment for two weeks, suggesting that short-course schedules could more likely ensure compliance.

Brain-sparing holo-cranial radiotherapy: a unique application of helical tomotherapy

AIMS

Diffuse and extensive involvement of the scalp/skull by malignancy mandates holo-cranial radiotherapy with the aim to deliver homogeneous doses to the planning target volume (PTV) while minimising the dose to surrounding organs at risk (OARs). Previously described techniques result in significant heterogeneity, suboptimal coverage or poor conformity and need complicated beam matching. Here we report our preliminary experience of planning and delivery of brain-sparing holo-cranial radiotherapy with helical tomotherapy.

MATERIALS AND METHODS

Three patients with extensive involvement of the scalp/skull by malignancy were planned and treated with image-guided intensity-modulated radiation therapy on helical tomotherapy. The plan evaluation was carried out using standardised dose metrics.

RESULTS

Helical tomotherapy achieved highly conformal and homogeneous dose distributions with substantial OAR sparing in all three patients. The volume of PTV receiving ≥95% of prescribed dose (V(95%)) was ≥98% in all three patients. The mean (standard deviation) homogeneity index and conformity index was 0.046 (0.006) and 0.783 (0.035), respectively. The mean dose to the brain parenchyma outside the PTV was 17.32 Gy (74%), 28.76 Gy (63.9%) and 26.7 Gy (59.3%) for the three patients. The mean (standard deviation) monitor units and beam-on time was 6939 (985) and 8.10 (1.137) min, respectively. Overall the treatment was very well tolerated with no significant acute toxicity. Early follow-up evaluation revealed a good clinicoradiological response and the absence of local disease progression with no significant sequelae, implying successful application of the treatment paradigm.

CONCLUSION

Helical tomotherapy is ideally suited for brain-sparing holo-cranial radiotherapy with its exceptional ability of tangential beam delivery resulting in highly conformal and homogenous dose distribution across large, complex target volumes with substantial OAR sparing.

PET/CT-guided radiation therapy planning: from present to the future

Molecular imaging using 18F-fluoro-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) has been successfully used in the diagnosis, initial staging, and response assessment of various malignant tumors. Advances in radiation therapy planning and delivery have ushered in the era of high-precision conformal radiotherapy allowing generation of dose distributions that conform closely to the shape of the target volume while minimizing high-dose regions in the surrounding normal tissues. Traditionally, radiation therapy planning has relied heavily on CT imaging, but recent times have witnessed tremendous enthusiasm for the use of PET/CT-guidance in radiotherapy planning. This has been largely stimulated by widespread availability and integration with treatment planning systems. However, several issues need to be addressed and challenges overcome to realize the full potential of this exciting technology. Integrating PET/CT fusion imaging into routine clinical practice can be challenging due to technical, administrative, financial, geographic, and personnel issues. Concerted efforts are urgently needed for the development of guidelines for appropriate application of this technology using standardized methodology. There is accumulating evidence that incorporating PET/CT imaging in radiotherapy planning for lung cancer, head and neck cancer and cervical cancer has a significant impact. This review highlights the promises and pitfalls of PET/CT imaging in radiotherapy treatment planning with a critical appraisal of the current best evidence for its application in the modern radiotherapy clinic, and provides a sneak preview into the future of such technology.

Patterns of neural activity associated with differential acute locomotor stimulation to cocaine and methamphetamine in adolescent versus adult male C57BL/6J mice

Adolescence is a time period when major changes occur in the brain with long-term consequences for behavior. One ramification is altered responses to drugs of abuse, but the specific brain mechanisms and implications for mental health are poorly understood. Here, we used a mouse model in which adolescents display dramatically reduced sensitivity to the acute locomotor stimulating effects of cocaine and methamphetamine. The goal was to identify key brain regions or circuits involved in the differential behavior. Male adolescent (postnatal day (PN), 30-35) and young adult (PN, 69-74) C57BL/6J mice were administered an i.p. injection of cocaine (0, 15, 30 mg/kg) or methamphetamine (0, 2, 4 mg/kg) and euthanized 90 min later. Locomotor activity was monitored continuously in the home cage by video tracking. Immunohistochemical detection of Fos protein was used to quantify neuronal activation in 16 different brain regions. As expected, adolescents were less sensitive to the locomotor stimulating effects of cocaine and methamphetamine as indicated by a rightward shift in the dose response relationship. After a saline injection, adolescents showed similar levels of Fos as adults in all regions except the dorsal caudate (CPuD) and lateral caudate (CPuL) where levels were lower in adolescents. Cocaine and methamphetamine dose dependently increased Fos in all brain regions sampled in both adolescents and adults, but Fos levels were similar in both age groups for a majority of regions and doses. Locomotor activity was correlated with Fos in several brain areas within adolescent and adult groups, and adolescents had a significantly greater induction of Fos for a given amount of locomotor activity in key brain regions including the caudate where they showed reduced Fos under baseline conditions. Future research will identify the molecular and cellular events that are responsible for the differential psychostimulant-induced patterns of brain activation and behavior observed in adolescent versus adult mice.

Analysis of microarchitectural changes in a mouse temporomandibular joint osteoarthritis model

OBJECTIVE

Little is known about the natural progression of the disease process of temporomandibular joint (TMJ) osteoarthritis (OA), which affects approximately 1% of the US population. The goal of this study was to examine the early microarchitectural and molecular changes in the condylar cartilage and subchondral bone in biglycan/fibromodulin (Bgn/Fmod) double-deficient mice, which develop TMJ-OA at 6 months.

METHODS

TMJs from 3-month-old (n=44) and 9-month-old (n=52) wild-type (WT n=46) and Bgn/Fmod (n=50) double-deficient mice were evaluated. Micro-CT analysis of the subchondral bone (n=24), transmission electron microscopy for condylar cartilage fibril diameters (n=26), and real-time PCR analysis for gene expression for bone and cartilage maturation markers (n=45) was performed.

RESULTS

A statistically significant increase in collagen fibril diameter of the condylar cartilage and a decrease in expression of Parathyroid related protein in the mandibular condylar head were observed in the 3-month Bgn/Fmod double-deficient mice compared to WT controls. The 9-month Bgn/Fmod double-deficient mouse demonstrated an increase in bone volume and total volume in subchondral bone, and an increase in the expression of Collagen Type X and Aggrecan in the mandibular condylar head compared to the WT controls.

CONCLUSION

We found that changes in the microarchitecture of the condylar cartilage preceded changes in the subchondral bone during OA in the TMJ in Bgn/Fmod double-deficient mice.

High-precision radiotherapy for craniospinal irradiation: evaluation of three-dimensional conformal radiotherapy, intensity-modulated radiation therapy and helical TomoTherapy

This study aimed to establish the feasibility of intensity-modulated radiation therapy (IMRT) in craniospinal irradiation (CSI) using conventional linear accelerator (IMRT_LA) and compare it dosimetrically with helical TomoTherapy (IMRT_Tomo) and three-dimensional conformal radiotherapy (3DCRT). CT datasets of four previously treated patients with medulloblastoma were used to generate 3DCRT, IMRT_LA and IMRT_Tomo plans. A CSI dose of 35 Gy was prescribed to the planning target volume (PTV). IMRT_LA plans for tall patients were generated using an intensity feathering technique. All plans were compared dosimetrically using standardised parameters. The mean volume of each PTV receiving at least 95% of the prescribed dose (V(95%)) was >98% for all plans. All plans resulted in a comparable dose homogeneity index (DHI) for PTV_brain. For PTV_spine, IMRT_Tomo achieved the highest mean DHI of 0.96, compared with 0.91 for IMRT_LA and 0.84 for 3DCRT. The best dose conformity index was achieved by IMRT_Tomo for PTV_brain (0.96) and IMRT_LA for PTV_spine (0.83). The IMRT_Tomo plan was superior in terms of reduction of the maximum, mean and integral doses to almost all organs at risk (OARs). It also reduced the volume of each OAR irradiated to various dose levels, except for the lowest dose volume. The beam-on time was significantly longer in IMRT_Tomo. In conclusion, IMRT_Tomo for CSI is technically easier and potentially dosimetrically favourable compared with IMRT_LA and 3DCRT. IMRT for CSI can also be realised on a conventional linear accelerator even for spinal lengths exceeding maximum allowable field sizes. The longer beam-on time in IMRT_Tomo raises concerns about intrafraction motion and whole-body integral doses.

Five-year survival data in newly diagnosed glioblastoma treated with radiotherapy along with concurrent and adjuvant temozolomide

e13009

Background: We report 5-year survival data in patients with newly diagnosed glioblastoma treated with radiotherapy along with concurrent and adjuvant temozolomide (TMZ). Methods: Between March 2001 to April 2008, 81 patients with newly diagnosed histopathologically proven glioblastoma underwent surgery followed by external radiotherapy to a total dose of 60 Gy in 30 fractions over 6 weeks. Concurrent oral TMZ (75 mg/m2) was given daily with RT followed by adjuvant TMZ for 5 days every 28 days for six cycles (150 mg/m2 for the first cycle and 200 mg/m2 for rest of the cycles). Patients were monitored clinicoradiologically as per standard practice. Results: Patients aged between 11–73 years with a median age of 49 years (60 males, 21 females). Forty per cent of patients underwent a gross total resection of tumour, 44% had partial resection, and 16% an open or stereotactic biopsy only. 79% of the patients had a post-operative Karnofsky Performance Score (KPS) of >80. All six adjuvant cycles were completed in 68%. The 2-, 3-, 4-, and 5-year survival was 34%, 24%, 11%, and 11%, respectively (95% CI 14.03–21.96). The median overall and progression-free survival was 18 (2–92 months) and 16 months (2–72 months), respectively. On multivariate analysis, completion of all six cycles of adjuvant TMZ was associated with significantly better survival (p = 0.000). Neurological performance score (NPS) of 2–3 (p = 0.06) and Recursive Partitioning Analysis class V (p = 0.093) showed a trend towards poorer outcome. Treatment was generally well tolerated with only 2.5% of patients developing grade 3 anemia, leucopoenia, and neutropenia. Grade 3 or 4 thrombocytopenia was seen in 5% patients. Conclusions: Concurrent radiotherapy and TMZ followed by adjuvant TMZ results in encouraging survival even at a long follow-up.

No significant financial relationships to disclose.

Patterns of failures after definitive conformal radiation therapy for head and neck cancers

e17037

Background: The primary objective of the study is to analyze patterns of failure in patients with head and neck cancer treated with definitive conformal radiotherapy with a focus on the location of failures in relation to the target volume coverage. Methods: Sixty patients with squamous cell carcinoma (stage: T1–3, N0–2b) were treated definitively on a prospective protocol with conformal techniques to conventional dose-fractionation equivalent of 70 Gy to the gross disease using standardized contouring guidelines. The recurrent or persistent tumor volume (Vf) was defined using positron imaging tomography (PET) and surgical-pathologic findings, and analyzed using dose-volume histograms. The failure was considered marginal when 20%-95% of Vf was within 95% isodose line. Results: At median follow-up of 12 months (range, 4–30) the 3-year actuarial local control, loco-regional control, disease-free survival, and overall survival Kaplan-Meier estimates were 86.4%, 80.5%, 62.6%, and 46.4% respectively. Of 12 (19.3%) patients with disease related events, 10 have loco-regional failures with a median time of 4 months (range, 0–22). Of 10 patients, 8 had in-field, one had marginal and one had failures of both patterns. Of seven (11.3%) local failure events, two were isolated and one had marginal failure. Of seven regional failure events, two were marginal including one with failure at peri-parotid contra-lateral neck. Another one had bilateral multiple nodal levels with supraclavicular recurrence. The remaining events were in-field were “true failures” with no apparent technical cause, none had out-field failures. Two patients were detected to have distant metastases and two developed second malignancies, one out-field and other marginal with upper esophagus carcinoma at gradient zone of previous radiation. Conclusions: Conformal radiotherapy does not compromise loco-regional control as compared to historical controls treated with conventional techniques. PET scans are useful in delineation of failure volumes. The majority of recurrences were ‘in-field‘ motivate studies of dose escalation to the highest risk regions and marginal failures in the high-dose gradient region highlight the potential hazard of high precision techniques and warrants careful consideration.

No significant financial relationships to disclose.

Planning and delivery of whole brain radiation therapy with simultaneous integrated boost to brain metastases and synchronous limited-field thoracic radiotherapy using helical tomotherapy: a preliminary experience

Lung cancer is the commonest source of brain metastases, which has been traditionally treated with Whole Brain Radiation Therapy (WBRT) with or without focal boost. We herein report our preliminary experience of the planning and delivery of WBRT with Simultaneous Integrated Boost (SIB) to brain metastases along with synchronous limited-field thoracic radiotherapy using Helical TomoTherapy in four patients with lung cancer. All plans were iteratively optimized for maximal target volume coverage and organ-at-risk (OAR) sparing. Standardized dose metrics were used for plan evaluation. All treated regions were imaged with a megavoltage computed tomography (CT) prior to treatment and co-registered with planning CT for image-guidance. Helical TomoTherapy was able to achieve highly conformal and homogeneous dose distributions with excellent OAR sparing both in the brain and the chest. The mean (standard deviation) Dose Homogeneity Index (DHI) and Conformity Index (CI) was 0.06 (0.01) & 0.79 (0.07); 0.04 (0.02) & 0.57 (0.22); and 0.03 (0.02) & 0.77 (0.06) for whole brain, brain metastases, and chest, respectively. The mean monitor units (MU) per fraction and time taken for delivery were 8595 and 9898 MU and 9.8 and 11.3 minutes for the brain and chest plans, respectively. Although the dosimetric equivalence of SIB to a single fraction radiosurgery might still be questionable, our preliminary experience of WBRT with SIB to individual brain metastases using Helical TomoTherapy has been encouraging. In addition, it allows synchronous irradiation of other involved primary or metastatic sites for palliative effect.

Altered functional loading causes differential effects in the subchondral bone and condylar cartilage in the temporomandibular joint from young mice

OBJECTIVE

Altered loading is an important etiological factor for temporomandibular joint (TMJ) disorders. Studies examining altered loading of the TMJ have been done in rats but the response of the TMJ to altered loading in mice is largely unknown. Therefore, due to the potential usefulness of genetically engineered mice, the goal of this study was to develop a mouse TMJ altered functional loading model.

METHODS

One hundred and thirty four, 21-day-old CD-1 female mice were divided into two groups: (1) normal loading (hard pellet diet) for 2-6 weeks and (2) altered functional loading (incisor trimming every other day and soft dough diet) for 2-6 weeks. The mandibular condylar cartilage was evaluated by histology, the subchondral bone was evaluated by microcomputed tomography (micro-CT) analysis and gene expression was evaluated by real time polymerase chain reaction (PCR) analysis.

RESULTS

Altered functional loading for 2-6 weeks caused significant reduction in the thickness of the condylar cartilage whereas, only at 4 weeks was there a significant decrease in the bone volume fraction and trabecular thickness of the subchondral bone. Gene expression analysis showed that altered functional loading for 4 weeks caused a significant reduction in the expression of SRY-box containing gene 9 (Sox9), Collagen type X (Col X), Indian hedgehog (Ihh), Collagen type II (Col II) and Vascular endothelial growth factor (Vegf) and altered loading for 6 weeks caused a significant decrease in the expression of Sox9, Col II, Vegf and Receptor activator of NF-kappaB ligand (Rankl) compared to the normal loading group.

CONCLUSION

Altered functional TMJ loading in mice for 2-6 weeks leads to a loss of the condylar cartilage and a transient loss in the density of the mandibular condylar subchondral bone.

Normative data of corpus callosal morphology in a North-West Indian population- an autopsy and MRI study

INTRODUCTION

Morphometric measurements of the corpus callosum (CC) are necessary to have normative values for studying sex, age and race related variations.

METHODS

Morphometry of the CC was done in preserved brain specimens and in MRI scans, in adults.The measurements included parameters like length, width, height of the cc, distances between genu and fornix, genu and anterior commissure, splenium and superior colliculus, distances from the different parts of the cc to the nearest cortical surfaces.

RESULTS

In the preserved brain group, the length CC was 6.98 cm (males) and 6.86 cm (females) while the corresponding values in the MRI group were 7.57 cm and 7.1 cm. The height CC was 2.15 cm (males) and 1.92 cm (females) in the preserved group, and 3.27 cm (males) and 2.59 cm (females) in the MRI group. The splenial width values were 1.12 cm (males) and 1.01 cm (female) in the preserved brains while the corresponding MRI values were 1.15 cm and 1.17 cm.

CONCLUSIONS

The values of different CC parameters observed were almost similar to the values reported in the other two Indian studies. However, Indian values were found to be more than the Japanese values for length, height and most of the widths of CC. The length and width of CC were found to be less than those of Caucasian population. Generation of this data will help in comparing the CC structure of different sex and ages, to study variations from the normal and may help in surgical planning.

Age and sex related variations in corpus callosal morphology

There is no unanimity in literature on sexual dimorphism or on age related morphophometric changes in the Corpus Callosum (CC). For comprehensive data 44 preserved human brains (22 male and 22 female) and 30 MRI scans from North-west Indian population were studied. Morphometric measurements of the CC and its subregions were taken at the midsagittal level in both the groups and subjected to statistical analysis. The only CC parameters which showed sexual dimorphism were (a) larger CC length in males in the MRI group, (b) the distance between the splenium and superior colliculus was more in males in preserved brains and (c) The distance between the genu and the fornix was more in older males than older females. Age related changes included (a) In males the distance between the genu and the fornix (in both the groups) was more in the older age group while the maximum width of the anterior half of the CC body was more in the younger age group (preserved brains) and (b) In females the height of the CC and the minimum width of the CC were more in the older females (preserved brains). No sexual dimorphism was observed in most of the CC parameters studied, including the splenium. Age related thinning of the anterior half of the CC in males could possibly be related to atrophic brain changes more common in males than females.

Post-operative radiotherapy for Ewing sarcoma: when, how and how much?

Postoperative radiotherapy in Ewing family of tumors has undergone continuous evolution over the last few decades to establish its role in the combined modality management of these tumors. The process of evolution is still far from over. This review analyzes the evidence from major multi-institutional prospective trials as well as large retrospective institutional series in Ewing tumors to determine the current standards and controversies in postoperative radiation. The indications of PORT, radiation dose-fractionation, timing, target volumes and treatment planning, as well as the late effects are reviewed. A summary of evidence based consensus is presented and unresolved aspects are discussed. Pediatr Blood Cancer 2008;51:575-580. (c) 2008 Wiley-Liss, Inc.

IL-1 and iNOS gene expression and NO synthesis in the superior region of meniscal explants are dependent on the magnitude of compressive strains

OBJECTIVE

Partial meniscectomy is known to cause osteoarthritis (OA) of the underlying cartilage as well as alter the load on the remaining meniscus. Removal of 30-60% of the medial meniscus increases compressive strains from a maximum of approximately 10% to almost 20%. The goal of this study is to determine if meniscal cells produce catabolic molecules in response to the altered loading that results from a partial meniscectomy.

METHOD

Relative changes in gene expression of interleukin-1 (IL-1), inducible nitric oxide synthase (iNOS) and subsequent changes in the concentration of nitric oxide (NO) released by meniscal tissue in response to compression were measured. Porcine meniscal explants were dynamically compressed for 2 h at 1 Hz to simulate physiological stimulation at either 10% strain or 0.05 MPa stress. Additional explants were pathologically stimulated to either 0% strain, 20% strain or, 0.1 MPa stress.

RESULTS

iNOS and IL-1 gene expression and NO release into the surrounding media were increased at 20% compressive strain compared to other conditions. Pathological unloading (0% compressive strain) of meniscal explants did not significantly change expression of IL-1 or iNOS genes, but did result in an increased amount of NO released compared to physiological strain of 10%.

CONCLUSION

These data suggest that meniscectomies which reduce the surface area of the meniscus by 30-60% will increase the catabolic activity of the meniscus which may contribute to the progression of OA.

Radiation recall dermatitis with gatifloxacin: a review of literature

Radiation recall dermatitis (RRD) is a hypersensitivity skin reaction at the previously irradiated site after the administration of certain pharmacologic agent, which recovers on stopping the medication. RRD is a well-recognized phenomenon with the use of chemotherapeutic agents; however, only a few cases have been reported with noncytotoxic antibiotics, despite their common use in patients with cancer. We report here a case of RRD with the use of gatifloxacin and describe the time dose factors of radiation exposure, characteristics of skin reactions, management and response and our reasons to label this case as RRD. We also discuss published work regarding proposed mechanisms, histological features, radiation dose threshold and response to rechallange with the RRD-triggering drug. If RRD is to be characterized unequivocally, all the potential areas of confusion must be clarified like radiosensitization, nonhealing of acute reactions and skin-related adverse effects of the RRD-triggering drug. With the same objective, we further discussed radiosensitization and photosensitizing potential of fluoroquinolones. Gatifloxacin, although devoid of photosensitivity reactions, may cause idiosyncratic hypersensitivity reaction to cause RRD and should be considered as a potential cause of RRD. Given the potential severity of the reaction and increasing use of gatifloxacin, it is important to be aware of this phenomenon.

Encouraging experience of concomitant Temozolomide with radiotherapy followed by adjuvant Temozolomide in newly diagnosed glioblastoma multiforme: single institution experience

The purpose of this study was to report our experience with concomitant and adjuvant temozolomide (TMZ) with radiotherapy in patients with newly diagnosed glioblastoma multiforme (GBM). Forty-two newly diagnosed histopathologically proven patients with GBM underwent maximal safe resection followed by external radiotherapy to a total dose of 60 Gy in 30 fractions over 6 weeks along with concomitant oral TMZ (75 mg/m2) daily followed by adjuvant TMZ for 5 days every 28 days for six cycles (150 mg/m2 for the first cycle and 200 mg/m2 for rest of the cycles). Patients were monitored clinicoradiologically as per standard practice. Patients were 13-69 years of age with a median age of 49.5 years (31 males, 11 females). Fifty per cent of patients underwent a gross total resection of tumour, 43% had partial resection, and 7% an open or stereotactic biopsy only. 53% of the patients had a post-operative Karnofsky Performance Score (KPS) of 60-80%. All patients received concomitant radiation and TMZ with 74% of the patients completing six cycles of adjuvant TMZ. At a median follow-up of 12.5 months, the 1- and 2-year survival was 67 and 29%, respectively. The median overall and progression-free survival was 16.4 and 14.9 months respectively. Patients with pretreatment KPS of >80% had significantly better overall survival as compared with those having KPS<or=80% (median survival 22.12 vs. 11.97 months; p=0.026). Treatment was generally well tolerated with 9% of patients developing grade 3 anaemia, 2% grade 3 leucopoenia, and 7% patients grade 3 or 4 thrombocytopenia respectively during the treatment. At last follow-up, among the surviving patients, 30% had a maintained KPS greater than 90%. Concomitant radiotherapy and TMZ followed by adjuvant TMZ prolongs survival in patients with glioblastoma multiforme and is well tolerated in our patient population.

Case report: Second primary small cell carcinoma of the trachea in a breast cancer survivor: a case report and literature review

Small cell carcinoma of the trachea is a rare entity and only a few cases have been described, none as a second malignant neoplasm. This is the first report of a metachronous second primary of the trachea with small cell histology in a breast cancer survivor. A 25-year-old woman was diagnosed initially with an infiltrating ductal carcinoma of the breast, and was treated with modified radical mastectomy followed by adjuvant chemo-radiotherapy. 10 years later, she presented with breathlessness and central airway obstruction. Bronchoscopy revealed an intraluminal lesion in the proximal trachea, which was reported as small cell carcinoma on biopsy. There was no evidence of loco-regional recurrence of the previously treated breast cancer. Whole-body positron emission tomography did not show any distant metastases. As it was a small cell carcinoma, she was treated with concurrent chemo-radiotherapy and remains loco-regionally controlled. Decision-making in such instances should take into account prior treatment and needs to be individualized. There is a need for increased awareness amongst primary care physicians regarding second malignant neoplasms in the long-term follow-up of breast cancer patients treated with radiation and chemotherapeutic agents that have carcinogenic potential.

Comparison of two schedules (previous evening versus same morning) of bowel preparation for colonoscopy

BACKGROUND AND AIMS

Evening preparation for colonoscopy is often unsatisfactory and inconvenient. We performed this study to compare the efficacy of bowel preparation at two different timings: previous evening and same morning and to compare the loss of working hours and sleep between these groups.

PATIENTS AND METHODS

In this prospective, investigator blinded, randomized trial, 201 patients were enrolled from February to June 2005. Patients aged between 18 to 80 years needing colonoscopy were included. Patients with prior bowel surgery, suspected bowel obstruction or contraindications to phosphate preparation were excluded. Patients received a phosphate based preparation on the previous evening or morning of the procedure. The endoscopist and an observer scored bowel preparation using the Ottawa and Aronchick scales. Using the Ottawa scale right, middle and left colon were separately assessed. Loss of sleep and working hours were noted.

RESULTS

One hundred and two patients received morning preparation and 99 patients received preparation on the previous evening. There was no significant difference in bowel preparation in both the groups using the Ottawa ( P = 0.87) or Aronchick ( P = 0.22) scales. Bowel preparation for right colon was significantly better in the morning group ( P = 0.008). More working hours were lost in the evening group (7.99 vs 10.17, P< 0.001). Sleep was disturbed in 15 patients in morning group and in 42 patients in evening group ( P< 0.001).

CONCLUSION

Both preparations had similar efficacy. Right side preparation was significantly better in the morning group. Evening preparation was associated with loss of more working hours and sleep.

Acute effects of naltrexone and GBR 12909 on ethanol drinking-in-the-dark in C57BL/6J mice

RATIONALE

Recently, a simple procedure was described, drinking in the dark (DID), in which C57BL/6J mice self-administer ethanol to the point of intoxication. The test consists of replacing the water with 20% ethanol in the home cage for 2 or 4 h early during the dark phase of the light/dark cycle.

OBJECTIVES

To determine whether the model displays predictive validity with naltrexone, and whether opioid or dopaminergic mechanisms mediate excessive drinking in the model.

MATERIALS AND METHODS

Naltrexone or GBR 12909 were administered via intraperitoneal injections immediately before offering ethanol solutions, plain tap water, or 10% sugar water to male C57BL/6J mice, and consumption was monitored over a 2- or 4-h period using the DID procedure.

RESULTS

Naltrexone (0.5, 1, or 2 mg/kg) dose dependently decreased ethanol drinking but these same doses had no significant effect on the consumption of plain water or 10% sugar water. GBR 12909 (5, 10, and 20 mg/kg) dose dependently reduced the consumption of ethanol and sugar water but had no effect on plain water drinking.

CONCLUSIONS

The DID model demonstrates predictive validity. Both opioid and dopamine signaling are involved in ethanol drinking to intoxication. Different physiological pathways mediate high ethanol drinking as compared to water or sugar water drinking in DID. DID may be a useful screening tool to find new alcoholism medications and to discover genetic and neurobiological mechanisms relevant to the human disorder.

Should early cancers of the oral tongue be kept under surveillance after wide excision alone? A prospective study

5541

Background: The treatment of the clinically N0 neck in early stage oral tongue cancer remains controversial. Several clinico-pathologic criteria that can reliably identify an increased risk of occult metastases in the neck have been proposed. Our aim was to assess the impact of elective neck dissection (END) on outcome and correlate it with clinico-pathologic criteria for patient selection for surveillance. Methods: Patients with early stage cancer of the oral tongue (T1–2, N0) after undergoing wide excision with or without END were prospectively kept under observation. Patients having adverse histological features necessitating adjuvant radiotherapy were excluded. All patients gave informed consent and were closely followed. Relapsers were offered appropriate salvage therapy. The primary end-point for our prospective phase II study was the impact of END on relapse-free survival (RFS) with an estimated sample size of 50 patients. Overall survival (OS) was a secondary endpoint. Results: Fifty three eligible patients were consecutively accrued on the trial after surgery. Forty eight patients underwent per oral wide excision, with only 5 requiring a neck approach. Twenty two patients underwent upfront END. Twenty four patients relapsed (23 of which had some loco-regional component). The risk of neck recurrence in patients whose necks were not dissected electively was significantly higher than in patients treated with END (55% vs 9% respectively, p = 0.0016). The 3-year RFS (69.1% vs 40.9%, p = 0.008) and OS (87.2% vs 42.6%, p = 0.0228) was significantly better for patients treated with END. Conclusions: Regional recurrences are the most important cause of failure after wide excision alone. END which achieves excellent disease control in the neck and significantly improves RFS and OS should be considered routine for early stage oral tongue cancer.

No significant financial relationships to disclose.

Radical Radiotherapy in Head and Neck Squamous Cell Carcinoma: An Analysis of Prognostic and Therapeutic Factors

AIMS

Head and neck squamous cell carcinoma (HNSCC) continues to be a leading cancer in developing countries. Definitive radiation therapy either primary or as postoperative adjuvant is offered to most patients. We aimed to identify prognostic and therapeutic factors that affect locoregional control and survival in patients undergoing radical radiotherapy for head and neck squamous cell cancers.

MATERIALS AND METHODS

A retrospective analysis of 568 previously untreated patients with squamous head and neck cancers, who received radical radiotherapy between 1990 and 1996, using local control, locoregional control and disease-free survival (DFS) as outcome measures.

RESULTS

With a median follow-up of 18 months for living patients, the 5-year local control, locoregional control and DFS for all 568 patients were 53%, 45% and 41%, respectively, for all stages combined. The 5-year local control, locoregional control and DFS as per the American Joint Committee on Cancer stage grouping were 78%, 70% and 70%; 64%, 59% and 57%; 51%, 42% and 37%; and 40%, 27% and 22% from stages I to IV, respectively, with highly significant P values. Patients receiving higher doses (> or = 66 Gy) had a significantly better outcome compared with lower doses. The 5-year local control (59% vs 48%, P = 0.0015), locoregional control (47% vs 41%; P = 0.0043) and DFS (44% vs 37%; P = 0.0099) were significantly better in patients receiving > or = 66 Gy. Site of primary also affected outcome significantly, with oral cavity lesions faring badly.

CONCLUSION

Tumour stage remains the most important factor affecting outcome in radical radiotherapy of HNSCC. A definite dose-response relationship exists with higher total doses, leading to better local control, locoregional control and DFS in all stages. Site of primary affects outcome too, with laryngeal primaries doing well and oral cavity cancers faring the worst.