Trial of ligation versus coagulation of lymphatics in dynamic inguinal sentinel lymph node biopsy for staging of squamous cell carcinoma of the penis

INTRODUCTION

Te principal advantage of dynamic sentinel lymph node biopsy (DSNB) over modified inguinal node dissection is the lower complication rate. The aim of this study was to identify factors associated with short-term complications of DSNB in order to lower morbidity of the procedure.

METHODS

Retrospective and prospective cohort studies were performed on patients undergoing DSNB between April 2005 and March 2010. Patients were categorised into three groups of 50 (from a total of 250 patients on the database). The patients of Group A, on whom ligaclips were the lymphovascular control technique, were compared with those of Group B, in whom diathermy was used. Incision length, operative time, number of nodes removed, antibiotics and co-morbidities were recorded. A prospective study on Group C, using ligaclips, was also performed.

RESULTS

Groups A (88 groins), B (75 groins) and C (68 groins) were explored with complication rates of 5.7%, 24.0% (p=0.0018) and 8.8% (p=0.0277). Co-morbidities, antibiotics (co-amoxiclav 1.2g intravenous as per protocol) and the mean number of nodes removed were similar in all groups. The mean incision length was 4.1cm (standard deviation [SD]: 1.0cm) for Group A, 5.6cm (SD: 1.0cm) for Group B (p=0.0001) and 5.6cm (SD: 0.8cm) for Group C (p=0.979). The mean operative times for Groups A, B and C were 15.8 (SD: 8.1), 19.3 (SD: 7.4) (p=0.0043) and 22.1 (SD: 7.7) (p=0.0301) minutes respectively.

CONCLUSIONS

Lymphovascular control with diathermy is associated with a statistically higher short-term complication rate compared with ligaclip usage (ie ‘permanent’ ligation). Lymphocoeles are the principal complication and can result in delayed wound infection and breakdown. A small but statistical increase in operative time and wound length is likely to be related to registrar training.

MO-F-213AB-05: Commissioning of Gated RapidArc Radiotherapy for Treatment of Moving Targets

PURPOSE

To commission and evaluate gated RapidArc radiotherapy of a linear accelerator (Varian TrueBeam) for treatment of moving targets using a programmable dynamic phantom.

METHODS

The phantom used had different dosimetry inserts for measurement of dose and dose distribution. It could be programmed to move in the anterior-posterior and superior-inferior axes with different motion patterns, amplitudes and frequencies to simulate lung motions of patients. A set of 4D CT images was acquired with the aid of a Varian RPM system. Images acquired at the 40, 50 and 60% of the motion cycle were selected and transferred to a treatment planning system (Varian Eclipse) for planning. A two-arc RapidArc treatment plan was generated for a C-shaped target volume with a conformity index of 1.49 and transferred to the TrueBeam for treatment delivery. Dose and dose distribution measurements were performed using a 0.057 cc ionization chamber and radiochromic films, respectively and compared with the TPS calculations. Five treatment fractions were given in three days with two different target motion patterns to assess the consistency of the dose delivery.

RESULTS

Agreement between TPS calculation and measurement were within 1.64% for dose and 3% or 3mm in distance to agreement for dose distribution. Repeatability of dose delivery between treatments was within 0.1% (1SD) in the five treatment fractions delivered in three days. The time required to deliver a dose of 2 Gy to a moving C-shaped target using gated RapidArc technique with two gantry rotations was about 15 minutes.

CONCLUSIONS

The geometric and dosimetric accuracy and consistency of gated RapidArc radiotherapy had been verified. Our study indicated that the accuracy and consistency of the treatment modality were acceptable for clinical implementation.

Models of care for early-stage breast cancer in Canada

There is growing evidence that follow-up for patients with early breast cancer (ebc) can be effectively carried out by the primary health care provider if a plan is in place. Here, we present data from a recent survey conducted in Ontario indicating that a shared-care model could work if communication between all health professionals involved in the care of ebc patients were to be improved. Patients and primary care providers benefit when the specialist provides written information about what their roles are and what to expect. Primary care providers need to have easy access to the specialist to discuss areas of concern. Patients also need to share responsibility for their care, ensuring that they attend follow-up visits on a regular basis and that they discuss areas of concern with their primary health care provider. A shared-care model has the potential to provide the best care for the least cost to the health system.

Chemotherapy for squamous cell carcinoma of the penis: An 8-year, single-institution experience

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Background: Penile cancer is a rare malignancy affecting approximately 400 men per year in the United Kingdom. There are relatively limited data regarding the role of chemotherapy, although it may be considered in the adjuvant setting for high-risk disease and for palliation of metastatic disease.

Methods: Patients treated with chemotherapy between June 2002 and March 2010 were identified from our prospectively maintained institutional database. Regimens were recorded and toxicity documented according to the Common Toxicity Criteria version 4.0. Response was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.0 until 2009 and then version 1.1.

Results: Twenty patients received chemotherapy either for adjuvant treatment (n=6) or for metastatic disease (n=14). Median age was 59 (range 33-80). Different regimens were used over the time period. In the adjuvant setting 4-6 cycles of chemotherapy were planned and all patients received cisplatin in combination with 5-FU or capecitabine. Five (83%) completed planned treatment with no grade 3 or 4 toxicities. One patient stopped after 2 cycles due to deteriorating renal function. Patients remained disease free at up to 22 months follow-up. In the metastatic setting, 10 patients received cisplatin and capecitabine, 1 cisplatin and 5-FU and 1 carboplatin and capecitabine. Of these 12 patients, 2 (17%) had partial response as their best response, 4 (33%) had stable disease (SD) and 6 (50%) had progressive disease (PD). Three patients (25%) experienced pulmonary embolism, 1 of whom died. Two (17%) developed grade 3 neutropenia. One patient received carboplatin, methotrexate and bleomycin with PD after 3 cycles and developed grade 3 neutropenia, stomatitis, and diarrhea. One patient received 3 cycles of paclitaxel, ifosfamide, and cisplatin with SD and no grade 3 or 4 toxicities.

Conclusions: Combination chemotherapy can be delivered with acceptable toxicity in the adjuvant setting. In the metastatic setting response rates were disappointing and treatments were associated with greater toxicity. New treatments are urgently required to improve outcomes in this difficult malignancy.

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Use of genetic instability to predict biochemical recurrence in intermediate-risk prostate cancer

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Background: Biomarkers of local and systemic recurrence are needed to individualize patient risk categories and better define treatment. We hypothesized that genomic instability, as measured by percent genome alteration (PGA), can predict for biochemical failure in intermediate- risk prostate cancer.

Methods: High-resolution array comparative genomic hybridization (arrayCGH) was used to identify PGA in frozen biopsies from 120 intermediate-risk prostate cancer patients. Our cohort included 39 T1c tumors, 78 T2 tumors and 2 T3 tumors. The Gleason score was 6 in 32 tumors, 7 in 82 tumors and 8–9 in 6 tumors. PSA ranged from 2.1–33 (median 8.0). Patients were treated with intensity-modulated radiotherapy (IMRT) with doses of 75.6–79.8 Gy in 1.8–2Gy fractions, or 60–66 Gy in 3 Gy fractions.. Twenty-five percent of patients also received neoadjuvant-concurrent bicalutamide (150mg po od). Biochemical failure, defined by Phoenix criteria or the initiation of salvage therapy, was observed in 35 patients after median follow-up of 5.4 years (range 0.9–8.8).

Results: Array CGH showed variable PGA ranging from <1% to 35% (median 6.7%). PSA and the use of hormonal therapy independently influenced biochemical relapse, and formed a baseline clinical model to which PGA was added. PGA was found to be a strong predictor of biochemical relapse (p<0.0001) independent of the clinical prognostic factors (pre-treatment PSA, Gleason score and T-category). PGA was also found to be associated with unique tumour suppressor and oncogene gene loci clusters involved in genetic stability (e.g. loss of PTEN, p53, RB, NKX3.1, ATM, PARP-1 and gain of c-MYC; validated by in situ FISH).

Conclusions: This is the first report to show genetic instability can independently predict for biochemical recurrence in intermediate-risk prostate cancer. Current studies are associating specific gene loci regions with clinical outcome. Our results could provide a way forward for individualized medicine for non-indolent prostate cancer based on initial daignostic biopsy material. Supported by Prostate Cancer Canada, The Terry Fox Foundation and the Canadian Cancer Society.

No significant financial relationships to disclose.

Genetic polymorphisms of Chinese patients with ischemic stroke and concurrent stenoses of extracranial and intracranial vessels

The etiology of concurrent stenoses of extracranial and intracranial vessels in patients with ischemic stroke is poorly understood, but hereditary factors are believed to be important. We aimed to determine whether genetic polymorphisms affecting homocysteine and lipid metabolism are associated with concurrent stenoses. The genotypes of 191 Han Chinese patients with acute ischemic stroke, of whom 47 (25%) had concurrent stenoses, and 167 healthy control patients in Hong Kong were examined for the following polymorphisms: paraoxonase 1 (PON1) Q192R, methylenetetrahydrofolate reductase (MTHFR) A222V, glutamate-cysteine ligase catalytic-subunit (GCLC)-129C>T, and oxidized low-density lipoprotein receptor (OLR) 3' untranslated region C>T (rs1050283). The genotype distributions of PON1 Q192R and MTHFR A222V, which affect lipid and homocysteine metabolism, differed significantly between patients with stroke and healthy controls. The presence of at least one R allele in PON1 Q192R and a TT allele in OLR rs1050283 were associated with concurrent stenoses. We also identified a possible association between the presence of at least one V allele in MTHFR A222V and concurrent stenoses. This study shows that genetic polymorphisms affecting homocysteine and lipid metabolism are possible risk factors for stroke and concurrent stenoses.

In a randomized, double-blinded, placebo-controlled trial, the single oral dose typhoid vaccine, M01ZH09, is safe and immunogenic at doses up to 1.7 x 10(10) colony-forming units

M01ZH09, S. Typhi (Ty2 Delta aroC Delta ssaV) ZH9, is a single oral dose typhoid vaccine with independently attenuating deletions. A phase II randomized, double-blind, placebo-controlled, dose-escalating trial evaluated the safety and immunogenicity of M01ZH09 to 1.7 x 10(10) colony-forming units (CFU). 187 Healthy adults received vaccine or placebo in four cohorts. Serologic responses and IgA ELISPOT were measured. At all doses, the vaccine was well tolerated and without bacteremias. One subject had a transient low-grade fever. 62.2-86.1% of subjects seroconverted S. Typhi-specific LPS IgG and 83.3-97.4% IgA; 92.1% had a positive S. Typhi LPS ELISPOT. M01ZH09 is safe and immunogenic up to 1.7 x 10(10)CFU. Efficacy testing of this single-dose oral typhoid vaccine is needed.

Safety of adjuvant endocrine therapies in hormone receptor-positive early breast cancer

Postmenopausal patients with hormone-sensitive early breast cancer are typically treated with adjuvant endocrine therapy, which significantly reduces the risk of recurrence. Because treatment is of a long duration, side effects from adjuvant therapy can be problematic. The aromatase inhibitors (AIS) are replacing tamoxifen as first-line treatment agents for early breast cancer. Here, we present the side-effect data associated with AIS in relation to bone, gynecologic, and cardiovascular health and to arthralgia and myalgia. Although AIS have been shown to decrease bone density, increase arthralgia, and affect vaginal health, these adverse events are usually manageable, and several strategies can be followed to improve quality of life in women on AI treatment. To optimize adherence to therapy. It is important that these issues are addressed so that women can benefit from treatment.

Use of magnetic resonance angiography to predict long-term outcomes of ischemic stroke patients with concurrent stenoses in Hong Kong

PURPOSE

To determine the long-term outcome of ischemic stroke patients with concurrent intracranial and extracranial atherosclerosis using magnetic resonance angiography.

METHODS

A prospective cohort of patients in Hong Kong with acute ischemic stroke was studied with magnetic resonance angiography of the brain and carotid duplex. All patients were followed up regularly for the development of recurrent stroke, cardiac events, or death.

RESULTS

Totally 343 patients with acute ischemic stroke were included, of whom 104 (30%) had concurrent intracranial and extracranial lesions. The follow-up period was up to 76 months (mean 44.5 months). Overall, 55 patients (15.5%) died of any cause and 91 patients (26.5%) suffered a further nonfatal vascular event. The overall 5-year cumulative rates of mortality, restroke and poor outcomes (combined death and further vascular events) were 18, 27 and 37%, respectively. In patients with concurrent lesions, these rates were 31, 41 and 51%, respectively. The corresponding rates were 13, 22 and 31% in patients without concurrent lesions. The risks were highest in the first year after stroke. More deaths (log rank, 16.3; p = 0.0001), restrokes (log rank, 9.71; p = 0.002) and poor outcomes (log rank, 13.87; p = 0.0001) were found among patients with concurrent lesions. The presence of concurrent vascular lesions, advanced age, smoking, hyperlipidemia and previous history of stroke were independent predictors of poor outcomes.

CONCLUSIONS

The long-term prognosis of ischemic stroke patients with concurrent atherosclerosis of intracranial and extracranial vessels is poor. They are at high risk of further vascular events or death.