Modified Two-Stage Approach for Management of Combined Rhegmatogenous Retinal Detachment and Choroidal Detachment With Extreme Hypotony

Combined rhegmatogenous retinal detachment (RRD) and serous choroidal detachment (CD) present a significant challenge. No global standard of care exists for treating these complex RRDs. There is a lower failure rate when such detachments are treated with pars plana vitrectomy than with scleral buckle alone. The use of pre-operative steroids may not work in cases with moderate-to-severe CDs with severe hypotony where suprachoroidal fluid drainage is required to reduce inflammatory mediators, thus preventing proliferative vitreoretinopathy (PVR). We report a case of a 62-year-old male who had a combined RRD and severe CD with vitreous hemorrhage in the left eye (LE). There was extreme hypotony leading to a severely deformed and distorted globe with poor visualization of the fundus. The patient was started on 60 mg of oral prednisolone, and a posterior subtenon injection of 20 mg of triamcinolone acetonide was given to reduce inflammation and CD. However, despite one week of pre-operative steroids, there was severe hypotony. The patient was taken for pars plana vitrectomy with drainage of suprachoroidal fluid. Intra-operatively even after drainage of suprachoroidal fluid via inferotemporal posterior sclerotomy, hypotony persisted, and media was very hazy, precluding us from proceeding with vitrectomy in the first sitting. Oral steroids were continued, and vitrectomy was done in the second sitting, 72 hours later, with long-term silicone oil tamponade. Post-operatively patient had a well-formed globe with an attached retina and a good visual acuity. Our case thereby highlights that combined retinal and CD is a complicated diagnosis that presents with many pre-operative, intra-operative, and post-operative challenges. We could achieve good anatomical and functional success using a modified two-stage approach in our unusual case of combined RRD wth CD with extreme hypotony.

Clinical profile and distribution of peripheral retinal changes in myopic population in a hospital-based study in North India

Purpose

To evaluate the prevalence of different types of peripheral retinal changes in a myopic population in North India and correlate them with axial length.

Methods

This cross-sectional, hospital-based survey included 600 eyes of 300 myopic individuals, aged between 10 and 40 years, attending the outdoor ophthalmology clinic of a tertiary eye care hospital in North India were examined from July 2019 to July 2020. They were divided into mild, moderate, high, and severe myopia according to the spherical equivalent of refraction. Axial length was recorded. Peripheral retinal changes were examined by scleral indentation binocular indirect ophthalmoscopy. Standardized findings considered with their fundus location were lattice degeneration, white without pressure and white with pressure, snail-track degenerations, peripheral chorioretinal atrophy, retinal holes, tears, and detachment. The study was approved by the institutional ethics committee, and all participants provided informed consent.

Results

Peripheral retinal degenerations were found in almost half (53%) of all myopes included in the study. The most common peripheral retinal degeneration found was lattice degeneration, followed by white without pressure, white with pressure, and chorioretinal atrophy. Most of the peripheral retinal degenerations were seen in the temporal quadrant of the fundus, either superotemporal or inferotemporal. There was a significant positive association between the prevalence of peripheral retinal degeneration with age, increased axial length, and severity of myopia.

Conclusion

The results of our study indicate the necessity for careful peripheral fundus examinations of all myopes, irrespective of age and degree of myopia, for early diagnosis and better management of visual-threatening complications like retinal detachment.

Results from a phase II randomized, placebo-controlled, double-blind trial suggest improved PFS with the addition of pertuzumab to gemcitabine in patients with platinum-resistant ovarian, fallopian tube, or primary peritoneal cancer

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Background: Pertuzumab (P) is a humanized monoclonal antibody that blocks the ability of HER2 to heterodimerize with other HER/ErbB receptors. As a single agent, P has demonstrated clinical activity in relapsed/refractory epithelial ovarian cancer (EOC). Since platinum-resistant (CDDP-R) EOC remains a difficult disease to treat, this phase II study was conducted to determine if addition of P to gemcitabine (G) would improve results. Methods: Patients with CDDP-R EOC (including ovarian, fallopian tube, or primary peritoneal cancer) who had received up to one prior treatment for CDDP-R disease were randomized to Gem 800 mg/m2 on D1, 8 of a 21-day cycle ± P or placebo (pl). P was given as an 840 mg initial dose followed by 420mg IV every 3 weeks. Tumor response was assessed by RECIST every 6 weeks using GOG criteria. The primary endpoint was progression free survival (PFS). Results: One hundred thirty patients (n = 65 each treatment cohort) were treated. Clinical characteristics were balanced between the treatment groups. Pts received a median of 2 prior regimens (range 1–6) for EOC. Based on 83 events, the adjusted hazard ratio for PFS was 0.67 (95% CI: 0.43–1.02), p =0.06 in favor of P+Gem. The median PFS was 3.0 months (0–8.7 months) vs. 2.6 months (0–9+ months), and the PFS rate at 4 months was 49% vs. 34% in the P+Gem and Gem/pl arms, respectively. The most common AEs increased in the P-treated pts were fatigue, nausea, diarrhea, back pain, Gr 3–4 neutropenia, rash, headache, stomatitis, epistaxis, and rhinorrhea. Clinically significant CHF was reported in one patient in the pertuzumab cohort. There was no imbalance in the LVEF results between treatment arms. One patient who received pertuzumab + gemcitabine experienced an adverse event that resulted in death (hemolytic-uremic syndrome). Conclusions: These data suggest that pertuzumab may add activity to gemcitabine as reflected by improvements in PFS in patients with CDDP-R ovarian, primary peritoneal, or fallopian tube cancer. Survival data will be presented at ASCO.

No significant financial relationships to disclose.

A randomized phase II trial with gemcitabine with or without pertuzumab (rhuMAb 2C4) in platinum-resistant ovarian cancer (OC): Preliminary safety data

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Background: Pertuzumab (P), a humanized HER2 antibody, represents a new class of targeted agents called HER dimerization inhibitors (HDIs). P inhibits dimerization of HER2 with EGFR, HER3 and HER4, and subsequently inhibits signaling through MAP and PI3 kinases. Single agent P has demonstrated clinical benefit in advanced OC (ASCO 2005 abstract #5051). Methods: 40 pts with platinum-resistant OC (progressed within 6 months of receiving a platinum-based chemotherapy) were enrolled in this 1:1 randomized, double blind, placebo controlled trial of gemcitabine with or without P. Gemcitabine was administered IV on day 1 and 8 at 800 mg/m2 of a 21 day cycle. Blinded placebo or 420 mg P was administered IV on day 1. Gemcitabine was dose reduced for neutropenia or thrombocytopenia. P was not dose reduced. Results: 40 pts have been enrolled and treated with at least 1 cycle of gemcitabine in combination with blinded study drug. The median age was 58.5 (range 18–82); 26 had PS ECOG 0, 13 ECOG 1, 1 ECOG 2. The most common grade 3/4 events were neutropenia in 7 pts (17.5%), thrombocytopenia in 6 pts (15%), small bowel obstruction in 4 pts (10%), constipation in 3 pts (7.5%) and elevated ALT in 3 pts (7.4%). There was one grade 3 diarrhea, but no grade 3 or 4 rash. There were 4 serious adverse events (SAEs) attributed to study drug. These were a pleural effusion, thrombocytopenia, febrile neutropenia, and a deep vein thrombosis. Nine pts required one or two dose reductions of gemcitabine for hematological toxicity. Of 29 pts with post-baseline echo or MUGA values obtained, no pt had LVEF drop to <50%. The adverse events evaluated after 40 pts did not meet the prespecified criteria to call for an independent safety monitoring board evaluation of unblinded data. Conclusions: Preliminary safety data indicate that pertuzumab or placebo combined with gemcitabine is well tolerated with no unexpected additive toxicity. The nature and frequency of the adverse events are similar to what has been observed with either single agent gemcitabine or P. Updated data will be presented at ASCO.

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Octreotide in Intestinal Lymphangiectasia: Lack of a Clinical Response and Failure to Alter Lymphatic Function in a Guinea Pig Model

Intestinal lymphangiectasia, which can be classified as primary or secondary, is an unusual cause of protein-losing enteropathy. The main clinical features include edema, fat malabsorption, lymphopenia and hypoalbuminemia. Clinical management generally includes a low-fat diet and supplementation with medium chain triglycerides. A small number of recent reports advocate the use of octreotide in intestinal lymphangiectasia. It is unclear why octreotide was used in these studies; although octreotide can alter splanchnic blood flow and intestinal motility, its actions on lymphatic function has never been investigated. A case of a patient with intestinal lymphangiectasia who required a shunt procedure after failing medium chain triglycerides and octreotide therapy is presented. During the management of this case, all existing literature on intestinal lymphangiectasia and all the known actions of octreotide were reviewed. Because some of the case reports suggested that octreotide may improve the clinical course of intestinal lymphangiectasia by altering lymphatic function, a series of experiments were undertaken to assess this. In an established guinea pig model, the role of octreotide in lymphatic function was examined. In this model system, the mesenteric lymphatic vessels responded to 5-hydroxytryptamine with a decrease in constriction frequency, while histamine administration markedly increased lymphatic constriction frequency. Octreotide failed to produce any change in lymphatic function when a wide range of concentrations were applied to the mesenteric lymphatic vessel preparation. In conclusion, in this case, octreotide failed to induce a clinical response and laboratory studies showed that octreotide did not alter lymphatic function. Thus, the mechanisms by which octreotide induced clinical responses in the cases reported elsewhere in the literature remain unclear, but the present study suggests that it does not appear to act via increasing lymphatic pumping.

Identification of genetic alterations related to chemoresistance in epithelial ovarian cancer

OBJECTIVE

After the completion of primary chemotherapy, the majority of advanced ovarian cancer patients have persistent, chemoresistant disease. Comparative genomic hybridization (CGH) has been used to study genetic alterations that may be responsible for chemoresistance in ovarian cancer. CGH is a useful, genomewide screen but resolution is limited to 5-10 Mb. Recently, quantitative microsatellite analysis (QuMA), a TaqMan-based quantitative PCR technology, has been used for higher resolution of DNA copy number abnormalities. Our goal is to identify specific chromosomal aberrations correlated with platinum resistance.

METHODS

Snap-frozen ovarian tissue samples taken from 22 patients with ovarian cancer between 1994 and 1998 were analyzed. Patients whose ovarian cancer actually demonstrated growth during platinum-combination treatment or no objective evidence of regression following four to six cycles of therapy were considered to have clinically defined platinum-resistant disease. QuMA was carried out at the following loci using the ABI Prism 7700 (TaqMan) instrument with a microsatellite repeat probe: D3S1553, D3S1617, D5S464, D5S630, D6S1581, D6S446, D8S557, D19S208, D20S196, DXS1068. Fisher's exact test, exact logistic regression, and the Cochran-Armitage trend test were used. Because of multiple hypothesis testing, the P values were adjusted with the Bonferroni procedure to limit the familywise error rate to at most 5%.

RESULTS

Of the 22 patients, 12 (54.5%) were platinum-sensitive and 10 (45.5%) were platinum-resistant. When comparing sensitive and resistant patients, no statistically significant difference was noted among stage, grade, histology, and age (P = 0.1292, P = 1.0000, P = 1.0000, P = 1.0000, respectively). In the QuMA analysis, 10 of the 14 (71.4%) patients who had a low copy number of D6S1581 were platinum-resistant, while none of the patients with a normal or high copy number of D6S1581 were platinum-resistant. This was statistically significant when the marker data were treated as either a continuous or a categorical variable (P = 0.0410 and P = 0.0170, respectively). No other loci correlated significantly with platinum resistance.

CONCLUSIONS

D6S1581 was the only genetic marker, of those examined, significantly related to chemoresistance. Patients with a loss of D6S1581 are more likely to be platinum-resistant. Identification of genetic alterations associated with platinum resistance detected by QuMA may contribute to a better understanding of clinical behavior and chemotherapy treatment options for patients.

Positron emission tomography/computed tomography imaging for the detection of recurrent ovarian and fallopian tube carcinoma: a retrospective review

PURPOSE

Imaging modalities to evaluate ovarian/fallopian tube cancer patients for recurrence are limited. Positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound lack the sensitivity to consistently detect recurrence or measurable disease in these patients. A new technique combines PET and CT (PET/CT) images to identify increased metabolic activity and to locate that signal with improved anatomic specificity. The objective of this study is to compare PET/CT, CT, and histologic findings in patients with recurrent ovarian/fallopian tube cancers.

METHODS

Retrospective chart review of eight patients with primary ovarian (n = 6) or fallopian tube (n = 2) cancer was performed. All eight patients underwent initial cytoreductive surgery. Five patients initially received chemotherapy, one received radioactive phosphorus ((32)P), one received tamoxifen, and one received no therapy. Seven of eight patients had a suspected recurrence based on clinical examination, elevated CA-125 level, and/or abnormal CT findings; one patient requested a PET/CT. Histologic findings from surgery were correlated with PET/CT and CT findings.

RESULTS

All eight patients had positive histology, and of these, seven patients had a negative CT and five patients had lesions that were correctly identified by PET/CT.

CONCLUSIONS

Five of the eight (62%) patients had recurrent disease based on correlative histology with a positive PET/CT and a negative CT. These preliminary findings suggest that combined PET/CT may be an effective means of identifying patients with recurrent ovarian/fallopian tube cancer. Such patients could potentially proceed to salvage treatment and avoid the morbidity and expense of surgical assessment. Pilot studies comparing CT, PET, PET/CT, and histologic findings are underway.

Ectomycorrhizal fungal associates of Pinus contorta in soils associated with a hot spring in Norris Geyser Basin, Yellowstone National Park, Wyoming

Molecular methods and comparisons of fruiting patterns (i.e., presence or absence of fungal fruiting bodies in different soil types) were used to determine ectomycorrhizal (EM) associates of Pinus contorta in soils associated with a thermal soil classified as ultra-acidic to extremely acidic (pH 2 to 4). EM were sampled by obtaining 36 soil cores from six paired plots (three cores each) of both thermal soils and forest soils directly adjacent to the thermal area. Fruiting bodies (mushrooms) were collected for molecular identification and to compare fruiting body (above-ground) diversity to below-ground diversity. Our results indicate (i) that there were significant decreases in both the level of EM infection (130 +/- 22 EM root tips/core in forest soil; 68 +/- 22 EM root tips/core in thermal soil) and EM fungal species richness (4.0 +/- 0.5 species/core in forest soil; 1.2 +/- 0.2 species/core in thermal soil) in soils associated with the thermal feature; (ii) that the EM mycota of thermal soils was comprised of a small set of dominant species and included very few rare species, while the EM mycota of forest soils contained a few dominant species and several rare EM fungal species; (iii) that Dermocybe phoenecius and a species of Inocybe, which was rare in forest soils, were the dominant EM fungal species in thermal soils; (iv) that other than the single Inocybe species, there was no overlap in the EM fungal communities of the forest and thermal soils; and (v) that the fungal species forming the majority of the above-ground fruiting structures in thermal soils (Pisolithus tinctorius, which is commonly used in remediation of acid soils) was not detected on a single EM root tip in either type of soil. Thus, P. tinctorius may have a different role in these thermal soils. Our results suggest that this species may not perform well in remediation of all acid soils and that factors such as pH, soil temperature, and soil chemistry may interact to influence EM fungal community structure. In addition, we identified at least one new species with potential for use in remediation of hot acidic soil.

Complications associated with intraperitoneal chemotherapy catheters

PURPOSE

The goal of this work was to determine the complication rate and any predisposing risk factors associated with subcutaneous intraperitoneal (ip) catheters used in the treatment of patients with advanced ovarian cancer.

METHODS

We retrospectively reviewed the charts of 301 patients who had a subcutaneous Bardport catheter placed for administration of ip chemotherapy at Memorial Sloan--Kettering Cancer Center (MSKCC) from December 1989 to May 1997.

RESULTS

Thirty (10%) patients were identified as having catheter-related complications, with 19 (6.3%) experiencing inflow obstruction and 11 (3.6%) experiencing infection. Only 21 of 301 (7%) required cessation of chemotherapy prior to its expected completion, with 14 (4.6%) occurring in the malfunction group and 7 (2.3%) in the infection group. Three hundred thirteen patients received an ip catheter; however, 12 patients who received their ip chemotherapy elsewhere were excluded when determining the complication rate. Overall, 218 of 313 (69.6%) catheters were placed at the time of laparotomy, 61 of 313 (19.5%) catheters were placed at the time of laparoscopy, and 34 of 313 (10.9%) were placed as a separate procedure. In the malfunction group, 18 of 19 (94.7%) patients had their catheters placed at the time of laparotomy, none were placed at the time of laparoscopy, and 1 of 19 (5.3%) was placed as a separate procedure. In the infection group, 8 of 11 (72.7%) catheters were placed at laparotomy, 2 of 11 (18.3%) were placed at the time of laparoscopy, and 1 of 11 (9.0%) was placed as a separate procedure. Complications occurred in 3 of 54 (5.5%) patients who received platinum alone, 11 of 134 (8.2%) who received platinum in combination, 2 of 43 (4.7%) who received paclitaxel alone, 13 of 61 (21.3%) who received mitoxantrone alone or in combination, and 1 of 9 (11.1%) who received other regimens.

CONCLUSION

Subcutaneous ip catheters are associated with a lower rate of catheter-related complications than previously reported, perhaps due in part to both avoiding insertion of ip catheters at the time of bowel surgery and placing ip catheters at the time of laparoscopy.

Intraperitoneal cisplatin and intravenous paclitaxel in the treatment of epithelial ovarian cancer patients with a positive second look

OBJECTIVE

The aim of this study was to review the role and safety of intraperitoneal (IP) cisplatin and intravenous (IV) paclitaxel in platinum-sensitive epithelial ovarian cancer patients who were found to have small-volume disease (<1 cm) at the time of their second-look procedure.

METHODS

In a retrospective review, 32 patients with small-volume disease had an IP Bardport catheter placed at the time of second look at Memorial Sloan-Kettering Cancer Center (1995-1998). Patients received IP cisplatin (75 mg/m(2)) every 3 weeks and either IV paclitaxel (135 mg/ m(2)) every 3 weeks or IV paclitaxel (80 mg/m(2)) weekly for a maximum of five cycles.

RESULTS

Twenty-four (75%) of 32 patients received IP cisplatin/IV paclitaxel every 3 weeks and 8 (25%) received IP cisplatin every 3 weeks with weekly IV paclitaxel. Seven (21.9%) of 32 patients required interruption of treatment secondary to neuropathy. Of these, 4 (15.6%) were changed to another IV chemotherapeutic agent, and 3 (9.3%) required discontinuation of IV paclitaxel only. Two (6%) patients required IP port removal secondary to malfunction and were changed to IV therapy and 1 (3%) requested discontinuation of IP therapy secondary to abdominal pain. Median follow-up was 19 months (mean, 20.1 months; range, 6-36 months). Progression of disease after completion of IP therapy was documented by clinical exam, abnormal CT, and/or rising CA-125 levels. The median progression-free interval was 13 months (mean, 15.1 months; range, 2-33 months). Median overall survival was 27 months (mean, 34.2 months; range, 10-42 months). At the time of review, 13 (40.6%) of the 32 patients were alive with disease, 7 (21.9%) were without evidence of disease, and 12 (37.5%) were dead of disease.

CONCLUSION

IP cisplatin in combination with IV paclitaxel appears to be no more effective than other reported regimens as second-line therapy for patients with persistent small-volume disease. Neurotoxicity is dose limiting, and the combination cannot be recommended for the routine care of persistent peritoneal cancers.

Taxol-induced bcl-2 phosphorylation in ovarian cancer cell monolayer and spheroids

Expression of Bcl-2, Bax, p53 and induction of apoptosis were studied in cisplatin or Taxol treated monolayer and spheroid cultures of ovarian cancer cell lines (SKOV-3, UL-1, UL-3C). While cisplatin (15-75 microg/ml) induced apoptosis in monolayer and spheroid cultures, Taxol (100-800 nM) induced fragmentation in monolayers only. Cisplatin induced up to 5-fold DNA fragmentation in monolayers, while 3-fold (UL-3C, SKOV-3), and 1.5-fold (UL-1) in spheroids. Taxol treatment of monolayers resulted in the characteristic phosphorylation of Bcl-2, which was not demonstrated in spheroid cultures. Bax expression was reduced in spheroids following cisplatin or Taxol treatment, while p53 levels remained unchanged.

Intraperitoneal chemotherapy strategies in the treatment of epithelial ovarian carcinoma

The intraperitoneal delivery of chemotherapeutic agents is presently being investigated as a part of salvage treatment for epithelial ovarian cancer. There are several promising new agents that appear to demonstrate a benefit in selected patients.

CA-125 levels after surgical exploration and radioactive chromic phosphate in ovarian cancer patients

Trends in CA-125 levels after completion of therapy in ovarian cancer patients who received intraperitoneal radioactive chromic phosphate therapy (32P) after primary surgical resection or second-look surgery were evaluated. Ninety patients who underwent surgical exploration and 32P were reviewed. Twenty-nine patients were excluded due to insufficient number of CA-125 levels or recurrence within 12 months, with 61 patients with serial CA-125 levels and no evidence of disease for 12 months available for analysis. 32P followed initial resection in 24 patients (16 Stage I, 3 Stage II, 5 Stage III). 32P followed chemotherapy and second-look procedures in 37 patients (4 Stage I, 3 Stage II, 27 Stage III, 3 Stage IV). Elevated CA-125 levels were present in 25 (41%) patients within 12 months of 32P (46% after primary exploration, 38% after second-look). The degree of CA-125 elevation (U/ml) was 30-100 (23%), 100-200 (11%), and >200 (7%). Of the 25 patients with an elevated CA-125, the elevation persisted more than 4 months in 11 (44%). All but two patients had normal CA-125 levels by 12 months. An abnormal elevation in CA-125 was seen in 33% of patients 4 months after receiving 32P and abdominal surgery, with values ranging as high as 500 U/ml. Although elevations in CA-125 are reported following surgery alone, the duration of elevation appears to be longer with 32P. Therefore, persistent elevations of CA-125 following 32P between 4 and 12 months should be judged with caution as they may not reflect recurrent disease.

Methylmercury induced biochemical and histochemical alterations in rat testis

The methylmercurry chloride (MMC) administered at doses of 5 and 10 micrograms/kg over a period of 90 days to male rats caused enzymatic impairments in testicular tissue. The study at intervals of 15, 30, 60 and 90 days showed gradual diminution of testicular weight and gradual decrements in testicular protein and inhibition in testicular succinic dehydrogenase activity. Histochemical and biochemical studies revealed that testicular acid phosphatase activity was also inhibited at both the doses of MMC treatment. The inhibition of enzyme activity in testicular tissues after MMC treatment caused the impairment of both spermatogenesis and steroidogenesis in rats.

Methylmercury- and mercuric-chloride-induced alterations in rat epididymal sperm

Four-week-old male albino rats weighing 70 +/- 5 g were treated intraperitoneally daily with 0, 5 and 10 micrograms methylmercuric chloride (MMC)/kg or 0, 50 and 100 micrograms mercuric chloride (MC)/kg body weight, respectively, over a period of 90 days. Studies were carried out a intermittent intervals, i.e. on days 0, 15, 30, 60 and 90 of the experiment. Gradual decrements in body and epididymal weights were observed from day 30 onwards in both the MMC- and MC-treated groups. Morphological deformations of epididymal epithelium were noted from day 30 onwards in the mercurial-treated groups. MMC treatment caused severe degeneration of the epididymal epithelium on days 60 and 90 in comparison to MC treatment. Total sperm count was significantly less in the MC-treated groups, while motile sperm count was affected most in the MMC-administered groups. The frequency of sperm abnormality increased consistently at both doses of mercurial treatment over a period of 90 days. Maximum sperm abnormality among the treated groups was noted in the groups given 10 micrograms MMC/kg. The observations revealed that MMC and MC have variable potency to alter epididymal structure and the sperm.