Acetylene Tunes Microbial Growth During Aerobic Cometabolism of Trichloroethene

Microbial aerobic cometabolism is a possible treatment approach for large, dilute trichloroethene (TCE) plumes at groundwater contaminated sites. Rapid microbial growth and bioclogging pose a persistent problem in bioremediation schemes. Bioclogging reduces soil porosity and permeability, which negatively affects substrate distribution and contaminant treatment efficacy while also increasing the operation and maintenance costs of bioremediation. In this study, we evaluated the ability of acetylene, an oxygenase enzyme-specific inhibitor, to decrease biomass production while maintaining aerobic TCE cometabolism capacity upon removal of acetylene. We first exposed propane-metabolizing cultures (pure and mixed) to 5% acetylene (v v-1) for 1, 2, 4, and 8 d and we then verified TCE aerobic cometabolic activity. Exposure to acetylene overall decreased biomass production and TCE degradation rates while retaining the TCE degradation capacity. In the mixed culture, exposure to acetylene for 1-8 d showed minimal effects on the composition and relative abundance of TCE cometabolizing bacterial taxa. TCE aerobic cometabolism and incubation conditions exerted more notable effects on microbial ecology than did acetylene. Acetylene appears to be a viable approach to control biomass production that may lessen the likelihood of bioclogging during TCE cometabolism. The findings from this study may lead to advancements in aerobic cometabolism remediation technologies for dilute plumes.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Propensity score regression analysis of oesophageal adenocarcinoma treatment with surgery alone or neoadjuvant chemotherapy

Background

Propensity score (PS) regression analysis can be used to minimize differences between cohorts in order to perform comparisons The aim of this study was to use PS analysis to examine the outcomes of oesophageal adenocarcinoma (OAC) treatment with surgery alone or neoadjuvant chemotherapy (NAC) followed by surgery (NACS), to see whether the benefits seen in a randomized trial (MRC OE02) were reproducible in a UK cancer network clinical practice.

Methods

Consecutive patients undergoing potentially curative treatment for OAC in a regional cancer network were studied. Multiple regression models, including PS analysis, were developed to account for confounding factors. Primary outcome measures were disease‐free (DFS) and overall (OS) survival.

Results

A cohort of 440 patients was included in a regression analysis controlling for confounders (176 surgery alone, 264 NACS). NACS was associated with a higher positive margin status rate compared with surgery alone (42·4 versus 26·7 per cent respectively; P < 0·001), an inferior 5‐year DFS rate (32·1 versus 56·9 per cent; P < 0·001) and a worse 5‐year OS rate (27·5 versus 47·3 per cent; P < 0·001). On regression adjustment based on propensity scores, NACS was not associated with DFS (P = 0·220) or OS (P = 0·431). The Mandard tumour regression grade (TRG) score was significantly associated with DFS (hazard ratio (HR) 0·21, 95 per cent c.i. 0·07 to 0·70) and OS (HR 0·27, 0·13 to 0·59). Five‐year DFS and OS rates related to TRG were 64 and 62 per cent respectively for 25 good responders versus 8·0 and 8·6 per cent for 127 poor responders (P < 0·001).

Conclusion

The prescription of NAC to all patients with OAC risks delay in effective treatment of patients who are relatively chemoresistant, given the variability in pathological response. Identification of patients with OAC who may derive the most benefit from NAC should be the focus.

Dysregulation of methionine metabolism in multiple sclerosis

We report a significant reduction in plasma methionine concentrations in relapse remitting multiple sclerosis (MS) patients compared to controls. In vivo studies demonstrate that changes in peripheral methionine levels in mice can regulate histone H3 methylation and expression of DNA methyltransferase 3A (DNMT3A) centrally, in the cerebral cortex. Therefore, we propose that decreases in circulating methionine represent one of the earliest manifestations of dysregulated methionine metabolism in MS with potential impacts on both histone H3 and DNA methylation in the central nervous system.

WSe₂ Light-Emitting Tunneling Transistors with Enhanced Brightness at Room Temperature

Monolayers of molybdenum and tungsten dichalcogenides are direct bandgap semiconductors, which makes them promising for optoelectronic applications. In particular, van der Waals heterostructures consisting of monolayers of MoS2 sandwiched between atomically thin hexagonal boron nitride (hBN) and graphene electrodes allows one to obtain light emitting quantum wells (LEQWs) with low-temperature external quantum efficiency (EQE) of 1%. However, the EQE of MoS2- and MoSe2-based LEQWs shows behavior common for many other materials: it decreases fast from cryogenic conditions to room temperature, undermining their practical applications. Here we compare MoSe2 and WSe2 LEQWs. We show that the EQE of WSe2 devices grows with temperature, with room temperature EQE reaching 5%, which is 250× more than the previous best performance of MoS2 and MoSe2 quantum wells in ambient conditions. We attribute such different temperature dependences to the inverted sign of spin-orbit splitting of conduction band states in tungsten and molybdenum dichalcogenides, which makes the lowest-energy exciton in WSe2 dark.

Quality Heterostructures from Two-Dimensional Crystals Unstable in Air by Their Assembly in Inert Atmosphere

Many layered materials can be cleaved down to individual atomic planes, similar to graphene, but only a small minority of them are stable under ambient conditions. The rest react and decompose in air, which has severely hindered their investigation and potential applications. Here we introduce a remedial approach based on cleavage, transfer, alignment, and encapsulation of air-sensitive crystals, all inside a controlled inert atmosphere. To illustrate the technology, we choose two archetypal two-dimensional crystals that are of intense scientific interest but are unstable in air: black phosphorus and niobium diselenide. Our field-effect devices made from their monolayers are conductive and fully stable under ambient conditions, which is in contrast to the counterparts processed in air. NbSe2 remains superconducting down to the monolayer thickness. Starting with a trilayer, phosphorene devices reach sufficiently high mobilities to exhibit Landau quantization. The approach offers a venue to significantly expand the range of experimentally accessible two-dimensional crystals and their heterostructures.

Electronic properties of graphene encapsulated with different two-dimensional atomic crystals

Hexagonal boron nitride is the only substrate that has so far allowed graphene devices exhibiting micrometer-scale ballistic transport. Can other atomically flat crystals be used as substrates for making quality graphene heterostructures? Here we report on our search for alternative substrates. The devices fabricated by encapsulating graphene with molybdenum or tungsten disulfides and hBN are found to exhibit consistently high carrier mobilities of about 60 000 cm(2) V(-1) s(-1). In contrast, encapsulation with atomically flat layered oxides such as mica, bismuth strontium calcium copper oxide, and vanadium pentoxide results in exceptionally low quality of graphene devices with mobilities of ∼1000 cm(2) V(-1) s(-1). We attribute the difference mainly to self-cleansing that takes place at interfaces between graphene, hBN, and transition metal dichalcogenides. Surface contamination assembles into large pockets allowing the rest of the interface to become atomically clean. The cleansing process does not occur for graphene on atomically flat oxide substrates.

Propensity score analysis of oesophageal cancer treatment with surgery or definitive chemoradiotherapy

BACKGROUND

The role of treatments involving surgery versus definitive chemoradiotherapy (dCRT) for oesophageal cancer remains controversial.

METHODS

Consecutive patients with oesophageal cancer were studied. Those whose treatment involved surgery alone or who received neoadjuvant chemotherapy or chemoradiotherapy were compared with those receiving dCRT. Multiple regression models, including propensity scores, were developed to assess confounding factors associated with undergoing surgery or dCRT, and the risk-adjusted association between treatment and survival.

RESULTS

From a total of 727 patients, regression adjustment to control for bias created a cohort of 521 patients available for comparison (277 in the surgery group and 244 in the dCRT group). Local and distant recurrence rates were 10·1 and 22·0 per cent respectively after surgery, compared with 26·2 and 11·9 per cent following dCRT (P < 0·001). Median survival, and 2- and 5-year survival rates after surgery were 27 months, 53·8 and 31·0 per cent respectively, compared with 28 months, 54·2 and 31·9 per cent after dCRT (P = 0·918). On multivariable analysis, disease-free survival was related to endosonographic tumour category (hazard ratio (HR) 0·76, 95 per cent confidence interval 0·10 to 6·04 for T1; HR 1·57, 0·21 to 11·58 for T2; HR 2·12, 0·29 to 15·49 for T3; HR 3·07, 0·41 to 23·16 for T4; P = 0·003, in relation to T0 as reference), lymph node metastasis count (HR 1·10, 1·04 to 1·15; P < 0·001) and total disease length (HR 0·96, 0·93 to 1·00; P = 0·041).

CONCLUSION

There was no difference in survival after oesophageal cancer treatment involving surgery or dCRT.

Epanolol as a Model for Assessing Patient Preference in Anti-Anginal Drug Therapy

Since drug therapy of angina is likely to produce a similar degree of efficacy for most drugs in common use, treatment choice should additionally focus on other factors, notably adverse events, quality of life, and convenience. Improvements in these factors can also lead to better compliance and can aid the doctor by cutting down the number of patient visits required to optimize therapy. The authors have evaluated the patient's overall assessment of symptomatic relief and adverse experiences in a comparative manner by means of the two-period crossover design using the patient's declared treatment preference as the primary measurement. This encapsulates several factors in a single assessment that can be understood by both physician and patient. The authors carried out two such studies of epanolol (Visacor), a novel anti-anginal agent with both beta-1 selective antagonist activity and also beta-1 selective partial agonist activity. In one study (n = 608) the comparator was metoprolol, and in the other (n = 571) it was nifedipine. This article describes and evaluates the methodology of these studies. To assess preference optimally, each patient had to receive both treatments in short but clinically relevant treatment periods, with no washout. Re-entry into the second period, after withdrawal from the first, was permitted. Both studies showed advantages for epanolol, more marked in the case of nifedipine, arising from equivalent efficacy but fewer adverse events.(ABSTRACT TRUNCATED AT 250 WORDS)

Large bowel obstruction due to colorectal carcinoma can be safely treated by colonic stent insertion--case series from a UK district general hospital

AIM

The aim of this study is to audit our outcomes and experience of colonic stent insertion for malignant bowel obstruction.

METHOD

Retrospective audit of all stent insertions in a single district general hospital between August 2003 and December 2009. All patients had presented with acute bowel obstruction caused by malignant colorectal disease and details were collected prospectively and contemporaneously onto a database. Stent insertion was a combined endoscopic and fluoroscopic procedure involving a colorectal surgeon and consultant radiologist.

RESULTS

Stenting was attempted on 62 occasions in 54 patients. The technical success rate was 86% and the clinical success rate 84%. The indications for stenting were for relief of acute bowel obstruction, palliation and as a bridge to surgery. There were complications in 14 cases (22.5%) including three perforations and one perioperative mortality. There were three cases of stent migration, six cases of re-stenosis and two stents became impacted with stool. There were no incidents of acute or delayed haemorrhage in any patients.

CONCLUSION

Our experience shows that stenting for obstructing colorectal cancer is a safe and effective method of alleviating acute and impending bowel obstruction and can be provided safely and effectively in a district general hospital.

Clinical trial: Efficacy of a low or modified fat diet for the prevention of gastrointestinal toxicity in patients receiving radiotherapy treatment for pelvic malignancies

BACKGROUND

Inflammatory responses to pelvic radiotherapy can result in severe changes to normal gastrointestinal function with potentially severe long-term effects. Reduced or modified fat diets may confer benefit.

METHODS

This randomised controlled trial recruited patients with gynaecological, urological or lower gastrointestinal malignancy due to receive radical radiotherapy. Patients were randomised to a low fat (20% total energy from long chain triglycerides), modified fat (20% from long chain triglycerides and 20% from medium chain triglycerides) or normal fat diet (40% total energy from long chain triglycerides). The primary outcome was a difference in change in Inflammatory Bowel Disease Questionnaire--Bowel (IBDQ-B) score, from the start to end of radiotherapy.

RESULTS

A total of 117 patients with pelvic tumours (48% urological; 32% gastrointestinal; 20% gynaecological), with mean (SD) age: 65 (11.0) years, male:female ratio: 79:38, were randomised. The mean (SE) fall in paired IBDQ-B score was -7.3 (0.9) points, indicating a worsening toxicity. Differences between groups were not significant: P = 0.914 (low versus modified fat), P = 0.793 (low versus normal fat) and P = 0.890 (modified versus normal fat). The difference in fat intake between low and normal fat groups was 29.5 g [1109 kJ (265 kcal)] amounting to 11% (of total energy intake) compared to the planned 20% differential. Full compliance with fat prescription was only 9% in the normal fat group compared to 93% in the low fat group.

CONCLUSIONS

A low or modified fat diet during pelvic radiotherapy did not improve gastrointestinal symptom scores compared to a normal fat intake. An inadequate differential in fat intake between the groups may have confounded the results.

On resonant scatterers as a factor limiting carrier mobility in graphene

We show that graphene deposited on a substrate has a non-negligible density of atomic scale defects. This is evidenced by a previously unnoticed D peak in the Raman spectra with intensity of ∼1% with respect to the G peak. We evaluated the effect of such impurities on electron transport by mimicking them with hydrogen adsorbates and measuring the induced changes in both mobility and Raman intensity. If the intervalley scatterers responsible for the D peak are monovalent, their concentration is sufficient to account for the limited mobilities currently achievable in graphene on a substrate.

Density of states and zero Landau Level probed through capacitance of graphene

We report capacitors in which a finite electronic compressibility of graphene dominates the electrostatics, resulting in pronounced changes in capacitance as a function of magnetic field and carrier concentration. The capacitance measurements have allowed us to accurately map the density of states D, and compare it against theoretical predictions. Landau oscillations in D are robust and zero Landau level (LL) can easily be seen at room temperature in moderate fields. The broadening of LLs is strongly affected by charge inhomogeneity that leads to zero LL being broader than other levels.

Gate tunable infrared phonon anomalies in bilayer graphene

We observe a giant increase of the infrared intensity and a softening of the in-plane antisymmetric phonon mode E(u) ( approximately 0.2 eV) in bilayer graphene as a function of the gate-induced doping. The phonon peak has a pronounced Fano-like asymmetry. We suggest that the intensity growth and the softening originate from the coupling of the phonon mode to the narrow electronic transition between parallel bands of the same character, while the asymmetry is due to the interaction with the continuum of transitions between the lowest hole and electron bands. The growth of the peak can be interpreted as a "charged-phonon" effect observed previously in organic chain conductors and doped fullerenes, which can be tuned in graphene with the gate voltage.

Self-assessment of morbidity following radical hysterectomy for cervical cancer

The aim of this study was to assess the magnitude of the morbidity following radical surgery for early stage cervical cancer. We performed a retrospective survey of all women who had undergone a radical hysterectomy and lymphadenectomy between the months of July 1995 and December 1996 inclusive at either the Royal Marsden or St George's Hospital (n =38), using a detailed questionnaire on bladder, ano-rectal and sexual function, both before and after treatment. Sixteen women (44.4%) received adjuvant radiotherapy. The mean interval between surgery and inquiry was 16.4% months (range 8-25 months). The mean age at the time of surgery was 40.5 years. Thirty-six out of 38 women contacted responded (94.7%). Overall 33 women (91.7%) reported new bladder, ano-rectal or sexual symptoms. Complaints of urinary incontinence, particularly of urge incontinence, and of voiding difficulties increased significantly after surgery (P <0.05). However, only 5.3% of women had sought treatment. Tenesmus increased significantly (P <0.05), while increases in diarrhoea and faecal incontinence were not statistically significant (P =0.051). Although 12.9% of women stated an improvement in their sex lives, 54.8% thought that their sex life was worse after treatment, and 12.9% of women had ceased sexual activity altogether. Of women of childbearing age 53.8% felt adversely affected by their loss of fertility. Bladder, ano-rectal and sexual symptoms are very common following radical hysterectomy for cervical cancer, with adverse effect on quality of life, and persist into the second year after treatment.

Control of graphene's properties by reversible hydrogenation: evidence for graphane

Although graphite is known as one of the most chemically inert materials, we have found that graphene, a single atomic plane of graphite, can react with atomic hydrogen, which transforms this highly conductive zero-overlap semimetal into an insulator. Transmission electron microscopy reveals that the obtained graphene derivative (graphane) is crystalline and retains the hexagonal lattice, but its period becomes markedly shorter than that of graphene. The reaction with hydrogen is reversible, so that the original metallic state, the lattice spacing, and even the quantum Hall effect can be restored by annealing. Our work illustrates the concept of graphene as a robust atomic-scale scaffold on the basis of which new two-dimensional crystals with designed electronic and other properties can be created by attaching other atoms and molecules.

Adjuvant external beam radiotherapy in the treatment of endometrial cancer (MRC ASTEC and NCIC CTG EN.5 randomised trials): pooled trial results, systematic review, and meta-analysis

BACKGROUND

Early endometrial cancer with low-risk pathological features can be successfully treated by surgery alone. External beam radiotherapy added to surgery has been investigated in several small trials, which have mainly included women at intermediate risk of recurrence. In these trials, postoperative radiotherapy has been shown to reduce the risk of isolated local recurrence but there is no evidence that it improves recurrence-free or overall survival. We report the findings from the ASTEC and EN.5 trials, which investigated adjuvant external beam radiotherapy in women with early-stage disease and pathological features suggestive of intermediate or high risk of recurrence and death from endometrial cancer.

METHODS

Between July, 1996, and March, 2005, 905 (789 ASTEC, 116 EN.5) women with intermediate-risk or high-risk early-stage disease from 112 centres in seven countries (UK, Canada, Poland, Norway, New Zealand, Australia, USA) were randomly assigned after surgery to observation (453) or to external beam radiotherapy (452). A target dose of 40-46 Gy in 20-25 daily fractions to the pelvis, treating five times a week, was specified. Primary outcome measure was overall survival, and all analyses were by intention to treat. These trials were registered ISRCTN 16571884 (ASTEC) and NCT 00002807 (EN.5).

FINDINGS

After a median follow-up of 58 months, 135 women (68 observation, 67 external beam radiotherapy) had died. There was no evidence that overall survival with external beam radiotherapy was better than observation, hazard ratio 1.05 (95% CI 0.75-1.48; p=0.77). 5-year overall survival was 84% in both groups. Combining data from ASTEC and EN.5 in a meta-analysis of trials confirmed that there was no benefit in terms of overall survival (hazard ratio 1.04; 95% CI 0.84-1.29) and can reliably exclude an absolute benefit of external beam radiotherapy at 5 years of more than 3%. With brachytherapy used in 53% of women in ASTEC/EN.5, the local recurrence rate in the observation group at 5 years was 6.1%.

INTERPRETATION

Adjuvant external beam radiotherapy cannot be recommended as part of routine treatment for women with intermediate-risk or high-risk early-stage endometrial cancer with the aim of improving survival. The absolute benefit of external beam radiotherapy in preventing isolated local recurrence is small and is not without toxicity.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy

BACKGROUND

Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one-third of total calories for 3 weeks.

AIM

To assess the feasibility and efficacy of replacing one-third of normal diet with elemental diet during the first 3 weeks of pelvic radiotherapy in reducing acute gastrointestinal toxicity.

METHODS

Patients were randomized to elemental diet or no intervention. Toxicity was assessed using the Inflammatory Bowel Disease Questionnaire, Vaizey Incontinence scale and Radiation Therapy Oncology Group tool. Faecal calprotectin measured intestinal mucosal inflammation.

RESULTS

Twenty-nine women and 21 men, median age 61.5 years were randomized. Patients taking elemental diet did not have lower gastrointestinal toxicity ratings or inflammatory markers (P > 0.2). The mean dose taken was 21% (2-36%) of total caloric requirements.

CONCLUSIONS

Patients cannot tolerate large volumes of oral elemental diet. The quantities consumed in this study produced no therapeutic benefit. Future studies should aim to replace a higher proportion of nutritional intake for a longer duration of radiotherapy treatment.

Can biological markers act as non-invasive, sensitive indicators of radiation-induced effects in the gastrointestinal mucosa?

BACKGROUND

Reliable, non-invasive biological markers of the severity of radiotherapy-induced damage to the gastrointestinal tract are not available. Clinicians continue to use symptom scores as surrogate indicators of toxicity.

AIM

To determine whether levels of potential biochemical markers of mucosal toxicity change during pelvic radiotherapy.

METHODS

Fifty-nine patients (30:29 males:females) with mixed pelvic malignancies, receiving 45-70 Gy were recruited. At baseline and weeks 4 or 5 of radiotherapy, blood samples for citrulline, C-reactive protein, eosinophil cationic protein and stool samples for faecal calprotectin were obtained. Symptoms were measured using the Inflammatory Bowel Disease Questionnaire - Bowel Subset, Radiation Therapy Oncology Group and Vaizey Incontinence Questionnaires. Paired t-tests of change in marker values were calculated.

RESULTS

Citrulline (P = 0.02) and faecal calprotectin (P = 0.01) values changed significantly between baseline and 4/5 weeks. Inflammatory Bowel Disease Questionnaire - Bowel Subset fell significantly (mean fall = 10 points, s.d.: 8.9). Changes in markers did not correlate with symptoms.

CONCLUSIONS

Some biochemical markers of mucosal toxicity change significantly during treatment. Further studies must investigate the timing of changes of these biochemical markers, their relationship to gastrointestinal physiological change and the radiotherapy dose delivered to the gastrointestinal tract and whether changes in markers acutely can predict the degree of long-term gastrointestinal dysfunction.

Detection of individual gas molecules adsorbed on graphene

The ultimate aim of any detection method is to achieve such a level of sensitivity that individual quanta of a measured entity can be resolved. In the case of chemical sensors, the quantum is one atom or molecule. Such resolution has so far been beyond the reach of any detection technique, including solid-state gas sensors hailed for their exceptional sensitivity. The fundamental reason limiting the resolution of such sensors is fluctuations due to thermal motion of charges and defects, which lead to intrinsic noise exceeding the sought-after signal from individual molecules, usually by many orders of magnitude. Here, we show that micrometre-size sensors made from graphene are capable of detecting individual events when a gas molecule attaches to or detaches from graphene's surface. The adsorbed molecules change the local carrier concentration in graphene one by one electron, which leads to step-like changes in resistance. The achieved sensitivity is due to the fact that graphene is an exceptionally low-noise material electronically, which makes it a promising candidate not only for chemical detectors but also for other applications where local probes sensitive to external charge, magnetic field or mechanical strain are required.

Adjuvant external beam radiotherapy (EBRT) in the treatment of endometrial cancer: Results of the randomised MRC ASTEC and NCIC CTG EN.5 trial

5504

Background: Patients with stage I endometrial cancer at high risk of relapse generally receive adjuvant EBRT following surgery, despite lack of evidence that radiotherapy improves overall survival (OS). ASTEC/EN.5 was designed to investigate whether OS is improved by adjuvant EBRT. An important secondary outcome was pelvic recurrence-free survival. Methods: Patients were randomised to receive immediate EBRT (with linear accelerator delivering 40–46Gy in 20–25 fractions to pelvis) or no EBRT until clinically indicated. Vault brachytherapy (4Gy in 2 fractions (HDR) or 15Gy (LDR)) could be used regardless of EBRT allocation. Centers were required to specify in advance whether brachytherapy would be offered to all patients or to none. The study was powered both to 1) detect a 9–10% absolute improvement in 5-year OS with adjuvant EBRT; and 2) reliably exclude an absolute 5% difference in 5-year OS when combined with other major studies (PORTEC and GOG 99). Results: Between Oct 1996 to Apr 2005, 906 patients (452 EBRT, 454 no EBRT) were randomised internationally. Pre-treatment characteristics were well balanced: median age 66 years; 98% of women WHO PS 0–1; 30% with lymph nodes removed at surgery; 84% endometrioid histology; depth of invasion to endometrium only, inner half and outer half of myometrium 3%, 20% and 77%, respectively; degree of differentiation to grade 1, 2, and 3 26%, 42%, and 31%, respectively. 92% patients in EBRT arm received immediate treatment, 90% receiving all protocol specified treatment. 2% patients in no EBRT arm received immediate EBRT. Brachytherapy was given to 52% patients in both arms. Morbidity was higher in EBRT arm, 56% compared with 24% in no EBRT arm reporting complications of treatment. Grade 3 or higher toxicity was rare. With a median follow-up of 46 months at the time of analysis, 117(13%) have died and 136(17%) have recurred or died. 130 deaths are required to detect a 10% difference in 5-year OS with 5% significance level and 90% power and this will be achieved by April 2007. Conclusions: Compliance was high. Serious complications were rare. The ASTEC/EN.5 trial alone and in combination with PORTEC and GOG99 will answer the question of the benefit of post-operative adjuvant EBRT in patients with endometrial cancer.

No significant financial relationships to disclose.

Recurrent endometrial cancer: patterns of recurrent disease and assessment of prognosis

AIM

To evaluate patterns of disease and identify factors predicting outcome in patients presenting with recurrent endometrial adenocarcinoma following primary surgery.

MATERIALS AND METHODS

A retrospective review was performed of the imaging and clinical data in 86 patients (median age 66 years, range 42-88 years) presenting with recurrent endometrial adenocarcinoma following primary surgery.

RESULTS

Following primary surgery recurrent disease occurred within 2 years in 64% and within 3 years in 87%. Relapse was seen within lymph nodes in 41 (46%), the vagina in 36 (42%) the peritoneum in 24 (28%) and the lung in 21 (24%). Unusual sites of disease included spleen, pancreas, rectum, muscle and brain. Univariate survival analysis showed the factors significant for poor outcome were: multiple sites of disease, liver and splenic disease, haematogenous, peritoneal and nodal spread, poorly differentiated tumour, and early relapse. The presence of disease within the vagina, bladder or lung was not associated with poor prognosis. Multivariate analysis identified multiple sites of disease, liver and splenic metastases to be independent predictors of poor outcome.

CONCLUSION

The most frequently observed sites of relapse are: lymph nodes, vagina, peritoneum and lung. Significant predictors of poor outcome in recurrent disease are multiple sites of disease and liver and splenic metastases.

Movement of the cervix in after-loading brachytherapy: implications for designing external-beam radiotherapy boost fields

AIMS

Women with invasive carcinoma of the cervix treated by chemo-radiotherapy and brachytherapy may also receive a pelvic sidewall boost using a midline shield (MLS). The purpose of this study was to assess the usefulness of implanted gold grains in detecting the movement of the cervix caused by the insertion of low-dose-rate brachytherapy applicators, and its implications in designing the MLS.

MATERIALS AND METHODS

The medical records of 42 women with various stages of cervical carcinoma, who were treated by radical chemo-radiotherapy, were reviewed. All of these women underwent examination under anaesthesia (EUA) and a gold-grain insertion to demarcate the vaginal tumour extent, in the antero-posterior and lateral planes, before starting external-beam radiotherapy. The isocentric orthogonal films (simulator films) of external radiotherapy and brachytherapy were compared to assess the change in position of the gold grains and the consequences for the design of the MLS for parametrial and pelvic sidewall boosts.

RESULTS

A significant shift in the position of the gold grains was noted in both the x (lateral) and the y (cranial/caudal) axes. The median shift of the midline, right and left lateral gold grains was 4.5, 5 and 7 mm in the x axis, whereas it was 10, 8 and 9.5 mm in the y axis, respectively. The median shift in the x and y axes was 5.5 and 9 mm, ranging from 1 to 40 mm and 1 to 45 mm, respectively. The gold grains were shifted cranially in 34 (80%) and laterally in 29 (69%) women. Thirty-two women (76.2%) received parametrial boost radiotherapy, of which 25 (59.5%) women had a customised, pear-shaped shield, and the remaining seven (16.7%) had a straight-sided, rectangular MLS. Four women (9.5%) relapsed locally, and three of them had been treated using a customised shield. In two of these four women, there was an absolute under-dosage of the central pelvis at the tip of the intra-uterine tube by 50% of the parametrial boost dose (5.4 Gy/3 fractions/3 days).

CONCLUSIONS

Insertion of the gold grains during pre-treatment EUA is a useful technique in detecting the movement of the cervix. A significant shift in the position of the gold grains was noted in both the x (lateral) and the y (cranial/caudal) axes. These shifts in the cervix can result in under-dosage of the central pelvis when delivering parametrial boosts with the MLS in place on the basis of the brachytherapy check films. When designing the individualised MLS, the resulting under-dosage could be avoided by taking account of the shift in the gold grain markers and allow the delivery of a more homogenous dose to the pelvis.

Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva

We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.

Evaluation of a software package for automated quality assessment of contrast detail images—comparison with subjective visual assessment

Contrast detail analysis is commonly used to assess image quality (IQ) associated with diagnostic imaging systems. Applications include routine assessment of equipment performance and optimization studies. Most frequently, the evaluation of contrast detail images involves human observers visually detecting the threshold contrast detail combinations in the image. However, the subjective nature of human perception and the variations in the decision threshold pose limits to the minimum image quality variations detectable with reliability. Objective methods of assessment of image quality such as automated scoring have the potential to overcome the above limitations. A software package (CDRAD analyser) developed for automated scoring of images produced with the CDRAD test object was evaluated. Its performance to assess absolute and relative IQ was compared with that of an average observer. Results show that the software does not mimic the absolute performance of the average observer. The software proved more sensitive and was able to detect smaller low-contrast variations. The observer's performance was superior to the software's in the detection of smaller details. Both scoring methods showed frequent agreement in the detection of image quality variations resulting from changes in kVp and KERMA(detector), which indicates the potential to use the software CDRAD analyser for assessment of relative IQ.

Do serum levels of eosinophil granule-derived protein change in patients undergoing pelvic radiotherapy?

AIMS

Eosinophils have an important role in the pathogenesis of inflammatory bowel disease, with faecal levels of the eosinophil granule proteins, eosinophil cationic protein (ECP) and eosinophil protein X (EPX) reflecting disease activity. Eosinophil crypt abscesses are a characteristic histological finding in acute gastrointestinal radiation-induced mucosal damage. This pilot study aimed to investigate changes in serum levels of ECP/EPX during pelvic radiotherapy.

MATERIALS AND METHODS

Patients with no history of inflammatory bowel disease, starting a 5-week course of pelvic radiotherapy, had serum ECP/EPX levels measured before radiotherapy and during the fourth week of treatment. Bowel toxicity was graded at week 4 using the Common Toxicity Criteria Scale.

RESULTS

Fifteen patients who were to undergo adjuvant radiotherapy for gynaecological cancer were recruited. The mean serum levels of ECP and EPX before treatment were 17.3 microg/l (range 2.0-49.3 microg/l) and 37.3 microg/l (range 12.0-94.0 microg/l), respectively. The mean serum levels during week 4 of radiotherapy for ECP and EPX were 43.0 microg/l (range 2.4-164.0 microg/l) and 38.7 microg/l (range 9.0-79.0 microg/l), respectively. Serum ECP levels increased at week 4 compared with levels before radiotherapy (P = 0.02). Acute bowel toxicity was seen in 12 patients (80%) at week 4: Grade 1 in 25% patients and Grade 2 in 75%. In this small study, no correlation was seen between acute bowel toxicity at week 4 and serum ECP or EPX levels.

CONCLUSIONS

Serum ECP levels increase in response to pelvic irradiation. This may reflect the known involvement of eosinophils in the acute response to radiotherapy. Further study is required to determine when levels start to rise and their relationship to the degree of acute bowel toxicity.

Is supplementation with elemental diet feasible in patients undergoing pelvic radiotherapy?

BACKGROUND

Acute gastrointestinal upset occurs in approximately 80% of patients undergoing radiotherapy for pelvic cancers. Underlying changes relate to denudation of the mucosal layer which renders the small intestine vulnerable to additional damage from proteolytic enzymes and bile acids. Severe acute bowel symptoms may predispose to progressive fibrotic and ischaemic changes. Elemental diet given during treatment may reduce acute and chronic bowel symptoms induced by pelvic radiotherapy.

METHODS

This study aimed to assess compliance with elemental diet during pelvic radiotherapy. Patients with gynaecological, urological or rectal malignancy undergoing radical or adjuvant pelvic radiotherapy were randomised to one of five groups. Each group was assigned a target quantity of three different elemental sip feeds (Group 1, 20%, Group 2, 50%, Group 3, 75% of calorie requirements taken as E028 extra liquid; Group 4, 50% of calorie requirements taken as E028 extra powder; Group 5, 50% of calorie requirements taken as Emsogen powder). Compliance was assessed using a diary card and weekly assessment. Statistical analyses were conducted on an intention to treat basis.

RESULTS

Fifty patients (44 female, six male) mean age 58 yr (95% CI 55-61), were recruited to the study (24 endometrial, 17 cervical, 7 rectal, 1 vulval and 1 bladder carcinoma). Mean weight at baseline was 74.5 kg (95% CI 69-80) and this did not change during treatment. Full compliance was achieved in three patients, all from Group 1. By week 5, only 46% of patients were consuming elemental diet. Post hoc analysis of variance with repeated measures indicated that there were no significant differences in volume of elemental diet consumed between groups (P = 0.937). There was a significant inverse linear relationship between intake of elemental diet and time (P < 0.001).

CONCLUSIONS

Different formulations of elemental diet do not influence compliance. Patients are unlikely to be able to consume more than one-third of their calorie requirements in the form of an elemental sip feed. Further investigation is warranted to determine if intervention with this volume of elemental diet is beneficial.

A modified Inflammatory Bowel Disease questionnaire and the Vaizey Incontinence questionnaire are simple ways to identify patients with significant gastrointestinal symptoms after pelvic radiotherapy

After radiotherapy for pelvic cancer, chronic gastrointestinal problems may affect quality of life (QOL) in 6–78% of patients. This variation may be due to true differences in outcome in different diseases, and may also represent the inadequacy of the scales used to measure radiotherapy-induced gastrointestinal side effects. The aim of this study was to assess whether outcome measures used for nonmalignant gastrointestinal disease are useful to detect gastrointestinal morbidity after radiotherapy. Results obtained from a Vaizey Incontinence questionnaire and a modified Inflammatory Bowel Disease questionnaire (IBDQ) – both patient completed – were compared to those from a staff administered Late Effects on Normal Tissue (LENT) – Subjective, Objective, Management and Analytic (SOMA) questionnaire in patients who had completed radiotherapy for a pelvic tumour at least 3 months previously. In all, 142 consecutive patients were recruited, 72 male and 70 female, median age 66 years (range 26–90 years), a median of 27 (range 3–258) months after radiotherapy. In total, 62 had been treated for a gynaecological, 58, a urological and 22, a gastrointestinal tract tumour. Of these, 21 had undergone previous gastrointestinal surgery and seven suffered chronic gastrointestinal disorders preceding their diagnosis of cancer. The Vaizey questionnaire suggested that 27% patients were incontinent for solid stools, 35% for liquid stools and 37% could not defer defaecation for 15 min. The IBDQ suggested that 89% had developed a chronic change in bowel habit and this change significantly affected 49% patients: 44% had more frequent or looser bowel movements, 30% were troubled by abdominal pain, 30% were troubled by bloating, 28% complained of tenesmus, 27% were troubled by their accidental soiling and 20% had rectal bleeding. At least 34% suffered emotional distress and 22% impairment of social function because of their bowels. The small intestine/colon SOMA median score was 0.1538 (range 0–1) and the rectal SOMA median score was 0.1428 (range 0–1). Pearson's correlations for the IBDQ score and small intestine/colon SOMA score was −0.630 (P<0.001), IBDQ and rectum SOMA −0.616 (P<0.001), IBDQ and Vaizey scores −0.599 (P<0.001), Vaizey and small intestine/colon SOMA 0.452 (P<0.001) and Vaizey and rectum SOMA 0.760 (P<0.001). After radiotherapy for a tumour in the pelvis, half of all patients develop gastrointestinal morbidity, which affects their QOL. A modified IBDQ and Vaizey questionnaire are reliable in assessing new gastrointestinal symptoms as well as overall QOL and are much easier to use than LENT SOMA.

The significance of rectal bleeding after pelvic radiotherapy

BACKGROUND

Rectal bleeding after pelvic radiotherapy is often attributed to radiation proctitis and patients do not routinely undergo flexible endoscopy.

AIMS

To assess the significance of bleeding after radiotherapy.

METHODS

We maintained a prospective register of all such patients referred to our endoscopy unit.

RESULTS

One hundred and thirty-nine men (median age 70 years; range 31-82), and 32 women (median age 61 years; range 30-81) were referred with rectal bleeding (median 2 years; range 0-21) after pelvic radiotherapy. Primary tumour sites were urological (n = 139), gastrointestinal (n = 7) and gynaecological (n = 25). Ninety patients had bleeding alone; 81 had other symptoms. One hundred and forty-one had typical radiation proctitis; in 65 this was the sole diagnosis; eight had cancer, nine had high-risk adenomas, and six had three or more small adenomas. Ninety-five other diagnoses were made. Eleven (73%) patients with advanced polyps or cancer required only flexible sigmoidoscopy to make the diagnosis, while four (27%) diagnoses were made only after colonoscopy; 47% of these patients had no other symptoms apart from rectal bleeding.

CONCLUSIONS

After pelvic radiotherapy, clinical symptoms are not reliable in differentiating between radiation proctitis alone or more significant pathology. It is mandatory that all patients with new onset rectal bleeding are investigated with, at least, flexible sigmoidoscopy.

Treatment of uterine sarcoma at the Royal Marsden Hospital from 1974 to 1998

AIMS

Uterine sarcomas are rare tumours with histopathological diversity characterised by rapid clinical progression and poor prognosis. Optimal management consists of complete surgical removal, but is not clear whether adjuvant radiotherapy improves the prognosis. The aim of this retrospective study was to investigate the clinical and histopathological characteristics together with treatment and outcome of patients with uterine sarcomas.

MATERIALS AND METHODS

Records of 100 patients treated at the Royal Marsden Hospital between 1974-1998 were reviewed: 47 leiomyosarcoma (LMS), 30 mixed mullerian tumours (MMT), 19 endometrial stromal sarcoma (ESS), one haemangiopericytoma, one rhabdomyosarcoma and two unspecified sarcoma. There were 50, 11, 21 and 18 patients with stage I, II, III and IV carcinoma, respectively. Thirty-four patients had high-grade disease. Fifty-three patients received adjuvant radiotherapy. The median age was 55 years (range: 18-83 years). The median follow-up was 54 months (range: 3 months to 27 years).

RESULTS

The overall 3, 5 and 10-year survival rates were 39%, 30% and 20%, respectively. Survival was significantly related to stage (P = 0.002), grade (P = 0.003) and histological type (P = 0.04), but not to use of postoperative irradiation. At 3 years, the survival rate was 42% for LMS, 22% for MMT and 63% for ESS. Local recurrence rate, however, was significantly improved after adjuvant radiotherapy with dose higher than 50 Gy (P = 0.001).

CONCLUSIONS

Prognosis is dependent on histopathological sub-type, grade and tumour stage. Adjuvant radiotherapy decreases local recurrence rate, but without significant impact on survival.

Uterine sarcoma: twenty-seven years of experience

PURPOSE

A correlation of treatment for uterine sarcoma with outcome, prognostic importance of pathology, and clinical parameters.

PATIENTS AND METHODS

One hundred forty-one patients (median age: 56 years, range: 19-85 years) with a histologically verified uterine sarcoma were identified from a database compiled at the Royal Marsden Hospital and the University of Florence between 1974 and 2001. Seventy-two patients had leiomyosarcoma, 42 had mixed müllerian tumors, 22 had endometrial stromal sarcoma, 1 hemangiopericytoma, 1 rhabdomyosarcoma, and 3 patients had unspecified sarcoma. According to FIGO classification, Stage I, II, III, and IV tumors were identified in 71, 13, 31, and 26 patients, respectively.

RESULTS

At the time of analysis, 73.7% of patients were dead, and 26.3% were alive with a median survival of 2 years from initial diagnosis. Univariate analysis for cause-specific survival demonstrated statistical significance for histology (p = 0.02), grade (p = 0.003), stage (p = 0.007), and age (p = 0.02). Multivariate analysis demonstrated significant prognostic values for stage (p = 0.02) and histology (p = 0.05) only. Postoperative radiotherapy with a total dose higher than 50 Gy seems to be significant (p = 0.001) in reducing local recurrence.

CONCLUSIONS

Our data favor treatment for Stages I, II, and III of uterine sarcoma with radical surgery plus radical dose irradiation comprising both external beam radiotherapy and brachytherapy.

Vulvar soft tissue tumors

OBJECTIVE

To report our incidence of soft tissue tumors at this site and to discuss various prognostic factors.

METHODS

All patients with a diagnosis of vulvar soft tissue neoplasms were studied from a prospective database at the Royal Marsden Hospital between January 1985 and July 2001.

RESULTS

Seventeen vulvar soft tissue neoplasms (11 malignant and six benign) were treated during this period. Leiomyosarcoma (n = 5) and aggressive angiomyxoma (n = 4) were the most frequent histologic types. According to the grade, there were four G3, three G2, three G1 and could not be assessed in one patient. Local recurrence occurred in six patients with sarcoma (three with high grade and one each with intermediate, low, and undetermined grade). In this group, five patients had negative microscopic margins and one patient had positive microscopic margins on excision. All three women with low-grade sarcomas are alive without evidence of disease. Three patients with aggressive angiomyxoma also had a local recurrence.

CONCLUSION

Surgical excision is the primary treatment where possible. The grade of the tumor is an important predictor for local recurrence and outcome. Aggressive angiomyxoma is a local problem. Leiomyosarcoma and aggressive angiomyxoma are the most frequent histologic types.