Clinical Outcomes for Patients with Brain Metastases from Upper Gastrointestinal Cancer Treated with Stereotactic Radiosurgery

PURPOSE/OBJECTIVE(S)

Prior studies have reported outcomes for brain metastases from gastrointestinal (GI) primary cancers treated with stereotactic radiosurgery (SRS); however, most include a majority of colorectal cancer. Few studies specifically evaluate SRS treatment response for brain metastases from upper GI cancers. We report our institutional outcomes for patients with upper GI cancers who were treated with SRS for brain metastases.

MATERIALS/METHODS

Patients with an upper GI cancer who underwent SRS for brain metastases between 1991 and 2021 were retrospectively reviewed from a single institution IRB-approved database. The primary endpoint was local failure (LF) and secondary endpoint was overall survival (OS). LF was estimated using the Cumulative Incidence Function with death as a competing risk. Survival analysis was performed with the Kaplan-Meier Method. Predictors of cumulative incidence of LF were assessed using competing risk regression.

RESULTS

Forty-nine patients with 107 brain metastases were analyzed. Forty-two (86%) patients were male. The median follow-up time was 6.7 months (range: 0.4-61.7 months) and median OS was 7.5 months (range: 0.9-61.7 months). The median Karnofsky Performance Score (KPS) was 80 (range: 40-100). The primary disease site was esophagus in 87 (81%) lesions, pancreas in 10 (9.3%) lesions, stomach in 5 (4.7%) lesions, liver in 2 (1.9%) lesions, gallbladder in 2 (1.9%) lesions, and small intestine in 1 (0.9%) lesion. The median metastasis size was 1.4 cm (range: 0.3-6.7 cm). The median prescription dose and fraction number were 24 Gy (range: 14-30 Gy) and 1 fraction (range: 1-2 fractions), respectively. The cumulative incidence of LF at 6 and 12 months was 5.6% (95% CI: 2.3-11%) and 12% (95% CI: 6.9-20%), respectively. Overall survival at 6 and 12 months was 59% (95% CI: 50-69%) and 35% (95% CI: 27-46%), respectively. On univariate analysis, female gender (HR = 0.19, 95% CI: 0.06-0.61, p = 0.005), Black race (HR = 0.09, 95% CI: 0.03-0.23, p = <0.001), and larger tumors (HR = 1.35, 95% CI: 1.03-1.78, p = 0.03) were significantly associated with local failure.

CONCLUSION

SRS for brain metastases from upper GI cancers is an appropriate treatment option and provides excellent local control. Unlike prior studies that have reported lower local control rates for all GI cancers with brain metastases treated with SRS, our data show that local failure rates in brain metastases from upper GI cancers specifically are more consistent with previously published data from other disease sites. Further studies evaluating SRS treatment response for brain metastases from GI cancers should separate upper GI and lower GI cancers.

Does prehospital time affect survival of major trauma patients where there is no prehospital care?

BACKGROUND

Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care.

MATERIALS AND METHODS

This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as "prehospital time" for the directly arriving patients and as "time to tertiary care" for those transferred. Primary outcome measure was in-hospital death (or discharge).

RESULTS

Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233-2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility.

CONCLUSION

Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.

Is ‘Clicky Hip’ a Risk Factor in Developmental Dysplasia of the Hip?

Background: The role of the ‘clicky hip’ symptom as a prognostic predictor of developmental dysplasia of hip (DDH) is controversial. We aim to study the role of isolated hip clicks as a prognostic predictor of DDH. Material and methods: 235 babits with persisting or referred with clicky hip beyond six weeks of age were prospectively followed up to note the incidence of DDH. Of these 176 babies were referred for a hip click without additional risk factors. Results: 7 out of 176 cases (4 - IIa, 2 - IIb, 1 - IIc) had initial abnormal ultrasound examination based on Graf classification. However, all babies with isolated hip clicks eventually had normal hips on clinical and radiographic examination. Discussion: While screening of babies with clicky hips does help in diagnosing the odd case of DDH this is not consistently reproducible. Modifying the targeted ultrasound screening by including clicky hip as a risk factor will not reduce the incidence of missed cases. Isolated clicks in the hip joint beyond six weeks age are rarely a predictor of DDH. However when in doubt such cases should be referred to be reviewed by an orthopaedic surgeon or a radiologist experienced in hip ultrasound.

Impact of obesity severity and duration on pancreatic β- and α-cell dynamics in normoglycemic non-human primates

OBJECTIVE

Obesity is associated with high insulin and glucagon plasma levels. Enhanced β-cell function and β-cell expansion are responsible for insulin hypersecretion. It is unknown whether hyperglucagonemia is due to α-cell hypersecretion or to an increase in α-cell mass. In this study, we investigated the dynamics of the β-cell and α-cell function and mass in pancreas of obese normoglycemic baboons.

METHODS

Pancreatic β- and α-cell volumes were measured in 51 normoglycemic baboons divided into six groups according to overweight severity or duration. Islets morphometric parameters were correlated to overweight and to diverse metabolic and laboratory parameters.

RESULTS

Relative α-cell volume (RαV) and relative islet α-cell volume (RIαV) increased significantly with both overweight duration and severity. Conversely, in spite of the induction of insulin resistance, overweight produced only modest effects on relative β-cell volume (RβV) and relative islet β-cell volume (RIβV). Of note, RIβV did not increase neither with overweight duration nor with overweight severity, supposedly because of the concomitant, greater increase in RIαV. Baboons' body weights correlated with serum levels of interleukin-6 and tumor necrosis factor-α soluble receptors, demonstrating that overweight induces abnormal activation of the signaling of two cytokines known to impact differently β- and α-cell viability and replication.

CONCLUSION

In conclusion, overweight and insulin resistance induce in baboons a significant increase in α-cell volumes (RαV, RIαV), whereas have minimal effects on the β cells. This study suggests that an increase in the α-cell mass may precede the loss of β cells and the transition to overt hyperglycemia and diabetes.

Co-trimoxazole-induced myopia in an HIV-positive patient

Co-trimoxazole is a commonly used drug in the treatment and prophylaxis of opportunistic infections in HIV seropositive patients. We report a case of a 35-year-old HIV-infected man who presented with blurring of vision one week following initiation of co-trimoxazole therapy. A diagnosis of co-trimoxazole-induced myopia, a known idiosyncratic drug reaction, was made. The drug was withheld and the myopia resolved completely. Although in this patient the ocular condition resolved completely, serious ocular adverse reactions have also been reported with co-trimoxazole. This case report highlights the occurrence of ocular adverse drug reactions (ADRs) in HIV-infected patients on co-trimoxazole and the complexity of drug interactions.

A rare case of Histoplasma fungemia in an AIDS patient

Disseminated cases of histoplasmosis in acquired immune deficiency syndrome (AIDS) are rarely reported from India. Most of these cases report isolation of this fungus from the bone marrow, lymph node aspirate, spleenic aspirate, and biopsies. We report isolation of Histoplasma capsulatum from the blood of an AIDS patient. A 30-year-old male from Utter Pradesh was admitted with fever, loss of appetite, and nausea since two months. Few intracellular and extracellular budding cells were observed on bone marrow examination on the fifth day of admission. Diagnosis was confirmed by blood cultures taken on the 11th day of admission. Amphotericin B was started, but the patient's condition deteriorated and he died.

Impaired regulation of the TNF-alpha converting enzyme/tissue inhibitor of metalloproteinase 3 proteolytic system in skeletal muscle of obese type 2 diabetic patients: a new mechanism of insulin resistance in humans

AIMS/HYPOTHESIS

TNF-alpha levels are increased in obesity and type 2 diabetes. The regulation of TNF-alpha converting enzyme (TACE) and its inhibitor, tissue inhibitor of metalloproteinase 3 (TIMP3), in human type 2 diabetes is unknown.

METHODS

We examined TACE/TIMP3 regulation: (1) in lean and obese normal glucose tolerant (NGT) individuals and in type 2 diabetes patients; (2) following 6 h of lipid/saline infusion in NGT individuals; and (3) in cultured human myotubes from lean NGT individuals incubated with palmitate. Insulin sensitivity was assessed by a euglycaemic clamp and TACE/TIMP3 was evaluated by confocal microscopy, RT-PCR, western blotting and an in vitro activity assay. Circulating TNF-alpha, TNF-alpha-receptor 1 (TNFR1), TNF-alpha-receptor 2 (TNFR2), IL-6 receptor (IL-6R), vascular cell adhesion molecule (VCAM) and intercellular adhesion molecule (ICAM) levels were evaluated.

RESULTS

TIMP3 levels were reduced and TACE enzymatic activity was increased in type 2 diabetes skeletal muscle. TACE expression, and TACE, TNF-alpha, TNFR1 and IL-6R levels were increased in type 2 diabetes, and positively correlated with insulin resistance. A 6 h lipid infusion into NGT individuals decreased insulin-stimulated glucose metabolism by 25% with increased TACE, decreased expression of the gene encoding TIMP3 and increased IL-6R release. Palmitate induced a dramatic reduction of TIMP3 and increased the TACE/TIMP3 ratio in cultured myotubes.

CONCLUSIONS/INTERPRETATION

TACE activity was increased in skeletal muscle of obese type 2 diabetes patients and in lipid-induced insulin resistance. We propose that dysregulation of membrane proteolysis by TACE/TIMP3 of TNF-alpha and IL-6R is an important factor for the development of skeletal muscle insulin resistance in obese type 2 diabetes patients by a novel autocrine/paracrine mechanism.

Potential pitfalls of a double PCL sign

The double posterior cruciate ligament (PCL) sign is seen on a midline sagittal MR image of the knee as a low-signal-intensity linear band paralleling the antero-inferior part of the PCL. Although the sign has a high specificity for a displaced bucket-handle tear of the medial meniscus, it can be mimicked by several normal and abnormal structures in the intercondylar region. Familiarity with these variants and identifying the other features supportive of meniscal injury will help to make a confident diagnosis of bucket-handle tear of the medial meniscus.

CT appearances of talc pleurodesis

AIM

To report the computed tomography (CT) appearances of talc pleurodesis in the management of patients with pleural effusions and spontaneous pneumothorax.

MATERIALS AND METHODS

The post-pleurodesis CT studies of 16 patients obtained over a 5-year period were reviewed. The mean age was 63 years (range 41-79 years). Ten patients were male. After pleurodesis, nine patients underwent a single chest CT examination and seven patients underwent more than one.

RESULTS

The characteristic finding observed in all patients, except one, was the presence of high-density deposits in the posterior basal regions of the pleural space. These were typically linear in seven patients, nodular in two, and a combination of linear and nodular in six. In five patients talc deposits were present on both the visceral and parietal pleura separated by an effusion (a variant of the split pleura sign). Talc deposits extended into an interlobar fissure with associated fissural thickening in five patients. In patients who underwent more than one CT study, the appearances remained stable.

CONCLUSIONS

The typical finding was the presence of high attenuation areas in the posterior basal regions of the pleural space. Two new appearances were observed: extension of talc deposits into the fissure and the presence of a variant of the split pleura sign. It is important to recognize these CT appearances so as not to confuse them with other conditions such as asbestos exposure.

Acetabular augmentation using a second cup during revision hip arthroplasty: an unusual case report

Acetabular wedge augmentation is a useful technique and is recommended in situations where cup revision is likely to be excessively difficult. Numerous augmentation designs that improve the stability of the hip are now available in the market. Occasionally, however, these devices are not readily available, particularly if problems such as instability and dislocation are not anticipated preoperatively. We report our experience in treating such a case, using an augment cut from a second cup with a follow-up for 30 months. Though there is no substitute for proper preoperative planning, awareness of this procedure is helpful as unexpected problems do arise in revision acetabular surgery.