Practical consensus recommendation on when to do BRCA testing

BRCA-mutation associated breast cancer and to future cancer risks and sensitivity to systemic therapies. Now that rapid genetic testing for BRCA1 and BRCA2 mutations is available, BRCA mutation status can be considered when making treatment and prevention decisions for BRCA testing, BRCA mutation carriers with breast cancer. Expert group used data from published literature, practical experience, and opinion of a large group of academic oncologists, to arrive at practical consensus recommendations for use by the community oncologists.

The Role and Timing of Treatment Strategies During Two-Stage Revision for Periprosthetic Joint Infections

INTRODUCTION

Prosthetic joint infection continues to be a source of significant morbidity to patients and an economic burden to society as a whole. Two-stage revision is the current gold standard for treatment of periprosthetic joint infection in North America. Despite this, much discussion persists about treatment strategies surrounding the interim of the two-stage revision and treatment beyond reimplantation. The aim of this review is to answer some of these questions, specifically: are C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) helpful prior to reimplantation, is aspiration helpful, what is the role and timing for systemic antibiotics, and is there a role for oral suppression following second-stage reimplantation?

METHODS

A literature review was completed in an attempt to address unanswered questions associated with two-stage reimplantation. Investigators' recommendations and current practices are described.

RESULTS

ESR and CRP are less reliable in the interim of a two-stage revision than for diagnosis of infection in a primary total joint arthroplasty. There is inconclusive evidence regarding the utility of joint aspiration in two-stage revisions. Additionally, no evidence has been developed for length of IV antibiotic treatment after second-stage reimplantation, and in a few studies, oral antibiotic suppression has shown some benefit in reducing reinfection rates.

CONCLUSION

The question of optimum treatment strategies has yet to be answered: attempts are underway to obtain suitable data with multi-center studies and large patient populations. Periprosthetic joint infection is a serious and life altering complication and with continued research we can further clarify treatment strategies.

Self injection of foreign materials into the penis

Injection of the subcutaneous tissues of the penis for enlargement of penile girth has been practised for many years by laypeople and medical practitioners alike. However, with recognition of the complications, the practice has died out. We report a series of five patients who presented having injected foreign materials into the subcutaneous tissues of their penises, including paraffin and mineral oils. Our patients had a variable time course of presentation ranging from 1 day following injection to over 26 years. Self-injection of the subcutaneous tissues of the penis is an unusual presentation for a penile mass but should be considered as a differential diagnosis in patients with a long latent period to presentation or with characteristic magnetic resonance imaging and histological appearances.

Minimal Invasive Management of Lymph Nodes

Penile cancer is a rare genitourinary malignancy. Lymph node involvement is the single most important factor determining survival in these patients, and those patients with occult disease are difficult to identify on conventional cross-sectional imaging. Until recently, lymph node sampling (eg, lymphadenectomy) has been the diagnostic modality of choice in the detection of micrometastasis. More recently, several novel molecular and minimally invasive diagnostic techniques have been developed, which have been demonstrated to decrease the false-negative and -positive results of conventional imaging and lymphadenectomy. This article focuses on the minimally invasive management of lymph nodes in men with penile cancer.

Schwannoma of the ansa cervicalis

Schwannomas are rare neoplasms that originate from Schwann cells. We present a case report of schwannoma of the ansa cervicalis in a patient where preoperative imaging suggested thyroid pathology. A 25-year-old man presented to the otolaryngology department with a one-year history of an asymptomatic, anterior triangle neck swelling. Imaging and FNA suggested a cystic lesion of the thyroid. However, intraoperatively, the lesion was found between the right sternohyoid and thyrohoid and histology showed findings consistent with a diagnosis of schwannoma, determined to originate from the ansa cervicalis based on its anatomical position. Schwannoma of the ansa cervicalis is extremely rare and there have only been four reported cases in the literature. Schwannomas are often misdiagnosed and confused for other lesions. In our case report we add to the sparse literature on this pathology and highlight common pitfalls in diagnosis and discuss the principles of management of this rare condition.

The Management of Stuttering Priapism within a Specialist Unit—A 25-Year Experience

Introduction:

Stuttering priapism is a rare condition characterised by recurrent prolonged erections. The condition is common in patients with sickle cell disease although a significant proportion suffer from idiopathic stuttering priapism. The management of this condition is mainly through anecdotal reports.

Methods:

We have retrospectively reviewed 60 patients with this condition in a single centre over a 25-year period. Risk factors were identified and the outcomes of both pharmacological therapies and surgical interventions were recorded.

Results:

Erections were characteristically nocturnal and painful in nature and lasted up to 72h in some patients. Analysis of the outcomes of both medical and surgical interventions has shown that the use of hormone analogues such as cyproterone acetate is the most efficacious treatment option as it allows a successful control of their erections without a significant loss of libido in 86% of patients. The most successful surgical option was the insertion of a penile prosthesis.

Conclusion:

Due to the rarity of this condition, the management is variable and based on anecdotal evidence. This study has reported our experience of the most efficacious treatment options for this condition. We also discuss the potential therapeutic role of PDE-5 inhibitors in this condition.

Stuttering priapism--a review of the therapeutic options

INTRODUCTION

Priapism is a urological emergency which is commonly classified into low-flow and high-flow priapism. Immediate intervention is required for low-flow cases as the development of ischaemia ultimately leads to long-term erectile dysfunction. Stuttering or recurrent priapism is less well understood. This subtype is characterised by short-lived painful erections and is commonly encountered in patients with sickle cell disease.

METHODS

A systematic review of the treatment options available for stuttering priapism is presented combined with our own experience in managing this condition over a period of 25 years.

RESULTS

Although numerous medical treatment options have been reported, the majority are through small trials or anecdotal reports.

CONCLUSIONS

Stuttering priapism is a condition which is still not well understood and there is no standardised algorithm for the management of this condition. A multicentre randomised trial is required to evaluate the treatment options.

Phosphodiesterase 5 inhibitors in the treatment of premature ejaculation

To date, there is no FDA-approved therapy for premature ejaculation (PE). Recently, phosphodiesterase 5 inhibitors (PDE5-Is) have been demonstrated to have encouraging results in the treatment of PE by a few studies. The aim of this review was to assess the updated manuscripts and thereafter present the practical recommendations and possible mechanisms concerning PDE5-Is for treating PE. Using MEDLINE, we searched and assessed the peer manuscripts published from 1 January 1996 to 1 September 2005 about PDE5-Is for treating PE. The results show that the number of patients in all the reports is very few and most of the studies do not employ double-blinded and placebo-controlled tests, though they are prospective and randomized. Therefore, the results and conclusions might be biased. PDE5-Is are suggested to be used in PE with old age or associated with erectile dysfunction (ED), or to be employed alone or in combination with selective-serotonin reuptake inhibitors (SSRIs) when SSRIs fail to treat PE; behavioural therapy is proposed to be used for preventing the recurrence of PE following withdrawal of PDE5-Is. In addition, for the PE patient with a definite aetiological cause, the aetiology should be cured first, if PE still exists, followed by PDE-Is prescription. Possible mechanisms that are involved include relaxing the smooth muscles of vas deferens, seminal vesicle, prostate and urethra; decreasing the central sympathetic output; inducing peripheral analgesia; prolonging the duration of erection; and increasing confidence, the perception of ejaculatory control, overall sexual satisfaction, and decreasing the post-orgasmic refractory time to achieve a second erection after ejaculation. Well-designed multicentre studies are urgently warranted to further elucidate the efficacies and safety as well as mechanisms of PDE5-Is in the treatment of PE.

Adjuvant trastuzumab (T) therapy in HER2+ breast cancer after ASCO 2005: Patients’ attitudes and immediate economic burden

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Background: Data from 3 large randomized trials documenting the efficacy of T in the adjuvant setting were reported at ASCO 2005, and subsequently published in NEJM 2005; 353: (16) pp 1659–72 and 1673–1684 . We decided to offer T, and attempted to assess patients’ characteristics that influence its acceptance, in a subgroup of HER2 + patients that had already completed adjuvant chemotherapy at our institution within 12 months prior to these reported results. Methods: Using Electronic Medical Records (OpTx, Canada), we identified HER2+ breast cancer patients who had completed adjuvant therapy within the prior 12 months and administered an informational synopsis about the study results. They then completed a questionnaire, including their demographic information, that established their understanding of the data and documented their decision to receive or to not receive adjuvant T as an afterthought. Results: We identified 1442 breast cancer patients in Optx that were seen at UTCI for initial or follow up visits between May 2004 and May 2005. Those with 3 or fewer visits within the last year and those who received no chemotherapy (n = 770) were excluded. Of the remaining 672 patients, only 104 (15%) had documented HER2+ disease. Fourteen HER2+ patients had metastatic disease, while 84 patients, though HER2+, had either completed adjuvant chemotherapy greater than 12 months prior or were currently receiving adjuvant therapy or T, and/or had other reasons to not be suitable for T. Six patients qualified for this study; 5 decided to receive adjuvant T and 1 chose not to because she perceived the additional benefit to be minimal. Conclusions: While our sample size was too small in the end to draw conclusions about patients’ attitudes towards new data on adjuvant T, we were struck by the small number of patients who could be offered T as an afterthought despite our large patient volume. The magnitude of the perceived economic burden and its imminence after the release of these data may have been overestimated.

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