Metastasectomy for melanoma in the VATS era

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Background: The role for metastasectomy in the setting of metastatic melanoma remains ill-defined. The aim of this study is to evaluate resection of limited metastases in the setting of melanoma comparing VATS and open approaches, specifically looking at perioperative morbidity and survival. Methods: All patients undergoing metastasectomy for melanoma with curative intent between January 1, 2001 and September 30, 2007 were included. Data was collected retrospectively from the UPMC tumor registry and chart review. Differences between groups were compared with the student's t-test. Results: Of 43 patients undergoing metastasectomy for melanoma, 31 patients were resected with intent to cure (16 VATS, 15 open). Complications were similar between the VATS (12%) and open (13%) groups. There were no perioperative deaths in either group. The median survival in the VATS group was 20.7 months, compared to 26.5 months in the open group (p = 0.17). Importantly, the VATS patients more frequently underwent resection of smaller, peripheral lesions via wedge resection (81%) and only 2 patients (13%) underwent lobectomy. Conversely, patients undergoing open procedures were more likely to have larger, more central lesions and undergo anatomic resections. There were 9 (60%) lobectomies, 3 (20%) segmentectomies 1 (7%) en bloc resection and only 2 (13%) wedge resections in the open group. Conclusions: Metastasectomy for metastatic melanoma in the thoracic cavity can be performed safely by a VATS or open approach. The two approaches have comparable morbidity, mortality and survival outcomes. Careful patient resection remains the hallmark of care in identifying appropriate candidates for metastasectomy. In the setting of patients with short life-expectancy, it may be advantageous to employ a VATS approach when possible to preserve quality of life while achieving similar oncologic outcomes to open procedures. Individuals with a radiographic indication of limited peripheral disease should be considered for a VATS approach to resection of melanoma metastases.

No significant financial relationships to disclose.

Management of cancer-related vertebral compression fracture: Comparison of treatment options: A literature meta-analysis

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Objective: The objective of this review was to compare the efficacy and safety of treatment options for management of vertebral compression fractures (VCF) secondary to multiple myeloma and/or metastatic tumors based on a meta-analysis of the literature. Methods: A search was performed of published literature through November 2008. All articles reporting at least one clinical outcome were included. VAS pain scores and cement extravasation were the most common efficacy and safety outcomes reported in the included studies and were considered for analysis. The mean weighted difference in VAS scores or the effect size was calculated using the number of patients in each study as the weights. The paired t-test was used to assess significance of these differences. A 95% confidence interval (CI) was computed around these differences. The significance of difference (VAS and % cement extravasations) between different modes of treatment was assessed using a two sample t-test. Results: A total of 59 studies met the inclusion criteria and were included in the meta-analysis. The majority of the included studies (56 studies) were case series. No randomized controlled study was identified. The total sample size from the included study was 4,460 patients - 73% of patients had a diagnosis of tumor metastasis to the vertebral column; 18% had a diagnosis of multiple myeloma. Percutaneous vertebroplasty (VP) was described in 57.6% studies; balloon kyphoplasty (BKP) in 20.3%; conservative/combined (CC) therapy in 22%. Results are shown in the Table . Conclusions: This meta-analysis indicates that BKP is more effective than either VP or conservative therapy in relieving pain secondary to cancer-related VCF and that BKP is a safer intervention than VP based on the analysis of the rates of cement extravasation.

[Table: see text]

No significant financial relationships to disclose.

Inflammatory response to isocyanates and onset of genomic instability in cultured human lung fibroblasts

Lungs comprise the primary organ exposed to environmental toxic chemicals, resulting in diverse respiratory ailments and other disorders, including carcinogenesis. Carcinogenesis is a multi-stage phenomenon, which involves a series of genetic alterations that begin with genomic instability provoked by certain factors such as inflammation and DNA damage and end with the development of cancer. Isocyanates such as methyl isocyanate are the chief metabolic intermediates in many industrial settings with diverse applications; exposure to them can lead to severe hypersensitive, mutagenic and genotoxic alterations. We examined the molecular mechanisms underlying isocyanate-mediated inflammatory responses and their probable role in the onset of genomic instability in cultured IMR-90 human lung fibroblasts. The isocyanates induced inflammation, resulting in extensive DNA damage, evidenced by increases in ATM, ATR, gammaH2AX, and p53 expression levels. The apoptotic index also increased. Chromosomal anomalies in treated cells included over-expression of centrosome protein and variable amplification of inter-simple sequence repeats, further demonstrating isocyanate-induced genomic instability. This information could be useful in the design of new approaches for risk assessment of potential industrial disasters.

Quantitative assessment of left ventricular function with dual-source CT in comparison to cardiac magnetic resonance imaging: initial findings

Cardiac magnetic resonance imaging and echocardiography are currently regarded as standard modalities for the quantification of left ventricular volumes and ejection fraction. With the recent introduction of dual-source computedtomography (DSCT), the increased temporal resolution of 83 ms should also improve the assessment of cardiac function in CT. The aim of this study was to evaluate the accuracy of DSCT in the assessment of left ventricular functional parameters with cardiac magnetic resonance imaging (MRI) as standard of reference. Fifteen patients (two female, 13 male; mean age 50.8 +/- 19.2 years) underwent CT and MRI examinations on a DSCT (Somatom Definition; Siemens Medical Solutions, Forchheim, Germany) and a 3.0-Tesla MR scanner (Magnetom Trio; Siemens Medical Solutions), respectively. Multiphase axial CT images were analysed with a semiautomatic region growing algorithms (Syngo Circulation; Siemens Medical Solutions) by two independent blinded observers. In MRI, dynamic cine loops of short axis slices were evaluated with semiautomatic contour detection software (ARGUS; Siemens Medical Solutions) independently by two readers. End-systolic volume (ESV), end-diastolic volume (EDV), ejection fraction (EF) and stroke volume (SV) were determined for both modalities, and correlation coefficient, systematic error, limits of agreement and inter-observer variability were assessed. In DSCT, EDV and ESV were 135.8 +/- 41.9 ml and 54.9 +/- 29.6 ml, respectively, compared with 132.1 +/- 40.8 ml EDV and 57.6 +/- 27.3 ml ESV in MRI. Thus, EDV was overestimated by 3.7 ml (limits of agreement -46.1/+53.6), while ESV was underestimated by 2.6 ml (-36.6/+31.4). Mean EF was 61.6 +/- 12.4% in DSCT and 57.9 +/- 9.0% in MRI, resulting in an overestimation of EF by 3.8% with limits of agreement at -14.7 and +22.2%. Rank correlation rho values were 0.81 for EDV (P = 0.0024), 0.79 for ESV (P = 0.0031) and 0.64 for EF (P = 0.0168). The kappa value of inter-observer variability were amounted to 0.85 for EDV, ESV and EF. DSCT offers the possibility to quantify left ventricular function from coronary CT angiography datasets with sufficient diagnostic accuracy, adding to the value of the modality in a comprehensive cardiac assessment. The observed differences in the measured values may be due to different post-processing methods and physiological reactions to contrast material injection without beta-blocker medication.

Totally extra-peritoneal repair of inguinal hernia by a glove-balloon: Technical innovation

Totally extra-peritoneal (TEP) laparoscopic repair of an inguinalhernia involves the creation of an extra-peritoneal space by blunt dissection or the use of commercial balloons. This new technique demonstrates the use of a device to create this extra-peritoneal space, without the need for any commercial balloons. The extra-peritoneal space was created using a glove-balloon. A total of 107 consecutive TEP repairs were carried out using the glove-balloon technique, these included ten bilateral and 17 recurrent inguinal hernias. This method is simple, cost-effective and easy to teach.

Cytokine-secreting herpes viral mutants effectively treat tumor in a murine metastatic colorectal liver model by oncolytic and T-cell-dependent mechanisms

In this model of hepatic micrometastases, the antitumor efficacy and role of the T-cell and natural killer (NK) cell populations were studied for oncolytic herpes simplex virus type-1 (HSV-1) viral mutants containing the granulocyte-monocyte colony stimulating factor (GM-CSF (NV1034)) or interluken-12 (IL-12 (NV1042)) cytokine genes. These were compared to saline and control virus (NV1023) in vitro and in vivo. HSV-1 mutants were assessed for cytotoxicity, replication and cytokine expression in CT-26 cells. A syngeneic micrometastatic liver model was then established in naive and immune cell-depleted animals to assess the antitumor efficacy of these viruses. In vitro cytotoxicity and viral replication were similar for each virus, resulting in greater than 80 and 98% cytotoxicity at multiplicity of infection of 1 and 10, respectively. Peak viral titers were 25- to 50-fold higher than initial titer and were not significantly different between viruses. In vivo, all three viruses reduced metastases relative to control, but cytokine-secreting viruses did so with greater efficacy compared to NV1023. This effect was abrogated by T-cell depletion, but not NK-cell depletion. Single-agent therapy with oncolytic viral agents containing GM-CSF or IL-12 is effective in a murine model of liver metastases and likely involves direct viral oncolysis and actions of specific immune effector cells.

Fluorescent cholangiography in a mouse model: an innovative method for improved laparoscopic identification of the biliary anatomy

BACKGROUND

Real-time imaging of the biliary anatomy may facilitate safe and timely completion of laparoscopic cholecystectomy. This study sought to determine whether the unique autofluorescent properties of bile could facilitate intraoperative identification of the biliary anatomy in mice using fluorescent cholangiography.

METHODS

Fluorimetry was performed on samples of mouse bile to determine excitation and emission spectra. For seven mice, chevron laparotomy was performed, followed by liver retraction to expose the porta hepatis. Using stereomicroscopy, photographs were taken in brightfield and fluorescent modes without a change in depth or focus. Six surgical residents evaluated the pictures and identified the gallbladder, cystic duct, common bile duct, and whether the cystic duct joined the right hepatic duct or the common bile duct.

RESULTS

Fluorimetry demonstrated autofluorescence of bile at an excitation wavelength of 475 nm. Intense emission was observed at 480 nm. At these settings, fluorescent stereomicroscopy easily identified the gallbladder and biliary tree in mice. This technique decreased diagnostic errors of the biliary anatomy 11-fold (2% vs 22%; p < 0.01), as compared with brightfield visualization. Fluorescent stereomicroscopy also was used to diagnose bile leak, obstruction, and complex anatomy. Using a prototype 5-mm laparoscope equipped with fluorescent filters, the results were reproduced.

CONCLUSIONS

Fluorescent cholangiography based solely on the autofluorescence of bile may facilitate real-time identification of the biliary anatomy during laparoscopic procedures, without the need for extraneous dye administration or the use of radiography. This technique has the potential to decrease the rate of iatrogenic biliary tract injuries during laparoscopic cholecystectomy.

A rare case of human trypanosomiasis caused by Trypanosoma Evansi

Human trypanosoma infections like the ones seen in Africa and South America are unknown in India. The only exception in literature is of two documented cases of a self-limiting febrile illness, being attributed to Trypanosoma lewisi like parasites. We are reporting an unusual case of trypanosomiasis from the rural parts of Chandrapur district in Maharashtra. An adult male farmhand who used to practice veterinary medicine also, presented with history of febrile episodes on and off since five months and drowsiness before admission to this Institute. Though routine blood and other investigations were within normal limits, the peripheral smear showed a large number of trypanosomes which morphologically resembled the species Trypanosoma evansi, the aetiological agent of surra - a form of animal trypanosomiasis. A battery of assays covering the spectrum of parasitology, serology, and molecular biology confirmed the infecting parasite to be T. evansi. Failure to demonstrate the central nervous system (CNS) involvement, as evidenced by the absence of parasite in cerebrospinal fluid (CSF) advocated the use of suramin - the drug of choice in early stage African trypanosomiasis without any CNS involvement. Suramin achieved cure in our patient. The case is being reported because of its unique nature as the patient was not immunocompromised and showed infestation with a parasite which normally does not affect human beings.

Nuclear DNA amounts in 112 species of tropical hardwoods -- new estimates

The 4C DNA values of 112 species, belonging to 37 families have a range from 0.83 pg (Bixa orellana) to 15.54 pg (Thryallis angustifolia), showing a 18.72-fold variation. The genome size varies from 0.21 pg (Bixa orellana) to 3.32 (Thespesia populnea), with a 15.8-fold difference. The Bombacaceae has the minimum range (1.08-fold) of variation, while the maximum (5.0-fold) is shown by the Fabaceae. The Boraginaceae, Lauraceae, Malpighiaceae, and Malvaceae generally have higher 4C DNA values of > 10 pg, while the Bixaceae, Caricaceae, Oxalidaceae, and Santalaceae have lower values of < 2.0 pg. These data add further to our knowledge on variation in DNA amount in tropical hardwoods.

Interspinous bursitis in an athlete

We present a case of L2/3 interspinous bursitis treated with extraspinal injections. No previous investigations have used fluoroscopically guided spinal injections to confirm the clinical relevance of the MRI features of this type of bursae. Autopsy studies have revealed an increased incidence of interspinous lumbar bursal cavities with advancing age. Afflicted patients present with localised, midline lower lumbar pain exacerbated by extension. In young athletes these symptoms can mimic spondylolysis. MRI is useful in detecting soft-tissue injury of the posterior elements.

Fluoroscopically guided diagnostic and therapeutic extraspinal injections can be used for confirmation and treatment of pain from such bursae.

Giant synovial cysts of the hip joint: An important but rare differential diagnosis of an inguinal swelling

Synovial cysts around the hip joint are commonly mistaken for other more common causes of an inguinal swelling. We present a report on two patients in whom abnormal pulsatile masses in the groin caused diagnostic difficulty. Patients were initially admitted under vascular surgeons with a clinical diagnosis of aneurysm. Ultrasound examination was useful in excluding aneurysm. Detailed clinical examination revealed painful restricted hip movements and a radiograph showed evidence of arthritis in the hip joint. CT scan confirmed it to be a synovial cyst. Computed arthrotomogram or arthrography showed communication of the cyst with the hip joint. Synovial cysts and iliopsoas bursa enlargement may be more common than previously reported and should be considered as a differential diagnosis in patients with unusual inguinal swelling. (Hip International 2004; 14: 51-4).

Ralstonia mannitolilytica infection in renal transplant recipient: first report

Ralstonia mannitolilytica is being increasingly identified as an opportunist pathogen in immunocompromised patients. We report the first case of post renal transplant infection by R. mannitolilytica, in a 14-year-old recipient. The graft and the patient were saved with prompt microbiological identification, sensitivity testing and subsequent administration of appropriate antibiotic.

Use of telemedicine in evading cholera outbreak in Mahakumbh Mela, Prayag, UP, India: an encouraging experience

Telemedicine (TM) services a process in which expert medical advice from afar is provided using electronic signals to transfer the medical data from one site to another. As a pilot project to assess the efficacy of TM in developing countries like India, a telemedicine center was set up at the main hospital of Mahakumbh mela--a grand religious fair, at Prayag, a city in north India. The daily reporting of the in-patient and outpatient cases at the fair revealed a surge of diarrhea cases among the pilgrims at the fair. This information was communicated to the referral center at Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), which, with the help of its microbiology department, conducted microbiological examinations of stool samples and rectal swabs of patients along with various water samples. Vibrio cholerae was isolated in 22.6% (7/31) of the samples. This information was immediately relayed to the Main Hospital at the fair online, and then to the health authorities, who took strict and prompt measures to improve hygiene. Subsequently, the number of diarrhea cases decreased considerably in a matter of a few days, and thus an epidemic disaster was averted, which could have created havoc in such a large gathering.