Port site metastasis after laparoscopic radical nephrectomy: a single-center experience

OBJECTIVE

To assess the incidence and review the probable etiologies of port site recurrence in patients undergoing laparoscopic radical nephrectomy.

MATERIALS AND METHODS

One hundred thirty-six patients undergoing laparoscopic surgeries for renal malignancy, including 133 radical nephrectomies and 3 partial nephrectomies, from December 1999 to December 2008 at our institution were followed up for a median period of 59 months (12-120 months). Of the procedures, 121 were performed by transperitoneal, 5 by retroperitoneal and 10 by combined approach (retroperitoneal renal artery clipping followed by transperitoneal nephrectomy). Formal lymphadenectomy was not performed. Postoperative surveillance after radical nephrectomy included history and physical examination with blood tests 3-6 monthly, chest X-ray yearly and abdominal contrast-enhanced computed tomography (CECT) 1-2 yearly. The development of port site recurrence was diagnosed by physical examination, CECT and pathological findings.

RESULTS

Conversion to open surgery was done in 33 patients. Two (1.47% overall) port site recurrences were observed, both after radical nephrectomies done for renal masses with clinical stages T2N0M0 and TIN0M0. The pathological staging in the two were T2N1M0 Fuhrman's Grade III and T3aN1M0 Grade III, respectively.

CONCLUSION

Our results report that laparoscopic approach does not necessarily increase the risk of port site recurrence, provided the cases are carefully chosen, principles of oncologic surgery are followed, and conditions that increase the risk of port site metastasis are avoided.

Dosimetric comparison of standard three-dimensional conformal radiotherapy followed by intensity-modulated radiotherapy boost schedule (sequential IMRT plan) with simultaneous integrated boost-IMRT (SIB IMRT) treatment plan in patients with localized carcinoma prostate

Aims:

Dosimeteric and radiobiological comparison of two radiation schedules in localized carcinoma prostate: Standard Three-Dimensional Conformal Radiotherapy (3DCRT) followed by Intensity Modulated Radiotherapy (IMRT) boost (sequential-IMRT) with Simultaneous Integrated Boost IMRT (SIB-IMRT).

Material and Methods:

Thirty patients were enrolled. In all, the target consisted of PTV P + SV (Prostate and seminal vesicles) and PTV LN (lymph nodes) where PTV refers to planning target volume and the critical structures included: bladder, rectum and small bowel. All patients were treated with sequential-IMRT plan, but for dosimetric comparison, SIB-IMRT plan was also created. The prescription dose to PTV P + SV was 74 Gy in both strategies but with different dose per fraction, however, the dose to PTV LN was 50 Gy delivered in 25 fractions over 5 weeks for sequential-IMRT and 54 Gy delivered in 27 fractions over 5.5 weeks for SIB-IMRT. The treatment plans were compared in terms of dose–volume histograms. Also, Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) obtained with the two plans were compared.

Results:

The volume of rectum receiving 70 Gy or more (V > 70 Gy) was reduced to 18.23% with SIB-IMRT from 22.81% with sequential-IMRT. SIB-IMRT reduced the mean doses to both bladder and rectum by 13% and 17%, respectively, as compared to sequential-IMRT. NTCP of 0.86 ± 0.75% and 0.01 ± 0.02% for the bladder, 5.87 ± 2.58% and 4.31 ± 2.61% for the rectum and 8.83 ± 7.08% and 8.25 ± 7.98% for the bowel was seen with sequential-IMRT and SIB-IMRT plans respectively.

Conclusions:

For equal PTV coverage, SIB-IMRT markedly reduced doses to critical structures, therefore should be considered as the strategy for dose escalation. SIB-IMRT achieves lesser NTCP than sequential-IMRT.

Thyroid hormone accelerates the differentiation of adult hippocampal progenitors

Disrupted thyroid hormone function evokes severe physiological consequences in the immature brain. In adulthood, although clinical reports document an effect of thyroid hormone status on mood and cognition, the molecular and cellular changes underlying these behavioural effects are poorly understood. More recently, the subtle effects of thyroid hormone on structural plasticity in the mature brain, in particular on adult hippocampal neurogenesis, have come to be appreciated. However, the specific stages of adult hippocampal progenitor development that are sensitive to thyroid hormone are not defined. Using nestin-green fluorescent protein reporter mice, we demonstrate that thyroid hormone mediates its effects on hippocampal neurogenesis by influencing Type 2b and Type 3 progenitors, although it does not alter proliferation of either the Type 1 quiescent progenitor or the Type 2a amplifying neural progenitor. Thyroid hormone increases the number of doublecortin (DCX)-positive Type 3 progenitors, and accelerates neuronal differentiation into both DCX-positive immature neurones and neuronal nuclei-positive granule cell neurones. Furthermore, we show that this increase in neuronal differentiation is accompanied by a significant induction of specific transcription factors involved in hippocampal progenitor differentiation. In vitro studies using the neurosphere assay support a direct effect of thyroid hormone on progenitor development because neurospheres treated with thyroid hormone are shifted to a more differentiated state. Taken together, our results indicate that thyroid hormone mediates its neurogenic effects via targeting Type 2b and Type 3 hippocampal progenitors, and suggests a role for proneural transcription factors in contributing to the effects of thyroid hormone on neuronal differentiation of adult hippocampal progenitors.

Reduced R2' in multiple sclerosis normal appearing white matter and lesions may reflect decreased myelin and iron content

BACKGROUND

R(2)' is an MRI measure of microscopic magnetic field inhomogeneity, and is increased by the paramagnetic effect of iron and the diamagnetic effect of myelin. R(2)' may detect features of multiple sclerosis (MS) not evident with conventional MRI.

METHODS

Multiecho T(2) and T(2)* weighted sequences were obtained from 21 healthy controls (nine men, 12 women; mean age 36 years) and 28 MS patients (seven men, 21 women; 18 relapsing remitting, 10 secondary progressive; mean age 42 years). T(2) and T(2)* relaxation time maps were created from the multiecho sequences, and R(2)' maps were created using the formula R(2)' = R(2)*-R(2) = 1/T(2)*-1/T(2). R(2)' was measured in MS white matter lesions and in regions of interest in normal appearing white matter (NAWM) and grey matter in all subjects.

RESULTS

R(2)' was reduced in NAWM in MS compared with controls (9.5/s vs 10.1/s, p=0.05). R(2)' was additionally reduced in lesions, both T(1) isointense (8.5/s vs 9.5/s, p=0.02) and T(1) hypointense (7.7/s vs 9.5/s, p=0.003) compared with NAWM. R(2)' tended to be higher in the basal ganglia of MS patients compared with controls, and was significantly higher in the caudate nucleus in secondary progressive MS (12.9/s vs 10.9/s, p=0.03). Increased T(2) lesion volume predicted an increase in R(2)' in the caudate (β=0.412, p=0.02).

CONCLUSIONS

Reduction in R(2)' in NAWM and lesions is consistent with a decreases in myelin, tissue iron and/or deoxyhaemoglobin. Increased caudate R(2)' in patients with secondary progressive MS is consistent with increased iron deposition, as corroborated by other techniques.

SU-E-T-211: Peer Review System for Ensuring Quality of Radiation Therapy Treatments

PURPOSE

To demonstrate a Web-based electronic peer review system that has the potential to improve quality of care for radiation therapy patients. The system provides tools that allow radiation oncologists to seek peer review of target and critical structure delineation, treatment plans, and share clinical data with peers to optimize radiation therapy treatments.

MATERIAL AND METHODS

Peer review of radiation therapy treatment planning data prior to its initiation improves the quality of radiation therapy and clinical outcomes. Web-based access to radiation therapy treatment planning data and medical records mitigate existing geographical and temporal constraints. With internet access, the healthcare provider can access the data from any location and review it in an interactive and collaborative manner. Interoperability standard like DICOM-RT and IHE-RO compliant RT Systems have facilitated the design and implementation of PRS with Silverlight Web technology, .net Framework and SQL Server. Local DICOM-RT archive and cloud based services are deployed to facilitate remote peer reviews.

RESULTS

To validate the PRS system, we tested the system for 100 patients with Philips Pinnacle v 9.0 and Varian Eclipse v 8.9 treatment planning system (TPS). We transmitted the DICOM RT data from the TPS to the cloud based services via the PRS local DICOM RT Archive. Various CT simulation based parameters such as orientation of CT, properties of RT structures etc. were compared between the TPS and PRS system. Data integrity of other parameters such as patient demographics (patient name, ID, attending physician etc.) and dose volume related parameters were also evaluated. Such rigorous testing allowed us to optimize the functionalities and clinical implementation of the PRS.

CONCLUSIONS

We believe that the PRS will improve the quality and safety of a broad spectrum of radiation therapy patients treated in underserved areas while discouraging the overutilization of expensive radiation treatment modalities. This research and development project is supported by the James and Ester King Biomedical Research Program grant # RC1-09KW-09-26829.

Longitudinal changes in magnetisation transfer ratio in secondary progressive multiple sclerosis: data from a randomised placebo controlled trial of lamotrigine

Sodium blockade with lamotrigine is neuroprotective in animal models of central nervous system demyelination. This study evaluated the effect of lamotrigine on magnetisation transfer ratio (MTR), a putative magnetic resonance imaging measure of intact brain tissue, in a group of subjects with secondary progressive multiple sclerosis (MS). In addition, the utility of MTR measures for detecting change in clinically relevant pathology was evaluated. One hundred seventeen people attending the National Hospital for Neurology and Neurosurgery or the Royal Free Hospital, London, UK, were recruited into a double-blind, parallel-group trial. Subjects were randomly assigned by minimisation to receive lamotrigine (target dose 400 mg/day) or placebo for 2 years. Treating and assessing physicians and patients were masked to treatment allocation. Results of the primary endpoint, central cerebral volume, have been published elsewhere. Significant differences between the verum and placebo arms were seen in only two measures [normal appearing grey matter (NAGM) p = 0.036 and lesion peak height (PH) p = 0.004], and in both cases there was a greater reduction in MTR in the verum arm. Significant correlations were found of change in MS functional composite with all MTR measures except lesion and normal appearing white matter (NAWM) PH. However, the change in MTR measures over 2 years were small, with only NAGM mean (p = 0.001), lesion peak location (p = 0.11) and mean (p < 0.0001) changing significantly from baseline. These data did not show that lamotrigine was neuroprotective. The clinical correlation of MTR measures was consistent, but the responsiveness to change was limited.

Congenital posterior urethral diverticula causing bladder outlet obstruction in a young male

We present a case of 26-year-old male presenting with mild renal failure. Ultrasound findings were suggestive of posterior urethral valve, but micturating cystourethrogram and endoscopic evaluation confirmed the diagnosis of posterior urethral diverticulae. Transurethral resection of diverticulae was performed. Patient is voiding well and his renal function has stabilized.

Quadruple malignancy in a single patient: a case report and comprehensive review of literature

The occurrence of multiple primary malignant neoplasias (MPMN) is a rare but increasingly frequently reported event. Many theories have been proposed to explain MPMNs, but none have been proven. The key risk factors appear to be smoking and family history. While numerous studies have been published on the development of second malignancies following a first primary, the literature contains only few case reports and reviews of patients with three or more malignancies. We report a case of a young female who, over a period of 30 years, developed four different malignancies and was treated radically on each occasion.

Polymorphisms in the vitamin D receptor and the androgen receptor gene associated with the risk of urolithiasis

Transcriptional activity of the vitamin D receptor (VDR) gene is regulated by androgen receptor (AR) gene and both are associated with renal stone formation. We examined gene polymorphisms of VDR (PCR-RFLP) and AR (GeneScan analysis) in 125 stone formers and 150 controls from north India. Genotype Ff of Fok-I and Tt of Taq-I demonstrated significantly higher risk (P<0.001, OR=3.559 and P=0.019, 1.830 respectively). Variant f allele exhibited 1.7-folds higher risk. Ff of Fok-I and Aa of Apa-I gene polymorphism showed higher risk in males only. Mean CAG repeat was significantly higher in hypercalciuric patients as compared to normocalciuric (mean=21.62 ± 3.384 vs. 20.11 ± 3.182; P=0.034). Combined effects 1.8-folds higher risk in patients with Tt genotype of Taq-I and short CAG repeat. Thus, association of FokI and TaqI VDR gene polymorphisms suggest VDR as an important genetic marker for urolithiasis. Further, patients with combination of Tt of Taq-I and short CAG repeat were at higher risk for stone formation.

Comparison of asthma knowledge, management, and psychological burden among parents of asthmatic children from rural and urban neighborhoods in India

INTRODUCTION

Asthma prevalence is increasing in developing countries such as India. Little is known on parental knowledge of asthma severity, management and psychosocial impact, particularly among rural dwellers. Further, it is not known whether the female asthmatic child is particularly vulnerable.

OBJECTIVE

To evaluate parental asthma knowledge and psychological impact of having an asthmatic child.

METHODS

134 consecutive caregivers were surveyed at the visit for their child's asthma exacerbation at an urban hospital in Kanpur, India between 3/2007-3/2008.

RESULTS

The child's age range was 5.7A +/- 2.7 years. 76% were urban city dwellers with significantly higher number having a college degree. 23% children had moderate to severe persistent asthma; however, only 42% were on inhaled steroids. Parental severity perception was comparable to National Heart, Lung and Blood Institute (NHLBI) classification. While 67% identified bronchoconstriction occurred with asthma, only 8.9% recognized that inflammation played a role. There was no difference in the perceived stress by area of residence with 89% reported not or only sometimes feeling stressed with having an asthmatic child. Similarly, the concern among those with a female asthmatic child did not differ with 73% of caregivers believing that asthma would not affect their daughter's future.

CONCLUSION

In an urban Indian hospital, 23% of asthmatic children had moderate to severe persistent asthma but only 9% were on controllers. Their parents were well educated, able to identify asthma severity appropriately and denied being stressed with having asthmatic children, irrespective of the gender of the child. However, their understanding of asthma pathophysiology was sub-optimal. Increased disease knowledge may lead to greater medication adherence among asthmatic children in India.