Isolated primary non-Hodgkin's lymphoma of the thoracic spine: a case report with a review of the literature

A case of isolated primary non-Hodgkin's lymphoma of the spine is presented along with a review of previous cases reported in the literature. An 80-year old immunocompetent man was admitted with progressive numbness and weakness of both lower extremities of 2 weeks' duration. Magnetic resonance imaging (MRI) of the cervicothoracic spine revealed an extradural spinal mass at the T1 - T3 level, with invasion into the T3 vertebral body. The lesion was at first thought to be a metastatic tumour. Because of the manifestations of compression, the patient underwent laminectomy and posterior decompression. Histopathological examination revealed diffuse large B-cell non-Hodgkin's lymphoma. All other investigations (including computed tomography of the chest and abdomen, bone scan, peripheral blood examination and tumour marker examination) were negative for occult disease. This case demonstrates that neurosurgeons should be aware of the occurrence of isolated primary spinal lymphoma, which should be included in the differential diagnosis of metastatic tumours.

Clinicopathological Features of Solitary Fibrous Tumours in the Extremities: Four Case Reports and a Literature Review

This paper reports on the clinicopathological features of four patients with solitary fibrous tumours arising from the extremities and presents a review of the relevant literature. The patients consisted of three women and one man, with a mean age of 47.8 years. Standard pre-operative work-up data were examined, including: history, clinical examination, plain radiography, computed tomography scans of the lesion and chest, magnetic resonance imaging, angiography, technetium-99m bone scan, thallium-201 scintigraphy and routine laboratory tests. Immunohisto chemical staining was performed for CD34, Bcl-2 protein, vimentin, S-100 protein, desmin and smooth muscle actin, and pathological material was reviewed for the presence of histologically malignant components. Immunohistochemically, all of the tumours were diffusely positive for CD34. Clinical and radiological findings of solitary fibrous tumours affecting the extremities are reminiscent of those of aggressive or malignant soft tissue tumours. Pathological and immunohistochemical studies are important in making the correct diagnosis.

Chemoradiation for the treatment of epidermoid anal cancer: 13-year follow-up of the first randomised UKCCCR Anal Cancer Trial (ACT I)

Background:

The first UKCCCR Anal Cancer Trial (1996) demonstrated the benefit of chemoradiation over radiotherapy (RT) alone for treating epidermoid anal cancer, and it became the standard treatment. Patients in this trial have now been followed up for a median of 13 years.

Methods:

A total of 577 patients were randomised to receive RT alone or combined modality therapy using 5-fluorouracil and mitomycin C. All patients were scheduled to receive 45 Gy by external beam irradiation. Patients who responded to treatment were recommended to have boost RT, with either an iridium implant or external beam irradiation. Data on relapse and deaths were obtained until October 2007.

Results:

Twelve years after treatment, for every 100 patients treated with chemoradiation, there are an expected 25.3 fewer patients with locoregional relapse (95% confidence interval (CI): 17.5–32.0 fewer) and 12.5 fewer anal cancer deaths (95% CI: 4.3–19.7 fewer), compared with 100 patients given RT alone. There was a 9.1% increase in non-anal cancer deaths in the first 5 years of chemoradiation (95% CI +3.6 to +14.6), which disappeared by 10 years.

Conclusions:

The clear benefit of chemoradiation outweighs an early excess risk of non-anal cancer deaths, and can still be seen 12 years after treatment. Only 11 patients suffered a locoregional relapse as a first event after 5 years, which may influence the choice of end points in future studies.

Supratentorial Brain AVM Embolization with Onyx-18 and Post-Embolization Management. A Single-Center Experience

SUMMARY

Onyx is increasingly used in endovascular therapy of intracranial arteriovenous malformations (AVMs). However, the embolic effect and post-embolization management are still under discussion. We report our experience in the treatment of supratentorial brain arteriovenous malformations (SBAVMs) with Onyx and discuss post-embolic management. From June 2006 to July 2008, 20 patients with SBAVM were embolized with Onyx. There were 14 men and six women ranging from 14 to 64 years of age (mean 38.3 years). Initial symptoms included spontaneous hemorrhage (n=12), headaches (n=4), seizure (n=3) and incidentally disclosed after head trauma (n=1). After the endovascular procedure, all had subsequent treatment (follow-up angiogram, stereotactic radiosurgery or microsurgery) according to the obliteration degree. At angiography, seven patients (35%, 7/20) were completely obliterated (over 95% closure) after embolization while one suffered a small subarachnoid hemorrhage without permanent clinical sequelae. Four patients (20%, 4/20) were subtotally obliterated (over 80% closure), one patient who suffered severe cerebral edema after embolization underwent decompressive craniectomy, two patients had additional radiosurgery and one patient had follow-up angiogram. Nine patients (45%, 9/20) were partially obliterated (20-80% closure), five patients had additional surgery, two patients had additional radiosurgery and two patients had follow-up angiogram (one patient had intraventricular hemorrhage three months after embolization). Of all 20 AVMs, an average of 2.2 ml Onyx was used per patient and average volume reduction was 80% (range, 30%-99%). Onyx is suitable for embolization of SBAVMs because of its diffuse controllable properties. We suggest clinical follow-up after complete obliteration, additional radiosurgery or angiographic follow-up after subtotal obliteration and additional surgery after partially obliteration. More cases with long-term follow-up are needed to evaluate the long-term prognosis of our post-embolization management.

A randomized trial of chemoradiation using mitomycin or cisplatin, with or without maintenance cisplatin/5FU in squamous cell carcinoma of the anus (ACT II)

LBA4009

Background: Chemoradiotherapy (CRT) with 5-fluorouracil (5-FU) and mitomycin-C (MMC) is standard treatment for anal cancer. This trial addresses two questions: whether (i) replacing MMC with cisplatin (CDDP) improves the complete response (CR) rate, and (ii) two cycles of maintenance chemotherapy after CRT reduces recurrence. Methods: Between 2001 and 2008, 940 patients (pts) were recruited to a multicenter, randomized factorial trial. Pts received 5-FU (1,000mg/m2/day on d1–4 and 29–32), radiotherapy (RT) (50.4Gy in 28 fractions), and either MMC (12mg/m2, d1; n=471) or CDDP (60mg/m2 on d1 and 29; n=469). Pts were also randomized to receive maintenance therapy (n=448) 4 weeks after CRT (two cycles of CDDP and 5-FU weeks 11 and 14) or no maintenance (n=446). Maintenance randomization was not considered appropriate in 46 pts. Statistical power was ≥80% to detect a difference in the CR rate of 5% (CDDP vs MMC), and 30% reduction in recurrence (maintenance vs no maintenance). Results: Median age 58 yrs; 62% male, 38% female; tumor site - canal (81%), margin (15%); stage T1-T2 (50%), T3-T4 (43%); node negative (62%), positive (30%). Median follow-up was 3 yrs. The CR rate was 94% MMC and 95% CDDP (p=0.53). MMC pts had more acute grade 3/4 haematological toxicities (25 vs 13%, p<0.001) but this did not result in an increase in neutropaenic sepsis (3.1 vs 3.2%, p=0.93). Non-haematologic grade 3/4 toxicities were similar (61 vs 65%, p=0.22). Preliminary analysis shows no statistically significant difference in recurrence free survival (RFS) (HR 0.89, 95% CI 0.68, 1.18; p=0.42) or overall survival (HR 0.79, 95% CI 0.56,1.12; p=0.19) for the maintenance comparison. The number of pre-treatment colostomies not reversed were similar between treatments (18 MMC vs 14 CDDP, p=0.65, Maint/No maint, p=0.23) and only 9 disease-free pts had colostomies performed (5 MMC, 4 CDDP). Conclusions: ACT II is the largest trial conducted in anal cancer. High CR (95%) and RFS (75% at 3 yrs) rates were achieved with this CRT. This excellent outcome may have been influenced by the absence of a gap in the RT schedule. There was no difference in CR rates between MMC and CDDP or in RFS rates with or without maintenance chemotherapy. 5-FU, MMC with RT remains the standard of care.

[Table: see text]

A randomized trial of chemoradiation using mitomycin or cisplatin, with or without maintenance cisplatin/5FU in squamous cell carcinoma of the anus (ACT II)

LBA4009

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]

Shunt implantation in a special sub-group of post-traumatic hydrocephalus--patients have normal intracranial pressure without clinical representations of hydrocephalus

BACKGROUND

Post-traumatic hydrocephalus (PTH) is a frequent complication secondary to traumatic brain injury (TBI) and controversy remains over whether to perform a shunt placement for patients with normal pressure hydrocephalus when the patient is too injured to display symptoms or has atypical symptoms.

METHOD

A hospital-based retrospective study was performed in patients who developed normal pressure hydrocephalus, without atypical symptoms, from January 2004 to June 2007. Information regarding patients' demographics, TBI, hydrocephalus and outcome was collected.

RESULTS

A total of 31 patients were involved in this study. At the 12-month follow-up, 20 patients (64.5%) showed clear improvement. Among the 10 patients who developed PTH after decompressive craniectomy, cranioplasty was performed after shunt implantation and clinical improvement was observed in nine patients. Additionally, in this series, the patients' age and the severity of hydrocephalus, assessed by CT imaging before shunt placement, significantly correlated with improvement.

CONCLUSION

Although the effect was not definitively established, many patients in the sub-group of PTH patients described here would benefit from shunt placement, especially when they simultaneously have large cranial defects after surgical decompression and underwent cranioplasties after shunt placement. Additionally, younger patients and those with less severe hydrocephalus before shunt placement may expect a better outcome after shunt placement.

Isolated intracranial Rosai-Dorfman disease mimicking suprasellar meningioma: case report with review of the literature

Rosai-Dorfman disease (RDD) is an idiopathic histiocytic proliferation affecting the lymph nodes. Isolated intracranial RDD is rare and usually appears as a well-defined, dural-based lesion without lymphadenopathy. The clinical and radiological features of intracranial RDD are similar to meningioma. Histopathology and immunohistochemistry are essential for a definitive diagnosis. This is a report of a 43-year old male with isolated intracranial RDD, which manifested as a suprasellar meningioma. The clinical, radiological and pathological aspects of the disease are discussed within the context of a review of previously reported cases.

Effects of aging on complement activation and neutrophil infiltration after intracerebral hemorrhage

Intracerebral hemorrhage (ICH)-induced brain edema and neurological deficits are greater in aged rats than in young rats. Complement activation and neutrophil infiltration contribute to brain injury after ICH. In this study, we investigated the effects of aging on activation of the complement cascade and neutrophil influx following ICH. Male Sprague-Dawley rats (3 or 18 months old) received an infusion of 100 microL autologous blood into right caudate. Rats were killed at 1, 3, 7, and 28 days after ICH and the brains were sampled for immunohistochemistry and Western blot analysis. Levels of complement factor C9 and clusterin were used as markers for complement activation, and myeloperoxidase (MPO) staining was performed to detect neutrophil infiltration. Western blot analysis showed that complement C9 and clusterin levels in ipsilateral basal ganglia after ICH were higher in aged rats than in young rats (p < 0.05). Immunohistochemistry showed there were more C9- and clusterin-positive cells around the hematoma in aged rats. However, MPO-positive cells in ipsilateral basal ganglia were fewer in aged rats (p < 0.05) after ICH. Our results suggest that ICH causes more severe complement activation and less neutrophil infiltration in aged rats. Clarification of the mechanisms of brain injury after ICH in the aging brain should help develop new therapeutic strategies for ICH.

Outbreak of measles in primary school students with high first dose MMR vaccination coverage

INTRODUCTION

Indigenous cases of measles continue to occur in Singapore despite the implementation of a two-dose mumps, measles and rubella (MMR) vaccination policy in 1998. We investigated a measles outbreak that took place in a primary school from April 17 to May 6, 2004 to identify all cases, evaluate vaccine efficacy (VE) and implement outbreak control measures.

METHODS

A case of measles was defined as anyone having generalised rash and fever with or without cough, coryza or conjunctivitis during the outbreak period, and who had either laboratory-confirmed acute measles infection or was epidemiologically linked to a patient with laboratory-confirmed measles infection. Vaccination status was obtained from the studentos health booklet and confirmed with the National Immunisation Registry. Attack rates in unvaccinated (ARU) and vaccinated (ARV) students were calculated and VE was evaluated using the formula: VE (percent) = [(ARU-ARV) / ARU] x 100 percent.

RESULTS

Nine students, aged between eight and 14 years, from five classes in primary three and primary six, were epidemiologically linked to have measles. None of them had received the second dose of the MMR vaccine. 93 percent of students in the affected classes (n = 184) had prior documented evidence of receiving at least one dose of MMR vaccination, as compared to 96.5 percent for the entire school enrolment (n = 1,309). The attack rate was 1.2 percent in the vaccinated group and 53.8 percent in the unvaccinated group. The VE for the primary dose of MMR in the affected classes was 97.8 percent.

CONCLUSION

It is important to achieve a high coverage for the primary dose of MMR vaccine in order to prevent any potential outbreaks prior to receiving the booster dose.

Modulation by simvastatin of iberiotoxin-sensitive, Ca2+-activated K+ channels of porcine coronary artery smooth muscle cells

BACKGROUND AND PURPOSE

Statins (3-hydroxy-3-methyl-glutaryl coenzyme A (HMG CoA) reductase inhibitors) have been demonstrated to reduce cardiovascular mortality. It is unclear how the expression level of HMG CoA reductase in cardiovascular tissues compares with that in cells derived from the liver. We hypothesized that this enzyme exists in different cardiovascular tissues, and simvastatin modulates the vascular iberiotoxin-sensitive Ca2+-activated K(+) (BK(Ca)) channels.

EXPERIMENTAL APPROACHES

Expression of HMG CoA reductase in different cardiovascular preparations was measured. Effects of simvastatin on BK(Ca) channel gatings of porcine coronary artery smooth muscle cells were evaluated.

KEY RESULTS

Western immunoblots revealed the biochemical existence of HMG CoA reductase in human cardiovascular tissues and porcine coronary artery. In porcine coronary artery smooth muscle cells, extracellular simvastatin (1, 3 and 10 microM) (hydrophobic), but not simvastatin Na+ (hydrophilic), inhibited the BK(Ca) channels with a minimal recovery upon washout. Isopimaric acid (10 microM)-mediated enhancement of the BK(Ca) amplitude was reversed by external simvastatin. Simvastatin Na+ (10 microM, applied internally), markedly attenuated isopimaric acid (10 microM)-induced enhancement of the BK(Ca) amplitude. Reduced glutathione (5 mM; in the pipette solution) abolished simvastatin -elicited inhibition. Mevalonolactone (500 microM) and geranylgeranyl pyrophosphate (20 microM) only prevented simvastatin (1 and 3 microM)-induced responses. simvastatin (10 microM ) caused a rottlerin (1 microM)-sensitive (cycloheximide (10 microM)-insensitive) increase of PKC-delta protein expression.

CONCLUSIONS AND IMPLICATIONS

Our results demonstrated the biochemical presence of HMG CoA reductase in different cardiovascular tissues, and that simvastatin inhibited the BK(Ca) channels of the arterial smooth muscle cells through multiple intracellular pathways.

Glucagon-like peptide-1 excites pancreas-projecting preganglionic vagal motoneurons

Glucagon-like peptide-1 (GLP-1) increases pancreatic insulin secretion via a direct action on pancreatic beta-cells. A high density of GLP-1-containing neurons and receptors is also present in brain stem vagal circuits; therefore, the aims of the present study were to investigate 1) whether identified pancreas-projecting neurons of the dorsal motor nucleus of the vagus (DMV) respond to exogenously applied GLP-1, 2) the mechanism(s) of action of GLP-1, and 3) whether the GLP-1-responsive neurons (putative modulators of endocrine secretion) could be distinguished from DMV neurons responsive to peptides that modulate pancreatic exocrine secretion, specifically pancreatic polypeptide (PP). Whole cell recordings were made from identified pancreas-projecting DMV neurons. Perfusion with GLP-1 induced a concentration-dependent depolarization in approximately 50% of pancreas-projecting DMV neurons. The GLP-1 effects were mimicked by exendin-4 and antagonized by exendin-(9-39). In approximately 60% of the responsive neurons, the GLP-1-induced depolarization was reduced by tetrodotoxin (1 microM), suggesting both pre- and postsynaptic sites of action. Indeed, the GLP-1 effects were mediated by actions on potassium currents, GABA-induced currents, or both. Importantly, neurons excited by GLP-1 were unresponsive to PP and vice versa. These data indicate that 1) GLP-1 may act on DMV neurons to control pancreatic endocrine secretion, 2) the effects of GLP-1 on pancreas-projecting DMV neurons are mediated both via a direct excitation of their membrane as well as via an effect on local circuits, and 3) the GLP-1-responsive neurons (i.e., putative endocrine secretion-controlling neurons) could be distinguished from neurons responsive to PP (i.e., putative exocrine secretion-controlling neurons).

Genetic regulation of patterned tubular branching in Drosophila

A common theme in organogenesis is the branching of epithelial tubes, for example in the lung, liver, or kidney. The later morphogenesis of these branched epithelia dictates the final form and function of the mature tissue. Epithelial branching requires the specification of branch cells, the eversion process itself, and, frequently, patterned morphogenesis to produce branches of specific shape and orientation. Using the branching of renal tubule primordia from the hindgut in Drosophila, we show that these aspects are coordinately regulated. Cell specification depends on Wnt signaling along the tubular gut and results in the spatially restricted coexpression of two transcription factors, Krüppel and Cut, in the hindgut, whose activity drives cells toward renal tubule fate. Significantly, these transcription factors also confer the competence to respond to a second signal; TGF-beta induces branching to form the four renal tubule buds. Differential activation of the TGF-beta pathway also patterns the tubules, resulting in the asymmetry in size and positioning that is characteristic of the two tubule pairs. High levels of TGF-beta promote the expression of Dorsocross1-3 and anterior tubule growth, whereas low levels allow the expression of the transcriptional repressor, Brinker, and thus promote posterior tubule identity. We show that patterning of the tubule primordium into two distinct pairs is critical for the eversion of tubule branches, as well as for their asymmetric morphogenesis.

Video assisted thoracic surgery in the management of spontaneous pneumothorax: the current status

Over the past decade, video assisted thoracic surgery (VATS) has changed the way spontaneous pneumothorax (SP) is managed. Benefits of VATS include less postoperative pain, shorter hospital stay, and attenuated postoperative inflammatory response are evident compared with open thoracic procedures. Furthermore, the increasing acceptance by patients and referring physicians is testament to its success. Recent studies and the authors decade of experience in management of SP by VATS show that it is quick, safe, and effective, with recurrence rates generally comparable to open procedures, with some exceptions. However, selecting the correct procedure and patient, as well as knowing the limitations of the surgeons and techniques are paramount for success. Even to this day, there are considerable variations in the treatment of SP and large scale controlled studies are needed to better define timing of surgery and the role of the different procedures in the treatment and prevention of SP.

Deferoxamine reduces CSF free iron levels following intracerebral hemorrhage

Iron overload occurs in brain after intracerebral hemorrhage (ICH). Deferoxamine, an iron chelator, attenuates perihematomal edema and oxidative stress in brain after ICH. We investigated the effects of deferoxamine on cerebrospinal fluid (CSF) free iron and brain total iron following ICH. Rats received an infusion of 100-microL autologous whole blood into the right basal ganglia, then were treated with either deferoxamine (100 mg/kg, i.p., administered 2 hours after ICH and then at 12-hour intervals for up to 7 days) or vehicle. The rats were killed at different time points from 1 to 28 days for measurement of free and total iron. Behavioral tests were also performed. Free iron levels in normal rat CSF were very low (1.1 +/- 0.4 micromol). After ICH, CSF free iron levels were increased at all time points. Levels of brain total iron were also increased after ICH (p < 0.05). Deferoxamine given 2 hours after ICH reduced free iron in CSF at all time points. Deferoxamine also reduced ICH-induced neurological deficits (p < 0.05), but did not reduce total brain iron. In conclusion, CSF free iron levels increase after ICH and do not clear for at least 28 days. Deferoxamine reduces free iron levels and improves functional outcome in the rat, indicating that it may be a potential therapeutic agent for ICH patients.

EXTRA Trial-Evaluation of capecitabine treatment with radiotherapy (RT) in anal cancer: Preliminary results on toxicity and outcome

14085

Background: Phase III trials have shown RT + 5-Fluorouracil (5-FU) + mitomycinC (MMC) as the standard treatment for patients with epidermoid anal carcinoma. The objective of this trial is to determine if capecitabine in combination with MMC has a similar outcome in terms of complete response (CR) rate and toxicity to a 5-day infusion of 5-FU. Capecitabine is a rational alternative to 5-FU as these cancers express high levels of thymidine phosphoralase. Methods: Main eligibility criteria are histologically proven anal carcinoma (epidermoid, squamous, basaloid), fit to receive capecitabine and MMC and ineligible for the ongoing phase III UK trial, ACT II. Exclusion criteria include complete local excision, prior chemoradiation, uncontrolled cardiovascular disease and known HIV+ve. All patients receive: 50.4Gy in 28F(RT) and capecitabine 1650mg/m2/day on each RT treatment day (M-F) over 6 weeks. In addition patients receive MMC 12mg/m2, day 1 only. Assessment of response is by CT scan at 4 wks post chemoradiation. Results: To date 18/30 patients have been registered. Pre-treatment characteristics are: median age 59 yrs (44–85); 7 male, 11 female; 13 Canal, 5 Margin; 5T1, 4T2, 6T3, 2T4, 1Tx; 4N+ve, 13N-ve, 1Nx. Data on 14 evaluable pts are presented here. RT compliance: 12 pts completed planned treatment, treatment was interrupted in 2 cases (chest pain 1; machine breakdown 1). Chemotherapy compliance: 10 pts completed protocol treatment, in 3 pts chemotherapy was affected due to toxicity (1 dose reduced, 2 stopped early 1 due to chest pain and 1 due to grade 3 skin and diarrhoea). One patient decided to stop treatment. Grade 3 toxicity was reported in 2 pts during treatment: dyspnoea 1, diarrhoea 1. Four weeks post chemoradition, 10 had CR, 3 had partial response and 1 pt was not assessable. Thirteen pts are alive and disease free at a median follow-up of 6 months (range 1 -13). One pt has relapsed in an inguinal node 9 months after the end of treatment following a previous CR. Conclusions: This early information suggests that this regimen can be given without interruption and with acceptable toxicity. The early response data is encouraging and the trial aims to reach target accrual by Summer 2006. Educational grant provided by Roche pharmaceuticals.

[Table: see text]