Effect of a Community-Based Medical Oncology Depression Screening Program on Behavioral Health Referrals Among Patients With Breast Cancer: A Randomized Clinical Trial

IMPORTANCE

Implementation of guideline-recommended depression screening in medical oncology remains challenging. Evidence suggests that multicomponent care pathways with algorithm-based referral and management are effective, yet implementation of sustainable programs remains limited and implementation-science guided approaches are understudied.

OBJECTIVE

To evaluate the effectiveness of an implementation-strategy guided depression screening program for patients with breast cancer in a community setting.

DESIGN, SETTING, AND PARTICIPANTS

A pragmatic cluster randomized clinical trial conducted within Kaiser Permanente Southern California (KPSC). The trial included 6 medical centers and 1436 patients diagnosed with new primary breast cancer who had a consultation with medical oncology between October 1, 2017, through September 30, 2018. Patients were followed up through study end date of May 31, 2019.

INTERVENTIONS

Six medical centers in Southern California participated and were randomized 1:1 to tailored implementation strategies (intervention, 3 sites, n = 744 patients) or education-only (control, 3 sites, n = 692 patients) groups. The program consisted of screening with the 9-item Patient Health Questionnaire (PHQ-9) and algorithm-based scoring and referral to behavioral health services based on low, moderate, or high score. Clinical teams at tailored intervention sites received program education, audit, and feedback of performance data and implementation facilitation, and clinical workflows were adapted to suit local context. Education-only controls sites received program education.

MAIN OUTCOMES AND MEASURES

The primary outcome was percent of eligible patients screened and referred (based on PHQ-9 score) at intervention vs control groups measured at the patient level. Secondary outcomes included outpatient health care utilization for behavioral health, primary care, oncology, urgent care, and emergency department.

RESULTS

All 1436 eligible patients were randomized at the center level (mean age, 61.5 years; 99% women; 18% Asian, 17% Black, 26% Hispanic, and 37% White) and were followed up to the end of the study, insurance disenrollment, or death. Groups were similar in demographic and tumor characteristics. For the primary outcome, 7.9% (59 of 744) of patients at tailored sites were referred compared with 0.1% (1 of 692) at education-only sites (difference, 7.8%; 95% CI, 5.8%-9.8%). Referrals to a behavioral health clinician were completed by 44 of 59 patients treated at the intervention sites (75%) intervention sites vs 1 of 1 patient at the education-only sites (100%). In adjusted models patients at tailored sites had significantly fewer outpatient visits in medical oncology (rate ratio, 0.86; 95% CI, 0.86-0.89; P = .001), and no significant difference in utilization of primary care, urgent care, and emergency department visits.

CONCLUSIONS AND RELEVANCE

Among patients with breast cancer treated in community-based oncology practices, tailored strategies for implementation of routine depression screening compared with an education-only control group resulted in a greater proportion of referrals to behavioral care. Further research is needed to understand the clinical benefit and cost-effectiveness of this program.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02941614.

The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience

PURPOSE

To compare long-term outcomes of high-grade, primary soft-tissue-sarcoma (STS), using Ifosfamide-Doxorubicin vs local therapy alone, in histology-specific sarcomas.

METHODS

Retrospective analysis was performed on 127 patients from 2005 to 2018, with high-grade STS of extremity or trunk, >5 cm, that were either Synovial-Cell, Dedifferentiated-Liposarcoma (DDL), Myxofibrosarcoma, Round-Cell-Liposarcoma (RCLS), Undifferentiated-Pleomorphic-Sarcoma (UPS), or Undifferentiated-Sarcoma-not-otherwise-specified (US-NOS), with central pathology review. Ifosfamide-Doxorubicin was generally given neoadjuvant over 5 cycles, followed by radiation and wide excision, with chemotherapy given in 38 patients, while 89 received local therapy alone. Multi-variable-analysis (MVA) of prognostic factors was performed, and local-recurrence-free-survival (LRFS), distant-metastases-free-survival (DMFS), disease-specific-survival (DSS), and overall-survival (OS) were estimated using Kaplan-Meier, and adjusted using propensity-score matching.

RESULTS

Median follow-up was 4.5 years. Younger age (p < 0.0001) and Synovial histology (p = 0.0002) were more likely to undergo chemotherapy. Ifosfamide-Doxorubicin improved 5-year DMFS (p = 0.02), DSS (p = 0.01), and OS (p = 0.01), by univariate comparisons, as well as sub-analysis of non-synovial histology, but significance was lost after propensity-score matching for DMFS (p = 0.10), DSS (p = 0.09), and OS (p = 0.07). Size >10 cm, trunk location, and lack of chemotherapy significantly lowered DMFS, DSS, and OS on MVA, while DDL had more favorable survival; although size, trunk location, and DDL histology were not significantly different between treatment groups. Ifosfamide-Doxorubicin independently improved DMFS (p = 0.001), DSS (p = 0.01), and OS (p = 0.001) on MVA.

CONCLUSION

Ifosfamide-Doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, STS of the trunk or extremity in Synovial-Cell, DDL, Myxofibrosarcoma, RCLS, UPS, and US-NOS.

Anti-PF4 VITT antibodies are oligoclonal and variably inhibited by heparin

Background

COVID-19 vaccines have been associated with a rare thrombotic and thrombocytopenic reaction, Vaccine-induced immune thrombotic thrombocytopenia (VITT) characterized by platelet-activating anti-PF4 antibodies. This study sought to assess clonality of VITT antibodies and evaluate their characteristics in antigen-based and functional platelet studies.

Methods

Anti-PF4 antibodies were isolated from five patients with VITT secondary to ChAdOx1 nCoV-19 (n=1) or Ad26.COV2.S (n=4) vaccination. For comparative studies with heparin-induced thrombocytopenia (HIT), anti-PF4 antibodies were isolated from one patient with spontaneous HIT, another with “classical” HIT, and two patients with non-pathogenic (non-platelet activating) anti-PF4 antibodies. Isolated antibodies were subject to ELISA and functional testing, and mass spectrometric evaluation for clonality determination.

Results

All five VITT patients had oligoclonal anti-PF4 antibodies (3 monoclonal, one bi- and one tri-clonal antibodies), while HIT anti-PF4 antibodies were polyclonal. Notably, like VITT antibodies, anti-PF4 antibodies from a spontaneous HIT patient were monoclonal. The techniques employed did not detect non-pathogenic anti-PF4 antibodies. The ChAdOx1 nCoV-19-associated VITT patient made an excellent recovery with heparin treatment. In vitro studies demonstrated strong inhibition of VITT antibody-induced platelet activation with therapeutic concentrations of heparin in this and one Ad26.COV2.S-associated VITT patient. Oligoclonal VITT antibodies with persistent platelet-activating potential were detected at 6 and 10 weeks after acute presentation in two patients tested. Two of the 5 VITT patients had recurrence of thrombocytopenia and one patient had focal seizures several weeks after acute presentation.

Conclusion

Oligoclonal anti-PF4 antibodies mediate VITT. Heparin use in VITT needs to be further studied.

Neural correlates of cognitive variability in childhood autism and relation to heterogeneity in decision-making dynamics

Heterogeneity in cognitive and academic abilities is a prominent feature of autism spectrum disorder (ASD), yet little is known about its underlying causes. Here we combine functional brain imaging during numerical problem-solving with hierarchical drift-diffusion models of behavior and standardized measures of numerical abilities to investigate neural mechanisms underlying cognitive variability in children with ASD, and their IQ-matched Typically Developing (TD) peers. Although the two groups showed similar levels of brain activation, the relation to individual abilities differed markedly in ventral temporal-occipital, parietal and prefrontal regions important for numerical cognition: children with ASD showed a positive correlation between functional brain activation and numerical abilities, whereas TD children showed the opposite pattern. Despite similar accuracy and response times, decision thresholds were significantly higher in the ASD group, suggesting greater evidence required for problem-solving. Critically, the relationship between individual abilities and engagement of prefrontal control systems anchored in the anterior insula was differentially moderated by decision threshold in subgroups of children with ASD. Our findings uncover novel cognitive and neural sources of variability in academically-relevant cognitive skills in ASD and suggest that multilevel measures and latent decision-making dynamics can aid in characterization of cognitive variability and heterogeneity in neurodevelopmental disorders.

Intravenous immunoglobulin as an adjunct therapy in persisting heparin-induced thrombocytopenia

Heparin induced thrombocytopenia (HIT) is a serious adverse drug reaction caused by transient antibodies against platelet factor 4 (PF4)/heparin complexes, resulting in platelet activation and potentially fatal arterial and/or venous thrombosis. Most cases of HIT respond to cessation of heparin and administration of an alternative non-heparin anticoagulant, but there are cases of persisting HIT, defined as thrombocytopenia due to platelet activation/consumption for greater than seven days despite standard therapy. These patients remain at high risk for thrombotic events, which may result in limb-loss and mortality. Intravenous immunoglobulin (IVIg) has been proposed as an adjunct therapy for these refractory cases based on its ability to saturate FcγRIIa receptors on platelets, thus preventing HIT antibody binding and platelet activation. We describe 2 cases of persisting HIT (strongly positive antigen and functional assays, and persisting thrombocytopenia >7 days) with rapid clinical response to IVIg. We performed in-vitro experiments to support IVIg response. Healthy donor platelets (1 × 10e6) were treated with PF4 (3.75 μg/mL) for 20 min followed by 1-hour incubation with patients' sera. Platelet activation with and without addition of IVIg (levels equivalent to those reached in a patient after treatment with 2 gm/Kg) was evaluated in the PF4-dependent P-selectin expression assay (PEA). A significantly decreased platelet activation was demonstrated after the addition of IVIg to both patient samples, which correlated well with the rapid clinical response that each patient experienced. Thus, our study supports the use of IVIg as an adjunct therapy for persisting HIT.

Suspected Hepadnavirus Association with a Hepatocellular Carcinoma in a Black-Tailed Prairie Dog (Cynomys ludovicianus)

Hepatocellular carcinomas are the most commonly reported neoplasm of black-tailed prairie dogs (Cynomys ludovicianus). In several other closely related Sciuridae species, infection with species-specific hepadnaviruses is associated with the development of these tumours, but such a hepadnavirus has not yet been identified in any prairie dog species, although its presence has been hypothesized previously. An adult prairie dog was humanely destroyed due to progressive illness and the identification of a cranial abdominal mass that was determined on histopathology to be a hepatocellular carcinoma. Deep sequencing of the tumour tissue identified the presence of a hepadnavirus, similar in its genetic structure to woodchuck hepatitis virus. Electron microscopy showed the presence of viral particles similar in structure to other hepadnaviral particles. This report suggests that a hepadnavirus may be associated with the development of hepatocellular carcinomas in the prairie dog.

Observation of interference between two distinct autoionizing states in dissociative photoionization of H2

Dissociative photoionization (DPI) of randomly oriented H(2) molecules has been studied using linearly polarized synchrotron radiation at selected photon energies of 31, 33, and 35 eV. Large amplitude oscillations in the photoelectron asymmetry parameter β, as a function of electron energy, have been observed. The phase of these β oscillations are in excellent agreement with the results of recent close coupling calculations [Fernández and Martín, New J. Phys. 11, 043020 (2009)]. We show that the oscillations are the signature of interferences between the 1Q(1) (1)Σ(u)(+) and 1Q(2) (1)Π(u) doubly excited states decaying at different internuclear distances. The oscillations thus provide information about the classical paths followed by the nuclei. The presence of such oscillations is predicted to be a general phenomenon in DPI.

HER-2/neu expression in glioblastoma multiforme (GBM)

e13035

Background: Glioblastoma multiforme (GBM) is a disease in which very few cytotoxic chemotherapy agents have been shown to have activity. This is partly due to their inability to cross the blood brain barrier. Trials with bevacizumab, a VEGF inhibitor that disrupts tumor angiogenesis, have demonstrated activity against this otherwise chemotherapy resistant disease. This has led to interest in other biologic agents that target angiogenic pathways for the treatment of GBM. Over-expression of HER-2/neu by human tumor cells is closely associated with increased angiogenesis and expression of VEGF. Lapatinib is a recently available low molecular weight immunotherapeutic agent that targets HER-2/neu proteins. In a recent study, breast cancer patients treated with lapatinib and capcitabine had decreased brain metastases indicating that lapatinib may cross the blood brain barrier and thus have potential in the treatment of malignant gliomas. Limited studies have evaluated HER-2/neu gene expression in GBM and the results are inconsistent. We evaluated the expression of Her-2/neu protein in 41 consecutive GBM cases to explore the potential utility of targeting this pathway. Methods: Archival histopathologic sections from 41 patients (age 26–89 years) with a diagnosis of GBM from 2004–2008 were reviewed. The diagnosis was confirmed and optimal sections were selected. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded tissue sections using the primary antibody against HER-2/neu (clone 4B5, Ventana). The results were evaluated by three independent investigators. Interpretation was performed using the semi-quantitative criteria (Score 0 to 3+) currently used for primary breast carcinomas. Results: 38 out of 41 cases showed no immunohistochemical staining with HER-2/neu antibody (score 0). Three cases demonstrated weak, incomplete membrane staining of rare tumor cells (score 1+) and were interpreted as negative. The positive and negative controls worked properly. Conclusions: Our study indicates that there is no significant immunohistochemical over-expression of HER-2/neu protein in GBM. This suggests that HER-2/neu over-expression is not a significant oncogenic pathway in GBM, and therefore may not be a potential therapeutic target in this disease.

No significant financial relationships to disclose.

Use of the haematopoietic progenitor cell parameter in optimizing timing of peripheral blood stem cell harvest

BACKGROUND AND OBJECTIVES

Timing of peripheral blood stem cell (PBSC) harvest is typically based on quantification of peripheral blood (PB) CD34+ cells. CD34 enumeration is expensive, requires expertise and takes a minimum of 1-2 h to perform. The Sysmex XE2100 is an automated haematology analyser that can rapidly and inexpensively identify haematopoietic progenitor cell (HPC) populations in PB. The aim of this study was to examine if HPC can be used to optimize timing of PBSC harvest.

MATERIALS AND METHODS

White blood cell (WBC), HPC and CD34 counts were determined in a total of 60 mobilized donors. Data were analysed to examine the utility of WBC and HPC counts in predicting preharvest CD34+ counts.

RESULTS

In adults presenting for autologous collection, a PB HPC threshold of > 30/microl predicts a preharvest CD34+ count of > 20/microl with sensitivity of 86% and positive predictive value (PPV) of 100%. Among paediatric patients with a diagnosis of neuroblastoma, an HPC threshold of > 16/microl yielded sensitivity and PPV of 100%, while in children with other diagnoses, an HPC cut-off of > 44/microl yielded sensitivity and PPV of 67% and 100%, respectively. Eighty per cent of adequately mobilized allogeneic donors were identified using an HPC threshold > 15/microl, with a PPV of 100%. PB WBC can also aid in predicting CD34 counts in most patient groups, albeit with lower sensitivity than HPC.

CONCLUSION

By virtue of being a sensitive and accurate predictor of preharvest CD34+ counts, our data support the use of the HPC parameter in optimizing the timing of PBSC harvest.

Bisphosphonate-induced osteonecrosis of the jaw: Risk factors and diagnostic utility of bone scans

9052

Background: Osteonecrosis of the jaw (ONJ) is a serious long-term effect of intravenous bisphosphonates. We report characteristics of patients with ONJ at Roswell Park Cancer Institute (RPCI) and utility of bone scans in its diagnosis. Methods: Patients were identified using RPCI database. ONJ diagnosed was staged using the system used for jaw osteoradionecrosis (Schwartz et al, Am J Clin Oncol, 2002). Controls included patients receiving bisphosphonates between July 2002 and 2006. Routine whole body bone scans were reviewed for jaw uptake. Statistical analysis was done using SAS 9.1. Results: Three hundred and fifty-four patients received intravenous bisphosphonates between July 2002 and 2006. Twenty-four (7%) were diagnosed with ONJ. Among patients with ONJ, fifteen (63%) had breast cancer, eight (33%) had multiple myeloma and one (4%) had lung cancer. Mean age was 56.8 years. (SD= 9.1) Thirteen patients (54%) had tobacco use, five (21%) had diabetes, nine (37.5%) had hypertension and twenty-three patients (96%) received chemotherapy. Five patients (21%) had caries, three (12.5%) had dental surgery, nine (37.5%) had periodontal disease, thirteen (54%) had extractions and one (4%) had prior dental trauma. Twenty-two patients (92%) presented with pain. Twelve patients (50%) had ONJ Stage 1, eight (33%) Stage 2 and four (17%) Stage 3. Median duration of exposure to bisphosphonates was 39 months. The difference between the average number of infusions in the ONJ group (11.2, CI: 11.3, 20.3) and control group (7.2, CI: 6.2, 8.2) was found to be significant (p<0.0009). Three patients (12.5%) had progressive ONJ. Thirteen patients with ONJ had bone scans and twelve (92%) showed jaw uptake. Among controls, one hundred and eighty-three had bone scans and one hundred and twenty-eight (70%) showed jaw uptake. This difference was not significant. (p=0.114, two-tailed Fisher's exact test). Conclusions: In our study, chemotherapy, smoking, prior dental extractions and the number of bisphosphonate infusions appear to be risk factors for ONJ. It has been recently reported (Chiandussi et al., Dentomaxillofacial Radiol. 2006) that bone scans can be used as a screening tool for ONJ, however, in our series jaw uptake on bone scan was not a reliable predictor for the development of ONJ.

No significant financial relationships to disclose.

Acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) following a diagnosis of breast cancer

7051

Background: Increasing use of chemotherapy and radiation therapy in breast cancer patients in the adjuvant setting heightens concern about therapy-related AML and MDS. Little is known about the characteristics of these disorders following breast cancer. Methods: Roswell Park Cancer Institute (RPCI) patients with diagnoses of MDS or AML by French-American-British Group or World Health Organization criteria following breast cancer were retrospectively reviewed. Results: 34 women were identified between 1983 and 2006. 10 (29%) were also diagnosed with additional malignancies, including non-Hodgkin lymphoma (NHL), bladder, colon, lung, uterine and thyroid cancers, Ewing sarcoma and angiosarcoma. 23 of 31 patients (74%) with family histories documented had first-degree relatives with cancers, including breast, lung, colon, stomach, pancreas, prostate, renal, melanoma, esophagus, thyroid, Hodgkin lymphoma and leukemia, compared to a 45% prevalence of first-degree relatives with cancer among 1982 control RPCI breast cancer patients (p= 0.001). Median age at breast cancer diagnosis was 58 (range, 37–85) years. Among the 29 patients with known treatment, 25 (86%) had received radiation therapy, 13 (45%) had received chemotherapy, including alkylating agents in all 13 (45%) and topoisomerase II inhibitors in 8(28%), while 4 (14%) had received no adjuvant therapy. Median age at AML/MDS diagnosis was 70 (range, 46–90) years. 26 patients had AML and 8 MDS, of whom 4 progressed to AML. Karyotypes were complex in 10 (29%), involved 11q23 rearrangements in 6 (18%), were favorable, normal and unknown in 5 each (45%), and had miscellaneous single structural abnormalities in 3 (9%); they did not strictly correlate with treatment received. Median survival (months) was 1 for complex karyotype, 6 for 11q23 translocation and 40 for favorable karyotype patients. Conclusions: The incidence of other cancers and of cancers in family members was unexpectedly high in breast cancer patients with AML and MDS, in the absence of known genetic syndromes, suggesting genetic polymorphisms predisposing to multiple cancers. Cytogenetic abnormalities included complex, 11q23 and favorable karyotypes, and survival reflected karyotypes.

No significant financial relationships to disclose.

Introduction of an early pregnancy assessment unit: audit on the first 6 months of service

BACKGROUND

Women experiencing bleeding in early pregnancy suffer considerable anxiety. Waiting for a considerable time for a diagnosis adds to their grievance. Early Pregnancy Assessment Unit (EPAU) is a dedicated service that provides quick and easy accessibility to diagnosis, treatment and support service.

AIM

To monitor the first 6 months of the EPAU service in the Rotunda Hospital, to identify its shortcomings, so that we can ensure effective EPAU care in future.

METHODS

A retrospective audit between July and December 2002 was performed.

RESULTS

A majority of patients (83.4%) were self-referrals. All patients were seen between 1 and 3 h. In the miscarriage group, 218/278 (78.4%) was managed surgically by evacuation and a further 60/278 (21.6%) received conservative or medical treatment. Among 13 ectopic pregnancies, 5/13 (39%) had laparoscopic management.

CONCLUSION

This clinic has enabled us to manage early pregnancy bleeding in an effective manner within a satisfactory time period. The high surgical intervention rate for miscarriages is highlighted to support the need for greater emphasis on medical and expectant management.

Thymoma: a pathological study of 50 cases

BACKGROUND

A combination of epithelial cells and lymphocytes results in a varied histomorphology of thymomas and consequent varied classification systems.

AIM

To correlate the Marino and Muller-Hermelink (MMH) classification with the invasive behaviour of thymomas.

SETTING AND DESIGN

Retrospective analysis.

MATERIALS AND METHOD

Thymomas encountered in the past 21 years were re-classified with the MMH classification and correlated with Masaoka's staging and clinical presentation.

RESULTS

The thymomas formed 91% of the primary thymic epithelial tumours. Predominantly cortical thymomas (n=21) and cortical thymomas (n=22) were the common subtypes and 60% and 77% of these, respectively, were in stages II or III. Cystic change, necrosis or haemorrhage played no role in predicting invasive behaviour. Cortical epithelium correlated well with the presence of para-thymic syndromes, especially myasthenia gravis.

CONCLUSION

MMH classification is easy to apply. Cortical thymomas in stage I should be followed up for possible recurrence.

T-level downstaging and complete pathologic response after preoperative chemoradiation for advanced rectal cancer result in decreased recurrence and improved disease-free survival

PURPOSE

Preoperative chemoradiation therapy is used widely in the treatment of rectal cancer. The predictive value of response to neoadjuvant remains uncertain. We retrospectively evaluated the impact of response to preoperative and, specifically, of T-level downstaging, nodal downstaging, and complete pathologic response after chemoradiation therapy on oncologic outcome of patients with locally advanced rectal cancer.

METHODS

There were 88 patients with ultrasound Stage T3/T4 midrectal (n = 37) and low rectal (n = 51) cancers (63 males; mean age 62.6 years). All patients were treated by preoperative 5-fluorouracil-based chemotherapy and pelvic radiation followed by surgical resection in six weeks or longer (56 sphincter-preserving resections).

RESULTS

T-level downstaging after neoadjuvant treatment was demonstrated in 36 (41 percent) of 88 patients, and complete pathologic response was observed in 16 (18 percent) of the 88. Of the 42 patients with ultrasound-positive nodes, 27 had no evidence of nodal involvement on pathologic evaluation (64 percent). The overall response rate (T-level downstaging or nodal downstaging) was 51 percent. At a median follow-up of 33 months, 86.4 percent of patients were alive. The overall recurrence rate was 10.2 percent (three patients had local and six had metastatic recurrences). Patients with T-level downstaging and complete pathologic response were characterized by significantly better disease-free survival (P = 0.03, P = 0.04) and better overall survival (P = 0.07, P = 0.08), according to Wilcoxon's test comparing Kaplan-Meier survival curves. None of the patients with complete pathologic response developed recurrence or died during the follow-up period.

CONCLUSION

T-level downstaging and complete pathologic response after preoperative chemoradiation therapy followed by definitive surgical resection for advanced rectal cancer resulted in decreased recurrence and improved disease-free survival. Advanced rectal cancers that undergo T-level downstaging and complete pathologic response after chemoradiation therapy may represent subgroups that are characterized by better biologic behavior.

High prevalence of microcytic anaemia in Omani children: a prospective study

Iron deficiency is a common cause of microcytic anaemia. However, a high prevalence of haemoglobinopathies in the Arab population makes differential diagnosis difficult. This prospective study of anaemia in children attending a regional hospital in the Sultanate of Oman looked at the prevalence and causes of anaemia in 256 children, 153 in the age group 3-5 years (group A) and 103 in the age group 10-12 years (group B). Of the children studied, 45.1% in group A and 37.9% in group B were anaemic according to WHO criteria. All the anaemic children had low mean corpuscular haemoglobin and 75% showed microcytosis. Serum ferritin levels were normal and glucose-6-phosphate dehydrogenase deficiency did not contribute to the anaemia. The microcytosis and microcytic anaemia in the study population could be attributed to the alpha-thalassaemia trait which is highly prevalent in Oman. The information is of value in any country where there is a significant prevalence of alpha-thalassaemia genes because these can confound the diagnosis of iron deficiency.

Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty

PURPOSE

This study evaluated the effectiveness of combining advancement flap with sphincteroplasty in patients symptomatic with rectovaginal fistula and anal sphincter disruption.

METHODS

Twenty patients with rectovaginal fistulas and anal sphincter disruptions after vaginal deliveries underwent combined rectal mucosal advancement flap and anal sphincteroplasty between July 1986 and July 1993. The mean age of the patients was 30 (range, 18-40) years and the mean duration of symptoms was 54.8 weeks (range, 7 weeks to 6 years). In addition to mucosal advancement flap repair, 13 patients underwent two-layer repair of anal sphincters (with reapproximation of the puborectalis in 8 of the patients); 6 patients underwent one-layer overlap repair of anal sphincters (with reapproximation of the puborectalis in 2 of the patients); and 1 patient underwent reapproximation of internal anal sphincter alone because squeeze pressures were adequate, as determined by anal manometry.

RESULTS

Postoperatively, vaginal discharge of stool and flatus was eliminated entirely in all 20 patients. Perfect anal continence of stool and flatus was restored in 14 patients (70 percent). Incontinence was improved but not eliminated in six patients (4 incontinent to liquid stool and 2 to flatus), and two patients required perineal pads. Subjectively, 19 patients (95 percent) reported the result as excellent or good. There were no complications.

CONCLUSION

The combination of mucosal advancement flap and anal sphincteroplasty is a safe and highly effective procedure for correcting rectovaginal fistula with sphincter disruption after obstetrical injuries.

Expression of Chinese hamster cAMP-dependent protein kinase in Escherichia coli results in growth inhibition of bacterial cells: a model system for the rapid screening of mutant type I regulatory subunits

The regulatory and catalytic subunits of cAMP-dependent protein kinase (PKA) were coexpressed within the same bacterial cell using a polycistronic bacterial T7 expression vector encoding Chinese hamster cDNAs for the type I regulatory (RI) and catalytic alpha (C alpha) subunits of PKA. Basal expression of active RI/C alpha holoenzyme in the BL21(DE3) strain of Escherichia coli caused severe growth inhibition resulting in extremely small colony size. Several lines of evidence demonstrate that this growth inhibition requires active PKA subunits and cAMP: (i) this phenotype is dependent on cAMP since it is not seen in a strain lacking adenylyl cyclase activity, but the growth rate of these transformants is slower when exogenous cAMP is added; (ii) normal growth occurs when wild-type RI cDNA is replaced by a mutant RI cDNA encoding a RI protein with reduced cAMP binding; and (iii) the growth-inhibited phenotype of the transformed BL21(DE3) cells requires soluble, active C alpha protein. Holoenzyme expressed in bacteria is activated by cAMP, which stimulates phosphorylation of an endogenous 50-kDa protein that is missing in four host mutants selected for normal growth after transformation with PKA holoenzyme. A mutant RI cDNA library was generated by PCR random mutagenesis and screened by polycistronic expression in BL21(DE3) cells. The RI cDNA sequence from one revertant has base-pair substitutions creating two amino acid substitutions within the cAMP binding sites. The coexpression of the RI/C alpha subunits in BL21(DE3) bacterial cells provides a system for rapidly selecting mutations in the RI subunits of PKA.

Abdominal colon and rectal operations in the elderly

Sixty-seven abdominal operations for colon and rectal disorders were performed on 56 patients 80 years of age or older from January 1, 1984 to June 30, 1989. Nine patients required multiple operations. Sixty-two procedures (92 percent) were performed on patients in their ninth decade; two operations were performed on patients 95 years of age or older. Forty-five patients (80 percent) were operated upon for carcinoma. Operations included segmental colectomy (33 patients), low anterior resection (12 patients), total abdominal colectomy (3 patients) and abdominoperineal resection (2 patients). Forty patients were classified as ASA Class III; the majority were monitored in the surgical intensive care unit for a mean of 2.84 days. Thirty patients were monitored with arterial catheters and 21 with central invasive monitoring. Operative mortality was 7 percent (4 patients). Two patients died from diffuse carcinomatosis; one patient had a fatal myocardial infarction. The final death occurred from multisystem organ failure following anastomotic dehiscence. Twenty-seven operations were performed without postoperative complications; 18 operations were followed by a single minor complication. The average hospital stay was 18.96 days. All patients were admitted from home. Thirty-three returned home postoperatively; 16 were discharged to an extended care facility. In conclusion, elderly patients with colon and rectal disorders can be operated upon with acceptable morbidity and mortality. Age alone should not interdict surgical therapy.

Squamous-cell carcinoma of the anal canal: management with combined chemo-radiation therapy

Twenty patients with squamous-cell carcinoma of the anal canal received combined chemo-radiation therapy as their primary treatment. There were 18 women and two men with a mean age of 63 years (range, 34-91 years). The mean follow-up was 34 months (range, 6-62 months). Anal margin cancers and adenocarcinomas were excluded. Fourteen of 20 patients treated had a complete response. There were six local failures: three with residual disease at the end of treatment and three with recurrent disease at a later date. Of the three with residual disease, one underwent abdominoperineal resection and two received salvage therapy (one with chemo-radiation and one with radiation alone). All three patients with recurrent disease were treated with abdominoperineal resection. All six were disease free at the end of the study. Of the 14 patients with complete local response, one presented with liver metastases 19 months later. Sixteen patients (80 percent) were alive at the end of the study, and 19 patients (95 percent) had no evidence of disease. These data add support for salvage therapy in the treatment of patients with residual disease following initial chemo-radiation therapy. Salvage options for patients with squamous-cell carcinoma of the anus who fail the Nigro protocol will be discussed.

Surgical treatment of low rectovaginal fistulas

Forty women with low rectovaginal fistulas were operated upon over a 9-year period. The etiology of the fistula in the majority was obstetric. Nine women had prior attempts to repair the fistula. All 40 women were managed with endorectal advancement flap with the addition of sphincteroplasty or perineal body reconstruction in 15 patients and rectocele repair in six patients. Postoperative complications included urinary difficulties (two patients) and wound complications (three patients). There were two recurrences. All women treated with sphincteroplasty or perineal body reconstruction were continent. Seven women complained of varying degrees of incontinence postoperatively; none had undergone sphincter or perineal body reconstruction. Endorectal advancement flap is a safe and effective operation for women with rectovaginal fistulas. Concomitant sphincteroplasty or perineal body reconstruction should be performed in women with historical, physical, or manometric evidence of incontinence.

Radiotherapy alone and chemoradiation for nonmetastatic esophageal carcinoma. A critical review of chemoradiation

Sixty-five patients with nonmetastatic (Stages I, II, and III) esophageal cancer (EC) were treated with radiotherapy (RT) alone (56.00 to 61.00 Gy in 6 to 7 weeks) or synchronous combinations of radiotherapy and chemotherapy (RT-CT). RT-CT consisted of 41.40 to 50.40 Gy in 4.5 to 8 weeks with continuous infusion 5-fluorouracil 5-FU (1000 mg/m2/d for 4 days in weeks 1, 4, and 8), mitomycin C (10 mg/m2 intravenously [IV] in weeks 1 and 8), cisplatin (75 mg/m2 IV in week 4). Maintenance CT consisted of methotrexate (200 mg/m2 IV), leucovorin (10 mg/m2 orally every 6 hours for 5 doses), and 5-FU (600 mg/m2 IV) in weeks 10, 12, and 14. Thirty-five patients treated by RT alone (Group A) were comparable in terms of age, sex, AJC staging, histologic condition, and location of primary with 30 patients treated by RT-CT (Group B). In Group A (range, 2- to 144+ months), two patients (42 and 144 months) are alive and well. In Group B (range, 2- to 59+ months), 12 patients (7 to 59 months) are alive and well. Median survival in Group A is 8 months, compared with 15 months for patients achieving a complete response (CR) in Group B. Patients in Group B achieved a 77% CR rate by endoscopy-biopsy, whereas 30% of the patients in Group A achieved a CR (P = 0.0001). The recurrence rates at the primary site/regional nodes were 77% and 27% in Groups A and B, respectively (P = 0.0001). The incidences of distant metastases were 29% and 20%, respectively (P = 0.423). In Group A, the 1-year and 2-year cumulative survival rates were 27% and 13%, respectively. In Group B, the cumulative survival rates were 53% at 1 year and 29% at 2 years (P = 0.023). Aside from reversible myelotoxicity, the incidences of pulmonary fibrosis, esophagitis, and fistulae formation were less frequent in the combined technique treatment group. A compilation of reported chemoradiation protocols for EC indicates consistently improved 1-year and 2-year survival rates, compared with surgical and RT series. The key to further improvement in the treatment of EC appears to lie in increasing the biologic response (RT fractionation and endocavitary RT) and optimal use of multiple effective CT agents with nonadditive toxicities.

Preliminary results of concomitant radiotherapy and chemotherapy in advanced cervical carcinoma

Ten patients with advanced and previously untreated squamous cell carcinoma of the cervix were treated with a synchronous course of radiotherapy (RT) and chemotherapy (CT). RT consisted of 3600 to 4500 cGy external pelvic treatments on a 6-MeV linear accelerator followed by two intracavitary applications administering a total of 4000 mg hr of radium equivalent cesium. CT consisted of a course of mitomycin C (10 mg/m2 iv bolus) and 5-fluorouracil (5FU; 1000 mg/m2/24 hr for 96 hr) during the second week of external RT and another course of cis-platinum (CDDP; 75 mg/m2, 1-6 hr infusion) and 5FU (1000 mg/m2/24 hr for 96 hr) during the first intracavitary cesium application. Toxicity was acceptable and complete clinical response was obtained in all patients at the end of the regimen. Nine patients are alive (eight without disease) 6 to 37 months following initiation of treatment (median 20 months). One patient has developed lumbar spine bone metastases and another died of local and pulmonary disease at 28 months. This combination of 5FU/mitomycin C/CDDP and RT appears to be a practical, well-tolerated, and highly effective regimen for advanced cervical carcinoma.

Clear cell myeloma

We report a case of clear cell myeloma misinterpreted at initial biopsy as liposarcoma. The patient had lytic skeletal lesions and monoclonal IgA, kappa, serum immunoglobulin. The tumor cells contained cytoplasmic vacuoles that produced a clear histologic appearance. The light-microscopic and ultrastructural findings are compared with those of other cases of lymphoplasmacytic disorders with prominent cytoplasmic inclusions.

Pancoast syndrome caused by extramedullary plasmacytoma

A 61-year-old patient had the clinical findings of Pancoast syndrome with shoulder pain, weakness and atrophy of band muscles, and an opacified area in the apical lung field. Unlike most cases with Pancoast syndrome in which the tumors are primary carcinomas of the lung, the present case was shown to have a plasmacytoma involving the apical parietal pleura and the adjacent chest wall. The need for histologic diagnosis before treating patients with Pancoast syndrome is emphasized.

Extraskeletal Ewings sarcoma

A case of Ewings sarcoma arising in the soft tissue of the thumb is described. This appears to be the first case of digital extraskeletal Ewings sarcoma. The soft tissue location, the primary rather than metastatic nature, and the tumor type in this case were well documented.

Malignant hemangiopericytoma of the gallbladder

A rare case of malignant hemangiopericytoma in the gallbladder is described perhaps for the first time in the literature. Areas of necrosis, mitotic activity within the tumor, and the presence of metastases in the regional lymph nodes and right ovary suggest an aggressive behavior of the tumor and poor prognosis.

Role of endoscopy in upper gastrointestinal bleeding in patients with malignancy

A retrospective review of upper gastrointestinal bleeding in 55 patients with malignant disease is presented here. Major causative factors seem to be superficial gastritis and gastric erosions. With aggressive endoscopy, a diagnostic accuracy of 90 percent has been achieved. However, having the exact diagnosis too often has little significance on the final outcome of these critically ill patients, unless therapy directed against bleeding can provide time for effective antineoplastic treatment. With the better understanding of the pathology of the superficial gastric erosions, a better program of management can be evolved.