Evaluation of a Novel Field-placement Algorithm for Locoregional Breast Cancer Radiotherapy Including the Internal Mammary Chain

AIMS

Irradiation of the internal mammary chain (IMC) is increasing following recently published data, but the need for formal delineation of lymph node volumes is slowing implementation in some healthcare settings. A field-placement algorithm for irradiating locoregional lymph nodes including the IMC could reduce the resource impact of introducing irradiation of the IMC. This study describes the development and evaluation of such an algorithm.

MATERIALS AND METHODS

An algorithm was developed in which six points representing lymph node clinical target volume borders (based on European Society for Radiotherapy and Oncology consensus nodal contouring guidelines) were placed on computed tomography-defined anatomical landmarks and used to place tangential and nodal fields. Single-centre testing in 20 cases assessed the success of the algorithm in covering planning target volumes (PTVs) and adequately sparing organs at risk. Plans derived using the points algorithm were also compared with plans generated following formal delineation of nodal PTVs, using the Wilcoxon signed rank test. Timing data for point placement were collected. Multicentre testing using the same methods was then carried out to establish whether the technique was transferable to other centres.

RESULTS

Single-centre testing showed that 95% of cases met the nodal PTV coverage dose constraints (binomial probability confidence interval 75.1-99.9%) with no statistically significant reduction in mean heart dose or ipsilateral lung V17Gy associated with formal nodal delineation. In multicentre testing, 69% of cases met nodal PTV dose constraints and there was a statistically significant difference in IMC PTV coverage using the points algorithm when compared with formally delineated nodal volumes (P < 0.01). However, there was no difference in axillary level 1-4 PTV coverage (P = 0.11) with all cases meeting target volume constraints.

CONCLUSIONS

The optimal strategy for breast and locoregional lymph node radiotherapy is target volume delineation. However, use of this novel points-based field-placement algorithm results in dosimetrically acceptable plans without the need for formal lymph node contouring in a single-centre setting and for the breast and level 1-4 axilla in a multicentre setting. Further quality assurance measures are needed to enable implementation of the algorithm for irradiation of the IMC in a multicentre setting.

Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings

OBJECTIVE

Existing evidence suggests low recognition of alcohol problems in primary care. This study aimed to determine the 12-month prevalence of harmful or hazardous drinking (HHD) in a population sample and to measure the relationship between HHD and talking about alcohol in primary care consultations in that period.

METHOD

A New Zealand population survey of 12 488 adults. Alcohol use in the past 12 months was assessed by the Alcohol Use Disorders Identification Test (AUDIT), with HHD defined as a total score of eight or above. Talking about alcohol was self-reported.

RESULTS

HHD was present in 17.7% and was commoner in men and in younger age groups, with the highest prevalence 53.6% in men aged 18-24. Three per cent of those who attended their usual primary care provider in the past 12 months reported being talked to about alcohol. Talking about alcohol increased with AUDIT score, but was not commoner in young people despite their higher prevalence of HHD. Overall, 9.4% of attendees with HHD reported talking about alcohol.

CONCLUSION

HHD is common but largely not detected in primary care. Improved detection would permit the delivery of effective treatments such as brief interventions.

Changing incidence and management of penetrating neck injuries in the South East London trauma centre

INTRODUCTION

A total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King's College Hospital over a 3-year period in the 1980s. In April 2010 King's College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years.

METHODS

Data were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment.

RESULTS

The past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality.

CONCLUSIONS

The increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.

Genetic and other effects on bacterial phagocytosis and killing by cultured peripheral blood monocytes of SLA-defined miniature pigs

The influence of miniature swine major histocompatibility complex genes (SLA) upon phagocytic and bactericidal activities of peripheral blood monocytes against Salmonella typhimurium and Staphylococcus aureus was measured in vitro using cultured cells and bacterial/enzyme-dependent tetrazolium dye (MTT) reduction. Haplotype significantly influenced uptake and killing of each bacterium by monocytes of 4- and 8-week-old pigs. Cells from 4-week-old SLA ad and aa pigs were significantly better than all others at phagocytizing S. aureus and cells from dg and gg were poorest. Killing of S. aureus was highest at 4 weeks in SLA cd pigs and in dg and gg pigs at 8 weeks of age. Uptake and killing of S. typhimurium was highest in homozygous aa and cc haplotypes at 4 weeks and pigs with the c x d recombinant haplotype had highest uptake and killing of S. typhimurium at 8 weeks. Litter, but not sire, also influenced significantly the uptake and killing of S. aureus and S. typhimurium.

Insights obtained from an evaluation of a falls prevention program set in a rural hospital

An evaluation of a Falls Prevention Program that took place in a 29-bed rural hospital in New South Wales is described. The aim of the project was to ascertain the overall effectiveness of the Program and to explore the usefulness of the assessment criteria in predicting falls. The sample consisted of 111 participants, representing all patients 65 years and over who were admitted to the general ward of the hospital between January and December 1997. The Falls Prevention Program had reduced the incidence of falls and was found to be effective for those patients requiring minimal assistance with walking. However, it was less effective for those using pick-up frames or forearm support frames. The patients who fell were more likely to be in the high risk category and it was concluded that while the assessment criteria was useful in predicting falls, the Falls Prevention Program could only limit the number of falls but not prevent them altogether. Age, mental status and mobility of patients in combination with time and location of falls suggested a pattern that was possibly peculiar to this rural hospital, which has implications for funding and staffing.

Assessment of the influence of background noise on escape-maintained problem behavior and pain behavior in a child with Williams syndrome

We examined the influence of background noise on levels of problem behavior and pain behavior under functional analysis conditions for a child with a diagnosis of Williams syndrome and hyperacusis. Background noise was associated with increases in escape-maintained problem behavior and increases in pain behavior such as clasping ears and crying. When the child was fitted with earplugs, there were substantial reductions in both problem and pain behavior under the background noise condition.

Toward a human papillomavirus vaccine

Much progress has been made over the past 10 years with regard to development of a vaccine active against HPV. Successful protection has been achieved in animal models using species-specific papillomaviruses; however, HPV diversity may delay the development of successful HPV vaccines, especially those designed as therapeutic vaccines for the treatment of HPV-induced carcinoma and high-grade dysplasia of the cervix. Difficulties arise with regard to assessment of efficacy of potential vaccines. The impetus for long-term studies on vaccine efficacy will initially stem from in vitro evidence of responsiveness to the vaccine. The time when a vaccine will have an impact on the prevalence of high-grade dysplasia and invasive cancer is still some way off.

The clinical load of HIV and AIDS for genitourinary physicians

We aimed to investigate the extent of genitourinary medicine (GUM) involvement in the clinical management of HIV. A questionnaire survey was conducted on GUM consultants in the UK and the Irish Republic. Clinics were divided into teaching hospitals (THs) undertaking both undergraduate and postgraduate training in GUM, non-teaching training (NTT) centres undertaking specialist training only and non-teaching (NT) centres. Information was obtained on 241 of the 250 consultants on the Royal College of Physician's GUM Committee's records from 117 GUM clinics (including all THs and NTT centres). Four (1 TH and 2 NTT centres) GUM clinics did not see HIV-positive patients, 62 saw 10-99 patients, 18 reported 100-999 and 4 with over 1000 patients attending in 1996. Thirty-five per cent of the 55 THs and NTT centres had over 100 HIV patients. Consultants were involved in the outpatient care of HIV patients in 99.5% and GUM trainees in 85.5% clinics. Overall 47 clinics have their own inpatient HIV beds and 176 consultants (73%) had full (100) or significant (76) input to inpatient HIV management. Only 29% of THs and 12.5% of NTT centres had none or minor input into HIV care. HIV inpatient on-call commitment by the GUM trainees was reported by 64% of training centres. GUM services provide a major input into outpatient and inpatient care of HIV-infected patients in the UK.

Peritoneal tumor: MR imaging with dilute oral barium and intravenous gadolinium-containing contrast agents compared with unenhanced MR imaging and CT

PURPOSE

To compare fat-suppressed, gadolinium-enhanced, breath-hold magnetic resonance (MR) imaging after administration of dilute oral barium solution with unenhanced MR imaging and computed tomography (CT) in the detection of peritoneal tumors.

MATERIALS AND METHODS

In 24 patients in whom peritoneal tumor was known or suspected, double-contrast MR imaging and CT were performed prospectively. MR imaging included T1-weighted, fast spin-echo T2-weighted, and immediate and delayed gadolinium-enhanced, breath-hold, fast multiplanar sequences with fat saturation. Helical and conventional dynamic CT were performed with intravenously and orally administered contrast media. MR images and CT scans were reviewed independently and prospectively by different pairs of radiologists for presence of peritoneal tumor in 17 anatomic sites. Imaging findings were compared with surgical and histopathologic results.

RESULTS

Of the 24 patients, 18 had peritoneal tumor confirmed at surgery. Detection of tumor sites was superior with double-contrast MR images (mean sensitivity, specificity, and accuracy, 84%, 87%, and 86%, respectively) compared with CT scans (mean sensitivity, specificity, and accuracy, 54%, 91%, and 74%, respectively). Double-contrast MR imaging enabled better detection of carcinomatosis and tumors less than 1 cm in diameter (75%-80%) than CT (22%-33%; P < .0001).

CONCLUSION

Double-contrast MR imaging demonstrated more peritoneal tumors than CT or unenhanced spin-echo MR imaging.

Two unusual presentations of müllerian adenosarcoma: case reports, literature review, and treatment considerations

Müllerian adenosarcomas of the uterus usually present as pedunculated endometrial masses in postmenopausal women with vaginal bleeding. Extraendometrial variants (originating in the ovary, adnexa, or myometrium) are much less common, and they tend to present at a more advanced stage due to their location. The sarcomatous portion of müllerian adenosarcoma can vary from low grade to very high grade and the clinical behavior of the tumors can be indolent or aggressive. We present two cases, one of which originated in the adnexa and the other in an apparent focus of uterine adenomyosis. These cases illustrate the difficulty of correct diagnosis and treatment.

An open, comparative, study of the efficacy of 0.5% podophyllotoxin lotion and 25% podophyllotoxin solution in the treatment of condylomata acuminata in males and females

The efficacy and safety of topical treatment for external condylomata acuminata with either self-applied 0.5% podophyllotoxin (PT) or hospital-applied 25% podophyllin (PODO) solution was compared in 138 males and 67 females in an open multicentre study. After one week of treatment, wart clearance was observed in 53% of males and 37% of females in the PT group as compared with 19% of males and 19% of females in the PODO group (P < 0.001 in males; P = 0.13 in females). At 5 weeks after commencing treatment, clearance of warts had been achieved in 86% males and 72% females in the PT group as compared with 78% of males and 62% females in the PODO group (P = 0.08 in males; P = 0.14 in females). Treatment had cleared 81% of 180 treated sites in all PT recipients as compared with 61% of 95 treated sites in all PODO recipients (P < 0.001). The increased speed of action of PT was associated with an increased incidence of symptoms and signs of inflammation at treatment sites in both males and females (P < 0.001). These were generally mild, did not interfere with continuing treatment, and were more frequent in those patients whose warts were eradicated most rapidly. Home-based treatment with 0.5% podophyllotoxin lotion in appropriately instructed patients of either sex is superior in efficacy to outpatient applied 25% podophyllin and has the potential to reduce the number of hospital attendances required in genital wart eradication.

Treatment of urinary conduit fistula by antegrade ureteral stent catheter

Two women with urinary conduit fistulas are presented. Both patients developed a conduit fistula postoperatively after total pelvic exenteration. The fistulas were managed successfully by inserting an antegrade ureteral stent catheter via a percutaneous nephrostomy. The details of the method used to perform this procedure are described in detail, and risks and benefits are reviewed.

Gynecologic masses: value of magnetic resonance imaging

Forty-two women with gynecologic abnormalities were studied with the use of magnetic resonance imaging. Magnetic resonance imaging correctly assessed the origin of the pelvic mass in all patients. In the evaluation of leiomyoma, magnetic resonance imaging accurately depicted the number, size, and location of the lesion. In the evaluation of endometrial carcinoma, magnetic resonance imaging depicted the location of the lesion, the presence of cervical extension, and the depth of myometrial penetration in the majority of the cases. In the analysis of adnexal cysts, magnetic resonance imaging was sensitive in localizing the lesion and was able to distinguish serous from hemorrhagic fluid. This preliminary report indicates that magnetic resonance imaging may become a valuable imaging modality in the diagnosis of gynecologic abnormalities.

In vitro reendothelialization. Microfilament bundle reorganization in migrating porcine endothelial cells

An experimentally induced wound made in a confluent monolayer culture of porcine thoracic aortic endothelial cells (ECs) was studied 22 hours after wounding using 7-nitrobenz-2-oxa-1,3-diazole (NBD) phallacidin and immunofluorescence microscopy to localize actin and myosin containing microfilament (MF) bundles. ECs extending from the wound edge back toward the confluent monolayer showed a specific change in cell shape and in MF bundle distribution and orientation, which correlated with the cell migration behavior observed using time-lapse cinemicrophotography. The migrating ECs in the first zone, the leading zone, were polygonal to partially elongated in shape, and contained distinct central MF bundles oriented both parallel and perpendicular to the wound edge. The second zone, the elongated zone, was characterized by elongated cells with central MF bundles oriented parallel to the direction of migration. A third zone, the transitional zone, showed nonmigrating polygonal ECs containing prominent central and dense peripheral bands (DPB) of MF bundles. The central MF bundles were oriented randomly with respect to the wound edge. The MF bundles of the confluent resting monolayer were both centrally and peripherally located with the latter being more prominent. The results indicate that the reorientation of central MF bundles and reduction in the peripheral MF bundles are probably important in the reorganization of the cytoskeletal system during the conversion of stationary cells to migrating cells.