Image-guided Interstitial Brachytherapy in the Treatment of Primary and Recurrent Vulvovaginal Gynaecological Malignancies

AIMS

To evaluate the use, outcomes and toxicities of high dose rate brachytherapy (HDRB) to the vulvovaginal region in previously irradiated and radiotherapy-naïve patients for primary or recurrent gynaecological malignancies.

MATERIALS AND METHODS

From January 2010 to December 2020, 94 women with a median age of 64 years (range 31-88 years) were treated with interstitial HDRB for vulvovaginal disease. Treatment details, including cumulative radiotherapy doses, were recorded together with reported toxicity, using Common Terminology Criteria for Adverse Events (CTCAE) grading. Dosimetric parameters, including D90, V100 and V150 together with treatment response at 3 months, overall survival, relapse-free survival and long-term toxicity data, were collated from referring centres.

RESULTS

The median follow-up was 78 months (range 2-301). Primary sites of disease included vagina (37), endometrium (29), vulva (16), ovary (7) and cervix (5). Eighty-six (91.5%) patients were treated with curative intent, eight (8.5%) were palliative treatments. Fifty patients received HDRB for recurrent disease, 39 patients for primary disease and five as part of adjuvant treatment. The anatomical site of disease treated with HDRB ranged from vagina (76), vulva (14) and peri-urethral sites (four). The 2- and 5-year local relapse-free survival rates were 76% and 72%, respectively; 15 patients experienced local failure only, whereas six patients had local and nodal/distant failure. The median time to local recurrence was 8 months (range 2-88 months). The 2- and 5-year overall survival rates for all patients were 67% and 47%, respectively; the median overall survival was 59 months. Seventy-nine (84%) patients had a complete response measured with imaging at 3 months. Grade 3 toxicity was reported in 14 patients (14.8%).

CONCLUSION

This retrospective series suggests the use of interstitial brachytherapy for vulvovaginal gynaecological malignancy to be an effective and safe treatment option. Good local control was achieved with a tolerable toxicity profile; it is a valuable treatment modality.

Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

Migraine in the emergency department: A retrospective evaluation of the characteristics of attendances in a major city hospital in the United Kingdom

Introduction:

Detailed Emergency Department attendance data for migraine are needed for service redesign.

Methods:

A service evaluation was undertaken, classifying adult emergency department headache attendances using the International Classification of Headache Disorders migraine C-E criteria, evaluating attendance characteristics.

Results:

Migraine/Probable migraine diagnosis was documented in 58% but coded in 24% attendances by ED clinicians. 29% of patients used no analgesia before attending, 43% attended ≥4 days after onset and 19% arrived by ambulance.

Conclusion:

This evaluation highlights sub-optimal acute management and discrepancy between migraine coding and diagnosis contributing to underreporting. We recommend further evaluation of identified cohorts and headache proforma use.

OP0297 EFFICACY AND SAFETY OF ROMOSOZUMAB AMONG POSTMENOPAUSAL WOMEN WITH OSTEOPOROSIS AND MILD-TO-MODERATE CHRONIC KIDNEY DISEASE

Background:

Osteoporosis and renal insufficiency are coexisting disease states in a substantial proportion of postmenopausal women. Since bisphosphonates are generally contraindicated in patients with estimated glomerular filtration rate (eGFR) <35 mL/min, it is important to evaluate other osteoporosis treatments in this setting.

Objectives:

To determine if baseline renal function affects the efficacy and safety of romosozumab.

Methods:

We performed post hoc analyses of two clinical trials of romosozumab in postmenopausal women with osteoporosis. In ARCH (NCT01631214), 4,093 patients were randomised 1:1 to romosozumab 210 mg monthly or alendronate 70 mg weekly for 12 months (mean age: 74.3 years; 96.1% with prevalent vertebral fractures [VFx]). In FRAME (NCT01575834), 7,180 patients were randomised 1:1 to romosozumab 210 mg or placebo monthly for 12 months (mean age: 70.9 years; 18.3% with prevalent VFx). For these analyses, patients were categorised by baseline eGFR (mL/min/1.73m2): normal renal function (eGFR ≥90), mild renal insufficiency (eGFR 60–89), or moderate renal insufficiency (eGFR 30–59). Least squares mean (LSM) percent change from baseline in bone mineral density (BMD) at the lumbar spine, total hip, and femoral neck; incidence of new VFx and adverse events (AEs); and changes in renal function were assessed for each eGFR category at Month 12 of the double-blind treatment period.

Results:

At baseline, most patients had mild/moderate renal insufficiency: 84% in ARCH, 88% in FRAME. In both studies, change from baseline in BMD was significantly higher in the romosozumab group across baseline eGFR categories (Figure). There was an interaction between BMD increase and renal function, and although BMD increase was not as large in women with impaired renal function, differences between romosozumab and control groups remained significant (Figure). In ARCH, among patients with eGFR ≥90, 60–89, and 30–59, the incidence of new VFx (romosozumab vs alendronate) at Month 12 was 3.3% vs 7.3%, 3.2% vs 3.9%, and 3.4% vs 6.2% in ARCH. In FRAME, the incidence of new VFx (romosozumab vs placebo) at Month 12 was 0.5% vs 3.0%, 0.4% vs 1.5%, and 0.6% vs 2.1%.

In both studies, the incidences of AEs and serious AEs were similar in both treatment groups within and across eGFR categories. AEs of mild-to-moderate hypocalcaemia (investigator reported) occurred in two patients in ARCH (one romosozumab [eGFR 60–89] and one alendronate [eGFR ≥90]), and one patient in FRAME (romosozumab [eGFR 60–89]). Five patients in ARCH (all in the alendronate group) and 19 patients in FRAME (14 romosozumab, 5 placebo) had decreases in serum Ca levels (albumin adjusted); in the romosozumab group all were mild (<LLN–8.0 mg/dL) or moderate (<8.0–7.0 mg/dL). A similar percentage of patients in each group had changes in renal function over 12 months of treatment.

Conclusion:

The efficacy and safety of romosozumab vs alendronate or placebo was similar among postmenopausal women with osteoporosis and different levels of renal function.

Acknowledgments:

This study was funded by Amgen, Astellas and UCB Pharma. Editorial services were provided by Costello Medical.

Disclosure of Interests:

Paul Miller Grant/research support from: Amgen, Radius Health, Ultragenyx, Consultant of: Amgen, Radius Health, Jonathan Adachi Consultant of: Amgen, Speakers bureau: Amgen, Ben-Hur Albergaria Consultant of: Amgen Inc., Eli Lilly, Speakers bureau: Amgen Inc., Eli Lilly, Angela M Cheung Consultant of: Amgen, Eli Lilly, Arkadi Chines Shareholder of: Amgen Inc., Employee of: Amgen Inc., Evelien Gielen Consultant of: Amgen Inc., Takeda, Sandoz and UCB Pharma, Speakers bureau: Amgen Inc., Takeda, Sandoz and UCB Pharma, Bente Langdahl Grant/research support from: Amgen, NovoNordisk, Consultant of: Amgen Inc., Eli Lilly, UCB Pharma, Akimitsu Miyauchi Consultant of: Amgen Inc., Astellas BioPharma K.K., Teijin Pharma, Mary Oates Shareholder of: Amgen Inc., Employee of: Amgen Inc., Ian Reid Consultant of: Amgen Inc., Eli Lilly, Speakers bureau: Amgen Inc., Eli Lilly, Norma Ruiz Santiago Shareholder of: Amgen Inc., Employee of: Amgen Inc., Mark Vanderkelen Employee of: UCB Pharma, Wenjing Yang Shareholder of: Amgen Inc., Employee of: Amgen Inc., Zhigang Yu Shareholder of: Amgen Inc., Employee of: Amgen Inc.

Use of dermal injection of activated protein C for treatment of large chronic wounds secondary to pyoderma gangrenosum

BACKGROUND

Pyoderma gangrenosum (PG) is a systemic disease that presents with cutaneous necrotizing ulceration, producing deep necrotic ulcers, usually with a raised, undermined, violaceous border. Treatment typically involves high dose immunosuppressive drugs, but more recently anti-tumour necrosis factor and monoclonal antibodies have been used. Activated protein C (APC) stimulates wound healing in patients with treatment-refractory skin ulcers, possibly by stimulating angiogenesis and re-epithelialization, and preventing inflammation.

AIM

To investigate whether APC may be beneficial as a treatment for ulcers related to cutaneous PG.

METHODS

Two patients were recruited with a clinical history and physical and histopathological evidence of acute PG. A total of 400 μg (1.0 mL) of APC was injected subcutaneously into the dermal edge of necrotic PG ulcers weekly for a total treatment period of 6 weeks. Photographs were taken, and clinical progress, ulcer size and pain score were monitored during this period and after the cessation of treatment, at weeks 8 and 12.

RESULTS

Over the 12 weeks of the trial, APC led to a reduction in wound size from 3.8 cm(2) to 0.8 cm(2) in patient 1 (78.9% decrease) and from 41 cm(2) to 16 cm(2) in patient 2 (70.0% decrease, respectively), and a reduction in pain scores from 10 to 0 (100% decrease) in both patients.

CONCLUSION

Although this study has limited because of its small sample size and lack of a true placebo group, it does indicate that APC has potential as a therapeutic option for patients with chronic skin ulcers from PG.

Changes in macroinvertebrate community structure provide evidence of neutral mine drainage impacts

Contamination of aquatic environments as a consequence of metal mining is an international issue. Most historic studies have considered the impact of acid mine drainage (pH < 6) on instream communities and comparatively little attention has been given to sites where drainage is typically circum-neutral (6 > pH < 8). Here, the impacts of historic mining activities on the benthic macroinvertebrate community of a circum-neutral river in Central Wales are assessed. Biotic and diversity indices, widely used for biomonitoring purposes, indicate aquatic macroinvertebrate assemblages within the Afon Twymyn to be in a good condition, despite severe metal contamination of bed sediments and river water. However, Canonical Correspondence Analysis identifies differences in community structure between mining impacted and unimpacted reaches of the river associated with chalcophile (Zn, Pb, Cu, Cd) and common (Fe and Mn) metals. Stream pH was not a significant factor structuring the macroinvertebrate community. Widely utilised macroinvertebrate indices failed to identify impacts at the community level because they either seek to identify impacts of a specific contaminant or are dependent on a model community response to a given stress. The nature of metal mine discharges is temporally complex, having highly variable chemical signatures and as a result, care is advised when interpreting and modelling community impacts. The use of standard macroinvertebrate biotic and diversity indices in the context of the EU Water Framework Directive could lead to erroneous classifications of aquatic ecosystem health when used for bio-monitoring rivers affected by neutral mine drainage where other indicators are unavailable.

Abstract P4-14-13: Therapeutic mammaplasty does not cause a delay in the delivery of chemotherapy in high risk breast cancer patients

Introduction: oncosurgical safety of therapeutic mammaplasty (TM) is widely investigated. The interval between surgery and delivery of adjuvant chemotherapy is an integral part of overall oncological safety. Therefore, we examined the time between TM and AC, and compared it to wide local excision (WLE) and mastectomy (Mx) with or without immediate breast reconstruction (IBR), respectively.

Methods: data of 174 patients who underwent TM, WLE and Mx±IBR was analyzed retrospectively. All patients were operated within three breast units of Glasgow during a period of 48 months. Time between decision to offer adjuvant chemotherpay and delivery of the first cycle of chemotherapy was analyzed. Significance was calculated with Mann-Whitney and Kruskal-Wallis tests (two and four groups compared, respectively).

Results: median time to adjuvant chemotherapy after TM (n = 36) was 29 [16–58] days, WLE (n = 66) was 29.5 [15–105], Mx only (n = 56) was 29 [15–57], and Mx and IBR (n = 16) was 31 [15–58] days. No significant difference was found in terms of time to adjuvant chemotherpay in patients treated with TM compared to WLE (p = 0.384), Mx only (p = 0.828) or Mx and IBR (p = 0.366). Further, there was no significant difference when a cumulative comparison of the four groups was carried out (p = 0.507).

Conclusions: our data indicate that oncosurgical safety of TM in terms of time to chemotherapy is similar to other high risk breast cancer patients treated WLE and Mx with or without IBR. This also suggests that there is no significant difference in postoperative complication rates after these four ways of surgical treatment of breast cancer, which would possibly be the primary cause for a delay in delivering adjuvant chemotherapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-13.

Impact of national guidelines on family history breast cancer surveillance

The breast cancer risk of women already under family history surveillance was accurately assessed according to national guidelines in an attempt to rationalize the service. Women attending two breast units in Glasgow between November 2003 and February 2005 were included. One thousand and five women under annual surveillance were assessed and had their relatives diagnoses verified. Four hundred and ninety-seven women were at significantly increased risk and eligible for follow-up. Five hundred and eight (50%) women attending were not eligible for family history surveillance, and 498 (98%) of these women accepted discharge. In conclusion, national guidelines have helped to more clearly define women who should undergo surveillance. This avoids unnecessary and potentially harmful routine investigations, and the service has been improved.

The Pathfinder image-guided surgical robot

This paper first describes the workflow of the Pathfinder image-guided surgical robot that has been designed to replace the stereotactic frame in neurosurgery, and then details the calibration stages employed in order to achieve submillimetre positioning accuracy of a tool tip. The process uses non-linear parameter identification techniques in conjunction with some procedures for camera calibration, which exploit the fact that the camera is mounted to a calibrated robot arm that executes precise motions.

Electronic structure of the organic semiconductor Alq3 (aluminum tris-8-hydroxyquinoline) from soft x-ray spectroscopies and density functional theory calculations

The element-specific electronic structure of the organic semiconductor aluminum tris-8-hydroxyquinoline (Alq(3)) has been studied using a combination of resonant x-ray emission spectroscopy, x-ray photoelectron spectroscopy, x-ray absorption spectroscopy, and density functional theory (DFT) calculations. Resonant and nonresonant x-ray emission spectroscopy were used to measure directly the carbon, nitrogen and oxygen 2p partial densities of states in Alq(3), and good agreement was found with the results of DFT calculations. Furthermore, resonant x-ray emission at the carbon K-edge is shown to be able to measure the partial density of states associated with individual C sites. Finally, comparison of previous x-ray emission studies and the present data reveal the presence of clear photon-induced damage in the former.

Dietary intervention in older adults with early-stage Alzheimer dementia: early lessons learned

In older adults, an adequate diet depends on their ability to procure and prepare food and eat independently or the availability of dietary assistance when needed. Inadequate food intake or increased nutritional requirements lead to poor nutritional status, which is considered a key determinant of morbidity, increased risk of infection, and mortality in elderly individuals. Weight loss among seniors also heralds increased morbidity and mortality. Dietary behaviour disorders affecting food consumption, nutrition status and maintenance of body weight are common in older adults, and have a substantial impact on nutritional status and quality of life among older adults with Alzheimer Dementia (AD). The Nutrition Intervention Study (NIS) is ongoing. It employs a quasi-experimental pre-post intervention design in physically-well, community-dwelling early stage AD patients aged 70 y or older. To date, 34 intervention group patients and 25 control group participants have been recruited with their primary caregivers (CG) from 6 hospital-based memory and geriatric clinics in Montreal. The NIS uses clinical dietetics principles to develop and offer tailored dietary strategies to patients and their CG. This paper reports on the application of dietary intervention strategies in two intervention group participants; one was deemed successful while the other was considered unsuccessful. The report documents challenges encountered in assessing and counselling this clientele, and seeks to explain the outcome of intervention in these patients.

A staff perspective of early warning signs intervention for individuals with psychosis: clinical and service implications

Research has established the benefits of early warnings signs monitoring in the prevention of relapse for individuals with psychosis. This study explored staff views (n = 8) of the implementation of an early warning signs clinic within a day hospital of an adult mental health service. A qualitative methodology using focus groups was adopted and content analysis was used to discover themes arising from the data. Overall, the data indicated a positive view of the early warning signs clinic, with benefits for clients, staff and their relationship; and for service delivery and resources. The clinical and service implications are discussed.

Photosynthetic light response curves determined with the leaf oxygen electrode: minimisation of errors and significance of the convexity term

From photosynthetic studies on a range of monocotyledonous (C-3 and C-4) and dicotyledonous (C-3) plants using a leaf oxygen electrode, we conclude the following. (i) A non-linear model [J.H.M. Thornley (1976) Mathematical models in plant physiology, Academic Press, London; B. Marshall and P.V. Biscoe (1980) J Exp Bot 31:29-39] significantly better describes the photosynthetic light response curve [rate of photosynthesis (P) versus incident photosynthetic photon flux density (I)] than the frequently used linear hyperbolic model [E.I. Rabinowich (1951) Photosynthesis and related processes, vol 2, Wiley, New York]. (ii) When used at the recommended CO2 partial pressures (Ca = 1-5 kPa), CO2 supply saturates the photosynthesis rate in the C-3 dicot Phaseolus coccineus L. but not in the C-3 monocot Hordeum vulgare L.. (iii) Fits using a linear hyperbolic model for P versus I produce relatively large and statistically significant errors (approximately 60%) in the estimation of Pmax and quantum efficiency (alpha) if Ca is not > 5 kPa. (iv) The convexity term, theta, incorporated into the non-linear models for P versus I appears to reflect the limitation placed on the carboxylation processes by the supply of CO2 to the chloroplast stroma. Therefore, the use of a non-linear model providing an estimate of theta should be encouraged, as it is likely to provide information on the physiological status of plants.

Muir-Torre syndrome

Muir-Torre syndrome is a rare autosomal dominant condition in which multiple primary malignancies occur together with a sebaceous gland tumour. Early recognition of the syndrome in patients with sebaceous gland tumours should facilitate early detection of subsequent malignancies if the patient with entered into appropriate screening programmes. A case occurring in Scotland is described and implications for management, screening for members of the family are discussed.

Osteoporosis in New Zealand

Individuals suffering from osteoporosis in New Zealand are predominantly European. Therefore, diagnostic criteria and therapeutic interventions have tended to follow similar patterns to those seen in the United States and in Europe.

Lysophosphatidic acid is an osteoblast mitogen whose proliferative actions involve G(i) proteins and protein kinase C, but not P42/44 mitogen-activated protein kinases

The simple glycerophospholipid lysophosphatidic acid (LPA) acts both as an intermediary in phospholipid metabolism and as an intercellular signaling molecule in its own right. In various cell types, LPA signals through its membrane-bound, G protein-coupled receptors to influence cellular processes such as proliferation, survival, and cytoskeletal function. Its actions in bone cells have not been studied. Here we show that the LPA receptor, LP(A1)/edg-2/vzg-1, is expressed in primary rat osteoblasts and the UMR 106-01 osteoblastic cell line. LPA potently induces DNA synthesis and an increase in cell number in cultures of osteoblastic cells. LPA rapidly (within 10 min) stimulates phosphorylation of p42/44 mitogen-activated protein (MAP) kinases in osteoblastic cells, an effect that is sensitive to inhibition of G(i) proteins, inhibition of influx of extracellular calcium, and inhibition of protein kinase C. LPA-induced DNA synthesis is partially inhibited by either pertussis toxin or calphostin C, but is insensitive to specific inhibitors of MEK, the kinase upstream of p42/44 MAP kinases, or of phosphatidylinositol-3 kinases. These data demonstrate that LPA is an osteoblast mitogen whose signaling effects in osteoblastic cells include activation of p42/44 MAP kinases. However, the LPA mitogenic signal in osteoblastic cells, while requiring G(i) proteins and protein kinase C, is independent of the activity of p42/44 MAP kinases.

One stop breast clinics--victims of their own success? A prospective audit of referrals to a specialist breast clinic

AIMS

We aimed to assess the number of unnecessary referrals to a specialist breast clinic, with special reference to urgent referrals, and to compare referrals with published guidelines for referral to these clinics.

METHODS

We carried out a prospective audit of new patient referrals from primary care to a specialist breast clinic. We assessed the total number of referrals, proportion of urgent and non-urgent referrals, proportion of unnecessary referrals according to published guidelines, waiting times for outpatient appointments and outcomes for these patients.

RESULTS

Of the total of 321 referrals, 35% were urgent. Twenty-eight per cent of urgent referrals and 37% of non-urgent were inappropriate according to published guidelines. Ten per cent of referrals had breast cancer while 90% had benign disease or no pathology.

CONCLUSIONS

There is a proliferation of guidelines (NHS, SIGN, BASO, Patients' Charter) for the organization of specialist breast clinics with the aim of providing rapid diagnosis for patients with malignant disease, or reassurance for symptomatic patients that they do not have breast cancer. However increasing numbers of patients are being referred to these clinics with minimal or no pathology, and this is not acknowledged by these guidelines. In this prospective study of referrals from primary care to a specialist breast clinic, one-third of referrals were inappropriate and this inevitably reduced the efficiency of the service provided for patients with significant symptoms.

Foodborne viral illness--status in Australia

Norwalk-like virus contamination of oysters and orange juice, and hepatitis A virus contamination of oysters have been responsible for large outbreaks of foodborne viral disease in Australia. Rotavirus, adenovirus, astrovirus, parvovirus and other enteroviruses also contribute to the incidence of gastroenteritis in this country but the role of foods and waters in transmitting these viruses is unclear. Protocols for the investigation, surveillance and reporting of foodborne viral illness require further development to enable a more accurate description of the problem. Few laboratories have the capability to analyse foods for viruses and specific training in this technology is needed. Management of food safety in Australia largely relies on the implementation of HACCP principles, but these need to be adapted to address the specific risks from viruses.

Pectinase in papermaking: solving retention problems in mechanical pulps bleached with hydrogen peroxide

Treatment with the enzyme pectinase has been reported to lower the cationic demand of thermomechanical pulp (TMP) bleached with alkaline peroxide in the laboratory. We have extended this discovery to bleached TMP produced industrially, and shown that commercial enzyme preparations can treat pulp within 15 min at the temperature and pH values prevalent in paper mills. About half of the cationic demand in the bleached pulp can be destroyed by pectinase. Dynamic drainage jar experiments show that the enzyme treatment improves the effectiveness of several cationic polymers to increase retention of fines and filler particles. It does not increase retention in the absence of retention aids or with nonionic polymers, and does not damage the strength properties of the pulp. Pectinase could be easily incorporated into paper machine stock preparation systems to lower the charges of cationic retention aids needed in furnishes containing peroxide-bleached mechanical pulp.

Plexosarcoma of the bladder

Plexosarcomas are rare soft tissue sarcomas, previously reported in association with gastrointestinal autonomic nerve (GAN) plexi. We report the first case arising from the autonomic nerve plexus of the bladder.

Tranexamic acid reduces blood loss and transfusion in reoperative cardiac surgery

PURPOSE

The objective of this study was to assess the effect of tranexamic acid (TA), a synthetic antifibrinolytic, on blood loss and the need for transfusion of blood products following repeat cardiac valve surgery.

METHODS

After ethics committee approval, 41 patients scheduled for reoperative valve replacement were enrolled in this randomized, double blind, placebo controlled study. Patients were randomized to receive TA (10 g in 500 ml NSaline) or placebo (NSaline) as an iv bolus over 30 min, after anaesthesia induction and prior to skin incision. Intraoperative blood loss was assessed by estimating blood volume on drapes, weighing surgical sponges, and measuring suction bottle returns. Postoperative blood loss was measured from mediastinal chest tube drainage following surgery. Blood products were transfused according to a standardized protocol.

RESULTS

Patient demographics were similar for age, sex, cardiopulmonary bypass pump time, cross clamp time, surgical time, preoperative haemoglobin, coagulation profile, and the number of valves replaced during surgery. Tranexamic acid administration reduced intraoperative blood loss [median (range)] from 1656 (575-6270) to 720 ml (355-5616) (P < 0.01) and postoperative blood loss from 1170 (180-4025) to 538 ml (135-1465) (Intent to Treat n = 41, P < 0.01). The total red blood cells transfused (median, range) was reduced from 1500 (0-9300) ml to 480 (0-2850) ml (P < 0.01) in the TA group. In hospital complications and mortality rates were not reduced in the TA group.

CONCLUSION

Tranexamic acid reduced blood loss and the need for blood product transfusion and appears to be an effective treatment for patients undergoing reoperative cardiac valvular surgery.

Delay in treatment for oesophageal cancer

BACKGROUND

Dysphagia is the cardinal symptom of oesophageal cancer, yet many patients present late. This study examined prospectively the interval between onset of dysphagia and treatment and identified reasons for delay.

METHODS

Patients with histologically confirmed oesophageal carcinoma were questioned about duration of symptoms and about each step of their diagnostic work-up. Delay was estimated from date of onset of symptoms to definitive treatment.

RESULTS

Median delay was 15 weeks for 78 patients with dysphagia, and 17 weeks for 22 patients with other symptoms. The most frequent cause of delay was late presentation to the family doctor (44 per cent). For patients treated with surgery alone there was a trend towards more advanced stage of disease with longer delay to treatment, but no correlation with survival (P = 0.25).

CONCLUSION

Lack of awareness of the sinister significance of dysphagia is the most important cause for delay in presentation of patients with oesophageal cancer.

Tumour marker detection in oesophageal carcinoma

Levels of the tumour markers CEA, CA 19-9, CA 125 and SCC were measured in 58 patients presenting with oesophageal carcinoma and compared with levels in patients with benign oesophageal disease and levels in normal volunteers. CEA and CA 19-9 were significantly increased in the patients with oesophageal cancer, however, individual sensitivity for CEA, CA 19-9, CA 125 and SCC was only 28, 34, 10, and 32%, respectively. The combined sensitivity of all markers was 64% and specificity was 80%. There was no difference in combined tumour marker sensitivity between squamous or adenocarcinomas of the oesophagus. No consistent change in marker levels occurred with treatment, and tumour marker levels could not be significantly correlated with stage of disease or short-term survival. These results indicate that tumour marker sensitivity is too low for oesophageal cancer screening and has poor prognostic significance in those undergoing treatment.