Mobilising Expertise and Resources to Close the Radiotherapy Gap in Cancer Care

Closing the gap in cancer care within low- and middle-income countries and in indigenous and geographically isolated populations in high-income countries requires investment and innovation. This is particularly true for radiotherapy, for which the global disparity is one of the largest in healthcare today. New models and paradigms and non-traditional collaborations have been proposed to improve global equity in cancer control. We describe recent initiatives from within the radiation oncology community to increase access to treatment, build the low- and middle-income countries' radiation oncology workforce, mobilise more professionals from within high-income countries and raise awareness of the global need for equitable cancer care.

Twin pregnancy in a woman on long-term epoprostenol therapy for primary pulmonary hypertension. A case report

BACKGROUND

Pregnancy associated with primary pulmonary hypertension is an uncommon observation, with maternal mortality > 50%. Experience treating this condition is limited. Past reports have emphasized the need for pregnancy termination. In the last few years there has been considerable interest in long-term intravenous use of epoprostenol (prostacyclin) in patients with primary pulmonary hypertension.

CASE

A woman with severe primary pulmonary hypertension who was on long-term epoprostenol therapy became pregnant with twins and was treated with high doses of epoprostenol and nitric oxide during delivery and the postpartum period. She was well six months later on continuous epoprostenol therapy. The one viable infant was alive and still hospitalized at this writing.

CONCLUSION

Epoprostenol therapy may be continued during pregnancy in patients with severe primary pulmonary hypertension for long-term pulmonary vasodilatation.

Giant megalo-ureter and duplex kidney in an asymptomatic adult

An abdominal mass was palpated in an asymptomatic adult during a routine medical check-up. Ultrasonography and computed tomography scan diagnosed a simple renal cyst, a mesenteric cyst and a seminal vesicle cyst. At laparotomy a complete ureteral duplication and a giant ectopic megalo-ureter were diagnosed. Other complications were ruled out in the follow-up. Ureterectomy without heminephrectomy was performed and the patient remains asymptomatic 5 years after surgery.

Primary amyloidosis presenting as renal infarction

We report a case of primary amyloidosis affecting the kidney and presenting as a renal infarction on computed tomography and ultrasound examination. To our knowledge, it is the first case in the radio-logical literature with these imaging characteristics.

Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters

Seventeen cirrhotics with refractory ascites were treated with transjugular intrahepatic portosystemic shunt (TIPS) and followed for 15.5 +/- 3.4 months. Five patients died, four within 3 months after TIPS (hepatocellular failure) and one after 22 months (cholangiocarcinoma). Six patients received transplants 1 to 10 months after the procedure. Actuarial survival at 6, 12, and 24 months was 75%, 75%, and 63%, respectively. Portosystemic venous pressure gradient decreased by 46% at 1 month and by 38% at 7 to 12 months. Eight patients presented 18 stenoses 1 to 18 months after TIPS. Twelve stenoses required balloon dilatation. Tense ascites was present before TIPS in 100% of the patients, whereas it was mild or absent in 56% at 1 month, in 66% at 3 to 6 months, in 57% at 7 to 12 months, and in 100% at 24 months after TIPS. Requirements for diuretics and paracentesis decreased after TIPS (P < .001, both). One month after TIPS, urinary and fractional sodium excretion increased (P < .001, both), plasma renin activity, plasma aldosterone (P < .005, both), and plasma norepinephrine (P < .05) decreased and cardiac output (P < .01) increased, systemic vascular resistances (P < .005) decreased, and arterial pressure did not change. Acute hepatic encephalopathy was frequent early after TIPS but was responsive to treatment and caused no long-term disability. In conclusion, TIPS is useful in the treatment of refractory ascites through lowering portal pressure and improving renal sodium excretion. This effect could be attributable to an increase in effective blood volume causing deactivation of vasopressor systems.

Transjugular intrahepatic portal-systemic shunt in the treatment of refractory ascites: effect on clinical, renal, humoral, and hemodynamic parameters

Seventeen cirrhotics with refractory ascites were treated with transjugular intrahepatic portosystemic shunt (TIPS) and followed for 15.5 +/- 3.4 months. Five patients died, four within 3 months after TIPS (hepatocellular failure) and one after 22 months (cholangiocarcinoma). Six patients received transplants 1 to 10 months after the procedure. Actuarial survival at 6, 12, and 24 months was 75%, 75%, and 63%, respectively. Portosystemic venous pressure gradient decreased by 46% at 1 month and by 38% at 7 to 12 months. Eight patients presented 18 stenoses 1 to 18 months after TIPS. Twelve stenoses required balloon dilatation. Tense ascites was present before TIPS in 100% of the patients, whereas it was mild or absent in 56% at 1 month, in 66% at 3 to 6 months, in 57% at 7 to 12 months, and in 100% at 24 months after TIPS. Requirements for diuretics and paracentesis decreased after TIPS (P < .001, both). One month after TIPS, urinary and fractional sodium excretion increased (P < .001, both), plasma renin activity, plasma aldosterone (P < .005, both), and plasma norepinephrine (P < .05) decreased and cardiac output (P < .01) increased, systemic vascular resistances (P < .005) decreased, and arterial pressure did not change. Acute hepatic encephalopathy was frequent early after TIPS but was responsive to treatment and caused no long-term disability. In conclusion, TIPS is useful in the treatment of refractory ascites through lowering portal pressure and improving renal sodium excretion. This effect could be attributable to an increase in effective blood volume causing deactivation of vasopressor systems.

Blunt traumatic rupture of the right hemidiaphragm and Budd-Chiari syndrome

We present 2 cases of delayed diagnosis of rupture of the right hemidiaphragm caused by blunt thoracic trauma, in which herniation of the liver toward the thoracic cavity had occurred. Both patients showed signs of noncardiogenic hepatic venous outflow obstruction. Venous outflow returned to normal on reintroduction of the liver into the abdominal cavity and closure of the defect in the diaphragm. The pathogenesis, diagnosis, and treatment of this problem are discussed.

Partial splenic embolization for the treatment of hypersplenism in cirrhosis

Hypersplenism is of great relevance in the management of cirrhosis because of the widespread use of myelodepressant drugs such as interferon or antineoplastic agents. Because no standard therapy exists for this complication, we have evaluated the efficacy and risks of splenic embolization in the treatment of hypersplenism in cirrhosis. Partial splenic embolization was performed in 40 consecutive patients with the following indications: 25 patients with active viral cirrhosis before interferon therapy, 8 patients with unresectable hepatocellular carcinoma before anti-neoplastic chemotherapy and 7 patients with thrombocytopenia associated with spontaneous bleeding events, with high risk of central nervous system hemorrhage or facing major surgery. After selective catheterization of the splenic artery, partial splenic embolization was performed by means of repeated injections of gelatin sponge until a 40% to 60% reduction in the splenic blood flow was achieved. After partial splenic embolization a significant and sustained increase in platelet and white blood cell count was observed during the follow-up period (mean = 13.9 +/- 2.2 mo; range = 1 to 36 mo). The goal of partial splenic embolization was achieved in all but two patients in whom a dose reduction of interferon was needed. Hypersplenism relapsed in only seven patients, and all of them exhibited an embolization of less than 50% of the splenic mass. Postembolization syndrome was the main side effect, but no life-threatening complications were detected. In conclusion, partial splenic embolization is a safe and effective therapy of hypersplenism in cirrhosis.

Double-minute chromosomes as megabase cloning vehicles

Radiation-reduced chromosomes provide valuable reagents for cloning and mapping genes, but they require multiple rounds of x-ray deletion mutagenesis to excise unwanted chromosomal DNA while maintaining physical attachment of the desired DNA to functional host centromere and telomere sequences. This requirement for chromosomal rearrangements can result in undesirable x-ray induced chromosome chimeras where multiple non-contiguous chromosomal fragments are fused. We have developed a cloning system for maintaining large donor subchromosomal fragments of mammalian DNA in the megabase size range as acentric chromosome fragments (double-minutes) in cultured mouse cells. This strategy relies on randomly inserted selectable markers for donor fragment maintenance. As a test case, we have cloned random segments of Chinese hamster ovary (CHO) chromosomal DNA in mouse EMT-6 cells. This was done by cotransfecting plasmids pZIPNeo and pSV2dhfr into DHFR-CHO cells followed by isolation of a Neo + DHFR + CHO donor colony and radiation-fusion-hybridization (RFH) to EMT-6 cells. We then selected for initial resistance to G418 and then to increasing levels of methotrexate (MTX). Southern analysis of pulsed-field gel electrophoresis of rare-cutting restriction endonuclease digestions of DNA from five RFH isolates indicated that all five contain at least 600 kb of unrearranged CHO DNA. In situ hybridization with the plasmids pZIPNeo and pSV2dhfr to metaphase chromosomes of MTX-resistant hybrid EMT-6 lines indicated that these markers reside on double-minute chromosomes.

Osteosarcoma: correlation between radiological and histological changes after intra-arterial chemotherapy

The statistical correlation between three different radiological methods (conventional radiography, computed tomography and angiography) and tumor necrosis (TN) of the resected specimen have been studied in a series of 31 patients diagnosed with osteosarcoma (OS). They were treated with a multidisciplinary approach including intraarterial and intravenous chemotherapy followed by limb salvage procedures, plus intraoperative radiotherapy and adjuvant chemotherapy. A clear statistical correlation has been obtained between TN and angiography (p = 0.02) and between TN and two specific radiological signs: 'tumoral stain and neovascularity' (p = 0.02) and 'peritumoral fat planes' (p = 0.05). Conventional radiography, computed tomography and other radiological signs studied (nutrient vessel, soft tissue mass and central peripheral calcifications) did not show any significant correlation with TN. These results seem to suggest that angiography is a method to evaluate TN preoperatively and also to define the efficacy of neoadjuvant chemotherapy in OS.

An unusual ring contraction in the formation of N-nitrosohexamethyleneimine and N-nitrosopiperidine from tolazamide

The previously reported reaction of tolazamide with nitrite, under physiological conditions, to form N-nitrosohexamethyleneimine and surprisingly, N-nitrosopiperidine was confirmed. By using the six-membered ring analogue of tolazamide, 1-(piperidyl)-3-(p-tolylsulfonyl)urea, which yields the corresponding N-nitrosopiperidine and N-nitrosopyrrolidine, the present study shows that an unusual ring contraction occurs, excising the carbon alpha to the nitrogen.

Portal thrombosis: percutaneous transhepatic treatment with urokinase--a case report

We present a case report of a patient suffering from portal and superior mesenteric vein thrombosis secondary to splenectomy. No surgical procedure could be performed due to the extension of thrombus. Local fibrinolysis treatment with urokinase through a percutaneous transhepatic approach was decided upon, and this procedure had a successful patient outcome.

The reliability and predictive value of an amniotic fluid scoring system in severe second-trimester oligohydramnios

Sixty-two cases of oligohydramnios diagnosed by ultrasound between 13-28 weeks' gestation were reviewed. Three experienced ultrasonographers used a subjective scale to rate the oligohydramnios as mild, moderate, severe, or anhydramniotic. Interobserver reliability was excellent (intraclass correlation coefficient 0.81). The overall perinatal mortality rate was 43%, and the incidence of pulmonary hypoplasia was 33%. One-third had lethal congenital anomalies. The frequency of adverse outcome correlated strongly with the most severe degrees of oligohydramnios; 88% of the fetuses with severe oligohydramnios or anhydramnios had lethal outcomes, compared with 11% in the mild/moderate group. The presence of an anuric urinary tract anomaly was associated with the most severe grades of oligohydramnios and was uniformly fatal. Pulmonary hypoplasia was diagnosed in 60% of the severe group versus 6% in the moderate group. We conclude that subjective grading of oligohydramnios by experienced observers is both reliable and predictive of outcome. The finding of severe oligohydramnios in the second trimester is highly predictive of poor fetal outcome and should stimulate a thorough search for etiology and consideration of intervention. Moderate grades of reduced amniotic fluid may be managed with relative optimism.

Study of the effect of high molecular weight kininogen upon the fluid-phase inactivation of kallikrein by C1 inhibitor

Plasma kallikrein and factor XIa circulate bound to high molecular weight kininogen, and such binding has been reported to protect these enzymes from inactivation by their respective inhibitors. However, this observation is controversial, and the effect of high molecular weight kininogen upon the interaction between kallikrein and C1 inhibitor (C1-INH) has been questioned. We have re-evaluated this reaction and studied the rate of inhibition of kallikrein by C1-INH in the presence and absence of high molecular weight kininogen. The second-order rate constant of inhibition of kallikrein by C1-INH was unaffected by saturating concentrations of high molecular weight kininogen. Our results suggest that although high molecular weight kininogen clearly augments the rate of formation of kallikrein and other enzymes of the contact activation pathway, it has no effect on the rate of enzyme inhibition by C1-INH.

Late onset epileptic seizures. A retrospective study of 250 patients

A retrospective study of 250 patients with late-onset epilepsy was carried out. The ages ranged from 22 to 88. The seizures were partial in 104 patients and generalized in 146. The neurological examination was abnormal in 41 patients and normal in 209. The EEG studies and CT scan revealed abnormalities in 76.5% and 50.8% respectively. The most frequent CT scan findings were diffuse atrophy (19.2%), tumors (16.4%) and cerebral infarct (8.8%). The clinical parameters which best predicted the CT scan abnormalities were an abnormal neurological examination and simple partial seizures. In seven of the 45 patients with space-occupying lesions, the clinical examination and EEG were normal. The etiology of the convulsions was established in 201 patients, the most frequent cause being chronic alcoholism (62 cases), tumors (41 cases), postischemic vascular epilepsy (33 cases) and postraumatic epilepsy (28 cases). We conclude that a CT scan is essential in the assessment of patients with epileptic convulsions of late onset, even when the EEG and clinical examination are normal.

Toy play, play tempo, and reaction to frustration in infants

Measures of toy play including duration and tempo of play were obtained for a combined sample of 7 male and 5 female infants 22 to 26 mo. of age. Additional measures of reaction to frustration were obtained during a second session where toys were placed out of reach of the subjects. Measures of frustration included crying, squirm/escape attempts, and non-crying vocalizations. Several correlations between toy play and reaction to frustration were found and were indicative of a general relationship between response persistence during play and attempts to escape from the frustrating situation.