A Lack of Palliative Therapy Use in Patients With Advanced Penile Cancer

OBJECTIVES

Advanced penile cancer is associated with a poor prognosis; therefore, providing patients with realistic expectations, addressing goals of care and offering palliative therapy when appropriate is critical. Our goal was to investigate the National Cancer Database (NCDB) and analyze the role and trends in use of palliative therapy in patients with advanced penile cancer.

METHODS

The NCDB 2004-2015 penile cancer data set was queried for patients with locally advanced, defined as cT4NanyM0 and cTanyN3M0, or metastatic disease regardless of tumor or nodal stage. Patients were categorized based on whether they did or did not receive palliative care. Palliative care was cataloged as pain management therapy, surgery, radiation or systemic treatment, any combination therapy or not otherwise specified (NOS). Our primary outcome was receiving palliative therapy. Secondary outcome was the temporal trends in palliative care. Logistic regression (LR) was performed.

RESULTS OBTAINED

385 and 279 patients were identified with locally advanced and metastatic penile cancer respectively. 27 (7.1%) and 49 (17.6%) patients received palliative care. Average age of patients accepting palliative care was 61.9 years old, about 5 years younger than their counterparts who declined therapy (p < 0.011) in the metastatic cohort. Other patient specific demographics and clinical tumor characteristics were not significantly different in either population. Of patients with locally advanced disease pursuing palliative therapy, radiation (29.6%), surgery (14.8%), systemic treatment (14.8%) and combination treatment (22.2%) were the more popular choices. In the metastatic population, radiation (32.7%) and systemic therapy (24.5%) were the most prevalent choices for palliative treatment followed by combination treatment (16.3%), surgery (12.2%), pain management (10.2%), or NOS (4.1%). LR for the receipt of "any palliative therapy" revealed that increasing age (OR 0.971, p = 0.032) decreased the likelihood of accepting palliative therapy in the metastatic population but not in the locally advanced group. Charlson score of 2 (OR 5.966, p = 0.025) and low income (OR 3.968, p = 0.002) predicted receipt of palliative therapy in the locally advanced group. In patients with metastatic disease, African-American race (OR 2.502, p = 0.025), Charlson score 1 (2.175, p = 0.047) and 3+ (5.386, p = 0.020) predicted an increased predilection for receiving palliative therapy. Interestingly, no statistically significant difference in mortality was noted in either cohort. No significant increase in the trend of palliative care administration was seen in locally advanced and metastatic penile cancer between 2004 to 2015 (p = 0.078 and p = 0.942, respectively).

CONCLUSION

Locally advanced and metastatic penile cancer carry a high mortality rate yet only 11.4% of all patients studied received palliative care. Its use is more common in younger patients, those with co-morbidities and/or those of black race in the metastatic group. Locally advanced patients with low income or comorbidities were also more likely to opt for palliative therapy. Receipt of palliative care did not affect mortality. No increase in frequency of palliative therapy was seen, suggesting much improvement needs to be done in adopting and implementing palliative care in this patient population.

Analysis of Inpatient Palliative Care Consultations for Patients With Metastatic Prostate Cancer

Objective:

To characterize the use of palliative care for patients with metastatic prostate cancer and identify its associations with costs, hospital course, and discharge.

Materials and Methods:

Using the National Inpatient Sample database from 2012 to 2013, we identified 99 070 patients with metastatic prostate cancer and analyzed the data from their hospital admissions using descriptive statistics, χ2 analysis, and regression modeling.

Results:

Palliative care services were consulted in 10.4% (10 300) of metastatic prostate cancer admissions. These admissions were associated with nonelective origin, acute complications, and reduced surgical procedures and chemotherapy. Patients in private, investor-owned hospitals had a 51.6% less consultations ( P < .001), while nonprofit and government, nonfederal hospitals had 4.7% and 7.8% more consultations ( P < .001). Median costs and charges were only marginally less (2.1% and 5.6%, respectively, P < .001), length of stay was 22% higher ( P < .001), and in-house mortality was 147.2% higher in the consultation group ( P < .001). Controlling for other factors, patients seen by palliative care were more likely to have do-not-resuscitate orders (odds ratio [OR]: 5.25, P < .001) and be transferred to another facility like hospice (OR: 3.90, P < .001) or to home health (OR: 3.85, P < .001).

Conclusions:

Palliative care consultation could improve care for patients with metastatic prostate cancer in a different manner than observed in other diseases. With our characterization of the incidence and patient and hospital factors, we can conclude that there is room to expand palliative care’s role beyond uninsured patients in large, urban teaching hospitals.

Outcomes of renal salvage for penetrating renal trauma: a single institution experience

INTRODUCTION

Conservative management of penetrating renal trauma is emerging, with data originating from centers with variable level of trauma care. This study reviews the outcomes of renal salvage after penetrating trauma at a level I trauma center.

MATERIALS AND METHODS

An institutional review board approved trauma registry at Saint Louis University Hospital was retrospectively analyzed, for patients with penetrating renal trauma from 2009 to 2014. Patients were divided into nephrectomy group (NG) or non-nephrectomy group (non-NG), and compared. A multi-variable analysis was performed to determine predictors of nephrectomy, with cross validation to evaluate the performance of the multi-variable model. Data was analyzed using R version 3.3.2. A p value of < 0.05 was considered as significant.

RESULTS

A total of 121 patients were identified with penetrating renal trauma. Gunshot injury was the leading cause of injury (87%). Eighteen (15%) patients required nephrectomy. The overall mean injury severity score (ISS). was 20. High grade (grade 4-5) renal injuries were noted in 41 patients (34%). Among these, 14 patients (34%) underwent a nephrectomy, while 27 patients (66%) were managed conservatively to salvage renal units. CT grade of renal injury was the only predictor of nephrectomy, on multi-variable analysis (OR 17.09 CI 2.75-105.99, p = 0.002). CT grade of injury and injury severity score were predictors of endoscopic intervention on a sub group analysis of non-NG.

CONCLUSIONS

CT grade of injury predicts nephrectomy after penetrating renal trauma. Conservative management is a feasible option in penetrating renal trauma even with a higher grade of injury.

Accelerated versus conventional radiation fractionation in early stage carcinoma larynx

INTRODUCTION

In our study, we have treated cases of early glottic carcinoma by two different dose-fractionation schedules in relation to overall treatment time.

MATERIALS AND METHODS

This is an analysis of 29 patients with invasive, previously untreated T1and T2squamous cell carcinoma of true vocal cord that was treated by radical radiation therapy.

DOSE AND FRACTIONATION

All patients were treated with a continuous course of radiation therapy with once-daily fractionation. All the patients were treated 5 days a week from Monday to Friday. The fractionation regime was either: (1) 62.5 Gy/25fractions/5 weeks at 2.5 Gy fractions (Regimen 1), (2) 70 Gy/35 fractions/7 weeks at 2 Gy/fraction (Regimen 2). Regimen 1 included 15/29 patients (51.72%) and Regimen 2 included 14/29 patients (48.27%). Patients were evaluated for: (1) Locoregional control, (2) acute and late radiation toxicities, (3) quality of voice.

RESULTS AND OBSERVATION

There was no significant difference in terms of locoregional control rate, acute and late radiation toxicities in both groups. Voice quality during and after radiation was comparable in both arms.

CONCLUSION

Use of high dose per fraction schedule with shorter duration of treatment results in comparable local control as well as the quality of voice to the protracted course of radiotherapy without increase in treatment-related toxicities. Shorter overall treatment time can be of great advantage in terms of time, cost, comfort, and acceptability by the patients.

Induction chemotherapy with cisplatin and ifosfamide in locally advanced inoperable squamous cell carcinoma of the head and neck: A single-institution experience

BACKGROUND

Induction chemotherapy (ICT) in patients with head and neck cancer has been studied since a long time. The addition of taxanes to the cisplatin and 5-fluorouracil (5FU) (PF) regimen results in superior antitumor activity. We did this study to see the response and toxicity of ICT with cisplatin and ifosfamide followed by concurrent chemoradiotherapy (CRT) in locally advanced, unresectable squamous cell carcinoma of head and neck (SCCHN).

AIMS

The aim of this study was to see the results of ICT using cisplatin and ifosfamide regimen in locally advanced unresectable SCCHN in terms of acute and chronic toxicity and response to treatment.

MATERIALS AND METHODS

Patients with Stage III and IV, nonmetastatic SCCHN were enrolled in the study. They were given two cycles of ICT with cisplatin and ifosfamide followed by CRT.

RESULTS

After ICT, the overall response rate (ORR) was 75.0% at the primary site and 70.0% at the nodal site. ORR for combined primary and nodal disease was observed to be 67.5%. The complete response (CR) and partial response (PR) for combined primary and nodal site were seen in 4 (10.0%) and 23 (57.5%) patients. Of 32 patients who received CRT after ICT, CR was 53.1% and PR was 31.3%. Mucositis, skin reaction, and pharyngeal and laryngeal toxicities were the most common but tolerable.

CONCLUSION

ICT with cisplatin and ifosfamide gives comparable results to the standard paclitaxel, PF regimen. We conclude that this combination regimen for ICT is not only an economical alternative of taxol-based regimen but also well tolerated by the patients.

Comparison of two different radiation fractionation schedules with concurrent chemotherapy in head and neck malignancy

INTRODUCTION

The worldwide incidence of head and neck malignancy exceeds half a million cases annually. In radiotherapy (RT), conventional fractionation comprises giving five fractions per week from Monday to Friday. Accelerated RT includes administration of six fractions per week is being advocated. It gives better locoregional control and the median overall treatment time is 39 days as compared to 46 days in conventional group. Our study involved comparison of conventional versus accelerated RT with concurrent chemotherapy, in evaluation of local control and toxicity in the two arms.

MATERIALS AND METHODS

Sixty patients of locally advanced squamous cell carcinoma head and neck region were studied. All the patients received cisplatin (30 mg/m2) weekly during the therapy. The patients received RT dose of 70 Gray (Gy) in 35 fractions (#). The patients were randomly assorted into two groups: Group 1 - Study group (n = 30) - Six fractions RT per week (Monday-Saturday). Group 2 - Control group (n = 30) - Five fractions RT per week (Monday-Friday). During and after the treatment, locoregional control, acute and late radiation toxicity were assessed. Results and Observation: There was no significant difference between the two schedules regarding locoregional control rate. The Grade 3 or higher acute toxicities were significantly higher in the accelerated arm although there was no significant difference in late toxicities between the two arms.

CONCLUSION

Accelerated fractionation regimen was not more efficacious than conventional fractionation in the treatment of previously untreated head and neck carcinoma.

A new, simple and precise method for measuring cyclotron proton beam energies using the activity vs. depth profile of zinc-65 in a thick target of stacked copper foils

The proton beam energy of an isochronous 18MeV cyclotron was determined using a novel version of the stacked copper-foils technique. This simple method used stacked foils of natural copper forming 'thick' targets to produce Zn radioisotopes by the well-documented (p,x) monitor-reactions. Primary beam energy was calculated using the (65)Zn activity vs. depth profile in the target, with the results obtained using (62)Zn and (63)Zn (as comparators) in close agreement. Results from separate measurements using foil thicknesses of 100, 75, 50 or 25µm to form the stacks also concurred closely. Energy was determined by iterative least-squares comparison of the normalized measured activity profile in a target-stack with the equivalent calculated normalized profile, using 'energy' as the regression variable. The technique exploits the uniqueness of the shape of the activity vs. depth profile of the monitor isotope in the target stack for a specified incident energy. The energy using (65)Zn activity profiles and 50-μm foils alone was 18.03±0.02 [SD] MeV (95%CI=17.98-18.08), and 18.06±0.12MeV (95%CI=18.02-18.10; NS) when combining results from all isotopes and foil thicknesses. When the beam energy was re-measured using (65)Zn and 50-μm foils only, following a major upgrade of the ion sources and nonmagnetic beam controls the results were 18.11±0.05MeV (95%CI=18.00-18.23; NS compared with 'before'). Since measurement of only one Zn monitor isotope is required to determine the normalized activity profile this indirect yet precise technique does not require a direct beam-current measurement or a gamma-spectroscopy efficiency calibrated with standard sources, though a characteristic photopeak must be identified. It has some advantages over published methods using the ratio of cross sections of monitor reactions, including the ability to determine energies across a broader range and without need for customized beam degraders.

Synthesis and characterization of π-conjugated copolymers with thieno-imidazole units in the main chain: application for bulk heterojunction polymer solar cells

In this paper the three new narrow bandgap D–A conjugated copolymers P1, P2 and P3 based on different weak donor fused thiophene-imidazole containing derivatives and the same benzothiadiazole acceptor unit were synthesized by Stille cross-coupling polymerization and characterized by 1H NMR, elemental analysis, GPC, TGA, DSC. These copolymers exhibit intensive absorbance in the range 350–900 nm and the optical bandgap lies in the range of 1.50–1.61 eV, which corresponds to the maximum photon flux of the solar spectrum. The electrochemical bandgap derived from cyclic voltammetry varies within the limits 1.47–1.65 eV and is approximately very close to the optical bandgap. The highest occupied molecular orbital (HOMO) energy level of all copolymers is deep lying (−5.24 eV and −5.37 eV and −5.25 eV for P1, P2 and P2, respectively) which shows that copolymers have good stability in the air and assured a higher open circuit voltage (Voc) for polymer BHJ solar cells. These copolymers were used as donors along with PC71BM and the BHJ polymer solar cells based on P1:PC71BM, P2:PC71BM and P3:PC71BM processed from chloroform (CF) solvent with 3 v% DIO as an additive showed an overall PCE of 4.55%, 6.76% and 5.16%, respectively.

Breast cancer management: past, present and evolving

Breast cancer is known from ancient time,and the treatment strategy evolved as our understanding of the disease changed with time. In 460 BC Hippocrates described breast cancer as a humoral disease and presently after a lot of studies breast cancer is considered as a local disease with systemic roots. For most of the twentieth century Halsted radical mastectomy was the "established and standardized operation for cancer of the breast in all stages, early or late". New information about tumor biology and its behavior suggested that less radical surgery might be just as effective as the more extensive one. Eventually, with the use of adjuvant therapy likeradiation and systemic therapy, the extent of surgical resection in the breast and axilla got reduced further and led to an era of breast conservation. The radiation treatment of breast cancer has evolved from 2D to 3D Conformal and to accelarated partial breast irradiation, aiming to reduce normal tissue toxicity and overall treatment time. Systemic therapy in the form of hormone therapy, chemotherapy and biological agents is now a well-established modality in treatment of breast cancer. The current perspective of breast cancer management is based on the rapidly evolving and increasingly integrated study on the genetic, molecular , biochemical and cellular basis of disease. The challenge for the future is to take advantage of this knowledge for the prediction of therapeutic outcome and develop therapies and rapidly apply more novel biologic therapeutics.

Characterisation of micro-sized and nano-sized tungsten oxide-epoxy composites for radiation shielding of diagnostic X-rays

Characteristics of X-ray transmissions were investigated for epoxy composites filled with 2-10 vol% WO3 loadings using synchrotron X-ray absorption spectroscopy (XAS) at 10-40 keV. The results obtained were used to determine the equivalent X-ray energies for the operating X-ray tube voltages of mammography and radiology machines. The results confirmed the superior attenuation ability of nano-sized WO3-epoxy composites in the energy range of 10-25 keV when compared to their micro-sized counterparts. However, at higher synchrotron radiation energies (i.e., 30-40 keV), the X-ray transmission characteristics were similar with no apparent size effect for both nano-sized and micro-sized WO3-epoxy composites. The equivalent X-ray energies for the operating X-ray tube voltages of the mammography unit (25-49 kV) were in the range of 15-25 keV. Similarly, for a radiology unit operating at 40-60 kV, the equivalent energy range was 25-40 keV, and for operating voltages greater than 60 kV (i.e., 70-100 kV), the equivalent energy was in excess of 40 keV. The mechanical properties of epoxy composites increased initially with an increase in the filler loading but a further increase in the WO3 loading resulted in deterioration of flexural strength, modulus and hardness.

Impact of adjuvant androgen deprivation therapy after radical prostatectomy on the survival of patients with pathological T3b prostate cancer

OBJECTIVE

To determine the impact of adjuvant androgen deprivation therapy (ADT) on survival in patients with seminal vesicle invasion (pT3b) at radical prostatectomy.

PATIENTS AND METHODS

We reviewed 12,115 patients who underwent radical prostatectomy between 1987 and 2002 to identify patients with pT3bN0 prostate cancer who received adjuvant ADT (n= 191). These patients were matched by clinical and pathological variables to a group of patients with pT3b prostate cancer who did not receive adjuvant ADT. Median postoperative follow-up was 10 years. Clinical endpoints included biochemical progression-free survival (BPFS), local recurrence-free survival (LRFS), systemic progression-free survival (SPFS), cancer-specific survival (CSS) and overall survival.

RESULTS

Patients who underwent adjuvant ADT experienced improved 10-year BPFS (60% vs 16%, P < 0.001), LRFS (87% vs 76%, P= 0.002), SPFS (91% vs 78%, P= 0.004) and CSS (94% vs 87%, P= 0.037). Overall survival was not significantly different between groups (75% vs 69%, P= 0.12). Both luteinizing hormone-releasing hormone agonists (hazard ratio, 0.26; 95% CI, 0.15-0.46; P < 0.001) and bilateral orchiectomy (hazard ratio, 0.13; 95% CI, 0.06-0.31; P < 0.001) improved BPFS. When stratified by type of ADT (hormonal therapy vs orchiectomy), there was no difference in survival outcomes.

CONCLUSIONS

Adjuvant ADT improves local, and systemic control after radical prostatectomy for pT3b prostate cancer. There is no difference in survival between patients receiving medical hormonal therapy vs patients undergoing orchiectomy. Given the lack of improvement in overall survival, continued investigation is needed to identify the cohort of pT3b patients at highest risk for cancer progression and therefore most likely to benefit from a multimodal treatment approach.

First Report of Fusarium Wilt in the Broomrape Parasite Growing on Brassica spp. in India

Broomrape (Orobanche aegyptiaca Pers.), an important obligate root parasitic weed in India, has a wide host range including several members of the Solanaceae, Leguminaceae, and Brassicaceae families, among others. Orobanche plants produce thousands of tiny seeds (250 × 300 μm), which can remain viable in the soil for as long as 13 years (3). Rapeseed-mustard (Brassica spp.) is one of the major oilseed crops in India, cultivated on 5.77 million ha with 6.59 million t produced during 2009-2010. Broomrape has been observed in India as a major angiospermic parasitic plant on rapeseed-mustard, tobacco, tomato, and potato. During a field visit to an experimental farm at the Directorate of Rapeseed-Mustard Research, Bharatpur (27°12'N, 77°27'E) in the winter of 2009-2010, symptoms of wilt disease were observed on Orobanche plants, 32.6% of which had wilted completely following root infection. Initial symptoms appeared as a browning of the flowering stalk with wilting. Direct observation of below ground plant parasite tissues revealed a necrosis starting at the radical and advancing to the collar region that shredded later on. Tissue fragments, excised from the internal portions of the diseased tissue, were surface sterilized with 0.1% HgCl₂, plated on 2% potato dextrose agar (PDA) adjusted to pH 7.0, and incubated at 22 ± 2°C for 7 days. The colonies that grew on PDA plates produced a bright purple color. Single-spore culturing of the fungus yielded Fusarium solani on the basis of morphological characteristics (2). The Fungal Identification Service, Mycology and Plant Pathology Group, Agharkar Research Institute, Pune, India (Accession No. 2156) confirmed the identity. The pathogenicity of the fungus was tested by inoculating five healthy Orobanche plants that were parasitizing Brassica spp. at the radicle region with 10-ml spore suspensions (2 × 10⁵ conidia/ml of sterile distilled water) derived from 7-day-old cultures of the fungus. Control plants were treated with sterile distilled water. F. solani-inoculated radicles developed typical wilting symptoms within 2 weeks of treatment, while the control as well as the Brassica spp. plants remained healthy. F. solani was reisolated from inoculated wilted plants, thus fulfilling Koch's postulates. To our knowledge, on the basis of the literature, this is the first report from India showing that F. solani infects O. aegyptica on Brassica spp. There are reports of fungi (50 different species) infecting different hosts in Southern Italy, including F. oxysporum and F. solani, which have been found to be pathogenic to O. ramose. The most pathogenic Fusarium isolates significantly increased the number of dead spikes of broomrape (1). Control of Orobanche spp. poses a challenge because of the lack of effective and economic control measures. F. solani thus offers a potentially promising management strategy that should be explored in the future for the control of O. aegyptiaca. References: (1) A. Boari et al. Biol. Control 30:212, 2004. (2) P. E. Nelson et al. Fusarium Species: An Illustrated Manual for Identification. 1st ed. Pennsylvania State University Press, University Park, 1983. (3) M.C. Press et al. Parasitic Plants. Chapman and Hall, London, UK, 1995.

Role of PSA velocity in predicting pathologic upgrade for Gleason 6 prostate cancer

BACKGROUND

Pathologic upgrading to Gleason 7 or higher on radical prostatectomy (RP) specimens occurs in many patients with Gleason 6 prostate cancer on preoperative biopsy. We evaluated whether biopsy characteristics and preoperative factors, including preoperative PSA velocity (PSAV), are predictive of pathologic upgrading.

MATERIALS AND METHODS

We identified 235 consecutive Gleason 6 prostate cancer patients who underwent biopsies at our institution, had multiple pre-biopsy PSA values, and eventually underwent RP. Preoperative biopsy, clinical characteristics, and PSAV were analyzed to determine the risk of pathologic upgrading or extracapsular extension. These clinical factors were evaluated for association with biochemical recurrence following RP.

RESULTS

Overall, 48% of patients were upgraded to Gleason grade 7 or higher following RP. Median PSAV was 0.61 ng/mL/y, and PSAV was similar between upgraded and non-upgraded patients (1.01 vs. 0.78, P = 0.1). PSA velocity level was not associated with extracapsular disease (P = 0.4). PSA velocity > 1 was associated with biochemical recurrence (HR 3.23, P = 0.01) but this was not statistically significant in a multivariable model. Increasing PSA density (HR 2.18, P < 0.001), bilateral cores positive (HR 1.89, P < 0.05), and any biopsy core involvement > 50% (HR 2.52, P < 0.05) were most associated with pathologic upgrading. On multivariate analysis, only bilateral cancer detection at biopsy (HR 1.90, P < 0.05) significantly predicted upgrading.

CONCLUSIONS

PSAV has a limited role in predicting Gleason 6 upgrading. Patients with bilateral cancer detected on transrectal biopsy should be encouraged to have radical local therapy due to high risk of harboring more aggressive disease.

Choice of hemostatic agent influences adhesion formation in a rat cecal adhesion model

INTRODUCTION

Hemostatic agents are frequently used during abdominal surgery and some are linked to adhesion formation. We sought to evaluate the impact of several commonly used hemostatic agents on adhesion formation in a rat peritoneal model.

METHODS

In our study, Wister outbred rats underwent laparotomy and excision of a portion of their peritoneum to initiate adhesion formation process. One of six different hemostatic agents, namely, activated starch microspheres (Arista AH; Medafor Inc., Minneapolis, MN), glutaraldehyde activated collagen (BioGlue; Cryolife Inc., Kennesaw, GA), thrombin coated collagen microspheres (FloSeal; Baxter Inc., Deerfield, IL), thrombin activated fibrin polymer (Tisseel, Baxter), polyethylene glycol polymer (CoSeal, Baxter), or oxidized cellulose (Surgicel; Ethicon Inc., Somerville, NJ), was placed in the area of peritoneal defect. All animals were sacrificed on post-op day 7 and strength and extent of adhesion formation was determined. Histopathological examination of rat caecum was also performed.

RESULTS

Arista and CoSeal showed significantly lower adhesion formation than controls (P < 0.05). Higher adhesion scores were seen in BioGlue (P < 0.05) treated rats. Additionally, histopathologic examination showed that BioGlue caused statistically more inflammation and necrosis than controls (P < 0.05). Total adhesion score increased with residual amount of agent present at 7 d.

CONCLUSIONS

Use of Arista and CoSeal may help in reducing peritoneal adhesions after intra-abdominal surgeries. Furthermore, there appears to be a relationship between the creation of inflammation and necrosis in tissues and the eventual formation of adhesions. This could aid in improving the design of these agents in the future.

Suppression of infectious TMV genomes expressed in young transgenic tobacco plants

Full-length cDNAs of the wild-type (wt) Tobacco mosaic virus (TMV) and of the coat protein gene-deleted (DeltaCP) derivative of wt-TMV, under control of the 35S promoter and downstream ribozyme sequence to produce accurate viral transcripts, were transformed to tobacco plants to analyze plant-virus interactions through different stages of plant development. Surprisingly, young wt-TMV transgenics accumulated only very low levels of viral RNA, remained free of symptoms, and were moderately resistant against exogenous inoculations. This early resistance caused significant stress to the plants, as indicated by reduced growth. Approximately 7 to 8 weeks after germination, the resistance was broken and plants developed typical wt-TMV symptoms, with high accumulation of the viral RNAs and proteins. The DeltaCP-TMV plants likewise were initially resistant to the endogenous inoculum and were stunted, although to a lesser extent than the wt-TMV plants. The resistance was broken at the same time as in the wt-TMV plants, but the mutant replicated to much lower levels and produced much milder symptoms than the wt virus. TMV-specific small interfering RNAs as well as increased transgene methylation were detected in the plants only after the resistance break, indicating that the resistance in the young plants was not due to RNA silencing.

Treatment of Prostate Cancer Local Recurrence After Radical Retropubic Prostatectomy with 17-Gauge Interstitial Transperineal Cryoablation: Initial Experience

OBJECTIVES

Interstitial transperineal cryoablation with 17-gauge cryoprobes is an accepted treatment modality for localized prostate cancer. The effectiveness of cryoablation in the treatment of local prostate cancer recurrence after radical retropubic prostatectomy (RRP) is unknown.

METHODS

We reviewed the outcome of cryoablative treatment in 15 patients for biopsy-proven locally recurrent prostate cancer after RRP. The follow-up data included prostate-specific antigen (PSA) level, imaging findings, side effects, and an assessment of voiding habits.

RESULTS

The mean follow-up time for the entire group was 20 months (range 4 to 32). Of the 15 patients, 6 (40%) had sustained declines in the PSA level (cryoablation success group) and 9 (60%) had disease progression (cryoablation failure group), defined as a PSA increase greater than 0.1 ng/mL from the PSA nadir, or the addition of external beam radiotherapy or androgen deprivation therapy. The pre-RRP PSA level and pre-cryoablation PSA level were similar for both groups. The pre-RRP biopsy Gleason scores (P = 0.03), RRP Gleason scores (P = 0.03), and lesion size on magnetic resonance imaging (P = 0.001) were lower in the success group than in the failure group. All patients who were recurrence free after cryotherapy had a biopsy and Gleason score of 6 or less. Of the 15 patients, 3 (20%) developed worsening of post-RRP incontinence.

CONCLUSIONS

Our preliminary results suggest that salvage cryoablation can be an effective and safe treatment modality and a possible alternative to external beam radiotherapy for targeted control of confirmed local recurrences after RRP, especially in those with favorable biopsy or pathologic Gleason scores before cryotherapy. Larger cohorts and longer follow-up are needed to assess the viability of this treatment.

Tumor-infiltrating Foxp3-CD4+CD25+ T cells predict poor survival in renal cell carcinoma

PURPOSE

Regulatory T cells (Tregs) have been implicated as inhibitors of antitumoral immunity, and evidence suggests that elimination of Tregs may augment natural and pharmacologic immunity. We tested for the presence of putative Tregs within renal cell carcinoma (RCC) tumors.

EXPERIMENTAL DESIGN

We identified 170 patients who underwent radical or partial nephrectomy for clear cell RCC between 2000 and 2002. Specimens were stained with anti-CD4, anti-CD25, and anti-Foxp3 antibodies and examined using confocal microscopy. Associations of CD4(+)CD25(+)Foxp3(-) and CD4(+)CD25(+)Foxp3(+) T cells with death from RCC were evaluated using Cox proportional hazards regression models.

RESULTS

At last follow-up, 46 of 170 patients had died; of these, 37 died from RCC at a median of 1.4 years following nephrectomy (range, 0-4.4). Among the 124 remaining patients, median follow-up was 3.7 years (range, 0-5.7). Forty-three (25.3%) tumors harbored CD4(+)CD25(+)Foxp3(+) T cells. The presence of Foxp3(+) T cells was not significantly associated with RCC death univariately. One hundred forty-three (84.1%) tumors harbored CD4(+)CD25(+)Foxp3(-) T cells. The indicator for >or=10% CD4(+)CD25(+)Foxp3(-) T cells was significantly associated with RCC death univariately [risk ratio (RR), 2.60; 95% confidence interval (95% CI), 1.35-4.98; P = 0.004], after adjusting for tumor B7-H1 expression (RR, 2.53; 95% CI, 1.32-4.85; P = 0.005) and lymphocytic infiltration (RR, 2.53; 95% CI, 1.32-4.87; P = 0.005).

CONCLUSIONS

Increased presence of CD4(+)CD25(+)Foxp3(+) T cells was not significantly associated with RCC death. In contrast, CD4(+)CD25(+)Foxp3(-) T cells, which may represent a unique set of Tregs or activated helper T cells, was significantly associated with outcome.

Assessment of the durability of robot-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse

Transabdominal sacrocolpopexy has been shown, in multiple long-term studies of its success and durability, to be the definitive treatment option for post-hysterectomy vaginal vault prolapse. It is, however, associated with greater morbidity than vaginal repair. We describe a minimally invasive technique for vaginal vault prolapse repair and present our experience with a minimum of one-year follow-up. The surgical technique involves five laparoscopic ports—three for the da Vinci robot and two for the assistant. After appropriate dissection a polypropylene mesh is attached to the sacral promontory and to the vaginal apex by use of Gore-Tex sutures. The mesh material is then covered by the peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction, and morbidity, with a minimum of 12 months follow-up. Forty-two patients with post-hysterectomy vaginal vault prolapse underwent robot-assisted laparoscopic sacrocolpopexy at our institute and 35 have a minimum of 12 months follow-up, with a mean follow-up of 36 months (range 12–48) in the group. Mean age was 67 (47–83) years and mean operating time was 3.1 (2.15–4.75) h for the entire cohort. All but one patient were discharged home on postoperative day one; one patient left on postoperative day two. One developed recurrent grade three rectocele, one had recurrent vault prolapse, and two suffered from vaginal extrusion of mesh. All patients were satisfied with their outcome. The robot-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the reduced morbidity of laparoscopy. We observed reduced hospital stay, low occurrence of complications, and high patient satisfaction, with a minimum of 1-year follow-up. Most importantly, the long-term results of the robotic repair are similar to those of open repair, but with significantly less morbidity.

Impact of tumor size on the predictive ability of the pT3a primary tumor classification for renal cell carcinoma

PURPOSE

The accuracy of the pT3a primary tumor classification for renal cell carcinoma has been questioned recently. We investigated the association of perinephric and renal sinus fat invasion with death from renal cell carcinoma independent of tumor size.

MATERIALS AND METHODS

We identified 2,165 patients treated with open radical nephrectomy or nephron sparing surgery for clinically localized, sporadic pT1a, pT1b, pT2 or pT3a renal cell carcinoma between 1970 and 2002. Patients with pT3a disease were then subdivided into 3 groups according to tumor size to match the size definitions for the pT1a, pT1b and pT2 tumor classifications.

RESULTS

There were 834 patients with pT1a RCC, 674 with pT1b, 494 with pT2 and 163 with pT3a RCC. At last followup 317 patients died of RCC at a median of 3.8 years following surgery. The median followup among the 1,087 patients still alive at last followup was 7.8 years (range 0 to 34). The risk ratios (95% CI) for the association between fat invasion and death from RCC among patients with tumors 4 cm or smaller, 4 to 7 cm and more than 7 cm were 6.15 (1.84-20.50, p = 0.003), 4.12 (2.50-6.78, p <0.001) and 2.13 (1.53-2.97, p <0.001), respectively. These associations remained statistically significant in a multivariate analysis that included nuclear grade and histological coagulative tumor necrosis.

CONCLUSIONS

Peripheral perinephric and renal sinus fat invasion was associated with death from RCC independent of tumor size. Our data contradict reports suggesting that pT3a tumors should be reclassified according to tumor size only.

Preventing pain during office biopsy of the prostate

BACKGROUND

A prospective, double-blind, 3-arm, parallel group, randomized clinical trial was performed to compare 3 anesthetic techniques for preventing pain during prostate biopsy.

METHODS

A total of 243 men undergoing a 12-core prostate biopsy were randomized to 1 of 3 anesthetic methods: 1) seminal vesical-prostatic base blockade, 2) intraprostatic blockade, and 3) apical-rectal blockade. Pain was estimated with the 10-point visual analog scale. Multivariate logistic regression evaluated factors predictive of pain. The Kruskal-Wallis test analyzed overall group comparisons and the Steel-Dwass test assessed between-group comparisons in pain scores. Proportional odds ordinal logistic regression quantified the ability of covariates and treatment arms to predict biopsy pain. These values are presented as odds ratios with confidence intervals (OR, 95% CI).

RESULTS

From November 2005 to June 2006, 81 men were randomized to 3 study arms. Lidocaine administration was the most painful element of the procedure, while probe insertion was the least. Apical biopsies were routinely more painful than mid-gland biopsies, which were more painful than base biopsies. The apical-rectal blockade was the most painful to administer, but has lasting effects and led to better pain control than the prostatic base-seminal vesicle blockade. Similarly, the intraprostatic blockade was more effective than the prostatic base-seminal vesicle blockade. Besides pain reported at the time of anesthetic injection, no difference was identified between the intraprostatic and apical-rectal blockades.

CONCLUSIONS

Mid and apical biopsies of the prostate are more painful than base biopsies. The seminal vesicle-prostatic base blockade is less effective than intraprostatic and apical-rectal blockade at controlling pain.

Obesity and survival after radical prostatectomy: A 10-year prospective cohort study

BACKGROUND

Obesity and prostate cancer are among the most common health problems affecting American men today. The authors' goal was to assess the impact of obesity on clinical and pathologic features of prostate cancer and long-term outcomes.

METHODS

The authors performed a prospective cohort study on 5313 men who underwent radical prostatectomy between 1990 and 1999. Patient height and weight were measured at the time of surgery to calculate the body mass index (BMI). The patients were separated into 3 BMI groups: BMI <25, 25-29.9, and > or =30 kg/m2. The associations between BMI and age, prostate-specific antigen (PSA) level, and Gleason score were assessed with the Spearman rank correlation test. The associations between BMI and pathologic features were assessed with the Mantel-Haenszel chi 2 test. Fifteen-year biochemical progression-free survival, systemic progression-free survival, cancer-specific survival, and overall survival were estimated using the Kaplan-Meier method and evaluated using Cox models. RESULTS.: The median length of follow-up for the entire cohort was 10.1 years. Clinical and pathologic features appear worse in patients with a higher BMI. On univariate and multivariate analyses, it was found that BMI had no impact on biochemical progression, systemic progression, prostate cancer survival, or overall survival.

CONCLUSIONS

Obese patients appear to have worse pathologic features at the time of prostatectomy. Despite these features, long-term oncologic outcomes, including cancer-specific survival, remain the same regardless of BMI. BMI appears to influence prostate cancer outcomes at the time of prostatectomy, as evidenced by more aggressive pathologic features. However, after prostatectomy, BMI does not appear to be an independent predictor of recurrence or survival.

Impact of Familial and Hereditary Prostate Cancer on Cancer Specific Survival After Radical Retropubic Prostatectomy

PURPOSE

Men with a family history of prostate cancer are at higher risk for prostate cancer. There are conflicting data regarding the impact of hereditary forms of prostate cancer on long-term outcomes after radical prostatectomy. We examined the impact of familial and hereditary prostate cancer treatment in the prostate specific antigen era.

MATERIALS AND METHODS

Patients who underwent radical prostatectomy for prostate cancer from 1987 to 1997 were surveyed (3,560 responders) to determine the family history of prostate cancer. Patients were categorized as having familial prostate cancer if they had at least 1 first-degree relative with prostate cancer. Hereditary prostate cancer was defined as nuclear families with 3 cases of prostate cancer, families with prostate cancer in each of 3 generations and families with 2 men diagnosed before age 55 years. Sporadic prostate cancer was defined as patients with no family history. Clinical and pathological features, and long-term outcome measures, including biochemical recurrence-free, systemic progression-free and cancer specific survival, were compared among patients with familial, hereditary and sporadic prostate cancer.

RESULTS

A total of 865 and 133 patients were categorized as having familial prostate cancer and hereditary prostate cancer, respectively. Preoperatively prostate specific antigen was higher in patients with hereditary prostate cancer than in the other 2 groups (p = 0.04). Ten-year biochemical progression-free, systemic progression-free and cancer specific survival were equivalent.

CONCLUSIONS

Except for preoperative prostate specific antigen, clinicopathological features and long-term oncological outcomes are equivalent after radical prostatectomy in patients with familial, hereditary and sporadic prostate cancer.

Impact of Patient Age at Treatment on Outcome Following Radical Retropubic Prostatectomy for Prostate Cancer

PURPOSE

Historically young patients with prostate cancer have been found to have poorer outcomes. Recent studies suggest favorable pathological findings and improved survival in younger patients undergoing RRP. We assessed age at treatment as a predictor of post-RRP survival.

MATERIALS AND METHODS

We identified 5,509 patients treated with RRP for prostate cancer at our institution between 1987 and 1995. Age at treatment was classified into categories of younger than 55, 55 to 59, 60 to 64, 65 to 69 and 70 years or older. CSS, sPFS and biochemical PFS were estimated by the Kaplan-Meier method and analyzed using Cox proportional hazard models.

RESULTS

Younger patients had lower preoperative prostate specific antigen, and tumor grade and stage. CSS, sPFS and biochemical PFS were similar across age groups but overall survival decreased with older age at treatment. After multivariate adjustment the risk of cancer death was lower in patients 70 years or older (RR 0.53, 95% CI 0.30 to 0.90), while the risk of progression was lower in all age groups compared to that in men younger than 55 years (RR 0.57 to 0.62). On stratified subset analysis sPFS was progressively worse with younger age in patients with high risk pathological findings. However, the addition of age to multivariate models incorporating preoperative prostate specific antigen, pathological features and adjuvant therapy failed to improve their predictive value for CSS and sPFS.

CONCLUSIONS

Despite more favorable clinicopathological features younger patients undergoing RRP for prostate cancer have survival similar to that of older counterparts. Given the greater proportionate impact of prostate cancer on survival, it is particularly important to pursue aggressive treatment in younger patients.

Dosimetry of a low-kV intra-operative X-ray source using basic analytical beam models

The low energy (30-50 kVp) beams from an intra-operative X-ray source are modelled using a basic analytical model considering just primary beam attenuation and absorption. Spatial dosimetry at such low energies is difficult due to the rapid changes in dose-rate from the radiation source. The purpose of the model was to determine the variation with distance in water of coefficients required for beam dosimetry and to validate beam measurements performed in water of high-gradient dose distributions. The model predicts a change in mean mass-energy absorption coefficient of up to 3 % over the range of clinically-relevant distances in water. Distance-dose distributions (variation in dose with distance in water) for the X-ray source were calculated with the model and found to be in agreement with measurement (at clinically-relevant distances), to within a spatial distance comparable to the dimensions and positional accuracy of the ionization chamber used, and comparable to the expected dosimetric anisotropy of the radiation source. Measured and calculated distance-doses begin to diverge at relatively large distances from the radiation source, which is where dose-rates are so low that detector signal levels are comparable with noise.

Structural basis for the activity of pp60(c-src) protein tyrosine kinase inhibitors

Conformational searches on three closely related pp60(c-src) protein tyrosine kinase inhibitors of varying potencies were performed to determine a structural basis for their activity. The first was a linear peptide (PDNEYAFFQf), the second its 10-membered cyclic analogue, and the third a cyclic analogue with a para carboxyphenylalanine in place of one the F residues. A common backbone conformation with an antiparallel beta-sheet-like geometry capped by similar beta-turns was found for all three peptides, which may be a binding conformation and gives a candidate pharmacophore for further testing. The interaction between some polar side chains and between some of the aromatic rings may be important for maintaining the correct conformation. The differences in potencies of these inhibitors may be attributed to certain thermodynamic and chemical reasons.

Dual ectopic thyroid: a report of two cases

Ectopic thyroid is an uncommon embryological aberration characterized by the presence of thyroid tissue at a site other than in its usual pretracheal region. Usually it occurs along the path of descent of the developing thyroid primodium from the foramen caecum, commonest being lingual followed by sublingual and in the anterior midline of neck at, or below, the level of the hyoid bone. It is unusual for lingual thyroid to present simultaneously with another ectopic thyroid; reported here are two such cases.

Changes in serum copper levels in patients with malignant diseases undergoing radiotherapy

Present study repots changes in serum copper levels (SCL) in various neoplastic diseases undergoing radiotherapy. We estimated SCLs in 140 individuals comprising of 90 previously untreated patients with various malignancies and 50 healthy controls. Patients received radiation in doses of 40-70 Gy in 4-7 weeks. SCLs were again estimated in patients following irradiation. The mean SCL was significantly higher (P<0.001) in cancer patients as compared to healthy controls. It declined significantly (P<0.001) following irradiation. However, it remained significantly higher as compared to healthy controls (P<0.01). Highest fall in SCL was seen in complete clinical responders and least in non-responders to radiation treatment. Serial estimation of SCLs may be useful in the treatment monitoring of the neoplasms undergoing radiation treatment.

Granulocytic sarcoma in patients with chronic myeloid leukaemia

Granulocytic sarcoma is an unusual variant of myeloid malignancy most commonly encountered in the course of chronic or acute myeloid leukaemia. Of 60 patients of chronic myeloid leukaemia studied over 21 months, we encountered 6 (10%) cases of granulocytic sarcoma. Four of these had granulocytic sarcoma on their first presentation. All those who were receiving hydroxyurea did not fare well but one who was put on DAT (daunorubicin, cyftosine arabinocide, 6 thioguanine)regimen went into remission with complete disappearance of lesions.

Incidence & immunological profile of multiple myeloma patients

Multiple myeloma was diagnosed in 84 residents of Jammu & Kashmir between 1984-1988. The data were analyzed for variations of demographic factors, ethnicity and location of residence (urban/rural). The average annual incidence per 100,000 residents was 1.28. The rates for males and females were 2.02 and 0.71 per 10(5) persons/year respectively. The average incidence rate for Muslims was significantly higher than that for Hindus. Urban residents had significantly higher rates than rural population. Highest incidence rate (14.39) was in the age group of 65 yr and above.

Haemostatic clips and clamps used in surgical neurology with special reference to non ferro magnetic Phynox spring clips by Aesculap

This paper concerns the historical developments and technical properties of haemostatic devices used in neurosurgery with the exception of coagulation. Therefore there are described haemostatic clips designed for the scalp, clips used on arteries and veins, a clamp for the reduction of the carotid diameter in the neck, and a clamp for closing the venous dural sinuses. Special reference will be made regarding non ferro magnetic Phynox clips by Aesculap.