Assessment of a novel, full-thickness incisional biopsy model to restage rectal tumours after neoadjuvant chemoradiotherapy: results of an ex vivo pilot study

BACKGROUND

There is currently no reliable means to restage rectal cancers after neoadjuvant chemoradiation. Recent histological evidence shows that the epicentre for residual cancer cells is focussed directly underneath any residual mucosal abnormality (RMA). This proof-of-concept study aimed to determine the utility of a novel, minimally invasive method of incisional biopsy as a restaging tool. A secondary aim was to compare its performance to clinical response assessment.

METHODS

After surgical resection, 0.5 × 0.5 cm, full-thickness incisional biopsy was performed in 15 rectal cancers. Of these, 13 had RMA and 2 had mucosal cCR but a palpable intramural abnormality. In all patients, a full-thickness incisional biopsy was taken through the centre of these areas. The ypT stage of the incisional biopsy and the final total specimen were compared. Complete mucosal clinical response was deemed to have occurred when either no residual tumour or only a flat mucosal scar remained.

RESULTS

Incisional biopsy correctly identified all patients that had been downstaged to ypT0; however, it also falsely identified 5 of 10 patients (50%) with yp residual disease as ypT0. Overall performance of incisional biopsy to detect residual cancer was 50% sensitivity, 100 % specificity, 100% PPV, and 50% NPV with an accuracy of 66%. A complete mucosal clinical response occurred in only one of five patients downstaged to ypT0 (20% sensitive). It also occurred in one patient, which was ultimately staged as ypT3.

CONCLUSION

This prospective data demonstrates that incisional biopsy is not suitable as a stand-alone method to restage rectal cancer after CRT. Alternate or complementary means of restaging are needed.

Depth and lateral spread of microscopic residual rectal cancer after neoadjuvant chemoradiation: implications for treatment decisions

AIM

The aim of this study was to determine the distribution of residual tumour within the bowel wall in relation to residual mucosal abnormalities (RMAs) and surrounding normal mucosa in patients with rectal cancer who underwent neoadjuvant chemoradiation followed by curative surgery.

METHOD

Archived pathological slides from a cohort of 60 patients with residual tumour were retrieved. The incidence, distance and depth of tumour spread (ypT) under RMAs and adjacent normal mucosa were reviewed and recorded.

RESULTS

Histological sections containing both RMA and adjacent normal mucosa were available for 45 of 60 patients with ypT1 (n = 6), ypT2 (n = 18) and ypT3 (n = 21) disease. The maximal depth of invasion, as measured by ypT stage, was found underneath the RMA in 44 of 45 (98%) patients. Microscopic tumour spread lateral to the RMA and under adjacent normal mucosa was found in 32 of 45 (71%) patients. The median and maximum distances of lateral spread for ypT1 tumours were 0 and 4 mm; for ypT2 were 2.5 and 9 mm; and for ypT3 were 4 and 9 mm respectively.

CONCLUSION

Lateral tumour spread under normal mucosa adjacent to RMAs is a common finding and extended up to 9 mm in this study. The epicentre for maximum depth of invasion was directly underneath the RMAs in nearly all cases. These data have clinical and technical implications if local excision is to be considered.

Predictive value of sperm-FISH analysis on the outcome of preimplantation genetic diagnosis (PGD) for a pericentric inversion inv5(p15.3q11.2) carrier

BACKGROUND

Pericentric inversions (PIs) are structural chromosomal abnormalities, potentially associated with infertility or multiple miscarriages. More rarely, at meiosis, odd numbers of genetic recombinations within the inversion loop produce recombinant gametes which may lead to aneusomy of recombination in the offspring.

METHODS

We report a FISH segregation analysis of an inv5(p15.3q11.2) carrier, both in sperm and blastomeres. In sperm, we directly evaluated the proportion of recombinant gametes and compared the results with chromosomal abnormalities found in blastomeres collected from embryos obtained following a preimplantation genetic diagnosis (PGD) procedure.

RESULTS

A total of 7006 sperm nuclei were analyzed. The size of the inverted segment represented 27% of the total length of chromosome 5. The frequencies of balanced chromosomes (normal or inverted), recombinant chromosomes and unbalanced combinations were 97.1, 0.17 and 2.73%, respectively. Of six embryos, PGD FISH analysis revealed that one was a balanced embryo, whereas five were unbalanced and there were no recombinants.

CONCLUSIONS

This study demonstrated the value of sperm-FISH analysis in providing reproductive genetic counseling for PI carriers. Our study also highlights the clinical relevance of performing PGD instead of prenatal diagnosis.

Botulinum toxin in the management of sialorrhoea: a systematic review

Sialorrhoea can be a significant problem in both adults and children and can cause both physical and psychosocial problems. Botulinum toxin has enjoyed an emergence in the treatment of sialorrhoea, a systematic review of the evidence for botulinum toxin reveals two randomised controlled trials (RCTs) and four other trials that fulfilled our inclusion criteria. Both RCTs demonstrate the effectiveness of botulinum toxin in the management of sialorrhoea. There was no clear evidence for one antigenic type of botulinum toxin over another and minimal evidence for the optimal dose of botulinum toxin for each antigenic type. No advantage is conferred in using ultrasound guidance in injecting the glands. None of the RCTs or other studies directly compared submandibular versus parotid injection or directly compared botulinum toxin against surgery. Minor side effects were reported in one of the RCTs but overall botulinum toxin is a safe, minimally invasive and effective means in the treatment of sialorrhoea with the potential to become the treatment of choice. Our review demonstrates that further randomised controlled trials are required to more fully evaluate this new modality of treatment.

Rheumatological prescribing in athletes: a review of the new World Anti-Doping Agency guidelines

Rheumatologists, with their musculoskeletal background, often care for athletes. The effect of a positive anti-doping test, whether through illegitimate use or accidental prescribing of banned drugs, is devastating to an athlete's career. It is therefore incumbent upon rheumatologists to be aware of issues relating to drugs in sport. This involves both therapeutic drugs and doping. It is vital to ensure that any substance prescribed should be approved for use and should not adversely affect (or benefit) the athlete's performance. In March 2004, 5 months prior to the 2004 Olympic Games in Athens, the joint World Anti-Doping Agency/International Olympic Committee published the revised list of banned substances in athletes. This article aims to provide an overview of the current status of medications commonly prescribed in rheumatological practice.

The perception of amplified speech by listeners with hearing loss: acoustic correlates

Audibility-based approaches to hearing-aid selection generally have focused on the long-term average speech spectrum (LTASS). Advances in amplification technology (e.g., multiband signal processing, level-dependent frequency shaping, full dynamic range compression, adaptive compression) make it difficult to predict the audibility of short-term components of speech from the amplified LTASS. This study was designed to quantify the audibility of a specific phonemes as processed by two different hearing-aid circuits (linear and full dynamic range compression), and to investigate the relation between audibility and performance on a nonsense syllable recognition task. Data were obtained from three subjects with moderate sensorineural hearing loss. Nine unvoiced consonants were presented in two vowel contexts (/i/ and /a/) in both the pre- and post-vocalic position at three intensities. While the performance on selected conditions appeared to vary by hearing-aid type, only one subject showed a statistically significant difference between the two hearing-aid systems. Acoustic analyses revealed a variety of spectral and temporal changes to the speech signal following processing. Estimates of audibility were based upon each subject's thresholds and an acoustic analysis of the amplified signal that varied across phonemes and consonant position. A signal detection approach was used to predict performance from a simple measure of audibility.