Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics

Introduction Proximal cervical internal carotid artery stenosis greater than 50% merits revascularization to mitigate the risk of stroke recurrence among large-vessel anterior circulation strokes undergoing mechanical thrombectomy. Carotid artery stenting necessitates the use of antiplatelets, and there is a theoretical increased risk of hemorrhagic transformation given that such patients may already have received intravenous thrombolytics and have a significant infarct burden. We investigate the outcomes of large-vessel anterior circulation stroke patients treated with intravenous thrombolytics receiving same-day carotid stenting or selective angioplasty compared to no carotid intervention. Materials and methods The study cohort was obtained from the National (Nationwide) Inpatient Sample database between 2006 and 2014, using International Statistical Classification of Diseases, ninth revision discharge diagnosis and procedure codes. A total of 11,825 patients with large-vessel anterior circulation stroke treated with intravenous thrombolytic and mechanical thrombectomy on the same day were identified. The study population was subdivided into three subgroups: no carotid intervention, same-day carotid angioplasty without carotid stenting, and same-day carotid stenting. Outcomes were assessed with respect to mortality, significant disability at discharge, hemorrhagic transformation, and requirement of percutaneous endoscopic gastronomy tube placement, prolonged mechanical ventilation, or craniotomy. Results This study found no statistically significant difference in patient outcomes in those treated with concurrent carotid stenting compared to no carotid intervention in terms of morbidity or mortality. Conclusions If indicated, it is reasonable to consider concurrent carotid stenting and/or angioplasty for large-vessel anterior circulation stroke patients treated with mechanical thrombectomy who also receive intravenous thrombolytics.

Prospective randomized controlled study comparing low-cost LED and conventional phototherapy for treatment of neonatal hyperbilirubinemia

Our objective was to carry out a prospective, randomized, single-blind study to evaluate whether light emitting diode (LED) phototherapy using a low-cost set of lights is as effective as conventional phototherapy in treating hyperbilirubinemia in neonates. The study included 45 pre-term neonates requiring phototherapy as per American Academy of Pediatrics guidelines; participants were randomized to receive phototherapy using LED-based lights, conventional fluorescent blue lights or conventional halogen lights. There were no statistically significant differences in the average bilirubin levels at the onset, at the maximum and at the end of treatment, nor in the duration of phototherapy treatment and the rate of decrease in bilirubin levels in the neonates receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy. (Differences were considered significant at p < 0.05). The average rate of decrease of bilirubin levels was 0.047 ± 0.037 mg dl(-1) h(-1), 0.055 ± 0.056 mg dl(-1) h(-1) and 0.057 ± 0.045 mg dl(-1) h(-1) in the groups receiving conventional fluorescent blue light, conventional halogen light and LED phototherapy, respectively. The average duration of phototherapy treatment in the three groups was 108.8 ± 85.9 h, 92.8 ± 38.1 h, 110.4 ± 42.6 h, respectively. In this pilot study, LED phototherapy using a simple, low-cost set of lights was as effective as conventional phototherapy in the treatment of neonatal hyperbilirubinemia. LED phototherapy lights that deliver 30-40 µW cm(-2 )nm(-1) can be assembled in small quantities for <US$ 100 each using off-the-shelf parts; such lights may enable phototherapy to be safely and reliably delivered in low-resource settings.

Surgical staging of uterine cancer: Randomized phase III trial of laparoscopy vs laparotomy—A Gynecologic Oncology Group Study (GOG): Preliminary results

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Background: Feasibility of laparoscopy has been demonstrated, but the toxicity, staging, and survival has not been adequately compared to the traditional open approach. A randomized Phase III trial of 2616 patients was conducted by the GOG from 5/1996 to 9/2005. QOL and complications of surgery were previously reported at SGO. FIGO pathologic staging is the basis of this report. Methods: Clinical Stage I-IIA uterine cancer were eligible, consenting to either technique. The randomization procedures yielded two on laparoscopy arm for every one on the laparotomy arm. Scope participants were required to undergo laparotomy if the complete surgical staging was not feasible, or for resection of cancer. The staging results include: FIGO surgical stage, peritoneal cytology, number of nodes per site, and percent positive nodes at each location: right pelvic, left pelvic, right para-aortic, left para-aortic. Results: 2616 were randomized, 403 were excluded for this analysis: 84 ineligible, 76 sarcoma, 198 incomplete data, 45 were stage IV, leaving 2213 evaluable for lymph node staging of endometrial carcinoma (781 open:1432 scope). Conversion to laparotomy from laparoscopy occurred in 23.7%. Positive or suspicious cytology was found in 5.6% of laparotomy and 7.8% of laparoscopy participants (p = 0.055 n.s.). Pelvic nodes were documented (R 98.8% vs 98.9%, L 98.5% vs 98.1% n.s.) and positive pelvics (any positive 8.8% vs 8.7%; R 5.5% vs 5.8%; L 6.9% vs 6.1% n.s.) were similar. Laparoscopic surgical staging cases were less likely to have para-aortic nodes sampled (L 91.3% vs 85.0% p < 0.001; R 96.0% vs 92.5% P = 0.001), but positve nodes were no different (any positive PA 5.0% vs 4.5%; R 4.1%, 3.4%; L 2.3%, 2.7% n.s.). Final FIGO Staging results (III A: 5.5% vs 5.7% n.s.& IIIC: 9.3% vs 9.5% n.s.) were the same by randomization arm. Conclusion: These results demonstrate that laparoscopic surgical staging of endometrial cancer can be completed in 76.3%. No difference in postive cytology, node positivity rate, or FIGO stage could be attributed to the laparoscopic approach. Conversion to laparotomy is advised when incomplete staging results would yield inadequate information for treatment planning. NCI Funding: UO1CA65221, CA 27469.

No significant financial relationships to disclose.

O6-methylguanine-DNA methyltransferase in ovarian malignancy and its correlation with postoperative response to chemotherapy

O6-Methylguanine-DNA methyltransferase (MGMT) in human neoplastic tissues has been associated with tumor resistance to alkylating agents. The purposes of this study are to assay MGMT activity in ovarian cancers and to correlate MGMT titers with chemotherapy response to cisplatin and cyclophosphamide in patients with ovarian cancer. MGMT levels were determined by a biochemical assay of tumor tissues from 20 patients with ovarian malignancy. The clinical stages of the patients studied were 4 in Stage I, 2 in Stage II, 12 in Stage III, and 2 in Stage IV. The mean MGMT activity was 34 +/- 9 fmole methyls transferred/mg protein. Among 13 patients with tumor MGMT levels more than 10 fmole/mg protein, 10 (77%) of them were resistant to postoperative combination chemotherapy. In the remaining 7 patients with low MGMT titer of less than 10 fmole/mg protein, a majority (71%) had a complete response (P < 0.10). These preliminary results indicate that ovarian cancer has detectable MGMT activity, and this activity is possibly correlated with treatment failure to a postoperative cisplatin regimen.

Stage I endometrial carcinoma. Role of omental biopsy and omentectomy

A prospective, routine histologic assessment of the omentum during primary surgery was conducted on 84 women with stage I endometrial carcinoma between February 1986 and June 1989. The purpose of the study was to determine the true incidence of omental involvement in early endometrial cancer and to detect risk variables associated with such metastases. Omental metastases were found in 7 (8.3%) of 84 patients with stage I endometrial carcinoma. A majority of the metastases (five) consisted of microscopic disease. Factors statistically significantly associated with omental metastasis were adnexal spread, cul-de-sac implantation, papillary serous carcinoma, a positive retroperitoneal lymph node and grade 3 tumor. The study indicated that silent metastases to the omentum frequently are neglected clinically in patients with stage I endometrial carcinoma during primary surgery and that a routine omental biopsy should be part of the procedure. Furthermore, for patients with high-risk variables, a complete omentectomy ought to be considered.

Assessment of criteria used in the histologic diagnosis of human papillomavirus-related disease of the female lower genital tract

The goal of this study was to evaluate the histologic criteria used to establish the diagnosis of human papillomavirus (HPV)-associated disease, especially in borderline lesions. In a completely blinded study, 21 patients had one biopsy each of the cervix and vulva. Each specimen was evaluated by RNA and DNA in situ hybridization, a histologic diagnosis was rendered, and then each was evaluated for 12 histologic criteria commonly associated with HPV. On the cervix only binucleation and dysplasia correlated well with in situ hybridization. Koilocytosis correlated very strongly with the histologic diagnosis. On the vulva, koilocytosis, papillomatosis, elongated rete pegs, binucleation, and hypergranulosis correlated well with in situ hybridization. When four other pathologists reviewed the slides, they agreed on the histologic diagnosis and the presence of koilocytosis, binucleation, and dysplasia on the cervix but on none of the other criteria. On the vulva the pathologists disagreed on the overall diagnosis and the presence of any of the criteria with the exception of papillomatosis. Nonclassic histologic criteria should not, by themselves, be used to make the diagnosis of condyloma. The use of such terminology as "suggestive of condyloma" in histologic diagnoses should be avoided in favor of more descriptive terminology to avoid possibly unnecessary treatment for lesions of questionable significance.

Adenofibroma of the uterus: multiple recurrences following wide local excision

The uterine adenofibroma is a form of mixed mesodermal tumor in which both epithelial and stromal components are benign. A case is presented in which a patient with this lesion was treated with excision of the tumor rather than hysterectomy. Two years later, she developed a recurrence of the lesion, which was again treated with wide local excision. A hysterectomy was done 9 months later, and a polypoid lesion was noted in the fundus of the uterus which on histologic examination was thought to be potentially either an adenofibroma precursor or a maturation of the previous cellular adenofibroma. Since uterine adenofibroma usually occurs in older patients, the standard treatment has been hysterectomy. Because of this patient's age, she was initially treated with a more conservative approach. However, despite the fact that the uterine adenofibroma is a benign lesion, it has an obvious potential to recur when treated conservatively.

Magnetic resonance imaging in stage I endometrial carcinoma

A prospective study was conducted on 50 consecutive patients with stage I endometrial cancer who had primary surgical treatment. The purpose of the study was to assess the value of magnetic resonance imaging (MRI) for accurate staging of early disease and determination of myometrial invasion. Features identified by MRI were correlated with surgical pathology. Preliminary MRI results provided additional valuable information. All but one of 18 patients with histologically proven deep myometrial invasion were predicted preoperatively by MRI. Of 17 patients with detached fragments of malignant tissue in the endocervical curettage (ECC) but with results inconclusive for actual cervical invasion, MRI revealed all three patients with true cervical tissue involvement. Magnetic resonance imaging detected all six patients with gross extrauterine spread and also precisely measured uterine enlargement by myomata. The extent and location of tumor growth in the uterus could be mapped out in the majority of cases. Based on these findings, a pretreatment MRI scan of the pelvis in presumably stage I endometrial carcinoma resulted in an advance in staging in 18% of the patients, and accurately predicted deep myometrial invasion in 94% of the cases. Inclusion of MRI in the routine work-up in stage I endometrial carcinoma should be considered for proper clinical staging, particularly in patients with a positive but nondiagnostic ECC, uterine papillary serous carcinoma, or grade 3 tumor.

Vaginal endometrioid adenocarcinoma arising in vaginal endometriosis: a case report and literature review

Presented here is the seventh reported case of vaginal endometrioid adenocarcinoma arising in vaginal endometriosis. This case has unique features. There is no evidence of endometriosis elsewhere, and the only metastasis is seen in one obturator lymph node. Thorough preoperative and intraoperative evaluation is stressed.