Anesthetic management in a huge hydrocephalus.

The pediatric age group with massive hydrocephalus posted for ventriculoperitoneal (VP) shunt presents a lot of confrontation to anesthesiologists due to macrocephalus and associated congenital anomalies. Here, we presented a case report with massive hydrocephalus with aqueduct stenosis, posted for VP shunt placement, and retained a difficult airway.

RésumésLe grouped'âgepédiatrique avec unehydrocéphalie massive affichée pour un shunt ventriculopéritonéal (VP) présente beaucoup de confrontation à l'anesthésisteen raison de la macrocéphalieet des anomalies congénitalesassociées. Ici, nous avonsprésentéun rapport de casd'hydrocéphalie massive avec sténose de l'aqueduc, affiché pour la miseen place d'un shunt VP, et conservéunevoierespiratoire difficile. Mots-clés : Pédiatrique, Voiesrespiratoiresdifficiles, hydrocéphalie, dérivationventriculopéritonéale.

Delivering PACE++ curriculum in community settings: Impact of TARA intervention on gender attitudes and dietary practices among adolescent girls in Bihar, India.

Adolescence phase has high intrinsic and instrumental relevance. The Transformative Action for Rural Adolescents intervention delivered PACE++ curriculum with innovations to introduce a) health and nutrition sessions and b) delivery of the content in community settings of rural Bihar. This paper examines impact of the intervention showcasing establishment of intergenerational community connect for empowering and invigorating adolescent girls on gender attitude, empowerment and adolescent health and nutrition. The impact evaluation is based on a two-arm (intervention and comparison groups) cluster randomized controlled design with two rounds of representative cross-sectional surveys. The baseline and endline sample comprised of 2327 and 2033 adolescent girls (15-19 years), respectively. Descriptive statistical, difference-in-differences and propensity score matching methods are used to confirm the program impact. The DID and PSM analyses confirm high significance of impact on gender equity norms, diets and nutritional knowledge and understanding of employee related rights and responsibilities. School-going adolescent girls performed better than those who have discontinued formal education. The intervention showcases the importance of delivering the modified PACE curriculum in rural settings through leveraging community platforms. The findings call for greater policy attention on scaling up of similar initiatives for empowerment and social capital development of adolescent girls.

Cardioprotective effect of antiviral therapy among hepatitis C infected patients: A meta-analysis.

Background: Hepatitis C (HCV) infections have been shown to be associated a with higher risk of atherosclerotic cardiovascular disease (CVD). However, the use of antiviral therapy (AVT) and the risk of CVD has not been well established with limited literature. Objective: We sought to evaluate the association between AVT use post-HCV infection and cardiovascular outcomes. Methods: We performed a systematic literature search using PubMed, Embase, and Scopus for relevant articles from inception until 10th March 2023. Primary clinical outcomes were the incidence of any CVD. Secondary endpoints were all-cause of mortality, stroke, myocardial infarction, and peripheral artery disease. Results: A total of 394,452 patients were included in the analysis (111,076 in the AVT group and 283,376 patients in the NAVT group). The mean age of patients among AVT and NAVT groups was comparable (58.7 vs 58.18). The pooled analysis of primary outcomes showed that AVT was associated with a significantly reduced risk of any CVD (HR, 0.55(95%CI: 0.41-0.75), P < 0.001) compared with the NAVT group of patients. Secondary outcomes including ACM (HR, 0.38(95%CI: 0.32-0.46), P < 0.001), MI (HR, 0.62(95%CI: 0.41-0.94), P = 0.02), and PAD (HR, 0.62(95%CI: 0.41-0.93), P = 0.02) were significantly lower among AVT groups compared with NAVT groups of patients with HCV infection. However, the risk of stroke was comparable between both groups of patients (HR, 0.79(95%CI: 0.58-1.07), P = 0.13). Conclusion: Our analysis shows HCV-infected patients post-AVT have a significantly lower risk of any CVD, MI, ACM, and PAD compared with NAVT groups of patients.

SGLT2 inhibitors among patients with heart failure with preserved ejection fraction: A meta-analysis of randomised controlled trials.

BACKGROUND: Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been recommended in the practice guidelines for the treatment of patients with heart failure with reduced ejection fraction; however, their effects among patients with preserved ejection fraction have been debatable. OBJECTIVE: We aim to evaluate the SGLT2 inhibitor effect among patients with heart failure with reduced ejection fraction, including DELIVER and EMPEROR-Preserved trials. METHODS: We performed a systematic literature search using the PubMed, Embase, Scopus, and Cochrane libraries for relevant articles from inception until August 30th, 2022. Statistical analysis was performed by calculating hazard ratio (HR) using the random effect model with a 95% confidence interval (CI) and probability value (P). Statistical significance was met if 95% CI does not cross numeric "1" and P < .05. RESULTS: Six studies with a total of 15,989 total patients were included in the final analysis. The mean age of patients enrolled in SGLT2 inhibitors and placebo was 69.13 and 69.37 years, respectively. The median follow-up duration was 2.24 years. SGLT2 inhibitors reduced composite cardiovascular mortality or first hospitalization for heart failure (HR, 0.80 [95% CI: 0.74-0.87], P < .001, I2 = 0%), heart failure hospitalization (HR, 0.74 [95% CI: 0.67-0.82], P < .001, I2 = 0%) compared with placebo. However, all-cause mortality (HR, 0.97 [95% CI: 0.89-1.06], P = .54, I2 = 0%) and cardiovascular mortality (HR, 0.96 [95% CI: 0.82-1.13), P = .66, I2 = 35.09%] were comparable between both groups. CONCLUSION: Our study finding shows that SGLT2 inhibitors significantly reduced the risk of first HF hospitalization or cardiovascular death and HF hospitalization; however, all-cause mortality was comparable between the groups.

Supraglottic airway devices versus endotracheal intubation for laparoscopic surgeries: An updated systematic review and meta-analysis of randomised controlled trials.

Background and Aims: Laparoscopic surgeries are among the most frequent procedures done worldwide. There is a gradual shift in the method of airway securement from endotracheal intubation to supraglottic airway devices (SAD). The objective of the current work was to perform a systematic review and meta-analysis of published RCTs on airway complications in laparoscopic surgery performed with a SAD or endotracheal intubation (ETT). Methods: The research was registered in PROSPERO, and a literature search was conducted in Google Scholar and PubMed until August 2022. Out of 78 studies, 31 studies were screened and 21 were included for analysis. RevMan 5.4 was used to analyse data on sore throat, hoarseness, nausea, vomiting, stridor and cough. Results: Twenty-one randomised controlled trials, enrolling a total of 2213 adult patients, were included in the quantitative analysis. A significant incidence of sore throat and hoarseness was seen at post-operative period in ETT group with risk ratio (RR) 0.44, P < 0.00001 [0.30, 0.65], i2 = 72% and RR 0.38, P < 0.001 [0.21, 0.69], i2 = 72%, respectively. However, incidence of nausea, vomiting and stridor was not significant with RR 0.83, P = 0.26 [0.60, 1.15], i2 = 52% for nausea and RR 0.55, P = 0.03 [ 0.33, 0.93], i2 = 14% for vomiting. Incidence of cough was more in ETT group with RR 0.11, P < 0.00001 [ 0.06, 0.20], i2 = 42%, as compared to SAD group. Conclusion: There was a substantial variation between SADs and ETTs with respect to the incidence of hoarseness, sore throat, nausea and cough. The existing literature is reinforced by the evidence uncovered in this updated systematic review.

The Racial Disparity Among the Clinical Outcomes Post Stroke and its Intervention Outcomes: A Systematic Review and Meta-analysis.

The Racial disparity between the clinical outcomes poststroke have not been well studied, with limited literature available. We conducted a meta-analysis to evaluate the poststroke outcomes among the White and Black race of patients. We systematically searched all electronic databases from inception until March 1, 2023. The primary endpoint was post stroke in-hospital mortality, and all-cause mortality. Secondary endpoints were poststroke intervention in-hospital mortality, intracerebral hemorrhage, and all-cause mortality (ACM). A total of 1,250,397 patients were included in the analysis, with 1,018,892 (81.48%) patients of the White race and 231,505 (18.51%) patients in the Black race. The mean age of the patients in each group was (73.55 vs 66.28). The most common comorbidity among White and Black patients was HTN (73.92% vs 81.00%), and DM (29.37% vs 43.36%). The odds of in hospital mortality post stroke (OR, 1.45 [95% CI:1.35-1.55], P <0.001), and all-cause mortality (OR, 1.40 [95% CI:1.28-1.54], P < 0.001) were significantly higher among White patients compared with Black patients. Among patients with post stroke intervention the odds of in-hospital mortality (OR, 1.29 (95% CI: 1.05-1.59, P = 0.02), and intracerebral hemorrhage (ICH) (OR, 1.15, [95% CI:1.06-1.26], P < 0.01) were significantly higher among White patients compared with Black patients post intervention. However, all-cause mortality (OR,1.21 [95% CI: 0.87-1.68, P = 0.25] was comparable between both groups. Our study is the most comprehensive and first meta-analysis with the largest sample size thus far, highlighting that White patients are at increased risk of mortality and post intervention intracerebral hemorrhage compared with Black patients.

Subclinical Hypothyroidism and Clinical Outcomes After Percutaneous Coronary Intervention: A Meta-Analysis.

While subclinical hypothyroidism (SCH) was reportedly associated with an increased risk of cardiovascular mortality, the relationship between SCH and clinical outcomes of patients undergoing percutaneous coronary intervention (PCI) is uncertain. The aim of this study was to assess the association of SCH and cardiovascular outcomes in patients undergoing PCI. We searched PubMed, Embase, Scopus, and CENTRAL databases from its inception until April 1, 2022 for studies comparing the outcomes between SCH and euthyroid patients undergoing PCI. Outcomes of interest include cardiovascular mortality, all-cause mortality, myocardial infarction (MI), major adverse cardiovascular and cerebrovascular events (MACCE), repeat revascularization and heart failure. Outcomes were pooled using the DerSimonian and Laird random-effects model and reported as risk ratios (RR) and 95% confidence intervals (CI). A total of 7 studies involving 1132 patients with SCH and 11,753 euthyroid patients were included in the analysis. Compared with euthyroid patients, patients with SCH had significantly higher risk of cardiovascular mortality (RR 2.16, 95% CI: 1.38-3.38, P < 0.001), all-cause mortality (RR 1.68, 95% CI: 1.23-2.29, P = 0.001) and repeat revascularization (RR 1.96, 95% CI: 1.08-3.58, P = 0.03). However, there were no differences between both groups in terms of incidence of MI (RR 1.81, 95% CI: 0.97-3.37, P = 0.06), MACCE (RR 2.24, 95% CI: 0.55-9.08, P = 0.26) and heart failure (RR 5.38, 95% CI: 0.28-102.35, P = 0.26). Our analysis suggests among patients undergoing PCI, SCH was associated with increased risk of cardiovascular mortality, all-cause mortality and repeat revascularization compared to euthyroid patients.

Sinonasal Schwannomas: Imaging Findings and Review of Literature.

OBJECTIVE: Schwannomas are common nerve sheath tumors and may occur anywhere in the body. 4% of head and neck schwannomas occur in the sinonasal cavity, and fewer yet have an intracranial component, making these presentations extremely rare. Furthermore, schwannomas present with nonspecific imaging signs and can only be definitively differentiated via histopathologic review, leading to misdiagnosis as various nasal tumors. We aim to conduct a review of published literature on sinonasal schwannomas with and without intracranial extension and provide additional case representations. METHODS: A literature review was conducted using the PubMed Database with the terms "sinonasal schwannoma," "intracranial," "anterior skull base," and "schwannoma." Results were reviewed, and additional cases identified were referenced and included in the study. Inclusion criteria were any case with intracranial extension of the schwannoma. There were no exclusion criteria. Review data was compiled into Excel and used for data analysis and comparison. Additionally, a search was done within our institution to identify additional cases of sinonasal schwannoma. RESULTS: We identified 17 cases of sinonasal schwannoma with intracranial extension, five from our institution and twelve from literature. Analysis revealed: 8 females (47%), 9 males (53%), 9 patients presented with headaches (53%), 6 patients presented with anosmia (35%), 4 patients presented with nasal obstruction (24%), and 2 patients with no symptoms (12%). Mean age and median were 39.4 ± 10.1 and 40, respectively. For treatment, 4 patients underwent endoscopic resection (24%), 11 underwent craniotomy (65%), and data was unavailable for 2 patients. Post-treatment complications occurred in 6 patients, 5 had CSF leaks (29%) and 1 had a hematoma (6%). CONCLUSION: We identified and discussed 17 cases of sinonasal schwannoma with intracranial extension. We hope our review provides insight for clinicians to maintain schwannoma as a potential differential when evaluating nasal and anterior skull base masses.

The Outcomes of Flexor Tendon Injury Repair of the Hand: A Clinico-Epidemiological Study.

Background and objective The incidence of flexor tendon injury is estimated to be 7-14 per 100,000 population. In India, such injuries are common and about 5% of these injuries require repair of the flexor tendon. In the present study, we share our experience of hand flexor tendon repair at a tertiary care center in western India. Material and methods Over a period of three years, 45 patients were admitted for tendon repair. After performing a proper evaluation, patients were taken for tendon repair. Primary outcome and secondary outcome parameters were assessed at the end of three months. Physiotherapy was continued for a longer duration in patients with movement restrictions. Data were compiled at each stage. Results The mean age of the patients was 28.84 years (range: 13-68 years) with a majority of the cases belonging to the age group 15-60 years. The majority of hand injuries were accidental (caused by work-related accidents, machine injuries, or animal bites) amounting to 80% (n=36), followed by assault cases (11%, n=5) and self-inflicted injuries, i.e., attempted suicides (around 9%, n=4). Among all injuries, the majority were in zone V (60%, n=27) followed by 24.4% (n=11) of cases in zone II. A few cases were in zone I, III, and IV (2.2%, 11.2%, and 2.2% respectively). The Buck-Gramcko scoring for primary injury was excellent with a recovery rate of 57.78%. Conclusion Flexor tendon injuries should be repaired with the aim of recovering strength as well as mobility. For optimal outcomes, total active motion protocol should be commenced immediately after the surgical repair. However, long-term physiotherapy may be required for attaining desired benefits.

Premedication with Diclofenac and Precurarization with Atracurium on Succinylcholine-Induced Myalgia in Laparoscopic Cholecystectomy: A Double-Blinded Randomized Study.

Background and Aims: Succinylcholine is the only available depolarizing neuromuscular blocker that has been widely used in the induction of anesthesia, and it is the drug of choice for rapid-sequence induction of anesthesia due to its rapid onset of effect and ultrashort duration of action owing to its rapid hydrolysis by acetyl-cholinesterase. Postoperative muscle pain (myalgia) and muscle stiffness are the most common side effects and are observed most frequently on the 1st postoperative day in ambulatory surgery. The use of succinylcholine in the induction of anesthesia and intubation in routine cases has been discouraged because of such adverse effects. However, because of its cost-effectiveness and easy availability, it is still used by some institutions routinely. This study aimed to study the efficacy of preoperative diclofenac along with atracurium precurarization in alleviating succinylcholine-induced myalgia. Materials and Methods: It is a double-blind randomized comparative study carried out in a tertiary care hospital. The study sample was 60 and divided into two equal groups. All data entered in MS-Excel Sheet and Wilcoxon signed-rank test were done for nonparametric data and one-way ANOVA for the parametric data. The normal distribution of the study sample was tested by the Shapiro - Wilk test. Results: The fasciculations in the test group were much less than in the control group with P < 0.00001. The results for the incidence of myalgia in the two groups were as follows: P value at 24 h was 0.00018 and at 48 h was 0.0028, respectively. Creatine kinase levels at preoperative and 24 h postoperative periods were 49.47 ± 7.24 in Group D, 53.30 ± 7.98 in Group B and 87.38 ± 15.16 in Group D, and 188.41 ± 33.27 in Group B, respectively. Conclusion: Succinylcholine-induced myalgia has a complex pathophysiology. However, the preemptive use of diclofenac in combination with precurarization can alleviate the incidence and severity of succinylcholine-induced myalgia. Therefore, its use may be considered in routine cases for induction of anesthesia for facilitating laryngoscopy and endotracheal intubation.

Effects of Epidural Analgesia on Labor Pain and Course of Labor in Primigravid Parturients: A Prospective Non-randomized Comparative Study.

BACKGROUND AND AIM:  The aim of this study was to compare the effects of epidural analgesia on relief of labor pain, progress, and outcome of labor in primigravid parturients to those who did not receive any analgesia. METHODS: This was a hospital-based, quasi-experimental study conducted on 70 primigravid parturients at term with a single fetus in a cephalic presentation in active labor. Parturients who were willing to receive epidural analgesia formed group S (n=35) and parturients who refused epidural analgesia formed group C (n=35). The primary objective was to compare alleviation of pain measured by the Visual Analogue Scale (VAS) score. Secondary objectives were to compare the duration of labor, mode of delivery, and neonatal outcome. RESULTS: Pain intensity was significantly lower in group S compared to group C at all measured points of time (p<0.001). There was a quick fall in mean VAS score in group S from 7.94 to 3.86 within 20 min with the bolus dose, it further dropped to 1.03 after 3 h. Further, 88.6% of parturients in groups rated their pain relief as excellent and good satisfaction score. Prolongation of active phase of the first stage of labor (>6 h) was not significant (17.1 % in epidural group versus 5.7% in control group; p=0.259). However, prolongation of the second stage of labor (> 2h) was significant (18.2% in study group versus 0% in control group; p=0.024). The rate of cesarean section, instrumental vaginal delivery, and neonatal outcome was similar in both groups. No adverse effects were observed on maternal vitals, fetal heart rate and Apgar score at 5 min. CONCLUSION:  Epidural analgesia alleviated labor pain in all primigravid parturients who opted for it, without an increase in cesarean section and instrumental vaginal birth. Improved parturients' satisfaction with associated neonatal safety provides a positive birth experience. There was no effect on duration of active phase of the first stage of labor, but the duration of the second stage of labor was slightly prolonged.

Morphine-Induced Fever: A Case Series.

The most common cause of postoperative fever is infection. Other causes include cancer, iatrogenic causes, venous thromboembolism, secondary to prosthetic implants, and pyrexia of unknown origin. Here, we describe five cases of opioid-induced pyrexia. In all cases, an injection of morphine was given for postoperative analgesia and all those patients developed fever. All the possible causes of fever were excluded and then opioid was substituted with non-steroidal anti-inflammatory agents. Fever subsided in all the cases. Cessation of the offending drug led to the resolution of the fever in all five cases, and the patient required subsequent supportive care. However, adjunctive pharmacotherapy may also be needed in some patients.

Better Anesthesia Technique: A Case Series of Cochlear Implants.

Cochlear implants are expensive surgeries. It was expected that by the end of the year 2021 about 80,000 cochlear implants will be shipped worldwide. Alone in India 500 cochlear implants are placed in a year. Patients for these procedures are mostly young children with prelingual deafness. They often pose challenges like anxiety, post operative nausea and vomiting, haemorrhage and CSF leak or flap necrosis. Parent child separation is another concern in a deaf paediatric patient. A meticulous anaesthetic management provides comfortable induction and a stable intra operative hemodynamics to give favourable outcomes.

A Randomized Comparative Study on Median and Paramedian Approaches for Subarachnoid Block using Sprotte Needle in the Cesarean Section: Quest for the Best.

Background: Since 1898 when August Bier, introduced spinal analgesia, there is lot of advancement made in the technique. There are various approaches and techniques for subarachnoid block. Aim: The aim of this study is to compare median and paramedian approach for spinal anesthesia for cesarean delivery using Sprotte needle in terms of number of attempts, success rate, adverse effects, and complications. Materials and Methods: One hundred patients were randomly divided into two equal groups and underwent subarachnoid block in median and paramedical block for elective cesarean section. Results: There is no significant difference between the two groups. Mean with standard deviation in the number of attempts for subarachnoid block through media and paramedian approach is 1.18 ± 0.48 and 1.06 ± 0.24, respectively (P = 0.51). The incidence of postdural puncture headache (PDPH) and lower backache was insignificant in both the groups (P = 0.218 and 0.646, respectively). Conclusions: Paramedian approach should not be considered as a reserve technique for spinal anesthesia and can be used as popularly as the median approach.

Inadvertent migration of guidewire into Murphy's eye of endotracheal tube during percutaneous dilatational tracheostomy.

Percutaneous dilatational tracheostomy is a commonly performed bedside procedure in the Intensive Care Unit. Although serious and fatal complications have been reported, the procedure is by and large safe to perform in experienced hands. We report here an innocuous problem encountered twice. After the guidewire insertion and dilatation, subsequent railroading became difficult owing to migration of guidewire into the Murphy's eye of the endotracheal tube (ETT). Awareness about this possibility can avert inadvertent delays and complications during the procedure. A tug or gentle pulling of ETT after insertion of the guidewire rules out an impaction in the eye or other part of the ETT.

Helical TomoTherapy versus sterotactic Gamma Knife radiosurgery in the treatment of single and multiple brain tumors: a dosimetric comparison.

The objective was to compare the dosimetry of Helical TomoTherapy (TOMO) and Gamma Knife (GK) treatment plans for tumor and normal brain in the treatment of single and multiple brain tumors. An anthropomorphic Rando Head phantom was used to compare the dosimetry of TOMO and GK. Eight brain tumors of various shapes, sizes and locations were used to generate 10 plans. The radiation dose was 20 Gy prescribed to the 100% isodose line for TOMO plans and to the 50% for the GK plans. Dose Volume Histograms for tumor and brain were compared. Equivalent Uniform Dose (gEUD), Tumor Control Probability (TCP) and Normal Tissue Complication Probability (NTCP) were performed and used for plan comparisons. Average minimum, mean, median and maximum tumor doses were 19.93, 27.83, 27.38, 39.60 Gy for GK and 20.17, 20.60, 20.59, 20.90 Gy for TOMO. Average gEUD values for tumor and normal brain were 25.0 and 7.2 Gy for GK and 20.7 and 8.1 Gy for TOMO. Conformity indices (CI) were similar for both modalities. Gradient indices (GI) were greater for TOMO. A combination plan was also generated using all eight tumors. TOMO was able to target all eight tumors simultaneously resulting in mean tumor and brain doses of 20.5 and 9.35 Gy, respectively. Due to the maximum limit of 50 beams per plan, GK was unable to provide a treatment plan for all eight tumors. GK provides an advantage for all tumor sizes with respect to tumor and normal brain dose. Clinical studies are needed to correlate these dosimetric findings with patient outcomes.

The impact of age on long-term outcome in patients with endometrial cancer treated with postoperative radiation.

PURPOSE: Endometrial cancer is the most commonly diagnosed gynecologic malignancy in the United States. Age has been associated with worse outcome in univariate analysis. However, the patterns of failure and associated risk factors in older patients remain unclear. We reviewed our institution's experience to assess the effect of age in a population of endometrial cancer patients treated with surgery and adjuvant radiation therapy. METHODS: From 1992-2002, 243 endometrial cancer patients underwent a total abdominal hysterectomy and adjuvant radiation. Forty-nine patients with stage I-II (occult) endometrial adenocarcinoma (no clear cell or serous papillary) were treated postoperatively with vaginal intracavitary high-dose rate (HDR) brachytherapy alone using Iridium-192 (median dose 30 Gy) to a median length of 4 cm. Forty-eight patients with stage I-III endometrial adenocarcinoma (no clear cell or papillary serous) were treated with postoperative pelvic RT (median dose 45 Gy) and intracavitary HDR brachytherapy (median dose 20 Gy). One hundred forty-six patients underwent postoperative whole abdomino-pelvic irradiation (WAPI) secondary to unfavorable histology (clear cell or serous papillary) or two of the following: deep myometrial invasion, grade 3, or FIGO stage III. Age was analyzed as a continuous and a categorical variable. The age of 63 year split the age group using various statistical analyses. RESULTS: Median follow-up of all patients was 4.2 years. Patients grouped by age of < or =63 years or older had similar FIGO stage (P = 0.5), grade (P = 0.09), treatment modality (P = 0.7), and lymphovascular space invasion (LVSI) (P = 0.6). Twenty-five percent (60/243) of patients developed recurrence. Of these failures, 15% (15/102) were age < or =63 years and 32% (45/141) were age >63 years at diagnosis (P = 0.02). For all patients, the 5-year event-free survival (EFS), cause specific survival (CSS), and overall survival (OS) were 64%, 82%, and 72%, respectively. Five-year EFS for patients age < or =63 years and >63 years was 76% vs. 55% (P < 0.001). Five-year OS for age < or =63 years and >63 years was 85% vs. 63% (P < 0.001). Five-year CSS for age < or =63 years and >63 years was 91% vs. 75% (P = 0.003). Various factors were analyzed to determine an association with age. Older patients with stage III-IVA had significantly more failures than patients less than age 63 (P = 0.002). Older patients (>63 years) were found to have serous papillary histology (28%) more often than younger patients (15%) (P = 0.02). Greater depth of invasion was associated with older age (P = 0.01). On univariate analysis, older age (P = 0.003), LVSI (P = 0.002), FIGO stage (P < 0.001), grade (P < 0.001), and depth of invasion (P = 0.03) predicted for failure. On Cox multivariate analysis, older age (P = 0.006, HR 2.83), higher FIGO stage (P = 0.001, HR 1.96), and higher grade (P = 0.002, HR 2.66) were significant prognostic factors for recurrence. No difference was seen between the two age groups from date of surgery and start of radiation. The duration of therapy was not different between the two groups. CONCLUSIONS: Older endometrial cancer (age >63 years) patients have a significantly decreased overall survival, cause-specific survival, and greater risk of recurrence following postoperative RT independent of other prognostic factors and/or treatment technique. The impact of treatment-related variables did not alter the age-related outcome.

Vaginal brachytherapy alone: an alternative to adjuvant whole pelvis radiation for early stage endometrial cancer.

OBJECTIVE: Postoperative management of early stage adenocarcinoma of the endometrium remains controversial. The use of pelvic radiation therapy as shown by the Gynecologic Oncology Group (GOG)-99 trial improves the event free interval at the cost of increased toxicity. We reviewed and compared our results treating early stage endometrial adenocarcinoma using hypofractionated high dose rate (HDR) vaginal brachytherapy (VB) alone with the results of the GOG-99. METHODS: From 1992 to 2002, 243 endometrial cancer patients were treated with TAH/BSO and selective lymph node dissection followed by adjuvant radiotherapy (RT). Of these, 50 FIGO stage I-II (occult) adenocarcinoma (no clear cell or serous papillary) of the endometrium were managed with HDR hypofractionated VB as monotherapy using Iridium-192 to a dose of 30 Gy in 6 fractions twice weekly prescribed to a depth of 5 mm and median length of 4 cm. The characteristics, toxicity rates, and outcomes of our patients were compared with the results of the GOG-99. The median follow up of our patients and the GOG-99 were 3.2 years and 5.8 years, respectively. RESULTS: Patient characteristics including age, stage, and grade were similar in our study and the GOG-99. The local recurrence rate in our study, the pelvic RT arm of the GOG-99, and the no RT arm of the GOG-99 were 4% (n = 2), 2% (n = 3), and 9% (n = 18), respectively. In our study, one patient failed in the vagina alone and a second patient failed in the vagina and pelvis. In the GOG-99, the vagina as a component of locoregional failure was also the most common failure site in the no RT arm 77.8% (n = 14) and in the RT arm 100% (n = 3). The 2-year cumulative recurrence rate in our study was 2%, which compares favorably with the GOG-99 pelvic RT arm (3%) and observation arm (12%). Four-year survival rates of the no RT arm of the GOG-99, the RT arm of the GOG-99, and our study with HDR VB were 86%, 92%, and 97%, respectively. Chronic grade 2 toxicity rates were reduced by the use of VB compared to pelvic RT, especially GI toxicity 0% vs. 34% (P value < 0.001), and GI obstruction 0% vs. 7% (P value = 0.08). CONCLUSION: Stage I-II (occult) endometrial adenocarcinoma treated with postoperative HDR vaginal brachytherapy has similar overall survival, locoregional failure rates, and cumulative recurrence rates to standard fractionation external beam pelvic RT with the benefit of much lower toxicity rates and shorter overall treatment time.