Watch and wait for Rectal Cancer: A 9 year Experience.

Background: Neoadjuvant long course chemoradiotherapy has become the standard treatment for locally advanced rectal cancer. It can reduce tumour bulk, downstage, reduce the risk of local recurrence, and increase the possibility of clear resection margins. The aim of our study is to evaluate all patients over a 9 year period who underwent neoadjuvant chemoradiotherapy for rectal cancer and entered our watch and wait programme. Methods: Data were analysed from a prospective database for all patients diagnosed with rectal cancer over a 9 year period (2011-2019 inclusive). Findings: Over a 9 year period, 532 patients were treated for rectal cancer, with 180 patients receiving long course chemoradiotherapy. 61 (11%) patients entered a watch and programme as they had a complete clinical and radiological response following chemoradiotherapy. Within this programme, 40 patients (65%) remain disease free over the follow-up period (mean 38 months); 12 (20%) patients had regrowth and proceeded to surgery; and 9 (15%) proceeded to palliation due to being unfit for surgery or had distant metastatic disease. Overall (all cause) mortality was 18% during follow-up period in the watch and wait group. Conclusions: Neoadjuvant long course chemoradiotherapy is the standard treatment for locally advanced rectal cancer. 34% of our patient group who received long course chemoradiotherapy entered a watch and wait programme with the majority avoiding major rectal surgery.

Re-Staging Following Long-Course Chemoradiotherapy For Rectal Cancer: Does It Influence Management?

BACKGROUND: In patients with locally advanced or low rectal cancers, long-course chemoradiotherapy (LCCRT) is recommended prior to surgical management.1 The need for restaging afterwards has been questioned as it may be difficult to interpret imaging due to local tissue effects of chemoradiotherapy. The purpose of this study was to determine if restaging affected the management of patients receiving long-course chemoradiotherapy for rectal cancer. METHODS: A retrospective review of patients with rectal cancer discussed at the South Eastern Health and Social Care Trust Lower Gastrointestinal Multi-Disciplinary Team Meeting (LGIMDT) in 2013 who had received long-course chemoradiotherapy was performed. Patients were identified from the Trust Audit Department, LGIMDT notes and patient records. Imaging results and outcomes from meetings were obtained through the Northern Ireland Picture Archiving and Communications System® (NIPACS) and Electronic Care Record® (ECR). Data including patient demographics, initial radiological staging and LGIMDT discussion, restaging modality and result, outcome from post-treatment LGIMDT discussion and recorded changes in management plans were documented using a proforma. RESULTS: Seventy-one patients with rectal cancer were identified as having LCCRT in 2013 (M:F 36:35; age range 31 - 85 years). Fifty-nine patients were restaged following long-course treatment with computed tomography (CT) and magnetic resonance imaging (MRI). Twelve patients did not undergo restaging. Data was not available for 6 patients, one patient underwent emergency surgery, two patients were not fit for treatment, one failed to attend for restaging and two patients died prior to completion of treatment. Of the 59 patients restaged, 19 patients (32%) had their management plan altered from that which had been proposed at the initial LGIMDT discussion. The most common change in plan was not to operate. Ten patients had a complete clinical and radiological response to treatment and have undergone intensive follow-up. Nine patients had disease progression, with 3 requiring palliative surgery and 6 referred for palliative care. CONCLUSION: Of those patients who were restaged, 32% had their management plan altered from that recorded at the initial LGIMDT discussion. Seventeen per cent of patients in this group had a complete clinical and radiological response to treatment. Fifteen percent demonstrated disease progression. We recommend, therefore, that patients with rectal cancer be restaged with CT and MRI following long-course chemoradiotherapy as surgery may be avoided in up to 27% of cases.

Laparoscopic restorative proctocolectomy with and without previous subtotal colectomy.

INTRODUCTION: Laparoscopic techniques have been applied to the procedure of restorative proctocolectomy (RPC). The aim of this study was to compare the outcomes of patients after laparoscopic ileal pouch-anal anastomosis (IPAA) with restorative proctocolectomy (RPC) and without previous colectomy [restorative proctectomy (RP)] and to highlight some technical tips. METHOD: Data were collected prospectively from all patients who underwent laparoscopic IPAA from July 2006 to December 2007. RESULTS: Thirty-six patients underwent IPAA either with total proctocolectomy (n = 25) or after previous emergency colectomy (n = 11). Postoperative morbidity occurred in 22% of patients. The overall median operative time was 210 (range 120-325), 240 (170-325) and 180 (120-240) min for RPC and RP respectively (P < 0.05). The median length of stay for all patients was 6 (3-26), 6 (4-26) and 4 (3-13) days for RPC and RP respectively (P < 0.05). There was no correlation between BMI, age, use of immunosuppressive agents and length of stay. The operative procedure was facilitated by the use of specific devices at particular stages of the operation. CONCLUSION: Laparoscopic IPAA is not only safe and feasible for the virgin abdomen but also for patients with a previous emergency colectomy through a midline laparotomy incision.

Retinal toxicity of intravitreal tenecteplase in the rabbit.

AIM: To investigate the retinal toxicity of intravitreal injection of a novel fibrinolytic tenecteplase in rabbit eyes. METHODS: Tenecteplase (25-350 micro g in 0.1 ml BSS) was injected into the vitreous cavity of normal rabbit eyes. Control (fellow) eyes received 0.1 ml of BSS. One day, 1 week, and 2 months post-injection, the eyes were examined by slit lamp biomicroscopy, indirect ophthalmoscopy, and electroretinography, and then harvested for histopathological examination. RESULTS: No evidence of retinal toxicity was seen with tenecteplase doses up to and including 50 micro g. At a dose of 150 micro g ophthalmoscopy was normal, but histology showed mild retinal damage in the inner nuclear layer and electroretinography showed a temporary reduction in B-wave amplitude. At doses of 200 micro g and above, there was evidence of retinal toxicity on electroretinography, ophthalmoscopy, and histology. Ophthalmoscopic findings included vitreal fibrosis, retinal necrosis and tractional retinal detachment and light microscopy revealed necrosis of retinal pigment epithelium and other retinal layers. Damage was centred around the injection site but was more widespread with the higher doses. CONCLUSION: A dose of 50 micro g tenecteplase appears safe for intravitreal injection in the rabbit. Tenecteplase could have potential applications in the treatment of submacular haemorrhage and retinal vein occlusion.

Vascular endothelial growth factor levels in serum and plasma following esophageal cancer resection--relationship to platelet count.

In patients with cancer circulating vascular endothelial growth factor (VEGF) may be tumor-derived and have prognostic significance. Activated platelets may also be a source of VEGF, releasing it in serum formation. Debate exists as to whether serum or plasma VEGF (S-VEGF, P-VEGF) is the most appropriate surrogate marker of tumor angiogenesis. As healing wounds produce VEGF that can spill over into the circulation, we aimed to investigate the potential confounding effects of cancer surgery on both perioperative S-VEGF and P-VEGF levels and to evaluate their relationship with platelet count. S-VEGF, P-VEGF and platelet counts were measured in 23 patients undergoing esophageal cancer resection. Samples were taken preoperatively and six weeks following surgery. Seven patients were also sampled on postoperative days 1, 5 and 10. VEGF was assayed using a commercial enzyme linked immunosorbent assay. S-VEGF and P-VEGF both rose after surgery (S-VEGF; day 5: 1017 [446-1224] pg/mL and day 10: 1231 [626-2046] pg/mL versus pre-op: 329 [189-599] pg/mL. P-VEGF; day 1: 55 [46-104] pg/mL and day 10: 58 [20-154] pg/mL versus pre-op: 23 [13-46] pg/mL), falling towards preoperative levels by six weeks. Platelet count correlated with S-VEGF (rho=0.281; p<0.05, Spearman's rank) and P-VEGF (rho=0.330; p<0.01, Spearman's rank). Platelets may contribute to VEGF levels in plasma as well as in serum. The effects of surgery on S-VEGF or P-VEGF levels are mainly transient. Care must be exercised when interpreting circulating VEGF levels in the early postoperative period.

Retinopathy in latent autoimmune diabetes of adults: the Fremantle Diabetes Study.

AIMS: To determine the prevalence of retinopathy and its associations in patients diagnosed clinically with Type 2 diabetes and serum antibodies to glutamic acid decarboxylase (GADA) from a community-based sample. METHODS: In a case-control design, 24 GADA-positive Type 2 patients from the Fremantle Diabetes Study (FDS) cohort were recruited and matched as closely as possible for age, sex and diabetes duration with 72 GADA-negative Type 2 patients from the FDS. Each patient had a detailed clinical and biochemical assessment including slit lamp biomicroscopy and colour fundus photography with Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) grading. RESULTS: The GADA-positive patients had a significantly higher HbA1c (median (interquartile range); 8.4 (7.3, 9.6)%) than those who were GADA-negative (7.2 (6.5, 8.1)%: P = 0.002). The overall prevalence of retinopathy amongst the 96 subjects was 26.0%. The majority (92%) of the retinopathy detected was mild and non-proliferative. GADA-positive patients had double the retinopathy prevalence of the GADA-negative group (41.7% vs. 20.8%; P = 0.044). In a logistic regression model, diabetes duration, HbA1c, systolic blood pressure and current smoking were each significantly and independently predictive of retinopathy (P < 0.025), but GADA status was not. CONCLUSIONS: These data show that GADA-positive patients have an increased prevalence of retinopathy compared with GADA-negative controls with Type 2 diabetes from an urban Australian community. This increased prevalence is due mainly to relatively poor glycaemic control in the GADA-positive group.

Prevalence of tattooing and body piercing in the Australian community.

Tattooing and body piercing are now worldwide fashion crazes. The health risks associated with these procedures are as yet unclear. This article examines the prevalence of body decoration and the associated health risks within the Australian population using a random sample survey of individuals aged 14 years and over, collected between June and September 1998 (n = 10,030). The results show that one in 10 people have had a tattoo at some point in their lives and 8 per cent some form of body piercing, excluding ear piercing. Men are more likely than women to report tattooing, while females are more likely to report body and ear piercing. Some 10 per cent of respondents report drinking alcohol or using other drugs when the procedures were undertaken. The prevalence of tattooing and body piercing is considerably higher among injecting drug users. Although the rates of transmission of bloodborne disease due to body decoration are believed to be low, the strong association with youth and with injecting drug use suggests considerable potential for transmission.

Bowel carcinoma metastatic to the retina.

The case is presented of metastatic carcinoma to the retina in a 63-year-old woman with known disseminated large bowel carcinoma. The clinical appearance and angiographic features are discussed.

Treatment of choroidal melanoma by stereotactic radiosurgery.

The case of a 49-year-old woman with an intermediate-sized choroidal melanoma who was treated with stereotactic radiosurgery with good tumour resolution is presented. Sight and globe preservation were achieved. The treatment technique is discussed.

Telemedicine screening of diabetic retinopathy using a hand-held fundus camera.

The objective was to evaluate digital images of the retina from a handheld fundus camera (Nidek NM-100) for suitability in telemedicine screening of diabetic retinopathy. A handheld fundus camera (Nidek) and a standard fundus camera (Zeiss) were used to photograph 49 eyes from 25 consecutive patients attending our diabetic clinic. One patient had cataracts, making it impossible to get a quality image of one of the eyes (retina). The Nidek images were digitized, compressed, and stored in a Fujix DF-10M digitizer supplied with the camera. The digital images and the photographs were presented separately in a random order to three ophthalmologists. The quality of the images was ranked as good, acceptable or unacceptable for diabetic retinopathy diagnosis. The images were also evaluated for the presence of microaneurysms, blot hemorrhages, exudates, fibrous tissue, previous photocoagulation, and new vessel formation. kappa Values were computed for agreement between the photographs and digital images. Overall agreement between the photographs and digital images was poor (kappa < 0.30). On average, only 24% of the digital images were graded as being good quality and 56% as having an acceptable quality. However, 93% of the photographs were graded as good-quality images for diagnosis. The results indicate that the digital images from the handheld fundus camera may not be suitable for diagnosis of diabetic retinopathy. The images shown on the liquid crystal display (LCD) screen of the camera were of good quality. However, the images produced by the digitizer (Fujix DF-10M) attached to the camera were not as good as the images shown on the LCD screen. A better digitizing system may produce better quality images from the Nidek camera.

Iodine-I25 episcleral plaque therapy in uveal melanoma.

PURPOSE: To assess the efficacy of iodine-125 (I-125) episcleral plaque therapy in the management of uveal melanoma with regard to local control, survival, globe preservation and visual outcome. METHODS: Between January 1985 and January 1997, 50 patients with the diagnosis of uveal melanoma were treated with I-125 episcleral plaques. The mean initial tumour height was 5.5 mm (range, 2.0-9.5 mm) and basal diameter 9.5 mm (range, 4.0-14.5 mm). I-125 seeds with a mean activity of 1259.1 MBq were used. The mean apical dose was 80.5 Gy (range, 68.0-95.0 Gy). Scleral dose ranged from 225.0 to 940.0 Gy. Pretreatment visual acuity was 6/60 or better in 43 patients. RESULTS: One patient was lost to follow up and excluded from analysis. The remaining 49 patients had a mean follow up of 39.5 months. There were seven local failures, with a mean duration to tumour progression of 16.7 months. All seven patients were successfully managed with enucleation. Five other enucleations were performed for treatment-related complications. At the time of analysis, 10 patients have died, five of metastatic melanoma. Of the patients with preserved globes, corrected visual acuity was 6/60 or better in 31 patients. CONCLUSIONS: Good local tumour control and survival can be achieved with episcleral plaque therapy. Globe preservation with useful vision was possible in the majority of cases. Our findings are in keeping with other reported series.

Laser-induced chorioretinal venous anastomosis for non-ischaemic hemi-central vein occlusion.

PURPOSE: To assess the effectiveness and complications of laser-induced chorioretinal venous anastomosis performed on eyes with non-ischaemic hemi-central retinal vein occlusions (hemi-CRVO). METHODS: Fourteen eyes with a hemi-CRVO which reduced the visual acuity to 6/24 or less were treated with argon laser photocoagulation in an attempt to create a chorioretinal venous anastomosis between a retinal vein and the choroidal circulation. RESULTS: Laser anastomoses were successfully created in six eyes (43%) and required a mean of 1.8 attempts in each eye. Of the eyes that developed an anastomosis, four had significant visual improvement. The distal retinal venous segment closed off in five eyes and these had prophylactic segmental argon pan-retinal photocoagulation performed. Two eyes had localized fibrovascular proliferation. No permanent vision-threatening complications were observed in any of the 14 eyes over the follow-up period. CONCLUSIONS: Successful anastomosis between the retinal and choroidal circulation in eyes with hemi-vein occlusions may reduce macular oedema and improve vision. Complications of the technique are significant and a randomized clinical trial is due to commence which may clarify the suitability of this treatment.

Laser-induced chorioretinal venous anastomosis for nonischemic central retinal vein occlusion: evaluation of the complications and their risk factors.

PURPOSE: To evaluate the complications of laser-induced chorioretinal venous anastomosis in nonischemic central retinal vein occlusion (CRVO) and to identify the associated risks. METHODS: A retrospective consecutive series of 91 eyes (91 patients) with nonischemic CRVO with a mean +/- SD duration of 15.0 +/- 15.2 weeks (range, 3 to 72 weeks )and corrected visual acuity reduced to 20/100 or less because of perfused macular edema were reviewed. All eyes had one or more anastomotic attempts using argon laser (combined with Nd-YAG laser in 46 eyes) and a minimum of 12 months of follow-up. RESULTS: Successful chorioretinal venous anastomoses were created in 49 eyes (54%). Eighteen eyes (20%) had neovascular complications. These consisted of intravitreal, intraretinal, and subretinal neovascular membranes and were significantly associated with retinal ischemia (P < .001). There was avascular fibrous tissue proliferation at the anastomotic site in eight eyes (9%), and it was not associated with retinal ischemia (P = .727). No eye developed further capillary nonperfusion once an anastomosis became functional. A chorioretinal venous anastomosis was associated with improved vision (P < .001); 84% of eyes had an average +/- SD improvement of 4.3 +/- 3.8 lines (range, 2 to 20 lines), with the remaining 16% having no improvement or reduced vision. CONCLUSION: The major vision-threatening complication of laser-induced chorioretinal venous anastomosis for nonischemic CRVO is neovascular membranes occurring at the anastomotic site; these are associated with retinal ischemia. Prompt laser photocoagulation to areas of retinal ischemia that develop after the anastomotic attempt has been made may reduce the risk and severity of this complication.

Non-mydriatic fundus photography: a viable alternative to fundoscopy for identification of diabetic retinopathy in an Aboriginal population in rural Western Australia?

PURPOSE: To evaluate the Canon CR5-45NM non-mydriatic fundus camera (Canon, Kanagawa, Japan) for identifying retinopathy and the need for laser treatment in a population of Aboriginal patients with diabetes mellitus in rural Western Australia. METHODS: Diabetic Aboriginal patients were photographed through undilated pupils using a Canon CR5-45NM non-mydriatic fundus camera, after which ophthalmoscopy was performed using indirect ophthalmoscopy through dilated pupils. The examining ophthalmologist recorded the presence of retinopathy and the need for laser treatment. A proportion of patients were rephotographed through dilated pupils. Photographs were reviewed by a second ophthalmologist who evaluated the quality of the image, the presence of retinopathy and the need for laser treatment. Results of fundus photographs and ophthalmoscopy were compared. RESULTS: Three hundred and twenty-eight eyes in 164 Aboriginal patients were examined. The mean patient age was 48.2 years (range 16-81 years) and the mean duration of diabetes was 7.5 years (range 1-35 years). Seventy-four eyes (22.6%) were diagnosed with retinopathy using combined examination techniques, 44 (59.5%) of which were identified by ophthalmoscopy and 55 (74.3%) by photography. Thirty-five eyes were deemed to need treatment, 18 (51.4%) of which were identified by ophthalmoscopy and 30 (85.7%) by photography. Kappa coefficient measurement for agreement for presence of retinopathy and need for referral was 0.41 and 0.53, respectively. Photograph quality was significantly improved following pupil dilation. CONCLUSIONS: The Canon CR5-45NM non-mydriatic fundus camera was relatively good at identifying diabetic retinopathy and could usefully be applied within a screening programme for treatable disease within this population.

Chorioretinal venous anastomoses: effect of different laser methods and energy in human eyes without vein occlusion.

BACKGROUND: This study was performed to determine the laser energy required to rupture both Bruch's membrane and retinal veins reliably in order to create a venous chorioretinal anastomosis. METHODS: A histological examination was conducted of argon green and YAG laser applications to the retina made prior to enucleation in eight eyes with large intraocular melanomas. RESULTS: Argon laser application of 50 microns in size and 0.1 s duration to intervascular areas of the retina will reliably rupture Bruch's membrane at a power level of at least 1.5 W. If the argon laser spot is placed overlying a retinal vein, a power level of up to 2.5-3.0 W will rupture Bruch's membrane in 60%, with only 34% of the retinal veins showing evidence of rupture. The YAG laser with power levels of 3-4 mJ will reliably rupture the retinal vein in cases where it has not previously been ruptured by the argon laser. CONCLUSION: When attempting to create a chorioretinal venous anastomosis in an eye with a non-ischaemic central retinal vein occlusion, Bruch's membrane should be ruptured first by placing the argon laser application at the side of the retinal vein before an attempt to rupture the retinal vein itself is made in case haemorrhage from the ruptured vein obscures the view. A power level of at least 2.5 W should be used. If the argon laser is unsuccessful in rupturing the retinal vein, a YAG laser (3-4 mJ) is effective.