Risk factors for cerebrospinal fluid shunt infections during an outbreak: a case-control study.

BACKGROUND: There are few published reports of cerebrospinal fluid (CSF) shunt infection outbreaks. In 2017-2018, British Columbia Children's Hospital (BCCH) experienced an increase in CSF shunt infections co-incident with a move to new operating rooms and a change in shunt catheters used. AIMS: To describe how an outbreak was detected, investigations were undertaken to determine the cause, risk factors associated with CSF shunt infection during the outbreak, and changes implemented to attempt to control the outbreak. METHODS: Retrospective case-control study. Population included patients who underwent new shunt insertion or revision. Univariate logistic regression models were fitted for each of the variables. Associations with P-values <0.2 were considered of potential interest for further investigation. FINDINGS: There were six cases of CSF shunt infection and 19 controls. The causative organism was different in each case. The only risk factors that met the criteria for further investigation were being a neonate at the time of surgery [odds ratio (OR) 9.0, 95% confidence interval (CI) 0.7-125.3, P=0.10] and the presence of gastrointestinal disease (OR 3.8, 95% CI 0.5-26.2, P=0.18). No association was found with the operating room used or the surgical staff. In response to the outbreak, human traffic through the operating rooms was limited, rigid adherence to the wearing of surgical masks was enforced, and return to the previous CSF shunt catheters used was implemented. CONCLUSION: No modifiable risk factors were associated with CSF shunt infection. After implementation of surgical protocol changes, no further cases of CSF shunt infection linked to the outbreak were identified.

Active elimination of radio frequency interference for improved signal-to-noise ratio for in-situ NMR experiments in strong magnetic field gradients.

Improvement in the signal-to-noise ratio of Nuclear Magnetic Resonance (NMR) systems may be achieved either by increasing the signal amplitude or by decreasing the noise. The noise has multiple origins - not all of which are strictly "noise": incoherent thermal noise originating in the probe and pre-amplifiers, probe ring down or acoustic noise and coherent externally broadcast radio frequency transmissions. The last cannot always be shielded in open access experiments. In this paper, we show that pulsed, low radio-frequency data communications are a significant source of broadcast interference. We explore two signal processing methods of de-noising short T2∗ NMR experiments corrupted by these communications: Linear Predictive Coding (LPC) and the Discrete Wavelet Transform (DWT). Results are shown for numerical simulations and experiments conducted under controlled conditions with pseudo radio frequency interference. We show that both the LPC and DWT methods have merit.

Nuclear-magnetic-resonance relaxation due to the translational diffusion of fluid confined to quasi-two-dimensional pores.

Nuclear-magnetic-resonance (NMR) relaxation experimentation is an effective technique for nondestructively probing the dynamics of proton-bearing fluids in porous media. The frequency-dependent relaxation rate T_{1}^{-1} can yield a wealth of information on the fluid dynamics within the pore provided data can be fit to a suitable spin diffusion model. A spin diffusion model yields the dipolar correlation function G(t) describing the relative translational motion of pairs of ^{1}H spins which then can be Fourier transformed to yield T_{1}^{-1}. G(t) for spins confined to a quasi-two-dimensional (Q2D) pore of thickness h is determined using theoretical and Monte Carlo techniques. G(t) shows a transition from three- to two-dimensional motion with the transition time proportional to h^{2}. T_{1}^{-1} is found to be independent of frequency over the range 0.01-100 MHz provided h≳5 nm and increases with decreasing frequency and decreasing h for pores of thickness h<3 nm. T_{1}^{-1} increases linearly with the bulk water diffusion correlation time τ_{b} allowing a simple and direct estimate of the bulk water diffusion coefficient from the high-frequency limit of T_{1}^{-1} dispersion measurements in systems where the influence of paramagnetic impurities is negligible. Monte Carlo simulations of hydrated Q2D pores are executed for a range of surface-to-bulk desorption rates for a thin pore. G(t) is found to decorrelate when spins move from the surface to the bulk, display three-dimensional properties at intermediate times, and finally show a bulk-mediated surface diffusion (Lévy) mechanism at longer times. The results may be used to interpret NMR relaxation rates in hydrated porous systems in which the paramagnetic impurity density is negligible.

Explicit calculation of nuclear-magnetic-resonance relaxation rates in small pores to elucidate molecular-scale fluid dynamics.

Nuclear-magnetic-resonance (NMR) spin-lattice (T_{1}^{-1}) and spin-spin (T_{2}^{-1}) relaxation rate measurements can act as effective nondestructive probes of the nanoscale dynamics of ^{1}H spins in porous media. In particular, fast-field-cycling T_{1}^{-1} dispersion measurements contain information on the dynamics of diffusing spins over time scales spanning many orders of magnitude. Previously published experimental T_{1}^{-1} dispersions from a plaster paste, synthetic saponite, mortar, and oil-bearing shale are reanalyzed using a model and associated theory which describe the relaxation rate contributions due to the interaction between spin ensembles in quasi-two-dimensional pores. Application of the model yields physically meaningful diffusion correlation times for all systems. In particular, the surface diffusion correlation time and the surface desorption time take similar values for each system, suggesting that surface mobility and desorption are linked processes. The bulk fluid diffusion correlation time is found to be two to five times the value for the pure liquid at room temperature for each system. Reanalysis of the oil-bearing shale yields diffusion time constants for both the oil and water constituents. The shale is found to be oil wetting and the water T_{1}^{-1} dispersion is found to be associated with aqueous Mn^{2+} paramagnetic impurities in the bulk water. These results escalate the NMR T_{1}^{-1} dispersion measurement technique as the primary probe of molecular-scale dynamics in porous media yielding diffusion parameters and a wealth of information on pore morphology.

Gray free-energy multiphase lattice Boltzmann model with effective transport and wetting properties.

The paper shows that it is possible to combine the free-energy lattice Boltzmann approach to multiphase modeling of fluids involving both liquid and vapor with the partial bounce back lattice Boltzmann approach to modeling effective media. Effective media models are designed to mimic the properties of porous materials with porosity much finer than the scale of the simulation lattice. In the partial bounce-back approach, an effective media parameter or bounce-back fraction controls fluid transport. In the combined model, a wetting potential is additionally introduced that controls the wetting properties of the fluid with respect to interfaces between free space (white nodes), effective media (gray nodes), and solids (black nodes). The use of the wetting potential combined with the bounce-back parameter gives the model the ability to simulate transport and sorption of a wide range of fluid in material systems. Results for phase separation, permeability, contact angle, and wicking in gray media are shown. Sorption is explored in small sections of model multiscale porous systems to demonstrate two-step desorption, sorption hysteresis, and the ink-bottle effect.

Model for the interpretation of nuclear magnetic resonance relaxometry of hydrated porous silicate materials.

Nuclear magnetic resonance (NMR) relaxation experimentation is an effective technique for probing the dynamics of proton spins in porous media, but interpretation requires the application of appropriate spin-diffusion models. Molecular dynamics (MD) simulations of porous silicate-based systems containing a quasi-two-dimensional water-filled pore are presented. The MD simulations suggest that the residency time of the water on the pore surface is in the range 0.03-12 ns, typically 2-5 orders of magnitude less than values determined from fits to experimental NMR measurements using the established surface-layer (SL) diffusion models of Korb and co-workers [Phys. Rev. E 56, 1934 (1997)]. Instead, MD identifies four distinct water layers in a tobermorite-based pore containing surface Ca2+ ions. Three highly structured water layers exist within 1 nm of the surface and the central region of the pore contains a homogeneous region of bulklike water. These regions are referred to as layer 1 and 2 (L1, L2), transition layer (TL), and bulk (B), respectively. Guided by the MD simulations, a two-layer (2L) spin-diffusion NMR relaxation model is proposed comprising two two-dimensional layers of slow- and fast-moving water associated with L2 and layers TL+B, respectively. The 2L model provides an improved fit to NMR relaxation times obtained from cementitious material compared to the SL model, yields diffusion correlation times in the range 18-75 ns and 28-40 ps in good agreement with MD, and resolves the surface residency time discrepancy. The 2L model, coupled with NMR relaxation experimentation, provides a simple yet powerful method of characterizing the dynamical properties of proton-bearing porous silicate-based systems such as porous glasses, cementitious materials, and oil-bearing rocks.

Gamma knife radiosurgery for high grade glial neoplasms: a Canadian experience.

OBJECT: To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating focally recurrent high grade glial neoplasms of World Health Organization (WHO) grade III or IV. METHODS: We conducted a retrospective cohort review of all patients treated with GK for focally recurrent high grade gliomas at our institution between November 2003 and April 2013. Data on age, sex, tumor volume, location and maximal diameter, presenting clinical status, complications and clinical outcome was recorded. RESULTS: A total of 33 patients were identified. Four were lost to follow-up. Average post-GK and overall survival was 20.4 months (range: 3­72) and 63.3 months (range: 10­214) respectively. For WHO grade IV gliomas, the average post-GK and overall survival was 15.8 months (range: 3­77) and 40.1 months (range: 13­148) respectively. Similarily, for WHO grade III gliomas, the average post-GK and overall survival was 34.9 months (range: 6­72) and 136.4 months (range: 22­214) respectively. Twenty-two patients (75.9%) had post-GK edema, with 14 requiring dexamethasone and eight being asymptomatic. Four patients (13.8%) had imaging defined radiation necrosis. CONCLUSIONS: Gamma Knife SRS affords an extension of local tumor control, acceptable morbidity, and potentially prolonged survival, for highly selected patients with focally recurrent high grade glial neoplasms.Radiochirurgie par scalpel gamma pour les néoplasies gliales de haut grade de malignité : une expérience canadienne.

Nuclear magnetic resonance relaxometry of water in two and quasi-two dimensions.

Molecular dynamics (MD) and Monte Carlo (MC) methods are used to determine the spin-pair correlation function G(*)(t) for the diffusion of bulk water in three dimensions (3D) and pore water in two dimensions (2D) and quasi-two dimensions (Q2D). The correlation function is required for the determination of the nuclear magnetic resonance spin-lattice and spin-spin relaxation times T(1) and T(2). It is shown that the analytic form of the powder-average correlation function, introduced by Sholl [Sholl, J. Phys. C: Solid State Phys. 7, 3378 (1974)] for the diffusion of spins on a 3D lattice, is of general validity. An analytic expression for G(*)(t) for a uniform spin fluid is derived in 2D. An analytic expression for the long-time behavior of G(*)(t) is derived for spins diffusing on 3D, 2D, and Q2D lattices. An analytic correction term, which accounts for spin pairs outside the scope of the numerical simulations, is derived for 3D and 2D and shown to improve the accuracy of the simulations. The contributions to T(1) due to translational and rotational motion obtained from the MD simulation of bulk water at 300 K are 7.4 s and 10±1 s, respectively, at 150 MHz, leading to an overall time of 4.3±0.4 s compared to the experimental value of 3.8 s. In Q2D systems, in which water is confined by alpha-quartz surfaces to thicknesses of 1-5 nm, T(1) for both translational and rotational relaxation is reduced due to the orientation and adsorption of spins at the surfaces. A method of parametrizing the MC lattice-diffusion simulations in 3D, 2D, and Q2D systems is presented. MC results for G(*)(t) for 3D and 2D systems are found to be consistent with an analytic uniform fluid model for t~/>40 ps. The value of TT(1) for translational diffusion obtained from the MC simulation of bulk water is found to be 4.8 s at 15 MHz. G(*)(t) obtained from MC simulations of Q2D systems, where water is confined by hard walls, is found to execute a distinct transition from 3D to 2D behavior. The T(1) is found to be similar to the 3D bulk water result at all pore thicknesses.

Gamma knife in the treatment of pituitary adenomas: results of a single center.

INTRODUCTION: Gamma Knife (GK) radiosurgery for pituitary adenomas can offer a means of tumor and biologic control with acceptable risk and low complication rates. METHODS: Retrospective review of all the patients treated at our center with GK for pituitary adenomas from Nov 2003 to June 2011. RESULTS: We treated a total of 86 patients. Ten were lost to follow-up. Mean follow was 32.8 months. There were 21 (24.4%) growth hormone secreting adenomas (GH), 8 (9.3%) prolactinomas (PRL), 8 (9.3%) adrenocorticotropic hormone secreting (ACTH) adenomas, 2 (2.3%) follicle stimulating hormone/luteinizing hormone secreting (FSH/LH) adenomas, and 47 (54.7%) null cell pituitary adenomas that were treated. Average maximum tumor diameter and volume was 2.21cm and 5.41cm³, respectively. The average dose to the 50% isodose line was 14.2 Gy and 23.6 Gy for secreting and non-secreting adenomas respectively. Mean maximal optic nerve dose was 8.87 Gy. Local control rate was 75 of 76 (98.7%), for those with followup. Thirty-three (43.4%) patients experienced arrest of tumor growth, while 42 (55.2%) patients experienced tumor regression. Of the 39 patients with secreting pituitary tumors, 6 were lost to follow-up. Improved endocrine status occurred in 16 (50.0%), while 14 (43.8%) demonstrated stability of hormone status on continued pre-operative medical management. Permanent complications included: panhypopituitarism (4), hypothyroidism (4), hypocortisolemia (1), diabetes insipidus (1), apoplexy (1), visual field defect (2), and diplopia (1). CONCLUSIONS: Gamma Knife radiosurgery is a safe and effective means of achieving tumor growth control and endocrine remission/stability in pituitary adenomas.

Gamma knife radiosurgery for large vestibular schwannomas: a Canadian experience.

OBJECT: To review our institutional experience with Gamma Knife (GK) stereotactic radiosurgery in treating large vestibular schwannomas (VS) of 3 to 4 cm diameter. METHODS: We conducted a retrospective cohort review of all patients treated with GK for VS at our institution between November 2003 and March 2012. Data on age, sex, VS volume, location and maximal diameter, House-Brackmann (HB) facial nerve scores pre and post-GK, Gardner-Robertson (GR) hearing score pre and post-GK, GK treatment parameters, VS response time, complications and clinical outcome was recorded RESULTS: A total of 28 patients during the defined time period were identified. Three patients were lost to follow-up. Mean follow-up was 34.5 months. Tumor control occurred in 92%, and was maintained in 85.7% at two years. Facial nerve or hearing preservation occurred in all treated compared to pre-GK status, as per HB and GR grading. Transient complications occurred in 80%. Temporary vestibular dysfunction occurred in seven patients (28%). One patient (4%) had the permanent complication of worsening pre-GK hemifacial spasm. Four patients (16%) developed hydrocephalus post-GK. CONCLUSION: GK stereotactic radiosurgery as a primary treatment modality for large VS can provide acceptable tumor control rates with good facial nerve and hearing preservation, and low complication rates.

Low faecal haemoglobin concentration potentially rules out significant colorectal disease.

AIM: The study aimed to determine whether faecal haemoglobin (Hb) concentration can assist in deciding who with lower abdominal symptoms will benefit from endoscopy. METHOD: Faecal Hb concentrations were measured on single samples from 280 patients referred for lower gastrointestinal tract endoscopy from primary care in NHS Tayside who completed a faecal immunochemical test (FIT) for Hb and underwent subsequent endoscopy. RESULTS: Among 739 invited patients, FIT and endoscopy were completed by 280 (median age 63 (18-84) years; 59.6% women), with a median time between FIT and endoscopy of 9 days. Six (2.1%) participants had cancer, 23 (8.2%) had high-risk adenoma (HRA) (more than three adenomas or any > 1 cm), 31 (11.1%) low-risk adenoma (LRA) and 26 (9.3%) inflammatory bowel disease (IBD) as the most serious diagnosis. Those with cancer had a median faecal Hb of > 1000 ng Hb/ml buffer. Those with cancer + HRA + IBD had a median faecal Hb concentration of 75 ng Hb/ml buffer (95% CI 18-204), which was significantly higher than that of all remaining participants without significant colorectal disease (P < 0.0001). Using a cut-off faecal Hb concentration of 50 ng Hb/ml buffer, negative predictive values of 100.0%, 94.4%, 93.4% and 93.9% were found for cancer, HRA, LRA and IBD. Patients with reasons for referral other than rectal bleeding and family history did not have high faecal Hb concentrations. CONCLUSION: Faecal Hb concentration measurements have considerable potential to contribute to reducing unnecessary endoscopy for the majority of symptomatic patients.

Gamma Knife radiosurgery of cavernous sinus meningiomas: an institutional review.

INTRODUCTION: Stereotactic radiosurgery offers a unique and effective means of controlling cavernous sinus meningiomas with a low rate of complications. METHODS: We retrospectively reviewed all cavernous sinus meningiomas treated with Gamma Knife (GK) radiosurgery between November 2003 and April 2011 at our institution. RESULTS: Thirty patients were treated, four were lost to follow- up. Presenting symptoms included: headache (9), trigeminal nerve dysesthesias/paresthesias (13), abducens nerve palsy (11), oculomotor nerve palsy (8), Horner's syndrome (2), blurred vision (9), and relative afferent pupillary defect (1). One patient was asymptomatic with documented tumor growth. Treatment planning consisted of MRI and CT in 17 of 30 patients (56.7%), the remainder were planned with MRI alone (44.3%). There were 8 males (26.7%) and 22 females (73.3%). Twelve patients had previous surgical debulking prior to radiosurgery. Average diameter and volume at time of radiosurgery was 3.4 cm and 7.9 cm3 respectively. Average dose at the 50% isodose line was 13.5 Gy. Follow-up was available in 26 patients. Average follow-up was 36.1 months. Mean age 55.1 years. Tumor size post GK decreased in 9 patients (34.6%), remained stable in 15 patients (57.7%), and continued to grow in 2 (7.7%). Minor transient complications occurred in 12 patients, all resolving. Serious permanent complications occurred in 5 patients: new onset trigeminal neuropathic pain (2), frame related occipital neuralgia (1), worsening of pre-GK seizures (1), and panhypopituitarism (1). CONCLUSION: GK offers an effective treatment method for halting meningioma progression in the cavernous sinus, with an acceptable permanent complication rate.

A transportable magnetic resonance imaging system for in situ measurements of living trees: the Tree Hugger.

This paper presents the design of the 'Tree Hugger', an open access, transportable, 1.1 MHz (1)H nuclear magnetic resonance imaging system for the in situ analysis of living trees in the forest. A unique construction employing NdFeB blocks embedded in a reinforced carbon fibre frame is used to achieve access up to 210 mm and to allow the magnet to be transported. The magnet weighs 55 kg. The feasibility of imaging living trees in situ using the 'Tree Hugger' is demonstrated. Correlations are drawn between NMR/MRI measurements and other indicators such as relative humidity, soil moisture and net solar radiation.

Gamma knife for cerebral arteriovenous malformations at a single centre.

BACKGROUND: We report the results of a consecutive series of patients treated with Gamma Knife (GK) Surgery for cerebral arteriovenous malformations (AVMs). METHODS: We retrospectively reviewed 69 patients treated with GK for cerebral AVMs between November 2003 and April 2009, recording clinical data, treatment parameters, and AVM obliteration rates in order to assess our effectiveness with GK in treating these lesions. RESULTS: Ten patients were lost to follow-up. Presentations included: seizure (24), hemorrhage (18), persistent headache (12), progressing neurological signs (10), and incidental (9). In 24 patients (34.8%) treatment planning consisted of digital subtraction angiography (DSA), magnetic resonance imaging (MRI), and computed tomogram (CT) angiography (CTA). Currently we rely predominantly on CTA and/or MRI scanning only. Fourty-one patients have been followed for a minimum of 3 years; average age 40.9 yr., 58.5% males. Average dose at the 50% isodose line was 20.3 Gy (range 16 to 26.4 Gy). Obliteration was observed in 87.8% by MRI, CT, or DSA. Not all obliteration was confirmed by DSA. Complications occurred in 12 of 59 (20.3%) patients, and in 11 of 41 (26.8%) with 3 year follow-up. Major (temporary) complications for the 59 included symptomatic cerebral edema (7), seizure (2), and hemorrhage (1). Major permanent complications occurred in one patient suffering a cranial nerve V deafferentation, and in two patients suffering a hemorrhage. CONCLUSION: GKS for cerebral AVM's offers an effective and safe method of treatment, with low permanent complication rate.

Experience with a wipe guaiac-based faecal occult blood test as an alternative test in a bowel screening programme.

The format of the traditional guaiac faecal occult blood test (gFOBT), particularly the collection technique, might cause difficulties for some. A multistage evaluation of alternative tests was performed. Firstly, four tests with different faecal collection approaches were assessed: a focus group recommended further investigation of a wipe gFOBT. Secondly, 100 faecal samples were analysed using two wipe tests and the routine gFOBT: no differences were found. Thirdly, a wipe gFOBT was introduced. Over 21 months, 400 requests were made and 311 wipe kit sets were submitted for analysis: 153 (49.2%) were negative, 21 (6.8%) positive (all 3 kits positive), 96 (30.9%) weak positive (1 or 2 positive) and 41 (13.2%) un-testable. Forty-three participants were referred for colonoscopy. Outcome data were provided on 39 participants: nine declined colonoscopy, two were judged unsuitable, two did not attend, two were already in follow-up, 13 had normal colonoscopy and two normal barium enema, two had diverticular disease, two had a metaplastic polyp, four had a low-risk adenoma and one had a high-risk adenoma. No participant had cancer. Detection of significant neoplasia was small. The use of the wipe gFOBT was ceased: it cannot be recommended as a screening test for bowel cancer.

Hypoxia-inducible factor-1alpha and -2alpha are expressed in most rectal cancers but only hypoxia-inducible factor-1alpha is associated with prognosis.

The hypoxia-mediated response of tumours is a major determining factor in growth and metastasis. Understanding tumour biology under hypoxic conditions is crucial for the development of antiangiogenic therapy. Using one of the largest cohorts of rectal adenocarcinomas to date, this study investigated hypoxia-inducible factor-1alpha (HIF-1alpha) and HIF-2alpha protein expression in relation to rectal cancer recurrence and cancer-specific survival. Patients (n=90) who had undergone surgery for rectal adenocarcinoma, with no prior neoadjuvant therapy or metastatic disease, and for whom adequate follow-up data were available were selected. Microvessel density (MVD), HIF-1alpha and HIF-2alpha expressions were assessed immunohistologically with the CD34 antibody for vessel identification and the NB100-131B and NB100-132D3 antibodies for HIF-1alpha and HIF-2alpha, respectively. In a multifactorial analysis, results were correlated with tumour stage, recurrence rate and long-term survival. Microvessel density was higher across T and N stages (P<0.001) and associated with poor survival (hazard ratio (HR)=8.7, P<0.005) and decreased disease-free survival (HR=4.7, P<0.005). hypoxia-inducible factor-1alpha and -2alpha were expressed in >50% of rectal cancers (HIF-1alpha, 54%, 48/90; HIF-2alpha, 64%, 58/90). HIF-1alpha positivity was associated with both TNM stage (P<0.05) and vascular invasion (P<0.005). In contrast, no associations were demonstrated [corrected] between HIF-2alpha [corrected] and any pathological features or [corrected] outcome. The study showed an independent association between HIF-1alpha expression and advanced TNM stage with poor outcome. Our results indicate that HIF-1alpha, but not HIF-2alpha, might be used as a marker of prognosis, in addition to methods currently used, to enhance patient management.

Assessment of microvessel density and carbonic anhydrase-9 (CA-9) expression in rectal cancer.

AIM: The mechanism by which neoplasias respond to hypoxia determines their biological behavior and prognosis. Understanding the biology of tumors under hypoxic conditions is crucial for the development of anti-angiogenic therapy. Using the largest cohort of rectal adenocarcinomas to date, this study aimed to assess microvessel density (MVD) and carbonic anhydrase-9 (CA-9) expression and to correlate the results with recurrence and cancer-specific survival. MATERIALS AND METHODS: Patients (n=101) who underwent surgery for rectal adenocarcinoma without previous neoadjuvant therapy or metastatic disease were selected. MVD and CA-9 expression were assessed immunohistologically by using the CD34 antibody and the MN/CA9 M75 antibody, respectively. In a multifactorial analysis, the results were correlated with tumor stage, recurrence rate, and long-term survival. RESULTS: MVD was higher with increased T- and N-stages (p<0.01) and associated positively with poor survival (hazard ratio (HR) 1.3 per 10 vessel increase, p<0.01). CA-9 was expressed in 73% of cancers. Negative lymph node status correlated with CA-9 positivity (p<0.05), reflected in a higher rate of CA-9 positivity in earlier Dukes' stages (p<0.05). CA-9 positivity across tumor node metastasis (TNM) stages approached significance (Stage I/II: 80% CA-9 positive vs. 20% CA-9 negative; Stage III: 63% CA-9 positive vs. 37% negative, p=0.051). A trend was seen towards better cancer-specific survival in patients with CA-9 positive carcinomas (HR 0.51, p=0.07) on univariate analysis. DISCUSSION: MVD was higher in more advanced T- and N-stages and may be used as a determinant of survival in patients with rectal adenocarcinomas. CA-9 expression was seen more often in earlier Dukes' stages, possibly representing an early tumor hypoxic response. CA-9 expression by adenocarcinoma cells may confer long-term survival advantage in surgically treated rectal cancer.

Chemo-radiotherapy: an alternative to surgery for squamous cell carcinoma of the rectum--report of six patients and literature review.

PURPOSE: Since 1943 [1], only 45 patients of squamous cancer of the rectum have been reported in the published reports and the largest series to date consists of 12 patients. Reports suggest that the primary treatment is surgical resection but, in the light of nonsurgical advances in the treatment of anal squamous cell carcinoma (SCC), we present a review of the literature and report six patients treated by chemoradiation therapy (CRT). METHOD: A literature search was undertaken using the keywords squamous cell, epidermoid, basaloid and cloacagenic and cancer of rectum and colon to provide evidence for this discussion from studies of surgery, radiation therapy and CRT in rectal SCC. A prospective database of the Mount Vernon Cancer Centre, UK was searched from 1995 to 2005 for patients diagnosed with pure SCC of the rectum. RESULTS: Six patients with histologically confirmed primary SCC of the rectum were treated with primary combination chemo-radiotherapy according to protocols used for SCC of the anal canal over a 15-year period. Surgery was avoided in four, and they remain disease-free on follow-up. CONCLUSIONS: Primary CRT, as currently utilized in anal cancer, can be extended to primary SCC of the rectum.

Can depth of tumour invasion predict lymph node positivity in patients undergoing resection for early rectal cancer? A comparative study between T1 and T2 cancers.

OBJECTIVE: The present study investigated the risk of lymph node metastasis according to the depth of tumour invasion in patients undergoing resection for rectal cancer. METHOD: The histology of patients undergoing oncological resection with regional lymphadenectomy for rectal cancer at St Marks Hospital from 1971 to 1996 was reviewed. Of the total number of 1549 patients, 303 patients with T(1) or T(2) rectal cancers were selected. The tumour type, grade, evidence of vascular invasion, depth of submucosal invasion (classed into 'sm1-3') were evaluated as potential predictors of lymph node positivity using univariate and multi-level logistic regression analysis. RESULTS: Tumour stage was classified as T(1) in 55 (18.2%) and T(2) in 248 (81.2%) patients. The incidence of lymph node metastasis in the T(1) group was 12.7% (7/55), compared to 19% (47/247) in the T(2) group. The node positive and negative groups were similar with regard to patient demographics, although the former contained a significantly higher number of poorly differentiated (P = 0.001) and extramural vascular invasion tumours (P = 0.002). There was no significant difference in the number of patients with sm1-3, or T(2) tumour depths within the lymph node positive and negative groups. On multivariate analysis the presence of extramural vascular invasion (odds ratio = 10.0) and tumour grade (odds ratio for poorly vs well-differentiated = 11.7) were independent predictors of lymph node metastasis. CONCLUSION: Whilst the degree of vascular invasion and poor differentiation of rectal tumours were significant risk factors for lymph node metastasis, depth of submucosal invasion was not. This has important implications for patients with superficial early rectal cancers in whom local excision is being considered.