Contact radiotherapy boost in association with 'watch and wait' for rectal cancer: initial experience and outcomes from a shared programme between a district general hospital network and a regional oncology centre.

AIM: Recent data have highlighted the potential of more intensive neoadjuvant protocols to increase and sustain the rate of complete response in rectal cancer managed nonoperatively. This study aimed to review the outcome of all patients from our district general hospitals network who had received standard neoadjuvant therapy and were additionally referred to a centre of excellence for contact X-ray brachytherapy or high-dose-rate brachytherapy boost. METHOD: A retrospective, chart-based review of all patients co-managed in this manner was performed. Patient details were retrieved from a prospectively maintained departmental database. Indications for treatment, patient outcome and serial data from follow-up clinical and radiological assessment were analysed. RESULTS: Seventeen patients treated over a 6-year period were identified. Median follow-up was 20 (5-54) months. Fourteen patients were clinically staged as T2 or T3 and eight were clinically node positive. Three patients died, of whom only one was initially a surgical candidate but refused an exenteration. Of the 14 patients who remain alive, 11 (79%) have a sustained complete (n = 8) or partial (n = 3) response. Two patients had an incomplete response, one is being palliated and the other awaits salvage surgery. One patient underwent abdominoperineal excision for suspected local recurrence. Currently 13 (93%) surviving patients are stoma free. CONCLUSIONS: This series shows that the addition of a radiotherapy boost offered sustained responses and stoma-free survival even in advanced disease and adverse patient populations whilst providing the majority of care closer to home.

The changing use of palliative chemotherapy for recurrent esophagogastric cancer: a single center retrospective 15-year review.

BACKGROUND: Palliative chemotherapy is often recommended in the treatment of recurrent esophagogastric (EG) cancer with limited evidence of its benefit. This study aims to define the current practice and benefit of this treatment. METHODS: Retrospective analysis of patients who developed EG cancer recurrence between 1991 and 2006 following surgery with curative intent. RESULTS: There were 336 recurrences. Median time to disease recurrence was 13.4 months (range 1.3-118). Survival after recurrence ranged from 0-93.2 months (six patients are currently alive). A significant increase in the use of chemotherapy was observed rising from 10% prior to 1999 (n = 100) to 23% (n = 236) after 1999. The median survival for patients receiving chemotherapy (n = 64) was 10.6 months (range 1.5-75.7), patients undergoing nonchemotherapy palliative intervention (n = 142) median survival was 2.85 months (range 0-93.2), and for patients having no active intervention (n = 130), median survival was 1.3 months (range 0-16.2). Median duration of chemotherapy was 3.1 months (range 0.5-9.2). Median survival for these patients after chemotherapy treatment was 6.6 months (range 0.4-73.5). Twenty-eight patients (44%) experienced side effects of chemotherapy. Ten cases required treatment to be modified or stopped and two patients died during chemotherapy. CONCLUSION: There has been a significant increase in the use of palliative chemotherapy for recurrent EG cancer. While survival appears improved, a substantial proportion of this time was spent receiving chemotherapy with many patients experiencing significant comorbidity. Further studies assessing both quality and quantity of life are required to fully evaluate the use of palliative chemotherapy and to identify patients most likely to benefit.

Gastrointestinal transit in the common brushtail possum measured by gamma scintigraphy.

This paper reports an example of the application of pharmaceutical technology to wildlife management, specifically the design of an oral delivery system for the common brushtail possum in New Zealand. Designing an oral delivery system requires a knowledge of the time taken for particulates to reach target sites within the gastrointestinal tract (GIT). The transit time for fluid and indigestible particles of two different size ranges was determined in the common brushtail possum (Trichosurus vulpecula). Technetium-labelled (99mTc) anion exchange resin particles (75-125 or 500-700 microm diameter) or solution (99mTc-labelled diethylenetriamine pentaacetic acid, 99mTc-DTPA) was administered orally. At predetermined times after dosing (3, 6, 12, 24 or 32 h), the distribution of radioactivity throughout excised gastrointestinal tracts was determined by gamma scintigraphy. The transit profile was similar for the three formulations investigated. Unlike other closely related hindgut fermenting marsupials, there was no evidence to support the presence of a colonic separating mechanism in the common brushtail possum. Gastrointestinal transit was independent of body mass, gender and time of day that the dose is given. To target the hindgut for oral delivery of protein and peptide biocontrol agents, the formulation would need to protect the bioactive for approximately 12 h prior to release.

Amyloid deposition in basal cell carcinoma: a cause of apparent lack of sensitivity to radiotherapy.

We describe a patient with a large nodular basal cell carcinoma (BCC), which was excised following apparent failure to respond to radiotherapy. Histological examination of the fully excised lesion demonstrated a solid mass of amyloid, which stained positively for cytokeratins, but there was no residual BCC.

Recommendations for a mammography quality assurance program.

In 1989 the ACPSEM published a position paper entitled "A Quality Assurance Programme for Mass Screening in Mammography". This paper described test parameters and performance specifications for the equipment related aspects of a mammography quality assurance program. Advice on test equipment selection was also provided. In the intervening period of time there have been considerable advances in mammography technology creating a need to review a number of the paper's recommendations. There have also been considerable developments in the mammography quality assurance (QA) field, not the least of which includes the American College of Radiology Mammography Accreditation Program (ACR-MAP) and the similarly structured Royal Australian and New Zealand College of Radiologists' Mammography Accreditation Program (RANZCR-MAP). In light of these developments it was decided by the Radiology Interest Group to review the ACPSEM position on those aspects of mammography QA that fall within the medical physicist's area of expertise. This document represents the outcome of those deliberations.

An ultrasound investigation of the lip levator musculature.

The aims of this study were to determine if there were any differences in the thickness of the lip levator musculature in men and women, and whether the height of the smile line in adults was related to the thickness of the lip levator musculature. Thirty Caucasian (13 males, 17 females), and 24 Asian (11 males, 13 females) undergraduate dental students participated in this study. The subjects were placed in high, medium, and low smile-line groups, according to the height of their upper lip while smiling. The thickness of the levator labii superioris and zygomaticus major muscles was measured on ultrasound scans of the relaxed muscles. Gender, right-left side, and ethnic differences in muscle thickness were determined, and the thicknesses of the lip levator musculature in subjects in the high, medium, and low smile-line groups were compared. There were significantly more women than men with high smile-lines and the zygomaticus major muscle was significantly thicker in the women, as compared with the men. There were, however, no statistically significant differences in muscle thickness in the three smile-line groups. While it appears that women have higher smile-lines and significantly thicker zygomaticus major muscles than men, the height of the smile line is not due to the thickness of either the levator labii superioris or zygomaticus major muscles.

Neutrophil count and activation in vascular disease.

An elevated peripheral leucocyte count is associated with an increased risk of myocardial infarction and progression of coronary artery disease. The aim of this study was to determine neutrophil count and activation, measured as an increase in plasma neutrophil elastase, in patients with stable ischaemic heart disease, insulin-dependent diabetes mellitus and essential hypertension compared with a comparable group of control subjects. Neutrophil count and neutrophil elastase were raised significantly for patients with ischaemic heart disease (p less than 0.005; p less than 0.002), diabetes mellitus (p less than 0.001; p less than 0.01) and hypertension (p less than 0.05; p less than 0.0001) respectively compared to the control subjects. Neutrophil elastase did not correlate with subject age or leucocyte count. This study confirms the association between leucocyte count and vascular disease, and is consistent with neutrophil activation contributing to the progression of vascular disease.

Estimating the size of myocardial infarction by magnetic resonance imaging.

OBJECTIVE: To develop a method to measure myocardial infarct size by magnetic resonance imaging and to compare the results with pyrophosphate scanning by single photon emission computed tomography. DESIGN: All patients underwent magnetic resonance imaging and pyrophosphate scanning 5-7 days after the onset of symptoms. Both measurements of infarct size were compared with the release of creatine kinase MB and with ventricular performance estimated by radionuclide ventriculography. PATIENTS: 19 patients (age 40-68 years) who had sustained their first uncomplicated myocardial infarction and who had not been treated with thrombolytic therapy. RESULTS: The site of infarction was clearly shown by both imaging techniques and was identical in each patient. The volume of infarcted tissue measured by magnetic resonance imaging agreed well with the infarct size measured by single photon emission tomography (mean difference 2.7 cm3). Correlations of both imaging techniques with the release of creatine kinase MB were best when total release rather than peak release was used. Both imaging techniques correlated closely with the subsequent ventricular performance. CONCLUSIONS: Magnetic resonance imaging after acute infarction allows measurement of infarct size and this may prove useful in assessing new treatments designed to salvage myocardium.

Inflammatory response, neutrophil activation, and free radical production after acute myocardial infarction: effect of thrombolytic treatment.

Activated neutrophils releasing proteolytic enzymes and oxygen free radicals have been implicated in extending myocardial injury after myocardial infarction. Neutrophil elastase was used as a marker of neutrophil activation and the non-peroxide diene conjugate of linoleic acid was used as an indicator of free radical activity in 32 patients after acute myocardial infarction; 17 were treated by intravenous thrombolysis. Patients with acute myocardial infarction had higher plasma concentrations of neutrophil elastase and the non-peroxide diene conjugated isomer of linoleic acid than normal volunteers or patients with stable ischaemic heart disease. Patients treated by thrombolysis had an early peak of neutrophil elastase at eight hours while those who had not been treated by thrombolysis showed a later peak 40 hours after infarction. The plasma concentration of non-peroxide conjugated diene of linoleic acid was highest 16 hours after the infarction irrespective of treatment by thrombolysis. Quantitative imaging with single photon emission tomography showed decreased uptake of indium-111 labelled neutrophils in the infarcted myocardium (as judged from technetium-99m pyrophosphate) in those who had received thrombolysis, suggesting a decreased inflammatory response. The results indicate increased neutrophil activation and free radical production after myocardial infarction; they also suggest that thrombolysis does not amplify the inflammatory response and may indeed suppress it.

Leiomyoma of the ovary with ascites and hydrothorax.

A case is described in which a leiomyoma of the ovary was accompanied by hydrothorax. There was no reaccumulation of fluid after oophorectomy.

Reduced venous compliance and increased transcapillary escape of protein in insulin-dependent diabetic patients.

Lower limb venous compliance and transcapillary escape rate of transferrin were measured in eight normotensive, insulin-dependent male diabetic patients and eight control subjects using a dual isotope technique. Technetium-99m labelled autologous erythrocytes were used to measure venous compliance and to correct for local changes in blood volume, whilst Indium-113m labelled transferrin was used to measure transcapillary escape of protein. The diabetic patients were found to have reduced venous compliance 1.5 (0.7 to 3.4) x 10(-2) mmHg-1 compared with controls 3.2 (2.4 to 4.1) x 10(-2) mmHg-1 (p less than 0.01). The diabetic patients were also found to have greater transcapillary escape of transferrin -2.7 (-1.5 to -5.3) x 10(-3), compared with control subjects -5.2 (-4.1 to -8.1) x 10(-3) (p less than 0.02) in response to increasing hydrostatic pressure. These results show reduced venous compliance in patients with a mean duration of diabetes of 15 years and with only at most, early complications of diabetes, and confirm previous observations showing increased transcapillary escape of protein.

Regional distribution of ventilation in chronic obstructive lung disease and the effect of salbutamol.

Regional distribution of ventilation was assessed in 5 normal volunteers, and 19 patients with symptomatic chronic obstructive lung disease (COAD) using the technique of gated lung ventilation imaging with 127Xe. The results of this technique were compared with the more conventional assessment of regional ventilation by analysis of 127Xe wash-out curves. Both techniques demonstrate loss of the normal gravitational distribution of ventilation in patients with severe COAD which is significantly reduced from normals in upper, middle and lower zones of each lung, being most marked in the lower zones (p less than 0.01). Gated lung imaging also shows a significant reduction of regional ventilation in patients with mild to moderate COAD compared to normals but only in the lower zones (p less than 0.05). Gated lung imaging provides a better quantitative method of assessing regional lung function than wash-out analysis and confirms loss of the normal gravitational distribution of ventilation in patients with obstructive lung disease and relates this to severity of disease. The distribution of ventilation was also assessed in 6 patients with severe COAD before and after placebo or salbutamol. There was a significant improvement of the distribution of ventilation to the lung bases after salbutamol (p less than 0.05).

Measurement of hand bone mineral content using single-photon absorptiometry.

A single photon absorption imaging technique has been developed to assess the bone mass of the hand, especially in patients with rheumatoid arthritis or bronchial asthma. A modified rectilinear scanner images the hand by transmission scanning in a water bath with a 7.4 GBq 125I source. A microcomputer is used to calculate the bone mineral distribution, and the total bone mineral content (BMC) of the hand is determined from that distribution. The precision (coefficient of variation) of the measurement is 1.9%. A control population of 20 men and 58 women has been studied to determine normal variations in hand bone mineral content with age, sex, body size, hand volume and years since menopause. The normal men are found to have an average hand BMC of 25.1 g with a coefficient of variation (CV) of 22%, which is reduced to 12% by normalising for body size using span. The normal women had an average hand BMC of 18.0 g +/- 15%. The CV is reduced to 13% by normalising for span and years post-menopause.

Prediction of fracture healing in the tibia by quantitative radionuclide imaging.

The uptake of 99mTc-MDP was studied in 73 patients after a tibial fracture. The image obtained five minutes after injection during a period between one and four weeks after fracture was found to be related to the incidence of non-union after six months. A ratio of 1.3 between the uptake at the fracture site and at normal bone adjacent to it predicted non-union in an individual patient with a sensitivity of about 70% and a specificity of 90%.

The acute inflammatory response to myocardial infarction: imaging with indium-111 labelled autologous neutrophils.

The uptake of indium-111 labelled neutrophils was examined in 30 patients with acute myocardial infarction by planar imaging and single photon emission computed tomography. The time from venepuncture to reinjection of the autologous labelled neutrophils was less than 2.5 hours and imaging was carried out 24 hours later. Twenty three patients had a positive uptake of neutrophils in the myocardium and imaging was improved by single photon emission computed tomography. There was a significant difference between the intervals from the onset of chest pain to injection of labelled neutrophils between patients with positive and negative images; early reinjection was more likely to produce a positive image. Indeed, all nine patients reinjected within 18 hours of the onset of symptoms had positive images. The results suggest that the stimulus for activation and migration of neutrophils is transient; this is an important factor if neutrophil release products play a role in cell damage after coronary occlusion.

Corticosteroids and bone mass in asthma: comparisons with rheumatoid arthritis and polymyalgia rheumatica.

Bone mass has previously been shown to be reduced at peripheral bone sites in patients with bronchial asthma receiving corticosteroids. To assess whether total bone mass is reduced in asthma total body calcium was measured by in vivo neutron activation analysis in patients receiving various treatments for asthma and compared with results from normal controls and patients with rheumatoid arthritis and polymyalgia rheumatica. Compared with controls total body calcium was reduced by 13.6% (p less than 0.001) in patients with asthma receiving daily oral corticosteroids but by only 9.0% (p less than 0.005) in a similar group of patients who had received oral calcium supplements at the start of their corticosteroid treatment. Total body calcium was also reduced in a group of patients receiving only inhaled corticosteroids (8.8%; p less than 0.001) but not significantly reduced in a small group of patients with asthma who had never received these drugs. When compared with controls a group of patients matched for age and for dose of corticosteroids given for rheumatoid arthritis had a similar reduction in total body calcium to the patients with asthma receiving daily oral treatment (17.7%; p less than 0.001), but no such reduction was shown in patients with polymyalgia rheumatica. These findings suggest that the risk of bone loss with low dose oral corticosteroids in similar in asthma and rheumatoid arthritis. Further work is required to assess the clinical relevance of small losses of bone associated with the use of inhaled corticosteroids.