Bilateral lingual artery stenosis: A rare, late complication of chemoradiotherapy.

INTRODUCTION: Carotid artery stenosis following radiotherapy (RT) is a known risk factor for the development of cerebrovascular disease with a risk of subsequent stroke or transient ischaemic attack. In contrast, small vessel disease in the neck following RT has been more rarely described. CASE REPORT: The authors report the case of a 61-year-old man who developed partial lingual necrosis 4 years after surgery and postoperative chemoradiotherapy for squamous cell carcinoma of the floor of the mouth. Contrast-enhanced CT scan confirmed subtotal to total occlusion of both lingual arteries. Surgical debridement of the necrosis allowed complete cure of the lesions. DISCUSSION: Small vessel disease is a possible complication in patients treated by RT for head and neck cancer. Although the risk of these complications is not directly related to the total radiation dose, higher doses appear to accelerate the development of vascular lesions. Practitioners must be aware of the possibility of these complications, especially in patients surviving more than 5 years.

Impact of p53 Status on Radiosensitization of Tumor Cells by MET Inhibition-Associated Checkpoint Abrogation.

UNLABELLED: Signaling via the MET receptor tyrosine kinase has been implicated in crosstalk with cellular responses to DNA damage. Our group previously demonstrated that MET inhibition in tumor cells with deregulated MET activity results in radiosensitization via downregulation of the ATR-CHK1-CDC25 pathway, a major signaling cascade responsible for intra-S and G2-M cell-cycle arrest following DNA damage. Here we aimed at studying the potential therapeutic application of ionizing radiation in combination with a MET inhibitor, EMD-1214063, in p53-deficient cancer cells that harbor impaired G1-S checkpoint regulation upon DNA damage. We hypothesized that upon MET inhibition, p53-deficient cells would bypass both G1-S and G2-M checkpoints, promoting premature mitotic entry with substantial DNA lesions and cell death in a greater extent than p53-proficient cells. Our data suggest that p53-deficient cells are more susceptible to EMD-1214063 and combined treatment with irradiation than wild-type p53 lines as inferred from elevated γH2AX expression and increased cytotoxicity. Furthermore, cell-cycle distribution profiling indicates constantly lower G1 and higher G2-M population as well as higher expression of a mitotic marker p-histone H3 following the dual treatment in p53 knockdown isogenic variant, compared with the parental counterpart. IMPLICATIONS: The concept of MET inhibition-mediated radiosensitization enhanced by p53 deficiency is of high clinical relevance, as p53 is frequently mutated in numerous types of human cancer. The current data point for a therapeutic advantage for an approach combining MET targeting along with DNA-damaging agents for MET-positive/p53-negative tumors.

Major bleeding of the upper aerodigestive tract due to oral anticoagulant/antibiotic interactions.

INTRODUCTION: Although a well-known complication in certain medical specialties, major bleeding due to the interaction between oral anticoagulants and antibiotics has been rarely reported concerning the upper aerodigestive tract. We report three cases of life-threatening bleeding of the upper aerodigestive tract in a context of antibiotic therapy in patients treated with oral anticoagulants. CASE SERIES: Three male patients under coumadin anticoagulation therapy presented major bleeding in three different contexts (epistaxis, peritonsillar abscess and postoperative course after total laryngectomy). Surgical intervention for hemostasis was required in all cases, with coagulation correction in two. Complications were severe anemia (2/3) and chronic heart failure (1/3). DISCUSSION/CONCLUSIONS: Interactions between two drugs commonly used in otolaryngology can result in major bleeding. The goal of this article is to raise practitioners' awareness of a potentially fatal, although rare, complication. We also review the main preventive strategies.

Paralyzed neonatal larynx in adduction. Case series, systematic review and analysis.

OBJECTIVE: Bilateral vocal cord abductor paralysis (BVCAbP) is considered a rare cause of stridor in the newborn. The goal of this work is to present a case series and to review systematically the literature on bilateral vocal cord abductor paralysis in the newborn to better characterize the current knowledge on this entity. METHODS: We performed a systematic literature review with Medline (1950-2011). The authors screened all cases of BVCAbP reported and selected those affecting newborns. RESULTS: Out of the 129 articles screened, 16 were included. A total of 69 cases could be retrieved and analyzed. Associated co-morbidities were found in 54% of the patients, most notably malformative conditions (intracranial or other), or a positive perinatal history (trauma/asphyxia, prematurity). Tracheostomy placement was required in 59% of children, and of these 44% were successfully decannulated. In terms of functional outcome full recovery or improvement were seen in 61% of patients. Major underlying co-morbidities affected negatively the functional outcome (p=.004), but not the need for tracheostomy (p=.604) or the decannulation success rate (p=.063). CONCLUSION: BVCAbP in the newborn is a serious cause of airway obstruction. It can be seen either in a context of multisystem anomalies or as an isolated finding. Newborns with major co-morbidities affecting their normal development are more likely to have poor functional outcomes and to remain tracheostomy-dependant.

Role of exercise tolerance test (ETT) and gated single photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in predicting severity of ischemia in patients with chest pain.

This was an observational study carried out in the department of cardiology. Bangabandhu Shikh Mujib Medical University (BSMMU), Dhaka in collaboration with Institute of Nuclear Medicine (INM), Shabag, Dhaka during the period October 2002-March 2003. A total of 54 patients presenting with Canadian Cardiovascular Society (CCS) class I-II severity of chest pain with mean +/-SD age 49.88 +/- 8.44 yrs and having male to female ratio 5.75:1 were included in the study. The main objective of the study was to predict severity of myocardial ischemia by Exercise Tolerance Test (ETT) determined by Duke Treadmill Score (DTS) and by perfusion pattern observed following Single-Photon Emission Computed Tomography myocardial perfusion imaging (SPECT-MPI). All patients underwent ETT and then SPECT-MPI scan using Tc-99m-tetrofosmin in one-day stress and rest protocol. Coronary angiogram (CAG) was done with in six months of the perfusion study. After performing ETT, patients were categorized by DTS and myocardial perfusion studies were also stratified according to severity of perfusion defect. The formula used to calculate the score was: Exercise time- (5 x ST segment deviation)-(4 X Treadmill angina index). The angiographic findings (significant >50% stenosis) and perfusion defects in MPI were compared with the severity of DTS. There were 31 patients who had CAG proven (>50% luminal diameter narrowing) CAD and 23 patients free of CAD. After ETT patients were categorized by Duke Treadmill Score into high DTS 12 (22.22%) patients, intermediate DTS 20 (37.03%) patients low DTS 22 (40.74%) patients. In high DTS group 91.66% patients had perfusion defect, whereas in intermediate and low risk group it was 60% and 40.9% respectively. In high DTS group 91.66% of patients had angiographicaly proven CAD, 58.33% of them had triple vessel disease (TVD) while in intermediate and low risk groups angiographically proven CAD were 65% and 22.72% of whom TVD only in 15% & 0% respectively. The results of ETT using DTS score were satisfactorily correlated with SPECT-MPI scanning in high DTS subsets of patients only. It is therefore, suggested that patient of high risk DTS do not need for myocardial perfusion imaging study and should undergo CAG for further evaluation. But the intermediate and low risk groups were needed myocardial perfusion imaging study to guide for further evaluation.

Lymphoscintigraphy in staging and management of breast cancer.

Internal mammary lymphoscintigraphy (IML) is a simple non-invasive and reproducible technique to determine the extent of the parasternal node invasion in patients suffering from breast cancer. A total forty four patients--37 before surgery or any sort of treatment and seven patients after having undergone surgery, chemotherapy and/or radiotherapy were included in this study to assess the potential role of lymphoscintigraphy in the context of the present 'state of the art' of staging and management of breast cancer patients in Bangladesh. The scintigraphic test was done using Technetium 99m (Tc-99m) Antimony sulfide colloid in a dose of 500 microCi injected interstitially into the sub-costal space. Images were obtained after two to three hours on a Gamma Camera and the study findings were then interpreted as normal, abnormal and equivocal. The scintigraphic images obtained in patients who had undergone surgery, chemotherapy and/or radiotherapy were difficult and more challenging to interpret than those images obtained from patients before surgery or other therapy. This was evidenced by the high number (71%) equivocal cases of IML findings in patients after treatment as compared to only 22% equivocal cases in patients studied before surgery or other therapy. Parasternal lymph node involvement was found to occur regardless of the site or size of the primary tumour. Thirty three percent of tumours located in the outer quadrant showed abnormal nodes on IML. When the size was considered, IML was found abnormal in 22.20% patients with tumour size less than 2 cm in diameter. Correlation of IML with clinically palpable lymph nodes showed abnormal scan findings in 18% patients without clinically demonstrable axillary lymph nodes. These findings are in agreement with previously published data and suggests that conventionally classified stage I patients may in effect be in stage II or even in stage III of the disease. In conclusion, when the technique of lymphoscintigraphy is done with a comprehensive overview of the patient, and when the interstitial injection site is correct, it will generally lead to a logical and clinically useful interpretation of the data for more efficient management of the patient with breast cancer.

Role of radioiodine in management of thyroid cancer: experience with 70 cases.

Results of 70 cases of differentiated thyroid carcinoma managed with I131 and surgery have been reported. These results add to the body of knowledge that already exists in the field of treatment of thyroid cancer with radioactive iodine. These results also indicate that the success of radioiodine therapy depends on adequate surgical removal of the thyroid tissue.