Outcomes Following Treatment with FOLFOX for Patients with Resectable or Potentially Resectable Metastatic Colorectal Cancer: A Population-based Cohort Study.

AIMS: To evaluate the safety and effectiveness of oxaliplatin-based combination chemotherapy for patients with metastatic colorectal cancer (mCRC) to extrahepatic sites. MATERIALS AND METHODS: We conducted a population-based retrospective study examining the safety and effectiveness of perioperative oxaliplatin for resectable or potentially resectable colorectal metastases in Ontario, Canada. Outcomes were also compared with patients with liver-only metastases. Patients received oxaliplatin for mCRC between 1 January 2013 and 30 June 2020. RESULTS: In total, 192 patients had extrahepatic metastases. Seventy per cent had R0 metastasectomy. The 3-year disease-free survival and overall survival were 62% and 79%, respectively; <4% of patients died within 60 days of metastasectomy and 74-90% of patients received treatment according to recommendations from a multidisciplinary setting. Compared with liver-only controls (n = 1306), patients had mCRC to the lung only (n = 115), lung and liver (n = 55) and liver with non-pulmonary site (n = 22). Extrahepatic metastases were more likely to be found for patients whose primary colorectal resection had positive margins (14% versus 7%, P = 0.005) and primary tumours located in the rectum [odds ratio 4.01 (2.31-6.97)]. After adjustment, there was no difference in overall survival between liver-only controls and patients with lung-only [hazard ratio 0.82 (0.59-1.15)] or liver and lung metastases [hazard ratio 1.26 (0.85-1.87)] (P = 0.24). In total, 79/115 (69%) of patients with lung-only metastases had a metastasectomy compared with 645/1306 (49%) and 15/55 (27%) of patients with liver-only and liver and lung metastases, respectively. Hospital visits were similar between patients with liver-only and extrahepatic metastases. CONCLUSION: Oxaliplatin-based chemotherapy for patients with resectable or potentially resectable mCRC with extrahepatic metastases was safe and resulted in similar outcomes in appropriately selected patients when compared with patients with liver-only metastases.

A population-based study of pulmonary monitoring and toxicity for patients with testicular cancer treated with bleomycin.

Background: Bleomycin is commonly used to treat advanced testicular cancer and can be associated with severe pulmonary toxicity. The primary objective of the present study was to describe the use of pulmonary function tests (pfts) and chest imaging before, during, and after treatment with bleomycin. Methods: To identify all incident cases of testicular cancer treated with bleomycin-based chemotherapy in the Canadian province of Ontario during 2005-2010, the Ontario Cancer Registry was linked with chemotherapy treatment records. Health administrative databases were used to describe use of pfts, chest imaging, and physician visits for respiratory complaints. Results: Of 394 patients treated with orchiectomy and chemotherapy who received at least 1 dose of bleomycin, 93% had complete chemotherapy records available. In the 4 weeks before, during, and within 2 years after finishing bleomycin-based chemotherapy, pfts were performed in 17%, 17%, and 29% of patients respectively. Chest imaging was performed in 68%, 62%, and 98% of patients in the same time periods. In the 2 years after bleomycin-based chemotherapy, 23% of treated patients had a physician visit for respiratory symptoms. That rate was substantially higher for men with greater exposure to bleomycin: 40% (24 of 60) for 10-12 doses bleomycin compared with 21% (53 of 250) for 7-9 doses and with 14% (8 of 58) for 1-6 doses (p = 0.002). Conclusions: Quality improvement initiatives are needed to increase baseline rates of chest imaging within 4 weeks of starting chemotherapy for testicular cancer; to understand why such a high proportion of men have chest imaging during bleomycin-based chemotherapy; and to mitigate the excess pulmonary toxicity seen with increasing exposure to bleomycin.

Association between waiting time for radiotherapy after surgery for early-stage breast cancer and survival outcomes in Ontario: a population-based outcomes study.

Background: After surgery for early-stage breast cancer (bca), adjuvant radiotherapy (rt) decreases the risk of locoregional recurrence and death from bca. It is unclear whether delays to the initiation of adjuvant rt are associated with inferior survival outcomes. Methods: This population-based retrospective cohort study included a random sample of 25% of all women with stage i or ii bca treated with adjuvant rt in Ontario between 1 September 2001 and 31 August 2002, when, because of capacity issues, wait times for radiation were abnormally long. Pathology reports were manually abstracted and deterministically linked to population-level administrative databases to obtain information about recurrence and survival outcomes. Cox proportional hazards modelling was used to evaluate the association between waiting time and survival outcomes. A composite survival outcome was used to ensure that all possible measurable harms of delay would be captured. The composite outcome, event-free survival, included locoregional recurrence, development of metastatic disease, and bca-specific mortality. Results: We identified 1028 women with stage i or ii bca who were treated with breast-conserving surgery and adjuvant rt. For the 599 women who were treated with adjuvant radiation without intervening chemotherapy, a waiting time of 12 weeks or more from surgery to the start of radiation appeared to be associated with worse event-free survival after a median follow-up of 7.2 years (hazard ratio for the composite outcome: 1.44; 95% confidence interval: 0.98 to 2.11; p = 0.07). For the 429 women who received intervening adjuvant chemotherapy, a waiting time of 6 weeks or more from completion of chemotherapy to start of radiation was associated with worse event-free survival after a median follow-up of 7.4 years (hazard ratio: 1.50; 95% confidence interval: 1.00 to 2.22; p = 0.047). Conclusions: Delay to the initiation of adjuvant rt after breast-conserving surgery is associated with inferior bca survival outcomes. The good prognosis for patients with early-stage bca limits the statistical power to detect an effect of delay to rt. Given that there is no plausible advantage to delay, we agree with Mackillop that time to initiation of rt should be kept "as short as reasonably achievable."

Venous Thromboembolism During Chemotherapy for Testicular Cancer: A Population-Based Study.

AIMS: Venous thromboembolism (VTE) is a potential complication among germ cell tumour patients. We evaluated the incidence rate, timing and factors associated with VTE among patients with germ cell cancer in routine practice. MATERIALS AND METHODS: The Ontario Cancer Registry was linked to electronic records of treatment to identify all cases of testicular cancer treated in Ontario during 2000-2010. Administrative databases were used to identify VTE in the 3 months before and 5 years after orchiectomy. We explored patient-, disease- and treatment-related factors associated with VTE among all patients as well as those with detailed chemotherapy records available. RESULTS: During 2000-2010, 2650 patients underwent orchiectomy for testicular cancer; among this cohort, 920 (33%) received chemotherapy. The VTE rate was 8% (69/920) among patients treated with chemotherapy and 0.6% (11/1730) among those without chemotherapy. Among the patients treated with chemotherapy who had VTE, 13% (9/69) occurred in the month before starting chemotherapy, 62% (42/69) in the first 3 months after starting and 25% thereafter. For patients who received three and four cycles, VTE rates were 8% (21/258) and 16% (19/121), respectively. In adjusted analyses, the only factor independently associated with VTE was increasing number of cycles (odds ratio 3.91 for four cycles, odds ratio 1.63 for three cycles (P = 0.022) compared with one to two cycles). CONCLUSION: This population-based study confirms findings from institutional case series regarding the high rate of VTE among patients with germ cell tumours treated with chemotherapy. Future studies should evaluate the extent to which VTE prophylactic strategies might mitigate this risk.

Neurotoxicity Among Survivors of Testicular Cancer: A Population-based Study.

AIMS: Neurotoxicity may affect the quality of life of survivors of testicular cancer. Understanding the burden of neurotoxicity is important to guide survivorship care. A population-based study was undertaken to describe the proportion of patients in the 'real world' with neurotoxicity. MATERIALS AND METHODS: A population-based, retrospective, cohort study of patients with advanced testicular cancer treated in the province of Ontario. The Ontario Cancer Registry was linked to electronic treatment records to identify all incident cases of testicular cancer during 2000-2010. Administrative databases were used to describe health system visits for symptoms potentially related to neurotoxicity. Health system visit rates were explored by number of chemotherapy cycles among patients treated during 2005-2010 for whom complete chemotherapy details were available. RESULTS: During 2000-2010, 2650 patients underwent an orchiectomy for testicular cancer; 920 (33%) also received chemotherapy. The proportion of patients with health system visits for neurotoxicity in the 2 years before surgery compared with the 2 years after surgery remained stable among patients treated with orchiectomy alone (18% [303/1730] versus 18% [316/1730], P = 0.523); however, there was a substantial increase among patients treated with chemotherapy (16% [151/920] versus 25% [231/920], P < 0.001). Among patients treated with chemotherapy in 2005-2010 for whom complete details were available regarding number of treatment cycles there was a dose-response effect. The increase in health system visits for neurotoxicity from 2 years before compared with 2 years after orchiectomy was greater among patients treated with four cycles of chemotherapy (17% [21/121] versus 37% [45/121]) and three cycles of chemotherapy (17% [45/258] versus 28% [72/258]) compared with those treated with one to two cycles of chemotherapy (<13% [<6/45] versus 20% [9/45], P = 0.013). CONCLUSIONS: This population-based study suggests that symptoms of neurotoxicity are common among survivors of testicular cancer and that this seems to be driven by increasing exposure to chemotherapy. Clinicians should carefully evaluate patients for neurotoxicity during the survivorship phase of treatment.

Secondary intervention following endovascular repair of abdominal aortic aneurysm: a single centre experience.

AIMS: We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions. METHODS: 108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied. RESULTS: There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05). CONCLUSIONS: Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.

Endoluminal repair of large abdominal aortic aneurysms using PTFE: a feasibility study.

PURPOSE: To investigate the feasibility of using predilated thin-wall polytetrafluoroethylene (PTFE) secured by extra-large Palmaz stents for endoluminal repair of abdominal aortic aneurysms (AAA). METHODS: Thirty-two patients (26 males; aged 69 to 83 years) from three centers (two in Europe, one in Australia) were selected for endoluminal stent-grafting using predilated B-mm PTFE graft material fitted with extra-large Palmaz stents at the terminal ends. Aortoaortic tube grafts were implanted in 12 patients, while the remainder received aortomonoiliac endografts and femorofemoral bypass. Follow-up at 5 days and then biannually was by contrast-enhanced computed tomography (CT) or duplex scanning. RESULTS: There were 13 conversions to open surgery; these patients died within 30 days. Nineteen patients were discharged with functioning endografts within 5 days of treatment. Of these, two have had their grafts removed owing to infection in one and distal stent migration in the other. Two endoleaks have been detected in follow-up; one has been sealed by covered stenting. One twisted graft was repaired by Wallstent implantation. Seventeen patients remain well, one with persistent distal endoleak, but none shows an increase in AAA diameter on imaging over the 6- to 26-month (median 13) follow-up. CONCLUSIONS: These results represent the learning curves of three separate centers. Technical failure and complications were more common early in the study. Advantages of the technique include relative low cost and the ability to tailor the stent-graft to the individual aneurysm.

Assessment of organ radiation doses and associated risk for digital bifemoral arteriography.

An assessment has been made of the absorbed dose associated with femoral arteriography using a digital imaging system. A bilateral femoral arteriogram was performed on 17 patients, using a filmless 1024 matrix digital image acquisition system with a discrete stepping tube-stand and 40 cm image intensifier. A standardized protocol of manual patient/tube-stand positioning under fluoroscopic control and automatic stepping digital acquisition was followed. Skin entry doses were measured with a dose-area product meter for each stage of the procedure, and the total gonad dose was assessed with thermoluminescent dosimeters (TLDs). Published Monte Carlo simulations were supplemented with further calculations to evaluate organ doses from the dose-area products measured. Comparison with the TLD measurements indicated that this technique over-estimated organ doses by about 30%. A mean effective dose of 3.1 +/- 1.8 mSv was calculated for the procedure, with the greatest dose burden being imposed by fluoroscopy during catheter manipulation. The related radiation detriment is 0.018%, which is insignificant when compared with the overall mortality from peripheral vascular disease.

A new complication of coronary arteriography.

The introduction of a sharply angulated catheter through an arterial sheath for percutaneous coronary arteriography was associated in 7 cases with dissection of the iliac arteries; this extended to the lumbar aorta at the level of the coeliac axis. The catheter tip should be introduced gently and preferably straightened out with a good length of guide wire to avoid this complication.

Iliac artery rupture during percutaneous angioplasty.

Percutaneous transluminal angioplasty of the iliac vessels is a generally safe procedure with good results. A rare but potentially fatal complication is iliac artery rupture; we present such a case with its management and review the literature.

The plain chest X-ray in acquired heart disease in adults.

The chest X-ray is a cheap, easily repeatable and reproducible method of investigating the structure and function of the heart. While it is rarely of decisive diagnostic importance in the setting of modern methods of noninvasive investigation, it is valuable in evaluating the severity of cardiac pathology and also in revealing unsuspected abnormalities which may complicate management. For this reason all patients should have a chest X-ray, preferably both frontal and lateral, at the first attendance for cardiac evaluation. In most cardiac departments a routine frontal chest X-ray is taken at each outpatient appointment.

Comparison of the ST/heart rate slope with the modified Bruce exercise test in the detection of coronary artery disease.

The rate of depression of the ST segment with increasing heart rate (HR) during exercise has been claimed to predict the extent of coronary artery disease (CAD). To determine whether the maximal ST/HR slope is better than the Bruce treadmill exercise test for predicting the presence of CAD, the maximal ST segment/HR slope was calculated in 81 patients and compared with the results of a standard 12-lead exercise test. In 21 patients (26%), the ST/HR slope could not be calculated. In 60 patients with ST/HR slope values, the extent of CAD was predicted in 24 patients (40%). The sensitivity and specificity of the ST/HR slope in predicting the presence of CAD in the 60 patients with slope values were 91% and 27%, respectively. The sensitivity and specificity of the modified Bruce treadmill exercise test in the 81 patients were 81% and 64%, respectively. Thus, the use of the ST/HR slope does not provide additional information that cannot be obtained using the standard Bruce exercise test.

Coronary transluminal angioplasty.

Obstructive coronary artery disease is widespread, fatal, and difficult to treat. Up to now, treatment has hinged on medical or surgical treatment. Transluminal angioplasty of the coronary arteries has been introduced as a simple method of relieving coronary artery obstruction with a high initial success rate and a short period of hospitalization.