A rare case of advanced sinonasal adenoid cystic carcinoma with intracranial and intradural extension.

Adenoid cystic carcinoma (ACC) is a rare cancer of the head and neck that primarily occurs in the salivary glands. Sino-nasal ACC (SNACC) is a much rarer entity; this paper presents an exceedingly rare case of SNACC with both intracranial and intradural extension which was ultimately treated with palliative radiotherapy due to its extensive invasion. In addition to this, a review of the literature has been performed to delineate specific learning points for the management of intracranial SNACC.

Immediate post-operative PDE5i therapy improves early erectile function outcomes after robot assisted radical prostatectomy (RARP).

To assess whether the timing of post-operative Phosphodiesterase Inhibitor (PDE5i) therapy after Robot-Assisted Radical Prostatectomy (RARP) is associated with a change in early erectile function (EF) outcomes, continence or safety outcomes. Data were prospectively collected from a single surgeon in one tertiary centre. 158 patients were treated with PDE5i therapy post RARP over a 2-year period. PDE5i therapy was started: immediately (day 1-2) post-op in 29%, early (day 3-14) post-op in 37% and late (after day 14) post-op in 34%. EPIC-26 EF scores were collected pre-op and post-op. There were no significant differences in pre-operative characteristics between the therapy groups. Drop in EF scores and percentage return to baseline for unilateral nerve sparing was, respectively, 9 and 11.1% of immediate therapy, 7 and 14.8% of early therapy and 9.7 and 9.5% of late therapy (p = 0.9 and p = 0.6). For bilateral nerve sparing, this was, respectively, 3.5 and 42.9% immediate therapy, 5.5 and 35.5% early therapy and 7.3 and 25% late therapy (p = 0.017 and p = 0.045). Pad free and social continence were achieved in 54% and 37% of those receiving immediate therapy, 60% and 33% for early therapy and 26% and 54% for late therapy. There were no differences in compliance, complication or readmission outcomes. In patients with bilateral nerve sparing RARP, immediate post-operative PDE5i therapy can protect EF and improve early continence outcomes. Therefore, immediate PDE5i therapy should be considered in patients following nerve sparing RARP to maximise functional outcomes.

Retained intravascular catheter fragment at removal of implantable vascular access device: Incidence, risk factors, and outcomes.

BACKGROUND: Retained intravascular catheter fragments (RICF) are a rare complication of implantable vascular access device (IVAD) removal for which there is limited understanding of aetiology. There is a varied approach to management among the currently published literature. AIMS: The aim of this study was to establish incidence, risk factors, and outcomes for RICF after attempted removal of IVADs. METHODS: A single institution retrospective review was undertaken of individuals ≤ 25 years undergoing removal of IVADs from October 2014 to June 2019. Risk factors for RICF were explored using univariable logistic and Cox regression analysis. RESULTS: Six cases of RICF were identified among 654 line removal episodes (0.92% (95% CI 0.37-2%)) in patients aged 6-17 years (median 11, IQR 6-15 years). The main risk factor for RICF at removal was found to be line duration (OR 3.5/year, 95% CI 2.1-5.84, p < 0.0001). No RICFs occurred in lines indwelling for < 3 years. Five children with RICF ≤ 16 years were discussed with a paediatric cardiothoracic centre, and all were left in situ with 4 remaining asymptomatic. One had the fragment tip extruded through a wound, which required trimming. The other (17 years of age) developed an infected sinus for which partial removal with open excision followed by full removal with endovascular snare retrieval was performed by the adult vascular surgeons. CONCLUSION: IVADs in-situ for longer than a three-year period are at greatest risk of RICF upon removal. Management with transfixion of line fragments to surrounding muscle seems prudent while invasive attempts at retrieval appear unwarranted.

Meta-analysis of the normal diffusion tensor imaging values of the median nerve and how they change in carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) leads to distortion of axonal architecture, demyelination and fibrosis within the median nerve. Diffusion tensor imaging (DTI) characterises tissue microstructure and generates reproducible proxy measures of nerve 'health' which are sensitive to myelination, axon diameter, fiber density and organisation. This meta-analysis summarises the normal DTI values of the median nerve, and how they change in CTS. This systematic review included studies reporting DTI of the median nerve at the level of the wrist in adults. The primary outcome was to determine the normal fractional anisotropy (FA) and mean diffusivity (MD) of the median nerve. Secondarily, we show how the FA and MD differ between asymptomatic adults and patients with CTS, and how these differences are independent of the acquisition methods. We included 32 studies of 2643 wrists, belonging to 1575 asymptomatic adults and 1068 patients with CTS. The normal FA was 0.58 (95% CI 0.56, 0.59) and the normal MD was 1.138 × 10-3 mm2/s (95% CI 1.101, 1.174). Patients with CTS had a significantly lower FA than controls (mean difference 0.12 [95% CI 0.09, 0.16]). Similarly, the median nerve of patients with CTS had a significantly higher mean diffusivity (mean difference 0.16 × 10-3 mm2/s [95% CI 0.05, 0.27]). The differences were independent of experimental factors. We provide summary estimates of the normal FA and MD of the median nerve in asymptomatic adults. Furthermore, we show that diffusion throughout the length of the median nerve becomes more isotropic in patients with CTS.

Hepatic Resection Following Selective Internal Radiation Therapy for Colorectal Cancer Metastases in the FOXFIRE Clinical Trial: Clinical Outcomes and Distribution of Microspheres.

The FOXFIRE (5-Fluorouracil, OXaliplatin and Folinic acid ± Interventional Radio-Embolisation) clinical trial combined systemic chemotherapy (OxMdG: Oxaliplatin, 5-fluorouracil and folic acid) with Selective Internal Radiation Therapy (SIRT or radio-embolisation) using yttrium-90 resin microspheres in the first-line management for liver-dominant metastatic colorectal cancer (CRC). We report clinical outcomes for patients having hepatic resection after this novel combination therapy and an exploratory analysis of histopathology. Multi-Disciplinary Teams deemed all patients inoperable before trial registration and reassessed them during protocol therapy. Proportions were compared using Chi-squared tests and survival using Cox models. FOXFIRE randomised 182 participants to chemotherapy alone and 182 to chemotherapy with SIRT. There was no statistically significant difference in the resection rate between groups: Chemotherapy alone was 18%, (n = 33); SIRT combination was 21% (n = 38) (p = 0.508). There was no statistically significant difference between groups in the rate of liver surgery, nor in survival from time of resection (hazard ratio (HR) = 1.55; 95% confidence interval (CI) = 0.83-2.89). In the subgroup studied for histopathology, microsphere density was highest at the tumour periphery. Patients treated with SIRT plus chemotherapy displayed lower values of viable tumour in comparison to those treated with chemotherapy alone (p < 0.05). This study promotes the feasibility of hepatic resection following SIRT. Resin microspheres appear to preferentially distribute at the tumour periphery and may enhance tumour regression.

Brief report: length of ileal resection correlates with severity of bile acid malabsorption in Crohn's disease.

PURPOSE: Bile acid malabsorption (BAM) is a common cause of diarrhoea in Crohn's disease (CD) patients with ileal resection. BAM is usually diagnosed by selenium-labelled homotaurocholic acid test (75SeHCAT) but its availability is limited. Consequently, a large proportion of patients either remain undiagnosed or subject to empirical therapy. There is a paucity of studies examining the correlation between length of ileal resection and severity of BAM, which will be of use to clinicians with no recourse to diagnostic testing for BAM. METHODS: We tested the correlation between length of resected ileum and percentage retention on 75SeHCAT of all CD patients with a prior surgical resection who underwent 75SeHCAT testing. Response to treatment with bile salt sequestrant and 75SeHCAT retention values was tested using Fisher's exact test. RESULTS: A total of 91 patients were identified with a median age of 47 (IQR 21-80). The median length of resected ileum was 24 cm (range 15-165 cm) with a median of 1 resection (range 1-4). Overall, 88 patients (97%) had 75SeHCAT retention values of < 10% and 85 (93%) had retention of < 5%. There was a modest correlation between 75SeHCAT retention and length of ileal resection (Spearman's rho - 0.392, P = 0.0001). Data on response to treatment was available for 57 (63%) patients, of who 38 (67%) responded to bile salt sequestrant. There was no difference in 75SeHCAT retention values between responders and non-responders. CONCLUSIONS: There was a modest correlation between length of ileal resection and severity of BAM as defined by 75SeHCAT retention values. Response to bile salt sequestrant therapy was not dependent on 75SeHCAT retention values.

A challenging abdomino-scrotal hydrocele-successful resolution with the help of interventional radiology guided sclerosis.

Abdomino-scrotal hydrocele is a rare condition that presents in male infants. There is no consensus in the literature over treatment. We present the case of a 4-year-old boy with what was thought to be a straight forward congenital hydrocele that persisted despite ligation of a patent processus vaginalis and a Jaboulay procedure. A subsequent Magnetic Resonance Imaging scan identified a large intra-abdominal component connecting to the scrotum. Laparoscopic excision of the intra-abdominal component was performed successfully, but the hydrocele persisted. The hydrocele resolved without complication following two episodes of image intensifier guided sclerotherapy carried out by the interventional radiology team.