Radiotherapy in adult low-grade glioma: nationwide trends in treatment and outcomes

Background Management of WHO grade II gliomas (LGG) can include a combination of observation, surgery, radiotherapy (RT), and chemotherapy; however, optimal management remains unclear in regards to RT. Objective The current study seeks to investigate the usage of RT in LGG and its effect on survival outcomes. Methods Patients with diagnosis codes specific for LGG were queried from the National Cancer Database (NCDB) during the years 2004–2016. Kaplan–Meier curves with log-rank testing, univariate and multivariate Cox regression analysis, and comparisons of estimated 3- and 7-year survival were performed to investigate the effect of RT on overall survival. Results 19,382 patients with LGG were identified with histologically confirmed disease. Kaplan–Meier testing demonstrated RT impacted survival in patients undergoing biopsy or no surgery (p < 0.0001), no chemotherapy (p < 0.0001), and in regimens with early RT (p < 0.0001) and high-dose RT (p < 0.0001). Cox multivariate regression demonstrated RT and age less than 40 (HR 0.93, 95% CI 0.89–0.97, p = 0.001), no chemotherapy (HR 0.82, 95% CI 0.77–0.87, p < 0.001), and astrocytoma histology (HR 0.72, 95% CI 0.66–0.79, p < 0.001) were associated with improved survival. 3-year survival of RT versus non-RT groups showed increased survival rates for age less than 40 years (+ 5.7%, p < 0.0001), no surgery or biopsy (+ 8.1%, p < 0.0001), no chemotherapy (+ 10.3%, p < 0.0001), mixed glioma (+ 6.7%, p < 0.0001), astrocytoma (+ 7.1%, p < 0.0001), and in regimens with early RT (+ 7.6%, p < 0.0001) and high-dose RT (+ 4.7%, p < 0.0001). Conclusion This nationwide analysis of LGG patients found that RT was associated with improved survival outcomes in patients less than 40 years of age, with histology subtypes of astrocytoma and mixed glioma, undergoing biopsy or no surgery, and in regimens with early RT and high-dose RT (AU)

Radiotherapy in adult low-grade glioma: nationwide trends in treatment and outcomes.

BACKGROUND: Management of WHO grade II gliomas (LGG) can include a combination of observation, surgery, radiotherapy (RT), and chemotherapy; however, optimal management remains unclear in regards to RT. OBJECTIVE: The current study seeks to investigate the usage of RT in LGG and its effect on survival outcomes. METHODS: Patients with diagnosis codes specific for LGG were queried from the National Cancer Database (NCDB) during the years 2004-2016. Kaplan-Meier curves with log-rank testing, univariate and multivariate Cox regression analysis, and comparisons of estimated 3- and 7-year survival were performed to investigate the effect of RT on overall survival. RESULTS: 19,382 patients with LGG were identified with histologically confirmed disease. Kaplan-Meier testing demonstrated RT impacted survival in patients undergoing biopsy or no surgery (p < 0.0001), no chemotherapy (p < 0.0001), and in regimens with early RT (p < 0.0001) and high-dose RT (p < 0.0001). Cox multivariate regression demonstrated RT and age less than 40 (HR 0.93, 95% CI 0.89-0.97, p = 0.001), no chemotherapy (HR 0.82, 95% CI 0.77-0.87, p < 0.001), and astrocytoma histology (HR 0.72, 95% CI 0.66-0.79, p < 0.001) were associated with improved survival. 3-year survival of RT versus non-RT groups showed increased survival rates for age less than 40 years (+ 5.7%, p < 0.0001), no surgery or biopsy (+ 8.1%, p < 0.0001), no chemotherapy (+ 10.3%, p < 0.0001), mixed glioma (+ 6.7%, p < 0.0001), astrocytoma (+ 7.1%, p < 0.0001), and in regimens with early RT (+ 7.6%, p < 0.0001) and high-dose RT (+ 4.7%, p < 0.0001). CONCLUSION: This nationwide analysis of LGG patients found that RT was associated with improved survival outcomes in patients less than 40 years of age, with histology subtypes of astrocytoma and mixed glioma, undergoing biopsy or no surgery, and in regimens with early RT and high-dose RT.

U-shaped relationship between depression and body mass index in the Korean adults.

BACKGROUND: Although a number of studies have examined the relationship between depression and obesity, it is still insufficient to establish the specific pattern of relationship between depression and body mass index (BMI) categories. Thus, this study was aimed to investigate the relationship between depression and BMI categories. METHODS: A cross-sectional study was conducted for a cohort of 159,390 Korean based on Kangbuk Samsung Health Study (KSHS). Study participants were classified into 5 groups by Asian-specific cut-off of BMI (18.5, 23, 25 and 30kg/m2). The presence of depression was determined by Center for Epidemiologic Studies-Depression scales (CES-D)≥16 and≥25. The adjusted odd ratios (ORs) for depression were evaluated by multiple logistic regression analysis, in which independent variable was 5 categories of BMI and dependent variable was depression. Subgroup analysis was conducted by gender and age. RESULTS: When normal group was set as a reference, the adjusted ORs for depression formed U-shaped pattern of relationship with BMI categories [underweight: 1.31 (1.14-1.50), overweight: 0.94 (0.85-1.04), obese group: 1.01 (0.91-1.12), severe obese group: 1.28 (1.05-1.54)]. This pattern of relationship was more prominent in female and young age group than male and elderly subgroup. BMI level with the lowest likelihood of depression was 18.5kg/m2 to 25kg/m2 in women and 23kg/m2 to 25kg/m2 in men. CONCLUSIONS: There was a U-shaped relationship between depression and BMI categories. This finding suggests that both underweight and severe obesity are associated with the increased risk for depression.

Clinical association between serum γ-glutamyltransferase levels and the development of insulin resistance in Korean men: a 5-year follow-up study.

AIMS: In recent years, γ-glutamyltransferase has emerged as a predictor of cardiovascular disease, Type 2 diabetes mellitus, the metabolic syndrome and hypertension. However, it is not yet certain whether γ-glutamyltransferase is a predictor for insulin resistance. The aim of this study was to examine the longitudinal association between baseline γ-glutamyltransferase level and the development of insulin resistance in Korean men. METHODS: We performed a prospective cohort study, involving 22 931 healthy Korean men without baseline insulin resistance (homeostasis model assessment of insulin resistance, HOMA-IR < 2.7) for 5 years. We checked the HOMA-IR serially to monitor the development of insulin resistance (incidence of HOMA-IR ≥ 2.7). A Cox proportional hazards model was used to determine hazard ratios for insulin resistance by quartile groups of baseline serum γ-glutamyltransferase levels. RESULTS: During 81 208.6 person-years of follow-up, 3856 (16.8%) cases of insulin resistance developed between 2006 and 2010. After adjusting for multiple covariates, including baseline HOMA-IR, the hazard ratios (95% CI) for incident insulin resistance comparing the second to the fourth quartile of baseline serum γ-glutamyltransferase levels with the first quartile were 1.19 (1.06-1.33), 1.38 (1.23-1.53) and 1.58 (1.41-1.77), respectively (P for trend < 0.001). CONCLUSIONS: Our findings show that serum γ-glutamyltransferase level could be a predictor of the development of insulin resistance in Korean men.

Reversed discrepancy between CT and diffusion-weighted MR imaging in acute ischemic stroke.

PURPOSE: We sought to determine whether an early CT ischemic lesion showing parenchymal hypoattenuation might be undetectable on diffusion-weighted imaging (DWI) in acute cerebral ischemia. MATERIALS AND METHODS: We retrospectively evaluated CT and MR images of 70 consecutive patients with acute middle cerebral artery (MCA) infarction. All patients underwent CT and MR imaging within 6 hours of symptom onset. We determined the presence of reversed discrepancy (RD), defined as an early ischemic lesion showing parenchymal hypoattenuation on CT but no hyperintensity on DWI. CT Hounsfield units (HU), apparent diffusion coefficients (ADCs), and perfusion parameters were calculated for RD lesions. RESULTS: RD was found in 9 (12.9%) patients and at basal ganglia (89%). The mean HU of RD lesion was lower than that of normal tissue (DeltaHU, 2.33 +/- 0.74, P < .001). RD lesions showed no significant decrease of ADC (ADC ratio, 0.97 +/- 0.07, P = .059) and cerebral blood flow (relative CBF, 0.87 +/- 0.20, P > 0.05). Delayed DWI hyperintensity occurred in 8 (88.8%) RD lesions, and all lesions progressed to infarction. In 6 (66%) of 9 patients with RD, Alberto Stroke Program Early CT scores of ischemic lesions were lower on CT than those on DWI. CONCLUSION: RD was uncommonly found mainly in basal ganglia, and all RD lesions progressed to infarction at follow-up. Early CT ischemic lesion showing parenchymal hypoattenuation may be undetectable on DWI, and DWI may underestimate extent of severe ischemic tissue in patients with acute MCA infarction.

Investigation of juxtasellar and cerebellopontine angle meningiomas and neurogenic tumours: two-phase helical CT.

We performed two-phase helical CT in 31 patients with juxtasellar region and cerebellopontine angle tumours to evaluate its usefulness in differentiating meningiomas from neurogenic tumours. After the intravenous injection of 90 ml contrast medium at 3 ml/s, axial helical images were obtained with delays of 30 and 120 s. After the delayed axial images, we acquired coronal images. Changes in attenuation were assessed visually and quantitatively (by comparing the attenuation in Hounsfield units). There were 17 meningiomas and 14 neurogenic tumours, all pathologically proven. Two-phase helical CT showed a decrease in attenuation in 15 (88%) meningiomas and an increase in 14 (100%) neurogenic tumours from early to delayed axial images. Coronal images showed a decrease in attenuation in all 17 meningiomas and an increase in 13 (93%) of the neurogenic tumours. The mean HU and their ratios were significantly different between meningiomas and neurogenic tumours.

Diffusion-weighted MR imaging of intracerebral hemorrhage.

OBJECTIVE: To document the signal characteristics of intracerebral hemorrhage (ICH) at evolving stages on diffusion-weighted images (DWI) by comparison with conventional MR images. MATERIALS AND METHODS: In our retrospective study, 38 patients with ICH underwent a set of imaging sequences that included DWI, T1-and T2-weighted imaging, and fluid-attenuated inversion recovery (FLAIR). In 33 and 10 patients, respectively, conventional and echo-planar T2* gradient-echo images were also obtained. According to the time interval between symptom onset and initial MRI, five stages were categorized: hyperacute (n=6); acute (n=7); early subacute (n=7); late subacute (n=10); and chronic (n=8). We investigated the signal intensity and apparent diffusion coefficient (ADC) of ICH and compared the signal intensities of hematomas at DWI and on conventional MR images. RESULTS: DWI showed that hematomas were hyperintense at the hyperacute and late subacute stages, and hypointense at the acute, early subacute and chronic stages. Invariably, focal hypointensity was observed within a hyperacute hematoma. At the hyperacute, acute and early subacute stages, hyperintense rims that corresponded with edema surrounding the hematoma were present. The mean ADC ratio was 0.73 at the hyperacute stage, 0.72 at the acute stage, 0.70 at the early subacute stage, 0.72 at the late subacute stage, and 2.56 at the chronic stage. CONCLUSION: DWI showed that the signal intensity of an ICH may be related to both its ADC value and the magnetic susceptibility effect. In patients with acute stroke, an understanding of the characteristic features of ICH seen at DWI can be helpful in both the characterization of intracranial hemorrhagic lesions and the differentiation of hemorrhage from ischemia.

Experimental support differenciating two proposed chiral recognition models for the resolution of N-(3,5-dinitrobenzoyl)-alpha-arylalkylamines on high-performance liquid chromatography chiral stationary phases.

In rationalizing the odd chromatographic behavior for the separation of the enantiomers of N-(3,5-dinitrobenzoyl)-alpha-arylalkylamines on HPLC chiral stationary phases (CSPs) derived from alpha-(6,7-dimethyl-1-naphthyl)alkylamines, we initially suggested the occurrence of two competing, opposite sense chiral recognition processes termed the "dipole-stacking process" and the "hydrogen-bonding process". A simplified "single mechanism" model was later suggested with the importance of face to edge pi-pi interaction between aromatic rings come to recognized. The initial and subsequent chiral recognition models can be differentiated by noting the chromatographic trends for the enantioseparation of a homologous series of N-(3,5-dinitrobenzoyl)-alpha-(p-alkylphenyl)ethylamines on the aforementioned CSPs. Data so obtained were consistent with the second "single mechanism" model but not with the first "two competing mechanism" model. From these results, it has been concluded that the "single mechanism" model is more plausible than the "two competing mechanism" model.

Solitary cutaneous myxoma.

We describe a case of a large pedunculated solitary cutaneous myxoma arising on the thigh of a 47-year-old man without evidence of Carney's complex, NAME, or LAMB syndromes. The diagnosis was confirmed by hematoxylin and eosin stain, special stains, and immunocytochemistry studies. The tumor was surgically resected with no evidence of recurrence after 6 months. Solitary cutaneous myxoma should be differentiated histologically from myxoid neurofibroma, neurothekeoma, and ossifying and nonossifying fibromyxoid tumor.

Uninterrupted moderately accelerated radiotherapy in the treatment of unresectable/advanced head and neck cancer: one institution's experience and a comparative review.

Conventional radiotherapy alone in treatment of unresectable or locally advanced head and neck cancer has poor results. To improve outcome without significant increase in acute and late morbidity, we began a moderately accelerated hyperfractionation radiation therapy protocol without breaks for treatment of unresectable/advanced head and neck malignancies. From August 1984 to June 1995, 48 patients with unresectable or advanced carcinoma of the head and neck were treated using a protocol of accelerated hyperfractionation radiation therapy at Kaiser Permanente Medical Center, Los Angeles. Patients were treated twice a day using 150 cGy per fraction, 4 days per week, to a final dose of 60 Gy. Two patients were excluded from this analysis because they did not complete treatment. With a median follow-up of 33 months, 31 (67%) patients have had disease recurrence, 30 (65%) of whom had a locoregional component to their failures. At the last follow-up, 12 patients (26%) were alive with no evidence of disease, 30 patients had died of disease, and 4 had died of intercurrent disease without recurrence. Nine (19%) patients required treatment interruptions averaging 8 days in duration. This accelerated regimen resulted in outcomes similar to those with conventional radiotherapy, most likely because of a conservative total dose. Further refinement of fractionation schedules with potential incorporation of chemotherapy must be investigated.

Enantioselective Relieving Activity of α-Methylbenzylphenylureas toward Bensulfuron-methyl Injury to Rice (Oryza sativa).

Optically active α-methylbenzylphenylureas were tested for their relieving activities toward just-germinated rice seedlings injured by bensulfuron-methyl (methyl 2- [[[[[(4,6-dimethoxy-2-pyrimidinyl)amino]carbonyl]amino]- sulfonyl]methyl]benzoate) in an agar test to evaluate the chiral requirement and enantioselectivity. Many kinds of derivatives of the α-methylbenzylphenylureas exhibited strong relieving activity without any affect on root growth at the highest concentration tested. Six compounds with an (S)-configuration were more active than daimuron. The log k' values of the most potent derivatives ranged from 0.42 to 0.65. A relatively strong parabolic relationship between the log k' value and the activity has only been found in the case of the (S)-enantiomers containing halogen atoms. The enantioselectivity of the chiral pairs was very high, and the chirality-activity function followed a Pfeiffer relationship, increasing the selectivity with increasing potency. Among them, the 2,3-Cl2, 2-F-4-CH3, 4-COOEt, 2-Cl and 2,5-F2 derivatives were highly enantioselective with a significantly high relieving activity. These results suggest that while hydrophobicity performed an important role, chirality and the mode of substitution essentially contributed to the activity.

Enantioselective Herbicidal Activity of Chiral α-Methylbenzylphenylureas against Cyperaceae and Echinochloa Paddy Weeds.

Optically active α-methylbenzylphenylureas were synthesized and tested for their herbicidal activities against barnyardgrass and Cyperaceae paddy weeds in a greenhouse to evaluate the cross intergenus phytotoxicity between rice and barnyardgrass and the enantioselective phytotoxicity to the weeds. Several compounds controlled the growth of the weeds, and a suitable enantiomer for successful weed control was dependent on the type of weed and on the substituent at the aniline moiety. The (R)-2-isoPr and (R)-2-tert-Bu derivatives significantly controlled barnyardgrass and both annual and perennial Cyperaceae paddy weeds. The (R)-2-Et and (R)-2-CF3 derivatives showed the strong herbicidal activity against perennial Cyperaceae paddy weeds, while the (S)-enantiomers of the unsubstituted and fluoro derivatives were active against barnyardgrass. The enantioselectivity of the most potent compounds was high.

Thoracic manifestations of Behçet syndrome: radiographic and CT findings in nine patients.

PURPOSE: To evaluate the radiographic and computed tomographic (CT) findings of patients with thoracic Behçet syndrome. MATERIALS AND METHODS: Chest radiographs and CT scans of nine patients with thoracic Behçet syndrome were retrospectively reviewed. Findings were compared. RESULTS: Radiographs of the nine patients showed mediastinal widening in five (56%), air-space consolidation in five (56%), and lung mass in three (33%). CT scans of the nine patients showed that mediastinal widening was due to thrombosis in four (44%) or narrowing of the superior vena cava in one [11%], which caused mediastinal edema; that air-space consolidation (seen on both radiographs and CT scans) was due to pulmonary hemorrhage or infarction in five (56%); and that lung mass was due to aneurysm of the right or left pulmonary artery in three (33%). In addition, CT scans showed hyperinflation in one patient. CONCLUSION: Chest radiographic findings of thoracic Behçet syndrome are variable and nonspecific. CT can be helpful in the assessment of the syndrome by showing thrombosis of the superior vena cava and characteristic aneurysms of the pulmonary arteries.

Mixed pulmonary blastoma and carcinosarcoma.

Pulmonary blastomas and carcinosarcomas are uncommon tumours, accounting for less than 1% of all lung neoplasms. Three previously described mixed epithelial and mesenchymal tumours having both adult and embryonal elements were termed 'transitional'. We report a similar case and evaluate the application of the term 'transitional tumour'.

Laparoscopic-Assisted Vaginal Hysterectomy: A Case Control Comparative Study with Abdominal Hysterectomy

A case control study of the operative time, blood loss, time for return to work, pain levels, and medications was conducted comparing laparoscopic-assisted vaginal hysterectomies (LAVH) with total abdominal hysterectomy (TAH). The average operating time for LAVH was 151 minutes whereas for TAH it was 99 minutes (P<.01). The average length of stay for the LAVH was 2.5 days and for the abdominal hysterectomy it was 3.5 days (P<.01). During hospitalization the LAVH group required an average of 180 mg of meperidine while the TAH group required 414 mg of meperidine (P<.01). Patients undergoing LAVH reported activity levels of 9.2 on a scale of 1 to 10, with 10 being unlimited activity, by day 14. Abdominal hysterectomy patients' activity was reported as only 6.4 on the same scale (P<.005). The LAVH group, although requiring more operating time, made a more rapid recovery, and less pain medication, and required shorter hospitalization than the TAH group.

Laparoscopic-assisted vaginal hysterectomy: a case control comparative study with total abdominal hysterectomy.

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner with age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LAVH was 144 minutes and for TAH 98 minutes, a significant difference (p <0. 005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436 mg meperidine during their hospital stay, significantly more than the 197 mg used by the LAVH group (p <0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p <0.001). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p <0.005). By the sixth postoperative week the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.

Morphometry of liver parenchyma in needle biopsy specimens from patients with alcoholic liver disease: preliminary variables for the diagnosis and prognosis of cirrhosis.

The diagnosis of liver cirrhosis depends on assessing fibrosis and architectural alterations of the liver. In a needle biopsy specimen the connective tissue is often inadequately sampled, which leads to an uncertain diagnosis. Parenchymal features alone are currently insufficient. We, therefore, carried out a comprehensive morphometric study to detect parenchymal structures that may be useful in the diagnosis and prognosis of cirrhosis. Five human liver biopsy specimens were selected from each of four alcoholic disease groups: fatty liver, alcoholic hepatitis, cirrhosis with greater-than-5-yr survival, and cirrhosis with less-than-2-yr survival. Volume fractions (Vv) and surface densities (Sv) were determined stereologically for parenchymal and hepatocellular compartments in electron micrographs. The differences between noncirrhosis and cirrhosis were (a) a doubling of the Vv of parenchymal interstitial space, (b) a nearly 25% increase in the Sv of hepatocyte plasma membrane, (c) a nearly 50% increase in the Sv of hepatocyte RER, and (d) a decrease in the Sv of the outer mitochondrial membrane. The significant difference between the greater than 5-yr and the less than 2-yr survivors of cirrhosis was the marked decrease in hepatocyte nuclear Vv in the latter group. Statistical analysis of our data showed that optimal sampling is achieved with as few as three micrographs from one block of tissue per biopsy specimen.