Outcomes following emergency colorectal cancer presentation in the elderly.

AIM: Colorectal cancer is predominantly a disease of the elderly and up to 30% of these patients will present as an emergency. We compared the outcomes of 'elderly' patients presenting to our unit with a colorectal cancer emergency over a 10-year period with those of a 'younger' cohort. METHODS: A single centre retrospective review of colorectal cancer emergencies between 1 April 2007 and 1 April 2017 was performed. Patients were separated into two cohorts: 'young' (< 75 years) and 'elderly' (≥ 75 years). Data collected included demographics, disease status, treatment and outcomes. RESULTS: A total of 341 patients (< 75 years: n = 154; ≥ 75 years: n = 187) presented as a colorectal cancer emergency. Significantly fewer 'elderly' patients underwent curative surgical procedures (72% vs 49%, P < 0.0001) or received adjuvant chemotherapy (56% vs 21%, P < 0.0001). 'Elderly' patients had significantly more postoperative cardio-respiratory complications (7% vs 36%, P < 0.0001), but despite this there was no significant difference in 30-day mortality (7% vs 12%) and survival rates at 1 year (75% vs 74%) or 3 years (56% vs 49%). Elderly patients treated with best supportive care had a median overall survival of just 62 (range 1-955) days. CONCLUSION: Patients ≥ 75 years presenting as a colorectal cancer emergency were significantly less likely to undergo emergency curative surgery or receive adjuvant chemotherapy than those < 75 years. However, the 30-day mortality, 1- and 3-year survival rates for patients undergoing curative surgery were comparable.

Gamma camera scintigraphy of tumours using (195m)Pt-cisplatin.

Platinum enriched with 194Pt was irradiated for 4 days in NRG's TIRO 1 reactor, to produce (195m)Pt. Spectral analysis of the product was performed using a calibrated hyper pure germanium detector and its constituent radioisotopes were identified as (195m)Pt, 199Au and 192Ir. Using the detector's intrinsic efficiency calibration, their activities were estimated to be 1049, 133 and 5.8 MBq, respectively. The performance of the gamma camera was tested using quality control procedures recommended by the Institute of Physics and Engineering in Medicine (IPEM) and was found to be satisfactory. A torso phantom was used to determine the minimum detection limit (MDL) of (195m)Pt in a 2 cm diameter tumour using SPECT acquisitions (32 steps, 60 s per step). The MDL was found to be 8 ppm assuming an administered patient dose of 50 MBq and a total cisplatin dose of 105 mg. This work indicates that (195m)Pt-cisplatin is suitable for clinical scintigraphy and has led to the development of a clinical protocol that has been approved for a pilot study.

Exenterative pelvic surgery--eleven year experience of the Swansea Pelvic Oncology Group.

AIMS: To review indications for surgery and outcomes of patients with complex locally advanced pelvic malignancies treated by a multidisciplinary Pelvic Oncology Group. PATIENTS AND METHODS: Between March 1992 and March 2003, 130 patients were jointly assessed in a monthly clinic involving urological, gynaecological, colorectal and plastic surgeons, an oncologist and nurse specialists. Seventy-six patients proceeded to exenterative surgery. RESULTS: Rectal carcinoma and gynaecological cancers were the two most common indications for surgery. Median follow-up was 14 months (range 1-120 months). There were no deaths within 30 days of surgery. The morbidity rate was 28%. Predicted 5 years survival was 53% in cases with clear histological margins and no lymph node metastasis. CONCLUSION: With careful patient selection and multi specialty care pelvic exenteration is a safe and effective option in the treatment of complex locally advanced pelvic malignancy.

Urinary modified nucleosides as tumor markers.

Extracts of urinary nucleosides have been sequentially purified and examined by mass spectrometric analysis. Seventeen modified nucleosides have been unequivocally identified and a further five provisionally identified. While several nucleosides were found only in a small number of extracts, the occurrence and levels of others were found to correlate with the tumour type and stage.

Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): a pilot study.

OBJECTIVE: To define the effects of Lee Silverman Voice Treatment (LSVT on swallowing and voice in eight patients with idiopathic Parkinson's disease. METHODS: Each patient received a modified barium swallow (MBS) in addition to voice recording before and after 1 month of LSVT. Swallowing motility disorders were defined and temporal measures of the swallow were completed from the MBS. Voice evaluation included measures of vocal intensity, fundamental frequency, and the patient's perception of speech change. RESULTS: before LSVT, the most prevalent swallowing motility disorders were oral phase problems including reduced tongue control and strength. Reduced tongue base retraction resulting in residue in the vallecula was the most common disorder in the pharyngeal stage of the swallow. Oral transit time (OTT) and pharyngeal transit time (PTT) were prolonged. After LSVT, there was an overall 51% reduction in the number of swallowing motility disorders. Some temporal measures of swallowing were also significantly reduced as was the approximate amount of oral residue after 3 ml and 5 ml liquid swallows. Voice changes after LSVT included a significant increase in vocal intensity during sustained vowel phonation as well as during reading. CONCLUSIONS: LSVT seemingly improved neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue base function during the oral and pharyngeal phases of swallowing as well as improving vocal intensity.

In vivo measurement of platinum in the kidneys using X-ray fluorescence.

A noninvasive in vivo method has been developed and optimized for measuring platinum concentrations in the kidneys of patients receiving chemotherapy. The method is based on polarizing the X-ray beam from an orthovoltage radiotherapy treatment unit, the Pantak DXT-300, and using the beam to produce emission of the characteristic platinum X-rays from the kidney. The platinum is derived from platinum-based chemotherapy drugs, such as cisplatin and its analogues (carboplatin and iproplatin), used to treat cancer patients. The clinical motivation for measuring the platinum concentration in both the kidneys and the tumor is to optimize the treatment by establishing the relationships between the accumulation of the drug at those sites. Such clinical information could be valuable in maximizing the therapeutic ratio toward the tumor tissue and limiting the hazards to the kidney. The performance of the system was experimentally optimized with respect to the applied X-ray tube voltage, filter material, and polarizer. Additionally, the MCNP-4B Monte-Carlo computer code was used to estimate the optimum shielding materials, the thickness surrounding the X-ray tube, and the arrangement of collimators, to protect patients from the hazards of the scattering radiation. Clinical measurements can be made with a combination of a bilayer of copper and silicon as polarizer, a 0.25-mm tin filter introduced in the path between the X-ray beam and the polarizer, and an operating voltage of 220 kV. The minimum detection limit achieved with this arrangement is 16 ppm, for a kidney depth of 3 x 3 cm, with a skin dose of 1.6 mGy and measurement time of 2,000 seconds.

Plane polarized x-ray fluorescence system for the in vivo measurement of platinum in head and neck tumours.

A plane polarized x-ray fluorescence system based on an orthovoltage radiotherapy treatment unit, the Pantak DXT-300, has been developed and optimized to measure tumour platinum concentration. The platinum derives from platinum based chemotherapy agents, such as cisplatin and carboplatin used to treat tumours in the head and neck region. Photons from an x-ray tube are polarized by scattering through 90 degrees, and used to stimulate the emission of characteristic platinum x-rays from the tumour. Information about the drug in the tumour could be of use in establishing dose-response relationships, in order to optimize the treatment and reduce the toxicity of the drug. The performance of the system was optimized with respect to the applied x-ray tube voltage, the current and the filter material; the effect on the minimum detection limit (MDL) of the thickness of the overlying tissue surrounding the tumour was investigated in detail. The lowest MDL is achieved using 0.25 mm of tin filter and x-ray tube voltage of 220 kV. This is 5.6 ppm for a tumour surrounded with 20 mm of overlying tissue, a measurement time of 2000 s and an estimated skin dose of 3.0 mGy. This represents the most sensitive in vivo XRF system to date. We have embarked on a clinical pilot study to measure the platinum concentration in tumours of the head and neck, and expect initial results to be available in the near future.

Body composition measurements using DXA and other techniques in tamoxifen-treated patients.

Tamoxifen is an anti-oestrogenic drug which is widely used in the treatment of patients with breast cancer. There is increasing interest in using the drug both for benign breast disease and as a chemo-preventative agent of the drug in women at high risk of breast cancer. Despite the fact that the acute side-effects of the drug are few, its agonistic and antagonistic oestrogenic effects are not fully known and may have some undesirable effects for patients treated with the drug for several years. A number of studies carried out recently indicate a varying degree of change in bone mineral content following treatment with tamoxifen. These studies concentrated mainly on bone mineral density measurements only and non of them reported the effects of tamoxifen on lean body mass and fat mass. In this study we measured lean body mass and fat mass in tamoxifen-treated females and a comparison group to determine the difference between the two groups. Twenty-six women receiving tamoxifen (20 mg/d) have participated in this study. The control group comprised 31 healthy women of a similar age. Total body bone mineral (TBBM) was measured using a dual-energy X-ray absorptiometry (DXA) (Hologic INV., Waltham, U.S.A.). Similarly, regional and total body soft tissue (lean and fat tissue) were measured using the DXA system. In addition to DXA measurements, percentage body fat (%BF) was measured using total body potassium counting (TBK), skinfold anthropometry (SF), infrared interactance (i.r.) and bioelectric impedance analysis (BIA). Results from DXA alone showed that there were no significant differences between the two groups for TBBM, regional and total body lean tissue mass. However, there was a significant difference between the two groups (P < 0.05) for %BF measurement. Similarly there was a significant difference between the two groups (P < 0.05) for %BF measured by other body composition techniques. Although there is no other research reported on the effects of tamoxifen on %BF, this retrospective study indicates that tamoxifen may lead to increase in fact content in women who are subjected to this treatment. We conclude that this observation is probably related to the agonistic oestrogenic effect of Tamoxifen on body fat. To our knowledge this deleterious effect has not been reported before and it should be taken into considerable when comprising different types of anti-oestrogenic drugs. Furthermore, patients should be warned about this side-effect when they are prescribed Tamoxifen therapy.

Optimisation of a polarised X-ray source for the in vivo measurement of platinum in head and neck tumours.

There is a continuing need to improve the understanding of kinetics of platinum-based chemotherapeutic agents, such as cisplatin and paraplatin. Although these agents demonstrate highly effective anti-cancer activity, they also have associated, often dose-limiting, side-effects such as nephrotoxocity. In vivo X-ray fluorescence (XRF) has been proven to be a suitable technique for measuring the uptake of these agents in tumour and critical organs, but radioisotope based systems have not found their way into routine clinical use due to their rapid increase in minimum detection limit (MDL) with depth. Polarised X-rays offer a solution to this problem by reducing the scattered background, which not only reduces the MDL, but also allows the intensity of the source to be increased without saturating the detector electronics. This paper describes the development and optimisation of a polarised XRF system for in vivo measurement of platinum in head and neck tumours, whose response to cisplatin is often unpredictable. The polarised X-ray source comprises a clinical X-ray therapy unit (the Pantak DXT-300) with removable purpose-built collimators. Optimisation studies have concentrated upon the operating voltage, polariser material and additional filtering. The optimum voltage was found to lie within the range 200-300 kV for all polarising materials. There was no significant difference using copper, aluminium or iron as the polariser. Increasing the additional filtering improved the MDL for a preset number of counts, but decreased the count-rate significantly, resulting in unacceptably long counting times. An MDL of 9 ppm was achieved for a phantom depth of 2 cm, using a copper polariser, 0.25 mm of tin filtering and an operating voltage of 220 kV. TLD measurements showed that the corresponding skin dose was 6 mGy. These results indicate a factor of improvement in the MDL from the previous 99mTc system, for a factor of two lower skin dose. The detection limit achieved is the lowest reported to date, and is considered adequate for a comprehensive patient study. It is anticipated that this will yield better information and the pharmacokinetics of platinum compounds and will lead to optimisation of both chemo and radiotherapy treatment. Additionally this technique can be easily integrated into any radiotherapy based department.

Implant rehabilitation of irradiated jaws: a preliminary report.

Ten patients (3 maxilla, 7 mandible), who had been treated for a head and neck malignancy by undergoing radiotherapy, had 42 implants (10 maxillary, 32 mandibular) placed into the irradiated sites and either an overdenture or a fixed prosthesis fabricated. Of the 10 implants placed in the maxilla, 6 were lost; however, there was a 100% survival rate of the implants placed in the mandible (mean duration = 33 months). The use of longer implants and pre- or postimplant hyperbaric oxygen may be necessary in maxillary situations.

Primary penile lymphoma: the case for combined modality therapy.

A patient with non-Hodgkin's lymphoma with a penile mass as the only apparent site of clinical involvement is presented, and the literature reviewed. Our patient was treated initially with partial penile amputation. A year later the lymphoma recurred in the chest and the right tonsil. Further chemotherapy failed to salvage the patient, who died of disseminated lymphoma. We suggest that, for patients presenting with a lymphomatous penile mass as the initial manifestation of non-Hodgkin's lymphoma, chemotherapy with or without radiotherapy as the initial treatment. Surgery should be reserved only for failures.

Management of residual thymic cysts in patients treated for mediastinal Hodgkin's disease.

The pathogenesis of residual thymic cysts after treatment for mediastinal Hodgkin's disease is uncertain. Their presence after adequate treatment often presents the oncologist and the thoracic surgeon with a therapeutic dilemma. Two patients with residual thymic cysts after curative treatment for mediastinal Hodgkin's disease are described and the management discussed.

133Xe for the in vivo X-ray fluorescence measurement of platinum.

In vivo measurements of platinum are important for studying the pharmacokinetics of platinum-based cytotoxic drugs. The technique of in vivo X-ray fluorescence can be utilized for such measurements. The feasibility of using 133Xe in near-backscatter (almost 180 degrees ) geometry has been investigated and results compared to phantom measurements made using 99Tcm in the same experimental set-up. An improvement in minimum detection limits is observed for all phantom depths less than 25 mm.

Malignant branchioma--a further insight.

Two cases presented with solitary cystic mass in the usual position of a branchial cyst in the neck are reported. Histology on both cysts reported as carcinoma of a branchial cyst (malignant branchioma). In addition to pre-operative radiotherapy to the neck, and ipsi-lateral radical neck dissection, the oropharynx is irradiated in prophylactic manner only in the second case. The first patient died of tonsillar carcinoma 3.5 years after diagnosis and the second case is well with no sign of recurrence 4 years after the initial diagnosis. The authors discuss the nature and management of the so called malignant branchioma.