Validation of predictors for lymph node status in penile cancer: Results from a population-based cohort.

INTRODUCTION: The ability to predict lymph node (LN) status is essential in the management of men with localized squamous cell carcinoma (SCC) of the penis. There has been limited external validation of available risk stratification tools, particularly in routine clinical care. The objective of this study was to evaluate the predictive variables of LN metastases within a large population-based cohort of patients. METHODS: In this population-based cohort study, surgical pathology reports were linked to the population-based Ontario Cancer Registry to identify all patients who were diagnosed with penile cancer in Ontario, Canada. Multivariable analyses were performed to evaluate predictive variables for LN involvement. Three contemporary risk stratification schemes used to predict LN status were analyzed by logistic regression. RESULTS: The study included 380 localized penile SCC cases treated between 2000 and 2010. Sixty-three (17%) had pathologically confirmed LN metastases. Among these, 35 (56%) were diagnosed within three months of the initial penile SCC diagnosis and these patients had a worse five-year disease-specific survival (43%; 95% confidence interval [CI] 26-64) compared to patients who were diagnosed at a delayed LN dissection. On multivariable analysis, age (odds ratio [OR] 0.68; 95% CI 0.52-0.88), pathological stage (≥pT1b; OR 3.32; 95% CI 1.38-8.01), and tumour grade (Grade 2 OR 2.98; 95% CI 1.26-7.62; Grade 3 OR 3.97; 95% CI 1.32-11.9) were associated with an increased risk of LN metastases. Candidate risk stratification schemes demonstrated moderate to good property, with C-statistics ranging from 0.662-0.747. CONCLUSIONS: Using a population-based cohort of penile cancer patients with a relatively low proportion of patients with pathologically confirmed LN involvement, we confirm and externally validate the importance of age, stage, and grade of the primary tumour in predicting nodal status.

Definitive proton beam therapy for adenoid cystic carcinoma of the nasopharynx involving the base of skull.

OBJECTIVES: Management of unresectable adenocystic carcinoma (ACC) of the nasopharynx is challenging given the high dose required for tumor control while respecting dose constraints. We evaluated long-term outcomes and toxicity in patients with unresectable ACC of the nasopharynx treated with definitive proton beam therapy. METHODS: Between 2000 and 2013, 14 patients with ACC of the nasopharynx were treated. Ninety-three percent had T4 disease. All had involvement of the skull base. Seventy-nine percent and 21% of patients underwent biopsy and endoscopic debulking surgery, respectively. Median dose was 73.8Gy (RBE). Fifty percent of patients received concurrent chemotherapy. Locoregional control and overall survival probabilities were estimated by the Kaplan-Meier method. Treatment toxicity was scored by the Common Terminology Criteria for Adverse Events version 4.0. RESULTS: Median follow-up of surviving patients was 69months. There were 3 local, 1 regional, and 4 distant failures. Median time of local failures was 69months (range: 63-161). All local recurrences were within previous high-dose regions. Four patients developed metastatic disease at a median of 30months (range: 4-64). Five-year overall survival was 59%. The most common cause of death was due to metastatic disease. There was one acute grade 3 toxicity. No patient required gastrostomy tube or hospitalization. Three patients developed grade 3 or higher late toxicity. Two of these patients received combined modality treatment. With 176months follow-up, no second cancer was observed. CONCLUSION: Proton beam therapy results in promising local control with acceptable toxicity in patients with unresectable ACC of the nasopharynx. As late recurrence is common, longer follow-up is necessary to confirm our findings.

Rapid improvement in pain and functional level in a patient with metastatic renal cell carcinoma: a case report and review of the literature.

Renal cell carcinoma (RCC) represents approximately 3% of all adult cancers and is more common in males. Systemic treatment for RCC has improved following the introduction of sunitinib. Bone metastases are present in up to 50% of RCC patients. We report a case of rapid improvement in metastatic bone lesions, recorded by nuclear bone scan, in a male patient receiving localized palliative radiotherapy in addition to systemic sunitinib and zoledronic acid. Concurrently, quality of life and performance status improved dramatically. Although we are unsure of the exact mechanism for such rapid improvement in metastatic bone lesions, the swiftness this improvement deserves reporting.

Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis.

BACKGROUND: Topical anesthetics, unlike injectable anesthetics, can be applied painlessly and can provide sufficient pain control to maintain patient comfort throughout a variety of laser procedures. Although the use of topical lidocaine is considered relatively safe, instances of cardiotoxic and neurotoxic adverse events have been reported to occur. OBSERVATIONS: A 52-year-old woman underwent fractional photothermolysis for management of severe hypopigmentation and scarring of several years' duration. Shortly after termination of treatment to her face and neck, which required prolonged exposure to a 30% lidocaine gel compound both before and during surgery, she developed clinical signs and symptoms consistent with systemic lidocaine toxicity. The results of laboratory studies confirmed serum lidocaine levels within the toxic range. We postulate that the combination of the high concentration of topical lidocaine required to achieve sufficient anesthesia, together with the laser-induced disruption in epidermal barrier function, may have been responsible for this phenomenon. CONCLUSIONS: Application of a 30% topical lidocaine gel to a limited area in conjunction with fractional photothermolysis may generate serum lidocaine levels high enough to elicit systemic toxicity. Laser surgeons should be alert to this phenomenon, particularly in patients with underlying hepatic, endocrine, cardiac, or central nervous system/psychiatric dysfunction; in patients with a low body mass index; and in patients who are taking medications that may interfere with hepatic lidocaine metabolism.