The Impact of High-Dose-Rate Brachytherapy: Measuring Clinical Outcomes in the Primary Treatment of Cervical Cancer.

PURPOSE: Radical concurrent chemoradiotherapy with combined external beam radiotherapy (EBRT) and brachytherapy is used to treat locally advanced cervical cancer. Our institution has transitioned to high-dose-rate (HDR) intracavitary brachytherapy (ICBT) from low-dose-rate (LDR) brachytherapy in 2008, and a review was conducted on the effect of this change on patient outcomes. METHODS AND MATERIALS: A single-arm retrospective chart review was performed on locally advanced (Fédération Internationale de Gynécologie et d'Obstétrique stage IB-IVA) patients with cervical cancer treated with combined external beam radiation therapy and HDR-ICBT with curative intent between 2008 and 2014. Clinical outcomes were evaluated, and multivariate analysis was performed to identify prognostic factors. RESULTS: Of the 76 patients selected, median age was 47.9 years and median follow-up was 5.2 years. Thirteen patients (17.1%) developed locoregional recurrence and 23 patients (30.3%) patients developed distant recurrence. Five-year progression-free survival and overall survival were 63.7% and 69.3%, respectively. A significant survival difference was found between stages (P < .001). Multivariate analysis found nodal involvement was strongly associated with poorer survival (P = .007). CONCLUSIONS: Our experience with the transition to HDR-ICBT as part of concurrent chemoradiotherapy in treatment of locally advanced cervical cancer resulted in acceptable long-term outcomes and toxicity to that of LDR brachytherapy. Potential further improvement of treatment outcomes for patients may be possible with image guided brachytherapy and the addition of effective systemic therapy.

The Utility of Penile Bulb Contouring to Localise the Prostate Apex as Compared to Urethrography.

PURPOSE: High-precision radiotherapy relies on accurate anatomic localisation. Urethrography is often used to localise the prostatic apex. However, urethrography is an invasive localisation procedure and may introduce a systemic error. The penile bulb (PB) is contoured to minimise the risk of erectile dysfunction. The purpose of this study is to assess the value of using the PB, as an alternative to urethrography, to localise the prostate. METHODS AND MATERIALS: The PB was localised on 10 patients treated with simplified intensity-modulated arc radiotherapy at computed tomography simulation during treatment weeks 1 and 7. All patients underwent placement of fiducial markers. Urethrography was used only at simulation. Distances from the superior PB contour to the inferior prostate contour, the apex fiducial marker, and to the inferior prostate contour were obtained as well. The PB was contoured by two observers independently. Agreement coefficients and analysis of variance were used to assess reliability between rates and consistency of measurements over time. RESULTS: The PB-apex distance was greater than or equal to the urethrogram-apex distance in 24/30 (80%) measurements, and the median difference was 3 mm and was consistent between raters. The greatest variation in PB-IM distance between weeks was 6 mm, the median was 3 mm, and the agreements of measurements between weeks for raters 1 and 2 were 0.79 and 0.69, respectively. These differences were not statistically different and were consistent with the computed tomography slice thickness. CONCLUSIONS: The PB can be used to identify the prostate apex and can be reliably contoured between observers. Measurements are consistent between patients and through the duration of treatment. The PB distance measurements support studies indicating that urethrography causes a shift of the prostate superiorly. The distance from the PB to prostate apex remains stable during treatment for individual patients but varies between patients.

Complete Remission in Locally Advanced Breast Cancer: What Comprehensive Multi-Modality Treatment Has to Offer in Sub-Saharan Africa.

Locally advanced breast cancer presents as a heterogeneous disease, but it is often best treated with aggressive combined modality therapy.  Commonly, it carries a more guarded prognosis. Given the above, it can be a particularly challenging entity to treat in resource-limited settings. We identify one such case with a relative lack of hormone receptor positivity in the sub-Saharan country of Zambia. Management of the disease was hampered by the challenges of resource constraints and communication gaps that are especially acute in low- to middle-income nations as compared to Western societies. However, with skilled interdisciplinary advice and the means available at a tertiary care facility, our patient was able to afford a superior clinical outcome in the form of a pathologic complete response via the use of surgical, systemic, and radiotherapy modalities. Additionally, the ensuing remission was corroborated by a careful follow-up regime. We thus reinforce the feasibility and value of a team-based approach in the management of this disease regardless of the setting.

Perianal Pagetoid Intraepithelial Carcinoma.

Extramammary Paget disease (EMPD) involving the perianal region is rare and challenging to manage. Primary EMPD involves stand-alone noninvasive lesions within the epidermis, while secondary EMPD involves phenotypically similar lesions derived from separate underlying malignancies. Differentiating between primary and secondary EMPD is challenging when no underlying malignancies are detected during workup. Continued reporting of perianal EMPD cases is encouraged so that risk stratification can be improved and patients can be managed with an appropriate level of aggressiveness. Herein, we report the case of a 74-year-old woman who chose aggressive surgical management after being diagnosed with perianal pagetoid intraepithelial carcinoma from a suspected occult underlying primary colorectal tumor.

Construction and validation of a low-cost laparoscopic simulator for surgical education.

INTRODUCTION: To construct a trainer that would achieve the equivalent goals of the Fundamentals of Laparoscopic Surgery (FLS) trainer at an economical cost. A validation study comparing our homemade (HM) trainer vs the FLS trainer was performed. A literature search as well as a price comparison with other commercially available laparoscopic trainers is presented. METHODS: The HM laparoscopic trainer was constructed using a prefabricated hard plastic frame with a vinyl plastic sheet affixed as the roof. A row of light-emitting diode lights and a charge-coupled device camera were mounted on the inside roof of the frame. Electrical wires were spliced to supply power to both the light-emitting diode lights and the camera. The charge-coupled device camera was connected to a liquid crystal display screen which was affixed directly across from the user. Subjects were prospectively randomized to perform the 5 tasks put forth by the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills on both the HM trainer and the FLS trainer (pegboard transfer, pattern cut, placement of ligating loop, extracorporeal knot suture, and intracorporeal knot suture). Simple paired t test was performed to compare times between the trainers. SETTING: The construction of the trainer and the validation study were performed at the Central Michigan University College of Medicine Department of Simulation. PARTICIPANTS: Subjects consisted of third- and fourth-year medical students (n = 30). RESULTS: A laparoscopic trainer box was constructed and assembled in 2 hours. The HM trainer cost $309 representing a cost savings of $1371. Results of the validation study demonstrated no statistical difference in times to complete 3 out of the 5 tasks as well as no difference in total time to complete all 5 tasks (p value< 0.05). CONCLUSION: Valid laparoscopic simulators can be constructed at an economical cost.