Ocular and adnexal rhinosporidiosis : the clinical profile and treatment outcomes in a tertiary eye care centre.

INTRODUCTION: Rhinosporidiosis may mimic a burst chalazion or a simple conjunctival polyp. OBJECTIVE: To study the demography, histopathological evaluation, treatment modalities, their outcomes and recurrence rates in patients clinically and histopathologically diagnosed as ocular and adnexal rhinosporidiosis. PATIENTS AND METHODS: The study was conducted in the Department of Orbit, Oculoplasty and Oncology at a tertiary eye care centre in South India. Fifty patients were included who were diagnosed with ocular and adnexal rhinosporidiosis. The conjunctival and lid mass underwent complete excision. All patients with rhinosporidiosis of the lacrimal system under went dacryocystectomy (DCT) with care taken to avoid spilling the spores. Diagnosis was confirmed histopathologically. RESULTS: The mean age at presentation was 30.42 years, standard deviation( SD) being 16.89 (1 - 70 years). The mean follow-up was 14.2 months (12 months - 18 months) . The most common site was conjunctiva (n = 26 eyes, 52 %), followed by the lacrimal sac ( n = 13, 26 %) and lids (n = 11, 22 %). All the cases were treated by surgical excision with cautery at the base. There was a single recurrence (2 %) involving the lacrimal sac. Endonasal polypectomy combined with exploration in the sac region was done. There were no further recurrences during subsequent follow-up. CONCLUSION: Rhinosporidiosis is an ocular disorder with high recurrence rates reported. We recommend histopathological examination in every case following excision biopsy for conclusive diagnosis. Recurrence rates can be very low if a complete meticulous excision coupled with cauterization of the lesion is performed.

Outcomes of manual small incision cataract surgery under topical anesthesia with lignocaine 2% jelly.

INTRODUCTION: The manual small incision cataract surgery (MSICS) is the surgery of choice in countries with a huge back-log of cataract blindness. OBJECTIVE: To evaluate the outcome of manual small incision cataract surgery (MSICS) under topical anesthesia with lignocaine 2 % jelly. MATERIALS AND METHODS: This study was a prospective interventional case series. One hundred and twenty eight patients of senile cataract were operated by MSICS under topical anesthesia using lignocaine 2% jelly. No intra-cameral anesthesia was used. The patients and the single operating surgeon were given a questionnaire to evaluate their experience in terms of pain, surgical experience and complications. RESULTS: The mean pain score was 0.82 (SD +/- 0.97). Seventy-one patients (55.4 %) had a pain score of zero, that is, no pain. One hundred and twenty one patients (94.5 %) had a score of 3 or less, that is, mild to none pain. All the surgeries except two were complication- free and the surgeon's experience was favorable in terms of the patient's cooperation, anterior chamber stability, difficulty, and complications. CONCLUSIONS: MSICS can be performed under topical anesthesia with lignocaine jelly, which makes the surgery patient-friendly, without compromising the outcome.

Pterygium surgery with conjunctival limbal autograft with fibrin glue under topical anaesthesia with lignocaine 2% jelly.

OBJECTIVE: To evaluate the efficacy of lignocaine 2 % jelly as topical anesthesia in pterygium surgery with conjunctival limbal autograft using fibrin glue. MATERIALS AND METHODS: A non-randomized interventional study was carried out including twenty-one patients who presented with primary pterygium. Under 2% lignocaine jelly, surgical dissection of the pterygium, scraping of corneal bed with crescent blade, excision of Tenons capsule, harvesting conjunctival limbal autograft superiorly, and securing it with respect to limbus and stromal orientation with fibrin glue were done. Postoperatively, the patients discomfort and pain were evaluated by Wongs pain scoring system. RESULTS: The mean pain score was 0.70 ± 0.97. Only one patient (4.76%) out of the whole series experienced pain who rated more than three on the visual analog scale of 5. Thirteen patients (61.9%) had pain score of zero, that is, no pain. The surgeons evaluation of the technique in terms of surgical ease and complications was favorable. There were no dislodged grafts and no cases required suturing. There were no cases of infection, significant inflammation, epithelial problems and reduction in visual acuity. There was a single case of recurrence (4.76%) five months postoperatively which was managed conservatively. CONCLUSIONS: Topical anesthesia with lignocaine 2% jelly using fibrin sealant is safe and effective in pterygium surgery allowing for short operative times. It results in low pain and good aesthetic and functional outcomes.

A multi-centre randomised phase III trial of Dexamethasone vs Dexamethasone and diethylstilbestrol in castration-resistant prostate cancer: immediate vs deferred Diethylstilbestrol.

BACKGROUND: The role of further hormone therapy in castration-resistant prostate cancer (CRPC) remains unclear. We performed a multi-centre randomised phase III study comparing the use of Dexamethasone, Aspirin, and immediate addition of Diethylstilbestrol (DAiS) vs Dexamethasone, Aspirin, and deferred (until disease progression) addition of Diethylstilbestrol (DAdS). METHODS: From 2001 to 2008, 270 men with chemotherapy-naive CRPC were randomly assigned, in a 1 : 1 ratio, to receive either DAiS or DAdS. They were stratified for performance status, presence of bone metastases, and previous normalisation of prostate-specific antigen (PSA) to androgen deprivation. The study end points were the proportion of patients achieving a 50% PSA response, progression-free survival (PFS), overall survival, and quality of life. Intention-to-treat analysis was carried out. The effect of treatment was studied first by Kaplan-Meier curves and log-rank test, and finally through multivariable stratified Cox's proportional hazards model adjusting for the effects of possible baseline prognostic factors. Quality of life was analysed using multivariate analysis of variance. RESULTS: At study entry, the median age was 76 years (inter-quartile range: 70-80 years), the median PSA was 79 ng ml(-1), and 76% of the cohort had metastatic disease. The response rates for DAiS (68%) and DAdS (64%) were not significantly different (P=0.49). Similar to the response rate, neither the PFS (median=8.1 months for both arms) nor the overall survival (19.4 vs 18.8 months) differed significantly between the DAiS and DAdS groups (P>0.20). However, the response rate for the DAiS (68%) was significantly higher than the response rate of DA (before adding Diethylstilbestrol) (50%) (P=0.002). Similarly, the median time to progression for DAiS (8.6 months) was significantly longer than that of DA (4.5 months) (P<0.001). Multivariable analysis showed that patients with previous haemoglobin ≥11 g dl(-1) decreased the risk of death significantly (hazard ratio: 0.44, 95% CI: 0.25-0.77). Patients treated with previous anti-androgens alone had more than 5 times more risk of death compared with patients treated with gonadorelin analogues throughout their castration-sensitive phase. Treatment sequencing did not affect the quality of life but pre-treatment performance status did. The incidence of veno-thromboembolic events was 22% (n=28) in DAiS and 11% (n=14) in the DA arm (P=0.02). Painful gynaecomastia occurred in only 1% on DA, whereas in 40% on DAiS (P=0.001). CONCLUSION: Dexamethasone and immediate Diethylstilbestrol resulted in neither higher PSA response rate nor higher PFS compared with Dexamethasone with deferred Diethylstilbestrol. There was no suggestion of significantly improved overall survival or quality of life. Given the significantly higher toxicity of Diethylstilbestrol, deferring Diethylstilbestrol until failure of Dexamethasone is the preferred strategy when using these agents in CRPC.

Pseudomyxoma peritonei.

Pseudomyxoma peritonei is a rare form of mucinous ascites associated with peritoneal and omental implants. The origin is controversial, and recent immunohistochemical and molecular genetic evidence suggests the appendix to be the likely site. The condition often presents as an incidental finding at laparotomy. Ultrasonography, computed tomography and magnetic resonance imaging aid in preoperative diagnosis. Treatment remains controversial, surgery being the main stay. The role of intraperitoneal and systemic chemotherapy is poorly defined. We review the literature on the pathology, clinical features and treatment options in pseudomyxoma peritonei.

Cells from individuals with SOD-1 associated familial amyotrophic lateral sclerosis do not have an increased susceptibility to radiation-induced free radical production or DNA damage.

Oxidative stress may play a role in the pathogenesis of familial amyotrophic lateral sclerosis (FALS). Superoxide dismutases (SODs) are enzymes that can influence free radical processes in irradiated cells and there is some evidence that manipulation of SODs can affect survival of cells after radiation treatments. SOD-1 associated FALS mutants may have an altered radiation response due to an enhanced generation of hydroxyl radicals or a compromised ability to neutralize free radicals. We have investigated the ability of the lymphoblastoid cell lines from FALS patients with SOD-1 gene mutations, patients with sporadic ALS and controls to handle oxidative stress induced by ionising radiation by measuring levels of intracellular reactive oxygen species and production of DNA double-strand breaks. Levels of reactive oxygen species, expressed as the slope of the relative fluorescence of a radical-reactive fluorochrome, in the cells from familial ALS patients with SOD-1 gene mutations (2.14+/-1.06 Gy(-1)) and patients with sporadic ALS (1.38+/-0.21 Gy(-1)) were not significantly different from the controls (1.54+/-0.39 Gy(-1)). No significant difference was observed in the production of DNA double-strand breaks between three groups. The ability of lymphoblastoid cells from FALS patients with SOD-1 gene mutations to scavenge radiation-induced free radicals is not compromised nor is their ability to protect DNA damage induced by ionising radiation.

DNA strand break rejoining defect in xrs-6 is complemented by transfection with the human Ku80 gene.

The radiosensitive mutant xrs-6, derived from Chinese hamster ovary cell line CHO-K1, has been demonstrated to be defective in DNA double-strand break repair and also in its proficiency to undergo V(D)J recombination. Recent work has provided both genetic and biochemical evidence that the M(r) 80,000 subunit of the Ku protein is able to complement the radiosensitivity and the V(D)J recombination defect in the xrs-6 mutant. We demonstrate here that complementation of the radiosensitive phenotype in xrs-6 cells by the introduction of Ku80 cDNA is accompanied by the concomitant restoration of DNA double-strand break rejoining proficiency to almost that of the parental CHO-K1 cells, as measured both by neutral single-cell microgel electrophoresis (Comet) technique and by pulsed-field gel electrophoresis. These results provide further biochemical evidence for the involvement of the Ku protein in the repair of DNA double-strand breaks.

Radiotherapy for bone pain.

Painful bone metastases are a common problem for cancer patients. Although current evidence supports the use of a single fraction of radiotherapy as the treatment of choice, many radiotherapists, for a variety of reasons, continue to use fractionated regimens. Over one six month period 105 patients received external beam irradiation for painful bone metastases at the Royal London Hospital (RLH). Thirty-one per cent of the patients were aged 70 or over. The treatment of 97 of these patients was assessed. They had a total of 280 sites treated over the course of their disease. Fifty-nine per cent of sites treated received a fractionated course of radiotherapy. Site significantly influenced fractionation. Overall response rates of 82% were achieved. Fractionation did not appear to influence this. Ten patients received large field irradiation. Fifteen patients had five or more sites irradiated, of whom only one received hemibody irradiation.

Retreatment with radiotherapy for painful bone metastases.

PURPOSE: To evaluate the response to reirradiation of painful bone metastases following initial treatment with radiotherapy. METHODS AND MATERIALS: A retrospective analysis of 105 consecutive patients treated with palliative radiotherapy for painful bone metastases. A total of 280 individual treatment sites were identified, of which 57 were retreated once and 8 were retreated twice. RESULTS: The overall response rate to initial treatment was 84% for pain relief, and at first retreatment this was 87%. Seven of eight patients retreated a second time also achieved pain relief. No relation to radiation dose, primary tumor type, or site was seen. CONCLUSIONS: In patients relapsing after radiotherapy to painful bone metastases who have responded initially, reirradiation can be recommended with a similar probability of response.

Reduced bone mineral density in long-term survivors of medulloblastoma.

Bone mineral density (BMD) reaches a peak at approximately 30 years of age, and may be influenced by radiotherapy before completion of skeletal maturation. Regional BMD has been measured using dual energy X-Ray absorptiometry (DEXA) in adults following craniospinal irradiation for medulloblastoma between ages 4 and 19 years, receiving doses of 3500-4000 cGy to the brain and spinal cord. Lumbar spine (LS) and was failure to achieve normal adult BMD at both LS and FN, with a mean reduction at LS of 12.1% +/- 2.4% (p < 0.01) and a mean reduction at FN of 14.3% +/- 3.4% (p < 0.01). The mean body mass index (BMI) was also less than that of a standard population (21.8 +/- 1.5), as were mean standing and sitting heights. No relationship was found between reduction in BMD at either site and age at irradiation, time elapsed since irradiation or BMI at time of scanning. Biochemical and endocrine markers including corrected calcium, alkaline phosphatase, sex hormones and IGF-1 were normal in all seven patients. The reduction in BMD outside the irradiated area suggests that indirect factors may be important in this effect.

External beam radiotherapy for carcinoma of the prostate: a retrospective study.

Two hundred and thirty-seven consecutive patients receiving radiotherapy for primary prostatic carcinoma have been reviewed. The presenting symptoms included acute retention (29%), chronic outflow obstruction (78%) and haematuria (12%). The diagnosis was confirmed at trans-urethral resection of the prostate (TURP) in 95%; all but seven patients had adenocarcinoma. The clinical stage at presentation was T0 (3%), T1 (9%), T2 (49%), T3 (21%) and T4 (17%). Two hundred and six patients (87%) received primary radiotherapy, 38 (16%) had concurrent endocrine therapy. Local relapse alone occurred in 38 patients (16%), distant relapse alone occurred in 30 (13%), and both local and distant relapse occurred in 30 (13%). Median time to local relapse alone was 25 months, distant relapse alone 14 months, and local and distant relapse 22 months. Overall survival was related to stage and grade at presentation. No influence of endocrine therapy, dose or planning technique was seen, but a significant advantage for those patients treated using a planned volume compared with parallel opposed fields was observed. Acute radiation toxicity affecting the bladder occurred in 42% and the bowel in 45%. Late toxicity affecting the bladder occurred in 7% and the bowel in 2%.