Outcomes of extended radical resections for locally advanced and recurrent pelvic malignancy involving the aortoiliac axis.

AIM: Currently, there is no clear consensus on the role of extended pelvic resections for locally advanced or recurrent disease involving major vascular structures. The aims of this study were to report the outcomes of consecutive patients undergoing extended resections for pelvic malignancy involving the aortoiliac axis. METHODS: Prospective data were collected on patients having extended radical resections for locally advanced or recurrent pelvic malignancies, with aortoiliac axis involvement, requiring en bloc vascular resection and reconstruction, at a single institution between 2014 and 2018. RESULTS: Eleven patients were included (median age 60 years; range 31-69 years; seven women). The majority required resection of both arterial and venous systems (n = 8), and the technique for vascular reconstruction was either interposition grafts or femoral-femoral crossover grafts. The median operative time was 510 min (range 330-960 min). Clear resection margins (R0) were achieved in nine patients. The median length of stay was 25 days (range 7-83 days). Seven patients did not suffer an early complication. There was one serious complication (Clavien-Dindo ≥ 3), an arterial graft occlusion secondary to thrombus in the immediate postoperative period, requiring a return to theatre and thrombectomy. The median length of follow-up in this study was 22 months (range 4-58 months). CONCLUSION: This series demonstrates that en bloc major vascular resection and reconstruction can be performed safely and can achieve clear resection margins in selected patients with locally advanced or recurrent pelvic malignancy at specialist surgery centres.

Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review.

AIM: Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer. METHODS: A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality. RESULTS: There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74 years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7 days, compared with 2.5-4.0 days, P < 0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P < 0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P < 0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P < 0.001). Two studies reported significantly higher lymph node harvest in RRH (P < 0.05). Overall morbidity and 30-day mortality were comparable in both approaches. CONCLUSION: Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.

Final overall survival analysis for the phase II RECORD-3 study of first-line everolimus followed by sunitinib versus first-line sunitinib followed by everolimus in metastatic RCC.

BACKGROUND: RECORD-3 compared everolimus and sunitinib as first-line therapy, and the sequence of everolimus followed by sunitinib at progression compared with the opposite (standard) sequence in patients with metastatic renal cell carcinoma (mRCC). This final overall survival (OS) analysis evaluated mature data for secondary end points. PATIENTS AND METHODS: Patients received either first-line everolimus followed by second-line sunitinib at progression (n = 238) or first-line sunitinib followed by second-line everolimus (n = 233). Secondary end points were combined first- and second-line progression-free survival (PFS), OS, and safety. The impacts of neutrophil lymphocyte ratio (NLR) and baseline levels of soluble biomarkers on OS were explored. RESULTS: At final analysis, median duration of exposure was 5.6 months for everolimus and 8.3 months for sunitinib. Median combined PFS was 21.7 months [95% confidence interval (CI) 15.1-26.7] with everolimus-sunitinib and 22.2 months (95% CI 16.0-29.8) with sunitinib-everolimus [hazard ratio (HR)EVE-SUN/SUN-EVE, 1.2; 95% CI 0.9-1.6]. Median OS was 22.4 months (95% CI 18.6-33.3) for everolimus-sunitinib and 29.5 months (95% CI 22.8-33.1) for sunitinib-everolimus (HREVE-SUN/SUN-EVE, 1.1; 95% CI 0.9-1.4). The rates of grade 3 and 4 adverse events suspected to be related to second-line therapy were 47% with everolimus and 57% with sunitinib. Higher NLR and 12 soluble biomarker levels were identified as prognostic markers for poor OS with the association being largely independent of treatment sequences. CONCLUSIONS: Results of this final OS analysis support the sequence of sunitinib followed by everolimus at progression in patients with mRCC. The safety profiles of everolimus and sunitinib were consistent with those previously reported, and there were no unexpected safety signals. CLINICAL TRIALS NUMBER: ClinicalTrials.gov identifier, NCT00903175.

Peritoneal implantation of ureter in cadaveric renal transplant.

We report here a case of complication of peritoneal implantation of ureter in cadaveric renal transplant. The patient presented with anuria and delayed graft function. The diagnosis was suspected upon physical examination and radiological investigation. The complication was managed with reimplantation of the ureter into the bladder and the patient recovered with good graft function. We discuss this case, review the literature on this rare complication, and share our suggestions on how it can be prevented.

Docetaxel chemotherapy for Chinese patients with castrate-resistant prostate cancer.

OBJECTIVE. To determine the effectiveness and toxicity of docetaxel for Chinese patients with castrate-resistant prostate cancer in a local Hong Kong hospital. DESIGN. Case series. SETTING. A tertiary cancer centre in Hong Kong. PATIENTS. In all, 39 castrate-resistant prostate cancer patients were treated with 3-weekly docetaxel at 75 mg/m(2) and prednisolone 10 mg daily between January 2006 and December 2011 in Queen Elizabeth Hospital. MAIN OUTCOME MEASURES. Prostate-specific antigen control rate, pain control rate, progression-free survival, overall survival, and complication rates. RESULTS. The prostate-specific antigen response rate was 36%, and 27 (69%) of the patients had improved pain control after chemotherapy. The median progression-free survival, cancer-specific survival, and overall survival was 7.8 (95% confidence interval, 4.9-10.8) months, 13.0 (95% confidence interval, 9.6-16.3) months, and 12.2 (95% confidence interval, 9.3-15.1) months, respectively. The grade 3 anaemia and thrombocytopenia rates were 5%, and the neutropenic fever rate was 8%. CONCLUSIONS. Chemotherapy with docetaxel at a dose of 75 mg/m(2) given once every 3 weeks together with daily prednisolone is well tolerated in Chinese and can offer good symptom palliation in suitable patients with castrate-resistant prostate cancer.

The first 5 years since trauma center designation in the Hong Kong Special Administrative Region, People's Republic of China.

BACKGROUND: In 1994, the Hong Kong Special Administrative Region (HKSAR) introduced plans to implement a trauma system based on the recommendations outlined by Professor Donald Trunkey in his report to the local Hospital Authority. Five government-subsidized public hospitals were subsequently designated as trauma centers in 2003. This article reviews the initial experience in these five centers. METHODS: Prospective trauma registries from January 2004 to December 2008 were reviewed. Primary clinical outcome measures were hospital mortality. The Trauma and Injury Severity Score methodology was used for benchmarking with the Major Trauma Outcome Study (MTOS) database. RESULTS: The majority (83.3%) of the 10,462 patients suffered from blunt trauma. Severe injury, defined as Injury Severity Score>15, occurred in 29.7% of patients. The leading causes of trauma were motor vehicle collisions and falls, with crude hospital mortality rates of 6.9% and 10.7%, respectively. The M-statistic was 0.95, indicating comparable case-mix with the MTOS. The worst outcome occurred in the first year. Significant improvement was seen in patients with penetrating injuries. By 2008, these patients had significantly higher survival rates than expected (Z-statistic=0.85). Although the overall mortality rates for blunt trauma were higher than expected, the difference was no longer statistically significant from the second year onward. CONCLUSIONS: The case-mix of trauma patients in the HKSAR is comparable with that of the MTOS. A young trauma system relatively unburdened by dissimilar reimbursement and patient access issues may achieve significant improvement and satisfactory patient outcomes. Our findings may serve as a useful benchmark for HK and other Southeast Asian cities and trauma systems to establish local coefficients for future evaluations.

A population-based analysis of incidence, mortality, and stage-specific survival of cervical cancer patients in Hong Kong: 1997-2006.

OBJECTIVES: To determine the trends in incidence and mortality of cervical cancer patients diagnosed during 1997 to 2006, and to describe stage-specific survival using population-based cancer registry data. DESIGN: Retrospective, population-based study. SETTING: Hong Kong. PATIENTS: All patients diagnosed with cervical cancer between 1997 and 2006. Patients eligible for survival analysis were followed up till 31 December 2007. MAIN OUTCOME MEASURES: Age-standardised incidence and mortality rates and average annual percent changes in these parameters were calculated using the Poisson regression model. Survival was expressed as relative survival rate using a period approach. Hazard ratios of mortality including 95% confidence intervals for certain variables were estimated using the Cox proportional hazards model. RESULTS: During the 10-year period of the study, overall annual incidence and mortality rates decreased by 4.2% and 6.0%, respectively. Significant rates of reduction were observed in all age-groups except those younger than 45 years. The reduction in incidence of squamous cell carcinoma (3.6% annually) was less than that of adenocarcinoma (5.2%) and other histological types (6.8%). In all, 3807 (86.4%) of the patients were included in survival analysis. The overall 5-year relative survival rate was 71.3% (95% confidence interval, 69.5-73.1%), while the values for stages I, II, III, and IV were 90.9%, 71.0%, 41.7%, and 7.8%, respectively. Age, stage, and histology were independent prognostic factors. Survival of stage IA patients was as good as that of the general population. CONCLUSIONS: As in other industrialised countries, the incidence and mortality rate of cervical cancer were decreasing. Stage-specific population-based cancer survival was available for the first time, and was useful as an indicator of cancer control. Collaboration between public and private sectors to further improve the follow-up data could provide more comprehensive surveillance information.

Sodium 5,6-benzylidene-L-ascorbate induces oxidative stress, autophagy, and growth arrest in human colon cancer HT-29 cells.

Our previous studies have demonstrated the oxidative stress properties of sodium ascorbate (SAA) and its benzaldehyde derivative (SBA) on cancer cell lines, but the molecular mechanisms mediating their cytotoxicity remain unclear. In this study, we treated human colon cancer HT-29 cells with SAA and SBA, and found a significant exposure time-dependent increase of cytotoxicity in both treatments, with a higher cytotoxicity for 24 h with SAA (IC(50) = 5 mM) than SBA (IC(50) = 10 mM). A short-term treatment of cells with 10 mM SAA for 2 h revealed a destabilization of the lysosomes and subsequent induction of cell death, whereas 10 mM SBA triggered a remarkable production of reactive oxidative species, phosphorylation of survival kinase AKT, expression of cyclin kinase-dependent inhibitor p21, and induction of transient growth arrest. The crucial role of p21 mediating this cytotoxicity was confirmed by isogenic derivatives of the human colon carcinoma HCT116 cell lines (p21(+/+) and p21(-/-)), and immunoprecipitation studies with p21 antibody. The SAA cytotoxicity was blocked by co-incubation with catalase, whereas the SBA cytotoxicity and its subsequent growth arrest were abolished by N-acetyl-L-cysteine (NAC), but was not affected by PI3K phosphorylation inhibitor LY294002, or catalase, suggesting two separated oxidative stress pathways were mediated by these two ascorbates. In addition, neither active caspase 3 nor apoptotic bodies but autophagic vacuoles associated with increased LC3-II were found in SBA-treated HT-29 cells; implicating that SBA induced AKT phosphorylation-autophagy and p21-growth arrest in colon cancer HT-29 cells through an NAC-inhibitable oxidative stress pathway.

Magnetoencephalography and its role in evaluation for epilepsy surgery.

Magnetoencephalography is a newly developed technology used for diagnostic and brain mapping imaging during the presurgical evaluation of patients with medically intractable epilepsy. It provides comprehensive localisation of an epileptogenic focus using simultaneous recordings from the entire brain surface. Magnetoencephalography and electroencephalography are considered complementary and confirmatory to one another. We present a patient with magnetic resonance imaging-negative, non-lesional, neocortical epilepsy. Magnetoencephalography was used for re-evaluation of the epileptogenic zone and this enabled subsequent surgical removal of the epileptic focus. The role of magnetoencephalography in epilepsy surgery is discussed in this report.

Combining functional and linkage disequilibrium information in the selection of tag SNPs.

UNLABELLED: We have developed an online program, WCLUSTAG, for tag SNP selection that allows the user to specify variable tagging thresholds for different SNPs. Tag SNPs are selected such that a SNP with user-specified tagging threshold C will have a minimum R2 of C with at least one tag SNP. This flexible feature is useful for researchers who wish to prioritize genomic regions or SNPs in an association study. AVAILABILITY: The online WCLUSTAG program is available at http://bioinfo.hku.hk/wclustag/

Improving observer variability in target delineation for gastro-oesophageal cancer--the role of (18F)fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography.

AIM: To evaluate the effect of the addition of fused positron emission tomography-computed tomography (PET-CT) imaging vs computed tomography alone in the identification of the gross tumour volume (GTV) in patients with gastro-oesophageal carcinoma. MATERIALS AND METHODS: Ten patients with gastro-oesophageal cancer referred for radiation therapy underwent both (18F)fluoro-2-deoxy-d-glucose-PET (FDG-PET) and computed tomography in the treatment position. Image sets were anonymised and co-registered. Six radiation oncologists independently defined the GTV, first using the computed tomography data alone supplemented by standardised clinical and diagnostic imaging information, and second, using co-registered computed tomography and FDG-PET data (PET-CT). The standard deviation for both GTV length and volume (excluding involved lymph nodes) was taken as a measurement of inter-observer and intra-observer variability. Computer software that calculates volume overlap between contours was also used to generate an observer agreement index to compare intra- and inter-observer variability. RESULTS: The addition of FDG-PET imaging decreased the median standard deviation for tumour length from 10 mm (range 8.1-33.3, mean 12.4 mm) for computed tomography alone to 8mm (range 4.4-18.1, mean 8.1 mm) for PET-CT (P = 0.02). Eight of the 10 patients showed an increase in volume of overlap between observers with the addition of FDG-PET imaging to the contouring process (P = 0.05). The average observer agreement index in PET-CT was 72.7% compared with 69.1% when using computed tomography alone. There was significantly less intra-observer variability in all measures when PET-CT was used. The median standard deviation in length improved from 5.3 to 1.8 mm, the median standard deviation in volume improved from 4.5 to 3 cm3 and the median observer agreement index improved from 76.2 to 78.7% when computed tomography alone was compared with PET-CT. The corresponding P values were 0.001, 0.033 and 0.022, respectively. CONCLUSIONS: The addition of FDG-PET to computed tomography-based planning for the identification of primary tumour GTV in patients with gastro-oesophageal carcinoma decreases both inter-observer and intra-observer variability.

Video-assisted anal fistula treatment: a high volume unit initial experience.

Introduction Perianal fistulas are a common problem. Video-assisted anal fistula treatment is a new technique for the management of this difficult condition. We describe our initial experience with the technique to facilitate the treatment of established perianal fistulas. Methods We reviewed a prospectively maintained database relating to consecutive patients undergoing video-assisted anal fistula treatment in a single unit. Results Seventy-eight consecutive patients had their perianal fistulas treated with video-assistance from November 2014 to June 2016. Complete follow-up data were available in 74 patients, with median follow-up of 14 months (interquartile range 7-19 months). There were no complications and all patients were treated as day cases. Most patients had recurrent disease, with 57 (77%) having had previous fistula surgery. At follow-up, 60 (81%) patients reported themselves 'cured' (asymptomatic) including 5 patients with Crohn's disease and one who had undergone 10 previous surgical procedures. Logistical stepwise regression did not demonstrate any statistically significant factors that may have been considered to affect outcome (age, gender, diabetes, previous I&D, Crohn's disease, smoking, type of fistula). Conclusions Our data have shown that video-assisted anal fistula treatment is safe and effective in the management of perianal fistulas in our patients and this suggests it may be applied to all patients regardless of comorbidity, underlying pathology or type of fistula.

The TIGR Gene Indices: clustering and assembling EST and known genes and integration with eukaryotic genomes.

Although the list of completed genome sequencing projects has expanded rapidly, sequencing and analysis of expressed sequence tags (ESTs) remain a primary tool for discovery of novel genes in many eukaryotes and a key element in genome annotation. The TIGR Gene Indices (http://www.tigr.org/tdb/tgi) are a collection of 77 species-specific databases that use a highly refined protocol to analyze gene and EST sequences in an attempt to identify and characterize expressed transcripts and to present them on the Web in a user-friendly, consistent fashion. A Gene Index database is constructed for each selected organism by first clustering, then assembling EST and annotated cDNA and gene sequences from GenBank. This process produces a set of unique, high-fidelity virtual transcripts, or tentative consensus (TC) sequences. The TC sequences can be used to provide putative genes with functional annotation, to link the transcripts to genetic and physical maps, to provide links to orthologous and paralogous genes, and as a resource for comparative and functional genomic analysis.

Oncogenic osteomalacia associated with an occult phosphaturic mesenchymal tumour: clinico-radiologico-pathological correlation and ultrastructural studies.

A middle-aged man presented with bone pain at multiple sites due to tumour-induced osteomalacia. The underlying occult phosphaturic mesenchymal tumour was identified by octreotide scan 5 years after presentation and confirmed by computed tomography. Tumour resection resulted in normalisation of blood chemistry and bone densitometry. Clinico-radiologico-pathological correlation and ultrastructural studies of the tumour threw light on the pathogenesis and pathophysiology of this rare disease.

Concurrent chemotherapy-radiotherapy compared with radiotherapy alone in locoregionally advanced nasopharyngeal carcinoma: progression-free survival analysis of a phase III randomized trial.

PURPOSE: Nasopharyngeal carcinoma (NPC) is highly sensitive to both radiotherapy (RT) and chemotherapy. This randomized phase III trial compared concurrent cisplatin-RT (CRT) with RT alone in patients with locoregionally advanced NPC. PATIENTS AND METHODS: Patients with Ho's N2 or N3 stage or N1 stage with nodal size > or = 4 cm were randomized to receive cisplatin 40 mg/m(2) weekly up to 8 weeks concurrently with radical RT (CRT) or RT alone. The primary end point was progression-free survival (PFS). RESULTS: Three hundred fifty eligible patients were randomized. Baseline patient characteristics were comparable in both arms. There were significantly more toxicities, including mucositis, myelosuppression, and weight loss in the CRT arm. There were no treatment-related deaths in the CRT arm, and one patient died during treatment in the RT-alone arm. At a median follow-up of 2.71 years, the 2-year PFS was 76% in the CRT arm and 69% in the RT-alone arm (P =.10) with a hazards ratio of 1.367 (95% confidence interval [CI], 0.93 to 2.00). The treatment effect had a significant covariate interaction with tumor stage, and a subgroup analysis demonstrated a highly significant difference in favor of the CRT arm in Ho's stage T3 (P =.0075) with a hazards ratio of 2.328 (95% CI, 1.26 to 4.28). For T3 stage, the time to first distant failure was statistically significantly different in favor of the CRT arm (P =.016). CONCLUSION: Concurrent CRT is well tolerated in patients with advanced NPC in endemic areas. Although PFS was not significantly different between the concurrent CRT arm and the RT-alone arm in the overall comparison, PFS was significantly prolonged in patients with advanced tumor and node stages.