Stricture rate after chemoradiotherapy and radiotherapy for oesophageal squamous cell carcinoma: a 20-year experience.

BACKGROUND: Definitive chemoradiation for oesophageal squamous cell carcinoma (SCC) is the first-line treatment in many centres. However, it is not without morbidity. We assess outcomes for patients treated with definitive chemoradiotherapy and radiotherapy. METHODS: A retrospective review of a prospectively maintained database (Radiotherapy Department, Canterbury District Health Board) was undertaken. All patients who underwent definitive radiotherapy for oesophageal SCC between October 1996 and April 2015 were included. RESULTS: Sixty patients underwent chemoradiotherapy with curative intent and 17 underwent definitive radiotherapy with curative intent. Median age was 69 years (44-84 years) for those undergoing chemoradiotherapy and 73 years (36-85 years) for those who underwent definitive radiotherapy. Tumour location in all patients was upper third in 14 (18%), middle third in 39 (51%), lower third in 22 (29%) cases and junctional tumour in two (3%). Staging information was complete for 73 of 77 patients (stage I 16/77 (21%), stage II 40/77 (52%), stage III 17/77 (22%)). Median dose of external beam radiotherapy for those who underwent definitive chemotherapy was 50.4 Gy (30-63 Gy) and 60 Gy (50-64 Gy) for definitive radiotherapy. Median length of follow-up was 39 months (range 4-120 months). Strictures developed in 58% of all patients (52% chemoradiotherapy and 76% definitive radiotherapy). Twenty-four (32%) patients were dilated and 14 (18%) stented. The chemoradiotherapy group had higher 5-year survival than definitive radiotherapy group (34% versus 6%, P = 0.0034). CONCLUSION: Oesophageal SCC treated with chemoradiation has a 5-year survival rate of 34%. Post-treatment strictures occur in 52% of patients with chemoradiotherapy and 76% with definitive radiotherapy.

Incidence of Achalasia in South Australia Based on Esophageal Manometry Findings.

BACKGROUND & AIMS: Achalasia is a disorder of esophageal motility with a reported incidence of 0.5 to 1.6 per 100,000 persons per year in Europe, Asia, Canada, and America. However, estimates of incidence values have been derived predominantly from retrospective searches of databases of hospital discharge codes and personal communications with gastroenterologists, and are likely to be incorrect. We performed a cohort study based on esophageal manometry findings to determine the incidence of achalasia in South Australia. METHODS: We collected data from the Australian Bureau of Statistics on the South Australian population. Cases of achalasia diagnosed by esophageal manometry were identified from the 3 adult manometry laboratory databases in South Australia. Endoscopy reports and case notes were reviewed for correlations with diagnoses. The annual incidence of achalasia in the South Australian population was calculated for the decade 2004 to 2013. Findings were standardized to those of the European Standard Population based on age. RESULTS: The annual incidence of achalasia in South Australia ranged from 2.3 to 2.8 per 100,000 persons. The mean age at diagnosis was 62.1 ± 18.1 years. The incidence of achalasia increased with age (Spearman rho, 0.95; P < .01). The age-standardized incidence ranged from 2.1 (95% CI, 1.8-2.3) to 2.5 (95% CI, 2.2-2.7). CONCLUSIONS: Based on a cohort study of esophageal manometry, we determined the incidence of achalasia in South Australia to be 2.3 to 2.8 per 100,000 persons and to increase with age. South Australia's relative geographic isolation and the population's access to manometry allowed for more accurate identification of cases than hospital code analyses, with a low probability of missed cases.

Update in achalasia: what the surgeon needs to know.

Achalasia is a motility disorder encountered by surgeons during the investigation and treatment of dysphagia. Recent advances in manometry technology, a widely accepted new classification system and a new treatment rapidly gaining international acceptance, have changed the working knowledge required to successfully manage patients with achalasia. We review the Chicago classification subtypes of achalasia with type II achalasia being a predictor of success and type III achalasia a predictor of treatment failure. We review per-oral endoscopic myotomy as an emerging treatment option and its potential for improving the treatment of type III achalasia.

Tracheo-oesophageal fistula after palliative treatment of oesophageal cancer.

We present a case of an 86-year-old male who presented with severe pneumonia in the context of having undergone radiotherapy and then an oesophageal stent insertion for palliation of oesophageal cancer. He was diagnosed with a tracheo-oesophageal fistula (TOF) which was successfully managed by deploying a second stent within the first stent.

Clinician-performed ultrasound in assessing potentially malignant thyroid nodules.

BACKGROUND: Ultrasound (US) is used in the workup of thyroid nodules. Ultrasonographic characteristics, such as an ill-defined margin, hypoechoicity or fine calcifications, are known to be associated with malignant thyroid lesions. The association between these characteristics and the risk of malignancy has been reported predominantly from series published where US is performed in radiology departments. Clinician-performed ultrasound (CPU) is increasingly being used as a modality, although there is little published literature validating this practice. METHOD: A prospectively collected database of known ultrasonographic characteristics of malignancy as determined by CPU on thyroid nodules is reported and correlated against adequate cytology or operative histopathology. RESULTS: In total, 157 thyroid nodules (28 malignant, 129 benign) were included and characteristics of poorly defined capsule (sensitivity 46%, specificity 91%), absence of halo (sensitivity 54%, specificity 80%), hypoechoicity (sensitivity 79%, specificity 54%), heterogeneity (sensitivity 64%, specificity 68%), fine calcifications (sensitivity 36%, specificity 95%) and central blood supply (sensitivity 71%, specificity 69%) were found to be associated with malignant thyroid nodules. Negative-predictive values (NPVs) for these characteristics were consistently high (89%, 89%, 92%, 90%, 87% and 94%, respectively). DISCUSSION: These results are consistent with the previously published datasets of ultrasonographic characteristics of malignancy and validate the use of CPU. The consistently high NPV suggests that the absence of ultrasonographic characteristics of malignancy correlates well with benign lesions. CPU is a reliable and useful tool in the hands of surgeons assessing and following potentially malignancy thyroid nodules.

Enhancing muscular qualities in untrained women: linear versus undulating periodization.

PURPOSE: This study compared linear (LP) and undulating periodization (UP) on strength changes in untrained women when total workload and average training intensity were matched by the end of training. METHODS: Twenty females (20 +/- 2 yr) were conditioned (3 wk) and assessed for one-repetition maximum squat (1RMSQ) and bench press (1RMBP) before being assigned to LP or UP training (9 wk), with training performed at 3 d.wk. Maximal strength, average power output during squat jumps with countermovement (SQJpwr) and bench press throws (BPTpwr), body mass, limb girth, and muscle cross-sectional area (CSA) were assessed at baseline (T1) and after every 3 wk (T2, T3, and T4) to differentiate the efficacy of LP and UP training. RESULTS: Both groups improved significantly (P < 0.05) in 1RMSQ (LP 34.8%, UP 41.2%), 1RMBP (LP 21.8%, UP 28.3%), SQJpwr (LP 10.4%, UP 9.5%), BPTpwr (LP 11.1%, UP 13.8%), arm girth (LP 1.14%, UP 1.73%), and thigh girth (LP 1.58%, UP 1.99%), with no significant difference between them. Muscle CSA for the LP group increased significantly at T2 before maintaining similar hypertrophic responses until T4, whereas the UP group recorded significant increments from T1 to T2 and T2 to T3, before stabilizing between T3 and T4. Pooled CSA increase was higher than previously found (6.8% at T2, 11.3% at T3, and 11.8% at T4). CONCLUSIONS: The comparison of LP and UP training with matched volume load and intensity suggests that both programs were equally adept in improving different strength qualities in active but untrained women. In addition, muscle hypertrophic responses were larger and occurred earlier than previously reported.

The physiological effects of IGF-1 (class 1:Ea transgene) over-expression on exercise-induced damage and adaptation in dystrophic muscles of mdx mice.

Duchenne muscular dystrophy (DMD) is a genetic disorder in which muscle weakness and fragility contribute to ongoing muscle degeneration. Although exercise-induced muscle damage is associated with adaptation that protects normal muscle from further damage, exploiting this process to protect dystrophic muscle has been avoided for fear of inducing excessive muscle degeneration. However, muscle-specific over-expression of the class 1:Ea isoform of insulin-like growth factor-1 (IGF-1) reduces myofibre necrosis in dystrophic mdx mice (a model for DMD) and, therefore, may enhance the adaptation process in response to eccentric exercise. To test this hypothesis, we evaluated the effect of transgenic class 1:Ea IGF-1 over-expression on the susceptibility to muscle damage and subsequent adaptation in 12-week-old dystrophic mdx and non-dystrophic control mice. Experiments were conducted in vivo using a custom-built isokinetic mouse dynamometer to measure the deficit in joint torque (indicating muscle damage) after 20 maximal lengthening (eccentric) contractions. Adaptation to this damaging exercise was evaluated by repeating the protocol 7 days after the initial exercise. The over-expression of IGF-1 significantly increased the normalised joint torque in non-dystrophic mice and appeared to ameliorate the muscle weakness in dystrophic mice. All mice displayed a marked reduction in the susceptibility to muscle damage on day 7; however, this adaptation was unaffected by IGF-1, showing that IGF-1 does not protect the dystrophic muscles of adult mdx mice against damage resulting from maximal lengthening contractions.

Knee strength and knee adduction moments following arthroscopic partial meniscectomy.

PURPOSE: This study investigated the relationship between muscular strength about the knee and knee joint moments during gait in patients who had undergone arthroscopic partial meniscectomy (APM). METHODS: One hundred and two APM patients and 42 age-matched nonoperated controls underwent strength testing and three-dimensional gait analysis. Patients were divided into weak and normal subgroups and compared with controls for spatiotemporal, kinematic, and kinetic gait parameters. RESULTS: Spatiotemporal parameters, kinematics, and sagittal plane kinetics were similar between APM patients and controls. The APM group displayed weaker concentric knee extension and flexion strength compared with controls. The weak APM subgroup had an increased average and peak knee adduction moments over stance compared with the APM subgroup with normal strength levels and controls. The normal strength APM subgroup had a larger peak knee adduction moment in early stance compared with controls. CONCLUSION: Achieving normal lower limb muscle strength following APM appears important to resume normal frontal plane loading of the knee while walking.