IMRT - Biomarkers for dose escalation, dose de-escalation and personalized medicine in radiotherapy for head and neck cancer.

Radiotherapy (RT) is an integral component in the management of head and neck cancer. Despite progress in several respects, a noteworthy proportion of the treated patients do not achieve complete response after RT. Regardless of novel dose delivery technologies, RT for head and neck cancer is still associated with acute as well as late toxicity. These challenges could potentially be addressed by means of personalized treatment. In this paper, we discuss the possibilities for dose escalation, dose de-escalation and allocation to systemic concomitant treatment based on prognostic and predictive markers for tumor control as well as predictive markers for normal tissue radiosensitivity.

Impact of adding a second layer to a single unlocked closure of a Cesarean uterine incision: randomized controlled trial.

OBJECTIVE: To investigate short- and long-term effects on residual myometrial thickness (RMT) of adding a second layer to a single unlocked closure of a Cesarean uterine incision. METHODS: This was a randomized double-blind controlled trial. Healthy nulliparous women scheduled for first-time elective Cesarean delivery were operated on using a modified version of the Misgav Ladach surgical technique. The women were examined by transabdominal ultrasound before discharge from the maternity ward and by transvaginal saline contrast sonohysterography at a minimum of 5 months postpartum. RESULTS: Seventy-six nulliparae met the criteria and agreed to participate in the study. Thirty-five women were assigned to the single-layer technique and 38 to the double-layer unlocked closure technique. Groups were comparable regarding gestational age at delivery, duration of surgery and perioperative blood loss. There was no difference in RMT between the two groups, both at time of discharge (mean ± SD, 20.2 ± 8.0 mm vs 21.0 ± 9.7 mm) and after 5 months postpartum (mean, 5.7 ± 2.9 mm vs 5.7 ± 2.2 mm). RMT was approximately half that of the normal myometrium at both examinations. CONCLUSION: The results of this study suggest that double-layer closure of a Cesarean uterine incision does not increase RMT compared with single-layer closure when an unlocked technique is used.

Fate and effects of esfenvalerate in agricultural ponds.

The fate of esfenvalerate was investigated by sampling and chemical analysis after spraying of an artificial pond (25 g a.i./ha) and in the laboratory with [14C]esfenvalerate by trapping of 14CO2 and fractionation of the sediment. The effects were investigated on pelagic communities in enclosures in a natural lake and in the laboratory on surface (Cymatia coleoptrata) and sediment (Chironomus riparius) insects. The latter were used in sediment-plus-water and in water-only tests, measuring effects on emergence and mortality. The measurements in the artificial pond indicated exposure concentrations in the surface microlayer, water column, and sediment of 0.4 microgram/L, 0.05 microgram/L, and 9 micrograms/kg dry weight, respectively, two weeks after application. The degradation studies showed a limited mineralization (26.5%) of [chorophenyl-14C]esfenvalerate during 112 d. Part of the substance was transformed to water-soluble compounds (18.1%) or compounds attached to fulvic acids (26.2%), humic acids (14.2%), or nonextractable sediment constituents (8.8%). The formulated product Sumi-Alpha 5 FW caused 100% mortality to Cymatia coleoptrata after surface application of 0.13 g a.i/ha. Effects on zooplankton were recorded at 0.005 microgram/L of esfenvalerate. The 96-h median lethal concentration for first-instar larvae of Chironomus riparius was 0.13 microgram/L, whereas the delayed emergence lowest-observed-effect concentration was 0.8 microgram/L.

The effect of humic acids on the water solubility and water-organic carbon partitioning of fluorene and its NSO-heteroanalogues: carbazole, dibenzofuran, and dibenzothiophene.

The solubilizing effect of humic acids on fluorene and its NSO analogues carbazole, dibenzofuran and dibenzothiophene has been studied. The interaction between these substances and humic acids was found to depend significantly on the actual humic acid concentration. A pronounced decrease in the interaction constant, as well as in the water-organic matter partitioning coefficient was observed with increasing humic acid concentration. The effects are discussed in terms of concentration dependent macromolecular structural changes in the humic acids. A linear free energy relation for the interaction is suggested.

Testicular masses.

Family physicians often must evaluate patients with testicular pain or masses. The incidental finding of a scrotal mass may also require evaluation. Patients may seek evaluation of a scrotal mass as an incidental finding. An accurate history combined with a complete examination of the male external genitalia will help indicate a preliminary diagnosis and proper treatment. Family physicians must keep in mind the emergency or "must not miss" diagnoses associated with testicular masses, including testicular torsion, epididymitis, acute orchitis, strangulated hernia and testicular cancer. Referral to a urologist should be made immediately if one of these diagnoses is suspected. Benign causes of scrotal masses, including hydrocele, varicocele and spermatocele, may be diagnosed and managed easily in the primary care office.

Serum prostate-specific antigen concentration before and after vasectomy.

Recent epidemiologic studies have suggested that a risk factor for the development of carcinoma of the prostate may be previous vasectomy. As a majority of prostate cancer cases diagnosed in the U.S. are detected by an elevation in prostate-specific antigen (PSA), an elevation in PSA due to vasectomy may underpin this association. There have been no published reports on the relationship between PSA before and after vasectomy. To study this relationship, this study was undertaken to determine the effects of vasectomy on PSA. Twenty-five men undergoing vasectomy were studied with serial PSA determinations prior to and following vasectomy. Analysis of data suggests that PSA is not affected by previous vasectomy and that other causes for an increased detection in this cohort may be operational.

Conservative management of rectocutaneous fistula following radical perineal prostatectomy.

Inadvertent rectal injury during radical perineal prostatectomy may sometimes lead to the development of a rectocutaneous fistula. This has traditionally been managed with diverting colostomy until closure of the fistula is assured. We report 3 cases of rectocutaneous fistula following radical perineal prostatectomy, which were managed in a more conservative fashion. This included appropriate wound care, antibiotics, bowel rest, parenteral hyperalimentation, and, in the presence of a concomitant urine leak in 1 case, optimal urinary diversion and bed rest. All fistulas healed without incident.

Rectal injuries during radical perineal prostatectomy.

OBJECTIVES: To review a contemporary series of rectal injuries occurring during radical perineal prostatectomy. METHODS: Of 81 patients who underwent radical perineal prostatectomy, 9 (11%) sustained a full-thickness laceration of the anterior rectal wall. All 9 patients had a preoperative bowel preparation, although only 1 received a complete oral lavage regimen. All received prophylactic perioperative intravenous antibiotics. None had undergone prior surgery to the rectum or perineum or received prior pelvic radiation therapy. RESULTS: In most cases injury occurred during division of the rectourethralis muscle, but in at least two instances the injury appeared to be the result of undue posterior retraction along the rectal wall. All injuries were recognized at the time of surgery and repaired primarily. No patient had associated postoperative complications. CONCLUSIONS: Rectal injury occurs with significantly greater frequency with radical perineal prostatectomy than with the retropubic approach. However, if the rectum is adequately prepared, the injury promptly recognized and repaired, and postoperative care appropriate, the great majority of cases will not lead to attendant morbidity.

Treatment options for prostate cancer.

The reader of the prostate cancer literature is often stunned by the lack of evidence of efficacy of one form of treatment over that of others. Indeed, information suggests that "no treatment" may be an effective option. Analyzing the available literature that reports the results of treatment versus observation for prostate cancer, Fleming et al. from the Prostate Patient Outcomes Research Team found that in most cases, treatment offered less than a 1-year improvement in quality-adjusted life expectancy. Using less optimistic assumptions, the authors also found that treatment could actually reduce quality-adjusted life expectancy. The decision of what form of treatment to offer the individual patient requires considerable discussion with the patient concerning his priorities and goals of therapy. For the younger patient with localized disease, the prevailing trend in the United States is toward radical prostatectomy. As the patient approaches the age of 70 years, the advantages of treatment versus observation alone evaporate. Because the disease is often of low biologic potential with a long doubling time, the option of observation initially with serial determinations of PSA is not unreasonable. If a slow rate of rise is noted, some patients may elect observation. However, with more rapid rises in PSA, a more aggressive stance may be appropriate. Because of the uncertainties inherent to treating this disease, it is imperative that the patient be brought into the treatment planning through education and through extensive discussions with health care providers and with family members. Only through such informed and deliberate discussions can a plan for treatment be reached with which the patient will be comfortable.

Laparoscopic management of incidentally noted omphalomesenteric duct remnant.

An adolescent undergoing laparoscopic varicocele ligation was incidentally found to have a persistent omphalomesenteric duct remnant. The fibrous band coursing between the umbilicus and terminal ileum was resected laparoscopically without difficulty. Remnants of the type presented herein should be removed to prevent subsequent complications.