Case report of uncontrollable pelvic bleeding--managed by a previously unreported method (QuikClot).

Pelvic haemorrhage can be difficult to control. Several measures including packing, drawing pins, stenting and embolization are available. We present a case where these measures failed to control catastrophic pelvic bleeding while operating in the pelvis to excise a dumbbell tumour involving the right S1 nerve root. Attempted surgical control by a vascular surgeon and radiological control through stenting and embolization failed to control the bleeding. QuikClot is an inert substance and acts as a selective sponge. This product is licensed for external use by the British military. We felt that 'internal' use of Quikclot in this situation might be lifesaving and was applied to the bleeding area, stopping the bleeding immediately.

From small acorns--developing a laparoscopic colorectal surgical service.

INTRODUCTION: Randomised controlled trials have shown that laparoscopic colorectal surgery is equal in terms of safety to open surgery. Benefits have been seen for length of stay, blood loss, immune suppression and analgesia requirements. The aim of this study was to assess the safety and feasibility of introducing laparoscopic colorectal surgery to our unit. PATIENTS AND METHODS: Prospectively collected cases of all patients undergoing laparoscopic colorectal surgery between July 2003 and July 2007 were reviewed. RESULTS: A total of 143 patients (75 males and 68 females) with a mean age of 65.8 years (range, 21-95 years) underwent surgery. Laparoscopic resection for colorectal malignancy was performed in 93 patients (65%). The conversion rate for all cases was 14.7%. Mean operative time was 203 min (range, 100-400 min), with a mean blood loss of 180 ml. The mean number of lymph nodes in malignant cases was 13.8 with clear resection margin in all but one case. The mean postoperative stay was 5.6 days (median, 4 days; range, 2-35 days). UKCCR standard for lymph node retrieval was achieved in 62.6% of cases. There were four postoperative deaths. The overall 30-day morbidity rate was 21.7%. The service is consultant-led with 9.8% of cases performed by senior trainees and 37% of procedures performed by two consultants. CONCLUSIONS: Laparoscopic colorectal surgery is technically feasible and safe in our hands. Although operative time is longer, this is counterbalanced by shorter hospital stay. The results from this series support the findings of others and continuing development of this service.

Optimizing localization accuracy in head and neck, and brain radiotherapy.

The purpose of this study was to investigate the impact on localization of utilizing contrast-enhanced CT scans and the formal input of a radiologist in the planning process. 25 head and neck/brain patients had pre- and post-contrast CT scans in the treatment position. Radiotherapy treatment was planned on the unenhanced CT images as per standard practice. Retrospectively, their scans (unenhanced and enhanced) were re-contoured by two oncologists and a radiologist. These new contours were compared with the original unenhanced treatment contours and differences in contour volume, geographical isocentre position and tolerance coverage of the associated planning target volumes (PTVs) were evaluated using the original plans. The use of contrast enhanced CT data during localization by the oncologist shows little change in gross tumour volumes (GTVs) or PTVs, geographical position or tolerance coverage for the targets in the brain studied here. Larger changes in mean volume are seen for the head and neck cases alone. Changes are greater and statistically significant (p < 0.05, Wilcoxon signed rank test) for localization by the radiologist. Furthermore, when comparing the original PTV marked by the oncologist with a new PTV re-contoured by the oncologist, but based on a GTV marked-up by the radiologist, again statistically significant (p < 0.01) changes in percentage volume are noted. Intraoperator precision is good, percentage volume differences being of the order 3-6%. PTVs also show improved standard deviations compared with GTVs. Geographic shifts are generally within our departmental tolerance levels for daily patient setup. Comparing precision of unenhanced data with enhanced, mean percentage volume changes are smaller, but not statistically significant. The use of enhanced scan data for localization has little effect on size, geographical position or tolerance coverage of PTVs marked up by the oncologists in this study. However, more important is the input from a radiologist. Statistically significant differences due to mark-up on enhanced scans by the radiologist are shown. Furthermore, significant differences are also seen between PTVs based on oncologist-generated GTVs, and those based on radiologist-generated GTVs.

An audit of the management of soft tissue sarcoma within a health region in the UK.

AIMS: Soft tissue sarcomas are rare and heterogeneous tumours only occasionally seen by most individual clinicians. Early recognition, appropriate referral and timely investigations markedly improve outcomes. Our aim was to retrospectively assess the referral patterns, investigation, surgery and outcomes of patients with soft tissue sarcoma in the Trent region of the UK. METHODS: Two hundred and four patients with soft tissue sarcoma registered with the Trent Cancer Registry in 1995-1997 were first studied. Clinical details, tumour characteristics, presentation, management and follow-up were recorded from the case notes and analysed.A further group of 40 patients referred to a single cancer centre in 1999 were audited to establish whether there had been any improvements/changes over the 2 years, since the completion of the first audit. RESULTS: In the first audit, 49.5% were first referred to general surgeons and 16% to orthopaedic surgeons. Only 15% of patients fit for surgery were referred to a surgeon with a specialist sarcoma interest prior to definitive exploration. Of the deep tumours, 64% had a preoperative biopsy and only 68% had a scan before biopsy or definitive surgery. Tumour grade, completeness of excision and site of the sarcoma influenced survival. The second audit performed on patients treated in 1999 showed only a marginal improvement in management when compared to the first audit.

Further observations on LKB1/STK11 status and cancer risk in Peutz-Jeghers syndrome.

Germline mutations in the LKB1/STK11 tumour suppressor gene cause Peutz-Jeghers syndrome (PJS), a rare dominant disorder. In addition to typical hamartomatous gastrointestinal polyps and pigmented perioral lesions, PJS is associated with an increased risk of tumours at multiple sites. Follow-up information on carriers is limited and genetic heterogeneity makes counselling and management in PJS difficult. Here we report the analysis of the LKB1/STK11 locus in a series of 33 PJS families, and estimation of cancer risks in carriers and noncarriers. Germline mutations of LKB1/STK11 were identified in 52% of cases. This observation reinforces the hypothesis of a second PJS locus. In carriers of LKB1/STK11 mutations, the risk of cancer was markedly elevated. The risk of developing any cancer in carriers by age 65 years was 47% (95% CI: 27-73%) with elevated risks of both gastrointestinal and breast cancer. PJS with germline mutations in LKB1/STK11 are at a very high relative and absolute risk of multiple gastrointestinal and nongastrointestinal cancers. To obtain precise estimates of risk associated with PJS requires further studies of genotype-phenotype especially with respect to LKB1/STK11 negative cases, as this group is likely to be heterogeneous.

Psychiatric morbidity and screening for colorectal cancer.

BACKGROUND: Several studies have shown that faecal occult blood (FOB) screening reduces mortality from colorectal cancer. However, concern has been expressed that health screening may have adverse psychological effects, particularly for the group returning false positive tests. OBJECTIVES: To evaluate any adverse psychological effects associated with faecal occult blood screening. SETTING: Randomised controlled trial of faecal occult blood screening for colorectal cancer. METHODS: Psychiatric morbidity was measured, using the general health questionnaire (GHQ) before and 3 months after the offer of screening for colorectal cancer with FOB testing. Scores were related to acceptance of the screening test. A smaller cohort, who had returned positive FOB tests, had anxiety levels measured, using the Spielberger anxiety inventory (SAI), at different times during screening, investigation, and follow up. RESULTS: A GHQ was sent to 2184 subjects before the offer of screening, and 1541 (70.6%) were returned. Of the 1693 subjects offered the GHQ 3 months after the offer of screening, 1303 (77%) returned it. A GHQ score of 5 or more, indicating possible psychiatric morbidity, was present in 454 subjects (29.5%) before screening and in 386 (29.6%) subjects 3 months after screening (NS). Of the 454 subjects who scored 5 or more, 241 (53.1%) accepted screening and 213 (46.9%) refused. A total of 1081 subjects scored less than 5, and of these 521 (48.2%) accepted screening and 560 (51.8%) refused (NS). Anxiety scores were measured in 100 test positive patients and were highest after notification of a positive test and before investigation by colonoscopy. In patients with false positive results, scores fell the day after colonoscopy and remained low 1 month later. CONCLUSIONS: The receipt of a screening test does not cause sustained anxiety and the existence of psychiatric morbidity is not a factor affecting a person's decision to accept or refuse a screening test for colorectal cancer.

High prevalence of undetected ulcerative colitis: data from the Nottingham fecal occult blood screening trial.

OBJECTIVES: Inflammatory bowel disease (IBD) is usually diagnosed as a result of symptoms but occasionally is found during investigation for other conditions. An earlier report from Nottingham had found a high prevalence of previously undetected "asymptomatic" IBD detected as a result of colorectal cancer screening, and the aim of this study was to reassess the prevalence, symptoms, and outcome in these patients. METHODS: We investigated subjects found to be fecal occult blood (FOB) positive in a randomized trial of FOB screening for colorectal cancer. All FOB-positive subjects were investigated by colonoscopy or flexible sigmoidoscopy and barium enema. Subjects with IBD were referred back to their general practitioner for any further investigation and treatment. RESULTS: Seventy-five thousand two hundred fifty-three subjects (aged 45-74) were sent FOB tests and 44,838 (60%) completed a series of tests on one or more occasions. Of 133,000 test series, 1.5% were positive. During investigation 53 cases of previously undetected IBD (52 of ulcerative colitis) were found; 52% (27/52) had proctosigmoiditis only, whereas 25% (13/52) had pancolitis. Only 17% (9/52) were completely asymptomatic, with a half or more reporting some rectal bleeding (54%) or diarrhea (50%). The overall prevalence of undetected ulcerative colitis was 69/10(5) (95% CI = 50-88/10(5)) in people offered screening and 116/10(5) (95% CI = 85-147/10(5)) in people accepting screening and was higher in men. Of 32 subjects followed up 2-12 yr after diagnosis, 91% (29) continued to have few or no symptoms, with only 12 currently receiving any treatment for their colitis. CONCLUSIONS: In comparison with detected disease, undetected ulcerative colitis is relatively common but does usually cause some symptoms. It generally appears to follow a benign course, but a significant proportion have extensive colitis and may therefore be at an increased risk of colorectal cancer.

Optimisation of radiotherapy for carcinoma of the parotid gland: a comparison of conventional, three-dimensional conformal, and intensity-modulated techniques.

BACKGROUND AND PURPOSE: To compare external beam radiotherapy techniques for parotid gland tumours using conventional radiotherapy (RT), three-dimensional conformal radiotherapy (3DCRT), and intensity-modulated radiotherapy (IMRT). To optimise the IMRT techniques, and to produce an IMRT class solution. MATERIALS AND METHODS: The planning target volume (PTV), contra-lateral parotid gland, oral cavity, brain-stem, brain and cochlea were outlined on CT planning scans of six patients with parotid gland tumours. Optimised conventional RT and 3DCRT plans were created and compared with inverse-planned IMRT dose distributions using dose-volume histograms. The aim was to reduce the radiation dose to organs at risk and improve the PTV dose distribution. A beam-direction optimisation algorithm was used to improve the dose distribution of the IMRT plans, and a class solution for parotid gland IMRT was investigated. RESULTS: 3DCRT plans produced an equivalent PTV irradiation and reduced the dose to the cochlea, oral cavity, brain, and other normal tissues compared with conventional RT. IMRT further reduced the radiation dose to the cochlea and oral cavity compared with 3DCRT. For nine- and seven-field IMRT techniques, there was an increase in low-dose radiation to non-target tissue and the contra-lateral parotid gland. IMRT plans produced using three to five optimised intensity-modulated beam directions maintained the advantages of the more complex IMRT plans, and reduced the contra-lateral parotid gland dose to acceptable levels. Three- and four-field non-coplanar beam arrangements increased the volume of brain irradiated, and increased PTV dose inhomogeneity. A four-field class solution consisting of paired ipsilateral coplanar anterior and posterior oblique beams (15, 45, 145 and 170 degrees from the anterior plane) was developed which maintained the benefits without the complexity of individual patient optimisation. CONCLUSIONS: For patients with parotid gland tumours, reduction in the radiation dose to critical normal tissues was demonstrated with 3DCRT compared with conventional RT. IMRT produced a further reduction in the dose to the cochlea and oral cavity. With nine and seven fields, the dose to the contra-lateral parotid gland was increased, but this was avoided by optimisation of the beam directions. The benefits of IMRT were maintained with three or four fields when the beam angles were optimised, but were also achieved using a four-field class solution. Clinical trials are required to confirm the clinical benefits of these improved dose distributions.

Risks, costs, and compliance limit colorectal adenoma surveillance: lessons from a randomised trial.

BACKGROUND AND AIMS: In the USA and many other countries, endoscopic surveillance of colorectal adenoma patients is now widely practised. However, the optimal frequency and mode of such surveillance are not yet established. The aim of this trial was to compare surveillance at one, two, or five year intervals using either flexible sigmoidoscopy or colonoscopy. METHODS: Analysis of a randomised trial of flexible sigmoidoscopy and colonoscopy over one, two, or five years after stratification for "high" or "low" risk of recurrent adenomas. The trial started in 1984. RESULTS: A total of 776 patients were stratified into "high" (n=307) and "low" (n=469) recurrence risk groups and randomised to flexible sigmoidoscopy or colonoscopy at varying intervals. Only 81 recurrent adenomas (30/81 were >1 cm in diameter) were detected in the 2307 person years of follow up within the surveillance study. Adenoma recurrence was significantly higher in the high risk group (relative rate 1.82; 95% confidence interval 1.2-2.9) but recurrence rates per 1000 person years were low and not significantly different in those surveyed by colonoscopy or flexible sigmoidoscopy. Loss to follow up was greatest in those having an annual examination compared with two or five yearly surveillance examinations. Despite surveillance, invasive cancer developed in four patients compared with an expected value of 9.12 for the general population in England (p=0.10); of these four patients who developed cancers, only one was detected by surveillance examination. CONCLUSIONS: Adenoma recurrence rates were much lower than expected in both high and low risk groups. This suggests that endoscopic surveillance should be targeted at high risk groups. A surveillance interval of five years was as effective as shorter intervals in terms of cancer prevention, and was associated with similar compliance to two yearly examinations.

The impact of virtual simulation in palliative radiotherapy for non-small-cell lung cancer.

BACKGROUND AND PURPOSE: Radiotherapy is widely used to palliate local symptoms in non-small-cell lung cancer. Using conventional X-ray simulation, it is often difficult to accurately localize the extent of the tumour. We report a randomized, double blind trial comparing target localization with conventional and virtual simulation. METHODS: Eighty-six patients underwent both conventional and virtual simulation. The conventional simulator films were compared with digitally reconstructed radiographs (DRRs) produced from the computed tomography (CT) data. The treatment fields defined by the clinicians using each modality were compared in terms of field area, position and the implications for target coverage. RESULTS: Comparing fields defined by each study arm, there was a major mis-match in coverage between fields in 66.2% of cases, and a complete match in only 5.2% of cases. In 82.4% of cases, conventional simulator fields were larger (mean 24.5+/-5.1% (95% confidence interval)) than CT-localized fields, potentially contributing to a mean target under-coverage of 16.4+/-3.5% and normal tissue over-coverage of 25.4+/-4.2%. CONCLUSIONS: CT localization and virtual simulation allow more accurate definition of the target volume. This could enable a reduction in geographical misses, while also reducing treatment-related toxicity.

Faecal occult blood screening for colorectal cancer at Nottingham: details of the verification process.

Cause specific mortality statistics derived from death certificates are highly dependent upon the accuracy of certification by the attending physician. In the Nottingham colorectal cancer screening trial, there were 12,624 deaths among the screening group and 12,515 among the control group during the period under consideration. There was no significant difference in all cause mortality rate (excluding deaths due to colorectal cancer) between the two study groups (rate ratio = 1.01, 95% confidence interval = 0.99 to 1.03). Disease specific mortality rates did not differ significantly between the two groups either. Overall, the agreement between verified and certified cause of death was 86%. Using the certified cause of death would have resulted in an underestimation bias of 6.27% for colorectal cancer deaths.

Laparoscopic colorectal cancer surgery.

BACKGROUND: A number of controversies exist in the laparoscopic treatment of colorectal cancer, and thus the technique has so far failed to gain widespread acceptance throughout the United Kingdom. This review aims to discuss these issues in the context of ongoing published trials, assessing both purported advantages and disadvantages. METHODS: The United States National Library of Medicine Medline database, and the Bath Information Data Service (BIDS) were searched using keywords related to laparoscopic colorectal cancer surgery. Recent surgical journals were also reviewed for relevant publications. Attempts have been made to quote only the most recent work from institutions with multiple publications using the same group of patients, in order to present the most coherent picture. The data are presented as randomized controlled trials, nonrandomized controlled studies, and series comprising more than 10 patients. CONCLUSIONS: This review confirms that laparoscopic colorectal cancer surgery is technically feasible. In addition patients lose less blood, have less immunosuppression, and have shorter postoperative ileus, in-patient stay, and require less analgesia. However, concerns still remain as to the development of port-site metastases, the longer operating times, and the overall cost of the equipment. In view of these concerns, the place of laparoscopically assisted colorectal cancer surgery is likely to remain controversial for some years yet. Randomized, controlled trials are as yet too few to provide definitive answers to all these issues.