Laser augmented by brachytherapy versus laser alone in the palliation of adenocarcinoma of the oesophagus and cardia: a randomised study.

BACKGROUND: Many patients with advanced malignant dysphagia are not suitable for definitive treatment. The best option for palliation of dysphagia varies between patients. This paper looks at a simple technique for enhancing laser recanalisation. AIM: To assess the value of adjunctive brachytherapy in prolonging palliation of malignant dysphagia by endoscopic laser therapy. PATIENTS: Twenty two patients with advanced malignant dysphagia due to adenocarcinoma of the oesophagus or gastric cardia, unsuitable for surgery or radical chemoradiotherapy. METHODS: Patients able to eat a soft diet after laser recanalisation were randomised to no further therapy or a single treatment with brachytherapy (10 Gy). Results were judged on the quality and duration of dysphagia palliation, need for subsequent intervention, complications, and survival. RESULTS: The median dysphagia score for all patients two weeks after initial treatment was 1 (some solids). The median dysphagia palliated interval from the end of initial treatment to recurrent dysphagia or death increased from five weeks (control group) to 19 weeks (brachytherapy group). Three patients had some odynophagia for up to six weeks after brachytherapy. There was no other treatment related morbidity or mortality. Further intervention was required in 10 of 11 control patients (median five further procedures) compared with 7/11 brachytherapy patients (median two further procedures). There was no difference in survival (median 20 weeks (control), 26 weeks (brachytherapy)). CONCLUSIONS: Laser therapy followed by brachytherapy is a safe, straightforward, and effective option for palliating advanced malignant dysphagia, which is complementary to stent insertion.

Laser and brachytherapy in the palliation of adenocarcinoma of the oesophagus and cardia.

BACKGROUND: Palliation of malignant dysphagia is possible by a variety of methods although all have significant drawbacks. Laser therapy is an effective and safe treatment but has to be repeated at four to five weekly intervals to maintain palliation. A means of augmenting the benefits while reducing the need for repeat treatments would be highly beneficial to these patients. AIMS: To prospectively explore the safety and efficacy of intraluminal radiotherapy (brachytherapy) when used to augment laser recanalisation for malignant dysphagia. PATIENTS: Nineteen patients with dysphagia due to advanced adenocarcinoma of the oesophagus or cardia were recruited. METHODS: All patients received laser recanalisation until able to swallow a soft diet or better, before the application of a single dose of brachytherapy (10 Gy at 1 cm from the source). Patients were followed up and treated promptly by further endoscopic means in the event of their dysphagia worsening. RESULTS: Six patients (32%) required no further treatment until death at a median of 10 weeks (range 1-20 weeks). Further therapy was required at a median of 11 weeks (range 4-37 weeks) after brachytherapy for those 13 patients with recurrent dysphagia. Subsequent symptom control required endoscopic intervention at an average of once every nine weeks. There was no mortality associated with laser or brachytherapy. Median survival from initial treatment and including the one survivor was 36 weeks (range 5-132 weeks). CONCLUSIONS: Laser plus brachytherapy offers a safe and effective means of palliating malignant dysphagia due to adenocarcinoma, with a longer dysphagia free interval than historical controls treated with laser alone.

Nd:YAG laser treatment for bleeding from radiation proctitis.

BACKGROUND AND STUDY AIMS: Chronic radiation proctitis is a serious complication of radiotherapy to the pelvis. It can lead to severe blood loss, and responds poorly to surgery or local drug therapy. This study looks at which of the patients affected may benefit from endoscopic treatment with Nd:YAG laser. PATIENTS AND METHODS: Nine patients who had previously undergone radiotherapy for pelvic malignancy a median of 14 months (range 4-43 months) before rectal bleeding started were included. Endoscopic Nd:YAG laser treatment commenced a median of four months (range 2-13 months) after the onset of blood loss, and was repeated monthly until bleeding stopped. Bleeding and transfusion requirements were documented before, during, and after a course of laser treatment. RESULTS: Patients received an average of three laser treatments (range 1-5). Six had received transfusions prior to referral, the average requirement being 1.3 units per patient month. Only one patient required transfusion after completion of treatment, during an average follow-up of 24 months. Bleeding was reduced to occasional spotting in six cases. There were no treatment-related complications. Two of the most severely affected patients died within three months of treatment, due to recurrence of their underlying malignancy. CONCLUSION: Endoscopic Nd:YAG laser treatment is safe and effective for patients with mild to moderate bleeding from radiation proctitis.

Management of strictures after radiotherapy for esophageal cancer.

BACKGROUND: Many esophageal cancer patients present with recurrent dysphagia after treatment with radiotherapy and are considered at high risk for further endoscopic intervention. We assessed whether the risks were really greater than those in patients not previously irradiated. METHODS: Over 6 years, 61 patients who had undergone previous radiotherapy required endoscopic dilation with or without intubation. The risk of dilating or intubating these patients was compared to that of a control group of 126 patients with similar malignancies who had not undergone previous radiotherapy. RESULTS: The perforation rate for dilation in the radiotherapy group was not significantly different from that in controls (3% radiotherapy vs 4.7% in controls per procedure; 6.5% radiotherapy vs 8% in controls per patient) and was unrelated to previous laser therapy. Half the perforations in the control group occurred at the first therapeutic procedure. Endoprostheses were inserted in 48% of radiotherapy patients and 79% of controls at some stage of the illness. The risks of perforation related to intubation in each group were similar (3% radiotherapy vs 4% in controls) although tube migration was more frequent in the radiotherapy group, 21% vs 3% in controls (p = 0.005). CONCLUSION: We conclude that there is no increased risk of perforation in endoscopic dilation or intubation for strictures occurring after radiotherapy.

A cost analysis of Nd:YAG laser ablation versus endoscopic intubation for the palliation of malignant dysphagia.

Although endoscopic intubation is the mainstay of non-surgical palliation of malignant dysphagia, Nd:YAG laser ablation has been shown to provide good palliation with few complications. The study reported here incorporates data from published and unpublished sources into a cost model which estimates the lifetime cost of palliation with the two therapies. It is estimated that, depending on the assumptions used, laser palliation costs between 153 pounds and 710 pounds more per patient than endoscopic intubation. Sensitivity analysis is used to assess whether variation in clinical practice and in the unit costs of resources will change the conclusions of the study. This indicates that, under most alternative sets of assumptions, intubation retains its cost advantage. However, factors that might reduce, or even eliminate, this cost differential include undertaking more laser procedures as day-cases, using more expensive expanding metal stents for intubation and reducing the need for follow-up laser procedures with palliative radiotherapy.

Hypoechoic fat: a sonographic pitfall.

Fat has classically been described as hyperechoic on sonograms because of its acoustic impedance relative to surrounding tissue, although certain types of fat in certain anatomic locations can be hypoechoic. Examples in the literature include hypoechoic fat in and around the kidneys as well as in ovarian neoplasms [1-3]. We present several cases of hypoechoic fat collections in various anatomic locations to illustrate the importance of its presence and to minimize the number of erroneous diagnoses.

Photosensitisation and photodynamic therapy of oesophageal, duodenal, and colorectal tumours using 5 aminolaevulinic acid induced protoporphyrin IX--a pilot study.

The first study of photodynamic therapy in the human gastrointestinal tract using 5 aminolaevulinic acid (ALA) induced protoporphyrin IX as the photosensitising agent is described. Eighteen patients with colorectal, duodenal, and oesophageal tumours were studied. After 30-60 mg/kg of ALA given orally, biopsy specimens of tumour and adjacent normal mucosa were taken 1-72 hours later. These specimens were examined by quantitative fluorescence microscopy for assessment of sensitisation with protoporphyrin IX. Ten patients were given a second dose of ALA a few weeks later and their tumours were treated with red laser light (628 nm). With 30 mg/kg ALA, the highest fluorescence values were detected in the duodenum and oesophagus, and the lowest in the large bowel. Doubling the ALA dose in patients with colorectal tumours gave protoporphyrin IX fluorescence intensities similar to those in patients with upper gastrointestinal lesions and improved the tumour:normal mucosa protoporphyrin IX sensitisation ratio. The treated patients showed superficial mucosal necrosis in the areas exposed to laser light. Six patients had transient rises in serum aspartate aminotransferases, two mild skin photosensitivity reactions, and five mild nausea and vomiting. In conclusion, photodynamic therapy with systemically administered ALA may be a promising technique for the treatment of small tumours and areas of dysplasia such as in Barrett's oesophagus.

Small bolus injections of intravenous midazolam for upper gastrointestinal endoscopy: a study of 788 consecutive cases.

1 A recent audit of upper gastrointestinal endoscopy carried out by the Royal College of Surgeons of England has shown that the majority of endoscopists use a bolus injection rather than a slow intravenous titration of benzodiazepine for intravenous sedation. In this study we have confirmed the theoretical premise that a reduced dose of midazolam is required when given as a bolus. A mean dose of 4.65 mg midazolam intravenously has been found to be effective and safe in sedating patients under 70 years (n = 552). The dose of midazolam needed is reduced in older patients: patients over 70 years (n = 236) needed a mean dose of 1.89 mg. 2 Topical pharyngeal anaesthesia was not required with these doses of midazolam, and it was our impression that the examination was equally well tolerated with a similar degree of anterograde amnesia as in the previous study. 3 Our data, together with the results of the audit, would suggest many endoscopists are employing unnecessarily large and at times potentially dangerous doses of intravenous sedation in elderly patients and that the vast majority of upper gastrointestinal endoscopies can be performed successfully, without topical pharyngeal anaesthesia, using a bolus injection techniquewith a reduced dosage of sedative agent.

Computed tomography-pathologic assessment of laser-induced necrosis in rat liver.

RATIONALE AND OBJECTIVES: Interstitial laser photocoagulation (ILP) causes localized tissue necrosis. This study was performed to determine 1) whether the changes seen on computed tomography (CT) correspond to the necrosis pathologically, and 2) which CT technique best shows the necrosis. METHODS: Eighteen Wistar rats had ILP to their liver using a neodymium yttrium aluminum garnet [Nd:YAG] laser. Radio-opaque markers attached to the liver defined an imaging plane. Precontrast "dynamic" and delayed CT scans were performed. The size of necrosis was measured on CT, and macroscopically after resecting the liver. Computed tomography density numbers were measured from the necrotic area and normal liver for each CT technique. RESULTS: There was a good correlation between the necrosis size on CT and pathologically (P < .001). Maximum lesion-to-liver contrast was obtained on "dynamic" CT scans. CONCLUSIONS: The extent of tissue density changes on CT in rat liver after ILP match the extent of necrosis seen pathologically. The best CT technique use assessed for evaluating laser-induced liver necrosis is dynamic contrast-enhanced scanning.

Quiz: case report 776. Chondromyxoid fibroma of femur.

CMF is a rare neoplasm of bone, comprising less than 1% of primary bone tumors. The neoplasm was first described in 1948 by Jaffe and Lichtenstein as a separate entity from chondrosarcomas, having slightly different plain film characteristics and a benign clinical course. As of 1985, Kreicbergs, Lonnquist, and Willems estimated that approximately 400 cases have been published. Recently, we encountered a CMF with an unusual clinical presentation. The efficacy of MRI studies is shown.

A comparison of the effects of gonadal steroids on naloxone-induced LH secretion in gonadectomized rats.

The effects of the opiate antagonist naloxone on serum LH concentrations was investigated in gonadectomized rats given different regimes of steroid pretreatment. Two injections of testosterone given 48 and 24 h before naloxone treatment failed to reinstate LH responses to this drug in castrated rats while subcutaneous testosterone-filled silicone elastomer capsules implanted for a week were effective in this respect. Injections of oestrogen, oestrogen plus progesterone or progesterone alone all restored LH responses to naloxone in ovariectomized rats when given 48 and/or 24 h before drug treatment, although the magnitude of these responses varied according to the precise steroid treatments. The hypothalamic-pituitary axis was also responsive to naloxone just before the progesterone-induced LH surge in oestrogen-primed ovariectomized rats. Results show that gonadal steroids are permissive to the effects of opiate drugs, but they suggest that endogenous opioid systems do not necessarily mediate the negative feedback effects of steroids. Some other factor(s), as yet unidentified in the rat, may control the opioid modulation of gonadotrophin secretion or exert an independent inhibitory effect on gonadotrophin release.