Report of a rare testicular teratoid Wilms Tumor in an adult patient.

Although primarily a pediatric disease, nephroblastomas (also known as Wilms tumor) occur in adults at a rate of less than 0.2 cases per million per year. Rarer still are teratoid Wilms tumors, which arise from teratomas and therefore can be extrarenal. We describe the sixth recorded case of a testicular teratoid Wilms tumor in an adult patient with accompanying histological images of the specimen. Following the case, there is a brief discussion of the current literature.

The acute effect of match play on hamstring strength and lower limb flexibility in elite youth football players.

The aim of this study was to investigate the effect of competitive football match play on hamstring strength and lower limb flexibility. Fifteen male international youth football players were included. Hamstring strength and associated pain ratings, ankle dorsiflexion, hip extension, knee extension and flexion range of motion were evaluated immediately post-match and at intervals of 24, 48, and 72 h post-match. Strength significantly reduced post-match (P < 0.01), mean difference -0.43 (CI95 : -0.56, -0.30) and 24 h post (P < 0.05) mean difference -0.12 Nm/kg (CI95 : -0.20, -0.04). The associated pain scores significantly increased at the post-match (P < 0.01, ES = 0.61) and 24 h (P < 0.01, ES = 0.55) time intervals. At the 48 and 72 h post-match tests no significant difference was found for strength or pain ratings. No significant differences were detected for any of the range of motion measures. Competitive football match play has a significant acute and transient effect on isometric hamstring strength and associated pain levels during resisted knee flexion in male international youth players. Range of motion measures appear to remain relatively unaffected by match play. Isometric hamstring strength testing and associated pain levels might be considered for inclusion in-season to monitor player's post-match hamstring recovery characteristics.

Human cytomegalovirus infection leads to elevated levels of transplant arteriosclerosis in a humanized mouse aortic xenograft model.

Recent findings emphasized an important role of human cytomegalovirus (HCMV) infection in the development of transplant arteriosclerosis. Therefore, the aim of this study was to develop a human peripheral blood lymphocyte (hu-PBL)/Rag-2(-/-) γc(-/-) mouse-xenograft-model to investigate both immunological as well as viral effector mechanisms in the progression of transplant arteriosclerosis. For this, sidebranches from the internal mammary artery were recovered during coronary artery bypass graft surgery, tissue-typed and infected with HCMV. Then, size-matched sidebranches were implanted into the infrarenal aorta of Rag-2(-/-) γc(-/-) mice. The animals were reconstituted with human peripheral blood mononuclear cells (PBMCs) 7 days after transplantation. HCMV-infection was confirmed by Taqman-PCR and immunofluorescence analyses. Arterial grafts were analyzed by histology on day 40 after transplantation. PBMC-reconstituted Rag-2(-/-) γc(-/-) animals showed splenic chimerism levels ranging from 1-16% human cells. After reconstitution, Rag-2(-/-) γc(-/-) mice developed human leukocyte infiltrates in their grafts and vascular lesions that were significantly elevated after infection. Cellular infiltration revealed significantly increased ICAM-1 and PDGF-R-ß expression after HCMV-infection of the graft. Arterial grafts from unreconstituted Rag-2(-/-) γc(-/-) recipients showed no vascular lesions. These data demonstrate a causative relationship between HCMV-infection as an isolated risk factor and the development of transplant-arteriosclerosis in a humanized mouse arterial-transplant-model possibly by elevated ICAM-1 and PDGF-R-ß expression.

Renal colic during pregnancy: a case for conservative treatment.

PURPOSE: We defined the merits of early evaluation and conservative treatment of pregnant patients admitted with renal colic. MATERIALS AND METHODS: We retrospectively evaluated 72 pregnancies in 70 patients who were hospitalized with the diagnosis of renal colic between 1984 and 1995. Urinalysis was performed in every case. Ultrasound was the primary diagnostic test in 65 patients. The patients were followed for 2 weeks to 3 months after delivery (mean 21 days). RESULTS: Mean patient age at presentation was 27.4 years. The majority of patients were multiparous (47 of 70) and presented in the third trimester (44 of 70). Microscopic urinalysis was not helpful in identifying stone disease in pregnant patients. The sensitivity of ultrasound for the diagnosis of renal calculi was 95.2%. Watchful conservative nonsurgical treatment resulted in spontaneous passage of stones in 64.3% of cases. Of the 19 pregnancies in which intervention was necessary cystoscopy and Double-J* silicone stent placement were done in 15, and ureteroscopy and stone basketing were done in 4. Two patients, who presented with pyelonephritis and premature ruptured membranes had fetal loss. Long-term antibiotic prophylaxis was maintained in all stented and bacteriuric patients. CONCLUSIONS: Renal colic in pregnant patients can be complicated by pyelonephritis and premature labor, especially if misdiagnosed or inadequately treated. Ultrasound is a safe and sensitive diagnostic test. Approximately two-thirds of renal calculi will pass spontaneously. For those who require intervention, placement of a Double-J stent is a safe and effective option.

Range spectra in electron penetration problems.

The theory of electron penetration as predicted by the Fokker-Planck equation is first reviewed within a restricted context that considers the multiple scattering and transport of charged particles. We then broaden the context and show that range straggling effects also fit successfully into this framework, which completes an electron model initiated by Yang. We introduce those effects with a superposition of Fokker-Planck solutions, i.e., by using an incident beam that contains a spectrum of initial energies, or equivalently, a set of csda ranges. Straggling effects appear to be a beam property in this approach but are returned to the material when we use it. All the information needed to construct the spectrum is obtained from a measurement of the electron rest charge distribution in polystyrene. To illustrate the correctness of this procedure, we consider the case of a 20 MeV electron beam incident on water. We predict the absorbed dose distribution as a function of depth and also measure it with an ionization chamber in a water tank. We find nearly perfect agreement between calculation and experiment in this case where all the results derive and apply to a clinically operational machine.

The need for individualized dosimetry for tangential breast treatment.

We have examined the isodose distributions of 119 intact breast patients treated on a 6 MV linac to determine if a library of treatment plans could be used instead of individualized computer plans for patient treatments without compromising the quality of those treatments. The parameters studied were: field width, baseline separation, central axis separation, wedge angle, and isodose coverage. At least two wedges were used in the computer plans for each patient and the best plan was then chosen. In order to construct a library of plans, the choice of wedge, treatment isodose, and dose uniformity should be predictable. Our results show that for 90 out of 119 plans (76%), the 30 degrees wedge was best. In the other 29 cases, either the 15 degrees or the 45 degrees wedge yielded better plans. On average, the improvement in dose homogeneity due to choice of wedge was about 2% (range 0-7%) for these cases. Although grouping like-patient parameters generally restricted the isodose variation to +/- 2.5%, there were five patients for which up to a 7% underdosage would not have been predicted. For the set of plans using a 30 degrees wedge, a significant correlation was found for the ratio of the baseline to central axis separation vs. treatment isodose. The average isodose which covered the target area was 97% (range 90-100%) and 102 out of 107 patient plans using the 30 degrees wedge fell between 94 and 100%. We conclude from these results that the variation in dose distribution found with seemingly similar sized breasts is due to the variation in breast shape and symmetry. The use of a library plan with a single wedge and a standardized isodose line for tangential field treatment of intact breast could cause up to a 7% dose difference compared to the actual dosimetry for that patient.

Feminization as a result of both peripheral conversion of androgens and direct estrogen production from an adrenocortical carcinoma.

A 45-year-old man presented with gynecomastia, hypertension and a large left adrenal mass. Further evaluation revealed elevated serum concentrations of estrogen, estrone sulfate, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulfate, deoxycorticosterone, and aldosterone and increased 24-hour urinary 17-ketosteroid and free cortisol excretion. Removal of a 10 kg adrenocortical carcinoma led to normalization of the hormone concentrations and partial resolution of the gynecomastia. There was no clinical evidence of metastases. Incubation of tumor slices demonstrated that the tumor had an active aromatase and sulfotransferase. We estimated that about half the serum estrone arose from peripheral conversion of androstenedione. Feminizing adrenocortical carcinomas are rare and this case is unusual given the lack of clinical metastases and the probable dual source of estrogen from tumor as well as from the peripheral conversion of tumor-derived androgens.

Splenosis presenting as a left renal mass: a report of two cases.

The development of splenosis is a recognized consequence of splenic trauma. We present 2 cases of splenosis that were initially diagnosed as left renal cell carcinomas. The diagnosis of splenosis was made by technetium sulfur colloid scans. The clinical presentation and diagnosis of these 2 cases of splenosis masquerading as renal cell carcinoma are reviewed.

An evaluation of the efficacy of postoperative irradiation in rectal adenocarcinoma.

Cancer of the colon and rectum is the second most common form of cancer in the United States. Although surgery is the primary treatment for rectal cancer, the overall 5-year survival approximates 50%. Pelvic failure rates and their associated morbidity have led to the use of postoperative irradiation, either alone or combined with chemotherapy. We reviewed 77 consecutive patients treated with postoperative irradiation to the pelvis following curative surgery. The prognosis is dependent on surgical stage and histologic grade. The minimal decrease in local recurrence in this study is offset by treatment-related small bowel injury. A subset of patients who may benefit from adjuvant treatment is yet to be defined.

Application of the ICRU Report 38 reference volume concept to the radiotherapeutic management of recurrent endometrial and cervical carcinoma.

Radiation therapy was given to 25 patients presenting with pelvic recurrence of endometrial (14) and cervical (11) cancer. Of these patients, all but one had undergone hysterectomy following their original diagnosis. Two endometrial patients received preoperative intracavitary irradiation. The recurrence-free interval ranged from 5 to 71 months (mean = 21 months). External beam radiation therapy for pelvic recurrence ranged from 3000 to 5000 cGy. Additional central radiation was given to 18 patients with either external beam, intracavitary, interstitial, or transvaginal technique. Dose and dose rates from brachytherapy are documented with maximum values, along with the location of these dose points. Such specification is essential in obtaining a more accurate impression of the total dose delivered to the patient, especially when different techniques are employed to increase the dose to the center of the pelvis. Reference volume dimensions, similar to those specified by ICRU Report 38 for intracavitary treatments, are presented. Mean follow-up from completion to radiotherapy is 22 months; 16 patients are dead, 2 are alive with disease, and 7 are alive with no evidence of disease.

Conversion from Cs-137 to Ir-192 for high dose rate remote afterloading: practical considerations.

High dose rate (HDR) remote afterloading is increasingly being used to replace many conventional low dose rate (LDR) brachytherapy procedures. Implementation of the microSelectron-HDR with Ir-192 at our facility necessitated this study to obtain equivalent dosimetric distributions with those of our LDR Cs-137 techniques using our current treatment planning system. Three anatomical sites are presented: nasopharynx, esophagus, and uterine cervix. Attention must be given to the anisotropy of Cs-137 tubes when converting to Ir-192; for linear geometries, total equivalent activity may be preserved but the shapes of the resulting isodose curves for Ir-192 are longer than those of Cs-137. In the case of Fletcher-Suit intracavitary treatments of the uterine cervix, the longer contours for Ir-192 in the vaginal ovoids results in higher isodose levels reaching the bladder and rectum. Maintaining the traditional dose levels to these organs is accomplished by modifying the loading of the ovoids to approximately 85% of the corresponding Cs-137 activity. Computerized dosimetry is presented, along with a chart we have devised to easily convert a standard LDR treatment to HDR dwell times. Our results are especially suitable to those users who will continue to make use of their present computer treatment planning system.

Iodine125 interstitial brachytherapy in the treatment of carcinoma of the lung.

In a prospective study, 14 patients with primary non-oat cell lung carcinoma were treated with intraoperative Iodine125 (I125) implantation of the lung tumor via lateral thoracotomy or median sternotomy. Staging mediastinal node dissection was performed in each case. Patients were selected when wedge or segmental resections were not technically feasible, such that lobectomy or completion pneumonectomy would have been required or pulmonary function studies were poor. Doses ranged from 8,000 cGy at the periphery to 20,000 cGy at the center. With a minimum 12 month follow-up, mean and median survivals were 16.7 and 15.1 months, respectively. Local control was achieved in 10 of 14 patients (71%) with all local failures occurring in pathologic stage III patients. When separated according to tumor size, local control was obtained in six of seven tumors of less than 3 cm and four of five tumors of 3-5 cm. Both cases with masses greater than 5 cm failed locally. There was one operative mortality and two postoperative complications. All other patients were discharged within one week of surgery. There was no radiation pneumonitis. I125 lung brachytherapy is an excellent alternative treatment for T1 and T2 tumors when medical conditions preclude curative resection.

Predicting normal tissue injury in radiation therapy.

We tested three radiobiologic models, the nominal standard dose (NSD), the biologic index of reaction (BIR), and the linear quadratic (LQ) models to determine which best predicts normal tissue injury in radiation therapy. Clinical data for radiation myelopathy, rib fracture and pericardial effusion were used for all three models to predict injury. We assumed that on the average injuries occurred at higher equivalent doses of radiation than were received by patients who were not injured. We used a t-test to determine whether there were in fact significant differences in the mean values of the equivalent doses among the injured and non-injured. The means were calculated for the four sets of injury by the three models. For the LQ model it was necessary to choose a value for the parameter alpha/beta; the results were not sensitive to the choice over the range of 1/2 to 12 Gy. None of these models showed a significant difference between injured and non-injured patients for all four sets of data. The BIR model showed significant differences in three sets, the LQ model was significant in two and marginally significant in one set, and the NSD was significant in two sets. This analysis illustrates therefore, that the linear quadratic model can be adopted for analysis of clinical data with results that are no worse and possibly better than the NSD model.

The CT scanner as a therapy machine.

Many tumors in the brain and in other tissues can be delineated precisely in images obtained with a CT scanner. After the scan is obtained the patient is taken to another room for radiation therapy and is positioned in the beam with the aid of external markers, simulators or stereotactic devices. This procedure is time consuming and subject to error when precise localization of the beam is desired. The CT scanner itself, with the addition of a collimator, is capable of delivering radiation therapy with great precision without the need for external markers. The patient can be scanned and treated on the same table, the isocenter of the beam can be placed precisely in the center of the lesion, the beam can be restricted to just those planes in which the lesion appears several arcs can be obtained by simply tilting the gantry, and the position of the patient in the beam can be monitored continuously during therapy. We describe here the properties of the CTX, the CT scanner modified for therapy.

Optimization of arc angles in rotational therapy.

Data is presented that will aid in optimizing the arc angles used for rotational therapy for a 6 Mv x-ray beam. Computer calculations of isodose distributions were carried out and the Ap and Lateral dimensions of the 95 and 100% isodose line were tabularized as a function of the field width (6-14 cm), distance between isocenter and patient midline (0-3 cm), and bilateral 120 or 100 degrees arc angle. The 300 degrees rotation cases we studied were generally found to be inferior to 120 degrees or 100 degrees bilateral arc rotations. 120 degrees arcs are best when the target center is within 2 cm of the patient's Ap center. As that separation increases, the bilateral arc angle should be decreased or wedges should be rotated through 300 degrees to avoid maximum doses greater than 105%. The data tables can be used as a starting point for computer calculations to select the field width and the arc angle for a particular target location and size. Of note is the degree to which the dimensions of the 100% isodose line decreases for small field widths and large isocenter to patient midline distances.

Buried penis. A novel approach.

Buried penis is a congenital abnormality in which the phallus is concealed within the subcutaneous tissue. The corporal bodies and glans have developed normally. A deficiency of penile shaft skin in association with abnormal mobility of the skin gives rise to the phenotypic appearance. The skin defect may be related to an abnormal attachment of dartos muscle during embryogenesis. Correction of this condition requires separation of these abnormal muscular attachments and provision of skin coverage of the penile shaft. It is imperative not to circumcise the patient as this will worsen the skin deficiency. We describe a novel technique for correcting buried penis performed on 12 patients at the Great Ormond Street Hospital for Sick Children. A satisfactory cosmetic result was obtained in all patients.