Preoperative considerations and benefits of neoadjuvant chemotherapy: insights from a 12-year review of the Hong Kong Breast Cancer Registry.

INTRODUCTION: Neoadjuvant chemotherapy (NAC) was initially used for locally advanced or inoperable breast cancers. Its extension to early disease has facilitated breast-conserving surgery (BCS). This study investigated the use of NAC in patients registered with the Hong Kong Breast Cancer Registry (HKBCR); it also assessed NAC effectiveness according to rates of pathological complete response (pCR) and BCS. METHODS: Records were retrieved from the HKBCR regarding 13 435 women who had been diagnosed with invasive breast cancer during the period of 2006 to 2017, including 1084 patients who received NAC. RESULTS: The proportion of patients treated with NAC nearly doubled from 5.6% in 2006-2011 to 10.3% in 2012-2017. The increase was most pronounced among patients with stage II or III disease. In terms of biological subtype, substantial increases in the receipt of NAC were evident among patients with triple-negative and human epidermal growth factor receptor 2 (HER2)-positive (non-luminal) tumours. The best rates of pCR were observed in patients with HER2-positive (non-luminal) [46.0%] tumours, followed by patients with luminal B (HER2-positive) [29.4%] and triple-negative (29.3%) tumours. After NAC, the rate of BCS was 53.9% in patients with clinical stage IIA disease, compared with 38.2% in patients with pathological stage IIA disease who did not receive NAC. CONCLUSION: The use of NAC in Hong Kong increased from 2006 to 2017. The findings regarding rates of pCR and BCS indicate that NAC is an effective treatment; it should be considered in patients with stage ≥II disease, as well as patients with HER2- positive (non-luminal) or triple-negative breast cancers.

A rare combination of recurrent pneumonia, diarrhoea, and visual loss in a patient after thymectomy: good syndrome.

This report describes a 68-year-old Chinese man who was diagnosed with Good syndrome 6 years after initial presentation when he underwent thymectomy. He presented with recurrent pneumonia, diarrhoea, weight loss, and visual symptoms. Extensive examination for anaemia and neutropenia was done, yet no conclusive diagnosis could be derived. During his last admission for pneumonia, his history of AB thymoma suggested the possibility of Good syndrome. Immunological testing revealed low T cells, absent B cells, and low immunoglobulin M and immunoglobulin G levels. Moreover, he had histologically identified cytomegalovirus pneumonia, cytomegalovirus colitis, and fundoscopic features of cytomegalovirus retinitis. He was treated with a 2-week course of intravenous ganciclovir, lifelong oral valganciclovir, and monthly immunoglobulin infusion. It took 6 years for the diagnosis to be established, therefore, early attention and vigorous search for such potentially treatable conditions in post-thymectomy patients presenting with recurrent infections is recommended.

Symptom burden and quality of life in end-stage renal disease: a study of 179 patients on dialysis and palliative care.

Palliative care for end-stage renal disease (ESRD) is developing in Hong Kong. This is the first local study to explore the symptom burden and quality of life (QOL) of ESRD patients on chronic dialysis and palliative care. This was a prospective cross-sectional study conducted on ESRD patients in a hospital in Hong Kong from January 2006 to April 2007. Data collected included demographics, socioeconomic status, modified Charlson Comorbidity Index (CCI), prevalence and intensity of 23 ESRD-related symptoms as rated by numerical rating scale (0-10), Brief Pain Inventory and QOL by MOS SF-36. A total of 179 ESRD patients completed the study; 45 patients (25.1%) were in the palliative care group and 134 patients (74.9%) in the dialysis group. The palliative care group were older (73.1 +/- 7.1 vs 58.2 +/- 11.4 years, P < 0.001), had marginally higher modified CCI (8.5 +/- 1.9 vs 6.1 +/- 2.4, P = 0.05), had more diabetics (62.2 vs 35.8%, P < 0.001) and were of poorer socioeconomic status than the dialysis group. The mean number of symptoms was 8.2 +/- 3.9 and 9.3 +/- 4.7 in the palliative care and the dialysis group, respectively (P = NS). Fatigue, cold aversion, pruritus, lower torso weakness and difficulty sleeping were the five most prevalent symptoms in both groups, and were also among the most intense symptoms. QOL was significantly impaired in both groups. Scores of all QOL domains correlated negatively with the number of symptoms (P < 0.001). Our ESRD patients under palliative care and dialysis had overlapping symptom prevalence and intensity, significant symptom burden and impaired QOL.

Acute angle closure glaucoma following head and orbital trauma.

The case is reported of a 52-year-old woman who suffered a minor head injury and orbital trauma and returned 2 days later with a unilateral headache, vomiting and photophobia. This was initially thought to be secondary to her head injury but, once severe visual impairment and a dilated unreactive pupil developed, the true diagnosis became obvious. A diagnosis of acute angle closure glaucoma was made and she was treated with no complications. This case highlights acute angle closure glaucoma as an important diagnosis to consider in patients who present with unilateral headache and dilated pupil after head injury.

Posttraumatic Stress after Treatment in an Intensive Care Unit.

OBJECTIVE: To study posttraumatic stress in patients after treatment in an intensive care unit (ICU). METHODS: This prospective cohort study included 136 adult patients with critical medical and surgical problems who were discharged from the ICU of the Caritas Medical Centre, Hong Kong. Their occurrence of posttraumatic stress disorder (PTSD), anxiety, and depression after ICU treatment were measured using the Impact of Event Scale-Revised and Hospital Anxiety and Depression Scale. Patient ICU experience was measured using the ICU Memory Tool. Multivariable analyses were conducted to examine the predictors of PTSD symptoms, anxiety, and depression. RESULTS: Symptoms of PTSD, anxiety, and depression were reported in 10% to 17% of patients. Symptom severity was associated with less factual memory, more vivid memory of feelings about and more delusional memory of the ICU experience, low emotional support, and high perceived life threat. CONCLUSIONS: Symptoms of posttraumatic stress, anxiety, and depression may occur after ICU treatment. Early identification and appropriate intervention for PTSD are important for rehabilitation.

High-resolution analysis of chromosome rearrangements on 8p in breast, colon and pancreatic cancer reveals a complex pattern of loss, gain and translocation.

The short arm of chromosome 8, 8p, is often rearranged in carcinomas, typically showing distal loss by unbalanced translocation. We analysed 8p rearrangements in 48 breast, pancreatic and colon cancer cell lines by fluorescence in situ hybridization (FISH) and array comparative genomic hybridization, with a tiling path of 0.2 Mb resolution over 8p12 and 1 Mb resolution over chromosome 8. Selected breast lines (MDA-MB-134, MDA-MB-175, MDA-MB-361, T-47D and ZR-75-1) were analysed further. Most cell lines showed loss of 8p distal to a break that was between 31 Mb (5' to NRG1) and the centromere, but the translocations were accompanied by variable amplifications, deletions and inversions proximal to this break. The 8p12 translocation in T-47D was flanked by an inversion of 4 Mb, with a 100 kb deletion at the proximal end. The dicentric t(8;11) in ZR-75-1 carries multiple rearrangements including interstitial deletions, a triplicated translocation junction between NRG1 and a fragment of 11q (unconnected to CCND1), and two separate amplifications, of FGFR1 and CCND1 . We conclude that if there is a tumour suppressor gene on 8p it may be near 31 Mb, for example WRN; but the complexity of 8p rearrangements suggests that they target various genes proximal to 31 Mb including NRG1 and the amplicon centred around ZNF703/FLJ14299.

Viral replication in the nasopharynx is associated with diarrhea in patients with severe acute respiratory syndrome.

The role of severe acute respiratory syndrome (SARS) coronavirus as an enteric pathogen was investigated in a cohort of 142 patients with SARS who were treated with a standard treatment protocol. Data from daily hematological, biochemical, radiological, and microbiological investigations were prospectively collected, and the correlation of these findings with diarrhea was retrospectively analyzed. Sixty-nine patients (48.6%) developed diarrhea at a mean (+/- standard deviation [SD]) of 7.6+/-2.6 days after the onset of symptoms. The diarrhea was most severe at a mean (+/-SD) of 8.8+/-2.4 days after onset, with a maximum frequency of 24 episodes per day (median, 5 episodes; range, 3-24 episodes). A higher mean virus load in nasopharyngeal specimens obtained on day 10 after the onset of symptoms was significantly associated with the occurrence of diarrhea (3.1 log10 vs. 1.8 log10 copies/mL; P=.01) and mortality (6.2 vs. 1.7 log10 copies/mL; P<.01). However, diarrhea was not associated with mortality. The lung and the gastrointestinal tract may react differently to SARS coronavirus infection. Additional investigation of the role of SARS coronavirus in the pathogenesis of diarrhea in patients with SARS should be conducted.

A computer-aided algorithm to quantitatively predict lymph node status on MRI in rectal cancer.

OBJECTIVE: The aim of this study was to demonstrate the principle of supporting radiologists by using a computer algorithm to quantitatively analyse MRI morphological features used by radiologists to predict the presence or absence of metastatic disease in local lymph nodes in rectal cancer. METHODS: A computer algorithm was developed to extract and quantify the following morphological features from MR images: chemical shift artefact; relative mean signal intensity; signal heterogeneity; and nodal size (volume or maximum diameter). Computed predictions on nodal involvement were generated using quantified features in isolation or in combinations. Accuracies of the predictions were assessed against a set of 43 lymph nodes, determined by radiologists as benign (20 nodes) or malignant (23 nodes). RESULTS: Predictions using combinations of quantified features were more accurate than predictions using individual features (0.67-0.86 vs 0.58-0.77, respectively). The algorithm was more accurate when three-dimensional images were used (0.58-0.86) than when only middle image slices (two-dimensional) were used (0.47-0.72). Maximum node diameter was more accurate than node volume in representing the nodal size feature; combinations including maximum node diameter gave accuracies up to 0.91. CONCLUSION: We have developed a computer algorithm that can support radiologists by quantitatively analysing morphological features of lymph nodes on MRI in the context of rectal cancer nodal staging. We have shown that this algorithm can combine these quantitative indices to generate computed predictions of nodal status which closely match radiological assessment. This study provides support for the feasibility of computer-assisted reading in nodal staging, but requires further refinement and validation with larger data sets.

Development of a psychological well-being scale for family caregivers in palliative care.

OBJECTIVE: A Psychological Well-being Scale for Caregivers (PWS-C) was developed to screen for psychological distress among family caregivers in a Palliative Care Unit for patients with advanced cancer. METHODS: To study the psychometric properties of the 11-item PWS-C which consisted of 5 subscales; 132 family caregivers completed the PWS-C, of whom 70 also answered the Hospital Anxiety and Depression Scale (HADS) questionnaire. Results of 15 caregivers who had received psychological intervention and completed the PWS-C before and after treatment were compared. RESULTS: The internal consistency and test-retest reliability of the scale were found to be satisfactory. A 4-factor structure was identified. Items for Life Meaning and Social Support subscales were accounted for by 1 factor. The subscales of Emotional Distress, Caregiving Inadequacy, and Hospital Care were accounted for by 3 other factors. The PWS-C subscale scores were moderately correlated with HADS scores. Significant changes in the subscales of Social Support and Life Meaning of the PWS-C were identified in pre-post treatment comparisons, which indicated the potential utility of the scale as an outcome measure. CONCLUSIONS: The PWS-C could be a reliable and valid tool useful for screening and measuring the outcome of psychological interventions for psychological well-being / distress reduction, for caregivers of patients receiving palliative care.

The impact of palliative care on cancer deaths in Hong Kong: a retrospective study of 494 cancer deaths.

OBJECTIVES: To study the utilization of public health care by advanced cancer patients in their last 6 months of life and their end-of-life process within the last 2 weeks of life. METHODS: This was a retrospective study on 494 cancer deaths from four public hospitals in 2005. This sample was selected from all in-patient cancer deaths by the ratio of one in four. Data were collected by review of charts and an electronic data base. RESULTS: A total of 494 cancer deaths were analysed. The mean age of all cancer patients (n = 494) was 72.6 years. Two-thirds of cancer patients received palliative care and half died in palliative care setting. Patients were categorized into three groups according to palliative care coverage and the place of death. The first group comprised of patients who received palliative care service and died in palliative care units (PCS-PCD group, n = 247); the second group of patients who received palliative care service within the last 6 months of life but died in non-palliative care wards (n = 86); and the third group of patients who never received palliative care and who died in non-palliative care wards (NPCS-NPCD group, n = 161). Differences among groups were tested by one way ANOVA. During the last 6 months of life, patients in the PCS-PCD group had less admission to acute care wards (P = 0.012), shorter duration of stay in acute care wards (P = 0.003), and less admission to an intensive care unit setting (P < 0.001). Within the last 2 weeks of life, the PCS-PCD group had fewer interventions initiated (P < 0.001); had higher number of symptoms documented in patient's record (P < 0.001); and were more likely to receive analgesics (P < 0.001), adjuvant analgesics (P < 0.001) and sedatives (P < 0.001). Patients in PCS-PCD group were more physically dependent in the last 2 weeks of life (P < 0.001), but mentally more alert at 72 hours before death (P < 0.001). Patients in the NPCS-NPCD group had fewer patients with a do not resuscitate order present (P < 0.001), and more patients with cardiopulmonary resuscitation performed (P < 0.001). CONCLUSION: Our results suggest that palliative care service has played a role in improving end-of-life cancer care in Hong Kong.

Viral loads in clinical specimens and SARS manifestations.

A retrospective viral load study was performed on clinical specimens from 154 patients with laboratory-confirmed severe acute respiratory syndrome (SARS); the specimens were prospectively collected during patients' illness. Viral load in nasopharyngeal aspirates (n = 142) from day 10 to day 15 after onset of symptoms was associated with oxygen desaturation, mechanical ventilation, diarrhea, hepatic dysfunction, and death. Serum viral load (n = 53) was associated with oxygen desaturation, mechanical ventilation, and death. Stool viral load (n = 94) was associated with diarrhea, and urine viral load (n = 111) was associated with abnormal urinalysis results. Viral replications at different sites are important in the pathogenesis of clinical and laboratory abnormalities of SARS.