Preferred Treatment Approach Research Articles

ES09.04 How I Decide 2nd Line Treatment Options for Relapsed/Refractory Metastatic NSCLC

ES09.04 How I Decide 2nd Line Treatment Options for Relapsed/Refractory Metastatic NSCLC

Outcome for Conservative Surgery for the Correction of Severe Mitral Valve Regurgitation in Children: A Single-Center Experience.

Evolving reconstructive techniques have progressively become the preferred approach for treatment of pediatric mitral valve regurgitation. We present our experience in a cohort of patients undergoing surgical correction for severe mitral regurgitation. Fifty-five patients (age 1month-18years; median 5years) were included in the present analysis. Different surgical techniques were used (posterior leaflet augmentation in 25, isolated cleft closure in 12, Alfieri-type procedure in 10, annuloplasty in 5, with artificial chordae in 2, and quadrangular resection with chordal transposition in 1). Follow-up time ranged from 1 to 192months (median 38[IQR 12-54] months). Operative and follow-up mortality was 0%. Reintervention in the whole population occurred in 31% of patients. However, when first surgery was performed under 2years of age (no = 17), reintervention reached nearly 50%. The degree of residual mitral regurgitation at follow-up remained stable after surgery, while a significant increase in mean transmitral gradient was observed over time (paired t test = 0.03). In multivariable Cox-regression analysis, post-surgical transmitral gradient was the only independent predictor for reintervention (p = 0.017; HR 2.4; 95%CI 1.2-5.1), after correcting for differences in age at surgery, type of reintervention, mitral annulus dimension, and BSA at the first surgery. ROC curve demonstrated that a post-surgical transmitral mean gradient value > 5mmHg, was predictive for reintervention (AUC = 0.89; Youden index = 0.44). Our study suggests that the use of conservative technique strategy achieves satisfactory functional results in infants and children with severe MR, although the rate of reoperation in younger patients remains substantial. Post-operative moderate mitral stenosis was the strongest predictor for reoperation.

Dentists’ Preferences in the Treatment of Congenitally Missing Maxillary Lateral Incisors

Objective: Congenitally missing maxillary lateral incisors present challenges to dentists in terms of treatment planning and can negatively affect aesthetics and function in patients. The aim of the present study was to determine the preferred treatment approach of dentists with different specialties. Material and Methods: We carried out a descriptive, cross-sectional study using a questionnaire that was self-administered to 12 specialists in removable prosthodontics, 18 specialists in restorative dentistry, 14 specialists in orthodontics, and 173 registered general dentists. Results: General practitioners (72.7%), prosthodontists (92.9%) and, restorative dentists (80%) preferred prosthodontic replacement of missing maxillary lateral incisors, while orthodontists (57.1%) preferred canine substitution. Most general practitioners (62.7%), prosthodontists (71.4%), and orthodontists (92.9%), as well as many restorative specialists (40%), preferred implant-retained crowns for prosthetic replacement of missing lateral incisors. The dental specialties differed significantly in terms of their preferred modalities for treating children over the age of 12 years. General practitioners (56%) preferred removable partial dentures (RPDs), while a mere 17.2% preferred to carry out no treatment. All prosthodontists (100%) preferred treatment with RPDs. Restorative dentists preferred RPDs and adhesive bridges in equal number (33.3% in each case). Fifty percent of orthodontists treating children with missing lateral incisors preferred RPDs, followed by (28.6%) who preferred canine substitution. Conclusion: Preference varied for several reasons among dentists’ treating both adults and children over 12 years of age. KeywordsMaxillary missing teeth; Dentist's preference; Teeth replacement; Dental implant.

Psychological Needs in Post-Genocide Cambodia: The Call for Family Therapy Services and the Implications for the “Majority World” Populations

ABSTRACTDuring the Khmer Rouge reign in Cambodia from 1975 to1979, approximately one-quarter of the country’s population lost their lives by starvation, disease, or execution. Most intellectual and academic institutions, including mental health services, were destroyed during this period by the Khmer Rouge regime who saw them as a threat. About 15 years ago mental health services began to be reinitiated in the country, usually in collaboration with Western academics and mental health experts. The call for these services was often in response to the high prevalence of post-traumatic stress disorders and other psychosocial problems. Today mental health issues still receive insufficient attention in Cambodia, mainly stemming from a lack of resources, knowledge about the general topic of mental health, and stigma. This article presents the results of a survey delivered to the first generation of psychology students since the end of the Khmer Rouge regime regarding their impressions of the current mental health needs in Cambodia. Respondents answered questions about the types of problems people bring to Cambodian counselors and therapist, the clinical populations in their work settings, their views of preferred treatment approaches in Cambodia, barriers to service delivery, and types of training needed to address the concerns of the people of Cambodia. The leading requests for the future development of mental health training included the need for training in marriage and family therapy, assessments, and play therapy. Domestic violence, depression, and anxiety/stress were also placed at the top of the mental health issues reported.

Rastelli Operation for D-Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis.

Our preferred approach for the surgical treatment of patients with D-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis has been the Rastelli operation. We herein evaluate our 30-year experience with this procedure. Clinical records for patients who underwent the Rastelli operation between 1988 and 2017 at our institution were retrospectively reviewed. Primary outcomes included freedom from death or cardiac transplantation and freedom from conduit reintervention. Forty-seven patients met inclusion criteria. Mean follow-up was 11.7 ± 6.8 years. Forty-three (91.5%) patients received a palliative systemic-to-pulmonary artery shunt and/or atrial septostomy prior to the Rastelli procedure. Five (10.6%) patients required ventricular septal defect enlargement at the time of the Rastelli procedure. The overall mean right ventricle-to-pulmonary artery conduit size was 17.0 mm. Mortalities included one early and three late deaths. Freedom from death or cardiac transplantation was 93% and 84% at 5 and 25 years, respectively. Seven patients required pacemaker placement, two immediately postoperatively and five late. Freedom from conduit replacement was 85% and 25% at 5 and 15 years, respectively. Seven (14.9%) patients required a second conduit intervention. Forty-one (87.2%) patients were New York Heart Association class I or II at the most recent follow-up. The Rastelli operation for D-transposition of the great arteries, ventricular septal defect, and pulmonary stenosis offers excellent mid- to long-term survival. The need for conduit replacement remains the most common indication for reintervention, and further study of the optimal choice of conduit will be useful.

Behçet's disease in children: single-center experience.

Aim:In this study, it was aimed to summarize the demographics, and clinical and laboratory findings of children who were diagnosed as having Behçet’s disease, and also to determine the efficacy, duration, and adverse effects of the treatments.Material and Methods:The records of 34 patients who were diagnosed according to the International Behçet Study Group criteria between 1980 and 2013 in the Department of Pediatric Nephrology and Rheumatology, Hacettepe University Faculty of Medicine, were retrospectively reviewed and all demographic and clinical features were recorded. In the light of these data, the sex and age distribution, clinical and laboratory findings, most commonly preferred treatment approaches, efficacy of treatments, and adverse effects during treatment were analyzed.Results:Of the 34 children with Behçet’s disease, 18 (53%) were male and 16 (47%) were female, and the mean age was 11.18±3.34 years. There was no significant difference in age distribution of the male and female patients (p<0.05). In 97% (n=33) of the patients, the first symptom was recurrent oral aphthae. In order of frequency, the other mucocutaneous findings were pseudofoliculitis and pustular lesions (82%), genital ulcers (62%), and pathergy positivity (50%). System involvements in order of frequency were as follows: joint findings (38%), ocular findings (35%), vascular involvement (32%), neurologic involvement (18%), gastrointestinal involvement (5.8%), and pulmonary involvement (5.8%). Colchicine was the most commonly preferred drug (88%). Steroids were added to treatment in patients with skin involvement. Azathioprine was added in patients with uveitis. Anticoagulant therapy, cyclophosphamide, and anti-tumor necrosis factor-alpha were added in patients with vascular involvement. In patients with gastrointestinal system involvement, sulfasalazine was added to treatment. Diarrhea was the most common adverse effect in patients who used colchicine. In the patients who used steroid treatment, gastrointestinal symptoms such as unintentional weight gain, acne, and agitation were observed (17%). One patient who received interferon treatment had symptoms of depression and agitation.Conclusion:The aim of this study was to review the general characteristics of pediatric patients with Behçet’s disease and to emphasize the importance of early diagnosis and correct treatment in terms of mortality and morbidity.

Current Management and Recent Advances in the Treatment of Chronic Myelomonocytic Leukemia.

Chronic myelomonocytic leukemia (CMML) is an aggressive myeloid neoplasm in which treatment strategies with the capacity to improve survival are currently lacking. Clinical features are heterogeneous and although the overall prognosis is poor, survival can vary significantly between individuals. This reflects the need for an individualized treatment approach which incorporates accurate risk stratification. Though numerous prognostic scores exist, newer CMML-specific models incorporating molecular data should be favored. While asymptomatic, low-risk patients should be observed until their disease progresses, the majority of patients will require treatment. Due to a deficiency in treatments with disease-modifying capacity, any patient who requires treatment should be considered for enrollment in clinical trials evaluating novel therapeutic approaches. Allogeneic stem cell transplant (allo-SCT) remains the only current therapy with the potential to cure the disease and should be considered in most patients with intermediate- to high-risk disease. However, substantial risks are involved and, in part, because of advanced age at diagnosis, a minority of patients are candidates. Hypomethylating agents (HMAs) have become a preferred treatment approach, and should be used in those with cytopenias. Patients presenting with proliferative features can be treated with hydroxyurea to manage their symptoms and control leukocytosis, though HMAs can be incorporated as well, particularly in patients with higher risk disease. HMAs should also be considered in patients with a high burden of disease prior to proceeding with allo-SCT. Induction chemotherapy should be reserved for younger, healthy patients who have transformed to acute myeloid leukemia to induce remission prior to transplant. Supportive care utilizing transfusion support, erythropoiesis-stimulating agents, and infection prevention measures should be incorporated into the care of all patients.

National Trends in Spinal Fusion Surgery for Neurofibromatosis

Study DesignAnalysis of a national database. ObjectiveTo analyze trends in spinal fusion surgery for neurofibromatosis type I (NF-1) patients and to compare the surgical approaches. Summary of Background DataThe preferred surgical approach for fusion treatment of spinal deformity in NF is not well established. MethodsWe identified 548 patients with a diagnosis of NF-1 who had received spinal fusion surgery between 2003 and 2014. We compared posterior spinal fusion (PSF), anterior-posterior spinal fusion (APSF), and anterior spinal fusion with respect to patient demographics, institutional characteristics, in-hospital complications, and hospitalization lengths and costs. Significance was set at a value of p less than .05. ResultsThe number of spinal fusions for NF-1 significantly increased (p = .02) over the study period. The rate of PSF surgeries increased 2.9-fold, whereas the rate of APSF surgeries decreased 2.2-fold. There was also a significant association between the location of the fusion and surgical approach (p<.01), with 66% of ASF cases being cervical spine cases. Compared with patients undergoing PSF and ASF, patients undergoing APSF were significantly younger (p<.01) and had significantly higher hospitalization lengths and costs (p<.01). APSF costs were $180,714 as compared to $144,027 for PSF and $105,312 for ASF. ConclusionsThere have been significant increases in the rate of spinal fusion surgeries for NF-1 patients. Surgical treatment has shifted over the years and is dependent on the location of the deformity. Patients undergoing APSF are significantly younger. Level of EvidenceLevel III.

Hemorrhagic colloid cyst

Colloid cysts are cystic lesions that are usually located in the anterior portion of the third ventricle near the foramen of Monro. Rarely, hemorrhagic cysts can lead to acute obstructive hydrocephalus or sudden death. We herein report 2 cases and a review literature. We examine a 47-year old male who presented with progressive headache and a 55-year old male who presented with progressive memory disturbance and unsteady gait. Both cases demonstrated typical imaging features of hemorrhagic colloid cyst, and were histopathologically confirmed. Total excision was achieved in both cases with good outcomes. Hemorrhagic colloid cysts are rare; however, bleeding tendencies should be carefully considered in patients with these cysts. The degree of rapidity with which clinical deterioration occurs may play a major role in the preferred treatment approach and subsequent outcomes.

Mental illness has multiple causes: beliefs on causes of mental illness by congregants of selected neo-prophetic churches in Ghana

ABSTRACTThe present study explored perceived causes of, and preferred treatment approach for, mental illness among congregants of six Neo-prophetic churches in Accra and Kumasi through in-depth interviews. Using thematic analysis, five themes emerged from participants’ causal attributions of mental illness. These included lifestyles and environmental stressors, spiritual causes, interaction of multiple factors, trauma and biological causes. Additionally, participants discussed four main mechanisms through which stress leads to mental illness. These included persistent worrying over stressors, use of inappropriate coping strategies to cope with stress, refusal to talk about one's problems and individuals’ appraisal of stress and available coping resources. These beliefs directly determined congregants’ preferred treatment approach. Implications of the findings are discussed.

Improving maraviroc oral bioavailability by formation of solid drug nanoparticles

Oral drug administration remains the preferred approach for treatment of HIV in most patients. Maraviroc (MVC) is the first in class co-receptor antagonist, which blocks HIV entry into host cells. MVC has an oral bioavailability of approximately 33%, which is limited by poor permeability as well as affinity for CYP3A and several drug transporters. While once-daily doses are now the favoured option for HIV therapy, dose-limiting postural hypotension has been of theoretical concern when administering doses high enough to achieve this for MVC (particularly during coadministration of enzyme inhibitors). To overcome low bioavailability and modify the pharmacokinetic profile, a series of 70 wt% MVC solid drug nanoparticle (SDN) formulations (containing 30 wt% of various polymer/surfactant excipients) were generated using emulsion templated freeze-drying. The lead formulation contained PVA and AOT excipients (MVCSDNPVA/AOT), and was demonstrated to be fully water-dispersible to release drug nanoparticles with z-average diameter of 728 nm and polydispersity index of 0.3. In vitro and in vivo studies of MVCSDNPVA/AOT showed increased apparent permeability of MVC, compared to a conventional MVC preparation, with in vivo studies in rats showing a 2.5-fold increase in AUC (145.33 vs. 58.71 ng h ml−1). MVC tissue distribution was similar or slightly increased in tissues examined compared to the conventional MVC preparation, with the exception of the liver, spleen and kidneys, which showed statistically significant increases in MVC for MVCSDNPVA/AOT. These data support a novel oral format with the potential for dose reduction while maintaining therapeutic MVC exposure and potentially enabling a once-daily fixed dose combination product.

Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

Intrinsic abnormalities of the mitral valve are common in patients with hypertrophic cardiomyopathy and may need to be addressed at operation. Consecutive patients undergoing transmitral septal myectomy were retrospectively reviewed. The ventricular septum was exposed through a left atriotomy, and the anterior leaflet of the mitral valve was detached from its annulus. An extended myectomy was performed to the base of the papillary muscles. After myectomy, the anterior leaflet was reattached and concomitant mitral valve repair or replacement was performed. In some cases, we performed a modified anterolateral commissural closure suture, which served to reposition the lateral aspect of the anterior leaflet out of the left ventricular outflow tract ("curtain stitch"). Twenty patients who underwent this procedure were identified (70% women; mean age 63 years). Mitral regurgitation was moderate in 55% and severe in 40%. Preoperative peak left ventricular outflow tract gradient was 92 ± 43 mm Hg. Mitral valve repair (n= 11) or replacement (n= 9) was performed. Predischarge transthoracic echocardiography demonstrated a left ventricular outflow tract gradient of 10 ± 5 mm Hg. There was no operative mortality. Follow-up was 100% complete and averaged 22 ± 25 months. No patient required reoperation, and there was no recurrence of left ventricular outflow tract obstruction or mitral regurgitation greater than mild. Potential advantages of transmitral myectomy include a panoramic view of the septum and mitral subvalvular apparatus and the ability to simultaneously address mitral valve pathology. Consideration should be given to using the transmitral approach to septal myectomy as the preferred approach for the surgical treatment of hypertrophic cardiomyopathy.

Stuttering in Preschool Children: Direct Versus Indirect Treatment.

The purpose of this article is to discuss the controversial topic of stuttering in preschool children and how to evaluate the options for treatment, emphasizing the role of external research evidence. A hypothetical but realistic case study of a 3-year-old boy who stutters is described. Two contrasting approaches to treatment are presented, the Lidcombe Program (LP) and the demands and capacities model (DCM). Studies published in peer-reviewed research journals that have examined the effectiveness of each approach are summarized and critiqued. The review indicates that the LP is the preferred treatment approach for stuttering in preschool children and that it offers the best opportunity for rapid success. The LP should be carried out by knowledgeable, experienced, and flexible speech-language pathologists who are able to accommodate the individual needs and differences of every child and family.

Strategies for the prevention and control of bleeding due to vascular injury in thoracoscopic lung surgery

The technique of thoracoscopic lung surgery has gradually matured. Nowadays, thoracoscope is recommended as the most preferred approach for surgical treatment of early stage non-small cell lung cancer in different guidelines. However, there are still some cases of accidential major bleeding due to vascular injury during thoracoscopic lung surgery. The wall of the hilum vessels is relatively thin. These vessels often involve a great portion of the cardiac output blood flow. Once the injury happened, the emergent condition may be life-threatening due to massive blood loss. Therefore, this became an important factor which hindered the development of thoracoscopic lung surgery. In this review, details of the vascular injury in thoracoscopic lung surgery were summarized, including the incidence of vascular injury, commonly injured sites and reasons of the injuries. Among all the cases of thoracoscopic major pulmonary resection, 2.9% to 9.2% may suffer from vascular injury during the operation. The most commonly injuried sites are pulmonary artery and the branches, and this is also the most critical situation during thoracoscopic lung surgery. Hilum adhesion is the most important risk factor for vascular injury. On the one hand, the suction-compressing angiorrhaphy technique was developed for bleeding control and angioplasty. On the other hand, the strategies like pre-control of the pulmonary, cut the bronchus in advance, and fire the bronchus and pulmonary artery together may decrease the incidence of vascular injury in patients with risk factors.

Non-epileptic seizures in children: Views and approaches at a UK child and adolescent psychiatry conference

PurposeTo describe clinical experiences of paediatric non-epileptic seizures (NES) among doctors attending a UK child and adolescent psychiatry conference. MethodsSixty-six participants completed a semi-structured bespoke questionnaire. Results are reported using descriptive statistics. ResultsTwo-thirds of respondents regarded the best name for the disorder to be “non-epileptic seizures”. Although most doctors saw new cases each year, two-thirds described their own service as poorly equipped to manage NES. Anti-epileptic drugs (AEDs) were commonly still being taken by children without epilepsy 6 months after their diagnosis. Preferred treatment approaches included supportive case management and cognitive behavioural therapy. Joint working with paediatrics and liaison with schools were seen as important. ConclusionDespite many clinicians having experience of the disorder, NES seemed to occupy a neglected status, often falling between paediatrics and child mental health, with inadequately defined care pathways leading to sub-optimal treatment. Re-configuration of services to prioritise liaison with paediatrics and education may support development of effective treatment, thus maximising health, social and educational opportunities for young people and their families.

Endoscopic Therapy for Esophageal Squamous High-Grade Dysplasia and Early Squamous Cell Carcinoma: A North American Experience

Introduction: Squamous cell cancer (SCC) represents the predominant histological subtype of esophageal cancer worldwide. Endoscopic mucosal resection (EMR) and ablative therapies, such as radiofrequency ablation (RFA) and photodynamic therapy (PDT), have become established treatments for early stage SCC in high-incidence regions. According to national guidelines, endoscopic therapy is the preferred treatment approach for high-grade dysplasia (HGD) and early stage SCC and adenocarcinoma; however, data supporting endoscopic therapy for SCC in low-incidence countries are limited. We report the experience with endoscopic treatment for this cancer subtype at a North American comprehensive cancer center. Methods: We performed a retrospective search of the institutional electronic medical record to identify cases of esophageal squamous HGD or early stage esophageal SCC between 1998 and 2017 that were managed endoscopically by EMR, RFA, PDT and/or argon plasma coagulation (APC). Demographic data, disease characteristics, and clinical outcomes were collected. Results: Twenty patients (11 Tis, 6 T1a, 3 T1b) were included in this study, with a median age of 73 years (IQR 65.5-77.9). There were 14 (70.0%) female patients in our series. Fifteen patients (75.0%) achieved an initial complete remission of dysplasia at a median of 95 days (IQR 78.5-265.0). The complete remission rates for Tis, T1a, and T1b lesions were 81.8%, 83.3% and 33.3%, respectively. Patients required a mean of 1.9 (range 1-4) endoscopic procedures to achieve remission. Five patients (25.0%) required further therapy, including esophagectomy (n=1), intraluminal brachytherapy (n=1), chemoradiation (n=1), or were lost to follow up (n=2). Eleven (73.3%) out of the fifteen patients, who achieved initial remission, remained disease-free at a median follow-up of 79.8 months (IQR 45.2-132.0). Four patients (26.6%) had disease recurrence requiring further endoscopic therapy (n=2) or chemoradiation (n=1), while one patient with low-grade dysplasia recurrence chose to undergo surveillance. Five of sixteen patients treated with EMR (31.3%) and two of eight patients treated with RFA (25.0%) developed minor complications. There were no severe complications.Table: Table. Demographic and Tumor CharacteristicsTable: Table. Treatment and OutcomesConclusion: This study describes a North American experience with squamous HGD and T1 SCC treated endoscopically. This study demonstrates that endoscopic therapy is highly effective and durable in eradicating squamous HGD and T1 SCC of the esophagus.

Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment.

ObjectiveTo explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH).ResultsDuring the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure.Materials and MethodsA DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed.ConclusionsDSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

Transmitral Septal Myectomy

In patients undergoing operative intervention for hypertrophic cardiomyopathy (HCM), intrinsic abnormalities of the mitral valve may need to be addressed at the time of septal myectomy. Advantages of a transmitral approach to septal myectomy include a panoramic view of the septum and the exposure necessary to address concomitant mitral valve pathology. Herein, we describe our technique for transmitral septal myectomy in symptomatic patients with HCM. The transmitral approach to septal myectomy should be given consideration as the preferred approach for the surgical treatment of HCM.

Recent Trends in Neuro-endovascular Treatment for Acute Ischemic Stroke, Cerebral Aneurysms, Carotid Stenosis, and Brain Arteriovenous Malformations.

The efficacy of mechanical thrombectomy with stent retrievers for emergent large vessel occlusion has been proved by randomized trials. Mechanical thrombectomy is increasingly being adopted in Japan since stent retrievers were first approved in 2014. An urgent clinical task is to offer structured systems of care to provide this treatment in a timely fashion to all patients with emergent large vessel occlusion. Treatment with flow-diverting stents is currently a preferred treatment option worldwide for large and giant unruptured aneurysms. Initial studies reported high rates of complete aneurysm occlusion, even in large and giant aneurysms, without delayed aneurysmal recanalization and/or growth. The Pipeline Embolic Device is a flow diverter recently approved in Japan for the treatment of large and giant wide-neck unruptured aneurysms in the internal carotid artery, from the petrous to superior hypophyseal segments. Carotid artery stenting is the preferred treatment approach for carotid stenosis in Japan, whereas it remains an alternative for carotid endarterectomy in Europe and the United States. Carotid artery stenting with embolic protection and plaque imaging is effective in achieving favorable outcomes. The design and conclusions of a randomized trial of unruptured brain arteriovenous malformations (ARUBA) trial, which compared medical management alone and medical management with interventional therapy in patients with an unruptured arteriovenous brain malformation, are controversial. However, the annual bleeding rate (2.2%) of the medical management group obtained from this study is worthy of consideration when deciding treatment strategy.

Results of intraoperative electron beam radiotherapy containing multimodality treatment for locally unresectable T4 rectal cancer: a pooled analysis of the Mayo Clinic Rochester and Catharina Hospital Eindhoven.

The aim of this study is to analyse the pooled results of intraoperative electron beam radiotherapy (IOERT) containing multimodality treatment of locally advanced T4 rectal cancer, initially unresectable for cure, from the Mayo Clinic, Rochester, USA (MCR) and Catharina Hospital, Eindhoven, The Netherlands (CHE), both major referral centers for locally advanced rectal cancer. A rectal tumor is called locally unresectable for cure if after full clinical work-up infiltration into the surrounding structures or organs has been demonstrated, which would result in positive surgical margins if resection was the initial component of treatment. This was the reason to refer these patients to the IOERT program of one of the centers. In the period from 1981 to 2010, 417 patients with locally unresectable T4 rectal carcinomas at initial presentation were treated with multimodality treatment including IOERT at either one of the two centres. The preferred treatment approach was preoperative (chemo) radiation and intended radical surgery combined with IOERT. Risk factors for local recurrence (LR), cancer specific survival, disease free survival and distant metastases (DM) were assessed. A total of 306 patients (73%) underwent a R0 resection. LRs and metastases occurred more frequently after an R1-2 resection (P<0.001 and P<0.001 respectively). Preoperative chemoradiation (preop CRT) was associated with a higher probability of having a R0 resection. Waiting time after preoperative treatment was inversely related with the chance of developing a LR, especially after R+ resection. In 16% of all cases a LR developed. Five-year disease free survival and overall survival (OS) were 55% and 56% respectively. An acceptable survival can be achieved in treatment of patients with initially unresectable T4 rectal cancer with combined modality therapy that includes preop CRT and IOERT. Completeness of the resection is the most important predictive and prognostic factor in the treatment of T4 rectal cancer for all outcome parameters. IOERT can reduce the LR rate effectively, especially in R+ resected patients.