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1.  What is the optimal management of dysphagia in metastatic esophageal cancer? 
Current Oncology  2012;19(2):e60-e66.
The palliation of dysphagia in metastatic esophageal cancer remains a challenge, and the optimal approach for this difficult clinical scenario is not clear. We therefore sought to define and determine the efficacy of various treatment options used at our institution for this condition.
We reviewed a prospective database for all patients managed in an esophageal cancer referral centre over a 5-year period. All patients receiving palliation of malignant dysphagia were reviewed for demographics, palliative treatment modalities, complications, and dysphagia scores (0 = none to 4 = complete). The Wilcoxon signed rank test was used to determine significance (p < 0.05).
During 2004–2009, 63 patients with inoperable esophageal cancer were treated for palliation of dysphagia. The primary treatment was radiotherapy in 79% (brachytherapy in 18 of 50; external-beam in 10 of 50; both types in 22 of 50), and stenting in 21%. Mean wait time from diagnosis to treatment was 22 days in the stent group and 54 days in the radiotherapy group (p = 0.003). Mean duration of treatment was 1 day in the stent group and 40 days in the radiotherapy group (p = 0.001). In patients treated initially by stenting, dysphagia improved within 2 weeks of treatment in 85% of patients (dysphagia score of 0 or 1). However, 20% of patients presented with recurrence of dysphagia at 10 weeks of treatment. In the radiotherapy group, the onset of palliation was slower, with only 50% of patients palliated at 2 weeks (dysphagia score of 0 or 1). However, long-term palliation was more satisfactory, with 90% of patients remaining palliated after 10 weeks of treatment.
In inoperable esophageal cancer at our centre, radiation treatment provided durable long-term relief, but came at a high price of a long wait time for initiation of treatment and a long lag time between initiation of treatment and relief of symptoms. On the other hand, endoluminal stenting provided more rapid and effective early relief from symptoms, but was affected by recurrence of dysphagia in the long-term. It is now time for a prospective randomized trial to assess the safety and efficacy of combined-modality treatment with both endoluminal stenting and radiation therapy compared with either treatment alone.
PMCID: PMC3320233  PMID: 22514498
Esophageal cancer; palliation; stents; radiation therapy
2.  Initial McGill experience with fluorodeoxyglucose pet/ct staging of soft-tissue sarcoma 
Current Oncology  2010;17(6):18-22.
Soft-tissue sarcoma spreads predominantly to the lung. The frequency with which positron-emission tomography (pet) detects metastases not already obvious by chest computed tomography (ct) or clinical examination is currently unclear.
We retrospectively identified cases of soft-tissue sarcoma. Ewing sarcoma, rhabdomyosarcoma, and gastrointestinal stromal tumour were excluded, as were cases in which patients underwent imaging for follow-up, response assessment, or recurrence. Patients all had undergone diagnostic chest ct as part of their staging. Directed studies were requested to follow up on abnormal findings in the clinical history or physical examination. All charts and pre-treatment imaging were reviewed retrospectively.
From 2004 to 2008, 75 patients met the criteria for the present review. Their median age was 51 years. In 21% of cases, the primary tumour had been removed (by excisional biopsy or unplanned excision) before staging. Of the previously unresected primary tumours, 97% were avid for fluorodeoxyglucose. Of all tumours, 81% were intermediate or high grade (Fédération Nationale des Centres de Lutte Contre le Cancer grades 2–3). The primary tumour was stage T2b in 69% of cases. The most common primary site was a lower extremity (55%). The most common pathologic diagnoses were leiomyosarcoma (21%), liposarcoma (19%), and synovial sarcoma (17%). At the end of staging, 17% of patients were considered to have metastatic disease.
Imaging by pet was negative for distant disease in 64 of the 75 cases. In 7 of the 64 cases, metastatic disease was evident on chest ct (negative predictive value: 88%). Imaging by pet was positive in 8 cases, with 5 of those already known to have metastases, 2 having pathologically proven false positives, and 1 being a new finding of a pulmonary metastasis (positive predictive value: 75%). The pet imaging was indeterminate in 3 patients (none of whom subsequently developed metastatic disease). Two incidental benign parotid tumours were found. Overall, only 1 patient was upstaged as a result of pet imaging (1.3%). In addition, pet did not alter the management of patients already know to have M1 disease (no new organ sites identified).
Although pet may be helpful in specific circumstances, routine use of fluorodeoxyglucose pet imaging for detection of metastatic disease as part of the initial staging of soft-tissue sarcoma added little to imaging by chest ct and was unlikely to alter management in our series.
PMCID: PMC2993434  PMID: 21151405
Soft-tissue sarcoma; positron-emission tomography; staging
3.  Fractionated stereotactic radiotherapy in the treatment of pituitary macroadenomas 
Current Oncology  2008;15(6):286-292.
The use of fractionated stereotactic radiotherapy (fsrt) has evolved with technical advances in noninvasive immobilization, radiation delivery, and image guidance. The application of fsrt to pituitary tumours is aimed at reducing toxicity through improved dose conformality and reduced treatment margins. The aim of the present paper is to report our own experience and to review the published data on fsrt for pituitary macroadenomas.
Between September 2000 and October 2005, 13 patients with pituitary macroadenoma underwent fsrt at our institution. In 12 patients, radiotherapy treatment followed surgical resection (transsphenoidal resection in 8, frontal craniotomy in 3, and multiple transsphenoidal resections followed by craniotomy in 1). In 4 patients, the tumours were functional (2 adrenocorticotropic hormone–secreting, 1 prolactinoma, and 1 growth hormone–secreting); the tumours in the remaining patients were clinically non-secretory. Before radiation, 3 patients had panhypopituitarism, and 6 patients had visual field defects. All patients were treated with fsrt using non-coplanar micro–multileaf collimation portals. A median dose of 50.4 Gy (range: 45–60 Gy) was prescribed to the 76.9%–95.2% isodose surface and delivered in 1.8-Gy fractions. The median planning target volume (gross tumour plus 3 mm) was 33.5 cm3 (range: 3.2–75 cm3).
After a median follow-up of 24 months (range: 6–60 months), local control was 100%. One patient achieved clinical complete response. Treatment was well tolerated acutely for all patients. Neither radiation-induced optic neuropathy nor any radiation-related endocrine dysfunction was observed in our patients.
In accordance with published series, we found fsrt to be safe and effective in the management of large pituitary macroadenomas.
PMCID: PMC2601024  PMID: 19079630
Radiotherapy; fractionated stereotactic radiotherapy; macroadenoma; pituitary adenoma
4.  Practice guidelines for clinical prevention: Do patients, physicians and experts share common ground? 
BACKGROUND: Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based. METHODS: Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews. RESULTS: Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity. INTERPRETATION: The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.
PMCID: PMC1230580  PMID: 10497607
5.  Cloning of porcine cytokine-specific cDNAs and detection of porcine tumor necrosis factor alpha, interleukin 6 (IL-6), and IL-1 beta gene expression by reverse transcription PCR and chemiluminescence hybridization. 
A reverse transcription PCR assay with porcine cytokine-specific primers was developed to clone cDNA fragments and generate cDNA probes that were specific for porcine tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6), and IL-1 beta. The specificities of the cDNA PCR products were confirmed by sequence analysis on the basis of known porcine cytokine gene sequences. The reverse transcription PCR assay was also used to study cytokine mRNA expression in lipopolysaccharide (LPS)-stimulated and control unstimulated porcine alveolar macrophages. The cDNA products were analyzed in ethidium bromide-stained agarose gels, and the transcription level of each cytokine was determined relative to the endogenous glyceraldehyde-3-phosphate dehydrogenase (GAPDH) RNA level of each cytokine by measuring the intensity of the chemiluminescence hybridization signals by densitometric scanning. Various levels of cytokine mRNAs were detected in both LPS-stimulated and control unstimulated cells. Thus, TNF-alpha mRNA levels were enhanced in the cell cultures stimulated for 6 h with LPS compared with those in control cell cultures. No differences in TNF-alpha transcription levels between LPS-stimulated and control cells were observed after incubation for 24 or 55 h. Enhancements of IL-6 and IL-1 beta mRNA levels were also observed in the cultures stimulated with LPS for 6 and 24 h compared with the cytokine mRNA levels in control cell cultures. The presence of cytokine mRNA transcripts in the LPS-stimulated macrophage cultures correlated with the detection of these soluble cytokines by the bioassays. In contrast, no soluble cytokine was detected in control macrophage culture supernatants in the presence of cytokine mRNA transcripts.
PMCID: PMC170217  PMID: 8574826

Results 1-5 (5)