Oncology

Not All That Glows Is Malignant: Actinomycosis as a Rare Mimic of Lung Cancer (2022)

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Type of publication:Conference abstract

Author(s):*Ekhelikar S.; Muthusami R.; *Orme R.; *Ahmad N.

Citation:American Journal of Respiratory and Critical Care Medicine. Conference: International Conference of the American Thoracic Society, ATS 2022. San Francisco, CA United States. 205(1) (no pagination), 2022.

Abstract:Introduction: Pulmonary actinomycosis is a rare bacterial infection that can mimic malignant and chronic suppurative lung conditions, and therefore is often misdiagnosed initially as one of the more common differential diagnoses. The challenge lies in diagnosing this condition prior to surgery as it is completely curable with antibiotics. Case description: A 48 year old man, cigarette smoker and previous intravenous drug user, presented with exertional breathlessness, persistent cough and night sweats. There was no fever or weight loss. A Chest Xray (CXR) and Computerised Tomography (CT) scan showed a left upper lobe cavitating lesion leading to differential diagnoses of bronchogenic malignancy and tuberculosis (TB). A Positron Emission Tomography (PET) scan confirmed a fluorodeoxyglucose (FDG) avid left upper lobe cavitating lesion with enlarged FDG avid thoracic lymphadenopathy. Bronchoscopy and Endobronchial Ultrasound (EBUS) were nondiagnostic. He underwent left upper lobectomy with histopathology confirming Pulmonary actinomycosis and was commenced on Amoxicillin treatment. <br/>Discussion(s): Pulmonary actinomycosis is the third most common type of actinomycosis, behind cervicofacial and abdominal, constituting 15% of total cases. It can occur at all ages, but most case series describe a peak incidence in the 4th and 5th decades. Symptoms are non-specific and often mimic those of it's more common differentials as above and so diagnosing this condition early presents a challenge. Basic laboratory tests reflect the non-specific inflammatory nature of the disease. Imaging modalities (CXR, CT, PET) are helpful, but not diagnostic. The gold standard for diagnosis remains histological examination & bacterial culture of lung biopsy specimen. Histopathologic evidence of granulomas containing neutrophils and sulfur granules with Actinomyces colonies are the hallmark of actinomycosis. Recent data suggests it is increasingly possible to avoid unwarranted surgical procedures, by performing bronchoscopic and percutaneous biopsy techniques. These represent the best chance at preventing unnecessary surgery and should be pursued as they can help exclude malignancy. Penicillin remains the drug of choice for Pulmonary actinomycosis and with correct treatment, the prognosis is excellent. However, those with complications may still require surgery. The chief challenge with Pulmonary actinomycosis is identifying it early, because it is rare, and it also mimics diseases like lung cancer and TB often. We were unable to exclude malignancy with pre-surgical diagnostics and so our patient had surgery. However, clinicians should be aware and consider Pulmonary actinomycosis as an important differential when investigating cavitating lung lesions as diagnosing it early could help prevent physical and psychological morbidity, including unwarranted surgery. (Figure Presented).

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Comparison of multiple gene expression platforms for measuring a bladder cancer hypoxia signature (2022)

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Type of publication:
Journal article

Author(s):
Smith TAD; Lane B; More E; Valentine H; Lunj S; Abdelkarem OA; Irlam-Jones J; Shabbir R; Vora S; *Denley H; Reeves KJ; Hoskin PJ; Choudhury A; West CML

Citation:
Molecular Medicine Reports, 2022 Aug; Vol. 26 (2)

Abstract:
Tumour hypoxia status provides prognostic information and predicts response to hypoxia modifying treatments. A previous study by our group derived a 24 gene signature to assess hypoxia in bladder cancer. The objectives of the present study were to compare platforms for generating signature scores, identify cut off values for prospective studies, assess intra tumour heterogeneity and confirm hypoxia relevance. Briefly, RNA was extracted from prospectively collected diagnostic biopsies of muscle invasive bladder cancer (51 patients), and gene expression was measured using customised Taqman Low Density Array (TLDA) cards, NanoString and Clariom S arrays. Cross platform transferability of the gene signature was assessed using regression and concordance analysis. The cut off values were the cohort median expression values. Intra and inter tumour variability were determined in a retrospective patient cohort (n=51) with multiple blocks (2 18) from the same tumour. To demonstrate relevance, bladder cancer cell lines were exposed to hypoxia (0.1% oxygen, 24 h), and extracted RNA was run on custom TLDA cards. Hypoxia scores (HS) values showed good agreement between platforms: Clariom S vs. TLDA (r=0.72, P<0.0001; concordance 73%); Clariom S vs. NanoString (r=0.84, P<0.0001; 78%); TLDA vs. NanoString (r=0.80, P<0.0001; 78%). Cut off values were 0.047 (TLDA), 7.328 (NanoString) and 6.667 (Clariom S). Intra tumour heterogeneity in gene expression and HS (coefficient of variation 3.9%) was less than inter tumour (7.9%) variability. HS values were higher in bladder cancer cells exposed to hypoxia compared with normoxia (P<0.02). In conclusion, the present study revealed that application of the 24 gene bladder cancer hypoxia signature was platform agnostic, cut off values determined prospectively can be used in a clinical trial, intra tumour heterogeneity was low and the signature was sensitive to changes in oxygen levels in vitro.

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Radiotherapy to the prostate for men with metastatic prostate cancer in the UK and Switzerland: Long-term results from the STAMPEDE randomised controlled trial (2022)

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Type of publication:
Randomised controlled trial

Author(s):
Parker CC; James ND; Brawley CD; Clarke NW; Ali A; Amos CL; Attard G; Chowdhury S; Cook A; Cross W; Dearnaley DP; Douis H; Gilbert DC; Gilson C; Gillessen S; Hoyle A; Jones RJ; Langley RE; Malik ZI; Mason MD; Matheson D; Millman R; Rauchenberger M; Rush H; Russell JM; Sweeney H; Bahl A; Birtle A; Capaldi L; Din O; Ford D; Gale J; Henry A; Hoskin P; Kagzi M; Lydon A; O'Sullivan JM; Paisey SA; Parikh O; Pudney D; Ramani V; Robson P; *Srihari NN; Tanguay J; Parmar MKB; Sydes MR; STAMPEDE Trial Collaborative Group

Citation:
PLoS Medicine, 2022 Jun 07; Vol. 19 (6), pp. e1003998

Abstract:
Background: STAMPEDE has previously reported that radiotherapy (RT) to the prostate improved overall survival (OS) for patients with newly diagnosed prostate cancer with low metastatic burden, but not those with high-burden disease. In this final analysis, we report long-term findings on the primary outcome measure of OS and on the secondary outcome measures of symptomatic local events, RT toxicity events, and quality of life (QoL).Methods and Findings: Patients were randomised at secondary care sites in the United Kingdom and Switzerland between January 2013 and September 2016, with 1:1 stratified allocation: 1,029 to standard of care (SOC) and 1,032 to SOC+RT. No masking of the treatment allocation was employed. A total of 1,939 had metastatic burden classifiable, with 42% low burden and 58% high burden, balanced by treatment allocation. Intention-to-treat (ITT) analyses used Cox regression and flexible parametric models (FPMs), adjusted for stratification factors age, nodal involvement, the World Health Organization (WHO) performance status, regular aspirin or nonsteroidal anti-inflammatory drug (NSAID) use, and planned docetaxel use. QoL in the first 2 years on trial was assessed using prospectively collected patient responses to QLQ-30 questionnaire. Patients were followed for a median of 61.3 months. Prostate RT improved OS in patients with low, but not high, metastatic burden (respectively: 202 deaths in SOC versus 156 in SOC+RT, hazard ratio (HR) = 0·64, 95% CI 0.52, 0.79, p < 0.001; 375 SOC versus 386 SOC+RT, HR = 1.11, 95% CI 0.96, 1.28, p = 0·164; interaction p < 0.001). No evidence of difference in time to symptomatic local events was found. There was no evidence of difference in Global QoL or QLQ-30 Summary Score. Long-term urinary toxicity of grade 3 or worse was reported for 10 SOC and 10 SOC+RT; long-term bowel toxicity of grade 3 or worse was reported for 15 and 11, respectively.Conclusions: Prostate RT improves OS, without detriment in QoL, in men with low-burden, newly diagnosed, metastatic prostate cancer, indicating that it should be recommended as a SOC.Trial Registration: ClinicalTrials.gov NCT00268476, ISRCTN.com ISRCTN78818544.

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Abiraterone acetate plus prednisolone for metastatic patients starting hormone therapy: 5-year follow-up results from the STAMPEDE randomised trial (NCT00268476) (2022)

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Type of publication:Randomised controlled trial

Author(s):James N.D.; Clarke N.W.; Cook A.; Ali A.; Hoyle A.P.; Attard G.; Brawley C.D.; Chowdhury S.; Cross W.R.; Dearnaley D.P.; de Bono J.S.; Montana C.D.; Gilbert D.; Gillessen S.; Gilson C.; Jones R.J.; Langley R.E.; Malik Z.I.; Matheson D.J.; Millman R.; Parker C.C.; Pugh C.; Rush H.; Russell J.M.; Berthold D.R.; Buckner M.L.; Mason M.D.; Ritchie A.W.; Birtle A.J.; Brock S.J.; Das P.; Ford D.; Gale J.; Grant W.; Gray E.K.; Hoskin P.; Khan M.M.; Manetta C.; McPhail N.J.; O'Sullivan J.M.; Parikh O.; Perna C.; Pezaro C.J.; Protheroe A.S.; Robinson A.J.; Rudman S.M.; Sheehan D.J.; *Srihari N.N.; Syndikus I.; Tanguay J.; Thomas C.W.; Vengalil S.; Wagstaff J.; Wylie J.P.; Parmar M.K.; Sydes M.R.

Citation:
International Journal of Cancer. 151(3) (pp 422-434), 2022. Date of Publication: 01 Aug 2022.

Abstract:Abiraterone acetate plus prednisolone (AAP) previously demonstrated improved survival in STAMPEDE, a multi-arm, multi-stage platform trial in men starting long-term hormone therapy for prostate cancer. This long-term analysis in metastatic patients was planned for 3yrs after the first results. Standard-of-care (SOC) was androgen deprivation therapy. The comparison randomized patients 1:1 to SOC-alone with or without daily abiraterone acetate 1000mg+prednisolone 5mg (SOC+AAP), continued until disease progression. The primary outcome measure was overall survival. Metastatic disease risk group was classified retrospectively using baseline CT and bone scans by central radiological review and pathology reports. Analyses used Cox proportional hazards & flexible parametric models, adjusted for baseline stratification factors. 1003 patients were contemporaneously randomized (Nov-2011–Jan-2014): median age 67yr; 94% newly-diagnosed; metastatic disease risk group: 48% high, 44% low, 8% un-assessable; median PSA 97ng/mL. At 6.1yr median follow-up, 329 SOC-alone deaths (118 low-risk, 178 high-risk) and 244 SOC+AAP deaths (75 low-risk, 145 high-risk) were reported. Adjusted HR = 0.60 (95%CI:0.50-0.71; P =0.31×10-9 ) favoured SOC+AAP, with 5-yr survival improved from 41% SOC-alone to 60% SOC+AAP. This was similar in low-risk (HR = 0.55; 95%CI:0.41-0.76) and high-risk (HR = 0.54; 95%CI:0.43-0.69) patients. Median and current maximum time on SOC+AAP was 2.4yr and 8.1yr. Toxicity at 4yr post-randomisation was similar, with 16% patients in each group reporting grade 3 or higher toxicity. A sustained and substantial improvement in overall survival of all metastatic prostate cancer patients was achieved with SOC+abiraterone acetate + prednisolone, irrespective of metastatic disease risk group.

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Severe hyponatraemia in two patients with breast cancer caused by low-dose cyclophosphamide and precipitated by aprepitant (2022)

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Type of publication:
Journal article

Author(s):
*Parikh S; *Pettit L; *AbdelGadir H

Citation:
BMJ Case Reports, 2022 Mar 22; Vol. 15

Abstract:
Two postmenopausal women with breast cancer developed acute confusion and seizures, less than 24 hours after the first cycle of neoadjuvant chemotherapy with fluorouracil, epirubicin and low-dose cyclophosphamide. They were found to have severe, life-threatening hyponatraemia with sodium levels of 113 and 115 mEq/L, respectively. Both women made a full recovery within 24 hours of admission with slow correction of sodium levels. Following investigational workup, the most likely diagnosis was cyclophosphamide-associated syndrome of inappropriate antidiuretic hormone secretion (SIADH). Aprepitant – a commonly used antiemetic and moderate cytochromeP450 3A4 inhibitor was identified as the precipitating factor. Aprepitant was discontinued and both women were successfully re-challenged with full dose cyclophosphamide in an outpatient setting with no subsequent adverse events. This is a typical case of a rare cause of a common medical problem. A systematic approach to diagnosis and treatment of hyponatraemia in an oncology patient requires awareness of toxicities of systemic anticancer agents.

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Observation versus screening spinal MRI and pre-emptive treatment for spinal cord compression in patients with castration resistant prostate cancer and spinal metastases in the UK (PROMPTS): an open-label, randomised, controlled, phase 3 trial (2022)

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Type of publication:Randomised controlled trial

Author(s):Dearnaley, David; Hinder, Victoria; Hijab, Adham; Horan, Gail; *Srihari, Narayanan; Rich, Philip; Houston, J Graeme; Henry, Ann M; Gibbs, Stephanie; Venkitaraman, Ram; Cruickshank, Clare; Hassan, Shama; Miners, Alec; Mason, Malcolm; Pedley, Ian; Payne, Heather; Brock, Susannah; Wade, Robert; Robinson, Angus; Din, Omar; Lees, Kathryn; Graham, John; Worlding, Jane; Murray, Julia; Parker, Chris; Griffin, Clare; Sohaib, Aslam; Hall, Emma; PROMPTS investigators

Citation:
The Lancet Oncology. 23(4) (pp 501-513), 2022. Date of Publication: April 2022.

Abstract:BACKGROUND Early diagnosis of malignant spinal cord compression (SCC) is crucial because pretreatment neurological status is the major determinant of outcome. In metastatic castration-resistant prostate cancer, SCC is a clinically significant cause of disease-related morbidity and mortality. We investigated whether screening for SCC with spinal MRI, and pre-emptive treatment if radiological SCC (rSCC) was detected, reduced the incidence of clinical SCC (cSCC) in asymptomatic patients with metastatic castration-resistant prostate cancer and spinal metastasis. METHODS We did a parallel-group, open-label, randomised, controlled, phase 3, superiority trial. Patients with metastatic castration-resistant prostate cancer were recruited from 45 National Health Service hospitals in the UK. Eligible patients were aged at least 18 years, with an Eastern Co-operative Oncology Group performance status of 0-2, asymptomatic spinal metastasis, no previous SCC, and no spinal MRI in the past 12 months. Participants were randomly assigned (1:1), using a minimisation algorithm with a random element (balancing factors were treatment centre, alkaline phosphatase [normal vs raised, with the upper limit of normal being defined at each participating laboratory], number of previous systemic treatments [first-line vs second-line or later], previous spinal treatment, and imaging of thorax and abdomen), to no MRI (control group) or screening spinal MRI (intervention group). Serious adverse events were monitored in the 24 h after screening MRI in the intervention group. Participants with screen-detected rSCC were offered pre-emptive treatment (radiotherapy or surgical decompression was recommended per treating physician's recommendation) and 6-monthly spinal MRI. All patients were followed up every 3 months, and then at month 30 and 36. The primary endpoint was time to and incidence of confirmed cSCC in the intention-to-treat population (defined as all patients randomly assigned), with the primary timepoint of interest being 1 year after randomisation. The study is registered with ISRCTN, ISRCTN74112318, and is now complete. FINDINGS Between Feb 26, 2013, and April 25, 2017, 420 patients were randomly assigned to the control (n=210) or screening MRI (n=210) groups. Median age was 74 years (IQR 68 to 79), 222 (53%) of 420 patients had normal alkaline phosphatase, and median prostate-specific antigen concentration was 48 ng/mL (IQR 17 to 162). Screening MRI detected rSCC in 61 (31%) of 200 patients with assessable scans in the intervention group. As of data cutoff (April 23, 2020), at a median follow-up of 22 months (IQR 13 to 31), time to cSCC was not significantly improved with screening (hazard ratio 0·64 [95% CI 0·37 to 1·11]; Gray's test p=0·12). 1-year cSCC rates were 6·7% (95% CI 3·8-10·6; 14 of 210 patients) for the control group and 4·3% (2·1-7·7; nine of 210 patients) for the intervention group (difference -2·4% [95% CI -4·2 to 0·1]). Median time to cSCC was not reached in either group. No serious adverse events were reported within 24 h of screening. INTERPRETATION Despite the substantial incidence of rSCC detected in the intervention group, the rate of cSCC in both groups was low at a median of 22 months of follow-up. Routine use of screening MRI and pre-emptive treatment to prevent cSCC is not warranted in patients with asymptomatic castration-resistant prostate cancer with spinal metastasis. FUNDING Cancer Research UK.

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Rare histological subtypes of breast cancer: A study of 10 years' experience at (SATH) UK District General Hospital (2022)

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Type of publication:Conference abstract

Author(s):*Mansour A.; *Pettit L.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: Breast cancer is a heterogeneous disease with different histologic subtypes, molecular characteristics, oestrogen receptors (ER) and HER2 status. Common subtype include lobular and ductal cancers. The rare subtypes are a heterogeneous group with differing behaviour specific for each subtype. This study aims to determine the clinicopathological features, management pathway and survival outcome of rare subtypes of invasive breast cancer (IBC) at a single U.K. hospital.Material(s) and Method(s): Data was obtained from the department of Cellular Pathology at The Shrewsbury and Telford Hospital (SATH) NHS Trust. All patients diagnosed with a rare subtype of breast cancer from January 2005 to December 2014 were identified. The histology diagnosis of a rare subtype of breast cancer was reviewed. Biological behaviour, management, follow up and prognosis were obtained from surgical and oncology clinic letters. Also, survival data and cause of death when applicable is reviewed from Clinical Portal (our hospital digital documentation system). Patients with imaging, after the introduction of the digital format to the system in 2012, were also reviewed.
Result(s): Total number of patients diagnosed with IBC was 3049. 201 patients (6.59%) were identified to have a rare subtype of IBC. Patients were divided into subgroups according to their specific rare subtype and included mucinous, tubular, medullary, metaplastic, papillary, neuroendocrine, cribriform, apocrine, malignant phyllodes, angiosarcoma, lymphoma and metastatic from non-breast primary. Some cancers had good prognosis with 100% 5 years overall survival like tubular carcinoma and some have poor prognosis like metaplastic and angiosarcoma.Conclusion(s): Our experience with these heterogeneous groups of rare subtypes of breast cancer identified the clinical behaviour and prognosis of each type. This could be the basis to improve the management of these subtypes and for further studies to improve the outcome for patients with identified breast cancer known to have poorer prognosis.

Her-2 expression pattern evaluation in breast invasive lobular carcinoma and its association to the clinicopathomorphological characteristics and female sex hormones expression in 71 cases (2022)

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Type of publication:Conference abstract

Author(s):Barron M.; Asaad A.; Ali S.; Chicken W.; Elamass M.; Alkistawi F.; Abdalla Al-Zawi A.S.; *Khan K.A.; Idaewor P.; Osayi K.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: HER2 status is considered as an important prognostic and predictive factor in breast cancer treatment The cellular E-cadherin protein (encoded by the CDH1 gene) is expressed in the breast epithelial cells. Its function is functions is epithelial-to epithelial cell adhesion and epithelial-to-mesenchymal transition. Invasive lobular carcinoma (ILC) is characterised by the absence of E-cadherin expression, usually its oestrogen /progesterone positive however lack Her-2 amplification. Approximately, about 20% of breast cancers are Her2 +ve. The evidence revealed that, HER2 amplification or overexpression is encountered predominantly in invasive ductal carcinomas (NST) of high nuclear grade and infrequently in pleomorphic lobular carcinomas. The aim is to analyse the Her-2 expression pattern in breast invasive lobular carcinoma.Material(s) and Method(s): The clinical records of 71 patients diagnosed in the period between 2014 -2019,with ILC has been analysed. The lobular phenotype was confirmed by the absence of E-cadherin expression. We have evaluated the following criteria: clinico-pathologic variables, female sex hormone receptor status as well as Her-2 expression status.Result(s): ILC cases has been identified in 71 cases, the age ranges between 39-85 yrs, with mean of 68.In 22.% of cases, the phenotype was mixed ILC& invasive ductal carcinoma. Her-2 overexpression detected in 13% cases, 89% of Her2+ve group are above 65 years of age. Her2 overexpression was more associated with ER+ve group (13%), where 60% were ER+ve,PR+ve and Her2-ve, also 23% noticed to have PR-ve status. Triple negative status was seen only in two cases(2.8%), one of them was pleomorphic lobular carcinoma, both cases age was > 80 yrs.Ki-67 was tested in 58 patients, it was low or moderate in 66%, 7% was Her2 +ve with high Ki-67.Her2+ve status was associated with tumour grade 2 in 7% of cases, grade 3(1.4%) and grade 1 (4%).Conclusion(s): ER expression is noticed to in HER2+ classical ILCs, in spite of the fact that the level of expression is significantly low, compared with the Her2ve- disease.

Pancreatic enzyme replacement therapy in patients with pancreatic cancer: A national prospective study (2021)

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Type of publication:Journal article

Author(s):Harvey P.R.; McKay S.C.; Wilkin R.J.W.; Layton G.R.; Powell-Brett S.; Okoth K.; Trudgill N.; Roberts K.J.; Baker G.; Brom M.K.; Brown Z.; Farrugia A.; Haldar D.; Kalisvaart M.; Marley A.; Pande R.; Patel R.; Stephenson B.T.F.; Baillie C.; Croitoru C.; Eddowes P.J.; Elshaer M.; Farhan-Alanie M.M.; Laing R.; Mann K.; Materacki L.; Nandi S.; Pericleous S.; Prasad P.; Rinkoff S.; Selvaraj E.; Shah J.; Sheel A.R.G.; Szatmary P.; Williams P.; Milburn J.; Bekheit M.; Ghazanfar M.; Curry H.; Persson P.; Rollo A.; Thomson R.; Harper S.; Varghese S.; Collins J.; Stupalkowska W.; Afzal Z.; Badran A.; Barker J.; Hakeem A.; Kader R.; Saji S.; Sheikh S.; Smith A.C.D.; Stasinos K.; Steinitz H.; Malik H.; Burston C.; Carrion-Alvarez L.; Shiwani M.; Ahmad G.; Allen T.; Darley E.; Patil S.; Brooks C.; Cresswell B.; Welsh F.; Cook C.; Smyth R.; Booth R.; West M.; King A.; Tucker O.; Phelan L.; Burahee A.; Devogel C.; Javed A.; Kay R.; Khan S.; Leet F.; Troth T.; Ward A.; Young J.; Murray E.; Gray T.; Johnson R.; Lockwood S.; Young R.; Zhou G.; Portal J.; Rees J.; Arnold B.; Scroggie D.; Abeysekera K.W.M.; Asif A.; Hay F.; Maccabe T.; Pathak S.; Robertson H.; Sandberg C.; Woodland H.; Charalabopoulos A.; Kordzadeh A.; Anderson J.; Napier D.; Hodges P.; Jones G.; Sheiybani G.; Archer T.; Khan A.; Kirk S.; Walker N.; Hassam U.; Wong I.; Silva M.; Jones K.; Allen J.; Abbas S.H.; Harborne M.; Majid Z.; Eardley N.; Reilly I.; Wadsworth P.; Bell C.; Holloway K.; Stockton W.; Thomas R.; Williams K.J.; Canelo R.; Tay Y.; Adnan M.; Aroori S.; Rajaretnam N.; Rekhraj S.; Wilkins A.; Nelapatia R.; Verebcean M.; Braithwaite S.; Apollos J.; Robertson N.; Belgaumkar A.; Brant A.; Shahdoost A.; French J.J.; Sen G.; Thakkar R.; Kanwar A.; Klaptocz J.; Rodham P.; O'Riordan B.; Maharaj G.; Davies M.; Higgs S.; Cutting J.; Joseph M.; Backhouse L.; Butler J.; Cooper J.; O'nions T.; Shaukat S.; Kumar A.; George V.; Ingmire J.; Saha A.; Coe P.; Noor R.; Lykoudis P.; Elshaer A.; Andreou A.; Clarke T.; Davies O.; Rimmer P.; Kanakala V.; Mitra V.; Akol G.; Burgess M.; Elzubier M.; Jones R.; Majumdar D.; Wescott H.; Bailey A.; Gomez M.; Herman O.; Deguara J.; Whitehead-Clarke T.; Gorard L.; Law R.; Leung L.Y.; Whitelaw D.; Adil M.; Krivan S.; Waters J.; Fernandes R.; Mealey L.; Merh R.; Okaro A.; Shepherd J.; O'Reilly D.; Pilkington J.; Hussain Z.; Ingram S.; Stott M.C.; Abbott S.; Bhamra N.; Hirri F.; Lee K.; Murrell J.; Resool S.; Taylor M.; King M.; Madhotra R.; Ayubi H.; Ali J.; Chander N.; Mckune G.; Wothers T.; Shingler G.; Mortimer M.; Dykes K.; Edwards H.; Menon S.; Gautham A.; Ali I.; Anjum R.; Brookes M.; Wilkinson B.; Tait I.; Noaman I.; Wilson M.; Mogan S.; Rushbrook S.; Hyde S.; Baker S.; Hall P.; Lucas H.; Pease J.; Millar A.; Tariq Z.; Blad W.; Cunningham M.; Hall M.; Luthra P.; Seymour K.; Aawsaj Y.; Jones M.; Elliott D.; Finch J.G.; Rajjoub Y.; Gupta A.; Molloy P.; Mykoniatis I.; Atallah E.; Albraba E.; Asimba V.; Baxter A.; Chin A.; Vojtekova K.; Ong L.; Modi H.N.; Muscara F.; Perry M.; Katz C.; Shaban N.; Dichmont L.; Dissanayake T.; Mostafa W.; Ghosh D.; Hwang S.; Bajomo O.; Lloyd T.; Wye J.; Holt A.; Pathanki A.; Townsend S.; Babar N.; Giovinazzo F.; Kennedy L.; Kandathil M.; King D.; Pillai M.; Glen P.; Holroyd D.; Drozdzik S.; Kourounis G.; Thompson J.; McNally S.; Thomas I.; Reddy Y.; Subar D.; Heywood N.; Khoo E.; Austin A.; Awan A.; Tan H.; Kasi M.; Prasad S.; Baqai M.; Abd Alkoddus M.; Al-Allaf O.; Mitchell K.; Mole S.; Yoong A.; Fusai G.; Brown S.; Bulathsinhala S.; Gilliland J.; Boyce T.; Al-Ardah M.; Matthews E.; Wakefield C.; Hou D.; Thomasset S.; Guest R.; Falconer S.; Hughes M.; Johnston C.; Kung J.W.C.; Lee E.; McNally E.; Sherif A.E.; Stutchfield B.; Baron R.D.; Dunne D.F.J.; Dickerson L.D.; Exarchou K.E.; Knight E.; Whelan P.; Hutchins R.; Wilson P.; Phillpotts S.; Badrulhisham F.; Dawes A.; Derwa Y.; Rajagopal S.; Ramoutar S.; Vaik T.; Bhogal R.H.; McLaren N.; Policastro T.; *Butterworth J.; *Riera M.; *Ismail A.; *Ahmed A.; *Alame R.; *Alford K.; *Banerjee S.; *Bull C.; *Kirby G.; Athwal T.; Hebbar S.; Ishtiaq J.; Kamran U.; Abbasi A.; Kamarul-bahrin M.; Banks A.; Khalil A.; Karanjia N.; Trivedi D.; Chakravaratty S.; Frampton A.; Gabriella J.; Pinn G.; Colleypriest B.; Betteridge F.; Murugiah D.; Rossiter A.; Yong K.; Sellahewa C.; Chui K.; Ehsan A.; Fisher N.; Iyer S.; McMurtry H.; Garbutt G.; Mahgoub S.; Alleyne L.; Harvey J.; Johnson K.; Richards E.; Palaniyappan N.; Bowler C.; Inumerable R.; Abu M.; Suhool A.; Talbot T.; Westwood J.; Zumbo G.; Osborne A.; Botes A.; Dyer S.; Thomas-Jones I.; Merker L.; Przemioslo R.; Roderick M.; Valverde J.; Zerafa A.; Barker S.; Wan A.; Lalani R.; Barrett C.; Kapirial N.; McCarthney K.; Ramamoorthy R.; Yalchin M.; Huggett M.; Macutkiewicz C.; Smith A.; Buchanan A.; Burke J.; Goodchild G.; Keane M.G.; Potts J.; Disney B.; McFarlane M.; Baker E.; Bullock S.; Coleman S.; Mcardle C.; Morgan J.; Mozdiak E.; Obisesan A.; O'Flynn L.; Mowbray N.; de Berker H.T.; Driscoll P.; Alberts J.C.; Sadien I.D.; Webb K.; Khalil H.; Parmar C.; Sadigh D.; Seyed-Safi P.; Shala L.; Somasundaram M.; Bryce G.; McCormack K.; Jamieson W.; Mitchell L.; Cheung D.; Hicken B.; Abbas N.; Kurian A.; Tahir I.; Spearman J.; Johnston T.; Jones C.

Citation:Pancreatology; Sep 2021; vol. 21 (no. 6); p. 1127-1134

Abstract:Objective: UK national guidelines recommend pancreatic enzyme replacement therapy (PERT) in pancreatic cancer. Over 80% of pancreatic cancers are unresectable and managed in non-surgical units. The aim was to assess variation in PERT prescribing, determine factors associated with its use and identify potential actions to improve prescription rates. Design(s): RICOCHET was a national prospective audit of malignant pancreatic, peri-ampullary lesions or malignant biliary obstruction between April and August 2018. This analysis focuses on pancreatic cancer patients and is reported to STROBE guidelines. Multivariable regression analysis was undertaken to assess factors associated with PERT prescribing. Result(s): Rates of PERT prescribing varied among the 1350 patients included. 74.4% of patients with potentially resectable disease were prescribed PERT compared to 45.3% with unresectable disease. PERT prescription varied across surgical hospitals but high prescribing rates did not disseminate out to the respective referring network. PERT prescription appeared to be related to the treatment aim for the patient and the amount of clinician contact a patient has. PERT prescription in potentially resectable patients was positively associated with dietitian referral (p = 0.001) and management at hepaticopancreaticobiliary (p = 0.049) or pancreatic unit (p = 0.009). Prescription in unresectable patients also had a negative association with Charlson comorbidity score 5-7 (p = 0.045) or >7 (p = 0.010) and a positive association with clinical nurse specialist review (p = 0.028). Conclusion(s): Despite national guidance, wide variation and under-treatment with PERT exists. Given that most patients with pancreatic cancer have unresectable disease and are treated in non-surgical hospitals, where prescribing is lowest, strategies to disseminate best practice and overcome barriers to prescribing are urgently required.

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Healing pattern of the cervical stroma following cold coagulation treatment for cervical intraepithelial neoplasia: A case report (2022)

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Type of publication:
Journal article

Author(s):
*Papoutsis D; *Williams J; *Underwood M; *Parry-Smith W

Citation:
Oncology letters; 2022 Mar; Vol. 23 (3), pp. 81

Abstract:
Cold coagulation of the cervix for cervical intraepithelial neoplasia (CIN), when compared with cervical excision, has previously demonstrated comparable cure rates and a reduction in the rate of spontaneous preterm birth. In the present report the healing pattern in the cervices of two women after cold coagulation is described. Both women underwent cold coagulation due to CIN3, which was found on pre-treatment cervical punch biopsies. They were followed up after cold coagulation and at 7 and 18 months, respectively, they underwent cervical excision. The histopathological slides from the excised specimen were reviewed, which represents the healed cervix after cold coagulation. A clear boundary of collagenisation was noted in the superficial stroma, which appeared to stop at the junction with the healthy muscular stroma. The collagenised superficial stroma depth, which represents the area that was thermally ablated and has now healed, measured 1.6 and 1.5 mm for the two women, respectively, which is less compared with that typically removed by cervical excision. Observations from these two cases indicate that cold coagulation does not appear to disrupt the deep tissue architecture of the cervix and could therefore explain the reduced levels of adverse obstetric morbidity in patients who underwent cold coagulation ablative treatment of the cervix, which has been previously reported.

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