Search

A generally well 71-year-old man presented to his general practitioner with altered bowel habit and haematochezia. Colonoscopy revealed a malignant-appearing rectal mass, with histological features of extrapulmonary small cell carcinoma (EPSCC) of the rectum. Imaging demonstrated limited stage disease with a threatened circumferential resection margin. He was treated with a modified platinum chemoradiotherapy regimen for small cell lung cancer with an excellent response. Unfortunately, his cardiac function precluded surgery at the time and the patient subsequently developed hepatic metastases with local disease recurrence, and died 15 months following his initial diagnosis. Rectal EPSCC is a rare diagnosis, and this case represented a challenge for the multidisciplinary team given the limited evidence base. Medical therapy reflects extrapolation of small cell lung cancer treatment and the role of surgery is less clearly defined given aggressive and refractory disease is common. Immunotherapy, however, represents an exciting development for metastatic disease.

Epidemiological studies have shown wide geographical and racial variation in the prevalence and patterns of immunodeficiency disorders. To determine the frequency of primary immunodeficiencies (PID) in Iran, the Iranian primary Immunodeficiencies Registry (IPIDR) was organized in 1999. the diagnosis of immunodeficiency in our patients was based on standard criteria. The patient’s data were extracted, by using a uniform questionnaire from their hospital records. Three hundred and twenty eight patients with PID have been registered in our registry till 2000. Among these patients, the following frequencies were found: predominantly antibody deficiency in 48.48% of patients (n=159), T-cell disorders in 25.91% (n=85), phagocytic disorders in 24.7% (n=81), and complement deficiencies in 0.91% (n=3). Common variable immunodeficiency was the most frequent disorder (n=73), followe by chronic granulomatous disease (n=55), ataxia telangiectasia (n=39), x-linked agammaglobulinemia (n=35), selective IgA deficiency (n=34). This study reveals that antibody deficiencies are the most frequent diagnosed primary immunodeficiency disorder in our patients, which is similar to that observed in other registries. A comparative study shows some differences between our results and other registries

The prevalence of HIV-related malignant disease is increasing, probably due to more effective management of opportunistic infection. The most frequent tumours are Kaposi's sarcoma, systemic non-Hodgkin's lymphoma and primary central nervous system lymphoma. Management of these conditions must take into account host indicators of immunosuppression and prognostic outcome in order to minimise treatment associated complications.

Background Following pelvic radiotherapy (RT), a proportion of women experience problems related to sexual function, which are multifactorial in origin. The physical components relate to distortion of the perineum and vagina, which may occur as a result of surgery and/or radiotherapy and compromise sexual activity resulting in considerable distress. Objectives The aim of this review was to evaluate the evidence for treatment options addressing the physical components of sexual dysfunction arising from pelvic radiotherapy as prevention or treatment of acute or late complications. Search methods The concepts used included synonyms for radiation therapy and brachytherapy and synonyms for the spectrum of physical aspects of sexual dysfunction in women. randomized. We searched the Cochrane Controlled Trials Register (CENTRAL), Issue 1, 2002, MEDLINE 1966 to 2002, EMBASE 1980 to 2002, CANCERCD 1980 to 2002, Science Citation Index 1991 to 2002, CINAHL 1982 to 2002, as well as sources of grey literature. We also hand searched relevant textbooks and contacted experts in the field. Selection criteria Any study describing the therapeutic trial of a treatment to relieve the physical aspects of female sexual dysfunction which had developed following pelvic radiotherapy was considered. The quality of each study was then assessed by two reviewers independently to determine its suitability for inclusion in statistical analysis. Data collection and analysis Thirty-two references met the inclusion criteria for the search but of these only four were suitable to be included for statistical analysis. Main results The strongest evidence for benefit is the grade IC data in the topical oestrogens and benzydamine sections which describes the treatment of acute radiation vaginal changes. The use of vaginal dilators to prevent the development of vaginal stenosis is supported by grade IIC evidence. The value of hyperbaric oxygen therapy and surgical reconstruction is supported by the much weaker grade IIIC evidence in the form of case series. Authors' conclusions These findings reflect the quality of published data regarding interventions for this aspect of the management of radiation induced complications. Although there is grade IC evidence, these studies are not recent, the allocation concealment is unclear in the text, and overall there is a variable level of assessment of the response, emphasising the need for more studies to be conducted with improved designs to clarify the investigative process and support the final result.

Background Chronic radiation proctitis (rectal inflammation) may develop after the completion of pelvic radiotherapy. Presently there is no recommended standard management. Objectives To assess the effects of various non-surgical options for managing late chronic radiation proctitis. Search methods In the first version of this review the following were searched : the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2001) Register 2001; MEDLINE 1966 to 2001; EMBASE 1980 to 2001; CANCERCD 1980 to 2001; Science Citation Index 1991 to 2001; CINAHL 1982 to 2001,and sources of grey literature. We also handsearched textbooks and contacted experts in the field. In the current update the search has been extended to April 2007. Selection criteria Studies (preferentially RCTs) of interventions for the non-surgical management of late radiation proctitis in patients who have undergone pelvic radiotherapy for cancer. Data collection and analysis Inclusion criteria were independently applied by two review authors (AD and EJM) and any disagreement resolved by involving a third reviewer. Main results In the original review there were six RCTs. None compared anti-inflammatories with placebo. However, rectal sucralfate showed greater clinical improvement for proctitis than anti-inflammatories (odds ratio (OR) 14.00, 95% confidence interval (CI) 1.46 to 134.26; n = 1 study) , though no difference was seen for endoscopic improvement (OR 2.74, 95% CI 0.64 to 11.76, n = 1 study). The addition of metronidazole to the anti-inflammatory regime also appeared to improve the response rate, as measured by reduction in rectal bleeding, diarrhoea, erythema and ulceration (n = 1 study). Similarly rectal hydrocortisone appeared to be more effective than rectal betamethasone for clinical improvement although no difference was seen in endoscopic improvement (n = 1 study). Short chain fatty acid enemas did not appear to be effective compared to placebo (n = 2 studies). Comparing the heater probe and bipolar electrocautery (n = 1 study), there was no discernible difference for severe bleeding after one year, but the heater probe demonstrated a greater increase in the haematocrit and reduced transfusion requirements. The current update has identified a further three RCTs and a phase II study. One of the RCTs (Clarke 2004) examines the effect of hyperbaric oxygen (HBO) versus placebo with significantly improved chance of healing following HBO for radiation proctitis (Relative Risk (RR) 2.7, 95% CI 1.2 to 6.0, P = 0.02, number to needed to treat (NNT) = 3). This RCT was included in the 2005 Cochrane Systematic review (Bennett 2005). Clarke 2004 is quoted as evidence for the benefit of late radiation injury to the pelvis with a significantly improved chance of healing following HBO therapy (HBOT) for radiation proctitis. The other RCT (Ehrenpreis 2005) reports a double-blind placebo RCT of vitamin A for symptomatic chronic radiation proctopathy where vitamin A significantly reduced rectal symptoms perhaps because of wound-healing effects. The third RCT (Kneebone 2005) is a large study where patients were randomised to receive oral sucralfate. This trial demonstrated no statistically significant reduction in the incidence of late rectal toxicity in patients randomised to receive sucralfate. However, this result was considered inconclusive, because the trial was unable to exclude clinically important differences in the late toxicity rates. The phase II series (Veerasarn 2006) is a study of long term follow up data been obtained from patients who have received WF10 therapy. In the phase II study the median follow up was 51 months. No adverse effects were found and there favourable results in terms of control of bleeding from late radiation cystitis and proctitis. Authors' conclusions Late radiation complications are relatively rare, involving potential carers and poor diagnostic criteria. Although certain interventions look promising (e.g. rectal sucralfate, adding metronidazole to the anti-inflammatory regime and heater probes), single small studies, even if well conducted provide insufficient evidence. The episodic and variable nature of late radiation proctitis requires large multi-centre placebo-RCTs to establish whether particular treatments are effective. Regional or centralised registers of radiation toxicity should be established so interventions can be administered in the setting of multi-centre RCTs with specific entry criteria, formal baseline and therapeutic assessments providing standardised outcome data including quality of life (QOL) evaluations.

Pulmonary Kaposi’s sarcoma is a frequent complication of human immunodeficiency virus (HIV) infection. This chapter will discuss pulmonary Kaposi’s sarcoma in the context of HIV disease in terms of epidemiology, pathogenesis, presentation and diagnosis. Current therapeutic approaches will also be outlined as will new potential treatments that may supercede our present management of this difficult condition.