Professor Renting Li’s Combination of Internal and External Treatment of Traditional Chinese Medicine in Treating Radiation Enteritis

Radiotherapy is a common treatment for abdominal and pelvic malignancies with bone metastases. However, some patients develop radiation enteritis (RE) during the treatment or 2 months or more after the treatment, which seriously affects their quality of life. At present, the curative effect of western medicine is poor. Professor Renting Li believes that radiation kills tumor cells but at the same time, it damages the healthy Qi of the human body. Radiation causes heat and poison to accumulate in the intestinal tract, consumes and hurts Yin fluid, burns the vein, leads to deficiency of healthy Qi and poor detoxification, as well as cause blood stasis after a period of time. All these result in the combination of heat, blood stasis, and poison, manifesting as abdominal pain, diarrhea, mucus in stools, purulent and bloody stools, etc. Therefore, Professor Renting Li proposed the use of traditional Chinese medicine retention enema combined with oral traditional Chinese medicine to reduce symptoms, remove toxins, and improve the quality of life of patients.

Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice

Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.

The impact of pelvic radiotherapy on the gut microbiome and its role in radiation-induced diarrhoea: a systematic review

Pelvic radiotherapy is the key treatment for pelvic malignancies, usually including pelvic primary tumour lesions and lymphatic drainage areas in the pelvic region. Therefore, the intestinal tract in the radiation field is inevitably damaged, a phenomenon clinically referred to as radiation enteritis, and diarrhoea is the most common clinical symptom of radiation enteritis. Therefore, it is necessary to study the mechanism of radiation-induced diarrhoea. It has been found that the gut microbiome plays an important role in the development of diarrhoea in response to pelvic radiotherapy, and the species and distribution of intestinal microbiota are significantly altered in patients after pelvic radiotherapy. In this study, we searched for articles indexed in the Cochrane Library, Web of Science, EMBASE and PubMed databases in English and CNKI, Wanfang data and SINOMED in Chinese from their inception dates through 13 March 2020 to collect studies on the gut microbiome in pelvic radiotherapy patients. Eventually, we included eight studies: one study report on prostatic carcinoma, five studies on gynaecological carcinoma and two papers on pelvic carcinomas. All studies were designed as self-controlled studies, except for one that compared toxicity to nontoxicity. The results from all the studies showed that the diversity of intestinal flora decreased during and after pelvic radiotherapy, and the diversity of intestinal flora decreased significantly in patients with diarrhoea after radiotherapy. Five studies observed that the community composition of the gut microbiota changed at the phylum, order or genus level before, during, and after pelvic radiotherapy at different time points. In addition, the composition of the gut microbiota before radiotherapy was different between patients with postradiotherapy diarrhoea and those without diarrhoea in five studies. However, relevant studies have not reached consistent results regarding the changes in microbiota composition. Changes in the intestinal flora induced by pelvic radiotherapy and their relationship between changes in intestinal flora and the occurrence of radiation-induced diarrhoea (RID) are discussed in this study, providing a theoretical basis for the causes of RID after pelvic radiotherapy.

A PECULIAR CASE OF ISOLATED METASTATIC INGUINAL LYMPHADENOPATHY IN A YOUNG LADY – A CASE REPORT

Lymphadenopathy refers to the swelling of lymph nodes which can be secondary to bacterial, viral or fungal infections, autoimmune disease and malignancy. Lymphadenopathy can be localized or diffuse. About 75% of most lymphadenopathies are localized, and about 50% of those occur in the head and neck regions . Inguinal lymphadenopathy (3) occurs at the groin region and most common causes include infections of leg or foot, STDs, non Hodgkin's lymphoma, tuberculosis and pelvic malignancies. One of the rare causes includes distant metastasis of nasopharyngeal carcinoma (NPC) which is present in our case. Nasopharyngeal cancer is an uncommon squamous cell carcinoma in the head and neck region, in most parts of the world. It has a high propensity for lymphatic spread and is known for regional metastases with occult primary at presentation . The incidence of distant (1) metastasis at presentation ranges from 4.4 to 6%. The most common sites of metastasis are bone (70%–80%) followed by liver (30%), lungs (18%) and distant lymph nodes (axillary, mediastinal, pelvic and inguinal, in that order) . About 98% of them are discovered within 3 (2) years of treatment. As it is a highly chemo and radio-sensitive tumor, radiotherapy with concurrent chemotherapy is the mainstay in the management of local and advanced diseases. Here we are presenting a peculiar case of previously treated NPC presenting as isolated left inguinal metastatic lymphadenopathy in a young lady

Clinical outcomes following definitive treatment of young-onset, locally advanced rectal cancer: A single institution experience.

e15601 Background: We evaluated demographic, treatment, and survival outcomes of adults age 18 to 49 years treated at our institution with long course chemoradiotherapy (CRT) followed by total mesorectal excision (TME) for locally advanced rectal cancer. Additionally, we compared outcomes between those age < 45 vs. > 45 years. Methods: The records of 219 patients diagnosed with non-metastatic, clinical T3, T4, or node positive rectal adenocarcinoma and treated between April 2000 and November 2017 were reviewed for age, sex, and presenting symptoms; clinical stage and microsatellite stable (MSS)/DNA mismatch repair (MMR) proficiency status; treatments delivered and sequence; pathologic response to pre-operative therapies; and the development of locoregional recurrence (LRR), distant metastasis (DM), and secondary pelvic malignancy. The Kaplan-Meier method and Log-Rank test were used to calculate and compare disease-free survival (DFS) and overall survival (OS) rates from the date of TME. Results: The median age at diagnosis was 44 years (range 19-49) and there was no sex predominance. Rectal bleeding was the most common presenting symptom (91%), with a median time to diagnosis of 5 months. Clinical tumor/nodal categories were T1-2 in 4%, T3 in 87%, T4 in 7%, N0 in 17%, and N1–2 in 80% of patients. MSS/MMR proficient disease was identified in 95% of tumors with status reported (n = 170). CRT followed by TME and post-operative chemotherapy was the most frequent treatment sequence (n = 196), with capecitabine (n = 176) and FOLFOX (n = 115) as the predominant concurrent and post-operative chemotherapies, respectively. Pathologic complete response at both primary and nodal sites occurred in 15% of all cases and 16% of MSS/MMR proficient cases. There was no difference in sex, tumor category, nodal category, MSS/MMR proficiency status, or pathologic complete response, by age ( < 45 years [n = 111] vs. > 45 years [n = 108]). At a median DFS follow-up time of 5.0 years, there were 11 LRR, 40 DM (including 11 DM detected prior to/at time of TME), and 1 synchronous presentation of LRR and DM. The 5-year rate of DFS was 70.4% for age < 45 years and 85.3% for age > 45 years ( P = 0.02). At an OS median follow-up time of 7.5 years, there were 38 deaths. The 5-year rate of OS was 87.7% for age < 45 years and 94.4% for age > 45 years ( P = 0.126). Two patients developed non-rectal pelvic malignancies. Conclusions: The outcomes reported here from one of the largest single-institution series for young-onset, locally advanced rectal cancer could serve as a benchmark to evaluate newer treatment approaches. Rectal bleeding was the leading presenting symptom, with approximately half-year delay from development of symptoms to diagnosis. Most tumors were MSS/MMR proficient. At 5 years’ follow-up time, the DFS rate was lower for patients age < 45 years when compared to those > 45 years. Secondary pelvic malignancies were a rare occurrence.

The rate and risk of secondary pelvic malignancies (SPM) in patients treated with definitive radiation for locally advanced rectal cancer.

12065 Background: With a rising incidence of younger patients diagnosed with rectal cancer, the long-term toxicity of cancer-related therapy is becoming even more relevant. Risk of SPM is a known potential consequence of both chemotherapy (chemo) and radiation therapy (RT), yet the rate of SPM in patients with rectal cancer is still not defined. We sought to further investigate factors associated with and outcomes of SPM after RT for rectal cancer. Methods: Patients diagnosed with stage II-III rectal cancer treated with chemo and/or RT from 1995-2019 were included in a retrospective study. Patients treated with palliative intent and those who survived < 5 years from treatment were excluded. RT-associated SPM was defined as a cancer occurring ³5 years after RT completion. Cumulative incidence (CI) of SPM was analyzed using a landmark analysis at 5 years with death as a competing risk. For patients with CT simulation scans available, dosimetric analyses evaluated doses to the organs developing SPM. Kaplan Meier analysis was used to evaluate overall survival among patients who developed an SPM. Results: A total of 2,700 patients were included (RT = 978; chemo = 1722). Demographic characteristics were equivalent apart from age, which was higher in the RT group (61 vs 59 years, p < 0.001). Five (0.3%) chemo patients developed an SPM, all within 5-10 years after treatment for rectal cancer, vs 48 (4.9%) RT patients. The 8-year CI of developing an SPM in the RT group was 4% (95% CI 2.4-6.2) and increased to 17% at 15 years (95% CI 12.1-21.8) and 21% at 20 years (95% CI 14.8-27.7). Most (89%) RT patients had received chemotherapy (most commonly 5-FU or FOLFOX). The median time to SPM was 108 months (interquartile range [IQR], 84-140). After pelvic RT, the most common SPM histology was endometrial (38%), followed by prostate (31%), bladder (23%), sarcoma (4.2%), and other gynecologic cancers (4.2%). Seven patients had CT simulations for dosimetric analyses: median of maximum dose to the organ with SPM was 5301cGy (IQR, 4928-5427), median of mean dose was 4551 cGy (IQR, 4476-4751). None of the patients who developed endometrial cancer had Lynch syndrome. Median OS for patients with SPM after RT was 5.1 years with 5-yr OS of 58% (95% CI 43-77); 44 out of 48 patients needed at least one treatment modality for their SPM, and 8 received trimodality treatment [surgery, chemo and RT]. Conclusions: The CI of SPM increased from 4% at 8 years to 17% at 15 years and 21% at 20 years following pelvic RT for rectal cancer. Endometrial cancer was the most common SPM and survival following treatment of SPM was favorable. These data serve as a foundation for future prospective studies evaluating ways to reduce SPM such as proton therapy.

Role of MRI in the Evaluation of Adnexal Masses - A Prospective Study

BACKGROUND Among all the disorders of female reproductive system, adnexal masses are one of the most common disorders. The main purpose of the study was to evaluate an adnexal mass and to differentiate the mass as benign or malignant and facilitate selection of appropriate treatment algorithm. For few benign lesions, radiological follow-up is very suitable for further management and additional follow-up may not be useful when an imaging abnormality is not found. METHODS Our study was conducted in Osmania General Hospital and its allied hospital named Government Maternity Hospital, Hyderabad, on about 150 patients. This is an institution-based, multicentric, cross-sectional, prospective, analytical study. All clinically suspected female patients with adnexal masses referred to the Department of Radiodiagnosis were evaluated. These patients were first subjected to ultrasonography, followed by magnetic resonance imaging (MRI) (plain and contrast wherever required). MRI findings were compared with ultrasonography. These findings were compared with operative findings and histopathological findings, wherever performed. RESULTS In the present study, females in the age group of 21 – 40 years showed majority of pelvic lesions - 81 (54 %). Most of the pelvic masses were arising from the ovary - 102 (68 %). Majority of the adnexal lesions on MRI were benign in nature - 132 (88 %). MRI showed a sensitivity of 100 %, specificity of 97.7 %, and a positive predictive value of 83 %, & a negative predictive value of 100 %. CONCLUSIONS In practice, ultrasonography (USG) is the primary modality for diagnosing the pelvic mass. MRI is superior to ultrasound and can be used as problem solving technique in the assessment of pelvic mass. The multiplanar imaging capability allows accurate identification of origin of mass and characterisation of mass. This is helpful to the preoperative planning of sonographically detected mass and avoids surgery in possible cases. MRI is the technique of choice for staging, treatment planning and post treatment follow-up of pelvic malignancies. KEYWORDS MRI, USG, Adnexal Masses, Ovarian Masses, Board Ligament Lesions, Fallopian Tube Lesions, Cysts

Pubic Osteolysis in an Elderly Masquerading as Malignancy: A Case Report and Review of Literature

Introduction: A rapidly progressive destructive lesion characterizes pubic osteolysis (PO) in the pubic bone due to an inadequate fracture healing response. It may be seen in pelvic insufficiency fractures (IF) secondary to radiation therapy (RT) of pelvic malignancies, occurring even in the absence of significant trauma. Such a radiological picture may distract the clinician towards a malignant etiology and may affect the management. Case Report: A 79- year- old female, known case of carcinoma of the urinary bladder, underwent contrast-enhanced computed tomography (CT) (CECT) of the abdomen and pelvis as a routine follow- up and was found to have an osteolytic lesion in the right pubic bone, suggesting a malignant pathology. CT- guided biopsy did not reveal any malignant or infective etiology. The patient showed recovery with conservative management. Conclusion: Osteolytic lesions of the pubic bone can often occur following radiation for pelvic malignancies. It occurs due to impaired fracture reparative response by a bone afflicted by radiation therapy RT. It can be managed effectively with conservative analgesics, bisphosphonates, calcium, and Vitamin D supplementation. The radiographic picture can imitate malignant or infective lesions and provoke invasive testing for confirmation. The clinicians need to be conscious of this clinical entity to initiate proper treatment and avoid unnecessary investigations. Keywords: Pubic Osteolysis; Insufficiency Fracture; Radiation; Pelvis.