Edward C. Halperin

Uveal Melanoma Treated With Iodine-125 Episcleral Plaque: An Analysis of Dose on Disease Control and Visual Outcomes

PURPOSE To investigate, in the treatment of uveal melanomas, how tumor control, radiation toxicity, and visual outcomes are affected by the radiation dose at the tumor apex. METHODS AND MATERIALS A retrospective review was performed to evaluate patients treated for uveal melanoma with (125)I plaques between 1988 and 2010. Radiation dose is reported as dose to tumor apex and dose to 5 mm. Primary endpoints included time to local failure, distant failure, and death. Secondary endpoints included eye preservation, visual acuity, and radiation-related complications. Univariate and multivariate analyses were performed to determine associations between radiation dose and the endpoint variables. RESULTS One hundred ninety patients with sufficient data to evaluate the endpoints were included. The 5-year local control rate was 91%. The 5-year distant metastases rate was 10%. The 5-year overall survival rate was 84%. There were no differences in outcome (local control, distant metastases, overall survival) when dose was stratified by apex dose quartile (<69 Gy, 69-81 Gy, 81-89 Gy, >89 Gy). However, increasing apex dose and dose to 5-mm depth were correlated with greater visual acuity loss (P=.02, P=.0006), worse final visual acuity (P=.02, P<.0001), and radiation complications (P<.0001, P=.0009). In addition, enucleation rates were worse with increasing quartiles of dose to 5 mm (P=.0001). CONCLUSIONS Doses at least as low as 69 Gy prescribed to the tumor apex achieve rates of local control, distant metastasis-free survival, and overall survival that are similar to radiation doses of 85 Gy to the tumor apex, but with improved visual outcomes.

Anxiety in first year medical students taking gross anatomy

To study anxiety levels in first‐year medical students taking gross anatomy. Thirty medical students per year, for 2 years, completed the Beck Anxiety Inventory (BAI) 10 times during a 13‐week gross anatomy course. In addition, behavioral observations were made by a psychiatrist during gross anatomy for demonstrations of assertive, destructive, neutral, or passive behavior. Additional qualitative outcome measures were group exit interviews with the faculty and students. The mean BAI for all 60 students per year, for 2 years, was 2.19 ± 3.76, 93% of the scores indicated minimal anxiety, and 89% of BAI values were less than five which confirmed a minimal level of anxiety. The low level of reported BAI contrasted sharply with verbal reports by the same students and face‐to‐face exit interviews with the psychiatrist. Symptoms of stress and anxiety emerged as a result of these conversations. The high levels of subjective stress and anxiety revealed by the interviews were unknown to the gross anatomy faculty. The low scores of students on the BAIs stand in sharp contrast to the BAIs reported for medical students in other published reports. Although it is possible that our students were truthfully devoid of anxiety, it is more likely that our students were denying even minimal anxiety levels. There have been reports that medical students feel that admitting stress, depression, or anxiety put their competitiveness for a residency at risk. We conclude that students may be in frank denial of experiencing anxiety and, if so, this behavior is not conducive to good mental health. Clin. Anat. 27:835–838, 2014.

Paediatric radiation oncology in the care of childhood cancer: A position paper by the International Paediatric Radiation Oncology Society (PROS)

Paediatric malignancies are a challenge for the radiation oncologist due to their rarity, the great variety of histological types, and the complexity of treatment concepts that evolve over time. The Paediatric Radiation Oncology Society (PROS) is the only internationally operating society for paediatric radiation oncology. The objectives of PROS are to set a world-wide standard of excellence with respect to radiation oncology aspects in curing children and adolescents with cancer, to provide a forum for communication between radiation oncologists, and to exchange information with all professionals involved in the management of paediatric and adolescent cancer. Challenges include the need to promote education and support practice in low and middle income countries (LMIC) as well as the cost and availability of modern treatment technologies for all but most especially these countries. Collaborations with other societies that include for example the education programmes provided jointly with ESTRO, and the upgraded technical platform of the PROS web site offer new possibilities to enhance the efficacy of PROS in education and support of paediatric radiation oncology practice world-wide. PROS has made an important contribution to the management of childhood malignancies over the past decade and new and developing collaborations between PROS and other societies or organizations will ultimately lead to a reduction in world-wide health care inequalities.

Dose intensification of methotrexate and cytarabine during intensified continuation chemotherapy for high-risk B-precursor acute lymphoblastic leukemia: POG 9406: A report from the children's oncology group

Purpose: To determine the efficacy and toxicity of higher dose versus standard dose intravenous methotrexate (MTX) and pulses of high-dose cytosine arabinoside with asparaginase versus standard dose cytosine arabinoside and teniposide during intensified continuation therapy for higher risk pediatric B-precursor acute lymphoblastic leukemia (ALL). Patients and Methods: From 1994 to 1999, the Pediatric Oncology Group conducted a randomized phase III clinical trial in higher risk pediatric B-precursor ALL. A total of 784 patients were randomized in a 2×2 factorial design to receive MTX 1 g/m2 versus 2.5 g/m2 and to cytosine arabinoside/teniposide versus high-dose cytosine arabinoside/asparaginase during intensified continuation therapy. Results: Patients receiving standard dose MTX had a 5-year disease-free survival (DFS) of 71.8±2.4%; patients receiving higher dose MTX had a 5-year DFS of 71.7±2.4% (P=0.55). Outcomes on cytosine arabinoside/teniposide (DFS of 70.4±2.4) were similar to higher dose cytosine arabinoside/asparaginase (DFS of 73.1±2.3%) (P=0.41). Overall survival rates were not different between MTX doses or cytosine arabinoside/teniposide versus cytosine arabinoside/asparaginase. Conclusions: Increasing MTX dosing to 2.5 g/m2 did not improve outcomes in higher risk pediatric B-precursor ALL. Giving high-dose cytarabine and asparaginase pulses instead of standard dose cytarabine and teniposide produced nonsignificant differences in outcomes, allowing for teniposide to be removed from ALL therapy.

The proton problem

1046 www.thelancet.com/oncology Vol 14 October 2013 *Jeff Dunn, Lisa Herron, Cary Adams, Suzanne Chambers Cancer Council Queensland, Brisbane, QLD, Australia (JD, LH, SC); Union for International Cancer Control, Geneva, Switzerland (CA); Griffi th Health Institute, Griffi th University, Southport, QLD, Australia (JD, SC); and Prostate Cancer Foundation Australia, Sydney, NSW, Australia (SC) jeff dunn@cancerqld.org.au

Striking a balance

I was recently consulted in the case of a child who was fully functional and attending school when headaches developed. An intracranial mass was identified. Surgery was performed and a partial resection was obtained of what proved to be a craniopharyngioma. Unfortunately, there was a massive intraoperative hemorrhage followed by 2 postoperative episodes of bacterial meningitis and extensive vasospasm. Now, 5 months postoperatively, magnetic resonance imaging shows extensive hypoxic brain injury, and the child is unresponsive and supported by a feeding tube and breathes through a tracheostomy. The tumor is regrowing. Is it technically possible to irradiate this craniopharyngioma? If so, technically how ought it be done, and with what dose and fractionation scheme? If there is no likelihood that radiation therapy will restore neurologic function, is it ethical to irradiate? The case calls for striking a balance between technical skills and humanistic professionalism. It illustrates one of the longstanding debates of higher education: the relative value of technical training versus a broad and liberal education. On the one hand, we hold forth as an ideal of higher education that learning is of value both for its own sake and to make us better people. On the other hand, higher education is generally expected to provide us with applicable skills that make us capable of earning a living. No one is made more directly capable of designing a bridge, starting an intravenous line, designing a radiation therapy field, or writing software code by virtue of studying Shakespeare’s sonnets, being guided through the history of Alexander the Great’s conquests, or learning

“This is a Christian institution and we will tolerate no Jews here”: The Brooklyn Medical Interns Hazings

ABSTRACT Anti‐Semitic quotas to restrict access to medical school, graduate medical education and hospital privileges were common in the United States from the 1920s to the 1960s. In Brooklyn, New York, medical education prejudice resulted in violence. In 1916 a Jewish intern at Kings County Hospital, Matthew Olstein, was bound and gagged by Christian interns, put on a train at Grand Central Station, and warned that if he returned he would be thrown in the East River. Olstein died in combat in World War I as an Army physician. In 1927 3 Jewish interns at Kings County Hospital were assaulted, bound, dumped in tubs of water and covered in black fluid. Six gentile physicians were charged with assault. Criminal proceedings and public investigations followed. These attacks are the only known episodes of violence associated with American medical education anti‐Semitism.