Join Y. Luh

Multimodality therapy for locoregional extrahepatic cholangiocarcinoma: a population based analysis

Although surgical resection is the mainstay of treatment for extrahepatic cholangiocarcinoma, the majority of patients present with advanced disease. Due in part to numeric rarity, the optimum role of radiotherapy (RT) for extrahepatic cholangiocarcinoma, as well as its relative benefit, is an area of debate. The specific aim of this series was to estimate survival for extrahepatic cholangiocarcinoma patients receiving surgery and adjuvant RT using a robust population‐based data set.

Poorly differentiated colon carcinoma with neuroendocrine features presenting with hypercalcemia and cutaneous metastases: Case report and review of the literature

Humoral hypercalcemia is rarely associated with colon carcinoma; cutaneous metastases from colon carcinoma are also infrequent. To the authors’ knowledge, no cases of colon carcinoma presenting with both hypercalcemia and cutaneous metastases have been reported to date. A case of advanced poorly differentiated colon carcinoma with neuroendocrine features with both humoral hypercalcemia of malignancy (HHM) and cutaneous metastases is presented. A poorly differentiated colon carcinoma with neuroendocrine features occurred in a 42-year-old patient with metastases to the liver, both femurs, left orbit, and scalp. The hypercalcemia was caused by the expression of a parathyroid hormone related peptide by both the primary and cutaneous metastatic tumors. Bisphosphonate treatment helped normalize serum calcium in a few days, but hypercalcemia recurred approximately 3 weeks later. Chemotherapy only mildly reduced the size of the cutaneous metastases. The patient died 8 months after initial diagnosis. To the authors’ knowledge, the case presented in the current study is the first to be reported with both HHM and cutaneous metastases. Hypercalcemia and cutaneous metastases are separately associated with a poor prognosis and indicate advanced and widely metastatic disease. Although still unclear, the mechanism by which colon cancer causes cutaneous metastases and hypercalcemia, in light of current theories presented in the literature, is discussed.

Case report and summary of literature: Giant perineal keloids treated with post-excisional radiotherapy

BackgroundKeloids are common benign tumors of the dermis, typically arising after insult to the skin. While typically only impinging on cosmesis, large or recurrent keloids may require therapeutic intervention. While no single standardized treatment course has been established, several series report excellent outcomes for keloids with post-surgery radiation therapy.Case presentationWe present a patient with a history of recurrent keloids arising in the absence of an ascribed trauma and a maternal familial history of keloid formation, whose physical examination several large perineal keloids of 6-20 cm in the largest dimension. The patient was treated with surgical extirpation and adjuvant radiation therapy. Radiotherapy was delivered to the scar bed to a total dose of 22 Gy over 11 daily fractions. Acute radiotherapy toxicity necessitated a treatment break due to RTOG Grade III acute toxicity (moderate ulceration and skin breakdown) which resolved rapidly during a 3-day treatment break. The patient demonstrated local control and has remained free of local recurrence for more than 2 years.ConclusionRadiotherapy for keloids represents a safe and effective option for post-surgical keloid therapy, especially for patients with bulky or recurrent disease.

MACRA Regulatory Burdens and the Threat of Physician Burnout

other settings. A recent retrospective study of patients treated with antibiotics for diverticulitis at Kaiser Permanente compared outpatients managed without CT with emergency department/inpatients managed with CT. More outpatients had prior diagnoses of diverticulitis, including outpatient-managed episodes, and they had increases in 8 symptombased somatic and 3 mental comorbidities as well as greater dispensing of antispasmodics, anxiolytics, and serotonin receptor agents. The somatic comorbidity that varied most between the groups was IBS, which had been diagnosed in 15.1% (2399/15,846) of outpatients vs 9.6% (361/3750) of emergency department/inpatients. Outpatients with a prior diagnosis of diverticulitis had 1.5-fold greater odds of having IBS than outpatients without this history. Although the investigators could not determine which patients had mild diverticulitis vs an exacerbation of IBS, these and other findings constitute multiple types of indirect and concordant evidence of the misattribution of IBS pain to diverticulitis. Extrapolation of the Kaiser Permanente data to the US population reveals that a misdiagnosis rate of only 10% in clinically diagnosed outpatients would approximate 40,000 patients a year. Misdiagnosis causes much unnecessary antibiotic use and inherent cost and risk. Thus, in addition to the structural disorders discussed in the differential diagnosis of diverticulitis, practitioners should carefully consider IBS in outpatients with lower abdominal pain, bowel habit abnormality, and abdominal tenderness. Chronicity of symptoms may be a particularly helpful feature. Also, Bharucha et al described details of the physical examination that can help distinguish functional from structural disorders, but there may be uncertainty in some cases. In view of the overlap of clinical features of IBS and mild diverticulitis and

Radiation Recall Reaction With Letrozole Therapy in Breast Cancer

Radiation recall reaction is a rare inflammatory skin condition that occurs in a previously irradiated field and is prompted by the administration of certain drugs. We report a case of a 74-year-old woman with stage IIA cancer of the right breast who was treated with lumpectomy and radiation and experienced radiation recall reaction after starting adjuvant letrozole. Discontinuing letrozole led to resolution of the skin reaction, after which the patient was able to resume the medication without complications. The pathophysiologic characteristics of radiation recall reaction are discussed.

Radiation Therapy for Gynecomastia

To the Editor: We read with interest the excellent review by Johnson and Murad1 on the pathophysiology, evaluation, and management of gynecomastia. Nevertheless, we want to point out another well-established management technique that was not mentioned in the article: radiation therapy.

Radiation Therapy in Gastric and Ocular Marginal Zone Lymphomas

1. Michelena HI, Khanna AD,MahoneyD, et al. Incidence of aortic complications in patients with bicuspid aortic valves. JAMA. 2011;306(10):1104-1112. 2. Tribouilloy C, Rusinaru D, Sorel C, et al. Clinical characteristics and outcome of infective endocarditis in adults with bicuspid aortic valves: a multicentre observational study. Heart. 2010; 96(21):1723-1729. 3. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30(4):633-638. 4. Tleyjeh IM, Steckelberg JM, Murad HS, et al. Temporal trends in infective endocarditis: a population-based study in Olmsted County, Minnesota. JAMA. 2005;293(24):3022-3028.

Posttreatment Prostate-Specific Antigen Surveillance After Primary Treatment of Prostate Cancer

To the Editor: We read with interest the article byNabhan et al on posttreatment prostate-specific antigen (PSA) surveillance and prostate cancer outcomes. Indeed, we agree with the authors that there exists a critical need for evidence-based guidelines for PSA surveillance after primary treatment. Nevertheless, wewere somewhat unclear as to how the authors came to the conclusion that higher intensity of PSA surveillance during the 2 years after radical prostatectomy (RP) or radiation therapy (RT) did not improve earlier detection of biochemical recurrence (BCR) or survival because (1) higher intensity of PSA surveillance was not defined and (2) it was not clear what higher intensity of PSA surveillance was being compared withdlower intensity of PSA surveillance? This, too, was not clearly defined. Information on the specific frequency of PSA testing was not provided in the “Patients and Methods” section. This is in contrast to the longterm active surveillance study conducted by Klotz et al, which clearly stated that a PSA test was performed every 3 months for 2 years and then