INTEGRATED CARE PATHWAYS IN LUNG CANCER: A QUALITY IMPROVEMENT PROJECT.

BACKGROUND: Non small cell lung cancer (NSCLC) diagnosis and treatment is a highly complex process, requiring managerial skills merged with clinical knowledge and experience. Integrated care pathways (ICPs) might be a good strategy to overview and improve patient's management. The aim of this study was to review the ICPs of NSCLC patients in a University Hospital and to identify areas of quality improvement. MATERIALS AND METHODS: The electronic medical records of 169 NSCLC patients visited at the University Hospital were retrospectively reviewed. Quality of care (QoC) has been measured trough fifteen indicators, selected according main international Guidelines and approved by the multi-disciplinary team for thoracic malignancies. Results have been compared with those of a similar retrospective study conducted at the same hospital in 2008. RESULTS: A total of 146 patients were considered eligible. Eight of fifteen indicators were not in line with the benchmarks. We compared the results obtained in the two separate periods. Moreover, we process some proposal to be discussed with the general management of the hospital, aimed to redesign NSCLC care pathways. CONCLUSIONS: ICPs confirm to be feasible and to be an effective tool in real life. The periodic measurement of QoC indicators is necessary to ensure clinical governance of patients pathways.

Incidence and risk factors of the intraoperative localization failure of nonpalpable breast lesions by radio-guided occult lesion localization: a retrospective analysis of 579 cases.

BACKGROUND: The radio-guided occult lesion localization (ROLL) technique allows the identification of nonpalpable breast lesions by means of the preoperative, intratumoral injection of a radiotracer. Our study aimed to determine the incidence and risk factors of ROLL failure. METHODS: We collected data about all women who underwent ROLL in our department from 2002 to 2009, focusing on patient characteristics such as breast size and density, lesion size, localization, histology, radiologist, and surgeon experience. Data were analyzed using R v2.10.1, considering p < 0.05 significant. RESULTS: A total of 579 ROLLs were performed on 555 women with a mean age of 58.7 (± 10.96) years. Incidence of ROLL failure at the first intervention was 4 % (23/579). Through monovariate analysis, ROLL failure was significantly influenced by stereotactic mammography-guided procedure, invasive tumors, pathological and radiological lesion size ≤ 5 mm, and the lesion's location in the central or upper breast quadrants. Through multivariate analysis, the most predictive factors for ROLL failure were as follows: lesion localization in the central quadrant, lesion radiological size ≤ 5 mm, and radiologist inexperience. CONCLUSIONS: The main risk factors for ROLL failure were the radiologist's inexperience, lesion size ≤ 5 mm, and its localization in the central subareolar quadrant, probably due to an unfavorable radiological and surgical reaching of the breast area.

Nine years of experience with the sentinel lymph node biopsy in a single Italian center: a retrospective analysis of 1,050 cases.

BACKGROUND: This study aims to determine the prevalence and predictive factors for recurrence after sentinel lymph node biopsy (SLNB) and for sentinel lymph node positivity by SLNB in our population. METHODS: We followed up all SLNBs performed between 2002 and 2010 and analyzed data by R (version2.10.1), considering p < 0.05 significant. RESULTS: Among 1,050 patients with SLNB, 23% (245/1050) underwent secondary axillary dissection (CALND). Axillary recurrence prevalence among patients with negative SLNB was 1% (6/805) at a mean follow-up of 54 months (±14), and 1.7% (95% CI 0.2-3.1%) after 6 years of follow-up, as all recurrences developed between the 3rd and the 6th years of follow-up. By multivariate analysis, axillary recurrence results correlated with large tumor size, high number of excised nodes, lymphovascular invasion, high grading, multifocality, Her-2 positivity, intraductal histology, and comedo-like necrosis. Moreover, SLNB positivity results correlated with young age, large tumor size, high number of excised nodes, negative history for second primary malignancies, lymphovascular invasion, and high grading. CONCLUSIONS: Cancer characteristics represent important predictive factors for SLNB positivity, as well as for axillary recurrence in patients with negative SLNB, independently, by surgical and nonsurgical treatment. Therefore, cancer biological behavior and the patient's hormonal profile should be evaluated with care to better tailor the follow-up of women with breast cancer.

Skeletal Muscle Metastases in HCC Revealed by 18F-Choline PET/CT.

ABSTRACT: We present a case of a 68-year-old woman undergoing 18F-choline PET/CT due to a history of hepatocellular cancer treated with multimodal therapies and with a rapid increase in α-fetoprotein. 18F-Choline PET/CT showed multiple uptakes in the skeletal muscles compatible with the recurrence of disease. The interpretation of 18F-choline PET/CT in this cancer should be careful and discussed in a multidisciplinary team.

An Incidental Pancreatic Finding at 18F-Choline PET/CT: Chronic Mass-Forming Pancreatitis.

We present a case of a chronic mass-forming pancreatitis (CMFP) detected by 18F-choline (FCH) PET/CT in a male affected by prostate cancer. FCH PET/CT scan showed a focal uptake in the uncinate process of the pancreas, later diagnosed as a CMFP at biopsy. Although the physiological distribution of FCH in the pancreas, a careful interpretation of the images in this area is warranted.

Sentinel lymph node biopsy in patients affected by breast ductal carcinoma in situ with and without microinvasion: Retrospective observational study.

With the introduction of an organized mammographic screening, the incidence of ductal carcinoma in situ (DCIS) has experienced an important increase. Our experience with sentinel lymph node biopsy (SLNB) among patients with DCIS is reviewed.We collected retrospective data on patients operated on their breasts for DCIS (pTis), DCIS with microinvasion (DCISM) (pT1mi) and invasive ductal carcinoma (IDC) sized ≤2 cm (pT1) between January 2002 and June 2016, focusing on the result of SLNB.543 DCIS, 84 DCISM, and 2111 IDC were included. In cases of DCIS and DCISM, SLNB resulted micrometastatic respectively in 1.7% and 6.0% of cases and macrometastatic respectively in 0.9% and 3.6% of cases. 5-year disease-free survival and overall survival in DCISM and IDC were similar, while significantly longer in DCIS. 5-year local recurrence rate of DCIS and DCISM were respectively 2.5% and 7.9%, and their 5-year distant recurrence rate respectively 0% and 4%. IDC, tumor grading ≥2 and lymph node (LN) macrometastasis were significant predictors for decreased overall survival. Significant predictors for distant metastases were DCISM, IDC, macroscopic nodal metastasis, and tumor grading ≥2. Predictors for the microinvasive component in DCIS were tumor multifocality/multicentricity, grading ≥2, ITCs and micrometastases.Our study suggests that despite its rarity, sentinel node metastasis may also occur in case of DCIS, which in most cases are micrometastases. Even in the absence of an evident invasive component, microinvasion should always be suspected in these cases, and their management should be the same as for IDC.

Applicability of two different validated models to predict axillary non-sentinel lymph node status by sentinel node biopsy in a single Italian center.

BACKGROUND: The necessity of complete axillary lymph node dissection (CALND) after sentinel lymph node biopsy (SLNB) for women with sentinel lymph node metastases is a matter of debate because non-sentinel lymph nodes after CALND contain no further metastases in about 50 % of cases. Our study aims to determine the applicability in our setting of two different validated nomograms to predict axillary lymph node status after SLNB. METHODS: We collected data about all women who underwent SLNB in our Department of Surgery from 2007 to 2010, focusing on tumor, patient, and breast characteristics. Data was analyzed by R (version 2.15.2); p < 0.05 was considered significant. RESULTS: Among 511 women who underwent SLNB, 126 received CALND due to sentinel lymph node metastasis, and 73.0 % of these had no further metastatic non-sentinel lymph node. The area under the receiver operating characteristic (ROC) curves for the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram and the Tenon score were 78.5 % (95 % CI 70.1-86.8 %) and 77.0 % (95 % CI 67.9-86.0 %) (p = 0.678), respectively. CONCLUSIONS: Both the MSKCC nomogram and the Tenon score were predictive for the axillary non-sentinel lymph node status by SLNB. The MSKCC nomogram was the more accurate of the two and the Tenon score was the easier one to apply.

Prevalence and risk factors of intraoperative identification failure of sentinel lymph nodes in patients affected by breast cancer.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) has progressively replaced complete axillary lymph node dissection in the evaluation of breast cancer patients with clinically node-negative disease. Our study investigates the rate of and risk factors involved in sentinel node identification failure. MATERIALS AND METHODS: We collected data on SLNBs performed during 2002-2010, focusing on tumor, patient, and breast characteristics, radioactivity parameters, and operators' experience. Data were analyzed by R (v2.14.2), considering significance at P values lower than 0.05. RESULTS: Among 1050 women who underwent an SLNB, the rate of identification failure was 2% (23/1050), which, on bivariate analysis, was seen to be significantly influenced (P<0.05) by the preoperative and intraoperative low radiotracer uptake (axilla/lesion radiotracer uptake ratio<1%), low level of experience of the specialist in nuclear medicine, luminal A subtype, and radiotracer uptake localization in internal mammary lymph nodes. On multivariate analysis, significant risk factors for sentinel node identification failure were found to be: axilla/lesion radiotracer uptake ratio less than 1%, radiotracer uptake localization in internal mammary lymph nodes, and luminal A subtype. Considering only the preoperative variables in our multivariate analysis, axilla/lesion radiotracer uptake ratio less than 1%, negative lymph node scintiscan, and radiotracer uptake localization in internal mammary lymph nodes had an area under the curve (receiver operating characteristic curve) of 96% (95% confidence interval 92-100%). Further, we built a nomogram based on these simple parameters for counseling the patient about the probability of not finding the sentinel lymph node during the surgical procedure. CONCLUSION: The relatively low prevalence of SLNB failure (2%) is indicative of the accuracy of the procedure when performed by experienced surgeons. The sentinel node identification failure in our population seemed to be related to biological tumor factors (luminal A subtype) and probably to physiological or pathological variations in the lymphatic drainage (axilla/lesion radiotracer uptake ratio<1% and radiotracer uptake localization in internal mammary lymph nodes).

Adopting integrated care pathways in non-small-cell lung cancer: from theory to practice.

INTRODUCTION: Integrated care pathways (ICPs) have been proposed as effective strategies for quality improvement. To date, limited data are available that detail the methodology to design an optimal care pathway for patients with non-small-cell lung cancer (NSCLC). The main aim of this study was to assess the quality of health care delivered to lung cancer patients referred to a hub university hospital. METHODS: All professionals involved with the management of NSCLC patients, in cooperation with health care researchers, identified 11 quality indicators and associated benchmarks. These were used to estimate the quality and efficiency of health care delivered to a cohort of 175 NSCLC patients. RESULTS: The gap between "desired" and "actual" performance has been measured by benchmarking current practice against key quality indicators. Diagnostic workup, multidisciplinary team care and medical treatment of advanced disease have emerged as areas of good performance. Conversely, the management of early-stage disease offers room for improvement, in terms of both accuracy of nodal staging and surgical timeliness. CONCLUSIONS: Analyzing the process of caring for NSCLC patients is feasible and offers room for improvement. Acquired knowledge may be shared with hospital administrators, guide the revision of ICPs, and enable the delivery of consistent, high-quality clinical standards.

Procalcitonin: a marker of severity of acute pyelonephritis among children.

OBJECTIVE: Febrile urinary tract infection (UTI) is a common problem among children. The diagnosis and management of acute pyelonephritis is a challenge, particularly during infancy. The distinction between acute pyelonephritis and UTI without renal involvement is very important, because renal infection may cause parenchymal scarring and thus requires more aggressive investigation and follow-up monitoring. However, this distinction is not easy among children, because common clinical findings and laboratory parameters are nonspecific, especially among young children. In an attempt to differentiate acute pyelonephritis from febrile UTI without renal lesions in a group of 100 children, we measured serum levels of procalcitonin (PCT), a new marker of infection. The objective of the study was to determine the accuracy of PCT measurements, compared with C-reactive protein (CRP) measurements, in diagnosing acute renal involvement during febrile UTI and in predicting subsequent scars, as assessed with 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy. DESIGN: Serum CRP levels, erythrocyte sedimentation rates, leukocyte counts, and PCT levels were measured for 100 children, 1 month to 13 years of age, admitted for suspected febrile UTI (first episode). Renal parenchymal involvement was evaluated with DMSA scintigraphy within 5 days after admission. The DMSA study was repeated 6 months later if the initial results were abnormal. RESULTS: The mean PCT level was significantly higher in acute pyelonephritis than in UTI without renal lesions (4.48 +/- 5.84 ng/mL vs 0.44 +/- 0.30 ng/mL). In these 2 groups, the mean CRP levels were 106 +/- 68.8 mg/L and 36.4 +/- 26 mg/L, mean erythrocyte sedimentation rates were 79.1 +/- 33 mm/hour and 58.5 +/- 33 mm/hour, and leukocyte counts were 18 492 +/- 6839 cells/mm3 and 16 741 +/- 5302 cells/mm3, respectively. For the prediction of acute pyelonephritis, the sensitivity and specificity of PCT measurements were 83.3% and 93.6%, respectively; CRP measurements had a sensitivity of 94.4% but a specificity of only 31.9%. Positive and negative predictive values for prediction of renal involvement with PCT measurements were 93.7% and 83% and those with CRP measurements were 61.4% and 83.3%, respectively. When inflammatory markers were correlated with the severity of the renal lesions, as assessed with DMSA scintigraphy, a highly significant correlation with both PCT and CRP levels was found. However, when the 2 parameters were correlated with renal scarring in follow-up scans, a significant positive association was found only for PCT levels. CONCLUSIONS: Serum PCT levels may be a sensitive and specific measure for early diagnosis of acute pyelonephritis and determination of the severity of renal parenchymal involvement. Therefore, this measurement could be useful for the treatment of children with febrile UTIs, allowing prediction of patients at risk of permanent parenchymal renal lesions.