A Pandora's box in feline medicine: presenting signs and surgical outcomes in 58 previously hoarded cats with chronic otitis media-interna.

OBJECTIVES: The aim of the present study was to report clinical findings, surgical complications and outcomes for previously hoarded cats treated surgically for otitis media-interna (OMI) and to investigate the risk factors for complications and poor outcomes. METHODS: A retrospective study was conducted of 58 cats from an institutional hoarding environment that underwent ventral bulla osteotomy (VBO). RESULTS: Inappetence was uncommon at presentation (9/58, 16%) compared with pruritus/alopecia (50%), nasopharyngeal signs (45%), otitis externa (OE) (79%) and otitis interna (OI) (ataxia ± head tilt/head excursions) in 40%. Purulent aural discharge occurred in 36% and polyps in 26%. The tympanic bulla wall was moderately or severely thickened radiographically in 38/108 (35%) ears. Cultures were positive for Streptococcus equi subspecies zooepidemicus in 26/48 (54%) cats. Of the 58 cats, 40 (69%) had complications after the first VBO and 19/30 (63%) after the second. Of 101 complications, 56 (55%), from 27/88 (31%) surgeries, were considered serious, including life-threatening perioperative complications in seven, OI in eight, prolonged anorexia in six and worsening of pruritus/alopecia in nine cases. Three cats developed xerostomia (dry mouth) after the second VBO. Pruritus/alopecia, nasopharyngeal signs, OE and purulent aural discharge resolved in a statistically significant proportion of cats but persisted in some. Full resolution of OI was uncommon. OI preoperatively, and surgery performed by a generalist (vs specialist) surgeon, were risk factors for OE at recheck (OI: odds ratio [OR] 4.35; 95% confidence interval [CI] 1.21-15.70; P = 0.02; surgery: OR 3.64; 95% CI 1.03-12.87; P = 0.045). No other prognostic indicators were identified. No variables tested were significantly associated with risk of serious complications or euthanasia. CONCLUSIONS AND RELEVANCE: Surgical management of chronic OMI was successful in most cases but was not benign and not always beneficial. The analysis was unable to identify clinically helpful outcome predictors. Optimal management of chronic feline OMI remains a challenge, particularly for animal shelters. Less invasive approaches and chronic medical management require further investigation.

Incidence trends in head and neck cancers and human papillomavirus (HPV)-associated oropharyngeal cancer in Canada, 1992-2009.

PURPOSE: Recently, human papillomavirus (HPV) infection has been causally associated with a subset of head and neck cancers, particularly oropharyngeal cancer. As national cancer reporting systems typically report incidence rates of oropharyngeal cancer grouped with other cancers of the head and neck region, the objective of this study was to present age-standardized incidence trends in oropharyngeal cancer Canada-wide. METHODS: Data were obtained from the Canadian Cancer Registry for cases diagnosed between 1992 and 2009. Trends in age-standardized incidence rates were described for head and neck cancers overall and for HPV-associated oropharyngeal cancer using Joinpoint regression. RESULTS: The age-standardized incidence of head and neck cancers declined significantly in Canada from 1992 to 1998 (annual percentage change [APC] = -3.0, p < 0.01), then remained stable through to 2009. In contrast, the age-standardized incidence of HPV-associated oropharyngeal cancer increased significantly during the same time period, from 1.6 per 100,000 in 1992 to 2.6 in 2009 (APC = 2.7, p < 0.001). The increase in HPV-associated oropharyngeal cancer was greater in males than in females and increased significantly in all age groups, particularly those aged 50-59 (APC = 5.4, p < 0.001). The age-standardized incidence rate of head and neck cancer overall was stable or declined in all age groups except those aged 50-59 where incidence decreased from 1992 to 1997, then increased through to 2009. CONCLUSIONS: The incidence patterns of HPV-associated oropharyngeal cancer and head and neck cancer overall show contrasting trends. Findings highlight the need to surveil HPV-associated oropharyngeal cancer separately from other cancers of the head and neck region in order to monitor these emerging trends.

The development and validation of a quality-of-life questionnaire for head and neck cancer patients with enteral feeding tubes: the QOL-EF.

PURPOSE: To develop a questionnaire that measures the impact of enteral feeding tubes (EFTs) on the quality of life (QOL) of head and neck cancer (HNC) patients METHODS: The development of the questionnaire (QOL-EF) was done in four phases. Phase 1-3 included: (1) literature review and consultation with an expert focus group (item generation), (2) pilot-testing in 12 patients and, (3) judgmental item reduction. In phase 4, the QOL-EF, FACT-H&N, and UW-QOL were administered to a cross-sectional group of HNC patients on active EFT feeding to test the reliability and validity of the QOL-EF. RESULTS: A 20-item QOL-EF was developed. In phase 4, 72 patients were accrued over 2.5 years, 31 of which were part of the test-retest subgroup. Cronbach's α for the QOL-EF was 0.73, and test-retest reliability was 0.83. Moderate correlations were observed between scores for the QOL-EF and both the FACT-H&N (-0.58) and the UW-QOL (-0.42). CONCLUSIONS: The QOL-EF is a treatment-specific QOL instrument developed and validated for use in HNC patients with EFTs. It may become an important tool in evaluating treatment outcomes and complications in these patients.

Molecular grade (FGFR3/MIB-1) and EORTC risk scores are predictive in primary non-muscle-invasive bladder cancer.

BACKGROUND: The European Organization for Research and Treatment of Cancer (EORTC) risk scores are not validated in an independent patient population. Molecular grade (mG) based on fibroblast growth factor receptor 3 (FGFR3) gene mutation status and MIB-1 expression was proposed as an alternative to pathologic grade in bladder cancer (BCa) [1]. OBJECTIVE: To validate the EORTC risk score and to determine its relation to mG in a series with long-term follow-up as well as to determine reproducibility of pathologic grade and mG. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter study, we included 230 patients with primary non-muscle-invasive BCa (NMIBC). MEASUREMENTS: Four uropathologists reviewed the slides. FGFR3 mutation status was examined by two assays. MIB-1 was assessed by immunohistochemistry. The EORTC risk scores for recurrence and progression were determined. Multivariable analyses were used to find prognostic factors. RESULTS AND LIMITATIONS: Median follow-up was 8.62 yr (interquartile range: 6.6-11.8). FGFR3 mutations were significantly related to favorable disease parameters, whereas altered MIB-1 was frequently seen with pT1, high grade, and high EORTC risk scores. EORTC risk scores were significant in multivariable analyses for recurrence and progression. In multivariable analyses for progression and disease-specific survival, the mG had independent significance. The addition of mG to the multivariable model for progression increased the predictive accuracy from 74.9% to 81.7% (p<0.001; Mantel-Haenszel test). The mG (89%) was more reproducible than the pathologic grade (41-74%). CONCLUSIONS: We validated the EORTC risk scores for primary NMIBC in a clinical and biomarker setting. Next to EORTC risk score, mG proved highly reproducible and predictive. Our long-term results justify an independent prospective analysis of mG and EORTC risk scores.

Prediction of pathologic fracture risk of the femur after combined modality treatment of soft tissue sarcoma of the thigh.

BACKGROUND: The objective of the current study was to formulate a scoring system to enable decision making for prophylactic stabilization of the femur after surgical resection of a soft tissue sarcoma (STS) of the thigh. METHODS: A logistic regression model was developed using patient variables collected from a prospectively collected database. The study group included 22 patients who developed a radiation-related pathological fracture of the femur after surgery and radiotherapy for an STS of the thigh. The control group of 79 patients received similar treatment but did not sustain a fracture. No patients received chemotherapy. The mean follow-up was 8.6 years. The variables examined were age, gender, tumor size, radiation dose (low [50 grays (Gy)] vs high [> or = 60 Gy]), extent of periosteal stripping (<10 cm, 10-20 cm, and >20 cm), and thigh compartment involvement (posterior, adductor, anterior or other [ie, abductors and groin]). RESULTS: On the basis of an optimal regression model, the ability to predict radiation-associated fracture risk was 91% sensitive and 81% specific. The area under the receiver operating characteristic curve was 0.9, which supports this model as a very accurate predictor of fracture risk. CONCLUSIONS: Radiation-related fractures of the femur after combined surgery and radiotherapy for STS are uncommon, but are difficult to manage and their nonunion rate is extremely high. The results of the current study suggest that it is possible to predict radiation-associated pathological fracture risk using patient and treatment variables with high sensitivity and specificity. This would allow for the identification of high-risk patients and treatment with either close follow-up or prophylactic intramedullary nail stabilization. The presentation of this model as a nomogram will facilitate its clinical use.

Cone-beam CT assessment of interfraction and intrafraction setup error of two head-and-neck cancer thermoplastic masks.

PURPOSE: To prospectively compare setup error in standard thermoplastic masks and skin-sparing masks (SSMs) modified with low neck cutouts for head-and-neck intensity-modulated radiation therapy (IMRT) patients. METHODS AND MATERIALS: Twenty head-and-neck IMRT patients were randomized to be treated in a standard mask (SM) or SSM. Cone-beam computed tomography (CBCT) scans, acquired daily after both initial setup and any repositioning, were used for initial and residual interfraction evaluation, respectively. Weekly, post-IMRT CBCT scans were acquired for intrafraction setup evaluation. The population random (sigma) and systematic (Sigma) errors were compared for SMs and SSMs. Skin toxicity was recorded weekly by use of Radiation Therapy Oncology Group criteria. RESULTS: We evaluated 762 CBCT scans in 11 patients randomized to the SM and 9 to the SSM. Initial interfraction sigma was 1.6 mm or less or 1.1 degrees or less for SM and 2.0 mm or less and 0.8 degrees for SSM. Initial interfraction Sigma was 1.0 mm or less or 1.4 degrees or less for SM and 1.1 mm or less or 0.9 degrees or less for SSM. These errors were reduced before IMRT with CBCT image guidance with no significant differences in residual interfraction or intrafraction uncertainties between SMs and SSMs. Intrafraction sigma and Sigma were less than 1 mm and less than 1 degrees for both masks. Less severe skin reactions were observed in the cutout regions of the SSM compared with non-cutout regions. CONCLUSIONS: Interfraction and intrafraction setup error is not significantly different for SSMs and conventional masks in head-and-neck radiation therapy. Mask cutouts should be considered for these patients in an effort to reduce skin toxicity.

A cinematic magnetic resonance imaging study of milk of magnesia laxative and an antiflatulent diet to reduce intrafraction prostate motion.

PURPOSE: To determine the reduction of prostate motion during a typical radiotherapy (RT) fraction from a bowel regimen comprising an antiflatulent diet and daily milk of magnesia. METHODS AND MATERIALS: Forty-two patients with T1c-T2c prostate cancer voided the bladder and rectum before three cinematic magnetic resonance imaging scans obtained every 9 s for 9 min in a vacuum immobilization device. The MRIs were at baseline without bowel regimen (MRI-BL), before CT planning with bowel regimen (MRI-CT), and before a randomly assigned RT fraction (1-42) with bowel regimen (MRI-RT). A single observer tracked displacement of the posterior midpoint (PM) of the prostate. The primary endpoints were comparisons of the proportion of time that the PM was displaced >3 mm (PTPM3) from its initial position, and the secondary endpoints were comparisons of the reduction of initial rectal area, with and without the bowel regimen. RESULTS: The mean rectal area was: 13.5 cm(2) at MRI-BL, 12.7 cm(2) at MRI-CT, and 12.3 cm(2) at MRI-RT (MRI-BL vs. MRI-CT, p = 0.11; MRI-BL vs. MRI-CT, p = 0.07). Moving rectal gas alone (56%) and moving gas and stool (18%) caused 74% of intrafraction prostate motion. The PTPM3 was 11.3% at MRI-BL, 4.8% at MRI-CT, and 12.0% at MRI-RT (MRI-BL vs. MRI-CT, p = 0.12; MRI-BL vs. MRI-RT, p = 0.89). CONCLUSION: For subjects voiding their rectum before imaging, an antiflatulent diet and milk of magnesia laxative did not significantly reduce initial rectal area or intrafraction prostate motion.

Operator is an independent predictor of detecting prostate cancer at transrectal ultrasound guided prostate biopsy.

PURPOSE: We investigated whether interoperator differences exist in the setting of prostate cancer detection by transrectal ultrasound guided prostate biopsy. Our secondary aim was to investigate whether a learning curve exists for prostate cancer detection. MATERIALS AND METHODS: A prospective database from 2000 to 2008 including 9,072 transrectal ultrasound guided prostate biopsies at our institution was limited to 4,724 done at initial presentation. Biopsies were performed by 4 uroradiologists. The OR for detecting cancer on transrectal ultrasound guided prostate biopsy was calculated for likely independent prognostic variables, including operator. We also examined the rate of biopsy positivity in increments, comparing the first and last cohorts. The senior radiologist (AT) with the most biopsies (75%) was considered the referent for prostate cancer detection. Univariate and multivariate logistic regression modeling was used to determine significant covariates with p <0.05 deemed relevant. RESULTS: Prostate cancer was detected in 2,331 men (49.3%). Operators performed a median of 514 transrectal ultrasound guided prostate biopsies (range 187 to 3,509) with a prostate cancer detection rate of 43.8% to 52.4% (p = 0.001). Other significant covariates were prostate specific antigen, suspicious lesions on ultrasound, nodule on digital rectal examination, smaller prostate volume and increasing patient age. Operator was a significant multivariate predictor of cancer detection (OR 0.67 to 0.89, p = 0.003). No learning curve was detected and biopsy rates were consistent throughout the series. CONCLUSIONS: Significant differences in prostate cancer detection exist among operators who perform transrectal ultrasound guided prostate biopsy even in the same setting. The volume of previously performed transrectal ultrasound guided prostate biopsies does not appear to influence the positive prostate cancer detection rate, nor could a learning curve be identified. Differences in prostate cancer detection among operators are likely related to unknown differences in expertise or technique. Further research is needed.

Interobserver variability between expert urologic pathologists for extraprostatic extension and surgical margin status in radical prostatectomy specimens.

Accurate Gleason score, pathologic stage, and surgical margin (SM) information is critical for the planning of post-radical prostatectomy management in patients with prostate cancer. Although interobserver variability for Gleason score among urologic pathologists has been well documented, such data for pathologic stage and SM assessment are limited. We report the first study to address interobserver variability in a group of expert pathologists concerning extraprostatic soft tissue (EPE) and SM interpretation for radical prostatectomy specimens. A panel of 3 urologic pathologists selected 6 groups of 10 slides designated as being positive, negative, or equivocal for either EPE or SM based on unanimous agreement. Twelve expert urologic pathologists, who were blinded to the panel diagnoses, reviewed 40x whole-slide scans and provided diagnoses for EPE and SM on each slide. On the basis of panel diagnoses, as the gold standard, specificity, sensitivity, and accuracy values were high for both EPE (87.5%, 95.0%, and 91.2%) and SM (97.5%, 83.3%, and 90.4%). Overall kappa values for all 60 slides were 0.74 for SM and 0.63 for EPE. The kappa values were higher for slides with definitive gold standard EPE (kappa=0.81) and SM (kappa=0.73) diagnoses when compared with the EPE (kappa=0.29) and SM (kappa=0.62) equivocal slides. This difference was markedly pronounced for EPE. Urologic pathologists show good to excellent agreement when evaluating EPE and SM. Interobserver variability for EPE and SM interpretation was principally related to the lack of a clearly definable prostatic capsule and crush/thermal artifact along the edge of the gland, respectively.

Systematic lateral prostate biopsy--are the benefits worth the costs?

PURPOSE: We quantified the additional benefit of routinely adding 4 lateral biopsies to the initial sextant and transrectal ultrasound lesion targeted biopsy pattern in terms of cancer detection. We related this to costs. MATERIALS AND METHODS: Prospective data were accrued on 1,010 consecutive patients referred for initial transrectal ultrasound directed prostate biopsy between June 16, 2000 and September 1, 2005. Costs were estimated for the pathology and clinical departments in terms of staff time. RESULTS: Of 1,010 patients 494 (48.9%) were diagnosed with prostate adenocarcinoma. In these cases 411 cancers (83%) were found in medial samples, including 107 (22%) isolated to medial cores alone and 304 (62%) in medial and lateral cores. Only 55 patients (5.4%) had cancer isolated to systematic lateral cores. Of these cancers 30 (3%) were defined as clinically significant based on Gleason grade 7 or greater, or Gleason grade 6 involving more than 5% of any core. There was a 24% increase in biopsy related costs and a 36% increase in pathology costs associated with the 4 additional lateral biopsies. CONCLUSIONS: Medial sextant and targeted biopsy directed at transrectal ultrasound identified lesions detects 94.6% of the prostate cancer that is detected with a 10 core biopsy protocol. The latter detects an extra 3% of clinically significant prostate cancer, while increasing costs by 30%. It is important to consider the absolute benefits of systematic lateral prostate biopsy in light of this additional expense when selecting an appropriate transrectal ultrasound biopsy regimen for a patient suspected of harboring prostate cancer.

The continuing importance of transrectal ultrasound identification of prostatic lesions.

PURPOSE: In light of a recent tendency toward systematic nontargeted biopsy we reassessed whether identification and biopsy of ultrasonographically suspicious lesions contribute to the detection of prostate cancer. MATERIALS AND METHODS: We reviewed prospectively gathered data on 7,426 transrectal ultrasound directed prostatic biopsies performed at our institution between June 16, 2000 and September 1, 2005. Patients underwent systematic biopsy (6 to 10 cores on initial biopsy and 13 to 15 on rebiopsy) with additional sampling of visible suspicious lesions. The RR for finding cancer in transrectal ultrasound positive and negative patients was calculated for likely independent prognostic variables. RESULTS: A total of 3,828 biopsies (51.5%) were transrectal ultrasound negative and 3,598 (48.5%) were transrectal ultrasound positive. Prostate cancer was detected in 3,258 biopsies (43.9%). For each independent variable the RR for prostate cancer was higher if a sonographic lesion was present. A lesion increased the likelihood of cancer detection (57.8% vs 30.8%, RR 1.8). Biopsies from lesions identified by transrectal ultrasound had a greater median percent of the core involved with cancer (50% vs 10%, p <0.001) and they were more likely to have Gleason score 7 or greater (69.3% vs 28.3%, p <0.001). CONCLUSIONS: Biopsies taken when a prostatic lesion is identified by transrectal ultrasound are almost twice as likely to show cancer than when no lesion is visible. These cancers are of higher grade and volume and, therefore, they are more clinically significant. The search for and targeted biopsy of suspicious lesions seen on transrectal ultrasound remains important for prostate cancer diagnosis.

Preoperative evaluation of the "hostile pelvis" in radical prostatectomy with computed tomographic pelvimetry.

OBJECTIVE: To determine whether preoperative pelvimetry based on computed tomography (CT) can be used to predict technical difficulties during open radical prostatectomy (RP). PATIENTS AND METHODS: An open RP database accrued prospectively between January 1997 and June 2005 was used to identify 450 patients with preoperative pelvic imaging. Of these, 165 had adequate imaging of the pelvis with CT to allow pelvimetry using software provided with the medical imaging records. Several pelvic measurements were recorded in conjunction with body mass index and transrectal ultrasonographic estimates of prostatic volume. Outcome measures used to reflect technical surgical difficulties included operative duration, blood transfusion requirements within 30 days of RP, the pathological positive surgical margin and prostatic capsular breech rate. Logistic and linear regression analyses were used to determine the relationship between variables before and after RP. RESULTS: The selected pelvimetric measurements failed to predict either operative duration or the peri-operative blood transfusion requirement. Prostatic volume was predictive of operative duration; for every increase of 20 mL in prostate volume the duration increased by 8.4 min. Although pelvimetric measures failed to predict positive surgical margins at pathology, the transverse diameter predicted the likelihood of a positive margin due to capsular breech. With every 8.6 mm (1 sd) decrease in transverse diameter, the odds of a capsular breech resulting in positive surgical margins increased 5.3 times (95% confidence interval 2.1-20.0, P = 0.002). CONCLUSIONS: Although the "hostile pelvis" influences the likelihood of prostatic capsular breech resulting in positive surgical margins, CT pelvimetric screening of patients before RP is unlikely to be cost-effective. Routine pelvic CT in the evaluation of patients before RP is not supported.

A magnetic resonance imaging study of prostate deformation relative to implanted gold fiducial markers.

PURPOSE: To describe prostate deformation during radiotherapy and determine the margins required to account for prostate deformation after setup to intraprostatic fiducial markers (FM). METHODS AND MATERIALS: Twenty-five patients with T1c-T2c prostate cancer had three gold FMs implanted. The patients presented with a full bladder and empty rectum for two axial magnetic resonance imaging (MRI) scans using a gradient recalled echo (GRE) sequence capable of imaging the FMs. The MRIs were done at the time of radiotherapy (RT) planning and a randomly assigned fraction. A single observer contoured the prostate surfaces. They were entered into a finite element model and aligned using the centroid of the three FMs. RESULTS: During RT, the prostate volume decreased by 0.5%/fraction (p = 0.03) and the FMs in-migrated by 0.05 mm/fraction (p < 0.05). Prostate deformation was unrelated to differential bladder and bowel filling, but was related to a transurethral resection of the prostate (TURP) (p = 0.003). The standard deviation for systematic uncertainty of prostate surface contouring was 0.8 mm and for FM centroid localization was 0.4 mm. The standard deviation of random interfraction prostate deformation was 1.5 mm and for FM centroid variability was 1.1 mm. These uncertainties from prostate deformation can be incorporated into a margin recipe to determine the total margins required for RT. CONCLUSIONS: During RT, the prostate exhibited: volume decrease, deformation, and in-migration of FMs. Patients with TURPs were prone to prostate deformation.

The potential role of breast conservation surgery and adjuvant breast radiation for adenoid cystic carcinoma of the breast.

PURPOSE: Adenoid cystic carcinoma (ACC) of the breast is a rare breast cancer variant and optimal management is unclear. A review of this unusual tumour was performed at our Institution, to assess the role of breast conservation in the management of this disease. METHODS AND MATERIALS: A review of all cases of ACC of breast (1960-2000) treated at Princess Margaret Hospital (PMH) was undertaken. Information was collected on age at diagnosis, presenting features, tumour size and treatment modalities. Treatment outcomes were evaluated. RESULTS: Eighteen female and one male patient were identified. Median age at diagnosis was 58 years (range 35-76 years). Four patients had lymph-node positive disease at presentation; the single male patient presented with metastatic disease. Surgery was either a lumpectomy (10 cases) or a simple, radical or modified radical mastectomy (9 patients). Nine of 19 patients received adjuvant radiotherapy (RT). The median follow-up time was 14 years; the recurrence rate at 10 years was 31% (95% CI 7-54%) with a range in time of recurrence from 2.3 to 11.9 years. Seven recurrences were identified (4 local, 1 regional, 2 metastatic). Two of these patients developed metastatic spread and died. Six of the 19 cases went on to develop second malignancies of whom four died. Among the 18 female patients, the 10-year overall (OS), cause-specific (CSS), and relapse free survival (RFS) rates were 75, 100, and 46% respectively. CONCLUSIONS: ACC of the breast has a relatively prolonged natural history, and responds well to conservative management at presentation, with good outcome, even following local recurrence.

Smoking cessation in patients diagnosed with head and neck cancer.

OBJECTIVE: To determine patients' smoking status after the diagnosis and treatment of squamous cell carcinoma of the head and neck (SCCHN) and to identify factors associated with smoking cessation. DESIGN: Cross-sectional survey study conducted over a 2-year period. SETTING: Head and neck surgery clinic of an academic tertiary care hospital. METHODS: Two hundred thirteen consecutive patients diagnosed with SCCHN were interviewed to ascertain patients' smoking status and the incidence of smoking cessation. Information on demographics, tobacco and alcohol history, disease characteristics, and treatment modality was also collected. MAIN OUTCOME MEASURES: The rate of smoking cessation was evaluated, in which smoking cessation is defined as the use of no cigarettes at least 1 month prior to the interview. Possible predictors of smoking cessation were evaluated. RESULTS: One hundred twenty-five patients were found to be smoking at the time of diagnosis. Among these patients, 53.6% stopped smoking after diagnosis or during treatment. In the univariate analyses, tumour site (p = .01), concurrent alcohol use (p = .03), and number of attempts to quit pre- (p = .03) and postdiagnosis (p = .001) were found to be highly predictive of patient smoking cessation. Multivariable modelling showed that gender, tumour site, and number of attempts to quit smoking were significantly and independently related to smoking cessation. CONCLUSIONS: Although smoking cessation would be presumed to be high after cancer diagnosis, this study has identified patient subgroups in which postdiagnosis smoking cessation intervention programs need to be made more effective.

Manually respiratory-triggered single-shot fast spin-echo: a non-breath-hold T2-weighted method for liver lesion detection.

OBJECTIVES: To determine whether manual respiratory triggering of a T2-weighted single-shot fast spin-echo sequence (M-SSFSE) improves detection and characterization of liver lesions compared with conventional breath-held single-shot fast spin-echo (C-SSFSE) technique. METHODS: M-SSFSE is performed by manually triggering a series of single-slice acquisitions through the liver at end of expiration. There were 171 hepatic lesions in 49 patients. Images were randomized and reviewed by 3 radiologists. Lesions were characterized as hemangiomas, cystic or solid. Dynamic gadolinium-enhanced sequences were used as the reference standard. Contrast-to-noise ratios (CNR) were calculated for all lesions that measured 1 cm or more. RESULTS: M-SSFSE was more sensitive than C-SSFSE in the detection of liver lesions (48%-58% v. 37%-46%, p < 0.001). There were no significant differences in the specificity of lesion detection between the 2 sequences. Artifacts were significantly less severe for M-SSFSE compared with C-SSFSE (p = 0.001). The CNR was significantly higher for all liver lesions on M-SSFSE compared with C-SSFSE (p < 0.001). CONCLUSION: M-SSFSE significantly improved hepatic lesion detection and, in particular, improved characterization of solid liver lesions and hemangiomas compared with C-SSFSE imaging.

Patient education and informed consent in head and neck surgery.

OBJECTIVE: To examine the effects of an educational intervention, in the form of printed material, on patient knowledge and recall of possible risks from parotidectomy or thyroidectomy. DESIGN: Prospective, randomized, controlled study conducted during a 9-month period. SETTING: Head and neck surgery clinic of an academic tertiary care hospital. PATIENTS: One hundred twenty-five consecutive patients older than 16 years who were undergoing thyroidectomy or parotidectomy at the head and neck surgery clinic were recruited. Four patients were excluded from analysis because their follow-up interview was not within the required limits. INTERVENTION: At the preoperative visit during the routine consent process, both groups received a verbally delivered checklist of risks specific for the surgery to be performed. The intervention group was also given a pamphlet with written information accompanied by illustrations. MAIN OUTCOME MEASURES: The effectiveness of the educational intervention was determined by comparing the average rate of risk recall between the intervention and control groups. The effects of age, sex, level of education, and time between the consent and recall interviews on recall rate were also assessed. RESULTS: The overall risk recall rate for both procedures was 39.1%. The recall rate of the intervention group was 50.3% compared with 29.5% for the control group (P<.001). CONCLUSIONS: The intervention consistently improved risk recall for all patients regardless of age, sex, and level of education. Patients' ability to recall potential risks was significantly increased by an educational intervention; all patients would benefit from this intervention.

Multi-detector row helical CT in preoperative assessment of small (< or = 1.5 cm) liver metastases: is thinner collimation better?

PURPOSE: To determine the value of collimations less than 5 mm in detecting hepatic metastases 1.5 cm or smaller by using multi-detector row helical computed tomography (CT). MATERIALS AND METHODS: Thirty-one patients underwent contrast material-enhanced multi-detector row helical CT before hepatic resection in this prospective study. Images were reconstructed at collimations of 5.00, 3.75, and 2.50 mm with 50% overlap and reviewed independently by three radiologists. Each lesion was characterized as metastatic, benign, or equivocal and graded for conspicuity. Criterion standards were pathologic assessment of the resected liver and follow-up of the nonresected liver. Only lesions 1.5 cm or smaller were analyzed. RESULTS: There were a total of 88 liver lesions 1.5 cm or smaller, and 25 of these were metastases. Pooled sensitivity for all lesions improved with thinner collimation (66% [58 of 88 lesions], 69% [61 of 88], and 82% [72 of 88] at collimations of 5.00, 3.75, and 2.50 mm, respectively), and this was statistically significant (P =.01). However, no significant difference was noted between collimations in the pooled sensitivity for metastatic lesions (80% [20 of 25 lesions] at all collimations) (P >.99). No statistical difference was noted in the conspicuity of lesions at different collimations (P =.18). CONCLUSION: Image reconstruction with multi-detector row helical CT at collimations less than 5 mm may not improve sensitivity in the detection of hepatic metastases 1.5 cm or smaller.