The impact of endoscopic ultrasound-guided fine-needle aspiration of lymph nodes on subsequent positron emission tomography/computed tomography imaging: a prospective study.

BACKGROUND: Modern cancer diagnostic work-up is based on multiple modalities within a short time period. The interplay between these modalities is complex and not well known. Performing biopsy procedures prior to (18)F-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) is considered to pose a risk of false-positive imaging results; however, this is not based on solid scientific evidence. The use of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used in upper gastrointestinal malignancies, is proven safe, and has very little risk of complications. This study aimed to assess whether EUS-FNA induces inflammation that would increase FDG uptake on subsequent PET/CT. METHODS: 27 patients who were referred for upper gastrointestinal EUS for different reasons initially underwent FDG-PET/CT to detect biopsy-eligible lymph nodes with no FDG uptake. Patients then underwent EUS-FNA of the benign lymph nodes, with a minimum of three passes. Patients were re-evaluated with FDG-PET/CT 1 week later, with specific emphasis on the biopsied lymph nodes. RESULTS: None of the biopsied lymph nodes showed increased FDG uptake on follow-up FDG-PET/CT. No adverse events occurred. CONCLUSION: EUS-FNA prior to FDG-PET/CT did not lead to false-positive FDG uptake. The interpretive impact of minor procedures prior to FDG-PET/CT needs to be re-evaluated.

[Hepatocellular adenoma as a cause of liver rupture and intrauterine foetal death].

During pregnancy, hepatocellular adenoma HCA may grow, which increases the risk of rupture. In this case report, a 34-year-old woman at gestational age 34+ weeks was admitted to hospital with abdominal pain, hypovolaemia and intrauterine foetal death from a ruptured hepatocellular adenoma. It was successfully managed with trans-arterial embolisation and caesarean section, followed by laparoscopic liver resection four weeks later. Spontaneous liver rupture during pregnancy is associated with an increased risk of maternal and foetal mortality, and appropriate interventional radiology and surgical measures are essential for successful treatment.

Personalized Clinical Decision Making in Gastrointestinal Malignancies: The Role of PET.

Gastrointestinal malignancies comprise a heterogeneous group of diseases that include both common and rare diseases with very different presentations and prognoses. The mainstay of treatment is surgery in combination with preoperative and adjuvant chemotherapy depending on clinical presentation and initial stages. This article outlines the potential use of fluorodeoxyglucose-PET/CT in clinical decision making with special regard to preoperative evaluation and response assessment in gastric cancer (including the gastroesophageal junction), pancreatic cancer (excluding neuroendocrine tumors), colorectal cancer, and gastrointestinal stromal tumors.

Laparoscopic appendectomy during pregnancy is safe for both the mother and the fetus.

INTRODUCTION: The diagnosis and treatment of acute appendicitis during pregnancy is still debated. While laparoscopic appendectomy in general has become the gold standard, this procedure has not generally been implemented for pregnant women. METHODS: We retrospectively reviewed the patient charts of all patients who underwent appendectomy during pregnancy in the period from 2000 to 2012. Open appendectomy (OA) was performed in 25 cases and laparoscopic (LA) in 19. RESULTS: We observed a significantly longer operation time (69 versus 49 min., p = 0.002), but fewer complications, a shorter hospital stay (2.6 versus 5.5 days, p = 0.004) and a lower rate of negative appendectomies (16% versus 52%, p = 0.02) in the LA group compared with the OA group. The mean gestation age at appendectomy was significantly lower in the LA group. There were no significant differences in gestational age at birth, Apgar score, birth weight or height between the two groups. Five births (11%) were categorised as mildly to moderately preterm. There were no cases of fetal loss. CONCLUSION: Laparoscopic appendectomy is safe for both the mother and the fetus during pregnancy irrespective of gestational age, and the procedure is associated with a low risk of post-operative complications. FUNDING: none. TRIAL REGISTRATION: not relevant.

Secondary oesophageal or gastric cancer in patients treated for head and neck squamous cell carcinoma.

INTRODUCTION: Patients with head and neck squamous cell carcinoma (HNSCC) are at an elevated risk of developing second primary malignancies (SPM). Our objectives were to estimate the excess risk of oesophageal and gastric SPMs in patients with malignancies of the pharynx or larynx and, additionally, to examine possible risk factors of developing SPMs. METHODS: Data on all patients treated for HNSCC with curative intent in the Region of Southern Denmark in the period between 1 January 2000 and 31 December 2010 were reviewed. A total of 1,172 patients were identified. The combined data from the DAHANCA database, the Danish National Pathology Registry and the patient charts were analysed. RESULTS: A total of 27 patients developed an SPM in the oesophagus or stomach corresponding to a standardised incidence ratio of 9.5 (95% confidence interval (CI): 6.5-13.9). Supraglottic (odds ratio (OR) = 6.9; p < 0.004) and hypopharyngeal (OR = 3.9; p < 0.049) index tumour sites were significant risk factors for developing SPM. The median survival of patients with SPM was 3.6 years (95% CI: 1.6-5.1; range: 0.7-12.4) from diagnosis of the index cancer compared with 3.4 years (95% CI: 3.1-4.3; range: 0.04-13.7) for patients without SPM. CONCLUSION: In this study, we confirm that there is an elevated risk of developing oesophageal and gastric cancer in the Danish population of patients with a cancer in the supraglottic or hypopharyngeal region. Therefore, we recommend close follow-up of these patients and a low threshold for examination of the oesophagus and stomach. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Perivascular epithelioid cell tumours in the liver]. / Perivaskulær epiteloidcelletumor i leveren

The PEComa family is a group of tumours having perivascular epithelioid cells (PEC) as the predominating component. PEComas occur in various organs and are considered to be benign tumours. However, rare cases showing pleomorphic morphology, atypical mitoses or necrosis should be considered malignant sarcomas. The precise incidence is unknown but PEComas are reported with increasing frequency. Standard treatment is surgery but there are no guidelines on further follow-up or treatment. PEComa in the liver is a rare tumour, and to our knowledge this is the first published case from Denmark.

Telephone hotline is an important part of overall patient management in upper gastrointestinal malignancies.

INTRODUCTION: As seven out of every ten patients with upper gastrointestinal malignancies (UGIM) are not eligible for curative treatment, life after diagnosis is characterised by a rapid deterioration and uncertainty. To accommodate these issues, we established a telephone hotline. MATERIAL AND METHODS: In a two-year period, all patients evaluated for UGIM were given the hotline phone number. The hotline was staffed by either a nurse or a secretary, and subsequently the specialist in charge of the patient would return the call. All calls were registered in a prospective database. The following data were recorded: diagnosis, time from call to return call, problem and solution to the problem. RESULTS: A total of 477 patients were included, and 172 (36%) patients used the Hotline a total of 254 times. Of the 254 calls, 210 (83%) were returned the same day. A total of 104 (41%) calls were made due to elaborative questions and 89% of these were solved over the phone. Dysphagia was the problem in 51 cases which gave rise to an endoscopy in 86% of cases. Pain was the problem in 35. Overall, of the 254 calls, 152 (60%) problems were solved over the phone. Furthermore, 75 calls triggered a hospital visit and 27 calls led to the patient being referred for further examinations. CONCLUSION: The establishment of a telephone hotline was feasible and it was used by some patients. Most of the callers only made one call. Nearly all calls (96%) were returned the day after the initial call, at the latest. The problem pattern did not differ between disease groups apart from dysphagia in oesophageal cancer. We found that the hotline was an effective and inexpensive part of overall patient management. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

Acceptable results after self-expanding metallic stent treatment for dysphagia in non-resectable oesophageal cancer.

INTRODUCTION: Dysphagia is the most common symptom of malignant obstruction in the oesophagus and at the gastro-oesophageal junction (GEJ) region, and the relief of dysphagia plays a major role in palliative treatment of this condition. The aim of the present study was to evaluate the need for and nature of re-intervention after self-expanding metallic stents (SEMS) insertion in patients who were palliated for cancer of the oesophagus or GEJ. MATERIAL AND METHODS: At a third-level referral centre in Denmark, all SEMS procedures were prospectively registered for SEMS characteristics and procedural events and data regarding re-interventions and survival were retrieved retrospectively in a six-year inclusion period. RESULTS: A total of 108 stents were inserted into 87 patients (63 males and 23 females) with a median age of 71 years (range: 41-94 years). The primary SEMS used was Ultraflex in 77, Cook or Choo in seven and Wallstent in three cases. All but one SEMS were successfully placed, and no perforations occurred. Fifty patients had their dysphagia scores recorded. The average score before and after stent insertion was 2.4 and 0.8, respectively, (p < 0.01). Two-thirds of the patients needed late re-interventions. The most common problem was tissue/tumour ingrowth (n = 40). Seven patients (8%) experienced stent migration. The average re-intervention rate was 2.8 per patient. The median survival after SEMS was 116 days (range 2-866 days). The median time to first re-intervention was 44 days. CONCLUSION: SEMS treatment was a safe and effective palliation of malignant obstruction in the oesophagus and GEJ region, but the procedure was associated with a frequent need for re-interventions.

[The umbilical cord of newborn babies should be clamped at least five centimetres from the abdominal wall]. / Nyfødte bør afnavles mindst fem centimeter fra navlen.

A three day-old boy was brought to a department of paediatric surgery with mechanical ileus under suspicion of morbus Hirschsprung. Early into surgery it was found that the cause of ileus was an iatrogenic clamping of a small unrecognized omphalocele. In view of recent literature there is not found any evidence of advantage of near skin clamping of the umbilical cord. It is therefore recommended that the clamping of the umbilical cord is done at least five centimetres from the abdominal wall. If the umbilical cord is broad-based it is also recommended to clamp at a safe distance from the basis.

[Endovascular treatment of ruptured splenic artery aneurysm]. / Endovaskulaert behandlet rumperet aneurisme på arteria lienalis.

Splenic artery aneurysms (SAA) are traditionally treated surgically, but endovascular techniques are becoming increasingly popular. A 64 year-old male with chest pain and low blood pressure was admitted under suspicion of AMI. A CT scan showed a 56 mm SAA with signs of rupture. The patient was treated with endovascular embolisation of the SAA with coils. Blood pressure and haemoglobin levels were stabilized and the patient was discharged. In the case of rupture the treatment of choice seems to be endovascular.