The role of PET/CT amyloid Imaging compared with Tc99m-HMPAO SPECT imaging for diagnosing Alzheimer's disease.

BACKGROUND: Imaging such as Tc99m-HMPAO single photon emission computed tomography (SPECT), and positron emission tomography/ computed tomography (PET/CT) amyloid scans are used to aid the diagnosis of Alzheimer's disease (AD). OBJECTIVE: We aimed to correlate the ability of these modalities to differentiate Probable AD and Possible AD using the clinical diagnosis as a gold standard. We also investigated the correlation of severity of amyloid deposit in the brain with the diagnosis of AD. METHODS: A retrospective study of 47 subjects (17 Probable AD and 30 Possible AD) who were referred for PET/CT amyloid scans to our centre was conducted. Hypoperfusion in the temporo-parietal lobes on Tc99m-HMPAO SPECT and loss of grey-white matter contrast in cortical regions on PET/CT Amyloid scans indicating the presence of amyloid ß deposit were qualitatively interpreted as positive for AD. SPECT and PET/CT were also read in combination (Combo reading). The severity of amyloid ß deposit was semiquantitatively assessed in a visual binary method using a scale of Grade 0-4. The severity of amyloid ß deposit was assessed in a visual binary method and a semi-quantitative method using a scale of Grade 0-4. RESULTS: There was significant correlation of Tc99m-HMPAO SPECT, PET/CT amyloid findings and Combo reading with AD. The sensitivity, specificity, PPV and NPV were 87.5%, 73.7%, 58.3% and 93.3% (SPECT); 62.5%, 77.4%, 58.8% and 80.0% (PET/CT) and 87.5%, 84.2%, 70.0% and 30.0% (Combo reading) respectively. The grade of amyloid deposition was not significantly correlated with AD (Spearman's correlation, p=0.687). CONCLUSION: There is an incremental benefit in utilizing PET/CT amyloid imaging in cases with atypical presentation and indeterminate findings on conventional imaging of Alzheimer's disease.

Recurrence of vulval intraepithelial neoplasia following treatment with cidofovir or imiquimod: results from a multicentre, randomised, phase II trial (RT3VIN).

OBJECTIVE: To compare the recurrence rates after complete response to topical treatment with either cidofovir or imiquimod for vulval intraepithelial neoplasia (VIN) 3. DESIGN: A prospective, open, randomised multicentre trial. SETTING: 32 general hospitals located in Wales and England. POPULATION OR SAMPLE: 180 patients were randomised consecutively between 21 October 2009 and 11 January 2013, 89 to cidofoovir (of whom 41 completely responded to treatment) and 91 to imiquimod (of whom 42 completely responded to treatment). METHODS: After 24 weeks of treatment, complete responders were followed up at 6-monthly intervals for 24 months. At each visit, the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was assessed and any new lesions were biopsied for histology. MAIN OUTCOME MEASURES: Time to histologically confirmed disease recurrence (any grade of VIN). RESULTS: The median length of follow up was 18.4 months. At 18 months, more participants were VIN-free in the cidofovir arm: 94% (95% CI 78.2-98.5) versus 71.6% (95% CI 52.0-84.3) [univariable hazard ratio (HR) 3.46, 95% CI 0.95-12.60, P = 0.059; multivariable HR 3.53, 95% CI 0.96-12.98, P = 0.057). The number of grade 2+ events was similar between treatment arms (imiquimod: 24/42 (57%) versus cidofovir: 27/41 (66%), χ2 = 0.665, P = 0.415), with no grade 4+. CONCLUSIONS: Long-term data indicates a trend towards response being maintained for longer following treatment with cidofovir than with imiquimod, with similar low rates of adverse events for each drug. Adverse event rates indicated acceptable safety of both drugs TWEETABLE ABSTRACT: Long-term follow up in the RT3VIN trial suggests cidofovir may maintain response for longer than imiquimod.

18F-FDG PET/CT as a potential predictor of survival in patient with oesophageal cancer: a preliminary result.

AIMS: A study was undertaken to investigate the value of pretreatment PET-CT in predicting survival in patients with oesophageal cancer (OC). METHODS: Between June 2010 and December 2011, 18 consecutive OC patients median (61.00 ± 12.07 years) with median survival of 7.5 month had a pretreatment PET-CT scan. Staging of the disease was made in accordance to the American Joint Committee on Cancer staging system (7th edition) and grouped as stage I-IIA and stage IIB-IV. Maximum standardized uptake value (SUVmax), size of a primary tumour and the presence of fluorodeoxyglucose (FDG)-avid lymph nodes were evaluated for all patients. Survival was analysed using the Kaplan-Meier product limit method and Cox proportional hazards regression model. RESULTS: PET-CT stages I-IIA and IIB-IV had a 1-year survival of 50% and 25%, respectively. Patient with size of primary tumour (<4.5 cm) had significantly (p < 0.036) better survival than those with large size (>4.5 cm). Multivariate Cox regression analysis showed that SUVmax of >5.5 in the primary tumour [hazard ratio (HR) 23.017; 95% confidence interval, p = 0.038] and the presence of FDG-avid lymph node (HR 1.248; p = 0.028) were strongly predictive of poor overall survival on multivariate analysis. CONCLUSION: Pretreatment 18F-FDG PET-CT SUVmax of a primary tumour and the presence of FDG-avid lymph nodes independently predict survival in patients with oesophageal carcinoma which may potentially be used as surrogate markers for prognostic and therapeutic purposes.

Localization and prediction of malignant potential in recurrent pheochromocytoma/paraganglioma (PCC/PGL) using 18F-FDG PET/CT.

BACKGROUND: To our knowledge, data are lacking on the role of 18F-FDG PET/CT in the localization and prediction of neuroendocrine tumors, in particular the pheochromocytoma/paraganglioma (PCC/PGL) group. PURPOSE: To evaluate the role of 18F-FDG PET/CT in localizing and predicting the malignant potential of PCC/PGL. MATERIAL AND METHODS: Twenty-three consecutive patients with a history of PCC/PGL, presenting with symptoms related to catecholamine excess, underwent 18F-FDG PET/CT. Final confirmation of the diagnosis was made using the composite references. PET/CT findings were analyzed on a per-lesion basis and a per-patient basis. Tumor SUVmax was analyzed to predict the dichotomization of patient endpoints for the local disease and metastatic groups. RESULTS: We investigated 23 patients (10 men, 13 women) with a mean age of 46.43 ± 3.70 years. Serum catecholamine levels were elevated in 82.60% of these patients. There were 136 sites (mean SUVmax: 16.39 ± 3.47) of validated disease recurrence. The overall sensitivities for diagnostic CT, FDG PET, and FDG PET/CT were 86.02%, 87.50%, and 98.59%, respectively. Based on the composite references, 39.10% of patients had local disease. There were significant differences in the SUVmax distribution between the local disease and metastatic groups; a significant correlation was noted when a SUVmax cut-off was set at 9.2 (P<0.05). CONCLUSION: In recurrent PCC/PGL, diagnostic 18F-FDG PET/CT is a superior tool in the localization of recurrent tumors. Tumor SUVmax is a potentially useful predictor of malignant tumor potential.

18[F]FDG-PET/CT is a useful molecular marker in evaluating tumour aggressiveness: a revised understanding of an in-vivo FDG-PET imaging that alludes the alteration of cancer biology.

Molecular imaging employing (18)[F]FDG-PET/CT enables in-vivo visualization, characterisation and measurement of biological process in tumour at the molecular and cellular level. In oncology, this approach can be directly applied as translational biomarkers of disease progression. In this article, the improved roles of FDG as an in-vivo glycolytic marker which reflect biological changes across in-vitro cellular environment are discussed. New understanding in how altered metabolism via glycolytic downstream drivers of malignant transformation as reviewed below offers unique promise as to monitor tumour aggressiveness and hence optimize the therapeutic management.

Improving patient care with shorter hospital admissions.

Prolonged hospital admissions frequently overshadow the experience of gynaecological cancer patients. In East Kent, we identified obstacles in the inpatient journey through the hospital by performing a patient pathway mapping audit of admissions in May/June 2006 and 2007. We achieved substantial reductions in the length of stay for major gynaecological oncology surgery. The number of the lead consultant's patients with a total duration of admission of no more than 5 days increased from one of 28 in Q1 2006 (3.6%), to 17 of 28 (60.7%) in Q4 2007. Identified problems prolonging the length of stay included admission the day before surgery, prolonged use of i.v. antibiotics and late referrals to social services. Early discharge planning involving staff and patients as active participants has the greatest impact on reduction of duration of hospital admission. A reduction in duration of hospital admissions is associated with an increase in the rate of readmissions.

Cervical cancer in women aged less than 25: East Kent experience.

The National Health Service Cervical Screening Programme (NHSCSP) guidelines raised the initiation of screening age from 20 to 25 years of age in 2004, on the basis that only 1.3% of cervical cancers occur in this age group. Between 2003 and 2005, cervical cancer was diagnosed in six women under 25 years in East Kent, 6.25% of 96 cervical cancers cases. All except one patient in our series presented with a cervical smear abnormality. High-grade cervical smear abnormalities were identified and treated in 187 women under 25 years during this period. Adoption of the guidelines may increase the incidence of invasive disease in young women, the stage at diagnosis and radicality of treatment required.

Mode of detection of recurrent gynecological malignancy: Does routine follow-up delay diagnosis and treatment?

To investigate value of routine scheduled follow-up in detecting recurrent gynecological cancer, the National Group of Gynaecology NSSG Leads conducted a national prospective audit of the mode of detection of disease recurrence under the auspices of the Department of Health Cancer Services Collaborative. Two hundred fourteen responses were received from 16 of 34 cancer networks in England in addition to one center from Wales between August 2004 and October 2005. Only 42.5% of disease recurrences was detected at routine follow-up. Only 26.2% was diagnosed during an unscheduled (expedited) clinic appointment, while 19.2% was diagnosed by another professional group and 12.1% by "other" means (routine Ca125 or imaging). Only 77.1% of patients had symptoms at the time of detection of recurrent disease. Sixty-one patients (28.5%) complained of symptoms when they attended for routine scheduled follow-up. This data suggest that if these patients had recognized the significance of these symptoms and requested early clinic review, the diagnosis may have been expedited. Diagnosis of recurrence may be delayed for a significant proportion of women because they await a routine scheduled follow-up clinic attendance to report the development of symptoms. Patient-initiated follow-up may provide a more reactive and flexible model of care that encourages women to present as soon as symptoms are experienced. This model will be assessed in the UK in a large, multicenter, randomized controlled trial, Follow-up in Gynaecological cancer Units: Randomised controlled trial for Endometrium (FIGURE trial).

Inguinal lymph node metastasis: an unusual presentation of fallopian tube carcinoma.

OBJECTIVES: Inguinal metastasis is a hitherto unreported presenting feature of fallopian tube adenocarcinoma. CASE: We describe a case of a 69-year-old patient whose first manifestation of fallopian tube adenocarcinoma was an enlarged inguinal lymph node. This was excised and confirmed to be metastatic adenocarcinoma. She was investigated by diagnostic laparoscopy and subsequently underwent laparotomy with total abdominal hysterectomy, omentectomy, and pelvic and para-aortic lymph node dissection. All but two of the lymph nodes extirpated were negative. CONCLUSIONS: Fallopian tube adenocarcinoma may rarely present with metastatic inguinal lymphadenopathy.

The role of surgery in invasive squamous carcinoma of the vagina.

OBJECTIVE: The aim of this study was to define the role of surgery in managing patients with a primary squamous vaginal cancer. METHODS: A retrospective review was conducted of patients with primary invasive vaginal cancer managed at one institution over a 25-year period. The results were compared with those of all major publications of the past 20 years. RESULTS: A total of 84 patients were reviewed. Forty-five (66%) were of squamous origin. The median follow-up was 45 months (range: 0.6-268). The patients were primarily treated by surgery in 67% and by radiotherapy alone in 33% of cases. The 5- and 10-year overall survival was, respectively, 74 and 58%. For stage I the figures were 91 and 70%. These survival rates compared favorably with those of published series of cases managed by radiotherapy alone. Univariate analysis showed that age (P = 0.004), size (P = 0.009), site (P = 0.016), lymph node status (P = 0.022), FIGO stage (P = 0.027), and treatment (P = 0.003) were relevant prognostic factors. Multiple regression analysis, however, revealed that only age (P = 0.009) and size (P = 0.037) were independent prognostic variables. CONCLUSIONS: Stage I and II squamous vaginal cancer patients have good outcomes in terms of survival and local tumor control if they are managed by initial surgery followed by selective radiotherapy.

Do elderly cancer patients care about cure? Attitudes to radical gynecologic oncology surgery in the elderly.

OBJECTIVE: The aim of this study was to address the hypothesis of no difference between elderly and younger patients' desire for optimal surgery and disease cure. METHODS: The new ARGOSE questionnaire with established instruments was administered to 189 gynecologic cancer patients (95 aged <65, 57 aged 65-74, and 37 aged 75+ years). RESULTS: Disease diagnosis differed between the <65 years and 65+ years cohorts (P < 0.001), but treatment modalities were similar (P = 0.28). Influences of family and friends and past experiences of cancer had little influence on treatment decisions. There was no difference between cohorts in desire for surgery offering a chance of disease cure (P = 0.75), except that the elderly desire cure more if treatment is associated with disfigurement than do the young. (P = 0.029). The elderly believe more strongly than the young that the elderly value cure (P < 0.001). Issues of sexuality and femininity associated with gynecologic cancer and treatment are more important to younger patients (P < 0.001). The elderly support equality of care with relation to age more strongly than the young. However, in a situation of resource limitation, inequality favoring the young is opposed less strongly by the elderly than by the young. Social desirability bias may have influenced this finding. All cohorts reported symptom palliation to be of secondary importance to treatments offering a possibility of cure (P = 0.26). The elderly believe more strongly that doctors should make management decisions (P < 0.001). CONCLUSION: The elderly desire radical surgery and disease cure as strongly as the young. They are less likely to question their doctors' decisions and are therefore vulnerable to physicians' age bias. There is no justification for rationing care on the basis of chronological age.

Dual phase 99m-technetium Sestamibi imaging with single photon emission computed tomography in primary hyperparathyroidism: influence on surgery.

The purposes of this study were to determine the positive and negative predictive values of 99m Technetium (99mTc) Sestamibi dual phase imaging with single photon emission computed tomography (SPECT) for parathyroid adenomata or hyperplasia and the effect of preoperative localization on duration of surgery. We reviewed 33 adults (14 men, 19 women; mean age 53 years) with newly diagnosed primary hyperparathyroidism who underwent neck exploration. The duration of surgery for this cohort was compared with a group of historical controls (n = 53) who underwent surgery without preoperative SPECT. At surgery, there were 21 adenomata (including one carcinoma), 10 patients with hyperplasia and two with no pathology detected. The positive predictive values (PPV) for adenomata and hyperplasia were 95% and 100%, respectively. The negative predictive values (NPV) for these entities were 67% and 22%, respectively. The mean weight of adenomata detected was 3.4 g (range 0.2-17 g). Mean duration of surgery was 112.6 min as compared with 113 min in the historical controls (P = not significant). We conclude that 99mTc Sestamibi dual phase imaging with SPECT has an excellent PPV for parathyroid adenomata and hyperplasia, but does not contribute to reduced duration of surgery in patients undergoing neck exploration for the first time. The NPV is low, suggesting that a negative result does not exclude an adenoma or hyperplasia.

Attitudes to radical gynecological oncology surgery in the elderly: a pilot study.

Does age-related inequality of cancer care reflect patient preference or physician prejudice? We hypothesize no difference between elderly and younger patients' desire for optimal surgery and disease cure, and psychological adaptation to cancer. A newly developed questionnaire to assess attitudes to radical gynecological surgery in the elderly (ARGOSE) and a battery of established instruments were administered to 54 gynecological cancer patients (32 aged 65 + years; and 22 aged < 65 years) by structured interview. Disease diagnosis differed between cohorts (P = 0.007), but treatment modalities were similar (P = 0.46). There was no difference between cohorts in desire for optimal surgery and disease cure. Trends suggest the young consider a patient's age is less important than do the elderly, but the elderly may oppose age-related economic rationing of treatment more than the young. Furthermore, elderly individuals tend to perceive their seniors too elderly for treatment, but not themselves. The elderly believe more strongly that doctors should make management decisions. Perceptions of change in body image after cancer treatment did not differ between cohorts. The influence of age in determining attitudes is complex. A larger study with increased power is indicated to examine trends revealed in this pilot study.

Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock.

OBJECTIVE: To evaluate the effects of dobutamine on peripheral and hepatic tissue oxygen tensions during the treatment of haemorrhagic shock. DESIGN: Randomised, controlled trial. SETTING: University hospital, Finland. SUBJECTS: 12 Piglets, weight 20 kg. INTERVENTIONS: Haemorrhagic shock (40% of blood volume removed) and resuscitation with crystalloid solution. Dobutamine infused (6.5 micrograms/kg/min) during resuscitation in 6 animals and 6 served as controls. MAIN OUTCOME MEASURES: Haemodynamic and systemic oxygen transport variables. Hepatic, subcutaneous, transcutaneous, and conjunctival oxygen tensions measured continuously with polarographic electrodes. RESULTS: All values decreased significantly during bleeding. Resuscitation restored the mean arterial pressure in both groups, and cardiac output exceeded the baseline by 24% in the dobutamine group (p < 0.05 compared with control). There was no difference in oxygen delivery and consequently tissue oxygen tensions remained at the control level in the dobutamine group. CONCLUSIONS: Dobutamine infusion did not improve tissue oxygenation when used in addition to crystalloids to treat hypovolaemic shock.

Primary carcinoma of the fallopian tube: a 20-year literature review.

Case series and important case reports of primary fallopian tube carcinoma published in the English literature from 1973 to 1992 are reviewed. Meta-analysis revealed a mean age of presentation of 56.7 years, with a nulliparity rate of 27.5 per cent and a mean parity of 1.7. Abnormal vaginal bleeding and discharge, and pelvic pain are the most common presenting symptoms. Despite developments in cytology, transvaginal ultrasound, and tumor markers, most cases remain undiagnosed preoperatively. In addition to direct intraperitoneal spread, early lymphatic spread is now recognized as a frequent cause of treatment failure. FIGO has recently released a staging classification for fallopian tube malignancy incorporating detailed surgical staging, which should allow uniformity and comparison between future series. Treatment regimes are empirically based on therapy for epithelial ovarian malignancy, but none have been subjected to controlled trials. Recent case series support extensive debulking surgery and adjuvant platinum-based combination chemotherapy for optimizing prognosis, although results from radiotherapy and hormonal therapy are largely disappointing. Promise is expressed in tumor markers and "second-look" laparotomy for monitoring disease response and planning management.

A prospective study of postpartum candy gift net weight: correlation with birth weight.

This study assesses the widely held but previously untested hypothesis that the net weight of postpartum candy gifts from parents to delivery suite and postnatal ward staff is proportional to their neonates' birth weight. Midwives at Musgrove Park Hospital in Taunton, Somerset, United Kingdom were requested to record the details of all candy gifts received over a 6-month period in 1992. Only 39 candy gifts from 1491 deliveries were documented, with a mean net weight of 416 g. The coefficient of correlation between candy weight and birth weight was 0.1477 (P = .2). The basis for the association is multifactorial. Socioeconomic and prematurity-related factors were responsible for poor candy giving following low birth weight deliveries. In contrast, factors related to the etiology and psychology of obesity and diabetes were implicated in generous candy giving by the high birth weight population.