The value of ultrasound-guided biopsy of fluorodeoxy-glucose positron emission tomography (FDG-PET)-positive supraclavicular lymph nodes in patients with suspected lung cancer.

BACKGROUND: Accurate lymph node staging is essential for adequate prognostication and therapy planning in patients with non-small cell lung cancer (NSCLC). FDG-PET/CT is a sensitive tool for the detection of metastases, including non-palpable supraclavicular lymph node (SCLN) metastases. Histological proof of metastatic spread and mutation analysis is crucial for optimal staging and therapy. The aim of this study was to investigate the value of ultrasound-guided fine needle aspiration cytology (FNAC) and core biopsy (CB) of FDG active, non-palpable SCLN's in patients with suspicion for lung cancer. METHODS: Twelve consecutive patients with suspected lung cancer and FDG-positive SCLN underwent FNAC (n = 11) and/or CB (n = 10) and were included and evaluated retrospectively in this study. Cytologic and/or histologic evaluation was performed to confirm initially suspected diagnosis (lung cancer), to confirm N3 stage, and to screen for driver mutations in lung adenocarcinoma. RESULTS: FNAC alone showed diagnostic success in 11/11 cases (100%), CB alone in 9/10 patients (90%), and the combination of both procedures was successful in 12/12 cases (100%). Lymph node metastases from NSCLC (7 adenocarcinoma, 2 squamous cell carcinoma) could be confirmed in 9 patients. Other diagnoses were small cell lung cancer (SCLC), breast cancer and sarcoidosis. There was enough material for immunhistochemistry in all patients. For molecular testing, material from this lymph node biopsies and lung biopsy was used. In two patients with adenocarcinoma of the lung driver mutations were detected (EGFR Exon 19 deletion and ALK rearrangement) out of the lymph node metastasis. CONCLUSIONS: US-guided combined FNAC and CB of FDG positive supraclavicular lymph nodes in patients with suspected lung cancer is a safe and effective procedure to confirm N3-stage and to obtain representative material for molecular testing.

Ultrasound-guided carotid sheath block for carotid endarterectomy: a case series of the spread of injectate.

INTRODUCTION: We aimed to show the spread of local anesthetic following an ultrasound-guided, double-injection technique of a carotid sheath block before carotid endarterectomy. METHODS: The study included 15 patients scheduled for elective carotid endarterectomy. The carotid sheath block was performed after ultrasound-guided localization of the carotid bifurcation (level C4-C6) at the posterior border of the sternocleidomastoid muscle. A mix of 7.5 mL ropivacaine 0.75%, 7.5 mL prilocaine1% and 3 mL iopromidum was injected at the base of the carotid bifurcation. An additional 15 mL of the mixture was administered subcutaneously at the surgical incision line. Thirty minutes after the block, a computed tomography scan of the head, neck region and upper thorax was performed to reconstruct a 3-D distribution of the injectate. RESULTS: All patients achieved C2-C4 dermatomal sensory blockade. None required conversion to general anesthesia. The injectate spread ranged from the vertebral body of C1 to the vertebral body of T3. The mean volume of distribution was 97±13 mL, the craniocaudal spread 138±19 mm, dorsoventral 57±8 mm and coronal 53±8 mm. The mean carotid artery circumference contact was 252°±77, with four patients (27%) presenting with a ring formation (360°) around the carotid artery. CONCLUSIONS: Ultrasound-guided carotid sheath block provided an extensive spread of local anesthetic. A complete ring formation of local anesthetic around the artery does not seem necessary for a successful anesthesia. The resulting nerve blockade thus appears sufficient for surgery, with minor risks compared to blind methods.

Imaging non-specific wrist pain: interobserver agreement and diagnostic accuracy of SPECT/CT, MRI, CT, bone scan and plain radiographs.

PURPOSE: Chronic hand and wrist pain is a common clinical issue for orthopaedic surgeons and rheumatologists. The purpose of this study was 1. To analyze the interobserver agreement of SPECT/CT, MRI, CT, bone scan and plain radiographs in patients with non-specific pain of the hand and wrist, and 2. to assess the diagnostic accuracy of these imaging methods in this selected patient population. MATERIALS AND METHODS: Thirty-two consecutive patients with non-specific pain of the hand or wrist were evaluated retrospectively. All patients had been imaged by plain radiographs, planar early-phase imaging (bone scan), late-phase imaging (SPECT/CT including bone scan and CT), and MRI. Two experienced and two inexperienced readers analyzed the images with a standardized read-out protocol. Reading criteria were lesion detection and localisation, type and etiology of the underlying pathology. Diagnostic accuracy and interobserver agreement were determined for all readers and imaging modalities. RESULTS: The most accurate modality for experienced readers was SPECT/CT (accuracy 77%), followed by MRI (56%). The best performing, though little accurate modality for inexperienced readers was also SPECT/CT (44%), followed by MRI and bone scan (38% each). The interobserver agreement of experienced readers was generally high in SPECT/CT concerning lesion detection (kappa 0.93, MRI 0.72), localisation (kappa 0.91, MRI 0.75) and etiology (kappa 0.85, MRI 0.74), while MRI yielded better results on typification of lesions (kappa 0.75, SPECT/CT 0.69). There was poor agreement between experienced and inexperienced readers in SPECT/CT and MRI. CONCLUSIONS: SPECT/CT proved to be the most helpful imaging modality in patients with non-specific wrist pain. The method was found reliable, providing high interobserver agreement, being outperformed by MRI only concerning the typification of lesions. We believe it is beneficial to integrate SPECT/CT into the diagnostic imaging algorithm of chronic wrist pain.

Guanylyl cyclase activator ataciguat improves vascular function and reduces platelet activation in heart failure.

INTRODUCTION: Endothelial dysfunction and platelet activation due to impaired endogenous platelet inhibition by nitric oxide (NO) are part of the cardiovascular phenotype in congestive heart failure (CHF). We investigated whether chronic activation of the NO target enzyme soluble guanylyl cyclase (sGC) would beneficially modulate vascular function and platelet activation in experimental CHF. MATERIALS AND METHODS: Chronic myocardial infarction was induced by coronary ligation in male Wistar rats. Animals were either treated with placebo or the sGC activator ataciguat (10 mg/kg/twice daily by gavage). After 10 weeks, hemodynamic assessment was performed and only animals with impaired left-ventricular end-diastolic pressures of more than 15 mmHg were included in the analysis. Vasomotor function was determined in organ bath studies. NO bioavailability was assessed by in vivo platelet vasodilator-stimulated phosphoprotein (VASP) phosphorylation. P-selectin was determined as a marker of platelet degranulation. RESULTS: Endothelium-dependent, NO-mediated vasorelaxation as well as vascular sensitivity to exogenous NO were significantly impaired in aortic rings from CHF rats and normalised by ataciguat. In parallel, in vivo VASP phosphorylation reflecting NO bioavailability was significantly attenuated in platelets from CHF rats and normalised by ataciguat. Platelet activation, which was increased in CHF, was reduced by treatment with ataciguat. CONCLUSION: Chronic sGC activation improved vasomotor function and reduced platelet activation in CHF rats.