Biochemically recurrent prostate cancer: rationalisation of the approach to imaging.

AIM: To assess the utility of magnetic resonance imaging (MRI) in addition to the additive benefit of the conventional imaging techniques, computed tomography (CT) and nuclear medicine (NM) bone scintigraphy, for investigation of biochemical recurrence (BCR) post-prostatectomy where access to prostate specific membrane antigen (PSMA) positron-emission tomography (PET)-CT is challenging. MATERIALS AND METHODS: Relevant imaging over a 5-year period was reviewed. Ethical approval was granted by the internal review board. All patients with suspected BCR, defined as a PSA ≥0.2 ng/ml on two separate occasions, underwent a retrospective imaging review. This was performed on PACS archive search database in a single centre using search terms "PSA" and "prostatectomy" in the three imaging methods; MRI, CT, and NM bone scintigraphy. All PSMA PET CT performed were recorded. RESULTS: One hundred and eighty-five patients were identified. Patients with an MRI pelvis that demonstrated distant metastases (i.e., pelvic bone metastases or lymph node involvement more cranial to the bifurcation of the common iliac arteries) were more likely to have a positive CT and/or NM bone scintigraphy. The Pearson correlation coefficient between the findings of M1 disease at MRI pelvis and the presence of distant metastases at CT thorax, abdomen, pelvis and NM bone scintigraphy was calculated at 0.81 (p<0.01) and 0.91 (p<0.01) respectively. CONCLUSION: An imaging strategy based on risk stratification and technique-specific selection criteria leads to more appropriate use of resources, and in turn, increases the yield of conventional imaging methods. MRI prostate findings can be used to predict the additive value of CT/NM bone scintigraphy allowing a more streamlined approach to their use.

ESGAR consensus statement on the imaging of fistula-in-ano and other causes of anal sepsis.

OBJECTIVES: To develop imaging guidelines for patients with fistula-in-ano and other causes of anal sepsis. METHODS: An expert group of 13 members of the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) used a modified Delphi process to vote on a series of consensus statements relating to the imaging of patients with potential anal sepsis. Participants first completed a questionnaire to gather practice information and to help frame the statements posed. RESULTS: In the first round of voting, the expert group scored 51 statements of which 45 (88%) achieved immediate consensus. The remaining 6 statements were redrafted following input from the expert group and consensus achieved for all during a second round of voting, including an additional statement drafted. No statement was rejected due to a lack of consensus. After redrafting to improve clarity, 53 individual statements were presented. CONCLUSION: These expert consensus statements can be used to guide appropriate indication, acquisition, interpretation and reporting of medical imaging for patients with potential fistula-in-ano and other causes of anal sepsis. KEY POINTS: • Medical imaging, notably magnetic resonance imaging, is used widely for the diagnosis and monitoring of fistula-in-ano and other causes of anal and perianal sepsis. • While the indexed medical literature is clear that diagnostic accuracy is potentially excellent, this depends on competent image acquisition and interpretation. • In order to facilitate this, the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) has produced expert consensus guidelines regarding the imaging of fistula-in-ano and related conditions.

National Survey of CT Colonography Practice in Ireland.

CT Colonography was first introduced to Ireland in 1999. Our aim of this study is to review current CT Colonography practices in the Republic of Ireland. A questionnaire on CT Colonography practice was sent to all non-maternity adult radiology departments in the Republic of Ireland with a CT scanner. The results are interpreted in the context of the recommendations on CT Colonography quality standards as published by the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus statement in the journal of European Radiology in 2013. Thirty centres provide CT Colonography; 21 of which responded (70%). Each centre performs median 90 studies per year; the majority follow accepted patient preparation and image acquisition protocols. Seventy-six percent of the centres repsonded that the majority of patients imaged are symptomatic. Of the 51 consultant radiologists reading CT Colonography, 37 (73%) have attended a CT Colonography course. In 17 (81%) of the centres the studies are single read although 81% of the centres have access to a second radiologist's opinion. Fourteen (67%) of the centres reported limited access to CT scanner time as the major limiting factor to expanding their service. CT Colonography is widely available in Ireland and is largely performed in accordance with European recommendations.

Laparoscopic hemicolectomy for cutaneous malignant melanoma metastasis to the ileocaecal valve.

Colonic tumours are most frequently primary and lesions secondary to metastasis are uncommon. Malignant melanoma is an aggressive cancer, with a tendency to metastasize and recur. This report describes the case of a 66-year-old man who underwent wide local excision and adjuvant therapy for malignant melanoma three years prior to presentation with loose stools, abdominal cramps and iron deficiency anaemia. CT colonography showed a 6cm ileocaecal mass, and following a laparoscopic right hemicolectomy, histological examination revealed a metastatic melanoma to the ileocaecal valve. Subsequent positron emission tomography showed no residual metastatic disease. Malignant melanoma metastasis to the colon is a rare clinical entity. Metastectomy via laparoscopic right hemicolectomy is an appropriate and effective treatment.

Encapsulating peritoneal sclerosis: experience of a tertiary referral center.

AIM: Encapsulating peritoneal sclerosis (EPS) is arguably the most serious complication of chronic peritoneal dialysis (PD) therapy with extremely high mortality rates. We aimed to establish the rates of EPS and factors associated with its development in a single center. METHODS: We retrospectively reviewed the records of all our PD patients from 1 January 1989 until 31 December 2008. All suspected cases were confirmed at laparotomy. Multifactorial models adjusted for potentially confounding variables such as age and sex. RESULTS: Eleven cases of EPS were identified giving a prevalence rate of 1.98%. Median duration on PD was substantially longer in affected versus unaffected patients (42.5 months versus 13.8 months; p = 0.0002). EPS patients had experienced a mean of 3.54 previous cases of peritonitis (1 infection per year versus 0.71 per year in unaffected patients; p = 0.075). Six patients died (54.5%) due to intra-abdominal sepsis including all five who presented with small bowel obstruction. Three patients had an omentectomy and adhesiolysis performed with a successful outcome. CONCLUSION: Our study reinforces the link between duration on PD and EPS. While mortality was high in our cohort, emerging surgical techniques demonstrate a favorable outcome that can be achieved even in severely affected cases.

Thrombotic thrombocytopenic purpura secondary to Streptococcus.

We describe a 16 year old female who developed thrombotic thrombocytopenic purpura (TTP) following infection due to Streptococcus. Initially presenting a fever and systemic upset she progressed to develop dialysis dependent acute renal failure, seizures, thrombocytopenia and a haemolytic anaemia--the pentad of features seen in TTP. Prior to the diagnosis she was found to have unexplained and previously undescribed MRI findings of diffuse increased signal intensity in the white matter of the left cerebellar hemisphere posteriorly and also increased signal intensity in the overlying cortex. She was commenced on plasmapheresis, and her anaemia, thrombocytopenia, creatinine and LDH all fully responded. In addition, she had no further seizures following plasmapheresis and has not relapsed to date. We review both the rare association of TTP and streptococcal infection, and the neuroradiological findings described in the literature. This is only the third case report describing TTP following streptococcal infection, and only the second in the era of plasmapheresis.

Inhibition of the adherence of Pseudomonas aeruginosa to epithelial cells by IgG subclass antibodies.

A beneficial role of the antibody response to Pseudomonas aeruginosa seen in cystic fibrosis (CF) patients has not been established. We investigated a possible role for these antibodies as inhibitors of the adherence of P. aeruginosa to mammalian cells. An adhesion model system was used, employing buccal epithelial cells in an enzyme-labelled immunoassay procedure on microtitration plates. Total levels of IgG, IgA, IgM and the four IgG subclasses were estimated in 11 CF patients and 10 healthy controls. Most of the CF patients demonstrated increased levels of all these immunoglobulin types. Sera from seven patients with elevated serum IgG were observed to cause greater inhibition of the adherence of P. aeruginosa to buccal cells than were the sera from four CF patients with low serum IgG and from ten healthy controls. Nevertheless, the levels of individual anti-P. aeruginosa IgG subclass antibodies varied amongst the patients and did not correlate with the degree of inhibition of bacterial adherence. Negative affinity chromatography was used to obtain antibody fractions enriched for IgG1, IgG2 or IgG4 and protein A-sepharose chromatography was used to isolate IgG3 antibodies from CF patients. The IgG1-, IgG2-, or IgG4-enriched fractions similarly inhibited the adherence of P. aeruginosa in the test system, whereas three of five IgG3-enriched fractions from CF patients had no greater effect on adhesion than did IgG from control individuals.

Role of IgG subclass response to outer-membrane proteins in inhibiting adhesion of Pseudomonas aeruginosa to epithelial cells.

The IgG subclass response to the major outer-membrane proteins (OMPs) of Pseudomonas aeruginosa was investigated in 11 cystic fibrosis (CF) patients and 10 healthy controls. Inhibition of adhesion of P. aeruginosa to buccal epithelial cells by the IgG serum fractions from the CF patients has been established previously. The CF patients demonstrated marked heterogeneity in their individual IgG subclass response to pseudomonal OMPs. The predominant IgG1 and IgG4 responses were directed towards OMPs F, H2 and, with IgG1 only, to protein I. Proteins of 42 and 46 kDa primarily elicited an IgG2 response but some patients produced IgG4 antibodies. The IgG3 response varied from very weak in some patients to a strong reaction with proteins D2, E, G and I in others. The range of antigen-specific IgG subclass responses was similar in CF patients whose IgG fractions strongly inhibited the adherence of P. aeruginosa to epithelial cells and in those whose fractions gave only weak inhibition of adherence. There was no indication that an antibody response towards any particular OMP was implicated in the inhibition of bacterial adherence. Thus, the IgG subclass response to OMPs did not exert a significant effect on adherence when investigated in isolation, but may possibly play some role in combination with other processes.

Techniques for liver MR imaging.

MR imaging provides exquisite, versatile, and unique soft tissue contrast, which allows for an effective evaluation of a wide range of liver disorders. A careful selection of imaging strategies can yield a comprehensive assessment of the liver in a reasonable examination time. Recent advances in MR hardware and software allow for rapid acquisition times that can bypass many of the motion artifacts that previously posed limitations to abdominal MR imaging. The ability to obtain artifact-free images with sufficient contrast-to-noise ratios across a broad range of techniques is now feasible with rapid scanning. This capability has emerged as the result of the implementation of high-performance gradient systems and localized phased-array body coils. In this article, the authors review the current status of MR imaging strategies for the evaluation of the liver, with an emphasis on the use of fast scanning techniques.

Contrast-Enhanced CT colonography.

Computed tomography (CT) colonography provides both a multiplanar and endoluminal perspective of the air-filled, distended, cleansed colon, offering an alternative to traditional approaches to colorectal cancer screening. However, there are still limitations associated with CT colonography that need to be resolved, including inadequate bowel distention and poorly prepared colons that make it difficult to distinguish between stool and mucosal lesions including submerged polyps as well as flat or sessile polyps which can often be overlooked. In an effort to help distinguish the bowel wall and mural abnormalities from luminal contents, we have found the use of intravenous contrast material significantly improves both bowel wall conspicuity and reader confidence for examining the colon. In addition, we have found that the use of intravenous contrast material improves the diagnostic accuracy for the detection of medium and probably large polyps.

Virtual colonography: techniques and current clinical applications.

The advent of volumetric helical computed tomography (CT), coupled with the almost universal use of oral and intravenous contrast agents, has resulted in CT becoming the diagnostic and therapeutic cornerstone for alimentary tract disease. Recent technical advances, further enhanced by innovative software developments, now permit multiplanar and endoluminal projections of the entire abdomen, and have resulted in the development of novel diagnostic applications in the abdomen.

The relationship between a nutritional index and acute physiology score in critical illness.

Prognostic indices derived from available physiological data (SAPS), complex nutritional and biochemical tests (PNI), grip strength and serum albumin were calculated in 16 critically ill patients receiving intravenous nutrition over a six week period. The aim was to compare these independently derived prognostic indices, to assess their response to feeding, and to determine suitability for use in Irish intensive care units. Mean SAPS (7.6 +/- 0.92), PNI (3.1 +/- 0.29), serum albumin (30.3 +/- 1.03 g/l) and grip strength (17.9 +/- 1.3%) were all suggestive of an "at risk" group. Significant associations were found between the accepted SAPS index and both PNI (r = 0.6, p < 0.001, n = 35) and grip strength (r = -0.68, p < 0.001, n = 44) but not with serum albumin. No consistent improvement was seen in response to feeding in any of the derived indices. The close correlation between prognostic indices derived from either physiological, nutritional or grip strength data in this study and the failure of prognostic indices to improve during hyperalimentation would support a common mechanism, e.g. endogenous mediators, for metabolic and physiological disturbance in critical illness. It suggests that the role of hyperalimentation is supportive rather than therapeutic and re-iterates the importance of managing underlying disease processes. Simple grip strength may be a useful alternative to complex nutritional indices.

The double-edged sword of vitamin D in Ireland: the need for public health awareness about too much as well as too little.

INTRODUCTION: The Institute of Medicine (IOM) 2011 on dietary references intakes for calcium and vitamin D specified that a 25-hydroxyvitamin D (25OHD) level below 30 nmol/L indicated risk of deficiency and that a level above 125 nmol/L indicated risk of harm. METHODS: We noted a high prevalence of hypovitaminosis D (23.9 %) and a substantive prevalence of hypervitaminosis D (4.8 %) in a retrospective audit of clinical samples (n = 10,181) obtained over 10 months in 2013. CONCLUSION: Hypovitaminosis D should be corrected by low dose supplementation (5 µg or 200 IU daily) with some at-risk groups needing higher doses (10 µg or 400 IU daily) based on 25OHD levels. Whereas, those taking high-dose vitamin D supplements based on mistaken beliefs about recently authorised claims of benefit for muscle function and misleading unauthorised claims need to be alerted to the potential harms of excessive supplementation.

A single centre experience of active surveillance as management strategy for low-risk prostate cancer in Ireland.

INTRODUCTION: Active surveillance (AS) is a management strategy for addressing the widely acknowledged problem of over diagnosis and over treatment of clinically indolent prostate cancer. METHODS: A total of 80 patients were enrolled on the AS program in our institution between January 2008 and June 2012. All data were collected prospectively in a secure database. RESULTS: The mean age of patients enrolled was 62.7 years (range 50-72). Median PSA at enrolment was 5.6 ng/mL (range 1.2-13.4). The mean follow-up was 32 months (range 2-54). In total, 85 % of patients had a repeat biopsy after 1-year with 30 % having another biopsy after 3 years. Overall, 45 % of patients remain on AS. In the remainder; 42.5 % of patients have been removed from AS for definitive treatment, while 8.75 % of patients are now on watchful waiting, 2.5 % of patients self discharged from the program and one patient died of cardiovascular disease. The prostate cancer specific survival rate is 100 %. Reasons for removal from AS and referral for treatment were; 67.6 % of patients had upgrade of disease on repeat biopsy, 17.6 % of patients had PSA progression, 11.8 % patients had progression of disease on MRI, and one patient developed a palpable nodule. Regarding definitive treatment; 52.9 % of patients have been for referred for external beam radiotherapy, 14.7 % have been referred for brachytherapy, 29.4 % have been referred for surgery and one patient has refused definitive treatment. CONCLUSION: Our findings to date support active surveillance as a valid strategy for early, localised prostate cancer.

Manifestations of Von Hippel Lindau syndrome: a retrospective national review.

INTRODUCTION: Von Hippel Lindau (VHL) disease is a syndrome that is defined by variety of tumours such as cerebellar haemangioblastomas, renal cell carcinomas, phaeochromocytomas, pancreatic adenomas and ear, nose and throat (ENT) adenomas. This disease is often genetic and inherited in an autosomal dominant fashion, and can present in childhood, adolescence or adult life. This study describes the presentation, natural history and manifestations of patients attending our institutions with this condition. We aim to highlight the importance of screening in diagnosing the manifestations of VHL. METHODS: A retrospective review was performed on all patients diagnosed with VHL and coded as such by the national Hospital Inpatient Enquiry Scheme at Beaumont Hospital Dublin and Cork University Hospital. This was performed over a 20 years period between 1989 and 2009. Age, sex, mode of presentation, presence or absence of end stage kidney disease and genotype were documented. Presence or absence of the characteristic tumours of VHL was also recorded, as were the initial presenting features of these tumours. RESULTS: Thirty-six patients were diagnosed with VHL. These patients ranged from 18 to 78 years old. Three patients were members of the Irish travelling community. The most frequent mode of presentation was altered neurological signs (40%), with a significant proportion presenting with haematuria (23%). Patients diagnosed prior to 1995 were more likely to have presented with significant complications of VHL, while those diagnosed after this time were more likely to have been diagnosed via screening. Genetic testing was performed on 17 patients; those who did not have genetic testing performed were more likely to have been diagnosed prior to the era of genetic testing. Thirty-one patients had received screening for complications of VHL including renal cell carcinomas, central nervous system (CNS) haemangioblastomas and phaeochromocytomas. The patients who did not receive any screening presented with neurological symptoms. CONCLUSION: Beaumont Hospital Dublin and Cork University Hospital are tertiary referral centres for nephrology, urology and neurosurgery and deals with a significant proportion of patients diagnosed with VHL in Ireland. This study highlights the significant burden of this illness and emphasizes the importance of screening for these renal/CNS and ENT complications. This study also highlights the importance of family screening in diagnosing this condition.

Secretin-assisted CT of the pancreas: improved pancreatic enhancement and tumour conspicuity.

PURPOSE: The primary aim of this prospective pilot study was to determine if the administration of intravenous secretin prior to contrast-enhanced computed tomography (CT) improves pancreatic enhancement and pancreatic tumor conspicuity. The second aim was to determine the optimal timing for secretin administration prior to contrast-enhanced CT. METHODS: Local ethics committee approval was obtained. 35 patients (18 men, 17 women; mean age, 67.6 years; age range; 25 to 86 years) with known or suspected pancreatic malignancy or an abdominal malignancy underwent a helical CT of the pancreas. The pancreas was first localised on an unenhanced scan using 10mm sections. Following 120 ml of intravenous 300 mg/ml of non ionic contrast medium (CM), injected at a rate of 5 ml/s, images of the pancreas (3mm slice thickness) and liver (8mm slice thickness) were obtained at 40 and 70 seconds respectively. A second CT was obtained 1-5 days after the first one using the same CT and intravenous contrast medium injection parameters. However 100 IU of secretin was given as an intravenous bolus between 0 and 5 min prior to intravenous contrast medium administration. Each patient acted as their own control. The attenuation in Hounsfield Units (HU) was recorded on non-contrast, pancreatic phase and portal venous phases for both secretin and non-secretin CTs, in the pancreas and pancreatic tumors (where present). Tumor conspicuity was calculated (in the 19 patients with pancreatic adenocarcinomas) by subtracting pancreatic tumor attenuation from pancreatic attenuation. Statistical evaluation comparing pre and post secretin enhancement was performed using matched paired t-tests. RESULTS: A significant increase in pancreatic enhancement was observed when secretin was injected at 2 to 3 min before contrast material injection (the increase in pancreatic density following secretin at 2 min was 31.5+/-10 HU (29.2%) (p=.035); and at 3 min was 23.2+/-7.8 HU (22.7%) (p=.041). Pancreatic tumor conspicuity in the pancreatic phase was most marked when secretin was injected between 2 to 4 min before contrast medium, with 4 min showing a statistically significant increase in tumor conspicuity, 48.2+/-14.2 HU (p=.04). CONCLUSION: Imaging in the pancreatic phase 2 to 4 min after administration of intravenous secretin leads to greater enhancement of the pancreas with greater tumor conspicuity, than imaging without secretin.

CD44v6 is not relevant in colorectal tumour progression.

BACKGROUND AND AIMS: There is a lack of consensus regarding the role of CD44 variants in colorectal cancer, with conflicting reports regarding their expression and correlation with prognosis. We investigated the expression and prognostic significance of CD44v6 protein in our series of colorectal tumour specimens and then analysed the pattern of CD44 variant mRNA transcript expression in a smaller series of colorectal tumour/normal tissue specimens, thus assessing what our data contributes to this debate. METHODS: Immunohistochemistry was used to detect CD44v6 protein expression, while reverse transcriptase-polymerase chain reaction in combination with Southern blotting was used to analyse CD44 mRNA transcript expression. RESULTS: Similar levels of expression of CD44v6 protein were observed in each of the Dukes' stages, ranging from 50% to 67%, indicating no correlation with progression of disease or survival rates. CD44 variant mRNA expression was found in 85% of the tumours and 75% of the normal specimens. The majority of tumours expressed each of the variants. The pattern of variant expression was maintained in the corresponding normal tissue in nearly one-half (47%) of the tumour specimens. A sequential pattern of variant expression was observed in the majority of specimens. There was no association between CD44 variant mRNA expression and Dukes' stage, tumour differentiation or survival. CONCLUSIONS: The data reported here, along with those already in the literature, suggest that CD44v6 does not play a pivotal role in colorectal cancer progression. Moreover, due to the pattern of expression of contiguous blocks of variant transcripts it is unlikely that expression of any single variant can predict outcome in vivo.

MR colonography: status and perspective.

With further improvements in multislice CT, enabling now the combination of lung and colon imaging within one breathhold with automated dose optimization, MR colonography has almost been given up. But similar to angiography, we are optimistic that MR can be compatible to CT in colonography and report in this article on the current status and perspective of MR colonography. For more information see www.multiorganscreening.org.