Unexpected symptoms after rhTSH administration due to occult thyroid carcinoma metastasis.

¹8F-fluorodeoxyglucose positron emission tomography (¹8FDG-PET) scintigraphy is a useful imaging technique in the evaluation of metastasised thyroid carcinoma. Administration of recombinant human thyrotropin (rhTSH, Thyrogen®) increases the diagnostic yield of this procedure. Here we present a 64-year-old male who was followed for Hürthle cell carcinoma of the thyroid with several intrapulmonary metastases. He developed sudden complaints of neck pain following rhTSH administration as part of the routine preparation for a diagnostic ¹8FDG-PET÷CT procedure. This investigation subsequently revealed a previously undetected metastatic lesion in the first cervical vertebra, with no signs of spinal cord compression. Treatment with a nonsteroidal anti-inflammatory drug reduced the symptoms sufficiently, and a few weeks later the neurosurgeon performed a complete resection of the metastasis. It is likely that the symptoms were caused by oedema and÷or increased blood flow to the lesion. Physicians should be aware that rhTSH administration to patients with disseminated thyroid carcinoma may lead to sudden onset of symptoms caused by previously occult metastases.

Discrepancy between second and first opinion in surgical oncological patients.

PURPOSE: To prospectively describe in a population of oncological second opinion patients: (1) the outcome of routine revisions of histopathological and radiological material, (2) the frequency and extent of discrepancy between the second and first opinion and (3) the location of further treatment or follow-up. PATIENTS AND METHODS: In a population of 466 consecutive patients seeking a second opinion at the Surgical Oncology Outpatient Clinic, demographic and clinical patient characteristics were registered prospectively, as were the results of routine revision of histopathological and radiological material and the location of further treatment or follow-up. A classification system was developed to categorize the differences between the second and first opinion. RESULTS: The mean age of the 403 eligible patients was 52 years. Most patients (87%) were women, of whom 83% were diagnosed with breast cancer. Revision of histopathological and radiological material was performed in 80 and 61% of the cases, respectively, and resulted in a major change in treatment or prognosis in 3 and 2% of patients, respectively. In 317 patients (79%), the second opinion could be compared with the first opinion, resulting in an identical advise in 68%, a minor discrepancy in 16% and a major discrepancy in another 16% of patients. For further treatment 78% of patients were referred back to their first specialist. CONCLUSION: One third of patient-initiated second opinion consultations resulted in a discrepancy with the first opinion. Half of these different advise lead to major changes in therapy or prognosis.

[Practice guideline 'Diagnostic techniques for soft tissue tumours and treatment of soft tissue sarcomas (revision)']. / Richtlijn 'Diagnostiek bij wekedelentumoren en behandeling van wekedelensarcomen (herziening)'.

Members of the Dutch working group on soft tissue tumours developed an up-to-standard evidence-based multidisciplinary clinical practice guideline for the diagnosis of soft tissue tumours and the treatment and follow-up of soft tissue sarcomas, in cooperation with the Dutch Association of Comprehensive Cancer Centres and the Dutch Institute for Healthcare Improvement. A soft tissue sarcoma is defined as every non-epithelial tumour that does not originate in haematopoietic or lymphatic system, central nervous system or bone. The guideline lists 'alarm signals' to raise awareness of malignancy and recommends consulting a multidisciplinary team. Non-invasive imaging has to be completed before proceeding to any invasive (diagnostic) procedure or assessment of dissemination. Aspiration cytology can be useful for differentiating between sarcoma and other malignancies. A definite diagnosis is obtained by means of image-guided needle biopsy. Tumours will be classified according to the World Health Organization and graded according to the Federation Nationale des Centres de Lutte Contre le Cancer. Surgical excision with a tumour free margin of 2 cm is the core of therapy, taking into account vital structures when necessary. In case of small superficial tumours (diameter < or = 3 cm) excision biopsy may be justified. Radiotherapy is almost always necessary and certainly indicated when wide margins are impossible even after re-resection. In the case of primary metastatic disease, an individual decision should be taken after multi-disciplinary consultation concerning the possibility of curative or palliative treatment. Neither neo-adjuvant nor adjuvant chemotherapy is standard. Chemotherapy may be useful in metastatic disease. The guideline advises referring patients who are eligible for chemotherapy to a centre and that they should be included in a study protocol.

Developments in treatment of primary irresectable rectal cancer.

Abstract The treatment options for primary irresectable rectal cancers are discussed. Assessment of tumour stage is the first step for an appropriate choice of treatment. Following a diagnosis of rectal cancer, a vast array of diagnostic procedures is available to determine its stage, and thereby its best treatment options. From the many (new) diagnostic options the merits and drawbacks are discussed. If a diagnosis of irresectability is made, further treatment options should include radiotherapy in most cases, some aspects of timing and application, i.e. intra-operative treatment are discussed. Chemotherapy options are manifold, the results are discussed and some new options are explored.

Multi-detector computed tomography and 3-dimensional imaging in a multi-vendor picture archiving and communications systems (PACS) environment.

RATIONALE AND OBJECTIVES: To show the impact of the introduction of multi-detector computed tomography (CT) on radiologic workflow and to demonstrate how this reflects on picture archiving and communications systems (PACS) requirements. MATERIALS AND METHODS: Production measurements were obtained from different CT scanners (first two single-slice CT scanners; from December 2001 single and 4-slice CT; from April 2002 single and 16-slice CT) in number of patients from the radiologic information system. Implications on our PACS were recorded in terms of images and studies stored. Furthermore, our PACS design was made so that optimal use of 3-dimensional imaging within the radiologic workflow was possible. Finally, the number of non-diagnosed studies were recorded every day since the start of the transition to a filmless radiology department. RESULTS: This PACS design achieved a high level of integration between simple viewing and advanced 3-dimensional imaging and is optimized for handling large amounts of data. Overall increase of patients scanned with CT from January 2002-December 2003 was 54%. The number of series increased by 286% from December 2001-April 2003 and by 130% from April 2002-December 2003. From January 2002-February 2003, the number of images per patient increased from 175 to 450 (157%). Non-diagnosed studies decreased from about 100-120 before to practically zero after PACS implementation. CONCLUSION: PACS significantly increases productivity because of availability of the images and elimination of certain manual tasks. These results show that although the amount of examinations increases significantly with the introduction of MDCT, simultaneous introduction of PACS and filmless operation allows radiologists to handle the growth in workload.

Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer.

BACKGROUND: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. METHODS: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. RESULTS: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. CONCLUSION: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.

Noninvasive coronary imaging using electron beam CT: surface rendering versus volume rendering.

OBJECTIVE: Three-dimensional data for noninvasive imaging of the coronary arteries are acquired from electron beam CT, multidetector CT, or MR imaging. Most commonly, surface rendering is used for three-dimensional processing, but recent advances in hardware and software technology have made it possible to use volume rendering. Our objective was to compare volume rendering with surface rendering for the visualization of the coronary artery tree. CONCLUSION: Our experience in the comparison of both techniques shows that because of intrinsic problems associated with surface rendering, volume rendering produces better image quality.

Lung scintigraphy and helical computed tomography for the diagnosis of pulmonary embolism: a meta-analysis.

To assess the diagnostic value of lung scintigraphy and helical computed tomography (hCT) in patients with suspected pulmonary embolism (PE), all English-language articles that described lung scintigraphy and hCT in patients with suspected PE were retrieved. Articles were assessed for strength of methodology, based on nine a priori-defined criteria. Parameters of diagnostic accuracy and results of management studies were calculated and evaluated. Lung scintigraphy is diagnostic in approximately 50% of patients with suspected PE. A normal perfusion scan has a chance of recurrent PE in two of 693 patients (0.3%; 95% CI: 0.2-0.4%; fatal in 0.15%). A high-probability lung scan is correlated with angiographically proven PE in 308 of 350 patients (88%; 95% CI: 84-91%). Pulmonary embolism was proven in 385 of 1529 patients (25%; 95% CI: 24-28%) with a nondiagnostic lung scan. Helical CT studies were compared with angiography and lung scintigraphy in 1171 patients, with a prevalence of PE of 39%. The sensitivity and specificity of hCT was 283/320 (88%; 95% CI: 83-91%) and 374/408 (92%; 95% CI: 89-94%), respectively. Only one prospective management study using hCT was available. In patients in whom anticoagulants were withheld based on a normal hCT study, recurrent thromboembolic events occurred in six of 109 patients (5.5%; 95% CI: 2-12%), with one fatality (1%; 95% CI: 0.02-4.3%). Lung scintigraphy is evaluated extensively and yields a diagnostic result in 50% of patients. Helical CT has similar positive predictive value to a high-probability lung scan. However, the exact role of hCT in the management of patients with suspected PE needs to be determined in prospective studies.

[Second Opinion Consult Clinic for Surgical Oncology in the Daniel den Hoed Clinic: analysis of the first 245 patients]. / De Tweedemeningpolikliniek Chirurgische oncologie in de Daniel den Hoed Kliniek: analyse van de eerste 245 patiënten.

OBJECTIVE: To determine the characteristics and outcome in patients visiting a surgical oncology outpatient clinic for a second opinion. DESIGN: Prospective and descriptive. METHOD: From October 1996 till December 1998, 245 patients visited the Second Opinion Outpatient Clinic of the department of Surgical Oncology of the University Hospital Rotterdam/Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands. The oncological data were recorded. The patient's satisfaction with their first physician and the hospital was scored in a standardized way. Cytological, histological and radiological material was revised and discrepancies with the results from elsewhere were recorded. The results of comparing the first and second opinion were retrospectively categorized as: identical; not identical without consequences for the prognosis but with implications for the quality of life; not identical with implications for the prognosis. RESULTS: The primary tumour was breast cancer in 58% of the patients, 19% had a tumour of the digestive tract, and 23% presented with a variety of malignancies. The main problems for which the second opinion was asked were treatment (69%), diagnosis (17%) and adjuvant treatment (11%). Of all patients 53% was satisfied with the communication with the primary physician, 24% was moderately satisfied and 23% was unsatisfied. Revision of pathological and radiological material was done in 214 and 157 patients, respectively, resulting in 1% and 3% major discrepancies with therapeutical implications. The second opinion was identical to the first opinion in 53% of the patients. In 24% it was different without and in 7% with possible implications for the prognosis. In 16% a comparison of the second with the first opinion was not possible. Seventy-one per cent of the patients were referred to the primary physician, while for 21% further treatment or follow-up was done in the Cancer Centre and 8% chose to be referred to another hospital. Of patients who were satisfied or moderately satisfied with the communication with their primary physician 83% and 79% respectively were referred to the primary physician compared with 31% of those who were unsatisfied.

Intravenous coronary angiography using electron beam computed tomography.

Intravenous coronary angiography with electron beam computed tomography (EBCT) allows for the noninvasive visualisation of coronary arteries. With dedicated computer hardware and software, three-dimensional renderings of the coronary arteries, veins, and other cardiac structures can be constructed from the individual transaxial tomograms. Interest in this technique is growing, and recently a number of clinical studies have been published comparing EBCT coronary angiography with conventional cine-coronary angiography. In this article, image acquisition, postprocessing techniques, and the results of recently published clinical studies are discussed. EBCT coronary angiography is a promising imaging technique of coronary arteries. Currently, it is a reasonably robust technique for the visualization and assessment of the left main and left anterior descending coronary artery. However, at the moment a relatively high proportion of the right and circumflex coronary angiograms are noninterpretable. Improvements in image acquisition and postprocessing techniques are expected to improve visualization and diagnostic accuracy of the technique.

In vivo assessment of three dimensional coronary anatomy using electron beam computed tomography after intravenous contrast administration.

Intravenous coronary angiography with electron beam computed tomography (EBCT) allows for the non-invasive visualisation of coronary arteries. With dedicated computer hardware and software, three dimensional renderings of the coronary arteries can be constructed, starting from the individual transaxial tomograms. This article describes image acquisition, postprocessing techniques, and the results of clinical studies. EBCT coronary angiography is a promising coronary artery imaging technique. Currently it is a reasonably robust technique for the visualisation and assessment of the left main and left anterior descending coronary artery. The right and circumflex coronary arteries can be visualised less consistently. Improvements in image acquisition and postprocessing techniques are expected to improve visualisation and diagnostic accuracy of the technique.

[Electron-beam computed tomography: preliminary experiences in the Netherlands]. / Elektronenbundeltomografie: eerste ervaringen in Nederland.

The difference between computer tomography (CT) and electron beam tomography (EBT) is that for CT the x-ray tube rotates in a ring round the patient, and for EBT the x-ray beam rotates itself. As a result, with EBT the speed of making images is not limited by the mechanical rotation of the tube, and 16 images can be made per second. An EBT scan of a whole thorax takes 9 seconds. Specific application areas are fast moving organs and patients who cannot remain in one position for long, e.g. children and intensive care patients. Research is being conducted into the possibilities of this non-invasive technique for the demonstration of coronary artery lesions, pulmonary embolism, pulmonary metastases and dynamic examination of the major respiratory tract. Costs of an EBT scan currently amount to Dfl. 450.--but they will probably decrease as this imaging system is developed further. The exposure to radiation is about the same as that caused by a (spiral) CT.

Haematuria: intravenous urography, ultrasound or both?

PURPOSE: To compare the diagnostic value of intravenous urography (IVU), ultrasound (US) and their combination in detecting upper urinary tract malignancies in patients with haematuria. MATERIALS AND METHODS: In a prospective study, 360 consecutive patients who consulted the urologist for haematuria without renal colic were scheduled for IVU and US on the same day. The two procedures were performed by two different radiologists and reported independently. Histology or clinical follow-up of one year served as the gold standard. RESULTS: 63 patients dropped out. Of the remaining 297 patients, 9 (3%) had a malignancy in the upper urinary tract. Sensitivity and specificity with regard to the upper urinary tract pathology were 67% and 91% for IVU and 56% and 94% for US, respectively. For both techniques combined this was 79% and 88%, respectively. CONCLUSION: An acceptable sensitivity for detecting upper urinary tract malignancies is obtained only by combining IVU and US.

Erectile dysfunction: timing of spectral wave-form analysis in the assessment of the function of the cavernosal arteries.

Color Doppler ultrasound seems to be an accurate method to evaluate vascular erectile function, in particular the arterial supply of the penis. Because of its relative noninvasiveness and easy performance, it has to precede more invasive evaluation (cavernosography and invasive angiography). Combination of wave form pattern analysis with peak systolic velocity measurements allows differentiation between arterial and venous insufficiency. Fifty-one patients suffering from erectile dysfunction, were examined with use of color Doppler ultrasound. Nine had adequate vascular function with good penile tumescence. However, during these adequate (late) stages of tumescence, peak systolic velocity fluctuated significantly. We conclude that in the late stages of tumescence, velocity measurements are not reliable as a parameter of arterial function.