Effect of delay between nuclear medicine scanning and sentinel node biopsy on outcome in patients with cutaneous melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is an important staging tool for the management of melanoma. A multicentre study was done to validate previous findings that the timing of lymphoscintigraphy influences the accuracy of SLNB and patient outcomes, particularly survival. METHODS: Data were reviewed on patients undergoing SLNB for melanoma at three centres in the UK and Sweden, examining the effect of timing of SLNB after nuclear medicine scanning. Kaplan-Meier survival analysis was used to assess overall (OS), disease-specific (DSS) and progression-free (PFS) survival, stratified by timing of lymphoscintigraphy. Independent risk factors for survival were identified by Cox multivariable regression analysis. RESULTS: A total of 2270 patients were identified. Median follow-up was 56 months. Univariable analysis showed a 4·2 per cent absolute and 35·5 per cent relative benefit in DSS (hazard ratio 1·36, 95 per cent c.i. 1·05 to 1·74; P = 0·018) for 863 patients whose SLNB was performed up to 12 h after lymphoscintigraphy compared with 1407 patients who had surgery after more than 12 h. There were similar OS and PFS benefits (P = 0·036 and P = 0·022 respectively). Multivariable analysis identified timing of lymphoscintigraphy as an independent predictor of OS (P = 0·017) and DSS (P = 0·030). There was an excess of nodal recurrences as first site of recurrence in the group with delayed surgery (4·5 versus 2·5 per cent; P = 0·008). CONCLUSION: Delaying SLNB beyond 12 h after lymphoscintigraphy with 99 Tc-labelled nanocolloid has a significant negative survival impact in patients with melanoma.

ANTECEDENTES: La biopsia de ganglio centinela (sentinel lymph node biopsy, SLNB) es una técnica importante para la estadificación y tratamiento del melanoma. Se realizó un estudio multicéntrico para validar hallazgos previos según los cuales el momento de la linfogammagrafía (lymphoscintigraphy, LS) influye en la precisión de la SLNB y en los resultados de los pacientes, especialmente en la supervivencia. MÉTODOS: Se revisaron los datos de los pacientes a los que se realizó una SLNB por melanoma en 3 centros en el Reino Unido y Suecia, con especial atención al efecto del período entre la inyección el material radioactivo y la SLNB. Se realizó un análisis de supervivencia mediante el método de Kaplan-Meier para la supervivencia específica de la enfermedad (disease-specific survival, DSS), supervivencia global (overall survival, OS) y supervivencia libre de progresión (progression-free survival, PFS), todas ellas estratificadas por el momento de la LS. Los factores de riesgo independientes para la supervivencia se determinaron mediante un análisis de regresión multivariable de Cox. RESULTADOS: Se incluyeron 2.270 pacientes. La mediana de seguimiento fue de 49 meses. El análisis univariado mostró un beneficio absoluto del 4,2% y relativo del 35,5% (cociente de riesgos instantáneos, hazard ratio, HR: 1,36 (i.c. del 95% 1,05-1,74, P = 0.02)) en la DDS para los pacientes a los que la SLNB se realizó < 12 horas después de la LS (n = 863) en comparación con aquellos realizados > 12 horas (n = 1407). Se detectaron beneficios similares para la OS y la PFS (P = 0,04 y P = 0,02, respectivamente). El análisis multivariable identificó el tiempo entre la LS y la SLNB como un factor independiente de OS (P = 0,017) y DSS (P = 0,03). Hubo un aumento en las recidivas ganglionares como primer sitio de recidiva en el grupo de > 12 horas (2,5% versus 4,5%; P = 0,008). CONCLUSIÓN: Estos datos validan nuestra investigación previa y tienen implicaciones significativas para las unidades de melanoma, en el sentido de que retrasar la SLNB más allá de las 12 horas después de realizar la LS con nanocoloides marcados con Tc99 tiene un impacto negativo significativo en la supervivencia de los pacientes y debe evitarse. Se presenta la hipótesis de que la causa subyacente es la migración temporal del trazador que determina una SLNB incorrecta. .

Neck dissection can be avoided after sequential chemoradiotherapy and negative post-treatment positron emission tomography-computed tomography in N2 head and neck squamous cell carcinoma.

AIMS: This study assessed neck control in patients with N2 head and neck squamous cell carcinoma (HNSCC) treated with sequential chemoradiotherapy (SCRT) and the incidence of neck recurrence when neck dissection was withheld in those with negative post-treatment fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET). MATERIALS AND METHODS: Thirty-four consecutive patients with N2 HNSCC who were treated with radical intent using SCRT were included. Twenty-seven patients received concomitant platinum-based chemotherapy with their radiotherapy. Nineteen patients were treated with intensity-modulated radiotherapy. PET-computed tomography (PET-CT) was obtained 3 months after the completion of radical radiotherapy. Neck dissection was carried out only in those with increased FDG uptake in the neck. RESULTS: The median follow-up was 39.1 months. One patient had increased FDG uptake in the neck post-treatment, which was false positive for malignancy. The remaining 33 patients were observed without neck dissection. No regional recurrence occurred. The negative predictive value (NPV) of post-treatment PET-CT was 100%. CONCLUSIONS: Good disease control in the neck can be achieved in patients with N2 HNSCC with SCRT. Post-treatment PET-CT has a high NPV. Neck dissection can be avoided if post-treatment PET-CT is negative.

A randomized, controlled trial of routine early abdominal computed tomography in patients presenting with non-specific acute abdominal pain.

AIM: To compare the effect of an initial early computed tomography (CT) examination versus standard practice (SP) on the length of hospital stay, diagnostic accuracy, and mortality of adults presenting with acute abdominal pain. MATERIALS AND METHODS: Two hundred and five adults presenting with acute abdominal pain were randomized to undergo an early CT examination or current SP, which comprised supine abdominal and erect chest radiography. One hundred and ninety-eight patients (99 in each arm) were included in the analysis. The primary endpoint was the duration of inpatient stay; secondary endpoints were diagnostic certainty and mortality. RESULTS: There was no significant difference in the length of hospital stay between the two arms (p=0.20). At randomization 36% (35 of 96) of CT patients and 49% (48 of 98) of SP patients were correctly diagnosed; 24h after randomization the correct diagnosis had been established in 84% of CT patients and 73% of SP patients. This refinement in diagnostic certainty was significantly better in the CT group (p<0.001). There was no difference in mortality between the two trial arms (p=0.31). CONCLUSION: Early abdominal CT in patients with acute abdominal pain improves diagnostic certainty, but does not reduce the length of hospital stay and 6 month mortality.

A simple processing method allowing comparison of renal enhancing volumes derived from standard portal venous phase contrast-enhanced multidetector CT images to derive a CT estimate of differential renal function with equivalent results to nuclear medicine quantification.

As iodinated contrast medium is cleared by glomerular filtration, it should be possible to apply the same principles utilized in radionuclide studies to derive differential renal function by comparison of enhancing renal volumes derived from contrast enhanced multidetector CT (CEMDCT). Having established a technique iteratively which appeared successful, a retrospective study was performed using 25 consecutive patients with a wide range of urological conditions who had undergone both CEMDCT, including the renal area in the portal venous phase, and nuclear medicine (NM) assessment of renal function with no urological intervention between the studies. Proprietary volume software was used to quantify the volume and attenuation of each kidney, the products of which (after subtraction of soft tissue attenuation derived from a region of interest over psoas) gave right and left enhancing renal volumes. The contribution by each kidney as a percentage of total renal enhancing tissue was derived. Comparison with NM studies resulted in excellent correlation of relative renal function by CEMDCT and NM assessments having a regression of near unity and a Pearson's correlation coefficient of 0.96. Bland Altman and Passing Bablock tests confirmed good agreement between the two methods with no bias. This is a simple, practicable processing technique using standard portal venous phase CEMDCT images to quantify differential function. This technique may allow a one-stop CT assessment of both anatomy and function.

Hepatocellular carcinoma tumour thrombus in a re-canalised para-umbilical vein: detection by 18-fluoro-2-deoxyglucose positron emission tomography imaging.

This case report describes an unusual site of tumour thrombus in a re-canalised para-umbilical vein, in a patient with hepatocellular carcinoma (HCC) and cirrhosis. The tumour thrombus was suspected on conventional radiography and confirmed using PET imaging, illustrating the complimentary value of structural and functional imaging in achieving the correct diagnosis.

Polycystic kidneys and renal transplant imaging.

Renal transplantation is an ever-increasing procedure. Baseline DTPA renography is routinely performed in these patients in many centers to assess transplant perfusion and function. This report describes 2 cases of unusual appearance at renography resulting from the native polycystic kidneys.

Classification, staging and prognosis of lung cancer.

Lung cancer has increased in incidence throughout the twentieth century and is now the most common cancer in the Western World. It has a poor prognosis, only 10-15% of patients survive 5 years or longer. Outcome is dependent on clinical stage and cancer cell type. Lung cancer is broadly subclassified on the basis of histological features into squamous cell carcinoma, adenocarcinoma, large cell carcinoma and small cell carcinoma. The histopathological type of lung cancer correlates with tumour behaviour and prognosis. Staging based on prognosis is essential in clinical trials comparing different management strategies, and enables universal communication regarding the efficacy of different treatments in specific patient groups. The anatomic extent of disease determined either preoperatively using imaging supplemented by invasive procedures such as mediastinoscopy, and anterior mediastinotomy or following resection are described according to the T-primary tumour, N-regional lymph nodes, M-distant metastasis classification. The International System for Staging Lung Cancer attempts to group together patients with similar prognosis and treatment options. Various combinations of T, N, and M define different clinical or surgical-pathological stages (IA-IV) characterised by different survival characteristics. Refinements in staging based on imaging findings have enabled clinical staging to more accurately reflect the surgical-pathological stage and therefore more accurately predict prognosis. Recent advances including the use of positron emission tomography in combination with conventional staging promises to increase the accuracy of staging and therefore to reduce the number of invasive staging procedures and inappropriate thoracotomies.