Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery.

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

No longer any role for routine follow-up chest x-rays in men with stage I germ cell cancer.

Following radical orchidectomy for testicular cancer, most patients undergo protocolled surveillance to detect tumour recurrences rather than receive adjuvant chemotherapy. Current United Kingdom national and most international guidelines recommend that patients require a chest x-ray (CXR) and serum tumour markers at each follow-up visit as well as regular CT scans; there is however, variation among cancer centres with follow-up protocols. Seminomas often do not cause tumour marker elevation; therefore, CT scans are the main diagnostic tool for detecting relapse. For non-seminomatous tumours, serum beta-HCG (HCG) and AFP levels are a very sensitive harbinger of relapse, but this only occurs in 50% of patients [1], and therefore, imaging remains as important. CXRs are meant to aid in the detection of lung recurrences and before the introduction of modern cross-sectional imaging in the early 1980s, CXRs would have been the only method of identifying lung metastasis. We examined the Thames Valley and Mount Vernon Cancer Centre databases to evaluate the role of CXRs in the 21st century for the follow-up of men with stage I testicular cancer between 2003 and 2015 to assess its value in diagnosing relapsed germ cell tumours. From a total of 1447 patients, we identified 159 relapses. All relapses were detected either by rising tumour markers or planned follow-up CT scans. Not a single relapse was identified on CXR. We conclude that with timely and appropriate modern cross-sectional imaging and tumour marker assays, the CXR no longer has any value in the routine surveillance of stage I testicular cancer and should be removed from follow-up guidelines and clinical practice. Omitting routine CXR from follow-up schedules will reduce anxiety as well as time that patients spend at hospitals and result in significant cost savings.

Bony metastases: assessing response to therapy with whole-body diffusion MRI.

There are no universally accepted methods for assessing tumour response in skeletal sites with metastatic disease; response is assessed by a combination of imaging tests, serum and urine biochemical markers and symptoms assessments. Whole-body diffusion magnetic resonance imaging excels at bone marrow assessments at diagnosis and for therapy evaluations. It can potentially address unmet clinical and pharmaceutical needs for a reliable measure of tumour response. Signal intensity on high b-value images and apparent diffusion coefficient values can be related to underlying biophysical properties of skeletal metastases. Four patterns of change in response to therapy are described this review. Therapy response criteria need to be tested in prospective clinical studies that incorporate conventional measures of patient benefit.

Review. 18F-FDG PET in the diagnosis and follow-up of thyroid malignancy.

The diagnosis of carcinoma of the thyroid is usually made in the process of investigating a thyroid nodule with clinical examination, Technetium-99m scan, ultrasonography and fine-needle aspiration (FNA) cytology. The follow-up is mainly based on 123-iodine and 131-iodine scans and serum thyroglogulin measurement. The aim of the present review was to establish the role of 18F-FDG PET in the differential diagnosis of doubtful thyroid nodules and in the follow-up of patients with increased serum thyroglobulin levels and negative iodine-scan. It remains to be defined if metabolic imaging with PET could be a useful routine procedure in the management of thyroid tumours since the majority of them are well-differentiated and therefore have less avidity to 18F-FDG. In the present work we collected the specific literature derived from MEDLINE over the last 10 years to clarify the potential clinical value of 18F-FDG PET in thyroid malignancies. An emerging role for 18F-FDG PET is in the assessment of incidental finding of a thyroid nodule which, when showing high FDG uptake should be regarded as a possible malignancy that needs further assessment. Another well-documented role for 18F-FDG PET is in the investigation of cases of established well-differentiated thyroid carcinomas presenting with high thyroglobulin and negative iodine imaging. An increase of the 18F-FDG uptake in these tumours indicates a shift towards lesser differentiation (with more aggression and poor prognosis) and may benefit from alternative management. 18F-FDG PET can be considered a routine functional imaging method in detecting iodine-negative recurrent disease in thyroid cancer patients with elevated serum thyroglobulin levels during follow-up. 18F-FDG PET seems to be useful also in differential diagnosis of suspected thyroid nodules, especially using the semi-quantitative SUV analysis.

EuroSCORE: a systematic review of international performance.

The validity of the cardiac surgical scoring system, EuroSCORE, has been assessed by several individual cardiac centres within and outside Europe. We chose to assess the overall international performance by systematic review of peer-reviewed literature. There were six studies meeting our criteria for assessment. Internationally, the evidence is highly suggestive that additive EuroSCORE performance generally over-estimates mortality at lower EuroSCOREs (EuroSCORE13). The effect of this could have serious misrepresentations for surgeons and hospitals operating on differing case-mixes. We suggest that further studies need to be performed on the logistic EuroSCORE calculation to ascertain whether predictive ability is improved. Overall, however, EuroSCORE is the most rigorously evaluated scoring system in cardiac surgery.