Simultaneous 18-FDG PET and MR imaging in lower extremity arterial disease.

Background: Simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) is a novel hybrid imaging method integrating the advances of morphological tissue characterization of MRI with the pathophysiological insights of PET applications. Aim: This study evaluated the use of simultaneous 18-FDG PET/MR imaging for characterizing atherosclerotic lesions in lower extremity arterial disease (LEAD). Methods: Eight patients with symptomatic stenoses of the superficial femoral artery (SFA) under simultaneous acquisition of 18-FDG PET and contrast-enhanced MRI using an integrated whole-body PET/MRI scanner. Invasive plaque characterization of the SFA was performed by intravascular imaging using optical coherence tomography. Histological analysis of plaque specimens was performed after directional atherectomy. Results: MRI showed contrast enhancement at the site of arterial stenosis, as assessed on T2-w and T1-w images, compared to a control area of the contralateral SFA (0.38 ± 0.15 cm vs. 0.23 ± 0.11 cm; 1.77 ± 0.19 vs. 1.57 ± 0.15; p-value <0.05). On PET imaging, uptake of 18F-FDG (target-to-background ratio TBR > 1) at the level of symptomatic stenosis was observed in all but one patient. Contrast medium-induced MR signal enhancement was detected in all plaques, whereas FDG uptake in PET imaging was increased in lesions with active fibroatheroma and reduced in fibrocalcified lesions. Conclusion: In this multimodal imaging study, we report the feasibility and challenges of simultaneous PET/MR imaging of LEAD, which might offer new perspectives for risk estimation.

Organophosphate poisoning in the developed world - a single centre experience from here to the millennium.

Organophosphate (OP) poisoning is still associated with high morbidity and mortality rates, both in resource-poor settings and in well-developed countries. Despite numerous publications dealing with this particular poison, detailed clinical data on more severe overdoses with these agents are relatively sparsely reported. A retrospective study was consequently conducted on 33 patients with OP poisoning admitted to our intensive care unit (ICU) to provide additional data on clinical features. We included moderate to severe poisonings between 2000 and 2012 who required admission to ICU. Patients ingested dimethyl-OPs in 19 cases, diethyl-OPs in 8 cases and otherwise classified OPs in 6 cases. Death (5/33) occurred rather late and only one of these fatalities died during on-going cholinergic crisis. Of the survivors (28/33), 71% recovered fully while 29% showed predominantly neurological disabilities before being transferred to neurologic rehabilitation. Aspiration pneumonia predominated in 27/33 patients and one patient died in refractory acute respiratory distress syndrome (ARDS). The intermediate syndrome occurred twice and cardiopulmonary resuscitation had to be performed in 6/33 patients. Fatalities showed a higher Poison-severity-score, APACHE-II-score and SOFA-score on admission compared with survivors and they showed significantly longer QTc-time in the ECG, lower systolic blood pressure and heart rate, a lower pH and a lower base excess on admission. Patients with diethyl-OPs required intubation significantly earlier and showed lower and more sustained inhibited activity of the plasma-cholinesterase on admission compared with patients ingesting dimethyl-OPs. Treatment with atropine and obidoxime was comparable between these groups and severity of poisoning, outcome, hemodynamics on admission, duration of mechanical ventilation and length of stay in the ICU did not significantly differ between the involved group of dimethyl- and diethyl-OPs. We conclude that the fatality rate in our patient cohort treated in a well-staffed and equipped ICU of a developed country is quite similarly high compared with the rate observed in developing countries. Patients died rather late when severe cholinergic crisis had mostly been overcome and death was therefore related to non-poison specific complications.

Morphological assessment of renal arteries after radiofrequency catheter-based sympathetic denervation in a porcine model.

OBJECTIVES: Catheter-based renal artery denervation has been successfully introduced as alternative treatment for patients suffering from drug-resistant essential hypertension. However, the local morphological changes within the vessel wall accompanying this technique remain elusive and we sought to characterize these by utilizing the simplicity radiofrequency catheter approach. METHODS: Following treatment of seven pigs, renal arteries were assigned to either the acute (n  =  6), subacute (10-day follow-up, n  =  6) or control (untreated, n  =  2) group. At follow-up blood analysis, final angiography and optical coherence tomography (OCT)-imaging of the treated arteries were performed and renal arteries and kidneys were processed for histopathology and immunohistochemistry. RESULTS: Radiofrequency-derived energy application to the vessel wall induced transmural tissue coagulation and loss of endothelium resulting in local thrombus formation also detectable by OCT. At 10 days, the luminal surface was almost completely re-endothelialized. Mural wall damage was replaced by fibrotic tissue and the adventitial layer showed strong inflammatory infiltration including vasculogenesis. Remnant autonomic nerve fascicles within the lesion segments of the subacute group displayed enhanced vacuolic degeneration and an impaired neurofilament protein immunostaining pattern. Examination of the kidneys revealed no abnormalities and blood parameters remained within the physiological range. CONCLUSION: Catheter-based application of radiofrequency energy resulted in circumscribed transmural injury within the arterial wall affecting autonomic nerve fascicles delayed to treatment. Acute loss of endothelialization resulted in thrombus formation leaving kidney perfusion apparently unimpaired.

Assessment of ErbB2 (Her2) in oesophageal adenocarcinomas: summary of a revised immunohistochemical evaluation system, bright field double in situ hybridisation and fluorescence in situ hybridisation.

Amplification and overexpression of ErbB2 (Her2) is a frequent event in oesophageal adenocarcinomas. Assessment of ErbB2 status is crucial for identifying patients who are likely to benefit from treatment with trastuzumab. In this study, we performed a comprehensive analysis of ErbB2 amplification and expression in 142 oesophageal adenocarcinomas by comparing the most commonly used methods for ErbB2 assessment: ErbB2 expression was determined by immunohistochemistry and was scored (0, 1+, 2+ and 3+) according to a recently described modified scoring system for gastric cancer. ErbB2 amplification was evaluated by bright field double in situ hybridisation. The results were compared with pathologic features, patients' survival and previously published data from fluorescence in situ hybridisation analysis. On the basis of immunohistochemistry, which was applicable in 110 cores of the cases, 83 tumours (75%) had a score of 0 or 1+ (immunohistochemistry negative), 13 tumours (12%) were scored as 2+ and 14 tumours (13%) were scored as 3+. In situ hybridisation data were obtained from 142 cases. There was a highly significant correlation of immunohistochemistry, bright field in situ hybridisation and fluorescent in situ hybridisation (P<0.001 each). In total, 41 tumours (29%) were categorised as ErbB2 positive, which was defined as immunohistochemistry 3+ and/or an ErbB2/Chr17 quotient of ≥2 as assessed by either bright field double in situ hybridisation or fluorescence in situ hybridisation. ErbB2 positivity was observed more frequently in tumours with lower differentiation grades (P=0.029). Patients with ErbB2-positive tumours had a significantly worse prognosis, both in univariate analysis (P=0.004) and in multivariate analysis (P=0.03). In conclusion, we demonstrate that a significant number of oesophageal adenocarcinomas are positive for ErbB2. Assessment of ErbB2 amplification can be equivalently performed by conventional fluorescence in situ hybridisation or other light-microscopy-based methods, such as the novel bright field double in situ hybridisation technique.

Cystic colon duplication causing intussusception in a 25-year-old man: report of a case and review of the literature.

BACKGROUND: Colonic intussusception is a rare congenital abnormality, mostly manifesting before the age of two with abdominal pain and acute intestinal obstruction with or without bleeding. In adults it may occur idiopathically or due to an intraluminal tumor mass. CASE PRESENTATION: A 25-year-old man presented with an acute abdomen and severe crampy abdominal pain. The clinical picture mimicked acute appendicitis. Transabdominal ultrasound examination revealed a 5 cm circular mass in the right upper abdomen. The ensuing computed tomography suggested an intussusception in the ascending colon. Intraoperatively, no full thickness invagination was detected. Due to a hard, intraluminal tumor a standard right hemicolectomy with ileotransversostomy was performed. The histopathological analysis revealed a cystic colon duplication leading to mucosal invagination and obstruction. CONCLUSIONS: In adults, colon intussusception is a rare event causing approximately 1% of all acute intestinal obstructions. Unlike its preferentially nonsurgical management in children, a bowel intussusception in adults should be operated because an organic, often malignant lesion is present in most cases.

B3 Lesions: Radiological Assessment and Multi-Disciplinary Aspects.

B3 lesions comprise different histopathological entities that are considered benign but 'of unknown biological potential'. These entities may act as risk indicators (for both breasts) or as non-obligatory precursors of malignancy. Being diagnosed at percutaneous breast biopsy, an additional risk of underestimate exists. Imaging appearances, histopathological appearance and risk of associated malignancy are presented. B3 lesions of high risk, which thus should usually be excised, include atypical ductal hyperplasia (ADH), pleomorphic or necrotic type of lobular neoplasia (LIN 3), and papillary lesions with atypias. Intermediate risk may be associated with classic lobular carcinoma in situ (LIN 2) or flat epithelial atypia (FEA), and low risk with radial sclerosing lesions (RSLs) and papillary lesions without atypias. LIN 1 is mostly an incidental finding acting as risk indicator. Follow-up is adequate if the initial diagnostic problem is solved. According to international guidelines, risk and subsequent recommendations should be discussed for each individual patient, taking into account biological risk, representative sampling, lesion size, lesion extent, percentage of lesion removal, other individual risks, and the possibility of surveillance. With vacuum-assisted breast biopsy (VABB), surgery may be avoided for more of the small lesions at low risk. Further data collection and diligent evaluation may help to better assess the individual risk, to better adapt treatment recommendations and avoid overtreatment.

Use of ultrasound-guided percutaneous vacuum-assisted breast biopsy for selected difficult indications.

To assess ultrasound-guided vacuum-assisted biopsy (US-VAB) for selected problem cases and to report experiences with two different biopsy systems. Fifty-one lesions have been biopsied using the Mammotome (n = 24) or the Vacora (n = 27) system. Main indications: lesion in scarring (n = 5), complex cystic >or=8 mm (n = 7), increase in size (n = 10), architectural distortion (n = 4), uncharacteristic palpable abnormality (2), small size (n = 22), regional microcalcifications (n = 1). Results are verified by surgical excision (n = 10) or follow-up (n = 40). One patient was lost to follow-up. In four of the cases preceding core biopsy was inconclusive. four invasive carcinomas, two ductal carcinoma in situ (DCIS), three papillomas, six fibroadenomas, one adenosis tumor, one hamartoma, 10 complex cysts, 16 benign changes, three fat necroses, two granulomas, three unspecific inflammatory changes are verified. Surgery confirmed five malignancies, four benign changes, and converted one uncertain diagnosis (architectural distortion) from "inflammatory" to DCIS. Documented removal of all or most of the lesions correctly increased the level of confidence and open surgery could be avoided in 41/51 lesions. The two systems show different advantages and drawbacks. US-VAB may improve the level of confidence in selected difficult cases. Careful case selection and systematic retrospective correlation of imaging and histology remain crucial.

Multicenter study using paraffin-embedded tumor tissue testing PITX2 DNA methylation as a marker for outcome prediction in tamoxifen-treated, node-negative breast cancer patients.

PURPOSE: We recently reported DNA methylation of the paired-like homeodomain transcription factor 2 (PITX2) gene to be strongly correlated with increased risk of recurrence in node-negative, hormone receptor-positive, tamoxifen-treated breast cancer patients using fresh frozen specimens. Aims of the present study were to establish determination of PITX2 methylation for routine analysis in formalin-fixed paraffin-embedded (FFPE) breast cancer tissue and to test PITX2 DNA methylation as a biomarker for outcome prediction in an independent patient cohort. PATIENTS AND METHODS: Real-time polymerase chain reaction (PCR) technology was validated for FFPE tissue by comparing methylation measurements in FFPE specimens with those in fresh frozen specimens from the same tumor. The impact of PITX2 methylation on time to distant metastasis was then evaluated in FFPE specimens from hormone receptor-positive, node-negative breast cancer patients (n = 399, adjuvant tamoxifen monotherapy). RESULTS: Reproducibility of the PCR assay in replicate measurements (r(s) > or = 0.95; n = 150) and concordant measurements between fresh frozen and FFPE tissues (r(s) = 0.81; n = 89) were demonstrated. In a multivariate model, PITX2 methylation added significant information (hazard ratio = 2.35; 95% CI, 1.20 to 4.60) to established prognostic factors (tumor size, grade, and age). CONCLUSION: PITX2 methylation can be reliably assessed by real-time PCR technology in FFPE tissue. Together with our earlier studies, we have accumulated substantial evidence that PITX2 methylation analysis holds promise as a practical assay for routine clinical use to predict outcome in node-negative, tamoxifen-treated breast cancer, which might allow, based on future validation studies, the identification of low-risk patients who may be treated by tamoxifen alone.

Patterns of alphavbeta3 expression in primary and metastatic human breast cancer as shown by 18F-Galacto-RGD PET.

UNLABELLED: The integrin alpha(v)beta(3) is a key player in angiogenesis and metastasis. Our aim was to study the uptake patterns of the alpha(v)beta(3)-selective PET tracer (18)F-galacto-RGD in invasive ductal breast cancer. METHODS: Sixteen patients with primary (n = 12) or metastasized breast cancer (n = 4) were examined with (18)F-galacto-RGD PET. Standardized uptake values (SUVs) were derived by region-of-interest analysis, and immunohistochemistry of alpha(v)beta(3) expression was performed (n = 5). RESULTS: (18)F-Galacto-RGD PET identified all invasive carcinomas, with SUVs from 1.4 to 8.7 (mean +/- SD, 3.6 +/- 1.8; tumor-to-blood and tumor-to-muscle ratios, 2.7 +/- 1.6 and 6.2 +/- 2.2, respectively). Lymph-node metastases were detected in 3 of 8 patients (mean SUV, 3.3 +/- 0.8). SUVs in distant metastases were heterogeneous (2.9 +/- 1.4). Immunohistochemistry confirmed alpha(v)beta(3) expression predominantly on microvessels (5/5) and, to a lesser extent, on tumor cells (3/5). CONCLUSION: Our results suggest generally elevated and highly variable alpha(v)beta(3) expression in human breast cancer lesions. Consequently, further imaging studies with (18)F-galacto-RGD PET in breast cancer patients for assessment of angiogenesis or planning of alpha(v)beta(3)-targeted therapies are promising.

Glomus tumor of the stomach simulating a gastrointestinal stromal tumor: a case report and review of literature.

Glomus tumor is an infrequent and in most cases benign mesenchymal neoplasia which affects subcutaneous/submucosal tissue and occurs in the gastrointestinal tract, solid organs (e.g. liver, kidney) and the extremities. Visceral glomus tumor of the stomach generally presents with non-specific epigastric pain, loss of appetite and GI bleeding (melaena), often without haemodynamic instability. Macroscopic appearances on upper GI endoscopy are non-diagnostic. Endosonographic appearances are generally heterogenous and poorly-reflective, hence fail to differentiate glomus tumor from other potential diagnoses. Histological confirmation of the diagnosis is only possible when a fine needle biopsy is inclusive of abnormal tissue. These difficulties in diagnosis mean that in many cases, only immunohistochemical analysis of surgically resected tissue can distinguish glomus tumor from several possible differentials. Therefore, endoscopically-assisted laparoscopic curative wedge-resection of a lesion suspicious for glomus tumor of the upper gastrointestinal tract must be considered first-line in terms of a combined investigative and curative approach.

Adoptive transfer of autologous, HER2-specific, cytotoxic T lymphocytes for the treatment of HER2-overexpressing breast cancer.

The human epidermal growth factor receptor 2 (HER2) has been targeted as a breast cancer-associated antigen by immunotherapeutical approaches based on HER2-directed monoclonal antibodies and cancer vaccines. We describe the adoptive transfer of autologous HER2-specific T-lymphocyte clones to a patient with metastatic HER2-overexpressing breast cancer. The HLA/multimer-based monitoring of the transferred T lymphocytes revealed that the T cells rapidly disappeared from the peripheral blood. The imaging studies indicated that the T cells accumulated in the bone marrow (BM) and migrated to the liver, but were unable to penetrate into the solid metastases. The disseminated tumor cells in the BM disappeared after the completion of adoptive T-cell therapy. This study suggests the therapeutic potential for HER2-specific T cells for eliminating disseminated HER2-positive tumor cells and proposes the combination of T cell-based therapies with strategies targeting the tumor stroma to improve T-cell infiltration into solid tumors.

Identification of gene signatures for invasive colorectal tumor cells.

BACKGROUND: Gene signatures of sporadic colorectal carcinoma tissues and microdissected colorectal tumor cells were analyzed to identify stromal and tumor cell-specific markers, respectively. METHODS: Serial sections of frozen colorectal tumors (n=29) were subjected to RNA isolation of (1) entire tissue sections with a various tumor cell content and of (2) microdissected invasive tumor cells. Three matching samples of microdissected normal colorectal epithelial and invasive tumor cells were similarly obtained. RNA samples were analyzed using the HG95A and HG95Av2 GeneChip microarrays (Affymetrix). The microarray data was evaluated by established methods and validated by Q-RT-PCR. RESULTS: Unsupervised hierarchical cluster analysis of 18 sample pairs (training set) clearly distinguished tumors from microdissected tumor cells. A 149-gene signature was identified using statistical methods, which was then validated by a hierarchical clustering analysis of 11 independent sample pairs (test set). Genes specifically associated with microdissected invasive tumor cells were for example CKS2 and NME1. In contrast, genes associated with stromal cells were for example MMP2, SDF1 and FBLN2. Finally, a 65-gene signature distinguished normal colorectal epithelial cells and invasive tumor cells, including down-regulation of BMP2 and ANPEP mRNA expression as well as up-regulation of TKT, SPARC, MCM5 mRNA expression. CONCLUSIONS: Our approach allowed precise evaluation of molecular signatures in morphologically defined cell populations and identified novel target genes related to stroma-tumor interactions in colorectal cancer. The approach enables further analysis of gene signatures in different tumor areas and cell types, such as within invasive margins to decipher molecular mechanisms of colorectal cancer invasion and metastasis.

DNA-methylation of the homeodomain transcription factor PITX2 reliably predicts risk of distant disease recurrence in tamoxifen-treated, node-negative breast cancer patients--Technical and clinical validation in a multi-centre setting in collaboration with the European Organisation for Research and Treatment of Cancer (EORTC) PathoBiology group.

Our aim was to identify and validate DNA-methylation markers associated with very good outcome in node negative, hormone receptor positive breast cancer patients after adjuvant endocrine therapy which might allow identifying patients who could be spared the burden of adjuvant chemotherapy. Using a methylation microarray, we analysed 117 candidate genes in hormone receptor-positive tumours from 109 breast cancer patients treated by adjuvant tamoxifen. Results were validated in an independent cohort (n=236, 5 centres). Independent methodological validation was achieved by a real-time polymerase chain reaction (PCR)-based technique. DNA methylation of PITX2 showed the strongest correlation with distant recurrence. Its impact on patient outcome was validated in the independent cohort: 86% of patients with low PITX2 methylation were metastasis-free after 10 years, compared to 69% with elevated PITX2 methylation. Moreover, PITX2 methylation added significant independent information to established clinical factors. All clinical and technical findings were confirmed by quantitative DNA-methylation PCR. These results provide strong evidence that DNA-methylation analysis allows clinically relevant risk assessment in tamoxifen-treated primary breast cancer. Based on PITX2 methylation, about half of hormone receptor-positive, node-negative breast cancer patients receiving adjuvant tamoxifen monotherapy can be considered low-risk regarding development of distant recurrences and may thus be spared adjuvant chemotherapy. In addition, these low-risk postmenopausal patients seem to respond sufficiently well to tamoxifen so that they may not require up-front aromatase inhibitor therapy.

Sentinel lymph node biopsy in colon cancer: a prospective multicenter trial.

INTRODUCTION: The clinical impact of sentinel lymph node biopsy (SLNB) in colon cancer is still controversial. The purpose of this prospective multicenter trial was to evaluate its clinical value to predict the nodal status and identify factors that influence these results. METHODS: Colon cancer patients without prior colorectal surgery or irradiation were eligible. The sentinel lymph node (SLN) was identified intraoperatively by subserosal blue dye injection around the tumor. The SLN underwent step sections and immunohistochemistry (IHC), if classified free of metastases after routine hematoxylin and eosin examination. RESULTS: At least one SLN (median, n = 2) was identified in 268 of 315 enrolled patients (detection rate, 85%). Center experience, lymphovascular invasion, body mass index (BMI), and learning curve were positively associated with the detection rate. The false-negative rate to identify pN+ patients by SLNB was 46% (38 of 82). BMI showed a significant association to the false-negative rate (P < 0.0001), the number of tumor-involved lymph nodes was inversely associated. If only slim patients (BMI < or =24) were investigated in experienced centers (>22 patients enrolled), the sensitivity increased to 88% (14 of 16). Moreover, 21% (30 of 141) of the patients, classified as pN0 by routine histopathology, revealed micrometastases or isolated tumor cells (MM/ITC) in the SLN. CONCLUSIONS: The contribution of SLNB to conventional nodal staging of colon cancer patients is still unspecified. Technical problems have to be resolved before a definite conclusion can be drawn in this regard. However, SLNB identifies about one fourth of stage II patients to reveal MM/ITC in lymph nodes. Further studies must clarify the clinical impact of these findings in terms of prognosis and the indication of adjuvant therapy.

Tissue characterization of locoregionally advanced head-and-neck squamous cell carcinoma (HNSCC) using quantified ultrasonography: a prospective phase II study on prognostic relevance.

BACKGROUND AND PURPOSE: Information on a patient's prognosis is important for the clinical decision-making process. This study explored the capacity of quantitative ultrasound imaging to increase prognostic information. MATERIALS AND METHODS: High-resolution B-scan and colour-coded duplex-sonography of the neck was prospectively applied to 50 HNSCC-patients stage IVA-B 05/99-01/02 before definite radio-(chemo-)therapy. Every lymph node >1.5 cm was scored for the following Malignancy Criteria: Inhomogeneity, Surface-irregularity, Missing hilar sign, Spherical form, Matting, Aberrant intranodal vessels, Infiltration of surrounding tissue, Intranodal cystic necrosis. RESULTS: Median Overall Survival (OS) was 1 year. High MMCC (Maximal Malignancy Criteria Count in a single node) predicted a poor outcome with a median OS of 8.1 months (MMCC=7-8, n=24) vs. 24.7 months for low MMCC (1-6, n=26, p=0.0004, logrank). Estimated 1- and 3-year-OS was 25% and 8% for high vs. 69% and 41% for low MMCC. Ten out of eleven living patients (follow-up 2.3-5.3 years) had a low MMCC. Of the clinical parameters determined, only pre-treatment hemoglobin levels <12 g/dl and treatment less radical than chemoradiation to 70 Gy predicted poor OS (univariate p=0.04 and 0.02, respectively). In multivariate Cox analysis, MMCC continued to significantly predict for OS (p=0.002) and Disease-Free Survival (p=0.002). CONCLUSIONS: Quantification of nodal ultrasonography offers valuable prognostic information for the conservative management of HNSCC.