External ultrasonography of the neck does not add diagnostic value to integrated positron emission tomography-computed tomography (PET-CT) scanning in the diagnosis of cervical lymph node metastases in patients with esophageal carcinoma.

One of the objectives of preoperative imaging in esophageal cancer patients is the detection of cervical lymph node metastases. Traditionally, external ultrasonography of the neck has been combined with computed tomography (CT) in order to improve the detection of cervical metastases. In general, integrated positron emission tomography-computed tomography (PET-CT) has been shown to be superior to CT or PET regarding staging and therefore may limit the role of external ultrasonography of the neck. The objective of this study was to determine the additional value of external ultrasonography of the neck to PET-CT. This study included all patients referred our center for treatment of esophageal carcinoma. Diagnostic staging was performed to determine treatment plan. Cervical lymph nodes were evaluated by external ultrasonography of the neck and PET-CT. In case of suspect lymph nodes on external ultrasonography or PET-CT, fine needle aspiration (FNA) was performed. Between 2008 and 2010, 170 out of 195 referred patients underwent both external ultrasonography of the neck and PET-CT. Of all patients, 84% were diagnosed with a tumor at or below the distal esophagus. In 140 of 170 patients, the cervical region was not suspect; no FNA was performed. Seven out of 170 patients had suspect nodes on both PET-CT and external ultrasonography. Five out of seven patients had cytologically confirmed malignant lymph nodes, one of seven had benign nodes, in one patient FNA was not performed; exclusion from esophagectomy was based on intra-abdominal metastases. In one out of 170 patients, PET-CT showed suspect nodes combined with a negative external ultrasonography; cytology of these nodes was benign. Twenty-two out of 170 patients had a negative PET-CT with suspect nodes on external ultrasonography. In 18 of 22 patients, cervical lymph nodes were cytologically confirmed benign; in four patients, FNA was not possible or inconclusive. At a median postoperative follow-up of 15 months, only 1% of patients developed cervical lymph node metastases. This study shows no additional value of external ultrasonography to a negative PET-CT. According to our results, it can be omitted in the primary workup. However, suspect lymph nodes on PET-CT should be confirmed by FNA to exclude false positives if it would change treatment plan.

Outcome of patients after cardiac surgery transferred to other hospitals following prolonged intensive care stay.

BACKGROUND: The steady rise in complex cardiac procedures as well as the increase in comorbidity often result in a prolonged intensive care unit (ICU) stay. As a consequence, considerable numbers of patients have to be transferred to other hospitals so that the primary institution can maintain its capacity. The purpose of this study was to investigate the outcome of these patients. METHODS: 1,175 consecutive patients underwent various open heart procedures. 115 patients (9.8 %) requiring prolonged ICU treatment were retrospectively analyzed. 74 patients (EuroSCORE 8.1) underwent transferral to either rehabilitation units with ventilation capacity, multidisciplinary ICUs, or cardiac ICUs. 41 patients (EuroSCORE 7.9) remained in our hospital. Morbidity, mortality, and clinical condition were assessed and compared. RESULTS: Transferred patients exhibited an overall mortality of 38 % compared to only 17 % in patients who remained. Mortality was 81 % in rehabilitation units, 30 % in multidisciplinary ICUs, and 16 % in cardiac ICUs. 66 % of the survivors among the transferred patients showed significantly impaired clinical condition (NYHA III-IV) compared to 33 % who showed a good postoperative condition (NYHA I-II). The patients who remained exhibited 44 % NYHA III-IV and 56 % NYHA I-II. CONCLUSION: Transferral of patients after prolonged intensive care stay to external hospitals carries significant risks for early death and impaired outcome. However, transferral to cardiac ICUs appears to be an adequate option. Further studies may identify potential subgroups of patients who do not benefit from transferral.

Preoperative diagnosis of ovarian tumors with MR imaging: comparison with transvaginal sonography, positron emission tomography, and histologic findings.

OBJECTIVE: Our study evaluated the diagnostic performance of MR imaging compared with that of transvaginal sonography and positron emission tomography (PET) in patients with clinically asymptomatic adnexal findings. An additional goal was to determine whether the combination of the three methods enhanced their diagnostic accuracy. SUBJECTS AND METHODS: Included in the study were 103 women with suspicious adnexal findings on sonography. Patients underwent transvaginal sonography, MR imaging, and PET within 3 weeks of the initial sonography. For MR imaging, axial and sagittal T1-weighted gradient-echo sequences (unenhanced and enhanced) and T2-weighted turbo-spin-echo sequences were acquired. Transvaginal sonography was performed with a 7.5-MHz transducer head. For PET, a modern full-ring scanner was used. The results of diagnostic imaging techniques were first evaluated separately, and reviewers were blinded to the results of other methods. Finally, a second session resulted in a consensus diagnosis based on the findings of all three methods. Results of histology were considered the gold standard. RESULTS: Histology revealed 12 malignant and 91 benign ovarian tumors. The following data were calculated for MR imaging, transvaginal sonography, PET, and consensus diagnosis: sensitivities, 83%, 92%, 58%, 92%; specificities, 84%, 59%, 78%, 84%; diagnostic accuracies, 83%, 63%, 76%, 85%, respectively. MR imaging, particularly with contrast-enhanced fat-saturated T1-weighted sequences, was found to correctly reveal dermoid and endometrial cysts. All three methods had false-negative findings with borderline tumors. CONCLUSION: Transvaginal sonography is the diagnostic method of choice as a screening technique for ovarian processes. Suspicious findings on transvaginal sonography should be confirmed on MR imaging. If MR imaging confirms a dermoid or endometrial cyst, further diagnostic procedures may be unnecessary. In all other cases, a surgical evaluation must be considered.

Classification of asymptomatic adnexal masses by ultrasound, magnetic resonance imaging, and positron emission tomography.

OBJECTIVE: The purpose of this study was to determine the diagnostic accuracy of sonography versus magnetic resonance imaging (MRI) and positron emission tomography (PET) in the characterization of adnexal masses. METHODS: One hundred and one patients with asymptomatic adnexal masses, which were scheduled for laparoscopy, underwent preoperative transvaginal ultrasound, MRI, and 2-[(18)F]fluoro-2-deoxy-d-glucose PET. Two different sonomorphological scoring systems were used to distinguish malignant from benign lesions. In addition, transvaginal Doppler flow velocimetry was performed and the resistance index (RI) of ovarian blood vessels was calculated. RI values below 0.45 were considered to indicate malignancy. MRI was evaluated on the basis of signal intensity and morphologic features such as wall thickness, septations, fluid or solid components, and vascularity. PET imaging was used to determine 2-[(18)F]fluoro-2-deoxy-D-glucose uptake. Malignancy was suspected if radiotracer uptake equaled or exceeded that of the liver. Based on histologic findings, sensitivity, specificity, positive and negative predictive values, and accuracy were first calculated independently for each imaging technique. Finally, a second session resulted in a consensus diagnosis being made based on the findings of all three modalities. RESULTS: Sonographic evaluation of adnexal masses resulted in correct classification of 11 of 12 ovarian malignancies (sensitivity 92%) but with a specificity of only 60%. With MRI and PET, specificities improved to 84 and 80% respectively, but sensitivities decreased. When all imaging modalities were combined, sensitivity and specificity were 92 and 85%, respectively, and accuracy was 86%. CONCLUSION: Combination of ultrasound with MRI and PET may improve accuracy in differentiation of benign from malignant ovarian lesions. However, negative MRI or PET results do not rule out early-stage ovarian cancer or borderline malignancies.

[Preoperative assessment of asymptomatic adnexal tumors by positron emission tomography and F 18 fluorodeoxyglucose]. / Präoperative Dignitätsbeurteilung asymptomatischer Adnextumoren mittels Positronen-Emissions-Tomographie und F-18-Fluordeoxyglukose.

AIM: To evaluate use of F-18-FDG-PET in assessment of dignity of asymptomatic adnexal masses. METHODS: 85 asymptomatic patients with suspicious, asymptomatic adnexal masses were evaluated. Static FDG-PET (Exact HR+ or ECAT 931) imaging of the abdomen was performed following application of 222-555 MBq F-18-FDG. Iterative reconstruction was applied. PET data were analysed visually, at first without and second together with MRT images. Final diagnosis was made by histopathology. RESULTS: FDG-PET allowed correct identification of 4 of 8 malignant adnexal tumors. False negative results were obtained in 2 adenocarcinomas stage pT1a and 2 borderline-tumors. In 60 out of 77 benign adnexal masses malignancy could be excluded. False positive FDG-uptake, partly because of misinterpretation of gastrointestinal activity, was found in 3 inflammatory processes, 1 teratoma, 1 benign schwannoma, 1 dermoid cyst, 1 benign thecoma, 1 serous cyst, 1 serous cystadenoma, 2 mucinous cystadenomas, 2 corpus luteum cysts, 3 endometriosic cysts and 1 sactosalpinx. The overall sensitivity and specificity of FDG-PET alone were 50% and 78%. Evaluation together with MRT images showed a sensitivity of 50% and a specificity of 86%. CONCLUSION: Sensitivity of FDG-PET in detection of borderline-tumors and early stage ovarian cancer seems to be limited. Low incidence of malignant ovarian tumors requires for assessment of dignity a procedure of high specificity, that is not reached by FDG-PET neither without nor together with MRT images for topographic orientation. Therefore use of FDG-PET for assessment of dignity in suspicious, asymptomatic ovarian tumors is limited.