Venous Arterialisation for Salvage of Critically Ischaemic Limbs: A Systematic Review and Meta-Analysis.

BACKGROUND: Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life. For CLI patients with no revascularisation options, venous arterialisation could be a last resort for limb salvage. OBJECTIVE: To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options. METHOD: Different databases were searched for papers published between January 1966 and January 2016. The criteria for eligible articles were studies describing outcomes of venous arterialisation, published in English, human studies, and with the full text available. Additionally, studies were excluded if they did not report limb salvage, wound healing or amputation as outcome measures. The primary outcome measure was post-operative limb salvage at 12 months. Secondary outcome measures were 30 day or in-hospital mortality, survival, patency, technical success, and wound healing. RESULTS: Fifteen articles met the inclusion criteria. The included studies described 768 patients. According to the MINORS score, methodological quality was moderate to poor. The estimated pooled limb salvage rate at one year was 75% (0.75, 95% CI 0.70-0.81). Thirty day or in-hospital mortality was reported in 12 studies and ranged from 0 to 10%. Overall survival was reported in 10 studies and ranged from 54% to 100% with a mean follow-up ranging from 5 to 60 months. Six studies reported on patency of the venous arterialisations performed, with a range of 59-71% at 12 months. CONCLUSION: In this systematic review on venous arterialisation in patients with non-reconstructable critical limb ischaemia, the pooled proportion of limb salvage at 12 months was 75%. Venous arterialisation could be a valuable treatment option in patients facing amputation of the affected limb; however, the current evidence is of low quality.

Metabolic activity measured by FDG PET predicts pathological response in locally advanced superior sulcus NSCLC.

OBJECTIVES: Pathological complete response and tumor regression to less than 10% vital tumor cells after induction chemoradiotherapy have been shown to be prognostically important in non-small cell lung cancer (NSCLC). Predictive imaging biomarkers could help treatment decision-making. The purpose of this study was to assess whether postinduction changes in tumor FDG uptake could predict pathological response and to evaluate the correlation between residual vital tumor cells and post-induction FDG uptake. METHODS: NSCLC patients with sulcus superior tumor (SST), planned for trimodality therapy, routinely undergo FDG PET/CT scans before and after induction chemoradiotherapy in our institute. Metabolic end-points based on standardized uptake values (SUV) were calculated, including SUV(max) (maximum SUV), SUV(TTL) (tumor-to-liver ratio), SUV(peak) (SUV within 1 cc sphere with highest activity), and SUV(PTL) (peak-to-liver ratio). Pathology specimens were assessed for residual vital tumor cell percentages and scored as no (grade 3), <10% (grade 2b) and >10% vital tumor cells (grade 2a/1). RESULTS: 19 and 23 patients were evaluated for (1) metabolic change and (2) postinduction PET-pathology correlation, respectively. Changes in all parameters were predictive for grade 2b/3 response. ΔSUV(TTL) and ΔSUV(PTL) were also predictive for grade 3 response. Remaining vital tumor cells correlated with post-induction SUV(peak) (R=0.55; P=0.007) and postinduction SUV(PTL) (R=0.59; P=0.004). Postinduction SUV(PTL) could predict both grades 3 and 2b/3 response. CONCLUSION: In NSCLC patients treated with chemoradiotherapy, changes in SUV(max), SUV(TTL), SUV(peak), and SUV(PTL) were predictive for pathological response (grade 2b/3 and for SUV(TTL) and SUV(PTL) grade 3 as well). Postinduction SUV(PTL) correlated with residual tumor cells.

Semiautomated volumetric response evaluation as an imaging biomarker in superior sulcus tumors.

BACKGROUND: Volumetric response to therapy has been suggested as a biomarker for patient-centered outcomes. The primary aim of this pilot study was to investigate whether the volumetric response to induction chemoradiotherapy was associated with pathological complete response (pCR) or survival in patients with superior sulcus tumors managed with trimodality therapy. The secondary aim was to evaluate a semiautomated method for serial volume assessment. METHODS: In this retrospective study, treatment outcomes were obtained from a departmental database. The tumor was delineated on the computed tomography (CT) scan used for radiotherapy planning, which was typically performed during the first cycle of chemotherapy. These contours were transferred to the post-chemoradiotherapy diagnostic CT scan using deformable image registration (DIR) with/without manual editing. RESULTS: CT scans from 30 eligible patients were analyzed. Median follow-up was 51 months. Neither absolute nor relative reduction in tumor volume following chemoradiotherapy correlated with pCR or 2-year survival. The tumor volumes determined by DIR alone and DIR + manual editing correlated to a high degree (R(2) = 0.99, P < 0.01). CONCLUSION: Volumetric response to induction chemoradiotherapy was not correlated with pCR or survival in patients with superior sulcus tumors managed with trimodality therapy. DIR-based contour propagation merits further evaluation as a tool for serial volumetric assessment.

[A woman with palpitations and dysphagia]. / Een vrouw met palpitaties en passageklachten.

A 55-year-old female experienced palpitations and thoracic pain. Coronary angiography showed a right sided aorta. The patient was diagnosed with a Kommerell's diverticulum that compressed the esophagus and trachea. During follow-up she developed dysphagia and she underwent a transposition of the left subclavian artery to the left common carotid artery followed by endovascular treatment of the distal aortic arch and thereby excluding the diverticulum.

Trimodality therapy for superior sulcus tumours: evolution and evaluation of a treatment protocol.

AIM: We studied the clinical outcomes of a trimodality protocol used for the treatment of superior sulcus tumours (SST) in a tertiary referral centre. METHODS: The details of all patients who underwent treatment for a SST between January 2003 and December 2009 were retrospectively analysed. Following pre-treatment staging, all patients underwent concurrent chemoradiotherapy with cisplatin/etoposide, followed by surgery. Outcomes studied were treatment-related complications, pathological response rates, recurrence rates and survival. RESULTS: Fifty-four patients were treated by chemotherapy (cisplatin/etoposide) and concurrent radiotherapy (46-66 Gy) followed by surgical resection. Minimum follow-up was 23 months. No 30-day mortality was observed. A complete (R0) resection was performed in 44 out of 54 patients. None had an R2 resection. Two-year survival was 50% (95%CI: 36.7-63.3). Patients who achieved a pathological complete response (n = 16) had a 2-year survival of 81% (95%CI: 62.1-100.0) versus a 37% 2-year survival (95%CI: 21.5-52.1) in patients with remaining vital tumour in their resection specimens (n = 38; P = 0.003). Five patients developed a local recurrence, and 23 patients a distant metastasis, mainly to the brain (n = 15). Two patients died from causes unrelated to cancer. CONCLUSIONS: Trimodality treatment of SST in accordance to our protocol achieved results comparable to previous reports. Pathological response rates to induction were an important prognostic factor, and distant metastasis remains a major problem.

[Treatment and prognosis of superior sulcus tumours]. / Behandeling en prognose van sulcus-superiortumoren.

Superior sulcus tumours (or Pancoast tumours) are non-small-cell lung carcinomas presenting with specific symptoms and requiring a specific approach to treatment due to their location in the pulmonary apex. Early recognition is rare as a result of the low incidence and the relatively late occurrence of symptoms .Shoulder pain, with or without radiation to the ipsilateral arm or hand, and Horner's syndrome are often presenting symptoms. The current standard of care for patients with resectable tumours is pre-operative chemoradiotherapy, followed by resection of the tumour and affected surrounding structures. This is associated with 5-year survival rates of more than 50%. Invasion of local structures, the presence of mediastinal lymph node metastases and, in a select group of patients, distant metastasis, are not necessarily contra-indications for surgical resection. Patients who have undergone complete resection, or demonstrate a pathologically complete response after induction therapy, have significantly higher survival rates. Treatment of superior sulcus tumours requires a multidisciplinary approach; considering the complexity of the treatment, patients should be referred to a specialised centre.

Clinical applications of FDG-probe guided surgery.

BACKGROUND: For a definitive diagnosis in many oncological, inflammatory and infectious diseases histological examination is required. Non-palpable lesions detected with PET/CT scanning that cannot be localized with conventional imaging methods can be localized and excised using FDG-probe guided surgery. We describe the application of FDG-probe guided surgery in 9 patients. METHODS: The application of FDG-probe guided surgery used in 9 consecutive patients with oncological and infectious diseases is described. Four hours before surgery, 3.5 MBq/Kg body weight FDG was intravenously administered after which a FDG-PET-scan was performed to confirm the FDG-avid lesion(s). The lesions with highest activity were detected with the FDG-probe and the lesions were subsequently excised and sent for histopathological examination. RESULTS: In all of the 9 cases the target lesion was successfully identified and subsequently removed. When multiple and/or macroscopically normal lymph nodes were found, the use of the FDG-probe allowed selection of the PET-avid lymph nodes for resection. CONCLUSION: FDG-probe guided surgery is a relatively simple surgical technique to identify and excise FDG-accumulating suspicious lesions in oncological, inflammatory and infectious diseases.

A rare pulmonary infection caused by Arthrographis kalrae.

Arthrographis kalrae is a rare isolate in clinical specimens. Only ten cases of infection with this species have been described so far. To our knowledge, we report the first case of a pulmonary infection caused by A. kalrae in a patient with a past history of stage IIA Hodgkin's lymphoma and demonstrate that this organism can act as an opportunistic human pathogen.

Physical activity and 5-year cognitive decline in the Doetinchem cohort study.

PURPOSE: It is hypothesized that the intensity of physical activity habits, rather than the time spent on those activities, might mediate cognitive function. This study tested a possible association between changes in the time spent on or the average intensity of weekly physical activities and changes in cognitive function in healthy men and women. METHODS: This longitudinal cohort study with 1,904 healthy men and women (45-75 years of age) assessed physical activity by a questionnaire and cognitive function with a neuropsychological test battery twice with an interval of 5 years. RESULTS: Multiple linear regression analyses showed that changes in the time spent on physical activities were not associated with changes in cognitive function over a 5-year period. By contrast, changes in average intensity of weekly activities were significantly and positively associated with processing speed (beta = 0.063; p < 0.05). CONCLUSIONS: In this longitudinal cohort study, an increase or smaller decline in average intensity was associated with a smaller age-related decline in processing speed, estimated at 6 years of aging.

Heterotopic gastric mucosa in the duodenal bulb: relationship to peptic ulcer.

Heterotopic gastric mucosa in the duodenal bulb causes a characteristic radiologic abnormality consisting of multiple small, well-defined nodules in the mucosa. This finding was identified in 92 (5%) of 1873 consecutive standard biphasic barium examinations of the upper gastrointestinal tract. Of these 92, only one patient (1%) had an associated duodenal ulcer as compared with the other 1781 patients without heterotopic gastric mucosa of whom 225 (13%) had duodenal ulcers or scars (p = .002). No gastric ulcers or ulcer scars were identified in the patients with heterotopic gastric mucosa, whereas ulcers or scars were identified in 88 patients (5%) without heterotopic gastric mucosa (p = .05). These data raise the possibility that heterotopic gastric mucosa protects against peptic ulceration.