Metastatic Adamantinoma of the Femur on FDG PET/CT: Atypical Presentation of a Rare Disease.

ABSTRACT: Adamantinomas are rare malignant primary bone tumors, which typically arise in young patients, are generally low-grade tumors, and classically arise from the anterior tibial diaphysis. We present the case of a 70-year-old woman who underwent repeat imaging with FDG PET for a pathologically proven case of femoral adamantinoma who experienced a relatively rapid development of metastatic disease with an atypical distribution of lesions.

An observational study on the rate of reporting of adverse event on healthcare staff in a mental health setting: An application of Poisson expectation maximisation analysis on nurse staffing data.

Evidence highlights the intrinsic link between nurse staffing and expertise, and outcomes for service users of healthcare, and that workforce retention is linked to the clinical and organisational experiences of employees. However, this understanding is less well established in mental health. This study comprises a retrospective observational study carried out on routinely collected data from a large mental healthcare provider. Two databases comprising nurse staffing levels and adverse events were modelled using latent variable methods to account for the presence of multiple underlying behaviours. The analysis reveals a strong dependence of the rate of adverse events on the location and perceived clinical demand of the wards, and a reduction in adverse events where registered nurses exceed 'clinically required levels'. In the first study of its kind, these findings present significant implications for nursing workforce policy and present an opportunity to not only improve safety but potentially impact nurse retention.

A population-based study of the use of radium 223 in metastatic castration-resistant prostate cancer: Factors associated with treatment completion.

INTRODUCTION: Radium 223 (Ra223) given for six cycles has proven efficacy in clinical trials, but its population-level generalizability has not been well-described. The objectives of this study were to describe population-based Ra223 use in the abiraterone and enzalutamide era and identify factors associated with completion. METHODS: All Ra223 patients at the British Columbia Cancer Agency between September 2013 and February 2016 were identified. Patients who completed <5 vs. ≥5 cycles were compared on patient characteristics, lines of prior therapy, prostate-specific antigen (PSA) and alkaline phosphatase (ALP) decline >30% from baseline (R30%), and survival, to identify factors associated with therapy completion. RESULTS: Ninety-one patients were identified; 48 (52.7%) completed >5 cycles. Median overall survival (mOS) was 10.7 months, PSA and ALP R30% were 21% and 52%, respectively. Completion of <5 cycles was associated with higher baseline ALP (p=0.05) and lower baseline hemoglobin (Hb) levels (p=0.03). Patients in the ≥5 cycles group had longer mOS than those in the <5 cycles group (16.2 vs. 5.9 months; p<0.0001), as well as higher PSA R30% (33.3% vs. 7.0%; p=0.002) and ALP R30% (66.7% vs. 34.9%; p=0.03). Patients with ALP ≥220 and Hb ≤118 had 3.85 times the odds of not completing ≥5 cycles vs. ALP <220 and Hb >118. CONCLUSIONS: Compared to clinical trials, patients in a population-based setting had more lines of therapy and shorter survival. Lower ALP and higher hemoglobin were associated with completion of >5 cycles, longer mOS, and greater incidence of PSA and ALP response.

Incorporating quantitative single photon emission computed tomography into radiation therapy treatment planning for lung cancer: impact of attenuation and scatter correction on the single photon emission computed tomography-weighted mean dose and functional lung segmentation.

PURPOSE: To assess the impact of attenuation and scatter corrections on the calculation of single photon emission computed tomography (SPECT)-weighted mean dose (SWMD) and functional volume segmentation as applied to radiation therapy treatment planning for lung cancer. METHODS AND MATERIALS: Nine patients with lung cancer underwent a SPECT lung perfusion scan. For each scan, four image sets were reconstructed using the ordered subsets expectation maximization method with attenuation and scatter corrections ranging from none to a most comprehensive combination of attenuation corrections and direct scatter modeling. Functional volumes were segmented in each reconstructed image using 10%, 20%, …, 90% of maximum SPECT intensity as a threshold. Systematic effects of SPECT reconstruction methods on treatment planning using functional volume were studied by calculating size and spatial agreements of functional volumes, and V(20) for functional volume from actual treatment plans. The SWMD was calculated for radiation beams with a variety of possible gantry angles and field sizes. RESULTS: Functional volume segmentation is sensitive to the particular method of SPECT reconstruction used. Large variations in functional volumes, as high as >50%, were observed in SPECT images reconstructed with different attenuation/scatter corrections. However, SWMD was less sensitive to the type of scatter corrections. SWMD was consistent within 2% for all reconstructions as long as computed tomography-based attenuation correction was used. CONCLUSION: When using perfusion SPECT images during treatment planning optimization/evaluation, the SWMD may be the preferred figure of merit, as it is less affected by reconstruction technique, compared with threshold-based functional volume segmentation.

Impact of F-18 fluorodeoxyglucose positron emission tomography-computed tomography on oncologic patient management: first 2 years' experience at a single Canadian cancer center.

PURPOSE: The purpose of this study was to assess the influence of positron emission tomography-computed tomography (PET-CT) results on patient management from a single Canadian oncology center during its first 2 years of operation. METHODS: A total of 3,779 consecutive patients, 18 years of age and older, who were referred for PET-CT imaging at the British Columbia Cancer Agency between July 1, 2005 and June 30, 2007, were included in this analysis. Results were tabulated from a standard questionnaire, which was given to referring physicians following completion of their patient's PET-CT study. RESULTS: From July 1, 2005 to June 30, 2007, 3,779 consecutive fluoro-2-deoxyglucose PET-CT examinations were performed in patients aged 18 years or older. A total of 3,429 referring-physician surveys (90.7%) were returned. The results of the PET-CT study resulted in a change in treatment decision in 49.8% of the studies and resulted in improved decision making in 83.2% of the studies. CONCLUSION: This series demonstrated that the results from PET-CT studies performed at a single Canadian oncology center during the first 2 years of its operation altered patient management in 50% of cases and resulted in improved decision making in the majority of cases.

Role of radionuclide imaging in the orthopedic patient.

Since its introduction more than 40 years ago, nuclear medicine has played an important role in the diagnosis and detection of soft tissue and skeletal disorders. Skeletal scintigraphy or bone scanning is a diagnostic study used to evaluate the distribution of osteoblastic activity or active bone formation within the body. Because no single imaging technique is ideal in all clinical situations, selecting an appropriate imaging test depends on understanding the pathophysiology of the suspected condition and limitations of each technique. This article provides a brief overview of bone scintigraphy, infection imaging, and positron emission tomography in the context of current, adult orthopedic practice.

Effect of patient location on the performance of clinical models to predict pulmonary embolism.

INTRODUCTION: Current clinical likelihood models for predicting pulmonary embolism (PE) are used to categorize outpatients into low, intermediate and high clinical pre-test likelihood of PE. Since these clinical prediction rules were developed using outpatients it is not known if they can be applied universally to both inpatients and outpatients with suspected PE. Thus, the purpose of this study was to determine the effect of patient location on the performance of clinical models to predict PE. MATERIALS AND METHODS: Two clinical models (Wells and Wicki) were applied to data from the multi-centered PIOPED study. The Wells score was applied to 1359 patients and the Wicki score was applied to 998 patients. 361 patients (27%) from the PIOPED study did not have arterial gas measurement and were excluded from the Wicki score patient group. Patients were stratified by their location at the time of entry into the PIOPED study as follows: outpatient/emergency, surgical ward, medicine/coronary care unit or intensive care unit. The diagnostic performance of the two clinical models was applied to the various patient locations and the performance was evaluated using the area under a fitted receiver operating characteristic curve (AUC). RESULTS: The prevalence of PE in the three clinical probability categories were similar for the two scoring methods. Both clinical models yielded the lowest diagnostic performance in patients referred from surgical wards. The AUC for both clinical prediction rules decreased significantly when applied to inpatients in comparison to outpatients. CONCLUSIONS: Current clinical prediction rules for determining the pre-test likelihood of PE yielded different diagnostic performances depending upon patient location. The performance of the clinical prediction rules decreased significantly when applied to inpatients. In particular, the rules performed least well when applied to patients referred from surgical wards suggesting these rules should not be used in this patient group. As expected the clinical prediction rules performed best in outpatients with the optimum diagnostic performance in patients referred from emergency and outpatient wards.

The value of FDG positron emission tomography in the management of patients with breast cancer.

Increasing experience with positron emission tomography (PET) scanning in breast cancer patients is revealing a significant role for this imaging modality. This report summarizes the experience of 2-[F18]fluoro-2-deoxy-D-glucose (FDG) PET scanning in 165 breast cancer patients from the BC Cancer Agency, British Columbia, Canada, and reviews the literature on this topic. Using the database at PETSCAN Vancouver, we identified imaged patients with a diagnosis of breast cancer. We then conducted a retrospective review of these patients' BC Cancer Agency charts to extract demographic and follow-up information. Between November 2000 and March 2003 we identified 165 patients with histologically confirmed breast cancer who had undergone PET scanning, were registered at the BC Cancer Agency, and had follow-up information. The median patient age was 52 years. The sensitivity of PET in detecting axillary metastases was 28%, and the specificity was 86%. At diagnosis, 5% of patients were diagnosed with distant metastases. In patients undergoing PET scanning because of suspected recurrence, the sensitivity and specificity for detecting recurrence were 89% and 88%, respectively. Distant metastases were demonstrated in 30% of patients who were thought only to have local-regional recurrence. The results suggest that there are two clinical situations in which PET appears to be particularly valuable. The first is in the evaluation of patients who are suspected of having a tumor recurrence. The other is in identifying patients with multifocal or distant sites of malignancy who otherwise appear to have an isolated, potentially curable, local-regional recurrence.

Radionuclide imaging of acute pulmonary embolism.

Pulmonary embolism (PE) is a potentially fatal condition for which treatment is highly effective. The diagnosis of PE can be challenging and often requires diagnostic imaging. For many years, chest radiographs and ventilation-perfusion (V/Q) scintigraphy have been the primary imaging modalities used in the evaluation of patients with suspected acute PE. The combination of clinical assessment, plus results of V/Q scintigraphy and a noninvasive venous study of the lower extremities can provide clinicians with the information needed to direct treatment in the majority of patients with suspected PE. More recently, advances in computerized tomography (CT) angiography have allowed for the direct visualization of PE, and this technique has emerged as an important diagnostic test in the evaluation of patients with suspected PE. Proponents suggest that CT angiography should be used as the first line imaging test in patients with suspected PE. Others suggest that V/Q scanning should remain as the first line diagnostic imaging test and that CT angiography should be used in patient's in whom the diagnosis remains uncertain. The combination of CT angiography and CT venography has the potential to provide a single comprehensive study of patients with suspected venous thromboembolism.