Direct-access to abdominal ultrasonic investigation from general practice­the role in earlier cancer diagnosis.

BACKGROUND: Abdominal ultrasound (US) is a safe and low-cost diagnostic tool for various abdominal symptoms. Direct-access to US from general practice has been suggested as a feasible option to promote earlier cancer diagnosis because abdominal cancer often presents with non-specific and vague symptoms, and the exact location may be difficult to identify on the basis of symptoms alone. OBJECTIVE: To describe patterns of use and cancer prevalence in referred patients when providing Danish GPs with direct-access to hospital-based US. METHODS: In an observational study, GPs were given the opportunity to either refer patients directly to US or through a waiting-list at Vejle Regional Hospital in Denmark; 701 patients were included between 1 August 2009 and 31 January 2010. Data were retrieved from the local Radiology Information System, GP referrals and the Danish Cancer Registry. RESULTS: GPs referred 60% of all patients to direct-access US. Cancer was diagnosed in 19 (2.7%) of the referred patients within 6 months after the US investigation. US gave rise to the suspicion of cancer in 11 of these patients (57.9%); 10 of these had been referred to direct-access US. At least one non-malignant diagnosis resulted from US in 59.5% of the cases, while 37.8% of the cases had no final diagnosis. CONCLUSION: The findings in this study might indicate that GPs refer patients assessed to have a higher risk of cancer through direct-access US. The finding was statistically non-significant, and further research is required to confirm this result.

Patients from general practice with non-specific cancer symptoms: a retrospective study of symptoms and imaging.

BACKGROUND: Patients with non-specific symptoms or signs of cancer (NSSC) present a challenge as they are a heterogeneous population who are not candidates for fast-track work-up in an organ-specific cancer pre-planned pathway (CPP). Denmark has a cancer pre-planned pathway for this population (NSSC-CPP), but several issues remain unclarified, for example, distribution and significance of symptoms and findings, and choice of imaging. AIM: To investigate symptoms, cancer diagnoses, and diagnostic yield of computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients on NSSC-CPP to improve the overall diagnostic process. DESIGN & SETTING: A retrospective medical chart review in a 1-year consecutive cohort (2020). METHOD: A total of 802 referrals were reviewed for diagnostic imaging in patients with NSSP from general practices, specialist practices, or the local hospital diagnostic centre responsible for NSSC-CPP. RESULTS: The study included 248 patients; 21% had cancer, most frequently gastrointestinal cancer (27%). The most frequent symptom was weight loss (56%). CT had a sensitivity of 85%, specificity of 87%, positive predictive value (PPV) of 65%, and negative predictive value (NPV) of 96%. For 18F-FDG-PET/CT, the numbers were sensitivity 82%, specificity 62%, PPV 33%, and NPV 94%. Patients frequently underwent subsequent examinations following initial imaging. CONCLUSION: The findings were in accordance with the literature. Patients with NSSC had a cancer prevalence of 21%, most frequently gastrointestinal. The most frequent symptom was weight loss and, even as the only symptom, it is a potential marker for cancer. CT and 18F-FDG-PET/CT were sensitive with high NPV, whereas PPV was superior in CT. Better stratification by symptoms or findings is an obvious focus point for future studies to further optimise the NSSC-CPP work-up strategy.

Cancers detected by thoracoabdominal computed tomography in patients with nonspecific symptoms.

INTRODUCTION Use of an urgent fast-track pathway comprising contrast-enhanced computed tomography (CECT) is a recognised method for diagnostic evaluation of patients with non-specific symptoms. This study focused on a subgroup of patients with non-specific symptoms who are diagnosed outside of fast-track pathways. To investigate the cancer prevalence in patients with non-specific symptoms outside of fast-track pathways undergoing a thoracoabdominal CECT. METHODSThis was a retrospective observational study including patients referred for a thoracoabdominal CECT. Patients with non-specified symptoms were included. All pathology reports were reviewed to confirm histopathological findings. Data were collected during a one-year period from the Department of Radiology, Vejle Hospital. RESULTS A total of 238 patients were included; 125 (52.5%) women and 113 (47.5%) men. The median age was 69 years (range: 29-99 years). Fifty (21%) patients (25 men and 25 women) were diagnosed with malignant conditions by computed tomography (CT), all of which were confirmed by biopsy (median age = 68 years, range: 43-87 years). An additional ten patients had CT findings consistent with malignancies that were not confirmed by biopsy (median age = 86 years, range: 58-93 years). CONCLUSION We found a 21% prevalence of cancer. FUNDING none. TRIAL REGISTRATION not relevant.

First-line treatment with bortezomib rapidly stimulates both osteoblast activity and bone matrix deposition in patients with multiple myeloma, and stimulates osteoblast proliferation and differentiation in vitro.

OBJECTIVES: The aim of the study was to investigate the effect of bortezomib on osteoblast proliferation and differentiation, as well as on bone matrix deposition for the first time in bisphosphonate-naïve, previously untreated patients with myeloma. METHODS: Twenty newly diagnosed patients received four cycles of bortezomib treatment, initially as monotherapy and then combined with a glucocorticoid from cycle two to four. Bone remodeling markers were monitored closely during treatment. Furthermore, the effects of bortezomib and a glucocorticoid on immature and mature osteoblasts were also studied in vitro. RESULTS: Treatment with bortezomib caused a significant increase in bone-specific alkaline phosphatase and pro-collagen type I N-terminal propeptide, a novel bone formation marker. The addition of a glucocorticoid resulted in a transient decrease in collagen deposition. In vitro bortezomib induced osteoblast proliferation and differentiation. Differentiation but not proliferation was inhibited by glucocorticoid treatment. CONCLUSIONS: Bortezomib used as first-line treatment significantly increased collagen deposition in patients with multiple myeloma and osteolytic lesions, but the addition of a glucocorticoid to the treatment transiently inhibited the positive effect of bortezomib, suggesting that bortezomib may result in better healing of osteolytic lesions when used without glucocorticoids in patients that have obtained remission with a previous therapy. The potential bone-healing properties of single-agent bortezomib are currently being explored in a clinical study in patients who have undergone high-dose therapy and autologous stem cell transplantation.

Predicting brain metastases of breast cancer based on serum S100B and serum HER2.

Brain metastases are a major cause of morbidity and mortality in breast cancer. The aim of the current study was to evaluate the prediction of brain metastases based on serum S100B and human epidermal growth factor receptor 2 (HER2). A total of 107 breast cancer patients were included in the current study from two prospective cohort studies with either elevated serum HER2 levels >15 ng/ml or brain metastases verified by magnetic resonance imaging (MRI) or computer tomography (CT). Following the exclusion of six patients, the remaining 101 patients were divided into two groups: Group 0 (n=55), patients with normal MRI results; and group 1 (n=46), patients with brain metastases. The levels of serum S100B and HER2 in the two groups were analyzed prior to MRI or CT of the brain, and no significant differences were identified in the serum HER2 (P=0.060) or S100B levels (P=0.623) between the groups. The univariate analysis of prognostic factors for brain metastases showed a significant correlation with systemic disease (P<0.001), axillary lymph node metastases (P=0.001) and serum HER2 >30 ng/ml (P=0.002). Only systemic disease (P<0.001) remained statistically significant in the multivariate analysis. In conclusion, serum levels of S100B and HER2 did not predict the risk of brain metastases. In the multivariate analysis, brain metastases were only found to correlate with systemic disease. However, in the univariate analysis, serum HER2 levels >30 ng/ml were identified to correlate with increased risk of brain metastases, which calls for further investigation.

Interobserver and intermodality agreement for detection of small bowel Crohn's disease with MR enterography and CT enterography.

BACKGROUND: Magnetic resonance enterography (MRE) and computed tomography enterography (CTE) visualizes small bowel Crohn's disease (CD) and its complications with high accuracy. The aim of this study was to determine the interobserver and intermodality agreement for detection of small bowel CD. METHODS: Fifty patients with suspected or known CD were included in the study and all patients underwent MRE and CTE on the same day. Four radiologists with experience in MRE and CTE techniques participated. Observers were blind to patient histories, results of ileocolonoscopies, and other small bowel examinations. Readers assessed the image quality, the presence of small bowel CD, and seven findings consistent with CD. RESULTS: The image quality was better with CTE than MRE (P < 0.001) but the diagnostic yields were comparable (P = 0.4). For detection of small bowel CD, the interobserver agreement was substantial in CTE (κ = 0.64) and moderate in MRE (κ = 0.48). The intermodality agreement was fair to substantial (κ = 0.40-0.64) for different observers. Two abscesses were detected and confirmed at subsequent surgery. One abscess was not detected with MRE and only recorded by two observers in CTE. A total of 10 fistulas were detected: three were confirmed at subsequent surgery and four were false-positive findings. CONCLUSIONS: MRE and CTE have comparable diagnostic yields in patients with suspected or known CD. However, CTE provides better image quality and interobserver agreement. In a substantial number of patients the diagnosis of small bowel CD is observer- and modality-dependent.