Whole-body magnetic resonance imaging for detection of skeletal metastases in children and young people with primary solid tumors - systematic review.

BACKGROUND: Many solid neoplasms have a propensity for osteomedullary metastases of which detection is important for staging and subsequent treatment. Whole-body magnetic resonance imaging (WB-MRI) has been shown to accurately detect osteomedullary metastases in adults, but these findings cannot be unconditionally extrapolated to staging of children with malignant solid tumors. OBJECTIVE: To conduct a literature review on the sensitivity of WB-MRI for detecting skeletal metastases in children with solid tumors. MATERIALS AND METHODS: Searches in MEDLINE and EMBASE databases up to 15 May 2017 were performed to identify studies on the diagnostic value of WB-MRI. Inclusion criteria were children and adolescents (age <21 years) with a primary solid tumor who were evaluated for skeletal metastases by WB-MRI and compared to any type of reference standard. The number of included patients had to be at least five and data on true positives, true negatives, false-positives and false-negatives had to be extractable. RESULTS: Five studies including 132 patients (96 patients with solid tumors) were eligible. Patient groups and used reference tests were heterogeneous, producing unclear or high risk of bias. Sensitivity of WB-MRI ranged between 82% and 100%. The positive predictive value of WB-MRI was variable among the studies and influenced by the used reference standard. CONCLUSION: Although WB-MRI may seem a promising radiation-free technique for the detection of skeletal metastases in children with solid tumors, published studies are small and too heterogeneous to provide conclusive evidence that WB-MRI can be an alternative to currently used imaging techniques.

Presacral masses in children: presentation, aetiology and risk of malignancy.

AIM: The risk of malignant changes in presacral tumours in children was investigated in relation to age at diagnosis, type of presentation and origin of the tumour. METHOD: A retrospective review was carried out in 17 patients surgically treated for congenital presacral masses over a 22-year period. RESULTS: Constipation was the main symptom in 14 (82%) of 17 patients. The lesions were evident on digital examination in 14 patients. Mature teratoma (n = 9, 64%) was the most common lesion, including three malignancies. Currarino syndrome was diagnosed in 10 (71%) patients. Two unclassified variant HLXB9 gene mutations were found in five (29%) patients who underwent genetic testing. CONCLUSION: Congenital presacral tumours in children were mostly mature teratomas, either as sacrococcygeal teratomas or as part of the Currarino syndrome. The risk of malignancy in patients older than 1 year necessitates early surgical resection.

Computed radiography versus mobile direct radiography for bedside chest radiographs: impact of dose on image quality and reader agreement.

AIM: To asses the image quality and potential for dose reduction of mobile direct detector (DR) chest radiography as compared with computed radiography (CR) for intensive care unit (ICU) chest radiographs (CXR). METHODS AND MATERIALS: Three groups of age-, weight- and disease-matched ICU patients (n=114 patients; 50 CXR per acquisition technique) underwent clinically indicated bedside CXR obtained with either CR (single read-out powder plates) or mobile DR (GOS-TFT detectors) at identical or 50% reduced dose (DR(50%)). Delineation of anatomic structures and devices used for patient monitoring, overall image quality and disease were scored by four readers. In 12 patients pairs of follow-up CR and DR images were available, and in 15 patients pairs of CR and DR(50%) images were available. In these pairs the overall image quality was also compared side-by-side. RESULTS: Delineation of anatomy in the mediastinum was scored better with DR or DR(50%) than with CR. Devices used for patient monitoring were seen best with DR, with DR(50%) being superior to CR. In the side-by-side comparison, the overall image quality of DR and DR(50%) was rated better than CR in 96% (46/48) and 87% (52/60), respectively. Inter-observer agreement for the assessment of pathology was fair for CR and DR(50%) (κ = 0.33 and κ = 0.39, respectively) and moderate for DR (κ = 0.48). CONCLUSION: Mobile DR units offer better image quality than CR for bedside chest radiography and allow for 50% dose reduction. Inter-observer agreement increases with image quality and is superior with DR, while DR(50%) and CR are comparable.

Diagnostic strategies in non-palpable breast lesions.

The number of non-palpable breast lesions is growing. Needle-localised breast biopsy (NLBB) is the gold standard for evaluating these lesions. Cost-saving techniques and less invasive alternatives such as core-needle biopsy (LCNB) and fine-needle aspiration (FNA) have emerged. The aim of this study was to find out if the lesions of patients who were sent directly for surgery to undergo a NLBB differed from lesions of patients who were send for a non-operative procedure. Furthermore, if a benign result was obtained, we assessed the total and kind of subsequent diagnostic procedures that were undertaken. A retrospective study on 718 women with 749 non-palpable breast lesions was performed. In 58% of women with non-palpable breast lesion, a non-surgical procedure was chosen. Lesions sent directly for surgery were more frequently not visible on ultrasound (62%) and mainly consisted of microcalcifications only (56%). In 45%, this primary surgical approach could have been avoided. If the non-operative procedure showed a non-malignant result, 41% of these women received an additional surgical diagnostic procedure. These figures obtained from routine daily practice show the importance of protocols in order to standardise diagnostic procedures and prevent unnecessary surgery.

Reduction in the number of sentinel lymph node procedures by preoperative ultrasonography of the axilla in breast cancer.

Currently, breast cancer patients without clinically suspicious lymph nodes are candidates for sentinel lymph node procedures (SLNPs). The aims of this study were to investigate whether preoperative axillary ultrasonography and fine-needle aspiration cytology (FNA) can reduce the number of the more time-consuming SLNPs, and to identify a subset of quantitative nodal features to predict metastatic involvement. 268 axillae were ultrasonographically examined. FNA was performed on suspicious nodes (smallest diameter > or =5 mm or atypical cortex appearance). SLNP was omitted if a tumour-positive node was found on FNA. Length, width, maximum cortex thickness and appearance of cortex and hilus were ultrasonographically established. In 93 axillae (35%), at least one node was detected with ultrasound. FNA was performed once per axilla on 66 nodes; 37 (56%) contained tumour cells. 31% of all tumour-positive axillae (macro-+micrometastases) was found by ultrasound and FNA (37/121). 41% of all axillae containing macrometastases was found by ultrasound and FNA (36/87). SLNPs were reduced by 14% (37/268). Maximum cortex thickness is the main feature to predict metastatic involvement (area under Receiver Operating Characteristic (ROC) curve (A(Z))=0.87).

Displacement of breast tissue and needle deviations during stereotactic procedures.

RATIONALE AND OBJECTIVES: The aim of this study was to quantify the displacement of breast tissue and the inaccuracy of needle positioning for biopsy (14-gauge) and localization (19.5-gauge) needles. METHODS: For displacement of breast tissue, differences between the coordinates of identifiable microcalcifications in the images before (baseline) and after needle positioning were analyzed (n = 52). For accuracy of needle positioning, differences between the coordinates of the needle tip and the target were analyzed in breast tissue (n = 97) and in air (n = 246). RESULTS: Average target displacement was 2.1 mm for biopsy needles (95% prediction interval [PI] 0.6-7.8) and 1.0 mm (95% PI 0.3-3.9) for localization needles. Mean inaccuracy of needle positioning in breast tissue was 1.1 mm (95% PI 0.4-3.0) and 1.8 mm (95% PI 0.7-4.6) for biopsy and localization needles, respectively. CONCLUSIONS: Tissue and needle displacements cause a total positioning error of 2.4 mm in stereotactic core biopsy, which will limit the attainable diagnostic accuracy.

Percutaneous radiological gastrostomy in patients with head and neck cancer.

AIM: To evaluate the results of percutaneous radiological gastrostomy in patients with head and neck cancer. PATIENTS AND METHODS: This was a retrospective study design. One hundred and eighteen patients with head and neck cancer were referred 130 times for gastrostomy tube placement between 1 April 1993 and 17 August 1998. Mean age was 60 years. All data were analysed by using the following parameters: success rate, complications and mortality. Complications were divided into major, minor (complication that needed only conservative treatment) and tube-related. RESULTS: The success rate of percutaneous radiological gastrostomy was 97%. Major complications occurred in 6% of patients after gastrostomy tube placement. Minor complications occurred in 15% of patients. There was one tube-related complication. Procedure-related mortality occurred in one patient. The results of this study show no difference from those known from the literature for the percutaneous method and confirm that radiological gastrostomy has significantly lower rates of major complications than other methods of gastrostomy placement. CONCLUSION: Percutaneous radiological gastrostomy tube placement is, in our opinion, an effective and reliable method for placing a feeding tube in patients with head and neck cancer.

Screening for distant metastases in patients with head and neck cancer.

OBJECTIVES: The detection of distant metastases at initial evaluation may alter the selection of therapy in patients with head and neck squamous cell carcinoma (HNSCC). In this study the value of screening for distant metastases is evaluated. STUDY DESIGN: Retrospective analysis. METHODS: The results of screening for distant metastases were retrospectively analyzed in 101 consecutive HNSCC patients with high-risk factors who were scheduled for major surgery. All patients had computed tomography (CT) scan of the thorax, bone scintigraphy, examination of the liver by ultrasound and/or CT scan, and blood tests. RESULTS: Distant metastases were found in 17% of the patients. Patients with four or more clinical lymph node metastases or low jugular lymph node metastases had the highest incidence of distant metastases (33%). CT scan of the thorax detected in 12 patients, lung metastases; in 4, mediastinal lymph node metastases; and in 2, primary lung tumors. Bone scintigraphy detected in four patients bone metastases; in all four patients lung or mediastinal lymph node metastases were also found. Ultrasound and/or CT scan of the liver revealed one patient with metastases. Blood tests did not show any significant difference between patients with or without bone or liver metastases. CONCLUSIONS: Screening in patients with three or more lymph node metastases, bilateral lymph node metastases, lymph nodes of 6 cm or larger, low jugular lymph node metastases, locoregional tumor recurrence, and second primary tumors revealed distant metastases in 10% or more. CT scan of the thorax is currently the single most important diagnostic technique for screening of distant metastases.

Radio-guided surgery improves outcome of therapeutic excision in non-palpable invasive breast cancer.

Intratumoral injection of a radiocolloid for lymphatic mapping enables the therapeutic excision of clinically occult breast cancer with the aid of a gamma-ray detection probe. The aim of this study was to determine the success rate of radio-guided tumour excision in addition to a guide wire and to identify factors predicting clear margins. Sixty-five consecutive patients underwent radio-guided tumour excision after intratumoral injection of 99mTc-nanocolloid guided by ultrasound or stereotaxis. A localization wire was inserted after scintigraphy had been performed (group 1). The results were compared with retrospective data from 67 consecutive patients who underwent therapeutic wire-directed excision alone (group 2). Factors predicting clear margins (> or = 1 mm) were determined in a logistic regression model. Adequate margins were obtained in 83% of group 1 and in 64% of group 2 (P = 0.014). The invasive component was incompletely excised in two patients in group 1 and in 14 patients in group 2. Further surgery was performed in four patients in group 1 and in 14 patients in group 2. Factors predictive of clear margins were decreasing pathological tumour diameter (P = 0.035), increasing weight of the specimen (P = 0.046), absence of microcalcifications (P = 0.004) and absence of carcinoma in situ component (P = 0.024). Radio-guided excision was an independent predictor of complete excision of the invasive component (P = 0.012). The application of radio-guided surgery combined with wire localization seems to improve the outcome of therapeutic excision of non-palpable invasive breast cancer compared with wire-directed excision alone.

Status of lymph node staging.

Sentinel node biopsy has the potential to provide more accurate staging information than axillary node dissection. Given the considerable morbidity of axillary node dissection this less invasive approach is attractive. However, there are a number of issues to be resolved before the best technique of sentinel node biopsy is determined. When large studies with long-term follow up demonstrate that lymphatic mapping to identify clinically occult lymph node metastases is as effective as we hope, then full axillary node dissection can be reserved to treat patients who indeed have lymph node metastases. Around 60% of the patients could then be spared an axillary node dissection that they do not need because they do not have metastases there. Modern technology is providing more accurate prognostic information based on primary tumor characteristics. Applying these technologies to sentinel lymph nodes may render the lymph node status even more relevant than it currently is.

Single intralesional tracer dose for radio-guided excision of clinically occult breast cancer and sentinel node.

BACKGROUND: The purpose of this study was to determine the feasibility of both lymphatic mapping and probe-guided primary tumor excision by use of intralesional tracer administration in clinically occult breast cancer. METHODS: Sixty patients with a clinically occult breast lesion were prospectively included. Lymphoscintigraphy was performed after intratumoral injection of 99mTc-labeled nanocolloid guided by ultrasound or stereotaxis. A catheter over a localization wire was inserted for intraoperative blue dye administration by using the same imaging techniques. After sentinel node identification, the gamma-ray detection probe was used for radio-guided wide local excision in patients who underwent breast-conserving therapy. RESULTS: A sentinel node was visualized on the scintigrams in 56 patients (93%) and could be identified intraoperatively in 58 patients (97%). A sentinel node contained tumor in 10 (17%) of these patients. Extra-axillary sentinel nodes were visualized in 43%, were collected in 38%, and contained metastasis in 7% of the patients. Complete excision of the primary tumor could be accomplished in 39 (87%) of 45 patients. CONCLUSIONS: Both sentinel node biopsy and probe-guided excision of a nonpalpable breast cancer is feasible with the aid of intralesional tracer administration. Sentinel node metastasis was found in 17% of the patients. A remarkably high percentage of extra-axillary drainage (43%) was observed.