Regional nodal relapse in surgically staged Merkel cell carcinoma.

PURPOSE: The nodal relapse pattern of surgically staged Merkel cell carcinoma (MCC) with/without elective nodal radiotherapy (RT) was studied in a single institution. METHOD: A total of 51 patients with MCC, 33% UICC stage I, 14% II, 53% III (4 lymph node metastases of unknown primary) were eligible. All patients had surgical staging: 23 patients sentinel node biopsy (SNB), 22 patients SNB followed by lymphadenectomy (LAD) and 6 patients LAD. In all, 94% of the primary tumors (PT) were completely resected; 57% of patients received RT, 51% of known PT sites, 33% (8/24 patients) regional RT to snN0 nodes and 68% (17/27 patients) to pN+ nodes, mean reference dose 51.5 and 50 Gy, respectively. Mean follow-up was 6 years (range 2-14 years). RESULTS: A total of 22% (11/51) patients developed regional relapses (RR); the 5-year RR rate was 27%. In snN0 sites (stage I/II), relapse occurred in 5 of 14 nonirradiated vs. none of 8 irradiated sites (p = 0.054), resulting in a 5-year RR rate of 33% versus 0% (p = 0.16). The crude RR rate was lower in stage I (12%, 2/17 patients) than for stage II (43%, 3/7 patients). In stage III (pN+), RR appeared to be less frequent in irradiated sites (18%, 3/14 patients) compared with nonirradiated sites (33%, 3/10 patients, p = 0.45) with 5-year RR rates of 23% vs. 34%, respectively. DISCUSSION: Our data suggest that adjuvant nodal RT plays a major role even if the sentinel nodes were negative. CONCLUSION: Adjuvant RT of the lymph nodes in patients with stage IIa tumors and RT after LAD in stage III tumors is proposed and should be evaluated prospectively.

Low-field MRI versus ultrasound: which is more sensitive in detecting inflammation and bone damage in MCP and MTP joints in mild or moderate rheumatoid arthritis?

OBJECTIVES: The aim of the present paper is to determine if the ultrasound of hands and feet is comparable to the MRI of the dominant hand to detect erosive disease and inflammation in mild or moderate rheumatoid arthritis (RA). METHODS: Twenty-six patients (14 females; mean age, 48 years) with active mild or moderate RA (mean DAS28, 3.9; mean disease duration, 19 months) were examined clinically, by ultrasound and by gadolinium-enhanced low-field MRI at baseline, after 6 and 12 months (78 examinations). Radiographs from hands and forefeet were taken at baseline and after 12 months. MRI was performed at the clinically most active (dominant) hand or forefoot evaluating the MCP 1-5 or MTP 1-5 joints. Ultrasound examination additionally included all other 2nd, 5th MCP and 5th MTP joints. RESULTS: MRI and ultrasound detected erosive disease in 67 and 56 of 78 examinations, respectively (p<0.01); radiography only in 8 of 52 examinations (p<0.001). MRI and ultrasound were equally sensitive to detect synovitis (in 64 and 66 examinations). Synovial power Doppler signals were present in 38 ultrasound examinations. Bone marrow oedema was present in 37 MRI examinations. Ultrasound was more sensitive than MRI to detect tenosynovitis (in 30 vs. 15 examinations; p=0.001). CONCLUSIONS: MRI of the dominant hand and bilateral ultrasound of MCP and MTP joints are superior to x-ray to detect erosive disease in mild and moderate RA. MRI is slightly, but significantly more sensitive than ultrasound for erosive disease, while ultrasound is more sensitive to detect tenosynovitis. Ultrasound and MRI are comparably sensitive to detect synovitis.

Do temporal artery duplex ultrasound findings correlate with ophthalmic complications in giant cell arteritis?

OBJECTIVE: Ophthalmic complications are common in acute GCA. Do temporal artery ultrasound and clinical parameters correlate with the occurrence and severity of ophthalmic complications? METHODS: The results of temporal artery ultrasound examinations are compared with the occurrence of anterior ischaemic optic neuropathy (AION), central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), diplopia and amaurosis fugax in 222 consecutive patients with newly diagnosed, active GCA. RESULTS: Temporal artery ultrasound displayed vasculitic wall swelling (halo), stenoses and/or acute occlusions in 84% (58% in 67 large-vessel GCA patients and 95% in 155 patients without proximal arm vasculitis). Ophthalmic complications occurred in 64 (29%), AION in 30 (14%), CRAO in 7 (3%), BRAO in 2 (1%), amaurosis fugax in 16 (7%) and diplopia in 9 patients (4%). Ophthalmic complications were insignificantly more common if temporal artery ultrasound was positive (31 vs 17%; P = 0.11) as a greater number of patients without arm vasculitis showed eye involvement (34 vs 18%; P = 0.02). The number of pathological temporal artery segments, presence of stenoses or bilateral findings did not correlate with ophthalmic complications. Age >or= 72 yrs at diagnosis correlated with a higher incidence of ophthalmic complications. CONCLUSION: Ophthalmic complications occurred less frequently if proximal arm vasculitis was present. Findings of temporal artery ultrasound did not correlate with eye complications.

Comparison of Photo Optical Imaging with Musculoskeletal Ultrasound and Clinical Examination in the Assessment of Inflammatory Activity in Proximal Interphalangeal Joints in Rheumatoid Arthritis and Osteoarthritis.

OBJECTIVE: Lightscan is a novel, rapid, low-cost, easily operated and noninvasive imaging technology used to assess inflammatory activity in proximal interphalangeal (PIP) joints. The results are calculated automatically. To our knowledge, this is the first comparative study of photo optical imaging (POI), with clinical examination (CE), disease activity score at 28 joints (DAS28)-erythrocyte sedimentation rate (ESR), and musculoskeletal ultrasonography (US) in healthy subjects and patients with rheumatoid arthritis (RA) or osteoarthritis (OA). METHODS: There were 688 PIP joints of both hands examined in 87 subjects (38 RA, 21 OA, 28 healthy) by Lightscan and compared with CE for clinically swollen and tender joints, DAS28-ESR (only RA), and US. RESULTS: With US as reference, POI had a sensitivity of 74% and a specificity of 93%. In the receiver-operating curve (ROC) analysis, the Lightscan showed a higher sensitivity and specificity [area under the curve (AUC) 0.879] for the distinction of healthy subjects versus patients (OA, RA) than US in greyscale (GSUS; AUC 0.797) and power Doppler (PDUS; AUC 0.67). POI correlated significantly with GSUS (r 0.473, p < 0.01) and PDUS (r 0.486, p < 0.01). The agreement rates between POI and GSUS were up to 79%, between POI and PDUS up to 92%, and between POI and CE up to 66%. POI did not correlate with DAS28-ESR. CONCLUSION: The Lightscan is a new technology offering sensitive imaging detection of inflammatory changes in subjects with RA and OA with PIP arthritis. POI was more sensitive than CE and correlated significantly to GSUS and PDUS, while presenting a higher sensitivity and specificity for the detection of healthy subjects versus patients (RA, OA) based on the ROC analysis.

Near-infrared Fluorescence Optical Imaging in Early Rheumatoid Arthritis: A Comparison to Magnetic Resonance Imaging and Ultrasonography.

OBJECTIVE: Near-infrared fluorescence optical imaging (FOI) is a novel imaging technology in the detection and evaluation of different arthritides. FOI was validated in comparison to magnetic resonance imaging (MRI), greyscale ultrasonography (GSUS), and power Doppler ultrasonography (PDUS) in patients with early rheumatoid arthritis (RA). METHODS: Hands of 31 patients with early RA were examined by FOI, MRI, and US. In each modality, synovitis of the wrist, metacarpophalangeal joints (MCP) 2-5, and proximal interphalangeal joints (PIP) 2-5 were scored on a 4-point scale (0-3). Sensitivity and specificity of FOI were analyzed in comparison to MRI and US as reference methods, differentiating between 3 phases of FOI enhancement (P1-3). Intraclass correlation coefficients (ICC) were calculated to evaluate the agreement of FOI with MRI and US. RESULTS: A total of 279 joints (31 wrists, 124 MCP and 124 PIP joints) were evaluated. With MRI as the reference method, overall sensitivity/specificity of FOI was 0.81/0.00, 0.49/0.84, and 0.86/0.38 for wrist, MCP, and PIP joints, respectively. Under application of PDUS as reference, sensitivity was even higher, while specificity turned out to be low, except for MCP joints (0.88/0.15, 0.81/0.76, and 1.00/0.27, respectively). P2 appears to be the most sensitive FOI phase, while P1 showed the highest specificity. The best agreement of FOI was shown for PDUS, especially with regard to MCP and PIP joints (ICC of 0.57 and 0.53, respectively), while correlation with MRI was slightly lower. CONCLUSION: FOI remains an interesting diagnostic tool for patients with early RA, although this study revealed limitations concerning the detection of synovitis. Further research is needed to evaluate its full diagnostic potential in rheumatic diseases.

Assessing Elementary Lesions in Gout by Ultrasound: Results of an OMERACT Patient-based Agreement and Reliability Exercise.

OBJECTIVE: To test the reliability of the consensus-based ultrasound (US) definitions of elementary gout lesions in patients. METHODS: Eight patients with microscopically proven gout were evaluated by 16 sonographers for signs of double contour (DC), aggregates, erosions, and tophi in the first metatarsophalangeal joint and the knee bilaterally. The patients were examined twice using B-mode US to test agreement and inter- and intraobserver reliability of the elementary components. RESULTS: The prevalence of the lesions were DC 52.8%, tophus 61.1%, aggregates 29.8%, and erosions 32.4%. The intraobserver reliability was good for all lesions except DC, where it was moderate. The best reliability per lesion was seen for tophus (κ 0.73, 95% CI 0.61-0.85) and lowest for DC (κ 0.53, 95% CI 0.38-0.67). The interobserver reliability was good for tophus and erosions, but fair to moderate for aggregates and DC, respectively. The best reliability was seen for erosions (κ 0.74, 95% CI 0.65-0.81) and lowest for aggregates (κ 0.21, 95% CI 0.04-0.37). CONCLUSION: This is the first step to test consensus-based US definitions on elementary lesions in patients with gout. High intraobserver reliability was found when applying the definition in patients on all elementary lesions while interobserver reliability was moderate to low. Further studies are needed to improve the interobserver reliability, particularly for DC and aggregates.

Laparoscopic surgery for colon and rectal cancer.

Use of laparoscopic resection for colorectal malignancy has raised concerns regarding local cancer control and the lack of long-term results. Most reported data are preliminary and medium-term results, at best. The aim of this study is to analyse all patients who underwent a laparoscopic resection for colorectal cancer at our department between November 1992 and July 2003. The cohort comprised a total of 394 patients (194 rectal cancer and 200 colon carcinoma). The most common procedures were high and low anterior resection with total mesorectum excision (TME) (176), followed by sigmoidectomy (89), right hemicolectomy (57), and left hemicolectomy (42). Mean operating time was 176 minutes. Conversion was necessary in 4 of the patients. Mean number of lymph nodes removed was 27. The postoperative complication rate was 20.1% (rectum) and 12.5% (colon). One patient died of myocardial infarction. Mean follow up was 45 (0.3-135) months. Port site metastasis occurred in 2 patients. The local recurrence rate was 4.1% after curative rectum resection and 0.5% in the colon group. After curative resection, the overall 5-year survival rate was 76.9% (rectum), and 81.4% (colon). Cancer-related survival rate after 5 years was 87.7% (rectum), and 91.3% (colon). Our results demonstrate that laparoscopic resection for colorectal cancer is not associated with higher morbidity and mortality rates. Established oncological principles are respected and long-term results are at least as good as those after open surgery.

Impact of lymph node metastases on serum level of melanoma inhibitory activity in stage III melanoma patients.

Melanoma patients in stage III have a considerable recurrence rate. The 10-year survival in this stage depends on the number and size of affected nodes. Currently, there is no optimal serum marker for early detection of relapse available. The goal of the study was to assess the utility of melanoma inhibitory activity (MIA) serum marker in the follow up and primary diagnosis of stage III melanoma patients. One hundred and thirty-eight melanoma patients in stage III at time of primary diagnosis were analyzed at time of primary diagnosis and during periodical routine follow up both for serum MIA using an enzyme-linked immunosorbent assay and for serum lactate dehydrogenase (LDH). Results were correlated with the positivity of the sentinel lymph node (SLN) and the number of lymph node metastases in the completion lymph node dissection at time of primary diagnosis. During follow up, the overall survival time was assessed using the Kaplan-Meier method in terms of elevated MIA (>12 ng/mL) values. Regarding SLN status, significant differences of MIA values (P = 0.024) and LDH (P = 0.007) were found, both within the normal cut-off. Having lymph node metastases in the completion lymph node dissection, significantly higher MIA values (12.55 ng/mL [±0.48], P < 0.0001) were found. In patients with three or more tumor-positive nodes, MIA values were significantly higher when compared to patients with one or two affected nodes (P = 0.024). In the routine follow-up, stage III patients with an MIA value of more than 12 ng/mL had a five times higher risk for developing recurrences (P < 0.0001). Patients with relapsing disease had a significantly (P < 0.0001) higher mean MIA value (13.76 ng/mL) compared to patients without relapse (7.52 ng/mL). The MIA serum marker can be helpful in patients undergoing lymph node dissection. Furthermore, during follow up, patients showing relapsing diseases can have an elevated MIA value.

Diagnostic value of melanoma inhibitory activity serum marker in the follow-up of patients with stage I or II cutaneous melanoma.

In the follow-up of melanoma patients, there is still a need for an optimal serum marker to discover recurrent disease at an early stage. Melanoma inhibitory activity (MIA) has been investigated as a serum marker for cutaneous melanomas. Although the prognosis for melanoma based on stage is generally good, the disease identified at later stages is associated with high levels of morbidity and mortality. The value of MIA testing in early-stage melanoma was the goal of this study. Five thousand three hundred and thirty-four MIA serum values from 1079 consecutive melanoma patients in stages I and II were obtained during routine follow-up at scheduled intervals. Sensitivity and specificity of MIA were calculated. The area under the receiver-operating characteristics curve and Somers' Dxy rank correlation were assessed. Metastasis occurred in 137 patients with a sensitivity of MIA testing of 67.6% in stage I and 65.6% in stage II patients. The specificity was 76.9% for stage I and 66.7% for stage II patients. The most reliable normal upper limit for MIA was redefined at 12.0 ng/ml, when compared with 8.8 and 15.0 ng/ml. Multivariate analysis revealed significantly more frequent false-positive values in elderly women and in men with an increased Breslow thickness.MIA adapted with a new cut-off level is then a useful serum marker even in the follow-up of not yet relapsed early-stage melanoma patients. In older women and in men with an increased tumor thickness, the higher rate of false-positive values should be considered before starting further diagnostics. Additional prospective studies to clarify the clinical combination with other serum markers seem promising.

Color Doppler ultrasonography of hand and finger arteries to differentiate primary from secondary forms of Raynaud's phenomenon.

OBJECTIVE: Modern ultrasound (US) equipment allows rheumatologists to directly visualize hand and finger arteries. How does US aid in diagnosis of Raynaud's phenomenon (RP)? METHODS: Color Doppler US of the proper and common palmar digital, radial, and ulnar arteries and the superficial palmar arch of both hands was performed in 135 consecutive patients who presented with suspected RP. RESULTS: US was pathologic in 63% of patients with secondary RP, in 6% with primary RP, and in none with pseudo-RP (p < 0.0001). We found 3 types of vascular pathology: Type 1 showed narrowing or chronic occlusion of some proper digital arteries; Type 2 was characterized by the same finding in all proper digital arteries; and Type 3 involved acute occlusions. Type 1 was found in 3 of 53 patients with primary RP and in 19 patients with secondary RP including 5 of 9 patients with anti-centromere positive systemic sclerosis (SSc); Type 2 occurred in 16 patients with SSc, MCTD, and dermatomyositis; and Type 3 was found in 8 patients with antiphospholipid antibody syndrome, thromboangiitis obliterans, vibration trauma, or vasculitis. The ulnar arteries were more commonly affected than the radial arteries. The 2nd radial, 3rd radial, 4th ulnar, and 5th ulnar proper palmar digital arteries were most commonly involved. CONCLUSION: Aiding in differentiating primary versus secondary RP, severe versus less severe disease, and acute versus chronic vascular occlusion, digital artery US depicts the same anatomical structures as angiography, but it is cheaper, faster, and noninvasive.