The Importance of Multi-Parametric MRI, PET/CT, and Biopsy for Identifying and Delineating the Extent of Locally Radiorecurrent Prostate Cancer: A Multi-institutional Analysis of the F-SHARP Clinical Trial

PURPOSE/OBJECTIVE(S)

Up to 50% of clinical recurrences after curative-intent radiation are intraprostatic local radiorecurrences (LRR), with improved detection through the recent incorporation of multi-parametric MRI and PET/CT in workup. Salvage local therapy (SLT) is increasingly being offered, particularly focal SLT to try to reduce toxicity due to prior radiation. Limited data exist on the incremental value of each imaging modality and biopsy in defining LRR. The objective of this study is to compare the findings of MRI, PET/CT and biopsy in patients with LRR prostate cancer, and the impact each modality has on identifying recurrence and defining the extent of prostate involvement.

MATERIALS/METHODS

This is a secondary analysis of 58 patients enrolled on the ongoing F-SHARP phase I/II clinical trial of salvage HDR brachytherapy from 3 institutions who underwent PSMA or fluciclovine PET/CT, MRI, and biopsy prior to enrollment. Recurrent tumor was delineated on each imaging modality and by inclusion of involved regions on biopsy. Descriptive statistics were used to compare the imaging-defined tumor with biopsy findings to assess the congruence between the imaging modalities and generate the percentage of patients with disease involvement on biopsy outside of the image-defined targets.

RESULTS

Initial therapy was conventional/moderately hypofractionated photons in 35 patients, LDR in 13, proton therapy in 7, SBRT in 2, and neutrons in 1. Recurrence Gleason grade groups included 1 (n = 3), 2 (17), 3 (12), 4 (8), 5 (9), and uninterpretable (9). MRI/TRUS sextant + fusion biopsy was performed in 40 patients, TRUS saturation biopsy in 4, and TRUS systematic biopsy in 14. The median number of cores involved and obtained were 6 and 14. The median number of discrete lesions on biopsy in different quadrants of the prostate was 3 (1-6). The median number of discrete lesions seen on MRI was 1 (0-4). MRI did not identity a discrete lesion in 4 patients. The sensitivity of MRI for detection of the LRR was 92.8%. The false negative rate for not detecting the focus of LRR on MRI was 7.2%. 68.4% of patients had biopsy-proven cancer outside of the MRI-defined target. Fluciclovine PET/CT was used in 45 patients, and 13 had PSMA PET/CT. The median number of lesions on PET/CT was 1 (0-2). PET/CT did not identify a discrete lesion in 8 patients. The pooled sensitivity of PET/CT in detecting the focus of LRR was 86.2% (Fluciclovine: 82.2%, PSMA: 100%). PET/CT false negative rate of PET/CT for not detecting the focus of LRR was 13.8% (Fluciclovine: 17.8%, PSMA 0%). 72.41% of patients had biopsy-proven cancer outside of the PET/CT-defined target (Fluciclovine: 77.8%, PSMA: 53.8%).

CONCLUSION

Although mpMRI and PET/CT are valuable tools for identifying LRR and delineating the extent of prostate/SV involvement, a thorough biopsy is mandatory if pursuing focal SLT. Such treatment should optimally be performed on a clinical trial with robust integration of all imaging and histopathologic data.

Comparative evaluation of Sapindus Mukorossi extract with 17% EDTA on smear layer removal in various parts of the tooth root

OBJECTIVES

This study aimed to compare the effectiveness of an experimental root canal irrigant and 17% Ethylene-di-amine tetra acetic acid for removal of the smear layer in the coronal, middle and apical portions of the root canal.

MATERIALS AND METHODS

Ninety human single rooted maxillary and mandibular teeth were selected for this study. The teeth were randomly divided into two experimental groups and one control group as follows: Group A (Ethanolic extract of Sapindus Mukorossi), Group B (17% EDTA), and Group C (Distilled water). The root canals of all three groups were prepared with stainless steel K-files by means of the standard step-back technique and irrigated with 5.25% sodium hypo chloride. The teeth were decoronated, following the irrigation and divided longitudinally into two-halves and visualized using scanning electron microscope (SEM) for the amount of smear layer present utilizing the three-point score system. The observations were noted both before and after the treatment. Nonparametric tests were applied for the comparison and p-value ⩽ 0.05 was considered as statistically significant.

RESULTS

It was evident from that smear layer was completely removed in coronal portion of 27 out of 30 teeth in-group A. For middle and apical areas of group A, 24 and 19 teeth showed complete smear layer removal. In-group B it was found that there were 24, 21, and 3 teeth at coronal, middle and apical, areas respectively where smear layer were completely absent. Intra group comparison showed a significant difference (p = 0.002) in smear layer removal was found for group A at coronal, middle and apical thirds. Similarly, a significant difference (p = 0.001) was also found for group B; however heavy smear layer was found among the three parts of the canal for group C.

CONCLUSIONS

Ethanolic extract of Sapindus Mukorossi have higher effectiveness in removing the smear layer from the root canal in comparison to 17% EDTA.

Effect of Pseudomonas aeruginosa Strain ZK Biofilm on the Mechanical and Corrosion Behavior of 316L Stainless Steel and α-brass

This research work aims to investigate the effect of the aerobic bacterium, Pseudomonas aeruginosa on the mechanical and electrochemical properties of the 316L stainless steel and α-brass. These properties of both the alloys were determined after 7 days of exposure to the controlled and inoculated media at 37°C. The microstructural and electrochemical test results revealed the deleterious effects of Pseudomonas aeruginosa. After exposure to the inoculated medium, the scanning electron microscopy (SEM) results showed the larger pitting and formation of relatively dense biofilm on α-brass compared to 316L stainless steel. The tensile strength and hardness of 316L stainless steel were slightly affected after exposure to the controlled and inoculated media. After exposure to the controlled medium and inoculated media, the tensile strength of the α-brass was least affected but a significant decrease in the hardness (from 165 HV to 124 HV) was observed due to the severe attack induced by the Pseudomonas aeruginosa. Similarly, the open-circuit potential of the 316L stainless steel in the inoculated medium was measured to be less active (−410 mV vs Ag/AgCl) than α-brass (−550 mV vs Ag/AgCl). In the inoculated medium, potentiodynamic polarization curves confirmed the severe attack of Pseudomonas aeruginosa on α-brass (7.15 × 10−2 mm/year) compared to 316L stainless steel which registered a corrosion rate of 5.14 × 10−4 mm/year.

Prevalence of intestinal parasites and associated risk factors in primary school children, Lahore

Intestinal parasites are the major reasons for deaths all over the world especially in the third world. Poverty, poor sanitation, unclean drinking water, moist environment are the conditions for these parasitic ailments. Poor personal hygiene among children is considered an effective cause of parasitic invasion. In present study the prevalence of intestinal parasites and their associated risk factors were determined among the school children of Lahore. A total of 150 faecal samples were collected from the children of 3-15 years of age belonging to Private and Government Schools. Different techniques like Direct smear method, Formalin ether concentration, Sedimentation and McMaster were used to identify different stages of intestinal parasites. The parasites found were Giardia lamblia (4.66%), Entamoeba histolytica (3.3%), Ascaris lumbricoides (4.66%), Taenia saginata (4%), Hymenolepis nana (2%), Trichuris trichura (2.66%) and Enterobius vermicularis (4%). A. lumbricoides was found to the most frequent of all parasites. The prevalence was higher among the children, with poor hygiene, having lack of education especially of mothers because they play a big role in child's upbringing and maintaining his good health. Educating cleanness alertness on parasitic diseases and application of helpful strategies for parents to raise socioeconomic circumstances may decrease the load of infection.

Key messages

Educating cleanness alertness on parasitic diseases and application of helpful strategies for parents to raise socioeconomic circumstances may decrease the load of infection. Health is Wealth.

Differentiation of Autoimmune Pancreatitis from Pancreatic Cancer Remains Challenging

BACKGROUND

Autoimmune pancreatitis (AIP) is an uncommon form of chronic pancreatitis. Whilst being corticosteroid responsive, AIP often masquerades radiologically as pancreatic neoplasia. Our aim is to appraise demographic, radiological and histological features in our cohort in order to differentiate AIP from pancreatic malignancy.

METHODS

Clinical, biochemical, histological and radiological details of all AIP patients 1997-2016 were analysed. The initial imaging was re-reviewed according to international guidelines by three blinded independent radiologists to evaluate features associated with autoimmune pancreatitis and pancreatic cancer.

RESULTS

There were a total of 45 patients: 25 in type 1 (55.5%), 14 type 2 (31.1%) and 6 AIP otherwise not specified (13.3%). The median (IQR) age was 57 (51-70) years. Thirty patients (66.6%) were male. Twenty-six patients (57.8%) had resection for suspected malignancy and one for symptomatic chronic pancreatitis. Three had histologically proven malignancy with concurrent AIP. Two patients died from recurrent pancreatic cancer following resection. Multidisciplinary team review based on radiology and clinical history dictated management. Resected patients (vs. non-resected group) were older (64 vs. 53, p = 0.003) and more frequently had co-existing autoimmune pathologies (22.2 vs. 55.6%, p = 0.022). Resected patients also presented with less classical radiological features of AIP, which are halo sign (0/25 vs. 3/17, p = 0.029) and loss of pancreatic clefts (18/25 vs. 17/17, p = 0.017). There were no differences in demographic features other than age.

CONCLUSION

Despite international guidelines for diagnosing AIP, differentiation from pancreatic cancer remains challenging. Resection remains an important treatment option in suspected cancer or where conservative treatment fails.

Identification of Cystic Lesions by Secondary Screening of Familial Pancreatic Cancer (FPC) Kindreds Is Not Associated with the Stratified Risk of Cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are associated with risk of pancreatic ductal adenocarcinoma (PDAC). It is unclear if an IPMN in individuals at high risk of PDAC should be considered as a positive screening result or as an incidental finding. Stratified familial pancreatic cancer (FPC) populations were used to determine if IPMN risk is linked to familial risk of PDAC.

METHODS

This is a cohort study of 321 individuals from 258 kindreds suspected of being FPC and undergoing secondary screening for PDAC through the European Registry of Hereditary Pancreatitis and Familial Pancreatic Cancer (EUROPAC). Computerised tomography, endoscopic ultrasound of the pancreas and magnetic resonance imaging were used. The risk of being a carrier of a dominant mutation predisposing to pancreatic cancer was stratified into three even categories (low, medium and high) based on: Mendelian probability, the number of PDAC cases and the number of people at risk in a kindred.

RESULTS

There was a median (interquartile range (IQR)) follow-up of 2 (0-5) years and a median (IQR) number of investigations per participant of 4 (2-6). One PDAC, two low-grade neuroendocrine tumours and 41 cystic lesions were identified, including 23 IPMN (22 branch-duct (BD)). The PDAC case occurred in the top 10% of risk, and the BD-IPMN cases were evenly distributed amongst risk categories: low (6/107), medium (10/107) and high (6/107) (P = 0.63).

CONCLUSIONS

The risk of finding BD-IPMN was independent of genetic predisposition and so they should be managed according to guidelines for incidental finding of IPMN.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Interseason variability of a functional movement test, the 9+ screening battery, in professional male football players

BACKGROUND

The Nine Plus screening battery test (9+) is a functional movement test intended to identify limitations in fundamental movement patterns predisposing athletes to injury. However, the interseason variability is unknown.

AIM

To examine the variability of the 9+ test between 2 consecutive seasons in professional male football players.

METHODS

Asymptomatic Qatar Star League players (n=220) completed the 9+ at the beginning of the 2013 and 2014 seasons. Time-loss injuries in training and matches were obtained from the Aspetar Injury and Illness Surveillance Program. No intervention was initiated between test occasions.

RESULTS

A significant increase in the mean total score of 1.6 points (95% CI 1.0 to 2.2, p<0.001) was found from season 1 (22.2±4.1 (SD)) to season 2 (23.8±3.3). The variability was large, as shown by an intraclass correlation coefficient (ICC) of 0.24 (95% CI 0.11 to 0.36) and a minimal detectable change (MDC) of 8.7 points. Of the 220 players, 136 (61.8%) suffered a time-loss injury between the 2 tests. There was an improvement in mean total scores in the injured (+2.0±0.4 (SE), p<0.001) group but not in the uninjured group (+0.9±0.5, p=0.089). The variability from season 1 to season 2 was large both in the injured (ICC 0.25, 0.09 to 0.40, MDC 8.3) and uninjured (ICC 0.24, 0.02 to 0.43, MDC 9.1) groups.

CONCLUSIONS

The 9+ demonstrated substantial intraindividual variability in the total score between 2 consecutive seasons, irrespective of injury. A change above 8 points is necessary to represent a real change in the 9+ test between seasons.

Impact of Ramadan intermittent fasting on cognitive function in trained cyclists: a pilot study

This study assessed selected measures of cognitive function in trained cyclists who observed daylight fasting during Ramadan. Eleven cyclists volunteered to participate (age: 21.6±4.8 years, VO2max: 57.7±5.6 ml kg(-1)·min(-1)) and were followed for 2 months. Cognitive function (Cambridge Neuropsychological Test Automated Battery (CANTAB), Reaction Time index (RTI) and Rapid Visual Information Processing (RVP) tests) and sleep architecture (ambulatory EEG) were assessed: before Ramadan (BR), in the 1st week (RA1) and 4th week of Ramadan (RA4), and 2 weeks post-Ramadan (PR). Both cognitive tests were performed twice per day: before and after Ramadan at 8-10 a.m. and 4-6 p.m., and during Ramadan at 4-6 p.m. and 0-2 a.m., respectively. Training load (TL) by the rating of perceived exertion (RPE) method and wellness (Hooper index) were measured daily. If the TL increased over the study period, this variable was stable during Ramadan. The perceived fatigue and delayed onset muscle soreness (DOMS) increased at RA4. Sleep patterns and architecture showed clear disturbances, with significant increases in the number of awakenings and light sleep durations during Ramadan (RA1 and RA4), together with decreased durations of deep and REM sleep stages at PR. RTI (simple and multiple reaction index) reaction and movement times did not vary over the study period. The RVP test showed reduced false alarms during Ramadan, suggesting reduced impulsivity. Overall accuracy significantly increased at RA1, RA4 and PR compared to baseline. At RA4, the accuracy was higher at 0-2 a.m. compared to 4-6 p.m. Despite the observed disturbances in sleep architecture, Ramadan fasting did not negatively impact the cognitive performance of trained cyclists from the Middle East.

How injuries affect rehabilitation workload in a National Team during an elite soccer event? An experience from the FIFA 2010 World Cup

AIM

Many epidemiological studies have been performed in soccer but none of them investigated the incidence of injury in association with the utilization of clinical and rehabilitation services of the medical team. This study aims to examine such correlation in a National football team during the recent 2010 World Cup.

METHODS

All injuries occurred to the Algerian National Team players during the pre competition stage and the World Cup were recorded, together with the exposure. Moreover, duration and frequency of each consultation performed by doctors, physiotherapists, masseurs and pitch rehabilitator was recorded.

RESULTS

Incidence of injuries was 7.54 per 1000h exposure and six players were injured at the beginning of the stage but all players were available for official matches. Difference in the duration of rehabilitation sessions on the field is present among the players who joined the camp already injured and the players who were not injured at the commencement of the camp (8.83±10.63 vs. 2.00±4.46 hours, P<0.05) while there was no difference in rehabilitation between players that occurred in an injury during after the beginning of the camp and uninjured players.

CONCLUSION

A medical team composed of two physicians, four physiotherapists, one pitch rehabilitator and two masseurs facilitated us to reasonably distribute this workload with good rehabilitation outcomes based on players' availability during competition. Moreover, the skills of a pitch rehabilitator appear to be useful, most evidently when starting the camp with previously injured athletes. Conversely, injuries occurring during the tournament didn't affect rehabilitation workload significantly.

Cross-matched blood in colorectal surgery: a clinical waste?

AIM

This study was carried out to determine the rate of perioperative blood transfusion and to create an evidence-based approach to requesting blood for elective colorectal surgery.

METHOD

A comparative cohort study was carried out of 164 patients (107 men, 57 women, median age 68 years) who underwent major colorectal surgery. Details obtained included demographic and operative information, the number of units of blood cross-matched, units used, the reasons for transfusion and patient suitability for electronic issue (EI). The cross-match to transfusion ratio (C:T ratio) was calculated for each procedure and for the whole group of colorectal procedures.

RESULTS

Some 162 units of blood were cross-matched for 76 (46%) patients, with the remaining 88 (54%) being grouped with serum saved. Twenty-one (13%) were transfused with a total of 48 units of blood. The C:T ratio for all procedures was 3.4/1. The commonest indication for transfusion was anaemia. One patient required an emergency transfusion. The majority (78%) of patients were suitable for EI. There were no significant differences between the transfused and nontransfused groups with regard to age, diagnosis (malignant vs benign) and laparoscopic or open colorectal procedure.

CONCLUSION

Only a small proportion of patients undergoing elective major colorectal surgery require perioperative blood transfusions, most of which are nonurgent. Blood should not be routinely cross-matched in patients who are suitable for EI.

Male breast cancer presenting as nipple discharge

Male breast cancer (MBC) is a rare disease and constitutes less than 1% of all breast carcinoma cases. Although MBC most often presents with a palpable mass, failure to recognise the significance of other symptoms may lead to a delay in diagnosis. Nipple discharge (ND) is a rare symptom in men, but it may herald an underlying malignancy. We present two cases of (MBC) presenting with ND and emphasise the importance of this clinical sign in suspecting underlying malignancy and an opportunity for early diagnosis. We also discuss the clinical significance of ND in men in relation to current literature.

Sciatic nerve injury induces functional pro-nociceptive chemokine receptors in bladder-associated primary afferent neurons in the rat

Visceral sensory afferents during disease or following injury often produce vague, diffuse body sensations, and pain referred to somatic targets. Alternatively, injury due to trauma or disease of somatic nerve targets can also lead to referred pain in visceral targets via a somatovisceral reflex. Both phenomenons are thought to be due to convergence of visceral and somatic afferents within the spinal cord. To investigate a potential peripheral influence for referred pain in visceral targets following somatic nerve injury, we examined whether a sciatic nerve injury known to produce hindpaw tactile hyperalgesia alters the frequency of micturition and the sensitivity of bladder-associated sensory neurons to pro-nociceptive chemokines. Adult female Sprague-Dawley rats received injections of cholera toxin B subunit conjugated to 555 into urinary bladder wall to retrogradely label visceral primary afferent neurons. After 7 days, the right sciatic nerve of these animals was subjected to a lysophosphatidylcholine (LPC)-induced focal demyelination injury. Pre- and post-injury tactile sensitivity in the hind paw and micturition frequency were assayed. Animals were allowed to survive for 14-28 days. Lumbosacral and lumbar dorsal root ganglia (DRG) ipsilateral to the nerve injury were acutely dissociated from sham and nerve injured animals. Bladder wall-associated sensory neurons identified via the retrograde marker were assayed for fluxes in intracellular calcium following administration of pro-nociceptive chemokines. The assayed chemokines included monocyte chemoattractant protein-1 (MCP1/CCL2) and stromal cell derived factor-1 alpha (SDF1/CXCL12). LPC nerve injured animals exhibited tactile hyperalgesia and increased micturition frequency for at least 28 days. Focal demyelination of the sciatic nerve also increased the number of injured L₄L₅ and non-injured L₆-S₂ bladder-associated sensory neurons that responded to MCP1 and SDF1 when compared with sensory neurons derived from uninjured naïve and sham-injured control animals. Taken together, these data suggest that some visceral hypersensitivity states may have a somatic origin. More importantly, nociceptive somatovisceral sensation may be mediated by upregulation of chemokine signaling in visceral sensory neurons.

Surgical lymph node clearance and pathologic evaluation in gastric cancer

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Background: Lymph node (LN) metastasis is common in gastric cancer, with survival implications. The number of LN with metastasis determines pathologic nodal stage; optimal staging requires examination of >14 LN. This requires adequate surgical LN clearance and careful pathology evaluation. Sub-optimal LN examination may be due to surgical or pathology laboratory quality problems, affecting the rational implementation of corrective measures. We evaluated LN examination practice in our community.

Methods: Review of all gastric resections at two hospital systems in Memphis, TN from 1999 to 2008, excluding patients with pre-operative chemo/radiation therapy. Two surgeons separately reviewed all operation reports for details of LN station clearance. We tested concordance between surgeons by the kappa statistic (k) and correlated surgeon reports of LN clearance to the number of examined LN in the pathology report.

Results: 51% of 116 operative reports did not state LN stations resected. The concordance rate between the two surgeons was high (k score per station ranging from 0.66 [very good] to 1.0 [perfect]). The median number of LN stations cleared was similar after proximal (PG) and distal gastrectomy (DG), but significantly more after total gastrectomy (TG) (p<0.0001). Only 39% of patients had >14 LN examined, 6% had none. The number of LN examined was lowest for PG, intermediate for DG and highest for TG patients (Table). There was no correlation between number of surgically cleared LN stations and number of examined LNs (Spearman correlation coefficient 0.23).

Conclusions: Operating surgeons frequently did not identify a LN dissection procedure. Fewer LN were retrieved by pathologists during examination of PG specimens although the surgeon-reported LN clearance was similar between PG and DG. The lack of correlation between LN stations cleared and number of LN examined suggests inadequate pathological examination of LNs submitted in surgical specimens.

[Table: see text]

No significant financial relationships to disclose.

A comparison of surgical resection for distal esophageal, gastroesophageal junction, and proximal gastric cancers in the Memphis metropolitan area (MMA)

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Background: The incidence of distal esophageal (DE) and gastroesophageal junction (GEJ) tumors has increased rapidly in recent decades. They are often included in gastric cancer trials. The 7th AJCC staging has reclassified tumors of the DE, GEJ, and proximal stomach (PS) as esophageal cancers. We compared the historical management of these tumors in our community.

Methods: Review of all curative-intent DE, GEJ, and PS cancer resections at two healthcare institutions in the MMA from 1999-2008.

Results: Seventy patients were identified (Table). Males predominated. The histology was adenocarcinoma in 48% of DE, 91% of GEJ, and 100% of PS cancers. Preoperative endoscopic ultrasound (EUS) was performed in 10% of DE, 6% of GEJ, and 7% of PS patients. Neoadjuvant therapy was given to 29% of DE, 35% of GEJ and 0% of PS patients. R0 resection rates were similiar. Fewer DE and GEJ patients had up to 15 lymph nodes removed, yet lymph node metastasis was identified in 52% and 35% respectively, compared to 20% of PS patients (Table). Five-year survival rates were numerically higher in the DE and GEJ patients.

Conclusions: We identified differences in DE, GEJ, and PS tumors in a community setting with respect to preoperative management and lymph node sampling. Reclassification of DE, GEJ, and PS tumors by the AJCC suggests these groups now be treated uniformly as esophageal cancers, a shift from previous management as gastric cancers. Further, prospective evaluation is needed to assess the patterns of management and outcomes in tumors of the DE, GEJ and PS.

[Table: see text]

No significant financial relationships to disclose.

Cowden syndrome

Cowden syndrome (CS) is a rare inherited condition characterised by multiple hamartomas in a variety of tissues from all three embryonic layers. It is a cancer predisposition syndrome with an increased risk of developing malignancy in many tissues but especially breast, thyroid and endometrium. It is inherited in an autosomal dominant manner with ∼80% of patients having a germ-line mutation of the PTEN tumour suppressor gene. Presenting signs and symptoms are highly non-specific. Nevertheless clinicians should be able to recognise this syndrome so that patients may be screened for cancerous growths and afforded the opportunity to have genetic testing to assist them and their family members in making medical management decisions. We present a review of this unusual but important condition with particular emphasis on the diagnostic criteria, clinical features, genetics, management and surveillance.

Measurements of CO(2) concentration and temperature at high pressures using 1f-normalized wavelength modulation spectroscopy with second harmonic detection near 2.7 microm

Tunable diode lasers (TDL) near 2.7 mum are used to measure high-resolution direct absorption and wavelength modulation with second harmonic (WMS-2f) spectra at high pressures for two CO(2) transitions near 3633.08 and 3645.20 cm(-1), belonging to the nu(1)+ nu(3) vibrational band. Important factors influencing the design of a high-pressure TDL sensor and the variation of WMS-2f line shape with changes in pressure and laser parameters are discussed. Measurements of line strength and line broadening parameters are carried out for the 3645.20 cm(-1) transition in an atmospheric-pressure, high-temperature cell. A room-temperature high-pressure cell is then used to measure the pressure shift for both CO(2) transitions. Deviation of the direct absorption and wavelength modulation spectroscopy (WMS) spectra from the Lorentzian profile is studied in a high-density (9.2 amagats) CO(2)-Ar mixture. The WMS spectra are shown to be negligibly affected by non-Lorentzian effects up to 10 atm and room temperature, in contrast with direct absorption. Measurements of CO(2) concentration and temperature are carried out in nonreactive shock-tube experiments (P approximately 8-12 atm, T~800-1200 K) to validate the accuracy and precision of wavelength-modulation-spectroscopy-based sensing. CO(2) time histories are then measured in heptane ignition experiments and compared with reaction kinetics mechanisms to demonstrate the use of this sensor in high-pressure combustion systems.

Outcome of surgical resection for pathologic Nx and N0 non-small cell lung cancer (NSCLC)

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Background: Metastasis to lymph nodes (LN) connotes poor prognosis in NSCLC. Sufficient LN must be examined to accurately determine LN negativity. Patients with no LN examined (pNx) may be incompletely staged and erroneously assigned to a low risk group. To evaluate this possibility, we compared the survival of patients with node negative disease and at least 1 LN examined (pN0) to those with pNx. Methods: Retrospective analysis of all resections for NSCLC from January 1, 2004 to December 31, 2007 identified through a search of pathology databases at hospitals in the Memphis Metropolitan Area. Benign and metastatic disease, pre-operative chemo/radio therapy, bronchoalveolar cell, small cell lung, carcinoid tumors and repeat lung resection were excluded. Date of death was obtained from a National Death Index search. Variables were compared by chi-squared test, survival estimates calculated by Kaplan Meier analysis, survival estimates compared by log-rank test. Results: 746 of 809 resections met inclusion criteria. 86 (11.5%) were pNx and 510 (68.4%) pN0. Demographic and histologic characteristics were similar ( Table 1 ). 55.8% of the pNx group had sublobar resection, compared to 5.7% of pN0 (p<0.0001). 179 pN0 patients (35.1%) had only hilar-intrapulmonary LN (stations 10–14), median 3 (range 1–18) examined. 46 patients (9.02%) had only mediastinal LN (stations 1–9), median 2 (1–13); 281 patients (55.1%) had both stations 10–14 and 1–9, median 7 (2–45). 85% of pN0 patients had <10 LNs examined. 3-year survival estimate for the T1NxM0 vs T1N0M0 patients was 69% vs 70% (p= 0.14); for T2NxM0 vs T2N0M0 it was 25% vs 65% (p <0.01). Conclusions: A high percentage of patients (11.5%) undergoing surgical resection for NSCLC had pNx. These patients were more likely to have sublobar resections. Most (85%) patients with pN0 had <10 nodes examined and a large proportion (35.1%) had no mediastinal LNs, raising the possibility of understaging. Patients with pT2NxM0 did significantly worse than those with pT2N0M0.

[Table: see text]

[Table: see text]

Quality of surgical resection for non-small cell lung cancer (NSCLC) in a U.S. metropolitan area

7512

Background: Curative treatment of early stage NSCLC requires good quality oncologic resection (GQR). For GQR, the National Comprehensive Cancer Network (NCCN) requires a minimum of segmentectomy, negative margins, lymph node (LN) sampling from stations 10–14 (level-1) and >2 mediastinal (level-2) stations. We reviewed details of consecutive resections for NSCLC to determine the proportion that met NCCN GQR criteria and the proportion who would have met eligibility for the RADIANT trial which requires >1 level-2 stations. Methods: Retrospective review of medical records of all patients who underwent curative- intent resection for NSCLC in the Memphis Metropolitan Area from 1/1/2004 to 12/31/2007. Resections for benign and metastatic disease were excluded. Death information was obtained from a national death index search. Categorical variables were compared by chi-square test or Fisher's exact test, survival curves by log-rank test. Results: 746 patients were eligible (Table). Median age was 67.7 (range, 36.5 - 89.4). 61/746 (8.2%) met NCCN GQR criteria. Black patients were more likely than whites to have GQR (P=0.022). No other patient demographic factor was associated with GQR. Three year survival was 72% in those with GQR versus 63% in those without GQR (P=0.50). There was a difference in achievement of GQR between the 3 major institutions where surgery was done (P=0.001) although it was low across the board. 77.9% of patients would have been disqualified from the RADIANT trial. Conclusions: Majority of surgical resections for NSCLC did not achieve GQR standards per RADIANT and NCCN. The greatest deficit is in surgical sampling of level-2 LNs, but evaluation of level-1 LNs is also frequently sub-optimal. Intervention is needed to improve current surgical and pathology practices in collection and examination of surgical specimens in order to achieve minimum standards for accurate staging, prognostication, determination of candidacy for post-operative adjuvant therapy, and eligibility for clinical trials.

[Table: see text]

[Table: see text]