Validation of the mIBG skeletal SIOPEN scoring method in two independent high-risk neuroblastoma populations: the SIOPEN/HR-NBL1 and COG-A3973 trials

BACKGROUND

Validation of the prognostic value of the SIOPEN mIBG skeletal scoring system in two independent stage 4, mIBG avid, high-risk neuroblastoma populations.

RESULTS

The semi-quantitative SIOPEN score evaluates skeletal meta-iodobenzylguanidine (mIBG) uptake on a 0-6 scale in 12 anatomical regions. Evaluable mIBG scans from 216 COG-A3973 and 341 SIOPEN/HR-NBL1 trial patients were reviewed pre- and post-induction chemotherapy. The prognostic value of skeletal scores for 5-year event free survival (5 yr.-EFS) was tested in the source and validation cohorts. At diagnosis, both cohorts showed a gradual non-linear increase in risk with cumulative scores. Several approaches were explored to test the relationship between score and EFS. Ultimately, a cutoff score of ≤3 was the most useful predictor across trials. A SIOPEN score ≤ 3 pre-induction was found in 15% SIOPEN patients and in 22% of COG patients and increased post-induction to 60% in SIOPEN patients and to 73% in COG patients. Baseline 5 yr.-EFS rates in the SIOPEN/HR-NBL1 cohort for scores ≤3 were 47% ± 7% versus 26% ± 3% for higher scores at diagnosis (p < 0.007) and 36% ± 4% versus 14% ± 4% (p < 0.001) for scores obtained post-induction. The COG-A3973 showed 5 yr.-EFS rates for scores ≤3 of 51% ± 7% versus 34% ± 4% for higher scores (p < 0.001) at diagnosis and 43% ± 5% versus 16% ± 6% (p = 0.004) for post-induction scores. Hazard ratios (HR) significantly favoured patients with scores ≤3 after adjustment for age and MYCN-amplification. Optimal outcomes were recorded in patients who achieved complete skeletal response.

CONCLUSIONS

Validation in two independent cohorts confirms the prognostic value of the SIOPEN skeletal score. In particular, patients with an absolute SIOPEN score > 3 after induction have very poor outcomes and should be considered for alternative therapeutic strategies.

Radiosynoviorthesis in hemophilic joints with yttrium-90 citrate and rhenium-186 sulfide and long term results

Repeated bleeding in the joint cavities is the most annoying symptom and often has disabling effects in patients with hemophilia (PWH). Our aim was to study the effect of radiosynovectomy (RSO) with beta particle-emitting radiocolloids in the treatment of hemorhagic arthropathy. We have treated 22 joints from 18 patients with hemophilia A, from April 2008 to February 2012, 5 knees, 11 elbows and 6 ankles. Joints were divided into two Groups, those treated with yttrium-90-citrate ((90)Y-C) (5 knees, 2 of them twice)-Group I and those with rhenium-186-sulfide ((186)Re-S) (11 elbows, 1 of them treated twice and 6 ankles)-Group II. A total of 25 treatments. Follow-up period was 3 months, 1 year and 3 years. Results showed a favourable subjective and a better objective result in all 5 joints of Group I and in 15/17 joints of Group II, respectively. Follow-up after 3 months showed significant improvement in Hemophilia Join Health Score (HJHS) after 20 treatments and steady score after 5 treatments. After 1 year, 19 treated joints had improved for the first time, 3 remained steady and 3 were not examined. After 3 years, 9 treated joints were HJHS steady, while 16 were not examined. One year after treatment, 13/14 joints of patients, aged 6-23 years showed better HJHS score, while 9/11 joints of patients aged 26-51 years, showed better HJHS. Synovial membrane thickness as measured by MRI in 8 joints, before and 3 months after treatment was not related to prognosis. In conclusion, in a small group of hemophilic patients with hemorrhagic arthropathy treated with (90)Y-C and with (186)Re-S, our study showed good results irrespective of age in 22/25 treatments after 3 months or 1 year. The thickness of synovial membrane in the 8 joints studied was not related to prognosis.

Computed tomography angiography-guided recanalization of saphenous vein graft chronic total occlusion

Computed tomography (CT) angiography can augment conventional coronary angiography relative to length of vessel occlusion and quality of distal run-off. In this case report we describe the significance of CT angiography in the revascularization decision-making process of a patient following occlusion of both coronary artery bypass grafts.

Lymphatic Mapping in Endometrial Cancer: Comparison of Hysteroscopic and Subserosal Injection and the Distribution of Sentinel Lymph Nodes

Introduction:

Endometrial cancer incidence increases over the age of 65 and lymphadenectomy in these women is a morbid procedure. Sentinel lymph node (SLN) should avoid extensive lymphadenectomy in node negative patients. The aim of this prospective study is to determine the feasibility and usefulness of lymphatic mapping and SLN identification in the management of endometrial cancer.

Methods:

From January 2004 to December 2007 101 women with endometrial cancer participated in the study. We injected 99Tc hysteroscopically, peritumorally 2 hours before laparotomy in 24 women. We applied 99Tc and blue dye subserously after laparotomy and before adhesiolysis in 67 women. Ten patients with metastatic disease in ovary, omentum, peritoneum, and bulky nodes were excluded from analysis.

Results:

We detected SLN in 12 women (50%) in hysteroscopic group and in 49 women (73.1%) in subserous group. We identified 133 SLNs in 61 women. We found 20 SLNs (15.0%) in supraobturator region, 78 (58.6%) in external iliac area, 11 (8.3%) in paraaortal area, 13 (9.8%) on common iliac artery, 8 (6.0%) in medial part of lateral parametrium, and 3 (2.3%) in presacral area.

Conclusions:

Sentinel lymph node identification is a new strategy that can be used to examine nodal status with a high successful rate in breast, cervical, and vulvar cancer. Results in endometrial cancer are not as successful, however. In the future, it will be necessary to find optimal timing, the best route of application, and the "right" size of the 99mTc particles. Subserous application seems to be superior to hysteroscopic application.

Further data on sentinel lymph node mapping in vulvar cancer by blue dye and radiocolloid Tc99

We studied the distribution of sentinel lymph nodes (SLNs) in vulvar cancer using blue dye and (99m)Tc radiocolloid and evaluated the techniques used, including the optimum timing of preoperative scintigraphy scans and its contribution to (99m)Tc SLN detection over that of the intraoperative handheld gamma probe. Fifty-nine women with squamous cell cancers <4 cm treated at our institution between December 2001 and December 2005 were included in this study. Blue dye alone was used in the first 16 women (group A) and the combination of (99m)Tc and blue dye was used on 43 women (group B). Of the 118 SLN detected in 82 groins, 83.9% (99) were sited in the superficial medial and intermediate inguinal chain, none were in superficial lateral groin, 16.1% (19) were deep femoral. The patient-specific SLN detection and false-negative rate in group B was 100% and 0%, compared to 68.8% (11/16 cases) and 6.3% (1/16) in group A. The optimum timing for preoperative lymphoscintigraphy scans was 45 min postinjection, but intraoperative use of the handheld gamma probe yielded 15% more "hot" nodes and allowed tailored placement of the lymphadenectomy incision. Eighty-four percent of SLNs were in the medial and intermediate region of the superficial inguinal chain, 16.1% were deep femoral. The combined use of (99m)Tc radiocolloid and blue dye was significantly superior at SLN detection than blue dye alone. (99m)Tc SLN detection using the intraoperative handheld probes was not enhanced by preoperative scintigraphy scans.

Comparison of the exercise ECG and stress myocardial SPECT in detection of the significant coronary artery disease in the asymptomatic patients with diabetes mellitus type 2

BACKGROUND

Diabetes mellitus is known to be a risk factor of the coronary heart disease even in the asymptomatic patients. Only a limited number of reports comparing the significance of different noninvasive stress tests in establishing the diagnosis of the advanced coronary lesions exists.

OBJECTIVES

The aim of the study was to compare the significance of 12-lead exercise ECG and the myocardial SPECT in order to detect the significant coronary heart disease in asymptomatic type 2 diabetics.

METHODS

126 type 2 diabetic patients with negative history and no clinical or electrocardiographic signs of coronary heart disease were examined with the exercise ECG and the stress myocardial SPECT. The selective coronary angiography (SCG) was recommended to all patients with an abnormal SPECT or (and) a positive exercise ECG. The SCG was recommended to patients with equivocal results of the stress myocardial SPECT as well.

RESULTS

33 out of 126 examined patients (26.2%) had an abnormal, 33 equivocal and 60 normal stress myocardial SPECT. The exercise test could be evaluated in 99 examined patients (78%). 25 diabetics had positive test (19.8%). The correlation between the results of 2 tests was very good (p=0.0001). 38 patients had SCG, 24 with the abnormal SPECT, 13 with equivocal and 1 with normal SPECT. Out of these 20 patients had positive, 10 negative and 8 non-assessable exercise ECG. The relation between the presence of significant coronary stenosis (stenosis >70%) and the presence of abnormal stress myocardial SPECT was stronger (p=0.006) when compared with the positive exercise test (p=0.037). For the significant coronary stenosis the positive predictive value was 90% with the stress myocardial SPECT and 68% with the exercise ECG.

CONCLUSION

The significance of the exercise ECG is lower predominantly due to high proportion of patients with non-assessable results. For the presence of significant coronary stenosis the positive predictive value of the stress myocardial SPECT is better than that of the exercise ECG. (Tab. 2, Ref: 25.)