Three-Dimensional Tumor Margin Demarcation Using the Hybrid Tracer Indocyanine Green-99mTc-Nanocolloid: A Proof-of-Concept Study in Tongue Cancer Patients Scheduled for Sentinel Node Biopsy

For radical resection of squamous cell carcinoma of the oral cavity, a tumor-free margin of at least 5 mm is required. Unfortunately, establishing in-depth margins is a surgical conundrum. Knowing that the hybrid sentinel node (SN) tracer indocyanine green (ICG)-^99mTc-nanocolloid generates temporary tattoolike markings at the site of administration, we studied the ability to apply this tracer for tumor margin demarcation combined with SN biopsy. Methods: Nineteen patients with clinical T1-T2 oral tongue tumors received the traditional superficial 3 or 4 deposits of ICG-^99mTc-nanocolloid (0.1 mL each), and in 12 patients additional deposits were placed deeply using ultrasound guidance (total of 6; 0.07 mL each). SN mapping was performed using lymphoscintigraphy and SPECT/CT. Before and directly after tumor excision, fluorescence imaging was performed to monitor the tracer deposits in the patient (fluorescent deposits were not used to guide the surgical excision). At pathologic examination, primary tumor samples were studied in detail. Results: The number of tracer depositions did not induce a significant difference in the number of SNs visualized (P = 0.836). Reproducible and deep tracer deposition proved to be challenging. The fluorescent nature of ICG-^99mTc-nanocolloid supported in vivo and ex vivo identification of the tracer deposits surrounding the tumor. Pathologic examination indicated that in 66.7% (8/12), all fluorescence was observed within the resection margins. Conclusion: This study indicates that tumor margin demarcation combined with SN identification has potential but that some practical challenges need to be overcome if this technique is to mature as a surgical guidance concept. Future studies need to define whether the technology can improve the radical nature of the resections.

MR and CT based treatment planning for mTHPC mediated interstitial photodynamic therapy of head and neck cancer: description of the method

BACKGROUND AND OBJECTIVE

Interstitial photodynamic therapy is a potentially important tool in the management of voluminous or deep-seated recurrent head and neck cancers.

STUDY DESIGN/METHODS

The described treatment algorithm in this manuscript consists of the treatment simulation, implantation of light sources, verification, modification of the treatment plan if necessary, and illumination. The tumor is delineated on imaging sections (CT, MRI, and/or PET/CT) and the treatment is simulated by virtually introducing light sources to the tumor volume on specially modified brachytherapy software. This enables us to determine if the treatment is technically feasible, and information about approximate number and location of light sources necessary. Following implantation of catheters in which the light sources will be introduced, CT or MR scan is performed to verify the actual location of the implanted catheters. The verification-CT is imported to the software and co-registered with pre-treatment images to observe the deviations from the simulation. The simulation is run again with the actual position of the light sources to determine if any additional light sources are necessary and adaptation of the source length in order to cover the tumor volume (modification). Thereafter the tumor is illuminated.

RESULTS

This method has the potential to help with identifying iPDT feasible patients by simulating before the actual treatment. The suboptimal placement of light sources can be identified and corrected. The simulations were documented and saved for subsequent evaluation of the technique.

CONCLUSION

The proposed technique can help standardize and document iPDT.

Ultrasound examination and fine needle aspiration cytology-useful for followup of the regional nodes in penile cancer?

PURPOSE

Routine followup of the groins of patients with penile squamous cell carcinoma after primary treatment consists of physical examination together with ultrasound of the groins, followed by fine needle aspiration cytology if suspicious. We assessed the value of this routine followup.

MATERIALS AND METHODS

Using ultrasound and fine needle aspiration cytology we assessed 247 patients during followup who were treated from 2004 to 2010 and underwent dynamic sentinel node biopsy only or observation of the inguinal regions. A negative result was defined as no evidence of metastatic disease after at least 2 years of followup. We calculated the sensitivity, specificity, and positive and negative predictive values of ultrasound and ultrasound guided fine needle aspiration cytology using standard statistical methods.

RESULTS

Recurrence was diagnosed in 47 of 247 patients (55 groins). In 40 of 55 groins (73%) recurrence was detectable by physical examination. In 12 of 15 cases of nonpalpable recurrence (80%) ultrasound guided fine needle aspiration cytology revealed the recurrence. We considered 217 groins to be suspicious on ultrasound followed by fine needle aspiration cytology. Fine needle aspiration cytology revealed tumor in 49 groins and showed false-positive findings in 1 patient after negative completion lymphadenectomy. Sensitivity and specificity were 87.3% (48 of 55 cases) and 99.9% (1,304 of 1,305), respectively.

CONCLUSIONS

Although inguinal recurrence manifests clinically in most patients, ultrasound guided fine needle aspiration cytology detected 80% of metastatic disease in patients with nonpalpable disease. Therefore, it has great value for detecting lymph node metastases during followup.

The role of FDG PET/CT in patients with locoregional breast cancer recurrence: a comparison to conventional imaging techniques

PURPOSE

The aim of this study was to evaluate the impact of (18)F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) on clinical management in patients with locoregional breast cancer recurrence amenable for locoregional treatment and to compare the PET/CT results with the conventional imaging data.

PATIENTS AND METHODS

From January 2006 to August 2008, all patients with locoregional breast cancer recurrence underwent whole-body PET/CT. PET/CT findings were compared with results of the conventional imaging techniques and final pathology. The impact of PET/CT results on clinical management was evaluated based on clinical decisions obtained from patient files.

RESULTS

56 patients were included. In 32 patients (57%) PET/CT revealed additional tumour localisations. Distant metastases were detected in 11 patients on conventional imaging and in 23 patients on PET/CT images (p < 0.01). In 25 patients (45%), PET/CT detected additional lesions not visible on conventional imaging. PET/CT had an impact on clinical management in 27 patients (48%) by detecting more extensive locoregional disease or distant metastases. In 20 patients (36%) extensive surgery was prevented and treatment was changed to palliative treatment. The sensitivity, specificity, accuracy, positive and negative predictive values of FDG PET/CT were respectively 97%, 92%, 95%, 94% and 96%.

CONCLUSIONS

PET/CT, in addition to conventional imaging techniques, plays an important role in staging patients with locoregional breast cancer recurrence since its result changed the clinical management in almost half of the patients. PET/CT could potentially replace conventional staging imaging in patients with a locoregional breast cancer recurrence.

CT detected indeterminate pulmonary nodules in a chemoprevention trial of fluticasone

INTRODUCTION

In animal models of lung carcinogenesis, inhaled corticosteroids appear to reduce the number of new lung tumors. In a trial of budesonide in smokers with bronchial dysplasia, the proportion of indeterminate CT detected pulmonary nodules that resolved was larger in the treatment group. We performed a secondary analysis of CT data of subjects at risk of lung cancer enrolled in a chemoprevention trial of fluticasone.

METHODS

Subjects with bronchial squamous metaplasia or dysplasia had a baseline chest CT scan. They were randomized to fluticasone or a placebo. After 6 months a repeat CT was performed and the change in number and size of nodules was evaluated.

RESULTS

Two hundred and one subjects were screened. Of the 108 volunteers included in the study, 74 were male, mean age was 53 years and mean number of pack years 48. Baseline: 35 subjects had 91 nodules in total, 62% <4mm. In the fluticasone arm more subjects had a decrease and fewer had an increase in number of nodules, however this trend did not reach statistical significance.

CONCLUSION

In this preliminary study there was a tendency of nodules to resolve, however, studies with CT detected nodules as inclusion criterion are needed.

Ultrasonography and Fine-needle Aspiration Cytology in the Preoperative Evaluation of Melanoma Patients Eligible for Sentinel Node Biopsy

BACKGROUND

Ultrasonography with fine-needle aspiration cytology (FNAC) has proven to be a valuable diagnostic tool in the preoperative workup of patients with breast cancer or penile cancer eligible for sentinel lymph node biopsy. The aim of this study was to evaluate the use of this technique in the initial assessment of patients with primary cutaneous melanoma.

METHODS

A total of 107 patients with cutaneous melanoma eligible for sentinel node biopsy with clinically negative nodes were studied prospectively. Patients underwent ultrasonography of potentially involved basins and FNAC in case of a suspicious lymph node. The sentinel node procedure was omitted in patients with tumour-positive lymph nodes in lieu of lymph node dissection.

RESULTS

Ultrasonography with FNAC correctly identified disease preoperatively in two of the 107 patients (2%). Thirteen of the 22 patients (59%) with a suspicious node on ultrasonographic imaging but a tumour-negative fine-needle aspirate were shown to have involved nodes. Of the 85 patients with ultrasonographically normal nodes, 25 (29%) were shown to have metastases. Of the total of 43 involved basins, 16 contained metastases > 2 mm and 25 < or = 2 mm.

CONCLUSIONS

In our hands, the sensitivity and specificity of preoperative ultrasonography to detect lymph node involvement in patients with melanoma are 34% and 87%, respectively. In combination with FNAC, this is 4.7% and 100%, respectively. This yield is insufficient for this technique to be used as a routine diagnostic tool in the selection of patients eligible for sentinel node biopsy.

Contrast-enhanced MRI in breast cancer patients eligible for breast-conserving therapy: complementary value for subgroups of patients

The aim of this study was to identify patients prior to breast-conserving therapy (BCT) who have complementary value of contrast-enhanced magnetic resonance imaging (MRI) over conventional imaging in the assessment of tumor extent. All patients were eligible for BCT according to conventional imaging, and underwent preoperative MRI as part of this study. One hundred and sixty-five patients (166 tumors) were included. MRI was defined to have complementary value if conventional imaging underestimated or overestimated tumor extent (by more than 10 mm compared to histology) and MRI assessed the extent accurately. Logistic regression was employed to identify characteristics that are predictive of the complementary value of preoperative MRI. MRI had complementary value in 39 cases (23%). Patients <58 years old with irregular lesion margins at mammography and discrepancy in tumor extent by more than 10 mm between mammography and ultrasonography had a 3.2x higher chance of accurate assessment at MRI (positive predictive value 50%, negative predictive value 84%, p=0.0002). Preoperative MRI in patients eligible for BCT is more accurate than conventional imaging in the assessment of tumor extent in approximately one out of four patients. Subgroups of patients in whom MRI has complementary value may be defined by the differences in clinical and imaging features.

[Pain in the hip area accompanied by a fever]

In 3 patients, 2 women aged 16 and 64 years and 1 man aged 64 years, with pain in the left hip region and fever, the diagnosis psoas abscess was made. After antibiotic treatment and drainage they recovered well. The primary from of psoas abscess is presumably caused by haematogenous spread of bacteria, mostly Staphylococcus aureus. The secondary form is caused by spread of infection from surrounding tissue, mostly gastrointestinal micro-organisms with Crohn's disease and diverticulitis. Painful passive extension and endorotation as well as a painful flexion stress-test of the hip joint can indicate a psoas abscess. Echography and blood cultures should be performed if a psoas abscess is suspected. If echography is inconclusive, CT-scan can establish the diagnosis. The psoas abscess should be treated by percutaneous or surgical drainage combined with antibiotic therapy. The underlying cause of a secondary psoas abscess should be treated separately.

The use of a computer in ventilation-perfusion scintigraphy with Tc-99m macroaggregates and Kr-81m, to obtain a physiological model

In this article we describe a computer program to demonstrate ventilation-perfusion relationships in the lungs, using 99mTc-MAA and 81mKr, with the patients sitting upright, the normal physiological situation. The ventilation and perfusion scans are performed simultaneously with both gamma camera and computer adjusted for dual isotope mode. Steady state images are acquired in the frontal, dorsal, and left and right posterior oblique positions. Additionally, in the dorsal and frontal projections, a sequence of 12 washout images (5 s) is registered, after closing the Krypton supply. After normalization and further computer processing, the following parameters are calculated in the frontal and dorsal projections, in the whole lung and in four horizontal subregions: washout values, ventilation-perfusion ratios, left to right ratios of ventilation and perfusion, and left to right ratios of the average pixel values for ventilation and perfusion. Results in a group of eight healthy volunteers are described and discussed.

Lung and renal uptake of technetium Tc 99m sulphur colloid related to disseminated intravascular coagulation

In addition to a recently published case study, we present another three cases in which we observed both lung and renal uptake of technetium Tc 99m sulphur colloid which was related to a period of disseminated intravascular coagulation. Being familiar with this relationship may influence the diagnosis and course of the illness in certain patients.

Ethanol embolization of a renal tumor, complicated by colonic infarction

Since 1981 ethanol has been used to ablate renal tumors. Although initially was stated that no danger exists of accidental embolization of other arteries recently 2 patients were described with colonic infarction following renal ablation. We present a similar case, in which emergency surgery was performed to resect a necrotized part of the colon, and a colostomy was constructed. Recommendations in order to prevent this complication are discussed.