Prognostic impact of progression to induction chemotherapy and prior paclitaxel therapy in patients with germ cell tumors receiving salvage high-dose chemotherapy in the last 10 years: a study of the European Society for Blood and Marrow Transplantation Solid Tumors Working Party.

Little is known about the prognostic impact of prior paclitaxel therapy and response to induction chemotherapy defined as the regimen preceding high-dose chemotherapy (HDCT) for the salvage therapy of advanced germ cell tumors. Twenty European Society for Blood and Marrow Transplantation centers contributed data on patients treated between 2002 and 2012. Paclitaxel used in either prior lines of therapy or in induction-mobilization regimens was considered. Multivariable Cox analyses of prespecified factors were undertaken on PFS and overall survival (OS). As of October 2013, data for 324 patients had been contributed to this study. One hundred and ninety-two patients (59.3%) had received paclitaxel. Sixty-one patients (19%) had a progression to induction chemotherapy, 234 (72%) a response (29 (9%) missing or granulocyte colony-stimulating factor without chemotherapy). Both progression to induction chemotherapy and prior paclitaxel were significantly associated with shorter OS univariably (P<0.001 and P=0.032). On multivariable analysis from the model with fully available data (N=216) progression to induction was significantly prognostic for PFS and OS (P=0.003), but prior paclitaxel was not (P=0.674 and P=0.739). These results were confirmed after multiple imputation of missing data. Progression to induction chemotherapy could be demonstrated as an independent prognostic factor, in contrast to prior paclitaxel.

Magnetic resonance imaging of normal levator ani anatomy and function.

OBJECTIVE: To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging. METHODS: Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied. RESULTS: The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally. CONCLUSION: The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.

Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging.

OBJECTIVE: Our purpose was to assess and compare a new technique of grading pelvic organ prolapse by using dynamic magnetic resonance imaging with the clinical staging proposed by the International Continence Society. STUDY DESIGN: In a cross-sectional study, 20 patients with pelvic organ prolapse underwent dynamic magnetic resonance imaging. Clinical staging (according to the International Continence Society) was compared with staging by magnetic resonance imaging. A new reference line, the midpubic line, was drawn on the magnetic resonance image to correspond to the hymenal ring marker used in the clinical staging. The levator-vaginal angle and the area of the genital hiatus were measured to indicate vaginal supports. Ten nulliparous, symptom-free women were studied as control subjects. RESULTS: The proposed staging by magnetic resonance imaging showed good correlation with the clinical staging (kappa = 0.61). Magnetic resonance imaging improved clinical assessment by its ability to measure the actual pelvic organ descent and to delineate prolapse of the pouch of Douglas accurately. The midpubic line was a useful reference line for grading prolapse on magnetic resonance imaging. The levator-vaginal angle and the area of the genital hiatus are useful in assessing vaginal support at different anatomic levels. CONCLUSIONS: This new method of grading by magnetic resonance imaging uses the same landmarks as the clinical grading, and this uniformity of approach allows an objective assessment of the results of surgical correction of pelvic organ prolapse.

Translevator gluteal hernia.

The authors report a case of a posterior translevator gluteal hernia in a woman with recurrent prolapse. This case illustrates the need to be aware of extravaginal perineal hernias. MRI proved useful in diagnosing this case preoperatively. This case highlights the need to exclude any associated pelvic hernias in women with complex prolapse preoperatively.

Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution.

Eighty-seven patients with hematologic malignancies and invasive pulmonary aspergillosis (IPA) were identified between 1982 and 1995. Of these, 39 underwent lung resection on the basis of radiological detection of at least 1 lesion with imaging suggestive of aspergillosis (LISA). IPA was confirmed histologically in 35. The presence of LISA had 90% positive predictive value for IPA. The actuarial survival at 2 years was 36% for 37 patients treated surgically, 20% for 12 patients with unresected LISA but no cultures of Aspergillus species, and 5% for 21 patients diagnosed only by isolation of Aspergillus from respiratory secretions. Analysis by proportional hazard models showed a significant independent negative association between the radiological appearance of LISA and death from all causes. Relapsed hematologic disease was independently significantly associated with death. Age, sex, surgery, previous bone marrow transplantation, or Aspergillus isolation were not independent predictors of death. IPA presenting as LISA carries a relatively good prognosis, possibly explaining the better survival of patients undergoing surgery for such lesions.

Should air contrast computed tomography become the first investigation of the colon of frail or elderly patients?

OBJECTIVE: Air contrast computed tomography (ACCT) is an alternative test to barium enema or colonoscopy. We review our experience of this test as the first investigation of frail, elderly patients with lower gastrointestinal symptoms, and record the subsequent clinical course of these patients to evaluate the efficacy of the technique. PATIENTS AND METHODS: We performed 109 ACCT studies on frail patients aged 70 years or over with lower gastrointestinal symptoms. The findings were correlated with subsequent investigations and surgical findings. Patients with normal scans were followed up in out-patients or by their GP. Average follow up was 17 months. RESULTS: A good quality complete examination of the colon was achieved in 97% of patients. Of 109 examinations 34 (31%) were reported as normal, 65 (60%) as diverticular disease, nine (8%) as demonstrating a colonic malignancy and one (1%) showed a benign polyp. One sigmoid tumour was missed initially but diagnosed on a repeat ACCT study. CONCLUSION: ACCT is a reliable, well-tolerated technique in elderly frail patients.

Imaging in the diagnosis of infections in immunocompromised patients.

Early use of CT and MRI helps to diagnose infection in immuno-compromised patients earlier and more precisely. Anti-fungal therapy can now be instituted in the knowledge that there is scan proven fungal disease and withheld when scans indicate other pathology. The optimal way to utilise these tests is described.

Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years' experience.

Over 13 years, we have seen 16 cases of proven invasive aspergillosis in 446 bone marrow transplant recipients, an incidence of 3.6%. The incidence of infection is low in patients with uncomplicated allogeneic or autologous bone-marrow transplants (< 2% and 0, respectively). Of the 16 episodes following transplantation, 10 occurred in patients with late transplant complications who were no longer in protective isolation. In patients who had focal pulmonary lesions (as diagnosed by computed tomographic scanning), culture of bronchoalveolar lavage (BAL) fluid was not an effective diagnostic procedure. In diffuse pulmonary disease due to Aspergillus, culture of BAL fluid had a sensitivity of 100%. Aspergillus species were isolated from an additional six patients who had no evidence of invasive aspergillosis. Graft rejection was a significant predisposing factor for the development of invasive aspergillosis (P < .001, log-rank test), and in our hospital, these patients now receive intravenous amphotericin B as prophylaxis. None of the six patients whose chest roentgenograms showed abnormalities before transplantation and who underwent surgical resection as part of the treatment for invasive aspergillosis developed recurrent infection.

Treatment of pyogenic liver abscesses by percutaneous needle aspiration.

Fifteen patients with solitary or multiple pyogenic liver abscesses diagnosed by ultrasound examination were treated by percutaneous aspiration under ultrasound guidance. The pus obtained was cultured immediately for aerobic and anaerobic organisms and appropriate antibiotic therapy was started. Anaerobic organisms were grown from this pus in nine patients. All patients improved after the aspiration and, apart from further aspirations in two cases, all abscesses healed without further intervention. No patient died from liver abscess or as a result of treatment. The technique is simple and harmless and is the method of choice for diagnosing and treating patients with pyogenic liver abscesses.

Screening for pancreatic disease: A comparison of grey-scale ultrasonography and isotope scanning.

The efficiency of ultrasound in the diagnosis of pancreatic disease was compared prospectively with that of selenomethionine isotope scanning in 46 patients presenting with abdominal pain or weight-loss or with jaundice. Of 14 patients who later proved to have pancreatic carcinoma, all had an abnormal isotope scan and 13 had an abnormal ultrasound scan. Of 10 patients with chronic pancreatitis, all had an abnormal isotope scan and 9 had an abnormal ultrasound scan. The small advantage of selenomethionine was, however, offset by a higher false-positive rate: of 22 patients who proved not to have pancreatic disease, 13 had abnormal isotope scans compared with only 3 with ultrasound. Review of earlier experience with the two techniques yielded similar results: in pancreatic carcinoma and chronic pancreatitis, isotope scanning gave slightly fewer false-negative results than ultrasound but many more false-positives. Because of its lower false-positive rate, because it avoids ionising radiation, and because it can usually distinguish carcinoma from pancreatitis, ultrasound is the procedure of choice for initial investigation of patients with suspected pancreatic disease.

The ultrasonic demonstration of portacaval shunts.

This study explores the use of ultrasound in the management of patients with portacaval anastomosis. Ten patients were studied; in 8 of these the status of the anastomosis was well demonstrated. It is suggested that ultrasound should be the initial investigation to determine the patency of a shunt.

Grey-scale ultrasonography of portal vein.

The state of the extrahepatic portal venous system was correctly assessed by grey-scale ultrasonography in twenty-one patients with extrahepatic portal-vein obstruction and the results agreed with those obtained by portal venography. In twenty-two age-matched controls a patent portal vein was displayed. The diameter of the portal vein on the ultrasound scan was significantly less in the twenty-two controls than in eighteen patients with chronic liver disease. Grey-scale ultrasonography is a reliable, inexpensive, and non-invasive method for diagnosing extrahepatic portal-vein obstruction.