PEARLS - A multicentre phase II/III trial of extended field radiotherapy for androgen sensitive prostate cancer patients with PSMA-avid pelvic and/or para-aortic lymph nodes at presentation.

PEARLS is a multi-stage randomised controlled trial for prostate cancer patients with pelvic and/or para-aortic PSMA-avid lymph node disease at presentation. The aim of the trial is to determine whether extending the radiotherapy field to cover the para-aortic lymph nodes (up to L1/L2 vertebral interspace) can improve outcomes for this patient group.

The Diagnostic Accuracy of 18 F-FGD-PET/CT for Cancer of the Gallbladder: A Retrospective Study.

Background Gallbladder cancer has a poor prognosis and imaging can have variable diagnostic accuracy. We assessed the ability of preoperative 18 F-fluorodeoxyglucose positron emission tomography computed tomography ( 18 F-FDG-PET/CT) imaging to predict a postoperative histological diagnosis of gallbladder cancer. Method A retrospective analysis was undertaken in a cohort of patients, who had suspected gallbladder cancer on cross-sectional imaging and that underwent preoperative FDG-PET/CT scan. The discriminatory power of FDG-PET/CT was determined in receiver operator characteristic (ROC) analysis and diagnostic accuracy parameters were estimated at different thresholds of maximum standard unit value (SUV max ) . Results Twenty-two patients were included in the study; 7 had malignant and 15 benign diagnoses. There was no statistically significant difference between the measured SUV max between the two groups ( p = 0.71). With an area under the curve of 0.486, the ROC curve did not indicate any discriminatory power of FDG-PET/CT at any potential threshold of SUV max. Conclusion This study indicates that the diagnosis of primary gallbladder cancer cannot be accurately confirmed with FDG PET/CT scanning.

Does the addition of whole-body MRI to routine imaging influence real-world treatment decisions in metastatic breast cancer?

BACKGROUND: The assessment of metastatic breast cancer (MBC) can be limited with routine imaging such as computed tomography (CT) especially in bone-only or bone-predominant disease. This analysis investigates the effects of the use of WBMRI in addition to the use of routine CT, bone scintigraphy (BS) and fluorine-18-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) on influencing systemic anti-cancer treatment (SACT) decisions in patients with known MBC. METHODS: MBC patients undergoing SACT who had WBMRI undertaken within 8 weeks of either a routine CT, BS or FDG-PET/CT were reviewed retrospectively. The clinical indications for undertaking the WBMRI examinations were recorded. Data on the extent and distribution of the disease were collected and discordance/concordance of disease status across the imaging modalities were compared. SACT decisions at each time point were also evaluated. RESULTS: There were 105 MBC patients with 148 WBMRI studies paired with CT, BS or FDG-PET/CT. 50 pairs (33.8%) showed differences in the extent of disease, with 44 pairs due to additional sites (AS) reported on WBMRI alone. 81 patients (Group 1) had one WBMRI paired with routine imaging due to a variety of indications, with clinical symptoms (such as bone pain) being the most common (24.7%). 24 patients (Group 2) had more than one WBMRI study paired with routine imaging comprising 67 pairs. 13/67 pairs (19.4%) showed discordance in assessments. 10/13 pairs had progressive disease (PD) reported on WBMRI alone. SACT change due to AS reported on WBMRI alone occurred in 21/23 pairs (91.3%) in Group 1. SACT change due to PD reported on WBMRI alone in Group 2 occurred in 6/14 pairs (42.9%). SACT change due to AS/PD in both groups occurred in 11/102 pairs (10.8%) with known invasive ductal carcinoma (IDC) and 13/28 pairs (46.4%) with invasive lobular carcinoma (ILC). CONCLUSIONS: The use of WBMRI in MBC led to earlier recognition of PD and SACT change compared with the other imaging modalities. A higher proportion of discordant response assessments and SACT changes were observed in ILC compared with IDC in our patient group, although larger-scale studies are required to investigate this further.

Prostate-specific membrane antigen expression in melanoma metastases.

BACKGROUND: Prostate-specific membrane antigen (PSMA) is a prostatic epithelial protein that is used as a radiotracer (68Ga-PSMA-11) for prostate cancer staging. PSMA-PET/CT (positron emission tomography/computed tomography) performed for prostate cancer has been observed to detect melanoma metastases. The aim of this study was to investigate the performance of PSMA immunohistochemistry on resected melanoma metastases to explore its use as a diagnostic imaging biomarker for melanoma. METHODS: A total of 41 specimens with stage III/IV melanoma were stained with PSMA immunohistochemistry. All specimens required both disease and control regions. Two pathologists scored the specimens and a receiver operating characteristic (ROC) curve was plotted. Western blot and multiplex immunofluorescence were also performed. RESULTS: The area under the ROC curve was 0.82, suggesting that PSMA has excellent discriminatory power in melanoma metastases. Sensitivity is 82.9% and specificity 73.2%. Immunohistochemistry and Western blot reveal that PSMA staining in melanoma consistently and most intensely occurs in tumor neovasculature. Multiplex immunofluorescence shows that melanocytes may also weakly express PSMA. CONCLUSION: The performance of PSMA immunohistochemistry in melanoma metastases contrasts with that reported in prostate cancer studies. This study indicates that PSMA shows promise for use as a novel biomarker in melanoma and justifies further research in the clinical setting with potential as a PET/CT radiotracer and intraoperative fluorescence marker for melanoma.

Parotid incidentalomas on positron emission tomography: what is their clinical significance?

OBJECTIVE AND AIM: The increased use of PET/CT in cancer staging has resulted in more incidental findings in unexpected locations, making this a challenge for the radiologist interpreting the study. Our aim was to determine the frequency of parotid incidentalomas and to assess the ability of PET/CT to characterize them. PATIENTS AND METHODS: At the Norfolk and Norwich University Trust, in between October 2010 to October 2015, 4044 patients had a PET/CT examination. The issued clinical reports that contained the word 'parotid' were traced and all patients selected for this study had no known or suspected parotid disease before the PET/CT scan. RESULTS: The prevalence of parotid incidentalomas was 1.73%; higher than expected as was the mean age of our study group. Ten per cent of patients had no focal lesion identified on subsequent ultrasound. Thirty-two per cent of patients had a biopsy which showed that the majority of these findings were benign and 13% had metastatic deposits, with the primary carcinoma in these cases being neuroendocrine colon carcinoma, non-Hodgkin's lymphoma and melanoma. CONCLUSION: The most common benign salivary tumour in our study was Warthin's tumour and the majority of these patients had a primary lung carcinoma. Given that the main predisposing factor for both pathologies is smoking, potentially this suggests an association between the incidence of primary lung carcinoma and Warthin's tumour. Ten (14%) patients in our study had a standardized uptake value of below 3.2 (using the VUE Point HD algorithm). These patients had either no identifiable lesion on ultrasound or no malignant features on histology; therefore, we propose that a cut-off of 3.2 on PET/CT could be used to differentiate between physiological or benign uptake from malignant fluorine-18-fluorodeoxyglucose uptake in the parotid gland.

Targeted ultrasound-guided hydrodilatation via the rotator interval for adhesive capsulitis.

OBJECTIVE: To describe and evaluate ultrasound-guided hydrodilatation via the rotator interval for the treatment of adhesive capsulitis. MATERIALS AND METHODS: Patients referred to our department with adhesive capsulitis were consented for hydrodilatation. Inclusion criteria included a failure to respond to conservative treatment and the absence of full thickness rotator cuff tear. Twenty-one milliliters of a mixture of local anesthetic and steroid was injected into the rotator interval using a 21-gauge needle. Patients were followed up at 2 weeks and 4 months, with documented pain scores from 0 to 10 on a visual analogue scale and the Oxford Shoulder Questionnaire. RESULTS: Twenty-two patients were suitable for inclusion in the study. Nineteen were female (86 %) and three were male. The mean age was 55 years (range, 32-71 years). The duration of symptoms ranged from 4 weeks to 20 months. At 4 months, 19/22 (86 %) of patients described either complete (7/22) or good (12/22) improvement in their symptoms. The mean pain score was 8.4 prior to the procedure, 3.1 at 48 h and 1.9 at 4 months, and 20/22 (91 %) had a lower pain score after 4 months. There was a statistically significant (p < 0.05) improvement in the Oxford shoulder score, from a mean of 13.6 pre-procedure to 36.5 at 4 months. CONCLUSIONS: The rotator interval and anterior joint capsule are strongly implicated in the symptomatology of adhesive capsulitis. The novel use of targeted ultrasound-guided hydrodilatation via the rotator interval gives good results in reducing shoulder pain and symptoms in adhesive capsulitis.

Bleeding post coronary artery bypass surgery. Clopidogrel--cure or culprit?

BACKGROUND: Clopidogrel, in addition to aspirin, has become a common treatment of acute coronary syndrome and for stent thrombosis prevention, when given before percutaneous transluminal coronary angioplasty. However, some patients turn out to have surgical coronary artery disease and are sent for coronary artery bypass grafting (CABG) where the irreversible effect of aspirin and clopidogrel on platelet function becomes a concern. This study was conducted to evaluate the role of preoperative use of clopidogrel in bleeding complications after CABG. MATERIAL AND METHODS: A total of 462 patients who underwent CABG between 2001 and 2003 were studied as a retrospective cohort. Comparison was made between patients who had taken clopidogrel within 7 days of surgery (n=162), and those who were not exposed to clopidogrel (n=300). Chest tube output and bleeding index (a modified TIMI criteria), were the primary outcomes measured. RESULTS: Our data showed that patients taking clopidogrel within 7 days of surgery have a higher bleeding index than those who were not exposed to the drug (p = 0.024). Similarly, chest tube output was significantly higher in those who were exposed to clopidogrel within 7 days compared to those not taking clopidogrel (p = 0.01). To further dissect this relationship, we divided our population into three categories. We found that patients taking clopidogrel within 3 days prior to CABG (immediate exposure) have a higher bleeding index and TIMI major bleeding than either patients taking the drug between 3 and 7 days (recent exposure) or patients not exposed to clopidogrel at all (p = 0.009 and 0.03 respectively for inter-groups comparison). The same was true for chest tube output (p = 0.05 and 0.01 respectively). CONCLUSION: Clopidogrel increased the risk of post-CABG bleeding if taken within three days prior to surgery but not if taken before that.

Massive bilateral perirenal hematoma following urinary catheterization for urinary obstruction.

Urinary tract obstruction is a common problem associated with many complications. Decompression of an enlarged bladder has been associated with several complications, mainly vesicular bleeding. We report a case of a 42-year-old male patient who developed bilateral renal subcapsular hematomas secondary to relief of an extremely enlarged bladder.

Coronary artery calcification is related to coronary atherosclerosis in chronic renal disease patients: a study comparing EBCT-generated coronary artery calcium scores and coronary angiography.

BACKGROUND: Coronary artery calcification (CAC) measured by electron beam computed tomography (EBCT) correlates with plaque burden, vessel stenosis and is predictive of future cardiac events in the general population. Extensive CAC has been described recently in dialysis cohorts. For the first time we studied the relationship between CAC and coronary angiographic findings in patients with chronic renal failure, on dialysis and after renal transplantation. METHODS: We studied 46 patients who all had an EBCT-derived Agatston coronary calcium score and a diagnostic coronary angiogram within a 12-month period. The mean age was 55.7+/-13.2 (SD) years (range 29-80). The mean duration of dialysis was 54.4 months (range 1-372). RESULTS: The mean CAC was 2370+/-352.8. The mean CAC in patients with an abnormal coronary angiogram (n = 35) was 2869.6+/-417.9, while that in patients with a normal coronary angiogram (n = 11) was 559.4+/-255.1 (P = 0.001 for the inter-mean comparison). Total CAC correlated with the number of diseased vessels (P = 0.0001) and with severity of atherosclerosis in all the vessels (P = 0.0001). The individual coronary artery calcification score correlated well with the severity of atherosclerotic coronary disease (P<0.0001 for all) in the left anterior descending, right coronary and circumflex arteries. Running a multivariate regression analysis for atherosclerosis burden, we found that the only predictor was CAC (r = 0.34, P = 0.0001). CONCLUSION: CAC is common and more severe in patients with chronic kidney disease. Although in chronic kidney disease patients CAC can occur in the absence of occlusive coronary atherosclerosis, our data suggest that, as in the general population, CAC in chronic kidney disease patients is associated with obstructive atherosclerosis and may therefore be associated with a worse outcome.

Inflammation and coronary calcification in renal patients--factors that may explain increased cardiovascular risk, and poorer results of coronary interventions?

Cardiovascular disease (CVD) is one of the major causes of mortality in patients with renal diseases, with increased odds ratio of mortality with risk factors as diverse as cholesterol, vascular stiffness, chronic inflammation and hyperhomocysteinemia. Several factors have been incriminated to explain the increase in coronary vascular calcification (CVC) in this particular population. Increased duration of dialysis, dyslipidemia, altered calcium-phosphorus metabolism, and chronic inflammation have all been associated with increased CVC. We present here four case reports illustrating the differences in the pathophysiology, therapy and prognosis of calcific coronary heart disease seen in uremic patients.

Cardiac calcification in renal patients: what we do and don't know.

Cardiovascular (CV) disease is one of the major causes of mortality in patients with renal diseases, with an increased odds ratio of mortality with risk factors as diverse as blood pressure (high or low), cholesterol level (high or low), left ventricular hypertrophy, vascular stiffness, chronic inflammation, and hyperhomocysteinemia. Mainly cross-sectional studies of renal patients showed excess CV calcification (CVC) compared with the general population, but a clear link between calcification and subsequent mortality is tenuous to date. Several factors have been incriminated to explain the increase in CVC in this particular population. Increased duration of dialysis therapy, dyslipidemia, altered calcium-phosphorus metabolism, and chronic inflammation have all been associated with increased CVC. However, with the shortage of large, observational, population-based, prospective studies tracking these potential risk factors and the pathogenesis of CVC in renal patients not yet sufficiently understood, it is difficult with the present state of knowledge to make robust recommendations about care strategies. The purpose of this review is to examine the 10 available studies of renal patients that have used modern CVC imaging and quantification techniques for clues to likely targets for future interventional studies.

The role of inflammation in acute coronary syndromes: review of the literature.

Extensive evidence supports a pathogenic role for both local and systemic inflammation in acute coronary syndrome (ACS). The determination of inflammatory markers levels in combination with the new imaging modalities can be used to identify patients at high risk of future cardiovascular events. Interestingly, this inflammatory component is a novel therapeutic target in ACS.