Incidental primary breast cancer detected on PET-CT.

The purpose of this study is to determine the incidence of primary breast cancer (PBC) detected on (18) F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) in patients with a known diagnosis of non-mammary malignancies. A database search was performed to identify patients with non-mammary malignancies who had undergone staging with FDG PET-CT at a single institution between September 2005 and September 2011 and with the word "breast" reported in the PET-CT dictation. Additional breast imaging studies, clinical data, and the final histopathology of the breast lesions were correlated with the PET-CT images. Of 1951 patients who underwent PET/CT, 440 incidental breast lesions were identified in 438 patients. Of these 440 lesions, 195 (45 %) were benign, 160 (37 %) malignant, and 85 (19 %) missing data. A total of 25 PBCs were diagnosed; with a median size of 1.8 cm (range 0.8-10.7 cm); and a median SUVmax of 4.4 (range 1.7-17.6). There were 19 invasive ductal cancers, 1 invasive lobular cancer, 2 papillary cancers, 1 tubular cancer, 1 sarcomatoid cancer, and 1 ductal carcinoma in situ. Eight patients had regional nodal disease. Mammography revealed the PBC in 19 of 23 tumors (83 %), sonography in 22 of 23 (96 %). Six percent (25 of 440) of incidental breast lesions identified on FDG PET-CT represent PBCs; more than half were at an early stage and potentially curable.

Thickness of superficial basal cell carcinoma (sBCC) predicts imiquimod efficacy: a proposal for a thickness-based definition of sBCC.

BACKGROUND: Basal cell carcinoma (BCC) is the most common malignancy in the white population. It is an important driver of healthcare costs and causes significant morbidity. Topical imiquimod is a good noninvasive treatment alternative for surgical excision in superficial BCC (sBCC). However, there are currently no uniform histological definitions of sBCC. A definition based on tumour thickness might be a good alternative. OBJECTIVES: To determine whether tumour thickness in sBCC is a predictor of treatment failure. METHODS: We retrospectively examined 127 histological biopsy specimens of sBCC treated primarily with imiquimod five times a week for 6 weeks. Mean follow-up was 34 months (range 3-91). Recurrence was evaluated clinically with histological verification. RESULTS: Among nonrecurrent cases the median tumour thickness was 0·26 mm (range 0·09-0·61), while for recurrent cases the median tumour thickness was 0·57 mm (range 0·41-1·41, P < 0·0001). Among lesions ≤ 0·40 mm in thickness, none recurred, whereas for lesions > 0·40 mm the recurrence rate was 58% (P < 0·0001). CONCLUSIONS: We recommend the use of tumour thickness to define the superficial pattern in pathology reports for BCC as this can help to determine treatment response of sBCC to imiquimod.

Adenoviral infections in adult allogeneic hematopoietic SCT recipients: a single center experience.

Disseminated adenoviral infection (AI) is associated with profound immunosuppression and poor outcome after allogeneic hematopoietic SCT (allo-HSCT). A better understanding of AI in allo-HSCT recipients can serve as a basis to develop more effective management strategies. We evaluated all adult patients who received allo-HSCT at MD Anderson Cancer Center between 1999 and 2008. Among the 2879 allo-HSCT patients, 73 (2.5%) were diagnosed with AI. Enteritis (26%) and pneumonia (24%) were the most common clinical manifestations; pneumonia was the most common cause of adenovirus-associated death. A multivariable Bayesian logistic regression showed that when the joint effects of all covariates were accounted for, cord blood transplant, absolute lymphocyte count (ALC) ≤ 200/mm(3) and male gender were associated with a higher probability of disseminated AI. The OS was significantly worse for patients with AI that was disseminated rather than localized (median of 5 months vs median of 28 months, P<0.001) and for patients with ALC ≤ 200/mm(3) (P<0.001). Disseminated AI, in patients who received allo-HSCT, is a significant cause of morbidity and mortality. Strategies for early diagnosis and intervention are essential, especially for high-risk patients.

Ultrasound surveillance for asymptomatic deep venous thrombosis after total joint replacement.

Prospective data on 202 consecutive patients who had a total of 123 total hip and ninety-four total knee arthroplasties were collected from two university medical centers. The findings of routine surveillance for deep venous thrombosis performed with ascending contrast venography were compared with those of surveillance with duplex ultrasonography complemented with color-flow Doppler imaging. All of the studies were performed between the third and seventh postoperative days. Of the 202 patients (342 extremities) who were examined, fifty-five (27 per cent) were found to have deep venous thrombosis; fifty-two (95 per cent) of the thrombi were in the calf and three (5 per cent) were in the proximal veins. All of the thrombi were clinically asymptomatic and all were nonocclusive, allowing passage of contrast medium around an intraluminal filling defect. Duplex ultrasonography with color-flow Doppler imaging correctly identified two of the three proximal thrombi and five of the fifty-two thrombi in the calf (sensitivity, 10 per cent). The sensitivity for the detection of thrombi in the calf was zero of sixteen at one of the institutions involved in the study and 14 per cent (five of thirty-six) at the other. There were two false-positive findings on ultrasonographic examination; one involved a proximal thrombus and one, a distal thrombus. We believe that the interinstitutional variability and insensitivity of duplex ultrasonography with color-flow Doppler imaging for the detection of asymptomatic deep venous thrombi in the calf after total joint replacement make it unreliable as a routine surveillance tool after total hip or knee arthroplasty.

Radiographic detection of single-leg fracture in Björk-Shiley Convexo-Concave prosthetic valves: a phantom model study.

Cineradiography can identify patients with single-leg fractured Björk-Shiley Convexo-Concave valves, although little is known about the sensitivity and specificity of this technique. We evaluated three normal and six (0 microm gap) single-leg fractured Björk-Shiley valves that were placed in a working phantom model. Valves were randomly imaged a total of 33 times and duplicated into a 120-valve series with a 1:9 ratio of abnormal/normal valves. Six reviewers independently graded each valve and demonstrated markedly different rates of identifying the fractured valves. Average sensitivity at the grade that clinically results in valve explanation was 47%. Among the normal valves, a correct identification was made 96% (range 91% to 99%) of the time. Present radiographic technology may have significant difficulty in identifying true single-leg fracture in Björk-Shiley valves with limb separations that are common among clinically explanted valves.

Experimental nonsurgical transcervical sterilization with a custom-designed platinum microcoil.

PURPOSE: Investigation of a technique for nonsurgical female sterilization. MATERIALS AND METHODS: A custom designed platinum microcoil with Dacron fibers was placed unilaterally into a fallopian tube and uterine horn of 10 rabbits after transcervical selective tubal catheterization with use of fluoroscopic guidance. The contralateral uterus and fallopian tube served as controls. After the rabbits were bred, pregnancy was determined by palpation and confirmed at autopsy. Postmortem histopathologic evaluation of uteri and fallopian tubes was performed. RESULTS: Nine of the 10 rabbits became pregnant. None of the animals had embryos on the microcoil side. Nine rabbits had a total of 45 embryos on the control side. One animal failed to become pregnant on either side. The microcoil remained in good position in all 10 rabbits. There was a microcoil-associated, mild inflammatory tissue response in the uteri and fallopian tubes. CONCLUSION: A platinum occlusion microcoil placed in a utero-tubal location has potential as a means for nonsurgical female sterilization.

PIP: At Milton S. Hershey Medical Center in Hershey, Pennsylvania, researchers used fluoroscopy to guide transcervical selective tubal catheterization in order to correctly insert a custom-designed platinum microcoil with Dacron fibers 1.5-6 cm into a fallopian tube and 1.5-5.5 cm into a uterine horn of 10 rabbits. The fallopian tube and uterine horn on the opposite side were the controls. The researchers sacrificed the rabbits to conduct histopathologic examination of the uteri and fallopian tubes in order to determine the presence or absence of embryos. One rabbit had no embryos on either side, even after 4 breeding attempts. Among the remaining 9 rabbits, there were no embryos on the microcoil side and 45 embryos on the control side. The position of the microcoil did not change in any rabbit. The microcoil caused a mild inflammatory tissue response in the uteri and fallopian tubes. Longer-term studies in more animals are necessary to confirm the efficacy and safety of this sterilization method as well as to determine the potential for retrievability of the microcoil and reversibility of the sterilization effect. In conclusion, a uterotubal coil may someday be a safe, effective, minimally invasive means of female sterilization.

Cumulative experience with 1,273 peripherally inserted central catheters at a single institution.

PURPOSE: To compare bedside insertion of peripherally inserted central catheters (PICCs) by specially-trained nurses with insertion by cardiovascular and interventional radiologists. MATERIALS AND METHODS: Nurses performed 327 bedside insertions with a palpatory, through-the-needle technique in 301 patients. Radiologists performed 542 insertions with a venographic-fluoroscopic direct puncture and sheath technique in 354 patients. RESULTS: A total of 869 PICCs were inserted in 655 patients. Compared with the first interval of the study (reported previously), bedside technical success improved from 74% to 82.6%, technical success decreased from 98.6% to 98.2%, and the service interval for a given PICC decreased from 72.7 to 28.1 days (because PICCs were used instead of peripheral intravenous lines). Rates of thrombophlebitis and infection remained low. Device failure continued to be a problem. About 25% of patients needed insertion of more than one PICC to complete therapy. CONCLUSION: Bedside insertion by specially trained nurses is less costly than insertion by radiologists, but radiologists are needed for difficult initial insertions, PICC salvage, and PICC exchange.

Development of a model angiography informed consent form based on a multiinstitutional survey of current forms.

PURPOSE: To develop an informative consent form for angiography that can be read and understood by a patient with an eighth-grade level of education. MATERIALS AND METHODS: Consent forms from 125 medical centers were evaluated with RightWriter 4.0 software. The readability index, a measure of educational grade level needed to understand a document, was determined for each form. Features of forms and discussion of complications were evaluated. A model consent form was developed. RESULTS: Analysis of 27 consent forms revealed a mean readability index of 14.2; to adequately understand the documents, an average of 2.2 years of college were required. Alternatives to the procedure were listed in 14 forms (52%). All consent forms listed potential complications, but only 15 (56%) identified specific numeric risks, and attempts to classify complications according to severity were made in only five (18%). CONCLUSION: An angiography consent form has been developed that can be understood with an eight-grade level of education. It should allow patients to more easily understand the procedure and its risks, benefits, and alternatives. It remains the obligation of the physician to tailor the discussion for each procedure to meet the needs of each patient.

Recombinant tissue plasminogen activator for the treatment of lower extremity peripheral vascular occlusive disease.

PURPOSE: Regional thrombolysis in the recanalization of peripheral vascular occlusive disease is an increasingly accepted therapeutic modality. Efficacy and complication rate are major issues in thrombolytic therapy. This prospective study was undertaken to determine if locally delivered recombinant tissue plasminogen activator (r-TPA) is safe and effective in clot lysis at non-weight-adjusted doses. PATIENTS AND METHODS: Twenty patients (undergoing 21 infusions) from two centers underwent fibrinolytic therapy with use of r-TPA, at a dose rate of 2 mg/h. The mean duration of arterial occlusion was 27.2 days (range, 1-117 days). Concomitant intravenous heparin anticoagulation was administered to all patients. A coaxial infusion delivery system was employed. Hematologic parameters and angiographic follow-up were evaluated at 4-hour intervals during thrombolytic infusion. The chosen maximum r-TPA dose of 40 mg could be extended at investigator discretion. RESULTS: Complete clot lysis was achieved in 18 of 21 (85.7%) infusions at a mean total dose of 38.9 mg (range, 8-84 mg). The mean infusion duration was 19.7 hours. In 16 of 19 (84.2%) infusions, in which the nadir fibrinogen level was recorded, it remained greater than 65% of baseline. Three of 21 (14.3%) infusions resulted in three major bleeding complications, one of which resulted in death. CONCLUSION: In this two-center trial, catheter-directed r-TPA infusion at 2 mg/h is effective for clot lysis. When combined with concomitant heparin administration, this treatment may result in an unacceptably high frequency of bleeding complications.

Evaluation of a second-generation tantalum biliary stent in a canine model.

PURPOSE: To evaluate the safety and feasibility of use of a balloon-expandable tantalum (Tantaflex) stent in the biliary tree in a canine model. MATERIALS AND METHODS: In this prospective, randomized trial, 10 tantalum stents were placed in eight dogs (two telescoping stents in two dogs), and six Wallstents were placed in six dogs as controls. Stents were deployed into the common bile duct via a cholecystostomy at laparotomy under fluoroscopic and cholangiographic guidance. Two dogs from each stent group were killed at 4, 12, and 26 weeks; the two dogs with telescoping stents were killed at 12 weeks. Premortem patency was confirmed cholangiographically. Postmortem stent explants were inspected grossly, and tissues were examined histologically. Bacteriologic evaluation of bile was performed. RESULTS: All 14 dogs survived until they were scheduled to be killed without clinical complication or evidence of jaundice. Patency was demonstrated at terminal cholangiography in 12 of 14 dogs and at explantation in 13 of 14 dogs. One Wallstent placed across the ampulla in a dog killed at 26 weeks became obstructed. In another dog, the presence of a cholelith in the cystic duct precluded filling of the common bile duct from the cholecystotomy. Only mild inflammatory changes were present in the bile ducts. CONCLUSION: The tantalum stent can be used safely and effectively in the common bile duct in normal dogs. Performance of a clinical trial in humans is supported finding of this study.

Recombinant tissue plasminogen activator for neonatal and pediatric vascular thrombolytic therapy.

Thrombotic vascular occlusion may complicate the clinical course of many neonatal and pediatric pathologic processes. Systemic thrombolytic therapy with heparin, urokinase, or streptokinase may not be appropriate in the critically ill neonate because these agents generate a diffuse coagulopathic state. Direct surgical intervention for repair may be precluded by the small size of the vessels involved. Recombinant tissue plasminogen activator (rTPA) induces only a minimal proteolytic state while inducing thrombolysis within the local environment of the clot. We report our experience with regional rTPA infusion in four critically ill patients with venous and arterial thrombotic disorders. there were two brachial artery occlusive lesions--a neonate with iatrogenic occlusion due to a misplaced intravenous catheter and a 2-year-old child with inadvertent arterial ligation during an attempted venous cutdown. Two venous lesions consisted of a full-term neonate with renal vein/inferior vena caval thrombosis and a 32-week infant with partial superior vena caval thrombosis due to a Broviac catheter. Systemic thrombolytic therapy was contraindicated in these patients because of underlying illnesses. Pretherapy vascular evaluation included Doppler examination and angiography. The rTPA infusion was continued until there was evidence of clot lysis by ultrasound, angiogram, or venogram. Infusion rate of rTPA was adjusted according to fibrinogen levels. All three neonates responded successfully to rTPA therapy. Two neonates required only bolus administration and one responded to combined bolus and continuous infusion therapy after 58 hours. rTPA failed to reverse brachial artery occlusion in the 2-year-old child with purpura fulminans.(ABSTRACT TRUNCATED AT 250 WORDS)

Interventional radiologic placement of peripherally inserted central catheters.

PURPOSE: This study examines the difference in success between bedside insertions of peripherally inserted central catheters (PICCs) performed by clinicians and fluoroscopically assisted insertions by cardiovascular/interventional (CV/I) radiologists. PATIENTS AND MATERIALS: Four hundred four PICCs were inserted in 305 patients, with a mean age of 48 years (range, 8-78 years), who required intermediate and long-term central venous access. One hundred fifty patients underwent bedside insertion, and 155 patients underwent fluoroscopically assisted insertion. Dual- and single-lumen PICC devices were used depending on venous access needs. RESULTS: Central venous access with the PICC device was achieved in 111 (74%) of 150 bedside insertions and in 153 (98.7%) of 155 fluoroscopic insertions. Average PICC dwell time was 72.7 days (range, 2-307 days). Of the 305 patients, 244 (73.4%) completed planned therapy with a single catheter, 54 patients (17.7%) required two PICCs at the same site, 15 patients (4.9%) required three or more PICCs at the same site, and 12 patients (4.0%) required PICC replacement to a different site to complete therapy. Complications with bedside insertions included upper extremity thrombophlebitis (n = 4), entry site infection (n = 6), and PICC shear with migration (n = 2), while complications with fluoroscopic insertions included entry site infection (n = 2). CONCLUSION: Because of the far greater placement success achieved by CV/I radiologists, all PICCs are now inserted fluoroscopically. The devices complete favorably with surgically placed central catheters with regard to service interval, morbidity, and cost. Use of fluoroscopic techniques enables placement of these devices in virtually all patients, even those with seemingly no peripheral veins.

High dose (bolus) intravenous methylprednisolone at the time of kidney homotransplantation.

A completely randomized double-blind study of bolus methylprednisolone versus dextrose in water, administered at the time of human kidney transplantation, has failed to demonstrate any beneficial effect of the steroid therapy. No differences were observed in the number of complete, irreversible graft rejections, the number of acute rejection episodes, or the number of postoperative steroid boluses administered in the treated or the control groups. Similarly, there were no differences in the mean serum creatinines at 30, 60, 90 days post-transplantation. There was a slight increase in mortality and incidence of complications in the group of patients receiving an intravenous bolus of methylprednisolone at the time of transplantation as compared to controls. The failure to demonstrate any beneficial effect and the slight increased mortality and morbidity associated with the bolus methylprednisolone dosage makes this therapy unjustifiable.

Prevention of transplant renal artery stenosis.

Transplant renal artery stenosis occurred in 17 of 142 consecutive transplants (12 percent). All stenoses were in the renal artery distal to the anastomosis and two separate forms are recognized: angulation and segmental stenosis. Successful surgical correction in 12 of 17 patients relieved the hypertension and resulted in improved renal function. No patients receiving dipyridamole, a drug which inhibits platelet aggregation and intravascular fibrin deposition, developed segmental renal artery stenosis. No other factors could be identified which were important in either causing or preventing renal artery stenosis. Since intrarenal vascular changes are an integral aspect of rejection, the protection afforded by dipyridamole against segmental renal artery stenosis indicates that segmental stenosis is probably a manifestation of rejection.