Impact of Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography in the Management of Oligometastatic Renal Cell Carcinoma.

Background: Prostate-specific membrane antigen (PSMA) is overexpressed in the neovasculature of renal cell carcinoma (RCC). However, there remains limited evidence regarding the use of PSMA positron emission tomography/computed tomography (PET/CT) in RCC. Objective: To assess the impact of PSMA PET/CT in the management of metastatic RCC. Design setting and participants: This was a retrospective review of patients who underwent PSMA PET/CT from 2014 to 2020 for restaging or suspected metastatic RCC in a tertiary academic setting. Outcome measurements and statistical analysis: Management plans before and after PSMA PET/CT were recorded. Impact was classified as high (change of treatment intent, modality, or site), medium (change in treatment method), or low. Secondary outcomes included the patient-level detection rate, PSMA PET/CT parameters, sensitivity, and comparison to CT and, if available, fluorodeoxyglucose (FDG) PET/CT. Results and limitations: Sixty-one patients met the inclusion criteria, of whom 54 (89%) had clear cell RCC. PSMA-positive disease was detected in 51 patients (84%). For 30 patients (49%) there was a change in management due to PSMA PET/CT (high impact, 29 patients, 48%). In 15 patients (25%), more metastases were detected on PSMA PET/CT than on CT. The sensitivity of combined PSMA PET/CT and diagnostic CT was 91% (95% confidence interval 77-98%). In a subcohort of 40 patients, the detection rate was 88% for PSMA and 75% for FDG PET/CT (p = 0.17). The maximum standardised uptake value (SUVmax) was higher for PSMA than for FDG PET/CT (15.2 vs 8.0; p = 0.02). Limitations include selection bias due to the retrospective design, and a lack of corresponding histopathology for all patients. Conclusions: PSMA PET/CT is a promising imaging modality in metastatic RCC and led to a change in management in 49% of patients. PSMA PET/CT detected additional metastases compared to CT in 25% of patients and registered a significantly higher SUVmax than FDG PET/CT. Prospective studies are required to further define its role. Patient summary: We report on a group of patients undergoing a new type of imaging for suspected advanced kidney cancer, called PSMA PET/CT. This imaging changed the management plan in 49% of the patients. PSMA PET/CT detected metastases in 84% of our patients and detected more metastases than computed tomography imaging in 25%.

Validation of a Head-mounted Virtual Reality Visual Field Screening Device.

PRéCIS:: The C3 fields analyzer (CFA) is a moderately reliable perimeter preferred by patients to standard perimetry. While it does not approximate the gold standard, it was sensitive and specific for clinically defined glaucoma (area under the receiving operator characteristic curve=0.77 to 0.86). PURPOSE: Testing the visual field is a vital sign for diagnosing and managing glaucoma. The current gold standard, the Humphrey visual field analyzer (HFA), is large, expensive and can be uncomfortable for some patients. The current study investigated the CFA, a virtual reality head-mounted visual field testing device, as a possible subjective field test for glaucoma screening and eventually glaucoma monitoring. PATIENTS AND METHODS: The CFA presented stimuli in the same 54 positions as the HFA 24-2 SITA Standard test using a suprathreshold algorithm approximating an 18 dB deficit. A total of 157 patients (both controls and glaucoma patients) at the Aravind Eye Hospital, Pondicherry, India, were tested with both devices. RESULTS: The number of stimuli missed on the CFA correlated with HFA mean deviation (r=0.62, P<0.001), and with pattern standard deviation (r=0.36, P<0.001). The area under the receiving operator characteristic curve was 0.77±0.06 for mild glaucoma (HFA mean deviation ≥-6 dB) and 0.86±0.04 for moderate-advanced glaucoma (HFA mean deviation <-6 dB). Patients with an 18 dB or worse deficit at a point in the visual field on the HFA failed to see the CFA stimulus at the same position 38% of the time. CONCLUSIONS: While the CFA did not reliably identify deficits that matched the HFA, it was moderately effective at identifying glaucoma subjects. Further refinements to the device will be required to improve point by point testing performance and screening performance.

Presentation is key to diagnosing salivary gland disorders.

Initial signs and symptoms offer the best guide to next steps in assessment, testing, and treatment, plus any needed referral or multidisciplinary care.

Chronic non-granulomatous supraglottitis of a male adolescent and its successful management with azathioprine.

Chronic non-granulomatous supraglottitis (CNGS) is a rare disorder of the supraglottic larynx, characterised by chronic supraglottic inflammation in the absence of granulomata, vasculitis, neoplasia, autoimmune disease or infective changes on histology. We present the case of a male adolescentwho attended with progressively worsening exertional dyspnoea, stridor and symptoms of obstructive sleep apnoea. Flexible nasendoscopy revealed marked supraglottic subepithelial thickening sparing the glottis and subglottis, confirmed on microlaryngoscopy. MRI of the head and neck demonstrated diffuse, homogenous supraglottic oedema. At the peak of his symptomology, the patient was admitted for further investigations and intravenous steroid therapy, and switched to prolonged oral steroids on discharge. Tracheostomy was avoided. After 3 months, he was successfully weaned from steroids to azathioprine with gradual symptomatic improvement. This case represents the first successful use of a steroid-sparing agent in the management of CNGS.

Effect of secondary penicillin prophylaxis on valvular changes in patients with rheumatic heart disease in Far North Queensland.

OBJECTIVE: To determine the effect of secondary penicillin prophylaxis on echocardiographic diagnosed valvular changes in patients with rheumatic heart disease or history of acute rheumatic fever in the Townsville Health district. DESIGN: Patients with known were identified from the North Queensland register, serial echocardiogram results and number of secondary penicillin prophylaxis doses received in 2014 were collated. Descriptive statistics were utilised. SETTING: Townsville Hospital and outreach clinics within the Townsville Health catchment zone. PARTICIPANTS: All patients diagnosed with acute rheumatic fever or rheumatic heart disease between 2010 and October 2013 who had serial echocardiograms prior to and post commencement of secondary penicillin prophylaxis were included. All patients were of Aboriginal or Torres Strait Islander descent. MAIN OUTCOME MEASURE: Progression of echocardiographic valvular changes and association with secondary penicillin prophylaxis compliance. Compliance with secondary penicillin prophylaxis among the study population was a secondary outcome measure. RESULTS: Twenty-three patients were recruited. Only those patients who were compliant with secondary penicillin prophylaxis had any improvement in valvular changes on echocardiogram. Four of six patients without any baseline valvular involvement developed new valvular changes. Seventy percent of patients received >75% of secondary penicillin prophylaxis doses. CONCLUSIONS: This small study of patients in Townsville suggests that with good secondary penicillin prophylaxis compliance there is regression of some cardiac lesions over time in people with rheumatic heart disease. Furthermore the natural history of acute rheumatic fever in the Indigenous population is progressive requiring strict adherence to secondary penicillin prophylaxis. Prospective studies or use of data from the nationwide RHD register and standardised reporting of cardiac echocardiograms will provide more robust evidence.

A rare case of paratesticular leiomyosarcoma.

Paratesticular leiomyosarcomas are rare and can lead to significant morbidity and mortality, if inadequately diagnosed or treated. We present a case of paratesticular leiomyosarcoma in an 88-year-old man presenting with a left scrotal mass with ultrasound revealing that the mass is extratesticular. Left radical orchidectomy was performed and pathological examination of the resected specimen confirmed the diagnoses of high grade leiomyosarcoma with surgical margins clear of tumour. The patient was free of metastatic disease on further imaging and has been disease-free for 18 months. A review of the literature regarding paratesticular leiomyosarcoma presentation, diagnosis, and treatment is also discussed.