Evidence for the use PET for radiation therapy planning in patients with cervical cancer: a systematic review.

BACKGROUND AND OBJECTIVE: In recent years, the role of positron emission tomography (PET) in the staging and management of gynecological cancers has been increasing. The aim of this study was to systematically review the role of PET in radiotherapy planning and brachytherapy treatment optimization in patients with cervical cancer. DESIGN AND SETTING: Systematic literature review. METHODS: Systematic review of relevant literature addressing the utilization of PET and/or PET-computed tomography (CT) in external-beam radiotherapy planning and brachytherapy treatment optimization. We performed an extensive PubMed database search on 20 April 2011. Nineteen studies, including 759 patients, formed the basis of this systematic review. RESULTS: PET/ PET-CT is the most sensitive imaging modality for detecting nodal metastases in patients with cervical cancer and has been shown to impact external-beam radiotherapy planning by modifying the treatment field and customizing the radiation dose. This particularly applies to detection of previously uncovered para-aortic and inguinal nodal metastases. Furthermore, PET/ PET-CT guided intensity-modulated radiation therapy (IMRT) allows delivery of higher doses of radiation to the primary tumor, if brachytherapy is unsuitable, and to grossly involved nodal disease while minimizing treatment-related toxicity. PET/ PET-CT based brachytherapy optimization allows improved tumor-volume dose distribution and detailed 3D dosimetric evaluation of risk organs. Sequential PET/ PET-CT imaging performed during the course of brachytherapy form the basis of “adaptive” brachytherapy in cervical cancer. CONCLUSIONS: This review demonstrates the effectiveness of pretreatment PET/ PET-CT in cervical cancer patients treated by radiotherapy. Further prospective studies are required to define the group of patients who would benefit the most from this procedure.

Characteristics of and therapeutic options for contralateral axillary lymph node metastasis in breast cancer.

AIM: Contralateral axillary metastasis (CAM) from breast cancer is uncommon. This papers aims to identify the features of our patients with CAM, as well as clarify management options. METHODS: We reviewed all of our breast cancer patients during the period from 2004 to 2009. All patients with a proven pathological diagnosis of CAM were included. Patients were evaluated for demographics, tumor features and management modalities. RESULTS: A total of 21 patients were included, forming 1.9% of our breast cancer population. The median age was 51 years (range 29-71). Twelve patients had large central or diffuse tumors. Most of the tumors were of invasive ductal type (95%), of high grade (81%) and with lymphovascular invasion (81%). The majority of cases were locally advanced (stage III: 90%). Hormonal receptor positivity and HER-2 overexpression were seen in 48% and 42% of cases, respectively. Those pathological features were significantly worse than those of patients without CAM. Ten patients had synchronous and 11 patients had metachronous CAM. Treatment modalities included axillary dissection, chemotherapy and hormonal therapy. Four patients died from metastatic disease and 5 patients are still alive without evidence of metastasis. CONCLUSION: CAM is associated with tumors with aggressive pathological features. Hormonal therapy is associated with an excellent response in patients whose tumors are hormone-receptor positive. Axillary dissection is indicated in patients with early-stage tumors, when there is no response to systemic therapy, or for palliation. It is associated with excellent local control.

Interventions for preventing venous thromboembolism following abdominal aortic surgery.

BACKGROUND: Deep vein thrombosis (DVT) is one of the most common, preventable complications of surgery. Although the relationship between surgery and DVT is well established in general surgical operations and most other subspecialties, the same cannot be said about arterial surgery. Deep vein thrombosis is believed to be less common in aortic surgery where its management is rather controversial with a reported incidence of DVT from 2% to 18%.Intra-operative heparin is believed to provide protection during the period when DVT is most likely to develop. However, the practice of using intra-operative heparin could increase the risk of haemorrhagic complications if further heparin is used during the recovery period. This can significantly limit the use of such prophylactic measures especially with the low perceived risk of venous thromboembolism (DVT or pulmonary embolism (PE)) following abdominal aortic surgery. However, vascular patients are usually older, with more co-morbidity and are subject to prolonged immobility, all of which increase the likelihood of developing venous thromboembolism. OBJECTIVES: To determine the efficacy of anticoagulant prophylaxis (with or without mechanical devices) in patients undergoing surgery for abdominal aortic aneurysm. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched 8 August 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, (last searched Issue 3, 2007). The authors searched for additional trials through reference lists of retrieved studies and conference proceedings. SELECTION CRITERIA: Randomised controlled trials comparing the use of anticoagulants (with or without mechanical devices) with control or no intervention in preventing DVT or PE after abdominal aortic operations. DATA COLLECTION AND ANALYSIS: Three authors independently selected potential trials and assessed trial quality. MAIN RESULTS: Two studies (n=147) were included. Both studies had methodological limitations. There were no data to indicate that post operative anticoagulation, with or without the use of mechanical devices, can safely reduce the incidence of DVT after aortic surgery. Neither study reported a significant effect of anticoagulants on the incidence of PE or related mortality. One study was terminated before recruiting sufficient participants due to a higher incidence of bleeding with the use of anticoagulants. The incidence of minor bleeding events was also slightly higher with anticoagulants. AUTHORS' CONCLUSIONS: There is not enough evidence to make a definitive conclusion about the use of anticoagulant drugs (with or without mechanical devices) for DVT prophylaxis in patients undergoing abdominal aortic surgery.