Radiofrequency ablation of neuroendocrine liver metastases—the Middlesex experience

Background Current treatment options for neuroendocrine liver metastases are not widely applicable or not that effective. Image-guided thermal ablation offers the possibility of a minimally invasive, albeit palliative, treatment that decreases tumor volume, preserves most of the normal liver, and can be repeated several times. We report our experience with image-guided thermal ablation in 25 patients with unresectable liver metastases.Methods Since 1990 we have treated 189 tumors at 66 treatment sessions in 25 patients (12 female, 13 male; median age, 56 years; age range, 26–78 years). Thirty treatments were performed with a solid-state laser, and 36 treatments were performed with radiofrequency ablation. All but one treatment was performed percutaneously under image guidance. Sixteen patients had metastases from carcinoid primaries, three from gastrinoma, two from insulinoma, and four from miscellaneous causes. Fourteen of 25 had symptoms from hormone secretion.Results Imaging follow-up was available in 19 patients at a median of 21 months (range, 4–75 months). There was a complete response in six patients, a partial response in seven, and stable disease in one; hence, tumor load was controlled in 14 of 19 patients (74%). Relief of hormone-related symptoms was achieved in nine of 14 patients (69%). The median survival period from the diagnosis of liver metastases was 53 months. One patient with end-stage cardiac disease died after a carcinoid crisis. There were eight (12%) complications: five local and three distant, four major and four minor.Conclusions As a minimally invasive, readily repeatable procedure that can be used to ablate small tumors, preferably before patients become severely symptomatic, radiofrequency ablation can provide effective control of liver tumor volume in most patients over many years.     

Should research be part of advance care planning?

Advance care planning is a process to help people to formulate and communicate their preferences regarding future care during critical illness. Reviews of the advance care planning process in its current form have been disappointing. Improvements in care at the end of life and palliative care are necessary for the provision of modern medical care. Medical research has led to many improvements at the physiological and technological levels. It is only by applying the same rigour of scientific study and research ethics that improvements in the advance care planning process can be made.     

Is intraoperative ultrasound (IOUS) still useful for the detection of liver metastases?

Purpose

To evaluate the clinical impact of intraoperative ultrasound (IOUS) in the detection of liver metastases during the years, as compared with those of other imaging modalities.

Materials and methods

All IOUS scans performed for detection of liver metastases from 2000 to 2006 were retrospectively reviewed and compared with the results of preoperative imaging modalities: Ultrasound (US), Computed Tomography (CT), and/or Magnetic Resonance (MR). The number of cases in which IOUS and preoperative imaging studies produced discordant results, in terms of presence/absence of focal liver lesions, was calculated per year. Statistical analysis was performed using the McNemar test. A p value < 0.05 was considered statistically significant.

Results

Eighty-three IOUS scans performed in 2000–2003 were reviewed, and discordance with preoperative imaging findings was found in 19/83 (23%) cases. Of the 42 IOUS scans done during the 2004–2006 period, 10/42 (24%) showed discordance with preoperative studies. All metastases diagnosed with imaging studies were pathologically confirmed. The number of discordant cases in the two periods were not significantly different (p = 0.2).

Conclusion

IOUS is still useful in the detection of liver metastases. Its decreased use is probably due to the improved accuracy of preoperative imaging modalities.     

Contrast-enhanced ultrasound of the small bowel in Crohn’s disease

Crohn’s disease (CD) is a chronic transmural inflammatory disease of the gastrointestinal tract characterized by episodes of inflammation alternating with periods of remission. Unenhanced grey-scale ultrasound may evaluate the localisation and the length of the affected intestinal segments and may detect transmural complications, including fistulas, abscesses and phlegmons, but it is less accurate to assess the CD activity. Contrast-enhanced ultrasound has become an important imaging modality in patients with CD for the grading of disease activity, the differentiation between small bowel stricture due to inflammation or mural fibrosis, and for the assessment of the response to specific therapy. New dedicated software packages allow the accurate quantification of the enhancement within the small bowel wall after microbubble contrast agent injection to obtain different kinetic semi-quantitative parameters—the percentage of the maximal enhancement, the time-to-the peak enhancement, and the area under the time–intensity curve—which are very useful to differentiate the inflammatory oedema from fibrosis and to differentiate responders from non-responders to the specific therapy among patients with CD.     

Should results of ultrasound Doppler studies be reported in units of frequency or velocity?

There is a current tendency to report the results of ultrasound Doppler studies in units of velocity instead of Doppler frequency. This is probably motivated by the intuitive feeling that blood flow studies should naturally be reported in cm/s and the notion that "velocity" is a normalizing factor for Doppler ultrasound studies. In order to determine velocity, the Doppler angle theta or angle formed by the ultrasound beam and flow velocity vector, must be known. It is not possible, using currently available systems, to obtain an accurate estimate of this angle. The physics related to the Doppler equation are reviewed in this paper along with examples to illustrate the origin and magnitude of errors that could arise when reporting in units of velocity. Guidelines are provided for thinking about and reporting results of Doppler studies in units of velocity. An understanding of the Doppler equation and its use in clinical studies are promoted in this paper to enhance the diagnostic usefulness of Doppler ultrasound studies and to reduce serious errors which could lead to faulty information dictating patient management.     

Should ultrasound guidance be used for central venous catheterisation in the emergency department?

In September 2002, the National Institute of Clinical Excellence (NICE) issued guidelines for England and Wales suggesting that ultrasound guidance should be used for all electives, and should be considered for most emergency, central venous catheterisations.1 These guidelines propose a major change of practice for most clinicians practising in UK Emergency Departments. There are also resource and training implications. In this paper we systematically review the literature to establish what evidence exists for the routine use of ultrasound guidance in the placement of central venous catheters in adult patients attending the Emergency Department, and provide an overview of the practical elements of this procedure.     

Should the rate of opioid dose escalation be included as a feature in a cancer pain classification system?

The purpose of this study was to assess the need for opioid dose escalation as a feature of a pain classification system for advanced cancer patients. Opioid dose escalation was included as a prognostic feature in the original Edmonton Staging System (ESS) for pain classification, but was not included among the five features of the revised ESS (rESS): pain mechanism, incident pain, psychological distress, addictive behavior, and cognitive function. Mercadante et al.'s definition of opioid escalation index percentage (OEI%) has been used as a surrogate marker for opioid responsiveness. Our hypothesis was that younger age (<60 years), neuropathic pain, incident pain, psychological distress, and addictive behavior would be associated with an OEI% >5%. Using data from a recent multicenter validation study of the rESS, a secondary analysis of a subsample of 532 advanced cancer patients with a pain syndrome was conducted. Approximately 44% (n=232) of the patients had an OEI% >5%. There were no significant associations between OEI% and age, neuropathic pain, incident pain, psychological distress, or addictive behavior. As originally proposed as a clinical marker, the OEI% may oversimplify the complexity of pain management in advanced cancer patients. Future studies are required to better elucidate the need for opioid dose escalation as a feature of a cancer pain classification system.     

Should pulse oximetry be included in GPs’ assessment of patients with obstructive lung disease?

Objective: To explore the associations between decreased pulse oximetry values (SpO₂) and clinical, laboratory, and demographic variables in general practice patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD), including those with both COPD and asthma in combination.Design/setting: A cross-sectional study in seven Norwegian general practices of patients aged 40 years or over who were diagnosed by their general practitioner (GP) with asthma and/or COPD. The patients were examined during a stable phase of their disease. Patients diagnosed with COPD (including those with combined COPD/asthma) and those diagnosed with asthma only were analysed separately.Main outcome measures: Decreased SpO₂ values (≤ 95% and ≤ 92%).Results: Of 372 patients included (mean age 61.5 years, 62% women), 82 (22.0%) had SpO₂ ≤ 95%, of which 11 had SpO₂ ≤ 92%. In both asthma and COPD patients, SpO₂ ≤ 95% was significantly associated with reduced lung function (spirometry), a diagnosis of coronary heart disease and older age (≥ 65 years). In the COPD group, haemoglobin above normal was associated with SpO₂ ≤ 95%. These associations were confirmed by multivariable logistic regression, where FEV₁% predicted < 50 was the strongest predictor of SpO₂ ≤ 95% (odds ratio 6.8, 95% confidence interval 2.8–16.4).Conclusion. Pulse oximetry represents a useful diagnostic adjunct for assessing the severity of obstructive pulmonary disease. Decreased pulse oximetry values in stable-phase patients with asthma and/or COPD should prompt the GP to consider revising the diagnosis and treatment and to look for co-morbidities.

Key Points

• Despite its common use in general practice, the diagnostic benefits of pulse oximetry remain to be established.
• Decreased pulse oximetry values are associated with both reduced lung function (spirometry) and with a diagnosis of coronary heart disease.
• Decreased pulse oximetry values may reflect suboptimal treatment and/or undiagnosed comorbidity.
• Pulse oximetry may therefore be a useful measure in the follow-up of asthma and COPD patients in general practice.

     

Should aminophylline be abandoned in the treatment of acute asthma in adults?

Intravenous aminophylline is widely used for the treatment of acute asthma and anecdotes about its apparent effectiveness abound. Early studies demonstrated that aminophylline is an inefficient bronchodilator compared with adrenergic agonists given by injection or inhalation. This paper presents the results of a review of randomized controlled trials examining the effect of adding aminophylline to standard modern therapy with a nebulized beta(2) agonist and systemic corticosteroids in acute asthma in adults. Six of the seven trials, comprising 343 patients, failed to demonstrate any beneficial effect of aminophylline. Furthermore, minor toxicity was common. There is presently no evidence to support the use of aminophylline in addition to standard therapy for acute asthma in adults.     

Dipyridamole stress echocardiography: to be included in the Guidelines or to be abandoned from the clinical arena?

Editorial Commentary

Dipyridamole stress echocardiography: to be included in the Guidelines or to be abandoned from the clinical arena?     

Should relatives be present in the resuscitation room?

Many Accident & Emergency (A & E) nurses will be familiar with the situation of resuscitating an individual who may be, for example, a husband, father or son. When the severity of illness gives rise to question the probability of continuing life, what about the relatives — those people who hold most importance to that individual?The relatives are sometimes unaware of the sudden illness and can be left isolated in the realisation that their loved one has died, and they were not there. How often are relatives there when an individual dies suddenly in the A & E department?These emotive factors led to this discussion and study of the attitudes of hospital and ambulance staff towards permitting relatives to be present during a resuscitation.