Bilateral uveal metastases from small-cell carcinoma of the lung.

Metastasis from small-cell carcinoma of the lung (SCCL) has most frequently been found in the lymph nodes, bones, brain, and liver. We have reported a case of metastatic SCCL located in the uveal layer of both eyes (choroidal in one and iridic in the other), an extremely rare occurrence.     

Biomarkers in melanoma: staging,prognosis and detection of early metastases

Currently, melanoma remains a surgical disease since early detection and excision of thin melanomas offers the best chance of a cure. Despite intensive clinical investigation, no effective systemic therapies exist for metastatic melanoma. Sentinel lymph node biopsy has greatly aided the staging and prognostic evaluation of primary cutaneous melanoma, however, approximately a third of patients diagnosed with metastatic melanomas present without prior regional lymph node involvement. Additional prognostic biomarkers exist which help determine the risk of advanced melanoma but the accuracy for each current marker is less than 100%. A greater understanding of the biology of melanomas and the development of new methods to identify patients with early (subclinical) metastatic disease may allow for selective and more effective therapy for patients at-risk for advanced disease. In this paper, current and novel potentially more accurate biomarkers for the staging and prognostic evaluation of melanoma patients, and for the detection of subclinical metastases are reviewed.     

CT and MR imaging in Hodgkin's disease--present and future

Initial staging of Hodgkin's disease is crucial to determine the location and extent of disease, and is the hallmark for the choice of treatment. At present, the established radiological technique for staging Hodgkin's disease is computed tomography (CT). Modern multidetector row CT scanners allow fast imaging from the scull base to the groins during a single breath hold with a spatial resolution of approximately 1 mm. Both, nodal and extranodal involvement of Hodgkin's disease can be diagnosed with CT. Magnetic resonance (MR) imaging is another useful cross-sectional imaging modality for staging Hodgkin's disease. The development of fast MR imaging techniques has considerably reduced imaging time without compromising the quality of MR images. As a consequence, MR imaging is now considered to be as diagnostic as CT for staging Hodgkin's disease. The excellent soft-tissue contrast and the lack of exposure to ionizing radiation are the main advantages of MR imaging. For the detection of extranodal Hodgkin's disease, MR imaging is superior to assess involvement of the brain, the spinal cord and bone marrow; while CT allows excellent evaluation of lung disease. Common major problems in staging Hodgkin's disease are still the detection of nodal involvement in normal sized lymph nodes and residual tumor masses after therapy. In the future, newly developed lymphotropic contrast agents for MR imaging might be helpful to answer these questions.     

Insufficiency fractures of the pelvis that simulate metastatic disease

Insufficiency fractures of the pelvis, which almost always occur in elderly women with osteoporosis, are often misinterpreted as metastatic disease. The initial symptom of such fractures is severe pain unassociated with an obvious history of trauma. The typical sites of involvement are the sacrum, the iliac bones, and the pubis. The plain film appearance of the sacral and iliac fractures is usually subtle and easily overlooked, and bone scans will show the abnormal areas more readily. The existence of multiple fractures not only in the pelvis but also in the vertebrae and ribs should suggest the diagnosis of insufficiency-type stress fractures. Computed tomography can exclude the presence of a destructive process and an associated soft tissue mass, as would be seen in metastatic disease. If insufficiency fractures are identified in the typical anatomic locations, bone biopsy is unnecessary.     

IMAGING AND STAGING OF SMALL-CELL LUNG CANCER: IS THERE A FUTURE ROLE FOR OCTREOTIDE SCINTIGRAPHY?

SUMMARY In small-cell lung cancer (SCLC), CT scan remains the most accurate imaging modality for evaluating local extension and specific sites of metastatic disease. The role of nuclear medicine in the work-up of SCLC is still limited to the detection of bone metastases. Recently, a new potential diagnostic tool has been introduced based on the presence of somatostatin receptors in SCLC. With the use of radiolabelled somatostatin analogues it is hoped that an equally effective but simpler staging system has been found that gives a better separation of prognostic subgroups. This article reviews the role of nuclear medicine in general and somatostatin receptor scintigraphy in particular in the imaging and staging of SCLC. Clinical value in terms of sensitivity and specificity is discussed in relation with other imaging and staging modalities.     

MRI相控阵线圈在直肠癌术前分期中的应用价值

目的 探讨MRI相控阵线圈在直肠癌术前分期中的应用价值.方法 43例经病理证实的直肠癌患者,术前应用MRI体表相控阵线圈检查.将术前MRIT分期结果及淋巴结转移诊断与术后病理组织学对照.结果 43例直肠癌病例术前T分期诊断准确率81.4%.诊断淋巴结转移的准确率83.7%.敏感度78.9%,特异度87.5%.转移性淋巴结在T2WI上表现为混杂信号,边缘形态不规则.结论 MRI体表相控阵线圈检查对于直肠癌T分期有着较高的诊断准确率,转移性淋巴结在MRI上具有一定特异性征象,MRI相控阵线圈在直肠癌术前分期中有较高的临床价值.     

骨显像在骨外恶性淋巴瘤的应用

目的:评价骨显像在恶性淋巴瘤中的应用价值。方法:经病理证实的骨外恶性淋巴瘤50例,何杰金病(HD)6例,非何杰金病(NHL)44例行骨显像检查,分析其结果。结果:经骨显像并结合临床及普通X线或CT、MRI确诊为累及骨病变者12例,占24%。HD和NHL累及骨发生率分别为16.7%(1/6)和25%(11/44)。除2例为全身弥漫性累及外,局灶性累及10例,2个病灶者3例,多发病灶者(≥3个病灶)7例;总病灶数48个,平均每例4.8个病灶。结论:本组资料提示,骨显像能为恶性淋巴瘤(特别是NHL)的诊断提供有价值的参考,并可作为其分期的手段。     

婴幼儿肺结核胸外播散的影像学表现

目的探讨婴幼儿肺结核发生胸外播散的影像特征。方法59例诊断肺结核的患儿（男35例,女24例,年龄1天至12个月）中,17例发生肺结核胸外播散,诊断均通过病理检查明确。回顾性分析全部胸片及CT的影像学表现和特征。结果在17例胸外播散的病灶中,包括结核性脑膜（脑）炎11例,腹膜结核6例,脾结核3例,肝结核2例,髋关节结核1例。增强CT显示全部病例均有纵隔淋巴结肿大,中心低密度的占70.6%;52.9%出现肺部团块样实变伴有灶性低密度;47.1%伴发胸腺萎缩;肺内播散结节发生率为29.4%;空洞17.6%;钙化11.7%。结论影像学检查能提供婴幼儿结核全身播散诊断证据,其中肺部急性播散结节、带有灶性低密度区的团块样实变和伴发的胸腺萎缩提示价值最大。     

Improved imaging and the clinician: the role of positron emission tomography in the management of colorectal cancer.

Colorectal cancer is the second most common cause of cancer death in the United States and Western Europe. Positron emission tomography (PET) has been shown to be a valuable tool for the evaluation of malignancies of the breast, lung, and gastrointestinal tract. Potential areas of utility in patients with colorectal cancer include early detection, improved staging at the time of initial diagnosis, the detection and staging of recurrent disease, and early determination of treatment response. Despite continued advancement in the technical aspects of PET, the true measure of its worth is how well it assists the clinician in the care of the patient. To best use the information provided by PET, the nuclear medicine physician and oncologist must both understand the treatment choices available for patients at various stages in the disease.     

The management of metastatic bone pain in a developing country: the role of radiotherapy as an adjunct to weak opioids

Bone pain secondary to metastatic cancer is the commonest intractable pain and is a major concern in most oncology units the world over. Cancer pain management is multidisciplinary in approach, so there is no universal or singular modality of treatment. In a developing country like Nigeria, only external radiotherapy and adjuvant weak opioids are readily available, so it is of interest to review the response of these patients to this management option. This is a retrospective review of 92 patients aged 16-80 years with radiologically confirmed metastatic bone disease associated with pain who received external radiotherapy and weak analgesics. The results showed that 23 (25%) patients had a complete response and 67 (73%) had a partial response within four weeks of treatment. Total response was over 90%, which suggests external radiotherapy has an effective palliative role. The study also demonstrated the pattern of bony involvement among the common cancers seen in our environment. The availability of strong opioids (e.g. morphine and pethidine) will obviously consolidate the gains achieved with external radiotherapy in the management of metastatic bone pain in our environment.     

Computed tomographic evaluation and staging of cecal carcinoma

The preoperative computed tomographic (CT) scans of 14 patients with biopsy-proven primary adenocarcinoma of the cecum were reviewed to assess clinical presentation, CT findings, and value of staging by CT. The correlation of CT evidence for tumor invasion beyond the bowel wall with histopathology had predictive value of negative examination of 33% with sensitivity of 78%. More importantly, the correlation of metastatic nodal involvement by CT had predictive value of negative examination of 22% with sensitivity of only 12%. Of chief concern was the involvement of pericolic and mesenteric nodal chains that were not discernible by CT. Computed tomographic tumor staging was accurate in 57% of cases and upgraded in 43%. This study concludes that, although predictive values of positive CT examination are high, CT tends to underestimate disease extent.     

Malignant bone pain: Pathophysiology and treatments

Metastatic involvement of the bone is one of the most frequent causes of pain in cancer patients and represents one of the first signs of widespread neoplastic disease. The pain may originate directly from the bone, from nerve root compression, or from muscle spasms in the area of the lesions. The mechanism of metastatic bone pain is mainly somatic (nociceptive), even though, in some cases, neuropathic and visceral stimulations may overlap. The conventional symptomatic treatment of metastatic bone pain requires the use of multidisciplinary therapies, such as radiotherapy, in association with systemic treatment (hormonotherapy, chemotherapy, radioisotopes) with the support of analgesic therapy. Recently, studies have indicated the use of bisphosphonates in the treatment of pain and in the prevention of skeletal complications in patients with metastatic bone disease. In some patients, pharmacologic treatment, radiotherapy, and radioisotopes administered alone or in association are not able to manage pain adequately. The role of neuroinvasive techniques in treating metastatic bone pain is debated. The clinical conditions of the patient, his life expectancy, and quality of life must guide the physician in the choice of the best possible therapy.     

Comparison of Positron Emission Tomography, Computed Tomography, and Endoscopic Ultrasound in the Initial Staging of Patients with Esophageal Cancer

Introduction Improvement in esophageal cancer staging is needed. Positron emission tomography (PET), computed tomography (CT), and endoscopic ultrasound (EUS) in the staging of esophageal carcinoma were compared. Methods PET, CT, and EUS were performed and interpreted prospectively in 75 patients with newly diagnosed esophageal cancer. Either tissue confirmation or fine needle aspiration (FNA) was used as the gold standard of disease. Sensitivity and specificity for tumor, nodal, and metastatic (TNM) disease for each test were determined. TNM categorizations from each test were used to assign patients to subgroups corresponding to the three treatment plans that patients could theoretically receive, and these were then compared. Results Local tumor staging (T) was done correctly by CT and PET in 42% and by EUS in 71% of patients (P value > 0.14). The sensitivity and specificity for nodal involvement (N) by modality were 84% and 67% for CT, 86% and 67% for EUS, and 82% and 60% for PET (P value > 0.38). The sensitivity and specificity for distant metastasis were 81% and 82% for CT, 73% and 86% for EUS, and 81% and 91% for PET (P value > 0.25). Treatment assignment was done correctly by CT in 65%, by EUS in 75%, and by PET in 70% of patients (P value > 0.34). Conclusions EUS had superior T staging ability over PET and CT in our study group. The tests showed similar performance in nodal staging and there was a trend toward improved distant disease staging with CT or PET over EUS. Assignment to treatment groups in relation to TNM staging tended to be better by EUS. Each test contributed unique patient staging information on an individual basis. This work was presented in part at The Society of Nuclear Medicine Annual Meeting, Los Angeles, CA June 15–19, 2002.     

Novel plasma extraction procedure and development of a specific enzyme-immunoassay of oxytocin: application to clinical and biological investigations of small cell carcinoma of the lung

Paraneoplastic secretion of the lactation-inducing hormone oxytocin (OT) has been reported in about 30% of cases of small cell carcinoma of the lung (SCCL). In order to investigate the role of OT in the biology of SCCL tumours, a specific enzyme-immunoassay (EIA) for OT, which can be applied to both human plasma and culture medium, has been developed. OT EIA is performed on 96-well microtiter plates coated with a rabbit polyclonal antibody (Ab) anti-OT (04). This antibody does not exhibit any significant cross-reactivity either with vasopressin (VP) or with vasotocin (VT). The immunological reaction involving Ab anti-OT is a competition between the tracer (biotinylated OT) and synthetic OT (standard curve) or OT present in biological samples. In order to limit interference induced by plasma proteins, plasma samples are filtrated by a one-step centrifugation on centricon YM-3 (cut-off 3000 Da). After plasma filtration, 90.7 +/- 5.1 (SD) % (n = 22) immunoreactive (IR) OT is recovered. The sensitivity of OT EIA is 1 pmol/L, while intra- and inter-assay coefficients of variation (CV) are around 3.41% and 2.84%, respectively. In healthy volunteers, plasma IR OT is 7.28 +/- 4.49 (SD) pmol/L (n = 32) with no gender difference. As shown by the data both from plasma of SCCL patients and from supernatants and cell contents of SCCL cell lines, this EIA procedure offers a novel, reproducible, specific and sensitive method for the measurement of IR OT.     

Treatment of small cell carcinoma of the lung with methotrexate, doxorubicin, cyclophosphamide, and lomustine: a community-based study

Forty-four patients with undifferentiated small cell carcinoma of the lung (SCCL) were diagnosed and treated at community hospitals. Patients with limited disease were treated with surgical resection or primary radiation therapy (RT) followed by chemotherapy; those with extensive disease received chemotherapy followed by RT if there was not a complete primary response. The chemotherapy used was a combination of methotrexate, doxorubicin, cyclophosphamide, and lomustine. Median survival for patients with both limited and extensive disease was 12 months, with a six-month survival of 89%. Half of the patients had recurrence in the lung. The toxicity was moderate and tolerable. We conclude that this combination chemotherapy plus radiation therapy carries acceptable toxicity and can be used in a community hospital to achieve response rates and survival of SCCL equivalent to that obtained in large cancer centers.     

Imaging of cervical lymphadenopathy

The identification and classification of cervical lymphadenopathy can be a challenging task for the general radiologist. Patients with a wide range of clinical presentation and disease states are often referred for imaging, although evaluation and staging of head and neck cancer is the most common indication. In addition to metastatic squamous carcinoma of the upper aerodigestive tract, the differential diagnosis of enlarged cervical lymph nodes includes the following: bacterial, mycobacterial and viral infections, granulomatous conditions such as sarcoidosis, primary and secondary involvement in lymphoma; other metastatic neoplasms such as from breast and lung, as well as more uncommon conditions such as sinus histiocytosis, eosinophilic granuloma, Kimura's disease, and Kikuchi's disease. This article will review the anatomy and regional classification of the cervical lymph node chains and discuss the common and uncommon etiologies of cervical lymph node enlargement.     

Identification of N-ethylglycine in urine of cancer patients with metastatic bone disease

BACKGROUND: Previously, a HPLC method for the determination of N-terminal prolyl dipeptides, proline and hydroxyproline in urine with fluorescence detection after pre-column derivatization with 4-(5,6-dimethoxy-2-phthalimidinyl)-2-methoxyphenylsulfonyl chloride (DMS-Cl) [Inoue H, Iguchi H, Kono A, Tsuruta Y. Highly sensitive determination of N-terminal prolyl dipeptides, proline and hydroxyproline in urine by high-performance liquid chromatography using a new fluorescent labelling reagent, 4-(5,6-dimethoxy-2-phthalimidinyl)-2-methoxyphenylsulfonyl chloride. J Chromatogr 1999;724:221-230] was developed to study the relation between those analytes and bone diseases. When the urinary analytes were measured, a large peak due to an unknown substance was recognized in the chromatograms of cancer patients with metastatic bone disease, although it was scarcely present in normal subjects. In this study, we identified the unknown substance. METHODS: The fluorescent fraction based on the unknown substance was collected using HPLC and the structure of the fluorescence product was analyzed with MS, (1)H NMR and (13)C NMR. RESULTS: The fluorescence product based on the unknown substance was established to be a DMS-derivative of N-ethylglycine. CONCLUSIONS: Excretion of N-ethylglycine in the urine of cancer patients with metastatic bone disease is recognized, although N-ethylglycine is scarcely excreted in the urine of normal subjects.     

Baseline radiological staging in primary breast cancer: impact of educational interventions on adherence to published guidelines

RATIONALE: The purpose of baseline radiological staging in newly diagnosed breast cancer patients is to rule out overt metastatic disease. We have previously compared the use of radiological staging at our institution with the recommendations of the Cancer Care Ontario Practice Guidelines Initiative (CCOPGI). Our results demonstrated that between January 2000 to December 2002, a high proportion of our cohort (n = 135) of patients underwent unnecessary investigations. OBJECTIVES: To implement and assess an educational intervention to encourage staging guideline utilization in a cohort of early breast cancer patients. METHODS: In January 2003, multidisciplinary educational rounds were held, highlighting the CCOPGI guidelines, and reporting results of the audit of staging investigations. The staging guidelines were then included in the Clinical Practice Guidelines of the Breast Disease Site Group, Toronto-Sunnybrook Regional Cancer Centre. A retrospective chart review was completed that assessed staging investigations from a random sample of a similar group of patients (n = 134) from January 2003 to April 2005, to explore the effects of these educational interventions on clinical practice. RESULTS: For patients with Stage I breast cancer, there was a significant decrease (P < 0.004) in each type of investigation: a twofold decrease in chest X-rays; 2.5-fold decrease bone scans and fourfold decrease in the number of abdominal ultrasounds. For patients in Stage II, there was no significant change in the proportion of patients undergoing radiological investigations. There was a non-significant trend towards appropriately receiving all three investigations for patients with Stage III disease. CONCLUSIONS: Our results demonstrate that prior to the educational intervention, many patients with early breast cancer were undergoing inappropriate radiological staging. Since 2003 however, for Stage I patients there has been a significant improvement in adherence with the guidelines. We hypothesize that our educational intervention had a positive impact on improving the utilization of baseline radiological staging in patients with primary breast cancer.     

Optimizing the role of FDG PET–CT for potentially operable metastatic colorectal cancer

Recent treatment advances now allow a realistic chance of cure in selected patients with metastatic colorectal carcinoma (CRC). Accurate pre-treatment staging is crucial to ensure appropriate management by identification of patients with more advanced disease who will not benefit from surgery. ¹⁸Fluorine 2-fluoro-2-deoxy-d-glucose positron emission tomography?Ccomputed tomography (PET?CCT) has a firmly established role in staging, restaging, and recurrence detection of a range of tumors. This article will review the role of PET?CCT in patients with CRC with a particular emphasis on optimizing the technique in patients with potentially operable metastatic disease.