Pathology and physiopathology of adenomyosis

Adenomyosis is defined by the presence of endometrial mucosa within the myometrium. This probably occurs by invagination of the basalis endometrium into the myometrium. The process of invagination and intramyometrial spreading may be facilitated by the non-cyclic, anti-apoptotic activity of the basalis associated with relative hyper-oestrogenic states. Most cases of adenomyosis are discovered in multiparous women during the 'transitional' years (40-50 years), and the condition is associated with menorrhagia, dysmenorrhoea, endometrial polyps and leiomyomata uteri. Endometrioid adenocarcinoma is often associated with adenomyosis, is frequently of early stage and low histological grade, is hormone-sensitive, and has an excellent prognosis. Extension of malignant growth into foci of adenomyosis has no adverse effect on prognosis. Definite diagnosis and treatment of adenomyosis are obtained by hysterectomy. Although adenomyotic endometrial glands are hormone-sensitive, exogenous progestogenic agents are ineffective for the treatment of adenomyosis. Anti-oestrogenic danazol and gonadotrophin-releasing hormone (GnRH) analogues induce suppression of adenomyosis, but their use must be of short duration. Surgical extirpation, therefore, is the best therapeutic option.     

Clinical management of upper airway obstruction: epiglottitis and laryngotracheobronchitis

OBJECTIVE: To present current concepts on diagnosis and treatment of upper airway obstruction, mainly related to differential diagnosis between acute viral laryngotracheobronchitis and epiglottitis.METHODS: Bibliographic review covering the last ten years, using both Medline system and direct research. The most relevant articles published about the subject were selected.RESULTS: Viral laryngotracheobronchitis is an acute self-limited disease of the upper airway in a child, clinically characterized by barking cough, stridor, hoarse voice, and upper respiratory symptoms. The disease is diagnosed by clinical signs and symptoms. Rarely, if no immediate airway management is needed, radiography of the neck may help to exclude other entities that cause laryngeal obstruction. In contrast to viral laryngotracheobronchitis, epiglottitis is characterized by inflammation of the supraglottic tissues and is caused mainly by Haemophilus influenzae type b. A previously healthy child suddenly develops a sore throat and fever. Within hours after the onset of symptoms the patient looks toxic, swallowing is painful and breathing is difficult. Drooling and cervical hyperextension are frequently present. Lateral neck radiograph is rarely required to the diagnosis and may delay appropriate management of the airway. Moderate viral laryngotracheobronchitis with stridor at rest and retractions should be treated with steroids (systemic or nebulized) and nebulized epinephrine. Severe viral laryngotracheobronchitis should be treated aggressively while arregements are made for endotracheal intubation. The diagnosis of epiglottitis requires immediate endotracheal intubation in the appropriate unit (emergency department, intensive care unit or surgical unit) and antimicrobial therapy. Alternatively at some medical centers children with severe upper airway obstruction have been treated with a mixture of helium and oxygen (70 to 80% concentration of helium) instead of room air or pure oxygen to avoid intubation.CONCLUSIONS: There are different levels of care for patients with upper airway obstruction, depending on their clinical presentation. The clinical manifestations of viral laryngotracheobronchitis may be confused with the presentation of epiglottitis. Despite this observation we believe that differential diagnosis between viral laryngotracheobronchitis and epiglottitis rests on clinical grounds.     

PET/CT in the staging of patients with a pelvic mass suspicious for ovarian cancer

Objective

To prospectively assess the value of PET/CT for staging, diagnosis and operability of ovarian cancer, with special attention to the peritoneal spread.

Methods

From June 2009 to March 2011, 69 patients with suspicion of having an ovarian cancer underwent an ¹⁸ F-FDG PET/CT. To identify the diagnostic value of PET/CT, the results were compared with the findings at diagnostic laparoscopy and/or debulking surgery.

Results

There were 56 patients with malignant tumors and 13 with benign tumors. We observed a sensitivity and specificity of 93% and 77%, respectively for malignant tumors with PET/CT. CT alone had a sensitivity and specificity of 96% and 38%, respectively. The overall FIGO classification evaluation for PET/CT and CT were the same. For the evaluation of metastases, the sensitivity of PET/CT was worse, while the specificity was better than CT. Retroperitoneal lymph node metastases were diagnosed better with PET/CT, while there was no difference for peritoneal spread and for the intestines. PET/CT detected another unknown primary tumor in 3 (4.3%) cases.

Conclusion

PET/CT is better than CT in detecting retroperitoneal lymph node metastases, but not for peritoneal metastases.     

Evaluation of the quality of the management of cancer of the corpus uteri — Selection of relevant quality indicators and implementation in Belgium

Objective

Describe the methodology and selection of quality indicators (QI) to be implemented in the EFFECT (EFFectiveness of Endometrial Cancer Treatment) project. EFFECT aims to monitor the variability in Quality of Care (QoC) of uterine cancer in Belgium, to compare the effectiveness of different treatment strategies to improve the QoC and to check the internal validity of the QI to validate the impact of process indicators on outcome.

Methods

A QI list was retrieved from literature, recent guidelines and QI databases. The Belgian Healthcare Knowledge Center methodology was used for the selection process and involved an expert's panel rating the QI on 4 criteria. The resulting scores and further discussion resulted in a final QI list. An online EFFECT module was developed by the Belgian Cancer Registry including the list of variables required for measuring the QI. Three test phases were performed to evaluate the relevance, feasibility and understanding of the variables and to test the compatibility of the dataset.

Results

138 QI were considered for further discussion and 82 QI were eligible for rating. Based on the rating scores and consensus among the expert's panel, 41 QI were considered measurable and relevant. Testing of the data collection enabled optimization of the content and the user-friendliness of the dataset and online module.

Conclusions

This first Belgian initiative for monitoring the QoC of uterine cancer indicates that the previously used QI selection methodology is reproducible for uterine cancer. The QI list could be applied by other research groups for comparison.     

Chemotherapy‐induced structural changes in cerebral white matter and its correlation with impaired cognitive functioning in breast cancer patients

A subgroup of patients with breast cancer suffers from mild cognitive impairment after chemotherapy. To uncover the neural substrate of these mental complaints, we examined cerebral white matter (WM) integrity after chemotherapy using magnetic resonance diffusion tensor imaging (DTI) in combination with detailed cognitive assessment. Postchemotherapy breast cancer patients (n = 17) and matched healthy controls (n = 18) were recruited for DTI and neuropsychological testing, including the self‐report cognitive failure questionnaire (CFQ). Differences in DTI WM integrity parameters [fractional anisotropy (FA) and mean diffusivity (MD)] between patients and healthy controls were assessed using a voxel‐based two‐sample‐t‐test. In comparison with healthy controls, the patient group demonstrated decreased FA in frontal and temporal WM tracts and increased MD in frontal WM. These differences were also confirmed when comparing this patient group with an additional control group of nonchemotherapy‐treated breast cancer patients (n = 10). To address the heterogeneity observed in cognitive function after chemotherapy, we performed a voxel‐based correlation analysis between FA values and individual neuropsychological test scores. Significant correlations of FA with neuropsychological tests covering the domain of attention and processing/psychomotor speed were found in temporal and parietal WM tracts. Furthermore, CFQ scores correlated negatively in frontal and parietal WM. These studies show that chemotherapy seems to affect WM integrity and that parameters derived from DTI have the required sensitivity to quantify neural changes related to chemotherapy‐induced mild cognitive impairment. Hum Brain Mapp 32:480–493, 2011. © 2010 Wiley‐Liss, Inc.     

Chemotherapy for cervical cancer

Therapeutic options for cervical cancer have improved extensively over the last decade with the introduction of neoadjuvant chemotherapy prior to surgery for stage IB2–IIB and chemoradiation (radiation with concomitant weekly cisplatinum). Both regimens showed an improvement in overall survival of 14 and 12%, respectively, in comparison with radiotherapy alone. As for metastatic or recurrent cervical cancer, chemotherapy regimens are changing from cisplatin only to combination chemotherapy. Cisplatin with topotecan is the first combination regimen that showed an improvement in overall survival. However, further randomized trials will be necessary to confirm the superiority of this combination.