The Role of FDG-PET in the Diagnosis and Staging of Ocular Adnexal Lymphoproliferative Disease

Purpose: To further evaluate fluorine 18 fluoro-deoxyglucose positron emission tomography (FDG PET) in the staging of ocular adnexal lymphoproliferative disease (OALD).

Methods: Retrospective and prospective case series with review of clinical and imaging records including computed tomography (CT), FDG PET (±PET/CT) and/or magnetic resonance imaging (MRI).

Results: Thirty-four patients had FDG PET and CT scans at initial staging. Eleven were retrospectively reviewed and 23 were prospectively enrolled. Of 34 patients, 17 (50%) had primary disease, 17 (50%) had secondary and of these, 13 patients (38%) had OALD as their initial manifestation. Sixteen patients had active systemic disease in conjunction with their orbital disease. Systemic disease was demonstrated by FDG PET (± CT) in 15 of 16 (94%) patients and 11 of 16 (69%) patients with CT. FDG PET found orbital disease in 27 of 34 patients (79%) versus 33 of 34 patients with orbital CT (97%). Four of 16 patients in which FDG-PET detected systemic disease where CT did not were upstaged and their management changed significantly in 5 cases.

Conclusions: This study reaffirms FDG PET as an important part of initial staging. Our study suggests FDG PET detects systemic disease more reliably than CT alone and results in significant changes in management. Our findings suggest FDG PET detection for local OALD is less sensitive than CT. MRI is helpful in augmenting other imaging modalities in further identifying disease. Given the prevalence of simultaneous systemic presentations of OALD, FDG PET in this regard is especially important and highlights the need for coordinated multidisciplinary care.     

Colorectal Cancer Staging: Reappraisal of N/PN Classification

PURPOSE: Current American Joint Committee on Cancer and the Union Internationale Contre le Cancer TNM classification disregards location of positive nodes, discontinuing N3 category, which constitutes a major modification to 1987 version. This study was designed to assess the impact of the recategorization of former N3 cases and the reliability of the current N1-N2 subcategorization of Stage III patients. METHODS: Prospectively collected data from 1,391 patients (55.8 percent males; median age, 64 (range, 21–97) years), operated on with curative intent between 1980 and 1999, were analyzed. The median follow-up was 60 (interquartile range, 27–97) months with 129 cases lost to follow-up. RESULTS: Of positive node cases, 25.3 percent were former N3. Among them, 30.5 percent migrated to the N1 group and 69.5 percent to the N2 group. The proportions of former N3 cases in N1 and N2 groups were 12.5 percent and 46.1 percent, respectively (P < 0.001). Node-positive patients had an actuarial five-year survival rate of 56.7 percent (95 percent confidence interval, 53–59), with a significant difference between N1/N2 categories (63.6 vs. 44.1 percent, respectively; P < 0.001). Although apical node involvement and more than three positive nodes were associated with poorer outcomes in univariate analysis, only the number of positive nodes had independent association (hazard ratio, 1.6 (range, 1.2–2.2); P < 0.001). Integration of former N3 cases did not modify outcomes. CONCLUSIONS: The recategorization of former N3 involved a high proportion of positive node cases. Current N1/N2 categories clearly defined different outcomes and were not modified by the integration of former N3.     

Regional amyloid distribution and impact on mortality in light-chain amyloidosis: a T1 mapping cardiac magnetic resonance study

Background: T1 mapping allows quantitative assessment of “diffuse” deposition of amyloid protein in the myocardium. Early detection of cardiac involvement and potential prognostic improvement could benefit patients with AL amyloidosis.

Objectives: This study aims to evaluate the regional variation of amyloid infiltration in the left ventricle and the prognostic value of T1 mapping in patients with AL amyloidosis.

Methods: We prospectively enrolled 77 patients with AL amyloidosis who underwent cardiac magnetic resonance on a 3.0-T scanner. Native T1 and extracellular volume (ECV) were quantitated on the basal, mid, and apical levels of the left ventricle. Late gadolinium enhancement (LGE) pattern (no or non-specific LGE, sub-endocardial LGE, and transmural LGE) was also assessed. Forty healthy subjects served as controls. The primary end point was all-cause mortality.

Results: Basal ECV (26.9?±?2.8% versus 31.1?±?4.9%, p?<?.001) were lower than apical ECV in the healthy controls; however, basal ECV (60.6?±?11.5% versus 53.0?±?9.6%, p?=?.003) were significantly higher than apical ECV in patients with transmural LGE. During the follow-up period (median duration, 28?months; 25th–75th percentile, 13.5–38.0?months), 46 patients died. Basal ECV has the largest area under the curve of 0.845 (95% CI, 0.747–0.917) to predict all-cause mortality. Multivariable Cox analysis indicated that basal ECV was an independent prognostic factor and showed incremental prognostic value beyond NYHA class, Mayo stage, and LGE pattern.

Conclusion: We demonstrated that T1 mapping may have the potential to detect a characteristic amyloid deposition with a decreasing gradient from base to apex. Furthermore, myocardial ECV indicated that basal amyloid infiltration provided robust and incremental prognostic value in patients with AL amyloidosis.     

Staging Dementia From Symptom Profiles on a Care Partner Website

Background

The World Wide Web allows access to patient/care partner perspectives on the lived experience of dementia. We were interested in how symptoms that care partners target for tracking relate to dementia stage, and whether dementia could be staged using only these online profiles of targeted symptoms.

Objectives

To use clinical data where the dementia stage is known to develop a model that classifies an individual’s stage of dementia based on their symptom profile and to apply this model to classify dementia stages for subjects from a Web-based dataset.

Methods

An Artificial Neural Network (ANN) was used to identify the relationships between the dementia stages and individualized profiles of people with dementia obtained from the 60-item SymptomGuide (SG). The clinic-based training dataset (n=320), with known dementia stages, was used to create an ANN model for classifying stages in Web-based users (n=1930).

Results

The ANN model was trained in 66% of the 320 Memory Clinic patients, with the remaining 34% used to test its accuracy in classification. Training and testing staging distributions were not significantly different. In the 1930 Web-based profiles, 309 people (16%) were classified as having mild cognitive impairment, 36% as mild dementia, 29% as moderate, and 19% as severe. In both the clinical and Web-based symptom profiles, most symptoms became more common as the stage of dementia worsened (eg, mean 5.6 SD 5.9 symptoms in the MCI group versus 11.9 SD 11.3 in the severe). Overall, Web profiles recorded more symptoms (mean 7.1 SD 8.0) than did clinic ones (mean 5.5 SD 1.8). Even so, symptom profiles were relatively similar between the Web-based and clinical datasets.

Conclusion

Symptoms targeted for online tracking by care partners of people with dementia can be used to stage dementia. Even so, caution is needed to assure the validity of data collected online as the current staging algorithm should be seen as an initial step.     

Prognostic value of the pretreatment albumin:globulin ratio combined with adult comorbidity evaluation 27 and TMN staging in patients with squamous cell carcinoma of the maxillary sinus

The albumin:globulin (A:G) ratio, adult comorbidity evaluation 27 (ACE-27), and TMN staging have been shown to be strong predictive indicators of the survival of patients with many types of tumours. We have investigated the prognostic value of pretreatment based on the A:G ratio combined with TMN staging and ACE-27 in patients with squamous cell carcinoma (SCC) of the maxillary sinus. We studied 196 patients, and the prognostic value was explored by univariate and multivariate Cox’s hazards analysis. Multivariate analyses suggested that pretreatment A:G ratio was independently associated with overall survival (hazard ratio (HR) 1.542, 95% CI 1.219 to 1.991, p = 0.002); disease-specific survival, (HR 1.499, 95% CI 1.197 to 1.842, p = 0.001); and disease-free survival (HR 1.452, 95% CI 1.207 to 1.834, p < 0.001). Additional prognostic factors shown in the survival analyses included ACE-27, pathological T stage, and pathological N stage. Pretreatment A:G ratio combined with ACE-27 and TMN staging were powerful prognostic indicators of outcome in patients with SCC of the maxillary sinus, which has potentially important ramifications for stratification of the disease in the future.     

MRI平扫结合扩散加权成像在直肠癌中的临床应用价值

目的:探讨MRI平扫结合扩散加权成像(DWI)在直肠癌中的临床应用价值.方法:对28例直肠癌患者行MRI平扫及DWI检查,评价肿瘤形态、T分期、淋巴结转移、环周切缘(CRM)状态、肿瘤下缘距肛缘的距离,并与术后病理结果进行对照.MRI与病理对T分期、N分期及环周切缘受累评估的一致性采用Kappa检验.结果:MRI平扫及DWI能准确显示肿瘤的部位及形态.MRI平扫结合DWI对28例直肠癌T分期总的诊断符合率为78.57％(22/28),T1～T2期、T3期、T4期的诊断符合率分别为85.71％、78.57％、92.86％,MRI与病理对T分期的诊断具有较高的一致性(Kappa值=0.656).MRI平扫结合DWI对判断N分期的符合率为71.43％ (20/28),判断淋巴结转移的敏感度为66.67％(6/9),特异度为73.68％(14/19),MRI与病理对N分期的诊断具有中度一致性(Kappa值=0.489).MRI判定CRM状态的总体符合率为85.71％ (24/28),敏感度为90.90％(10/11),特异度为82.35％(14/17),阳性预测值为76.92％(10/13),阴性预测值为93.33％(14/15),MRI与病理对环周切缘受累的评估具有较高的一致性(Kappa值=0.710).MRI矢状面图像能测量18例下段直肠癌肿瘤下缘距肛缘的曲线距离.结论:MRI平扫结合DWI对直肠癌、T分期、环周切缘状态的判断及肿瘤下缘距肛缘的距离的测量有重要临床价值.     

Staging laparoscopy leads to rapid induction of chemotherapy for unresectable pancreatobiliary cancers

Preoperatively evaluating the resectability of pancreatobiliary cancers is difficult. The aim of this study was to investigate the benefit of staging laparoscopy in unresectable pancreatobiliary cancers. Between 2010 and 2013, 25 patients with pancreatobiliary cancers underwent staging laparoscopy after conventional tumor staging; they were compared with 10 patients who had unresectable or metastatic tumors that were found during laparotomy. Staging laparoscopy did not show unresectable factors in 11 patients, and resections were performed in these patients. Unresectable factors were found in other 14 patients who underwent staging laparoscopy. In these patients, chemotherapy was started after median postoperative day 3 (range, 2–10 days). This period was significantly longer in patients who received unnecessary laparotomy; chemotherapy was started after median postoperative day 11 (range, 6–15 days). These results suggest that staging laparoscopy, while avoiding laparotomy with unsuccessful resection, can lead to rapid induction of chemotherapy for unresectable pancreatobiliary cancers.     

Multiparametric magnetic resonance imaging localizes established extracapsular extension of prostate cancer

ObjectiveTo define the accuracy of multiparametric magnetic resonance imaging (MP-MRI) for identifying focal and established extracapsular extension (ECE) in various zones of the prostate.MethodsBetween 2010 and 2013, 342 patients underwent MP-MRI of the prostate (3 T, no endorectal coil with axial perfusion and diffusion images). The findings of the images were reported as negative, suspicious, or positive for ECE by a single expert radiologist. Radical prostatectomy specimens were reviewed to confirm the size and the location of ECE and further defined as focal or established ECE. Established ECE included extension that was multifocal or involving more than 5 glands. The accuracy of MRI in localizing focal and established ECE to each zone of the prostate was determined. Regression analyses were performed to identify predictors of ECE.ResultsWe identified 112 patients who underwent prostate MP-MRI and radical prostatectomy. MRI findings considered suspicious or definite for ECE accurately predicted pathologic ECE (P<0.001). MP-MRI identified established ECE but not focal ECE. Sensitivity, specificity, positive predictive value, and negative predictive value of MP-MRI for established ECE were 70.7%, 90.6%, 57.1%, and 95.1%, respectively. MRI identified ECE to the left vs. right side as well as each zone of the prostate; however, sensitivity was lowest at the apex. On multivariate analysis, MRI was a significant predictor of ECE that was independent of prostate-specific antigen level, Gleason score, and clinical stage.ConclusionMP-MRI is useful for identifying established but not focal ECE in all zones of the prostate. MRI was a significant independent predictor of established ECE and may be a useful adjunct in staging prostate cancer.