tumor. Recently, investigators from University of California published an article on how integration of molecular prognostic classifier into TNM system might improve identification of high-risk patients and predict survival in non-metastatic NSCLC. They used 11 cancer-related target genes; however, they did not include current biomarkers such as EGFR, KRAS ALK, which was recognized as an important drawback of their study. 27
There are some important limitations to the current analysis. It was not possible to find reliable metastatic information for about 25% of
Roberta Fusco, Mario Petrillo, Vincenza Granata, Salvatore Filice, Mario Sansone, Orlando Catalano and Antonella Petrillo
tissues with similar absorption such as different soft tissues, including tumours. 47
PET/CT provides functional tissue information concerning metabolic activity fused with the morphological details of CT. The integration of tissue metabolic activity with anatomic information can improve its accuracy more that PET or CT when considered alone. 48 - 49
Morphological MRI (T2 weighted images) has shown superior potential because it can provide an accurate evaluation not only of the tumour extent, but also of the adjacent soft tissues. Morphological MRI allows for
Theodora Benedek, Pál Maurovich-Horváth, Péter Ferdinandy and Béla Merkely
Acute coronary syndromes represent the most severe consequences of atherosclerosis, most often triggered by the rupture of a coronary plaque, which, for various reasons, has become unstable. In many cases, these rupture-prone vulnerable plaques are difficult to diagnose, because they do not always cause significant obstruction noticeable by coronary angiography. Therefore, new methods and tools for the identification of vulnerable plaques have been proposed, many of which are currently under study. Various biomarkers have been suggested as predictors of a vulnerable plaque, as well as indicators of an increased inflammatory status associated with higher patient susceptibility for plaque rupture. Integration of such biomarkers into multiple biomarker platforms has been suggested to identify superior diagnostic algorithms for the early detection of the high-risk condition associated with an unstable plaque. The aim of this review is to summarize recent research related to biomarkers used for the early detection of vulnerable plaques and vulnerable patients.
Idil Gunes Tatar, Aydin Kurt, Kerim Bora Yilmaz, Mehmet Doğan, Baki Hekimoglu and Sema Hucumenoglu
Background. Ultrasound is as a noninvasive method commonly used in the work-up of thyroid nodules. This study aimed to evaluate the usefulness of sonographic and elastosonographic parameters in the discrimination of malignancy.
Patients and methods. 150 thyroid nodules were evaluated by gray-scale, Doppler and elastosonography. The cytological analysis revealed that 141 nodules were benign and 9 were malignant.
Results. Orientation of the nodule was the only sonographic parameter associated with malignancy (p = 0.003). In the strain ratio analysis the best cut-off point was 1.935 to discriminate malignancy (p = 0.000), with 100% sensitivity, 76% specificity, 100% negative predictive value, 78.5% positive predictive value and 78% accuracy rate. There was a statistically significant correlation between the elasticity score and malignancy (p = 0.001). Most of the benign nodules had score 2 and 3, none of them displayed score 5. On the other hand, none of the malignant nodules had score 1 and 2, most of them displaying score 5.
Conclusions. A change in the diagnostic algorithm of the thyroid nodules should be considered integrating the elastosonographic analysis
Evaluation of clinical interventions made by pharmacists in chemotherapy preparation
Background. Cancer drugs are high risk drugs and medication errors in their prescribing, preparation and administration have serious consequences, including death. The importance of a multidisciplinary approach and the benefits of pharmacists' contribution to cancer treatment to minimise risk have been established. However, the impact of services provided by pharmacists to cancer patient care is poorly studied. This study explored the clinical interventions made by pharmacists in dispensing of chemotherapy doses, and evaluated pharmacists' contribution to patient care.
Methods. Pharmacists at the Chemotherapy Preparation Unit at a tertiary cancer centre in London were shadowed by two research pharmacists during the clinical screening of chemotherapy prescriptions and release of prepared drugs. An expert panel of pharmacy staff rated the clinical significance of the recorded interventions.
Results. Twenty-one pharmacists' interventions were recorded during the screening or releasing of 130 prescriptions or drugs. "Drug and therapy" (38%), "clerical" (22%) and "dose, frequency and duration" (19%) related problems most often required an intervention, identifying areas in chemotherapy prescribing that need improvement. The proposed recommendations were implemented in 86% of the cases. Many recorded interventions (48%) were ranked to have had a "very significant" influence on patient care.
Conclusion. Clinical interventions made by pharmacists had a significant impact on patient care. The integration of pharmacists' technical and clinical roles into dispensing of chemotherapy doses is required for providing high-quality cancer services.
Sofiane Maza, Ralph Buchert, Winfried Brenner, Dieter Ludwig Munz, Eckhard Thiel, Agnieszka Korfel and Philipp Kiewe
Background. Positron emission tomography (PET) with F-18-labeled fluorodeoxyglucose (FDG) provides remarkable accuracy in detection, treatment monitoring and follow-up of systemic malignant lymphoma. Its value in the management of patients with primary central nervous system lymphoma (PCNSL) is less clear.
Patients and methods. In a prospective trial, 42 FDG-PET examinations were performed in ten immunocompetent patients with newly diagnosed or recurrent PCNSL before and repeatedly during and after the treatment. Brain and whole body FDG-PET were compared to brain MRI and extra-cerebral CT, respectively.
Results. Before the treatment, 6 of 10 patients had congruent findings on FDG-PET and MRI of the brain. Three patients had lesions on brain MRI, not detected by FDG-PET. One patient had additional FDG-PET positive lesions inconspicuous in MRI. The follow-up suggested FDG-PET to be false positive in these lesions. After the treatment, brain PET was in agreement with MRI in 6 of 8 patients. In the remaining 2 patients there were persistent lesions in brain MRI whereas FDG-uptake was reduced to normal values. In the long-term follow-up of 5 patients (63-169 weeks), 3 patients retained normal in both PET and MRI. In 2 patients a new focal pathologic FDG-uptake was detected 69 and 52 weeks after the end of the treatment. In one of these patients, recurrence was confirmed by MRI not until 9 weeks after PET.
Conclusions. Brain FDG-PET may contribute valuable information for the management of PCNSL, particularly in the assessment of the treatment response. Integration of FDG-PET into prospective interventional trials is warranted to investigate prognostic and therapeutic implications.
Background. In melanoma, radiotherapy has generally been considered as a palliative treatment option indicated only for advanced cases or disseminated disease. In the 70s of the previous century, the technological advances in radiotherapy, linked to rapid development of computer sciences, resulted in restored interest for radiotherapy in melanoma management. Although a fundamental lack of well designed prospective and/or randomized clinical trials critically influenced the integration of radiotherapy into treatment strategies in melanoma, radiotherapy was recently recognized as an indispensable part in the multidisciplinary management of patients with melanoma. Altogether, approximately 23% of melanoma patients should receive at least one course of radiotherapy during the course of the disease. In this review, radiobiological properties of melanoma that govern the decisions for the fractionation patterns used in the treatment of this disease are described. Moreover, the indications for irradiation and the results of pertinent clinical studies from the literature, creating a rationale for the use of radiotherapy in the management of this disease, are reviewed and a brief description of radiotherapy techniques is given.
Conclusions. Basic treatment modality in melanoma is surgery. However, whenever surgery is not radical or there are adverse prognostic factors identified on histopathological examination of resected tissue specimen, it needs to be supplemented. Also, in patients with unresectable disease or in those not being suitable for major surgery or who refuse proposed surgical intervention, other effective mode(s) of therapy need to be implemented. From this perspective, supported by clinical experiences and literature results, radiotherapy is a valuable option: it is effective and safe, in curative and palliative setting.
Anoop Haridass, Jillian Maclean, Santanu Chakraborty, John Sinclair, Janos Szanto, Daniela Iancu and Shawn Malone
Background. Successful radiosurgery for arteriovenous malformations (AVMs) requires accurate nidus delineation in the 3D treatment planning system (TPS). The catheter biplane digital subtraction angiogram (DSA) has traditionally been the gold standard for evaluation of the AVM nidus, but its 2D nature limits its value for contouring and it cannot be imported into the Cyberknife TPS. We describe a technique for acquisition and integration of 3D dynamic CT angiograms (dCTA) into the Cyberknife TPS for intracranial AVMs and review the feasibility of using this technique in the first patient cohort.
Patients and methods. Dynamic continuous whole brain CT images were acquired in a Toshiba 320 volume CT scanner with data reconstruction every 0.5 sec. This multi-time-point acquisition enabled us to choose the CT dataset with the clearest nidus without significant enhancement of surrounding blood vessels. This was imported to the Cyberknife TPS and co-registered with planning CT and T2 MRI (2D DSA adjacent for reference). The feasibility of using dCTA was evaluated in the first thirteen patients with outcome evaluation from patient records.
Results. dCTA data was accurately co-registered in the Cyberknife TPS and appeared to assist in nidus contouring for all patients. Imaging modalities were complementary. 85% of patients had complete (6/13) or continuing partial nidus obliteration (5/13) at 37 months median follow-up.
Conclusions. dCTA is a promising imaging technique that can be successfully imported into the Cyberknife TPS and appears to assist in radiosurgery nidus definition. Further study to validate its role is warranted.
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