Targeted Therapy in the Management of Elderly Patients with Pancreatic Metastases from Renal Cell Carcinoma

Background: The pancreas is an uncommon but recognizable site for metastases from renal cell carcinoma (RCC). Isolated pancreatic RCC metastases are still rarer and often present years after initial nephrectomy. Surgical resection has been the treatment of choice because of superior patient survival compared with traditional immunotherapy. In recent years, the advent of targeted therapy has transformed the outcomes of patients with metastatic RCC although little evidence is available on its effectiveness on this subset of patients. We report our experience of 6 patients with pancreatic RCC metastases. Patients and Methods: Between 2007 and 2012, 6 patients (2 men, 4 women; median age 78 years) were diagnosed to have pancreatic RCC metastases at our institute. The clinical features, treatment and outcomes were examined. Results: All 6 patients had a primary RCC of clear cell type. The median interval between initial curative nephrectomy and re-presentation with pancreatic metastases was 12.5 years. Four patients were asymptomatic at the time of diagnosis, one presented with obstructive jaundice and another with acute gastrointestinal bleed. Four patients had extra-pancreatic disease. All were deemed unsuitable or unfit for surgical metastasectomy. Five patients had a Memorial Sloan-Kettering Cancer Center (MSKCC) score of 1 (moderate risk) and the other patient had a score of 0 (good risk). Two patients were commenced on Sunitinib, one received Pazopanib and one received Temsirolimus. Two patients did not undergo further treatment. Of the 4 patients who underwent targeted therapy, the median follow up was 33 months with a median progression free survival of 16 months. One achieved complete response but recurred soon after treatment was stopped. Targetted therapy was recommenced and the disease remained stable. A second patient had long period of stable disease before disease progression. A third achieved partial response since started on targeted therapy and a fourth had disease progression despite treatment. Of the four patients who underwent systemic therapy, three are still alive at the time of this report. Conclusion: Pancreatic metastasis from RCC is a unique subgroup of disease which runs an indolent course, and a higher incidence in an elderly population. Our results demonstrate that targeted therapy can be efficacious in some patients where surgical resection is not suitable or possible.published_or_final_versio

Leiomyosarcoma of the portal vein: a case report and review of the literature

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Validity of electron beam computed tomography for coronary artery disease: asystematic review and meta-analysis

Background: Electron beam computed tomography (EBCT) is a method for measuring coronary calcification and has been promoted as a possible non-invasive screening/diagnostic tool for coronary artery disease (CAD). Our objective was to carry out a systematic review and meta-analysis of EBCT for the screening of asymptomatic patients and the diagnosis of symptomatic patients for CAD. Methods: Studies were identified from the PUBMED, MEDLINE, EMBASE, Current Contents, INAHTA and Cochrane Collaboration databases. We identified studies published in English evaluating EBCT using: (1) a prospective design among asymptomatic patients where CAD was measured in terms of clinical outcomes (e.g. myocardial infarction, death, revascularization); and (2)a cross-sectional design among symptomatic patients where CAD was measured by coronary angiography. We compared the risk of CAD in EBCT score categories defined as low (0-10), moderate (11-400) and high (>400). A hierarchical meta-analysis was used to pool risk ratios comparing categories across studies. Results: We identified 9 studies of asymptomatic patients and 10 studies of symptomatic patients. In both types of studies, we found variability in EBCT category distribution and risk of CAD within categories. For studies of asymptomatic patients we estimated the following risk ratios (95% credible intervals): moderate versus low 3.5 (2.4, 5.1) and high versus low 9.9 (5.3, 17.6). Similar results were obtained for studies of symptomatic patients. Ratios comparing the risk of no CAD among symptomatic patients were as follows: moderate versus low 0.5 (0.3, 0.8) and high versus low 0.12 (0.05, 0.2). Conclusion: Increasing EBCT scores indicate higher risk for CAD in both asymptomatic and symptomatic patients. In general, asymptomatic patients with EBCT scores in the high category can perhaps be considered for preventive medical therapy and risk factor modification. Symptomatic patients with EBCT scores in the low category can perhaps, at least temporarily, avoid invasive coronary angiography. However, the non-uniform quality of studies and the lack of availability of individual-level data preclude the extension of our results to individual patients. © 2007 Dendukuri et al; licensee BioMed Central Ltd

Ultrasound measurement for abdominal aortic aneurysm screening: a direct comparison of the three leading methods

Objectives: Ultrasound (US) is non-invasive and cost-effective for screening abdominal aortic aneurysms (AAAs) but there is no universally accepted method to measure the aortic diameter. This study evaluates the accuracy, reproducibility, and repeatability of three methods: inner-to-inner (ITI), leading-to-leading edge (LTL), and outer-to-outer (OTO). The secondary objective of this study was to determine whether aneurysm size or grade of operator had any effect on either intra- or inter-observer variability. Methods: Fifty static US images were measured by six assessors (2 vascular radiologists, 2 interventional radiology trainees, and 2 sonographers) on two separate occasions 6 weeks apart. Repeatability and reproducibility were calculated and compared with computed tomography (CT) as the gold standard. Results: All three methods have high repeatability and reproducibility when static images are used. The inter-observer reproducibility coefficients between assessors were 0.48 cm, 0.35 cm, and 0.34 cm for ITI, LTL and OTO, respectively. The intra-observer repeatability coefficients between assessors were 0.30 cm, 0.20 cm, and 0.19 cm for ITI, LTL and OTO, respectively. The mean difference between CT and OTO, LTL, and ITI was 1 mm, 3 mm, and 5 mm, respectively (all underestimations) (p < .0001). Conclusions: US consistently underestimates aortic size when compared with CT, with ITI demonstrating the greatest underestimation (on average 5 mm). In the UK, this underestimation by the NHS Abdominal Aortic Aneurysm screening programme reduces the sensitivity of the screening test and may impact on the way in which vascular specialists interpret the findings of the screening programme. © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.published_or_final_versio

Intraoperative contrast-enhanced sonography of bowel blood flow: preliminary experience

The potential to predict, and therefore avoid, anastomotic failure has eluded generations of colon and rectal surgeons to date. A reliable, reproducible method of assessing bowel blood flow therefore would be of enormous potential clinical relevance. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We present our study assessing the feasibility of using contrast-enhanced sonography to study bowel perfusion intraoperatively. We studied 8 patients (4 male and 4 female) with an age range of 52 to 81 years who underwent colorectal surgery (right hemicolectomies, n = 3; Hartmann procedure, n = 1; anterior resections, n = 2; and bowel resections with ileocolic anastomoses, n = 2). A 5-mL bolus of a sulfur hexafluoride contrast agent solution was injected before and after vascular ligation with simultaneous noncompression ultrasound scanning directly over the large bowel. The patients were followed clinically to assess for leaks. Contrast-enhanced sonographic time-intensity curves were generated for the time to peak and maximum amplitude. Moderate interobserver agreement was shown for the time to peak (κ = 0.50) and maximum amplitude (κ = 0.42), and moderate intraobserver agreement was shown for the time to peak (κ= 0.53) and maximum amplitude (κ= 0.53). No significant differences were shown between the time to peak (P = .28) and maximum amplitude (P = .49) for the preligation and postligation scans. To our knowledge, intraoperative contrast-enhanced sonography of the bowel has not been performed previously. We have shown the technique to be feasible with good intraobserver and interobserver agreement. Further work is ongoing to optimize the technique and assess its use in predicting anastomotic breakdown.published_or_final_versio

Association Patterns of Ontological Features Signify Electronic Health Records in Liver Cancer

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Liver Cancer: Multimodal imaging

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Value of dual phase 11C-Acetate (DP Ac) PET in the assessment of Hepatocellular Carcinoma (HCC) in dual tracer (DT) PET-CT

Purpose : The aim of this study is to evaluate the additional value DP Ac PET for differentiation between HCC and other liver lesions compared with conventional DT PET-CT. Material & Method Patients who underwent Dual Tracer PET-CT (Ac and 18F FDG) for suspected HCC in our centres from 2014-16 with histological confirmation were identified. Kinetics analysis were carried out on Ac positive lesions, defined as Ac uptake above liver background. The maximum standardised uptake value (SUVmax) of the lesion and normal liver on Ac PET, and their ratios at 2 mins and 11 mins after tracer injection were obtained. The Ac uptake ratio and difference between the two ratios (R) were calculated. A R>0 was deemed to be predictive of HCC using previously published data. The findings were compared with conventional DT PET-CT and histology. McNemar’s test was used to compare the two methods. Results Forty-eight hepatic lesions were identified on histology, mean size was 30 mm (range 8-112 mm). 34/46 were Ac avid including 28 HCC and 6 non-HCC. 40/46 lesions were DT positive including 33 HCC and 7 non-HCC. The sensitivity, specificity, PPV and NPV for diagnosing HCC based on DT avidity were 94%, 46%, 82% and 75% respectively. 20/34 Ac avid lesion had a positive R including 18 HCC and 2 non-HCC. The sensitivity, specificity, PPV and NPV for DT with DP Ac were 80%, 77%, 90% and 59% respectively (p = 0.0077). False positives were seen in one colon metastasis and one scar tissue. Conclusion: DP Ac significantly increased the specificity of DT PET-CT. Although sensitivity is reduced using this method, DT with DP Ac remains at a clinically acceptable level

Esophageal cancer

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