Anatomic variability of groin innervation

Inguinal hernia repairs are very common yet fairly complex surgical procedures.Variations in the anatomical course of the inguinal nerves require that diligenceis taken in their proper recognition. Inadvertent surgical injury to these nerves isassociated with long term postoperative pain and complications. The aim of thepresent study was to highlight the complexity and variation in the innervation ofthe inguinal region in order to increase proper nerve identification during surgicalinterventions. Bilateral dissection of the inguinal and posterior abdominal regionsin one human male cadaver revealed an atypical anatomic topography of thegroin innervation. This unusual case was observed at the Jagiellonian UniversityAnatomy Department during routine cadaveric preparations. The left ilioinguinalnerve was absent. The left genital branch of the genitofemoral nerve arose higherthan expected from the lumbar plexus and supplied the groin region, which istypically innervated by the ilioinguinal nerve. Furthermore, the left lateral cutaneousfemoral nerve and the right genital branch of the genitofemoral nerve alsofollowed uncharacteristic courses. Awareness of topographical nerve variationsduring inguinal hernia repair will help surgeons identify and preserve importantnerves, thus decreasing the incidence of chronic postoperative pain

Editorial: The Mammary Stroma in Normal Development and Function

The mammary gland can no longer be simply viewed as an organ composed of epithelial cells within a passive stromal microenvironment. Many lines of evidence have evolved to reinforce the notion that mammary epithelial cell growth, differentiation, lactation and progression to cancer involves bidirectional interactions between the epithelial population and its surrounding stroma. Within this stroma are numerous systems that are all capable of modulating epithelial function. In this context, the mammary stroma is not simply a depot of adipose tissue in which mammary epithelial cells undertake a unique growth and differentiation process, although adipocytes can impart numerous modulatory signals to epithelial cells, and vice versa. Rather, the stromal environment constitutes and supports a critical vasculature that supplies nutrients and endocrine cues, a lymphatic system that not only removes metabolites but also provides an intimate interface with the immune system, and an extracellular matrix scaffold in which epithelial cells grow, differentiate and regress. Ultimately all of these components play a critical role in directing the epithelial phenotype during normal mammary gland growth and function. An increasing appreciation for these different systems demands a view of mammary epithelial cells in a much different light, and further necessitates the development of model systems that incorporate and integrate increasing complexity

Integration of CT urography improves diagnostic confidence of 68Ga-PSMA-11 PET/CT in prostate cancer patients

Background: To prove the feasibility of integrating CT urography (CTU) into 68Ga-PSMA-11 PET/CT and to analyze the impact of CTU on assigning focal tracer accumulation in the ureteric space to either ureteric excretion or metastatic disease concerning topographic attribution and diagnostic confidence. Methods: Ten prostate cancer patients who underwent 68Ga-PSMA-11 PET/CT including CTU because of biochemical relapse or known metastatic disease were retrospectively analyzed. CTU consisted of an excretory phase 10 min after injection of 80 mL iodinated contrast material. Ureter opacification at CTU was evaluated using the following score: 0, 0% opacification; 1, < 50%; 2, 50–99%; 3, 100%. Topographic attribution and confidence of topographic attribution of focal tracer accumulation in the ureteric space were separately assessed for 68Ga-PSMA-11 PET/CT without and with CTU. Diagnostic confidence was evaluated using the following score: 0, < 25% confidence; 1, 26–50%; 2, 51–75%; 3, 76–100%. Results: At CTU, mean ureter opacification score was 2.6 ± 0.7. At 68Ga-PSMA-11 PET/CT without CTU, mean confidence of topographic attribution of focal tracer accumulation was 2.5 ± 0.7 in total and 2.6 ± 0.7 for metastatic disease. At 68Ga-PSMA-11 PET/CT with CTU, mean confidence of topographic attribution of focal areas of tracer accumulation was significantly higher with 2.9 ± 0.2 in total and 2.7 ± 0.9 for metastatic disease (p < 0.001). In 4 of 34 findings (12%) attribution to either ureteric excretion or metastatic disease was discrepant between 68Ga-PSMA-11 PET/CT without and with CTU (n.s). Conclusions: Integration of CTU into 68Ga-PSMA-11 PET/CT is feasible and increases diagnostic confidence of assigning focal areas of tracer accumulation in the ureteric space to either metastatic disease or ureteric excretion

Power, norms and institutional change in the European Union: the protection of the free movement of goods

How do institutions of the European Union change? Using an institutionalist approach, this article highlights the interplay between power, cognitive limits, and the normative order that underpins institutional settings and assesses their impact upon the process of institutional change. Empirical evidence from recent attempts to reinforce the protection of the free movement of goods in the EU suggests that, under conditions of uncertainty, actors with ambiguous preferences assess attempts at institutional change on the basis of the historically defined normative order which holds a given institutional structure together. Hence, path dependent and incremental change occurs even when more ambitious and functionally superior proposals are on offer

Joint EANM/SNMMI procedure guideline for the use of 177Lu-labeled PSMA-targeted radioligand-therapy (177Lu-PSMA-RLT)

Prostate-specific membrane antigen (PSMA) is expressed by the majority of clinically significant prostate adenocarcinomas, and patients with target-positive disease can easily be identified by PSMA PET imaging. Promising results with PSMA-targeted radiopharmaceutical therapy have already been obtained in early-phase studies using various combinations of targeting molecules and radiolabels. Definitive evidence of the safety and efficacy of [177Lu]Lu-PSMA-617 in combination with standard-of-care has been demonstrated in patients with metastatic castration-resistant prostate cancer, whose disease had progressed after or during at least one taxane regimen and at least one novel androgen-axis drug. Preliminary data suggest that 177Lu-PSMA-radioligand therapy (RLT) also has high potential in additional clinical situations. Hence, the radiopharmaceuticals [177Lu]Lu-PSMA-617 and [177Lu]Lu-PSMA-I&T are currently being evaluated in ongoing phase 3 trials. The purpose of this guideline is to assist nuclear medicine personnel, to select patients with highest potential to benefit from 177Lu-PSMA-RLT, to perform the procedure in accordance with current best practice, and to prepare for possible side effects and their clinical management. We also provide expert advice, to identify those clinical situations which may justify the off-label use of [177Lu]Lu-PSMA-617 or other emerging ligands on an individual patient basis