Pheochromocytomas

Pheochromocytomas are rare catecholamine-secreting neuroendocrine tumors derived from chromaffin tissue of the adrenal medulla. Such tumors arising from the sympathetic ganglia of the thorax, abdomen, or pelvis are termed “paragangliomas” or “extra-adrenal pheochromocytomas.” The classic symptoms of these tumors are due to excess circulating levels of norepinephrine, epinephrine, or dopamine. Although 21% may be asymptomatic, the most common symptoms associated with pheochromocytomas include sweating, palpitations, and headaches in association with intermittent hypertension. If left untreated, excess catecholamines may result in hypertensive crisis leading to cardiac complications, cerebrovascular stroke, or ultimately sudden death. These catecholamine-secreting tumors are most commonly sporadic, but about 30% of patients have this disease as part of a familial disorder such as multiple endocrine neoplasia type 2 (MEN2) or von Hippel-Lindau (VHL) syndrome. Although most are benign, accurate recognition of pheochromocytomas with malignant potential and distant metastases remains a major diagnostic challenge. Advances in the field of molecular genetics have led to novel diagnostic and therapeutic strategies in an attempt to address this dilemma. Surgical excision of pheochromocytomas and paragangliomas is the mainstay of treatment and offers the only potential for cure. This chapter focuses on recent developments in the diagnosis of pheochromocytomas, encompassing biochemical, radiologic, histologic, and molecular analyzes. In addition, novel therapeutic strategies and advances in individualized targeted therapies for malignant pheochromocytomas will be discussed

A descriptive model of shared decision making derived from routine implementation in clinical practice ('Implement-SDM'): Qualitative study

Objective Research is needed to understand how Shared Decision-Making (SDM) is enacted in routine clinical settings. We aimed to 1) describe the process of SDM between clinicians and patients; 2) examine how well the SDM process compares to a prescriptive model of SDM, and 3) propose a descriptive model based on observed SDM in routine practice. Methods Patients with chronic kidney disease and early stage breast cancer were recruited consecutively via Cardiff and Vale University Health Board (UK) teams. Consultations were audio-recorded, transcribed and thematically analysed. Results Seventy-six consultations were observed: 26 pre-dialysis consultations and two consultations each for 25 breast cancer patients. Key stages of the ‘Three Talk Model’ were observed. However, we also observed more elements and greater complexity: a distinct preparation phase; tailored and evolving integrative option conversation; patients and clinicians developing ‘informed preferences’; distributed and multi-stage decisions; and a more open-ended planning discussion. Use of decision aids was limited. Conclusion A more complex picture was observed compared with previous portrayals in current theoretical models. Practice iImplications The model can provide a basis for future training and initiatives to promote SDM, and tackle the gap between what is advocated in policy, but rarely achieved in practice

The ability of observer and self-report measures to capture shared decision making in clinical practice in the United Kingdom: a mixed-methods study.

Objectives: To examine how observer and self-report measures of shared decision-making (SDM) evaluate the decision-making activities that patients and clinicians undertake in routine consultations. Design: Multi-method study using observational and self-reported measures of SDM and qualitative analysis. Setting: Breast care and predialysis teams who had already implemented SDM. Participants: Breast care consultants, clinical nurse specialists and patients who were making decisions about treatment for early-stage breast cancer. Predialysis clinical nurse specialists and patients who needed to make dialysis treatment decisions. Methods Consultations were audio recorded, transcribed and thematically analysed. SDM was measured using Observer OPTION-5 and a dyadic SureScore self-reported measure. Results: Twenty-two breast and 21 renal consultations were analysed. SureScore indicated that clinicians and patients felt SDM was occurring, but scores showed ceiling effects for most participants, making differentiation difficult. There was mismatch between SureScore and OPTION-5 score data, the latter showing that each consultation lacked at least some elements of SDM. Highest scoring items using OPTION-5 were ‘incorporating patient preferences into decisions’ for the breast team (mean 18.5, range 12.5–20, SD 2.39) and ‘eliciting patient preferences to options’ for the renal team (mean 16.15, range 10–20, SD 3.48). Thematic analysis identified that the SDM encounter is difficult to measure because decision-making is often distributed across encounters and time, with multiple people, it is contextually adapted and can involve multiple decisions. Conclusions: Self-reported measures can broadly indicate satisfaction with SDM, but do not tell us about the quality of the interaction and are unlikely to capture the multi-staged nature of the SDM process. Observational measures provide an indication of the extent to which elements of SDM are present in the observed consultation, but cannot explain why some elements might not be present or scored lower. Findings are important when considering measuring SDM in practice

Parameters affecting the enhanced permeability and retention effect: the need for patient selection

The enhanced permeability and retention (EPR) effect constitutes the rationale by which nanotechnologies selectively target drugs to tumors. Despite promising pre-clinical and clinical results, these technologies have, in our view, underachieved compared to their potential, possibly due to a suboptimal exploitation of the EPR effect. Here, we have systematically analyzed clinical data to identify key parameters affecting the extent of the EPR effect. An analysis of 17 clinical studies showed that the magnitude of the EPR effect was varied and was influenced by tumor type and size. Pancreatic, colon, breast, and stomach cancers showed the highest levels of accumulation of nanomedicines. Tumor size also had an effect on the accumulation of nanomedicines, with large size tumors having higher accumulation than both medium- and very large- sized tumors. However, medium tumors had the highest percentage of cases (100% of patients) with evidence of the EPR effect. Moreover, tumor perfusion, angiogenesis, inflammation in tumor tissues, and other factors also emerged as additional parameters that might affect the accumulation of nanomedicines into tumors. At the end of the commentary, we propose two strategies for identification of suitable patient sub-populations, with respect to the EPR effect, in order to maximize therapeutic outcome

Evolution of breast cancer management in Ireland: a decade of change

Abstract Background Over the last decade there has been a paradigm shift in the management of breast cancer, subsequent to revised surgical oncology guidelines and consensus statements which were derived in light of landmark breast cancer clinical trials conducted throughout the latter part of the 20th century. However the sheer impact of this paradigm shift upon all modalities of treatment, and the current trends in management of the disease, are largely unknown. We aimed to assess the changing practices of breast cancer management over the last decade within a specialist tertiary referral Breast Cancer Centre. Methods Comparative analysis of all aspects of the management of breast cancer patients, who presented to a tertiary referral Breast Cancer Centre in 1995/1996 and 2005/2006, was undertaken and measured against The European Society for Surgical Oncology guidelines for the surgical management of mammographically detected lesions [1998]. Results 613 patients' case profiles were analysed. Over the last decade we observed a dramatic increase in incidence of breast cancer [>100%], a move to less invasive diagnostic and surgical therapeutic techniques, as well as increased use of adjuvant therapies. We also witnessed the introduction of immediate breast reconstruction as part of routine practice Conclusion We demonstrate that radical changes have occurred in the management of breast cancer in the last decade, in keeping with international guidelines. It remains incumbent upon us to continue to adapt our practice patterns in light of emerging knowledge and best evidence.</p

Evolution of breast cancer management in ireland: a decade of change

Background: Over the last decade there has been a paradigm shift in the management of breast cancer, subsequent to revised surgical oncology guidelines and consensus statements which were derived in light of landmark breast cancer clinical trials conducted throughout the latter part of the 20th century. However the sheer impact of this paradigm shift upon all modalities of treatment, and the current trends in management of the disease, are largely unknown. We aimed to assess the changing practices of breast cancer management over the last decade within a specialist tertiary referral Breast Cancer Centre. Methods: Comparative analysis of all aspects of the management of breast cancer patients, who presented to a tertiary referral Breast Cancer Centre in 1995/1996 and 2005/2006, was undertaken and measured against The European Society for Surgical Oncology guidelines for the surgical management of mammographically detected lesions [1998]. Results: 613 patients' case profiles were analysed. Over the last decade we observed a dramatic increase in incidence of breast cancer [&amp;gt;100%], a move to less invasive diagnostic and surgical therapeutic techniques, as well as increased use of adjuvant therapies. We also witnessed the introduction of immediate breast reconstruction as part of routine practice Conclusion: We demonstrate that radical changes have occurred in the management of breast cancer in the last decade, in keeping with international guidelines. It remains incumbent upon us to continue to adapt our practice patterns in light of emerging knowledge and best evidence