Locoregional Node Involvement Research Articles

155. Locoregional lymph node involvement on 18F-FDG PET/CT and estimation of risk for locoregional recurrence in stage II–III breast cancer patients

Background: Risk for locoregional recurrence (LRR) in breast cancer depends on tumor size and the number and location of tumor-positive locoregional nodes. Postoperative irradiation of chest wall and/or locoregional nodes is advised in patients at high risk for LRR, but remains controversial in patients at intermediate risk. Treatment with neoadjuvant chemotherapy (NAC) hinders risk estimation and radiotherapy planning even further, since conventional locoregional staging techniques are inaccurate and/or do not provide information on number of tumor-positive nodes.

Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy

The optimal method for locoregional staging in patients treated with neoadjuvant chemotherapy (NAC), usually ultrasound (US) and pre- or post-chemotherapy sentinel lymph node biopsy (SLNB), remains subject of debate. The aim of this study was to assess the value of 18F-FDG PET/CT for detecting locoregional lymph node metastases in primary breast cancer patients scheduled for NAC. 311 breast cancer patients, scheduled for NAC, underwent PET/CT of the thorax in prone position with hanging breasts. A panel of four experienced reviewers examined PET/CT images, blinded for other diagnostic procedures. FDG uptake in locoregional nodes was determined qualitatively using a 4-point scale (0 = negative, 1 = questionable, 2 = moderately intense, and 3 = very intense). Results were compared with pathology obtained by US-guided fine needle aspiration or SLNB prior to NAC. All FDG-avid extra-axillary nodes were considered metastatic, based on the previously reported high positive predictive value of the technique. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-avid nodes for the detection of axillary metastases (score 2 or 3) were 82, 92, 98, 53, and 84 %, respectively. Of 28 patients with questionable axillary FDG uptake (score 1), 23 (82 %) were node-positive. Occult lymph node metastases in the internal mammary chain and periclavicular area were detected in 26 (8 %) and 32 (10 %) patients, respectively, resulting in changed regional radiotherapy planning in 50 (16 %) patients. In breast cancer patients scheduled for NAC, PET/CT renders pre-chemotherapy SLNB unnecessary in case of an FDG-avid axillary node, enables axillary response monitoring during or after NAC, and leads to changes in radiotherapy for a substantial number of patients because of detection of occult N3-disease. Based on these results, we recommend a PET/CT as a standard staging procedure in breast cancer patients scheduled for NAC.

Current management of gastric cancer

Gastric cancer is a disease with high incidence and mortality in our population. The prognosis of patients with this disease is closely related to the neoplasm stage at diagnosis, including the following characteristics of the tumor: extension into the gastric wall thickness, spread to locoregional lymph nodes and the ability to generate distant metastases, as described by the TNM classification. For localized tumors characterized only by invasion of mucosa or submucosa at diagnosis, survival at 5 years is between 70 and 95% with exclusive surgical management; however, when extension into the gastric wall is higher and/or there is locoregional nodal involvement, survival decreases to 20-30% at 5 years. Currently, at high-volume centers, the extent of gastrectomy is individualized based on several parameters, which in an increasing number of cases allows a total gastrectomy with D2 lymphadenectomy and preservation of the spleen and pancreas. This improved procedure increases the chance of R0 surgery and improves the relationship between resected and affected lymph nodes, resulting in a decreased risk of the long-term locoregional recurrence. To improve these results, different therapeutic strategies combining chemotherapy or chemoradiotherapy with surgery have been tested. Previously, the Intergroup 0116 clinical trial, published in 2001, which changed clinical practice in the United States, showed that adjuvant chemoradiotherapy improved survival (from 26 to 37 months overall survival) of these patients. In Europe, perioperative chemotherapy has been considered the standard treatment, since the publication of two randomized phase III trials showed an increase at 5 years survival in the group treated with chemotherapy.

Pretreatment Staging Positron Emission Tomography/Computed Tomography in Patients With Inflammatory Breast Cancer Influences Radiation Treatment Field Designs

Positron emission tomography/computed tomography (PET/CT) is increasingly being utilized for staging of inflammatory breast cancer (IBC). The purpose of this study was to define how pretreatment PET/CT studies affected postmastectomy radiation treatment (PMRT) planning decisions for IBC. We performed a retrospective analysis of 62 patients diagnosed with IBC between 2004 and 2009, who were treated with PMRT in our institution and who had a staging PET/CT within 3 months of diagnosis. Patients received a baseline physical examination, staging mammography, ultrasonographic examination of breast and draining lymphatics, and chest radiography; most patients also had a bone scan (55 patients), liver imaging (52 patients), breast MRI (46 patients), and chest CT (25 patients). We compared how PET/CT findings affected PMRT, assuming that standard PMRT would target the chest wall, level III axilla, supraclavicular fossa, and internal mammary chain (IMC). Any modification of target volumes, field borders, or dose prescriptions was considered a change. PET/CT detected new areas of disease in 27 of the 62 patients (44%). The areas of additional disease included the breast (1 patient), ipsilateral axilla (1 patient), ipsilateral supraclavicular (4 patients), ipsilateral infraclavicular (1 patient), ipsilateral IMC (5 patients), ipsilateral subpectoral (3 patients), mediastinal (8 patients), other distant/contralateral lymph nodes (15 patients), or bone (6 patients). One patient was found to have a non-breast second primary tumor. The findings of the PET/CT led to changes in PMRT in 11 of 62 patients (17.7%). These changes included additional fields in 5 patients, adjustment of fields in 2 patients, and higher doses to the supraclavicular fossa (2 patients) and IMC (5 patients). For patients with newly diagnosed IBC, pretreatment PET/CT provides important information concerning involvement of locoregional lymph nodes, mediastinal lymph nodes, and unsuspected sites of distant metastasis. This information is important in the design of radiotherapy treatment fields and, therefore, we recommend that PET/CT be a component of initial staging for IBC.

Comparison of 11C-Choline PET/CT and Enhanced CT in the Evaluation of Patients With Pulmonary Abnormalities and Locoregional Lymph Node Involvement in Lung Cancer

BackgroundThis study compares the diagnostic abilities of integrated 11C-choline PET/CT imaging and contrast-enhanced helical CT imaging in pulmonary lesions and locoregional lymph node metastases in patients with lung cancer. Patients and MethodsOne hundred eight patients with proven or suspected lung cancer underwent integrated 11C-choline PET/CT and contrast-enhanced CT, followed by surgical resection and nodal staging. ResultsThe 11C-choline PET/CT and CT diagnoses of pulmonary lesions and locoregional lymph node metastases were compared with pathologic findings, which revealed benign lesions in 26 patients (tuberculoma [8 patients], inflammatory pseudotumor [7 patients], hamartoma [6 patients], sclerosing hemangioma [4 patients], and pulmonary sequestration [1 patient]) and lung cancers in 82 patients (adenocarcinoma [39 patients], squamous cell carcinoma [23 patients], carcinoid [7 patients], small-cell lung cancer [5 patients], adenosquamous carcinoma [5 patients], and large-cell lung cancer [3 patients]). The accuracy, sensitivity, and specificity of 11C-choline PET/CT for diagnosing lung cancer were 82.4%, 85.4%, and 73.1%, respectively, compared with 73.1%, 76.8%, and 61.5%, respectively, for CT. Differences between 11C-choline PET/CT and CT in diagnosing lung cancer were not statistically significant (p = .503, .118, and .375, respectively). We used receiver operating characteristic (ROC) curve for analysis, finding the ROC of standard uptake value (SUVmax) for diagnosing lung cancer. The cutoff value of SUVmax was 3.54. Preoperative nodal staging was compared with postoperative histopathologic staging. 11C-choline PET/CT correctly staged 80.5% of patients, 12.2% were overstaged, and 7.3% were understaged; for CT these values were 58.5%, 24.4%, and 17.1%, respectively. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 11C-choline PET/CT for lymph nodes were 83.8%, 82.4%, 84.1%, 50.3%, and 96.1%, respectively, compared with 69.3%, 63.7%, 71.2%, 30.2%, 91.0%, respectively, for CT. ConclusionDifferences in the accuracy, sensitivity, specificity, PPV, and NPV between 11C-choline PET/CT and CT are thus statistically significant for nodal staging (p = .003, .007, .000, .000, and .004, respectively). Although 11C-choline PET/CT is not significantly better at diagnosing pulmonary lesions than is enhanced CT, 11C-choline PET/CT has improved sensitivity, specificity, accuracy, PPV, and NPV relative to enhanced CT in the evaluation of locoregional lymph nodes.

The rising PET: the increasing use of choline PET/CT in prostate cancer

The paper by Castellucci et al. [1] which appears in this issue of the journal is the last contribution, just in terms of time, dealing with the use of choline PET in the evaluation of biochemical relapse from prostate cancer. The paper adds an important voice in the discussion on the management of prostate cancer patients after prostatectomy. In particular, the authors aimed at studying the clinical utility of Ccholine PET/CT in patients with a “mild” serum prostatespecific antigen (PSA) increase after radical prostatectomy. Although “mild” is not a numeric value, they set the PSA cutoff at less than 1.5 ng/ml. One hundred and two patients were enrolled with an increase of serum PSA during follow-up ranging from 0.2 to 1.5 ng/ml. Choline PET/CT was used as the first diagnostic procedure and results were compared to pathology or a 12-month follow-up. Data from PSA kinetics, such as doubling time and velocity, were also evaluated. The study reports positive C-choline PET/CT findings in 29% of patients, including those who had local relapse, positive locoregional nodes or bone metastasis. Notably, the paper also suggested that PSA doubling time and locoregional lymph node involvement at diagnosis were the only significant independent predictive factors for relapse in multivariate analyses. The authors concluded that Ccholine PET/CT is effective in determining the best treatment strategy in patients with early, or mild, PSA relapse, namely below 1.5 ng/ml. This paper stresses again the rising importance of PET/ CT in prostate cancer, a field in which F-FDG is of negligible use, therefore underlining the importance of PET as a technique able to study different entities, using different, specific radiopharmaceuticals. The increasing ageing of the population, particularly in more developed countries, has resulted in an increase of prostate cancer incidence and this disease is now one of the leading causes of death in men [2]. After radical prostatectomy or radical radiation treatment, prostate cancer recurs in 20–50% of patients, and PSA increase is detectable before the disease can be confirmed with any imaging modality. Of course, PSA is not able to distinguish between local relapse, involvement of locoregional nodes or distant metastases; this is why imaging comes into play. Literature data confirmed that, as often occurs, detection of anatomical changes with magnetic resonance (MR), computed tomography (CT) or transrectal ultrasound (TRUS) has limited accuracy for assessment of recurrent disease [3]. In order to tailor a patient’s therapy to the status of the illness, there needs to be an imaging method capable of assessing the real tumour burden and to localize all, or almost all, localizations. Treatment strategies at relapse vary depending on disease extension, including surgery, radiation treatment, hormonal therapy and palliative care. Molecular imaging with PET is able to detect the diffusion of cancer before morphological changes can be identified with other imaging methods, and this is true also for prostate cancer. Different radiopharmaceuticals have been proposed, both for PET and SPECT, as well as potential applications of PET/MR imaging, as summarized in a recent review [4]. A. Chiti (*) Department of Nuclear Medicine, IRCCS Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, MI, Italy e-mail: arturo.chiti@humanitas.it

Comparison of Endoscopic Ultrasound (EUS) and Computed Tomography (CT) in Assessing Loco-regional Lymph Node Involvement, Vascular Invasion, and Resectability of Pancreatic Cancer: A Meta-analysis

Comparison of Endoscopic Ultrasound (EUS) and Computed Tomography (CT) in Assessing Loco-regional Lymph Node Involvement, Vascular Invasion, and Resectability of Pancreatic Cancer: A Meta-analysis

Modern Staging and Utility of PET Imaging in Esophageal Cancer Management

Esophageal cancer is the eighth most common cancer worldwide, and one of the most fatal diseases despite modern medical treatment. Because correct staging and surveillance of neoadjuvant therapy for esophageal cancer is mandatory for further treatment planning, choosing a modern imaging system is important. The development of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) has provided alternate means of tumor detection distinct from more conventional methods. This modality has extraordinary performance in detecting locoregional lymph node involvement and distant metastatic disease, and has been introduced as a powerful tool in many guidelines. However, some factors still lead to false-negative or -positive results, raising questions of its accuracy. This article discusses the clinical efficacy of PET in staging and surveillance of neoadjuvant therapy in esophageal cancer, comparing its accuracy with conventional imaging modalities.

Survival of Patients with Small Bowel Neuroendocrine Tumors

Purpose: Neuroendocrine tumors (NETs) are the most common small bowel malignancy. Because these rare tumors have variable clinical courses, the European NETS classification was established to help predict outcome. The aim of this study was to study the relationship of several demographic and histopathologic features of the ENET system with overall survival. Methods: 134 patients with small bowel neuroendocrine tumors, diagnosed between 1992–2005, were identified by querying the Mount Sinai Gastrointestinal Pathology Database. These patients were treated and referred by a variety of physicians and surgeons affiliated with Mount Sinai. We performed a retrospective review of demographic and histopathologic data of these patients. Data collected included age, gender, primary tumor size, tumor number, nodal/metastasis status, stage, and tumor grade (Ki-67). We ascertained survival status of each patient by querying the National Death Index (NDI). Statistical analysis was performed using Kaplan–Meier survival curves, and log rank test to determine differences between groups. Results: 74/134 (55%) patients were female. The mean age at time of pathologic diagnosis was 60.2 years. The average size of the primary tumor was 1.9 cm (range 0.4–11 cm). 34% (43/121) of patients had multiple tumors. 81% (77/94) of patients had locoregional nodal involvement. Approximately half of patients had a Ki-67 analysis performed. 31 patients (23%) were identified as deceased as of December 31, 2005. The overall mean survival was 4.28 years. Age over 60 at time of diagnosis was significantly associated with worse survival (Figure 1). There was a trend toward improved survival for patients with Grade 1 vs. Grade 2 or 3 tumors (P= 0.61). No significant difference between survival of patients based on gender, tumor count, tumor size, or stage was detected.Figure 1: Kaplan–Meier analysis of survival based on age at time of pathologic diagnosis.Conclusion: This analysis of a large cohort of patients with small bowel NETs confirms that older age at diagnosis predicts worse survival. We suspect that further analysis may demonstrate that low tumor grade predicts improved survival. Further study is required to clarify the potential of the histopathologic markers used in the ENET system in predicting prognosis of small bowel carcinoids.

Extrahepatic bile duct adenocarcinoma: patients at high-risk for local recurrence treated with surgery and adjuvant chemoradiation have an equivalent overall survival to patients with standard-risk treated with surgery alone.

Patients with resected extrahepatic bile duct adenocarcinoma who have microscopically positive resection margins and/or pathologic locoregional nodal involvement (R1pN1) have a high-risk of locoregional recurrence, and therefore, we advocate the use of adjuvant chemoradiation. To evaluate the safety and effectiveness of this treatment, we compared survival and side effects outcomes between such patients and patients with negative resection margins and pathologically negative nodes (R0pN0) who did not receive adjuvant treatment. Between 1984 and 2005, 65 patients were treated with curative-intended resection for extrahepatic bile duct adenocarcinoma. Patients with tumors arising in the gallbladder and periampullary region were excluded. Pathology and diagnostic images were centrally reviewed. Overall survival and locoregional recurrence outcomes for patients with standard-risk R0pN0 (surgery alone, or S group, n = 23) were compared with those of patients with high locoregional recurrence risk, R1 and/or pN1 (R1pN1) status who received adjuvant chemoradiation (S-CRT group, n = 42). The median follow-up for the entire group was 31 months. Patients in the S-CRT and S groups had a similar 5-year overall survival (36% vs. 42%, P = .6) and locoregional recurrence (5-year rate: 38% vs. 37%, P = .13). In the S-CRT group, three patients (7%) experienced an acute (grade 3 or more) side effect. Our finding of a lack of a survival difference between the S and S-CRT groups suggests that for patients with extrahepatic bile duct adenocarcinoma at high risk for locoregional recurrence (i.e., R1 resection or pN1 disease), adjuvant chemoradiation provides an equivalent overall survival despite of these worse prognostic features.

Role of positron emission tomography in the management of head and neck cancer in the molecular therapy era

The utility of positron emission tomography-computed tomography has increasingly been studied during the last years. Positron emission tomography-computed tomography offers a holistic approach of cancer diagnosis as it can integrate structural, functional, metabolic, and molecular information of tumour. The technique offers three-dimensional, high-resolution, whole body, and quantitative imaging. 18F-Fluoro-2-deoxy-D-glucose still remains the only tracer widely available. Other tracers have been designed for assessment of proliferation, amino acid uptake, and hypoxia. 18F-Fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography seems the most appropriate technique for the assessment of locoregional lymph node involvement in head and neck cancer. False negativity of positron emission tomography-computed tomography in case of micrometastatic lymph node disease should be compensated by the implementation of the sentinel node scintigraphy guided biopsy. 18F-Fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography has a very high sensitivity and negative predictive value in detecting residual disease after radiotherapy or early recurrent disease. Radiotherapy planning can use the 18F-fluoro-2-deoxy-D-glucose uptake distribution for increasing the accuracy of delineation of the target volumes in conformal radiotherapy. Positron emission tomography-computed tomography with other tracers such as deoxy-18F-fluorothymidine for proliferation mapping and [F-18] fluoromisonidazole for hypoxia mapping are currently being studied. Major studies have now confirmed the utility of positron emission tomography-computed tomography in the different phases of diagnostic and therapeutic phases of the management of patients with head and neck cancer.

Contribution of SLN investigation with 99mTc-nanocolloid in clinical staging of thyroid cancer: technical feasibility

It is a matter of controversy whether prophylactic lymph node dissection improves prognosis and survival in papillary thyroid carcinoma (PTC) patients without suspicion of lymph node metastases either clinically or on ultrasonography. It is possible that in such patients the use of lymphatic mapping and sentinel lymph node (SLN) biopsy, as are employed for other tumours, will be of assistance. The aim of this study was to evaluate the feasibility of preoperative 99mTc-nanocolloid lymphoscintigraphy and an intra-operative SLN procedure in the management of PTC patients. Twenty-five consecutive patients were entered in the study between April 2005 and October 2005. All had a preoperative diagnosis of malignancy obtained by fine-needle aspiration cytology (FNAC), without clinical or ultrasonographic evidence of loco-regional lymph node involvement. Patients underwent preoperative lymphoscintigraphy after the injection of 99mTc-nanocolloid [median 6 MBq (range 4-9 MBq) in 0.1-0.2 ml saline injected intratumorally under ultrasound guidance] and an intra-operative SLN procedure using a hand-held gamma probe. Surgery was performed by the same surgeon in all patients. Preoperative lymphoscintigraphy identified at least one SLN in all patients. During surgery, using the gamma probe, the surgeon was able to find at least one SLN in all cases. A good correlation was found between preoperative imaging and probe results. Metastasis was found in at least one SLN in 12 (48%) patients. In seven (28%) patients the involved SLN was the most radioactive SLN, while in five (20%) patients a less radioactive SLN was involved by malignancy. Ten of these 12 patients had only micrometastases (<2 mm). Micrometastases were found in the most radioactive SLN in six cases and in less radioactive SLNs in four cases, while in two patients more lymph nodes visualised at lymphoscintigraphy ipsilateral to the primary tumour were sites of metastasis. The rate of nodal involvement was very high in our series: in 48% of patients at least one metastatic lymph node was found. From a technical point of view the intra-operative SLN procedure in PTC patients was easy to perform, without major intra-operative complications. Our promising preliminary experience needs to be confirmed in larger series of patients series with longer follow-up.

5-fluorouracil (5-FU) plus cisplatin (CDDP) induction chemotherapy followed by combined external bean radiation therapy (XRT) and mitomycin-C (MMC) and 5-FU chemotherapy in locally advanced anal canal cancer (ACC)

14016 Background: Definitive chemoradiation therapy is the standard of care for squamous or cloacogenic cell ACC. The chemotherapy regimen comprising 5-FU and MMC is the most commonly used among patients with ACC, nearly 70% of patients can get complete response (CR), with the benefit of sphincter preservation, but patients with a large tumors (T3/T4) or nodal metastases have a response of 50%. Methods: To improve outcome, we conducted a phase II, study of 5-FU and CDDP followed by combined XRT plus 5-FU and MMC. Eligibility included patients withT3/T4 ACC with limited locoregional nodal involvement (N0/N1). Treatment: 5-FU 1000 mg/m2/days 1 to 5 in continuous i.v. infusion plus CDDP 100 mg/m2 i.v. day 1 q21d was administered for 2 cycles (weeks 1 and 4) followed by XRT (4.5 Gy) during 6 weeks (weeks 7 to12) with concurrent 5-FU 1000 mg/m2/days 1 to 4 in continuous i.v. infusion plus MMC 10 mg/m2 i.v. day 1 (weeks 9 and 17). RECIST criteria were used to assess tumor response Results: 59 patients were entered on this study from 8/2000 to 2/2005. Median age: 57 yrs (37–83), 49 F/10 M, median ECOG PS 0 (0–1), T3/T4 44/15, N0/N1 20/39. 54 patients were evaluable for clinical response: Induction chemotherapy led to 13 (24%) CR, 38 (70%) partial responses (PR) and 2 (6%) stable disease. After combined modality treatment, there were a total of 36 (67%) CR, 13 (24%) PR, 5 (9%) SD. Median follow up was 21.6 months (5–52).The median time to progression is 20.5 months (3–52). Toxicity grade 3/4: Neutropenia 20% (10/54), thrombocytopenia 13% (7/54), radiodermatitis 13% (7/54), nausea/vomiting 7% (4/54). Our previous experience with concurrent treatment without induction (n=27) resulted in a CR 59%, PR 37%, and 4% progressive disease Conclusions: We concluded that induction chemotherapy followed by combined XRT and chemotherapy could be an option in treatment of locally advanced ACC. No significant financial relationships to disclose.

Prognostic Factors in a Recent Series of Patients Treated with Radical Cystectomy for Bladder Cancer

Objective: To identify the clinical and pathological prognostic factors in a homogeneous series of patients with bladder cancer who had undergone radical cystectomy in the late 1990s. Materials and Methods: We retrospectively analyzed the clinical data of 156 patients who had undergone radical cystectomy and iliac-obturator lymphadenectomy for bladder carcinoma at our department between 1995 and 2001. Results: The mean follow-up was 39.71 ± 26.2 months. The 5-year overall and cancer-specific survival rates were 47.2 and 54.7%, respectively. Upper urinary tract obstruction (p = 0.03), clinical stage of both the primary tumor (p = 0.0001) and loco-regional lymph nodes (p = 0.04), pathological stage (2002 TNM) of the primary tumor (p < 0.0001), pathological loco-regional lymph node involvement (p < 0.0001), and vascular embolization (p = 0.005) were significant on univariate analysis. Pathological lymph node involvement (p = 0.001) and both pathological (p = 0.022) and clinical stages of the primary tumor (p = 0.002) turned out to be independent predictors of cancer-specific survival. Conclusion: Pathological lymph node involvement, clinical and pathological stage of the primary tumor were the cancer-specific, survival-independent, predictors in our series. Our multivariate analysis data identified pT3–4 and pN+ patients as those with the worst prognosis.

Primary carcinoid tumor of prostate presenting with bone marrow metastases

Primary carcinoid tumor of the prostate is a rare tumor derived from the amine precursor uptake and decarboxylation cells of the prostate. We report a case of a 71-year-old man who presented with progressive anemia due to bone marrow metastases from primary carcinoid tumor of the prostate. No other metastasis was found clinically. This pattern of metastasis is very unusual and illustrates that carcinoid tumor of the prostate may metastasize distantly without locoregional lymph node involvement. This unique case highlights the need for a multidisciplinary approach to the evaluation of a metastatic carcinoid tumor of an unknown primary and that it should include the prostate.

Tumor Related Factors Influencing the Accuracy of Endoscopic Ultrasound in Cancer of the Esophagus and the Gastro-esophageal Junction

Background: Endoscopic Ultrasound (EUS) is the most accurate method to assess the extent of the tumor and involvement of locoregional lymph nodes in patients with cancer of the esophagus or gastro-esophageal junction (GEJ). Especially in combination with Fine Needle Aspiration (FNA), EUS is the first line method to assess the lymph nodes at celiac axis. Tumor related factors and patients characteristics that might influence the accuracy of EUS were examined. Patients and Methods: Between January 1997 and September 2002, 280 patients underwent EUS for cancer of the esophagus or GEJ. Retrospectively, the influence of patients characteristics, presence of Barrett's epithelium or stenosis, histopathology, localization and length of the primary tumor on the accuracy of EUS was examined. Results: Overall accuracy of EUS to assess T-, N- and M-stage were 73%, 80% and 78%, respectively. Age and sex, histopathology, presence of Barrett's epithelium or stenosis did not influence the accuracy. However, the accuracy of EUS was higher in tumors <5 cm compared with tumors >5 cm (82% vs 52% for T-stage; 88% vs 59% for N-stage; 92% vs 56% for M-stage). Accuracy of EUS was significantly higher for esophageal tumors compared to GEJ tumors, especially in determining celiac trunk metastases (93% vs 63%: p<0.001). Conclusion: The accuracy of EUS is lower in tumors >5 cm and in tumors of the GEJ as compared with tumors of <5 cm and above the gastro-esophageal junction.

Descriptive epidemiology of thyroid carcinoma in Carinthia, Austria: 1984-2001. Histopathologic features and tumor classification of 734 cases under elevated general iodination of table salt since 1990: population-based age-stratified analysis on thyroid carcinoma incidence.

The aim of the study was to investigate the current thyroid carcinoma (TC) incidence in Carinthia, a former iodine-deficient, goiter-endemic region in Austria with approximately 550,000 inhabitants from 1984 to 2001. Using age-cohort analysis we analyzed the TC incidence under the impact of two regional risk factors: the contamination of Austrian soils by the radioactive fallout in from Chernobyl 1986 and the increased iodination of table salt in a general program of goiter prophylaxis begun in 1991. To evaluate the characteristics of TC incidence, we compared the results of the periods 1984-1989, 1990-1995, and 1996-2001. A total of 734 TC cases were diagnosed. Papillary, follicular, medullary, oxyphilic, and anaplastic TC accounted for 76%, 18%, 3%, 1%, and 2%, respectively. The female to male ratio was 3:1. The annual incidence rate increased by 8.05% in females and 11.6% in males. TC cases younger than 40 years of age accounted for 22.6%, with a rate increase of 18% per year in young males, the female-to-male ratio decreased from 8.3, 6.1, 2.7 younger than 40 in the compared periods. Along with a further increase in papillary TC incidence and papillary thyroid carcinoma (PTC) follicular thyroid carcinoma (FTC) ratio in the adult population, the ratio tended to decrease in the younger than 40-year-old population. T4 class TC and loco-regional lymph node involvement increased significantly. The observed changes in TC incidence, particularly in the young population, as in adults, could be linked to the abovementioned risk factors involved in the initiation and early growth of TC, and iodine may play a role in stimulating overall thyroid activity.

A comparison of computerised tomography, laparoscopic ultrasound and endoscopic ultrasound in the preoperative staging of oesophago-gastric carcinoma

Introduction and objective: Oesophago-gastric carcinoma is associated with a poor prognosis despite advances in diagnosis and treatment. Accurate preoperative staging of gastro-oesophageal carcinoma is, therefore, essential in order to determine patient selection for potentially curative resection. The aim of this study was to evaluate and compare the role of computerised tomography (CT), laparoscopic ultrasound (LapUS) and endoscopic ultrasound (EUS) in the staging of oesophago-gastric carcinoma. Methods and patients: Thirty-six patients with histologically proven carcinoma of the oesophagus or stomach who were considered fit for surgical resection were identified from a prospectively collected database. All patients underwent spiral CT, LapUS and EUS as part of their preoperative staging investigations. Results from the staging modalities were compared retrospectively with final histopathology where available and to intraoperative findings where the tumour was irresectable. Results: Locally advanced tumours (T3/T4) were accurately identified by CT in 15/16 (94%) and by EUS in 14/16 (88%). LapUS was unable to detect 11 tumours (of which five were T3/T4) because they were above the diaphragm, but in the locally advanced cases where the tumour could be seen the accuracy was 10/12 (83%). EUS was the best modality for assessing early tumours and locoregional nodal involvement with accuracies of 8/13 (62%) and 21/29 (72%), respectively. EUS accuracies rose to 64, 92 and 83% for T1/T2, T3/T4 and N staging with the exclusion of those patients ( n=6) in whom strictures prevented full assessment. LapUS had a specificity of 100%, compared to 90% for CT and was more accurate than CT for assessing distant metastases (accuracy of 26/32 (81%) compared to 23/32 (72%) for CT). Conclusions: Although this study is small it has confirmed that CT, EUS and LapUS act in a complimentary manner to provide the most complete preoperative staging for patients with oesophago-gastric cancer.

Early, late symptoms and histological type of nasopharyngeal carcinoma.

After a wide literature review, we retrospectively analyzed the accurately recorded early onset and late symptoms at first diagnosis of nasopharyngeal carcinoma (NPC) in a series of 85 patients. Thirty-seven (44%) and 48 (56%) of cases had a squamous (SCC) and undifferentiated (UCNT) histological NPC subtype, respectively. Thirteen (15%), 21 (25%) and 51 (60%) of cases were T2, T3 and T4, respectively. The involvement of locoregional lymph nodes resulted significantly more frequent in UCNT with respect to SCC (35% versus 18% respectively; p<0.05). Overall, the early onset symptoms were represented by locoregional lymph node enlargement in 35% of cases; nasal symptoms in 32%, otological symptoms in 36%, while neurological symptoms were reported in only 2% of cases. On the contrary, symptoms at first diagnosis were more frequently represented by lymph node enlargement (53%) and nasal symptoms (68%) which were the symptoms effectively conducting the patients to the specialist. A protocol for management of ORL symptomatic patients according to the incidence of described early onset and at first diagnosis symptoms is suggested.

CT evaluation of treatment response in advanced gastric cancer

Ninety-one patients with advanced gastric carcinoma were followed by serial computed tomography (CT) in a phase II study using multi-agent chemotherapy. Regression of primary tumour was seen in 43, with complete resolution in 5 and > 50% regression in 29. Involvement of loco-regional lymph nodes was seen in 43 patients, with complete resolution in 16, and > 50% regression in 21. Hepatic metastases were seen in 40 patients, with complete resolution in three and > 50% regression in 17. Regression in other less common sites in the chest and abdomen were also documented. The pattern of maximum response in all sites of disease was seen within the first 12 weeks of chemotherapy. The difficulties of disease management are discussed and recommendations for CT evaluation in this group of patients are made.