Oncologic Conditions Research Articles

PCN43 - A TARGETED REVIEW OF NICE SINGLE TECHNOLOGY APPRAISALS (STAS) IN UROTHELIAL CANCER SINCE THE INTRODUCTION OF THE NEW CANCER DRUGS FUND (CDF)

This review investigates trends in NICE single technology appraisals (STAs) in urothelial cancer since the introduction of the new Cancer Drugs Fund (CDF) in July 2016, to better understand decision making. A targeted review was conducted of NICE STAs in urothelial cancer published on the NICE website. All STAs with a Technology Appraisal Guidance (TAG) or Final Appraisal Determination published since the introduction of the new CDF in July 2016 were included. A total of five STAs were identified, assessing three immunotherapies for untreated and treated metastatic urothelial cancer. All of the appraised therapies are indicated for other oncology conditions and have Managed Access Agreements in place. The clinical evidence packages at the time of NICE appraisal varied from Phase II trial data only (3) to Phase II and III data (2). In order to derive comparative efficacy data due to lack of Phase III data, a simulated treatment comparison approach was taken in three STAs. The economic assessments for all therapies were based on end-of-life criteria, allowing for a higher cost-effectiveness threshold. The recommendations varied: baseline commissioning (1), not recommended (1), and CDF – due to plausible potential of the therapy to be cost-effective pending further data collection (3). For CDF recommended therapies, the uncertainties were around the lack of direct comparative data, immaturity of survival data, methods for indirect treatment comparisons (ITC), and utility values upon disease progression. Three indications were recommended for interim funding on the new CDF. The drivers for a CDF recommendation include non-comparative evidence, immature survival data, and uncertainty around the robustness of ITCs. Further research should assess whether data collection through the CDF can sufficiently reduce these uncertainties for decision making purposes, and allow new therapies to be granted a final positive recommendation through NICE.

MiR-1290 Contributes to Colorectal Cancer Cell Proliferation by Targeting INPP4B.

Colorectal cancer (CRC) is one of the most common oncological conditions worldwide, to date. MicroRNA-1290 (miR-1290) has been demonstrated to regulate its progression. We studied the role of miR-1290 in CRC progression. The gene was upregulated in CRC tissues and cells. Its overexpression promoted CRC cell proliferation analyzed by MTT assay, colony formation assay, and soft agar growth assay. In addition, miR-1290 knockdown inhibited CRC cell proliferation. We also found that miR-1290 overexpression reduced the p27 level and increased cyclin D1 at both the mRNA and protein levels, whereas miR-1290 knockdown increased p27 and reduced cyclin D1, confirming miR-1290 promoted CRC cell proliferation. Inositol polyphosphate 4-phosphatase B (INPP4B) was the target of miR-1290. Luciferase reporter assay revealed that miR-1290 directly bound to the 3′-UTR of INPP4B; the mutated seed sites in miR-1290 abrogated this effect. Double knockdown of INPP4B and miR-1290 promoted CRC cell proliferation, suggesting miR-1290 promoted CRC cell proliferation by targeting INPP4B.

PMU51 - The Identification of Patient-Centric Value Drivers for Self-Paid Treatments in Asia

To assess patients' aspirations during their treatment journey in Asia, which will support the identification of value drivers that resonate with patients and drive their choice of treatment and willingness to pay A high level meta-analysis was conducted across relevant studies (n=6) undertaken by GfK since July 2016 involving the assessment of patient journeys of those affected by oncology, immunology and neuromuscular conditions in Singapore, Taiwan, China, Hong Kong and Japan. Primary focus was to assess drivers for treatment initiation and continuation. The studies involved secondary and primary research on patients’ aspirations from the perspective of patients, physicians, nurses and caregivers. MaxDiff analysis was employed to confirm the ranking of value drivers. The analysis identified many commonalities in patient aspirations across the different therapeutic areas. Compared to patients that are taking reimbursed therapies, those who are paying out-of-pocket costs for medications are more involved in treatment decision making. For those who suffer from oncology and neuromuscular conditions, prolonging life is not as attractive if they cannot have good quality of life (QoL). Immunology patients see similar importance in QoL and consider being able to resume their daily routine the greatest driver for treatment choice. There are also subtle value driver differences between treatment initiation and continuation – cost can be a key barrier for initiation but it rarely causes discontinuation whereas safety/ tolerability issues are the opposite. Moreover, caregivers have better understanding of patient value drivers compared to physicians or nurses. Shared decision making in medicine has become more common in Asia and clear communication on QoL benefits are important to drive patient-focused treatment decisions and willingness to pay for self-pay treatment. However, there is evidence of an understanding gap, and a consequent need to improve patient-physician communication.

Radiological characteristics and predisposing factors of venous tumor thrombus in pelvic osteosarcoma: A mono-institutional retrospective study of 115 cases.

BackgroundVenous tumor thrombus (VTT) in pelvic osteosarcoma has been regarded as a rare oncological condition and few literatures investigated this issue.MethodsWe retrospectively reviewed 115 cases of pelvic osteosarcoma treated in our center from 2006 to 2016. Diagnosis of VTTs was made based on histo‐pathological findings. We summarized the radiological manifestations of VTTs on CT, MRI, and PET/CT. We also compared the demographical, oncological, and radiological data between cases with or without VTTs to identify its predisposing factors.ResultsSeventeen cases (14.8%) were diagnosed with VTT. Manifestations of VTTs on CT included increased caliber (64.7%), calcification (47.1%), low density on plain scan (100%), filling defect (100%), and streak‐like enhancement (35.7%) on contrast enhancement. On MRI, the VTTs could be hypo‐ or iso‐intense on T1WI (100%), hyperintense on T2WI (100%), and filling defect on contrast enhancement (100%). PET/CT showed high metabolic activity of the VTTs. The ranges of the VTTs included unilateral external iliac vein (EIV) (two cases), unilateral internal iliac vein (IIV) (one case), unilateral common iliac vein (CIV) and IIV (five cases), unilateral CIV + EIV (two cases), inferior vena cava (IVC) and unilateral CIV + EIV (one case), IVC and unilateral CIV + IIV (four cases), IVC and bilateral CIVs + IIVs (two cases). Multivariate analysis indicated that chondroblastic subtype and involvement of L5/S1 intervertebral foramen might predispose to VTTs.ConclusionThe incidence of VTTs in pelvic osteosarcoma was 14.8%. Comprehensive radiological studies help preoperative diagnosis of VTTs. Predisposing factors included chondroblasic subtype and involvement of L5/S1 intervertebral foramen.

The Current State of Advanced Therapy Medicinal Products in the Czech Republic.

Advanced therapy medicinal products (ATMPs) represent a new generation of biopharmaceuticals that comprise gene therapy medicinal products (GTMPs), somatic cell therapy products (CTMPs), tissue engineered products (TEPs), and combined advanced therapy medicinal products (cATMPs). The joint effort of the academia-industry-regulatory triangle translated scientific progress into ten authorized ATMPs in the European Community. This notion holds promise for the whole field of ATMP therapies that have been increasingly evaluated in a number of clinical studies, also in the Czech Republic (CR). Here, we prepared an overview of regulatory framework, past and present clinical studies, and already authorized ATMPs in the CR. Clinical studies on ATMPs in the CR were mapped using public databases, particularly ClinicalTrials.gov, the European Union Clinical Trials Register, and the State Institute for Drug Control database. We found 50 registered clinical studies using ATMPs in the CR that mostly involve CTMPs (n = 36), followed by GTMPs (n = 4) and TEPs (n = 4). The majority of the studies use autologous ATMPs (76%) and are aimed at the treatment of oncologic conditions (58%) and musculoskeletal disorders (24%). The most frequent autologous cell type was dendritic cells (42%), bone marrow mononuclear cells (16%) and bone marrow mesenchymal stromal cells (13%). Allogeneic ATMPs (12%) are mostly aimed at the treatment of venous ulcers (33%) and utilize keratinocytes and fibroblasts (33%). In summary, ATMPs are increasingly tested in clinical trials in the CR, which will most likely lead to their translation into broader clinical use. However, to stimulate market viability of registered ATMPs, implementation of the sophisticated reimbursement system will be required.

Building a patient-centered and interprofessional training program with patients, students and care professionals: study protocol of a participatory design and evaluation study

BackgroundA common approach to enhance patient-centered care is training care professionals. Additional training of patients has been shown to significantly improve patient-centeredness of care. In this participatory design and evaluation study, patient education and medical education will be combined by co-creating a patient-centered and interprofessional training program, wherein patients, students and care professionals learn together to improve patient-centeredness of care.MethodsIn the design phase, scientific literature regarding interventions and effects of student-run patient education will be synthesized in a scoping review. In addition, focus group studies will be performed on the preferences of patients, students, care professionals and education professionals regarding the structure and content of the training program. Subsequently, an intervention plan of the training program will be constructed by combining these building blocks. In the evaluation phase, patients with a chronic disease, that is rheumatoid arthritis, diabetes and hypertension, and patients with an oncologic condition, that is colonic cancer and breast cancer, will learn together with medical students, nursing students and care professionals in training program cycles of three months. Process and effect evaluation will be performed using the plan-do-study-act (PDSA) method to evaluate and optimize the training program in care practice and medical education. A modified control design will be used in PDSA-cycles to ensure that students who act as control will also benefit from participating in the program.DiscussionOur participatory design and evaluation study provides an innovative approach in designing and evaluating an intervention by involving participants in all stages of the design and evaluation process. The approach is expected to enhance the effectiveness of the training program by assessing and meeting participants’ needs and preferences. Moreover, by using fast PDSA cycles and a modified control design in evaluating the training program, the training program is expected to be efficiently and rapidly implemented into and adjusted to care practice and medical education.

A window beneath the skin: how computed tomography assessment of body composition can assist in the identification of hidden wasting conditions in oncology that profoundly impact outcomes.

Advancements in image-based technologies and body composition research over the past decade has led to increased understanding of the importance of muscle abnormalities, such as low muscle mass (sarcopenia), and more recently low muscle attenuation (MA), as important prognostic indicators of unfavourable outcomes in patients with cancer. Muscle abnormalities can be highly prevalent in patients with cancer (ranging between 10 and 90 %), depending on the cohort under investigation and diagnostic criteria used. Importantly, both low muscle mass and low MA have been associated with poorer tolerance to chemotherapy, increased risk of post-operative infectious and non-infectious complications, increased length of hospital stay and poorer survival in patients with cancer. Studies have shown that systemic antineoplastic treatment can exacerbate losses in muscle mass and MA, with reported loss of skeletal muscle between 3 and 5 % per 100 d, which are increased exponentially with progressive disease and proximity to death. At present, no effective medical intervention to improve muscle mass and MA exists. Most research to date has focused on treating muscle depletion as part of the cachexia syndrome using nutritional, exercise and pharmacological interventions; however, these single-agent therapies have not provided promising results. Rehabilitation care to modify body composition, either increasing muscle mass and/or MA should be conducted, and its respective impact on oncology outcomes explored. Although the optimal timing and treatment strategy for preventing or delaying the development of muscle abnormalities are yet to be determined, multimodal interventions initiated early in the disease trajectory appear to hold the most promise.

Information architecture for a patient-specific dashboard in head and neck tumor boards.

Overcoming the flaws of current data management conditions in head and neck oncology could enable integrated information systems specifically tailored to the needs of medical experts in a tumor board meeting. Clinical dashboards are a promising method to assist various aspects of the decision-making process in such cognitively demanding scenarios. However, in order to provide extensive and intuitive assistance to the participating physicians, the design and development of such a system have to be user-centric. To accomplish this task, conceptual methods need to be performed prior to the technical development and integration stages. We have conducted a qualitative survey including eight clinical experts with different levels of expertise in the field of head and neck oncology. According to the principles of information architecture, the survey focused on the identification and causal interconnection of necessary metrics for information assessment in the tumor board. Based on the feedback by the clinical experts, we have constructed a detailed map of the required information items for a tumor board dashboard in head and neck oncology. Furthermore, we have identified three distinct groups of metrics (patient, disease and therapy metrics) as well as specific recommendations for their structural and graphical implementation. By using the information architecture, we were able to gather valuable feedback about the requirements and cognitive processes of the tumor board members. Those insights have helped us to develop a dashboard application that closely adapts to the specified needs and characteristics, and thus is primarily user-centric.

Recent use of medical infrared thermography in skin neoplasms.

Infrared thermal imaging captures the infrared radiation emitted by the skin surface. The thermograms contain valuable information, since the temperature distribution can be used to characterize physiological anomalies. Thus, the use of infrared thermal imaging (IRT) has been studied as a possible medical tool to aid in the diagnosis of skin oncological lesions. The aim of this review is to assess the current state of the applications of IRT in skin neoplasm identification and characterization. A literature survey was conducted using the reference bibliographic databases: Scopus, PubMed and ISI Web of Science. Keywords (thermography, infrared imaging, thermal imaging and skin cancer) were combined and its presence was verified at the title and abstract of the article or as a main topic. Only articles published after 2013 were considered during this search. In total, 55 articles were encountered, resulting in 14 publications for revision after applying the exclusion criteria. It was denoted that IRT have been used to characterize and distinguish between malignant and benign neoplasms and different skin cancer types. IRT has also been successfully applied in the treatment evaluation of these types of lesions. Trends and future challenges have been established to improve the application of IRT in this field, disclosing that dynamic thermography is a promising tool for early identification of oncological skin conditions.

Patterns of paediatric end-of-life care: a chart review across different care settings in Switzerland

BackgroundPaediatric end-of-life care is challenging and requires a high level of professional expertise. It is important that healthcare teams have a thorough understanding of paediatric subspecialties and related knowledge of disease-specific aspects of paediatric end-of-life care. The aim of this study was to comprehensively describe, explore and compare current practices in paediatric end-of-life care in four distinct diagnostic groups across healthcare settings including all relevant levels of healthcare providers in Switzerland.MethodsIn this nationwide retrospective chart review study, data from paediatric patients who died in the years 2011 or 2012 due to a cardiac, neurological or oncological condition, or during the neonatal period were collected in 13 hospitals, two long-term institutions and 10 community-based healthcare service providers throughout Switzerland.ResultsNinety-three (62%) of the 149 reviewed patients died in intensive care units, 78 (84%) of them following withdrawal of life-sustaining treatment. Reliance on invasive medical interventions was prevalent, and the use of medication was high, with a median count of 12 different drugs during the last week of life. Patients experienced an average number of 6.42 symptoms. The prevalence of various types of symptoms differed significantly among the four diagnostic groups. Overall, our study patients stayed in the hospital for a median of six days during their last four weeks of life. Seventy-two patients (48%) stayed at home for at least one day and only half of those received community-based healthcare.ConclusionsThe study provides a wide-ranging overview of current end-of-life care practices in a real-life setting of different healthcare providers. The inclusion of patients with all major diagnoses leading to disease- and prematurity-related childhood deaths, as well as comparisons across the diagnostic groups, provides additional insight and understanding for healthcare professionals. The provision of specialised palliative and end-of-life care services in Switzerland, including the capacity of community healthcare services, need to be expanded to meet the specific needs of seriously ill children and their families.

Managing dysfunctional central venous access devices: a practical approach to urokinase thrombolysis.

Tunnelled central venous access devices (CVADs) are defined as any intravenous multipurpose catheters placed within the central veins for use in haemodialysis and administration of blood products or chemotherapy in oncology and haematological conditions. Frequent complications include thrombosis and catheter-related infection, which may lead to significant adverse patient outcomes. Once thrombosis is suspected correction should be attempted empirically with thrombolytic agents. Commonly available thrombolytic agents in the UK include urokinase (Syner-Kinase) and alteplase (Cathflo). It is well recognised that urokinase usage differs widely and concerns were raised by clinicians about the variation of dose regimens nationally. The objective of the CVAD Focus Group was to address this issue and offer guidance in the management of suspected thrombosis of CVAD with urokinase using two algorithms for renal and non-renal dysfunctional CVAD and to audit prospectively the outcomes of intervention.

Changes in Distress Measured by the Distress Thermometer as Reported by Patients in Home Palliative Care in Germany.

To identify changes in distress as reported by patients in a home palliative care program over a 2-week period. Prospective study in West Germany with consecutive patients cared for at home by a palliative care specialty team. Exclusion criteria were patients under 18 years of age, mentally or physically not able to complete the assessment questionnaires, or unable to comprehend German language. Distress was measured using the distress thermometer (DT); sociodemographic and medical data were collected from the patients' records. One hundred three participated in the study (response rate of 69%) and 39 participants completed DT at 2-week follow-up (T1; response rate = 38%; mean age = 67; female = 54.4%; married = 67%; living home with relatives = 60.2%; oncological condition = 91.3%; Karnofsky performance status [KPS] 0-40 = 18.9%, KPS 50-70 = 70.3%, KPS >80 = 10.8%). The mean DT score at the first visit (T0) was 5.9 (2.3), with 82.1% of the participants scoring DT ≥5. At the 2-week follow-up (T1), mean DT score was 5.0 (2.0), with 64.1% scoring DT ≥5, showing a statistically significant difference between T0 and T1. Comparing the single scores at T0 and T1 of each participant, the difference in DT scores was -0.9 (2.27). The DT is a useful tool for screening severity and changes in psychological distress as well as sources of distress. The DT detected change in self-reported distress within a short treatment period, indicating success or failure of the palliative care treatment approaches.

Supervised, Individualized Exercise Programs Help Mitigate Costs during Cancer Treatment

Background: Cancer and its associated treatments often result in long-term physical and psychological side effects that negatively impact the cancer survivor's quality of life. In addition, the financial costs of cancer are substantial and are projected to reach $158 billion by the year 2020. Research indicates that endurance exercise training is helpful in attenuating the deleterious effects of cancer treatments by increasing survival, attenuating myocardial lesions and myocyte disarray, increasing levels of antioxidants, decreasing lipid peroxidation induced by oxidative stress and markers of apoptosis, and preserving cardiac function. However, nationally less than 5% of patients are ever referred to a cancer rehabilitation exercise program. Cost is a barrier to these programs, as they often are not reimbursable under most insurance plans. Purpose: Therefore, the purpose of this investigation was to determine if exercise training during cancer treatment helped to minimize side effects and reduce health care costs. Specifically, treatment tolerance, length of hospital stay, hospital readmits, ER visits, and treatment compliance were measured. Methods: This was a retrospective, two-group study which ascertained the protective effect of an exercisetraining program during cancer treatment. All oncology patients who received cancer treatment at Kettering Medical Center in Dayton, Ohio between January-December 2016 were identified by office staff. Their medical records were pulled and patients were placed in one of two groups: those who exercised during treatment, and those who remained sedentary. The medical records were reviewed to determine outcome data for length of hospital stays, hospital readmits, ER visits, treatment compliance, fatigue, and anxiety/depression related to oncology conditions. The age range of the patients was 21-93 years. Patients were excluded if they had pre-existing cardiac, liver, and bone marrow conditions prior to treatment. Individuals in the exercise group (EX, n=672) completed 12 weeks of prescribed, individualized exercise that included cardiovascular, strength training, and flexibility components. The intensity level for the cardiovascular exercise ranged from 30%-45% of the individual’s predicted VO2max. The strength training involved a full body workout, with emphasis on all major muscle groups. Individuals in the sedentary group (SED, n=728) did not participate in an exercise program during treatment. Results: Patients in the EX group had significantly lower reports of fatigue, pain, and cardiac problems (p<0.05), as well as fewer notes of depression and anxiety than their SED group counterparts. In addition, the EX group tolerated their treatment significantly better than the SED group (p<0.05). Finally, the EX group had a significantly lower number of ER visits (EX=2, SED=14, p<0.05), 30-day readmits (EX=2, SED=53, p<0.05) as well as a shorter length of stay (EX=0.75, SED=3 p<0.05). Conclusion: Results from this investigation point to a protective effect of moderate-intensity exercise that translated to reductions in ER visits, 30-day readmits, and length of hospital stay, which translated into cost savings for the payer, provider, and patients, alike.

Chromogranin A as circulating marker for diagnosis and management of neuroendocrine neoplasms: more flaws than fame

Owing to the heterogeneity of neuroendocrine neoplasms (NENs), the availability of reliable circulating markers is critical for improving diagnostics, prognostic stratification, follow-up and definition of treatment strategy. This review is focused on chromogranin A (CgA), a hydrophilic glycoprotein present in large dense core vesicles of neuroendocrine cells. Despite being long identified as the most useful NEN-related circulating marker, clinical application of CgA is controversial. CgA assays still lack standardization, thus hampering not only clinical management but also the comparison between different analyses. In the diagnostic setting, clinical utility of CgA is limited as hampered by (a) the variety of oncological and non-oncological conditions affecting marker levels, which impairs specificity; (b) the fact that 30-50% of NENs show normal CgA, which impairs sensitivity. Regarding the prognostic phase, there is prospective evidence which demonstrates that advanced NENs secreting CgA have poorer outcome, as compared with those showing non-elevated marker levels. Although the identification of cut-offs allowing a proper risk stratification of CgA-secreting patients has not been performed, this represents the most important clinical application of the marker. By contrast, based on prospective studies, the trend of elevated circulating CgA does not represent a valid indicator of morphological evolution and has therefore no utility for the follow-up phase. Ultimately, current knowledge about the role of the marker for the definition of treatment strategy is poor and is limited by the small number of available studies, their prevalent retrospective nature and the absence of control groups of untreated subjects.

Participatory design of a patient-centered and interprofessional training program for patients, students and care professionals

Introduction: Next to training care professionals, training of patients is essential to enhance patient-centeredness of care. To simultaneously train patients and (future) care professionals, a training program will be constructed, wherein patients, students and care professionals learn together by exchanging experiences, knowledge and skills. The training program was co-created with participating groups and education professionals in a design-based and participatory approach by engaging them in the design process. Methods: Four focus group studies were performed with patients, students, care professionals and education professionals. Topic guides of focus group interviews focused on the ideas and preferences on the structure, content and educational design of the program. A concept map was created based on the results of the focus group studies and combined with a scoping review on student provided patient education to find matching educational principles, topics and methods (1). Based on the concept map, the structure and content of the program was created by the research team and discussed with an advisory board of patients, care professionals and education professionals. Results: The training program will consist of base meetings on the condition, treatment process and options, self-management, healthcare system, shared-decision making, and the role of the patient and technology in healthcare. In addition, personalized meetings, e.g., around consultations, will be organized based on the needs of patients. Learning goals for patients are focused on enhancing their disease knowledge, disease attitude, self-management skills, and communication skills and self-efficacy in relations with care professionals. Learning goals for students are aimed at improving their knowledge of patients’ perspective, trust in patients, attitude towards patient-centeredness, communication skills and shared-decision making skills. Learning goals for care professionals are improving their insight in the patients’ and students’ perspective, trust in patients and attitude towards patient-centeredness. Discussions/conclusions/lessons learned: We provide an innovative approach in combining patient education and medical education, which was co-created with patients, students, care professionals and education professionals. By grounding the structure and content of the program on the perspectives of participating groups, we expect to enhance the effects of the program on participants. Previous studies have shown the effects of involving students in providing patient education on patients and students (1), we expect to simultaneously improve the knowledge, attitude and skills of patients, students and care professionals in our training program. Limitations: Although the structure and content of the program are based on the perspectives of participating groups with personalized elements, full personalization of the program to the needs of individual participants was decided to be too challenging. To improve personalization, we will assess if the program fitted participants’ personal needs, preferences and capacities during program evaluation and adapt the structure and content of the program during evaluation of the program in practice. Suggestions for future research: In future studies, we will test the program in regular care practice and medical education for patients with a chronic condition and patients with an oncologic condition by conducting process and effect evaluation of the program using rapid plan-do-study-act cycles of three months.

EP29.12: Pelvic pathology diagnosed with transvaginal ultrasound

Throughout the world, transvaginal ultrasound (TVU) is considered a fundamental tool for gynecological work-up. TVU was initially adopted only to investigate pathologies of female genital tract, but currently TVU is also used to evaluate the extension of pathologies into the pelvis, outside the uterus or ovaries (oncological conditions and endometriosis). Moreover TVU can visualise structures that cannot be classified as gynecological pathologies but rather as pelvic pathologies. The aim of this study is to relate our experience with pelvic pathologies and our attempts to interpret those new US findings properly in order to achieve the correct diagnosis. We reviewed our case series and we selected cases of 1 pelvic schwannomas, 2 cases of GIST (gastrointestinal stromal tumours), 4 cases of post-operative urinoma, 1 case of bowel cancer, 1 case of cyst of sacral roots, 1 case of ectopic spleen, 1 case of pelvic lymphoma, 1 case of metastasys of pancreatic cancer; one case of pelvic recidive of Vater papilla tumour; one case of pelvic spread of melanoma; 1 case of chorincarcinoma arising from ectopic tubal pregnancy; 1 case of bowel volvulus. At TVU, pelvic schwannomas appeared as rounded masses, with a semi-solid structure having a regular border and intralesional hyperechoic areas. GISTs at ultrasound can show a hyperechoic core due to mixoid degeneration or leiomyomas or microcystis into the mass. Urinoma is a “pelvic pseudocyst” due to ureteral injury and is identified mainly on colour Doppler examination. Other lesions appear like a solid mass with irregular borders with eterogeneous echogenicity, highly vascularised at power Doppler investigation. Bowel volvulus was suspected by abnormal morphology of visceral wall, by intestinal contents and by clinical symptoms. Not only can the genital tract be visualised during TVU, but with this imaging method it is possible to visualise other pathological conditions as well, including those unrelated to gynecology.

Molecularly targeted agents in oculoplastic surgery.

Significant advances have been made in oncology and rheumatology with the introduction of molecularly targeted agents (MTAs). MTAs consist of monoclonal antibodies and small molecule inhibitors. The purpose of this manuscript is to review the recent applications of MTAs to orbital, lacrimal, and eyelid disease. The use of monoclonal antibodies has been described in the treatment of orbital vascular lesions, lymphoma, and squamous cell carcinoma. Inflammatory conditions treated with monoclonal antibodies include thyroid eye disease, IgG4 disease, and granulomatosis with polyangiitis. Immunotherapy with checkpoint inhibitors has also found applications to orbital disease. Use of small molecule inhibitors has been described in the treatment of basal cell carcinoma, squamous cell carcinoma, and Erdheim-Chester disease. There are many orbital, lacrimal, and eyelid side effects of MTAs with which the oculoplastic surgeon should be familiar, including hypertrichosis, edema, and orbital and eyelid inflammation. MTAs represent the future of treatment of oncologic and inflammatory conditions. Application of these agents to orbital, lacrimal, and eyelid disease will continue to expand. Elucidating the molecular mechanisms of oculoplastic disorders will facilitate additional potential pathways that could be targeted for therapy.

Serum carbohydrate antigen 19-9 in pancreatic adenocarcinoma: a mini review for surgeons.

The optimal management of oncological conditions is reflected by the careful interpretation of investigations for screening, diagnosis, staging, prognostication and surveillance. Serum tumour markers are examples of commonly requested tests in conjunction with other imaging and endoscopic tests that are used to help clinicians to stratify therapeutic decisions. Serum carbohydrate antigen 19-9 (CA19-9) is a key biomarker for pancreatic cancers. Although this biomarker is considered clinically useful and informative, clinicians are often challenged by the accurate interpretation of elevated serum CA19-9 levels. Recognizing the pitfalls of normal and abnormal serum CA19-9 concentrations will facilitate its appropriate use. In this review, we appraised the biomarker, serum CA19-9, and highlighted the clinical utility and limitations of serum CA19-9 in the investigation and management of pancreatic cancers.

Readmission After Gynecologic Surgery

To compare 30-day postsurgical readmission rates and associated risk factors for readmission among women undergoing gynecologic surgery for benign and malignant conditions. In a retrospective cohort study, we identified patients after surgery for benign and malignant gynecologic conditions in the National Surgical Quality Improvement Program database between January 1, 2011, and December 31, 2012. Data collected included surgical factors, perioperative characteristics, surgical complications, and 30-day readmissions. The primary study outcome was readmission rates after gynecologic surgery for benign and oncologic conditions. Secondary study outcomes were risk factors associated with readmission among gynecologic surgeries performed for benign and oncologic conditions. Approximately 3% (1,444/46,718) compared with 8.2% (623/7,641) of patients who underwent gynecologic surgery for benign and malignant indications, respectively, were readmitted (P<.01). Compared with patients with benign surgical indications, those with uterine cancer (readmission rate 6.6%; odds ratio [OR] 2.21, 95% CI 1.95-2.51), ovarian cancer (readmission rate 10.9%; OR 3.82, 95% CI 3.29-4.45), and cervical cancer (readmission rate 10.1%; OR 3.51, 95% CI 2.71-4.53) were more likely to be readmitted. In multivariable models, independent risk factors for readmission for gynecologic cancer surgery included worse preoperative conditions (OR 1.49, 95% CI 1.17-1.90) and major complications (OR 17.84, 95% CI 14.19-22.43). In comparison, independent risk factors for readmission after surgery for benign indications included comorbid conditions (OR 1.36, 95% CI 1.18-1.57), operative time (15-59 minutes: referent; 60 minutes or greater: 1.37, 95% CI 1.14-1.63) and major complications (OR 53.91, 95% CI 46.98-61.85). Among gynecologic surgeries, those performed for oncologic indications were associated with readmission rates 2.8 times that of surgeries performed for benign indications. In adjusted models, worse preoperative conditions and surgical complications remained independent risk factors associated with the higher rate of readmission among patients with gynecologic cancer.

Outpatient dermatology consultation impacts the diagnosis and management of pediatric oncology patients: A retrospective study

The impact of dermatology consultation on the care of children with oncologic conditions is unknown. To review outpatient dermatology visits and the resulting impact on diagnosis and management of pediatric oncology patients. Retrospective review of pediatric oncology patients with outpatient dermatology visits at a tertiary care center from 2008 to 2015. The most common dermatologic diagnoses in 516 patients were skin infections (21.3%) and nonmalignant skin eruptions (33.4%). A diagnosis of significant impact (ie, malignancy, adverse cutaneous drug reaction, graft-versus-host disease, varicella-zoster virus, or herpes simplex virus infection), was made at the dermatology clinic in 14.7% of visits. Consultation resulted in a change in diagnosis in 59.8% of patients, change in dermatologic management in 72.4% of patients, and change in management of noncutaneous issues in 12.4% of patients. The use of electronic medical records, the nongeneralizable study population, and the retrospective design represent potential limitations. Outpatient dermatology consultation can affect the care of pediatric oncology patients with respect to diagnosis and treatment of skin conditions and management of nondermatologic issues.