paywalled: Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: A meta-analysis

Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: A meta-analysis

Abstract 

Objectives

To compare the diagnostic performances of computed tomography (CT), magnetic resonance (MR) imaging, and positron emission tomography (PET or PET/CT) for detection of metastatic lymph nodes in patients with ovarian cancer.

Methods

Relevant studies were identified with MEDLINE and EMBASE from January 1990 to July 2010. We estimated the weighted summary sensitivities, specificities, OR (odds ratio), and summary receiver operating characteristic (sROC) curves of each imaging technique and conducted pair-wise comparisons using the two-sample Z-test. Meta-regression, subgroup analysis, and funnel plots were also performed to explain the between-study heterogeneity.

Results

Eighteen eligible studies were included, with a total of 882 patients. PET or PET/CT was a more accurate modality (sensitivity, 73.2%; specificity, 96.7%; OR [odds ratio], 90.32). No significant difference was detected between CT (sensitivity, 42.6%; specificity, 95.0%; OR, 19.87) and MR imaging (sensitivity, 54.7%; specificity, 88.3%; OR, 12.38). Meta-regression analyses and subgroup analyses revealed no statistical difference. Funnel plots with marked asymmetry suggested a publication bias.

Conclusion

FDG-PET or FDG-PET/CT is more accurate than CT and MR imaging in the detection of lymph node metastasis in patients with ovarian cancer.

abstract: Preoperative PET/CT in early-stage breast cancer (including ovarian cancer primary/metastases)

Preoperative PET/CT in early-stage breast cancer

Abstract

Background: The aim of this study was to assess the diagnostic and therapeutic impact of preoperative positron emission tomography and computed tomography (PET/CT) in the initial staging of patients with early-stage breast cancer. 

Patients and methods: A total of 103 consecutive patients with newly diagnosed operable breast cancer with tumors ≥2 cm were independently examined preoperatively with conventional assessment (mammography, breast/axillary ultrasound, chest X-ray and blood samples) and PET/CT with no prior knowledge of the other. 

Results: PET/CT identified a primary tumor in all but three patients (97%). PET/CT solely detected distant metastases (ovary, bones and lung) in 6 patients and new primary cancers (ovary, lung) in another two patients, as well as 12 cases of extra-axillary lymph node involvement. In 15 patients (15%), extra-axillary malignancy was detected by PET/CT only, leading to an upgrade of initial staging in 14% (14/103) and ultimately a modification of planned treatment in 8% (8/103) of patients. 

Conclusions: PET/CT is a valuable tool to provide information on extra-axillary lymph node involvement, distant metastases and other occult primary cancers. Preoperative ¹⁸F-fluorodeoxyglucose–PET/CT has a substantial impact on initial staging and on clinical management in patients with early-stage breast cancer with tumors ≥2 cm.

Clinical value of 18F-FDG PET-CT in detecting primary tumor for patients with carcinoma of unknown primary

Clinical value of 18F-FDG PET-CT in detecting primary tumor for patients with carcinoma of unknown primary: Publication year: 2012


Objective: 
To investigate the clinical value in detecting occult primary tumors with ¹⁸F-FDG PET-CT whole body imaging.

Methods: 
120 patients with unknown primary origin were referred for ¹⁸F-FDG PET-CT whole body imaging. All patients were performed ¹⁸F-FDG PET-CT whole body scan. PET-CT images were interpreted by visual inspection and semi-quantitative analysis (standardized uptake value, SUV). Histopathological and formal clinical follow-up findings were used to assess the value of FDG PET-CT.

Results: 
FDG PET-CT was able to detect the primary tumor in 54/120 patients (42.5%). The primary tumors were confirmed by histopathologic and formal clinical follow-up findings, and located in the head and neck (n =17), the lung (n =19), the breast (n =2), the esophagus (n =1), the stomach (n =2), the bile ducts (n =1), the pancreas (n =3), the co1on (n =3), the ovary (n =2), the prostate (n =l), others (n =3). FDG PET results were proved false positive in 9 patients (7.5%), which were located in the head and neck (n =3), the lung (n =1), the gastric (n =1), the colon (n =2), the ovary (n =1), the prostate (n =l).

During the clinical follow-up of median 32months (range, 2–45months), primary tumor was found in only 5 patients of 60 cases unidentified by PET-CT (breast cancer, gastric cancer, co1on cancer, prostate cancer and urinary tumors, respectively). The sensitivity, specificity, and accuracy of ¹⁸F-FDG PET-CT in the detection of the primary tumor site were 91.5%, 85.2%, and 88.3%, respectively.

Conclusion:
¹⁸F-FDG PET-CT whole body imaging is both a noninvasive and a very sensitive tomographic whole-body imaging modality, allowing for the detection of a primary tumor and complete tumor staging in single examination, which can contribute substantially to selecting appropriate therapeutic methods and evaluating prognosis. Perhaps ¹⁸F-FDG PET-CT whole body imaging should be used as a first-line imaging modality for patients with carcinoma of unknown primary rather than using it after other diagnostic procedures have failed to identify a primary tumor.

abstract: Presence of key findings in the medical record prior to a documented high-risk diagnosis.

Presence of key findings in the medical record prior to a documented high-risk diagnosis.


Abstract

Background
Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation.
  
Methods
A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls.

Results
25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD.
  
Conclusions
In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.

abstract: External Validation of Diagnostic Models to Estimate the Risk of Malignancy in Adnexal Masses (in research)

Purpose: To externally validate and compare the performance of previously published diagnostic models developed to predict malignancy in adnexal masses.

Results: Seven hundred and forty-two (74%) benign and 255 (26%) malignant masses were included. ........ The superior performance of the IOTA models was most pronounced in premenopausal patients but was also observed in postmenopausal patients. IOTA models were better able to detect stage I ovarian cancer.

Conclusion: External validation shows that the IOTA models outperform other models, including the current reference test RMI, for discriminating between benign and malignant adnexal masses

open access: Diagnostic Pathology | Abstract | Carcinoma involving the gallbladder: A retrospective review of 23 cases - pitfalls in diagnosis of gallbladder carcinoma

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• Abstract
• Provisional PDF (1.1MB) 

Background

Carcinoma of the gallbladder (GBC) clinically mimics benign gallbladder diseases and often escapes detection until advanced stage. Despite the frequency of cholecystectomy, diagnosis of GBC remains problematic in many situations. We sought to identify pathologic features that contribute to the difficulty in recognition of GBC. 

Methods

We identified 23 patients (ranged from 45 to 86 years, male to female ratio 1:4.5) with carcinoma involving the gallbladder referred to an academic medical center over a period of 10 years for study. This includes 10 cases of primary GBC, 6 cases of metastatic tumor to gallbladder, 6 cases of directly invasive adenocarcinoma arising elsewhere in the biliary tree, and one case of unidentified origin adenocarcinoma. Primary tumors include adenocarcinoma not otherwise specified (NOS) in 6 cases, papillary adenocarcinoma in 2 cases, and single cases of undifferentiated carcinoma and combined adenocarcinoma and neuroendocrine carcinoma (NEC). Metastatic tumors to gallbladder were from a wide range of primary sites, predominantly the gastrointestinal tract. 

• (included) Table 2 - Summary of case details in problematic cases:

•  ref. 10. Jain V, Gupta K, Kudva R, Rodrigues GS: A case of ovarian metastasis of gallbladder carcinoma simulating primary ovarian neoplasm: diagnostic pitfalls and review of literature. Int J Gynecol Cancer 2006, 16(Suppl 1):319-321

abstract: Comparing diagnostic delay in cancer: a cross-sectional study in three European countries with primary care-led health care systems (UK, Netherlands, Sweden)

Conclusions. A large-scale study comparing cancer delays in European countries and based on primary care-held records is feasible but would require supplementary sources of data in order to maximize information on demographic variables, the cancer stage at diagnosis and treatment details. Such a large-scale study is timely and desirable since our findings suggest systematic differences in the way cancer is managed in the three countries.

abstract: Metastatic neoplasms of the ovaries: a clinicopathological study of 97 cases (metastatic breast, GI neoplasms....)

OBJECTIVE: To present the clinicopathological features of metastatic ovarian neoplasms with emphasis in the diagnostic challenge.
METHODS: This is a retrospective study including 97 patients with pathological diagnosis of metastatic ovarian neoplasms, examined during the decade 2000-2009. The gross, microscopical and immunohistochemical characteristics as well as the clinical data (age of the patients, origin of the neoplasm, symptoms, treatment options) and 5-year survival rates were examined.
RESULTS: The mean age of the patients is 55 years (range 26-78 years). 62.89% of the tumors were metastatic from extragenital organs (from stomach 21.65%, breast 15.46%, colon 15.46%, appendix 3.09%, pancreas 2.06%, lung 1.03% and kidney 1.03%, sarcoma 1.03% melanoma 1.03%) and 37.11% tumors originated from the genital tract. The 3-year survival rates ranged from 25.39% for metastatic ovarian neoplasms originating outside the genital tract up to 29.41% for those originating from the genital tract. Tumor immunohistochemistry is a helpful aid in the differential diagnosis mainly between primary mucinous ovarian tumors and metastatic colon cancers and in the recognition of metastatic breast cancers and other neoplasms of the GI tract.
CONCLUSION: The management of metastatic ovarian neoplasms should include specific immunohistochemical methods in order to identify the primary neoplasm site. The differential diagnosis of a pelvic mass should always include metastatic neoplasms of the ovaries.

Editorial: The Elusive Goal of Maintaining Population (Breast) Cancer Screening: It Is Time for a New Paradigm JNCI

"The promise of breast cancer screening has fallen short of its goals because of its imprecision, failure to screen those at highest risk, lack of compliance with screening continuance over recommended periods of time, and gaps in access to or quality of diagnostic follow-up and treatment (20). It is no longer enough to simply conduct more interventions to understand which work best in motivating individuals to undergo repeat cancer screening. New paradigms, guided by evidence from modeling, novel trials, and new scientific discovery, will be needed to realize the promise of eliminating the burden of cancer."

Mucinous Adenocarcinoma Involving the Ovary: Comparative Evaluation of the Classification Algorithms using Tumor Size and Laterality

Evidence-Based Medicine Requires Appropriate Clinical Context - re: Deep VeingThrombosis (excerpt)

"What if a patient—after diagnostic tests have been performed and there is no more certainty to obtain—still has a 1 in 100 chance of having venous thromboembolism (VTE)? Should the patient's physician engage the patient in a discussion of the harm and benefit of anticoagulation? What if the chance of VTE was 1 in 20? Or even 1 in 10?"