Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians

Abstract

Purpose

Benign paroxysmal positional vertigo (BPPV) is a frequently underdiagnosed cause of vertigo, potentially due to the underuse of diagnostic and therapeutic canalith repositioning procedures (CRPs). We aimed to investigate self-reported use of the diagnostic and therapeutic approach to BPPV patients by Lithuanian neurologists, ear, nose, and throat (ENT) physicians, and general practitioners (GPs), and to explore potential reasons for the underuse of the maneuvers.

Methods

Neurologists, ENT physicians, and GPs were invited to complete a written questionnaire focused on diagnostic and therapeutic practices related to BPPV. Between-group differences and associations between responses were analyzed statistically.

Results

In total, 97 neurologists, 85 ENT physicians and 142 GPs (21.1%, 26.8%, and 5.7%, respectively, of all corresponding licensed Lithuanian physicians) completed the questionnaire. 24% of neurologists, 33% ENT physicians and 50% GPs do not perform diagnostic maneuvers for patients with suspected BPPV, and 28%, 61%, and 84%, respectively, do not perform CRPs. Years of clinical experience was a negative predictor of CRP performance [OR 0.97 (95% CI 0.95–0.99), p = 0.001]. Frequent reasons for not performing CRPs were time taken for the procedure, fear of provoking symptoms, and lack of knowledge. All physicians frequently ordered additional imaging or consultations for suspected BPPV and reported prescribing a range of medications.

Conclusions

A significant proportion of Lithuanian neurologists, ENT physicians, and GPs do not employ diagnostic maneuvers and CRPs for BPPV patients, contrary to established guidelines. Lack of expertise and time available is a common culprit that leads to unnecessary drug prescribing and investigation.

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Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians

Abstract

Purpose

Benign paroxysmal positional vertigo (BPPV) is a frequently underdiagnosed cause of vertigo, potentially due to the underuse of diagnostic and therapeutic canalith repositioning procedures (CRPs). We aimed to investigate self-reported use of the diagnostic and therapeutic approach to BPPV patients by Lithuanian neurologists, ear, nose, and throat (ENT) physicians, and general practitioners (GPs), and to explore potential reasons for the underuse of the maneuvers.

Methods

Neurologists, ENT physicians, and GPs were invited to complete a written questionnaire focused on diagnostic and therapeutic practices related to BPPV. Between-group differences and associations between responses were analyzed statistically.

Results

In total, 97 neurologists, 85 ENT physicians and 142 GPs (21.1%, 26.8%, and 5.7%, respectively, of all corresponding licensed Lithuanian physicians) completed the questionnaire. 24% of neurologists, 33% ENT physicians and 50% GPs do not perform diagnostic maneuvers for patients with suspected BPPV, and 28%, 61%, and 84%, respectively, do not perform CRPs. Years of clinical experience was a negative predictor of CRP performance [OR 0.97 (95% CI 0.95–0.99), p = 0.001]. Frequent reasons for not performing CRPs were time taken for the procedure, fear of provoking symptoms, and lack of knowledge. All physicians frequently ordered additional imaging or consultations for suspected BPPV and reported prescribing a range of medications.

Conclusions

A significant proportion of Lithuanian neurologists, ENT physicians, and GPs do not employ diagnostic maneuvers and CRPs for BPPV patients, contrary to established guidelines. Lack of expertise and time available is a common culprit that leads to unnecessary drug prescribing and investigation.

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Conceptions of Learning and Thinking Styles Among Deaf, Hard-of-Hearing, and Hearing Students

This study explores how students ' conceptions of learning relate to their thinking styles by administering the Conceptions of Learning Inventory III and the Thinking Styles Inventory-Revised II to 350 deaf or hard-of-hearing (DHH) and 463 hearing university students in mainland China. The reliabilities for the two inventories we re first estimated using Cronbach's alpha coefficients. Then, confirmatory factor analysis (CFA) was conducted to test the validity of the COL-III. Finally, to predict thinking styles from conceptions of learning, hierarchical multiple regressions were conducted. Results showed that, among both DH H and hearing students, qualitative conceptions of learning (understanding,personal change,continuous,social competence, andduty) were significantly positively assoc...

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The Design of Low-Power 16-Band Nonuniform Filter Bank for Hearing Aids

A computationally efficient, low-power (107.6 $mu$W@1.1 V), small core area (2.82 $text{mm}^2$@0.35 $ mu$m), 16-band nonuniformly spaced digital filter bank with stop-band attenuation of more than 60 dB is designed and implemented for hearing aid applications using a 0.35 $ mu$m CMOS process. The low computational complexity of the filter bank is achieved using a frequency response masking technique with multiple band-edge shaping filters. The proposed filter bank yields significant improvements in both power consumption and group delay. By coefficient sharing scheme, the implementation of such a filter bank requires only three multipliers. (Source: IEEE Transactions on Biomedical Circuits and Systems)

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Smartphone-Based Hearing Self-Assessment System Using Hearing Aids With Fast Audiometry Method

The objective measurement of the demo system verifies the precision of the sound level within a variation less than 0.5 dB HL for all six frequency bands. The subjective test with 20 samples with different levels of hearing loss in a sound-proof booth indicates that the SHSA system has an average difference of less than 6 dB HL for different hearing-loss severity, and is capable of saving more than 50% hearing test time on average compared to the conventional hearing test. (Source: IEEE Transactions on Biomedical Circuits and Systems)

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New Insights into the Utility of Omalizumab

(Source: Journal of Allergy and Clinical Immunology)

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New Insights into the Utility of Omalizumab

(Source: Journal of Allergy and Clinical Immunology)

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Transarterial radioembolization in patients with hepatocellular carcinoma of intermediate B2 substage

Abstract

Purpose

Patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B according to the Barcelona Clinic Liver Cancer classification) are a heterogeneous group with different degrees of liver function impairment and tumour burden. The recommended treatment is transarterial chemoembolization (TACE). However, patients in this group may be judged as poor candidates for TACE because the risk-benefit ratio is low. Such patients may receive transarterial radioembolization (TARE) only by entering a clinical trial. Experts have proposed that the stage could be further divided into four substages based on available evidence of treatment benefit. We report here, for the first time, the outcome in patients with BCLC-B2 substage HCC treated with TARE.

Methods

A retrospective analysis of the survival of 126 patients with BCLC-B2 substage HCC treated with TARE in three European hospitals was performed.

Results

Overall median survival in patients with BCLC-B2 substage was not significantly different in relation to tumour characteristics; 19.35 months (95% CI 8.27–30.42 months) in patients with a single large (>7 cm) HCC, and 18.43 months (95% CI 15.08–21.77 months) in patients with multinodular HCC (p = 0.27). However, there was a higher proportion of long-term survivors at 36 months among those with a single large tumour (29%) than among those with multiple tumours (16.8%).

Conclusion

Given the poor efficacy of TACE in treating patients with BCLC-B2 substage HCC, TARE treatment could be a better choice, especially in those with a large tumour.

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Comparison of 18 F-GE-180 and dynamic 18 F-FET PET in high grade glioma: a double-tracer pilot study

Abstract

Background

PET represents a valuable tool for glioma imaging. In addition to amino acid tracers such as ¹⁸F-FET, PET targeting the 18-kDa mitochondrial translocator-protein (TSPO) is of high interest for high-grade glioma (HGG) imaging due to its upregulation in HGG cells. ¹⁸F-GE-180, a novel TSPO ligand, has shown a high target-to-background contrast in HGG. Therefore, we intra-individually compared its uptake characteristics to dynamic ¹⁸F-FET PET and contrast-enhanced MRI in patients with HGG.

Methods

Twenty HGG patients (nine IDH-wildtype, 11 IDH-mutant) at initial diagnosis (n = 8) or recurrence (n = 12) were consecutively included and underwent ¹⁸F-GE-180 PET, dynamic ¹⁸F-FET PET, and MRI. The maximal tumour-to-background ratios (TBR_max) and biological tumour volumes (BTV) were evaluated in ¹⁸F-GE-180 and ¹⁸F-FET PET. Dynamic ¹⁸F-FET PET analysis included the evaluation of minimal time-to-peak (TTP_min). In MRI, the volume of contrast-enhancement was delineated (VOL_CE). Volumes were spatially correlated using the Sørensen–Dice coefficient.

Results

The median TBR_max tended to be higher in ¹⁸F-GE-180 PET compared to ¹⁸F-FET PET [4.58 (2.33–8.95) vs 3.89 (1.56–7.15); p = 0.062] in the overall group. In subgroup analyses, IDH-wildtype gliomas showed a significantly higher median TBR_max in ¹⁸F-GE-180 PET compared to ¹⁸F-FET PET [5.45 (2.56–8.95) vs 4.06 (1.56–4.48); p = 0.008]; by contrast, no significant difference was observed in IDH-mutant gliomas [3.97 (2.33–6.81) vs 3.79 (2.01–7.15) p = 1.000]. Only 5/20 cases showed higher TBR_max in ¹⁸F-FET PET compared to ¹⁸F-GE-180 PET, all of them being IDH-mutant gliomas. No parameter in ¹⁸F-GE-180 PET correlated with TTP_min (p > 0.05 each). There was a tendency towards higher median BTV_GE-180 [32.1 (0.4–236.0) ml] compared to BTV_FET [19.3 (0.7–150.2) ml; p = 0.062] with a moderate spatial overlap [median Sørensen–Dice coefficient 0.55 (0.07–0.85)]. In MRI, median VOL_CE [9.7 (0.1–72.5) ml] was significantly smaller than both BTV_FET and BTV_GE180 (p < 0.001 each), leading to a poor spatial correlation with BTV_GE-180 [0.29 (0.01–0.48)] and BTV_FET [0.38 (0.01–0.68)].

Conclusion

PET with ¹⁸F-GE-180 and ¹⁸F-FET provides differing imaging information in HGG dependent on the IDH-mutational status, with diverging spatial overlap and vast exceedance of contrast-enhancement in MRI. Combined PET imaging might reveal new insights regarding non-invasive characterization of tumour heterogeneity and might influence patients' management.

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Diagnostic performance of choline PET for detection of hyperfunctioning parathyroid glands in hyperparathyroidism: a systematic review and meta-analysis

Abstract

Purpose

Hyperparathyroidism (HPT) is a common endocrine disorder caused by hyperfunctioning parathyroid glands (HP). The correct detection and localization of HP is challenging but crucial, as it may guide surgical treatment, particularly in patients with primary HPT. There is a growing body of data regarding the role of radiolabelled choline positron emission tomography (PET) in this setting. Therefore, we performed a systematic review and meta-analysis of the diagnostic performance of this method in detecting HP in patients with HPT.

Methods

This systematic review and meta-analysis was carried out according to PRISMA guidelines. A comprehensive computer literature search of PubMed/MEDLINE, EMBASE and Cochrane Library databases for studies published through May 2018 was performed using the following search algorithm: (a) "choline" or "fluorocholine" or "F-choline" or "C-choline" or "FCH" or "CH" or "FECH" or "FMCH" and (b) "PET" or "positron emission tomography" and (c) "parathyroid" or "hyperparathyroidism". The diagnostic performance of radiolabelled choline PET was expressed as sensitivity and positive predictive value (PPV) on a per-patient and per-lesion basis and as detection rate (DR) on a per-patient basis, with pooled proportion and 95% confidence interval (95% CI) obtained using a random-effects model.

Results

Eighteen studies were included in the systematic review. Fourteen articles (517 patients) were selected for the meta-analysis. The meta-analysis provided the following results on a per-patient analysis analysis: sensitivity 95% (95% CI: 92–97%), PPV 97% (95% CI: 95–98%) and DR 91% (95% CI: 87–94%). On a per-lesion analysis, pooled sensitivity and PPV were 92% (95% CI: 88–96) and 92% (95% CI: 89–95%), respectively. No significant heterogeneity was found among the selected studies.

Conclusions

Radiolabelled choline PET demonstrated excellent diagnostic performance in detecting HP in patients with HPT. Large multicentre studies and cost-effectiveness analyses are needed to better define the role of this imaging method in this setting.

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Regulation of human brown adipose tissue by adenosine and A 2A receptors – studies with [ 15 O]H 2 O and [ 11 C]TMSX PET/CT

Abstract

Purpose

Brown adipose tissue (BAT) has emerged as a potential target to combat obesity and diabetes, but novel strategies to activate BAT are needed. Adenosine and A_2A receptor (A2AR) agonism activate BAT in rodents, and endogenous adenosine is released locally in BAT as a by-product of noradrenaline, but physiological data from humans is lacking. The purpose of this pilot study was to investigate the effects of exogenous adenosine on human BAT perfusion, and to determine the density of A2ARs in human BAT in vivo for the first time, using PET/CT imaging.

Methods

Healthy, lean men (n = 10) participated in PET/CT imaging with two radioligands. Perfusion of BAT, white adipose tissue (WAT) and muscle was quantified with [¹⁵O]H₂O at baseline, during cold exposure and during intravenous administration of adenosine. A2AR density of the tissues was quantified with [¹¹C]TMSX at baseline and during cold exposure.

Results

Adenosine increased the perfusion of BAT even more than cold exposure (baseline 8.3 ± 4.5, cold 19.6 ± 9.3, adenosine 28.6 ± 7.9 ml/100 g/min, p < 0.01). Distribution volume of [¹¹C]TMSX in BAT was significantly lower during cold exposure compared to baseline. In cold, low [¹¹C]TMSX binding coincided with high concentrations of noradrenaline.

Conclusions

Adenosine administration caused a maximal perfusion effect in human supraclavicular BAT, indicating increased oxidative metabolism. Cold exposure increased noradrenaline concentrations and decreased the density of A2AR available for radioligand binding in BAT, suggesting augmented release of endogenous adenosine. Our results show that adenosine and A2AR are relevant for activation of human BAT, and A2AR provides a future target for enhancing BAT metabolism.

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Highly favourable outcomes with peptide receptor radionuclide therapy (PRRT) for metastatic rectal neuroendocrine neoplasia (NEN)

Abstract

Purpose

Rectal neuroendocrine neoplasia (NEN) is more common than other NEN origins, but is less commonly metastatic. However, when present, distant disease carries a particularly poor prognosis. Evidence guiding optimal treatment of such patients is lacking. We assessed PRRT outcomes in patients with somatostatin receptor (SSTR) positive metastatic rectal NEN from two referral centres.

Methods

Patients treated with PRRT were retrospectively reviewed. Morphologic (RECIST 1.1), SSTR imaging responses and toxicity were assessed 3 months post-PRRT. Kaplan-Meier estimate was used to determine progression-free survival (PFS) and overall survival (OS) from start of PRRT.

Results

Twenty-seven consecutive patients (M = 20, age 31-81 years) were reviewed. The majority (70%) had ENETs grade 2 disease (19 patients), three had Grade 3, one Grade 1, and four not documented. Overall, 63% (10/16 patients with available FDG PET/CT) had FDG avid disease. Twenty-six patients were treated for disease progression. Most had ¹⁷⁷Lu-DOTA-octreotate with median cumulative activity of 30 GBq, median four cycles. 14 patients had radiosensitising chemotherapy (5FU or capecitabine). At 3 months post-PRRT, CT disease control rate (DCR) was 96%: partial response was observed in 70% (19/27) and stable disease in 26%. All but one had partial SSTR imaging response. The median PFS was 29 months. Ten patients died, with median overall survival 81 months with a median follow-up of 67 months. Seventeen patients had further treatments after initial PRRT (10 had further cycles of PRRT). Three patients had grade 3 lymphopenia, without significant renal toxicity, MDS or leukaemia.

Conclusion

Our results indicate high efficacy and morphologic responses with minimal toxicity and very encouraging survival from PRRT in patients with metastatic rectal NEN despite the adverse prognostic features of this cohort. Further prospective PRRT trials are warranted in this subgroup.

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Bombardieri E, Seregni E, Evangelista L, Chiesa C, Chiti A (Eds.) Clinical Applications of Nuclear Medicine Targeted Therapy. Springer International Publishing Switzerland 2018. ISBN 978-3-319-63067-0

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FET PET reveals considerable spatial differences in tumour burden compared to conventional MRI in newly diagnosed glioblastoma

Abstract

Purpose

Areas of contrast enhancement (CE) on MRI are usually the target for resection or radiotherapy target volume definition in glioblastomas. However, the solid tumour mass may extend beyond areas of CE. Amino acid PET can detect parts of the tumour that show no CE. We systematically investigated tumour volumes delineated by amino acid PET and MRI in patients with newly diagnosed, untreated glioblastoma.

Methods

Preoperatively, 50 patients with neuropathologically confirmed glioblastoma underwent O-(2-[¹⁸F]-fluoroethyl)-l-tyrosine (FET) PET, and fluid-attenuated inversion recovery (FLAIR) and contrast-enhanced MRI. Areas of CE were manually segmented. FET PET tumour volumes were segmented using a tumour-to-brain ratio of ≥1.6. The percentage overlap volumes, and Dice and Jaccard spatial similarity coefficients (DSC, JSC) were calculated. FLAIR images were evaluated visually.

Results

In 43 patients (86%), the FET tumour volume was significantly larger than the CE volume (21.5 ± 14.3 mL vs. 9.4 ± 11.3 mL; P < 0.001). Forty patients (80%) showed both increased uptake of FET and CE. In these 40 patients, the spatial similarity between FET uptake and CE was low (mean DSC 0.39 ± 0.21, mean JSC 0.26 ± 0.16). Ten patients (20%) showed no CE, and one of these patients showed no FET uptake. In five patients (10%), increased FET uptake was present outside areas of FLAIR hyperintensity.

Conclusion

Our results show that the metabolically active tumour volume delineated by FET PET is significantly larger than tumour volume delineated by CE. Furthermore, the results strongly suggest that the information derived from both imaging modalities should be integrated into the management of patients with newly diagnosed glioblastoma.

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Comprehensive anatomical and functional imaging in patients with type I neurofibromatosis using simultaneous FDG-PET/MRI

Abstract

Purpose

To demonstrate the clinical use of FDG-PET/MRI for monitoring enlargement and metabolism of plexiform neurofibromas (PNF) in patients with neurofibromatosis type 1 (NF1), in whom the development of a malignant peripheral nerve sheath tumor (MPNST) is often a life limiting event.

Methods

NF1 patients who underwent a simultaneous FDG-PET/MRI examination in our institution from September 2012 to February 2018 were included. Indication was suspicion of malignant transformation of a PNF to MPNST. A maximum of six peripheral nerve lesions per patient were defined as targets. Standardized uptake values (SUV) and apparent diffusion coefficients (ADC) were measured. The presence of target sign and contrast-medium enhancement was visually recorded. Growth rates were estimated comparing prior or follow-up examinations and correlated with FDG uptake and ADC values. The presence of CNS lesions in cerebral T2 weighted images was recorded.

Results

In 28 NF1 patients a total number of 83 peripheral nerve tumors, 75 benign PNFs and eight MPNSTs, were selected as target lesions. The SUVs of MPNSTs were significantly higher than the SUVs of PNF (3.84 ± 3.98 [SUV_mean MPNSTs] vs. 1.85 ± 1.03 [SUV_mean PNF], P < .01). Similarly, lesion SUV_mean-to-liver SUV_mean ratios significantly differed between MPNSTs and PNF (3.20 ± 2.70 [MPNSTs] vs. 1.23 ± 0.61 [PNF]; P < .01). For differentiation between still benign PNF and MPNSTs, we defined SUV_max ≥ 2.78 as a significant cut-off value. Growth rate of PNF correlated significantly positively with SUV_mean (r_s = .41; P = .003). MRI parameters like ADC_mean (1.87 ± 0.24 × 10⁻³ mm²/s [PNF] vs. 1.76 ± 0.11 × 10⁻³ mm²/s [MPNSTs]; P > .05], contrast medium enhancement (P = .50) and target sign (P = .86) did not differ between groups.

Conclusion

Simultaneous FDG-PET/MRI is a comprehensive imaging modality for monitoring PNF in NF1 patients. The combined acquisition of both morphologic information in MRI and metabolic information in PET enables the correlation of lesion growth rates with metabolic activity and to define SUV thresholds of significance to identify malignant transformation, which is of utmost clinical significance.

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The EANM practical guidelines for sentinel lymph node localisation in oral cavity squamous cell carcinoma

Abstract

Purpose

Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized oral cavity squamous cell carcinoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery, and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with early N0 oral cavity squamous cell carcinoma.

Methods

These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) and the International Atomic Energy Agency (IAEA) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, and national nuclear medicine societies. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

These guidelines, together with another two focused on Surgery and Pathology (and published in specialised journals), are part of the synergistic efforts developed in preparation for the "2018 Sentinel Node Biopsy in Head and Neck Consensus Conference".

Conclusion

The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of early N0 oral cavity squamous cell carcinoma patients.

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Additional value of integrated 18 F-choline PET/4D contrast-enhanced CT in the localization of hyperfunctioning parathyroid glands and correlation with molecular profile

Abstract

Purpose

The localization of hyperfunctioning parathyroid gland(s) (HPTG) in patients with primary hyperparathyroidism (PHPT) with negative or inconclusive first-line imaging is a significant challenge. This study aimed to evaluate the role of integrated ¹⁸F-choline PET/4D contrast-enhanced computed tomography (4DCeCT) in these patients, compare its detection rate and sensitivity with those of ¹⁸F-choline PET/CT and (4DCeCT), and analyse the association between choline metabolism and morphological, biochemical and molecular parameters of HPTG.

Methods

We prospectively enrolled 44 PHPT patients with negative or inconclusive first-line imaging. ¹⁸F-Choline PET/CT and 4DCeCT were performed at the same time, and integrated ¹⁸F-choline PET/4DCeCT images were obtained after coregistration. Experienced physicians examined the images. The SUVratio and degree of contrast enhancement were recorded for each positive finding. Histopathology, laboratory and multidisciplinary follow-up were used as the standard of reference. Both the detection rates and sensitivities of the three imaging modalities were calculated retrospectively. Immunohistochemistry was performed to evaluate the molecular profile of HPTGs.

Results

¹⁸F-Choline PET/4DCeCT was positive in 32 of 44 patients with PHPT (detection rate 72.7%), and 31 of 31 surgically treated patients (sensitivity 100%). These results were significantly (p < 0.05) better than those of ¹⁸F-choline PET/CT (56.8% and 80%, respectively) and those of 4DCeCT (54.5 and 74%, respectively). A significant correlation between SUV and calcium level was found. In a multivariate analysis, only calcium level was significantly associated with ¹⁸F-choline PET/4DCeCT findings. SUVratio and Ki67 expression were significantly correlated.

Conclusion

Integrated ¹⁸F-choline PET/4DCeCT should be considered as an effective tool to detect PHPT in patients with negative or inconclusive first-line imaging. Choline metabolism is correlated with both calcium level and Ki67 expression in HPTG.

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Yttrium-90 glass microspheres radioembolization (RE) for biliary tract cancer: a large single-center experience

Abstract

Purpose

Radioembolization (RE) is a promising treatment option for biliary tract cancers (BTC). We report here the largest series to date using this treatment modality.

Methods

We retrospectively studied data from 64 patients treated outside prospective clinical trial at our institution. We studied baseline characteristics as potential prognostic factors. We studied dose delivered to the tumor as predictive factors of outcomes in patients not receiving concomitant chemotherapy.

Results

The Progression-Free Survival and Overall Survival (OS) were 7.6 months [95% Confidence Interval (CI): 4.6–10.6] and 16.4 months [95% CI: 7.8–25.0] in the whole cohort. The factors independently associated with OS in multivariable analysis were the primary localization of ICC (HR = 0.27, 95% CI: 0.11–0.68, p = 0.005) and a PS > 0 (HR = 2.21, 95% CI: 1.11–4.38, p = 0.024). During follow-up, 12 patients (19%) underwent surgery following downstaging, with a median OS of 51.9 months. In patients not treated with concomitant chemotherapy (n = 31), OS was significantly higher in patients with a dose delivered to the tumor 260Gy or higher than in patients with a dose delivered to the tumor lower than 260Gy (median 28.2 vs 11.4 months, log-rank p = 0.019).

Conclusion

Our results confirm that RE is a promising treatment modality in BTC. A high proportion of patients could be downstaged to surgery, with promising long-term survival. Dose delivered to the tumor correlated with clinical outcomes when chemotherapy was not used concomitantly.

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Transarterial radioembolization in patients with hepatocellular carcinoma of intermediate B2 substage

Abstract

Purpose

Patients with hepatocellular carcinoma (HCC) of intermediate stage (BCLC-B according to the Barcelona Clinic Liver Cancer classification) are a heterogeneous group with different degrees of liver function impairment and tumour burden. The recommended treatment is transarterial chemoembolization (TACE). However, patients in this group may be judged as poor candidates for TACE because the risk-benefit ratio is low. Such patients may receive transarterial radioembolization (TARE) only by entering a clinical trial. Experts have proposed that the stage could be further divided into four substages based on available evidence of treatment benefit. We report here, for the first time, the outcome in patients with BCLC-B2 substage HCC treated with TARE.

Methods

A retrospective analysis of the survival of 126 patients with BCLC-B2 substage HCC treated with TARE in three European hospitals was performed.

Results

Overall median survival in patients with BCLC-B2 substage was not significantly different in relation to tumour characteristics; 19.35 months (95% CI 8.27–30.42 months) in patients with a single large (>7 cm) HCC, and 18.43 months (95% CI 15.08–21.77 months) in patients with multinodular HCC (p = 0.27). However, there was a higher proportion of long-term survivors at 36 months among those with a single large tumour (29%) than among those with multiple tumours (16.8%).

Conclusion

Given the poor efficacy of TACE in treating patients with BCLC-B2 substage HCC, TARE treatment could be a better choice, especially in those with a large tumour.

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Comparison of 18 F-GE-180 and dynamic 18 F-FET PET in high grade glioma: a double-tracer pilot study

Abstract

Background

PET represents a valuable tool for glioma imaging. In addition to amino acid tracers such as ¹⁸F-FET, PET targeting the 18-kDa mitochondrial translocator-protein (TSPO) is of high interest for high-grade glioma (HGG) imaging due to its upregulation in HGG cells. ¹⁸F-GE-180, a novel TSPO ligand, has shown a high target-to-background contrast in HGG. Therefore, we intra-individually compared its uptake characteristics to dynamic ¹⁸F-FET PET and contrast-enhanced MRI in patients with HGG.

Methods

Twenty HGG patients (nine IDH-wildtype, 11 IDH-mutant) at initial diagnosis (n = 8) or recurrence (n = 12) were consecutively included and underwent ¹⁸F-GE-180 PET, dynamic ¹⁸F-FET PET, and MRI. The maximal tumour-to-background ratios (TBR_max) and biological tumour volumes (BTV) were evaluated in ¹⁸F-GE-180 and ¹⁸F-FET PET. Dynamic ¹⁸F-FET PET analysis included the evaluation of minimal time-to-peak (TTP_min). In MRI, the volume of contrast-enhancement was delineated (VOL_CE). Volumes were spatially correlated using the Sørensen–Dice coefficient.

Results

The median TBR_max tended to be higher in ¹⁸F-GE-180 PET compared to ¹⁸F-FET PET [4.58 (2.33–8.95) vs 3.89 (1.56–7.15); p = 0.062] in the overall group. In subgroup analyses, IDH-wildtype gliomas showed a significantly higher median TBR_max in ¹⁸F-GE-180 PET compared to ¹⁸F-FET PET [5.45 (2.56–8.95) vs 4.06 (1.56–4.48); p = 0.008]; by contrast, no significant difference was observed in IDH-mutant gliomas [3.97 (2.33–6.81) vs 3.79 (2.01–7.15) p = 1.000]. Only 5/20 cases showed higher TBR_max in ¹⁸F-FET PET compared to ¹⁸F-GE-180 PET, all of them being IDH-mutant gliomas. No parameter in ¹⁸F-GE-180 PET correlated with TTP_min (p > 0.05 each). There was a tendency towards higher median BTV_GE-180 [32.1 (0.4–236.0) ml] compared to BTV_FET [19.3 (0.7–150.2) ml; p = 0.062] with a moderate spatial overlap [median Sørensen–Dice coefficient 0.55 (0.07–0.85)]. In MRI, median VOL_CE [9.7 (0.1–72.5) ml] was significantly smaller than both BTV_FET and BTV_GE180 (p < 0.001 each), leading to a poor spatial correlation with BTV_GE-180 [0.29 (0.01–0.48)] and BTV_FET [0.38 (0.01–0.68)].

Conclusion

PET with ¹⁸F-GE-180 and ¹⁸F-FET provides differing imaging information in HGG dependent on the IDH-mutational status, with diverging spatial overlap and vast exceedance of contrast-enhancement in MRI. Combined PET imaging might reveal new insights regarding non-invasive characterization of tumour heterogeneity and might influence patients' management.

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Christopher E. Comstock, Christiane Kuhl (Eds.): Abbreviated MRI of the Breast: A Practical Guide

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Diagnostic performance of choline PET for detection of hyperfunctioning parathyroid glands in hyperparathyroidism: a systematic review and meta-analysis

Abstract

Purpose

Hyperparathyroidism (HPT) is a common endocrine disorder caused by hyperfunctioning parathyroid glands (HP). The correct detection and localization of HP is challenging but crucial, as it may guide surgical treatment, particularly in patients with primary HPT. There is a growing body of data regarding the role of radiolabelled choline positron emission tomography (PET) in this setting. Therefore, we performed a systematic review and meta-analysis of the diagnostic performance of this method in detecting HP in patients with HPT.

Methods

This systematic review and meta-analysis was carried out according to PRISMA guidelines. A comprehensive computer literature search of PubMed/MEDLINE, EMBASE and Cochrane Library databases for studies published through May 2018 was performed using the following search algorithm: (a) "choline" or "fluorocholine" or "F-choline" or "C-choline" or "FCH" or "CH" or "FECH" or "FMCH" and (b) "PET" or "positron emission tomography" and (c) "parathyroid" or "hyperparathyroidism". The diagnostic performance of radiolabelled choline PET was expressed as sensitivity and positive predictive value (PPV) on a per-patient and per-lesion basis and as detection rate (DR) on a per-patient basis, with pooled proportion and 95% confidence interval (95% CI) obtained using a random-effects model.

Results

Eighteen studies were included in the systematic review. Fourteen articles (517 patients) were selected for the meta-analysis. The meta-analysis provided the following results on a per-patient analysis analysis: sensitivity 95% (95% CI: 92–97%), PPV 97% (95% CI: 95–98%) and DR 91% (95% CI: 87–94%). On a per-lesion analysis, pooled sensitivity and PPV were 92% (95% CI: 88–96) and 92% (95% CI: 89–95%), respectively. No significant heterogeneity was found among the selected studies.

Conclusions

Radiolabelled choline PET demonstrated excellent diagnostic performance in detecting HP in patients with HPT. Large multicentre studies and cost-effectiveness analyses are needed to better define the role of this imaging method in this setting.

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Regulation of human brown adipose tissue by adenosine and A 2A receptors – studies with [ 15 O]H 2 O and [ 11 C]TMSX PET/CT

Abstract

Purpose

Brown adipose tissue (BAT) has emerged as a potential target to combat obesity and diabetes, but novel strategies to activate BAT are needed. Adenosine and A_2A receptor (A2AR) agonism activate BAT in rodents, and endogenous adenosine is released locally in BAT as a by-product of noradrenaline, but physiological data from humans is lacking. The purpose of this pilot study was to investigate the effects of exogenous adenosine on human BAT perfusion, and to determine the density of A2ARs in human BAT in vivo for the first time, using PET/CT imaging.

Methods

Healthy, lean men (n = 10) participated in PET/CT imaging with two radioligands. Perfusion of BAT, white adipose tissue (WAT) and muscle was quantified with [¹⁵O]H₂O at baseline, during cold exposure and during intravenous administration of adenosine. A2AR density of the tissues was quantified with [¹¹C]TMSX at baseline and during cold exposure.

Results

Adenosine increased the perfusion of BAT even more than cold exposure (baseline 8.3 ± 4.5, cold 19.6 ± 9.3, adenosine 28.6 ± 7.9 ml/100 g/min, p < 0.01). Distribution volume of [¹¹C]TMSX in BAT was significantly lower during cold exposure compared to baseline. In cold, low [¹¹C]TMSX binding coincided with high concentrations of noradrenaline.

Conclusions

Adenosine administration caused a maximal perfusion effect in human supraclavicular BAT, indicating increased oxidative metabolism. Cold exposure increased noradrenaline concentrations and decreased the density of A2AR available for radioligand binding in BAT, suggesting augmented release of endogenous adenosine. Our results show that adenosine and A2AR are relevant for activation of human BAT, and A2AR provides a future target for enhancing BAT metabolism.

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Ectopic corticotropin-releasing hormone syndrome caused by pancreatic neuroendocrine tumor localized by 68 Ga-DOTATATE PET/CT

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Highly favourable outcomes with peptide receptor radionuclide therapy (PRRT) for metastatic rectal neuroendocrine neoplasia (NEN)

Abstract

Purpose

Rectal neuroendocrine neoplasia (NEN) is more common than other NEN origins, but is less commonly metastatic. However, when present, distant disease carries a particularly poor prognosis. Evidence guiding optimal treatment of such patients is lacking. We assessed PRRT outcomes in patients with somatostatin receptor (SSTR) positive metastatic rectal NEN from two referral centres.

Methods

Patients treated with PRRT were retrospectively reviewed. Morphologic (RECIST 1.1), SSTR imaging responses and toxicity were assessed 3 months post-PRRT. Kaplan-Meier estimate was used to determine progression-free survival (PFS) and overall survival (OS) from start of PRRT.

Results

Twenty-seven consecutive patients (M = 20, age 31-81 years) were reviewed. The majority (70%) had ENETs grade 2 disease (19 patients), three had Grade 3, one Grade 1, and four not documented. Overall, 63% (10/16 patients with available FDG PET/CT) had FDG avid disease. Twenty-six patients were treated for disease progression. Most had ¹⁷⁷Lu-DOTA-octreotate with median cumulative activity of 30 GBq, median four cycles. 14 patients had radiosensitising chemotherapy (5FU or capecitabine). At 3 months post-PRRT, CT disease control rate (DCR) was 96%: partial response was observed in 70% (19/27) and stable disease in 26%. All but one had partial SSTR imaging response. The median PFS was 29 months. Ten patients died, with median overall survival 81 months with a median follow-up of 67 months. Seventeen patients had further treatments after initial PRRT (10 had further cycles of PRRT). Three patients had grade 3 lymphopenia, without significant renal toxicity, MDS or leukaemia.

Conclusion

Our results indicate high efficacy and morphologic responses with minimal toxicity and very encouraging survival from PRRT in patients with metastatic rectal NEN despite the adverse prognostic features of this cohort. Further prospective PRRT trials are warranted in this subgroup.

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Treatment of aggressive recurrent meningiomas: spinning towards peptide receptor radionuclide therapy

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Bombardieri E, Seregni E, Evangelista L, Chiesa C, Chiti A (Eds.) Clinical Applications of Nuclear Medicine Targeted Therapy. Springer International Publishing Switzerland 2018. ISBN 978-3-319-63067-0

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Safety and efficacy of targeted alpha therapy with 213 Bi-DOTA-substance P in recurrent glioblastoma

Abstract

Treatment options for recurrent glioblastoma multiforme (GBM) are very limited. GBM cells express high levels of the GPCR neurokinin type 1 receptor (NK-1R), and a modified substance P can be used as its ligand for the tumor cell targeting. Targeted alpha therapy with DOTA-Substance P labeled with the short range alpha emitter ²¹³Bi allows for selective irradiation and killing of tumor cells.

Material and methods

Twenty patients with recurrent GBM were included into the study following a standard therapy. 1–2 intracavitary or intratumoral port-a-cath systems were stereotactically inserted. Patients were treated with 1–7 doses of ²¹³Bi-DOTA-Substance P (²¹³Bi-DOTA-SP) in 2-month intervals. ⁶⁸Ga-DOTA-Substance P (⁶⁸Ga-DOTA-SP) was co-injected with ²¹³Bi-DOTA-SP to assess the biodistribution using PET/CT. Therapeutic response was monitored with performance status and MRI imaging.

Results

Treatment with activity up to 11.2 GBq ²¹³Bi-DOTA-SP was well tolerated with only mild and transient adverse reactions. The median progression free survival was 2.7 months. The median overall survival from the first diagnosis was 23.6 months and median survival after recurrence was 10.9 months. The median survival time from the start of ²¹³Bi-DOTA-SP was 7.5 months.

Conclusions

Treatment of recurrent GBM with ²¹³Bi-DOTA-SP is safe and well tolerated. The median overall survival after recurrence of 10.9 months compares favorably to the available alternative treatment options. Once the supply of high activity ²²⁵Ac/²¹³Bi radionuclide generators is secured, targeted alpha therapy with ²¹³Bi-DOTA-SP may evolve as a promising novel option to treat recurrent GBM.

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FET PET reveals considerable spatial differences in tumour burden compared to conventional MRI in newly diagnosed glioblastoma

Abstract

Purpose

Areas of contrast enhancement (CE) on MRI are usually the target for resection or radiotherapy target volume definition in glioblastomas. However, the solid tumour mass may extend beyond areas of CE. Amino acid PET can detect parts of the tumour that show no CE. We systematically investigated tumour volumes delineated by amino acid PET and MRI in patients with newly diagnosed, untreated glioblastoma.

Methods

Preoperatively, 50 patients with neuropathologically confirmed glioblastoma underwent O-(2-[¹⁸F]-fluoroethyl)-l-tyrosine (FET) PET, and fluid-attenuated inversion recovery (FLAIR) and contrast-enhanced MRI. Areas of CE were manually segmented. FET PET tumour volumes were segmented using a tumour-to-brain ratio of ≥1.6. The percentage overlap volumes, and Dice and Jaccard spatial similarity coefficients (DSC, JSC) were calculated. FLAIR images were evaluated visually.

Results

In 43 patients (86%), the FET tumour volume was significantly larger than the CE volume (21.5 ± 14.3 mL vs. 9.4 ± 11.3 mL; P < 0.001). Forty patients (80%) showed both increased uptake of FET and CE. In these 40 patients, the spatial similarity between FET uptake and CE was low (mean DSC 0.39 ± 0.21, mean JSC 0.26 ± 0.16). Ten patients (20%) showed no CE, and one of these patients showed no FET uptake. In five patients (10%), increased FET uptake was present outside areas of FLAIR hyperintensity.

Conclusion

Our results show that the metabolically active tumour volume delineated by FET PET is significantly larger than tumour volume delineated by CE. Furthermore, the results strongly suggest that the information derived from both imaging modalities should be integrated into the management of patients with newly diagnosed glioblastoma.

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Personalized 177 Lu-octreotate peptide receptor radionuclide therapy of neuroendocrine tumours: initial results from the P-PRRT trial

Abstract

Purpose

Peptide receptor radionuclide therapy (PRRT) is mostly administered using a fixed injected activity (IA) per cycle. This empiric regime results in highly variable absorbed doses to the critical organs and undertreatment of the majority of patients. We conceived a personalized PRRT protocol in which the IA is adjusted to deliver a prescribed absorbed dose to the kidney, with the aim to safely increase tumour irradiation. We herein report on the initial results of our prospective study of personalized PRRT, the P-PRRT Trial (NCT02754297).

Methods

PRRT-naïve patients with progressive and/or symptomatic neuroendocrine tumour (NET) were scheduled to receive a four-cycle induction course of ¹⁷⁷Lu-octreotate with quantitative SPECT/CT-based dosimetry. The IA was personalized according to the glomerular filtration rate and the body surface area for the first cycle, and according to the prior renal Gy/GBq for the subsequent cycles. The prescribed renal absorbed dose of 23 Gy was reduced by 25–50% in case of significant renal or haematological impairment. Responders were allowed to receive consolidation or maintenance cycles, for each of which 6 Gy to the kidney were prescribed. We simulated the empiric PRRT regime by fixing the IA at 7.4 GBq per cycle, with the same percentage reductions as above. Radiological, molecular imaging, biochemical, and quality of life responses, as well as safety, were assessed.

Results

Fifty-two patients underwent 171 cycles. In 34 patients who completed the induction course, a median cumulative IA of 36.1 (range, 6.3–78.6) GBq was administered, and the median cumulative kidney and maximum tumour absorbed doses were 22.1 (range, 8.3–24.3) Gy and 185.7 (range: 15.2–443.1) Gy respectively. Compared with the simulated fixed-IA induction regime, there was a median 1.26-fold increase (range, 0.47–2.12 fold) in the cumulative maximum tumour absorbed dose, which was higher in 85.3% of patients. In 39 assessable patients, the best objective response was partial response in nine (23.1%), minor response in 14 (35.9%), stable disease in 13 (33.3%) and progressive disease in three patients (7.7%). In particular, 11 of 13 patients (84.6%) with pancreatic NET had partial or minor response. The global health status/quality of life score significantly increased in 50% of patients. Acute and subacute side-effects were all of grade 1 or 2, and the most common were nausea (in 32.7% of patients) and fatigue (in 30.8% of patients) respectively. Subacute grade 3 or 4 toxicities occurred in less than 10% of patients, with the exception of lymphocytopenia in 51.9% of patients, without any clinical consequences however. No patient experienced severe renal toxicity.

Conclusions

Personalized PRRT makes it possible to safely increase tumour irradiation in the majority of patients. Our first results indicate a favourable tolerance profile, which appears similar to that of the empiric regime. The response rates are promising, in particular in patients with NET of pancreatic origin.

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Comprehensive anatomical and functional imaging in patients with type I neurofibromatosis using simultaneous FDG-PET/MRI

Abstract

Purpose

To demonstrate the clinical use of FDG-PET/MRI for monitoring enlargement and metabolism of plexiform neurofibromas (PNF) in patients with neurofibromatosis type 1 (NF1), in whom the development of a malignant peripheral nerve sheath tumor (MPNST) is often a life limiting event.

Methods

NF1 patients who underwent a simultaneous FDG-PET/MRI examination in our institution from September 2012 to February 2018 were included. Indication was suspicion of malignant transformation of a PNF to MPNST. A maximum of six peripheral nerve lesions per patient were defined as targets. Standardized uptake values (SUV) and apparent diffusion coefficients (ADC) were measured. The presence of target sign and contrast-medium enhancement was visually recorded. Growth rates were estimated comparing prior or follow-up examinations and correlated with FDG uptake and ADC values. The presence of CNS lesions in cerebral T2 weighted images was recorded.

Results

In 28 NF1 patients a total number of 83 peripheral nerve tumors, 75 benign PNFs and eight MPNSTs, were selected as target lesions. The SUVs of MPNSTs were significantly higher than the SUVs of PNF (3.84 ± 3.98 [SUV_mean MPNSTs] vs. 1.85 ± 1.03 [SUV_mean PNF], P < .01). Similarly, lesion SUV_mean-to-liver SUV_mean ratios significantly differed between MPNSTs and PNF (3.20 ± 2.70 [MPNSTs] vs. 1.23 ± 0.61 [PNF]; P < .01). For differentiation between still benign PNF and MPNSTs, we defined SUV_max ≥ 2.78 as a significant cut-off value. Growth rate of PNF correlated significantly positively with SUV_mean (r_s = .41; P = .003). MRI parameters like ADC_mean (1.87 ± 0.24 × 10⁻³ mm²/s [PNF] vs. 1.76 ± 0.11 × 10⁻³ mm²/s [MPNSTs]; P > .05], contrast medium enhancement (P = .50) and target sign (P = .86) did not differ between groups.

Conclusion

Simultaneous FDG-PET/MRI is a comprehensive imaging modality for monitoring PNF in NF1 patients. The combined acquisition of both morphologic information in MRI and metabolic information in PET enables the correlation of lesion growth rates with metabolic activity and to define SUV thresholds of significance to identify malignant transformation, which is of utmost clinical significance.

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The EANM practical guidelines for sentinel lymph node localisation in oral cavity squamous cell carcinoma

Abstract

Purpose

Sentinel lymph node biopsy is an essential staging tool in patients with clinically localized oral cavity squamous cell carcinoma. The harvesting of a sentinel lymph node entails a sequence of procedures with participation of specialists in nuclear medicine, radiology, surgery, and pathology. The aim of this document is to provide guidelines for nuclear medicine physicians performing lymphoscintigraphy for sentinel lymph node detection in patients with early N0 oral cavity squamous cell carcinoma.

Methods

These practice guidelines were written and have been approved by the European Association of Nuclear Medicine (EANM) and the International Atomic Energy Agency (IAEA) to promote high-quality lymphoscintigraphy. The final result has been discussed by distinguished experts from the EANM Oncology Committee, and national nuclear medicine societies. The document has been endorsed by the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

These guidelines, together with another two focused on Surgery and Pathology (and published in specialised journals), are part of the synergistic efforts developed in preparation for the "2018 Sentinel Node Biopsy in Head and Neck Consensus Conference".

Conclusion

The present practice guidelines will help nuclear medicine practitioners play their essential role in providing high-quality lymphatic mapping for the care of early N0 oral cavity squamous cell carcinoma patients.

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Additional value of integrated 18 F-choline PET/4D contrast-enhanced CT in the localization of hyperfunctioning parathyroid glands and correlation with molecular profile

Abstract

Purpose

The localization of hyperfunctioning parathyroid gland(s) (HPTG) in patients with primary hyperparathyroidism (PHPT) with negative or inconclusive first-line imaging is a significant challenge. This study aimed to evaluate the role of integrated ¹⁸F-choline PET/4D contrast-enhanced computed tomography (4DCeCT) in these patients, compare its detection rate and sensitivity with those of ¹⁸F-choline PET/CT and (4DCeCT), and analyse the association between choline metabolism and morphological, biochemical and molecular parameters of HPTG.

Methods

We prospectively enrolled 44 PHPT patients with negative or inconclusive first-line imaging. ¹⁸F-Choline PET/CT and 4DCeCT were performed at the same time, and integrated ¹⁸F-choline PET/4DCeCT images were obtained after coregistration. Experienced physicians examined the images. The SUVratio and degree of contrast enhancement were recorded for each positive finding. Histopathology, laboratory and multidisciplinary follow-up were used as the standard of reference. Both the detection rates and sensitivities of the three imaging modalities were calculated retrospectively. Immunohistochemistry was performed to evaluate the molecular profile of HPTGs.

Results

¹⁸F-Choline PET/4DCeCT was positive in 32 of 44 patients with PHPT (detection rate 72.7%), and 31 of 31 surgically treated patients (sensitivity 100%). These results were significantly (p < 0.05) better than those of ¹⁸F-choline PET/CT (56.8% and 80%, respectively) and those of 4DCeCT (54.5 and 74%, respectively). A significant correlation between SUV and calcium level was found. In a multivariate analysis, only calcium level was significantly associated with ¹⁸F-choline PET/4DCeCT findings. SUVratio and Ki67 expression were significantly correlated.

Conclusion

Integrated ¹⁸F-choline PET/4DCeCT should be considered as an effective tool to detect PHPT in patients with negative or inconclusive first-line imaging. Choline metabolism is correlated with both calcium level and Ki67 expression in HPTG.

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Yttrium-90 glass microspheres radioembolization (RE) for biliary tract cancer: a large single-center experience

Abstract

Purpose

Radioembolization (RE) is a promising treatment option for biliary tract cancers (BTC). We report here the largest series to date using this treatment modality.

Methods

We retrospectively studied data from 64 patients treated outside prospective clinical trial at our institution. We studied baseline characteristics as potential prognostic factors. We studied dose delivered to the tumor as predictive factors of outcomes in patients not receiving concomitant chemotherapy.

Results

The Progression-Free Survival and Overall Survival (OS) were 7.6 months [95% Confidence Interval (CI): 4.6–10.6] and 16.4 months [95% CI: 7.8–25.0] in the whole cohort. The factors independently associated with OS in multivariable analysis were the primary localization of ICC (HR = 0.27, 95% CI: 0.11–0.68, p = 0.005) and a PS > 0 (HR = 2.21, 95% CI: 1.11–4.38, p = 0.024). During follow-up, 12 patients (19%) underwent surgery following downstaging, with a median OS of 51.9 months. In patients not treated with concomitant chemotherapy (n = 31), OS was significantly higher in patients with a dose delivered to the tumor 260Gy or higher than in patients with a dose delivered to the tumor lower than 260Gy (median 28.2 vs 11.4 months, log-rank p = 0.019).

Conclusion

Our results confirm that RE is a promising treatment modality in BTC. A high proportion of patients could be downstaged to surgery, with promising long-term survival. Dose delivered to the tumor correlated with clinical outcomes when chemotherapy was not used concomitantly.

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Supernumerary incisive canals in a cadaver: a rare anatomical variation

Abstract

We present a rare anatomical variation in which an additional incisive canal was observed during the routine dissection of the palatal region in a cadaver. The diameter of the incisive and additional incisive canals measured 4.59 mm and 0.91 mm, respectively. Even though this variation is rare, oral surgeons should be aware of such anatomical variations for a better understanding.

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Supernumerary incisive canals in a cadaver: a rare anatomical variation

Abstract

We present a rare anatomical variation in which an additional incisive canal was observed during the routine dissection of the palatal region in a cadaver. The diameter of the incisive and additional incisive canals measured 4.59 mm and 0.91 mm, respectively. Even though this variation is rare, oral surgeons should be aware of such anatomical variations for a better understanding.

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Ultrashort Time to Echo Magnetic Resonance Evaluation of Calcium Pyrophosphate Crystal Deposition in Human Menisci

Objectives In human menisci, we aimed to investigate whether calcium pyrophosphate crystal deposition (CPPD) affects biomechanical and quantitative MR properties, and their zonal distribution. Materials and Methods From 9 cadaveric knees, sectioned triangular meniscus pieces were harvested. Samples were classified into "normal" or "CPPD" groups based upon visual inspection. Micro computed tomography scan verified CPPD. Using magnetic resonance imaging, ultrashort echo time (UTE) T2* and spin echo (SE) T2, quantitative values in 3 zones (red, red-white, and white) were determined. Using biomechanical test, indentation forces in the same zones were determined. Effects of CPPD and meniscal zone on indentation force and quantitative MR values were compared. Results On UTE MRI scans, CPPD-affected menisci exhibited punctate dark regions, found mostly (92%) in avascular white and red-white zones. Indentation forces were significantly higher for CPPD samples in the red-white (all P 0.2). Similarly, UTE T2* red zone values were similar between both groups (~6.6 milliseconds, P = 0.8), whereas in the red-white and white zones, CPPD samples had significantly lower values (~5.1 milliseconds, P = 0.005 to 0.007). In contrast, SE T2 values showed no difference with CPPD (P = 0.12 to 0.16). UTE T2*, but not SE T2, correlated significantly with indentation force (R = −0.29, P = 0.009). Conclusions Dark CPP deposits were detectable on UTE images featuring high signal intensity from surrounding meniscal tissue. Preliminary results indicate that CPP deposits were almost exclusively found in the avascular zones. Compared with normal, CPPD menisci featured higher indentation stiffness and lower UTE T2* values in the affected zones. Received for publication November 6, 2018; and accepted for publication, after revision, December 18, 2018. Conflicts of interest and sources of funding: The study was funded by grants from VA (I01 CX000625) and NIH NIAMS (R01 AR064321) in support of Prof C.B. Chung, and NIH NIAMS (R01 AR066622). Furthermore, this work was supported by grant funding from RSNA Research Fellow Grant (RF1730), Swiss National Science Foundation (P2SKP3_168412), and Swiss Society of Radiology in support of Dr Finkenstaedt. We disclose any financial support or author involvement with organization(s) with financial interest in the subject matter. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Correspondence to: Christine B. Chung, MD, Department of Radiology, VA San Diego Healthcare System, 3350 La Jolla Village Dr, MC-114, San Diego, CA 92161. E-mail: cbchung@ucsd.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure

Abstract

Dysphagia is common in hospitalized patients post-extubation and associated with poor outcomes. Laryngeal sensation is critical for airway protection and safe swallowing. However, current understanding of the relationship between laryngeal sensation and aspiration in post-extubation populations is limited. Acute respiratory failure patients requiring intensive care unit admission and mechanical ventilation received a Flexible Endoscopic Evaluation of Swallowing (FEES) within 72 h of extubation. Univariate and multivariable analyses were performed to examine the relationship between laryngeal sensation, length of intubation, and aspiration. Secondary outcomes included pharyngolaryngeal secretions, pneumonia, and diet recommendations. One-hundred and three patients met inclusion criteria. Fifty-one patients demonstrated an absent laryngeal adductor reflex (LAR). Altered laryngeal sensation correlated with the presence of secretions (p = 0.004). There was a significant interaction between the LAR, aspiration, and duration of mechanical ventilation. Altered laryngeal sensation was significantly associated with aspiration on FEES only in patients with a shorter length of intubation (p = 0.008). Patients with altered laryngeal sensation were prescribed significantly more restricted liquid (p = 0.03) and solid (p = 0.001) diets. No relationship was found between laryngeal sensation and pneumonia. There is a high prevalence of laryngeal sensory deficits in mechanically ventilated patients post-extubation. Altered laryngeal sensation was associated with secretions, aspiration, and modified diet recommendations especially in those patients with a shorter length of mechanical ventilation. These results demonstrate that laryngeal sensory abnormalities impact the development of post-extubation dysphagia.

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Ultrashort Time to Echo Magnetic Resonance Evaluation of Calcium Pyrophosphate Crystal Deposition in Human Menisci

Objectives In human menisci, we aimed to investigate whether calcium pyrophosphate crystal deposition (CPPD) affects biomechanical and quantitative MR properties, and their zonal distribution. Materials and Methods From 9 cadaveric knees, sectioned triangular meniscus pieces were harvested. Samples were classified into "normal" or "CPPD" groups based upon visual inspection. Micro computed tomography scan verified CPPD. Using magnetic resonance imaging, ultrashort echo time (UTE) T2* and spin echo (SE) T2, quantitative values in 3 zones (red, red-white, and white) were determined. Using biomechanical test, indentation forces in the same zones were determined. Effects of CPPD and meniscal zone on indentation force and quantitative MR values were compared. Results On UTE MRI scans, CPPD-affected menisci exhibited punctate dark regions, found mostly (92%) in avascular white and red-white zones. Indentation forces were significantly higher for CPPD samples in the red-white (all P 0.2). Similarly, UTE T2* red zone values were similar between both groups (~6.6 milliseconds, P = 0.8), whereas in the red-white and white zones, CPPD samples had significantly lower values (~5.1 milliseconds, P = 0.005 to 0.007). In contrast, SE T2 values showed no difference with CPPD (P = 0.12 to 0.16). UTE T2*, but not SE T2, correlated significantly with indentation force (R = −0.29, P = 0.009). Conclusions Dark CPP deposits were detectable on UTE images featuring high signal intensity from surrounding meniscal tissue. Preliminary results indicate that CPP deposits were almost exclusively found in the avascular zones. Compared with normal, CPPD menisci featured higher indentation stiffness and lower UTE T2* values in the affected zones. Received for publication November 6, 2018; and accepted for publication, after revision, December 18, 2018. Conflicts of interest and sources of funding: The study was funded by grants from VA (I01 CX000625) and NIH NIAMS (R01 AR064321) in support of Prof C.B. Chung, and NIH NIAMS (R01 AR066622). Furthermore, this work was supported by grant funding from RSNA Research Fellow Grant (RF1730), Swiss National Science Foundation (P2SKP3_168412), and Swiss Society of Radiology in support of Dr Finkenstaedt. We disclose any financial support or author involvement with organization(s) with financial interest in the subject matter. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Correspondence to: Christine B. Chung, MD, Department of Radiology, VA San Diego Healthcare System, 3350 La Jolla Village Dr, MC-114, San Diego, CA 92161. E-mail: cbchung@ucsd.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Relationship Between Laryngeal Sensation, Length of Intubation, and Aspiration in Patients with Acute Respiratory Failure

Abstract

Dysphagia is common in hospitalized patients post-extubation and associated with poor outcomes. Laryngeal sensation is critical for airway protection and safe swallowing. However, current understanding of the relationship between laryngeal sensation and aspiration in post-extubation populations is limited. Acute respiratory failure patients requiring intensive care unit admission and mechanical ventilation received a Flexible Endoscopic Evaluation of Swallowing (FEES) within 72 h of extubation. Univariate and multivariable analyses were performed to examine the relationship between laryngeal sensation, length of intubation, and aspiration. Secondary outcomes included pharyngolaryngeal secretions, pneumonia, and diet recommendations. One-hundred and three patients met inclusion criteria. Fifty-one patients demonstrated an absent laryngeal adductor reflex (LAR). Altered laryngeal sensation correlated with the presence of secretions (p = 0.004). There was a significant interaction between the LAR, aspiration, and duration of mechanical ventilation. Altered laryngeal sensation was significantly associated with aspiration on FEES only in patients with a shorter length of intubation (p = 0.008). Patients with altered laryngeal sensation were prescribed significantly more restricted liquid (p = 0.03) and solid (p = 0.001) diets. No relationship was found between laryngeal sensation and pneumonia. There is a high prevalence of laryngeal sensory deficits in mechanically ventilated patients post-extubation. Altered laryngeal sensation was associated with secretions, aspiration, and modified diet recommendations especially in those patients with a shorter length of mechanical ventilation. These results demonstrate that laryngeal sensory abnormalities impact the development of post-extubation dysphagia.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B7Yple

Tongue Lumps and Bumps: Histopathological Dilemmas and Clues for Diagnosis

Abstract

Exophytic lesions of the tongue encompass a diverse spectrum of entities. These are most commonly reactive, arising in response to local trauma but can also be neoplastic of epithelial, mesenchymal or miscellaneous origin. In most cases, the microscopic examination is likely to provide a straightforward diagnosis. However, some cases can still raise microscopic diagnostic dilemmas, such as conditions that mimic malignancies, benign tumors with overlapping features and anecdotal lesions. A series of "lumps and bumps" of the tongue are presented together with suggested clues that can assist in reaching a correct diagnosis, emphasizing the importance of the clinico-pathological correlations.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G7qH2u

A Rainbow of Colors and Spectrum of Textures: An Approach to Oral Mucosal Entities

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FZ9zNl

HPV-Related Papillary Lesions of the Oral Mucosa: A Review

Abstract

Human papillomaviruses (HPVs) are causative of a group of clinically papillary lesions. The HPV-related lesions of the oral cavity include squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia. Benign entities, such as verruciform xanthoma or giant cell fibroma, as well as malignancies, such as papillary squamous cell carcinoma and verrucous carcinoma, may be considered in the clinical and/or histologic differential diagnoses of these lesions. Mechanisms of infection, epidemiology, clinical presentations, histologic features, and differential diagnoses of the HPV-related oral pathologies are discussed. Current concepts of viral transmission, especially as pertaining to lesions in pediatric patients, and the impacts of HPV vaccination are reviewed.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FYoPtE

Candidiasis: Red and White Manifestations in the Oral Cavity

Abstract

Candidiasis is a very common malady in the head neck region. This review will concentrate on intraoral, pharyngeal and perioral manifestations and treatment. A history of the origins associated with candidiasis will be introduced. In addition, oral conditions associated with candidiasis will be mentioned and considered. The various forms of oral and maxillofacial candidiasis will be reviewed to include pseudomembranous, acute, chronic, median rhomboid glossitis, perioral dermatitis, and angular cheilitis. At the end of this review the clinician will be better able to diagnose and especially treat candidal overgrowth of the oral facial region. Of particular interest to the clinician are the various treatment modalities with appropriate considerations for side effects.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G7qMmO

Non-HPV Papillary Lesions of the Oral Mucosa: Clinical and Histopathologic Features of Reactive and Neoplastic Conditions

Abstract

Excluding human papillomavirus (HPV)-driven conditions, oral papillary lesions consist of a variety of reactive and neoplastic conditions and, on occasion, can herald internal malignancy or be part of a syndrome. The objectives of this paper are to review the clinical and histopathological features of the most commonly encountered non-HPV papillary conditions of the oral mucosa. These include normal anatomic structures (retrocuspid papillae, lingual tonsils), reactive lesions (hairy tongue, inflammatory papillary hyperplasia), neoplastic lesions (giant cell fibroma), lesions of unknown pathogenesis (verruciform xanthoma, spongiotic gingival hyperplasia) and others associated with syndromes (for instance Cowden syndrome) or representing paraneoplastic conditions (malignant acanthosis nigricans). Common questions regarding differential diagnosis, management, and diagnostic pitfalls are addressed, stressing the importance of clinico-pathologic correlation and collaboration.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FUqLDk

Lumps and Bumps of the Gingiva: A Pathological Miscellany

Abstract

Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gingivae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological differential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FWagql

Erythematous and Vascular Oral Mucosal Lesions: A Clinicopathologic Review of Red Entities

Abstract

Erythematous lesions of the oral mucosa are common and can reflect a variety of conditions, ranging from benign reactive or immunologically-mediated disorders to malignant disease. Together with vascular abnormalities, which can vary from reddish to bluish-purple in color, the differential diagnosis for erythematous oral mucosal change is quite diverse. This review focuses on salient clinical features and histopathologic findings of selected conditions which clinically present as red or vascular-like oral mucosal alterations, including oral vascular malformations and neoplasms, pyogenic granuloma, localized juvenile spongiotic gingival hyperplasia, denture stomatitis, benign migratory glossitis (geographic tongue), orofacial granulomatosis, granulomatosis with polyangiitis (Wegener granulomatosis), megaloblastic anemia, and erythroplakia. Recognition of the characteristic clinical features of these conditions, in conjunction with thorough patient history, will allow clinicians to narrow the differential diagnosis and guide appropriate clinical decision making, including the need for tissue biopsy, in order to complete the diagnostic process and initiate optimal patient care.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G7qUmo

Black and Brown Oro-facial Mucocutaneous Neoplasms

Abstract

Black and brown-colored mucocutaneous lesions present a differential diagnostic challenge, with malignant melanoma being the primary clinical concern. The vast majority of pigmented lesions in the head and neck region are the result of benign, reactive factors such as post-inflammatory melanosis. However, it is not uncommon to discover a range of muco-cutaneous black and brown neoplasms in the oro-facial area. The majority of black/brown pigmented neoplasms are melanocytic in origin; these are neoplasms of neural crest derivation. Melanocytic nevi are a diverse group of benign neoplasms that are the result of specific oncogenic mutations. They are common on cutaneous surfaces but can manifest in mucosal sites. Currently, nevi are classified based on clinical and histological criteria. The most common cutaneous and oral mucosal nevus is the acquired melanocytic nevus; nevi do not pose an increased risk for the development of malignant melanoma. Emerging information on specific genetic differences supports the notion of biologically distinct nevi. This article will review the classic clinical and microscopic features of nevi commonly found in the head and neck region, and discuss emerging concepts in nevus pathogenesis and taxonomy. Melanoma is a malignant melanocytic neoplasm and is a result of cumulative genetic deregulation. The etiology of malignant melanoma (MM) is multifactorial and includes underlying genetic susceptibility, UV radiation, skin-type, and race. The majority of MM occurs on cutaneous surfaces and less commonly on mucosal and extra-cutaneous visceral organs. Regardless of location, MM exhibits clinical-pathological features that relate to horizontal or vertical tumor spread. Cutaneous and mucosal MM typically present as asymmetrical, irregularly bordered, large (> 0.5 cm), heterogeneous brown-black lesions with foci of erythema, atrophy or ulceration. As with melanocytic nevi, advances in melanomagenesis research have revealed primary oncogenic BRAF and NRAS mutations associated with cutaneous MM. Unlike their cutaneous counterparts, mucosal melanomas exhibit primary oncogenic alterations in c-KIT and other genes. This article will discuss the role of specific primary oncogenic and secondary/tertiary genetic defects in differential clinical presentation, anatomic distribution, future classification changes, and targeted therapy of melanoma. The clinical and microscopic features of mucosal melanomas and a summary of management guidelines will be discussed. Additionally, this article will cover the salient features of melanocytic neuroectodermal tumor of infancy, a neoplastic entity that can involve the oro-facial region, and the clinical-pathological features of selected, commonly occurring pigmented ectodermally-derived neoplasms that are often part of the clinical differential diagnosis of black–brown pigmented lesions.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G6YR6q

A Guide to Yellow Oral Mucosal Entities: Etiology and Pathology

Abstract

When faced with an uncertain clinical pathosis in the oral cavity, identifying the color of the mucosal lesion helps to narrow down a differential diagnosis. Although less common than red and white lesions, yellow lesions encompass a small group of distinct mucosal pathologic entities. Adipose tissue, lymphoid tissue, and sebaceous glands are naturally occurring yellow constituents of the oral cavity and become apparent with associated developmental or neoplastic lesions. Reactive and inflammatory lesions can create a yellow hue due to purulence, necrosis, and calcification. Some systemic diseases are known to deposit yellow bi-products such as amyloid or bilirubin into the oral mucosa of an affected person, and while not always yellow, unusual entities like verruciform xanthoma and granular cell tumor fall under the umbrella of yellow lesions given their occasional propensity to demonstration the color. This chapter aims to explore the unique group that is yellow lesions presenting in the oral mucosa.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2TfsKp2

Tongue Lumps and Bumps: Histopathological Dilemmas and Clues for Diagnosis

Abstract

Exophytic lesions of the tongue encompass a diverse spectrum of entities. These are most commonly reactive, arising in response to local trauma but can also be neoplastic of epithelial, mesenchymal or miscellaneous origin. In most cases, the microscopic examination is likely to provide a straightforward diagnosis. However, some cases can still raise microscopic diagnostic dilemmas, such as conditions that mimic malignancies, benign tumors with overlapping features and anecdotal lesions. A series of "lumps and bumps" of the tongue are presented together with suggested clues that can assist in reaching a correct diagnosis, emphasizing the importance of the clinico-pathological correlations.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G7qH2u

HPV-Related Papillary Lesions of the Oral Mucosa: A Review

Abstract

Human papillomaviruses (HPVs) are causative of a group of clinically papillary lesions. The HPV-related lesions of the oral cavity include squamous papilloma, condyloma acuminatum, verruca vulgaris, and multifocal epithelial hyperplasia. Benign entities, such as verruciform xanthoma or giant cell fibroma, as well as malignancies, such as papillary squamous cell carcinoma and verrucous carcinoma, may be considered in the clinical and/or histologic differential diagnoses of these lesions. Mechanisms of infection, epidemiology, clinical presentations, histologic features, and differential diagnoses of the HPV-related oral pathologies are discussed. Current concepts of viral transmission, especially as pertaining to lesions in pediatric patients, and the impacts of HPV vaccination are reviewed.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FYoPtE

Non-HPV Papillary Lesions of the Oral Mucosa: Clinical and Histopathologic Features of Reactive and Neoplastic Conditions

Abstract

Excluding human papillomavirus (HPV)-driven conditions, oral papillary lesions consist of a variety of reactive and neoplastic conditions and, on occasion, can herald internal malignancy or be part of a syndrome. The objectives of this paper are to review the clinical and histopathological features of the most commonly encountered non-HPV papillary conditions of the oral mucosa. These include normal anatomic structures (retrocuspid papillae, lingual tonsils), reactive lesions (hairy tongue, inflammatory papillary hyperplasia), neoplastic lesions (giant cell fibroma), lesions of unknown pathogenesis (verruciform xanthoma, spongiotic gingival hyperplasia) and others associated with syndromes (for instance Cowden syndrome) or representing paraneoplastic conditions (malignant acanthosis nigricans). Common questions regarding differential diagnosis, management, and diagnostic pitfalls are addressed, stressing the importance of clinico-pathologic correlation and collaboration.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FUqLDk

Lumps and Bumps of the Gingiva: A Pathological Miscellany

Abstract

Lesions of the gingivae are amongst the commonest lesions seen in patients and the vast majority are reactive hyperplasias, related to a number of chronic irritant stimuli. However, there are a number of entities that have a predilection for the gingivae, which are much less common in other parts of the oral cavity. The purpose of this paper is to discuss the clinical and histological differential diagnoses when presented with a lump on the gingivae, including the approach to diagnosis and diagnostic pitfalls.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2FWagql

Erythematous and Vascular Oral Mucosal Lesions: A Clinicopathologic Review of Red Entities

Abstract

Erythematous lesions of the oral mucosa are common and can reflect a variety of conditions, ranging from benign reactive or immunologically-mediated disorders to malignant disease. Together with vascular abnormalities, which can vary from reddish to bluish-purple in color, the differential diagnosis for erythematous oral mucosal change is quite diverse. This review focuses on salient clinical features and histopathologic findings of selected conditions which clinically present as red or vascular-like oral mucosal alterations, including oral vascular malformations and neoplasms, pyogenic granuloma, localized juvenile spongiotic gingival hyperplasia, denture stomatitis, benign migratory glossitis (geographic tongue), orofacial granulomatosis, granulomatosis with polyangiitis (Wegener granulomatosis), megaloblastic anemia, and erythroplakia. Recognition of the characteristic clinical features of these conditions, in conjunction with thorough patient history, will allow clinicians to narrow the differential diagnosis and guide appropriate clinical decision making, including the need for tissue biopsy, in order to complete the diagnostic process and initiate optimal patient care.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G7qUmo

Black and Brown Oro-facial Mucocutaneous Neoplasms

Abstract

Black and brown-colored mucocutaneous lesions present a differential diagnostic challenge, with malignant melanoma being the primary clinical concern. The vast majority of pigmented lesions in the head and neck region are the result of benign, reactive factors such as post-inflammatory melanosis. However, it is not uncommon to discover a range of muco-cutaneous black and brown neoplasms in the oro-facial area. The majority of black/brown pigmented neoplasms are melanocytic in origin; these are neoplasms of neural crest derivation. Melanocytic nevi are a diverse group of benign neoplasms that are the result of specific oncogenic mutations. They are common on cutaneous surfaces but can manifest in mucosal sites. Currently, nevi are classified based on clinical and histological criteria. The most common cutaneous and oral mucosal nevus is the acquired melanocytic nevus; nevi do not pose an increased risk for the development of malignant melanoma. Emerging information on specific genetic differences supports the notion of biologically distinct nevi. This article will review the classic clinical and microscopic features of nevi commonly found in the head and neck region, and discuss emerging concepts in nevus pathogenesis and taxonomy. Melanoma is a malignant melanocytic neoplasm and is a result of cumulative genetic deregulation. The etiology of malignant melanoma (MM) is multifactorial and includes underlying genetic susceptibility, UV radiation, skin-type, and race. The majority of MM occurs on cutaneous surfaces and less commonly on mucosal and extra-cutaneous visceral organs. Regardless of location, MM exhibits clinical-pathological features that relate to horizontal or vertical tumor spread. Cutaneous and mucosal MM typically present as asymmetrical, irregularly bordered, large (> 0.5 cm), heterogeneous brown-black lesions with foci of erythema, atrophy or ulceration. As with melanocytic nevi, advances in melanomagenesis research have revealed primary oncogenic BRAF and NRAS mutations associated with cutaneous MM. Unlike their cutaneous counterparts, mucosal melanomas exhibit primary oncogenic alterations in c-KIT and other genes. This article will discuss the role of specific primary oncogenic and secondary/tertiary genetic defects in differential clinical presentation, anatomic distribution, future classification changes, and targeted therapy of melanoma. The clinical and microscopic features of mucosal melanomas and a summary of management guidelines will be discussed. Additionally, this article will cover the salient features of melanocytic neuroectodermal tumor of infancy, a neoplastic entity that can involve the oro-facial region, and the clinical-pathological features of selected, commonly occurring pigmented ectodermally-derived neoplasms that are often part of the clinical differential diagnosis of black–brown pigmented lesions.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G6YR6q

Spotlight on Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia)

By Megan Urban When did you join your SIG—and what made you want to join? I've been a SIG 13 member since at least 2010. At that time, I had recently been promoted from clinician to manager and sought increased opportunities for networking and continuing education to stay current with changes in the field. I found that SIG 13 provides a community for dedicated clinicians who are especially interested in swallowing and swallowing disorders. How has your involvement with the SIG helped you in your career? SIG 13 has provided the opportunity to earn low-cost, high-quality ASHA CEUs by reading Perspectives articles and attending SIG 13-sponsored CEU events, which were especially helpful for my application for board certification in swallowing and swallowing disorders. Following...

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CV0xgm

Spotlight on Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia)

By Megan Urban When did you join your SIG—and what made you want to join? I've been a SIG 13 member since at least 2010. At that time, I had recently been promoted from clinician to manager and sought increased opportunities for networking and continuing education to stay current with changes in the field. I found that SIG 13 provides a community for dedicated clinicians who are especially interested in swallowing and swallowing disorders. How has your involvement with the SIG helped you in your career? SIG 13 has provided the opportunity to earn low-cost, high-quality ASHA CEUs by reading Perspectives articles and attending SIG 13-sponsored CEU events, which were especially helpful for my application for board certification in swallowing and swallowing disorders. Following...

MedWorm Message: Have you tried our new medical search engine? More powerful than before. Log on with your social media account. 100% free.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CV0xgm

Spotlight on Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia)

By Megan Urban When did you join your SIG—and what made you want to join? I've been a SIG 13 member since at least 2010. At that time, I had recently been promoted from clinician to manager and sought increased opportunities for networking and continuing education to stay current with changes in the field. I found that SIG 13 provides a community for dedicated clinicians who are especially interested in swallowing and swallowing disorders. How has your involvement with the SIG helped you in your career? SIG 13 has provided the opportunity to earn low-cost, high-quality ASHA CEUs by reading Perspectives articles and attending SIG 13-sponsored CEU events, which were especially helpful for my application for board certification in swallowing and swallowing disorders. Following...

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CV0xgm

Spotlight on Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia)

By Megan Urban When did you join your SIG—and what made you want to join? I've been a SIG 13 member since at least 2010. At that time, I had recently been promoted from clinician to manager and sought increased opportunities for networking and continuing education to stay current with changes in the field. I found that SIG 13 provides a community for dedicated clinicians who are especially interested in swallowing and swallowing disorders. How has your involvement with the SIG helped you in your career? SIG 13 has provided the opportunity to earn low-cost, high-quality ASHA CEUs by reading Perspectives articles and attending SIG 13-sponsored CEU events, which were especially helpful for my application for board certification in swallowing and swallowing disorders. Following...

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2CV0xgm

How aspirin may benefit some people with head and neck cancer

Source: http://bit.ly/O45xlc Author: Catharine Paddock PhD, fact checked by Paula Field Recent research has tied regular use of nonsteroidal anti-inflammatory drugs, […]

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B8ZGsh

How aspirin may benefit some people with head and neck cancer

Source: http://bit.ly/O45xlc Author: Catharine Paddock PhD, fact checked by Paula Field Recent research has tied regular use of nonsteroidal anti-inflammatory drugs, […]

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B8ZGsh

Influence of the Maillard Reaction on the Allergenicity of Food Proteins and the Development of Allergic Inflammation

Abstract

Purpose of Review

The Maillard reaction (MR) is a non-enzymatic reaction between reducing sugars and compounds with free amino groups such as proteins and takes place during thermal processing and storage of foods. This review aims to discuss potential effects of dietary MR products on the pathological mechanisms of allergic diseases.

Recent Findings

Since the MR leads to modification of proteins with various types of glycation structures, the impact of the MR on the immunogenicity and potential allergenicity of food proteins in many allergenic foods has been assessed. In addition, recent studies have suggested that the MR products, in particular "advanced glycation end products (AGEs)," contained in the diet may be involved in the development of chronic inflammation by acting as inflammatory components and affecting the gut microbiome.

Summary

This review found that the biological, immunological, and allergic properties of dietary MR products are diverse due to the complexity of the MR.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B7oCAp

Next-Generation Approaches for the Treatment of Food Allergy

Abstract

Purpose of Review

IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance.

Recent Findings

Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options.

Summary

This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2Tgz53j

Influence of the Maillard Reaction on the Allergenicity of Food Proteins and the Development of Allergic Inflammation

Abstract

Purpose of Review

The Maillard reaction (MR) is a non-enzymatic reaction between reducing sugars and compounds with free amino groups such as proteins and takes place during thermal processing and storage of foods. This review aims to discuss potential effects of dietary MR products on the pathological mechanisms of allergic diseases.

Recent Findings

Since the MR leads to modification of proteins with various types of glycation structures, the impact of the MR on the immunogenicity and potential allergenicity of food proteins in many allergenic foods has been assessed. In addition, recent studies have suggested that the MR products, in particular "advanced glycation end products (AGEs)," contained in the diet may be involved in the development of chronic inflammation by acting as inflammatory components and affecting the gut microbiome.

Summary

This review found that the biological, immunological, and allergic properties of dietary MR products are diverse due to the complexity of the MR.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B7oCAp

Next-Generation Approaches for the Treatment of Food Allergy

Abstract

Purpose of Review

IgE-mediated food allergies are an increasing health concern, and current management includes food avoidance and use of emergency medications. Effective treatment of food allergy is highly desirable. Next generation approaches for the treatment of food allergy aim to improve both safety and efficacy, potentially including long-term tolerance.

Recent Findings

Oral immunotherapy (OIT) and epicutaneous immunotherapy (EPIT) will likely be integrated into clinical practice as part of food allergy management in the near future. Newer approaches, such as sublingual immunotherapy (SLIT), modified proteins, lysosomal-associated membrane protein DNA (LAMP DNA) vaccines, and the use of immunomodulatory agents, are early in development and depending on results, could also become important treatment options.

Summary

This is a review of novel approaches to the treatment of food allergy that are currently under investigation, including the use of SLIT, modified proteins, probiotics, Chinese herbal supplements, biologic therapies, and DNA vaccines, as well as a summary of the current status of OIT and EPIT.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2Tgz53j

How aspirin may benefit some people with head and neck cancer

Source: http://bit.ly/O45xlc Author: Catharine Paddock PhD, fact checked by Paula Field Recent research has tied regular use of nonsteroidal anti-inflammatory drugs, […]

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B8ZGsh

How aspirin may benefit some people with head and neck cancer

Source: http://bit.ly/O45xlc Author: Catharine Paddock PhD, fact checked by Paula Field Recent research has tied regular use of nonsteroidal anti-inflammatory drugs, […]

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2B8ZGsh

Ultra-high-resolution subtraction CT angiography in the follow-up of treated intracranial aneurysms

Abstract

In subtraction CT angiography (CTA), a non-contrast CT acquisition is subtracted from a contrast-enhanced CTA acquisition. Subtraction CTA can be applied in the detection, classification, and follow-up of intracranial aneurysms and is advantageous over conventional angiography because of its non-invasive nature, shorter examination time, and lower costs. Recently, an ultra-high-resolution CT scanner has been introduced in clinical practice offering an in-plane spatial resolution of up to 0.234 mm, approaching the resolution as seen during conventional invasive digital subtraction angiography (DSA). The twofold increase in spatial resolution as compared to a conventional CT scanner could improve the evaluation of small vascular structures and, coupled with dedicated post-processing techniques, further reduce metal artifacts. Technical considerations using a state-of-the-art high-resolution subtraction CTA protocol are discussed for application in the follow-up of surgical and endovascular treated intracranial aneurysms.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2G4INSF

Strategic research agenda for biomedical imaging

Abstract

This Strategic Research Agenda identifies current challenges and needs in healthcare, illustrates how biomedical imaging and derived data can help to address these, and aims to stimulate dedicated research funding efforts.

Medicine is currently moving towards a more tailored, patient-centric approach by providing personalised solutions for the individual patient. Innovation in biomedical imaging plays a key role in this process as it addresses the current needs for individualised prevention, treatment, therapy response monitoring, and image-guided surgery.

The use of non-invasive biomarkers facilitates better therapy prediction and monitoring, leading to improved patient outcomes. Innovative diagnostic imaging technologies provide information about disease characteristics which, coupled with biological, genetic and -omics data, will contribute to an individualised diagnosis and therapy approach.

In the emerging field of theranostics, imaging tools together with therapeutic agents enable the selection of best treatments and allow tailored therapeutic interventions.

For prenatal monitoring, the use of innovative imaging technologies can ensure an early detection of malfunctions or disease.

The application of biomedical imaging for diagnosis and management of lifestyle-induced diseases will help to avoid disease development through lifestyle changes.

Artificial intelligence and machine learning in imaging will facilitate the improvement of image interpretation and lead to better disease prediction and therapy planning.

As biomedical imaging technologies and analysis of existing imaging data provide solutions to current challenges and needs in healthcare, appropriate funding for dedicated research is needed to implement the innovative approaches for the wellbeing of citizens and patients.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2sShMKE

Abdominal applications of ultrasound fusion imaging technique: liver, kidney, and pancreas

Abstract

Fusion imaging allows exploitation of the strengths of all imaging modalities simultaneously, eliminating or minimizing the weaknesses of every single modality. Ultrasound (US) fusion imaging provides benefits in real time from both the dynamic information and spatial resolution of the normal US and the high-contrast resolution and wider field of view of the other imaging methods. US fusion imaging can also be associated with the use of different ultrasound techniques such as color Doppler US, elastography, and contrast-enhanced US (CEUS), for better localization and characterization of lesions. The present paper is focused on US fusion imaging technologies and clinical applications describing the possible use of this promising imaging technique in the liver, kidney, and pancreatic pathologies.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2MDUhxC

The value of CSF flow studies in the management of CSF disorders in children: a pictorial review

Abstract

CSF flow disorders are frequently encountered in children. The advent of MR technology with the emergence of new pulse sequences allowed better understanding of CSF flow dynamics. In this pictorial review, we aim to conduct a comprehensive review of the MR protocol used to study CSF flow disorders and to discuss the utility of each pulse sequence in the adopted protocol. We will focus on the key anatomical structures that should be examined to differentiate hydrocephalus form ventricular dilatation ex-vacuo. The MR features of obstructive and communicating hydrocephalus will be discussed, in addition to the manifestations of CSF disorders associated with posterior fossa malformations (Dandy-Walker malformation, Chiari, and Blake's pouch cyst). Moreover, the value of MRI in the assessment of patients following interventional procedures (ventriculoperitoneal shunt and third ventriculostomy) will be addressed.

from #Head and Neck by Sfakianakis via simeraentaxei on Inoreader http://bit.ly/2sOTmBF