Ambulatory mediastinal biopsy for hematologic malignancies

Recent advances in the roles of exosomal microRNAs (exomiRs) in hematologic neoplasms: pathogenesis, diagnosis, and treatment

In clinical diagnosis, the capability of exosomes to serve as biomarkers is one of the most important biological functions of exosomes. The superior stability of exosome biomarkers makes them superior to those isolated from traditional samples such as serum and urine. Almost all body fluids contain exosomes, which contain proteins, nucleic acids, and lipids. Several molecular components of exosomes, including exosome proteins and microRNAs (miRNAs), are promising diagnostic biomarkers. These exosomes may carry genetic information by containing messenger RNA (mRNA) and miRNA. The miRNAs are small noncoding RNAs that regulate protein-coding genes by acting as translational repressors. It has been shown that miRNAs are mis-expressed in a range of conditions, including hematologic neoplasms. Additionally, miRNAs found within exosomes have been linked with specific diseases, including hematologic neoplasms. Numerous studies suggest that circulating exosomes contain miRNAs similar to those found in parental cancer cells. Exosomes contain miRNAs that are released by almost all kinds of cells. MiRNAs are packaged into exosomes and delivered to recipient cells, and manipulate its function. It has been recognized that exosomes are new therapeutic targets for immunotherapy and biomedicine of cancers. The current review discusses the current evidence around exosomal miRNAs involved in the pathogenesis, diagnosis, and treatment of hematologic neoplasms. Video Abstract.

[Outpatient thoracic surgery: Evolution of the indications, current applications and limits]

The objectives of outpatient surgery are to reduce the risks connected to hospitalization, to improve postoperative recovery and to decrease the health costs. Few studies have been performed in the field of thoracic surgery and there remains great scope for progress in outpatient lung surgery. The purpose of this article is to present a revue of the current situation and the prospects for the development of out patient thoracic surgery.

Detection and Identification of Hematologic Malignancies and Solid Tumors by an Electrochemical Technique

Purpose

Develop and evaluate an electrochemical method to identify healthy individuals, malignant hematopathic patients and solid tumor patients by detecting the leukocytes in whole-blood.

Methods

A total of 114 individual blood samples obtained from our affiliated hospital in China (June 2015- August 2015) were divided into three groups: healthy individuals (n = 35), hematologic malignancies (n = 41) and solid tumors (n = 38). An electrochemical workstation system was used to measure differential pulse voltammetry due to the different electrochemical behaviors of leukocytes in blood samples. Then, one-way analysis of variance (ANOVA) was applied to analyze the scanning curves and to compare the peak potential and peak current.

Results

The scanning curve demonstrated the specific electrochemical behaviors of the blank potassium ferricyanide solution and that mixed with blood samples in different groups. Significant differences in mean peak potentials of mixture and shifts (ΔEp (mV)) were observed of the three groups (P< = 0.001). 106.00±9.00 and 3.14±7.48 for Group healthy individuals, 120.90±11.18 and 18.10±8.81 for Group hematologic malignancies, 136.84±11.53 and 32.89±10.50 for Group solid tumors, respectively. In contrast, there were no significant differences in the peak currents and shifts.

Conclusions

The newly developed method to apply the electrochemical workstation system to identify hematologic malignancies and solid tumors with good sensitivity and specificity might be effective, suggesting a potential utility in clinical application.

Fatal mediastinal biopsy: How interventional radiology saves the day

This was a case of a 35-year-old man with mediastinal mass requiring computed tomography (CT)-guided biopsy for tissue diagnosis. A posterior approach with an 18-gauge biopsy needle was used to obtain tissue sample. Post biopsy, patient condition deteriorated and multiphase CT study detected active bleeding in arterial phase at the biopsy site with massive hemothorax. Subsequent angiography showed arterial bleeder arising from the apical branch of the right pulmonary artery. Selective endovascular embolization with NBCA (n-Butyl cyanoacrylate) was successful. Patient survived the complication. The case highlighted a rare complication in a common radiology procedure and the value of the interventional radiology unit in avoiding a fatal outcome.

Invasive staging of mediastinal lymph nodes: mediastinoscopy and remediastinoscopy

Nodal status in lung cancer is essential for planning therapy and assessing prognosis. The involvement of ipsilateral and contralateral mediastinal lymph nodes is associated with poor prognosis and usually excludes patients from upfront surgical treatment. Mediastinoscopy is a time-honored procedure that allows the surgeon to access the upper mediastinal lymph nodes for either biopsy or removal. Remediastinoscopy is mainly indicated to assess objective tumor response in mediastinal lymph nodes after induction therapy for locally advanced lung cancer and to indicate further therapy.

FDG PET scan strategies and long-term outcomes after first-line therapy in Hodgkin's disease

BACKGROUND

The use of positron emission tomography with fluoro-deoxy-glucose (FDG PET) in Hodgkin's disease (HD) is continuing to expand worldwide, with response assessment after completion of therapy being its most widely utilized application. A positive scan has been associated with high relapse rates and disease progression.

METHODS

A decision analysis was performed to determine the long-term impact of FDG PET restaging both with and without computed tomography (CT) in terms of the 5-year progression-free survival (5yrPFS). Outcomes and utilities were based on published data. The first strategy involved CT restaging after first-line therapy, with or without subsequent FDG PET, while the second strategy used FDG PET scan alone. All positive test required histological examination. Upon histological confirmation of active lymphoma, patients were considered candidates for autologous transplantation and long-term outcomes were retrieved. The expected clinical benefit of the two strategies was calculated and depicted, along with the mean costs. One-way and two-way sensitivity analyses were performed to ensure the validity of the results.

RESULTS

CT restaging plus FDG PET when residual mass is detected, results in a 2% benefit at 5yrPFS at baseline compared to FDG PET-alone restaging and remains positive for a wide range of probabilities. This strategy reduces the average cost by euro 1863 per patient, including costs of biopsy and autologous transplantation.

CONCLUSION

A more conservative approach that includes CT restaging after first-line therapy and FDG PET scan only on residual mass, is the preferred strategy in HD. Furthermore it appears to confer the maximal diagnostic yield along with a substantial reduction in the mean cost.

Chronic lymphocytic leukemia: economic burden and quality of life: literature review

The purpose of this review was answer 2 main questions: what is the impact of chronic lymphocytic leukemia (CLL) on the patient's quality of life and how great is the economic burden of this disease on the health care payers and providers. Patients with CLL typically do not receive any treatment soon after the initial diagnosis. Although there is no known cure for CLL yet, when treated, the patients receive aggressive and expensive therapies (eg, chemotherapy or bone marrow transplantation). A rigorous and systematic literature review was performed of English-language articles published in 1990-2002. It was supplemented with additional articles published before 1990 for completeness and additional references to fill the gaps identified in the published medical literature. The literature on the quality of life (QOL) of CLL patients is very limited. We identified only 8 articles, and none of them analyzed the QOL in untreated CLL patients. Because CLL is a disease affecting adults, especially the elderly, all 8 studies measured the QOL in the adult population. QOL difficulties include fear of death and disability, problems gaining employment or health insurance, and fatigue. No specific leukemia or CLL instruments but general QOL instruments (eg, I-HRQL) were identified and some cancer-specific ones (eg, EORTC QLQ-C30, FACT-G, FACT Anemia, FACT-Fatigue). Interestingly, a FACT-Bone Marrow Transplant instrument exists, although we found no study on CLL that used it. Even the literature on the economic burden of CLL is very limited. We identified 13 studies on the cost of CLL: Most of them were cost-identification or cost-comparison studies, and 5 dealt with the cost-effectiveness of medical interventions to treat CLL. Cost drivers identified for CLL were the chemotherapy costs, intravenous immunoglobulin costs, transplantation costs, and costs associated with the differential staining cytotoxicity assay. We identified very few articles on the QOL of CLL patients and therefore cannot draw strong conclusions about the key QOL predictors. Nevertheless, patients with anemia were found to have a better QOL if they had higher hemoglobin counts and good response to erythropoietin treatment. The articles published seem to demonstrate that the older the age of the patient was, the poorer the QOL. The main cost drivers identified for CLL were related to the treatment chosen (eg, chemotherapy, bone marrow transplantation). There are hints that higher costs often result from the delivery of non-optimal therapy that leads to adverse events, infections, and drug resistance. In summary, the impact of this disease on the health care budget of the different health care providers and payers as well as on the patient's QOL is substantially unknown, calling for appropriate economic and QOL studies.

Economic assessment on the management of chronic lymphocytic leukaemia

In the last decade, several new promising treatments for chronic lymphocytic leukaemia (CLL) have been developed. Healthcare costs are increasing and new treatments tend to be very expensive; therefore, information about the cost effectiveness in treatments for CLL is urgently needed. The authors performed a literature review on the currently available economic evaluations on CLL treatments. A total of 65 articles were found, of which 11 could be included. These articles were evaluated on the basis of six methodological requirements for economic evaluations, enabling readers to judge the value of the studies. Only a small amount of information was available on the costs of CLL treatments. Future economic evaluations should be performed according to the methodological requirements for these studies, which should also be properly documented.

Biopsy of anterior mediastinal masses under local anesthesia

Treatment of most primary mediastinal tumors is based on positive histological diagnosis; we describe a variation of anterior mediastinoscopy under local anesthesia. After infiltration with local anesthetic, a transverse skin incision is made in the second, third, or fourth interspace. The endothoracic fascia is incised vertically adjacent to the periosteum and a mediastinoscope is inserted in the mediastinum. Between 1995 and 2001, we have employed this technique in 46 patients with anterior mediastinal tumors. Histological diagnosis was obtained in all patients. Pneumothorax (2 patients) was drained by a tube removed at the end of the procedures. No other complications occurred and all patients were discharged from hospital within 24 hours. Mediastinoscopy under local anesthesia proved safe and effective for diagnosing anterior mediastinal tumors.

The effects of prebiopsy corticosteroid treatment on the diagnosis of mediastinal lymphoma

BACKGROUND/PURPOSE

For children with probable mediastinal lymphoma and a high risk of cardiorespiratory morbidity, many centers recommend delaying the diagnostic biopsy for 24 to 48 hours while corticosteroids are administered to reduce tumor size and morbidity. This study was undertaken to determine the effect of preoperative steroid use on the accuracy of the pathological diagnosis and incidence of perioperative cardiorespiratory morbidity.

METHODS

From 1988 to 1998, 86 children were treated for mediastinal lymphoma. Twenty-three received steroid before biopsy (study group) because of clinical evidence of respiratory compromise, and the remaining 63 served as controls. Clinical parameters, steroid use, and detailed pathological findings obtained at initial and subsequent biopsies were reviewed. Steroid treatment was considered to have had an adverse effect on the pathological diagnosis if (1) a definitive diagnosis was delayed more that 1 month, (2) a definitive diagnosis could not be made, or (3) the extent of disease could not be staged with certainty.

RESULTS

Steroid treatment had an adverse effect on the pathological diagnosis in 5 of 23 (22%) children: 1 diagnostic delay, 3 failures of a definitive diagnosis, and 1 possible failure of staging. A definitive diagnosis was made in all control patients. Perioperative survival was 100% in both groups. At biopsy, only 3 children in the steroid treatment group and 2 children in the control group had moderate, nonfatal cardiorespiratory instability. Parameters of steroid use among children who had inaccurate pathological diagnoses or cardiorespiratory morbidity were not significantly different from those who did not.

CONCLUSIONS

Steroid treatment before biopsy of mediastinal lymphoma may adversely affect the pathological accuracy or cause a delay in definitive diagnosis in a minority of cases. The dose and duration of steroid use was not related to outcome. Prebiopsy steroid appears to minimize the likelihood of cardiorespiratory morbidity in high-risk patients.

Lymphomas of the anterior mediastinum

Lymphomas are the most common cause of masses in the pediatric mediastinum. More than 50% of children with lymphoblastic lymphoma present with an anterior mediastinal mass, and more than one third of all patients with non-Hodgkin's lymphoma have their primary sites in the mediastinum. Hodgkin's disease also frequently involves this anatomic compartment with approximately two thirds of all pediatric cases manifesting mediastinal adenopathy. Although surgical resection generally is not involved in the primary treatment of these diseases, surgeons often play a key role in obtaining adequate tissue for proper diagnostic analysis. Surgical access to the mediastinum often is required in the acquisition of a specimen.

Diagnosis of mediastinal masses in pediatric patients using mediastinoscopy and the Chamberlain procedure

BACKGROUND/PURPOSE

Mediastinal masses commonly are referred to the pediatric surgeon and can be difficult diagnostic problems. Various techniques have been used to perform biopsy in the mediastinum, but there are few reports of mediastinoscopy or Chamberlain procedure in children in the literature. The authors reviewed their experience with these techniques in a pediatric oncology population.

METHODS

The medical records of all patients on the pediatric surgical service between 1987 and 1997, inclusive, who underwent mediastinoscopy or Chamberlain procedure were reviewed. Demographic data, diagnostic accuracy, complications, operating time, and blood loss were recorded.

RESULTS

Sixteen consecutive patients underwent 13 Chamberlain procedures and six mediastinoscopies over the above period. Diagnostic accuracy was found to be 95% overall (100% for Chamberlain procedure, 83% for mediastinoscopy). Five complications occurred in the Chamberlain group and none in the mediastinoscopy group. No complication required thoracotomy or sternotomy. Among patients whose sole reason for admission was diagnosis of a mediastinal mass, the mean hospital stay was 1.7+/-0.8 days (n = 7) for those who underwent Chamberlain procedure and 1.4+/-0.9 days (n = 4) for those who underwent mediastinoscopy. One mediastinoscopy was performed as an ambulatory procedure.

CONCLUSION

Mediastinoscopy and the Chamberlain procedure are effective and safe techniques for biopsy of mediastinal masses in this age group.