Germ cell cancer in pregnancy - Successfully treated with chemotherapy and surgery

A 31-year-old primigravida, with spontaneous singleton pregnancy, presented in 21 weeks of gestation with abdominal pain. Abdominal ultrasound (USS) and Magnetic Resonance Imaging (MRI) showed a 12 × 14cm large complex lesion arising from the right ovary suspicious for an ovarian malignancy. The radiological staging demonstrated no further metastatic disease; however, it also revealed a 6 cm lesion in the contralateral ovary, consistent with a dermoid cyst. After tumour board discussion the patient underwent a mid-line laparotomy with right oophorectomy, cytology, and peritoneal and omental staging, under oral tocolysis with indomethacin. The left presumed ovarian dermoid was left in situ to avoid additional surgical and obstetrical morbidity. Histology confirmed a grade 3 immature teratoma with primitive neuroepithelium focally present on the capsular surface and atypical cells in the cytology amounting to a stage 1 C2 disease at least. Due to high-risk disease, she was offered adjuvant treatment. The patient received one cycle of intravenous paclitaxel, etoposide, and cisplatin chemotherapy, in an adjuvant setting. She underwent an elective caesarean section at 36 weeks, with the safe delivery of a healthy baby girl. After 6 weeks of her delivery, she received three further cycles of etoposide, and cisplatin to complete her course of adjuvant chemotherapy. Three months after the last chemotherapy cycle, she underwent a laparoscopic removal of the left ovarian dermoid that had increased in size to 8 cm. Final histology revealed no immature elements. To this point, 2 years after initial diagnosis, both mother and child are healthy with no long-term complications. The patient has resumed her normal menstrual cycle and being in remission, she wishes soon to try for a second child. To our knowledge, this is the only reported case of ovarian immature teratoma in pregnancy treated successfully with surgery and adjuvant iv paclitaxel, etoposide, and cisplatin chemotherapy regime.

Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Bony metastases: assessing response to therapy with whole-body diffusion MRI

There are no universally accepted methods for assessing tumour response in skeletal sites with metastatic disease; response is assessed by a combination of imaging tests, serum and urine biochemical markers and symptoms assessments. Whole-body diffusion magnetic resonance imaging excels at bone marrow assessments at diagnosis and for therapy evaluations. It can potentially address unmet clinical and pharmaceutical needs for a reliable measure of tumour response. Signal intensity on high b-value images and apparent diffusion coefficient values can be related to underlying biophysical properties of skeletal metastases. Four patterns of change in response to therapy are described this review. Therapy response criteria need to be tested in prospective clinical studies that incorporate conventional measures of patient benefit.

Review. 18F-FDG PET in the diagnosis and follow-up of thyroid malignancy

The diagnosis of carcinoma of the thyroid is usually made in the process of investigating a thyroid nodule with clinical examination, Technetium-99m scan, ultrasonography and fine-needle aspiration (FNA) cytology. The follow-up is mainly based on 123-iodine and 131-iodine scans and serum thyroglogulin measurement. The aim of the present review was to establish the role of 18F-FDG PET in the differential diagnosis of doubtful thyroid nodules and in the follow-up of patients with increased serum thyroglobulin levels and negative iodine-scan. It remains to be defined if metabolic imaging with PET could be a useful routine procedure in the management of thyroid tumours since the majority of them are well-differentiated and therefore have less avidity to 18F-FDG. In the present work we collected the specific literature derived from MEDLINE over the last 10 years to clarify the potential clinical value of 18F-FDG PET in thyroid malignancies. An emerging role for 18F-FDG PET is in the assessment of incidental finding of a thyroid nodule which, when showing high FDG uptake should be regarded as a possible malignancy that needs further assessment. Another well-documented role for 18F-FDG PET is in the investigation of cases of established well-differentiated thyroid carcinomas presenting with high thyroglobulin and negative iodine imaging. An increase of the 18F-FDG uptake in these tumours indicates a shift towards lesser differentiation (with more aggression and poor prognosis) and may benefit from alternative management. 18F-FDG PET can be considered a routine functional imaging method in detecting iodine-negative recurrent disease in thyroid cancer patients with elevated serum thyroglobulin levels during follow-up. 18F-FDG PET seems to be useful also in differential diagnosis of suspected thyroid nodules, especially using the semi-quantitative SUV analysis.

EuroSCORE: a systematic review of international performance

The validity of the cardiac surgical scoring system, EuroSCORE, has been assessed by several individual cardiac centres within and outside Europe. We chose to assess the overall international performance by systematic review of peer-reviewed literature. There were six studies meeting our criteria for assessment. Internationally, the evidence is highly suggestive that additive EuroSCORE performance generally over-estimates mortality at lower EuroSCOREs (EuroSCORE</=6) and under-estimates mortality at higher EuroSCOREs (EuroSCORE>13). The effect of this could have serious misrepresentations for surgeons and hospitals operating on differing case-mixes. We suggest that further studies need to be performed on the logistic EuroSCORE calculation to ascertain whether predictive ability is improved. Overall, however, EuroSCORE is the most rigorously evaluated scoring system in cardiac surgery.