Molecular Diagnostics and [18F]FDG-PET/CT in Indeterminate Thyroid Nodules: Complementing Techniques or Waste of Valuable Resources?

Background: An accurate preoperative workup of cytologically indeterminate thyroid nodules (ITN) may rule out malignancy and avoid diagnostic surgery for benign nodules. This study assessed the performance of molecular diagnostics (MD) and 2-[18F]fluoro-2-deoxy-d-glucose ([18F]FDG)-positron emission tomography/computed tomography (PET/CT) in ITN, including their combined use, and explored whether molecular alterations drive the differences in [18F]FDG uptake among benign nodules. Methods: Adult, euthyroid patients with a Bethesda III or IV thyroid nodule were prospectively included in this multicenter study. They all underwent MD and an [18F]FDG-PET/CT scan of the neck. MD was performed using custom next-generation sequencing panels for somatic mutations, gene fusions, and copy number alterations and loss of heterozygosity. Sensitivity, specificity, negative and positive predictive value (NPV, PPV), and benign call rate (BCR) were assessed for MD and [18F]FDG-PET/CT separately and for a combined approach using both techniques. Results: In 115 of the 132 (87%) included patients, MD yielded a diagnostic result on cytology. Sensitivity, specificity, NPV, PPV, and BCR were 80%, 69%, 91%, 48%, and 57% for MD, and 93%, 41%, 95%, 36%, and 32% for [18F]FDG-PET/CT, respectively. When combined, sensitivity and specificity were 95% and 44% for a double-negative test (i.e., negative MD plus negative [18F]FDG-PET/CT) and 68% and 86% for a double-positive test, respectively. Concordance was 63% (82/130) between MD and [18F]FDG-PET/CT. There were more MD-positive nodules among the [18F]FDG-positive benign nodules (25/59, 42%, including 11 (44%) isolated RAS mutations) than among the [18F]FDG-negative benign nodules (7/30, 19%, p = 0.02). In oncocytic ITN, the BCR of [18F]FDG-PET/CT was mere 3% and MD was the superior technique. Conclusions: MD and [18F]FDG-PET/CT are both accurate rule-out tests when unresected nodules that remain unchanged on ultrasound follow-up are considered benign. It may vary worldwide which test is considered most suitable, depending on local availability of diagnostics, expertise, and cost-effectiveness considerations. Although complementary, the benefits of their combined use may be confined when therapeutic consequences are considered, and should therefore not routinely be recommended. In nononcocytic ITN, sequential testing may be considered in case of a first-step MD negative test to confirm that withholding diagnostic surgery is oncologically safe. In oncocytic ITN, after further validation studies, MD might be considered. Clinical Trial Registration: This trial is registered with ClinicalTrials.gov: NCT02208544 (August 5, 2014), https://clinicaltrials.gov/ct2/show/NCT02208544.

Persistent chronic peri-aortitis (‘inflammatory aneurysm’) after abdominal aortic aneurysm repair: systematic review of the literature

Abstract

Data on the outcome of aneurysmal chronic peri-aortitis (‘inflammatory aneurysm’) after open surgical aneurysm repair are few and contradictory. To what extent this inflammatory process is reversed after endovascular aneurysm repair (EVAR) is even more unclear. The objective of this review was to study the outcome of peri-aortic fibrosis (PAF) and ureteral obstruction in patients with aneurysmal chronic peri-aortitis treated with open surgery or EVAR. Medical literature was searched for pertinent articles on the outcome of PAF and ureteral obstruction after open surgery or EVAR from 1970 through October 2007. Studies were included if specific follow-up data were available on outcomes of interest. A total of 19 studies were included comprising 478 patients (open surgical, n = 426; EVAR, n = 52). Age, sex and percentage of patients with ureteral obstruction (31% vs 37%) did not differ between groups. Regression of PAF occurred more frequently after open surgery compared to EVAR (86% vs 60%; p < 0.0001). Complete regression of PAF was more frequent after open surgery compared to EVAR (52% vs 14%; p < 0.0001). After excluding patients in whom concurrent ureterolysis was performed, the frequency of persistent ureteral obstruction remained lower in patients treated surgically compared to patients treated with EVAR, albeit not statistically significant (32% vs 56%; p = 0.09). In conclusion, although open surgery is superior to EVAR in achieving regression of chronic peri-aortitis, the frequency of persistent PAF and/or ureteral obstruction is not negligible. Additional medical and/or urological treatment should be considered in selected cases of aneurysmal chronic peri-aortitis.

The incidence of sudden cardiac death in the general population

BACKGROUND AND OBJECTIVES

To determine the incidence of sudden cardiac death in a general (Dutch) population.

METHODS

Cohort study in the Integrated Primary Care Information (IPCI) project, a database with all medical data from 150 general practices in The Netherlands. The study population comprised 249,126 subjects with a mean follow-up of 2.54 years.

RESULTS

In this period 4,892 deaths were identified, 582 of which were classified as (probable) sudden cardiac death. The overall incidence of sudden cardiac death in this population was 0.92 cases per 1,000 person-years (95%CI: 0.85-0.99). The risk was 2.3-fold higher in men than in women, and increased with age. The incidence of sudden cardiac death peaked in October and was lowest in August.

CONCLUSIONS

The incidence of sudden cardiac death in the general Dutch population was almost 1 per 1,000 person-years per year during the period 1 January, 1995 to 1 April, 2001. Most of the cases occurred at home.

Treatment Strategies, Patterns of Drug Use and Treatment Discontinuation in Men with LUTS Suggestive of Benign Prostatic Hyperplasia: The Triumph Project

OBJECTIVES

We aimed to describe treatment strategies for lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH), adherence to and persistence with pharmacological treatment and the association between the type of LUTS/BPH complaints and early treatment discontinuation.

METHODS

Within a large GP database (IPCI) in the Netherlands we identified all males > or =45 years newly diagnosed with LUTS/BPH during 1995-2000. Details on treatment were assessed from the electronic patient records. Logistic regression analysis was used to estimate the association between the type of main urinary complaints and early treatment discontinuation.

RESULTS

Of the 2214 men with incident LUTS/BPH, 1075 received pharmacological treatment and 238 underwent prostate surgery. The average adherence differed slightly between drugs: 67% for alpha-blockers, 73% for 5alpha-reductase inhibitors and 71% for combination therapy. 26% of the treated patients discontinued treatment early. The probability of early discontinuation was higher if patients mainly expressed one type of complaint: voiding (OR(adj) 3.38; 95%CI: 1.89-6.04), post micturition (OR(adj) 2.37; 95%CI: 1.15-4.87) or storage symptoms (OR(adj) 1.85; 95%CI: 1.16-2.95) as compared to patients expressing a combination of symptoms. The risk of early discontinuation was higher if patients had a normal PSA measurement. Older age and a higher chronic disease score protected against early treatment discontinuation.

CONCLUSIONS

Almost half of newly diagnosed LUTS/BPH patients are pharmacologically treated, and a quarter discontinues very rapidly. Stopping early is more frequent among younger persons, persons with only one type of main urinary complaint, no other co-morbidity and a normal PSA.

Fatal combination of moclobemide overdose and whisky

The antidepressant moclobemide (Aurorix) is a reversible inhibitor of monoamine oxidase-A. Pure moclobemide overdose is considered to be relatively safe. Mixed drug overdoses including moclobemide are potentially lethal, especially when serotonergical drugs are involved. So far, only one fatality due to moclobemide mono-overdose has been reported. We report here on a fatality following the ingestion of a moclobemide overdose in combination with half a bottle of whisky. Although dietary restrictions during moclobemide therapy are not considered necessary, the combination of large quantities of moclobemide and tyramine-containing products seems to be lethal, probably because monoamine oxidase-A selectivity is overwhelmed after massive overdoses. Since there is no specific antidote and treatment is only symptomatic, the severity of an overdose with moclobemide must not be underestimated.

Incidence and prevalence of lower urinary tract symptoms suggestive of benign prostatic hyperplasia in primary care--the Triumph project

OBJECTIVE

Benign prostatic hyperplasia (BPH) is one of the most common conditions associated with ageing in men. BPH often presents as lower urinary tract symptoms (LUTS) due to difficulties in voiding and irritability of the bladder. We conducted a retrospective cohort study within the Integrated Primary Care Information (IPCI) database, a general practitioners database in The Netherlands, to assess the incidence of LUTS suggestive of BPH (LUTS/BPH) in the general population.

MATERIALS

Our study population comprised all males, 45 years or older who were registered for at least 6 months prior to start of follow-up. The study period lasted from 1 January 1995 to 31 December 2000. Cases of LUTS/BPH were defined as persons with a diagnosis of BPH, treatment or surgery for BPH, or urinary symptoms suggestive of BPH that could not be explained by other co-morbidity.

RESULTS

The study cohort comprised 80,774 males who contributed 141,035 person-years of follow-up. We identified 2181 incident and 5605 prevalent LUTS/BPH cases. The overall incidence rate of LUTS/BPH was 15 per 1000 man-years (95% CI: 14.8-16.1). The incidence increased linearly (r(2) = 0.99) with age from three cases per 1000 man-years at the age of 45-49 years (95% CI: 2.4-3.6) to a maximum of 38 cases per 1000 man-years at the age of 75-79 years (95% CI: 34.1-42.9). After the age of 80 years, the incidence rate remained constant. For a symptom-free man of 46 years, the risk to develop LUTS/BPH over the coming 30 years, if he survives, is 45%. The overall prevalence of LUTS/BPH was 10.3% (95% CI: 10.2-10.5). The prevalence rate was lowest among males 45-49 years of age (2.7%) and increased with age until a maximum at the age of 80 years (24%).

CONCLUSIONS

The incidence rate of LUTS/BPH increases linearly with age and reaches its maximum at the age of 79 years.

Pergolide-induced pleuropulmonary fibrosis

Pleuropulmonary fibrosis is a rare, but well-recognized adverse effect of ergot alkaloids. We report on four patients who developed pleural and/or pulmonary fibrosis during treatment with pergolide and give characteristics of 87 cases with one or more symptoms of serosal fibrosis. Retroperitoneal and pleuropulmonary fibrosis are serious conditions, which are often irreversible after drug withdrawal. Increased awareness may help to diagnose these complications at an earlier stage and to minimize any permanent damage to the patient.

[Drug-induced heart failure]

Although heart failure is predominantly caused by cardiovascular disorders, several classes of drugs may induce heart failure in patients with pre-existing normal left ventricular function or may precipitate the occurrence of heart failure in patients with left ventricular impairment. These drugs are predominantly those belonging to the categories of cytostatics, anti-arrhythmics, beta-blockers, nonsteroidal anti-inflammatory drugs, calcium channel blockers and anaesthetics. Drug-induced heart failure should be regarded as a potentially preventable cause of heart failure, although sometimes therapeutic alternatives are scarce (e.g. anthracycline-induced cardiomyopathy). Awareness of the possibility of adverse effects on cardiac performance by several classes of drugs, particularly in patients with pre-existing ventricular impairment, may contribute to prevention or timely diagnosis and treatment of drug-induced heart failure.