EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Long Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound (INVUS) assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, and safe and effective performance of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Short Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, safety and efficacy of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (short version; a long version is published online).

Ultrasound-guided trans-rectal high-intensity focused ultrasound (HIFU) for advanced cervical cancer ablation is feasible: a case report

INTRODUCTION

High-intensity focused ultrasound (HIFU) is an ablative treatment undergoing assessment for the treatment of benign and malignant disease. We describe the first reported intracavitary HIFU ablation for recurrent, unresectable and symptomatic cervical cancer.

CASE DESCRIPTION

A 38 year old woman receiving palliative chemotherapy for metastatic cervical adenocarcinoma was offered ablative treatment from an intracavitary trans-rectal HIFU device (Sonablate® 500). Pre-treatment symptoms included vaginal bleeding and discharge that were sufficient to impede her quality of life. No peri-procedural adverse events occurred. Symptoms resolved completely immediately post-procedure, reappeared at 7 days, increasing to pre-procedural levels by day 30.

DISCUSSION AND EVALUATION

This first time experience of intracavitary cervical HIFU suggests that it is feasible for palliation of advanced cervical cancer, with no early evidence of unexpected toxicity. Ethical approval had also been granted for the use of per-vaginal access if appropriate. This route, alone or in combination with the rectal route, may provide increased accessibility in future patients with a redesigned device more suited to trans-vaginal ablations.

CONCLUSION

Intracavitary HIFU is a potentially safe procedure for the treatment of cervical cancer and able to provide symptomatic improvement in the palliative setting.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

Local ablative procedures of the liver

Local ablative therapies have become an important part in the portfolio of treatment for patients with malignant tumors especially in the liver. Although percutaneous ethanol injection still plays a role, current guidelines favor radiofrequency ablation with a higher efficacy for complete tumor destruction. Nevertheless transplantation and surgical resection remain the gold standard due to their superiority in local control and improved survival. In this manuscript we discuss the technique in detail.

High-intensity focused ultrasound: advances in technology and experimental trials support enhanced utility of focused ultrasound surgery in oncology

High-intensity focused ultrasound (HIFU) is a rapidly maturing technology with diverse clinical applications. In the field of oncology, the use of HIFU to non-invasively cause tissue necrosis in a defined target, a technique known as focused ultrasound surgery (FUS), has considerable potential for tumour ablation. In this article, we outline the development and underlying principles of HIFU, overview the limitations and commercially available equipment for FUS, then summarise some of the recent technological advances and experimental clinical trials that we predict will have a positive impact on extending the role of FUS in cancer therapy.

An EFSUMB introduction into Dynamic Contrast-Enhanced Ultrasound (DCE-US) for quantification of tumour perfusion

Dynamic Contrast Enhanced Ultrasound (DCE-US) is an imaging technique that utilizes microbubble contrast agents in diagnostic ultrasound. The EFSUMB guidelines published in 2004, updated in 2008 and 2011 focused on the use of DCE-US, including essential technical requirements, training, investigational procedures and steps, guidance on image interpretation, established and recommended clinical indications and safety considerations. However the quantification of images acquired with ultrasound contrast agents (UCAs) is not discussed in the guidelines. The purpose of this EFSUMB document is to provide some recommendations and descriptions of the quantification of ultrasound images, technical requirements for analysis of time-intensity curves (TICs), methodology for data analysis, and interpretation of the results.

An unusual finding in the inguinal canal of a 26-week pregnant patient

Inguinal herniae are a common pathology found in both paediatric and adult populations. The presence of bowel in the hernia sac is anticipated; however, occasionally other structures may be found within the sac. We describe a case of a leiomyoma that had undergone red degeneration in the inguinal canal of a 26-week pregnant female. With this case report, we hope to expand the diagnostic paradigm in the setting of a painful swelling in the inguinal canal of a pregnant female.

Primary retroperitoneal mucinous cystadenoma-A case study and review of the literature

INTRODUCTION

Primary retroperitoneal tumours of mucinous type are extremely rare and can be further sub-divided into benign, borderline or cystadenocarcinoma. Prompt diagnosis of retroperitoneal tumours is important as the majority are malignant.

PRESENTATION OF CASE

Our case describes a 30year old woman, presenting with a 3month history of intermittent right iliac fossa pain. Abdominal examination demonstrated a mass palpable in the right iliac fossa. Ultrasonography of the abdomen demonstrated a cystic mass with a magnetic resonance imaging (MRI) scan of the pelvis further defining the lesion. Laparoscopy was performed to further evaluate and ultimately remove the retroperitoneal mass. Macroscopic and microscopic examination reported mucinous epithelium of endocervical type with no evidence of invasion. Findings were consistent with primary retroperitoneal mucinous cystadenoma.

DISCUSSION

This is the 19th reported case of a benign primary retroperitoneal mucinous cystadenoma in the English literature. The origin of mucinous cystadenomas in the retroperitoneum is widely debated with multiple theories suggested. Diagnosis of retroperitoneal tumours is important but difficult as serological investigations, ultrasonography, computed topography and magnetic resonance imaging, although useful, cannot allow a confident diagnosis.

CONCLUSION

Primary retroperitoneal mucinous cystadenoma is a benign tumour, however because of the malignant nature of the majority of mucinous retroperitoneal tumours they should be considered in the differential of chronic abdominal pain despite their rarity.

Transrectal high-intensity focused ultrasonography is feasible as a new therapeutic option for advanced recurrent rectal cancer: report on the first case worldwide

High-intensity focused ultrasonography is the only completely non-invasive thermal therapy. To date its applications have been limited but clinical indications are expanding with enhanced technological advances that have increased the accuracy of targeting and decreased the duration of treatment times. We report its first use for rectal cancer.

Evidence for a synchronous operative approach in the treatment of colorectal cancer with hepatic metastases: a case matched study

BACKGROUND

Traditionally, a staged operative approach has been used for patients with synchronous colorectal cancer and liver metastases in the U.K. With improved outcomes from hepatic resection the role of a synchronous operative approach needs re-evaluated.

METHODS

32 consecutive patients with colorectal cancer and hepatic metastases that underwent a synchronous operative approach were individually case matched (according to: age; sex; ASA grade; type of hepatic and colonic resection) with patients that had undergone a staged approach. The following variables were analysed: operative blood loss; in hospital morbidity and mortality; duration of hospital stay; disease free and overall survival.

RESULTS

Operative blood losses were: synchronous group, median 475mL (range 150-850mL) vs median 425mL (range 50-1700mL), (p>0.050). There were no significant differences in morbidity: (34% synchronous group vs 59%, p=0.690) with no recorded mortality. Synchronous group had a shorter hospital stay (median 12 days [range 8-21] vs 20 [range 7-51], p=0.008). There were no statistical differences between synchronous and staged patients for disease free and overall survival: 10 months (95% CI 5.8-13.7) versus 14 (95% CI 12.2-16.3; p=0.487) and 21% versus 24% at 5 years (p=0.838).

CONCLUSION

This present study provides supporting evidence for synchronous operative procedures in patients with colorectal liver metastases.

Intra-operative examination of the sentinel node in breast cancer

Intra-operative sentinel node analysis allows immediate progression to axillary clearance in patients with node positive breast cancer and reduces the need for re-operation. Despite this, intra-operative sentinel node analysis is infrequently performed in Ireland. We report our experience using this technique. Sentinel node biopsy was performed in 47 consecutive patients with symptomatic T1-T2 clinically node negative breast cancer. Sentinel nodes were examined intra-operatively by frozen section and imprint cytology and definitive histological assessment was performed on paraffin-embedded tissue. The sentinel node was identified in 46 (98%) patients. Twelve patients had axillary metastases. The sensitivity of intra-operative analysis in identifying nodal metastases was 92%. False negative rate was 8%, negative predictive value 97%, and specificity 100%. Intra-operative analysis of the sentinel node allowed re-operation to be avoided in 92% of patients with axillary node metastases. In our experience this technique can be readily introduced with reliable outcomes.

Selective continuous vascular occlusion and perioperative fluid restriction in partial hepatectomy. Outcomes in 101 consecutive patients

BACKGROUND

This study documents patient outcomes with one department's approach to performing partial hepatectomy.

METHODS

101 consecutive patients underwent: preoperative dehydration; intraoperative CVP <5 cm H(2)O and selective continuous vascular occlusion.

OUTCOME VARIABLES

pathology; type of hepatic resection; intraoperative blood loss and transfusion rate; 30 day morbidity and mortality; disease free and long term survival. Perioperative liver function was assessed by serial blood sampling.

RESULTS

Of 101 resections: 90% malignant disease; 59% major resections and 35% synchronous procedures. Median estimated blood loss was 400 mL (mean 512 mL, range 50-3000 mL) with postoperative transfusions in 4%. Thirty day morbidity was 20% with no deaths. Median time to local recurrence after colorectal liver metastases resection was 17.1 months with 3 year survival of 51%. Distinct perioperative changes in hepatic function were seen.

CONCLUSION

Selective continuous vascular occlusion and perioperative fluid restriction result in minimal blood loss, low morbidity and zero mortality in patients undergoing partial hepatectomy.

The renal sequelae of a novel triphasic approach to blood loss reduction during hepatic resection

AIMS

To report our novel triphasic approach to minimising blood loss during hepatic resection and the renal sequelae.

METHODS

Fifty consecutive patients (median age 63.3 years, range 37-86) underwent hepatic resection. Triphasic approach consisted of: pre-operative bowel preparation with no supplementary fluids; intraoperative intravenous fluid restriction with low central venous pressure (<5 cmH2O) and continuous selective occlusion of the left or right portal structures and corresponding hepatic vein/s. The following variables were analysed: blood loss; transfusion requirements; perioperative renal function; perioperative morbidity and mortality.

RESULTS

Median estimated blood loss was 330 mL (range 50-1200). No patient was transfused intraoperatively, with two patients transfused post-operatively. Median intraoperative urine output prior to hepatic re-perfusion was 28.4 mL/h (range 13.3-40.0) with no patient developing renal impairment. Morbidity occurred in 22% of patients with no documented hepatic failure. There was zero 30-day mortality.

CONCLUSIONS

Pre-operative dehydration and intraoperative fluid restriction combined with continuous selective vascular occlusion minimizes blood loss during hepatic resection with no consequent detriment to renal function.

Acromegaly secondary to growth hormone releasing hormone secretion

BACKGROUND

Acromegaly secondary to growth hormone releasing hormone (GHRH) secretion is exceptionally rare.

AIM

To report a case of acromegaly diagnosed in 1984 and assumed to be pituitary in origin. Sixteen years later, the cause was found to be a GHRH secreting neuroendocrine pancreatic tumour.

METHOD

A case report.

CONCLUSION

Although ectopic GHRH production is very rare, endocrinologists should be aware of this possibility in acromegaly patients if a pituitary tumour was not detected using pituitary imaging.

The relationship between hypoalbuminaemia, tumour volume and the systemic inflammatory response in patients with colorectal liver metastases

The relationship between hypoalbuminaemia, tumour volume and C-reactive protein was examined in patients with colorectal liver metastases (n=57). On multiple regression analysis, albumin concentrations were independently associated with C-reactive protein (r=0.56, P<0.001) but not percentage hepatic replacement (P=0.34). These results show that hypoalbuminaemia is associated with the presence of a systemic inflammatory response rather than tumour volume in patients with colorectal liver metastases.

A novel application of ultrasound contrast: demonstration of splenic arterial bleeding

Recent research in the use of ultrasound contrast agents has found they are able to increase the diagnostic power of ultrasound, to a level that may exceed other imaging modalities, in the diagnosis of liver lesions. Their application in the assessment of haemorrhage following angiographic embolisation has not previously been described. We report on a case where metal coil embolisation of a bleeding splenic artery aneurysm was completed to angiographic satisfaction, but on injection of ultrasound contrast medium, the aneurysm, distal to the embolisation, showed the presence of ultrasound contrast medium within it. We suggest that contrast enhanced ultrasound may be more sensitive than conventional angiography in the assessment of blood flow through intra-abdominal small vessel aneurysms or solid organs.

Recurrent aneurysmal fibrous histiocytoma

Aneurysmal fibrous histiocytoma is a rare variant of cutaneous fibrous histiocytoma that results from blood vessel proliferation and haemorrhage into a fibrous histiocytoma. The resulting lesion has a very different clinical appearance, hence the potential confusion with other skin lesions. This report describes the case of a 48 year old woman with a recurrent fibrous histiocytoma with prominent vasculature, which over a three year period recurred on two occasions, showing more progressive features of the aneurysmal variant. In addition, squamous lined cysts were present within this tumour, a finding that has not been described previously. The histological features of this rare lesion and the importance of the differential diagnosis from other similar appearing malignant lesions will be discussed.

Cytokeratin 7/20 and mucin expression patterns in oesophageal, cardia and distal gastric adenocarcinomas

AIMS

The current study examined cytokeratin (CK)7 and 20 as well as MUC1-6 immunoprofiles in oesophageal, gastric and gastro-oesophageal junction (GOJ) adenocarcinomas. The aim was to compare expression patterns in these locations as aids to accurate classification of these morphologically similar carcinomas which all may involve the GOJ.

METHODS AND RESULTS

Tissue microarrays were constructed using tissue from 14 oesophageal, 78 gastric and 39 GOJ adenocarcinomas. Sections were immunostained with CK7, CK20, MUC1, MUC2, MUC5AC and MUC6. The results of this study showed no differences in CK7 and CK20 expression patterns in the three locations. MUC2 expression was higher proximally (43% of oesophageal, 28% of GOJ and 17% of gastric carcinomas) and MUC6 expression was higher distally (7% of oesophageal, 28% of GOJ and 15% of gastric carcinomas). MUC1 expression was associated with higher pTNM-stage.

CONCLUSIONS

CK 7/20 profiles have no role in distinguishing tumours of the three locations. Mucin expression patterns differed in oesophageal and gastric adenocarcinomas, although not sufficiently to classify individual cases. GOJ adenocarcinomas showed a mucin expression pattern that was partly 'gastric', and partly 'oesophageal'. MUC1 expression was associated with a higher pTNM stage.

Effect of neoadjuvant chemoradiotherapy on angiogenesis in oesophageal cancer

Background

Vascular endothelial growth factor (VEGF) levels are raised in the serum of patients with oesophageal carcinoma. The aim of this study was to evaluate the tumour microvasculature and the role of tumour-associated macrophages in VEGF production after neoadjuvant chemoradiotherapy and surgery for oesophageal cancer.

Methods

Sections from 92 consecutively resected oesophageal tumours were stained for VEGF, von Willebrand factor and CD68. Twenty-seven patients received preoperative chemoradiation and 65 underwent surgical excision alone. The cellular source of VEGF was determined by parallel-section staining. Microvessel density and macrophage count were determined for each tumour by means of image analysis software.

Results

There were no significant differences between the two groups in age, sex or tumour type. Local downstaging of disease was evident in most specimens of tumours that had received preoperative chemoradiation. All tumours stained positive for VEGF, including those demonstrating a complete pathological response. Staining of parallel sections confirmed macrophages as the principal source of VEGF. Mean microvessel density was 6·4 per high-power field (h.p.f.) in tumours that received preoperative chemoradiation compared with 5·3 per h.p.f. in those treated by surgery alone (P = 0·130). A significant increase in tumour-associated macrophage infiltration was noted in tumours treated with neoadjuvant chemoradiation (22·1 per h.p.f.) compared with those treated by surgery alone (14·3 per h.p.f.) (P = 0·042).

Conclusion

Preoperative chemoradiation had little effect on the local angiogenic profile of the tumour in patients with oesophageal cancer. Tumour-infiltrating macrophages seem to be the source of persistent VEGF production after chemoradiotherapy and might explain the raised serum levels. Addition of an antiangiogenic agent to this regimen may be worthwhile in patients with oesophageal carcinoma.

Multi-centre clinical study evaluating the efficacy of SonoVue (BR1), a new ultrasound contrast agent in Doppler investigation of focal hepatic lesions

OBJECTIVES

SonoVue is a new ultrasound contrast agent, which consists of stabilised microbubbles of a sulphur hexafluoride gas. The aim of the study was to assess its efficacy in the Doppler investigation of focal hepatic lesions.

MATERIALS AND METHODS

Seventy patients with focal liver tumours were studied. Four doses (0.3, 0.6, 1.2 and 2.4 ml) of SonoVue were administered intravenously with at least 10 min delay between each injection. A complete colour/power and spectral Doppler imaging investigation of the lesions was performed at baseline pre-dosing and after each SonoVue injection. All examinations were recorded on SVHS videotapes. Baseline and post contrast videotapes were reviewed by the on-site (un-blinded) investigators and by two off-site blinded readers (a) to grade the global quality of the Doppler scans of the focal lesions vascularity and the normal parenchymal vessels (b) to measure the duration of clinically useful Doppler signal enhancement and (c) to determine the diagnostic accuracy and performance of the enhanced versus unenhanced scans using histopathology, tumour markers, CT and/or MR as the reference standard.

RESULTS

A statistically significant improvement was observed at all four SonoVue doses in the off site assessment of global quality of the Doppler examination of tumoral and normal parenchymal vessels in comparison with the baseline (P < 0.05). The median duration of clinically useful enhancement was significantly increased with increasing doses (P < 0.001), ranging between 1.4-2.2 min for the lowest dose and 3.2-3.8 min for the highest dose for the off-site readers. On-site assessment of diagnostic accuracy showed a significant increase in the specificity of the Doppler diagnoses (P < 0.0016) with an increase in the positive and negative predictive values and in the likelihood ratio in differentiating between benign and malignant lesions. Off-site evaluation showed a significant increase in the accuracy of enhanced Doppler diagnosis in comparison with the baseline performance.

CONCLUSION

The results suggest that SonoVue is effective in improving the display of tumoral vascularisation and may be useful in the characterisation of focal liver lesions.

A simple technique for vascular control during hepatectomy: the half-Pringle

BACKGROUND

Hemorrhage during hepatectomy remains the major cause of morbidity and mortality associated with this surgery. Traditionally, a Pringle technique is employed to reduce vascular inflow during parenchymal transection.

METHODS

This paper describes a simple method to achieve unilateral vascular control during hepatic surgery. The technique has been used in the most recent 10 hepatectomies performed in this unit.

RESULTS

During the hepatectomies, the pattern of vascular inflow was documented with a series of color Doppler images. These images illustrated the effectiveness of the maneuver.

Ultrasound contrast harmonic imaging of abdominal organs

Ultrasound contrast agents consist of microbubbles, which are the most effective acoustic backscatters. The interaction between the insonating ultrasound beam and the microbubbles is very complex and basic understanding of their behavior under various sound fields has been fundamental to the development of improved methods of visualizing and displaying the contrast agents. Although echo enhancers have been under development for a long time, their clinical applications have been limited to enhancing the Doppler signals in difficult cases. However, recent advances in harmonic imaging and the development of new tissue-specific contrast agents stand to broaden the scope of ultrasound diagnostic potential beyond simply rescuing failed Doppler examinations. This article reviews the current and potential applications of ultrasound contrast harmonic imaging in the abdomen.

Ultrasound contrast harmonic imaging of abdominal organs

Ultrasound contrast agents consist of microbubbles, which are the most effective acoustic backscatters. The interaction between the insonating ultrasound beam and the microbubbles is very complex and basic understanding of their behavior under various sound fields has been fundamental to the development of improved methods of visualizing and displaying the contrast agents. Although echo enhancers have been under development for a long time, their clinical applications have been limited to enhancing the Doppler signals in difficult cases. However, recent advances in harmonic imaging and the development of new tissue-specific contrast agents stand to broaden the scope of ultrasound diagnostic potential beyond simply rescuing failed Doppler examinations. This article reviews the current and potential applications of ultrasound contrast harmonic imaging in the abdomen.

The effect of resecting the primary tumour on the Doppler Perfusion Index in patients with colorectal cancer

AIM

In patients undergoing apparently curative resection for colorectal cancer, an elevated Doppler Perfusion Index (DPI; ratio of hepatic arterial to total liver blood flow) before surgery is associated with a high risk of recurrence. The role of the primary tumour in inducing and sustaining these blood flow changes is unknown. The aim of this study was to assess the impact of removing the primary tumour on the DPI.

MATERIALS AND METHODS

Using duplex/colour Doppler sonography, the DPI was measured both before and after surgery (median, 9 months) in 14 patients undergoing apparently curative resection for colorectal cancer.

RESULTS

In the five patients with a normal pre-operative DPI (< 0.30), there was no significant change following surgery. In the nine patients with an abnormal pre-operative DPI, there was a small but significant fall from 0.38 (SEM 0.02) to 0.33 (0.02) following surgery (P = 0.04). However, DPI values remained abnormally elevated in seven of these nine patients.

CONCLUSION

These results suggest that the primary tumour plays a relatively minor role in inducing an abnormally elevated DPI in patients undergoing apparently curative resection for colorectal cancer.Oppo, K. (2000). Clinical Radiology55, 791-793.

Improved characterisation of focal liver tumours: dynamic power Doppler imaging using NC100100 echo-enhancer

OBJECTIVE

To assess the vascularisation of focal hepatic tumours using NC100100, enhanced power Doppler imaging.

METHODS

Twenty-two patients with focal liver tumours (12 metastases and ten hemangiomas) were studied. Using standardised settings, power Doppler imaging with ATL HDI3000 was performed before and after intravenous administration of NC100100 contrast agent. The video-recorded examinations were digitised for off-line analysis on a personal computer. Regions of interest were defined over the entire tumour and a neighbouring area of the normal liver parenchyma. The temporal changes of the mean power Doppler signal intensity (PDSI) was quantified to provide contrast agent wash-in (PDSI-time) curves for the initial 40 s.

RESULTS

Liver metastases were characterised by a rapid increase in PDSI, while the PDSI-time curves within hemangiomas were flat. The PDSI within the tumour increased significantly in ten subjects with liver metastases and only one subject with hemangioma. An enhanced rim around hemangiomas was seen in four subjects. There was no clear relationship between the contrast agent dose and the peak PDSI within metastases.

CONCLUSIONS

Power Doppler imaging with NC100100 contrast agent enhances tumour visualisation and may aid differential diagnosis of focal liver lesions.

Potential role of doppler perfusion index in selection of patients with colorectal cancer for adjuvant chemotherapy

BACKGROUND

As yet there is no established method of accurately identifying patients with colorectal cancer who, despite undergoing apparently curative resection, are at high risk of recurrence. We assessed whether the doppler perfusion index (DPI; ratio of hepatic arterial to total liver blood flow) could be used to select patients who should receive adjuvant chemotherapy.

METHODS

We studied 120 patients undergoing curative surgery for colorectal cancer. DPI was measured before surgery with colour duplex doppler ultrasonography. A DPI value of at least 0.3 was defined as abnormal. All patients were followed up until death or for at least 5 years.

RESULTS

At 5 years, patients with Dukes' stage A or B tumours (n=61) had recurrence-free survival of 57% and overall survival of 64%, compared with 39% and 42% for patients with Dukes' stage C tumours (n=59; p=0.016 and p=0.008, respectively). 47 patients had normal DPI values and 73 patients had abnormal values. Patients with normal DPI had recurrence-free survival of 89% and overall survival of 91%, compared with 22% and 29% for those with abnormal DPI values (both p<0.0001).

CONCLUSIONS

DPI can be used to identify patients with colorectal cancer at high risk of recurrence who are in need of adjuvant treatment. However, further studies with larger numbers of patients are needed to confirm these findings.

Liver-specific imaging with SHU 563A: diagnostic potential of a new class of ultrasound contrast media

The purpose of this study was to evaluate the imaging properties and diagnostic potential of the novel polymeric ultrasound contrast agent SHU 563 A. After i. v. injection, the agent circulates in the blood pool for about 10 min and is then subsequently sequestered by the RES cells predominantly in the liver. The acoustic emission capabilities enable a very sensitive detection during the blood pool phase and after uptake in the RES cells, contributing to differential diagnosis as well as detection of liver lesions. During a multicenter study, 28 patients with liver lesions were examined. In all patients the results were compared to baseline ultrasound and Contrast enhanced Spiral CT. With respect to lesion size and location, very good agreement between SHU 563 A ultrasound and Spiral CT was achieved. Additional lesions could be shown in the RES phase by SHU 563 A enhanced ultrasound. 26 further patients were examined in other indications. The results in all 54 patients indicate good safety and tolerance of SHU 563 without limitations for diagnostic use. SHU 563 A enhanced ultrasound adds significantly to the detection and delineation of focal liver lesions by improving conspicuity due to RES based contrast after uptake.

Fatal phenytoin hypersensitivity syndrome

The phenytoin (hydantoin) hypersensitivity syndrome is rare but potentially fatal. Often, as in this case, it presents with non-specific symptoms and signs, requiring a high degree of clinical suspicion for diagnosis.

The effect of sibutramine on resting energy expenditure and adrenaline-induced thermogenesis in obese females

BACKGROUND

Sibutramine, an inhibitor of serotonin and noradrenaline uptake, reduces appetite to cause weight loss. This study tested the hypothesis that an increase in energy expenditure also contributes to this weight loss. In addition, the effects of sibutramine on adrenaline induced changes in heart rate and cardiac output were determined

METHODS

Nineteen obese females randomly received either sibutramine 15 mg daily or placebo for 12 weeks along with dietary advice. Resting energy expenditure (REE) was measured and then energy expenditure was measured during a 30 min infusion of adrenaline (25 ng/min/kg IBW). Cardiac output and heart rate, measured by Duplex Colour Doppler ultrasonography, were similarly measured in the basal state and post adrenaline. All measurements were recorded at baseline and then after 12 weeks.

RESULTS

Ten patients who received sibutramine reduced their weight by 8.1+/-3.8% while 9 placebo treated subjects reduced their weight by 5.1+/-4.4%, P=0.13. In absolute terms, REE decreased in placebo subjects from 1500+/-201 kcal/24 h to 1357+/-231 kcal/24 h (9.4+/-9.9%) and in sibutramine subjects from 1540+/-184 kcal/24 h to 1444+/-128 kcal/24 h (5.3+/-12.0%), P=0.77. The increased weight loss in the sibutramine group was associated with an increase in the FFM adjusted REE (2.2+/-16.1%) unlike the expected decrease (5.8+/-9.5%) in the placebo group (P=0.11). There was some suggestion (P=0.09) that the usual positive correlation between loss of weight and decline in REE was lost in the sibutramine group (r=-0.30) compared with placebo (r=0.35). There was a negative correlation between loss of FFM and decline in REE/kg FFM and (P=0.029) which was not evident in placebo (P=0.83). Adrenaline induced energy expenditure was similar in the two groups at the end of the 12 week period and there were no significant cardiovascular changes between the two groups.

CONCLUSIONS

Sibutramine limits the decline in REE associated with weight loss, equivalent to about 100 kcal/d. This could allow greater numbers of people to maintain a greater degree of weight loss.

The detection of occult liver metastases of colorectal carcinoma

Despite undergoing an apparently curative surgery, over 50% of colorectal cancer patients will die within 5 years, the majority within the first 2 years from disseminated disease. Occult liver metastases are reported to be present in approximately 30% of patients and they predominantly determine the likelihood of dying from disseminated disease. The question is how to detect these occult hepatic metastases. This article reviews some of the alternative techniques, such as dynamic scintigraphy, functional computerized tomography, and duplex colour Doppler sonography (DCDS), which have been developed to predict which patients harbor these occult metastases. More recently, DCDS measurements of the Doppler perfusion index (DPI: ratio of hepatic arterial to total liver blood flow) have been shown to be highly accurate in the detection of these occult liver metastases. In addition, irrespective of Dukes stage, patients with abnormal DPI were shown to have a very poor outcome while for those with normal DPI, the prognosis was excellent. If the data are reproduced, the administration of adjuvant chemotherapy should be based on DPI status rather than Dukes stage.

Evaluation of a follow-up programme after curative resection for colorectal cancer

Frequent liver imaging can detect liver metastases from colorectal cancer at an asymptomatic stage.

Hepatic blood flow changes in chronic hepatitis C measured by duplex Doppler color sonography: relationship to histological features

Our aim was to determine if portal vein and hepatic artery blood flow indices are a noninvasive index of severity of liver disease in chronic hepatitis C. The effect of interferon-alpha treatment on liver blood flow was also studied. Liver blood flow measurements were recorded by duplex Doppler color sonography in 39 patients with chronic hepatitis C, 50 healthy controls, and a single patient with hepatocellular carcinoma. Doppler perfusion index (DPI) (calculated as the ratio of hepatic artery flow to total hepatic flow) and the congestive index of the portal vein (area/velocity) were calculated. Liver biopsies were scored for hepatic inflammation and fibrosis. Hepatic arterial flow (415.7+/-329.1 ml/min vs 195.1+/-103.5 ml/min) and DPI (0.27+/-0.14 vs. 0.17+/-0.06) were elevated in chronic hepatitis C patients compared to controls (P = 0.0002 and 0.0003, respectively) while portal vein flow and total hepatic flow were similar. Portal vein congestive index was similar in chronic hepatitis C (0.106+/-0.05) compared to controls (0.125+/-0.08) P 0.52. Hepatic blood flow indices were not related to the grade of hepatic inflammation or the stage of hepatic fibrosis. Twelve weeks of treatment with interferon-alpha had no effect on liver blood flow. In conclusion, patients with chronic hepatitis C have elevated hepatic artery blood flow. Hepatic blood flow indices have no relationship to the severity of histological liver injury in chronic hepatitis C, and these flow indices are unaffected by a 12-week course of interferon-alpha.