The Role of the New Imaging Modalities in the Investigation of Menière's Disease

Thirty one patients with Menière's disease investigated with HRCT and MRI of the inner ear are presented. The parameters evaluated were:

a) Pneumatization of the petrous bone, b) Width of the vestibular aqueduct (VA) in its postisthmic segment, c) Visualization of the endolymphatic duct (ELD).

A similar survey was performed in other 50 patients with no previous history of ear disease which served as controls. There was evidence of statistically significant differences in the pneumatization of the petrous bones (p<0.05), as well as the width of the vestibular aqueducts (p<0.001) between the two groups of patients. Also the percentage of the visualized endolymphatic ducts was higher in the control group as compared to the patients with Menière's disease (p<0.05).

Self-efficacy beliefs and levels of anxiety in advanced cancer patients

The aims of this study were to investigate the self-efficacy and anxiety in advanced cancer patients in a palliative care unit. The subject is some 99 advanced cancer patients, treated for pain relief and cancer-related symptoms. Patients completed the General Perceived Self-Efficacy Scale (GSE) and the Spielberger's State-Trait Anxiety Inventory (STAI). The Eastern Cooperative Oncology Group was used to measure patients' performance status. Statistically significant associations were found between GSE, patients' gender, performance status, opioids and all the STAI scales. The multiple regression analysis revealed that self-efficacy was predicted by patients' age, performance status, gender, as well as by their high levels on two STAI scales, in a model explaining 39.7% of the total variance. In advanced cancer patients, self-efficacy is significantly correlated with levels of anxiety, patients' physical condition and demographic characteristics. Also, it seems to be influenced by components of the STAI, patients' age, physical performance and gender.

How is sleep quality affected by the psychological and symptom distress of advanced cancer patients?

The aim of this study was to assess the relationship between sleep quality, pain, psychological distress, cognitive status and post-traumatic experience in advanced cancer patients. Participants were 82 advanced cancer patients referred to a palliative care unit for control of pain and other symptoms. A variety of assessment tools were used to examine the prevalence of sleep disturbance, the severity of pain and depression, hopelessness, cognitive function and quality of life. Using the Pittsburgh Sleep Quality Index (PSQI) 96% of patients were 'poor sleepers'. Statistically significant associations were found between PSQI and the SF-12 (Short Form-12) Quality of Life Instrument (MCS, P < 0.0005, PCS, P < 0.0005), depression (Greek Depression Inventory) (P < 0.0005) and hopelessness (Beck Hopelessness Scale) (P = 0.003). Strong associations were also found between PSQI and IES-R (Impact of Event Scale-Revised) (P = 0.004). The strongest predictors of poor sleep quality in this model were MCS (P < 0.0005), PCS (P < 0.0005) and IES-R (P = 0.010). Post-traumatic experience and quality of life seemed to be the strongest predictors of sleep quality in a sample of advanced cancer patients referred for palliative care.

Beck Depression Inventory: exploring its psychometric properties in a palliative care population of advanced cancer patients

To validate the Greek version of the Beck Depression Inventory (BDI)-21 items in advanced cancer patents attending a palliative care unit. The scale was translated with the forward-backward procedure into Greek. It was administered twice, with a 1-week interval, to 105 patients with advanced cancer. The patients also completed the Hospital Anxiety and Depression (HAD) scale, while researchers recorded data on demographic characteristics, disease status and treatment regimen. The Greek version of the BDI had overall Cronbach's alpha 0.906. The most significant correlations were found between BDI and performance status (P < 0.0005), gender (P = 0.031) and family status (P = 0.009). The test-retest reliability in terms of Spearman-rho, Pearson-rho coefficient and Kendall's tau-b was also satisfactory (P < 0.0005). Validity as performed using known-group analysis showed good results. The Inventory discriminated well between subgroups of patients differing in disease severity as defined by the Eastern Cooperative Oncology Group performance status. Correlations between the BDI and the HAD scale was 0.544 for the anxiety subscale and 0.657 for the depression subscale. Multiple regression analysis was conducted and predicted that the contribution of gender, family status and performance status to BDI is high. These psychometric properties of the Greek version of the BDI confirm it as a valid and reliable measure when administered to patients with advanced cancer.

Ibandronate reduces radiotherapy-resistant metastatic bone pain in patients with solid tumors: A comparison of i.v. and oral formulations

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Background: Bisphosphonates are used to treat metastatic bone disease (MBD). However, some bisphosphonates are associated with renal toxicity. Ibandronate (IA) is a single-nitrogen, noncyclic bisphosphonate with a renal safety profile similar to placebo in phase III trials. This study compares the effects of i.v. IA 6mg and oral IA 50mg on bone pain, analgesic intake and renal safety. Methods: Recruited patients fulfilled the following criteria: age ≥18, solid tumors with at least one bone lesion, normal renal (serum creatinine ≤1.5mg/dL) and hepatic function, WHO performance status 0, I or II, life expectancy ≥6 months, normal serum calcium or asymptomatic hypercalcemia. Patients were excluded if they were pregnant or lactating, taking nephrotoxic drugs or osteoclast activity modulators. Eligible patients (n=52) were recruited for a two-arm study, with 26 patients per group treated over 6 months. Groups were matched for age, gender, weight, height, blood pressure, site of primary tumor, site and number of bone metastases and number of irradiated sites. Intravenous IA 6mg was administered over 15 minutes every 4 weeks. Oral IA 50mg was administered as a single, daily tablet before breakfast. Studies were ceased on occurrence of new bone events. Primary endpoint was reduction in bone pain and reduced analgesic use. Results: There were no significant differences in patient demographics between the two treatment arms. The percentage of patients receiving i.v. IA that achieved stable or progressive disease was 15.4%; those receiving oral IA attained 11.5% stable or progressive disease. Pain (Brief Pain Inventory questionnaire) and analgesic intake were assessed at baseline, 3 and 6 months. Both i.v. and oral IA caused a significant and sustainable decrease in each of the pain indices (p<0.0005) with no significant difference between i.v. and oral groups. Both i.v. and oral IA treatment led to a trend in decrease of analgesic use. Conclusions: Oral and i.v. ibandronate have comparable efficacy for palliation of bone pain in MBD patients.

No significant financial relationships to disclose.

Optimization of doses received by the hospital staff and the members of the family of patients undergoing 111In-DTPA-D-Phe1-Octreotide therapy

According to the Euratom Directives (96/29, 97/43), the doses received by the workers as well as the family of patients and third persons during medical exposures, should conform to the dose constraint levels (DCLs), established by the authorities for each group in the context of optimisation. This study deals with the implementation of a radiation protection protocol, concerning the aforementioned group members for patients undergoing treatment with 111In-DTPA-D-Phe1-Octreotide, after intra-arterial infusion. It is shown that by applying this protocol the annual doses to the medical and technical staff are considerably reduced and remain below the established DCLs. Following the post-release behaviour instructions given to the patient, doses to the family and third persons may be kept lower than the corresponding DCLs provided by the National Regulations.

Interstitial magnetic resonance lymphography with gadobutrol in rabbits and an initial experience in humans

The purpose of this study was first to evaluate gadobutrol as a contrast agent for interstitial Magnetic Resonance Lymphography (MRL) in rabbits, and second, to extend the study to humans, if the initial results were satisfactory. In our experiment, gadobutrol was injected into twelve white New Zealand rabbits. In nine animals, 0.5 ml of gadobutrol was subcutaneously administered through each foot pad of the hindlegs while in the remaining three animals the agent was given in each foot of the forelegs. In four of the nine rabbits, slight local massage was applied at the site of administration. Subsequently, we proceeded to administer 5 ml (4.5 ml gadobutrol mixed with 0.5 ml hydrochloride lidocaine) into the limbs of two healthy humans. We achieved imaging of four lymph node groups (popliteal, inguinal, iliac and paraortic) in the hind-legs of the nine-rabbit group, whereas, in the forelegs of the remaining three rabbits, three lymph node groups (axillary, parasternal, mediastinal) were depicted. The flow of the contrast agent was significantly faster in the rabbits that received local massage (P<0.02). In humans, normal lymph vessels, as well as inguinal lymph nodes, were depicted in the legs. No side-effects were observed either in the rabbits or humans.

Prophylactic tropisetron versus rescue tropisetron in fractionated radiotherapy to moderate or high emetogenic areas: a prospective randomized open label study in cancer patients

AIM

A prospective randomized open label study was carried out to evaluate the efficacy and effectiveness of prophylactic tropisetron versus rescue tropisetron in fractionated radiotherapy.

PATIENTS AND METHODS

The study sample consisted of 288 cancer patients randomly allocated (3:4 ratio) into two treatment groups: 120 patients received prophylactic antiemetic treatment with tropisetron and 168 patients received rescue tropisetron. To determine the efficacy of prophylactic antiemetic treatment, nausea and vomiting were evaluated 1 d before radiation therapy (RT), at 24 and 72 h, at the end of every week during RT, and finally 1 wk after RT. Diary cards were used to record the intensity of nausea and vomiting as well as the incidence of adverse effects.

RESULTS

In the odds of nausea and vomiting, statistically significant differences were found between the two treatment groups over time. The incidence of nausea and vomiting were 1.89 (p = 0.009) and 2.19 (p = 0.001) times higher in the rescue tropisetron group than in the prophylactic tropisetron group. Factors that related significantly with increased nausea were primary cancer, rescue tropisetron, and radical RT. Moreover, factors for vomiting were primary cancer type, metastasis, palliative RT, and rescue tropisetron.

CONCLUSIONS

Higher numbers of patients receiving prophylactic tropisetron completed RT with lower incidence of nausea and vomiting than those in the rescue tropisetron group.

Intratesticular arteriovenous malformation. Clinical course, ultrasound and MRI findings of an extremely rare lesion on a 7 year follow-up basis

We present the clinical course, sonographic and MRI findings of an intratesticular arteriovenous malformation (AVM) found in a patient during routine check-up for infertility evaluation. Seven years ago, patient's refusal for surgical removal of the lesion led to follow-up ultrasound examinations and finally to an MRI examination. Arteriovenous malformations of male genitalia have been reported in the literature (penis, scrotum, spermatic cord and epididimys). However, this is the second case of an intratesticular AVM and the first one with a long clinical follow-up.

Acute Iliac Artery Rupture: Endovascular Treatment

The authors present 7 patients who suffered iliac artery rupture over a 2 year period. In 5 patients, the rupture was iatrogenic: 4 cases were secondary to balloon angioplasty for iliac artery stenosis and 1 occurred during coronary angioplasty. In the last 2 patients, the rupture was secondary to iliac artery mycotic aneurysm. Direct placement of a stent-graft was performed in all cases, which was dilated until extravasation was controlled. Placement of the stent-graft was successful in all the cases, without any complications. The techniques used, results, and mid-term follow-up are presented. In conclusion, endovascular placement of a stent-graft is a quick, minimally invasive, efficient, and safe method for emergency treatment of acute iliac artery rupture, with satisfactory short- and mid-term results.

An evaluation of the TSE MR sequence for time efficient data acquisition in polymer gel dosimetry of applications involving high doses and steep dose gradients

The use of magnetic resonance imaging as a readout method for polymer gel dosimetry commonly involves long imaging sessions, particularly when high spatial resolution is required in all three dimensions, for the investigation of dose distributions with steep dose gradients and stringent dose delivery specifications. In this work, a volume selective turbo spin echo (TSE) pulse sequence is compared to the established Carr-Purcell-Meiboom-Gill (CPMG) multiecho acquisition with regard to providing accurate dosimetric results in significantly reduced imaging times. Polyethylene glycol diacrylate based (PABIG) gels were irradiated and subsequently scanned to obtain R2 relaxation rate measurements, using a CPMG multiecho sequence and a dual echo TSE utilizing an acceleration (turbo) factor of 64. R2 values, plotted against corresponding Monte Carlo dose calculations, provided calibration data of PABIG gels dose response over a wide dose range. A linear R2 versus dose relationship was demonstrated for both sequences with TSE results presenting reduced dose sensitivity. Although TSE data were found to deviate from linearity at lower doses compared to CPMG data, a relatively wide dynamic dose range of response extending up to approximately 100 Gy was observed for both sequences. The TSE and CPMG sequences were evaluated with a brachytherapy irradiation using a high dose rate 192Ir source and a gamma knife stereotactic radiosurgery irradiation with a single 4 mm collimator helmet shot. Dosimetric results obtained with the TSE and CPMG are shown to compare equally well with the expected dose distributions for these irradiations. The 60-fold scan time reduction achieved with TSE implies that this sequence could prove to be a useful tool for the introduction of polymer gel dosimetry in clinical radiation therapy applications involving high doses and steep dose gradients.

Technical note: evaluation of dosimetric performance in a commercial 3D treatment planning system

The aim of this work was to evaluate the dosimetric performance of a commercial treatment planning system (TPS) which employs a three-dimensional calculation algorithm (Nucletron Plato version 2.2.3), following the guidelines of the AAPM Task Group 23 (TG23). Seven test cases were used to test the TPS dosimetric performance in homogeneous water. These cases involved absolute dose measurements on central as well as off-axis points situated at various depths, using simple field arrangements, and comparison with corresponding TPS calculations. This comparison yielded differences within +/-2% at all points, for all test cases. To test the ability of the TPS to account for tissue inhomogeneities, corresponding comparisons were performed with the presence of a low-density material in the beam to resemble an air inhomogeneity. Absolute dose measurements and corresponding TPS calculations showed a mean deviation of the order of +/-3.5%, reaching a maximum of 11.5% for small field sizes (5 cm x 5 cm). In summary, observed deviations are well within the set tolerance levels while comparison with previous TPS versions showed that Plato version 2.2.3 is significantly improved, especially in dose calculations in the presence of low density inhomogeneities.

Assessment of Anxiety and Depression in Advanced Cancer Patients and their Relationship with Quality of Life

The growing interest in the mental health and quality of life of cancer patients, has been the major reason for conducting this study. The aims were to compare advanced cancer patients' responses to Hospital Anxiety and Depression (HAD) scale with those to European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30, version 3.0), as well as the impact of quality of life dimensions (as measured by EORTC QLQ-C30) on the levels of anxiety and depression. The analysis, conducted in 120 advanced cancer patients, showed that the most significant associations were found between emotional functioning and HAD-T (total sum of scores) (r=-0.747; p < 0.0005), HAD-A (anxiety) (r=-0.725; p < 0.0005) and HAD-D (depression) (r=-0.553; p < 0.0005). In the prediction of HAD-T, the contribution of physical, emotional, role, and social functioning along with nausea-vomiting, dyspnea, sleep disturbance and gender is high. For anxiety, the predictor variables were physical, role, cognitive, emotional, and social functioning, followed by dyspnea, sleep disturbance, and appetite loss, while depression was predicted by physical, role, emotional, and social functioning, the symptoms of nausea-vomiting, pain, sleep disturbance, constipation, as well as the variables of age, gender, anticancer treatment and performance status. Concluding, psychological morbidity, in this patient population, was predominantly predicted by the emotional functioning dimension of EORTC QLQ-C30.

Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society

The issue of whether, how and how much to tell cancer patients concerning diagnosis is still approached in various ways across different countries and cultures. The health care team-patient relationship is a triangle consisting of the health care professionals, the patient and the family. Each part supports the other two and is affected by the changes that happen in the triangle. The objective of the study was to investigate the communication context through which health care professionals and families with cancer patients interact. In Greece, physicians have the tendency to tell the truth more often today than in the past, although the majority still disclose the truth to the next of kin. Nurses in Greece are considered to be the most suitable health care professionals for the patients to share their thoughts and feelings with. Nevertheless, the decision on information disclosure lies with the treating physician. In Greek society the patient's family plays an important role in the provision of care and information disclosure. They often decide on the patient's behalf.

Endovascular Treatment of Renal Arteriovenous Malformations

We report a case of renal arteriovenous malformation treated with superselective endovascular embolization using a light mixture of n-butyl-2-cyanoacrylate and Lipiodol. Diagnostic imaging modalities and treatment methods are discussed. In conclusion, successful superselective embolization should be the standard of care.

Image findings of a tailgut cyst. Case report and short review of the literature

We present a case of retrorectal hamartoma (tailgut cyst). Imaging findings on ultrasound, computed tomography and magnetic resonance imaging, pathologic findings, as well as the diagnostic pitfalls during the patient's management are documented. As it is a rare lesion with a non specific clinical presentation, it is usually misdiagnosed. Our aim is to present image characteristics of these lesions in all modalities and include retrorectal hamartomas in our differential diagnosis in patients with lesions with similar image findings.

Random walk through fractal environments

We analyze random walk through fractal environments, embedded in three-dimensional, permeable space. Particles travel freely and are scattered off into random directions when they hit the fractal. The statistical distribution of the flight increments (i.e., of the displacements between two consecutive hittings) is analytically derived from a common, practical definition of fractal dimension, and it turns out to approximate quite well a power-law in the case where the dimension D(F) of the fractal is less than 2, there is though, always a finite rate of unaffected escape. Random walks through fractal sets with D(F)< or =2 can thus be considered as defective Levy walks. The distribution of jump increments for D(F)>2 is decaying exponentially. The diffusive behavior of the random walk is analyzed in the frame of continuous time random walk, which we generalize to include the case of defective distributions of walk increments. It is shown that the particles undergo anomalous, enhanced diffusion for D(F)<2, the diffusion is dominated by the finite escape rate. Diffusion for D(F)>2 is normal for large times, enhanced though for small and intermediate times. In particular, it follows that fractals generated by a particular class of self-organized criticality models give rise to enhanced diffusion. The analytical results are illustrated by Monte Carlo simulations.

Detection of malignant bone marrow involvement with dynamic contrast-enhanced magnetic resonance imaging

BACKGROUND

The purpose of this study was to evaluate the role of dynamic contrast-enhanced magnetic resonance imaging (dMRI) in detecting bone marrow involvement in cancer patients.

PATIENTS AND METHODS

We studied 50 consecutive patients with histologically confirmed malignant dissemination to the bone marrow, using dMRI of the lumbosacral spine. Time-signal intensity curves were generated from regions of interest (ROIs) obtained from areas of obvious bone marrow disease (group B). In 16 patients from group B with focal disease, ROIs were also placed on areas with apparently normal bone marrow on static magnetic resonance images (group C). Twenty-two patients with no history of malignancy were used as a control group (group A). Wash-in (WIN) and wash-out (WOUT) rates, time to peak (TTPK), time to maximum slope (TMSP) values and WIN/TMSP ratios were calculated for each patient. Mean values for the three groups were compared statistically. Six patients from group B had follow-up dMRI after chemotherapy: four patients achieved a clinical partial response and two had resistant disease.

RESULTS

A significant difference was found between groups A and B for all values. Between groups A and C, in spite of the similar static MRI appearance, all values were significantly different. Between groups B and C, a significant difference was found for WIN, WOUT rates and WIN/TMSP ratio. Follow-up dMRI data analysis correlated well with clinical staging.

CONCLUSIONS

dMRI can distinguish normal from malignant bone marrow. It may identify malignant bone marrow infiltration in patients with negative static MRI and serve as both a diagnostic and prognostic tool for patients with bone marrow malignancies.

Cytoprotective effect of amifostine in radiation-induced acute mucositis - a retrospective analysis

PURPOSE

To study the cytoprotective impact of amifostine against acute radiation mucositis.

PATIENTS AND METHODS

A total of 117 cancer patients with carcinomas localized in pelvic organs, lung and head and neck were entered into this study. In a retrospective way, and in order to minimize the bias related to the investigator, 138 patients as historical controls were randomly selected from a database in our hospital. Acute radiation-induced gastrointestinal mucositis, esophagitis and stomatitis were assessed using the common toxicity criteria scale. The most severe grade recorded was evaluated as the final morbidity score for this patient. Mean toxicity score (MTS) was the mean value of recorded acute radiation toxicity. Mean interruption time (MIT) was the mean value of recorded interruption time due to radiation toxicity.

RESULTS

A significantly reduced severity of symptomatology related to oral, esophageal and rectal mucosa was noted in the amifostine group (group A) (p < 0.05, chi-square test). Furthermore, a significant reduction of MTS as well as MIT was observed in group A versus the historical controls (group B) (p < 0.05, Mann-Whitney U test).

CONCLUSION

The administration of amifostine seems to protect patients against radiation-induced mucositis, but further investigation with randomized trials is needed.

Intraoperative hyperthermia in conjunction with multi-schedule chemotherapy (pre-, intra- and post-operative), by-pass surgery, and post-operative radiotherapy for the management of unresectable pancreatic adenocarcinoma

The aim of this study was to evaluate the potential role of intraoperative hyperthermia (IOHT) in the management of stage IV pancreatic adenocarcinoma. Twenty-seven patients (group A) received pre-operative chemotherapy (5-FU), by-pass surgery with intraoperative bolus infusion of 5-FU and post-operatively multi-agent chemotherapy plus sandostatin and external beam irradiation (45Gy, 25 fractions, 5 days a week). In a non-randomized way, 10 patients (group B) received an additional single session of IOHT (43-45 degrees C, 1h) performed directly on the tumour using a waveguide applicator (433MHz) with interstitial measurements of temperature measured. A brief instrument was developed for evaluating patients' quality of life. No progressive disease (PD) was noticed in group B vs 11% (3/27) of PD in group A. There was also a significant increase of overall survival (OS) in group B vs A patients (p = 0.029, log-rank test). Moreover, there was a significant improvement for group B vs A patients regarding Karnofsky performance status (p < 0.001, Mann-Whitney test), pain score (p < 0.001, Mann-Whitney test) and quality of life score (p = 0.031, Mann-Whitney test). A significant correlation was noticed between OS and thermal parameters such as average T(min) (p = 0.043), average T(max) (p = 0.027) and cumulative minutes T(90) >or= 44 degrees C (p < 0.001). Combined IOHT with chemotherapy (pre-, intra- and post-operative) and external beam post-operative radiotherapy seem to have a potential benefit in the management of unresectable adenocarcinoma of the pancreas, concerning local response, OS and quality of life. Further clinical studies to evaluate the benefit of IOHT suggested in this study are warranted.

A short radiotherapy course for locally advanced non-small cell lung cancer (NSCLC): effective palliation and patients' convenience

In order to facilitate patients with symptomatic locally advanced NSCLC, especially those coming from remote areas we have employed two palliative RT schedules. The first (S1) is the well known from Medical Research Council (MRC) randomized studies 2 x 8.5 Gy one week apart and the second (S2) is a two-day RT schedule: three fractions of 4.25 Gy are given on the first day and two fractions of 4.25 Gy on the second day. The records of 92 patients were reviewed (48 for S1 and 44 for S2). Patients, disease characteristics and results were similar for both groups; rates of symptom disappearance were for S1 and S2, respectively: cough 24 and 20%, hemoptysis 60 and 67%, chest pain 57 and 64% and dyspnoea 55 and 45% The overall condition improved in 39 and 36%, respectively. The median palliation time in days was in S1 and S2, respectively: cough 70 and 66, haemoptysis 133 and 139, chest pain 68 and 62 and dyspnoea 74 and 69 days. The median survival was 25 weeks in both S1 and S2 groups (P=0.89 log-rank test). At 52 weeks (one year), ten (21%) and seven (16%) of the patients were alive in S1 and S2 groups, respectively. At 104 weeks, the corresponding figures were two (4%) and two (4.7%) for S1 and S2. Our results are in accordance to those reported in literature regarding the safety and efficacy of palliative hypofractionated radiotherapy schemes. Their use in selected patients could be cost-effective and convenient for patients especially those coming from remote areas.

Prognostic factors for survival in invasive squamous cell vulvar carcinoma: a univariate analysis

The charts of 50 women with invasive squamous cell vulvar carcinoma were reviewed retrospectively, and pathologic, medical and life style factors were analyzed for their possible influence on survival using the Cox regression univariate model. The median age of the cohort was 73.5 years. The patient distribution according to stage was as follows: stage I: 17; stage II: 16; stage III: 12, and stage IVa: 5 patients. The median follow-up was 61 months. The univariate analysis revealed that the overall survival was decreased by age > or = 73.5 years (p = 0.0185), advanced stage (p = 0.0026), grade III differentiation (p < 0.0001), ulcerative type of the tumor (p = 0.0055), tumor diameter >40 mm (p = 0.0053), obesity (p = 0.011), smoking (p = 0.0177), diabetes (p = 0.0122) and hypertension (p = 0.044), but not with clitoral involvement.

Focal nodular hyperplasia: imaging findings

Focal nodular hyperplasia is an uncommon benign hepatic tumor that continues to pose diagnostic dilemmas. Imaging techniques are of great value in diagnosis of this tumor. In this article we present the US, CT, MR imaging, scintigraphy, and angiography findings. The demonstration of a central vascular scar is very helpful. Although the radiologic features may be diagnostic, many atypical cases must be differentiated from other benign or malignant hepatic tumors. In these cases excisional biopsy and histopathologic examination are necessary to determine a definite diagnosis.

From codeine to transdermal fentanyl for cancer pain control: a safety and efficacy clinical trial

BACKGROUND

Fentanyl is a synthetic opioid, suitable for transdermal delivery, offering an interesting solution as a step 3 opioid in cancer pain treatment. The purpose of the study was to carefully investigate: 1) the feasibility of the direct conversion from codeine to TTS fentanyl, in patients already receiving codeine and requiring strong opioids for their analgesia; 2) the safety of 25 microg/hour incremental steps and at shorter than 72-hour intervals, if clinically required.

PATIENTS AND METHODS

130 patients were judged eligible for the study. All the patients were receiving 280-360 mg or more of codeine and required strong opioid for their analgesia. The study lasted 56 days. The initial dose was 25 microg/hour. TTS fentanyl for all patients. Data assessments were made on baseline, day 1, day 2, day 3, in the hospital and thereafter on days 7, 14, 21, 28, 42 and 56. After the patch application, all the patients were given an immediate release oral morphine (5 mg) every 4-6 hours for the first 12 hours and then if needed only as rescue doses. The patients remained in the hospital for the first three days of the study where follow-up (pain score, satisfaction, side effects etc.). was recorded by the palliative care team and by daily cards.

RESULTS

The itnitial dose of fentanyl was 25 microg/hour while the mean dose on day 3 was 45.9 microg/hour. All the patients required upward titration of the study medication during follow-up visits. On day 56 the mean dose of fentanyl was 87.4 microg/hour. Mean pain intensity decreased from an initial 5.96 on the baseline to 0.83 on day 3. Karnofsky scale measurements between treatment phases revealed non-significant changes. The rate of overall satisfaction was quite high. Nine patients discontinued the study due to inadequate pain relief or side effects between day 7 and day 28, while five patients died between day 28 and day 56. Constipation, nausea and vomiting were the most common side effects. Skin reaction was relatively mild and acceptable during the study.

CONCLUSION

Under controlled conditions, TTS fentanyl seems to be feasible for direct conversion from mild to strong opioids and additionally, 25 microg/hour incremental steps day by day can be made by palliative care specialists, if clinically required for cancer pain management.

The diagnostic X-ray protection characteristics of Panelcrete, Aquapanel, Betopan and Gypsoplak Superboard

Panelcrete, Aquapanel and Betopan are cement-based building materials with uses similar to those of gypsum wallboard, whose properties as a diagnostic X-ray shielding material have been extensively studied. The X-ray attenuation characteristics of these cement-based boards as well as those of a gypsum wallboard, Gypsoplak Superboard, are investigated for broad beam geometry conditions and for tube potentials of 50 kVp, 70 kVp, 100 kVp, 125 kVp and 140 kVp. Comparisons between these materials as well as with published data for gypsum wallboard are made. An example of their use as secondary barriers is given. Furthermore, it is confirmed that when building materials are considered for diagnostic X-ray shielding, calculations based on data for similar materials and corrected for density differences can be used only as an approximation.

Greek brief pain inventory: validation and utility in cancer pain

OBJECTIVE

The Brief Pain Inventory (BPI) is a pain assessment tool. It has been translated into and validated in several languages. The purpose of this study was the translation into and validation of the BPI in Greek. Moreover, we wanted to detect cultural and social differences, if any, of pain interference in patients' lives.

METHODS

The translation and validation of the inventory took place at the Areteion Hospital. The final validation sample consisted of 220 cancer patients (123 males, 97 females, age range 21-87 years, mean age 61.3). Primary cancer locations were lung 25.6%, gastrointestinal tract 25.6%, breast 11.5%, prostate 7.07%, gynecological cancers 9.6% and others 20.57%. The patients themselves completed the majority of the Greek BPI (G-BPI) papers. The pain management index (PMI) was also calculated in order to assess the adequacy of pain treatment. Assessing the reliability and the validity made the actual validation of the G-BPI.

RESULTS

Pain severity and pain management: 147 patients reported severe pain, 48 patients moderate, and 25 patients mild pain (mean average pain 6.22). From these patients only 21 were found on strong and 33 on weak opioid treatment, while 166 patients were found on no opioid analgesic treatment. In agreement with these data is the PMI which was positive only for 9 patients, while 44 patients had PMI = 0 and all the others had negative PMI scores. Reliability and Validity of the G-BPI: Coefficient alphas were 0.849 for the interference items and 0.887 for the severity items. Additionally, the factor analysis of the G-BPI items results in a two-factor solution, that satisfies the criteria of reproducibility, interpretability and confirmatory setting.

CONCLUSION

This study shows the efficacy of the G-BPI for the assessment of pain severity as well as the pain management in Greece, and therefore its utility in improving the analgesic treatment outcome in Greek patients.

Cystic pancreatic neoplasms: computed tomography and magnetic resonance imaging findings

Cystic pancreatic neoplasms include serous cystadenomas (SCA), mucin-producing cystic tumors, cystic islet-cell tumors, and cystic solid and papillary epithelial neoplasms. Imaging techniques are of great value in the demonstration and differential diagnosis of these tumors. In this article we present the computed tomography (CT) and magnetic resonance imaging (MRI) findings of the aforementioned cystic neoplasms. Although the radiological features are in many cases informative, a significant overlap does exist; fine-needle aspiration biopsy and cytology or excisional biopsy and histological examination are necessary to determine a definitive diagnosis.

Psychophysiological evaluation of short-term neurotoxicity after prophylactic brain irradiation in patients with small cell lung cancer: a study of event related potentials

BACKGROUND

The aim of this study was to show, whether a certain prophylacting applicable radiation affects the cognition, particularly, the specific cognitive components P50, N100, P300 and N400 of auditory event related potentials (ERPs) during a short memory test.

METHODS AND MATERIALS

Eleven patients with small cell lung cancer (SCLC), who had presented complete response of disease after chemotherapy and radical radiotherapy in the lung, were prescribed to receive a prophylacting cranial irradiation (PCI) with a 6 MeV linear accelerator. The dose schedule was consisting of a total dose up to 30 Gy in 10 fractions, within 12 days (5 days a week). The psychophysiological approach before and after PCI was assessed by measurements of the auditory ERPs during a short memory performance using the digit-span Wechsler test. Components of ERP were recorded from 15 scalp electrodes. Additionally, symptomatology of depression and anxiety were assessed using Zung Self-Rating Depression Scale and Spielberger Anxiety Inventory, respectively, for pre- and post-PCI.

RESULTS

No significant difference was noticed pre- and post-radiotherapy of all particular level of psychophysiological analysis concerning both the latencies and the amplitudes of ERPs auditory components P50, N100, P300 and N400 (P > 0.05, Wilcoxon signed test). Additionally, no changes were found with regard to behavioral performance (memory recall), depression symptomatology and state anxiety, according to pre- and post-radiation measurements. However, the self-reported depression symptomatology showed that the patients presented moderate depression.

CONCLUSION

No short-term psychophysiological neurotoxicity was detected with this PCI schedule using these instruments, lending additional support to evidence suggesting the benefit of this certain PCI schedule for patients with SCLC.

Management of renal angiomyolipoma by selective arterial embolization

4 Patients with renal angiomyolipomas are presented. One of them had tuberous sclerosis with synchronous bilateral tumors. All the patients were symptomatic, 2 of them with retroperitoneal hemorrhage. In all patients selective arterial embolization was performed. Permanent control of the symptoms was successful in 2 patients. In 1 patient temporary resolution of the symptoms was observed, and a second embolization was required. Retroperitoneal bleeding in 1 patient continued and nephrectomy was undertaken.

Continuous subcutaneous octreotide in gastrointestinal cancer patients: pain control and beta-endorphin levels

BACKGROUND

Somatostatin is a naturally occurring hormone widely identified in a number of human tissues, with a broad spectrum of physiological actions. Octreotide is a synthetic analogue of somatostatin, which seems to be promising in clinical use.

AIMS

a. to evaluate the efficacy of octreotide in pain control of patients with advanced gastrointestinal cancer, as well as octreotide's outcome in the hepatic function; b. to investigate the relationship between pain intensity and beta-endorphin blood levels in the patients.

PATIENTS

The study group consisted of 25 patients (age range: 48-89 years, 14 males, 11 females) with far advanced gastrointestinal cancer.

METHODS

All the patients were under s.c. morphine administration using a continuous infusion pump. When pain intensity increased, 0.6 mg/day of octreotide was added to the therapeutic regimen in the same syringe of the continuous infusion pump. Pain intensity and beta-endorphin blood levels were measured five times: Once before octreotide administration and the other four 12, 24, 48 hours and 7 days after. A complete blood count and a biochemical screening profile were taken before the administration of octreotide as well as on the 7th and the 14th day.

RESULTS

24 out of 25 cases showed a reduction in pain intensity (pretreatment x = 5.3, post-treatment x = 0.6). beta-endorphin blood levels increased significantly during the study (an increase of 184.78% was observed on the 7th treatment day). In one patient pain control was achieved by increasing morphine dosage. Statistically significant changes were observed in hepatic function indices (p < 0.02). Significant side-effects were not observed.

CONCLUSION

Octreotide can be used as an adjuvant analgesic in the management of gastrointestinal cancer pain which is managed by continuous s.c. administration. Although fuither research needs to be done, octreotide's administration seemed to improve hepatic function of these patients, therefore, it could potentially have a positive effect in the patient's quality of life.

Comparison of CT, MRI and CT during arterial portography in the detection of malignant hepatic lesions

BACKGROUND/AIMS

A prospective study was performed to compare the sensitivities of computed tomography, magnetic resonance imaging and CTAP (CT during arterial portography) in the detection of focal malignant hepatic lesions.

METHODOLOGY

Twenty-eight (28) patients with primary and secondary hepatic malignant tumors were evaluated. All of these patients underwent hepatic resection and a lesion-to-lesion imaging-pathological analysis was performed.

RESULTS

The overall sensitivities were 53% for CT, 66% for MRI sequences and 88% for CTAP. For lesions smaller than 1 cm the sensitivities were 6% for CT, 17% for MRI and 72% for CTAP. The combination of CTAP and MRI yielded an overall detection rate of 93%. The difference between the sensitivity of CTAP and that of the other two imaging techniques was statistically significant (P < 0.04) according to the McNemar test. CTAP demonstrated four false-positive lesions, two of which were correctly characterized by MRI and one by CT. In 6 patients (21.4%) the surgical plan was modified after CTAP.

CONCLUSIONS

We conclude that, CTAP has the highest sensitivity and should be part of the preoperative examination. In some instances, the addition of MR imaging must be considered a helpful adjuvant. Both techniques should be considered complementary in the preoperative diagnostic algorithm.

Role of the new imaging modalities in the investigation of Meniere's disease

The incidence of nonvisualization of the vestibular aqueduct and the endolymphatic duct-endolymphatic sac (ED-ES) complex as well as the type of periaqueductal pneumatization were evaluated in 23 patients with definite Meniere's disease (MD) by high-resolution CT and by MRI. Fifty subjects with no previous history of any ear disease were used as a control group. High-resolution CT results disclosed that in the control group the percentage of nonvisualized vestibular aqueduct (3.4%) was statistically significantly lower than in the MD group, when either the diseased ear (27.8%) or the nondiseased ear of the same group (22.2%) was examined. In addition, no differences were observed between the diseased and nondiseased ears of the patients with MD. The periaqueductal pneumatization was also found to be statistically significantly lower in the MD group. As regards the MRI examination, the results of the analysis showed that the ED-ES complex was visualized more frequently in the ears of the control subjects (64.1%) than in the diseased ears of the patients with Meniere's disease (39.1%). This difference had a marginal statistical significance (P approximately 0.05). We discussed the results in relation to possible underlying pathophysiologic mechanisms involving the flow of endolymph toward the ES during the different stages of the disease.

Comparison of dual spin echo echo planar imaging (SE_EPI), turbo spin echo with fat suppression and conventional dual spin echo sequences for T(2)-weighted MR imaging of focal liver lesions

The performance of T(2)-weighted spin-echo version of echo planar imaging (SE_EPI), conventional spin echo (SE) and fat-suppressed turbo spin-echo (TSE_SPIR) sequences for the detection of focal liver lesions was evaluated. Twenty patients that were included in our study, had CT examinations prior to the MR study and were scheduled for surgery for removal of liver lesions. All patients had intraoperative sonographic examinations. Qualitative and quantitative analysis of the images was performed. Overall image quality of SE_EPI sequences was better than SE (p<0.001) and similar to TSE_SPIR sequences. There were fewer motion and ghost artifacts on SE_EPI and TSE_SPIR images compared to SE images (p<0.001). Susceptibility artifacts were statistically equivalent on SE_EPI and SE images (p<0.001) while chemical shift artifacts were equally observed on SE and SE_EPI sequences. Overall image quality of EPI-SE and TSE_SPIR sequences was better compared to SE sequences. There was no significant difference in the number of lesions detected by each of the three sequences. Quantitative analysis showed that liver/lesion contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of liver, lesion, spleen was higher on TSE_SPIR sequences (p<0.001) while SE_EPI and SE sequences showed non-significant differences (p>0.05). SE_EPI sequences of the liver resulted in fewer artifacts and shorter acquisition times than SE sequences. They provide a diagnostic performance similar to TSE_SPIR and better than that of SE sequences.

Arteriovenous shunting in a giant renal angiomyolipoma. A rare condition

We report a case of a 33-year-old woman with tuberous sclerosis and bilateral angiomyolipomas. She suffered from acute left flank pain due to retroperitoneal haemorrhage. During renal arteriography an arteriovenous shunting was found in the left tumour. Angiomyolipoma is a rare cause of angiographically demonstrable arteriovenous shunting.

Selective arterial embolization in the management of symptomatic renal angiomyolipomas

Current management of renal angiomyolipomas (AMLs) include observation, transcatheter embolization and partial or total nephrectomy. Patients symptoms and size of the lesion are the determinants for the choice of the treatment. In general symptomatic or greater than 8 cm masses require intervention. A retrospective study of five patients presented with symptomatic lesions and treated with selective transcatheter embolization, over a 3 year period was performed in our hospital. A total of eight embolizations were performed, all on an emergency basis due to retroperitoneal bleeding or significant hematuria. Surgical intervention was necessary in one case, due to massive rebleeding on the fourth post-procedural day. Two patients rebled within 6 months and 2 years respectively, and were managed successfully with additional embolization. The remaining two patients are still asymptomatic 26 and 18 months after the successful initial result. Experience with this procedure is reported on with emphasis to the clinical outcome. It is believed that selective arterial embolization should be the standard initial therapy for symptomatic renal AMLs.

Continuous subcutaneous administration of high-dose salmon calcitonin in bone metastasis: pain control and beta-endorphin plasma levels

This prospective nonrandomized trial was performed to evaluate the efficacy of salmon calcitonin (sCT) in controlling pain related to bone metastasis in cancer patients and the relation of sCT's analgesic efficacy with beta-endorphin blood levels. The study group consisted of 22 cancer patients with bone metastases (male 13 and female 9, age range 38-77 years). Pain control was first achieved by continuous subcutaneous (s.c.) morphine administration. The next increase in pain was managed with continuous s.c. administration of 400 IU/day sCT. Beta-endorphin blood levels were measured before and during sCT administration. The first measurement was taken before sCT administration; subsequent measurement occurred at 12, 24, and 48 hours and 7 days after the commencement of treatment. Pain scores were monitored by a visual analogue scale. A complete blood count and a biochemical screening profile were taken before the administration of calcitonin and also on the seventh and the fifteenth day of the administration. The results showed a satisfactory analgesic effect. The mean pain score before the calcitonin administration was 4.43 and the score on the seventh day was 1.17. The gradual reduction of pain score was associated with an increase in beta-endorphin blood levels (increase to 147.2% of baseline on the seventh treatment day). In three cases, no satisfactory analgesic effect was obtained and pain control was achieved by increasing the continuous s.c. morphine dosage. No significant side effects were observed. These data suggest that sCT in high doses may be a useful adjuvant analgesic when combined with low doses of morphine in continuous s.c. administration for the management of metastatic bone pain.

Optimizing hospital-based home care for dying cancer patients: a population-based study

Health-related quality of life (HRQL) is difficult to define and measure. It is a generic term that includes concepts such as physical health, life satisfaction, psychological well-being and self-integrity. Realizing and appreciating the importance of HRQL is crucial for physicians if they are to be in a position to offer appropriate suggestions in assisting patients and their families in the decision-making process regarding cancer treatment and terminal care. In order to determine whether Greek physicians take into consideration HRQL when assessing different therapeutic options, we conducted a postal survey. A total of 1500 Greek physicians (internists, oncologists and anaesthesiologists) were asked to complete a questionnaire. We received replies from 1280 (85%). In summary, we found that Greek physicians: (1) have already started taking HRQL into consideration when reviewing their therapeutic options; (2) increasingly include HRQL in research studies as an outcome measure; (3) do not yet have thoroughly sufficient training in the holistic care of cancer patients and their families; (4) mostly do not have the opportunity to work in interdisciplinary therapeutic teams where they can exchange ideas and consider different aspects of alternative therapeutic methods. It is concluded that HRQL has already been introduced as an important determinant of therapeutic choices in cancer care in Greece. However, efforts need to be made to allow HRQL to enjoy its appropriate place in cancer care.

Abdominal retained surgical sponges: CT appearance

Retention of surgical sponges is rare. They cause either an aseptic reaction without significant symptoms or an exudative reaction which results in early but nonspecific symptoms. Computed tomography is very useful for recognition of retained sponges. The appearance of retained sponges is widely variable. Air trapping into a surgical sponge results in the spongiform pattern which is characteristic but unfortunately uncommon. A low-density, high-density, or complex mass is found in the majority of cases, but these patterns are not specific. Sometimes, a thin high-density capsule may be seen. Rim or internal calcification is a rare finding. Finally, a radiopaque marker is not a reliable sign. Differentiation from abscess and hematoma is sometimes difficult.

Endovaginal color Doppler sonographic evaluation of ectopic pregnancy in women after in vitro fertilization and embryo transfer

The aim of this study was to evaluate the value of endovaginal color Doppler ultrasonography in the early diagnosis of ectopic pregnancy in women after in vitro fertilization and embryo transfer, and to correlate the sonographic findings with ss-hCG serum levels. Thirty-five patients had proven ectopic pregnancies and 4 other patients had heterotopic pregnancies. The diagnosis was disclosed correctly in all cases by endovaginal color Doppler US by identifying an adnexal mass with placental flow and a nongravid uterus called a "cold uterus". An intrauterine sac with "double ring sign" was found in all normal intrauterine pregnancies when the hCG levels exceeded 1000 IU/l but in none of the patients with ectopic pregnancy (EP). These findings suggest the efficacy of the discriminatory hCG serum level of 1000 IU/l in the investigation of EP. In conclusion, this study describes the diagnostic importance of transvaginal color Doppler US in correlation with hCG serum levels in the early detection of EP avoiding life-threatening complications and improving patient outcome.

Bone lesions with soft-tissue mass: magnetic resonance imaging diagnosis of lymphomatous involvement of the bone marrow versus multiple myeloma and bone metastases

Bone metastases from solid primary tumors, as well as multiple myeloma and secondary lymphoma may all present with bone lesions and associated soft-tissue masses on magnetic resonance images of the spine. In bone metastases and myeloma, the cortex of the affected bone is usually destroyed and a bulging contour is observed at the site of extraosseous spread. In cases of lymphomatous involvement of the bone marrow, however, we have observed that spread to the extraosseous soft-tissues occurs without alteration of the shape or contour of the affected bone. In order to assess whether this pattern of spread is indeed suggestive or even diagnostic of lymphoma of the bone marrow, we reviewed spinal bone marrow MR images of 66 patients, with bone metastases from solid primary tumors (33 patients), multiple myeloma (20 patients) and stage IV lymphoma with bone marrow involvement (13 patients), who had bone lesions and contiguous soft-tissue masses. If tumor was present on either side of the bony cortex but the contour of the affected bone was preserved, a "wrap-around" sign was diagnosed. A "wrap-around" sign was found in 12 of the 13 patients with lymphoma but in none of the patients with metastases or myeloma. On MR images of the bone marrow, the demonstration of tumor spread beyond the bony cortex without disruption of the outline of the diseased bone may favor the diagnosis of lymphoma more than that of metastases or multiple myeloma.