Frequency of Circulating Tumor Cells (CTC) in Patients with Brain Metastases: Implications as a Risk Assessment Marker in Oligo-Metastatic Disease

Forty percent of non-small cell lung cancer (NSCLC) patients develop brain metastases, resulting in a dismal prognosis. However, patients in an oligo-metastatic brain disease setting seem to have better outcomes. Here, we investigate the possibility of using circulating tumor cells (CTCs) as biomarkers to differentiate oligo-metastatic patients for better risk assessment. Using the CellSearch® system, few CTCs were detected among NSCLC patients with brain metastases (n = 52, 12.5% ≥ two and 8.9% ≥ five CTC/7.5 mL blood) and especially oligo-metastatic brain patients (n = 34, 5.9%, and 2.9%). Still, thresholds of both ≥ two and ≥ five CTCs were independent prognostic indicators for shorter overall survival time among all of the NSCLC patients (n = 90, two CTC ≥ HR: 1.629, p = 0.024, 95% CI: 1.137⁻6.465 and five CTC ≥ HR: 2.846, p = 0.0304, CI: 1.104⁻7.339), as well as among patients with brain metastases (two CTC ≥ HR: 4.694, p = 0.004, CI: 1.650⁻13.354, and five CTC ≥ HR: 4.963, p = 0.003, CI: 1.752⁻14.061). Also, oligo-brain NSCLC metastatic patients with CTCs had a very poor prognosis (p = 0.019). Similarly, in other tumor entities, only 9.6% of patients with brain metastases (n = 52) had detectable CTCs. Our data indicate that although patients with brain metastases more seldom harbor CTCs, they are still predictive for overall survival, and CTCs might be a useful biomarker to identify oligo-metastatic NSCLC patients who might benefit from a more intense therapy.

First salvage treatment in patients with advanced germ cell cancer after cisplatin-based chemotherapy: analysis of a registry of the German Testicular Cancer Study Group (GTCSG)

PURPOSE

We analyzed prognostic categories at first relapse according to the International Prognostic Factors Study Group (IPFSG) criteria as well as the efficacy of salvage treatment.

METHODS

143 patients with relapsed or refractory germ cell cancer undergoing first salvage treatment with conventional-dose (CD-CX, n = 48) or high-dose chemotherapy with autologous stem cell support (HD-CX, n = 95) contributed by nine centers were retrospectively analyzed.

RESULTS

Prognostic subgroups according to IPFSG criteria were: very low risk 13/143, low risk 36/143, intermediate risk 66/143, high risk 22/143, and very high risk 6/143 patients. The IPFSG categories significantly correlated with overall survival (OS) (p = 0.025) after 1st salvage treatment. After a median follow-up of 19 months, 55 % of all patients had relapsed and 33 % had died. For the entire cohort, progression-free survival (PFS) rate after 2 years was 43 %, and OS rate after 5 years was 52 %. Compared to the HD-CX group, vital carcinoma was found more often in secondarily resected lesions following CD-CX (22/29 vs. 22/45; p = 0.021). Second relapse rate was higher with 75 versus 44 %, resulting in a shorter median PFS with 8 versus 42 months (p < 0.001), but this did not translate into different OS (p = 0.931). At subsequent relapses, 26/36 patients received HD-CX as ≥2nd-salvage treatment.

CONCLUSION

This analysis confirms the prognostic value of the IPFSG prognostic score. HD-CX seemed superior to CD-CX as first salvage treatment with respect to PFS in this retrospective analysis.

First-salvage treatment in patients with recurrent or refractory advanced germ-cell cancer after cisplatin-based chemotherapy: A database of the German Testicular Cancer Study Group

4559

Background: About 20-30% of patients (pts) with advanced germ-cell cancer (GCC) relapse after cisplatin-based chemotherapy. This database evaluates first salvage treatment and the prognostic categories at first relapse according to the International Prognostic Factors Study Group (= IPFSG; JCO 2010). Methods: A total of 144 pts (78% nonseminoma) with relapsed or refractory GCC undergoing 1st salvage treatment with either conventional (CD-CX) or high-dose chemotherapy with autologous stem cell support (HD-CX) from 16 German centers were retrospectively analysed. Results: Subgroups according to the IPFSG prognostic categories, were: very low risk in 9/144 (6%), low risk in 26/144 (18%), intermediate risk in 78/144 (54%), high risk in 27/144 (19%), and very high risk in 4/144 pts (3%). 1st salvage treatment consisted of HD-CX in 96 (67%) and CD-CX in 48 pts (33%). Treatment response was CR/PR- in 60%, PR+/SD in 33%, and PD in 7%. After a median follow-up (mFU) of 21 months (mos) (range, 0 – 193), 53% of all pts had relapsed and 30% had died resulting in a median progression-free survival (PFS) of 7 mos (95%CI 0-16) and overall survival (OS) of 47 mos (95%CI 21-73). At subsequent relapses, 25/48 pts (52%) received HD-CX as > 2nd-salvage treatment. For the total cohort, PFS rate after 2 years was 35%, and OS rate after 5 years was 53%. Stratification according to IPFSG prognostic categories significantly correlated with PFS (p=0.001) and OS (p=0.004) after 1st salvage treatment. Even among high-risk and very high risk (n=31, mFU 12 mos) a PFS of 37 % at 2 years and an OS of 60 % at 2 years was observed, after 1st or 2nd salvage treatment, which might be due to patient selection and short follow-up. Conclusions: IPFSG prognostic categories highly correlated with observed PFS and OS after first salvage treatment in this cohort of pts with refractory or relapsed GCC. First salvage treatment with CD- or HD-CX resulted in overall 5 year-OS rates of about 50% across all prognostic categories. Even pts with high and very high risk achieved 2 year-OS rates of about 60% with salvage HD-CX at first or subsequent relapses.

Bone metastases in patients with relapsed/refractory germ cell tumors (GCT) undergoing first salvage chemotherapy: A retrospective analysis of a large international database

4597

Background: Bone metastases (mets) are rare events in GCT patients (pts) and data on characteristics, risk factors, treatment and outcome in these pts are largely missing. Methods: A subgroup of 104 ptswith bone metsfrom the IPFSG database was analyzed. All patients experienced unequivocal relapse/progression after > 3 cycles of cisplatin-based chemotherapy and received conventional-dose (CDCT) or high-dose salvage chemotherapy (HDCT). Results: 104 / 1594 pts presented with bone mets (6,5%) at first relapse. Histology was pure seminoma in 26%, and non-seminoma in 74%. At initial diagnosis, 54% of pts had presented with "poor risk" according to IGCCCG. Overall response rate (ORR; CR+PR) to 1st-line chemotherapy was 89%. Median PFS after primary treatment was 3 months (range 0 - 140). Bone mets at first relapse were accompanied by abdominal, lung, mediastinal, liver and brain mets in 54%, 48%, 28%, 36%, and 14%, respectively. Tumor marker profiles were heterogeneous (elevation of AFP / ß-HCG: 51% / 37%). Salvage treatment was CDCT in 34%, and HDCT in 66% of pts. ORR to salvage chemotherapy was 68% for the total cohort, and 43% vs. 81% for CDCT vs. HDCT (p<.01). For the total cohort, 2y-PFS and 5y-OS were 24% and 16%, respectively. 2y-PFS and 5y-OS were significantly higher in pts after HDCT compared to CDCT (2y-PFS 29% vs. 14%, p=.01; 5y-OS 19% vs. 9%, p=.04). Conclusions: Pts relapsing with bone mets after platinum-based CTX were characterized by "poor risk" disease at initial diagnosis, but characteristics at first relapse were heterogeneous. Treatment response and outcome was improved in pts with HDCT compared to CDCT. Further prospective evaluation of characteristics and treatment approaches in GCT pts with bone mets is warranted.

Imaging in the diagnosis of infections in immunocompromised patients

Early use of CT and MRI helps to diagnose infection in immuno-compromised patients earlier and more precisely. Anti-fungal therapy can now be instituted in the knowledge that there is scan proven fungal disease and withheld when scans indicate other pathology. The optimal way to utilise these tests is described.

Translevator gluteal hernia

The authors report a case of a posterior translevator gluteal hernia in a woman with recurrent prolapse. This case illustrates the need to be aware of extravaginal perineal hernias. MRI proved useful in diagnosing this case preoperatively. This case highlights the need to exclude any associated pelvic hernias in women with complex prolapse preoperatively.

Magnetic resonance imaging of normal levator ani anatomy and function

OBJECTIVE

To evaluate the anatomy and function of the levator ani in normal women by dynamic magnetic resonance imaging.

METHODS

Twelve asymptomatic, nulliparous, premenopausal women with no previous pelvic surgery underwent a dynamic magnetic resonance imaging scan of their pelvis. The origin, orientation, thickness, and function of the two components of the levator ani were studied.

RESULTS

The ileococcygeus is a thin muscle with an upward convexity. It slopes forward and medially. It is of variable thickness (mean thickness 2.9 mm, standard deviation 0.8 mm). There are apparent gaps in the muscle diaphragm and at its site of origin from the obturator fascia. The puborectalis is a thicker muscle. It is shaped like a belt encasing the pelvic organs. It is taller posteriorly than anteriorly. It is not attached to the bladder neck, but the midurethra and lower urethra lie in close proximity to it. The puborectalis moves dorsoventrally, whereas the ileococcygeus moves craniocaudally.

CONCLUSION

The levator ani is not a single muscle but has two functional components that vary in thickness, origin, and function. The ileococcygeus has a mainly supportive function, whereas the puborectalis has a sphincteric function. Gaps in the diaphragmatic portion of the ileococcygeus are a normal finding. Individual components of the levator ani may be prone to different types of childbirth trauma and should therefore be assessed separately when planning rehabilitation.

Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging

OBJECTIVE

Our purpose was to assess and compare a new technique of grading pelvic organ prolapse by using dynamic magnetic resonance imaging with the clinical staging proposed by the International Continence Society.

STUDY DESIGN

In a cross-sectional study, 20 patients with pelvic organ prolapse underwent dynamic magnetic resonance imaging. Clinical staging (according to the International Continence Society) was compared with staging by magnetic resonance imaging. A new reference line, the midpubic line, was drawn on the magnetic resonance image to correspond to the hymenal ring marker used in the clinical staging. The levator-vaginal angle and the area of the genital hiatus were measured to indicate vaginal supports. Ten nulliparous, symptom-free women were studied as control subjects.

RESULTS

The proposed staging by magnetic resonance imaging showed good correlation with the clinical staging (kappa = 0.61). Magnetic resonance imaging improved clinical assessment by its ability to measure the actual pelvic organ descent and to delineate prolapse of the pouch of Douglas accurately. The midpubic line was a useful reference line for grading prolapse on magnetic resonance imaging. The levator-vaginal angle and the area of the genital hiatus are useful in assessing vaginal support at different anatomic levels.

CONCLUSIONS

This new method of grading by magnetic resonance imaging uses the same landmarks as the clinical grading, and this uniformity of approach allows an objective assessment of the results of surgical correction of pelvic organ prolapse.

Should air contrast computed tomography become the first investigation of the colon of frail or elderly patients?

OBJECTIVE

Air contrast computed tomography (ACCT) is an alternative test to barium enema or colonoscopy. We review our experience of this test as the first investigation of frail, elderly patients with lower gastrointestinal symptoms, and record the subsequent clinical course of these patients to evaluate the efficacy of the technique.

PATIENTS AND METHODS

We performed 109 ACCT studies on frail patients aged 70 years or over with lower gastrointestinal symptoms. The findings were correlated with subsequent investigations and surgical findings. Patients with normal scans were followed up in out-patients or by their GP. Average follow up was 17 months.

RESULTS

A good quality complete examination of the colon was achieved in 97% of patients. Of 109 examinations 34 (31%) were reported as normal, 65 (60%) as diverticular disease, nine (8%) as demonstrating a colonic malignancy and one (1%) showed a benign polyp. One sigmoid tumour was missed initially but diagnosed on a repeat ACCT study.

CONCLUSION

ACCT is a reliable, well-tolerated technique in elderly frail patients.

Management of invasive pulmonary aspergillosis in hematology patients: a review of 87 consecutive cases at a single institution

Eighty-seven patients with hematologic malignancies and invasive pulmonary aspergillosis (IPA) were identified between 1982 and 1995. Of these, 39 underwent lung resection on the basis of radiological detection of at least 1 lesion with imaging suggestive of aspergillosis (LISA). IPA was confirmed histologically in 35. The presence of LISA had 90% positive predictive value for IPA. The actuarial survival at 2 years was 36% for 37 patients treated surgically, 20% for 12 patients with unresected LISA but no cultures of Aspergillus species, and 5% for 21 patients diagnosed only by isolation of Aspergillus from respiratory secretions. Analysis by proportional hazard models showed a significant independent negative association between the radiological appearance of LISA and death from all causes. Relapsed hematologic disease was independently significantly associated with death. Age, sex, surgery, previous bone marrow transplantation, or Aspergillus isolation were not independent predictors of death. IPA presenting as LISA carries a relatively good prognosis, possibly explaining the better survival of patients undergoing surgery for such lesions.

Progress in the diagnosis and management of aspergillosis in bone marrow transplantation: 13 years' experience

Over 13 years, we have seen 16 cases of proven invasive aspergillosis in 446 bone marrow transplant recipients, an incidence of 3.6%. The incidence of infection is low in patients with uncomplicated allogeneic or autologous bone-marrow transplants (< 2% and 0, respectively). Of the 16 episodes following transplantation, 10 occurred in patients with late transplant complications who were no longer in protective isolation. In patients who had focal pulmonary lesions (as diagnosed by computed tomographic scanning), culture of bronchoalveolar lavage (BAL) fluid was not an effective diagnostic procedure. In diffuse pulmonary disease due to Aspergillus, culture of BAL fluid had a sensitivity of 100%. Aspergillus species were isolated from an additional six patients who had no evidence of invasive aspergillosis. Graft rejection was a significant predisposing factor for the development of invasive aspergillosis (P < .001, log-rank test), and in our hospital, these patients now receive intravenous amphotericin B as prophylaxis. None of the six patients whose chest roentgenograms showed abnormalities before transplantation and who underwent surgical resection as part of the treatment for invasive aspergillosis developed recurrent infection.

Treatment of pyogenic liver abscesses by percutaneous needle aspiration

Fifteen patients with solitary or multiple pyogenic liver abscesses diagnosed by ultrasound examination were treated by percutaneous aspiration under ultrasound guidance. The pus obtained was cultured immediately for aerobic and anaerobic organisms and appropriate antibiotic therapy was started. Anaerobic organisms were grown from this pus in nine patients. All patients improved after the aspiration and, apart from further aspirations in two cases, all abscesses healed without further intervention. No patient died from liver abscess or as a result of treatment. The technique is simple and harmless and is the method of choice for diagnosing and treating patients with pyogenic liver abscesses.

Screening for pancreatic disease: A comparison of grey-scale ultrasonography and isotope scanning

The efficiency of ultrasound in the diagnosis of pancreatic disease was compared prospectively with that of selenomethionine isotope scanning in 46 patients presenting with abdominal pain or weight-loss or with jaundice. Of 14 patients who later proved to have pancreatic carcinoma, all had an abnormal isotope scan and 13 had an abnormal ultrasound scan. Of 10 patients with chronic pancreatitis, all had an abnormal isotope scan and 9 had an abnormal ultrasound scan. The small advantage of selenomethionine was, however, offset by a higher false-positive rate: of 22 patients who proved not to have pancreatic disease, 13 had abnormal isotope scans compared with only 3 with ultrasound. Review of earlier experience with the two techniques yielded similar results: in pancreatic carcinoma and chronic pancreatitis, isotope scanning gave slightly fewer false-negative results than ultrasound but many more false-positives. Because of its lower false-positive rate, because it avoids ionising radiation, and because it can usually distinguish carcinoma from pancreatitis, ultrasound is the procedure of choice for initial investigation of patients with suspected pancreatic disease.

The ultrasonic demonstration of portacaval shunts

This study explores the use of ultrasound in the management of patients with portacaval anastomosis. Ten patients were studied; in 8 of these the status of the anastomosis was well demonstrated. It is suggested that ultrasound should be the initial investigation to determine the patency of a shunt.

Grey-scale ultrasonography of portal vein

The state of the extrahepatic portal venous system was correctly assessed by grey-scale ultrasonography in twenty-one patients with extrahepatic portal-vein obstruction and the results agreed with those obtained by portal venography. In twenty-two age-matched controls a patent portal vein was displayed. The diameter of the portal vein on the ultrasound scan was significantly less in the twenty-two controls than in eighteen patients with chronic liver disease. Grey-scale ultrasonography is a reliable, inexpensive, and non-invasive method for diagnosing extrahepatic portal-vein obstruction.

Azathioprine and penicillamine in treatment of rheumatoid arthritis: a controlled trial

Sixty-five patients, 33 receiving azathioprine and 32 receiving penicillamine, took part in a one-year, single-blind external-observer trial designed to compare the efficacy and toxicity of these two drugs in the treatment of rheumatoid arthritis. By six months there was a significantly greater rise in haemoglobin and fall in erythrocyte sedimentation rate among those receiving penicillamine, and by one year this difference remained only in the increase in haemoglobin levels. Fifteen patients, 10 on azathioprine and 5 on penicillamine, had to stop treatment because of side effects; 90 single side effects occurred, 48 in those on penicillamine and 42 in those on azathioprine. After one year both drugs were similar in efficacy and toxicity, but longer-term trials are needed. Both drugs were effective.