Jari Ovaska

A prospective diagnostic accuracy study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography, multidetector row computed tomography, and magnetic resonance imaging in primary diagnosis and staging of pancreatic cancer.

Objective:To prospectively compare the accuracy of combined positron emission tomography/computed tomography using 18F-fluorodeoxyglucose (FDG-PET/CT), multidetector row computed tomography (MDCT), and magnetic resonance imaging (MRI) in the evaluation of patients with suspected pancreatic malignancy. Summary Background Data:FDG-PET/CT imaging is increasingly used for staging of pancreatic cancer. Preliminary data suggest a significant influence of FDG-PET/CT on treatment planning, although its role is still evolving. Methods:Thirty-eight consecutive patients with suspicion of pancreatic malignancy were enrolled. Patients underwent a protocol including FDG-PET/CT, MDCT, and MRI combined with magnetic resonance cholangiopancreatography, all of which were blindly evaluated. The findings were confirmed macroscopically at operation and/or by histopathologic analysis (n = 29) or follow-up (n = 9). Results of TNM classification of different imaging methods were compared with clinical TNM classification. Results:Pancreatic adenocarcinoma was diagnosed in 17 patients, neuroendocrine tumor in 3, mass-forming pancreatitis in 4, cystic lesion in 6, and fibrosis in 2. Six patients had a finding of a normal pancreas. The diagnostic accuracy of FDG-PET/CT for pancreatic malignancy was 89%, compared with 76% and 79% for MDCT and MRI, respectively. In the differential diagnosis of suspected malignant biliary stricture at endoscopic retrograde cholangiopancreaticography (n = 21), FDG-PET/CT had a positive predictive value of 92%. In 17 patients with advanced pancreatic adenocarcinoma, FDG-PET/CT had a sensitivity of 30% for N- and 88% for M-staging. Both MDCT and MRI had sensitivities of 30% for N- and 38% for M-staging. Furthermore, the clinical management of 10 patients (26%) was altered after FDG-PET/CT. Conclusion:FDG-PET/CT was more sensitive than conventional imaging in the diagnosis of both primary pancreatic adenocarcinoma and associated distant metastases. In contrast, the sensitivity of FDG-PET/CT was poor in detecting local lymph node metastasis, which would have been important for an assessment of resectability. We recommend the use of FDG-PET/CT in the evaluation of diagnostically challenging cases, especially in patients with biliary strictures without evidence of malignancy in conventional imaging.

Adenocarcinoma arising in Barrett's esophagus

The main goal of this study was to evaluate the development of adenocarcinoma in patients with Barretts esophagus. During the period from January 1975 to December 1985, a total of 134 patients had endoscopically severe esophagitis and/or Barretts esophagus. In these patients, 32 (24%) met the macroscopic and histologic criteria for the diagnosis of Barretts esophagus. A check-up study of these patients was performed in 1987. Adenocarcinoma developed in three patients during the follow-up period of 166.1 patient-years. Dysplasia in the columnar epithelium was found in two of these patients six and 15 months before the diagnosis of adenocarcinoma. The third patient with adenocarcinoma was detected in endoscopic follow-up in 1987. In addition, the endoscopic examination showed unchanged Barretts epithelium in all but three patients despite the operative and/or medical treatment 3–12 years (mean 6.7 years) earlier. We conclude that Barretts esophagus is a potential premalignant condition and careful endoscopic surveillance for dysplasia in the columnar epithelium of the distal esophagus is mandatory in patients with Barretts esophagus.

Blood Transfusion and Prognosis in Colorectal Carcinoma

The association of perioperative blood transfusion and cancer recurrence was analyzed in a 10-year series of 520 patients with colorectal carcinoma undergoing curative surgery. Cancer recurrence was observed in 35 of 165 (19%) non-transfused and in 119 of 355 (34%) transfused patients (p less than 0.001). A significant difference in favor of the non-transfused group was also evident in cases of colonic (p less than 0.05) and rectal (p less than 0.01) tumors separately. The transfused group had both more recurrences and higher mortality. Although there were no differences in age, sex, and Dukess stage between the two groups, further analysis showed other significant variables explaining the different result. First, there were significantly more patients with rectal cancer in the transfused group. In addition, emergency operations for obstruction and resections of adjacent organs for tumor invasion were significantly commoner in transfused patients. Exclusion of such patients and those with small tumors excised locally per anum resulted in the disappearance of the prognostic difference between the transfused and non-transfused groups (marginally significant difference in rectal carcinoma; p = 0.05). It is concluded that the seemingly adverse effect of blood transfusion on the prognosis of colorectal carcinoma may largely be explained by other associated variables.

The Value of a Follow-up Programme after Radical Surgery for Colorectal Carcinoma

To evaluate the effectiveness of a follow-up programme after curative surgery for colorectal carcinoma, a 10-year series of 402 patients was surveyed for the detection rate of potentially curative recurrences and metachronous neoplasms. There were 120 recurrences (30%), and 100 of them (83%) were detected at scheduled check ups. Initial suspicion of recurrence was most often based on physical examination, carcinoembryonic antigen assay, or sigmoidoscopy. Reoperation was undertaken in 62 patients, in 26 cases (22%) for cure. The 5-year survival was 48% after curative reoperations. Metachronous adenomas and carcinomas occurred in 38 and 11 patients, respectively, giving corresponding cumulative 5-year incidences of 13% and 3.8%. Altogether, 37 patients (9.2%) had a curative reoperation for recurrent or metachronous carcinoma, and a further 38 patients (9.5%) had adenomas removed by polypectomy. It is concluded that regular follow-up is useful for the patients, and the follow-up schedule must be planned to detect both early recurrences and metachronous neoplasms.

Comparison of endoscopic Nd:YAG laser therapy and oesophageal tube in palliation of oesophagogastric malignancy.

The clinical results of 96 patients with upper gastrointestinal malignancy have been evaluated retrospectively. Sixty-nine patients with a mean age of 72 years (35 men and 34 women) were treated with endoscopic laser therapy, and 27 patients with a mean age of 67 years (16 men and 11 women) with insertion of an oesophageal tube. After laser therapy the bulk of the tumour was reduced in 87%, and in 55% clear signs of relieved dysphagia were seen. The insertion of an oesophageal tube was successful in 89%. In the laser group no fatal complications occurred, and the overall complication risk was 8.7%. The 1-year survival in all laser patients was 12%, and in patients with impassable tumour stenosis the survival was 6%. The mortality related to the insertion of an oesophageal tube was 11%, and complications occurred in 48% of the patients. The 1-year survival of the tube group was nil. It is concluded that endoscopic laser therapy and insertion of oesophageal tube are both effective methods in palliation of oesophagogastric malignancy, but the mortality and risk for complications were markedly lower after laser therapy.

Surgical treatment of gastric carcinoma

To investigate changes in the results of treatment of gastric carcinoma, two 10-year periods between 1963 and 1982 with 641 and 630 patients, respectively, were compared. In the two groups, 94 percent and 92 percent of patients were operated on. The operation was considered curative in 200 and 265 patients in Groups 1 and 2, respectively. There was a shift towards more radical operations, with 215 total or subtotal gastrectomies in Group 2 compared with 76 in Group 1, when distal gastric resection was considered radical enough. Despite the increasing number of curative operations and more radical surgery in Group 2, no progress in the 5-year survival rate was noted. Distal and subtotal gastrectomies gave slightly better results than total gastrectomies, but the most important single factor contributing to the long-term survival was cancerous invasion of the serosa. It is concluded that in the past 20 years, the results of surgical treatment of gastric carcinoma have not improved, despite the more advanced diagnostic methods and more radical surgery.

Nd-YAG laser in subtotal thyroidectomy: A prospective randomized study

Thirty patients for thyroid resection were allocated into conventional (n=15) or laser (n=15) operations. The age and sex distribution were similar, as was the relation between unilateral and bilateral resections between the groups. A contact Nd-YAG laser was used for dissection and resection in the laser group, where there was significantly less bleeding than in the conventional group (p<0.05). The operation was also faster in the laser group. No complications occurred. It is concluded that the contact Nd-YAG laser technique can safely be used in resection of the thyroid gland.