Victoria S. Warbey

Neuroendocrine tumors: role of interventional radiology in therapy.

The management of neuroendocrine tumors (NETs) is complex. Although NETs can affect a variety of organ systems, hepatic metastatic disease in particular lends itself to a wide range of interventional treatment options. Prior detailed radiologic assessment and careful patient selection are required. Curative surgery should always be considered but is rarely possible. Embolization, radionuclide therapy, or ablative techniques may then be undertaken. Transcatheter arterial embolization (TAE) may be used alone or in combination with transcatheter arterial chemoembolization (TACE). NET type and extent of hepatic involvement are factors that can help predict the success of either TAE or TACE. Embolization techniques can also be useful in patients with nonhepatic NETs. Radionuclide therapy is emerging as a valuable adjunct and is dependent on positive somatostatin receptor status. Therapeutic radiopeptides may be delivered arterially. Ablative techniques have been shown to play a role in the palliation of symptoms and principally involve radiofrequency ablation. Hepatic cryotherapy and percutaneous ethanol injection have also been used. A multidisciplinary approach to treatment and follow-up is important. Imaging should involve dual-phase multidetector computed tomography and contrast material-enhanced magnetic resonance imaging. The role of the interventional radiologist will continue to expand as imaging techniques become more refined.

Regression of melanoma metastases following treatment with the n-bisphosphonate zoledronate and localised radiotherapy

We report a case of regression of pulmonary and bony metastases in a patient with malignant melanoma following palliative treatment with systemic zoledronate and localised radiotherapy to the bone. Zoledronate is a potent new bisphosphonate used for the treatment of metabolic bone diseases including bone metastases due to its inhibitory effect on osteoclasts. In the context of metastatic cancer zoledronate is routinely used to improve bone pain and reduce the frequency of skeletal events. There is also an increasing body of evidence suggesting that bisphosphonates exhibit anti-tumour properties. Bisphosphonates are able to activate Vgamma9Vdelta2 gamma-delta T cells which can be key players in the immune defence against malignant cells. Furthermore bisphosphonates have direct anti-proliferative, anti-metastatic and pro-apoptotic effects on tumour cells. These actions, together with their low side effect profile, may prove to be useful therapeutic tools in the treatment of cancer even in the absence of bone metastases. On the basis of this case report we here review the current literature on present preclinical and clinical studies using bisphosphonates for the treatment of cancer.

The role of 99mTc-depreotide in the management of neuroendocrine tumours

Background111In-pentetreotide scan (OctreoScan) is a widely available agent with high sensitivity for imaging neuroendocrine tumours. Negative 111In-pentetreotide poses diagnostic as well as therapeutic problems in terms of staging and consideration of targeted radionuclide therapy. AimTo assess the role of 99mTc-depreotide in patients with negative or weakly positive OctreoScan (Krenning score≤1; measured on a scale range 0–4). To determine the usefulness of 99mTc-depreotide scintigraphy for highlighting lesions that may be missed by OctreoScan and/or CT/MRI imaging. Study designProspective analysis of 25 patients with neuroendocrine tumours, with negative or weakly positive 111In-pentetreotide scans, who were consecutively enrolled to undergo 111In-pentetreotide and 99mTc-depreotide imaging. The results were compared with either CT or MRI scans. ResultsHistology was available for 20 of 25 patients: of these 40% had high-grade tumours (cellular proliferation marker Ki-67 score >20%), a further 35% had intermediate-grade tumours (Ki-67 2–20%), and the remaining 25% had low-grade tumours (Ki-67 <2%). Fifty-two percent of patients had completely negative and 48% had weakly positive OctreoScan results. Thirty-two percent of these same patients had significantly positive 99mTc-depreotide scans (Krenning score≥2), with the histology demonstrating intermediate-grade or high-grade tumours. Conclusion99mTc-depreotide imaging has low sensitivity but is useful in a one-third of OctreoScan-negative patients, displaying significantly better uptake than 111In-pentetreotide in this patient group. It aids diagnosis by highlighting lesions not seen by OctreoScan and/or CT/MRI imaging, and can possibly identify a group of patients amenable to therapy with radionuclide agents, such as SOM230, targeting somatostatin receptor subtypes 2, 3 and 5.

Interim fluoro-2-deoxy-D-glucose-PET predicts response and progression-free survival in patients with Hodgkin lymphoma and HIV infection

Background:Interim PET scans in HIV-negative patients with Hodgkin lymphoma has emerged as one of the most important prognostic tools. However, equivalent studies in HIV-positive patients are yet to be performed. Objective:We evaluated the prognostic value of interim [18F]-fluoro-2-deoxy-D-glucose–PET (18F-FDG PET) after two or three cycles of chemotherapy using adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) with concomitant HAART in HIV-positive patients with Hodgkin lymphoma. Methods:Patients with advanced HIV–Hodgkin lymphoma (HIV-HL) from six UK centres were included. Interim PET scans after two or three cycles of ABVD (PET-2 or PET-3) were carried out. Prognostic analysis correlated the 2-year progression-free survival (PFS) rate with the interim PET result. Results:Twenty-three evaluable patients were assessed, 21 achieved a negative interim PET and 22 achieved complete remission by computerized tomography scan criteria after ABVD therapy. After a median follow-up of 27 months (range 12–50), disease progression was seen in one patient. Treatment failure was seen in one of the two interim PET-positive patients and none of the interim PET-negative patients. The 2-year PFS for interim PET-positive patients was 50%, and 100% for interim PET-negative patients (P = 0.0012). Conclusion:A negative interim 18F-FDG PET result is highly predictive of treatment success in HIV-HL patients.

Advanced vulvar apocrine carcinoma expressing estrogen receptors that responds to tamoxifen therapy

Primary vulvar carcinoma is rare and thought to arise from either anogenital mammary-like glands or native apocrine sweat glands. The diagnosis is predominantly based on tumor morphology with supportive evidence from immunohistochemical staining and exclusion of a primary breast carcinoma. The primary modality of treatment is surgery, while optimal managment of advanced disease is unclear. We present the case of a lady who had metastatic recurrent apocrine carcinoma expressing estrogen receptors, who had a complete response assessed by PET-CT scanning after 7 months of tamoxifen therapy. The report includes a discussion of the histological diagnosis and assessment of response to treatment by PET-CT scanning.

Nonhealing surgical wound due to cutaneous malakoplakia

W. Alwan, W. Rickaby, M.-L. Jullie, M. Green, E. Ypsilantis, V. Warbey, M. George and S. Whittaker St. John’s Institute of Dermatology, Department of Histopathology and Department of General Surgery, Guy’s and St. Thomas’ Hospitals NHS Foundation Trust, London, UK; and Department of Cancer Imaging and King’s College London and Guy’s and St Thomas’ PET Centre, Division of Imaging Sciences and Biomedical Engineering, King’s College London, London, UK