Asbestos-related neoplastic and nonneoplastic diseases of the lungs and pleura range from pleural effusion and pleural plaques to lung cancer and malignant mesothelioma. Pleural effusions are typically hemorrhagic exudates of mixed cellularity but do not typically contain asbestos bodies. The classic distribution of pleural plaques seen on chest radiographs is the posterolateral chest wall between the seventh and tenth ribs, lateral chest wall between the sixth and ninth ribs, the dome of the diaphragm, and the mediastinal pleura. Computed tomographic (CT) findings support this distribution but also show anterior and paravertebral plaques not well shown at chest radiography. Imaging features of diffuse pleural thickening include a continuous sheet, often involving the costophrenic angles and apices, that rarely calcifies. The typical CT features of round atelectasis are of a round or oval mass that abuts the pleura, a "comet tail" of bronchovascular structures going into the mass, and thickening of the adjacent pleura. Features of asbestosis on chest radiographs include ground-glass opacification, small nodular opacities, "shaggy" cardiac silhouette, and ill-defined diaphragmatic contours. CT, however, is more sensitive in their detection. Chest radiography in patients with malignant mesothelioma may show an effusion, pleural thickening, and as the tumor progresses, a more lobulated outline. CT can help identify the disease in its early stages. Asbestos-related cancers can occur anywhere in the lungs. Recognition of the clinical, radiologic, and pathologic features of these diseases will be important for some years to come.
Background Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective total mesorectal excision could reduce the adverse effects of treatment without substantially compromising oncological outcomes. We investigated the feasibility of recruiting patients to a randomised trial comparing an organ-preserving strategy with total mesorectal excision.Methods TREC was a randomised, open-label feasibility study done at 21 tertiary referral centres in the UK. Eligible participants were aged 18 years or older with rectal adenocarcinoma, staged T2 or lower, with a maximum diameter of 30 mm or less; patients with lymph node involvement or metastases were excluded. Patients were randomly allocated (1:1) by use of a computer-based randomisation service to undergo organ preservation with short-course radiotherapy followed by transanal endoscopic microsurgery after 8-10 weeks, or total mesorectal excision. Where the transanal endoscopic microsurgery specimen showed histopathological features associated with an increased risk of local recurrence, patients were considered for planned early conversion to total mesorectal excision. A non-randomised prospective registry captured patients for whom randomisation was considered inappropriate, because of a strong clinical indication for one treatment group. The primary endpoint was cumulative randomisation at 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, and health-related quality of life assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and CR29 in the intention-to-treat population. This trial is registered with the ISRCTN Registry, ISRCTN14422743.
Background:National guidelines recommend that fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is performed in all patients being considered for radical treatment of oesophageal or oesophago-gastric cancer without computerised tomography scan (CTS) evidence of metastasis. Guidance also mandates that all patients with cancer have treatment decisions made within the context of a multi-disciplinary team (MDT) meeting. Little is known, however, about the influence of PET-CT on decision making within MDTs. The aim of this study was to assess the role of PET-CT in oesophago-gastric cancer on MDT decision making.Methods:A retrospective analysis of a prospectively held database of all patients with biopsy-proven oesophageal or oesophago-gastric cancer discussed by a specialist MDT was interrogated. Patients selected for radical treatment without CTS evidence of M1 disease were identified. The influence of PET-CT on MDT decision making was examined by establishing whether the PET-CT confirmed CTS findings of M0 disease (and did not change the patient staging pathway) or whether the PET-CT changed the pathway by showing unsuspected M1 disease, refuting CTS suspicious metastases, or identifying another lesion (needing further investigation).Results:In 102 MDT meetings, 418 patients were discussed, of whom 240 were initially considered for radical treatment and 238 undergoing PET-CT. The PET-CT confirmed CTS findings for 147 (61.8%) and changed MDT recommendations in 91 patients (38.2%) by (i) identifying M1 disease (n=43), (ii) refuting CTS suspicions of M1 disease (n=25), and (iii) identifying new lesions required for investigations (n=23).Conclusion:The addition of PET-CT to standard staging for oesophageal cancer led to changes in MDT recommendations in 93 (38.2%) patients, improving patient selection for radical treatment. The validity of the proposed methods for evaluating PET-CT on MDT decision making requires more work in other centres and teams.
Background and Objectives: The optimal time of rectal resection after long-course
A pseudoaneurysm is a contained leak from an artery which re− mains in communication with the arterial lumen. Pseudoaneu− rysm formation is an uncommon but well−recognised complica− tion of pancreatitis [1]. It is associated with a mortality of up to 50 % [1], or over 90 % if leaking or ruptured and untreated [2]. Conventional treatment is surgical ligation but, more recently, treatment strategies that utilise interventional radiological tech− niques such as angiographic embolisation have been developed to treat pseudoaneurysms. These techniques require selective catheterisation of the vessel supplying the pseudoaneurysm and its occlusion with coils or other thrombogenic agents.Thrombin injection directly into pseudoaneurysms is a technique which was developed to treat pseudoaneurysms that formed fol− lowing femoral artery puncture, with a success rate of up to 97 % [2]. More recently, direct percutaneous thrombin injection into pancreatitis−induced pseudoaneurysms, guided either by ultra− sound [2 ± 4] or by computed tomography [1], has been described.The use of endoscopic ultrasound (EUS) in the diagnosis of pseu− doaneurysms secondary to pancreatitis has been reported [5,6].In this report, we describe the injection of thrombin into a supe− rior mesenteric artery pseudoaneurysm under EUS guidance. As far as we are aware, this technique has not been reported pre− viously. Case ReportA 32−year−old man with a history of chronic heavy alcohol con− sumption was admitted following an episode of fresh rectal bleeding and melaena. During several similar admissions over the previous 18 months, upper gastrointestinal endoscopy and sigmoidoscopy had not revealed a source of bleeding. On admis− sion, he had a tachycardia and was hypotensive, with a haemo− globin of 7.4 g/dl. Following resuscitation, upper gastrointestinal endoscopy demonstrated blood in the stomach, but revealed no bleeding point. He had further episodes of melaena over the next 2 weeks, and repeat endoscopy once again showed blood in the stomach but no bleeding point. He required 23 units of blood in total during this period. Computed tomography demonstrated a pseudoaneurysm adjacent to the pancreatic head, arising from the superior mesenteric artery (Figure 1). This was confirmed by mesenteric angiography, but it was not possible to selectivelyWe describe the treatment of a superior mesenteric artery pseu− doaneurysm caused by pancreatitis by transduodenal injection of thrombin under endoscopic ultrasound guidance. This was a minimally invasive intervention, which has meant that, so far, we have been able to avoid performing a major and complex lap− arotomy in this patient. Although the long−term efficacy is not yet established, the technique is promising.
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