Breast-conserving surgery (BCS) is the primary treatment for early-stage breast cancer, but more accurate techniques are needed to assess resection margins during surgery to avoid the need for follow-up surgeries. Now, in a first-in-human study, British researchers have provided a possible solution using Cerenkov luminescence imaging (CLI), which combines optical and molecular imaging by detecting light emitted by the PET radiotracer F-18-fluorodeoxyglucose (F-18-FDG). CLI’s high-resolution and small-sized imaging equipment make it a promising technology for assessing tumour margins during breast tumour surgery.

‘Currently, approximately 1 in 5 women who undergo breast-conserving surgery, also known as lumpectomy, require repeat surgery due to inadequate excision of the tumour during the initial surgical procedure,’ explains Arnie D. Purushotham, MD, professor at King’s College London, UK. ‘By accurately assessing tumour resection margins intraoperatively with CLI, surgeons may be able to completely clear the cancer with a single operation, thereby reducing the number of breast cancer patients requiring a second, or even third, surgical procedure. Ultimately this could lead to improved patient care and reduced healthcare costs if confirmed in larger clinical studies.’

This study included 22 patients with invasive breast cancer. F-18-FDG was injected 45-60 minutes before surgery. Immediately after the excision of tumours, specimens were imaged intraoperatively in an investigational CLI imaging system. The first 10 patients were used to optimize the imaging protocol; the remaining 12 were included in the analysis dataset. Ten of the 12 patients had an elevated tumour radiance on CLI, and agreement among raters on margin distance was good. Sentinel lymph nodes, which used technetium-99m to facilitate identification, were successfully detected and biopsied in all patients.

F-18-FDG CLI is, therefore, a promising, low-risk technique for intraoperative assessment of tumour margins in breast-conserving surgery. A randomized controlled trial will evaluate the impact of this technique on re-excision rates.

Purushotham points out, ‘The feasibility of intraoperative CLI as shown in this study, in combination with the wide applicability of F-18-FDG across a range of solid cancers, provides a stepping stone for clinical evaluation of this technology in other solid cancer types that also experience incomplete tumour resection due to close or involved margins.’ He also notes, ‘CLI offers the ability to image clinically approved and widely used PET tracers intraoperatively by using small-sized imaging equipment, thus expanding the field of traditional nuclear medicine.’

EurekAlert www.eurekalert.org/pub_releases/2017-06/sonm-coa060117.php

There is effective protection against hip fracture for the many elderly people whose skeleton is declining in strength, as a side effect of cortisone treatment. If patients receive the osteoporosis medication alendronate, it reduces the risk of hip fracture by 65 percent, as a study reveals.
“The low number of people who receive this protective treatment is often due to a lack of knowledge and procedures in this area within the healthcare system,” says Mattias Lorentzon, a professor of geriatric medicine at Sahlgrenska Academy’s Institute of Medicine, and a senior physician at Sahlgrenska University Hospital.
Hip fractures usually affect older people and often lead to disability, a worse quality of life and premature death. For many aged 80 or over, the combination of extensive surgery, immobility and long hospital stays, with a risk of infection, blood clots and confusion, is simply too much.
Cortisone treatment to counteract inflammation conditions such as rheumatoid or muscular arthritis, meanwhile, doubles the risk of hip fracture. This latest study has revealed, however, that just one in four patients treated with cortisone receive the osteoporosis medication alendronate.
The aforementioned study was made possible by interlinking several registers in Sweden, namely Senior Alert, the patient register, the drug register, the cause of death register and the population register.
From a base group of over 400,000 elderly patients, 1802 were prescribed alendronate after starting treatment with the cortisone preparation prednisolone in tablet form. They had been taking the drug for at least three months, at a dosage of at least five milligrams per day.
The group with matched controls, which also consisted of 1802 people, took prednisolone tablets, but did not receive the protective alendronate treatment.
Of those who took cortisone tablets, but did not receive protective treatment, 4.1 percent had broken their hip after around 15 months (1.3 years). In the group that also received alendronate (the protective substance), the equivalent figure was 1.5 percent. This represented a significant reduction in the risk, i.e. 65 percent less, covering other fractures too.
“If a patient receives the protective treatment, the risk of suffering a new fracture, and in particular the new hip fractures that we are really keen to prevent, reduces dramatically,” says Kristian Axelsson, co-author and doctoral candidate, who also works as a resident physician in the orthopedics department at Skaraborgs Hospital.
“The number of patients receiving the treatment is quite low at present, but we are hoping this study will mean more prednisolone patients will receive the fracture-preventing treatment,” he continues.
Most hip fractures occur in older women. The average age in the study was around 80 years, and seven out of ten of the patients were women. There was no increased risk of side effects linked to the alendronate treatment, and for Mattias Lorentzon, it is clear what the study has achieved.
“This drug costs around SEK 200 per person per year, which is nothing really, thanks to the fact that it’s a generic drug for which no patent is outstanding. It’s unlikely any company will invest large amounts of money on a randomized trial to investigate whether it prevents hip fractures in cortisone patients. It perhaps wouldn’t be too ethical either, because there is already indirect evidence that it should work,” he tells us.
“That’s why we wanted to look at the question at issue as part of a major retrospective observational study. The data we now have really supports the argument that it provides effective protection against hip fracture, one of the most costly complaints within the Swedish healthcare system, and something that many people of this age die from. It really helps if you can avoid it,” he concludes.

University of Gothenburg
www.gu.se/english/about_the_university/news-calendar/News_detail/?languageId=100001&contentId=1492013&disableRedirect=true&returnUrl=http%3A%2F%2Fwww.gu.se%2Fomuniversitetet%2Faktuellt%2Fnyheter%2Fdetalj%2F%2Feffektivt-skydd-mot-hoftfraktur-vid-kortisonbehandling.cid1492013

Patients at risk of developing bowel cancer can significantly benefit from a follow-up colonoscopy.

Currently, everyone in the UK over the age of 60 is invited to be screened for bowel cancer, also known as colorectal cancer. It is a major cause of illness and death in developed countries. Small growths in the bowel, called polyps or adenomas, can develop into cancer over a long period of time. However, removing these precancerous growths can drastically reduce the risk of developing bowel cancer.

The new research, funded by the National Institute for Health Research (NIHR), shows that most patients who have had treatment to remove growths in their bowel and are classed as being at ‘intermediate risk’ can benefit substantially from a follow-up or ‘surveillance’ colonoscopy. However, a proportion of this group of patients are at low risk compared with the general population and are unlikely to benefit significantly from colonoscopy surveillance.

The researchers suggest the findings could lead to changes in the way patients are screened and followed-up, and even reduce costs for healthcare services.

Professor Wendy Atkin, from the Department of Surgery and Cancer at Imperial College London and chief investigator on the study, said: ‘The findings could influence national and international guidelines for the screening and surveillance of bowel cancer and could lead to cost savings for the NHS by reducing unnecessary procedures.’

Those patients who have one-to-two large adenomas (1 cm or larger) or three-to-four small adenomas are classed as being at ‘intermediate risk’ and are recommended to have a follow-up colonoscopy three years after their adenomas are removed. Most patients offered this surveillance are at intermediate risk

In the latest study, researchers from Imperial College London looked at the incidence of bowel cancer and the effectiveness of follow-up colonoscopies in reducing incidence in people found to have intermediate-risk adenomas. The study was commissioned on behalf of the UK National Screening Committee to help inform its current bowel cancer screening programme for the NHS.

Professor Atkin, said: ‘Colonoscopies carry a small risk of complications for patients, and are demanding on NHS resources, with around 20 per cent of colonoscopies in the UK performed for surveillance. It is therefore important to assess whether all people classed as being at intermediate risk need to undergo follow-up colonoscopy.’

Researchers looked at data for more than 250,000 patients and identified approximately 12,000 people who were diagnosed with intermediate-risk adenomas across 17 UK hospitals. These patients were monitored over an eight year period, and the incidence of bowel cancer was compared in those who had a follow-up colonoscopy with those who had not.

They identified a subgroup of patients within the intermediate-risk group, with large adenomas (2 cm or larger), advanced pathology in the adenomas, or polyps in the upper half of the large bowel who were at a higher risk of developing bowel cancer. These ‘higher-risk’ patients appeared to benefit substantially from at least one follow-up colonoscopy.

In addition, intermediate-risk patients who fell into the ‘lower-risk’ subgroup were found to have a smaller chance of developing bowel cancer than that of the general population. For this group of patients, the researchers suggest that follow-up colonoscopies may not be warranted at all if the initial colonoscopy is of high quality.

According to the researchers, the findings will help to shape current and future guidelines on bowel cancer screening both in the UK and internationally. If the changes are adopted, they could lead to cost savings for the NHS and reallocating of resources to focus on those most at risk.

EurekAlert

In the first such collaboration of its kind, an expert panel of rheumatologists and orthopaedic surgeons has developed guidelines for the perioperative management of anti-rheumatic medication in patients undergoing total hip or knee replacement.
"Patients with rheumatic diseases who have joint replacement surgery are at increased risk for joint infection, a potentially devastating complication," said Susan Goodman, MD, co-principal investigator and a rheumatologist at Hospital for Special Surgery in New York City. "As infection risk is linked to the use of anti-rheumatic medication, our goal was to develop recommendations on when to stop medication prior to joint replacement and the optimal time for patients to restart treatment after surgery. Appropriate medication management in the perioperative period may provide an important opportunity to lower the risk of an infection or other adverse outcome."
The expert panel consisted of 31 specialists from more than 20 hospitals and professional organizations. The medication guidelines concern adults with rheumatoid arthritis; spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis; juvenile idiopathic arthritis; and lupus undergoing hip or knee replacement.
The study included traditional disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids. The panel developed guidelines on when to continue, when to withhold, and when to restart these medications, as well as the optimal perioperative dosing of corticosteroids.
Among the main recommendations:

• Non-biologic DMARDs may be continued throughout the perioperative period in patients with rheumatoid arthritis, spondyloarthritis, juvenile idiopathic arthritis and lupus undergoing elective hip or knee replacement.
• Biologic medications should be withheld as close to one dosing cycle as scheduling permits prior to elective hip or knee replacement and restarted after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.

The patient panel, which had significant input, attached far greater importance to preventing infection at the time of surgery than to the possibility of a disease flare from stopping medication.
"The recommendations are intended for use by clinicians, including orthopaedists, rheumatologists, and other physicians performing risk assessment and evaluation, as well as by patients," Dr. Goodman noted. "Communication is key. It is imperative that open and informed communication between the patient, orthopaedic surgeon and rheumatologist take place."

Hospital for Special Surgery
www.hss.edu/newsroom_expert-panel-rheumatologists-press-release.asp

Siemens Healthineers is joining forces with U.S.-based Imricor Medical Systems, Inc. to develop an integrated solution that combines the clinical benefits of real-time MRI scans with 3D-guided cardiac ablation. MRI-compatible devices are planned to be able to translate information on cardiac conduction, morphological substrates and individual patient anatomy into better treatment outcomes. This approach will potentially enable electrophysiologists around the world to treat heart arrhythmia without radiation and to use the visualization of soft tissue information obtained through MRI for this purpose.
“We are very excited about this development partnership, since it is changing the way we look at ablation and its resulting physiological effects for higher precision and better treatment outcome,” explains Dr. Philipp Fischer, head of Cardiology at Siemens Healthineers. Steve Wedan, CEO of Imricor Medical Systems, Inc. describes the partnership’s objectives: “We are thrilled to partner with Siemens Healthineers with a goal of delivering comprehensive solutions for MRI-guided ablations. Together, we look forward to providing patients and physicians with MRI-compatible devices from Imricor that are fully integrated with Siemens’ iCMR-EP labs around the world. Our shared goal is to unlock the potential of interventional MRI for electrophysiology by providing better, faster, and less expensive treatment options.”
Electrophysiology is one of the fastest growing fields within cardiology, especially the interventional therapy of complex arrhythmia such as atrial fibrillation (AFib/AF) and ventricular tachycardia (VT). The intervention itself involves inserting a special catheter into the heart to treat a cardiac conduction defect, a complex procedure in which optimum imaging is essential. “This partnership is planned to help us better translate patients’ individual pathophysiology into personalized treatment approaches. MRI guidance will not only minimize radiation exposure to patients and EP staff. This technology will enable more detailed insights into the target anatomy and tissue properties, and holds the potential to improve clinical outcomes in arrhythmia therapy,” explains Dr. Christoph Zindel, Senior Vice President and General Manager of Magnetic Resonance Imaging at Siemens Healthineers. “Together with our partner Imricor, we are committed to further developing EP solutions for the benefit of the rising population of arrhythmia patients”.
www.siemens.com/healthineers         www.imricor.com