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BACKGROUND Endobronchial ultrasound guided (EBUS) fine-needle aspiration (FNA) biopsy has become widely used to evaluate patients with thoracic abnormalities. Rapid on-site evaluation (ROSE) can provide the bronchoscopist with immediate evaluation findings during the procedure. This study examines EBUS FNA biopsy procedures with and without ROSE, and investigates the impact of ROSE service on the EBUS procedure and laboratory resource utilization. METHODS The cytopathology database at Washington University Medical Center, St. Louis, Missouri, was searched for EBUS FNA biopsy cases before and after introduction of ROSE service, and a matched cohort was collected. Reports were reviewed and pertinent data was collected, such as sites biopsied, ROSE performance, slide smears, cell blocks, and diagnostic categories. Statistical analysis of the results was performed. RESULTS A matched case-controlled EBUS FNA cohort of 340 patients (680 total) for each category of non-ROSE and ROSE service were identified. There was a 33% reduction in the number of sites biopsied with ROSE. A total of 68% of patients with ROSE had just one biopsy site compared to only 36% of non-ROSE patients. There was a 30% decrease in total slides (mean, 5.27 slides) after the introduction of ROSE. All of these improvements were statistically significant. CONCLUSIONS EBUS FNA biopsy ROSE service benefits patients by contributing to significantly fewer biopsies and improved utilization of health care resources. ROSE service results in substantially fewer total slides, which has a significant impact on the cytopathology laboratory work effort. The use of ROSE for EBUS FNA biopsy provides significant improvements in patient care and laboratory resource utilization. Cancer (Cancer Cytopathol) 2013;121:544-551. © 2013 American Cancer Society. [ABSTRACT FROM AUTHOR]

BACKGROUND Rapid on-site evaluation (ROSE) for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy of the pancreas provides immediate feedback regarding cellular adequacy to aid in obtaining a definitive diagnosis and has the potential to avoid repeat procedures. The objective of the current study was to measure the impact of ROSE service on the incidence of repeat EUS FNA biopsy procedures. METHODS Over a consecutive 3-year period, the pathology database at Washington University Medical Center was searched for patients with both an initial and subsequent EUS FNA biopsy demonstrating a solid lesion of the pancreas. These were divided temporally between the time before and after the introduction of ROSE service. Reports were reviewed and results were recorded. RESULTS A total of 379 patients underwent ROSE service and 377 patients did not. The percentage of repeat non-ROSE EUS FNA cases was 5.8% and the percentage of repeat ROSE EUS FNA cases was 2.9%. The use of the ROSE service was found to decrease the number of repeat procedures by approximately 50% ( P = .024). For those patients who underwent a repeat EUS-FNA procedure, the ROSE service provided a higher rate of definitive diagnosis among patients undergoing repeat procedures (67%) versus the non-ROSE cohort (27%). CONCLUSIONS The use of ROSE for EUS-FNA biopsy of the pancreas was found to result in fewer patients undergoing repeat procedures. Patients who required a repeat procedure with the use of ROSE had a higher percentage of definitive diagnostic categorization on the repeat biopsy. Initial use of ROSE for EUS-FNA of solid pancreatic lesions was found to decrease the number of patients who required a repeat procedure. Cancer (Cancer Cytopathol) 2013;121:518-24. © 2013 American Cancer Society. [ABSTRACT FROM AUTHOR]

Purpose: Benign tumors that arise from the meninges can be difficult to treat due to their potentially large size and proximity to critical structures such as cranial nerves and sinuses. Single fraction radiosurgery may increase the risk of symptomatic peritumoral edema. In this study, we report our results on the efficacy and safety of five fraction image-guided radiosurgery for benign meningiomas. Materials/Methods: Clinical and radiographic data from 38 patients treated with five fraction radiosurgery were reviewed retrospectively. Mean tumor volume was 3.83mm3 (range, 1.08-20.79 mm3). Radiation was delivered using the CyberKnife, a frameless robotic image-guided radiosurgery system with a median total dose of 25 Gy (range, 25 Gy-35 Gy). Results: The median follow-up was 20 months. Acute toxicity was minimal with eight patients (21%) requiring a short course of steroids for headache at the end of treatment. Pre-treatment neurological symptoms were present in 24 patients (63.2%). Post treatment, neurological symptoms resolved completely in 14 patients (58.3%), and were persistent in eight patients (33.3%). There were no local failures, 24 tumors remained stable (64%) and 14 regressed (36%). Pre-treatment peritumoral edema was observed in five patients (13.2%). Post-treatment asymptomatic peritumoral edema developed in five additional patients (13.2%). On multivariate analysis, pre-treatment peritumoral edema and location adjacent to a large vein were significant risk factors for radiographic post-treatment edema (p = 0.001 and p = 0.026 respectively). Conclusions: These results suggest that five fraction image-guided radiosurgery is well tolerated with a response rate for neurologic symptoms that is similar to other standard treatment options. Rates of peritumoral edema and new cranial nerve deficits following five fraction radiosurgery were low. Longer follow-up is required to validate the safety and long-term effectiveness of this treatment approach. [ABSTRACT FROM AUTHOR]

BACKGROUND: With the introduction of new treatment modalities and guidelines, it is important to subclassify primary pulmonary non-small cell carcinoma (NSCCA). Subsequent treatment and testing is dependent on accurate subclassification. Endobronchial ultrasound fine-needle aspiration (EBUS FNA) is used for primary evaluation and diagnosis, and can provide a cell block for ancillary testing. METHODS: EBUS FNA cases from primary pulmonary NSCCA with an immunohistochemical (IHC) panel performed on a cell block with concomitant surgical pathology biopsy were analyzed. Cell block preparations underwent an IHC panel including monoclonal antibodies for napsin A (nap-A), thyroid transcription factor (TTF-1), p63, and cytokeratin 5/6 (CK5/6). RESULTS: A total of 81 cases from 81 patients were identified. Of these, 69 cases (85%) were provided a specific diagnosis of adenocarcinoma (ADCA) or squamous cell carcinoma (SCCA) on the EBUS FNA. In 12 cases (15%), a diagnosis of NSCCA, not otherwise specified was provided. For specific subclassifications, there were 35 ADCA cases, 34 SCCA cases, and 12 NSCCA, not otherwise specified cases. For ADCA, nap-A showed granular cytoplasmic staining and TTF-1 nuclear staining. For SCCA, CK5/6 showed cytoplasmic staining and p63 nuclear staining. Surgical pathology concomitant material was present in 29 of 81 cases with 18 correlations and 11 noncorrelations. CONCLUSIONS: With new treatment guidelines for patients with primary pulmonary NSCCA, specific diagnosis is increasingly important. EBUS FNA with cell block provided a specific subclassification of NSCCA in 85% of cases when used in conjunction with a specific IHC panel including nap-A, TTF-1, CK5/6, and p63. Cancer (Cancer Cytopathol) 2013. © 2012 American Cancer Society. [ABSTRACT FROM AUTHOR]

Brain metastases are unfortunately very common in the natural history of many solid tumors and remain a life-threatening condition, associated with a dismal prognosis, despite many clinical trials aimed at improving outcomes. Radiation therapy options for brain metastases include whole brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS). SRS avoids the potential toxicities of WBRT and is associated with excellent local control (LC) rates. However, distant intracranial failure following SRS remains a problem, suggesting that untreated intracranial micrometastatic disease is responsible for failure of treatment. The oral alkylating agent temozolomide (TMZ), which has demonstrated efficacy in primary malignant central nervous system tumors such as glioblastoma, has been used in early phase trials in the treatment of established brain metastases. Although results of these studies in established, macroscopic metastatic disease have been modest at best, there is clinical and preclinical data to suggest that TMZ is more efficacious at treating and controlling clinically undetectable intracranial micrometastatic disease. We review the available data for the primary management of brain metastases with SRS, as well as the use of TMZ in treating established brain metastases and undetectable micrometastatic disease, and suggest the role for a clinical trial with the aims of treating macroscopically visible brain metastases with SRS combined with TMZ to address microscopic, undetectable disease. [ABSTRACT FROM AUTHOR]

Standard treatment for operable patients with single peripheral lung metastases is metastasectomy. We report mature CyberKnife outcomes for high-risk surgical patients with biopsy proven single peripheral lung metastases. Twenty-four patients (median age 73 years) with a mean maximum tumor diameter of 2.5 cm (range, 0.8-4.5 cm) were treated over a 6-year period extending from September 2004 to September 2010 and followed for a minimum of 1 year or until death. A mean dose of 52 Gy (range, 45-60 Gy) was delivered to the prescription isodose line in three fractions over a 3-11 day period (mean, 7 days). At a median follow-up of 20 months, the 2-year Kaplan-Meier local control and overall survival rates were 87 and 50%, respectively. CyberKnife with fiducial tracking is an effective treatment for high-risk surgical patients with single small peripheral lung metastases. Trials comparing CyberKnife with metastasectomy for operable patients are necessary to confirm equivalence. [ABSTRACT FROM AUTHOR]

Standard treatment for operable patients with single peripheral lung metastases is metastasectomy. We report mature CyberKnife outcomes for high-risk surgical patients with biopsy proven single peripheral lung metastases. Twenty-four patients (median age 73 years) with a mean maximum tumor diameter of 2.5 cm (range, 0.8-4.5 cm) were treated over a 6-year period extending from September 2004 to September 2010 and followed for a minimum of 1 year or until death. A mean dose of 52 Gy (range, 45 to 60 Gy) was delivered to the prescription isodose line in 3 fractions over a 3 to 11 day period (mean, 7 days). At a median follow-up of 20 months, the 2-year Kaplan-Meier local control and overall survival rates were 87% and 50%, respectively. CyberKnife with fiducial tracking is an effective treatment for high-risk surgical patients with single small peripheral lung metastases. Trials comparing CyberKnife with metastasectomy for operable patients are necessary to confirm equivalence. [ABSTRACT FROM AUTHOR]

The article discusses the abundance of Semipalmated Sandpipers in the Arctic region. Data were reviewed to examine trends in densities of Semipalmated Sandpipers at breeding sites across Alaska and arctic Canada. Sandpipers either increased or were at least stable at six sites and decreased at one site in Alaska. Analysis was made using the Northwest Territories and Nunavut Checklist Survey. Overall data do not support a range-wide decline in the abundance of Semipalmated Sandpipers.

Compared with direct-gap semiconductors, the valley degeneracy of silicon and germanium opens up new channels for spin relaxation that counteract the spin degeneracy of the inversion-symmetric system. Here the symmetries of the electron-phonon interaction for silicon and germanium are identified and the resulting spin lifetimes are calculated. Room-temperature spin lifetimes of electrons in silicon are found to be comparable to those in gallium arsenide, however, the spin lifetimes in silicon or germanium can be tuned by reducing the valley degeneracy through strain or quantum confinement. The tunable range is limited to slightly over an order of magnitude by intravalley processes. [ABSTRACT FROM AUTHOR]

Introduction: With conventional radiation technique alone, it is difficult to deliver radical treatment (⩾ 60 Gy) to gliomas that are close to critical structures without incurring the risk of late radiation induced complications. Temozolomide-related improvements in high-grade glioma survival have placed a higher premium on optimal radiation therapy delivery. We investigated the safety and efficacy of utilizing highly conformal and precise CyberKnife radiotherapy to enhance conventional radiotherapy in the treatment of high grade glioma. Methods: Between January 2002 and January 2009, 24 patients with good performance status and high-grade gliomas in close proximity to critical structures (i.e. eyes, optic nerves, optic chiasm and brainstem) were treated with the CyberKnife. All patients received conventional radiation therapy following tumor resection, with a median dose of 50 Gy (range: 40 - 50.4 Gy). Subsequently, an additional dose of 10 Gy was delivered in 5 successive 2 Gy daily fractions utilizing the CyberKnife image-guided radiosurgical system. The majority of patients (88%) received concurrent and/or adjuvant Temozolmide. Results: During CyberKnife treatments, the mean number of radiation beams utilized was 173 and the mean number of verification images was 58. Among the 24 patients, the mean clinical treatment volume was 174 cc, the mean prescription isodose line was 73% and the mean percent target coverage was 94%. At a median follow-up of 23 months for the glioblastoma multiforme cohort, the median survival was 18 months and the two-year survival rate was 37%. At a median follow-up of 63 months for the anaplastic glioma cohort, the median survival has not been reached and the 4-year survival rate was 71%. There have been no severe late complications referable to this radiation regimen in these patients. Conclusion: We utilized fractionated CyberKnife radiotherapy as an adjunct to conventional radiation to improve the targeting accuracy of high-grade glioma radiation treatment. This technique was safe, effective and allowed for optimal dose-delivery in our patients. The value of image-guided radiation therapy for the treatment of high-grade gliomas deserves further study. [ABSTRACT FROM AUTHOR]

Background & Aims: Serial analysis of gene expression has helped identify several proteins that are expressed differentially in pancreatic cancer and are highly sensitive and specific for pancreatic adenocarcinoma. We evaluated if the diagnostic accuracy of pancreatic cancer from endoscopic ultrasound (EUS)–fine-needle aspiration (FNA) can be improved by combined evaluation of cytology and immunostaining with these markers. Methods: This study involved the use of archived specimens from patients treated at Saint Louis University Hospital from 2002 to 2006. We identified 5 protein markers that appeared most promising from published literature. We sequentially evaluated immunostaining with these markers in (1) surgical resection specimens, (2) cell blocks from EUS-FNA, and (3) direct smears of EUS-FN aspirates. Finally, we performed a combined evaluation of cytology and immunostaining in direct smears that were difficult to interpret and required a second consultative cytologic opinion. Results: In resection specimens, the majority of pancreatic adenocarcinomas expressed all 5 markers but fascin, maspin, and carcinoembryonic antigen–related cell adhesion molecule 6 also were expressed abnormally in normal pancreata and in chronic pancreatitis. Further evaluation therefore was limited to the other 2 markers: mesothelin and 14-3-3σ. It was feasible and useful to perform immunostaining in cell blocks and direct smear for diagnosing pancreatic cancer. In cases requiring a second cytologic consultation, a combined evaluation of cytologic morphology and immunostaining had 90% accuracy for a pancreatic adenocarcinoma diagnosis. Conclusions: In conclusion, immunostaining with newer protein markers is feasible in EUS-FNA specimens and can assist cytopathologists in diagnosing pancreatic cancer. Among the currently available protein immunomarkers, a combination of mesothelin and 14-3-3σ seems most promising, but needs to be validated in prospective studies before routine clinical use. [Copyright &y& Elsevier]

The article focuses on a study on the outcomes between patients with spinal metastases from breast cancer treated with CyberKnife stereotactic radiosurgery and patients who received conventional external beam radiotherapy (CRT). The study found that CyberKnife and CRT groups were comparable along all matching dimensions and in performance status before treatment. Additionally, outcomes of treatment were similar for patients in both groups. The study also revealed that survival and the number of complications appeared to favor the CyberKnife group.

Double sampling involves combining information from inexpensive rapid counts with intensive complete counts to provide an efficient population estimate. This technique is a valuable approach for calibrating population indices based on incomplete counts and improving the precision of monitoring studies. Data collected through a double-sampling protocol can be analyzed with either a ratio or a regression estimator. The ratio estimator is recommended when the relationship of the actual count to the rapid count is a straight line through origin, which may not be valid when surveying populations that have a small number of individuals per site and a low detection probability. In such situations, the regression estimator may be more appropriate. I investigated the properties of these two different estimators through a simulation study and tabulated sample sizes to control bias of the population average and standard error. Further, I used the results to evaluate when double sampling is a cost-effective design and how to design surveys that meet precision requirements. The design process is illustrated with the Spring Eastern Waterfowl Survey, which shows that double sampling is not always appropriate. [ABSTRACT FROM AUTHOR]

Background: Recent developments in radiotherapeutic technology have resulted in a new approach to treating patients with localized lung cancer. We report preliminary clinical outcomes using stereotactic radiosurgery with real-time tumor motion tracking to treat small peripheral lung tumors. Methods: Eligible patients were treated over a 24-month period and followed for a minimum of 6 months. Fiducials (3-5) were placed in or near tumors under CT-guidance. Non-isocentric treatment plans with 5-mm margins were generated. Patients received 45-60 Gy in 3 equal fractions delivered in less than 2 weeks. CT imaging and routine pulmonary function tests were completed at 3, 6, 12, 18, 24 and 30 months. Results: Twenty-four consecutive patients were treated, 15 with stage I lung cancer and 9 with single lung metastases. Pneumothorax was a complication of fiducial placement in 7 patients, requiring tube thoracostomy in 4. All patients completed radiation treatment with minimal discomfort, few acute side effects and no procedurerelated mortalities. Following treatment transient chest wall discomfort, typically lasting several weeks, developed in 7 of 11 patients with lesions within 5 mm of the pleura. Grade III pneumonitis was seen in 2 patients, one with prior conventional thoracic irradiation and the other treated with concurrent Gefitinib. A small statistically significant decline in the mean % predicted DLCO was observed at 6 and 12 months. All tumors responded to treatment at 3 months and local failure was seen in only 2 single metastases. There have been no regional lymph node recurrences. At a median follow-up of 12 months, the crude survival rate is 83%, with 3 deaths due to comorbidities and 1 secondary to metastatic disease. Conclusion: Radical stereotactic radiosurgery with real-time tumor motion tracking is a promising welltolerated treatment option for small peripheral lung tumors. [ABSTRACT FROM AUTHOR]

Background & Aims Enlarged periportal lymph nodes often are noticed during imaging of the upper abdomen. Malignant infiltration and enlargement of periportal nodes occur in patients with cancers of the liver, gallbladder, biliary tree, and pancreas and lymphoma. However, there are no published data on the significance and differential diagnosis of enlarged periportal lymph nodes in patients without the above mentioned cancers. Methods We searched our database for patients who (1) underwent endoscopic ultrasound for evaluation of enlarged periportal nodes or (2) were found to have enlarged periportal lymph nodes (≥10 mm) during endoscopic ultrasound (EUS) examination. Patients with identifiable pancreatic, biliary, gallbladder, or liver cancers were excluded. EUS-guided fine-needle aspiration of one or more nodes was performed. Results Sixty-four patients with periportal lymph nodes 10–40 mm in size met the inclusion criteria. In 24 patients, enlarged periportal nodes were noted in the computerized tomography or magnetic resonance imaging scans. Fifty-one patients had multiple enlarged periportal nodes. Concomitantly, enlargement was seen in peripancreatic nodes (n = 14), celiac nodes (n = 14), and mediastinal nodes (n = 11). Twelve of the 64 patients (18.8%; 95% confidence interval, 9.2%–28.4%) had a malignant cause of enlarged periportal lymph nodes: 5 with metastatic carcinoma and 7 with non-Hodgkin’s lymphoma. Significant cytologic findings in benign nodes included granulomas (n = 4) and lipogranulomatosis (n = 8). Conclusions A significant number of patients with enlarged periportal lymph nodes without identifiable pancreatobiliary and liver cancer harbor malignancy and other identifiable pathologic processes. We recommend that these nodes be sampled with fine-needle aspiration at the time of EUS examination. [Copyright &y& Elsevier]

Background & Aims: Current management guidelines for hepatocellular carcinoma (HCC) do not require biopsy to prove the diagnosis. We evaluated our experience of patients with liver disease and hepatic lesions suspicious for HCC who underwent both fine-needle aspiration and core biopsy and correlated the results with those from commonly used noninvasive approaches. Methods: We retrospectively reviewed the outcomes of a series of patients undergoing biopsy because of a suspicion of HCC and compared sensitivity, specificity, and predictive value of biopsy with existing noninvasive methods for diagnosing HCC. Results: HCC was diagnosed by biopsy in 74 (63%) of 118 cases, and an additional 10 were found to have HCC on follow-up. Patients with positive biopsy results had significantly higher serum α-fetoprotein levels (median, 57 vs 12; P = .014) than those with negative biopsies, although these 2 groups were otherwise similar with regard to tests of liver function, lesion size on imaging, and Child-Pugh class. No patient developed evidence of tumor spread along the needle track after biopsy. We compared the diagnosis of HCC by biopsy with noninvasive diagnostic criteria advocated by the European Association for the Study of the Liver and those used by the United Network for Organ Sharing. Compared with criteria of the European Association for the Study of the Liver and the United Network for Organ Sharing, biopsy had greater sensitivity, specificity, and predictive value. Conclusions: We recommend a greater role for image-guided biopsy of lesions greater than 1 cm clinically suspicious for HCC to allow adequate treatment planning because the risks of biopsy appear small and the potential benefits significant. Obtaining material for both cytologic and histologic examination at biopsy maximizes the diagnostic yield. [Copyright &y& Elsevier]

Background: In patients with pancreatic cancer, the presence of malignant mediastinal lymphadenopathy (MML) would preclude definitive resection. A recent study suggested routine evaluation for mediastinal lymph-node metastases in all patients being evaluated for pancreaticobiliary masses. In our practice, we routinely assess for mediastinal lymph-node metastases in all patients undergoing EUS for pancreaticobiliary cancer. Methods: We retrospectively evaluated the presence of MML by EUS-guided FNA (EUS-FNA) in 160 consecutive patients with a definite diagnosis of pancreaticobiliary cancer (pancreatic and periampullary cancers) who underwent EUS-FNA by a single operator from 2000 to 2004. Lymph nodes that were round and hypoechoic with sharp margins were considered suspicious and were sampled by FNA. Results: Of the 160 patients included in this study, 78 had peripancreatic lymph nodes (49%: 95% CI[41%, 58%]), 25 had celiac lymph nodes (16%: 95% CI[10%, 22%]), and 14 patients had mediastinal lymph nodes (9%: 95% CI[4%, 13%]) that were suspicious for malignancy by morphologic criteria. In 8 of 14 patients with suspicious mediastinal lymph nodes, FNA documented MML in 5%: 95% CI[2%, 8%]. Only one of these 8 patients with MML had other sites of documented distant metastases by CT and/or positron emission tomography scans. However, 7 of 8 patients had locally advanced cancers. Conclusions: MML is detected by staging EUS-FNA in 5% of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy. [Copyright &y& Elsevier]

This article focuses on a survey which presents an evidence of recent population increases in common eiders breeding in Labrador and Newfoundland. Populations of several sea ducks are declining across their North American ranges, including populations of all 4 eider species. Factors identified as causing these declines include human disturbance, overharvesting, and climatic events. Labrador has breeding populations of the northern common eider, the American common eider and intergrades of the 2 subspecies. Researchers documented this zone of overlap, but the geographic extent and consequences for population structure and recruitment have not been fully explored. In 1998, the Canadian Wildlife Service in conjunction with the Labrador Inuit Association, initiated surveys on the Labrador coast to collect information to estimate breeding eider population trends. Results based on islands surveyed a minimum of 4 years showed an average apparent annual increase of 2 1.6% for Nain, 13.4% for Hopedale, and 18.1% for all areas over the 6-year period from 1998 to 2003.

Presents a letter to the editor about dilated pancreatic duct and common bile duct in a patients with abdominal pain and weight loss published in the 2004 issue of the "American Journal of Gastroenterology."

In this article the author views on telecytopathology's use in site evaluation in endoscopic ultraound fine-needle aspiration (FNA) for improving patient outcomes. The author views that rapid on site evaluation for FNA biopsy is valuable service that is integral to optimal patient care and diagnosis. The author also views that a nondiagnostic classification led to delay in the patient's treatment.

Presents a letter to the editor about radiation recall dermatitis, published in the March 2004 issue of the "The Breast Journal."