Publications by authors named "Lee Grant"

36 Publications

Growth and renal function dynamics of renal oncocytomas in patients on active surveillance.

BJU Int 2021 May 28. Epub 2021 May 28.

Division of Surgery and Interventional Science, University College London, London, UK.

Objectives: To study the natural history of renal oncocytomas and address indications for intervention by determining how growth is associated with renal function over time, the reasons for surgery and ablation, and disease-specific survival.

Patients And Methods: The study was conducted in a retrospective cohort of consecutive patients with renal oncocytoma on active surveillance reviewed at the Specialist Centre for Kidney Cancer at the Royal Free London NHS Foundation Trust (2012 to 2019). Comparison between groups was performed using Mann-Whitney U-tests and chi-squared tests. A mixed-effects model with a random intercept for patient was used to study the longitudinal association between tumour size and estimated glomerular filtration rate (eGFR).

Results: Longitudinal data from 98 patients with 101 lesions were analysed. Most patients were men (68.3%) and the median (interquartile range [IQR]) age was 69 (13) years. The median (IQR) follow-up was 29 (26) months. Most lesions were small renal masses, and 24% measured over 4 cm. Over half (64.4%) grew at a median (IQR) rate of 2 (4) mm per year. No association was observed between tumour size and eGFR over time (P = 0.871). Nine lesions (8.9%) were subsequently treated. Two deaths were reported, neither were related to the diagnosis of renal oncocytoma.

Conclusion: Natural history data from the largest active surveillance cohort of renal oncocytomas to date show that renal function does not seem to be negatively impacted by growing oncocytomas, and confirms clinical outcomes are excellent after a median follow-up of over 2 years. Active surveillance should be considered the 'gold standard' management of renal oncocytomas up to 7cm.
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http://dx.doi.org/10.1111/bju.15499DOI Listing
May 2021

The European Association of Urology COVID Intermediate-priority Group is Poorly Predictive of Pathological High Risk Among Patients with Renal Tumours.

Eur Urol 2021 Aug 20;80(2):265-267. Epub 2021 May 20.

UCL Medical School, University College London, London, UK; Specialist Centre For Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.eururo.2021.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136273PMC
August 2021

Impact of the first surge of the COVID-19 pandemic on a tertiary referral centre for kidney cancer.

BJU Int 2021 May 8. Epub 2021 May 8.

Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK.

Objective: To analyse the impact of the COVID-19 pandemic on a centralized specialist kidney cancer care pathway.

Materials And Methods: We conducted a retrospective analysis of patient and pathway characteristics including prioritization strategies at the Specialist Centre for Kidney Cancer located at the Royal Free London NHS Foundation Trust (RFH) before and during the surge of COVID-19.

Results: On 18 March 2020 all elective surgery was halted at RFH to redeploy resources and staff for the COVID-19 surge. Prioritizing of patients according to European Association of Urology guidance was introduced. Clinics and the specialist multidisciplinary team (SMDT) meetings were maintained with physical distancing, kidney surgery was moved to a COVID-protected site, and infection prevention measurements were enforced. During the 7 weeks of lockdown (23 March to 10 May 2020), 234 cases were discussed at the SMDT meetings, 53% compared to the 446 cases discussed in the 7 weeks pre-lockdown. The reduction in referrals was more pronounced for small and asymptomatic renal masses. Of 62 low-priority cancer patients, 27 (43.5%) were deferred. Only one (4%) COVID-19 infection occurred postoperatively, and the patient made a full recovery. No increase in clinical or pathological upstaging could be detected in patients who underwent deferred surgery compared to pre-COVID practice.

Conclusion: The first surge of the COVID-19 pandemic severely impacted diagnosis, referral and treatment of kidney cancer at a tertiary referral centre. With a policy of prioritization and COVID-protected pathways, capacity for time-sensitive oncological interventions was maintained and no immediate clinical harm was observed.
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http://dx.doi.org/10.1111/bju.15441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8239749PMC
May 2021

Pharmacist value-added to neuro-oncology subspecialty clinics: A pilot study uncovers opportunities for best practices and optimal time utilization.

J Oncol Pharm Pract 2020 Dec 17;26(8):1937-1941. Epub 2020 Sep 17.

Neuroscience Institute, Commonwealth School of Medicine, Danville, PA, USA.

Purpose: To evaluate neuro-oncology clinician time utilization for medication management and identify a cost beneficial role for integration of a dedicated pharmacy specialists.

Methods: A pharmacist was temporarily integrated into a neuro-oncology clinic for a 30-day period to evaluate the clinical practice and perform a 14-day clinical chart evaluation and patient interactions as part of a single institutional exploratory analysis. The pharmacist completed screenings for drug-drug interactions, new therapies, medication reconciliation, and advanced interventions as part of a collaborative practice agreement for pharmacist autonomy. Pharmacist time spent was calculated and documented within the patient encounters to support physician decision-making. A comparative estimate of pharmacist versus physician time utilization and cost for each was completed to derive a savings analysis for integration of a dedicated clinic pharmacist.

Result: During the 14-day clinical assessment, the pharmacist completed 147 encounters with 338 interventions. Of the encounters, 90% (n = 132) were higher complexity requiring plan modification, and approximately 48% (n = 162) of all interventions required ≥10 minutes of the pharmacist's time. Physician non-patient-facing time devoted to medication tasks was 5-hours weekly (0.125 FTE, full time equivalents), an estimated direct salary cost of $937/week ($45,000 yearly). Hire of a part-time pharmacist at 0.50 FTE would cover the clinical need with supported documentation and medication monitoring at a cost of $45,000/year.

Conclusion: Defining the roles for dedicated neuro-oncology clinic pharmacists allows for cost-savings through re-allocation of physician time and improves subspecialty clinic operations as well as patient care.
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http://dx.doi.org/10.1177/1078155220957738DOI Listing
December 2020

The TP53 mutation rate differs in breast cancers that arise in women with high or low mammographic density.

NPJ Breast Cancer 2020 7;6:34. Epub 2020 Aug 7.

Cancer Genetics Laboratory, Peter MacCallum Cancer Centre, Melbourne, VIC Australia.

Mammographic density (MD) influences breast cancer risk, but how this is mediated is unknown. Molecular differences between breast cancers arising in the context of the lowest and highest quintiles of mammographic density may identify the mechanism through which MD drives breast cancer development. Women diagnosed with invasive or in situ breast cancer where MD measurement was also available ( = 842) were identified from the Lifepool cohort of >54,000 women participating in population-based mammographic screening. This group included 142 carcinomas in the lowest quintile of MD and 119 carcinomas in the highest quintile. Clinico-pathological and family history information were recorded. Tumor DNA was collected where available ( = 56) and sequenced for breast cancer predisposition and driver gene mutations, including copy number alterations. Compared to carcinomas from low-MD breasts, those from high-MD breasts were significantly associated with a younger age at diagnosis and features associated with poor prognosis. Low- and high-MD carcinomas matched for grade, histological subtype, and hormone receptor status were compared for somatic genetic features. Low-MD carcinomas had a significantly increased frequency of mutations, higher homologous recombination deficiency, higher fraction of the genome altered, and more copy number gains on chromosome 1q and losses on 17p. While high-MD carcinomas showed enrichment of tumor-infiltrating lymphocytes in the stroma. The data demonstrate that when tumors were matched for confounding clinico-pathological features, a proportion in the lowest quintile of MD appear biologically distinct, reflective of microenvironment differences between the lowest and highest quintiles of MD.
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http://dx.doi.org/10.1038/s41523-020-00176-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414106PMC
August 2020

Measurement challenge: protocol for international case-control comparison of mammographic measures that predict breast cancer risk.

BMJ Open 2019 12 31;9(12):e031041. Epub 2019 Dec 31.

University of Hawai'i Cancer Center, Honolulu, Hawaii, USA.

Introduction: For women of the same age and body mass index, increased mammographic density is one of the strongest predictors of breast cancer risk. There are multiple methods of measuring mammographic density and other features in a mammogram that could potentially be used in a screening setting to identify and target women at high risk of developing breast cancer. However, it is unclear which measurement method provides the strongest predictor of breast cancer risk.

Methods And Analysis: The measurement challenge has been established as an international resource to offer a common set of anonymised mammogram images for measurement and analysis. To date, full field digital mammogram images and core data from 1650 cases and 1929 controls from five countries have been collated. The measurement challenge is an ongoing collaboration and we are continuing to expand the resource to include additional image sets across different populations (from contributors) and to compare additional measurement methods (by challengers). The intended use of the measurement challenge resource is for refinement and validation of new and existing mammographic measurement methods. The measurement challenge resource provides a standardised dataset of mammographic images and core data that enables investigators to directly compare methods of measuring mammographic density or other mammographic features in case/control sets of both raw and processed images, for the purposes of the comparing their predictions of breast cancer risk.

Ethics And Dissemination: Challengers and contributors are required to enter a Research Collaboration Agreement with the University of Melbourne prior to participation in the measurement challenge. The Challenge database of collated data and images are stored in a secure data repository at the University of Melbourne. Ethics approval for the measurement challenge is held at University of Melbourne (HREC ID 0931343.3).
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http://dx.doi.org/10.1136/bmjopen-2019-031041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955467PMC
December 2019

Protocol for a feasibility study of a cohort embedded randomised controlled trial comparing phron paring reatment (NEST) for small renal masses.

BMJ Open 2019 06 11;9(6):e030965. Epub 2019 Jun 11.

Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, London, UK.

Introduction: Small renal masses (SRMs; ≤4 cm) account for two-thirds of new diagnoses of kidney cancer, the majority of which are incidental findings. The natural history of the SRM seems largely indolent. There is an increasing concern regarding surgical overtreatment and the associated health burden in terms of morbidity and economy. Observational data support the safety and efficacy of percutaneous cryoablation but there is an unmet need for high-quality evidence on non-surgical management options and a head-to-head comparison with standard of care is lacking. Historical interventional trial recruitment difficulties demand novel study conduct approaches. We aim to assess if a novel trial design, the cohort embedded randomised controlled trial (RCT), will enable carrying out such a comparison.

Methods And Analysis: Single-centre prospective cohort study of adults diagnosed with SRM (n=200) with an open label embedded interventional RCT comparing nephron sparing interventions. Cohort participants will be managed at patient and clinicians' discretion and agree with longitudinal clinical data and biological sample collection, with invitation for trial interventions and participation in comparator control groups. Cohort participants with biopsy-proven renal cell carcinoma eligible for both percutaneous cryoablation and partial nephrectomy will be randomly selected (1:1) and invited to consider percutaneous cryoablation (n=25). The comparator group will be robotic partial nephrectomy (n=25). The primary outcome of this feasibility study is participant recruitment. Qualitative research techniques will assess barriers and recruitment improvement opportunities. Secondary outcomes are participant trial retention, health-related quality of life, treatment complications, blood transfusion rate, intensive care unit admission and renal replacement requirement rates, length of hospital stay, time to return to pre-treatment activities, number of work days lost, and health technologies costs.

Ethics And Dissemination: Ethical approval has been granted (UK HRA REC 19/EM/0004). Study outputs will be presented and published.

Trial Registration: ISRCTN18156881; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2019-030965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6577353PMC
June 2019

Molecular comparison of interval and screen-detected breast cancers.

J Pathol 2019 06 8;248(2):243-252. Epub 2019 Mar 8.

Cancer Genetics Laboratory, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.

Breast cancer (BC) diagnosed after a negative mammogram but prior to the next screening episode is termed an 'interval BC' (IBC). Understanding the molecular differences between IBC and screen-detected BCs (SDBC) could improve mammographic screening and management options. Therefore, we assessed both germline and somatic genomic aberrations in a prospective cohort. Utilising the Lifepool cohort of >54 000 women attending mammographic screening programs, 930 BC cases with screening status were identified (726 SDBC and 204 IBC). Clinico-pathological and family history information were recorded. Germline and tumour DNA were collected where available and sequenced for BC predisposition and driver gene mutations. Compared to SDBC, IBCs were significantly associated with a younger age at diagnosis and tumour characteristics associated with worse prognosis. Germline DNA assessment of BC cases that developed post-enrolment (276 SDBCs and 77 IBCs) for pathogenic mutations in 12 hereditary BC predisposition genes identified 8 carriers (2.27%). The germline mutation frequency was higher in IBC versus SDBC, although not statistically significant (3.90% versus 1.81%, p = 0.174). Comparing somatic genetic features of IBC and SDBC matched for grade, histological subtype and hormone receptor revealed no significant differences, with the exception of higher homologous recombination deficiency scores in IBC, and copy number changes on chromosome Xq in triple negative SDBCs. Our data demonstrates that while IBCs are clinically more aggressive than SDBC, when matched for confounding clinico-pathological features they do not represent a unique molecular class of invasive BC, but could be a consequence of timing of tumour initiation and mammographic screening. Copyright © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/path.5251DOI Listing
June 2019

Prospective validation of the NCI Breast Cancer Risk Assessment Tool (Gail Model) on 40,000 Australian women.

Breast Cancer Res 2018 12 20;20(1):155. Epub 2018 Dec 20.

Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, 3000, Australia.

Background: There is a growing interest in delivering more personalised, risk-based breast cancer screening protocols. This requires population-level validation of practical models that can stratify women into breast cancer risk groups. Few studies have evaluated the Gail model (NCI Breast Cancer Risk Assessment Tool) in a population screening setting; we validated this tool in a large, screened population.

Methods: We used data from 40,158 women aged 50-69 years (via the lifepool cohort) participating in Australia's BreastScreen programme. We investigated the association between Gail scores and future invasive breast cancer, comparing observed and expected outcomes by Gail score ranked groups. We also used machine learning to rank Gail model input variables by importance and then assessed the incremental benefit in risk prediction obtained by adding variables in order of diminishing importance.

Results: Over a median of 4.3 years, the Gail model predicted 612 invasive breast cancers compared with 564 observed cancers (expected/observed (E/O) = 1.09, 95% confidence interval (CI) 1.00-1.18). There was good agreement across decile groups of Gail scores (χ = 7.1, p = 0.6) although there was some overestimation of cancer risk in the top decile of our study group (E/O = 1.65, 95% CI 1.33-2.07). Women in the highest quintile (Q5) of Gail scores had a 2.28-fold increased risk of breast cancer (95% CI 1.73-3.02, p < 0.0001) compared with the lowest quintile (Q1). Compared with the median quintile, women in Q5 had a 34% increased risk (95% CI 1.06-1.70, p = 0.014) and those in Q1 had a 41% reduced risk (95% CI 0.44-0.79, p < 0.0001). Similar patterns were observed separately for women aged 50-59 and 60-69 years. The model's overall discrimination was modest (area under the curve (AUC) 0.59, 95% CI 0.56-0.61). A reduced Gail model excluding information on ethnicity and hyperplasia was comparable to the full Gail model in terms of correctly stratifying women into risk groups.

Conclusions: This study confirms that the Gail model (or a reduced model excluding information on hyperplasia and ethnicity) can effectively stratify a screened population aged 50-69 years according to the risk of future invasive breast cancer. This information has the potential to enable more personalised, risk-based screening strategies that aim to improve the balance of the benefits and harms of screening.
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http://dx.doi.org/10.1186/s13058-018-1084-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6302513PMC
December 2018

Evaluation of Clinical Prognostic Factors and Further Delineation of the Effect of Mesenteric Fibrosis on Survival in Advanced Midgut Neuroendocrine Tumours.

Neuroendocrinology 2018 28;107(3):292-304. Epub 2018 Aug 28.

Neuroendocrine Tumour Unit, Centre for Gastroenterology, ENETS Centre of Excellence, Royal Free London NHS Foundation Trust, London, United Kingdom.

Background: Small intestinal neuroendocrine tumours (SI NETs) represent 30-50% of small bowel neoplasms and often present at an advanced stage. To date, there is relatively limited literature regarding prognostic factors affecting overall survival (OS) in stage IV disease. In addition, the prevalence of mesenteric fibrosis (MF) in SI NETs and its effect on OS have not been sufficiently explored in the literature.

Aim: The primary aim of this study was to perform a large-scale survival analysis in an institutional cohort of 387 patients with metastatic (stage IV) SI NETs. The secondary aim was to provide epidemiological information regarding the prevalence of MF and to evaluate its effect on OS.

Results: The median OS was 101 months (95% CI 84, 118). Age > 65 years, mesenteric metastases with and without desmoplasia, liver metastases, carcinoid heart disease (CHD) and bone metastases were associated with a significantly shorter OS, while primary tumour resection was predictive of a longer OS. The benefit of surgical resection was limited to symptomatic patients. MF was present in approximately 50% of patients with mesenteric lymphadenopathy. Elevated urinary 5-HIAA levels correlated strongly with the presence of CHD (p < 0.001) and to a lesser extent (p = 0.02) with MF. MF and CHD did not usually co-exist, suggesting that different mechanisms are likely to be involved in the development of these fibrotic complications.

Conclusions: This study has identified specific prognostic factors in a large cohort of 387 patients with advanced SI NETs and has provided useful epidemiological data regarding carcinoid-related fibrotic complications.
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http://dx.doi.org/10.1159/000493317DOI Listing
January 2019

Host seeking parasitic nematodes use specific odors to assess host resources.

Sci Rep 2017 07 24;7(1):6270. Epub 2017 Jul 24.

Department of Nematology, University of California, Riverside, California, 92521, USA.

Entomopathogenic nematodes (EPNs) are insect parasites used as biological control agents. Free-living infective juveniles (IJs) of EPNs employ host-seeking behaviors to locate suitable hosts for infection. We found that EPNs can differentiate between naïve and infected hosts, and that host attractiveness changes over time in a species-specific manner. We used solid-phase microextraction and gas chromatography/mass spectrometry to identify volatile chemical cues that may relay information about a potential host's infection status and resource availability. Among the chemicals identified from the headspace of infected hosts, 3-Methyl-2-buten-1-ol (prenol) and 3-Hydroxy-2-butanone (AMC) were selected for further behavioral assays due to their temporal correlation with the behavioral changes of IJs towards the infected hosts. Both compounds were repulsive to IJs of Steinernema glaseri and S. riobrave in a dose-dependent manner when applied on an agar substrate. Furthermore, the repulsive effects of prenol were maintained when co-presented with the uninfected host odors, overriding attraction to uninfected hosts. Prenol was attractive to dauers of some free-living nematodes and insect larvae. These data suggest that host-associated chemical cues may have several implications in EPN biology, not only as signals for avoidance and dispersal of conspecifics, but also as attractants for new potential hosts.
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http://dx.doi.org/10.1038/s41598-017-06620-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524962PMC
July 2017

Predictive factors of antiproliferative activity of octreotide LAR as first-line therapy for advanced neuroendocrine tumours.

Br J Cancer 2016 Nov 3;115(11):1321-1327. Epub 2016 Nov 3.

Centre for Gastroenterology, Neuroendocrine Tumour Unit, Centre for Gastroenterology, Royal Free Hospital NHS Foundation Trust, London NW3 2QG, UK.

Background: The antiproliferative activity of octreotide LAR in neuroendocrine tumours (NETs) has been demonstrated by small retrospective studies and confirmed by a prospective phase III trial (PROMID). However, there are limited data about the duration and predictors of response. The aim of our retrospective study was to determine the time to radiological progression (TTRP) of disease and the factors that were associated with better response.

Methods: A total of 254 treatment naïve patients with advanced NETs and positive somatostatin receptor scintigraphy were included. Mean follow-up period was 42 months.

Results: The location of primary was in the small bowel in 204, pancreas in 22, lungs in 14, rectum in 7 and unknown in 7 patients. Most tumours were well-differentiated, G1 (58%) and G2 (23%). The majority of patients commenced octreotide LAR due to functional symptoms (57%), radiological progression (10%) or in the presence of asymptomatic and stable disease on the basis of data from the PROMID trial (18.5%). Partial response occurred in 5%. For all patients, the median TTRP was 37 months (95% confidence interval, CI: 32-52 months). There was a statistically significant shorter TTRP in patients with pancreatic tumours, liver metastases and intermediate grade tumours. Extremely raised (>10 times the upper limit of normal) baseline chromogranin A levels were associated with an unfavourable outcome. In contrast, male sex, carcinoid heart disease and initiation of treatment in the presence of stable disease were predictive of a better response. Age, extra-hepatic metastases, presence of mesenteric desmoplasia, previous resection and functional status of the primary tumour did not affect response.

Conclusions: The duration of the antiproliferative effect of octreotide LAR seems to be longer than previously reported. This study has identified several predictors of response in a large cohort of patients with NETs on somatostatin analogue therapy.
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http://dx.doi.org/10.1038/bjc.2016.349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5129835PMC
November 2016

Selective Sentinel Lymph Node Dissection in Lower Extremity Melanoma.

Plast Reconstr Surg 2016 Mar;137(3):1031-1038

San Francisco, Calif. From The Buncke Clinic, California Pacific Medical Center; the Departments of Surgery and Dermatology, University of California, San Francisco; Medivation Biostatistics; and the Center for Melanoma Research & Treatment, California Pacific Medical Center & Research Institute.

Background: There is debate as to whether deep inguinal lymph nodes should be removed with the superficial or femoral lymph nodes during sentinel lymph node biopsy for lower extremity melanoma, when both superficial and deep inguinal lymph nodes are identified by preoperative lymphoscintigraphy. This study evaluated the lymphatic drainage patterns in lower extremity melanoma to determine whether certain patterns could be used to limit the level of node removal and define the extent of dissection.

Methods: A retrospective outcomes review was performed of lower extremity melanoma patients with excision and sentinel lymph node biopsy from 1995 to 2010. Outcomes included location of sentinel lymph node drainage basins, sentinel lymph node-positivity, and disease-free and overall survival, with drainage patterns compared between above- and below-knee melanomas.

Results: Of 499 patients with lower extremity melanoma having sentinel lymph node biopsy, 356 had below-the-knee and 143 had above-the-knee melanoma. For below-knee melanoma, the node-positivity rate was 23 percent (63 of 271) for superficial inguinal, 0 percent (zero of three) for deep inguinal, and 50 percent (one of two) for popliteal basins. For above-knee melanoma, the positivity rate was 21 percent (24 of 113) for superficial inguinal, 33 percent (one of three) for deep inguinal basins, and 0 percent (zero of zero) for popliteal basins. Importantly, no patients with a negative superficial inguinal sentinel lymph node had a positive deep inguinal sentinel lymph node on final pathologic evaluation [corrected].

Conclusions: A difference was noted in patterns of sentinel lymph node drainage from lower extremity melanoma below and above the knee. Biopsy for deep inguinal basins may be deferred if there is simultaneous drainage to the superficial inguinal basin by preoperative lymphoscintigraphy.

Clinical Question/level Of Evidence: Risk, II.
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http://dx.doi.org/10.1097/01.prs.0000479990.65243.ebDOI Listing
March 2016

Robotic gastric electrical stimulator placement: technique and literature review.

J Robot Surg 2014 Sep 11;8(3):285-7. Epub 2013 Dec 11.

Department of Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA.

Gastroparesis in a chronic setting is a disorder that results in diminished quality of life. Laparoscopic gastric electrical stimulator (GES) placement is now being performed in patients with medically refractory gastroparesis. During this procedure, a significant amount of suturing is required to anchor the electrodes to the gastric wall. Robotic surgery may provide surgeons with several technical and ergonomic advantages during this procedure, when compared with a standard laparoscopic approach. The aim of this study is to present a case and review the technique and literature for robotic placement of GES. This report demonstrates the safety and feasibility of robotic GES placement.
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http://dx.doi.org/10.1007/s11701-013-0440-1DOI Listing
September 2014

Failure of portal venous embolization. ALPPS as salvage enabling successful resection of bilobar liver metastases.

J Gastrointest Cancer 2014 Dec;45 Suppl 1:233-6

Division of HPB and Liver Transplant Surgery, Royal Free Hospital and Medical School, Pond Street, London, NW3 2QG, UK,

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http://dx.doi.org/10.1007/s12029-014-9643-6DOI Listing
December 2014

Small bowel MR enterography: problem solving in Crohn's disease.

Insights Imaging 2012 Jun 17;3(3):251-63. Epub 2012 Mar 17.

Department of Radiology, Guy's & St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK,

Magnetic resonance enterography (MRE) is fast becoming the first-line radiological investigation to evaluate the small bowel in patients with Crohn's disease. It can demonstrate both mural and extramural complications. The lack of ionizing radiation, together with high-contrast resolution, multiplanar capability and cine-imaging make it an attractive imaging modality in such patients who need prolonged follow-up. A key question in the management of such patients is the assessment of disease activity. Clinical indices, endoscopic and histological findings have traditionally been used as surrogate markers but all have limitations. MRE can help address this question. The purpose of this pictorial review is to (1) detail the MRE protocol used at our institution; (2) describe the rationale for the MR sequences used and their limitations; (3) compare MRE with other small bowel imaging techniques; (4) discuss how MRE can help distinguish between inflammatory, stricturing and penetrating disease, and thus facilitate management of this difficult condition. Main Messages • MR enterography (MRE) is the preferred imaging investigation to assess Crohn's disease. T2-weighted, post-contrast and diffusion-weighted imaging (DWI) can be used. • MRE offers no radiation exposure, high-contrast resolution, multiplanar ability and cine imaging. • MRE can help define disease activity, a key question in the management of Crohn's disease. • MRE can help distinguish between inflammatory, stricturing and penetrating disease. • MRE can demonstrate both mural and extramural complications.
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http://dx.doi.org/10.1007/s13244-012-0154-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369125PMC
June 2012

Magnetic resonance cholangiopancreatography: the ABC of MRCP.

Insights Imaging 2012 Feb 28;3(1):11-21. Epub 2011 Sep 28.

Department of Radiology, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK,

Magnetic resonance cholangiopancreatography (MRCP) is a technique that has evolved over the past two decades. It continues to have a fundamental role in the non-invasive investigation of many pancreatico-biliary disorders. The purpose of this review is to summarise the key concepts behind MRCP, the different techniques that are currently employed (including functional and secretin-stimulated MRCP), the pitfalls the reader should be aware of, and the main clinical indications for its use.
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http://dx.doi.org/10.1007/s13244-011-0129-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292642PMC
February 2012

Pelvi-perineal flap reconstruction: normal imaging appearances and post-operative complications on cross-sectional imaging.

Insights Imaging 2011 Jun 2;2(3):215-223. Epub 2011 Feb 2.

Radical pelvic surgery is often required in patients with advanced, persistent or recurrent gynaecological and anorectal malignancies. In the last decade, pedicled flap reconstructions have been increasingly used for pelvic floor and neovaginal reconstruction, introducing well-vascularised non-irradiated tissue into the wound cavity and hence reducing wound complications. The aim of this pictorial review is to describe the normal post-operative cross-sectional imaging appearances of the most commonly used pelvi-perineal flap reconstructions and to illustrate the complications that may arise at the flap donor and recipient sites.
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http://dx.doi.org/10.1007/s13244-011-0070-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259312PMC
June 2011

Common primary tumours of the abdomen and pelvis and their patterns of tumour spread as seen on multi-detector computed tomography.

Insights Imaging 2011 Jun 14;2(3):205-214. Epub 2011 Apr 14.

BACKGROUND: Multidetector computed tomography (MDCT) has become the main investigation of choice for staging of many cancers. AIM: The purpose of this pictorial review is to discuss the imaging appearances on CT of some of the more common cancers arising within the abdomen and pelvis and to describe their typical sites of local, nodal and haematogenous tumour spread. METHODS: Cancers arising from the stomach, pancreas, colon, kidney, ovary and prostate will be reviewed. RESULTS: Awareness of the characteristic sites of tumour spread is important to allow accurate identification of all sites of disease. CONCLUSION: This will clearly have an impact on both patient management and prognosis.
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http://dx.doi.org/10.1007/s13244-011-0089-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259344PMC
June 2011

The value of postoperative/preadjuvant chemotherapy computed tomography in the management of patients with ovarian cancer.

Int J Gynecol Cancer 2011 Feb;21(2):296-301

FRCR, University Department of Radiology, Addenbrooke’sHospital, Hills Rd, Cambridge CB2 0QQ, United Kingdom.

Objective: The objectives of the study were to compare the operative assessment of residual disease with the postoperative computed tomography (CT) findings in patients with ovarian cancer who underwent primary surgical cytoreduction or interval debulking surgery to residual disease 1 cm or less and to assess the effect of potential prognostic factors on patient survival.

Methods: Patients scheduled for surgery and with an available postoperative CT were eligible for the study. Images were retrospectively analyzed in consensus by 2 radiologists.A 5-point qualitative scoring system was used to evaluate the CT findings (1 = tumor definitely absent, 2 = tumor probably absent, 3 = tumor possibly present, 4 = tumor probably present, 5 = tumor definitely present).

Results: Between September 2005 and December 2008, 206 consecutive patients were enrolled; 51 were eligible. In 30 cases (59%), the postoperative CT findings correlated with the surgeon's assessment of residual disease. For the univariate analyses, the only significant prognostic factors associated with overall survival were no residual disease versus residual disease of less than 1 cm as assessed by the surgeon (hazard ratio [HR], 3.06; 95%confidence interval [CI], 1.29--7.27; P = 0.011) and no residual disease versus residual disease greater than 1 cm on CT (HR, 2.57; 95% CI, 1.02--6.48; P = 0.045). The interaction of surgical residual disease and stage 3 was significant (HR, 3.40; 95% CI, 1.42--8.16;P = 0.006) in the multivariate Cox model.

Conclusions: There was only 59% correlation between the surgical assessment and post operative CT findings of residual disease in patients reported to have undergone optimal surgery. Stage and residual disease as assessed by the surgeon were significant prognostic factors for overall survival. The value for postoperative CT may lie in those cases with small-volume residual disease (visible but reported as G1 cm) at surgery.
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February 2011

Spectral domain optical coherence tomography and autofluorescence in a case of acute posterior multifocal placoid pigment epitheliopathy mimicking Vogt-Koyanagi-Harada disease: case report and review of literature.

Ocul Immunol Inflamm 2011 Feb 31;19(1):42-7. Epub 2010 Oct 31.

Department of Ophthalmology, Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Purpose: To report a case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with exudative retinal detachment, simulating acute Vogt-Koyanagi-Harada (VKH) disease and to review relevant imaging literature.

Methods: Ophthalmologic examination, laboratory evaluation, fluorescein angiography, and B-scan ultrasonography performed at baseline, as well as spectral domain optical coherence tomography (OCT) and fundus autofluorescence performed upon initial presentation and at 5-day, 1-month, and 3-month follow-up.

Results: OCT demonstrated outer retinal hyperreflectance and subretinal fluid in the acute phase that disappeared 5 days later. Choroidal thickening was noted on OCT and ultrasonography. Retinal pigment epithelium lesions were hypoautofluorescent acutely but became hyperautofluorescent later in the disease course.

Conclusions: At presentation, there can be considerable overlap in both clinical and imaging findings in APMPPE mimicking acute VKH, making it difficult to differentiate these two entities. Cerebral spinal fluid analysis and follow-up examinations could help in arriving at proper diagnosis.
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http://dx.doi.org/10.3109/09273948.2010.521610DOI Listing
February 2011

Congenital and acquired conditions of the vulva and vagina on magnetic resonance imaging: a pictorial review.

Semin Ultrasound CT MR 2010 Oct;31(5):347-62

Department of Radiology, Royal Marsden Hospital, London, UK.

Magnetic resonance imaging (MRI) has become an established imaging modality for characterizing pelvic pathology, chiefly because of superb contrast resolution and lack of ionizing radiation. In recent years, MRI has been used to stage vulval and vaginal malignancies and assist detection of recurrence. It has also proved useful in the characterization of Müllerian duct anomalies. We review the typical imaging characteristics on MRI of congenital and acquired conditions involving the vulva and vagina.
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http://dx.doi.org/10.1053/j.sult.2010.07.001DOI Listing
October 2010

Adnexal masses: characterization and imaging strategies.

Semin Ultrasound CT MR 2010 Oct;31(5):330-46

Department of Radiology, Guys and St. Thomas' Hospital NHS Foundation Trust, London, UK.

The differential diagnosis for adnexal masses is wide, encompassing a range of benign, borderline, and malignant entities. Stratification of risk is made on age, menopausal status, imaging features, and tumor markers. This review outlines the different imaging modalities available to characterize adnexal masses, describes the typical ultrasound and magnetic resonance imaging features of the most commonly encountered adnexal lesions, and provides a suggested imaging algorithm in the management of such patients.
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http://dx.doi.org/10.1053/j.sult.2010.07.002DOI Listing
October 2010

Anal carcinomas: the role of endoanal ultrasound and magnetic resonance imaging in staging, response evaluation and follow-up.

Eur Radiol 2011 Apr 3;21(4):776-85. Epub 2010 Oct 3.

Department of Radiology, Guys and St Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.

Anal carcinoma is an important but rare condition, managed in specialist centres. Both endoanal ultrasound and magnetic resonance imaging (MRI) can be used in the locoregional staging and follow-up of patients with anal cancer, and both may assist in treatment planning and prognosis. Recent guidelines published by the European Society for Medical Oncology have recommended MRI as the technique of choice for assessment of locoregional disease. This paper describes the techniques for both endoanal ultrasound and MRI, and compares the relative merits and disadvantages of each in the local assessment of anal carcinoma.
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http://dx.doi.org/10.1007/s00330-010-1980-7DOI Listing
April 2011

Visceral abdominal obesity--is there an increased prevalence in men presenting with testicular teratoma?

Acta Radiol 2010 Jul;51(6):687-92

Department of Radiology, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge.

Background: There is evidence to suggest a link between the accumulation of visceral abdominal adipose tissue and an increased incidence of prostate, endometrial, breast, and colonic cancer.

Purpose: To investigate whether an increase in ratio of visceral to subcutaneous abdominal adipose tissue is demonstrated in patients with testicular teratoma.

Material And Methods: Following ethical approval, 22 male patients who had undergone staging computed tomography (CT) between 2004 and 2007 for testicular teratoma were identified from our database. Abdominal adipose tissue distribution for these 22 patients was compared with that of 22 control patients, standardized for age, sex, and body mass index. Visceral and subcutaneous adipose tissue volumes were calculated from a single axial CT slice at the level of the umbilicus. A two-sample t test for the difference in volume ratio between the two groups was used. A P value of < 0.05 was considered statistically significant.

Results: There was a statistically significant difference in the mean ratio of visceral to subcutaneous volumes between the teratoma patients and controls (P=0.02). The ratio in teratoma patients was 1.56 times greater than seen in control patients.

Conclusion: Patients with testicular teratoma have a relatively greater proportion of abdominal visceral adipose tissue compared with controls. This is concordant with published literature for other malignancies.
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http://dx.doi.org/10.3109/02841851003743077DOI Listing
July 2010

A pilot study to assess the feasibility of measurement of adrenal gland volume by magnetic resonance imaging.

Acta Radiol 2010 Feb;51(1):117-20

Department of Radiology, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, United Kingdom.

Background: Repeated computed tomography (CT) assessment of the adrenal glands is associated with a significant radiation burden. The increasing capabilities of magnetic resonance (MR) volumetric analysis of the adrenals make this a potentially alternative technique in man.

Purpose: To determine whether MR imaging could be used to measure adrenal volume, and to determine the intra- and interobserver variation and repeatability of MR volume imaging of adrenals in healthy human subjects.

Material And Methods: This was a single-cohort, sequential design, three-part study involving four MRI examinations per subject following ethical approval and informed consent. Information was collected on four healthy subjects (three male and one female). Two different investigators estimated the area of the adrenal gland for each of the 3-mm contiguous slices (and consequently adrenal volume). In order to estimate inter- and intrareader variability, a repeated-measures mixed model was fitted with adrenal volume as the dependent variable. In order to estimate any bias between readers, Bland-Altman methodology was applied.

Results: Intraobserver variation for adrenal gland volume is approximately 5% of a 3-cm(3 )adrenal gland. Interobserver variation is approximately 9% of a 3-cm(3) adrenal gland. Potential variation in measurement for adrenal volume from all sources equates to approximately 14% of a 3-cm(3) adrenal gland. Verification of image reading by a second investigator (consensus reading) reduces variability.

Conclusion: Analysis of adrenal gland volume using MRI is a potentially reliable technique that could be used to assess a pathological change in adrenal size.
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http://dx.doi.org/10.3109/02841850903352620DOI Listing
February 2010

The use of intraoperative PET probe to resect metastatic melanoma.

BMJ Case Rep 2010 Jul 15;2010. Epub 2010 Jul 15.

Department of Surgery, University of California, San Francisco, San Francisco, California, USA.

Two cases of metastatic melanoma resected with assistance of an intraoperative handheld positron emission tomography (PET) probe are reported. The PET probe is increasingly being used to complement findings made during surveillance monitoring. In qualified surgical candidates metastectomy may completely remove tumour burden on the patient. Two women, one 46-year-old and another 38-year-old, presented with recurrence after having initial exploration for melanoma surgical staging performed either at the University of California, San Francisco (UCSF) or at outside institutions. Combined PET/CT scans were performed preoperatively for each patient, and the use of the PET handheld probe during surgery aided the detection of the previously undetected metastases. Neither patient suffered perioperative complications.
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http://dx.doi.org/10.1136/bcr.12.2009.2593DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3034212PMC
July 2010

Computed tomography in metastatic renal cell carcinoma.

Semin Ultrasound CT MR 2009 Aug;30(4):359-66

Department of Radiology, Guy's and St. Thomas' Hospital, London, UK.

Recent developments in chemotherapy have resulted in several new drug treatments for metastatic renal cell carcinoma (RCC). These therapies have shown improved progression-free survival and are applicable to many more patients than the conventional cytokine-based treatments for metastatic RCC. Consequently imaging is playing a greater part in the management of such patients. Computed tomography (CT) remains the primary imaging modality with other imaging modalities playing a supplementary role. CT is used in the diagnosis and staging of metastatic RCC. It is used in the follow-up of patients after nephrectomy, in assessing the extent of metastatic disease, and in evaluating response to treatment. This review looks at the role of CT in patients with metastatic RCC and describes the appearances of metastatic RCC before and following systemic therapy.
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http://dx.doi.org/10.1053/j.sult.2009.03.007DOI Listing
August 2009

Image-guided biopsy in patients with suspected ovarian carcinoma: a safe and effective technique?

Eur Radiol 2009 Jan 15;19(1):230-5. Epub 2008 Aug 15.

Department of Radiology, Addenbrooke's Hospital, Cambridge, UK.

In patients with suspected advanced ovarian carcinoma, a precise histological diagnosis is required before commencing neo-adjuvant chemotherapy. This study aims to determine the diagnostic accuracy and complication rate of percutaneous biopsies performed under ultrasound or computed tomography guidance. Between 2002 to 2007, 60 consecutive image-guided percutaneous biopsies were performed in patients with suspected ovarian cancer. The following variables were recorded: tissue biopsied, imaging technique, experience of operator, biopsy needle gauge, number of passes, complications, and final histology. Forty-seven patients had omental biopsies, 12 pelvic mass biopsies, and 1 para-aortic lymph node biopsy. Thirty-five biopsies were performed under ultrasound, 25 under computed tomography guidance. Biopsy needle gauges ranged from 14-20 swg with two to five passes for each patient. There were no complications. Histology was obtained in 52 (87%) patients. Percutaneous image-guided biopsy of peritoneal disease or pelvic mass is safe with high diagnostic accuracy. The large-gauge biopsy needle is as safe as the small gauge needle, but has the added value of obtaining tissue samples for immunohistochemistry and genomic studies.
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http://dx.doi.org/10.1007/s00330-008-1121-8DOI Listing
January 2009

Medical image. Equine anatomy.

N Z Med J 2008 Jun 20;121(1276):108-9. Epub 2008 Jun 20.

Department of Radiology, Cambridge University Teaching Hospitals NHS Foundation Trust, Cambridge, United Kingdom.

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June 2008
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