Cancer Treatment Today » Technology Assessments

New type of brochoscopy: ENB

M Levin, MD — Sun, 16 Dec 2012 20:11:12 +0000

ENB (Electromagnetic Navigation Bronchoscopy) or EMN bronchoscopy is a type of bronchoscopy that uses electromagnetic guidance to project catheters into and through bronchial passages. Using a virtual, three-dimensional (3D) bronchial map from a recent CT scan and disposable catheters, it makes it possible toget to preselected spaces and to take biopsies or plan radiation. FDA cleared it in 2004 through the 510(k) process. Studies suggest a higher success rate, but less so for lower lung lobes than the rest of the lung. The British Thoracic Society guidelines for advanced diagnostic and therapeutic flexible bronchoscopy in adults (Du Rand et al, 2011) said that electromagnetic bronchoscopy may be considered for the biopsy of peripheral lesions or to guide trans-bronchial needle aspiration for sampling mediastinal lymph nodes (grade D). Undortunately, one one randomized study had been eprformed and the British Society’s guideline is at a fairly low level of confidence.

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MRI for back pain

M Levin, MD — Fri, 07 Sep 2012 22:12:49 +0000

Back pain is very common. It widely acknowledged that there should be definitive standar5ds on when and how frequently MRI scans should be performed to assess back pain. The American College of Physicians (ACP) and the American Pain Society (APS) have issued a comprehensive joint clinical practice guideline for the diagnosis and treatment of low back pain, which is published in the October 2, 2007 issue of the Annals of Internal Medicine.

For patients with nonspecific low back pain, clinicians should not routinely order imaging studies, including radiographs, computerized tomography (CT) scans, magnetic resonance imaging (MRI), or other diagnostic tests. These tests should be used to evaluate only those patients who have severe or progressive neurologic deficits or who are suspected to have cancer, infection, or other underlying condition as the cause of their low back pain.

For patients with nonspecific low back pain, clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence). These patients should be treated and imaging considered if conservative treatment fails.

Patients with severe or progressive neurologic deficits, or in whom history and physical examination suggest cancer, infection, or other underlying condition as the cause of their low back pain, should undergo imaging studies and other appropriate diagnostic tests (strong recommendation; moderate-quality evidence).

Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if positive results would potentially lead to surgery or epidural steroid injection for suspected radiculopathy. In choosing an imaging procedure, MRI is preferred to CT (strong recommendation; moderate-quality evidence).

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MRI in the Diagnosis and Followup of Multiple Sclerosis

M Levin, MD — Tue, 17 Jul 2012 16:28:21 +0000

Magnetic Resonance Imaging (MRI) of the brain is useful in the diagnosis and treatment of multiple sclerosis (MS), because it is an inflammatory, demyelinating condition of the central nervous system (CNS) that MRI can visualize. Therefore, the activity of the disease can be quantified and tracked over time, with treatment. White matter tracts are affected, including those of the upper brain, lower brain, and spinal cord. MS lesions, known as plaques, may form in white matter in any location; thus, clinical symptoms may be diverse depending on where in the brain or spinal cord the disease is most active. MRI can identify the activity and explain the symptoms. MRI was widely used to in the diagnosis of multiple sclerosis (MS) and increasingly in follow-up. At the same time, it was not entirely clear how to use MRI. A consensus meeting was convened in 2008 to review and update the guidelines. The new guidelines incorporate new information and practice recommendations that will benefit patients and will be useful for physicians and care providers. This consensus recommends a for a baseline evaluation for patients with a Clinically Isolated Syndrome (CIS) and suspected MS. A Brain MRI with gadolinium, a Spinal Cord MRI if there is persisting uncertainty about the diagnosis and/or the findings on Brain MRI are equivocal should be performed, as well as a Spinal Cord MRI if presenting symptoms or signs are at the level of the spinal cord.

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OVA-1 Testing in Ovarian Cancer

M Levin, MD — Mon, 02 Jul 2012 16:44:37 +0000

OVA1 test is FDA cleared for women who meet the following criteria: (i) over age 18, (ii) ovarian mass present for which surgery is planned, and (iii) not yet referred to an oncologist. It is an aid to assess the likelihood that ovarian cancer is present when a physician is not sure. The test should not be used without a prior independent prior clinical/radiological evaluation and is not intended to be a screening test or to determine whether a patient should proceed to surgery. Incorrect use of the OVA1 Test carries the risk of unnecessary testing, surgery, and/or delayed diagnosis. The test has certain advantages. Two recent articles in Obstetrics and Gynecology suggest that it is a more sensitive test than Ca-125. However, sensitivity comes at the price of more false positive tests. The OVA1 test incorrectly identified non-cancerous masses about twice as often as CA 125 or clinical assessment. A higher false positive rate may increase patient distress and the number of surgeries that end up being performed.

Of more importance is the decreased number of false negatives or undetected cancers when OVA1 is added to a physician’s assessment This number is reduced from 28% to 8% in non-gynecologic oncologist assessment and from 21% to 1% in gynecologic oncologist assessment. This translates into potentially more cancers being referred to a gynecologic oncologist for initial surgery. The investigators go on to say, “Hopefully, earlier referral of patients with ovarian cancer will improve survival and reduce the number of required re-operation.” However, guidelines have not fully incorporated this test into their follow-up strategy or their assessment of recommendations on how to assess an ovarian mass. NCCN does not recommend or discuss this test.

ACOG/SGO Committee Opinion: Number 477 (March 2011) recommends that a woman with a suspicious or persistent complex ovarian mass requires surgical evaluation by a physician trained to appropriately stage and reduce the bulk of ovarian cancer. When referring to OVA1, the Committee states that OVA1 “appears to improve the predictability of ovarian cancer in women with pelvic masses. “A letter dated September 2009 issued by the Society of Gynecologic Oncologists recognized the importance of OVA1 stating that it “…may help healthcare providers better detect when referral to a gynecologic oncologist is indicated.”

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