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Occipitocervical Junction: Imaging, Pathology, Instrumentation
Left Anterior Fascicular Block Voids Exercise ECG Results
Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.
Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.
Disclosures: Dr. Mousa declared having no financial conflicts.
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.
Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.
Disclosures: Dr. Mousa declared having no financial conflicts.
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.
Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.
Disclosures: Dr. Mousa declared having no financial conflicts.
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient's exercise stress test, Dr. Tarek M. Mousa said at the meeting.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Appropriate Use Eludes Nuclear Cardiologists
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.
The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
None of the speakers has relevant financial interests.
'Your rating for appropriate test candidates is going to be used as a quality metric.'
Source DR. SHAW
Source Elsevier Global Medical News
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.
The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
None of the speakers has relevant financial interests.
'Your rating for appropriate test candidates is going to be used as a quality metric.'
Source DR. SHAW
Source Elsevier Global Medical News
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC's appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called “Excellence in Imaging.” The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging's clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
“By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members' commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care,” promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
“What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric,” she explained.
The educational portion of the Excellence in Imaging campaign will include continuing medical education that is designed to raise the quality of imaging by ASNC members, and webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed for smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Dr. Manuel D. Cerqueira later observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is “easy to say, hard to do.”
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
“They're worried about liability, they're worried about their 1-year contract that gets reviewed by the hospital, and they're worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital,” said Dr. Cerqueira, professor of radiology and medicine at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years show that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
“Basically, if it's an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it's not necessary,” explained Dr. Hendel, professor of medicine and radiology at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. (See graphic.) If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
“Imaging in Focus” is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It's designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate imaging in 3 years. Dr. Hendel announced that the program has already resoundingly surpassed that target. In its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
None of the speakers has relevant financial interests.
'Your rating for appropriate test candidates is going to be used as a quality metric.'
Source DR. SHAW
Source Elsevier Global Medical News
Nuclear Cardiology Group Launches Self-Improvement Program
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.
The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
"This is very exciting," he said.
None of the speakers had relevant financial interests.
Myocardial perfusion imaging, MPI, Leslee J. Shaw, Ph.D., Excellence in Imaging,
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.
The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
"This is very exciting," he said.
None of the speakers had relevant financial interests.
DENVER – The majority of nuclear cardiology labs are not utilizing the American College of Cardiology appropriate use criteria for myocardial perfusion imaging, according to the preliminary results of an American Society of Nuclear Cardiology membership survey.
The revelation that only 48% of nuclear cardiology imaging labs employ the ACC appropriate use criteria is disturbing. It comes at a time when nuclear cardiologists are already drawing heat from payers, clinicians, patients, and Congress for perceived overutilization of testing and a casual attitude toward patient exposure to radiation.
The ACC’s appropriate use criteria (AUC) program is a high-profile quality improvement initiative. The myocardial perfusion imaging AUC were developed jointly by the ACC, ASNC, and other key specialty societies. Myocardial perfusion imaging (MPI) was the first topic selected for the program, which has since gone on to develop AUC for other common cardiovascular tests and procedures. MPI was selected to go first because of concerns raised by the explosive growth and substantial regional variation in the procedures. The initial version of the MPI AUC was published in 2005, with an updated rendition appearing 2 years ago (J. Am. Coll. Cardiol. 2009;53:2201-9).
ASNC President Leslee J. Shaw, Ph.D., presented the preliminary membership survey results during her presidential address at the annual meeting of the American Society of Nuclear Cardiology. She also took that occasion to unveil an ambitious new multifaceted ASNC campaign called "Excellence in Imaging." The program is designed to improve the practice of nuclear cardiology through education and advocacy, and by fostering high-quality research that demonstrates nuclear imaging’s clinical value. ASNC members who take the Excellence in Imaging pledge commit themselves to following the AUC.
"By taking a proactive stance on defining quality in nuclear cardiology and demonstrating our members’ commitment to these defined quality measures, ASNC will lead the discussion about appropriate use and set the standards by which our patients receive optimal care," promised Dr. Shaw, professor of medicine at Emory University, Atlanta.
"What the survey results say to me is that we need to do a better job of providing you with tools where you can see the value in improving your process of care, and how the AUC can be utilized to actually identify appropriate patient referral patterns and track your success. This is increasingly going to be a performance metric. Your rating for appropriate test candidates is going to be used as a quality metric," she explained.
The educational portion of the Excellence in Imaging campaign will not only include continuing medical education that is designed to raise the quality of imaging by ASNC members, but also webinars for referring physicians aimed at fostering appropriate referral patterns. Clinical decision support tools are being developed that can be embedded in smart phones to assist referring physicians in selecting the optimal test for a given patient, rather than leaving the testing decision to be made downstream when the patient arrives at the nuclear cardiology clinic. There will also be public education efforts to dispel widespread misconceptions about radiation safety.
Later, Dr. Manuel D. Cerqueira observed that shifting the timing of appropriate test decision making to the point when testing is ordered by referring physicians is "easy to say, hard to do."
No matter how many conversations he has with emergency department physicians at outlying hospitals about not sending him low-risk, inappropriate candidates for imaging procedures involving ionizing radiation exposure when there are better nonradioactive tests available, they continue to do so.
"They’re worried about liability, they’re worried about their 1-year contract that gets reviewed by the hospital, and they’re worried about the pressure the hospital puts on them to do more procedures that are lucrative for the hospital," said Dr. Cerqueira, professor of radiology and medicine and chairman of the nuclear medicine imaging institute at the Cleveland Clinic Foundation.
In a separate presentation, Dr. Robert C. Hendel, who chaired the writing group for the updated MPI AUC, said a dozen studies presented in the past 5 years demonstrate that 10%-15% of all MPIs are inappropriate, as defined by the AUC.
"Basically, if it’s an inappropriate indication, by definition the risks exceed the benefits. The best radiation safety we can do is not to perform the test – not to expose the patient – when it’s not necessary," explained Dr. Hendel, professor of medicine and radiology and director of cardiac imaging and outpatient services at the University of Miami.
He led a six-center study called SPECT-MPI involving roughly 6,000 consecutive patients who underwent single photon emission CT. Overall, inappropriate use of the procedure occurred in 14.4% of patients, with rates ranging from 4% to 22% among the practices.
The SPECT-MPI study identified the major problem areas for inappropriate utilization. Topping the list was the use of MPI to detect CAD in asymptomatic patients at low risk for coronary heart disease; this accounted for 45% of all inappropriate tests and 6% of total testing.
The five most common inappropriate-use indications accounted for 92% of all inappropriate tests. If all testing done for these five inappropriate reasons were to be eliminated, total imaging volume would be reduced by 12.4% (J. Am. Coll. Cardiol. 2010;55:156-62).
"Imaging in Focus" is an ACC-sponsored national quality improvement initiative aimed at helping cardiovascular physicians to reduce inappropriate imaging in a collaborative, nonconfrontational way through the use of webinars, blogs, and other tools. It’s designed as a learning community whose stated goal is to achieve a 50% reduction in inappropriate cardiovascular imaging in 3 years. Dr. Hendel announced some good news: The program has already resoundingly surpassed that target. In just its first year of operation, imaging centers participating in Imaging in Focus reduced their inappropriate imaging by 50% from a baseline rate of 10%.
"This is very exciting," he said.
None of the speakers had relevant financial interests.
Myocardial perfusion imaging, MPI, Leslee J. Shaw, Ph.D., Excellence in Imaging,
Myocardial perfusion imaging, MPI, Leslee J. Shaw, Ph.D., Excellence in Imaging,
FROM THE ANNUAL MEETING OF THE AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY
Left Anterior Fascicular Block Voids Exercise ECG
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Dr. Mousa declared having no financial conflicts.
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Dr. Mousa declared having no financial conflicts.
DENVER – The presence of left anterior fascicular block on a resting ECG indicates an ECG exercise stress test will have significantly diminished diagnostic accuracy, according to a retrospective study.
Thus, this finding on the resting ECG warrants giving serious consideration to adding an imaging modality such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging to the patient’s exercise stress test, Dr. Tarek M. Mousa said at the annual meeting of the American Society of Nuclear Cardiology.
He presented a retrospective study of 1,403 patients who underwent both a maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia. In all, 62 patients (4.4%) had left anterior fascicular block (LAFB) on their resting ECG, including 24 who had both LAFB and right bundle branch block.
The exercise ECG stress test showed greatly reduced sensitivity for myocardial ischemia in patients with LAFB on their resting ECG: 39% as compared with 70% in the 1,341 patients without LAFB.
On the other hand, a finding of greater than 1 mm of exercise-induced ST-segment depression in at least two contiguous leads had significantly greater specificity as an indicator of inducible myocardial ischemia when it occurred in the setting of LAFB: 96% as compared with 79% in controls, added Dr. Mousa of New York Hospital Queens in Flushing.
The presence or absence of right bundle branch block in patients with LAFB on their resting ECG did not affect the diagnostic accuracy of their ECG exercise stress test.
Dr. Mousa declared having no financial conflicts.
THE ANNUAL MEETING OF THE AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY
Major Finding: Exercise ECG stress test showed a sensitivity of 39% for myocardial ischemia in patients with LAFB on their resting ECG, compared with 70% in the patients without LAFB.
Data Source: Retrospective study of 1,403 patients who underwent both maximal treadmill exercise stress ECG test and SPECT myocardial perfusion imaging in search of inducible myocardial ischemia.
Disclosures: Dr. Mousa declared having no financial conflicts.
Unmasking gastric cancer
A 50-year-old male Japanese immigrant with a history of smoking and occasional untreated heartburn presented with the recent onset of flank pain, weight loss, headache, syncope, and blurred vision.
Previously healthy, he began feeling moderate pain in his left flank 1 month ago; it was diagnosed as kidney stones and was treated conservatively. Two weeks later he had an episode of syncope and soon after developed blurred vision, mainly in his left eye, along with severe bifrontal headache. An eye examination and magnetic resonance imaging of the brain indicated optic neuritis, for which he was given glucocorticoids intravenously for 3 days, with moderate improvement.
As his symptoms continued over the next 2 weeks, he lost 20 lb (9.1 kg) due to the pain, loss of appetite, nausea, and occasional vomiting.
Positron emission tomography showed the retroperitoneal infiltrative process and the thickened gastric cardia to be hypermetabolic (Figure 1C).
The area of retroperitoneal infiltration was biopsied under CT guidance, and pathologic study showed poorly differentiated carcinoma with signet-ring cells, a feature of gastric cancer.
The patient underwent lumbar puncture. His cerebrospinal fluid had 206 white blood cells/μL (reference range 0–5) and large numbers of poorly differentiated malignant cells, most consistent with adenocarcinoma on cytologic study.
duodenoscopy (EGD) revealed a large, ulcerated, submucosal, nodular mass in the cardia of the stomach extending to the gastroesophageal junction (Figure 2A). Biopsy of the mass again revealed poorly differentiated adenocarcinoma with scattered signet-ring cells undermining the gastric mucosa, favoring a gastric origin (Figure 2B).
THREE SUBTYPES OF GASTRIC CANCER
Worldwide, gastric cancer is the third most common type of cancer and the second most common cause of cancer-related deaths.1 In the United States, blacks and people of Asian ancestry have almost twice the risk of death, with the highest incidence and mortality rates.2,3
Most cases of gastric adenocarcinoma can be categorized as either intestinal or diffuse, but a new proximal subtype is emerging.4
Intestinal-type gastric adenocarcinoma is the most common subtype and accounts for almost all the ethnic and geographic variation in incidence.2 The lesions are often ulcerative and distal; the pathogenesis is stepwise and is initiated by chronic inflammation. Risk factors include old age, Helicobacter pylori infection, tobacco smoking, family history, and high salt intake, with an observed risk-reduction with the use of nonsteroidal anti-inflammatory drugs and with a high intake of fruits and vegetables.3
Diffuse gastric adenocarcinoma, on the other hand, has a uniform distribution worldwide, and its incidence is increasing. It typically carries a poor prognosis. Evidence thus far has shown its pathogenesis to be independent of chronic inflammation, but it has a strong tendency to be hereditary.3
Proximal gastric adenocarcinoma is observed in the gastric cardia and near the gastroesophageal junction. It is often grouped with the distal esophageal adenocarcinomas and has similar risk factors, including reflux disease, obesity, alcohol abuse, and tobacco smoking. Interestingly, however, H pylori infection does not contribute to the pathogenesis of this type, and it may even have a protective role.3
DIFFICULT TO DETECT EARLY
Gastric cancer is difficult to detect early enough in its course to be cured. Understanding its risk factors, recognizing its common symptoms, and regarding its uncommon symptoms with suspicion may lead to earlier diagnosis and more effective treatment.
Our patient’s proximal gastric cancer was diagnosed late even though he had several risk factors for it (he was Japanese, he was a smoker, and he had gastroesophageal reflux disease) because of a late and atypical presentation with misleading paraneoplastic symptoms.
Early diagnosis is difficult because most patients have no symptoms in the early stage; weight loss and abdominal pain are often late signs of tumor progression.
Screening may be justified in high-risk groups in the United States, although the issue is debatable. Diagnostic imaging is the only effective method for screening,5 with EGD considered the first-line targeted evaluation should there be suspicion of gastric cancer either from the clinical presentation or from barium swallow.6 Candidates for screening may include elderly patients with atrophic gastritis or pernicious anemia, immigrants from countries with high rates of gastric carcinoma, and people with a family history of gastrointestinal cancer.7
- Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55:74–108.
- Crew KD, Neugut AI. Epidemiology of gastric cancer. World J Gastroenterol 2006; 12:354–362.
- Shah MA, Kelsen DP. Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease. J Natl Compr Canc Netw 2010; 8:437–447.
- Fine G, Chan K. Alimentary tract. In:Kissane JM, editor. Anderson’s Pathology. 8th ed. Saint Louis, MO: Mosby; 1985:1055–1095.
- Kunisaki C, Ishino J, Nakajima S, et al. Outcomes of mass screening for gastric carcinoma. Ann Surg Oncol 2006; 13:221–228.
- Cappell MS, Friedel D. The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. Med Clin North Am 2002; 86:1165–1216.
- Hisamuchi S, Fukao P, Sugawara N, et al. Evaluation of mass screening programme for stomach cancer in Japan. In:Miller AB, Chamberlain J, Day NE, et al, editors. Cancer Screening. Cambridge, UK: Cambridge University Press; 1991:357–372.
A 50-year-old male Japanese immigrant with a history of smoking and occasional untreated heartburn presented with the recent onset of flank pain, weight loss, headache, syncope, and blurred vision.
Previously healthy, he began feeling moderate pain in his left flank 1 month ago; it was diagnosed as kidney stones and was treated conservatively. Two weeks later he had an episode of syncope and soon after developed blurred vision, mainly in his left eye, along with severe bifrontal headache. An eye examination and magnetic resonance imaging of the brain indicated optic neuritis, for which he was given glucocorticoids intravenously for 3 days, with moderate improvement.
As his symptoms continued over the next 2 weeks, he lost 20 lb (9.1 kg) due to the pain, loss of appetite, nausea, and occasional vomiting.
Positron emission tomography showed the retroperitoneal infiltrative process and the thickened gastric cardia to be hypermetabolic (Figure 1C).
The area of retroperitoneal infiltration was biopsied under CT guidance, and pathologic study showed poorly differentiated carcinoma with signet-ring cells, a feature of gastric cancer.
The patient underwent lumbar puncture. His cerebrospinal fluid had 206 white blood cells/μL (reference range 0–5) and large numbers of poorly differentiated malignant cells, most consistent with adenocarcinoma on cytologic study.
duodenoscopy (EGD) revealed a large, ulcerated, submucosal, nodular mass in the cardia of the stomach extending to the gastroesophageal junction (Figure 2A). Biopsy of the mass again revealed poorly differentiated adenocarcinoma with scattered signet-ring cells undermining the gastric mucosa, favoring a gastric origin (Figure 2B).
THREE SUBTYPES OF GASTRIC CANCER
Worldwide, gastric cancer is the third most common type of cancer and the second most common cause of cancer-related deaths.1 In the United States, blacks and people of Asian ancestry have almost twice the risk of death, with the highest incidence and mortality rates.2,3
Most cases of gastric adenocarcinoma can be categorized as either intestinal or diffuse, but a new proximal subtype is emerging.4
Intestinal-type gastric adenocarcinoma is the most common subtype and accounts for almost all the ethnic and geographic variation in incidence.2 The lesions are often ulcerative and distal; the pathogenesis is stepwise and is initiated by chronic inflammation. Risk factors include old age, Helicobacter pylori infection, tobacco smoking, family history, and high salt intake, with an observed risk-reduction with the use of nonsteroidal anti-inflammatory drugs and with a high intake of fruits and vegetables.3
Diffuse gastric adenocarcinoma, on the other hand, has a uniform distribution worldwide, and its incidence is increasing. It typically carries a poor prognosis. Evidence thus far has shown its pathogenesis to be independent of chronic inflammation, but it has a strong tendency to be hereditary.3
Proximal gastric adenocarcinoma is observed in the gastric cardia and near the gastroesophageal junction. It is often grouped with the distal esophageal adenocarcinomas and has similar risk factors, including reflux disease, obesity, alcohol abuse, and tobacco smoking. Interestingly, however, H pylori infection does not contribute to the pathogenesis of this type, and it may even have a protective role.3
DIFFICULT TO DETECT EARLY
Gastric cancer is difficult to detect early enough in its course to be cured. Understanding its risk factors, recognizing its common symptoms, and regarding its uncommon symptoms with suspicion may lead to earlier diagnosis and more effective treatment.
Our patient’s proximal gastric cancer was diagnosed late even though he had several risk factors for it (he was Japanese, he was a smoker, and he had gastroesophageal reflux disease) because of a late and atypical presentation with misleading paraneoplastic symptoms.
Early diagnosis is difficult because most patients have no symptoms in the early stage; weight loss and abdominal pain are often late signs of tumor progression.
Screening may be justified in high-risk groups in the United States, although the issue is debatable. Diagnostic imaging is the only effective method for screening,5 with EGD considered the first-line targeted evaluation should there be suspicion of gastric cancer either from the clinical presentation or from barium swallow.6 Candidates for screening may include elderly patients with atrophic gastritis or pernicious anemia, immigrants from countries with high rates of gastric carcinoma, and people with a family history of gastrointestinal cancer.7
A 50-year-old male Japanese immigrant with a history of smoking and occasional untreated heartburn presented with the recent onset of flank pain, weight loss, headache, syncope, and blurred vision.
Previously healthy, he began feeling moderate pain in his left flank 1 month ago; it was diagnosed as kidney stones and was treated conservatively. Two weeks later he had an episode of syncope and soon after developed blurred vision, mainly in his left eye, along with severe bifrontal headache. An eye examination and magnetic resonance imaging of the brain indicated optic neuritis, for which he was given glucocorticoids intravenously for 3 days, with moderate improvement.
As his symptoms continued over the next 2 weeks, he lost 20 lb (9.1 kg) due to the pain, loss of appetite, nausea, and occasional vomiting.
Positron emission tomography showed the retroperitoneal infiltrative process and the thickened gastric cardia to be hypermetabolic (Figure 1C).
The area of retroperitoneal infiltration was biopsied under CT guidance, and pathologic study showed poorly differentiated carcinoma with signet-ring cells, a feature of gastric cancer.
The patient underwent lumbar puncture. His cerebrospinal fluid had 206 white blood cells/μL (reference range 0–5) and large numbers of poorly differentiated malignant cells, most consistent with adenocarcinoma on cytologic study.
duodenoscopy (EGD) revealed a large, ulcerated, submucosal, nodular mass in the cardia of the stomach extending to the gastroesophageal junction (Figure 2A). Biopsy of the mass again revealed poorly differentiated adenocarcinoma with scattered signet-ring cells undermining the gastric mucosa, favoring a gastric origin (Figure 2B).
THREE SUBTYPES OF GASTRIC CANCER
Worldwide, gastric cancer is the third most common type of cancer and the second most common cause of cancer-related deaths.1 In the United States, blacks and people of Asian ancestry have almost twice the risk of death, with the highest incidence and mortality rates.2,3
Most cases of gastric adenocarcinoma can be categorized as either intestinal or diffuse, but a new proximal subtype is emerging.4
Intestinal-type gastric adenocarcinoma is the most common subtype and accounts for almost all the ethnic and geographic variation in incidence.2 The lesions are often ulcerative and distal; the pathogenesis is stepwise and is initiated by chronic inflammation. Risk factors include old age, Helicobacter pylori infection, tobacco smoking, family history, and high salt intake, with an observed risk-reduction with the use of nonsteroidal anti-inflammatory drugs and with a high intake of fruits and vegetables.3
Diffuse gastric adenocarcinoma, on the other hand, has a uniform distribution worldwide, and its incidence is increasing. It typically carries a poor prognosis. Evidence thus far has shown its pathogenesis to be independent of chronic inflammation, but it has a strong tendency to be hereditary.3
Proximal gastric adenocarcinoma is observed in the gastric cardia and near the gastroesophageal junction. It is often grouped with the distal esophageal adenocarcinomas and has similar risk factors, including reflux disease, obesity, alcohol abuse, and tobacco smoking. Interestingly, however, H pylori infection does not contribute to the pathogenesis of this type, and it may even have a protective role.3
DIFFICULT TO DETECT EARLY
Gastric cancer is difficult to detect early enough in its course to be cured. Understanding its risk factors, recognizing its common symptoms, and regarding its uncommon symptoms with suspicion may lead to earlier diagnosis and more effective treatment.
Our patient’s proximal gastric cancer was diagnosed late even though he had several risk factors for it (he was Japanese, he was a smoker, and he had gastroesophageal reflux disease) because of a late and atypical presentation with misleading paraneoplastic symptoms.
Early diagnosis is difficult because most patients have no symptoms in the early stage; weight loss and abdominal pain are often late signs of tumor progression.
Screening may be justified in high-risk groups in the United States, although the issue is debatable. Diagnostic imaging is the only effective method for screening,5 with EGD considered the first-line targeted evaluation should there be suspicion of gastric cancer either from the clinical presentation or from barium swallow.6 Candidates for screening may include elderly patients with atrophic gastritis or pernicious anemia, immigrants from countries with high rates of gastric carcinoma, and people with a family history of gastrointestinal cancer.7
- Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55:74–108.
- Crew KD, Neugut AI. Epidemiology of gastric cancer. World J Gastroenterol 2006; 12:354–362.
- Shah MA, Kelsen DP. Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease. J Natl Compr Canc Netw 2010; 8:437–447.
- Fine G, Chan K. Alimentary tract. In:Kissane JM, editor. Anderson’s Pathology. 8th ed. Saint Louis, MO: Mosby; 1985:1055–1095.
- Kunisaki C, Ishino J, Nakajima S, et al. Outcomes of mass screening for gastric carcinoma. Ann Surg Oncol 2006; 13:221–228.
- Cappell MS, Friedel D. The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. Med Clin North Am 2002; 86:1165–1216.
- Hisamuchi S, Fukao P, Sugawara N, et al. Evaluation of mass screening programme for stomach cancer in Japan. In:Miller AB, Chamberlain J, Day NE, et al, editors. Cancer Screening. Cambridge, UK: Cambridge University Press; 1991:357–372.
- Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin 2005; 55:74–108.
- Crew KD, Neugut AI. Epidemiology of gastric cancer. World J Gastroenterol 2006; 12:354–362.
- Shah MA, Kelsen DP. Gastric cancer: a primer on the epidemiology and biology of the disease and an overview of the medical management of advanced disease. J Natl Compr Canc Netw 2010; 8:437–447.
- Fine G, Chan K. Alimentary tract. In:Kissane JM, editor. Anderson’s Pathology. 8th ed. Saint Louis, MO: Mosby; 1985:1055–1095.
- Kunisaki C, Ishino J, Nakajima S, et al. Outcomes of mass screening for gastric carcinoma. Ann Surg Oncol 2006; 13:221–228.
- Cappell MS, Friedel D. The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. Med Clin North Am 2002; 86:1165–1216.
- Hisamuchi S, Fukao P, Sugawara N, et al. Evaluation of mass screening programme for stomach cancer in Japan. In:Miller AB, Chamberlain J, Day NE, et al, editors. Cancer Screening. Cambridge, UK: Cambridge University Press; 1991:357–372.
