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The Bupa Cromwell Hospital magazine for General Practitioners
Issue 09
Published May 2014
In this issue
Chronic Cough and
the ENT Surgeon
Transforming the
Diagnosis and Treatment
of Prostate Cancer
Dupuytren’s Disease
Primary Hyperparathyroidism
NEWS
WELCOME
Welcome to the ninth issue of MEDIscene, which contains in-depth articles from some of our
leading consultants, a larger news section and profiles of our Palliative Nurse Specialist and a
highly regarded Ophthalmic Surgeon.
Philippa Fieldhouse
It’s been a busy few months at the Cromwell; we’ve launched a new Paediatric Walk-in Centre,
introduced a Tilt table service and developed our Prostate Service and multi-disciplinary team.
Consultant Urologist Mr Hashim Ahmed, who contributes an article on diagnosis and treatment
of prostate cancer in this issue, is closely involved with the Prostate Service.
Other articles include an overview of Dupuytren’s Disease by Consultant Hand and
Orthopaedic Surgeon Mr Maxim Horwitz, Mr Gupreet Sandhu’s detailed look at the treatment
of chronic cough, and Consultant Endocrine Surgeon Mr Fausto Palazzo’s very informative
piece on primary hyperparathyroidism.
We always welcome feedback and would be very pleased to receive your comments about the
magazine, or thoughts on the hospital’s services. Please contact our GP Liaison team (details
below) to pass these on.
I hope that you enjoy this issue, and look forward to seeing you at one of our upcoming GP
symposium events (listed on page 13).
With warm regards,
New Prostate Service
Our new Prostate Service is now up and running at Bupa Cromwell Hospital, offering very accurate diagnostic testing
and highly effective treatment.
Diagnosis
The unit offers multi-parametric MRI prior to decision about a
biopsy, and targeted transperineal image-fusion prostate biopsy.
Men with an elevated PSA blood test will undergo clinical review
and examination followed by a high quality multi-parametric
MRI of the prostate. This is followed by targeted biopsies (taken
through the perineal skin rather than back passage) to areas of
suspicion. The test is a safer, more accurate and less painful test
than the standard Transrectal Ultrasound Guided Biopsy.
Treatment
A multi-disciplinary team of urology, oncology, radiology and
histopathology specialists will review each case of prostate
cancer to recommend treatment options, which may include:HIFU (Focused Ultrasound): focal therapy and whole-gland therapy.
Cryotherapy: focal therapy and whole-gland therapy.
Active surveillance with repeat multi-parametric MRI +/-targeted biopsy when appropriate.
Philippa Fieldhouse
General Manager
Bupa Cromwell Hospital
Key links with oncologists and surgeons performing radical prostatectomy for those requiring or choosing to undergo these procedures.
GP LIAISON TEAM
Richard
Longes
Laxmi
Sonara
Following diagnosis, most men have a choice between active surveillance and radical
surgery or radiotherapy. The latter improves survival by 3-5% over 10-15 years but carries
side-effects such as incontinence, impotence and rectal toxicity due to damage of
collateral tissue.
Amisha
Patel
The GP Liaison team provides a bespoke service for GPs. We can assist you with any enquiries you may have, and
help facilitate patient referrals via Cromwell Direct – 0800 783 9229. This is a dedicated line for GPs wishing to refer
patients (both children and adults) for appointments with consultants, diagnostic tests and admission to the hospital.
We are pleased to welcome Amisha Patel as a new member of our team. Amisha is the GP Liaison Assistant and will
be the first point of contact for educational events including our Symposium series.
We understand that our GP colleagues want to keep up to date with new treatments, diagnostics and services.
Therefore, we work closely with our consultants, many of whom are from London’s top teaching hospitals, to coordinate
our educational programme. Please see the health professionals area of our website for more information.
We would also be happy to arrange a practice visit at a convenient time for you in order to:
discuss the latest developments at the hospital
explore how we can work together more effectively
introduce new consultants
If you would like to discuss your educational needs and arrange a practice visit, or would like further information
about Bupa Cromwell hospital, please contact us:
Laxmi Sonara
Richard Longes
+44 (0)20 7460 5909
07714 386 680
+44 (0)20 7460 5842
07743 884 513
[email protected]
[email protected]
Front Cover: Research into novel antibiotics, showing a technician innoculating a series of agar (culture medium) plates with
bacteria, as part of research into new forms of antibiotics. Pellets of drugs under test are typically placed on the agar plate
and inhibition of bacterial growth is looked for after the plates have been cultured. A bacterial inhibition zone appears as a
clear, circular region around the pellet of an effective antibiotic.
However, one of the consultants, Mr Hashim Ahmed (pictured) has pioneered the role
of focal therapy using minimally-invasive ablative therapies which only target the areas
of cancer, leading to a much lower incidence of side-effects. See his article on page 11
for more details on this. The new Prostate Service also offers effective treatment for radiorecurrent prostate cancer
as well as lower urinary tract symptoms, benign prostate hyperplasia, bladder outlet syndrome, urethral stricture and
haematuria.
Improvements to our
Well Woman Clinic
Bupa Cromwell Hospital’s Well Woman Clinic offers everything
from routine check-ups with highly skilled consultants and
specialist nurses, to diagnostic investigations (including bone
density scans and mammograms) and treatment, all in one
convenient location.
We recently installed a new Vacuum Assisted Breast Biopsy unit
(VABB), which provides an improved breast imaging service at the
Well Woman Clinic and greatly reduced recovery times. The VABB
procedure is carried out under local anaesthetic and leaves only
a small incision that does not require stitches, offering patients
a much less invasive alternative to open surgical biopsy. VABB
retrieves larger amounts of tissue for diagnosis than surgical
biopsy, and the procedure takes less than an hour. Patients can
return to normal activities straight afterwards.
For more information on our Well Woman Clinic, please visit bupacromwellhospital.com/women.
The opinions expressed in this magazine are the personal views of the
authors and do not necessarily reflect those of Bupa Cromwell Hospital.
MEDIscene - ISSUE 09
08
cromwell direct 0800 783 9229
NEWS
NEWS
Lung Cancer Screening
Tilt and Syncope Service
Bupa Cromwell Hospital offers a dedicated lung cancer screening service, aimed at men and
women from the age of 50 who are current or previous smokers.
We have just launched a new Tilt testing service. This non-invasive
procedure can help to diagnose patients with unexplained syncope
when a cardiac arrhythmia is unlikely. It does this by confirming or
refuting a neurally-mediated or postural cause of syncope by tilting
the patient from a horizontal position to an angle of 60 degrees
(head up) on a specially designed bed. Heart rate, beat to beat blood
pressure and symptoms are monitored through this process.
Would you benefit from lung cancer screening?
Lung cancer is the leading cause of cancer deaths in both men and women. By the time symptoms develop it is often
late in the disease and much harder to treat. A CT scan shows an abnormality in around one in four heavy smokers, and
early detection of lung cancer saves lives. Regular screening over the age of 50 can give you peace of mind or provide
early detection of lung cancer.
Five minutes of recumbent data is recorded before the table is tilted
upwards. If, within 20 minutes of tilting, no symptoms or a typical
cardiovascular response (eg. hypotension, bradycardia) are induced,
then sublingual nitrates are administered and data is recorded for
another 20 minutes. If there are still no symptoms, bradycardia
or hypotension apparent after this then carotid sinus massage is
performed to provoke a response. At the end of the test, or when
the diagnosis is achieved, the tilt table is returned to the horizontal
position.
Personalised specialist service
We have a team of dedicated lung specialists, including chest radiologists, chest surgeons, chest physicians and chest
pathologists all under one roof. Combined with our dedicated lung function laboratories, this means that results will be
obtained quickly and you can be confident of experiencing a high quality, personalised service.
Lung screening appointment
During your appointment, which will normally last 2 hours, you will undergo formal lung function testing and a CT scan.
The CT scan will be interpreted by a chest specialist radiologist and you will meet Mr Eric Lim, Consultant Thoracic
Surgeon, who will document your risk factors, discuss the results of the CT and lung function and offer advice. If you
need further treatment, the consultant is able to arrange any further tests or quickly refer you to the right specialist at
the Hospital. We use the very latest screening technology - a GE 128 slice CT scanner which is designed to minimise
your exposure to radiation.
The test is performed as an outpatient
investigation in a designated Tilt
testing room in the Cardiology
department, and is available Monday to
Friday 9:30am - 7:00pm.
The lung screening service is offered at a fixed price of £1,500. Please contact our Lung Screening Coordinator on
+44 (0)20 7460 5836 or email [email protected] for further information.
Referrals made by a non-Cardiologist/
Neurologist will require a full
syncope assessment by a Consultant
Cardiologist specialising in VasoVagal
Syncope. This will include a clinical
assessment with Carotid Sinus Massage
(if appropriate), 48 hour Holter
monitoring, ECG and Tilt test.
Gamma Knife - still the gold standard
for treating brain tumours
Appointments are available
Monday to Friday 9:30am - 7:00pm.
Please contact +44 (0)20 7460
5755/6 or email cardiologydept@
cromwellhospital.com
Our Gamma Knife Centre opened in 1998 and was the first in London.
Used to treat both benign and malignant conditions affecting the
brain, head and neck, Gamma Knife allows for shorter hospital stays
and has an excellent success rate. Over 2,000 patients have been
treated at the Cromwell.
Professor Christer Lindquist and Professor Bodo Lippitz lead the
service and have over 45 years of Gamma Knife surgery experience
between them.
What does Gamma Knife surgery involve?
The patient is fitted with an aluminium head frame and the area to be
treated then mapped using the latest in neuro-imaging techniques.
The optimal dose of radiation is then delivered to the exact shape
of the tumour through focused beams which are accurate to within
0.5mm – the width of a human hair.
NEW CONSULTANTS
Bupa Cromwell Hospital gives a warm welcome to the new consultants who were recently granted practice privileges.
Our consultants are committed to an extremely high level of care and provide an excellent service to our patients. We
are delighted to offer the innovation and expertise of the following new consultants at the hospital:
Dr Adil Ajuied
Consultant Orthopaedic Surgeon
Adult Privileges
Mr Eric Alexandre Chung
Consultant General Surgeon
Adult Privileges
Benefits for the patient:-
Mr David Hargreaves
Consultant Trauma and Orthopaedic Surgeon
Paediatric Privileges
•non-invasive • no incision; no need for head shaving; no scars to heal
•no hair loss or nausea • fast recovery time – patients can usually resume normal activity in a day or two
Mr Giles Heilpern
Consultant Trauma and Orthopaedic Surgeon
Adult Privileges
Mr David Houlihan-Burne
Consultant Trauma and Orthopaedic Surgeon
Adult and Paediatric Privileges
Dr Bruce Martin
Consultant Anaesthetist
Adult and Paediatric Privileges
Dr Ahmed Massoud
Consultant Paediatrician
Paediatric Privileges
Mr Edward McKintosh
Consultant Neurosurgeon
Adult Privileges
Professor Abhiram Prasad
Consultant Cardiologist
Adult Privileges
Mr Andrew Ramwell
Consultant General Surgeon
Adult Privileges
Miss Iman Riad
Consultant Gynaecologist
Adult Privileges
Professor Lindquist comments; “Gamma Knife treatment is so effective as it is very focused on the tumour. Breast
cancer patients can live many years if their secondaries elsewhere are well controlled, but if brain tumours aren’t treated
patients can die within months, and this is the most effective way to treat those tumours.
Since July 2003, the London Specialised Commissioning Group has recommended the Bupa Cromwell Hospital Gamma
Knife Centre to provide radiosurgery for NHS patients. For further information please contact +44 (0)20 7460 5938 or
[email protected]
MEDIscene - ISSUE 09
cromwell direct 0800 783 9229
Dupuytren’s
Disease
Mr Maxim Horwitz
Mr Maxim Horwitz MBChB FRCS (Orth) Dip Hand Surg is a Consultant
Hand and Orthopaedic Surgeon at Chelsea and Westminster
Hospital and Bupa Cromwell Hospital
D
upuytren’s disease is a condition of nodular
hypertrophy and contracture of the palmar
fascia of the hands. The contraction leads to
multi-level deformity with a loss of function.
It is more common in males and usually affects
patients over the age of 40, often presenting
between 50 and 70 years of age. It is commonly
bilateral. There is a hereditary predisposition for it
and an association with diabetes and epilepsy, as
well as Nordic ancestry, and it can be precipitated
by trauma.
There is a small group of people who have what
is known as a Dupuytren’s diathesis, in which the
disease progresses rapidly. Patients are usually
male and present at a younger age with more
severe disease. The diathesis is associated with a
similar condition on the soles of the feet as well as
Peyronie’s disease.
Early on patients with this progressive disease
present with pitting, nodules and thickening of
the fascia in the hand, which can be painful and
may irritate when the hand is used for grasping
or holding objects. Later on this progresses to
deformity at both the metacarpo-phalangeal
(MCPJ) and proximal inter-phalangeal (PIP) joints.
Another sign is the thickening of the skin over the
back of the PIP joints - known as Garrod’s knuckle
pads. Patients may tell you that they are having
trouble with washing, as the finger gets in the way.
Early referral of the condition is recommended so
that fixed contracture can be prevented. Surgery is
not recommended for very early disease (nodules
and pits with no deformity) as this can exacerbate
the diseases.
Surgery is recommended when deformity occurs.
This is usually when the MCPJ contracture is 30°
or beyond with any contracture of the PIPJ. Range
of movement can be assessed grossly and by
using Hueston’s table top test, which says that if
the hand can’t be put flat on a table then it needs
surgery. It must be noted that surgery does not
prevent a recurrence of the disease, and if there is
also significant contracture of the joints then a full
correction of deformity may not be possible.
The following is a useful examination
strategy for these patients:
Treatment options:
Ask them to show the palms of their hands
and straighten their fingers.
Dupuytren’s disease cannot be completely cured
but two main treatment options are available;
surgery and collagenase injection.
Look and feel to establish:
which fingers are affected
degree of MCP and PIP flexion
cords and pits
nodules or palpable masses
scars of surgery including previous skin
graft
webspace contractures
dorsal hand: Garrods pads
other sites: feet (Ledderhose Disease) and
penile involvement (Peyronie’s)
MEDIscene - ISSUE 09
Management:
Surgery takes place under a regional block or a
general anaesthetic as a day case. The patient
goes home in a bulky dressing and will usually
commence hand therapy within a week. Sutures
are removed at approximately 12 days and a splint
may be needed for the day and night for between
four and eight weeks.
Another option is Collagenase injection with
subsequent manipulation. Collagenase clostridium
histolyticum (such as Xiapex or Xiaflex) is a
new medicine for the treatment of contractures
caused by Dupuytren’s disease. It may not be
appropriate for every patient and is best suited for
localised cords over one joint. Patients undergo an
outpatient injection with a follow up 24-48 hours
later and a manipulation under local anaesthetic.
They then see the hand therapist and may well
need a splint but do not have a significant wound.
There is often a small skin slit after manipulation.
As always, patient choice, severity of disease
and surgeons experience will play a role in the
ultimate treatment decision. Long-term follow up is
recommended as recurrence and new lesions can
occur a long time after treatment.
To make an appointment please call 0800 783 9229
References:
Efficacy and safety of collagenase Clostridium histolyticum
injection for Dupuytren contracture: report of 40 cases. Albert
on F, Corain M, Garofano A, Pangallo L, Valore A, Zanella V,
Adani R.
Musculoskeletal Surg. 2013 Nov 20.
Injectable collagenase Clostridium histolyticum: a new
nonsurgical treatment for Dupuytren's disease. Gilpin D,
Coleman S, Hall S, Houston A, Karrasch J, Jones N.J Hand Surg
Am. 2010 Dec;35(12):2027-38.
Surgical management of Dupuytren's contracture in Europe:
regional analysis of a surgeon survey and patient chart
review. Dias J, Bainbridge C, Leclercq C, Gerber RA, Guerin
D, Cappelleri JC, Szczypa PP, Dahlin LB.Int J Clin Pract. 2013
Mar;67(3):271-81.
Current concepts in Dupuytren's disease.Lo S, Pickford M.
Curr Rev Musculoskelet Med. 2013 Mar;6(1):26-34.
cromwell direct 0800 783 9229
Chronic
Cough
and the
ENT
Surgeon
Mr Gurpreet
Sandhu
Mr Gurpreet Sandhu MD FRCS
(Eng) FRCS (Orl-Hns) is a
Consultant ENT Surgeon at
Charing Cross Hospital and
Bupa Cromwell Hospital
C
hronic cough is defined as lasting longer than eight weeks and
is experienced by approximately 40% of people at some stage
in their lives. It seems to affect women more than men.
Chronic cough often starts with a ‘cold’ or ‘flu’ like illness, but the
cough persists beyond the acute phase of the illness. It is possible
that one or more pre-existing factors such as gastro-oesophageal
reflux or post-nasal drip, whilst not previously sufficient to initiate a
cough, now help to perpetuate it in combination with the trauma to
the larynx from the physical act of coughing.
This chronic airway inflammation, perpetuated by multiple
aetiologies, has been termed a ‘cough hypersensitivity syndrome’. The concept of a hypersensitised larynx
serves as a good model when advising patients on a treatment plan. It is also important to bear in mind
the concept of ‘one airway, one disease’, which considers the upper and lower airway as a continuum and
accepts that pathology in one site may affect others.
The most common causes of chronic cough are post nasal drip (PND), asthma related syndromes and
gastro-oesophageal reflux disease (GORD). GPs usually refer patients with a persistent cough to an ENT
specialist after lower respiratory tract pathologies have been excluded, to determine if the cause is related
to PND or GORD. This can be difficult as some patients exhibit clear symptoms and signs whilst others have
none.
A careful history needs to be taken by the specialist followed by an examination, including endoscopy of
the nasal cavity, larynx and pharynx. A chest X-ray will be requested, if not done already, with referral to
a respiratory physician as findings dictate. Skin allergy tests will be performed where there is suspicion of
allergy, and a CT scan may be advisable for patients with sinus symptoms.
A gastroenterology referral is made either when a patient reports symptomatic severe reflux, or a definitive
trial of medical therapy has failed to bring about relief. Where there is concern about the safety of
swallowing, or oesophageal dysmotility is suspected, then a Video Fluoroscopic assessment of swallowing
is recommended.
In the absence of pathology, a cough that fails to resolve spontaneously or in response to definitive medical
treatment may be described as idiopathic, however some of these cases will be psychogenic. Some reports
suggest that up to one third of cases are idiopathic, but in my experience the incidence is much lower.
Chronic cough is defined as lasting longer than eight weeks and is
experienced by approximately 40% of people at some stage in their lives.
It seems to affect women more than men.
Post Nasal Drip
Photo - Science Photo Library
Secretions from the nose (20–40 mls each day) commonly enter the pharynx, through the ciliary action of
the nasal mucosa, and are swallowed. Post-nasal drip however is when patients report having the sensation
of mucus tracking down into the throat.
Antihistamines should be introduced if symptoms
of sneezing, itchy eyes and clear nasal discharge are
evident.
Laryngopharyngeal infections
Upper respiratory tract infections are most commonly
viral and are associated with inflammation of the larynx
and pharynx. Treatment should be conservative as the
majority of these infections resolve spontaneously with
voice rest, steam inhalation and adequate hydration. Some
may be bacterial however, and should be treated with
antibiotics.
Some cases of chronic cough may be due to a postviral laryngeal sensory neuropathy. Cranial nerves can
be affected by inflammatory neuropathic processes, as
seen in Bell’s palsy and trigeminal neuralgia. These can also
result in altered sensory and motor nerve function. Sensory
neuropathic cough is thought to correspond to the lowered
threshold to stimuli seen in cases of trigeminal or postherpetic neuralgias. With the Vagus nerve this can lead to a
‘bogus tickle’ and uncontrollable coughing. These cases have
responded to Amitryptilline, which may lower the sensory
threshold for the afferent nerve endings but can also have a
psychotropic effect.
Laryngopharyngeal reflux
Gastro-oesophageal reflux disease (GORD) is the cause of
chronic cough in up to 40% of patients and diagnosis is based
on well defined symptom scoring and 24 hour pH testing. Those
who argue for different diagnostic criteria for laryngopharyngeal
reflux (LPR), do so on the basis that the larynx is poorly protected
against even transient reflux episodes and that the reflux material
contains proteolytic enzymes and bile salts, both of which can
cause laryngeal irritation.
The gold standard for diagnosis of LPR remains
multi-channel intraluminal impedance manometry. It
is accepted practice to treat with a trial of proton
pump inhibitors when suspecting reflux as a
cause for chronic cough, resorting to further
investigations if medical therapy fails.
Aggressive treatment (twice daily)
with a proton pump inhibitor may
be necessary for three months to
reverse the effects of LPR. An
alginate, such as Gaviscon
Advance, should be used
after the evening meal to
deal with the non-acidic
components of the
refluxate.
Rhinological conditions associated with post-nasal drip include allergic rhinitis, chronic rhinosinusitis and
nasal polyps. Chronic rhinosinusitis is recognised as the main cause of PND and is defined as inflammation
of the lining of the nose and paranasal sinuses.
There has been much debate as to whether post-nasal drip is associated with chronic cough. It would be
reasonable to expect that many patients with chronic rhinosinusitis would complain of PND and cough, yet
very few do so. The American College of Chest Physicians recommend using the term upper airway cough
syndrome (UACS) instead of PND, as conditions causing the syndrome, such as rhinitis, may be linked with
coexisting inflammation of the larynx through the same aetiological factors.
The treatment of PND is directed at the cause. Based on Allergic Rhinitis and its impact on Asthma, firstline treatment should be with intra-nasal corticosteroids (usually as a spray) for at least three months.
MEDIscene - ISSUE 09
cromwell direct 0800 783 9229
Lifestyle changes are crucial and complementary in the long-term management of these patients. This often
includes weight-loss, dietary changes such as limiting caffeine consumption and leaving two to three hours
after the evening meal before sleep.
BUPA CROMWELL HOSPITAL
Severe cases of GORD related cough which don’t respond to medical treatment may be referred for antireflux surgery.
NEW
PAEDIATRIC
WALK-IN
CENTRE
Dysphagia
Any disturbance of normal swallowing may result in aspiration and chronic cough. However, poor clearance
of secretions in the hypopharynx and dysmotility can have similar affects. A pharyngeal pouch must be
excluded when considering the laryngopharyngeal causes of chronic cough and can be identified by a
contrast study, such as a barium swallow.
Airway Stenosis
Laryngotracheal stenosis usually causes breathing difficulty and is associated with poor exercise tolerance,
but it can also lead to a chronic cough. It is sometimes misdiagnosed as Asthma and causes can be
congenital or acquired. In the adult population 50% of cases are related to ventilation on the intensive care
unit. The diagnosis can be made on CT imaging or bronchoscopy, but flow volume loops are an excellent
screening tool.
Systemic inflammatory conditions
The most common systemic conditions associated with cough are sarcoidosis and granulomatosis with
polyangitis. The diagnosis is made based on the clinical picture, blood markers and histology.
Mr Fausto Palazzo
Head and neck conditions
Benign or malignant lesions of the larynx may be associated with a cough. The management of these is
beyond the scope of this article, but may include endoscopic or open surgical procedures, or radiotherapy.
Psychogenic cough
Much research has been undertaken investigating the role of higher brain areas in cough, however there is
little systematic behavioural research on the role of psychological factors. Evidence supports the role of
basic psychological processes on cough behaviour, cognition, emotion, learning and social factors are all
thought to impact on this, but evidence is sparse.
Photo - Science Photo Library - Nasal endoscopy The endoscope has been introduced into the patient’s
body through his nose. It is a fibre optic cable that provides views of the body’s interior.
Table 1. Causes of Chronic Cough seen in the ENT clinic
Nasal
Laryngeal
Lower resp. tract
Others
Post-nasal drip
GORD/LPR
Asthma
Idiopathic
Laryngeal dysfunction
Eosinophilic bronchitis
Psychogenic
Laryngotracheal stenosis
COPD
Swallowing problems
Interstitial lung disease
Systemic diseases
Neoplasm
Neurological
Chronic infection
Drugs
Foreign body
OSAS
Conclusion
Chronic cough is a common but complex
symptom that requires careful consideration
within the context of each case, and a multidisciplinary approach is advised. The ENT
specialist needs to consider the upper and lower
airways as a continuum, and independently
understand the conditions that contribute to
cough. Direct endoscopic examination of the
nose, larynx and pharynx enable the identification
of signs that would otherwise be missed. The
management very much depends upon the
aetiology and all potential causes should be
treated aggressively and simultaneously.
Coming into hospital can be stressful both for children and their parents, but Bupa
Cromwell Hospital’s experienced paediatric team ensures the best possible care for
children in a calm, comfortable environment. The team delivers a wide range of services
for babies and children up to 16 years of age, from simple day case procedures to more
complex treatment.
We have launched a Paediatric Walk-in Centre for children with minor injuries and
illnesses, giving parents and carers peace of mind with instant appointments and first
class care. So you can now avoid NHS queues and get immediate out of hours treatment.
Patients are seen by a fully qualified practitioner and pay a fee of £100 for an initial
consultation, with further charges for extra treatment if necessary. No appointment
is necessary, and patients have the benefit of being treated in a fully equipped private
hospital, with instant referral to leading specialists if required.
Minor injuries or conditions treated at the Walk-in Centre include:
acute infectious illnesses
cuts, abrasions, lacerations and wounds
ear, nose and throat conditions
feeding problems
gastroenterological or respiratory illnesses
general medical conditions
Monday to Friday 5.00pm -9.00pm
Saturday 10.00am -8.00pm
Sunday/ Bank Holidays 10.00am -6.00pm
t: +44 (0)20 7460 5878
e: [email protected]
w: bupacromwellhospital.com/childrens-walk-in
To make an appointment please call 0800 783 9229
MEDIscene - ISSUE 0X
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cromwell direct 0800 783 9229
TRANSFORMING THE DIAGNOSIS
AND TREATMENT OF LOCALISED
PROSTATE CANCER
be recommended conservative management in contrast
to radical therapy, and men with low-risk disease are
recommended radical therapy ‘just in case’.
Three-quarters of men report at least one minor
complication after prostate biopsy:-
Risks and Complications from Transrectal Biopsy
INFECTION
Bacteriuria: 20%-50%
Bacteraemia: 20%-70%
Urinary tract infection: 1-8%
Mr Hashim
Ahmed
Mr Hashim Ahmed PhD, FRCS(Urol), BM, BCh (Oxon), BA(Hons) is a
Consultant Urologist at University College London and Bupa
Cromwell Hospital
The current diagnostic and therapeutic strategy for localised prostate cancer is not working. In fact it is
severely flawed and fraught with controversy. This has not been helpful to patients who are considering
entering the diagnostic pathway or who have, inadvertently, found themselves within it. Due to the
random nature in which we carry out prostate biopsies there is inaccuracy in detection, localisation and
characterisation of cancers. Much debate has centred on these errors, but what is clear is that current
principles of diagnosis and treatment lead to significant harm with little benefit. Despite a general
acceptance that these problems are real and serious, few corrections have been put forward to help
mitigate them. That is, until now.
The current strategy has arisen from our imprecise
diagnostic pathway. We don’t know where the cancer is,
so subject the prostate to randomly placed needles via a
Trans Rectal Ultrasound (TRUS) Guided Biopsy in the hope
of hitting the tumour. This leads to over-diagnosis, underdiagnosis, miss-classification of risk, and both over
and under-treatment. If we do find cancer,
we usually subject the entire prostate to
radiotherapy or surgery, which damages
surrounding structures like neurovascular bundles, the external urinary
sphincter, rectum and bladder neck.
If the benefit of treatment was
significant, then the resulting 10%
chance of incontinence, 20% chance
of impotence and 10% chance of rectal
side-effects (pain, bleeding, diarrhoea)
might be justifiable. The benefit of radical
therapy is small however, and although
treating intermediate and high risk localised
prostate cancer in this way could be justified (c. 5%
absolute risk reduction in mortality at 10-15 years), there
seems to be no benefit in survival for low-risk disease.
Ultimately, TRUS biopsy performs poorly because it is
conducted without knowledge of the cancer location.
TZ
Random deployment of the
needle leads to a clinically
important tumour being
missed
Figure 1.
MEDIscene - ISSUE 09
Ultrasound is used simply to determine that the needle
has targeted prostate tissue, and as a result these
biopsies over-diagnose clinically insignificant prostate
cancer. A man who undergoes transrectal biopsy has
a one in four chance of being diagnosed with prostate
cancer, yet most of these cancers will be the
indolent type that men die with, not from.
Conversely, transrectal biopsies miss
clinically significant cancers, (Figures
1-3). Due to their random nature, they
have an estimated false negative rate of
one in three. Men who test negative for
prostate cancer are either discharged to
the community for yearly PSA testing, or
the same unreliable and harmful test can
be repeated several times over a number of
years in one man.
BLEEDING
Systematic error leads to a
clinically important tumour
being missed higher up in the
prostate
Random deployment of the
needle leads to a clinically
significant tumour being
missed in the anterior TZ
Random deployment
of the needle leads to a
clinically significant tumour
being under-sampled and
categorised as low risk
Figure 2.
Figure 3.
Figure 4.
Life-threatening sepsis: 1-4%
Who should be referred for a pre-biopsy MRI and/or
transperineal targeted biopsy at the Cromwell?
Haematuria: 50%
- Elevated age-specific PSA
Rectal bleeding: most
URINARY
Acute urinary retention: 1%-2%
Voiding symptoms: 10%
- High PSA density 0.15ng/ml/ml if a transrectal ultrasound
volume has been calculated
- High PSA velocity. 0.35 ng/ml/year for PSA values
<4ng/ml and 0.75ng/ml/year for PSA values >/=4ng/ml
- Elevated PSA with first degree relatives with prostate
cancer and/or ethnic risk eg. afro-caribbean/black men
SYSTEMIC
Vasovagal reaction 8%
Imaging is redefining our pathway
Magnetic resonance imaging can change all of this and
improve the care we offer men. Multi-parametric MRI,
(Figure 5), coupled with targeted biopsies, can rule out
clinically significant lesions with a negative predictive
value in the order of 90-95%.
A number of trial groups have shown encouraging
detection rates using multi-parametric MRI to target
areas of suspicion. MRI can provide an accurate volume
with indicators of higher Gleason grade prior to biopsy,
and act as a triage test to identify those men who
require biopsies. This allows men with no clinically
significant cancer to avoid entering the pathway, avoid
having biopsies and potentially unnecessary treatment
altogether.
Prostate cancer in
left peripheral zone
confirmed with
targeted transperineal
biopsies
R= rectum
R
TZ
TZ
FOCAL THERAPY - Treating the tumour and not
the whole prostate
Haematospermia: 30%
They can also be unrepresentative of the true
burden of cancer, (Figure 4). One in three men deemed
low risk on transrectal biopsies can have a higher
volume or grade cancer, or both when a more accurate
biopsy test is applied. The cancer risk attribution
errors of transrectal biopsy result in inappropriate
treatment allocation; men with high-risk disease might
TZ
anaesthetic; carrying out 100,000 biopsies in the UK or 1
million biopsies across Europe under general anaesthetic
is not viable. However, subjecting a man to ‘transfaecal’
biopsies is questionable when an alternative is available.
My research group has been the first to show that
transperineal targeted biopsies under local anaesthetic
are feasible, tolerable and accurate. They can be carried
out in clean non-theatre settings at low cost, with each
procedure lasting only 20 minutes.
Red-line outlines
prostate
Figure 5.
Once an image is available, targeting a suspicious
lesion accurately is crucial. A number of trial groups
conduct targeted biopsies transrectally, again
traversing contaminated mucosa. Until now the
alternative, transperineal biopsies, have required general
- Normal PSA but abnormal free/total PSA ratio (defined
by each lab but usually <25%)
- Men advised to have repeat TRUS biopsy following a
previous negative biopsy due to persistent indication
- Men who are on active surveillance for presumed low risk
prostate cancer
- Men considering minimally invasive therapies such as
HIFU or cryotherapy
A dilemma awaits any man diagnosed with localised
prostate cancer, as he will eventually be forced to choose
between radical therapy or active surveillance. Radical
treatment maximises the chances of cure, but comes
with a 50% chance of serious impact on sexual and/or
urinary function. With active surveillance, genito-urinary
function is preserved in exchange for the psychological
and healthcare burden of intensive surveillance.
Compared to other malignancies, prostate cancer is
an outlier. Breast, renal, thyroid, liver, and pancreas all
involve tissue-preserving therapies, if appropriate, which
are dependent on location and the burden of cancer.
These areas of oncological surgery developed tissuepreservation, as opposed to Halsted principles for wider
surgical margins, due to improvements in diagnostic
tools which are reliant on finding measurable disease
which undergoes targeted sampling and treatment. The
transrectal biopsy has done the opposite for prostate
cancer. Random blind sampling has forced our hands as
clinicians so that we have to apply radical whole-gland
principles. But this is changing.
Studies show that it is sufficient to treat less than the
whole-gland. This is called focal therapy, (Figure 6 - see
over), and it leads to far less genito-urinary and rectal
side-effects. There are currently two modalities approved
by NICE in the UK for delivering focal therapy; high
intensity focused ultrasound (HIFU) and cryotherapy.
NICE have stated that Focal HIFU and Focal Cryotherapy
for localised prostate cancer can be offered to
cromwell direct 0800 783 9229
Black area shows
lack of perfusion
as a result of focal
HIFU treatment to
the tumour.
A CO N V E R SAT I O N W I T H
be applied for men who require and stand to benefit
from treatment, and in that setting it retains the benefits
of cancer control whilst reducing the side-effects
significantly. Current data from over 3000 men treated
internationally and 600 men treated in my own group
shows that incontinence after focal therapy is 0-5%
(radical therapy can lead to incontinence in 15-20%),
whilst erectile dysfunction occurs in 5-10% of men with
good baseline function (radical therapy rates vary from
30% to 60%). Early to medium cancer control using
biopsies after treatment shows between 80-90% have a
successful treatment, with 10-15% of men requiring redotreatment with minimal additional morbidity.
our Palliative Clinical Nurse Specialist
Martina Mitchell
Conclusion
Figure 6.
appropriately selected patients subject to their informed
consent, the notification of local clinical governance
leads, and stipulation that all patients are treated within
a clinical trial or entered into a prospective registry. Both
of these mechanisms are now in place in the UK.
There is a clear consensus that focal therapy should only
The current pathway for prostate cancer diagnosis and
treatment is letting many men down. Recent advances in
imaging and minimally invasive focal therapy mean that
we can start to redress the balance so that the risk and
benefits to men and their families is finally going in the
right direction.
To make an appointment please call 0800 783 9229
BUPA CROMWELL HOSPITAL
SYMPOSIUM
SERIES 2014
W
hat made you want to become a Nurse?
I liked the idea of not doing the conventional
nine to five desk job, so it was just a natural
progression for me after leaving school. I did surgical
nursing initially and became a midwife for three years,
before coming to London. I began work here at the
Cromwell 17 years ago on the oncology unit and have
progressed in various oncology roles since then.
H
ow did you decide upon your specialism?
I gradually developed into the role of palliative
care and symptom control from being an oncology
nurse. Some patients suffered with treatment side
effects, and I became interested in supporting them.
I carried out further study at King’s College, which
enabled me to become the Palliative Care Nurse here
at the Cromwell.
W
hat’s the difference between being a nurse, and
being a palliative care nurse?
Our 2014 series of lectures will be led by our renowned consultants, many
of whom are from London’s top teaching hospitals, to bring you the latest
updates and advances in healthcare. Topics have been tailored with primary
care GPs in mind.
Saturdays - 9.00am-2.00pm
Kensington Town Hall
28 JUNE 20 SEPTEMBER
W
hat’s the best thing about your job?
Hot Topics
Women’s Health
18 OCTOBER
Orthopaedics
22 NOVEMBER
Cardiology / Respiratory
how to register
t: +44 (0)20 7460 5973
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w: register online at bupacromwellhospital.com/GPevents
Scan QR code to go directly to our registration page
MEDIscene - ISSUE 09
I don’t usually get involved in the physical care of
patients, I focus on discharge planning and symptom
control. My role is very much overseeing, signposting
and planning a patient’s journey. Focusing on the care
they may need after treatment, whether they are in
recovery or in the terminal phase of their treatment.
No two days are the same. For me, when you
can give somebody in a vulnerable phase of their life
what they want, and make things as stress free as
possible for both them and their family, that is quite
rewarding.
then I do a ward round to check on all the patients,
and if any need further care I arrange this. I organise
referrals for patients to see dieticians or counsellors,
or talk to family members if they want to discuss
anything. I work with Macmillan and the benefits
helpline, as some patients do not have plans in place
for paying the mortgage etc.
There is a degree of social work involved in my job
and I spend a fair amount of time filling out forms
for patients who may be struggling with bills or their
employers. My afternoon is normally spent writing up
notes and documenting patients’ progress.
I meet with the Therapy department to see
how patients are doing with mobility, and if any
amendments need to be made to their care. I also
educate staff on the wards to ensure they know the
end of life care pathway at the Cromwell.
I
s this role different in the NHS to the private sector?
The only difference is that I am the only palliative
nurse at the Cromwell, whereas NHS trusts have a few
in each hospital.
W
hat advice would you give to someone hoping
to follow in your footsteps? to follow in your
Get a good basic understanding of the treatments
available for the different diseases as this gives
good progression from being an oncology nurse into
palliative care.
H
ow would a patient end up seeing a Palliative
Nurse?
I see oncology, cardiac and liver disease patients at
the hospital, however I spend more time with those
in declining health. Most of the time consultants will
ring me if a patient is very unwell in order to begin
planning the next phase of their treatment.
W
hat is an average day like for you?
I begin my day by liaising with district nurses,
cromwell direct 0800 783 9229
Primary
Hyperparathyroidism
Surgery for Primary Hyperparathyroidism
Figure 1.
Mr Fausto Palazzo
Mr Fausto Palazzo MS FRCS(Eng) FRCS(Gen) is a Consultant Endocrine
Surgeon at Hammersmith Hospital and Bupa Cromwell Hospital
Primary hyperparathyroidism (pHPT) is the inappropriate excess secretion of parathyroid hormone (PTH)
from one or more parathyroid glands in the absence of an external abnormality, such as renal failure. In
pHPT one or more diseased parathyroid glands have escaped the normal negative feedback associated
with hypercalcaemia, which normally leads to a decrease in PTH production when the serum calcium
rises. This is the key distinguishing feature compared with other causes of hypercalcaemia.
Figure 2.
Table 1. Diagnosis of primary hyperparathyroidism
Malignant hypercalcaemia
pHPT
Calcium
Very high
High
Phosphorous
Low
Low or normal
PTH
Suppressed
Inappropriately high
Urinary Calcium
High
High
The excess serum PTH culminates in
hypercalcaemia due to:
calcium mobilisation from bone
increased renal re-absorption at the expense
of phosphate
indirect increase in gastro-intestinal calcium
absorption
Most pHPT occurs after the age of 45 and
is sporadic, but the condition may occur in
younger patients, when it is more likely to be
associated with one of the Multiple Endocrine
Neoplasia (MEN) or tumour jaw (HRPT2
mutation) syndromes. The incidence of the
disease is rising due to an increase in average
longevity and a higher detection rate.
peak incidence between 50 - 60 years of age
female to male ratio of 3.5:1
>85% of pHPT is caused by a single
parathyroid tumour (adenoma)
multiple gland disease (adenomas or
hyperplasia) is encountered in up to 15% of
MEDIscene - ISSUE 09
cases and can occur either sporadically or as a
part of MEN I or II syndromes
parathyroid carcinoma accounts for less than
0.5% of pHPT
other than family history, radiation exposure,
lithium use and chronic vitamin D deficiency, little
is additionally known of the risk factors for pHPT
The traditional clinical manifestations of pHPT
are:
bones: bone pain due to osteoporosis,
pathological fractures or in extreme cases
osteitis fibrosa cystica and brown tumours
(Figure 1)
stones: nephrolithiasis or nephrocalcinosis
affect 20% of patients with possible alteration
of renal function (Figure 2)
Other clinical
features include
hypertension,
gout, normocytic
normochromic
anaemia and subtle
neurocognitive
symptoms, which
currently represent
the most common
manifestations of the
disease. Untreated
pHPT is associated
with incompletely understood increased risk of
mainly cardiovascular death and a significantly
decreased quality of life.
Treatment of Primary Hyperparathyroidism
Surgery is the only definitive cure of
hyperparathyroidism. The current international
guidelines recommend parathyroidectomy in:all symptomatic patients irrespective of age
evidence of end organ damage (osteoporosis/
nephrocalcinosis etc)
asymptomatic patients that have one or more of
the following:
abdominal groans due to the effects of
hypergastrinaemia or pancreatitis
Markedly elevated serum calcium (>0.25mmol/L
above normal range).
psychic moans: multiple nonspecific symptoms
are frequent and include depression, anxiety
and cognitive difficulties
Creatinine clearance reduced by 30% with age
matched normal subjects.
Age <50 years.
The operative management of primary
hyperparathyroidism has changed significantly
since the first parathyroidectomy which was
performed at the beginning of the 20th century.
The operation, which could last hours and
be full of pathological uncertainty, as well as
lead to a prolonged length of stay, has been
refined to become a safe operation taking a
predictable length of time and only one night
stay in hospital. The procedure has evolved over
decades around the principle that abnormal
glands are removed and the normal glands
left in situ. The gold standard procedure of
bilateral neck exploration has been joined by
the co-gold standard of minimally invasive
parathyroidectomy in appropriately selected
patients. There is now rarely need for frozen
section with either procedure.
The neck exploration is reserved for patients
with unlocalised disease but is performed via
considerably smaller and more cosmetically
acceptable scars than in the past. It allows the
direct visualisation of all parathyroid glands
and evidence suggests that in the hands
of high volume parathyroid surgeons (>50
parathyroidectomies a year) it remains the
approach that is associated with the highest cure
rate from first time surgery.
The advantages of this are:
it allows the management of nearly all
scenarios including multiple gland disease
(double adenomas and hyperplasia), ectopic
glands, supernumerary glands etc.
it has minimal morbidity and no mortality
Since over 85% of pHPT is caused by a single
benign tumour however, the possibility of
focusing on the removal of the single abnormal
gland and avoiding extra dissection and
manipulation of normal parathyroid glands has
been seen as desirable. This is the conceptual
platform on which focused/minimally invasive
parathyroid surgery is based.
Minimally invasive parathyroidectomy was, for
many years, hindered by the lack of reliable
pre-operative localisation methods. Sequential
breakthroughs have now facilitated focused
parathyroid surgery:
cromwell direct 0800 783 9229
the arrival of Tc-99m Sestamibi scanning (Figure 3)
improvements in ultrasound scanning and radiological specialisation
the development of intraoperative quick PTH with a two-site antibody immune-radiometric assay
popularised by Irvin in Miami.
4D CT - the latest state of the art imaging modality for selected cases (Figure 4)
Mr Naresh Joshi
DO FRCOphth, Consultant Ophthalmic Surgeon
M
r Naresh Joshi is a Consultant Oculoplastic surgeon at Chelsea and
Westminster Hospital NHS Trust, and Honorary Consultant to the The Royal
Marsden NHS Foundation Trust. He is also an Honorary Senior Lecturer in the
Faculty of Medicine, Imperial College London.
Mr Joshi focuses on reconstructive ophthalmic plastic surgery in craniofacial
anomalies. He is the co-founder of the Craniofacial Ophthalmic Plastic Service
(COPS) at Chelsea and Westminster Hospital, and has lectured worldwide on
reconstructive and aesthetic ophthalmic plastic surgery. Mr Joshi has worked
at Bupa Cromwell Hospital since 1996 and is available on Monday and Thursday
mornings, and Tuesday afternoons.
Secretary: Wendy Addison T: +44 (0)20 7460 5739
Why did you study medicine?
I have two doctors in my family so was guided into
medicine as a potential career. I knew their lifestyle
and often accompanied my father to the hospital.
That’s what initially gave me the idea about going
into medicine.
Figure 4.
Minimally invasive parathyroidectomy
Various minimally invasive parathyroidectomy
(MIP) techniques exist, and almost all have
been used by the author. The principle of
the surgery remains the same irrespective of
the approach – the removal of a previously
localised parathyroid adenoma via:
•focused lateral mini incision
What made you pursue your speciality?
Figure 3.
suspicion of carcinoma
morbid obesity
Intraoperative PTH may offer additional benefit
to the surgery although this is less valuable to
the patient than surgical expertise and practice
volume.
•endoscopic assisted
•radio guidance
•video assistance
Cure is denoted by the “Miami criteria” of a drop
of 50% or more from the highest value of PTH
encountered perioperatively (either pre-operative
baseline or pre-excision) 10 minutes after removal
of the diseased gland. Failure for the PTH to fall
suggests multiple gland disease and the need for
four gland exploration.
•robotic
Conclusions
primary hyperparathyroidism is increasing
in incidence and has detrimental effects
beyond bones, stones and moans, including
cardiovascular illness and quality of life
Figure 5
In addition to unlocalised disease there are some
patients that should not have minimally invasive
parathyroid surgery:
history of neck irradiation and prior neck surgery
What is the most
challenging part of your
job?
The most challenging
part of the job is dealing
with difficult individuals
as opposed to difficult
cases. Difficult cases can be
worked out technically, but
difficult individual demands
that are beyond normal
expectations are more
challenging.
What is the most rewarding
part of your job?
standard parathyroid surgery is now performed
via very small incisions
When patients are grateful and happy; when they
receive the outcome that they wanted. Patient
gratitude is by far the greatest joy.
parathyroid surgery is associated with 98% cure
rates even in the absence of localisation when
performed by high volume parathyroid surgeons
concomitant multinodular goitre or
autoimmune thyroiditis (relative contraindication)
diagnosis of Multiple Endocrine Neoplasia Type 1
To make an appointment please call please call
0800 783 9229
One of the things that we do is charitable work. I
work with Facing the World, a charity which helps
children with facial deformities. The Cromwell has
been very supportive of Facing the World and it’s the
charity that I actively support and am involved in.
What do you enjoy doing in your spare time?
Consultant
parathyroid imaging has made minimally invasive
parathyroidectomy the co-gold standard
Mr. Palazzo’s practice is entirely related to thyroid,
parathyroid (over 160 parathyroidectomies a year)
and adrenal surgery.
MEDIscene - ISSUE 09
Once again I have two ophthalmologists in my
family, so was inspired by
them. My own speciality
is very different to theirs
however; they are general
ophthalmologists whilst my
speciality is Oculoplastic
surgery. This includes a
wide variety of surgical
procedures that deal with
the eye socket, eyelids, tear
ducts, and the face.
Can you tell me about a project that you consider to
be significant to your career?
Can you describe a typical working day?
A typical day at the Cromwell - on Tuesday mornings
I have porridge for breakfast with my wife and then
walk to the hospital. I arrive around 7:45am and start
my operating list at 8:00am. That carries on until
around 1:30pm when I’ll have salad for lunch (I like to
be healthy). I then run a clinic, seeing patients from
2:00pm to 5:00pm at the hospital. I am home in time
for supper at 6:00pm with my wife and children.
We travel a lot - I lecture in
about 10 different countries
a year. In terms of sport I
walk a lot and enjoy playing
golf... I also have a passion
for wine!
What is your most prized
possession?
My most prized possession is
my family.
Where is your favourite
place in the world?
My favourite place in the
world is home.
The best soundtrack for a
dinner party is...?
Depends what sort of dinner
parties I have! We usually
listen to something classical;
my wife is very into opera –
so it’s usually something that
she chooses!
If you had one super power
what would it be and why?
I would like the power to put more smiles on people’s
faces. I would like more people to be kind and
content. There are many people who are not kind
enough or content with their lives. I would have the
power to make people happier!
If you could be any biscuit, what biscuit would you
be and why?
I would be a chocolate bourbon because it’s
indulgent, and has a soft centre, like me.
If you were a movie character who would you be?
A movie character – I would be Robert Redford
because my wife fancies Robert Redford! The young
one of course...
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