Serum chromogranin A is the most useful general and prognostic tumour marker available for neuroendocrine tumour (NET) patients. The role of other tumour markers is less clear. In order to determine the diagnostic and prognostic value of serum afetoprotein (AFP) and human chorionic gonadotrophin-b (hCGb) in NETs, a database containing biochemical, histological, and survival data on 360 NET patients was constructed. This data was statistically assessed, using Statistical Package for the Social Sciences, to determine the utility of commonly measured tumour markers with particular emphasis on AFP and hCGb. a-Fetoprotein and hCGb were raised in 9.5 and 12.3% of patients respectively and jointly raised in 9.1% of patients in whom it was measured. aFetoprotein levels associated strongly and positively with tumour grade, serum CgA and hCGb levels, and worse survival. Human chorionic gonadotrophin-b levels also associated strongly and positively with serum CgA and AFP levels, and worsening survival. aFetoprotein and hCGb are elevated in high-grade NETs, with a rapidly progressive course and poorer survival. They also correlate with chromogranin-A, which is known to be a marker of tumour burden and to have prognostic value. Thus AFP and hCGb are clinically important in NETs and when elevated are poor prognostic markers.

Herniation of the ureter is a rare, but potentially serious, cause of ureteral obstruction. Until 1992, there were 128 cases of ureteral herniation reported in the literature with the most common region for ureteral herniation outside the abdominal cavity being the inguinoscrotal region. 1The most common age of presentation is between 40-60 years and, in women, isolated ureteral hernias are most often femoral. 1Ureteral hernias into the sciatic foramen are extremely rare. To our knowledge there have only been four cases reported 2-5 with the most recent being in 1985. All cases presented with colicky ureteral pain, as did our patient. The more recent case reports that the patient had a urinary tract infection, as did our patient. Imaging has shown dilated hydroureters with a loop of ureter present at the sciatic foramen. Treatment has consisted of open operation to dissect the ureter free from the sciatic foramen and then ensuring that the ureter is held away from the defect. Our case has demonstrated that this rare herniation of the ureter can be successfully treated laparoscopically, without the need for open operation. Case report Presentation and initial investigationA 59-year-old Caucasian woman presented to accident and emergency in septic shock. She was confused and complained of colicky abdominal pain. On examination, she had a temperature of 38.9°C, a tachycardia of 160 beats/min and there was pus discharging from the urethra. She had not previously suffered from any urinary tract symptoms although she had a 30-year history of multiple sclerosis and was wheelchair-bound.Her blood tests revealed elevated inflammatory markers with a white count of 23.4 and a CRP of 135. Urea and creatinine were also raised at 8.4 and 94, respectively. She was catheterised, commenced on broad spectrum antibiotics and given i.v. fluids. A urinary specimen was sent for culture. Two days post admission, she continued to spike temperatures and the CRP rose to 221. Proteus spp. were identified on the urinary culture and appropriate antibiotics were commenced.

Thyroid disease management has changed little over the last 60 years and recent work suggests that the older approach remains the most effective. Treatment of benign hyperthyroidism has shown that functional imaging is essentially linked to therapy and uptake of iodine-131 ((131)I) cannot be assumed but should be tested by pre-imaging with radio-isotopes as 10% of patients may not be suitable for (131)I therapy and 1% may have a co-existent cancer. Differentiated thyroid cancer remains unique in that it is almost alone among common solid tumors in that it is routinely cured even if cannot all be removed by surgery. This is achieved in the majority of patients by a treatment introduced in the 1940s and does not involve the use of chemotherapy drugs but a simple and cheap isotope preparation; (131)I. However, in some differentiated thyroid cancers there is no accumulation of (131)I and we know this is due to the loss, or downregulation of the sodium iodide symporter gene. This has led to the development of several strategies to overcome this loss/downregulation, for example with the use of lithium or retinoids or gene treatment. However, all these approaches have yet to be proved in a randomized controlled trial. Advances in imaging especially using (18)F-fluorodeoxy-glucose PET has enabled patients with thyroid cancer to be more accurately imaged, resulting in a greater chance of cure through surgery and external-beam radiotherapy, especially if uptake of (131)I is poor. Another approach has been the idea of using radiolabeled somatostatin analogs, which are able to demonstrate uptake in the tumor and, more recently, beta-emitting isotopes have been used for therapy when other options have failed. Therefore, whilst the treatment of differentiated thyroid cancer is, to some degree, 60 years old, new methods have been proposed and are now being tested in this disease.

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