Society Consensus Research Articles

Review of the Chest CT Differential Diagnosis of Ground-Glass Opacities in the COVID Era.

Coronavirus disease 2019 (COVID-19), a recently emerged lower respiratory tract illness, has quickly become a pandemic. The purpose of this review is to discuss and differentiate COVID-19 typical imaging findings from other diseases, which can appear similar in the first instance. The typical CT findings of COVID-19 are bilateral and peripheral predominant ground glass opacities. As per the Fleischner Society consensus statement, CT is appropriate in certain scenarios, including patients who are at risk for and/or develop clinical worsening. The probability, that CT findings represent COVID-19, however, depends largely on the pre-test probability of infection, which is in turn defined by community prevalence of infection. When the community prevalence of COVID-19 is low, a large gap exists between positive predictive values of chest CT vs. RT-PCR. This implies that with usage of Chest CT there are a large number of false positive results. Imaging differentiation is important, for management and isolation purposes, and for appropriate disposition of CT false positive patients. We will discuss differential pathology with close imaging resemblance to typical CT imaging features of COVID-19, and, highlight CT features that may help in differentiation from other conditions.

Laparoscopic and Robotic Urology Surgery during Global Pandemic COVID19.

ABSTRACTKnown laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID-19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID-19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID-19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

Saudi Epilepsy Society consensus on epilepsy management during the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) emerged in late 2019 in Wuhan, China.[1][1] The outbreak was confirmed as a pandemic on February 11, 2020, by the World Health Organization (WHO). By the end of April 2020, more than 3.5 million people were infected worldwide. The number of affected people in

The Effect of Severe Femoropopliteal Arterial Calcification on the Treatment Outcome of Femoropopliteal Intervention in Patients with Ischemic Tissue Loss.

PurposeWe investigated the effect of severe calcification of the femoropopliteal artery on intervention outcomes in patients with ischemic tissue loss.Materials and MethodsA retrospective review of the first endovascular treatment of the femoropopliteal artery for ischemic tissue loss between May 2010 and February 2018 was performed. The calcification of femoropopliteal lesions was estimated by the Compliance 360° score, and lesions with a score of 4 were defined as severe calcification lesions.ResultsOverall, 135 first femoropopliteal endovascular procedures on 135 limbs from 112 patients were included in this study. Among the 135 limbs that received treatement of the femoropopliteal arteries, 74 limbs had Trans-Atlantic Inter Society Consensus (TASC) A or B lesions and 61 limbs had TASC C or D lesions. Among 61 cases of TASC C or D lesions, 21 limbs (34.4%) had severe calcification; there was no statistically significant difference in limb salvage (P=0.75), and amputation-free survival (P=0.11) based on the degree of calcification. However, the survival rate in TASC C or D lesions was significantly different between the two groups (non-severe calcification group vs severe calcification group at 1-year, 2-years, and 3-years: 88.6%, 79.7%, and 61.0% vs 70.0%, 56.0%, and 28.0%, respectively, P=0.01). In multivariate analysis of influencing factors for poor survival in TASC C or D using the Cox proportional hazards model, severe calcification (hazard ratio, 2.362; 95% confidence interval, 1.035-5.391; P=0.041) was a statistically significant risk factor.ConclusionSevere femoropopliteal artery calcification was associated with poor survival, especially in TASC C or D lesions.

Comparison of Atherectomy to Balloon Angioplasty and Stenting for Isolated Femoropopliteal Revascularization

The use of atherectomy for lower extremity revascularization is increasing despite concerning reports about its long-term safety and effectiveness. This study compares the outcomes of atherectomy to percutaneous transluminal angioplasty (PTA) and stenting for treatment of isolated femoropopliteal disease. All patients undergoing endovascular treatment of isolated femoropopliteal lesions in the Vascular Quality Initiative (2009-2018) were identified. Patients with concomitant open surgery, acute limb ischemia, or iliac or tibial intervention were excluded. Patients were divided into 3 treatment groups: atherectomy with or without PTA, PTA alone, and stenting alone. Propensity matching was performed based on age, gender, race, ambulatory status, diabetes, smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, dialysis, prior inflow bypass and intervention, prior major ipsilateral amputation, indication, length of treated lesion, American Society of Anesthesiologists class, and Trans-Atlantic Society Consensus II classification. The perioperative and one-year outcomes of the matched groups were compared. A total of 10,007 cases of atherectomy, 22,000 cases of PTA, and 27,579 cases of stenting of isolated femoropopliteal disease were identified. After matching, there were 6,372 procedures in atherectomy and PTA groups, respectively. Atherectomy was associated with higher likelihood of technical success (98.3% vs. 97.5%; P<0.001) and shorter length of stay (1.8±8.2days vs. 2.7±15.7days; P<0.001), but had increased rate of distal embolization (2% vs. 1.1%; P<0.001) compared with PTA. At one year, atherectomy was associated with improved primary patency (84.2% vs. 82%; P=0.047) and survival rate (91.1% vs. 90%; P=0.044), but was also associated with a higher reintervention rate (15.7% vs 13.6%; P=0.033) compared with PTA. There was no difference in the rates of major amputation, ambulatory status improvement, or ankle brachial index (ABI) improvement. In the second analysis, after matching, there were 6,877 procedures in the atherectomy and stenting groups, respectively. Atherectomy was associated with lower rate of dissection (3.7% vs. 8.2%<0.001), lower rate of perforation (0.6% vs. 1.2%; P<0.001), and a shorter length of stay (1.9±8.1 vs. 2.9±9.8days; P<0.001) than stenting. However, patients treated with atherectomy had a lower rate of technical success (98.3% vs. 99.2%; P<0.001) and a higher rate of distal embolization (2% vs. 1.2%; P<0.001) than stenting. At one year, atherectomy was associated with a higher rate of major ipsilateral amputation (5.3% vs. 4.1%; P=0.046) and less improvement in ABI (0.19±0.42 vs. 0.25±0.4; P<0.001) than stenting. There was no difference in rates of primary patency, survival, reintervention, and ambulatory status improvement at one year. Atherectomy does not seem to confer any significant additional clinical benefit compared with balloon angioplasty or stenting. Further research is needed to justify its additional cost over other endovascular modalities.

The Turkish army at the turn of the 1960s and 1970s: from left-wing conspiracy to right-wing coup

This is the first paper in Russian historiography dedicated to the struggle of left and right groups in the Turkish army on the eve of a military coup on March 12, 1971. By 1970, an alliance of leftist intellectuals and officers was formed, led by the editor of the Devrim newspaper, Dogan Avjioglu and one of the organizers of the 1960 coup, a retired lieutenant general Jemal Madanoglu, received the conditional name of the organization of national revolutionaries. The members of the organization sought to approve the socialist system of the bassist type in the country and outlined the number of military coups March 9, 1971. However, the death of one and the opportunist position of two other leaders of the military wing led to the failure of the attempt of a leftist coup. On the contrary, on March 12, 1971, a right-wing military coup took place in Turkey. In the course of subsequent repressions, a powerful blow was dealt to the left groups in the army and in Turkish society as a whole. In an effort to end the repression and achieve consensus in society, moderately leftist forces led by B. Ejevit entered into a coalition with their opponents religious conservatives led by N. Erbakan.

Supera Stent for Management of Occlusive Popliteal Artery Disease: an Indian Experience

IntroductionPopliteal artery occlusion is common in elderly, smokers, and patients with diabetes, with globally rising incidence. Angioplasty and stenting are common treatment options available to manage lower limb occlusive diseases. As popliteal artery experiences high biomechanical stress, Supera stent is designed to reduce the risk of stent fractures and for better patency across the knee joint.Aim & ObjectivesThe aim of this study is to evaluate the Supera stent in the management of popliteal artery occlusive disease. The objectives of this study are (1) to evaluate the efficacy of Supera stent in the management of popliteal artery occlusive disease and (2) to prove it as a relatively safe to use option.Material & MethodsPatients who underwent stent implantation in popliteal artery were analyzed with regular/serial follow-up. Critical limb ischemia and intermittent claudication patients were included. Medical records, radiographs, and procedural data were examined. The patients were classified according to Trans-Atlantic Inter Society Consensus II criteria. The femoropopliteal lesions which were classified into TASC B and C categories were included in the study. Stents of 5 mm and 5.5 mm diameter and with various lengths were used to treat all the patients.ResultsA total number of patients with tissue loss and rest pain analyzed were eighty-six and all of them were treated by implanting stents in popliteal artery. In 71.4% of cases, the lesions were found in the proximal segment of the artery. In nearly 95% of cases, technical success was achieved with the use of single stent. The primary and assisted primary patency rates at 24 months were found to be 86.04% and 95.34%, respectively. Notwithstanding the stent placement at a region of high biomechanical stress, there was no case of stent fracture. The limb salvage rate was 100%. The patients who died due to unrelated causes within 90 days of procedure were two.ConclusionThe present study demonstrated that Supera stent is a safe and effective procedure for treating claudication and limb ischemia due to popliteal artery disease.

The American Brachytherapy society consensus statement for skin brachytherapy

PurposeKeratinocyte carcinoma (KC, previously nonmelanoma skin cancer) represents the most common cancer worldwide. While surgical treatment is commonly utilized, various radiation therapy techniques are available including external beam and brachytherapy. As such, the American Brachytherapy Society has created an updated consensus statement regarding the use of brachytherapy in the treatment of KCs. MethodsPhysicians and physicists with expertise in skin cancer and brachytherapy created a consensus statement for appropriate patient selection, data, dosimetry, and utilization of skin brachytherapy and techniques based on a literature search and clinical experience. ResultsGuidelines for patient selection, evaluation, and dose/fractionation schedules to optimize outcomes for patients with KC undergoing brachytherapy are presented. Studies of electronic brachytherapy are emerging, although limited long-term data or comparative data are available. Radionuclide-based brachytherapy represents an appropriate option for patients with small KCs with multiple techniques available. ConclusionsSkin brachytherapy represents a standard of care option for appropriately selected patients with KC. Radionuclide-based brachytherapy represents a well-established technique; however, the current recommendation is that electronic brachytherapy be used for KC on prospective clinical trial or registry because of a paucity of mature data.

SUN-914 Peptide Receptor Radionuclide Therapy for an Inoperable Small Cell Neuroendocrine Tumor in the Philippines

Background: Peptide Receptor Radionuclide Therapy treatment for neuroendocrine tumors is a well-tolerated treatment option for patients not amenable to receiving chemotherapy and radiotherapy. Clinical Case: A 42-year-old female was evaluated by a cardiologist for complaints of new onset recurrent throat discomfort, chest pain and palpitations. Two-Dimensional echo showed a large extra-cardiac mass compressing the main pulmonary artery. Chest CT with contrast reveal a 5.8 x 6.0 x 7.2 cm enhancing lobulated anterior mediastinal mass. Attempts to excise the mass failed due to the proximity to major blood vessels. Biopsy revealed a Carcinoid Tumor that was Chromogranin A positive but was asymptomatic for carcinoid syndrome. Everolimus treatment was given but was halted due to stomatitis. The patient remained fully functional. Re-evaluation of the mass with FDG PET show an increase in tumor size. Biopsy tissue re-testing showed small cell neuroendocrine carcinoma. Urine 5-hydroxyindoleacetic acid, plasma 5-hydroxyindoleacetic acid, and serum Chromogranin A were normal. A 68Ga-DOTATATE PET/CT scan reveal a slight increase in the mass that was intensely DOTATATE-avid. Two sessions of Peptide Receptor Radionuclide Therapy (PRRT) Lutetium-177 DOTATATE given at an 8-month interval were given. SPECT/CT re-evaluation showed good response and no evidence of metastases. A 68Ga-DOTA-octreotate PET-CT scan was done and showed good response to treatment. According to treatment guidelines, small cell neuroendocrine carcinoma that are non-resectable are treated with radiotherapy plus chemotherapy. But since the patient is fully functional and has minimal symptoms, other means of treatment such as PRRT may be well suited due to good tolerability and good treatment outcomes. Conclusion: PRRT is a promising treatment for NETs that is well tolerated giving better functionality and quality of life for patients opting not to undergo chemotherapy and radiotherapy. Reference: Cadiot, G. (2019). French and European Neuroendocrine Tumor Society consensus guidelines. Annales d’Endocrinologie, 80(3), p.174.

SUN-902 Bradycardia as a Presentation of Malignant Pheochromocytoma

IntroductionPheochromocytoma usually presents with tachycardia, hypertension and other symptoms related to catecholamine release. Bradycardia has been reported in up to 10% of patients and is due to an unusual reflex to cathecolamine surge.Case Report:57-year-old morbidly obese female with a history of COPD, hypertension, paroxysmal bradycardia, and urinary incontinence was referred to endocrinology clinic after an adrenal mass was found incidentally as part of a work-up for microscopic hematuria and urinary incontinence. CT abdomen showed unilateral 3.3 x 3.9 cm left lobular adrenal mass. Family history was negative for malignancies or pheochomocytoma. Patient denied substance abuse or ethanol use. Her medications include amlodipine, hydrochlorothiazide and albuterol. Physical exam was remarkable for a BMI of 51.6 and bradycardia of 50 bpm and well controlled blood pressure. On further review of her history, patient had prior visits to outpatient and emergency department for chronic headaches, insomnia, palpitations and sweating. Patient had a previous admission 13 years prior for chest pain and hypertensive urgency associated with headache and junctional bradycardia.Laboratory workup was significant for serum metanephrine levels of 749 pg/ml (normal <42), serum normetanephrine 185 pg/ml(normal <145), serum chromogranin A 130 ng/L(normal <39) and 24hr urine metanephrine of 1340 ug/24hr (normal <96) and urine normetanephrine of 357 ug/24hr (normal <80). Previous ECG showed sinus bradycardia. Echo-cardiogram revealed normal ejection fraction with left atrial enlargement.MIBG showed large focal area of intense radio-tracer accumulation in left mid abdomen and small focal lesions in the liver. Diagnosis of malignant pheochromocytoma was made and patient was referred to another institution for further management.Conclusion:Malignant pheochromocytoma is a rare neuroendocrine tumor that usually presents with tachycardia and hypertension. 10% of patients with malignant pheochromocytoma can debut with bradycardia due to sinus arrest. Although malignant and benign pheochromocytoma share the same clinical and histological features, the presence of metastasis is the main clue to differentiate them. Surgery remains the main treatment option even if complete debulking cannot be achieved. Nuclear radiation therapy or chemotherapy are two other therapeutic options that can be considered alone or in combination with surgery depending on the patients’ comorbidities. Lifetime surveillance is recommended as recurrence can occur up to 40 years after original resection. References-Chen H, Sippel RS, O’Dorisio MS, Vinik AI, Lloyd RV, Pacak K. The North American Neuroendocrine Tumor Society consensus guideline for the diagnosis and management of neuroendocrine tumors: pheochromocytoma, paraganglioma, and medullary thyroid cancer. Pancreas. 2010 Aug;39(6):775-83.

Acute respiratory distress syndrome subphenotypes and therapy responsive traits among preclinical models: protocol for a systematic review and meta-analysis

BackgroundSubphenotypes were recently reported within clinical acute respiratory distress syndrome (ARDS), with distinct outcomes and therapeutic responses. Experimental models have long been used to mimic features of ARDS pathophysiology, but the presence of distinct subphenotypes among preclinical ARDS remains unknown. This review will investigate whether: 1) subphenotypes can be identified among preclinical ARDS models; 2) such subphenotypes can identify some responsive traits.MethodsWe will include comparative preclinical (in vivo and ex vivo) ARDS studies published between 2009 and 2019 in which pre-specified therapies were assessed (interleukin (IL)-10, IL-2, stem cells, beta-agonists, corticosteroids, fibroblast growth factors, modulators of the receptor for advanced glycation end-products pathway, anticoagulants, and halogenated agents) and outcomes compared to a control condition. The primary outcome will be a composite of the four key features of preclinical ARDS as per the American Thoracic Society consensus conference (histologic evidence of lung injury, altered alveolar-capillary barrier, lung inflammatory response, and physiological dysfunction). Secondary outcomes will include the single components of the primary composite outcome, net alveolar fluid clearance, and death. MEDLINE, Embase, and Cochrane databases will be searched electronically and data from eligible studies will be extracted, pooled, and analyzed using random-effects models. Individual study reporting will be assessed according to the Animal Research: Reporting of In Vivo Experiments guidelines. Meta-regressions will be performed to identify subphenotypes prior to comparing outcomes across subphenotypes and treatment effects.DiscussionThis study will inform on the presence and underlying pathophysiological features of subphenotypes among preclinical models of ARDS and should help to determine whether sufficient evidence exists to perform preclinical trials of subphenotype-targeted therapies, prior to potential clinical translation.Systematic review registrationPROSPERO (ID: CRD42019157236).

Vascular toxic effects of cancer therapies.

Cancer therapies can lead to a broad spectrum of cardiovascular complications. Among these, cardiotoxicities remain of prime concern, but vascular toxicities have emerged as the second most common group. The range of cancer therapies with a vascular toxicity profile and the clinical spectrum of vascular toxic effects are quite broad. Historically, venous thromboembolism has received the greatest attention but, over the past decade, the arterial toxic effects, which can present as acute vasospasm, acute thrombosis and accelerated atherosclerosis, of cancer therapies have gained greater recognition. This Review focuses on these types of cancer therapy-related arterial toxicity, including their mechanisms, and provides an update on venous thromboembolism and pulmonary hypertension associated with cancer therapies. Recommendations for the screening, treatment and prevention of vascular toxic effects of cancer therapies are outlined in the context of available evidence and society guidelines and consensus statements. The shift towards greater awareness of the vascular toxic effects of cancer therapies has further unveiled the urgent needs in this area in terms of defining best clinical practices. Well-designed and well-conducted clinical studies and registries are needed to more precisely define the incidence rates, risk factors, primary and secondary modes of prevention, and best treatment modalities for vascular toxicities related to cancer therapies. These efforts should be complemented by preclinical studies to outline the pathophysiological concepts that can be translated into the clinic and to identify drugs with vascular toxicity potential even before their widespread clinical use.

Appendicitis and Cholecystitis in Pregnancy.

Up to 2% of pregnant women develop a disease that requires nonobstetrical operative intervention during pregnancy. We discuss the issues unique to pregnant patients as they pertain to the presentation, diagnosis, and management of nonobstetric surgical disease, with an emphasis on 2 of the most common diseases that affect pregnant women: appendicitis and cholecystitis. Surgery has been demonstrated to be safe and effective during pregnancy, provided proper precautions are taken into account. It is the consensus of multiple professional committees and societies that no pregnant women should be delayed or denied a necessary surgery because of pregnancy.

C-reactive protein is not a screening tool for late periprosthetic joint infection

BackgroundPreoperative diagnosis of periprosthetic joint infection (PJI) is important because of the therapeutic consequences. The aim of the present study is to investigate whether the serum C-reactive protein (CRP) level can be used as a screening tool for late PJI.Materials and methodsA cohort of 390 patients with revision surgery of total hip prostheses (200) or total knee prostheses (190) was assessed for late PJI by determining CRP serum level and performing preoperative aspiration with cultivation and intraoperative tissue analyses with cultivation and histologic examination, using the Musculoskeletal Infection Society (MSIS) and International Consensus Meeting (ICM) criteria.ResultsA total of 180 joints were rated as PJI (prevalence 46%). Of these, 42.8% (77) showed a CRP level below 10 mg/L and 28.3% (51) showed a normal CRP level of less than 5 mg/L. The 76.9% of the cases with slow-growing bacteria showed a CRP level below 10 mg/L, and 61.5% showed a normal CRP level.ConclusionsSerum CRP level should not be used as a screening tool to rule out late PJI.Level of evidenceLevel 2 (diagnostic study).

Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel.

Abstract

International microsurgery simulation society (IMSS) consensus statement on the minimum standards for a basic microsurgery course, requirements for a microsurgical anastomosis global rating scale and minimum thresholds for training

IntroductionMicrosurgery is a surgical technique that uses optical magnification as well as specific instruments to address necessary reconstructive procedures in different medical specialties. The apprenticeship of this technique requires overcoming a steep learning curve. There is a need for standardization of the training criteria in microsurgery. The International Microsurgery Simulation Society (IMSS) was born in 2011, since then its main objective has been to connect the main international specialists and educators of this sub-specialty to share and discuss the ethical and scientific basis of preclinical microsurgery teaching. MethodsIn order to achieve a consensus on the minimum standards for the organization of basic microsurgery training courses, the requirements for a microsurgical anastomosis global rating scale and minimum thresholds for training, a total of nineteen independent global experts participated in a formal consultative consensus development program. The agreement criteria for each statement was established when consensus of 65–100% was reached. ResultsThere have been established six recommendations concerning minimum standards for a basic microsurgery course, one recommendation in relation to minimum thresholds for training and four recommendations regarding the global rating scale as gold standard for a microsurgical anastomosis assessment. The eleven defined recommendations reached the agreement threshold of 65–100%. ConclusionsThe development of this consensus sets the minimum recommended requirements for conducting basic microsurgery training courses, as well as suggestions for objective assessment of the learning curve and skills of trainees.

Posttransplant Management of Recipients Undergoing Liver Transplantation for Hepatocellular Carcinoma. Working Group Report From the ILTS Transplant Oncology Consensus Conference.

Although liver transplantation (LT) is the best treatment for patients with localized hepatocellular carcinoma (HCC), recurrence occurs in 6%-18% of patients. Several factors, particularly morphological criteria combined with dynamic parameters, known before LT modify this risk and combined in prediction models may be used to stratify patients at need of variable surveillance strategies. Additional variables though likely explain differences in recurrence rates in patients with the same pre-LT HCC status. One of these variables is possibly immunosuppression (IS). Once recurrence takes place, management is highly heterogenous. Within the International Liver Transplantation Society Consensus Conference on Liver Transplant Oncology, working group 4 aim was to analyze the data regarding posttransplant management of recipients undergoing LT for HCC. Three areas of research were considered: (1) cancer prediction models and surveillance strategies; (2) tailored IS for cancer recipients; and (3) new adjuvant therapies for HCC recurrence. Following formulation of several questions, a literature search was undertaken with abstract review followed by article retrieval and full-data extraction. The grading of recommendations assessment, development and evaluation (GRADE) system was used for evidence rating incorporating strength of recommendation and quality of evidence.

A dosimetric evaluation of a single urethral constraint for high-dose-rate prostate brachytherapy

PurposeThe American Brachytherapy Society (ABS) consensus guidelines for high-dose-rate (HDR) prostate brachytherapy suggest 11 different dose constraints for the urethra. The purpose of this study is to evaluate whether a single urethral constraint of D0.1 cm3 < 110% could meet all the proposed ABS urethral constraints and to evaluate the heterogeneity and similarities of other portions of the dose-volume histogram (DVH) when only optimizing to a single constraint. MethodsThis is a retrospective study of 18 consecutively treated HDR prostate brachytherapy patients treated between May 2018 to November 2018. Nine patients underwent HDR brachytherapy combined with external beam radiation therapy, and nine underwent HDR brachytherapy as monotherapy. Additional DVH values were extracted for the whole, proximal, middle, and distal urethra and compared for differences. ResultsNone of the ABS suggested constraints were violated when optimizing the urethra D0.1 cm3 dose to be less than 110% of the prescription. An evaluation of the DVHs for the whole, proximal, middle, and distal urethra showed a large variation in the shape of the remainder of the DVH for all parts of the urethra. The largest standard deviations in dose to the whole and middle urethra were at the V14 dose level, and that to the proximal and distal urethra were at the V10 dose level. ConclusionA single urethral dose constraint of D0.1 cm3 < 110% can meet all the proposed ABS constraints. There is high variability in other parts of the urethra DVH when only using a single constraint. Additional data is needed to determine ideal constraints for the entirety of the urethra DVH.

Metachronous liver metastases after long-term follow-up of endoscopic resection for rectal neuroendocrine neoplasms: a report of three cases

BackgroundRectal neuroendocrine neoplasms (NENs) are rare, but their incidence has increased in recent years. The metastasis rate is low in cases of a tumor diameter < 1 cm or depth of invasion lower than the submucosa; therefore, the European Neuroendocrine Tumor Society (ENETS) and the North American Neuroendocrine Tumor Society (NANETS) consensus guidelines recommend endoscopic resection. Since little has been reported on the long-term prognosis of endoscopic resection for rectal NEN, consensus is lacking regarding the follow-up period after endoscopic resection.Case presentationHere, we report three cases of metachronous liver metastasis after long-term follow-up of endoscopic mucosal resection (EMR) for rectal NEN. The pathological findings indicated a depth lower than the submucosa and complete radical resection in all cases and lymphovascular invasion in only one case. All three cases showed metachronous multiple liver metastases after 9–13 years of follow-up for EMR, despite achieving complete resection and without muscular invasion.ConclusionsMetachronous liver metastases may occur after long interval following endoscopic resection; thus, long-term follow-up is necessary after endoscopic resection for rectal NEN.

Consensus of the Ibero-American Oculoplastic Society for selecting the ideal orbital implant in the anophthalmic socket

Consensus of the Ibero-American Oculoplastic Society for selecting the ideal orbital implant in the anophthalmic socket