Contrast-enhanced CT Of Abdomen Research Articles

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis.

Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis scorewere found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

Artificial Intelligence for Improved Hepatosplenomegaly Diagnosis.

Hepatosplenomegaly is commonly diagnosed by radiologists based on single dimension measurements and heuristic cut-offs. Volumetric measurements may be more accurate for diagnosing organ enlargement. Artificial intelligence techniques may be able to automatically calculate liver and spleen volume and facilitate more accurate diagnosis. After IRB approval, 2 convolutional neural networks (CNN) were developed to automatically segment the liver and spleen on a training dataset comprised of 500 single-phase, contrast-enhanced CT abdomen and pelvis examinations. A separate dataset of ten thousand sequential examinations at a single institution was segmented with these CNNs. Performance was evaluated on a 1% subset and compared with manual segmentations using Sorensen-Dice coefficients and Pearson correlation coefficients. Radiologist reports were reviewed for diagnosis of hepatomegaly and splenomegaly and compared with calculated volumes. Abnormal enlargement was defined as greater than 2 standard deviations above the mean. Median Dice coefficients for liver and spleen segmentation were 0.988 and 0.981, respectively. Pearson correlation coefficients of CNN-derived estimates of organ volume against the gold-standard manual annotation were 0.999 for the liver and spleen (P < 0.001). Average liver volume was 1556.8 ± 498.7 cc and average spleen volume was 194.6 ± 123.0 cc. There were significant differences in average liver and spleen volumes between male and female patients. Thus, the volume thresholds for ground-truth determination of hepatomegaly and splenomegaly were determined separately for each sex. Radiologist classification of hepatomegaly was 65% sensitive, 91% specific, with a positive predictive value (PPV) of 23% and an negative predictive value (NPV) of 98%. Radiologist classification of splenomegaly was 68% sensitive, 97% specific, with a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 99%. Convolutional neural networks can accurately segment the liver and spleen and may be helpful to improve radiologist accuracy in the diagnosis of hepatomegaly and splenomegaly.

Renal cell carcinoma on imaging unveiled as a primary Ewing’s sarcoma

BackgroundEwing sarcoma represents a spectrum of aggressive malignancies with the poor outcome. Primary renal Ewing sarcoma is rare and accounts for less than 1% of renal masses.Case presentationWe present a case of a 45-year-old male presented in OPD with complaint of right flank pain and hematuria. He underwent a contrast-enhanced CT abdomen which depicted a right renal mass with liver lesions. He underwent Robotic Right Radical Nephrectomy and a pathological diagnosis of Ewing Sarcoma was made after which he was started on chemotherapy.ConclusionsOwing to presentation in younger age group with poor prognosis, an integrated analysis including radiological imaging, histopathology, and immune-histological staining is essential for early detection of renal Ewing sarcoma.

307 Intraluminal Migration of Gossypiboma and rectal expulsion an unusual Case- Case Report

Abstract Background Gossypiboma refers to foreign body retained in the body at the end of operation and can be in the form of gauze, sponge or any form of textile resulting in grave consequences for both the patient and the surgeon. Case Summary A 23-year-old female presented with complain of generalized abdominal pain along with non-bilious vomiting since 10 days. She also had relative constipation since four days. Her past surgical history was unremarkable except for three elective lower segment caesarean sections at another hospital. Upon abdominal examination, she had a scar of pfannenstiel incision along with 3x4 cm swelling in umbilical region with positive cough impulse. Her bowel sounds were exaggerated. DRE was unyielding. Clinical diagnosis of subacute intestinal obstruction was made and she was managed conservatively. Ultrasound abdomen showed dilated gut loops with hyperperistalsis. It also revealed a defect measuring 8.5 cm in the supraumbilical region of anterior abdominal wall through which fat content was seen protruding. She was advised contrast enhanced CT abdomen, developed diarrhoea and later on expelled the surgical sponge per rectally. After passage of surgical sponge, condition of patient improved and symptoms resolved. Discussion Diligent efforts are required to prevent this human error by ensuring meticulous sponge count, use of radio-opaque sponges, adjunctive use of WHO safety checklist and introduction of new advancements like tagging system in our healthcare system. Conclusion Gossypiboma is under-reported due to reluctance of institutions to report it to governing body. Reporting of such dreadful complications of surgery and analysis of their root cause should be done to prevent such events from happening.

E020 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Abstract Background/Aims Pneumatosis intestinalis (PI) is a rare complication of systemic sclerosis (SSc), characterised by submucosal and/or subserosal collections of free gas, forming cystic lesions within the gastrointestinal (GI) tract. Methods A 67-year-old man with SSc-myositis overlap syndrome presented acutely unwell with worsening abdominal pain, bloating, bloody diarrhoea and vomiting for three weeks. He was afebrile and haemodynamically stable. His abdomen was distended with generalised tenderness but soft and regular bowel sounds were audible. There were no palpable organomegaly or signs of peritonism. He had raised CRP, serum amylase, serum lactate and pre-renal acute kidney injury. He tested positive for ANA Hep2 (speckled) and anti-Mi-2b. His contrast-enhanced CT abdomen and pelvis displayed extensive pneumatosis changes, moderately dilated small bowel loops and pneumoperitoneum without portal venous gas or acute thrombotic occlusion in the main-stem superior or inferior mesenteric arteries. He was managed conservatively with bowel rest, elemental diet, cycling antibiotics for small intestinal bacterial overgrowth (SIBO) and commenced on end-of-life care as surgical exploration was deemed too risky considering that he has exceedingly poor cardiac reserve. He made a surprisingly excellent recovery and his repeat CT scans at approximately 11 weeks showed a complete resolution of pneumatosis intestinalis and pneumoperitoneum. Results PI in SSc generally runs a benign course and is usually managed conservatively. The development of PI is multifactorial, involving a complex interplay between mechanical, biochemical, bacterial and drug factors. PI is usually asymptomatic but patients can present with GI and constitutional symptoms or peritonism. CT scan is the most preferred diagnostic modality for PI. Conservative management is preferable to surgical intervention after careful exclusion of acute surgical causes. The underlying cause of PI should be appropriately addressed and managed in all cases. The management of PI is based on the severity of symptoms and it includes bowel rest, elemental diet or parenteral nutrition, antibiotics, high concentration oxygen, hyperbaric oxygen therapy and/or octreotide. Our patient was managed conservatively as he did not exhibit clinical signs of peritonism or bowel ischaemia and surgical interventions were deemed too risky. He was treated with and has responded well to cycling oral antibiotics for SIBO which was thought to be contributory to his PI. Conclusion This case illustrates that PI with or without pneumoperitoneum could be a rare complication of SSc, and contrary to common belief, it is usually benign and managed conservatively with favourable outcome. An accurate interpretation of its clinical significance is crucial as acute presentations and ambiguous imaging findings can simulate acute surgical emergency leading to diagnostic dilemma and unnecessary or risky surgical interventions. However, emergency laparotomy should be considered in patients who exhibit signs of peritonism or bowel ischaemia and therefore timely involvement of surgeons and multidisciplinary team is essential. Disclosure K. Lim: None. S. Knights: None. J. Pauling: None. J. Gotto: None.

The Role of Non-Contrast CT in the Diagnosis of a Rare Cause of Small Bowel Obstruction Due to Bezoar

Contrast Enhanced CT Abdomen is usually used to investigate the source of the small bowel obstruction. A 13-year old girl presented with signs of small bowel obstruction and was complicated with acute renal injury. Non-contrast CT Abdomen showed findings consistent with bezoar, and the findings are similar to the features seen in a contrast study. This case shows that both the plain and the contrast CT abdomen give similar findings of bezoar, one not inferior to the other.

Imaging Recommendations for Diagnosis, Staging, and Management of Uterine Cancer

AbstractUterine cancers are classified into cancers of the corpus uteri (uterine carcinomas and carcinosarcoma) and corpus uteri (sarcomas) by the AJCC staging system (eighth edition). Endometrial carcinoma is the most common amongst these with prolonged estrogen exposure being a well-known risk factor. The FIGO staging system for endometrial carcinoma is primarily surgical and includes total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Imaging is useful in the preoperative evaluation of tumor stage, especially assessment of myometrial invasion and cervical stromal extension. Dynamic contrast enhanced MRI with DWI has a high staging accuracy and is the preferred imaging modality for primary evaluation with contrast-enhanced CT abdomen being indicated for recurrent disease. PET/CT is considered superior in evaluation of lymph nodes and extra pelvic metastases.

Diagnostic Accuracy Of Contrast Enhanced Ct For Detection Of Renal Cell Carcinoma Taking Histopathology As Gold Standard.

Renal cell carcinoma being the commonest primary renal malignancy of adulthood accounts for approximately 80-90% renal malignant lesions. The purpose of radiological imaging modalities when devising the treatment options for renal masses is crucial as it significantly influence the clinical outcome and prognosis of the disease. Subjective impression by a radiologist for diagnosing a mass lesion is known to be critical and its precision is improved by contrast enhanced CT as demonstrated by certain retrospective analyses. We aimed to ascertain the diagnostic accuracy of contrast enhanced computed tomography to diagnose renal cell cancers by verifying through histopathology reported diagnoses. This Cross-sectional (validation) study was carried out in Radiology and Urology departments of Ayub Teaching Hospital; Abbottabad, from 1st November 2020 to 30th April 2022. The study population included all admitted symptomatic patients with age range 18-70 years of either gender. The patients were subjected to detailed clinical examination and history and an ultrasound and contrast enhanced CT abdomen and pelvis. CT scans were reported under supervision of single consultant radiologist. Data was analysed in SPSS version 20.0. Mean age of the patients was 38.88±11.62 years ranging from 18-70 years and mean duration of symptoms was 54.64±49.171 ranging from 3-180 days. All of the total 113 patients underwent contrast enhanced CT scan and later operated to confirm the diagnoses by histopathology. The comparison yielded true positive (TP) cases to be 67, True Negative (TN) 16, False Positive (FP) 26, and 4 False Negative (FN) as per CT scan diagnoses. CT scan had a diagnostic Accuracy of 73.45% with 94.37% sensitivity and 38.10% specificity. Contrast-enhanced CT has a high sensitivity for making the diagnosis of renal cell carcinoma; however, its specificity is low. A multidisciplinary approach is necessary to overcome the low specificity. Therefore, collaboration between radiologists and urologic oncologists should be considered while devising treatment plan for patients.

Rapunzel Syndrome in a Teenage Girl: A Case Report

Trichobezoars are concretions of retained, undigested material, mostly hair or hair-like fibers in the stomach. Rapunzel syndrome is the condition when trichobezoars extend into the small bowel, leading to various complications including bowel obstruction, and perforation due to pressure necrosis. We present an interesting case of trichobezoar in a 15-year-old female patient, who presented with abdominal pain for one month duration. The exam was notable for a firm palpable mass in the epigastric area associated with localized tenderness and guarding. Contrast-enhanced CT of the abdomen showed a distended stomach with the bezoar, dilated duodenal loops, and clumping of proximal jejunal loops. Upper gastrointestinal endoscopy showed a trichobezoar extending from the oesophagogastric junction to the pylorus. Endoscopic removal of the trichobezoar was not successful. An elective laparotomy was performed, during which the stomach, duodenum, and proximal jejunum were dilated. The trichobezoar, measuring 35 cm in length, extended from the body of the stomach to the proximal jejunum and caused jejunal perforation due to pressure necrosis. The trichobezoar was removed and primary closure of jejunal perforation with diversion gastrojejunostomy and jejunostomy was done. There were no postoperative complications. The patient followed up with psychiatry in the clinic after discharge, she was diagnosed with trichotillomania and started on fluoxetine, with improvement in her behavioral symptoms. In young female patients with nonspecific chronic abdomen pain and a palpable mass, trichobezoar should be considered in the differential diagnosis. Contrast-enhanced abdomen CT is the preferred imaging modality and removal of the trichobezoar with an appropriate endoscopic or surgical procedure is the treatment of choice. It is essential to diagnose and treat the underlying behavioral condition to prevent recurrent episodes.

S96 Overutilization of Contrast-enhanced CT (CECT) Abdomen in the Diagnosis of Acute Pancreatitis (AP) in the Emergency Department (ED)

Introduction: AP is an inflammatory disorder of the pancreas which is one of the leading causes of gastrointestinal disorder admissions in the United States (US). As incidence of AP increases, so does the demand for effective means of diagnosis. According to revised Atlanta classification of 2012, typical abdominal pain in the epigastrium or left upper quadrant along with an elevated lipase level greater than 3-5 times the upper limit of normal is enough to diagnose AP. Contrast-enhanced CT (CECT) should only be obtained in cases of atypical presentation or failure to improve in 48-72 hours. However, availability of CECT has led to overutilization of its use in the diagnosis of AP, which can lead to delay in management, unnecessary radiation, and increased cost burden. Here we report a one-year data from a single medical center to assess utilization of CECT in the emergency department (ED) in the diagnosis of AP and if it changed management, length of stay (LOS), or outcomes. Methods: Data from 2018 to 2019 for all patients diagnosed with AP in the ED were analyzed. In total, 140 patients, 68 males and 72 females were analyzed. We evaluated lipase levels, CECT findings, LOS, and outcome. We used t-test to compare average means. Results: The most common etiology causing AP was alcohol abuse (37%), idiopathic (28%), gallstones (22%), followed by 8 cases due to drugs, 6 due to hypertriglyceridemia, 2 due to hypercalcemia, and 1 due to a pancreatic mass. All patients had presented with epigastric pain. Average lipase among all patients was 1727 U/L with a median of 530 U/L. CECT imaging was performed in 105 patients (75%). Among those who underwent CECT abdomen, 80 cases (76%) had positive finding for AP, while remaining 25 (24%) did not. Average lipase values were significantly elevated (2290 U/L vs 1732 U/L) among those who did not undergo CECT abdomen compared to those who did (P-value < 0.02). There were no statistical significance in both groups as far as management, LOS, hospitalization course, or outcomes. Conclusion: The purpose of this study was to assess how frequently was CECT used in the initial diagnosis in the ED setting and if it was helpful in changing management. Our results indicated that routine use of imaging in the diagnosis of AP is not necessary and has no impact on management and outcome. However, it can lead to increased radiation exposure and cost burden. Therefore, we recommend judicious use of CECT and recommend against routine utilization in the initial diagnosis of AP.

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

OA20 Pneumatosis intestinalis with spontaneous pneumoperitoneum in a patient with systemic sclerosis-myositis overlap syndrome: a case report and review of the literature

Can radiomic feature analysis differentiate adrenal metastases from lipid-poor adenomas on single-phase contrast-enhanced CT abdomen?

To assess if radiomic feature analysis could help to differentiate between the lipid-poor adenomas and metastases to the adrenal glands. Eighty-six patients (women:men 42:44; mean age 66 years) with biopsy-proven adrenal metastases and 55 patients (women:men 39:16; mean age 67 years) with lipid-poor adenomas who underwent contrast-enhanced, portal-venous phase CT of the abdomen. Radiomic features were extracted using the PyRadiomics extension for 3D Slicer. Following elastic net regularisation, seven of 1,132 extracted radiomic features were selected to build a radiomic signature. This was combined with patient demographics to create a predictive nomogram. The calibration curves in both the training and validation cohorts were assessed using a Hosmer-Lemeshow test. The radiomic signature alone yielded an area under the curve of 91.7% in the training cohort (n=93) and 87.1% in the validation cohort (n=48). The predictive nomogram, which combined age, a previous history of malignancy, and the radiomic signature, had an AUC of 97.2% in the training cohort and 90.4% in the validation cohort. The present nomogram has the potential to differentiate between a lipid-poor adrenal adenoma and adrenal metastasis on portal-venous CT.

Diagnostic Accuracy of Extended Focused Assessment with Sonography For Trauma (E-FAST) Keeping Contrast Enhanced CT Chest And Abdomen As Gold Standard

Objective: To determine the diagnostic accuracy of extended focused assessment with sonography for trauma (E-FAST) for detecting thoraco-abdominal trauma, keeping contrast-enhanced CT chest and abdomen as the gold standard.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Radiology, Combined Military Hospital, Quetta, from Jan 2020 to Aug 2021.&#x0D; Methodology: A total of (n=196) patients, of age 18-60 years, of both genders, who sustained thoraco-abdominal injuries and were referred for contrast-enhanced Computed tomography of the chest and abdomen were enrolled in the study. Patients were subjected to the thorax and abdomen ultrasonographic examination first and then underwent a contrast-enhanced CT scan of the thorax and abdomen. The findings of both modalities were recorded and subjected to statistical analysis to confirm the accuracy of ultrasound, considering CT-scan as a gold standard procedure.&#x0D; Results: The mean age of the patients was 35 10.6. There were 164 (83.7%) males and 32 (16.3%) females. Blunt trauma was seen in 131 (66.8%) and penetrating trauma in 65 (32.2%) patients. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of E-FAST for chest trauma was 79.4%, 94.7%, 87.6%, 90.7% and 89.8% respectively, for abdominal trauma was 68.6%, 95.2%, 88.8%, 84.5% and 85.7% respectively and for combined chest and abdominal trauma was 77.1%, 95.9%, 85.9%, 92.8% and 91.3% respectively.&#x0D; Conclusion: E-FAST has good diagnostic accuracy for the chest, abdominal and both thoraco-abdominal trauma and can be incorporated into the routine assessment of patients presenting with trauma.

Image quality assessment of pediatric chest and abdomen CT by deep learning reconstruction

BackgroundEfforts to reduce the radiation dose have continued steadily, with new reconstruction techniques. Recently, image denoising algorithms using artificial neural networks, termed deep learning reconstruction (DLR), have been applied to CT image reconstruction to overcome the drawbacks of iterative reconstruction (IR). The purpose of our study was to compare the objective and subjective image quality of DLR and IR on pediatric abdomen and chest CT images.MethodsThis retrospective study included pediatric body CT images from February 2020 to October 2020, performed on 51 patients (34 boys and 17 girls; age 1–18 years). Non-contrast chest CT (n = 16), contrast-enhanced chest CT (n = 12), and contrast-enhanced abdomen CT (n = 23) images were included. Standard 50% adaptive statistical iterative reconstruction V (ASIR-V) images were compared to images with 100% ASIR-V and DLR at medium and high strengths. Attenuation, noise, contrast to noise ratio (CNR), and signal to noise (SNR) measurements were performed. Overall image quality, artifacts, and noise were subjectively assessed by two radiologists using a four-point scale (superior, average, suboptimal, and unacceptable). A phantom scan was performed including the dose range of the clinical images used in our study, and the noise power spectrum (NPS) was calculated. Quantitative and qualitative parameters were compared using repeated-measures analysis of variance (ANOVA) with Bonferroni correction and Wilcoxon signed-rank tests.ResultsDLR had better CNR and SNR than 50% ASIR-V in both pediatric chest and abdomen CT images. When compared with 50% ASIR-V, high strength DLR was associated with noise reduction in non-contrast chest CT (33.0%), contrast-enhanced chest CT (39.6%), and contrast-enhanced abdomen CT (38.7%) with increases in CNR at 149.1%, 105.8%, and 53.1% respectively. The subjective assessment of overall image quality and the noise was also better on DLR images (p < 0.001). However, there was no significant difference in artifacts between reconstruction methods. From NPS analysis, DLR methods showed a pattern of reducing the magnitude of noise while maintaining the texture.ConclusionCompared with 50% ASIR-V, DLR improved pediatric body CT images with significant noise reduction. However, artifacts were not improved by DLR, regardless of strength.

S2244 Unusual Presentation of Strongyloides with Microscopic Colitis

Introduction: Strongyloides is an endemic helminth in the tropical regions of the world. It has varied presentation from asymptomatic infection to having hyper-infection syndrome and disseminated disease. We present a case of Strongyloides with microscopic colitis- whether they coexist or lead to one another. Case Description/Methods: A 57 year old male presented with multiple episodes of bilious, non-projectile vomiting and bilateral pedal edema for 15 days. He has past history for L5-S1 radiculopathy for which he was given steroids for 3 months and they were tapered off in that period. Antiemetics were started, but there was no relief. His routine blood investigations were normal except for low serum albumin. Contrast enhanced CT Abdomen was normal. Upper GI endoscopy was normal, biopsies from second part of duodenum was taken. Colonoscopy was done;the mucosa was normal and segmental biopsies were taken. Stool examination and duodenal mucosa showed presence of the larva of Strongyloides. Histopathoplogy of colonic mucosa showed features of microscopic colitis; lamina propria in the ileum and caecum showed inflammatory infiltrate and lymphoid aggregates with eosinophils. Transverse colon stroma showed mixed inflammatory infiltrate with many eosinophils and occasional lymphoid aggregates. Oral ivermectin was started and given for 5 days. Along with anti-helminthic, oral budesonide was also given for microscopic colitis. His symptoms improved and was doing well on follow up. Discussion: S.stercorails has the unique ability to complete its life cycle within the host through an asexual autoinfective cycle, allowing infection to persist in the host indefinitely. Immunocompromised state can precipitate hyperinfection syndrome. Hallmark of hyperinfection syndrome is the increase in the larvae in the stool or the sputum leading to gastrointestinal and pulmonary symptoms. GI symptoms include abdominal pain, nausea, diarrhoea and rarely intestinal obstruction and GI hemorrhage. Our patient didn’t develop any of these symptoms while on steroids. On the other hand, microscopic colitis presents with chronic diarrhoea. These symptoms were also not present. Our patient had symptoms due to increased larval load leading to repeated episodes of vomiting. There is scant literature if Strongyloides leads to microscopic colitis. Bacterial infection leading to microscopic colitis is known but parasitic cause is not known yet.Figure 1.: A: Normal stomach with food residue. B: Normal appearing mucosa of the ascending colon. C: Homogeneous eosinophilic deposits of amyloid in submucosal blood vessels of the small bowel (conventional haematoxylin and eosin-stained section 20x) D: Reddish-orange appearance of amyloid protein deposit in submucosal blood vessels of small bowel (congo red-stained section 20x).

Characterization of Benign and Malignant Pancreatic Lesions with DECT Quantitative Metrics and Radiomics

To compare dual energy CT (DECT) quantitative metrics and radiomics for differentiating benign and malignant pancreatic lesions on contrast enhanced abdomen CT. Our study included 103 patients who underwent contrast-enhanced DECT for assessing focal pancreatic lesions at one of the two hospitals (Site A: age 68 ± 12 yrs; malignant = 41, benign = 18; Site B: age 46 ± 2 yrs; malignant = 23, benign = 21). All malignant lesions had histologic confirmation, and benign lesions were stable on follow up CT (>12 months) or had characteristic benign features on MRI. Arterial-phase, low- and high-kV DICOM images were processed with the DECT Tumor Analysis (DETA) to obtain DECT quantitative metrics such as HU, iodine and water content from a region of interest (ROI) over focal pancreatic lesions. Separately, we obtained DECT radiomics from the same ROI. Data were analyzed with multiple logistic regression and receiver operating characteristics to generate area under the curve (AUC) for best predictive variables. DECT quantitative metrics and radiomics had AUCs of 0.98-0.99 at site A and 0.89-0.94 at site B data for classifying benign and malignant pancreatic lesions. There was no significant difference in the AUCs and accuracies of DECT quantitative metrics and radiomics from lesion rims and volumes among patients at both sites (p > 0.05). Supervised learning-based model with data from the two sites demonstrated best AUCs of 0.94 (DECT radiomics) and 0.90 (DECT quantitative metrics) for characterizing pancreatic lesions as benign or malignant. Compared to complex DECT radiomics, quantitative DECT information provide a simpler but accurate method of differentiating benign and malignant pancreatic lesions.

POS-713 TACROLIMUS INDUCED HEPATIC VENO OCCLUSIVE DISEASE IN RENAL TRANSPLANT PATIENT

Tacrolimus is widely used immunosuppressive agent used in solid organ transplant recipients to prevent rejection. It is a calcineurin inhibitor which results in reduced transcription of IL-2 levels thereby mediating the process of preventing rejection. It is extensively metabolized by cytochrome P-450 CYP3A enzymes in the liver and its drug level monitoring is very crucial in managing such patients as it is associated with wide array of adverse effects and multiple drug-drug interactions. Hepatic veno occlusive disease a non thrombotic veno occlusion of hepatic vein is a rare and reversible adverse effect of tacrolimus is being discussed. A 39 year old male with native kidney disease of IgA nephropathy presented 10 months post transplant with fever and cough. He was triple immunosuppression with tac level of 5.8 ng/ml on Tacrolimus 2mg twice daily. He was diagnosed with Aspergillus fumigatus pneumonia for which he was started on Voriconazole. On third day of antifungal he developed acute onset abdominal distension with ascites. Ascitic fluid analysis was suggestive of high SAAG, high protein fluid and contrast enhanced CT abdomen showed significant stenosis of hepatic vein at its confluence of IVC. Concomitantly checked Tacrolimus trough level was greater than 40ng/ml. Gradually tacrolimus dose was reduced and Tacrolimus trough levels were maintained between 2-5 ng/ml. With reduction of tacrolimus dose his ascites reduced and repeat CT abdomen showed opening of hepatic veins.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Hepatic veno occlusive disease is more common in patients with stem cell transplant recipients rather than solid organ transplant patients. HVOD in SOT recipients has been mostly related to the use of Azathioprine and has been rarely reported with pancreas and lung transplant patients. Herewith reporting an rare case of Tacrolimus induced hepatic veno occlusive disease in a renal transplant patient associated with raised tacrolimus trough levels > 40ng/ml due to the concomitant usage of Voriconazole (Known to inhibit metabolism of Tacrolimus). This patient had a complete recovery of symptoms following reduction in dosage of Tacrolimus. In summary, tacrolimus (especially in the event of an overdose), alone or in combination with drugs known to cause VOD (like Azathioprine, valaciclovir) or known to inhibit the metabolism of CNIs may give rise to VOD. It is therefore necessary to monitor tacrolimus levels and liver parameters throughout treatment. In the event of clinical or biochemical abnormalities, appropriate monitoring of drug levels, reduction in dosage of tacrolimus may completely reverse this dreadful life threatening complication.

Staging 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Changes Treatment Recommendation in Invasive Bladder Cancer

Given the high risk of systemic relapse following initial therapy for muscle-invasive bladder cancer (MIBC), improved pretreatment staging is needed. We evaluated the incremental value of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) after standard conventional staging, in the largest cohort of MIBC patients to date. This is a retrospective analysis of 711 consecutive patients with invasive urothelial bladder cancer who underwent staging contrast-enhanced CT (chest and abdomen) and FDG-PET/CT in a tertiary referral center between 2011 and 2020. We recorded the clinical stage before and after FDG-PET/CT and treatment recommendation based on the stage before and after FDG-PET/CT. Clinical stage changed after FDG-PET/CT in 184/711 (26%) patients. Consequently, the recommended treatment strategy based on imaging changed in 127/711 (18%) patients. In 65/711 (9.1%) patients, potential curative treatment changed to palliative treatment because of the detection of distant metastases by FDG-PET/CT. Fifty (7.0%) patients were selected for neoadjuvant/induction chemotherapy based on FDG-PET/CT. Moreover, FDG-PET/CT detected lesions suspicious for second primary tumors in 15%; a second primary malignancy was confirmed in 28/711 (3.9%), leading to treatment change in ten (1.4%) patients. Contrarily 57/711 (8.1%) had false positive secondary findings. In conclusion, FDG-PET/CT provides important incremental staging information, which potentially influences clinical management in 18% of MIBC patients, but leads to false positive results as well. Patient summaryIn this report, we investigated the impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scanning on treatment of bladder cancer patients. We found that FDG-PET/CT potentially influences the treatment of almost one-fifth of patients. We therefore suggest performing FDG-PET/CT as part of bladder cancer staging.

A QUANTITATIVE, CROSS-SECTIONAL STUDY TO MEASURE AORTA SACRAL PROMONTORY DISTANCE AMONG FEMALES REFERRED FOR CONTRAST ENHANCED CT ABDOMEN

Aim: This study was carried out to measure the aorta sacral promontory distance among the females referred for contrast enhanced CT abdomen in a tertiary hospital.&#x0D; Material and methods: A quantitative, cross-sectional study was conducted in the Department of radiology, Indira Gandhi Institute of Medical Science, Patna, Bihar, India from December 2019 to October 2020.Total of 140 patients who underwent Contrast Enhanced CT abdomen. The age, height and weight of the patients were noted. In this study, aorta sacral promontory distance was determined.&#x0D; Results: The mean age was found to be 51.37 years, mean APT distance 4.61±0.80 cm and mean BMI 24.88. Increased in age was correlated with decrease in APT distance but there was no correlation between BMI and APT distance. According to this study, APT distance was decreased in elderly female patients but no significant change in BMI and APT. Conclusion: we conclude that the age increased, APT distance decreased and there was no significant change in relation to BMI. Therefore, during sacral colpopexy, the surgeon should be careful and consider the aorta sacral promontory distance in the elder female patients while performing dissection.&#x0D; Keywords: aorta sacral promontory distance, pelvic organ prolapse, sacral colpopexy.

A Case Report on a Pancreatic Enigma: Metastatic Solid Pseudopapillary Neoplasm

Introduction: Solid pseudopapillary neoplasm is a unique enigmatic disease typically affecting young females. Being a low-grade neoplasm surgical resection is often curative. Rare cases (5-15%) present with distant metastasis. Only 2% has lymph nodal metastasis. This is a case report of metastatic SPN with both visceral and lymph nodal involvement. The work has been reported in line with the SCARE criteria. Case Presentation: The authors present a case of metastatic SPN in an 18-year-old female who came with an abdominal lump. Contrast enhanced CT abdomen findings were in favour of huge SPN arising from pancreatic tail. The prime concern was the coexistence of bilobar liver metastasis predominantly involving right lobe. The complexity of surgical resection along with metastatectomy in a young female was herculean. This clinical dilemma was tackled with staged resection. Conclusion: Even in metastatic SPN a reasonable survival can be achieved by surgical debulking. We emphasize the importance of aggressive approach in operable metastatic SPN.