Modern Era Of Imaging Research Articles

A rare presentation of cubital tunnel syndrome by accessory anconeus muscle

Cubital tunnel syndrome (Cu TS) is the second most frequent upper extremity compressive neuropathy after carpal tunnel syndrome. Cu TS is idiopathic; however, it has been linked to ulnar nerve vulnerability and anconeus epitrochlearis (AE) muscle hypertrophy. Although there are few studies in the literature that reveal AE muscle as one of the causes of Cu TS, its prevalence is low. The goal of this case report is to raise awareness regarding the existence of AE muscle as a potential cause of Cu TS, as well as the imaging findings of Cu TS in magnetic resonance imaging (MRI). A 17-year-old male patient complained of intermittent pain in the medial aspect of the left elbow and paresthesia in the left hand. Examination revealed hyperextension of meta carpalphalangeal joints and flexion of proximal interphalangeal joints of the 4th and 5th digits, besides the sensory deficit along the ulnar border of the 5th digit. A nerve conduction study revealed non-stimulable sensory and motor components of the right ulnar nerve. MRI with T1-weighted fast spin echo, Fat sat proton density-weighted, and gradient echo T2*-weighted sequence showed AE - on the posteromedial aspect of the elbow. The ulnar nerve within the cubital tunnel appeared thickened and edematous with bright perineural fat signals with maintained fascicular architecture, secondary to compression by the anconeus muscle. This paper reviews imaging findings of ulnar neuropathy secondary to accessory anconeus muscle and explains the importance of MRI imaging for accurate diagnosis. Knowing MRI imaging is vital in the modern imaging era for accurate diagnosis.

Free TcO 4- in 99m Tc-PSMA Scan : A Case Report and Review of an Old Pitfall in the New Era of Modern Imaging.

In a recent 99m Tc-HYNIC-PSMA study conducted at our department, we examined 2 patients with prostate cancer referred for initial staging on the same day. The whole-body scans revealed radiotracer uptake in the gastric mucosa and thyroid glands, alluding to high levels of free TcO 4- in the injected vial. The scans were repeated after confirming acceptable radiopharmaceutical purity of 97% (normal range, 95%-100%). Interestingly, 1 patient had liver metastases at presentation, which remained non-PSMA-avid after repeating the scan. We have reviewed this pitfall, which has been reported with many radiotracers, yet not reported with PSMA tracers.

Laparoscopic surgery for the diagnosis of abdominal effusion in the modern era of imaging - a retrospective study in a low-to-middle-income country.

We retrospectively identified patients who could not be diagnosed by clinical examination, laboratory investigations, and imaging tests. A total of 103 (55 male and 48 female) patients were selected. The median age of the study group was 54 years (range 38-64 years). Typical clinical symptoms included fever (58.2%), abdominal pain (56.3%), and digestive disorders (62.1%). Fever and digestive disorders were higher in the peritoneal tuberculosis (TB) group than in the metastatic cancer group [(62.1% vs. 12.5%, P=0.009) and (66.3% vs. 12.5%, P=0.004)]. Abdominal pain was more common in the metastatic cancer group than in the other groups (100% vs. 55.8%, P=0.020). Patients in the TB and chronic inflammation groups had lower red blood cell counts and blood albumin (41 vs. 42, P=0.039) than those in the metastatic cancer group, respectively. The rate of intestinal wall thickening on ultrasound and peritoneal thickening on computed tomography was higher in the cancer group than in the benign group (87.5% vs. 7.4%, P=0.000) (75% vs. 23.2%, P=0.005), respectively. There was no difference in the median peritoneal fluid volume between the two groups (390 vs. 340, P=0.058). Pathological results showed 88.3%, 7.8%, and 3.9% of peritoneal TB, metastatic cancer, and chronic inflammatory lesions, respectively. The median hospital stay did not differ between the two groups (4 vs. 3 days, P=0.051). Both groups of patients had no morbidity or mortality. Unidentified ascites and peritonitis must be difficult for making diagnose by conventional methods. Laparoscopy might be supportive of making a rapid diagnosis and starting early treatment.

Predicting Pathologic Lymph Node Positivity in cN0 Pharynx and Larynx Cancers in the Modern Imaging Era

<h3>Purpose/Objective(s)</h3> Neck dissection is a standard of care for pharynx and most larynx cancer patients undergoing surgery even with clinically node-negative (cN0) necks. This is based largely on historical series showing high rates of occult pathologic node-positivity (pN+) in cN0 patients. However, in the modern era with more sensitive imaging modalities, it is possible that certain patients with sufficiently low risk of pN+ could have elective neck dissection omitted, thereby reducing toxicity. <h3>Materials/Methods</h3> Patients with cN0 oropharynx, larynx (excluding T1-2 glottic), and hypopharynx cancers diagnosed from 2010-2015 and undergoing primary surgery were identified in the National Cancer Data Base. Multivariable logistic regression was performed to assess predictors of pN+. Predictive nomograms based on these predictors were generated. <h3>Results</h3> 4117 cN0 patients met inclusion criteria, including 2033 larynx (L), 293 hypopharynx (HP), 503 HPV(-) oropharynx (OP), and 1288 HPV(+) OP patients. The overall rate of pN+ among cN0 patients was 29.4%. Probability of pN+ was > 25% for all anatomic subsites (L: 26.9%; HP: 27.6%: HPV(-) OP: 32.4%; HPV(+) OP: 32.7%). In multivariable logistic regression, the presence of lymphovascular invasion (LVI) was the strongest predictor of pN+ (odds ratio [OR] = 4.19, 95% confidence interval [CI] 3.56-4.93, <i>P</i> < 0.001). Histologic grade also strongly predicted pN+ (high- vs. low-grade: OR 2.58, 95% CI 1.88-3.59, <i>P</i> < 0.001; intermediate- vs. low-grade: OR 1.90, 95% CI 1.40-2.62, <i>P</i> < 0.001). However, increasing pT-classification was not associated with increased rate of LN positivity. A nomogram predicting the probability of pN+ for cN0 patients was created. Using this nomogram, < 2% of patients had an estimated pN+ risk below 10%, < 10% of patients had pN+ risk below 15%. <h3>Conclusion</h3> LVI and histologic grade are the strongest predictors of pN+ among patients with cN0 pharynx and larynx cancers. Even with modern imaging, pN+ rates are high for cN0 patients, and the benefits of neck dissection likely outweigh the risks in virtually all patients undergoing surgery.

Asymptomatic Superior Mesenteric Arterial Stenosis: Primum non nocere

In this era of modern imaging the issue of how to handle asymptomatic lesions is a common discussion at hospital rounds worldwide. When I was a young surgical trainee in the 1970s, the most common abdominal surgical procedure was diagnostic laparotomy, imagine! Fortunately, that was a long time ago, but the present situation, in which we are exposed to multiple asymptomatic lesions, creates a new challenge.

Isolated septic facet joints: an underdiagnosed distinct clinical entity

We review a series of isolated septic facet joints (ISFJ) that present as a distinct clinical entity compared with spondylodiscitis. We aim to raise awareness that septic facet joints are not a rare entity in the era of modern imaging. We reviewed 353 patients with confirmed spine infections from 2008 to 2017. Of the 353 cases, there were 152 septic facet joints based on MR imaging. Sixty-two presented as ISFJ without evidence of spondylodiscitis and were reviewed. Patients were predominantly male 38/62 (61%). The mean age was 56.7years. Onset of back pain was more acute compared with spondylodiscitis and usually unilateral. The distribution was as follows: 6 cervical, 12 thoracic, and 44 lumbar facets. The majority of ISFJ, 53/62 (85%), were associated with an epidural abscess (EDA) 53/62. The cervical and thoracic EDA required surgical decompression more frequently than lumbar; 100%, 75%, and 53% respectively. Pathogen was identified in 59/62 (95%) cases. Most cases were associated with bacteremia 50/62 (81%). Seven ISFJ were introduced iatrogenically. All iatrogenic ISFJ required surgical decompression. Septic facet joints are not rare, but frequently overlooked as the origin of an epidural abscess. The majority of cases are hematogenously seeded and associated with bacteremia. Surgical decompression is frequently required secondary to the high incidence of associated epidural abscess. Iatrogenic septic facet joints are rare but associated with significant morbidity. From a clinical standpoint, it is helpful to delineate the origin of EDA as either secondary to spondylodiscitis or SFJ.

Abstract TP221: Cerebellar Infarction Presentations: A Population-Based Study From the Greater Cincinnati/Northern Kentucky Stroke Study

Background: Cerebellar lesions reportedly account for 2-7% of acute infarct visits, but this may be an underestimate since prior studies were not population-based or from the modern imaging era. Cerebellar symptoms are also often nonspecific such that increased MRI use might lead to a higher proportion of stroke due to cerebellar lesions. Details about presenting features of cerebellar infarcts and baseline medication use are also not well known. Methods: We used the 2010 Greater Cincinnati/Northern Kentucky Stroke Study. Strokes were identified by screening ICD9 codes 430-436 and physician verification. Infarct location was categorized as isolated cerebellar, mixed cerebellar (cerebellar plus ≥1 other location), or non-cerebellar. Isolated dizziness was defined as dizziness/vertigo without other focal symptoms. Atherosclerotic cardiovascular disease (ASCVD) 10-year risk scores were calculated. Descriptive statistics and multivariable logistic regression were used to compare infarct categories. Results: Isolated cerebellar lesions occurred in 4.6% (90/1940; 95% CI, 3.7%-5.7%) of infarct events. An additional 4% (77/1940; 95%CI, 3.1%-4.9%) were mixed cerebellar infarcts. Mixed cerebellar infarcts had clinical characteristics more similar to non-cerebellar events than to cerebellar events. The multivariable model found an association of isolated cerebellar infarct with low NIHSS (odds ratio [OR] 2.3, 95% CI 1.1-4.8) and any dizziness/vertigo (OR 5.1, 95% CI, 2.4-10.6), but not with isolated dizziness/vertigo, age, or sex. Median ASCVD scores were high in all infarct categories (21, interquartile range [IQR] 9-35 for isolated cerebellar; 32, IQR 15-42 for mixed cerebellar; 31, IQR 16-52 for all others). Both cerebellar and non-cerebellar strokes had a high frequency of baseline antiplatelet or anticoagulant use (52.1% vs 56.2%), whereas baseline statin therapy was less common in isolated cerebellar infarcts (34.1% vs 43.8%). Conclusions: This population-based study during the modern imaging era found that about 5% of stroke cases have isolated cerebellar infarcts and nearly 9% have any cerebellar infarct. Both cerebellar and non-cerebellar presentations have high baseline vascular risk and antiplatelet/anticoagulant use.

Oesophago-gastric cancer and the role of staging laparoscopy in the era of modern imaging

Oesophago-gastric cancer and the role of staging laparoscopy in the era of modern imaging

Limited-Stage Small Cell Lung Cancer: Is Prophylactic Cranial Irradiation Necessary?

Prophylactic cranial irradiation (PCI) reduces the incidence of brain metastases in patients with limited stage small cell lung cancer (LS-SCLC). However, PCI is associated with significant neurocognitive sequelae. In prior studies assessing the role of PCI in SCLC, patients have not been consistently staged with pretreatment magnetic resonance imaging (MRI). Modern improvements in staging imaging continue to enhance the ability to detect early brain metastases. We sought to determine if PCI was associated with improved overall survival (OS), progression free survival (PFS), and cumulative incidence (CI) of brain metastases in LS-SCLC patients in the modern era of MRI staging. We identified patients with LS-SCLC treated with curative intent between 2006-2018 staged initially with MRI and no progression of disease after initial therapy. Kaplan-Meier estimates of OS and PFS were calculated and multivariate Cox proportional hazards models were generated. The cumulative incidence of brain metastases was estimated using competing risks methodology. In total, 96 patients were identified, 39 (41%) of whom received PCI. Median follow-up was 39 months. The median OS for the cohort was 34.0 months (95% CI 23.9-55.2) and PFS was 18.3 months (95% CI 10.3-29.9). Median OS in those treated with PCI versus those not treated with PCI was 35.8 months (95% CI 31.8-NR) versus 30.5 months (95% CI 16.1-56.1, p=0.09) while median PFS was 24.4 months (95% CI 19.1-NR) versus 10.6 (95% CI 9.2-29.9, p=0.04). At 2 years, the CI of brain metastases was 12% with PCI and 33% without PCI; this increased to 39% and 33% by 4 years (p=0.68). Multivariate analysis revealed age ≥70 (HR 1.97) and partial response/stable disease after initial therapy (PR/SD) versus complete response (CR; HR 4.26) as significant factors influencing OS. Patients with a PR/SD had an increased of HR 4.99 for PFS whereas patients treated with PCI had a reduced HR for PFS. Stratified by disease response, patients with CR did not benefit from PCI (p=0.67), while those with PR/SD had improved PFS (p=0.02). Overall, PCI was associated with improved PFS and reduced cumulative incidence of brain metastases in the MRI era. Patients who achieved a CR to initial therapy did not experience a significant PFS benefit with the addition of PCI. This data is hypothesis generating and may indicate that subsets of LS-SCLC patients may potentially be spared from the significant neurotoxic sequelae of PCI in the era of modern imaging. Further prospective studies are needed.

Delayed splenic hemorrhage: Myth or mystery? A Western Trauma Association multicenter study

BackgroundMulti-detector computed tomography imaging is now the reference standard for identifying solid organ injuries, with a high sensitivity and specificity. However, delayed splenic hemorrhage (DSH), defined as no identified injury to the spleen on the index scan but delayed bleeding from a splenic injury, has been reported. We hypothesized that the occurrence of DSH would be minimized by utilization of modern imaging techniques. MethodsData was retrospectively collected from 2006 to 2016 in 12 adult Level I and II trauma centers. All patients had an initial CT scan demonstrating no splenic injury but subsequently were diagnosed with splenic bleeding. Demographic, injury characteristics, imaging parameters and results, interventions and outcomes were collected. ResultsOf 6867 patients with splenic injuries, 32 cases (0.4%) of blunt splenic hemorrage were identified. Patients were primarily male, had blunt trauma, severely injured (ISS 32 (9–57) and with associated injuries. Injuries of all grades were identified up to 16 days following admission. Overall, half of patients required splenectomy. All index images were obtained using multi-detector CT (16–320 slice). Secondary review of imaging by two trauma radiologists judged 72% (n = 23) of scans as suboptimal. This was due to poor scan quality primary from artifact(23), single phase contrast imaging (16), and/or poor contrast bolus timing or volume (6). Notably, only 28% of scans in patients with DSH were performed with optimal scanning techniques. ConclusionThis is the largest reported series of DSH in the era of modern imaging. Although the incidence of DSH is low, it still occurs despite the use of multi-detector imaging and when present, is associated with a high rate of splenectomy. Most cases of DSH can be attributed to missed diagnosis from suboptimal index imaging and ultimately be avoided.

Limited-Stage Small Cell Lung Cancer: Is Prophylactic Cranial Irradiation Necessary?

PurposeProphylactic cranial irradiation (PCI) reduces the incidence of brain metastases in patients with limited stage small cell lung cancer (LS-SCLC). However, PCI is associated with neurotoxicity. Previous studies have not consistently used pretreatment magnetic resonance imaging. Modern imaging improvements continue to enhance early metastasis detection, potentially decreasing the utility of PCI. We sought to determine whether PCI was associated with improved outcomes in LS-SCLC patients with modern imaging. Methods and MaterialsWe identified LS-SCLC patients with no intracranial disease who were treated between 2007 and 2018. Kaplan-Meier estimates of overall survival (OS) and progression-free survival (PFS) were calculated and multivariate Cox proportional hazards models were generated. The cumulative incidence of brain metastases was estimated using competing risks methodology. ResultsNinety-two patients were identified without intracranial disease at initial staging, 39 of whom received PCI. Median follow-up was 56.7 months. The median OS for the cohort was 35.5 months (95% CI, 25.8-49.3), and median PFS was 19.1 months (95% CI, 12.3-30.5). Median OS with PCI versus observation was 37.9 months (95% CI, 31.8-not reached) versus 30.5 months (95% CI, 14.6-56.1; P = .07), whereas median PFS was 26.3 months (95% CI 19.1-not reached) versus 12.3 months (95% CI, 8.5-30.5; P = .02), respectively. Overall, at 2 years, the cumulative incidence of brain metastases was 10% with PCI and 29% without; this increased to 32% and 29% by 4 years (P = .66). In those patients who had negative magnetic resonance imaging of the brain after completing initial treatment, the 1-year cumulative incidence of brain metastasis was not significantly different at 8% versus 11% (P = .46) respectively. Both PCI and treatment response were independent predictors for PFS on multivariate analysis. Stratified by disease response, patients with a complete response did not benefit from PCI (P = .50), whereas those with partial response or stable disease experienced improved PFS (P = .01). ConclusionsOverall, PCI was associated with improved PFS and reduced early incidence of brain metastases. Patients achieving a complete response to initial therapy did not experience a PFS benefit with PCI. This may indicate that subsets of LS-SCLC patients can potentially be spared from PCI in the era of modern imaging.

Role of Surveillance CT in Detection of Pre-Clinical Relapse in Patients with B-Cell Lymphoma : A Retrospective Study

Background: with the evolution of curative treatment regimen, the rate of complete remission achieved in patients with diffuse aggressive non-Hodgkin lymphoma is continuously rising. It is achievable at the end of primary treatment in about 60-80%. On the other hand relapse is very common in the 1st two years after end of primary treatment in diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma, that is to say, about 20-25% of patients relapse after complete response. Use of routine surveillance imaging for relapse detection is still an area of controversy. Evidence is still lacking to support the utility of routine imaging (namely CT scan) in detection of pre-clinical relapse in diffuse aggressive non-Hodgkin lymphoma (NHL). This work aims at adding further evidence to the pool of studies available in the literature which might encourage, or disapprove the rule of CT as a routine imaging procedures in lymphoma patients who achieved CR. Objectives: I. To clarify whether surveillance CT scan has a significant role in early detection of asymptomatic relapse in B-Cell lymphoma patients. II. To assess the contribution of image-based relapse detection to the overall survival of B-Cell lymphoma patients. Design: this is a retrospective cohort study in which 50 Patients with B-Cell lymphoma diagnosed between 2014 and 2016 were selected from the PACS of Radiology Department at Ain Shams University Hospitals. Age ranges between 20 and 70 year-old. All diagnoses were confirmed by histopathology studies. All patients underwent treatment and follow-up strategy as planned by their treating oncologist/hematologist, after which they entered CR or SD according to IWG Cheson criteria of treatment response. Disease progression was retrospectively reviewed over a period of 6 months up to 2 years. Surveillance CT scan was performed on the neck, chest, abdomen and pelvis on each of the planned follow-up visits. Relapses were defined as “asymptomatic” if there were no reported symptoms and a normal examination was recorded. Results: the most common cause of relapse detection was patient-reported symptoms alone (41%) or in combination with abnormal blood tests and/or physical examination (23%). Routine imaging was responsible for relapse detection in 27% of the patients. The unadjusted median OS for patients with imaging-detected relapse was 90 months versus 38 months for patients non imaging-detected relapse (P = 0.0008). Although surveillance imaging proved no significance in detection of pre-clinical relapse, our regression analysis showed that it remained significantly associated with reduced risk of death. Conclusion: clinical symptoms remain the leading factor in diagnosing recurrent lymphoma in the era of modern imaging, and this study questions the clinical relevance of current practice. A possible survival advantage was seen for patients with image-detected relapse.

A reappraisal of staging laparoscopy in three subtypes of cholangiocarcinoma: A multi-institution analysis from the U.S. Extrahepatic Biliary Malignancy Consortium.

226 Background: Staging laparoscopy (SL) has been shown to be useful in extrahepatic biliary tumors (EHBTs) to avoid unnecessary laparotomies in unresectable disease. However, the added value of SL for EHBTs has not been well characterized in the era of modern imaging. Methods: We reviewed patients from ten institutions who underwent attempted resection of EHBTs between 1998 and 2015, including gallbladder, distal, and hilar subtypes. Yield of laparoscopy = (Number of positive SL / Total number of SL). Accuracy of laparoscopy = (Number of positive SL / Patients with unresectable disease). These data were compared by use of the chi-squared test and significance was p &lt;.05. Results: A total of 1,075 patients were taken to the OR for attempted curative resection, of which 250 patients (23%) underwent staging laparoscopy. SL identified unresectable disease in 42 patients (yield 17%). Of 208 patients who underwent exploratory laparotomy (EL) after negative SL, 19 were found to be unresectable (false negative rate 9%). Amongst gallbladder, hilar, and distal pathology types, the yield of SL were 18%, 13%, 17%, respectively (p=0.78). Accuracy of SL was 61%, 71%, and 91% respectively (p=0.17), with an accuracy of 68%. A total of 825 patients went directly to EL, of which 103 (13%) failed. The rate of failure for patients going straight to EL was significantly higher for patients with gallbladder (n=66/287, 23%) when compared with hilar (n=15/274, 6%) and distal EHBT (n=22/264, 8%) (p&lt;0.001). Conclusions: Our analysis demonstrates that staging laparoscopy still has added utility in preventing unnecessary laparotomies in unresectable disease for selected patients with EHBTs, although the overall yield is low. Patients with gallbladder cancer had high rates of failed laparotomies, representing a subset who may benefit from more frequent use of staging laparoscopy at the time of resection. [caption]Yield and accuracy of detecting unresectable disease with staging laparoscopy. [/caption] [Table: see text]

The Importance of Neurologic Examination in Modern Imaging Era: A Case Study and Discussion

The Importance of Neurologic Examination in Modern Imaging Era: A Case Study and Discussion

Is Exam under Anesthesia Still Necessary for the Staging of Bladder Cancer in the Era of Modern Imaging?

Background: The ability to accurately determine tumor stage in bladder cancer is critical because it impacts the management paradigm and overall prognosis. There is often discrepancy between clinical and pathologic staging. Historically, exam under anesthesia (EUA) has been recommended to assist in the staging of bladder cancer.Objective: In this era of modern imaging technology, we sought to determine if EUA still contributes meaningfully to the local staging of bladder cancer.Methods: We retrospectively reviewed the charts of 1898 patients from 1994–2013 in our radical cystectomy database at MD Anderson Cancer Center. There were 414 patients that had complete information including EUA and whose surgery was performed by one of two surgeons and included in the final analysis. Univariate and multiple logistic regression models were generated to determine the ability of EUA, imaging, and other patient characteristics to predict pathological fat extension at the time of cystectomy.Results: 38% of patients had≥pT3 disease at the time of cystectomy. 30.9% of patients had findings on EUA suggestive of T3 disease and 28.7% had radiologic findings suggestive of T3 disease. In a model including age, BMI, ethnicity, year of operation, and neoadjuvant chemotherapy among other factors, the only factors predictive of pT3 disease were EUA and imaging (p = 0.002). The combination of EUA and imaging improved the accuracy of clinical staging compared to either modality alone. Conclusions: Despite modern advances in imaging, EUA contributes meaningfully to accurate determination of local bladder cancer stage.

Neuroimaging of first-ever seizure: Contribution of MRI if CT is normal

We read the interesting study pertaining to neuroimaging in first-ever seizure by Ho et al.1 In the era of modern imaging, CT and MRI are the modalities of choice, along with EEG. Imaging helps rule out structural lesions, which at times require medical treatment, e.g., tuberculoma and neurocysticercosis, in addition to seizures. Some of …

MP65-03 IS EXAM UNDER ANESTHESIA STILL NECESSARY FOR THE STAGING OF BLADDER CANCER IN THE ERA OF MODERN IMAGING?

You have accessJournal of UrologyBladder Cancer: Staging1 Apr 2014MP65-03 IS EXAM UNDER ANESTHESIA STILL NECESSARY FOR THE STAGING OF BLADDER CANCER IN THE ERA OF MODERN IMAGING? Alexander Rozanski, Jacob A. McCoy, Cooper R. Benson, Charles Green, H. Barton Grossman, Robert Svatek, and Jay Shah Alexander RozanskiAlexander Rozanski More articles by this author , Jacob A. McCoyJacob A. McCoy More articles by this author , Cooper R. BensonCooper R. Benson More articles by this author , Charles GreenCharles Green More articles by this author , H. Barton GrossmanH. Barton Grossman More articles by this author , Robert SvatekRobert Svatek More articles by this author , and Jay ShahJay Shah More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1900AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The ability to accurately determine tumor stage in bladder cancer is of critical importance because it impacts the management paradigm and overall prognosis. Despite advances in modern imaging technology, there is still a discrepancy between clinical and pathological staging. Historically, exam under anesthesia (EUA) has been a useful tool to assist in the staging of bladder cancer. In this era of modern imaging technology, we sought to determine if EUA provides any additional contribution in the clinical staging of bladder cancer. METHODS The medical records of patients who were treated at MD Anderson Cancer Center and managed by one of two urologists, whose practice is focused on bladder cancer, were retrospectively reviewed. Univariate and multivariate analyses were performed and logistic regression models were generated to determine the ability of EUA, imaging, and other patient characteristics to predict pathological fat extension at the time of cystectomy. RESULTS There were 414 patients in our cystectomy database included in the analyses. 38% of the patients had ≥ pT3 disease at the time of cystectomy. We found that 31.9% of patients had findings on EUA suggestive of T3 disease, whereas 28.7% had radiologic findings suggestive of T3 disease. In the multivariate model including age, BMI, ethnicity, year of operation, neoadjuvent chemotherapy the only factors predictive of pT3 disease were EUA and imaging, which can be found in Table 1. We also observed that utilizing both EUA and imaging, compared to imaging alone, improved the accuracy of clinical staging. CONCLUSIONS Despite advances in modern imaging over the last several decades, the performance of a thorough EUA remains a critical aspect of the staging evaluation in bladder cancer. The EUA should not be omitted as it provides unique information that is not provided by imaging alone. Multivariate analysis of factors predicting pathological fat invasion at the time of radical cystectomy Odds Ratio [95% CI] p-value Age 1.02 [0.99-1.04] 0.19 Race White Referent Black 1.15 [0.37-3.59] 0.81 Hispanic/Latino 0.91 [0.34-2.42] 0.85 Asian 1.55 [0.12-20.5] 0.74 Gender Male Referent Female 1.49 [0.85-2.61] 0.17 BMI 0.85 [0.59-1.22] 0.37 Year of surgery 1.00 [0.99-1.00] 0.53 Imaging type (CT v. MRI) 0.38 [0.11-1.31] 0.13 Neoadjuvant chemotherapy 0.77 [0.46-1.28] 0.31 EUA suggestive of T3 2.22 [1.34-3.69] 0.002 Imaging suggestive of T3 2.18 [1.33-3.58] 0.002 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e692 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Alexander Rozanski More articles by this author Jacob A. McCoy More articles by this author Cooper R. Benson More articles by this author Charles Green More articles by this author H. Barton Grossman More articles by this author Robert Svatek More articles by this author Jay Shah More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Holes in the heart: an atlas of intracardiac injuries following penetrating trauma

The extraordinarily high rate of penetrating heart injuries in South Africa provides a substantial denominator from which we derive a subset of patients with intracardiac lesions as a result of these injuries. The surgical literature, which consists largely of case reports and case series, describing various patterns of injury is dated and a review of management in the era of modern imaging and surgical techniques is warranted. A retrospective observational chart review of all patients with intracardiac injuries following penetrating trauma who were referred to the Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, during the 10-year period between July 2003 and July 2013 was performed. The spectrum of pathology encountered included ventricular septal defects, valve apparatus lacerations, intracardiac fistulae, ventricular aneurysms and retained intracardiac missiles. Of the 17 patients, 10 required operative repair of the intracardiac lesions using cardiopulmonary bypass, with no early mortality noted. Seven patients were treated non-operatively, for reasons that varied from insignificant haemodynamic shunts to advanced human immunodeficiency virus (HIV) infection. The in-hospital mortality in this group consisted of 1 patient, who was moribund at presentation. The referral of patients for the repair of intracardiac injuries following penetrating cardiac trauma is often delayed. Symptoms of cardiac failure should be optimized medically prior to undertaking definitive surgical repair, thereby also allowing for detailed preoperative imaging to guide appropriate intervention. Utilizing standard principles of intracardiac shunt repair, as well as contemporary valve repair techniques, favourable surgical outcomes may be reproduced. Percutaneous catheter device techniques may prove useful in patients deemed unsuitable for surgical repair, such as patients with sternal wound sepsis.

Diagnostic laparoscopy in the era of modern imaging—retrospective analysis from a single center

A retrospective analysis of utility and outcomes of diagnostic laparoscopy at our center in the last 5 years was done. In the last 5 years, we subjected 90 patients to diagnostic laparoscopy (DL) when final diagnosis could not be achieved after all necessary imaging methods and serological, cytological, and microbiological investigations. DL was performed under sedation and local anesthesia, and patients were discharged within 24 h. Video documentation along with guided biopsies/collection of the samples for culture and other tests was performed. The commonest indication was ascites (46/90), followed by diffuse liver disease (15), focal liver disease (9), intraabdominal malignancies (10), and miscellaneous (10). Overall accuracy of DL was 91 %. In 64 % of patients, laparoscopy confirmed the clinical diagnosis, and in 27 % of patients, laparoscopy was useful in correcting the diagnosis. DL was performed in 46 patients with low-serum ascitic fluid albumin gradient ascites and ascites of mixed etiology. DL confirmed the suspected diagnosis in 48 %, corrected in 38 %, and yielded unsuspected diagnosis in 15 % patients. In 6 % of patients, laparoscopy was inconclusive. In three patients, there were extensive intraperitoneal adhesions, and adequate examination was not possible. No serious complications were encountered. Minor complications of pain at the port site, ascitic fluid leakage, and port site infection were seen in three, two, and one patient, respectively. DL is useful in patients when diagnosis and extent of the disease were unclear especially in ascites of undetermined etiology.

Frozen Section versus Gross Examination for Bone Marrow Margin Assessment During Sarcoma Resection

Complete resection is critical for local control of primary bone sarcomas. Intraoperative consultation, including frozen section of bone marrow margins, frequently is used to aid in this goal. We therefore sought to determine (1) how often intraoperative frozen section of a bone marrow margin correlates with inspection of the gross split specimen and, in cases of a discrepancy, what clinical decision is made; and (2) how well each of these assessments agrees with the final pathologic assessment of a marrow margin. One hundred ninety-five bone marrow margins from 142 patients (74 males, 68 females; mean age, 12.8 years) with primary sarcomas who underwent resection and had frozen section(s) performed on a bone marrow margin were analyzed. Agreement between frozen section interpretation and inspection of the split gross specimen was analyzed in their application to determine adequacy of the bone marrow margin intraoperatively. In 179 margins, the frozen section agreed with the gross inspection decision (95.6% negative agreement, 38.5% positive agreement). Decisions regarding further surgical action in all 16 instances of disagreement were based on inspection of the split gross specimen, and the frozen section was disregarded. In 195 of 195 margins, intraoperative decisions were made based on gross specimen inspection. Full pathologic examination confirmed negative final bone marrow margins in all patients. Frozen section is commonly redundant or disregarded for intraoperative surgical decisions, and it may be omitted, saving operative time and cost. Examination of split gross specimens appears an adequate adjunct to clinicoradiographic assessment to achieve negative margins in the current era of modern imaging and surgical techniques. Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.