Follow-up Computed Tomography Scan Research Articles

CASE REPORT: BI-APICAL PULMONARY FIBROSIS WITH BRONCHIECTASIS IN A PATIENT WITH ANKYLOSING SPONDYLITIS

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting joints of the axial skeleton. In addition to disabling joint changes, pulmonary manifestations beyond the mechanical restrictive syndrome imposed by costovertebral joint ankylosis have been described [1]. These changes are seen on chest X-ray (CXR), pulmonary function tests (PFTs), bronchoalveolar lavage (BAL), and high-resolution chest tomography (HRCT) in varying degrees. They do not correlate with severity and duration of the primary disease [2]. Of the pulmonary findings, apical fibrosis is among the most distinctive. CASE PRESENTATION: We report a case of a 56-year-old male with long-standing AS (on indomethacin) who developed a dry cough with intermittent dyspnea and lung changes that were followed radiographically for several years. An initial CXR obtained for unrelated pre-operative purposes was unremarkable 21 years into his AS disease course. Two years after the first CXR, a right apical mass-like density with associated pleural thickening was detected. A QuantiFERON test was negative. Further evaluation by a computed tomography (CT) scan of the chest demonstrated volume loss of the right upper lobe with associated ground-glass opacities and pleural thickening. PFTs were consistent with a restrictive pattern, though the results were technically confounded by cough. Three years later, a follow-up CT scan of the chest showed significant progression to severe bi-apical fibrosis of the lungs with bronchiectasis and pleural thickening. Throughout this time, his joint disease remained stable, but his chronic cough worsened to the point of post-tussive emesis. DISCUSSION: The literature reports that a patient with AS with a normal CXR, normal PFTs, and lack of respiratory symptoms can still have pulmonary manifestations detectable by HRCT [3]. This patient’s cough first started 12 years before his first abnormal CXR. Despite his initial normal CXR, it is likely that radiographic evidence of the pulmonary changes predates this if evaluated by advanced chest imaging modalities. The pathogenesis of these pulmonary complications remains unknown; however, studies of BAL fluid have shown that subclinical inflammation of the alveoli is not a contributor [2-3]. CONCLUSIONS: The clinical significance of these early pulmonary changes is not known. There is a lack of studies evaluating benefit in obtaining advanced chest imaging on asymptomatic patients with AS. These changes were thought to be rare; however, newer studies suggest a higher prevalence. For patients presenting with respiratory symptoms with inflammatory arthritis, it is important to consider pleuropulmonary changes (ranging from airway disease to parenchymal scarring) in setting of AS. Reference #1: Kiris A, Ozgocmen S, Kocakoc E, Ardicoglu O, Ogur E. Lung findings on high resolution CT in early ankylosing spondylitis. Eur J Radiol. 2003;47(1):71-76. Reference #2: Kchir MM, Mtimet S, Kochbati S, et al. Bronchoalveolar lavage and transbronchial biopsy in spondyloarthropathies. J Rheumatol. 1992;19(6):913-916. Reference #3: Quismorio FP. Pulmonary involvement in ankylosing spondylitis. Curr Opin Pulm Med. 2006;12(5):342-345. https://doi.org/10.1097/01.mcp.0000239551.47702.f4 DISCLOSURES: No relevant relationships by Sudhir Rajan, source=Web Response No relevant relationships by Eduardo Solbes, source=Web Response No relevant relationships by Paulina Sun, source=Web Response

SPINDLE CELL CARCINOMA OF THE LUNG: A RARE, AGGRESSIVE TUMOR ELUSIVE TO TYPICAL DIAGNOSTIC METHODS

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Spindle cell carcinoma is a subtype of sarcomatoid carcinoma, which encompasses a rare group of non-small cell lung carcinomas (NSCLC) that contain true sarcoma or sarcoma-like elements. Less than one percent of all lung cancers are sarcomatoid carcinomas. Here we present a case of spindle cell carcinoma that proved difficult to diagnose in the absence of surgical lobectomy. CASE PRESENTATION: A previously healthy 73-year-old female non-smoker presented to her primary care physician for a persistent non-productive cough. A chest radiograph revealed a large left upper lobe (LUL) mass. A computed tomography (CT) scan of the chest was performed, which demonstrated a 7.5cm LUL mass with a necrotic-appearing center and mediastinal lymphadenopathy. A subsequent positron emission tomography (PET)-CT scan showed uptake around the rim of the mass, sparing the center. She underwent bronchoscopy with endobronchial ultrasound-transbronchial needle aspirations of the mediastinal lymph nodes as well as radial probe ultrasound-guided transbronchial biopsies of the mass, with pathology showing inflammation and no evidence of malignancy. Shortly after the bronchoscopy, she became febrile with shaking chills. She was started on amoxicillin-clavulanate for possible lung abscess. A three-week follow-up CT scan showed no improvement in the size of the mass, so she underwent a CT-guided core biopsy, the pathology from which revealed extensive necrosis but was again negative for malignancy. A thoracentesis was also performed for a small left pleural effusion, during which 470ml of hemorrhagic fluid was drained. Fluid cytology and cultures were negative. Antibiotics were discontinued and she was referred for a lobectomy for definitive diagnosis. She underwent a left upper lobectomy, with pathology revealing an 8.5cm spindle cell carcinoma with visceral pleural invasion and involvement of the internal mammary and levels 5 and 6 lymph nodes, consistent with stage IV disease. A PET-CT performed three weeks post-operatively was highly concerning for residual or recurrent neoplasm in the left anterior chest wall. Radiation therapy was initiated. Genetic testing revealed a MET exon 14 deletion as well as a high expression of PD-L1. The patient is planning to start chemotherapy with pembrolizumab and crizotinib in the near future. DISCUSSION: This case highlights a rare form of lung cancer that was very difficult to diagnose, with false negative bronchoscopic biopsies and CT-guided percutaneous core needle biopsy. Such biopsy methods may not be capable of detecting epithelial and sarcomatous components, which could lead to a missed diagnosis. CONCLUSIONS: Given the high clinical suspicion for malignancy in this patient with a persistent and enlarging lung mass, a surgical biopsy was necessary to obtain a definitive diagnosis. Reference #1: Franks TJ, Galvin JR. Sarcomatoid carcinoma of the lung: histologic criteria and common lesions in the differential diagnosis. Arch Pathol Lab Med. 2010;134(1):49-54. Reference #2: Girard N, Cadranel J, Brambilla E, Cordier J-F. Rare primary lung tumors. In: Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. United States: Elsevier; 2016:965-980. Reference #3: Tazelaar, HD. Pathology of lung malignancies. UpToDate. https://www.uptodate.com/contents/pathology-of-lung-malignancies?search=sarcomatoid%20carcinoma&source=search_result&selectedTitle=1∼29&usage_type=default&display_rank=1. Updated November 16, 2018. Accessed March 13, 2019. DISCLOSURES: No relevant relationships by Stephanie Hart, source=Web Response No relevant relationships by Leah Lande, source=Web Response No relevant relationships by Kriti Pathak, source=Web Response

Computed tomographic findings of macrolide-resistant Mycobacterium massiliense pulmonary disease and changes after antibiotic treatment.

The purpose of this study was to present the computed tomographic (CT) findings of lung abnormalities in macrolide-resistant Mycobacterium massiliense pulmonary disease and its changes in follow-up CT after antibiotic treatment.Chest CT scans of patients with macrolide-resistant M massiliense pulmonary disease (n = 19) were retrospectively reviewed. Patients were treated with multidrug therapy, and sputum examinations were performed. Follow-up CT scans obtained during antibiotic treatment after detection of macrolide resistance were also reviewed, if available (n = 13). The CT scores at detection of macrolide resistance and at the last follow-up periods were also compared.Of all patients with macrolide-resistant M massiliense pulmonary disease, 2 (11%) patients achieved sputum culture conversion during the follow-up period. The most common CT findings of M massiliense pulmonary disease at detection of macrolide resistance were bronchiectasis and bronchiolitis (n = 19, 100%), followed by consolidation (n = 16, 84%), cavities (n = 11, 58%), and nodules (n = 6, 32%). On the last follow-up CT, overall CT scores were increased in 8 (62%) of 13 patients, and total mean CT score was significantly increased (P = .021). For each CT pattern, the cavity showed the greatest increase in CT score (P = .027), followed by bronchiectasis (P = .038).Common CT findings of macrolide-resistant M massiliense pulmonary disease were similar to those of pulmonary disease caused by other species of nontuberculous mycobacteria at presentation. However, in macrolide-resistant M massiliense pulmonary disease, serial CT scans showed deterioration with cavitary and bronchiectatic change in most patients despite multidrug antibiotic therapy.

Association Between Long-term Exposure to Ambient Air Pollution and Change in Quantitatively Assessed Emphysema and Lung Function

While air pollutants at historical levels have been associated with cardiovascular and respiratory diseases, it is not known whether exposure to contemporary air pollutant concentrations is associated with progression of emphysema. To assess the longitudinal association of ambient ozone (O3), fine particulate matter (PM2.5), oxides of nitrogen (NOx), and black carbon exposure with change in percent emphysema assessed via computed tomographic (CT) imaging and lung function. This cohort study included participants from the Multi-Ethnic Study of Atherosclerosis (MESA) Air and Lung Studies conducted in 6 metropolitan regions of the United States, which included 6814 adults aged 45 to 84 years recruited between July 2000 and August 2002, and an additional 257 participants recruited from February 2005 to May 2007, with follow-up through November 2018. Residence-specific air pollutant concentrations (O3, PM2.5, NOx, and black carbon) were estimated by validated spatiotemporal models incorporating cohort-specific monitoring, determined from 1999 through the end of follow-up. Percent emphysema, defined as the percent of lung pixels less than -950 Hounsfield units, was assessed up to 5 times per participant via cardiac CT scan (2000-2007) and equivalent regions on lung CT scans (2010-2018). Spirometry was performed up to 3 times per participant (2004-2018). Among 7071 study participants (mean [range] age at recruitment, 60 [45-84] years; 3330 [47.1%] were men), 5780 were assigned outdoor residential air pollution concentrations in the year of their baseline examination and during the follow-up period and had at least 1 follow-up CT scan, and 2772 had at least 1 follow-up spirometric assessment, over a median of 10 years. Median percent emphysema was 3% at baseline and increased a mean of 0.58 percentage points per 10 years. Mean ambient concentrations of PM2.5 and NOx, but not O3, decreased substantially during follow-up. Ambient concentrations of O3, PM2.5, NOx, and black carbon at study baseline were significantly associated with greater increases in percent emphysema per 10 years (O3: 0.13 per 3 parts per billion [95% CI, 0.03-0.24]; PM2.5: 0.11 per 2 μg/m3 [95% CI, 0.03-0.19]; NOx: 0.06 per 10 parts per billion [95% CI, 0.01-0.12]; black carbon: 0.10 per 0.2 μg/m3 [95% CI, 0.01-0.18]). Ambient O3 and NOx concentrations, but not PM2.5 concentrations, during follow-up were also significantly associated with greater increases in percent emphysema. Ambient O3 concentrations, but not other pollutants, at baseline and during follow-up were significantly associated with a greater decline in forced expiratory volume in 1 second per 10 years (baseline: 13.41 mL per 3 parts per billion [95% CI, 0.7-26.1]; follow-up: 18.15 mL per 3 parts per billion [95% CI, 1.59-34.71]). In this cohort study conducted between 2000 and 2018 in 6 US metropolitan regions, long-term exposure to ambient air pollutants was significantly associated with increasing emphysema assessed quantitatively using CT imaging and lung function.

Changes in Apposition of Endograft Limbs in the Iliac Arteries After Endovascular Aneurysm Repair: Determination With New Computed Tomography–Applied Software

Purpose: To validate new computed tomography (CT)–applied software used to determine endograft limb position and apposition after endovascular aneurysm repair (EVAR). Materials and Methods: Twelve EVAR patients (mean age 81±6 years; 10 men) with distal stent-graft extensions for 15 (3 bilateral) type Ib endoleaks during follow-up were selected based on the availability of the following CT studies: pre-EVAR, 1 month, and the penultimate scan prior to the scan disclosing the type Ib endoleak. Twelve patients (mean age 82±7 years; 11 men) without endoleak and a similar interval between the primary EVAR procedure and the penultimate CT scan of the endoleak group were selected as controls using measurements from both endograft limbs (n=21, 3 excluded). Prototype Vascular Imaging Analysis software was adapted to calculate 6 parameters for the distal apposition zone: fabric distance, shortest apposition length, endograft diameter, iliac seal surface (ISS), iliac endograft apposition surface (IEAS), and percentage of iliac surface coverage (IEAS/ISS × 100). Measurements were performed on the preoperative, first postoperative, and penultimate/matched follow-up CT scans. Interobserver variability was assessed with the intraclass correlation coefficient (ICC). Continuous data are presented as the median [interquartile range (IQR) Q1, Q3]. Results: CTA follow-up was not significantly different between the endoleak and control groups [30 months (IQR 18, 58) vs 36 months (IQR 21, 59), p=0.843]. Interobserver agreement was good to excellent for all parameters (ICC 0.879–0.985). Preoperative anatomy and endograft dimensions on the first follow-up CTA scan did not differ significantly between the groups. When the penultimate CTA scan was compared with the first postoperative CT scan, endograft dimensions had significantly changed in the endoleak group; importantly, apposition was significantly decreased, and fabric distance was significantly increased, indicating limb retraction. Differences in changes in endograft dimensions were significant between the groups. Conclusion: New CT-applied software was introduced to visualize apposition and position changes of endograft limbs during follow-up. The software demonstrated good-to-excellent interobserver agreement and enabled accurate analysis of post-EVAR endograft dimensions. Significant changes in apposition and position were observed with the software on the penultimate CT scan prior to diagnosis of type Ib endoleak.

Safety and Effectiveness of Percutaneous Axillary Artery Access for Complex Aortic Interventions

The aim of this study is to evaluate the safety and effectiveness of percutaneous axillary artery access in patients requiring upper extremity large sheath access during complex aortic interventions. Consecutive patients who had percutaneous axillary artery access with a large-bore sheath during endovascular thoracoabdominal aortic artery aneurysm repair within an Food and Drug Administration-approved, physician-sponsored investigational device exemption study or visceral artery interventions during other complex aortic interventions were included in the study. All patients had percutaneous axillary artery ultrasound-guided access and deployment of 2 Perclose ProGlide devices (Abbott Vascular, Santa Clara, CA) prior to introduction of a large sheath. Completion angiography was performed to assess technical success of percutaneous access site closure, which was defined as hemostatic arterial closure without evidence of axillary artery stenosis or occlusion requiring intervention. Follow-up computed tomography scans and patient records were also reviewed for access site associated complications. A total of 46 patients underwent percutaneous axillary artery access. Largest sheath profile was 16F in 1 (2%), 12F in 42 (91%), 10F in 1 (2%), 9F in 1 (2%), and 8F in 1 (2%) patient. Technical success was achieved in 41 of 46 patients (89%). Five patients required endovascular covered stent placement during the index operation to control persistent access site bleeding. Two of 46 patients (4%) suffered access-related complications; both patients experienced ipsilateral upper extremity paresthesias without motor weakness, with persistent digit numbness in one. There was no incidence of conversion to open axillary artery repair and no additional access site complications (stenosis, occlusion, or dissection) but neurologic complications were observed during follow-up. Percutaneous axillary artery access can be used to provide upper extremity arterial access during complex aortic interventions with high rates of safety and technical success. Overall complication rates are low and occurred mainly during the early experience, indicating that there is an associated learning curve effect. Elimination of surgical cutdown incisions and arterial conduits by using percutaneous axillary access may reduce operative times and wound-related complications during complex aortic interventions requiring large-bore upper extremity access.

Endoscopic Ultrasonography-Guided Versus Percutaneous Drainage for the Recurrent Pancreatic Fluid Collections.

BackgroundUltrasonography-guided percutaneous drainage for pancreatic fluid collections is associated with a high recurrence rate and endoscopic ultrasonography (EUS)-guided drainage is a valuable approach. Our aim was to compare the efficacy and safety of percutaneous and EUS-guided drainage for the recurrent pancreatic fluid collections.Material/MethodsA retrospective analysis of percutaneous-guided and EUS-guided procedures for pancreatic fluid collections drainages at a single tertiary care center between February 2017 and May 2018 was performed. Treatment success, adverse events, recurrence, need for surgery, length of hospital stays, and number of follow-up computed tomography (CT) scan were assessed.ResultsA total of 119 pancreatic fluid collections treated with initial percutaneous drainage were included in this study and 35 patients had recurrent pancreatic fluid collections. Recurrent patients were classified based on drainage method: EUS-guided drainage (18 patients) and the second percutaneous drainage (17 patients). EUS-guided drainage revealed a shorter length of hospital stays (P<0.001), less re-intervention (P=0.047), fewer number of follow-up CT scans (P=0.006) compared with the initial percutaneous drainage. Furthermore, we also compared the clinical outcomes between the EUS-guided drainage and the second percutaneous drainage for the recurrent PFC after initially failed percutaneous drainage. EUS-guided drainage showed higher clinical success (P=0.027), shorter length of hospital stays (P<0.001), less re-intervention (P=0.012), fewer number of follow-up CT scan (P<0.001) and less recurrence P=0.027) compared to the second percutaneous drainage procedure.ConclusionsEUS-guided drainage is an effective and appropriate method to treat the recurrent pancreatic fluid collections after initially failed percutaneous drainage procedure, with the advantage of higher clinical success, shorter length of hospital stays, less re-intervention, fewer number of follow-up CT scan and less recurrence compared to the percutaneous drainage.

Pulmonary Computed Tomography Parenchymal and Vascular Features Diagnostic of Postablation Pulmonary Vein Stenosis.

The purpose of this study was to define the full spectrum of pulmonary computed tomography (CT) changes characteristic of postablation pulmonary vein stenosis (PVS). We retrospectively reviewed our pulmonary vein isolation database. PVS was graded as follows: grade 1:<50%, grade 2: 50% to 75%, grade 3: 76% to 99%, and grade 4: total occlusion. CT parenchymal and vascular changes were detected and correlated with clinical course and nuclear scans. Of 486 patients who underwent pulmonary vein isolation, 56 patients (11%) were symptomatic, prompting referral to CT evaluation. Grades 1, 2, 3, and 4 PVS were documented in 42, 1, 2, and 11 patients, respectively. Apart from PVS, abnormal CT findings were present only in patients with PVS grades 2 to 4. Pulmonary parenchymal changes (consolidation, "ground glass" opacities, interlobular septal thickening, and volume loss) were found in PVS grades 2 to 4. Pulmonary vascular changes (oligemia, "sluggish flow," and collateral mediastinal vessels) were shown in patients with grades 3 to 4 PVS. Concomitant nuclear scans documented reduced lung perfusion. All findings were located to the lobe drained by the affected vein. Complete resolution of pulmonary findings on follow-up CT scans was demonstrated in 20% of patients. Eleven stents were inserted in 7 patients with PVS grades 2 to 4, none of which demonstrated radiologic or clinical resolution. A typical CT complex of both parenchymal and vascular findings in the affected lobe is diagnostic of postablation PVS. Lack of clinical and radiologic resolution in most patients, even after stent insertion, further highlights the importance of early recognition of this underdiagnosed condition.

Effect of internal fixation of the sternum using bioabsorbable pins in small children.

A sternal pin can be used to internally fix the reapproximated sternum after midline sternotomy. This paper will evaluate the effectiveness of using a sternal pin in small children by means of a computer tomography scan. Propensity score matching was performed for patients undergoing a first-time median sternotomy from April 2012 to December 2014 with a follow-up computer tomography scan after 6 months. Seventeen matched patients were selected for both the control and the sternal pin groups. The angle of the sternal reflection at the joint surface was measured by computer tomography scan. In addition, the Haller index was measured at each thoracic vertebral level. The angle of the sternal reflection was more variable in the control group compared with the sternal pin group: the standard deviation was 31.6° for the control group and 10.2° for the sternal pin group (P value = .0009). Seven out of 17 patients in the control group had a negative angle (excavated sternum) compared with 1 out of 17 in the sternal pin group (P = .0391). In the other patients, the angle was 23.9° ± 3.6° in the control group and 10.1 ± 2.8 in the sternal pin group (P = .0061). The Haller index was also more variable in the control group, and it was significantly different from the sternal pin group at the ninth vertebral level (P = .0409). The study demonstrated that the use of a sternal pin was associated with decreased variation in the sternal angles and decreased incidence and severity of sternal protrusion and excavation in small children.

Minimal Computed Tomography Attenuation Value Within the Hematoma is Associated with Hematoma Expansion and Poor Outcome in Intracerebral Hemorrhage Patients.

Early hematoma expansion in intracerebral hemorrhage (ICH) patients is associated with poor outcome. We aimed to investigate whether the minimal computed tomography (CT) attenuation value predicted hematoma expansion and poor outcome. This study involved spontaneous ICH patients of two cohorts who underwent baseline CT scan within 6h after ICH onset and follow-up CT scan within 24h after initial CT scan. We determined the critical value of the minimal CT attenuation value via retrospective analysis of the data from a derivation cohort. Then, a prospective study on the validation cohort of three clinical centers was performed for determining the association between the minimal CT attenuation value and hematoma expansion as well as poor outcome (modified Rankin Scale scores > 3) at 90days by using univariate and multivariate logistic regression analyses. One hundred and forty eight ICH patients were included in the derivation cohort. Minimal CT attenuation value ≤ 31 Hounsfield units (HU) was demonstrated as the critical value to predict hematoma expansion by using receiver operating characteristic analysis. A total of 311 ICH patients were enrolled in the validation cohort, 86 (27.7%) and 133 (42.8%) of which were found hematoma expansion and poor outcome. Minimal CT attenuation value ≤ 31 HU was positive in 73 patients (23.5%). The multivariate logistic regression analysis demonstrated minimal CT attenuation value and minimal CT attenuation value ≤ 31 HU independently predicted hematoma expansion (p < 0.001) and poor outcome (p < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of minimal CT attenuation value ≤ 31 HU for hematoma expansion and poor outcome prediction were 64.0, 92.0, 75.3, 87.0, 84.2 and 45.1%, 92.7%, 82.2%, 69.3%, 72.3%, respectively. The minimal CT attenuation value independently predicts early hematoma expansion and poor outcome in patients with ICH.

Transcatheter arterial chemoembolization improves the resectability of malignant breast phyllodes tumor with angiosarcoma component: a case report

BackgroundA giant phyllodes tumor of the breast is a rare fibroepithelial lesion, and its treatment is controversial. Many case reports have reported performing skin graft reconstruction after tumor excision. Chest wall resection may be required if the tumor has invaded the chest muscle layer. We speculated that transcatheter arterial chemoembolization (TACE) can improve the resectability of malignant phyllodes tumor of the breast without requiring skin grafting. The English literature contains only one case report similar to our experience.Case presentationWe report a rare case of a 51-year-old woman who had a giant malignant phyllodes tumor with heterologous sarcomatous differentiation in her right breast. The tumor was 19.43 × 12.98 × 21.47 cm. Whole-body computed tomography (CT) and bone scan did not reveal distant metastasis. Chest magnetic resonance imaging showed chest wall tumor invasion. Considering that skin defects after mastectomy can be extensive, we administered four courses of chemoembolization in the 5 weeks before surgery (30 mg of epirubicin and embozene microspheres [400, 500, and 700 μm]/week). Each process was well tolerated, with no serious complications. Only fever and local pain at the tumor site were noted, and these symptoms resolved with time. The follow-up CT scan showed a 45% reduction in tumor volume. Therefore, simple mastectomy was performed without skin grafting reconstruction. Wound healing was satisfactory, and the patient was discharged 1 week after surgery. Pathological and immunohistochemistry (IHC) findings showed a malignant phyllodes tumor with an angiosarcoma component. Because of tumor invasion of the chest wall, we recommended the patient receive radiotherapy, but she refused. Two months after surgery, recurrence of the malignant phyllodes tumor with right axillary lymph node involvement and lung metastasis was confirmed.ConclusionInitial surgical resection of giant phyllodes tumors is often challenging. For initial presentation with unresectable giant phyllodes tumor, we recommend to perform TACE prior to surgery. In our patient, preoperative TACE was effective and safe. If the tumor has invaded the chest wall, early radiotherapy after surgery may be recommended for preventing recurrence.

Outcomes of patients with disease recurrence after treatment for locally advanced non-small cell lung cancer detected by routine follow-up CT scans versus a symptom driven evaluation

ObjectivesThe majority of patients with locally advanced non-small cell lung cancer (LANSCLC) will recur after receiving multimodal treatment with curative intent. Current guidelines recommend routine follow-up with computerized tomography (CT) scans, though minimal data exist on the utility of this approach nor has an optimal follow-up strategy to detect recurrence been defined. This study examined whether survival varied if relapse was detected with scheduled follow-up CT versus symptoms, and whether the pattern of recurrence affected these outcomes. Materials and methodsSingle institution retrospective review of patients who had undergone definitive management of LANSCLC with chemoradiotherapy +/- surgical resection. Standard follow-up testing consisted of routine exam and chest CT beginning at every 3 months in the first year and decreasing to annually after the fifth year. Results311 patients were assessed, of which 167 patients recurred and were evaluable. 104 progressions were detected by follow-up and 63 by symptoms. For the entire group, there was no difference in overall survival (OS) for those detected by scans vs. symptoms (7.6 vs. 6.1 months, p = 0.797). After excluding patients with oligometastatic (1–3) brain metastases (OBM), OS was superior in patients with scan detected relapse (7.5 vs. 3.4 months, p = 0.013). ConclusionsRoutine surveillance by CT chest detects more localized disease than symptom driven follow-up, though OS does not differ. This null result is largely driven by the favorable outcomes for patients with OBM who present symptomatically. A strategy of both chest and brain imaging could be considered and warrants further investigation.

Osseous Healing With Non-Rigid Suture Fixation Offers a Compelling Alternative to Conventional Latarjet Procedure

Objectives: The Latarjet procedure, both open and arthroscopically, is a popular means to surgically address anterior glenohumeral (GH) joint instability. Though the arthroscopic approach to the Latarjet is becoming increasingly common, challenges persist: (1) technical difficulty positioning the bone block flush with the glenoid and the screws parallel to the glenoid surface (2) postoperative complications secondary to the two bicortical fixation screws, and (3) considerable risk of neurological injury. Recently, a novel surgical technique has been described which uses a guided surgical approach for graft positioning with non-rigid fixation via a suture suspensory system. The objective of our retrospective study was to evaluate healing rates and long-term stability of shoulders who underwent this new technique of anterior glenoid augmentation. The specific aims of our study were to assess (1) if this non-rigid suture fixation system is stable enough to allow the autograft bone to heal onto the native glenoid appropriately and (2) if the autograft bone could be reliably placed without migration of the graft. Methods: In this retrospective study, we gathered anonymized DICOM computed tomography (CT) datasets from a total of 107 patients who underwent non-rigid suture fixation with a cortical button fixation device in lieu of the traditional bicortical screws during arthroscopic Latarjet procedure. Of the 107 patients, only 75 patients had at least two CT scans performed at two different time periods which could be compared in terms of osseous healing and potential migration. The first CT scan for each patient was 2 weeks postoperative. Each patient’s CT scans were compared side-by-side by the same fellowship-trained musculoskeletal radiologist on a diagnostic workstation. Data recorded included the age, gender, date of each scan, initial graft position on the glenoid, presence and degree of graft migration on delayed follow-up scan (minimum 3 months), and the percentage of osseous healing (as assessed by osseous bridging) on the delayed follow-up scan. A minority of patients had several delayed timepoint scans (several years out), and those were evaluated as well. Descriptive statistics were calculated evaluating the average migration and average percent healing at both timepoints. Results: Our population (n=75) consisted of 61 men (81.3%) and 14 women (18.7%). The mean age of was 27.3 ± 1.1 years. The mean time period between initial CT scan (2 weeks postoperative) and follow-up CT scan to assess for healing and migration was 27 ± 2 weeks. At delayed follow-up scan, the average percent healing on follow-up scan was 78% ± 4%. A total of 61 out of 75 (81%) patients had greater than 75% healing on follow-up scan. The average migration of the coracoid graft in our study was 1.45 ± 0.23 mm, ranging from 0 mm to 8.75 mm. A total of 37/75 (49.3%) of the patients had no migration at all on follow-up scan, and 63/75 (84%) had migration of &lt; 2 mm. Conclusion: Based on these findings, non-rigid suture fixation with a cortical button device offers a safe alternative to traditional screw fixation for the Latarjet procedure. Though a non-rigid fixation system, osseous healing with minimal migration of the graft can be predicted. [Figure: see text]

REMOVING A RETROSELLAR PITUITARY ADENOMA VIA THE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL TRANSCAVERNOUS APPROACH

The study objective is to describe the removal of the pituitary adenoma from the posterior cranial fossa through endoscopic transsphenoidal trans-cavernous approach, when the main surgical corridor was the tumor-intact cavernous sinus. Materials and methods. A 55-year-old male patient with endosupraretrosellar endocrine-inactive pituitary adenoma was admitted to N.N. Burdenko Research Center of Neurosurgery. The patient had earlier undergone two surgeries for pituitary adenoma. Using the endoscopic endonasal transsphenoidal approach, we found that these surgeries resulted in the formation of scar-altered adipose tissue in the sphenoid sinus and partly in the sella turcica; anatomical landmarks indicating the midline and the location of the internal carotid arteries were absent. We formed an access to both retro- and suprasellar portions of the tumor between the sella turcica and cavernous segment of the internal carotid artery (through the cavernous sinus); then we dissected anterior and posterior walls of the sinus and revealed a soft capsule-free pituitary adenoma, which was completely removed by a vacuum aspirator. The skull base defect was repaired using the multilayer technique with autologous tissues. Results. After surgery, neurological status and visual functions did not change. In the postoperative period, we observed no oculomotor disorders, pituitary insufficiency, diabetes insipidus, or nasal liquorrhea. Follow-up computed tomography scans revealed no signs of intracranial complications or obvious residual tumor tissue. Magnetic resonance imaging 4 month postoperatively demonstrated small laterosellar fragments of the tumor in the sella turcica. The patient was further followed up. Conclusion. Cavernous sinus is a natural anatomical corridor providing access to the structures of the posterior cranial fossa and interpeduncular cistern. The main risk (damage to the cavernous segment of the internal carotid artery) can be minimized by using intraoperative dopplerography and visual control of all manipulations.

The Safety of Multimodality Monitoring Using a Triple-Lumen Bolt in Severe Acute Brain Injury

Multimodality monitoring is used frequently to guide care of patients with severe acute brain injury. The aim of this study was to examine the safety and reliability of multimodality monitoring. From a prospective observational database at a Level I trauma center, 501 patients, including 300 men and 201 women (mean age 58 ± 39 years) were identified retrospectively. Each patient received a triple-lumen bolt and 3 monitors: intracranial pressure, brain temperature, and brain oxygen. Intensive care unit and hospital records were examined to identify complications, reasons for device replacement, malfunction and infection. Head computed tomography (CT) scans performed before and after the monitors were inserted were examined for evidence of monitor-related adverse effects. A total of 696 triple-lumen bolts were placed. Median duration of monitoring was 78.88 hours (interquartile range, 33.0-133.2 hours). Bilateral monitors were inserted in 22 (3.16%) patients. Ten (1.43%) monitors were replaced to allow magnetic resonance imaging, and 40 (5.74%) monitors were replaced to facilitate additional cranial surgery. Of 35 (5.02%) monitors that were replaced because they were thought to not be functioning properly, 19 (54.29%) were subsequently found to be functioning normally. Follow-up CT scans were compared with CT scans obtained before insertion of monitors; 9 (2.13%) small contusions and 10 (2.36%) extra-axial hematomas associated with the devices were identified. Based on the CT findings, the hematomas were thought to be associated with the insertion technique rather than the device; 4 hematomas required treatment. Twenty-two (3.16%) devices were incorrectly placed (e.g., the probe was in an infarct or an already existing contusion). Only 1 associated infection was identified. Placement of intracranial monitors for multimodality neuromonitoring using a triple-lumen bolt appears to be safe. The complication rate is similar to published complication rates for single-lumen bolts and single monitors.

A Prospective Study of Magnetic Resonance Imaging Assessment of Post-radiation Changes Following Stereotactic Body Radiation Therapy for Non-small Cell Lung Cancer

AimsFollow-up computed tomography scans after lung stereotactic body radiation therapy (SBRT) are difficult to interpret due to the presence of benign fibrosis, which can make the detection of local recurrence difficult. The objective of this study was to determine the feasibility of a novel thoracic magnetic resonance imaging (MRI) protocol incorporating diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) imaging for the assessment of the treated lung parenchyma after SBRT. Materials and methodsOn a prospective trial, post-treatment MR images were acquired in 30 patients treated with SBRT (divided into three different cohorts according to the likelihood of local recurrence as per an expert panel). These images were assessed by an expert thoracic radiologist blind to clinical data, who indicated local recurrence in a dichotomous manner. Local recurrence was confirmed by biopsy or subsequent growth on follow-up computed tomography scans. ResultsThirty patients underwent MRI as part of this study; 27/30 patients were analysable for local recurrence. MRI was conducted at a median of 27.3 months (range 6.5–71 months) from SBRT. No side-effects resulted from either MRI or contrast administration. At a median follow-up time of 45 months after treatment, three local recurrence episodes have occurred. MRI assessment diagnosed seven patients as having a local recurrence, which was later confirmed in three and did not miss any of the true local recurrences. When comparing apparent diffusion coefficient (ADC) values according to local recurrence, the mean ADC value for the local recurrence-free group was 1770 × 10−3 mm/s2 (range 1038–3105 × 10−3 mm/s2) versus 981 × 10−3 mm/s2 (range 926.6–1065 × 10−3 mm/s2) for the local recurrence group (P = 0.0014). ConclusionsA novel 3.0 T MRI protocol incorporating DWI and DCE was feasible and confirmed the suspicion of local recurrence in patients with highly suspicious computed tomography scans. This imaging tool could potentially aid in selecting patients for salvage treatment after local SBRT failure. Future work should be pursued to validate these findings.

Blood Type O Predicts Hematoma Expansion in Patients with Intracerebral Hemorrhage

Background: Hematoma expansion after acute spontaneous intracerebral hemorrhage (ICH) is well established to result in poor prognosis. Recent studies have demonstrated that the ABO blood type system has potential implications on hemostatic properties. The purpose of this study was to explore the potential association of blood type O with hematoma expansion in patients with ICH and validate the usefulness in predicting early hematoma expansion. Methods: We retrospectively enrolled consecutive patients with ICH who underwent baseline computed tomographic (CT) scan within 6 hours after onset of symptoms. The follow-up CT scan was available within 48 hours after the baseline CT scan. Hematoma expansion was defined as total volume increase more than 33% or more than 6 mL. We performed univariate and multivariate logistic regression analyses to investigate the relationship between the different types of blood (type O versus other types) and hematoma expansion. Results: A total of 210 patients were included in the study. Among them, 72 patients (34.3%) carried blood type O. Hematoma expansion was more common in patients with blood type O (41.7%) than those with other blood types (18.1%; P < .001). Furthermore, the time to baseline CT scan, blood type O, and admission Glasgow Coma Scale score were demonstrated to be independent predictors of hematoma expansion in multivariate logistic regression analysis model. The sensitivity, specificity, positive, and negative predictive values of blood type O for predicting hematoma expansion were 54.5%, 72.9%, 41.6%, and 81.9%, respectively. Conclusions: Our findings suggest that blood type O represents an independent predictor of hematoma expansion after ICH. Hemostasis seems to be involved in expansion and may represent an important treatment target.

Isolated Superior Mesenteric Artery Dissection Following Liver Transplant: Report of 3 Cases

BackgroundIsolated superior mesenteric artery (SMA) dissection (SMAD) is considered a relatively rare disease. Especially, isolated SMAD following liver transplant has been rarely reported. Report of CasesAmong 96 consecutive adult recipients who underwent liver transplant at our institution, 3 recipients (3.1%) demonstrated isolated noncommunicating SMAD, type IV according to Sakamoto's classification. Patient characteristics are the following: mean age, 53 years (range, 49–60 years); male to female ratio, 2:1, right lobe graft to left lobe graft ratio, 2:1; operating time, 760 minutes (range, 614–880 minutes); and blood loss, 6570 mL (range, 2435–13,329 mL). New onset of abdominal pain was noted in 33.3% (1/3). The diagnosis was made by the first follow-up computed tomography scan after liver transplant. The mean distance between the proximal end of SMAD and the root of SMA was 21.3 mm (range, 9–40 mm). There were no signs of ischemic changes in the small intestine in any of the 3 patients. Thus, conservative managements such as anticoagulation therapy were performed without other aggressive interventions. One patient died because of subarachnoid hemorrhage. In the other 2 patients, SMAD disappeared at 6 months following the diagnosis. DiscussionThe morbidity of isolated SMAD is around less than 0.1% at the autopsy. Compared with this result, we found significantly higher morbidity rate in liver transplant recipients. It is true that mechanical stress from retraction of the stomach to the caudal end including the root of SMA may play an important role in the onset of SMA dissection. ConclusionIsolated SMA dissection following living donor liver transplant is a rare but potentially life-threatening condition. It is required to ascertain whether emergency revascularization should be considered.

Neuroimaging Findings in Tuberculosis: A Single‐Center Experience in 559 Cases

There is a paucity of literature related to the neuroimaging of CNS tuberculosis (TB) and largely covers pediatric CNS TB. The objective of this study was to determine the frequency of different forms of CNS TB and its associated complications and to study longitudinal disease course using computed tomography (CT) and MRI. Retrospective chart and imaging review of patients diagnosed with CNS TB in a tertiary care hospital in Pakistan over a 10-year period. A total of 452 initial brain MRI and 209 CT scans were reviewed by an expert radiologist specialized in neuroimaging. This was followed by review of 53 MRI/52 CT and 7 MRI/14 CT first and second follow-up scans, respectively. Note that 559 patients, 296 males and 263 females were included in the study. On the initial CT scans, tuberculomas were found in 25 (12%), infarction in 54 (25%), basal meningeal enhancement in 29 (14%), and hydrocephalus in 84 (40%). On initial MRI, tuberculomas were found in 182 (40%), infarction in 120 (27%), basal meningeal enhancement in 184 (41%), and hydrocephalus in 116 (26%). On review of follow-up CT scans, 13 (25%) showed new or worsening hydrocephalus, 8 (15%) showed new infarcts, 1 exhibited new tuberculoma, and 5 showed worsening cerebral edema. On review of follow-up MRI scans, new or worsening hydrocephalus was seen in 3 (6%), new infarcts in 3 (6%), new tuberculoma in 10 (19%), worsening cerebral edema in 7 (13%), and TB myelitis in 4 (8%) patients. Tuberculoma, hydrocephalus, and cerebral infarcts are the most prominent findings in CNS tuberculosis. Our study showed development of new lesions on subsequent neuroimaging suggesting a dynamic and progressive nature of the disease process in some individuals.

Prediction of hematoma expansion in spontaneous intracerebral hemorrhage using support vector machine.

BackgroundSpontaneous intracerebral hemorrhage (ICH) is a devastating disease with high mortality rate. This study aimed to predict hematoma expansion in spontaneous ICH from routinely available variables by using support vector machine (SVM) method.MethodsWe retrospectively reviewed 1157 patients with spontaneous ICH who underwent initial computed tomography (CT) scan within 6 h and follow-up CT scan within 72 h from symptom onset in our hospital between September 2013 and August 2018. Hematoma region was manually segmented at each slice to guarantee the measurement accuracy of hematoma volume. Hematoma expansion was defined as a proportional increase of hematoma volume > 33% or an absolute growth of hematoma volume > 6 mL from initial CT scan to follow-up CT scan. Univariate and multivariate analyses were performed to assess the association between clinical variables and hematoma expansion. SVM machine learning model was developed to predict hematoma expansion.Findings246 of 1157 (21.3%) patients experienced hematoma expansion. Multivariate analyses revealed the following 6 independent factors associated with hematoma expansion: male patient (odds ratio [OR] = 1.82), time to initial CT scan (OR = 0.73), Glasgow Coma Scale (OR = 0.86), fibrinogen level (OR = 0.72), black hole sign (OR = 2.52), and blend sign (OR = 4.03). The SVM model achieved a mean sensitivity of 81.3%, specificity of 84.8%, overall accuracy of 83.3%, and area under receiver operating characteristic curve (AUC) of 0.89 in prediction of hematoma expansion.InterpretationThe designed SVM model presented good performance in predicting hematoma expansion from routinely available variables.FundThis work was supported by Health Foundation for Creative Talents in Zhejiang Province, China, Natural Science Foundation of Zhejiang Province, China (LQ15H180002), the Science and Technology Planning Projects of Wenzhou, China (Y20180112), Scientific Research Staring Foundation for the Returned Overseas Chinese Scholars of Ministry of Education of China, and Project Foundation for the College Young and Middle-aged Academic Leader of Zhejiang Province, China. The funders had no role in study design, data collection, data analysis, interpretation, writing of the report.