Follow-up CT Scans Research Articles

Dedicated software to harmonize the follow-up of oncological patients

ObjectiveTo test and evaluate a sofware dedicated to the follow-up of oncological CT scans for potential use in the Radiology department. Materials and methodsIn this retrospective study, 37 oncological patients with baseline and follow-up CT scans were reinterpreted using a dedicated software. Baseline CT scans were chosen from the imaging reports available in our PACS (picture archiving and communicatin systems). Follow-up interpretations were independently assessed with the software. We evaluated the target lesion sums and the tumor response based on RECIST 1.1 (Response Evaluation Criteria in Solid Tumors). ResultsThere was no significant difference in the target lesion sums and the tumor response assessments between the PACS data and the imaging software. There was no over or underestimation of the disease with the software. There was a sigificant deviation (progression versus stability) in three cases. For two patients, this difference was related to the evaluation of the response of non-target lesions. The difference in the third patient was due to comparison with a previous CT scan than to the baseline exam. There was a miscalculation in 13 % of the reports and in 28 % of the cases the examination was compared to the previous CT scan. Finally, the tumor response was not detailed in 43 % of the follow-up reports. ConclusionThe use of dedicated oncology monitoring software could help in reducing intepretation time and in limiting human errors.

SURGICAL RESECTION OF A COMPLEX TUBERCULUM SELLAE MENINGIOMA ENCASING MAJOR ARTERIES

Introduction Though constituting only a minor proportion (1%) of sellar masses, suprasellar meningiomas pose a significant diagnostic challenge within the region of sellar and suprasellar tumors. Pituitary adenomas, at nearly 90% prevalence, dominate this anatomical region. Distinguishing these two entities is paramount, as both clinical presentation and, to some extent, biochemical profiles exhibit notable overlap. Accurate preoperative differentiation is critical due to the contrasting behaviors of these tumors. Meningiomas, with their robust vascularity supplied by dural and osseous arteries, present a heightened risk of intraoperative hemorrhage. Clinical Case A 53-year-old woman presented with a two-month history of worsening headaches and gradual vision loss. Neurological examination revealed only visual acuity decline. Her hormone profile showed elevated prolactin but lacked clinical features of prolactin excess, suggesting a possible prolactin-secreting pituitary macroadenoma. A contrast-enhanced MRI confirmed a significant sellar and suprasellar mass with homogeneous enhancement, extending to the right paramedian region and encasing the right internal carotid artery (ICA) at its critical segment involving the cavernous and supraclinoid portions. Furthermore, the right middle meningeal artery (M1) and anterior cerebral artery (A1) originated from this same location, highlighting the high surgical risk. Surgical resection was deemed necessary. The patient underwent a right pterional craniotomy, revealing a grayish, extradural soft mass lesion encasing the ICA bifurcation. Careful microsurgical dissection with basal devascularization was performed, followed by near-complete tumor removal using an ultrasonic aspirator to minimize damage to the encased arteries. Postoperative follow-up CT scan confirmed successful near-total tumor ablation. Conclusion This case underscores the critical role of meticulous preoperative diagnosis in managing complex sellar tumors. While pituitary adenomas dominate this region, suprasellar meningiomas, despite their rarity, demand a high index of suspicion. Overlapping clinical and biochemical presentations highlight the reliance on advanced imaging for accurate differentiation. The intricate vascularity of meningiomas, as exemplified by the encasement of critical arteries in this case, necessitates meticulous surgical technique with devascularization strategies. This successful near-complete tumor removal emphasizes the importance of such surgical expertise in navigating these diagnostically challenging sellar lesions.

VS 09 - HPB Laparoscopic Trans-Cystic Bile Duct Exploration is Safe and Feasible even after previous Cholecystectomy

Abstract Background Laparoscopic trans-cystic bile duct exploration is well know to have less comorbidity that conventional trans-ductal approach. A 56-year-old female underwent emergency laparoscopic cholecystectomy in 2019 for cholecystitis. Subsequently treated conservatively for ascending cholangitis due to large stone in the bile duct on MRCP. She underwent two unsuccessful ERCPs due to anatomical challenges; large hiatus hernia and duodenal diverticulum. The MDT determined bile duct exploration was necessary as no endoscopic options remained. After assessing previous imaging, laparoscopic trans-cystic exploration was chosen to minimise complications. This video highlights the feasibility of laparoscopic trans-cystic CBD post-cholecystectomy. Method Standard four-port technique with 10mm, 30-degree laparoscope. Blunt, sharp, energised and hydro-dissection were employed. Indocyanaine green(ICG) helped identify the bile duct(CBD) and the cystic duct(CD) stump. CD was dissected from the gallbladder bed and opened for a cholangiogram; confirming a large stone in the distal bile duct. A 3.5 mm choledochoscope with electrohydraulic lithotripsy(EHL) was used to explore the bile duct and fragment the stone for extraction. Remaining small fragments were flushed into the duodenum after 20mg buscopan intravenously. Final cholangioscopy and cholangiogram through the choledochoscope showed clear ducts with good flow into the duodenum. Results The patient was started on IV antibiotics due to pyrexia on the first night of admission. The abdominal drain was removed after 48 hours, and the patient was discharged on day three to complete a five-day course of antibiotics. Nine months post-operatively, she presented with a 3x5x7.5 cm sub-hepatic abscess, requiring interventional radiology (IR) drainage and a six-week course of antibiotics. The drain was removed after a follow-up CT scan three weeks post-drainage showed resolution. There have been no further episodes of cholangitis, and she has returned to her baseline quality of life. Conclusion This case shows laparoscopic trans-cystic approach remains viable post-cholecystectomy. Advanced imaging and tools including 3.5mm choledochoscope and EHL aid safer surgery with reduced morbidity, shorter stays and faster recovery. Antibiotics may be necessary for cases with longstanding bile duct stones. Furthermore, this case highlights the importance of intraoperative cholangiography and bile duct exploration. The patient had an MRCP in 2019 that showed no bile duct stones but a dilated CBD associated with deranged LFTs. This suggests that her journey might have been less complicated if a cholangiogram had been performed during the initial laparoscopic cholecystectomy.

BS SO17 - Large Bowel Occlusion as a Manifestation of Gastric Adenocarcinoma in a Patient with Previous Gastric Bypass

Abstract Background Gastric bypass surgery has become one of the hallmarks of the treatment of obesity and metabolic syndrome. Over the last decade, an increasing number of gastric cancer cases have been reported following gastric bypass, particularly in the excluded stomach. The anatomical changes and the difficult access to the excluded stomach via endoscopy hinder the diagnosis and treatment of this cancer. Method Literature review and clinical case analysis through clinical records and exam results. Results A 59-year-old male with a history of gastric bypass 15 years prior was admitted to the emergency department with bowel occlusion. A CT scan revealed colonic obstruction due to invasion by a neoplastic/inflammatory process. Consequently, a right hemicolectomy was performed. Histopathological analysis revealed infiltration of the colonic wall by poorly cohesive gastric carcinoma cells. A follow-up CT scan confirmed a lesion in the excluded stomach. A LAMS (lumen-apposing metal stent) was placed to repermeabilize the excluded stomach, and biopsies confirmed gastric mixed adenocarcinoma. A gastroduodenal stent was placed for antropyloric stenosis. A multidisciplinary team opted for palliative chemotherapy. Conclusion The association between bariatric surgery and gastric cancer remains controversial. As described in previous studies, this clinical case demonstrates that gastric adenocarcinoma in patients who underwent gastric bypass often presents as an aggressive and advanced-stage disease. Given the mortality associated with gastric cancer and the increasing number of bariatric surgeries, this case report highlights the important need to develop patient selection protocols for gastric bypass and respective appropriate follow-up.

Upper and Lower Endoscopic Findings in Mesenteric Panniculitis Patients: A Case-Control Study

Background: The natural history and prognosis of mesenteric panniculitis (MP) are not well-described. Despite referral for colonoscopy being common for this indication, colonoscopy findings in MP patients have not been reported. Therefore, we aimed to describe upper and lower gastrointestinal (GI) endoscopy findings in patients with mesenteric panniculitis, compared to matched controls, to investigate their clinical outcomes including incidence of malignancy and mortality. Methods: Retrospective case–control study was conducted, and included patients who were diagnosed with mesenteric panniculitis according to Coulier radiologic criteria on abdominal computerized tomography between 1/2005 and 12/2019, and followed to 12/2021. The case group was compared to a matched control group without MP on abdominal CT. Clinical data and the upper and lower endoscopies’ reports were reviewed in both groups. We excluded patients who, beyond diagnosis of MP, were also diagnosed with current malignancy, significant intra-abdominal morbidity or inflammatory bowel disease. Results: The initial set of 376 patients with MP, after exclusion, included 187 patients. A total of 56.1% were male, with a mean age 60 ± 15 years. Of them, 74 (39%) patients underwent follow-up CT scans, which demonstrated, in 66 (89.2%) patients, a stable MP without any aggravation. Colonoscopy was performed in 89 MP patients, and 98/187 controls. No significant difference in the colonoscopies’ findings was found between the two groups. Gastroscopy was performed in 84 MP and 79 controls. No case of gastric cancer was found. No statistically significant difference was found in the rate of gastroscopy findings. By the end of the follow-up period, malignancy was diagnosed in four patients of the MP group. None were colon cancer. The mortality rate in the MP group was 3.2%, without a significant difference compared to the controls. None were MP related. Conclusions: MP identified on abdominal CT is not associated with pathologic endoscopy findings or future diagnosis of colon cancer, and also has no impact on mortality rate. Since repeating abdominal CT did not reveal any disease progression, the necessity of follow-up imaging for MP should be carefully reconsidered.

Medial intracranial carotid artery calcifications and hematoma expansion in deep intracerebral hemorrhage.

Medial intracranial carotid artery calcifications (ICAC) are associated with impaired vascular physiology, increased arterial stiffness and pulse pressure. Their presence might therefore be associated with increased risk of intracerebral hemorrhage (ICH) expansion, according to the avalanche model. We explored the association between ICAC presence and pattern and hematoma expansion (HE). Retrospective analysis of a monocentric, prospectively collected cohort of ICH patients admitted between June 2017 and October 2023. ICAC pattern was determined by Kockelkoren's rating scale on admission CT; medial ICAC were defined with a >6 points cutoff. A follow-up CT scan was performed within 72 h. HE was analyzed as a dichotomous (≥6 mL and/or ≥33%) and as a categorical (none/mild/moderate/severe) variable, and its predictors were explored with logistic and ordinal regression respectively, accounting for baseline volume, onset-to-CT time, and anticoagulation. All the analyses were stratified by ICH location (supratentorial deep vs lobar ICH). A total of 201 patients were included (median age 78, 42% females, 59% deep ICH). Medial ICAC were significantly more common in deep ICH with HE compared with non-expanders (72% vs 49%, p = 0.03), whereas there was no association between ICAC and HE in lobar ICH (53% vs 52%, p = 0.85). This association between medial ICAC and HE in deep ICH remained significant in logistic (aOR 3.11, 95% CI [1.19-9.06], p = 0.03) and ordinal regression (acOR 2.42, 95% CI [1.19-4.99], p = 0.01). Ipsilateral medial ICAC are associated with higher odds of HE in deep ICH. Our findings are best interpreted as hypothesis generating, requiring prospective validation and further research to characterize the underlying biological mechanisms.

A Novel Unilateral Bi/Multi-Portal Endoscopic Transforaminal Interbody Fusion Utilizing Uniaxial Spinal Endoscope Instead of Arthroscope: Technical Note and Preliminary Clinical Results.

Currently, traditional UBE surgery, which is based on arthroscope, has been increasingly employed for complex lumbar degenerative diseases. However, this approach is associated with complications such as intraoperative dural sac tears, nerve root injuries, and postoperative epidural hematomas. In response to these challenges, we propose a novel technique utilizing uniaxial spinal endoscope to replace arthroscope-Unilateral Bi/Multi-Portal Endoscopy (UME). This new method has successfully treated complex lumbar disc herniation and spinal stenosis, resulting in improved postoperative outcomes and a reduction in complications. Based on the previous findings, we utilized uniaxial spinal endoscopy as the primary operating method, with the assistance of multi-portal endoscopic techniques (UME-TLIF), to perform transforaminal lumbar interbody fusion. The feasibility and preliminary clinical results have been presented in this paper. A total of 18 patients (8 men and 10 women, aged 52.6 ± 15.29 years) diagnosed with lumbar degenerative diseases, such as giant lumbar disc herniation, severe lumbar spinal stenosis, or lumbar spondylolisthesis, were included in this study from January 2022 to March 2023. Various parameters including operation time, ambulatory time, intraoperative fluoroscopy times, hospitalization days, and complications were recorded during the perioperative period. Clinically relevant symptoms were evaluated and documented 1, 3, 6, and 12 months postoperatively. Visual analogue scale (VAS) scores for lower back pain and leg pain, as well as the Oswestry disability index (ODI), were measured. The extent of lumbar interbody fusion was assessed using lumbar X-ray and CT scans at the 12-months follow-up. MRI was performed to assess the degree of nerve decompression in patients at the same time points. The paired t-test or Wilcoxon signed-rank test were used as statistical methods. The single-segment UME-TLIF procedure had an average operation time of 211 ± 53.3 min, and the average number of X-rays taken during the operation was 11.78 ± 5.32. Patients were able to walk and perform functional exercises approximately 35.11 ± 8.41 h post-surgery, and the average duration of hospital stay was 8.5 ± 2.27 days. The VAS and ODI values at each time point post-surgery were significantly lower than the respective pre-surgery values (p < 0.05). Two patients developed postoperative sensory disturbances which significantly improved with conservative treatment. Furthermore, a follow-up CT scan conducted 12 months post-surgery showed 100% fusion rate of the surgical segments in all patients. UME-TLIF is an endoscopy-assisted fusion procedure that minimizes muscle damage in patients and allows early rehabilitation. This technique broadens the surgical applications of uniaxial spinal endoscope as a surgical tool, particularly benefitingpatients diagnosed with severe lumbar disc herniation and lumbar instability.

Precise Thoracoscopic Pneumonectomy Using Fluorescence Imaging After Aerosolized Indocyanine Green Inhalation: A Novel Strategy for Treating Congenital Pulmonary Airway Malformation

BackgroundLobectomy resection is the standard treatment for patients with congenital pulmonary airway malformation (CPAM). However, accurate localization of CPAM lesions and avoiding excessive resection of normal lung tissue are one of the critical issues that can impact postoperative pulmonary function. Indocyanine green (ICG) can be adopted in lung preservation surgery, to minimize damage to normal lung tissue during thoracoscopic pneumonectomy. ObjectiveTo demonstrate the potential benefits of aerosol inhalation of ICG followed by thoracoscopic precision pneumonectomy for the treatment of CPAM. MethodsFrom January 2023 to March 2024, we prospectively collected clinical data from 34 pediatric patients diagnosed with CPAM and treated with thoracoscopic surgery. Patients inhaled ICG aerosol solution (0.5 mg/kg) approximately 30-60 minutes before the operation. During surgery, fluorescence thoracoscopy was used to clearly locate the lesion boundaries and achieve precise resection. ResultsAll patients successfully underwent thoracoscopic precise resection of CPAM lesions without conversion to open surgery. The mean operation time was 100.3 ± 24.6 minutes, and the mean intraoperative blood loss was 30.5 ± 25.6 mL. The mean total length of hospital stay (tLOS) was 6.6 ± 3.2 days. No adverse reactions to ICG were observed. Postoperative complications included one case of pneumothorax (5.9%) and three cases of subcutaneous emphysema (17.6%), all of which resolved without special intervention. Follow-up CT scans and pulmonary function tests conducted 6 months post-surgery demonstrated the absence of residual or recurrent lesions and notable enhancement in pulmonary function. ConclusionPreliminary results indicated that the treatment of CPAM with aerosolized ICG followed by thoracoscopic precise pneumonectomy is safe and feasible.

CT surveillance for type 1 autoimmune pancreatitis: cumulative radiation dose and diagnostic performance for disease relapse.

Long-term follow-up is essential for type 1 autoimmune pancreatitis (AIP) patients due to high relapse rates. The cumulative radiation dose from repeated CT scans during follow-up should not be ignored. We aim to investigate the cumulative radiation dose in AIP patients undergoing CT surveillance and the diagnostic performance of CT in detecting disease relapse. The diagnostic performance of MRI from a secondary cohort during the same period was also investigated. This retrospective single-institutional study included 247 type 1 AIP patients with one or more follow-up CT scans, and 120 patients with MR follow-ups. Four metrics were utilized to report the radiation dose, including the volume computed tomography dose index, the dose length product, size-specific dose estimate and effective dose. The diagnostic performance for AIP relapse was assessed, taking the final clinical diagnosis in retrospect as the reference standard. With a median 2.3-year follow-up period, AIP patients followed up with CT exhibited a median cumulative radiation dose of 37.5 mSv. 11.3% of patients have accumulated doses exceeding 100 mSv. For the 169 patients followed over a year, 30.8% sustained an average annual radiation dose surpassing 20 mSv. The sensitivity/specificity/accuracy of CT for detecting abdominal organ relapse was 64.1%/99.6%/97.0%. For AIP patients followed up with MRI, the sensitivity for detecting disease relapse was 90.5%. Considering the accumulation of radiation dose in AIP patients and the insufficient sensitivity in detecting disease relapse with CT, safer and more sensitive imaging follow-up strategies should be explored. Question CT, as the primary imaging modality for autoimmune pancreatitis (AIP) follow-up, raises concerns regarding radiation exposure and lacks reported diagnostic performance in detecting AIP relapse. Findings CT in AIP follow-up causes significant cumulative radiation exposure and exhibits insufficient sensitivity in relapse detection. Clinical relevance Type 1 AIP necessitates long-term imaging follow-up, yet current guidelines lack consensus regarding the prioritization of CT or MRI for such follow-up. CT is widely used but has radiation concerns and limited sensitivity, calling for safer, efficient strategies.

Reliability of ABC/2 volumetric estimation in spontaneous intracerebral hemorrhage for hematoma expansion prediction scores.

Prediction scores for hematoma expansion in spontaneous intracerebral hemorrhage (ICH), such as the 9-point and BRAIN scores, were developed predominantly using planimetry to measure hematoma volume. In this study, we aim to investigate whether the ABC/2 formula, which is known to overestimate hematoma volume, can be reliably used as a substitute for planimetry in these prediction scores. A total of 429 patients from four hospitals were retrospectively enrolled. CT scan and clinical data at admission and follow-up CT scan were collected. The 9-point and BRAIN scores were calculated using hematoma volume from ABC/2 and planimetry. Hematoma expansion was assessed using hematoma volume from planimetry. The median hematoma volume measured by ABC/2 was 11.97 ml (interquartile range [IQR], 4.8-30.0), whereas the volume measured by planimetry was 11.70 ml (IQR, 4.9-26.6). The median measurement error between ABC/2 and planimetry was 0.30 ml (IQR, -0.72-2.87). ABC/2 overestimated hematoma volume in 244 patients (56.9%) compared to planimetry. In the 9-point score, the area under the curves (AUCs) for predicting hematoma expansion were 0.735 (95% confidence interval [CI], 0.675-0.796) with ABC/2 and 0.732 (95% CI, 0.672-0.793) with planimetry. In the BRAIN score, the AUCs were 0.753 (95% CI, 0.693-0.813) with ABC/2 and 0.745 (95% CI, 0.688-0.803) with planimetry. The 9-point and BRAIN scores using hematoma volume measured by ABC/2 and planimetry showed good performance in predicting hematoma expansion in ICH. ABC/2 volumetric estimation proved to be reliable for these scores.

Radiological indicators of chronicity in patients with acute symptomatic pulmonary embolism treated with ultrasound-assisted catheter-directed thrombolysis: a study of 180 consecutive cases

Abstract Background Radiological signs of chronic thrombi are present in up to 20% of patients that present acutely with pulmonary embolism (PE). Ultrasound-Assisted Catheter-Directed Thrombolysis (USAT) can swiftly reverse right ventricular dysfunction in patients with acute PE. Purpose To investigate the frequency of radiological signs of chronic PE and pre-existing chronic thromboembolic pulmonary hypertension in patients treated with USAT and their impact on early and long-term hemodynamic and clinical outcomes. Methods The index CT scans of patients receiving USAT for acute intermediate-high and high-risk PE at a tertiary academic institution (2017-2022) were adjudicated by three expert radiologists blinded for treatment scheme and outcomes. Changes in invasively-measured mean pulmonary artery pressure (mPAP) at 24 hours post USAT, presence of post-PE impairment (PPEI), and CTEPH diagnoses after at least 3 months were studied. A total of 15 radiological signs of chronicity were assessed, including 6 major criteria that have been previously validated to raise the suspicion of pre-existing CTEPH. In this study, acute-on-chronic PE was defined when at least 3 of the 6 validated radiological criteria for chronicity were present together with acute findings. Pre-existing CTEPH was defined based on the results of follow-up (vs. index) CT scan and on the anatomical consistency of pathology specimens after pulmonary endarterectomy. PPEI was defined by the presence of residual respiratory symptoms and right ventricular dysfunction during follow-up. Results Of 180 consecutive patients (median age 65 years, 61% men, 17% high-risk PE), 31 had at least 3 of 6 radiological criteria at the time of acute presentation; Table 1. The median modified Miller Score was 24 points and baseline mPAP was 35 mmHg in both groups. The absolute mPAP reduction after USAT was 11 (Q1-Q3: 5-17) mmHg in patients with &amp;lt;3 and 10 (Q1-Q3: 5, 17) mmHg in those with ≥3 criteria; Table 2. Three (1.7%) patients were diagnosed with CTEPH after a median of 3 months and underwent pulmonary endarterectomy: in all 3 patients, CTEPH was pre-existing. At least 3 of the 6 previously validated criteria were present in all CTEPH patients at index CT. In the 3 patients with acute PE on pre-existing CTEPH, the median baseline mPAP was much higher (median 53 mmHg) than in the remaining patient group and the absolute reduction after USAT was 9 mmHg, corresponding to a relative reduction of 19%. During follow-up, PPEI was more frequent in patients with &amp;lt;3 signs (n=4, 2.7%) than in those with ≥3 signs (n=4, 12.9%). Conclusion(s) The evaluation of six radiological parameters in initial CT scans successfully identified all cases of pre-existing CTEPH in patients presenting with acute PE. However, these parameters did not prove effective in determining which patients would benefit from USAT in terms of mPAP reduction.Baseline characteristicsHemodynamic and clinical outcomes

Development of a nomogram-based model incorporating radiomic features from follow-up longitudinal lung CT images to distinguish invasive adenocarcinoma from benign lesions: a retrospective study

PurposeTo develop and validate a radiomic model for differentiating pulmonary invasive adenocarcinomas from benign lesions based on follow-up longitudinal CT images.MethodsThis is a retrospective study including 336 patients (161 with invasive adenocarcinomas and 175 with benign lesions) who underwent baseline (T0) and follow-up (T1) CT scans from January 2016 to June 2022. The patients were randomized in a 7:3 ratio into training and test sets. Radiomic features were extracted from lesion volumes of interest on longitudinal CT images at T0 and T1. Differences in radiomic features between T1 and T0 were defined as delta-radiomic features. Logistic regression was used to build models based on clinicoradiological (CR), T0, T1, and delta radiomic features and compute signatures. Finally, a nomogram based on the CR, T0, T1 and delta signatures was constructed. Model performance was evaluated for calibration, discrimination, and clinical utility.ResultsThe T1 radiomic model was superior to the other independent models. In the training set, it had an area under the curve (AUC) of 0.858), superior to the CR model (AUC 0.694), the T0 radiomic model (AUC 0.825), and the delta radiomic model (AUC 0.734). In the test set, it had an AUC of 0.817, again outperforming the CR model (AUC 0.578), the T0 radiomic model (AUC 0.789), and the delta radiomic model (AUC 0.647). The nomogram incorporating the CR, T0, T1 and delta signatures showed the best predictive performance in both the training (AUC: 0.906) and test sets (AUC: 0.856), and it exhibited excellent fit with calibration curves. Decision curve analysis provided additional validation of the clinical utility of the nomogram.ConclusionA nomogram utilizing radiomic features extracted from longitudinal CT images can enhance the discriminative capability between pulmonary invasive adenocarcinomas and benign lesions.

8621 A Challenging Case of Preoperative Management of Pheochromocytoma Presenting With Recurrent Hypotension

Abstract Disclosure: N. Shripad: None. R. Osman: None. Introduction: Pheochromocytoma is a neuroendocrine tumor that clinically manifests due to the hypersecretion of catecholamines. Preoperative management typically involves alpha- and beta-adrenergic blockade. Patients commonly present with hypertension; however, in rare cases, patients may be hypotensive due to other comorbidities, posing a challenge to preoperative management. The following is a case of management of a pheochromocytoma with recurrent preoperative hypotension before the initiation of blood pressure-lowering agents. Case: A 47-year-old female presented to the hospital with dizziness and hypotension. The patient has a history of bilateral nephrectomy with left-sided adrenalectomy secondary to left-sided renal cell cancer and is hemodialysis-dependent. A right-sided pheochromocytoma was diagnosed a year ago on a follow-up CT scan done for monitoring renal cell cancer. The diagnosis was later confirmed with a DODATE scan and, eventually, a biopsy. Normetanephrine levels were between 581-735 pg/mL (0-88 pg/mL), with normal metanephrine levels. She denies having hyperadrenergic spells. She was started on metoprolol and doxazosin the year prior to presentation; however, she self-discontinued doxazosin after experiencing dizziness and palpitations on hemodialysis days. On admission, she was afebrile with a blood pressure of 103/66 mm Hg and a heart rate of 115 BPM. After an interdisciplinary decision was made for surgical resection, she was restarted on a lower dose of doxazosin (1 mg) and metoprolol was increased to the goal heart rate. Despite fewer hypotensive episodes on a reduced dose of doxazosin, the patient remained hypotensive on hemodialysis days. Salt tablets were started post-dialysis after clearance from nephrology, and an improvement in blood pressure was noted. She underwent a right adrenalectomy without receiving saline infusion before surgery due to concerns about volume overload. She was started on stress dose steroids due to her history of left adrenalectomy. She remained stable during and following surgery and did not require any vasopressor support. Discussion: Perioperative management of pheochromocytoma can be challenging in hypotensive patients and is poorly documented. Midodrine, an alpha-1 agonist that is typically used in dialysis-induced hypotension, is contraindicated in the setting of pheochromocytoma. We opted to manage our patient with a reduced dose of doxazosin and beta-blocker initially; however, with continued hypotensive episodes, the addition of salt tablets preoperatively on dialysis days helped to alleviate the hypotension. Although our patient did not require it, a preoperative overnight albumin infusion is a viable alternative to saline to prevent volume overload. Despite the limited literature, the patient was treated successfully through an interdisciplinary approach. Presentation: 6/3/2024

Pneumatosis cystoides intestinalis in granulomatosis with polyangiitis: a case report.

This study aims to investigate the clinical manifestations, imaging features, and treatment considerations in the rare occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA). We present the case of a 71-year-old Chinese woman diagnosed with GPA, who, despite exhibiting fatigue, knee pain, and nasosinusitis, remained asymptomatic for PCI. Regular follow-up revealed laboratory and imaging evidence indicative of clinical relapse. The patient received GPA treatment but was not specifically managed for PCI. Serial abdominal CT scans were performed to monitor the progression of PCI. Radiological diagnosis confirmed the presence of gas within the colon wall, indicating pneumatosis cystoides intestinalis. Notably, the patient remained asymptomatic for abdominal complaints. Despite ongoing GPA treatment, a follow-up CT scan 2months later revealed persistent gas within the colon wall, suggesting a persistent state of PCI. Patient consent was obtained for the publication of this case report, and ethical approval was not obtained as this study constitutes a retrospective review. This case underscores the importance of recognizing pneumatosis cystoides intestinalis as a potential complication in GPA patients, even in the absence of typical abdominal symptoms. Further research is warranted to elucidate the underlying mechanisms and optimal management strategies for this rare association. Key points • Rare association: This case report sheds light on the uncommon occurrence of pneumatosis cystoides intestinalis (PCI) within the context of granulomatosis with polyangiitis (GPA), adding to the understanding of the spectrum of manifestations of GPA. • Clinical manifestations: Despite being diagnosed with GPA and experiencing symptoms such as fatigue, knee pain, and nasosinusitis, the patient remained asymptomatic for PCI, emphasizing the importance of vigilant clinical monitoring in GPA patients. • Imaging features: Radiological imaging, including serial abdominal CT scans, played a crucial role in diagnosing and monitoring the progression of PCI in the absence of typical abdominal complaints, highlighting the utility of imaging modalities in detecting silent manifestations of gastrointestinal complications in GPA. • Treatment considerations: The case highlights the challenge of managing PCI in GPA patients, especially when asymptomatic, and raises questions about the optimal management strategies for such rare associations, underscoring the need for further research in this area.

The Growth of Screening-Detected Pure Ground-Glass Nodules Following 10 Years of Stability

It remains uncertain how long pure ground-glass nodules (pGGNs) detected on low dose computed tomography (LDCT) should be followed. Further studies with longer follow-up periods are needed to determine the optimal follow-up duration for pGGNs. What is the percentage of enlarging nodules among pGGNs that have remained stable for 10 years? This was a retrospective cohort study originating from subjects with pGGNs detected on LDCT scans between 1997 and 2006, whose natural courses were reported in 2013. We re-analyzed all the follow-up data until July 2022. The study subjects were followed by our institutional guidelines until they were no longer a candidate for definitive treatment. The growth of the pGGNs was defined as an increase in the diameter of the entire nodule by 2 mm or more or the appearance of new solid portions within the nodules. A total of 89 patients with 135 pGGNs were followed for a median of 193 months. Of 135 pGGNs, 23 (17.0%) increased in size, and the median time to the first detection of a size change was 71 months. Of the 23 growing pGGNs, 122 were detected on the first LDCT, and 13 were newly detected on the follow-up CT scan. An increase in size was observed within 5 years in 8 nodules (34.8%), between 5 and 10 years in 12 nodules (52.2%) and after 10 years in 3 nodules (13.0%). Fifteen nodules were histologically confirmed as adenocarcinoma by surgery. Among the 76 pGGNs stable for 10 years, 3 (3.9%) increased in size. Among pGGNs that remained stable for 10 years, 3.9% eventually grew, indicating that some pGGNs can grow even after a long period of stability. We suggest that pGGNs may need to be followed for more than 10 years to confirm growth.

Impact on Prognosis of Stage I Non-Small Cell Lung Cancer Secondary to Delays in Diagnostic Workup.

Background Diagnostic workup of small pulmonary nodules often requires follow-up CT scans to confirm nodule growth before invasive diagnostics or treatment. Purpose To confirm prior results from the International Early Lung Cancer Action Program (I-ELCAP) on quantifying decreases in lung cancer prognosis by using two large databases, the National Lung Screening Trial (NLST) and International Association for the Study of Lung Cancer (IASLC). Materials and Methods In this retrospective study, a model was developed to predict cure rates based on size of solid nodules using the NLST (August 2002 to summer 2007) and IASLC (January 2011 to December 2019) databases, focusing on stage I non-small cell lung cancer (NSCLC). Kaplan-Meier methods were used to calculate 10-year lung cancer-specific survival and 5-year overall survival rates for different tumor sizes. Tumor diameter increases after 90-, 180-, and 365-day delays were estimated using volume doubling times (VDTs) of 60, 120, and 240 days corresponding to fast, moderate, and slow tumor growth. Initial and delayed lung cancer cure rates were assessed across nine scenarios of time delays and tumor growth rates and compared with the previous results of the I-ELCAP database. Results Using regression models based on 166 NLST and 22 590 IASLC patients with NSCLC, 10-year lung cancer-specific survival and 5-year overall survival, respectively, for tumors 4.0-20.0 mm in diameter were estimated. For a 20.0-mm tumor with a 60-day VDT in the NLST database, the lung cancer-specific survival decreased from 83.4% to 76.5%, 66.8%, and 32.3% after 90, 180, and 365 days, respectively. The IASLC database showed similar decreases in 5-year overall survival, from 81.2% to 73.4%, 62.4%, and 23.3% after 90, 180, and 365 days, respectively. Comparison across NLST, IASLC, and I-ELCAP databases revealed minor variations in lung cancer cure rates between 79.9% and 83.4%, with reductions of 6.9%-8.3% after a 180-day delay with a 120-day VDT. Conclusion The NLST and IASLC databases confirmed prior estimates from the I-ELCAP database for the decrease in lung cancer prognosis due to diagnostic delays. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Park and Lee in this issue.

Exploring 3D Printed Implants With Anti-Dropout Function to Overcome Time Constraints in Acute Orbital Fractures for Patient-Specific Implants.

Orbital wall reconstruction and implant insertion are crucial procedures for temporarily replacing the orbital walls in cases of significant fractures. Traditional methods using planar orbital implants have faced challenges owing to their flat shape, which increases the risk of dislocation from improper cuts and necessitates the use of screws in the orbital rim. This study aims to improve outcomes by employing customized 3-dimensional implants, thereby reducing complications and risk of dislocation resulting from external shock or implant weight postinsertion. This prospective study included 12 Korean individuals diagnosed with facial fractures (orbital wall injuries). Surgeries were performed on 12 patients, and follow-up CT scans were conducted on 10 of them. Therefore, the authors could only address the results for the 10 patients. The authors used bioactive glass ceramics and medical-grade poly-e-caprolactone to 3D print personalized implants, completing the manufacturing process in an average of 4.6 days. Computed tomography scans guided measurements of orbital volumes and exophthalmos. After surgery, we found that the difference values for bone orbital volumes (<0.1mL) and exophthalmos (<1mm except one) decreased compared with presurgery values. Independent t tests and Pearson correlation analysis revealed no significant changes between normal and affected sides in both phases. However, R-values increased in the postsurgery phase. Patients monitored postsurgery at 2 weeks, 3 months, and 6 months showed no complications. The 3D-printed patient-specific implants, customized to individual fracture shapes and featuring distinct implants and locking parts with notches, effectively restore bony orbital volumes and reduce exophthalmos. They have been proven feasible and applicable for reconstructing acute orbital wall fractures.

The efficacy of flexible ureteroscopy for large volume stones and hazards of ureteral access sheath usage: A prospective randomized study

ABSTRACT Objectives We aimed to assess the stone free rate of flexible ureteroscopy and laser lithotripsy (FURL) in upper urinary tract stones (UUTS) >20 mm and the risk of complications from ureteral access sheath (UAS) usage. Methods This is a prospective randomized clinical trial that included patients with UUTS larger than 20 mm who underwent FURL after randomization into two groups: group A (UAS) and group B (non-UAS). Data were collected for patients’ demographics, stone parameters, operative and postoperative complications, and the outcome of FURL regarding stone-free rate (SFR) and perioperative complications, with a 6-month follow-up. Stone clearance was defined as the absence of fragments or the presence of fragments smaller than 2 mm on follow-up CT scans of the urinary tract (CTUT). Results One hundred and fifty-nine patients were evaluated. The mean stone size was 27.08 ± 6.185 mm. Complete stone-free status was achieved in 84.9% of the patients. No significant difference was detected between both groups regarding operative time or SFR. The ureteric injury was identified in 13 (8.1%) patients (10 in group A and 3 in group B, p: 0.0481). Five of them, from group A, revealed hydronephrosis after stent removal. Postoperative pain and fever were documented in 50 and 22 patients, respectively, without significant differences between both groups. Postoperative sepsis occurred in 7 patients (2 in group A, 5 in group B, p: 0.380) who required supportive care. Conclusion FURL without UAS is a safe and efficient treatment for upper urinary tract stones larger than 20 mm in the form of lower risk of ureteric injury.

EP142 - "Unravelling the Enigma: Navigating the Diagnostic Dilemma of Abdominal Toxoplasmosis"

Abstract Introduction Abdominal toxoplasmosis, an infrequent yet medically significant manifestation of Toxoplasma infection, primarily caused by the protozoan parasite Toxoplasma gondii. Although toxoplasmosis can affect various organs, its occurrence in the abdominal region introduces unique diagnostic complexities, presenting symptoms such as abdominal pain, gastrointestinal disruptions, and systemic complications. Case Report In a notable case, a middle-aged patient presented with perplexing gastrointestinal symptoms, including nausea, vomiting, abdominal pain, and irregular bowel habits. With a history of anaemia and thrombocytopenia necessitating transfusions and yielding inconclusive bone marrow biopsies, the patient underwent OGD and colonoscopy with biopsies during initial management, revealing a hiatus hernia and diverticulosis that did not explain the symptoms. Despite being discharged pending biopsy results, subsequent normal findings failed to clarify. Upon readmission with persistent gastrointestinal complaints, a CTAP revealed two suspicious neoplastic focal areas of small bowel wall thickening and enlarged mesenteric lymph nodes. The MDT discussions ensued to rule out malignancy, leading to a follow-up PET scan suggesting nodal disease, raising concerns about lymphoma, small bowel adenocarcinoma, or carcinoid tumour and recommended an ultrasound-guided lymph node biopsy, 5 HIAA if asymptomatic, and diagnostic laparoscopy if symptomatic or obstructed. Subsequent core biopsy of a neck lymph node unveiled appearances consistent with toxoplasmosis, prompting treatment with anti-parasitic drugs. The patient awaits capsule endoscopy, and a follow-up CT scan displayed a reduction in bowel lesions and lymph nodes. Conclusion This case highlights the swift and precise identification of toxoplasmosis, resulting in an optimal patient outcome. The clinical manifestations of toxoplasmosis are diverse and lack distinct characteristics, making it challenging to definitively diagnose, particularly in immunocompetent individuals.

CLINICAL MANAGEMENT OF CHRONIC ORANGUTAN RESPIRATORY DISEASE SYNDROME IN THREE ADULT MALE BORNEAN ORANGUTANS (PONGO PYGMAEUS).

Orangutan respiratory disease syndrome (ORDS) is a disease unique to orangutans (Pongo sp), characterized by chronic bacterial infection and inflammation of any region or combination of regions of the respiratory tract, including the sinuses, air sacs, cranial bones, airways, and lung parenchyma. Aggressive early intervention during a first episode may prevent progression to chronic disease. However, in the setting of an established chronic disease, intermittent acute exacerbations are associated with worsening symptoms and increased infection and inflammation. ORDS is ultimately fatal due to loss of respiratory function resulting from chronic structural damage. Utilizing potentially lifelong medications to slow the progression of chronic, destructive inflammation in the respiratory tract, chronic treatment is aimed at stabilizing the animals' respiratory function, decreasing the frequency of recurrent exacerbations, and improving their general well-being. Three adult male Bornean orangutans (Pongo pygmaeus) housed at an orangutan rehabilitation and reintroduction center in Indonesia have long histories of recurrent respiratory disease. Each underwent CT scans confirming ORDS with chronic airway disease prior to initiation of a long-term treatment protocol. Based on data-driven medical management of bronchiectasis in humans, the three orangutans have been treated with long-term combination regimens of oral azithromycin, nebulized salbutamol, and nebulized hypertonic saline. Follow-up CT scans in all three animals at least 1 yr following treatment initiation showed improvements throughout their respiratory tracts. The duration of each exacerbation period decreased, and the orangutans have longer symptom-free periods compared to before the start of treatment. At an average of 5 yr into the long-term treatment protocol, all three orangutans are thriving. Chronic medical management of ORDS modeled after human treatment of bronchiectasis has been efficacious in these three orangutans and encourages further study of this approach.