Identification Of High-risk Lesions Research Articles

Carotid Plaque Phenotyping by Correlating Plaque Morphology from Computed Tomography Angiography with Transcriptional Profiling

<h3>Objective</h3> Ischaemic strokes can be caused by unstable carotid atherosclerosis, but methods for identification of high risk lesions are lacking. Carotid plaque morphology imaging using software for visualisation of plaque components in computed tomography angiography (CTA) may improve assessment of plaque phenotype and stroke risk, but it is unknown if such analyses also reflect the biological processes related to lesion stability. Here, we investigated how carotid plaque morphology by image analysis of CTA is associated with biological processes assessed by transcriptomic analyses of corresponding carotid endarterectomies (CEAs). <h3>Methods</h3> Carotid plaque morphology was assessed in patients undergoing CEA for symptomatic or asymptomatic carotid stenosis consecutively enrolled between 2006 and 2015. Computer based analyses of pre-operative CTA was performed to define calcification, lipid rich necrotic core (LRNC), intraplaque haemorrhage (IPH), matrix (MATX), and plaque burden. Plaque morphology was correlated with molecular profiles obtained from microarrays of corresponding CEAs and models were built to assess the ability of plaque morphology to predict symptomatology. <h3>Results</h3> Carotid plaques (<i>n</i> = 93) from symptomatic patients (<i>n</i> = 61) had significantly higher plaque burden and LRNC compared with plaques from asymptomatic patients (<i>n</i> = 32). Lesions selected from the transcriptomic cohort (<i>n</i> = 40) with high LRNC, IPH, MATX, or plaque burden were characterised by molecular signatures coupled with inflammation and extracellular matrix degradation, typically linked with instability. In contrast, highly calcified plaques had a molecular signature signifying stability with enrichment of profibrotic pathways and repressed inflammation. In a cross validated prediction model for symptoms, plaque morphology by CTA alone was superior to the degree of stenosis. <h3>Conclusion</h3> The study demonstrates that CTA image analysis for evaluation of carotid plaque morphology, also reflects prevalent biological processes relevant for assessment of plaque phenotype. The results support the use of CTA image analysis of plaque morphology for risk stratification and management of patients with carotid stenosis.

Fractional Flow on TOF-MRA as a Measure of Stroke Risk in Children with Intracranial Arterial Stenosis.

Conventional angiography is the criterion standard for measuring intracranial arterial stenosis. We evaluated signal intensity ratios from TOF-MRA as a measure of intracranial stenosis and infarct risk in pediatric stroke. A retrospective study was undertaken in children with intracranial arterial stenosis, who had TOF-MRA and conventional angiography performed within 6 months. Arterial diameters were measured for percentage stenosis. ROI analysis on TOF-MRA measured signal intensity in pre- and poststenotic segments, with post-/pre-signal intensity ratios calculated. The Pearson correlation was used to compare percentage stenosis on MRA with conventional angiography and signal intensity ratios with percentage stenosis; the point-biserial correlation was used for infarcts compared with percentage stenosis and signal intensity ratios. Sensitivity, specificity, and positive and negative predictive values were calculated for determining severe (≥70%) stenosis from MRA and signal intensity ratios against the criterion standard conventional angiography. P < .05 was considered statistically significant. Seventy stenotic segments were found in 48 studies in 41 children (median age, 11.0 years; range, 5 months to 17.0 years; male/female ratio, 22:19): 20/41 (48.8%) bilateral, 11/41 (26.8%) right, and 10/41 (24.4%) left, with the most common site being the proximal middle cerebral artery (22/70, 31%). Moyamoya disease accounted for 27/41 (65.9%). Signal intensity ratios and conventional angiography stenosis showed a moderate negative correlation (R = -0.54, P < .001). Receiver operating characteristic statistics showed an area under the curve of 0.86 for using post-/pre-signal intensity ratios to determine severe (≥70%) carotid stenosis, yielding a threshold of 1.00. Sensitivity, specificity, and positive and negative predictive values for severe stenosis were the following-MRA: 42.8%, 58.8%, 30.0%, and 71.4%; signal intensity ratio >1.00: 97.1%, 77.8%, 71.7%, and 97.4%; combination: 75.5%, 100%, 100%, and 76.8%, respectively. Signal intensity ratios decreased with increasing grade of stenosis (none/mild-moderate/severe/complete, P < .001) and were less when associated with infarcts (0.81 ± 0.52 for arteries associated with downstream infarcts versus 1.31 ± 0.55 for arteries without associated infarcts, P < .001). Signal intensity ratios from TOF-MRA can serve as a noninvasive measure of intracranial arterial stenosis and allow identification of high-risk lesions in pediatric stroke.

Abstract: Craniofacial Dermoid Cysts: Experiences from the Royal Children’s Hospital in Melbourne, Australia

PURPOSE: To ascertain the clinical spectrum of severity of dermoid cysts within the paediatric population, and to contribute to the understanding of which lesions are at higher risk of intracranial extension and warrant more thorough pre-operative work up. METHODS: We conducted a single-centre, consecutive, non-randomized comparative case series, reviewing the case notes of all patients treated surgically for craniofacial dermoids at the Royal Children’s Hospital in Melbourne, Australia. The study period was between August 2013 and May 2017, and a total of 221 patients were identified using coding for “dermoid cyst” procedures. Of these, 147 were identified as having craniofacial dermoids and included in the study. Three surgical units were involved in care (Plastic and Reconstructive Surgery, Neurosurgery and Paediatric Surgery). The data collected included demographic information, pre-operative assessment, pre-operative imaging, date of surgery, age at surgery, surgical details, pathology reports and post-operative follow up. RESULTS: 147 patients are presented within this series, with a total of 149 dermoid cysts removed. The age at surgery ranged from 2 months to 15 years, with an average age of 20 months. 88 (60%) children presented with lesions of the lateral brow. The next most common locations in descending order were midline nasal with 17 (11.5%), 11 occipital (7.5%), 9 temporal (6%), 6 midline frontal (4%), 5 medial brow/medial canthus (3.5%), 3 glabella (2%), 3 anterior fontanelle (2%), 3 posterior auricular (2%), and 2 parietal (1.5%). 53 of the 147 patients identified had preoperative imaging (36%). 21 patients underwent CT scan alone (40%), 18 underwent MRI alone (34%), 8 patients underwent combined CT and MRI scans (15%), 4 patients underwent ultrasound alone (7.5%), 1 patient had a plain radiograph (2%) and 1 patient underwent combined MRI and ultrasound (2%). In 4 cases (7.5%) the reported imaging was discordant with the operative findings. 3 of these cases failed to report attachment of the lesion to the underlying dura, and 1 failed to report a small breach of the inner table. To classify the depth of the lesions, we modified the system used by Hartley et al1 to describe midline nasal lesions and applied it to lesions in all locations within the head and neck. We divided the lesions into superficial (type 1), bony remodelling/stalk to suture (type 2), intraosseous (type 3), intracranial extradural (type 4) and intracranial intradural (type 5). In this study, 96 lesions were classified as superficial, 31 showed a significant stalk to a suture or bony remodelling, 8 lesions were interosseous, 10 lesions were intracranial extradural and 2 lesions were intracranial intradural. Average age at surgery was highest in group 2 and lowest in group 5. CONCLUSION: Based on our data, we propose a system using specific classification of anatomical location to assist in the prompt identification of high risk lesions and facilitate sound pre-operative planning.

Infantile haemangioma: their presentation and management.

Haemangiomas are the commonest type of vascular tumour in infancy. This article summarizes the pathophysiology and classification of the subtypes as early identification of high-risk lesions is essential for consideration of treatment to prevent short- and long-term complications from the condition.

Evaluation of MAGE-A expression and grade of dysplasia for predicting malignant progression of oral leukoplakia

The risk of the malignant transformation of oral leukoplakia (OLP) is difficult to predict by histopathology. Melanoma-associated antigen-A (MAGE-A) expression is restricted to malignant cells and may be useful for the more accurate estimation of the potential malignant transformation of pre-malignant lesions. The aim of the present study was to investigate whether the expression of MAGE-A can be used to predict the malignant transformation of OLP. Paraffin-embedded tissue samples of OLP from 74 patients followed-up for at least 5 years were included. A total of 24 progressing and 50 non-progressing OLP, 18 corresponding tumor and 30 healthy mucosa specimens were analysed for MAGE-A 1, 3, 4, 6 10 and 12 expression by nested real‑time RT-PCR and graded for dysplasia. In total, 46% of the progressing lesions expressed at least 1 out of the examined MAGE-A antigens, whereas no expression was detected in any of the non-progressing OLP and normal specimens. The correlation between malignant transformation and MAGE-A expression was statistically significant (p=0.00001). Furthermore, 42% of the progressing OLPs without dysplasia (D0) expressed at least 1 antigen. The correlation between the grade of dysplasia and MAGE-A staining in the malignant transformation group was not significant (p=0.08). The detection of at least 1 MAGE-A antigen may allow the identification of high-risk lesions that may progress into carcinoma with time. Therefore, the investigation of MAGE-A expression should be assessed in order to obtain a more accurate evaluation of the potential cancer risk of OLP.

CT evaluation of vulnerable plaque: noninvasive fortune-telling?

Recently, cardiac CTA has been proposed as a promising noninvasive tool for identification of rupture-prone plaques prior to a subsequent coronary event. This task is particularly challenging but the reward is high: identification of high-risk lesions could preclude plaque thrombosis and possibly prevent acute coronary syndromes. We present a case of a borderline mixed plaque with positive remodeling in the proximal left anterior descending artery (LAD). After 6 months and despite aggressive medical therapy, the patient developed acute ST-elevation myocardial infarction caused by a thrombotic lesion in the proximal LAD. We review the literature on CT characteristics of vulnerable plaque and discuss the possible preventive interventions.

Identification of high-risk lesions through automated natural language processing (NLP) of pathology reports.

Abstract Abstract #3001 Purpose&amp;#x2028; Pathology reports contain extensive research information that is inaccessible except through costly and time consuming chart reviews. This is due to the fact that pathology reports are recorded as semi-structured prose with critically important descriptive text intended for human interpretation. Key challenges for processing this data include interpreting multiple methods of describing the same finding, and subsequently aggregating the findings of multiple reports into episodes of care. Investigators tested NLP techniques in the processing of pathology reports into structured data and episodes of care, allowing for the rapid identification and epidemiologic modeling of high-risk breast lesions.&amp;#x2028; Methods&amp;#x2028; Using state-of-the-art NLP software (ClearForest, A Thomson Reuters Company, Waltham, MA), breast pathology reports stored as text files were processed into a structured electronic database using these steps: 1) identification of diagnosis of interest (i.e. high risk lesions, cancer), 2) use of NLP to identify all terms and phrases used to report each finding (e.g. atypical hyperplasia, hyperplasia with atypia), 3) grouping of relevant terms into categories, 4) identification of categories occurring in each patient report, and 5) grouping of patient reports into episodes of care (defined as all reports within 6 months of an initial diagnosis).&amp;#x2028; Results&amp;#x2028; Under IRB approval, 27,931 breast pathology reports from Massachusetts General Hospital in 16,208 patients seen between 1990-2007 were analyzed. The results were compared against manually reviewed pathology reports for quality control. For DCIS diagnoses, the initial error rate for both the NLP process and the manual process was 2%. The NLP process was then re-tuned using the identified discrepancies which reduced the error rate to zero. Using the refined model, we identified 1) patients with atypical lesions (atypical ductal hyperplasia (ADH), severe ADH, atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS)) without prior or concurrent cancer, and 2) patients who developed cancer greater than 6 months post diagnosis.&amp;#x2028; &amp;#x2028; Conclusion&amp;#x2028; This process successfully identified high-risk diagnoses that were otherwise relatively inaccessible, and appears to match the accuracy of a human research associate. The results of this first implementation are promising and will be further validated over time. In the future, this approach can be applied to other medical reports and diseases. NLP has significant potential to decrease the cost of research and for improving patient care. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3001.

Applications of multislice coronary computed tomographic angiography to percutaneous coronary intervention: How did we ever do without It?

By providing data previously available only by intravascular ultrasound, 64-slice multidetector computed tomographic angiography (CTA) will impact percutaneous coronary intervention (PCI) in multiple areas: (1) pre-PCI patient selection; (2) identification of significant lesions; (3) in-stent restenosis; (4) procedure planning: stent sizing, choice of intervention, and equipment, chronic total occlusions, 3D-CTA in the catheterization laboratory; (5) plaque evaluation and identification of high-risk lesions; (6) postcatheterization decisions, and (7) structural heart disease. The likely outcome is transformation of the catheterization laboratory into a streamlined interventional suite, utilizing on-line CTA data in an interactive format.

MANAGEMENT OF MUCOSAL PREMALIGNANT LESIONS

SUMMARY Oral precancer, consisting of leukoplakia, erythroplakia, and oral submucous fibrosis, has a well-documented malignant transformation rate that may be related to the prevalence and degree of dysplasia present in the lesion. This rate does not diminish with duration of the lesion; therefore, long-term surveillance is essential for the proper management of patients afflicted with these lesions. Prevention consists of removal of risk factors, particularly the use of tobacco products and alcohol. To prevent submucous fibrosis, chewing of betel products must cease. ST is a risk factor for leukoplakia and cancer. Identification of high-risk lesions is facilitated by regular complete clinical examination supplemented by vital staining with toluidine blue. Treatment consists of removal of the lesion by surgery (laser, scalpel, or electrosurgery) and occasionally by cryotherapy. The laser is least damaging to surrounding normal tissue, does not cause scarring or edema, and is not painful. Biologic manipulation with retinoids holds promise but is not yet adequately reliable or sustainable because of side effects.

Echocardiographic assessment of patients with infectious endocarditis: Prediction of risk for complications

To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics.The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%).In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.

Auricular malignant neoplasms. Identification of high-risk lesions and selection of method of reconstruction.

A prospective study of 17 auricular malignant neoplasms was conducted comparing recommended margins for conventional surgical excision to the actual margins obtained after microscopically controlled excision (Mohs' chemosurgery technique) to identify lesions at high risk for inadequate excision with conventional excision. High-risk lesions included all tumors larger than 1 cm, morpheaform basal cell carcinoma, and multiply recurrent lesions of any size. Successful excision by conventional surgery would have resulted in a defect notably larger than the actual Mohs' defect in all cases. The excess tissue excised by conventional surgery averaged 180% larger than the actual defect in primary lesions and 347% larger in recurrent lesions. Methods of reconstruction used include the following: secondary intention (granulation), primary closure, skin grafts, local flaps, and meatoplasty. The incidence, indications, and usual results obtained are discussed in detail. Mohs' chemosurgery technique provides substantial benefit and should be considered in all recurrent lesions and primary lesions larger than 1 cm to reduce recurrence and minimize the resultant deformity.