Initial Modality Research Articles

Cardiac intima sarcoma: a rapid review of case reports

Background and purpose: Cardiac intimal sarcoma (CIS) is a rare and often misdiagnosed clinical entity with notably high morbidity and mortality rates. Urgent efforts are required to comprehensively the disease and establish evidence-based management guidelines. Given the relative scarcity of data and the imperative for consensus on management strategies, this review assumes critical importance. Through a rapid review approach, we aims to synthesize and consolidate information gleaned from published case reports, thereby offering an up-to-date resource for CIS’s natural history. Methods: Utilizing inductive content analysis, we systematically searched for and synthesized case reports and series. Keywords related to CIS guided our search on Medline via Ovid, Scopus, and Web of Science from inception until March 17, 2024. Results: Our review identified 79 CIS, characterized by a mean age of 52 years, predominantly male (58%), with left-sided lesions. Approximately one-third of the patients presented with cardiovascular symptoms, and transthoracic echocardiography emerged as the preferred initial diagnostic modality in most cases. Fluorescence in situ hybridization (FISH) analysis on pre-operative tissue biopsies found murine double minute 2 (MDM2) amplification in 95% of cases tested. While surgery remained the cornerstone of treatment, recurrence occurred in 14% of cases postoperatively, with 28% succumbing to the disease despite therapeutic interventions. Conclusions: This synthesis of published case reports and series provides updated insights into the clinical profile CIS. Our findings highlight the need for increased clinical awareness, precise data collection, and further research to enhance diagnostic accuracy, treatment approaches, and patient outcomes in CIS.

Healing and long-term prognosis of root-fractured permanent teeth: a retrospective longitudinal study.

The purpose of the present study was to evaluate permanent teeth with post-traumatic transversal root fractures, for their initial healing modality, the effect of candidate predictors and their long-term prognosis. A retrospective longitudinal clinical study was conducted to evaluate records from patients bearing transversal root fractures in permanent teeth in order to radiographically assess short-term healing and non-healing events in the fracture line, their prognostic factors and their relationship with long term outcomes. The inter-fragmentary tissues were classified as healing: hard tissue (HT), connective tissue (CT) or connective tissue and bone (CT + B) and non-healing: interposition of granulation tissue (GT). A competing risk survival analysis was conducted to estimate the hazards of healing and non-healing events in the short-term and the effect of demographic, clinical, and treatment variables was assessed using the subdistribution regression model (Fine & Gray). Radiographic findings showed 61.4% of healing in the short-term being strongly influenced by the presence and type of concomitant injuries to the coronal fragment. Teeth with concomitant crown fractures (sHR 24.38, 95% CI [3.16-188.3], p = 0.0022), luxations with dislocations (sHR 10.58, 95% CI [1.37-81.9], p = 0.0240) and subluxations (HR 9.66, 95% CI [1.14-81.7], p = 0.0370) were more likely to present non-healing of root fractures in the short-term. The healing rate in the long-term was of 75.9%, most of them with interposition of bone and connective tissue. Kappa statistics demonstrated an overall agreement of 67.1% between short and long-term healing patterns, in special HT and CT + Bone modalities. Healing at the fracture site was the most frequent outcome, both in the short-term and in the long-term. Short-term healing modality was strongly influenced by the presence and type of concomitant injuries to the crown fragment, being the worst prognosis observed in root-fractured teeth with concomitant crown fractures, followed by concomitant luxations with dislocation. Post-traumatic transversal root fractures have a positive prognosis supporting therefore, a more conservative approach for these teeth before considering more radical treatments.

The OEIS National Registry: Rationale, Context, and Current Status

Office based interventional procedures continue to increase in number and scope. An overview of the Outpatient Endovascular and Interventional Society (OEIS) National Registry (OEISNR) is described in this article. Currently there is one production module enrolling peripheral artery interventional procedures, and a new cardiac module encompassing both diagnostic catheterization/percutaneous coronary interventions and electrophysiology procedures is undergoing beta testing. A new embolization module with uterine fibroid embolization (UFE) as the initial modality is nearly initial development completion and expected to enter beta in 2024. The OEISNR has over 338 participating physicians and has enrolled over 42,000 cases since inception in 2017 with an extremely high rate of technical success (97%) and very low complication rates (2.15% overall, 1.65% minor complications, 0.53% major complications). More detailed data breakdowns including patient demographics and comorbidities, indications, lesion characteristics, treatment modalities and device utilization, complication details, and data integrity data are contained in this report. Sample analytics, sample dashboards, and structural details are illustrated and included.

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis.

Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). One hundred-fifty-three ICUs in 13 countries. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). None. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007). Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Noninvasive Respiratory Support for Pediatric Critical Asthma: A Multicenter Cohort Study.

Noninvasive respiratory support (NRS) for pediatric critical asthma includes CPAP; bi-level positive airway pressure (BPAP); and heated, humidified, high-flow nasal cannula (HFNC). We used the Virtual Pediatric System database to estimate NRS by prescribing rates for pediatric critical asthma and characterize patient clinical features and in-patient outcomes by the initial NRS device applied. We performed a retrospective cohort study from 125 participating pediatric ICUs among children 2-17 years of age hospitalized for critical asthma and prescribed NRS from 2017 through 2021. The primary outcomes were NRS modality prescribing rates and trends. Secondary outcomes were descriptive and included demographics, comorbidities, severity of illness indices, and NRS failure rates (defined as escalation from the initial NRS modality to invasive ventilation, HFNC to BPAP or CPAP, or CPAP to BPAP). Of the 10,083 encounters studied, the initial NRS modalities prescribed varied widely by hospital center (HFNC: 69.7 ± 29.6%; BPAP: 27.2 ± 7.1%; CPAP: 3.1 ± 5.9%). The mean rates of HFNC use increased from 59.7% in 2017 to 71.9% in 2021 (+2.5%/y). In contrast, BPAP (-1.6%/y) and CPAP (-0.8%/y) utilization declined throughout the study period. Older children who were obese and with a higher Pediatric Risk of Mortality III-Probability of Mortality score were more frequently prescribed BPAP and CPAP compared with HFNC. Those children on HFNC experienced higher noninvasive respiratory support failure rates versus BPAP (7.3% vs 2.4%; P < .001) but a lower subsequent invasive ventilation rate versus BPAP (0.8% vs 2.4%; P < .001). In this multi-center cohort study, we observed that children with critical asthma are increasingly exposed to HFNC compared with BPAP and CPAP. Rates of HFNC failure were greater than those of BPAP failure, but a majority were transitioned to BPAP without subsequent invasive ventilation. The next steps include prospective trials, including practical end points such as patient comfort and optimal delivery of nebulized treatments to distinguish device superiority and suitable NRS utilization.

Nonmalignant tracheal stenosis: presentation, management and outcome in limited resources setting

BackgroundNonmalignant tracheal stenosis is a potentially life threatening conditions that develops as fibrotic healing from intubation, tracheostomy, caustic injury or chronic infection processes like tuberculosis. This is a report of our experience of its management with tracheostomy, rigid bronchoscopic dilation and surgery.MethodsRetrospective study design was used. 60 patients treated over five years period were included.ResultsMean age was 26.9 ± 10.0 with a range of 10–55 years. Majority (56 patients (93.3%)) had previous intubation as a cause for tracheal stenosis. Mean duration of intubation was 13.8 days (range from 2 to 27 days). All patients were evaluated with neck and chest CT (Computed Tomography) scan. Majority of the stenosis was in the upper third trachea − 81.7%. Mean internal diameter of narrowest part was 5.5 ± 2.5 mm, and mean length of stenosed segment was 16.9 ± 8 mm. Tracheal resection and end to end anastomosis (REEA) was the most common initial modality of treatment followed by bronchoscopic dilation (BD) and primary tracheostomy (PT). The narrowest internal diameter of the tracheal stenosis (TS) for each initial treatment category group was 4.4 ± 4.3 mm, 5.1 ± 1.9 mm and 6.7 ± 1.6 mm for PT, tracheal REEA and BD respectively, and the mean difference achieved statistical significance, F (10,49) = 2.25, p = 0.03. Surgery resulted in better outcome than bronchoscopic dilation (89.1% vs. 75.0%).Discussion and conclusionNonmalignant tracheal stenosis mostly develops after previous prolonged intubation. Surgical resection and anastomosis offers the best outcome.

Laparoscopic deroofing of a recurrent giant simple hepatic cyst in a geriatric female: Case report.

Liver cysts often have no symptoms, are benign and are usually encountered during routine abdominal imaging for other conditions. Giant cysts have a higher risk of complications. Recurrence is common, and most research papers support laparoscopic deroofing as the initial management modality even in the recurrent cases as it avoids the morbidity of laparotomy and gives better short- and long-term post-operative outcomes. Here, we present a case of a 68-year-old female who presented to the outpatient department with complaints of right-sided dull-aching abdominal pain, heaviness, early satiety and significant weight loss for the past 2 months. A laparoscopic drainage and deroofing were done, and histopathological examination of the cystic wall was consistent with benign pathology. The patient has been doing well for the past year.

Multimodal therapy and use of adjunctive therapies to BoNT-A in spasticity management: defining terminology to help enhance spasticity treatment.

Spasticity management should be provided within the context of a comprehensive person-centered rehabilitation program. Furthermore, active goal setting for specific spasticity interventions is also important, with a well-established "more is better" approach. It is critical to consider adjunctive therapy and multimodal approaches if patients are not attaining their treatment goals. Often used interchangeably, there may be confusion between the terms adjunctive and multimodal therapy. Yet it is imperative to understand the differences between these approaches to achieve treatment goals in spasticity management. Addition of a secondary pharmacologic or non-pharmacologic treatment to optimize the efficacy of the initial modality, such as adding electrical stimulation or casting to BoNT-A, is considered an adjunctive therapy. Adjunctive therapy is time-specific and requires the added therapy be initiated within a specific period to enhance the primary treatment; usually within 2 weeks. Multimodal therapy is an integrated, patient-centric program of pharmacologic and non-pharmacologic strategies utilized in a concurrent/integrated or sequential manner to enhance the overall treatment effect across a variety of spasticity-associated impairments (e.g., neural and non-neural components). Moreover, within a multimodal approach, adjunctive therapy can be used to help enhance the treatment effect of one specific modality. The objectives of this paper are to clarify the differences between adjunctive and multimodal therapies, provide a brief evidence-based review of such approaches, and highlight clinical insights on selecting multimodal and adjunctive therapies in spasticity management.

A Retrospective Study on Comparison Between Surgical and Endoscopic Management of Pancreatic Pseudocyst and Walled-off Pancreatic Necrosis

BACKGROUND: Surgical management is the standard approach for pancreatic pseudocyst and walled off pancreatic necrosis. With newly evolving procedures and a comprehensive approach, management of walled off pancreatic necrosis and pancreatic pseudocyst is taking a new turn. A multi-centric study comparing surgical and endoscopic management of pancreatic pseudocyst and walled off pancreatic necrosis was performed. METHODS: Data was collected retrospectively from multiple centers and patients were followed up till date since the time of intervention. The outcomes were therapeutic success, post-operative complications, recurrence rate, mortality and duration of hospitalization. RESULTS: At the end of the follow-up period, none of the patients who received endoscopic intervention had a recurrence, compared to 2 patients in the surgical group. There was 16.67% mortality in the surgical group and only 3.33% mortality in the endoscopic group. Significantly high mortality was seen in the patients with Walled-Off Pancreatic Necrosis treated surgically, compared to no mortality in the patients treated endoscopically. 86 % of the patients in the endoscopic group had resolution of the disease following intervention compared to 70% in the other group. There were no statistically significant differences in mortality, resolution or recurrence of disease following intervention between the two groups. However, the length of hospital stay was significantly shorter for patients who underwent endoscopic intervention than open surgery. CONCLUSION: Endoscopic drainage of Pancreatic Pseudocysts and Walled off Pancreatic necrosis have demonstrated a therapeutic success rate, mortality and recurrence statistically comparable to that seen in surgical treatment, but with reduced time of hospitalization, supporting its use as the preferred initial modality for drainage.

Role of contrast-enhanced ultrasound for differentiation of benign vs. malignant portal vein thrombosis in hepatocellular carcinoma - Asystematic review a meta-analysis.

Patients with cirrhosis and hepatocellular carcinoma (HCC) can develop both benign and malignant portal vein thrombosis (PVT). Characterising the nature of PVT is important for planning an optimal therapeutic strategy. In the absence of typical findings or contraindications to computed tomography (CT) or magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS) could help in this differentiation. The present meta-analysis aimed to evaluate the performance of CEUS for characterising PVT in patients with HCC. Electronic databases of PubMed, Embase and Scopus were searched from inception to 31 December 2022 for studies analysing the role of CEUS in the differentiation of benign and malignant PVT in HCC. Using the bivariate random effect model, pooled sensitivity and specificity were calculated, and the summary receiver operating characteristic (sROC) curve was plotted. A total of 12 studies with data from 712 patients were included in the meta-analysis. The pooled sensitivity and specificity of CEUS for the diagnosis of tumour in vein were 97.0% (95% CI: 93.0-98.7) and 96.8% (95% CI: 92.1-98.7), respectively, without significant heterogeneity. A sROC curve was plotted, and the area under the receiver operating characteristic was 0.99 (95% CI: 0.98-1.00). Despite the presence of publication bias, sensitivity analysis did not show any change in sensitivity and specificity. Our meta-analysis summarises the accuracy data from 12 studies, including >700 subjects. Contrast-enhanced ultrasound had excellent diagnostic accuracy with pooled sensitivity and specificity of 97.5% (95% CI: 93.5-99.1) and 98.2% (95% CI: 91.5-99.6), respectively, without any significant heterogeneity. Additionally, the pooled positive LR, negative LR and DOR were 54.6 (95% CI: 11.1-25.6), 0.02 (0.01-0.07) and 2186.8 (318.3-15022.2), respectively. A positive result increases the pretest probability of malignant PVT from 50% to 98%, whereas a negative result decreases it from 50% to 2%. Most of the studies included in our meta-analysis used identical techniques and 6-12-month follow-up scans to check for thrombus progression or regression. Our analysis showed no significant heterogeneity in the studies, and area under receiver operating characteristic curve (AUROC) with 95% CI was 1.00 (95% CI: 0.99-1.00). This critical meta-analysis thus propels CEUS to the forefront for differentiating benign from tumoural PVT and suggests routinely using CEUS in patients presenting with HCC and evidence of thrombus on greyscale ultrasound. Contrast-enhanced ultrasound is an effective diagnostic modality differentiation of benign and malignant PVT in patients with HCC and can be an alternative modality to CT or MRI. Further studies are required to study the role of CEUS as initial diagnostic modality for the characterisation of PVT in HCC.

EE52 Evaluation of the Economic Impact of Initial Diagnostic Modality Selection for Patients Suspected of Having Colorectal Cancer Liver Metastases or Hepatocellular Carcinoma in the UK

EE52 Evaluation of the Economic Impact of Initial Diagnostic Modality Selection for Patients Suspected of Having Colorectal Cancer Liver Metastases or Hepatocellular Carcinoma in the UK

An Observational Study on Evaluation of IOTA Ultrasound Simple Rules to Distinguish Benign and Malignant Ovarian Masses and Histopathological Correlation in a Tertiary Care Hospita

Background: The international ovarian tumor analysis (IOTA) study technique is a specialized method for classifying and identifying adnexal growths. It employs 10 simple ultrasound directions to characterize masses as benign or malignant. Objectives: This study aims to provide pre-operative information to help gynecologists manage ovarian masses, avoiding delays in malignancy treatment and unnecessary surgery for benign lesions.&#x0D; Methods: This was a hospital-based observational study conducted in the radiology department on patients with clinical diagnoses of ovarian masses from August 2020 to March 2022 by prospective randomized sampling method. Patients with suspected ovarian pathology were evaluated using IOTA ultrasound rules and designated benign or malignant. The patients underwent a thorough history and clinical examination. Ultrasound was used to confirm the ovarian origin of the mass and differentiate it as benign or malignant. A transvaginal ultrasound was performed where necessary. Histopathological examination was the gold standard to confirm ultrasound and Doppler findings. Descriptive stats: Frequencies/percentages for categorical data, mean ± SD for normal, median with IQR for non-normal. Uncertainty measured by 95% CI.&#x0D; Results: During the study, 50 women were eligible for the study, and the mean age of the participants was 45.3 years. Of 50 patients who underwent surgery, 38 cases were considered benign based on IOTA USG rules, of which 35 were benign and 3 were malignant histologically. Eight cases were considered malignant based on IOTA USG rules, of which 6 were malignant and 2 were benign. Four cases were considered indeterminate, with two being benign and two being malignant histologically. If inconclusive cases are classified as malignant, the sensitivity and specificity are 75% and 88%, respectively.&#x0D; Conclusions: USG is an easily available imaging tool that can be used as an initial modality in evaluating ovarian masses. IOTA simple ultrasound rules have diagnostic accuracy in distinguishing benign and malignant ovarian masses and help in management.

Impact of initial dialysis modality on the survival of patients with ESRD: a propensity-score-matched study

BackgroundStudies comparing the survival of hemodialysis (HD) and peritoneal dialysis (PD) patients are controversial. This study evaluated the impact of initial dialysis modality on the survival of patients with end-stage renal disease (ESRD) in a matched-pair cohort.MethodsA retrospective cohort study was performed on ESRD patients who initiated renal replacement treatment between January 1, 2010, and December 31, 2018. Propensity score matching was applied to balance the baseline conditions, and multivariate Cox regression analysis was applied to compare mortality between HD and PD patients and evaluate correlations between mortality and various baseline characteristics. Subgroup analysis was performed with respect to diabetes status.ResultsThere were 739 patients in our center in the Chinese National Renal Data System (CNRDS) between 2010 and 2018. Of these, 125 PD patients were matched with 125 HD patients. The 1-, 2-, and 3-year survival rates were 96.5%, 90.7%, and 82.5%, respectively, in the HD group and 99.5%, 97.8%, and 92.5%, respectively, in the PD group (log-rank P < 0.001). Among the propensity score-matched cohorts, no significant differences in Kaplan–Meier curves were observed between the two groups (log-rank P = 0.514). Age at dialysis initiation, CCI, congestive heart failure and cerebrovascular disease were risk factors in the multivariable-adjusted model. In subgroups defined by diabetes status, the Kaplan‒Meier survival curve showed that PD survival was significantly higher than that of HD (log-rank P = 0.022).ConclusionsHD and PD were not significantly different regarding the survival of patients with ESRD. PD was associated with better survival in diabetic ESRD patients.

Ultrasound Imaging of Thyroid Pathologies: A Pictorial Review

AbstractWith its complex embryological origin, the thyroid can be affected by various congenital, developmental, benign, and malignant pathologies. Ultrasound, which is free from radiation and offers good spatial resolution, is the initial modality of choice in congenital hypothyroidism and is used in conjunction with scintigraphy. High-resolution ultrasound also aids in early diagnosis, risk stratification, and follow-up of nodules. While fine-needle aspiration cytology is the preferred method for further evaluation of thyroid nodules, ultrasound guidance reduces the likelihood of obtaining nondiagnostic samples. Numerous risk stratification guidelines for thyroid nodules have been developed by various societies over the past decade, with the most popular being the American College of Radiology—Thyroid Imaging Reporting and Data System. A comprehensive understanding of the varying morphological appearances of thyroid nodules and the consistent use of risk stratification guidelines can accurately detect incidental malignancies while avoiding unnecessary intervention in seemingly benign nodules.

L’ombre est tombée sur le corps : Georges Perec

ObjectivesThis article delves into an understanding of the figures of the body in the creative process of Georges Perec's autobiographical work, “W or the Memory of Childhood,” as well as “A Man Asleep.” It seeks to examine how the shadow of Perec's parents, who disappeared during his early childhood, cast itself upon his body and his writing, resonating with Freud's famous expression to define melancholy: “the shadow of the object has fallen upon the ego.” Drawing inspiration from Didier Anzieu's work on the “Body of the Work,” this article aims to define the role played by the shadow of the object that falls upon the body in the creative process of contemporary works. Additionally, it aims to explore an interpretative key for Perec's work and creative processes in general. This exploration takes place in light of the evolving paradigms of current psychoanalytic interpretation, focusing on the crucial representation of the object's absence, as opposed to other modes of interpretation. MethodologyThe method employed for “listening” to literary texts draws inspiration from clinical psychoanalysis. This article proposes an examination of “W or the Memory of Childhood” and “A Man Asleep” through the lens of psychoanalytic practice with patients who, like Perec, claim to lack childhood memories and show signs of being marked by significant losses and/or traumas during their early years. Contemporary clinical practice often encounters states of subjective withdrawal that numerous forms of contemporary art attempt to represent. The interaction between a psychoanalytic approach to Perec's work and psychoanalytic clinical work can shed light on certain particularities of the creative process. The focus will be on listening to the sensory impressions conveyed in the text and the writer's associations stemming from his bodily experiences as a child. ResultsThis contribution puts forth the hypothesis of the role played in the creative process by incorporative identification. The shadow of Perec's parents’ bodies is particularly evident in the autobiographical fiction of “W,” where the writing portrays a body fragmented into shattered islands – memories and body parts crushed, wrecked, and petrified. These enigmatic traces of object presence gradually gain coherence as we progress in our reading. According to this perspective, the writing is unconsciously driven to “disincorporate,” so to speak, the petrified objects within the writer, attempting to emerge from psychic petrification. In “A Man Asleep,” another autobiographical fiction related to the author's late adolescence, the shadow of what did not take place with the object inhabits the narrative. This text encourages the psychoanalyst, particularly in clinical practice with patients suffering from chronic depression, to try to release the patients from melancholic incorporations, enabling them to break free from petrification and revitalize their psychic life. In the creative process of Perec's two books, as well as in listening to patients with borderline issues, the aim is to identify a form of associativity in the sequence of hallucinated sensations, much like the formal signifiers that stem from primary forms of symbolization. These signifiers somehow narrate the initial modalities of the relationship with the object. DiscussionThis analysis of the creative process based on the figures of the body and the role played by incorporative identifications opens up a discussion on a psychoanalytic approach centered around the theorization of the symbolization of absence in the therapeutic process, specifically in the presence/absence of the analyst. This approach could facilitate the process of mourning the mother. ConclusionGeorges Perec's autobiographical work resonates with the analytical listening to certain patients who also claim to have no childhood memories. One way of listening to experiences of blankness, erasure, or annihilation, with zones of withdrawal from subjectivity, involves paying attention to how the shadow of the object has fallen upon the patient's body. The analytical work consists of attempting to weave together disparate bodily experiences with fragments of memories related to the object, essentially recontextualizing sensory impressions within the history of the patient's early attachments to objects. The dynamics of the creative act, both in writing and in therapy, thus involve an internal constraint to give form and meaning to traumatic experiences rooted in the body.

Patterns of Utilization and Outcomes of Perioperative Chemotherapy in Patients With Locally Advanced-urothelial Bladder Cancer (LABC)-Real World Data From an Indian Tertiary Care Cancer Center.

Optimal utilization of perioperative systemic therapy in locally advanced bladder cancer (LABC) holds the key in improving the survival outcomes. We aim to analyze the oncological outcomes of clinically locally advanced urothelial bladder cancer patients treated with neoadjuvant (NACT) or adjuvant chemotherapy or without any systemic therapy in the perioperative period of radical cystectomy. We retrospectively analyzed the medical records of patients with cancer of the urinary bladder diagnosed between 2012 and 2020. The demographic profile, and the treatment received, was recorded for all patients. Oncological outcomes of the patients based on these variables were analyzed. Two hundred and twenty nine (229) locally advanced bladder cancer patients were included in the study. Eighty eight (38%) of them underwent upfront radical cystectomy and 141 (62%) received neoadjuvant chemotherapy (NACT). With a median follow-up of 27 months, the 2-year DFS in either of the groups was 65.4% and 67.1% respectively (P - 0.373). In the multivariate analysis, the pathological lymph nodal status and lymph vascular invasion (LVI) status influenced the DFS. The initial modality of management chosen did not affect the outcome. (HR - 0.688; 95% CI: 0.38-1.21). The commonest reason for not receiving NACT was Cisplatin ineligibility due to malignant obstructive uropathy and a subgroup analysis of this set of patients also did not show any significant difference in 2 year DFS compared to those who received NACT. A significant proportion of patients with LABC are unable to receive the recommended neoadjuvant chemotherapy and obstructive uropathy is the commonest reason for this in our centre. In our single centre series upfront radical cystectomy followed by adjuvant platinum based therapy had an outcome similar to neoadjuvant chemotherapy in LABC patients, in patients who were unable to receive the same due to various reasons.

Treatment of Recurrent Orbital Rhabdomyosarcoma with Exenteration and HDR Brachytherapy in a Custom Mold

Rhabdomyosarcoma (RMS) is the most frequent cancer affecting the orbit in children. The orbit is classified as a favorable site for RMS as treatment with chemotherapy and radiation is effective. Local failure for patients with RMS of the orbit has ranged from 2-16% on IRS and COG protocols. In the event of local recurrence, survival is poor, and management is difficult. We report four patients with local recurrence of orbital RMS managed with orbital exenteration followed by high dose rate (HDR) brachytherapy. Four patients were treated from 2016-2022. HDR brachytherapy with Ir-192 was delivered in a custom mold of the orbit made after the orbital exenteration procedure. Brachytherapy was given in 6-7 twice daily (BID) fractions starting 1 week after the orbital exenteration. At the time of brachytherapy, patient ages were 3, 1, 7, and 7 years. Three patients had embryonal histology and underwent initial systemic therapy with ARST0331 regimen A. The fourth patient had alveolar, FOXO1 fusion positive RMS and was initially treated as per COG D9803 regimen A. All patients had received proton radiotherapy as part of initial treatment. Three received 50.40 Gy and one received 45 Gy. Patients developed biopsy-proven, recurrent disease an average of 56 weeks (range 38-77) after initial diagnosis. All patients received salvage chemotherapy before undergoing orbital exenteration at an average of 12 weeks after recurrence (range 5-16). Three patients received 30 Gy in 6 BID fractions, and one patient received 28 Gy in 7 fractions with HDR brachytherapy using an Ir-192 source. All four patients are alive without evidence of disease at an average of 27 months (range 6-70) from recurrence and 39 months (range 21-78) from initial diagnosis. All patients have acceptable orbit healing. Two patients have asymptomatic evidence of frontal lobe edema (and in one case possible necrosis) extending 1-2 cm above the orbit. This appears to be beyond the range of the brachytherapy dosimetry, but the combination of proton beam and brachytherapy are implicated. No other toxicities have occurred. Orbital RMS has a favorable prognosis, but local failure after initial combined modality therapy can be fatal. Options for successful local salvage are limited. Orbital exenteration with HDR brachytherapy in a custom mold is an effective and safe procedure for local control in these difficult cases.

OA09 Vertebral fractures on bisphosphonates

OA09 Vertebral fractures on bisphosphonates

The Role of Hepatobiliary Scintigraphy as the Initial Investigative Modality for Significant Bile Leak following Laparoscopic Cholecystectomy

Introduction: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak. Methods: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments. Results: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients. Conclusions: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities.

Computed tomography versus ultrasonography in the evaluation of periumbilical abdominal pain

Background: The objective of this study was to study, assess, and make early diagnosis of periumbilical pain abdomen accurately. Aims and Objectives: To study, assess, and diagnose causes of periumbilical abdominal pain accurately so as to minimize the unnecessary exploratory laparotomy and operations and consequently improved patient care and to compare the role of ultrasonography (USG) and computed tomography (CT) in the evaluation of various causes of periumbilical abdominal pain. Materials and Methods: This prospective study (CTRI/2023/01/048809) was done on 315 patients with periumbilical pain at M.L.B. Medical College Jhansi, Uttar Pradesh on PHILIPS 16 Slice multi-detector CT SCAN machine and GE Vivid T8 ultrasound machine. These patients were blindly and randomly divided by chit system into two groups irrespective of their age and gender. The first group of patients which included 160 patients undergoes ultrasonographic evaluation and the other group of patients which includes 155 patients undergoes contrast-enhanced computed tomographic evaluation. Results: Among 315 patients, the most common cause of periumbilical pain was found to be appendicitis followed by bowel pathologies which include gastrointestinal tuberculosis. Conclusion: USG is the initial modality and modality of choice in female and young (3rd and 4thdecade) patients presenting with periumbilical pain as it is diagnostic in gynecological causes of periumbilical pain and also minimizes unnecessary radiation exposure to female and young patients. Contrast-enhanced CT is the modality of choice in male and old age patients (5th and 6th decade) as it is diagnostic in vascular causes. Overall plain CT has limited role.