Mm In Maximum Diameter Research Articles

Pulmonary nodules precision localization techniques.

The advent of helical high-resolution CT scanners, the application of screening programs and the follow-up of patient with oncological history, led to an increasing number of diagnosis of small pulmonary nodule (less than 10 mm in maximum diameter), partially solid nodule or completely ground glass ones. Their management is controversial. Excisional biopsy by mean of video-assisted thoracic surgery is often a viable choice but to locate these lesions intraoperatively can be impossible without the aid of preoperative or intraoperative localization techniques. In this brief review we will analyze the benefit of adopting localization techniques prior to pulmonary resection for small pulmonary lesions and face the advantages and problems with the main techniques described in the literatures.

Genomic comparisons between different radiological features in ground glass nodules under 20 mm in diameter.

e13664 Background: Radiological features still matters in the management of ground glass nodules (GGNs). The 20 mm in maximum diameter and consolidation tumor ratio (CTR) under 0.5 are pivotal indexes from the lobectomy to segmentectomy decision. However, the feasibility of limited resection remains controversial. Understanding the relationship between genomic characteristics and radiological features of GGNs will provide critical insights to theoretical basis of surgical method decision and expand a novel perspective to risk-stratify patients. Methods: In total, 297 surgically resected GGNs (≤ 20 mm in maximum diameter) were consecutively collected in the study. The summarized radiological features are shown (Table). In order to obtain their comprehensive genomic profiling, these tumor samples were performed using customized panels of 1021 genes. Fisher's exact test, Mann Whitney test and Kruskal-Wallis test were used for statistical analysis. Results: Higher TMB was found in subgroups with the maximum diameter > 10 mm, the volume > 0.40 mL, the CT value > -500 HU, and the mass > 200 mg ( p < 0.05). However, TMB was not associated with the increase of CTR. These data suggested that enlarged nodules occurred with increased mutation events. EGFR, RET, TP53 and RBM10 mutations were significantly enriched in groups with maximum diameter > 10 mm, volume > 0.40 mL, and mass > 0.200 g ( p < 0.05), and significant enrichment in p53-pathway and Myc-pathway were also found ( q < 0.05). ERBB2 and BRAF mutations were significantly enriched in the subgroups with maximum diameter ≤ 10 mm, volume ≤ 0.40 mL, or mass ≤ 0.200 g ( p < 0.05). As compared to the cohort of CTR ≤ 0.5 in all nodules, mutation frequencies of EGFR, RBM10 were similar, those of RET, ALK and TP53 were relatively higher ( p < 0.05), and that of ERBB2 was lower ( p = 1.7×10−5) in the cohort of CTR > 0.5. Conclusions: Our study provides the comprehensive description of the mutational landscape and radio-genomic features of GGNs under 20 mm in diameter. [Table: see text]

MON-450 Prophylactic Thyroidectomy in a Patient with Codon 891 Mutation of the RET Proto-Oncogene

Background: Medullary thyroid cancer (MTC) is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland, accounting for 1-2% of thyroid cancers in the United States. About 25% MTCs are familial as a part of the MEN2 syndrome or familial MTC (FMTC). Germline mutations in codon 891 are predominantly associated with FMTC. Case: 65-year-old Caucasian male was referred to the Endocrinology clinic after bilateral thyroid nodules were found on thyroid US. The patient had requested an ultrasound of his thyroid after his brother was diagnosed with MTC following fine-needle aspiration for an incidental thyroid nodule prompting total thyroidectomy and genetic testing. The patient’s brother was found to be heterozygous for RET mutation (c.2617T>G;pSer891Ala). This resulted in screening of the other siblings including this patient, also found to be heterozygous for this mutation. Both parents were deceased, and their clinical history is not known. Only one of the remaining two siblings had genetic testing; one brother refused testing for the mutation and one sister was positive for the mutation but had no thyroid nodules on ultrasound. She underwent prophylactic thyroidectomy. Neither the patient, nor his siblings, have any progeny. The patient screened negative for primary hyperparathyroidism and pheochromocytoma. Calcitonin (739, normal </=14.3 pg/mL)and CEA levels (31.7, 0-3.0 ng/mL) were elevated. Thyroid ultrasound (US) showed two solid hypoechoic nodules with lobulated margins and internal coarse calcifications in the right and two in the left thyroid lobe; 1.5 cm and 1.2 cm in maximum diameter, and 1.2 cm and 3 mm in maximum diameter, respectively. Based on elevated calcitonin and CEA levels, known RET mutation and evidence for thyroid nodules, we recommended a total thyroidectomy and central neck dissection. Pathology revealed multifocal, bilateral medullary carcinoma (largest focus of 1.5 cm), with 4/4 lymph nodes positive for metastasis. This was classified as mpT1bN1aM0 (Stage III). Patient was started on levothyroxine with plans to repeat calcitonin and CEA levels and neck ultrasound, 3 months following surgery. CT chest, abdomen and pelvis did not reveal any distant metastasis. Conclusion: Inherited MTCs are rare. Early diagnoses by screening of at-risk family members in MEN2 kindreds is important because MTC can be life-threatening and can be cured and prevented by early thyroidectomy. While our suspicion for FMTC in this patient and his siblings is high, FMTC is now considered a variant of MEN2A and ongoing screening for pheochromocytoma and primary hyperparathyroidism is recommended.

Primary chemoablation of low-grade upper tract urothelial carcinoma using UGN-101, a mitomycin-containing reverse thermal gel (OLYMPUS): an open-label, single-arm, phase 3 trial

Most patients with low-grade upper tract urothelial cancer are treated by radical nephroureterectomy. We aimed to assess the safety and activity of a non-surgical treatment using instillation of UGN-101, a mitomycin-containing reverse thermal gel. In this open-label, single-arm, phase 3 trial, participants were recruited from 24 academic sites in the USA and Israel. Patients (aged ≥18 years) with primary or recurrent biopsy-proven, low-grade upper tract urothelial cancer (measuring 5-15 mm in maximum diameter) and an Eastern Cooperative Oncology Group performance status score of less than 3 (Karnofsky Performance Status score >40) were registered to receive six instillations of once-weekly UGN-101 (mitomycin 4 mg per mL; dosed according to volume of patient's renal pelvis and calyces, maximum 60 mg per instillation) via retrograde catheter to the renal pelvis and calyces. All patients had a planned primary disease evaluation 4-6 weeks after the completion of initial therapy, in which the primary outcome of complete response was assessed, defined as negative 3-month ureteroscopic evaluation, negative cytology, and negative for-cause biopsy. Activity (complete response, expected to occur in >15% of patients) and safety were assessed by the investigator in all patients who received at least one dose of UGN-101. Data presented are from the data cutoff on May 22, 2019. This study is registered with ClinicalTrials.gov, NCT02793128. Between April 6, 2017, and Nov 26, 2018, 71 (96%) of 74 enrolled patients received at least one dose of UGN-101. 42 (59%, 95% CI 47-71; p<0·0001) patients had a complete response at the primary disease evaluation visit. The median follow-up for patients with a complete response was 11·0 months (IQR 5·1-12·4). The most frequently reported all-cause adverse events were ureteric stenosis in 31 (44%) of 71 patients, urinary tract infection in 23 (32%), haematuria in 22 (31%), flank pain in 21 (30%), and nausea in 17 (24%). 19 (27%) of 71 patients had study drug-related or procedure-related serious adverse events. No deaths were regarded as related to treatment. Primary chemoablation of low-grade upper tract urothelial cancer with intracavitary UGN-101 results in clinically significant disease eradication and might offer a kidney-sparing treatment alternative for these patients. UroGen Pharma.

Unclassified sex cord / gonadal stromal testis tumour with a pure spindle cell component

Incompletely differentiated sex cord / gonadal stromal tumours of the testis (SCST) of pure spindle cell morphology are extremely rare with only four reported cases in the literature.1 We report a case of a 73-year-old man who presented with acute on chronic renal failure and noted to have an enlarged tender left testicle. Ultrasound examination revealed an enlarged testis (40 cc) with diffuse heterogeneity of the testicular parenchyma. A radical orchiectomy procedure was performed. The histological examination revealed a well circumscribed tumour (55 mm in maximum diameter) comprised purely of fascicles of spindle cells with elongated to ovoid nuclei. Immunohistochemical stains demonstrated positive staining for Vimentin, S100, SMA, Inhibin, Calretinin and CD99. EMA, Cam 5.2, AE1&3, Desmin, CD34, Melan-A, HMB-45, Sox10, CD117 and PLAP stains were negative. The overall features were consistent with the diagnosis of unclassified SCSTs of pure spindle cells morphology. Due to the rarity, SCST of spindle cell morphology are under studied. They are of unknown clinical behaviour. However, they should be considered in the differential diagnosis of spindle cell lesions of the testis.

A Geomorphic Framework for the Analysis of Microplastics in Riverine Sediments

The wide-spread use and persistence of plastics in the environment have placed them on the list of significant emerging pollutants. In contrast to marine environments, the analysis of plastic debris, including microplastics (particles &lt;5 mm in maximum diameter), in freshwater systems is limited, and even fewer studies have examined microplastics in riverine sediments. Nonetheless, it has become clear that microplastics are now a ubiquitous component of riverine ecosystems and their distribution is dependent on anthropogenic inputs and the physical and chemical processes that control their transport, transformation, and deposition along the drainage network. In many ways, the transport and fate of microplastics will parallel that of other particulate matter that has been extensively studied for at least the last 50 years. Here, we briefly explore the application of a geomorphic approach to the assessment of sediment-contaminated rivers to the microplastic problem, and argue that future studies can significantly benefit by incorporating the principles of this approach into their analyses.

Efficacy of a 14-coil for Framing in Coil Embolization of Small Cerebral Aneurysms.

The purpose of this study was to demonstrate the efficacy of a 14-coil (Target XL) for framing in coil embolization of small cerebral aneurysms. Between January 2017 and December 2018, 46 patients underwent coil embolization of a small cerebral aneurysm that was less than 5 mm in maximum diameter. They were categorized into 26 patients in whom only 10-coils were used and 20 in whom Target XL was used for framing. The volume embolization rate (VER) and recanalization rate were compared between the two groups. Although there were two patients in whom Target XL was replaced with a 10-coil for framing, no adverse events associated with the use of Target XL were noted. The mean VER of the first framing coil was significantly higher in aneurysms that were framed with Target XL than in those framed with a 10-coil (Target XL 22.6 ± 4.5%, 10-coil 17.9 ± 8.4%; p = 0.03). Furthermore, the mean VER at the end of the procedure was significantly higher in aneurysms with Target XL used for framing than in those embolized using only 10-coils (14-coil: 36.8 ± 7.8%, 10-coil: 32.0 ± 6.5%; p = 0.03). No recanalization was observed in aneurysms for which Target XL was used for framing, whereas five aneurysms embolized using only 10-coils were recanalized. Target XL may be safe and feasible as a framing coil in coil embolization of small cerebral aneurysms, which may result in a high VER, low recanalization rate, and good outcome.

P1465 Ventricular septal defect and pulmonary artery aneurysm; How does it look by three dimensional echocardiography

Abstract Introduction Pulmonary artery (PA) aneurysms (PAAs) are rare and infrequently diagnosed . The upper limit of the main PA diameter (29 mm) was defined as a PAA. Congenital causes have been recognized as the major reason for PAA formation. More than 50% of all cases were associated with congenital heart disease. The 3 most frequent congenital heart defects associated with a PAA are, in decreasing order, persistent ductus arteriosus (PDA), ventricular septal defects (VSD) , and atrial septal defects (ASD).En face visualization of the whole circumference of the VSD and its relation to the surrounding structures can help in better understanding of the shear stress that promote PAA formation. Case report A 35 year old female patient with no previous cardiac history .She presented to our medical facility complaining of exertional dyspnea since 2 years . On clinical examination, she had harsh pansystolic murmur heard over left parasternal area . 2D Transthoracic Echocardiography revealed an aneurysmally dilated pulmonary artery (40mm in maximum diameter) and a wide VSD. 3D transthoracic and transesophageal echocardiography showed a wide subarterial VSD which is immediately located below the pulmonary valve. Therefore , that increased flow caused by left-to-right shunt caused by the intimate location of the VSD to the pulmonary valve results in increased hemodynamic shear stress on the vessel walls and therefore promotes aneurysm formation .Surgical closure of the VSD was done successfully with no residual defects. Conclusion PAAs seldom occur, are rarely diagnosed, and do not present with distinct symptoms. With the help of 3D echocardiography , direct visualization of the surrounding septal defects helps better understanding of mechanism of the aneurysm formation. Abstract P1465 Figure.

Not all lesions are created equal: removal of a cavernous hemangioma.

A 63-year-old woman was referred for evaluation of a subepithelial esophageal mass and dysphagia. Endoscopy at an outside hospital reported an increase in the size of the mass. Endoscopic ultrasound showed a hypoechoic well-defined subepithelial mass originating within the submucosa and measuring 23 mm in maximum diameter. Fine-needle aspiration of the mass was nondiagnostic. Owing to the dysphagia and the increase in size, we proceeded with endoscopic resection ([Video 1]).

Sixteen-Year Survival after Endovascular Abdominal Aortic Aneurysm Repair with the Zenith Stent Graft

Introduction - Although endovascular aneurysm repair (EVAR) is in widespread use, truly long-term data is still lacking. This study characterizes our sixteen year experience of EVAR using the Zenith stent graft in a single academic center. Methods - Between 2000 and 2010, 282 patients with abdominal aortic aneurysm (AAA) underwent elective EVAR using the Zenith stent graft (Cook Inc. Bloomington, Ind). Patients were annually monitored thereafter. Primary outcomes were overall and AAA-rupture free survival. Secondary outcomes were survival from graft-related complications and re-interventions. Results - Mean age was 75 years (range, 49- 92 years) and mean aneurysm diameter 61mm (range, 40-110mm) at the time of the initial treatment. The mean follow-up was 79 months (range, 0-201 months). The overall survival was 93%, 61%, 25% and 9% at 1, 5, 10 and 16 years. Even for those ≥80 years, the survival was 46% at 5 years. Five AAA ruptures occurred during the follow-up, four of which were fatal. Consequently, cumulative AAA-rupture free survival was 100%, 99%, 97% and 97% at 1, 5, 10 and 16 years. Freedom from any stent graft related complications was 68%, 58%, 54%, 52%, and from graft-related re-interventions 95%, 80%, 73%, 70% at 1, 5, 10 and 16 years, respectively. Only five (1.8%) late conversions to open repair were required during the follow-up. Aneurysm sac shrinkage ≥5mm was seen in 60% of the cases with the mean decrease of 18.5mm in maximum diameter. Conclusion - Fatal AAA rupture after EVAR is a rare phenomenon and patients eventually die from natural causes. Even octo-and nonagenarians seem to tolerate the procedure well as almost half of the patients are still alive at five years. The number of graft-related complications is relatively high, but according to our findings, they don’t always require re-intervention and can safely be followed. New complications keep appearing years after the initial procedure thus suggesting the life-long surveillance as mandatory.

Outcome of endoscopic resection of colonic polyps larger than 10 mm in patients with inflammatory bowel disease.

Background and study aims There are limited published data on endoscopic removal of colorectal polyps by endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD) in patients with inflammatory bowel disease (IBD). Patients and methods We performed a retrospective review of patients with colonic IBD and colonic polyps >10mm who underwent EMR and/or ESD at our institution between January 1, 2012 and June 31, 2016. Results Ninety-seven patients with pathology-confirmed IBD (median disease duration 16 years) were included. Mild or moderate active colitis (in background biopsies) was seen in 85 %. Of the total 124 polyps, location was ascending colon in 44 %, transverse in 15 % and sigmoid in 18.5 %; of the total, 55 % were < 20 mm and 45 % were ≥20mm in maximal diameter. Using the Paris classification, 56 % of polyps were polypoid sessile (Is) polyps, while 38 % were non-polypoid (IIa, IIb, IIc). EMR was used in 118 polyps, three required ESD, and three by combined EMR-ESD. Seventy-two percent were resected en-bloc; 28 % underwent piecemeal resection. Histology included low-grade dysplasia in 75, serrated adenoma in 31, and tubular adenoma in 14 polyps. Chromoendoscopy was used in 33 (26.6 %). Adverse events occurred in three patients. Colectomy was performed in 11 patients within 12 months. Recurrence was seen in 20 polyps, 11 of which were successfully resected en-bloc using EMR. Polyps ≥ 20 mm and polyps treated with APC were found to have a statistically significantly higher risk of recurrence. Conclusion This study demonstrates the efficacy and safety of endoscopic resection of large polyps in patients with IBD, making them effective alternatives to colectomy.

Blue nodule on the finger

A 67-year-old woman sought treatment for a painful nodule on the perionychium of the right second finger that had rapidly enlarged over the previous year. The patient reported that the point of a lead pencil had become lodged in her skin at the age of 10 years. The nodule was blue-gray in color, 9.6 mm in maximum diameter, and unattached to the subcutaneous tissue (Fig 1). Dermoscopic examination found homogeneous blue pigmentation (HBP) over the lesion. Several dotted vessels were observed in the lesion center under higher magnification (Fig 2). Histologic findings confirmed a diagnosis of pencil-core granuloma (Fig 3).Key messageThis case displayed HBP by dermoscopy that resembled a blue nevus. HBP generally corresponds to dermal melanin granules of melanocytic tumors, such as blue nevus, but is also observed in hemangioma, dermatofibroma, and other nonmelanocytic tumors.1Longo C. Scope A. Lallas A. et al.Blue lesions.Dermatol Clin. 2013; 31: 637-647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Histopathologic examination found that the HBP in this case was caused by the dermal deposition of graphite and graphite accumulation within macrophages. Several cases of pencil-core granuloma have been reported to exhibit HBP on dermoscopy,2Menzies S.W. Moloney F.J. Byth K. et al.Dermoscopic evaluation of nodular melanoma.JAMA Dermatol. 2013; 149: 699-709Crossref PubMed Scopus (76) Google Scholar with a history of embedded pencil-tip graphite at the site representing a clue for correct diagnosis. However, melanoma could not be completely excluded in this case because of the dermoscopic finding of dotted vessels and the rapid size increase of the tumor. Close attention is necessary for nodular melanoma, as it frequently shows a symmetrical pigmentation pattern without pigment network.2Menzies S.W. Moloney F.J. Byth K. et al.Dermoscopic evaluation of nodular melanoma.JAMA Dermatol. 2013; 149: 699-709Crossref PubMed Scopus (76) Google Scholar Pencil-core granulomas may suddenly develop long after the initial trauma, presumably because of delayed granulomatous reactions towards the graphite, clay, wax, and other components of pencil cores.3Terasawa N. Kishimoto S. Kibe Y. Takenaka H. Yasuno H. Graphite foreign body granuloma.Br J Dermatol. 1999; 141: 774-776Google Scholar This case displayed HBP by dermoscopy that resembled a blue nevus. HBP generally corresponds to dermal melanin granules of melanocytic tumors, such as blue nevus, but is also observed in hemangioma, dermatofibroma, and other nonmelanocytic tumors.1Longo C. Scope A. Lallas A. et al.Blue lesions.Dermatol Clin. 2013; 31: 637-647Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Histopathologic examination found that the HBP in this case was caused by the dermal deposition of graphite and graphite accumulation within macrophages. Several cases of pencil-core granuloma have been reported to exhibit HBP on dermoscopy,2Menzies S.W. Moloney F.J. Byth K. et al.Dermoscopic evaluation of nodular melanoma.JAMA Dermatol. 2013; 149: 699-709Crossref PubMed Scopus (76) Google Scholar with a history of embedded pencil-tip graphite at the site representing a clue for correct diagnosis. However, melanoma could not be completely excluded in this case because of the dermoscopic finding of dotted vessels and the rapid size increase of the tumor. Close attention is necessary for nodular melanoma, as it frequently shows a symmetrical pigmentation pattern without pigment network.2Menzies S.W. Moloney F.J. Byth K. et al.Dermoscopic evaluation of nodular melanoma.JAMA Dermatol. 2013; 149: 699-709Crossref PubMed Scopus (76) Google Scholar Pencil-core granulomas may suddenly develop long after the initial trauma, presumably because of delayed granulomatous reactions towards the graphite, clay, wax, and other components of pencil cores.3Terasawa N. Kishimoto S. Kibe Y. Takenaka H. Yasuno H. Graphite foreign body granuloma.Br J Dermatol. 1999; 141: 774-776Google Scholar

Giant peritoneal loose body: A case report.

Peritoneal loose body (PLB) is a rare finding and it is usually incidentally discovered during laparotomy, examination or autopsy, as it is usually asymptomatic or presents with non-specific symptoms. In particular, giant PLBs, measuring >50 mm in maximum diameter, are even more rare, and only a few cases of laparoscopic extraction of these giant bodies have been reported in the literature to date. We herein describe our experience with the diagnosis and treatment of a giant PLB in a 49-year-old male patient who was admitted with complaints of intermittent pain the in lower abdomen 3 months earlier. An abdominal computed tomography scan revealed a 5.5x5.0-cm midline mass with central high density. The diagnosis was confirmed by open surgery and postoperative pathological examination. The postoperative recovery of the patient was uneventful and he was discharged from the hospital 7 days after surgery.

Diagnostic Accuracy and Usefulness of Intraoperative Margin Assessment by Frozen Section in Gastric Cancer.

Intraoperative frozen examination is clinically important for negative margin confirmation in cancer surgery. We investigated the diagnostic accuracy of frozen-section assessment and risk factors for positive resection margins by studying gastric cancer specimens from 1115 patients treated at our hospital. The results of gastric cancer patients who had undergone intraoperative margin assessment, employing frozen examination, with curative intent in our unit between 2000 and 2017 were retrospectively analyzed. Frozen section assessments were compared with the corresponding permanent section assessments to evaluate the accuracy, sensitivity, and specificity of the former. The causes of discordances between two assessments were examined. In addition, risk factors associated with positive margins were identified. In total, 1241 specimens were obtained from the 1115 patients. The accuracy, sensitivity, and specificity of frozen-section assessments were 99.4%, 99.5%, and 97.8%, respectively. There were eight discordant cases. Two false-negative cases required another gastrectomy after final pathological diagnosis because of missed neoplastic cells. Six false-positive cases underwent unnecessary additional resection due to false positive results. In our frozen series, 89 cases had a positive margin on permanent section. Multivariate regression analysis of patients with positive surgical margins revealed large diameter (≥ 50mm) and T4 tumor to be independent risk factors. Intraoperative frozen examination is a highly accurate method that is useful for achieving negative margins. This procedure is especially recommended for patients with a tumor larger than 50mm in maximum diameter or serosal invasion to confirm a negative margin.

Resection of Cerebellopontine Angle Meningioma via Retrosigmoid Approach Aiming for Hearing Improvement.

We present a 71-year-old female case of left cerebellopontine angle (CPA) meningioma who presented with progressive hearing loss. The tumor was 35 mm in maximum diameter, obviously compressed the brain stem and cerebellum, and also displaced cranial nerves 7th and 8th anteriorly ( Fig. 1 ). Retrosigmoid approach was chosen to resect the tumor aiming for hearing improvement. We performed dissection of the tumor from cranial nerves 7th and 8th gently and resection of the tumor except for the part adhesive to these cranial nerves ( Fig. 2 ). Postoperative course was good without any new neurological deficit. Postoperative examination also showed improvement of high-frequency hearing of the left side, and auditory brainstem response demonstrated wave 2 to 5, which was not identify on preoperative examination. These procedures enabled safe and effective resection of the tumor and contributed to hearing improvement. The link to the video can be found at: https://youtu.be/hkRSCxtV3bY .

P113 Efficacy, safety and long-term durability of endovascular treatment of MCA aneuryms: a review of 161 treated aneurysms

ObjectivesThe aim of this study was to assess the long-term outcomes of endovascular treatment of MCA aneurysms and identify factors associated with recurrence.Subjects161 aneurysms in 147 patients treated between January 2008 and August 2011.MethodsA retrospective case note review was performed. Aneurysm occlusion was assessed using the Raymond-Roy classification. Clinical outcome was graded using the mRS.ResultsThe minimum period of follow up was 65 months, with a maximum follow up period of 120 months. 49% of aneurysms were ruptured at the time of treatment. Morbidity was observed in 15% of the unruptured aneurysms (6% permanent neurological deficit), and in 33% of ruptured aneurysms (15% permanent neurological deficit). 84% of aneurysms were fully occluded following first treatment. Of these, 34% demonstrated angiographic recurrence and 10% required re-intervention. 25% of aneurysms≤7 mm in maximal diameter demonstrated angiographic recurrence, as compared with 50% of aneurysms&gt;7 mm. Aneurysm size &gt;7 mm was associated with a significantly shorter time to recurrence (log rank=9.655, p=0.002).ConclusionsThis is a large series of MCA aneurysms with a long period of follow up. Our results demonstrate that endovascular treatment of MCA aneurysms is associated with a low morbidity and mortality. Given the increasing use of adjunctive devices (stents, web devices) full occlusion of ruptured aneurysms in the acute phase is not necessary, and deliberate staged treatment a reasonable strategy.

Accuracy of a Novel Histoplasmosis Enzyme Immunoassay to Evaluate Suspicious Lung Nodules.

Granulomas caused by infectious lung diseases present as indeterminate pulmonary nodules (IPNs) on radiography. Newly available serum enzyme immunoassay (EIA) for histoplasmosis has not been studied for the evaluation of IPNs. We investigated serum biomarkers of histoplasmosis antibodies as an indication of benign disease in IPNs from a highly endemic region. A total of 152 serum samples from patients presenting with pulmonary nodules ≤30 mm in maximum diameter were analyzed for histoplasmosis antibodies by immunodiffusion and EIA IgG and IgM tests. Serology and FDG-PET/CT scan diagnostic test characteristics were estimated and compared. Cancer prevalence was 55% (n = 83). Thirty-nine (26%) individuals were positive for IgG histoplasmosis antibodies. Twelve samples were IgM antibody positive. Immunodiffusion serology was similar to IgM antibody results with 13 positive tests. Diagnostic likelihood ratios for benign disease were 0.62, 0.33, and 0.28 for FDG-PET/CT, IgG, and IgM antibodies, respectively. When both IgG and IgM were positive (n = 8), no nodules were cancerous and six were FDG-PET/CT avid. A positive EIA test for both IgM and IgG strongly suggested histoplasmosis etiology and benign granuloma for 12% of benign nodules arising from a highly endemic region. Presence of either IgG or IgM histoplasma antibodies was associated with benign disease. The EIA test was more sensitive in assessing histoplasma exposure than immunodiffusion serology. A new CLIA-certified histoplasmosis antibody EIA test measures histoplasmosis exposure, offers a possible alternative clinical diagnosis for benign IPNs, and may improve IPN evaluation while avoiding harmful invasive biopsies.

Survival with Parenchymal and Pleural Invasion of Non–Small Cell Lung Cancers Less than 30 mm

ObjectiveTo determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter. MethodsKaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11–20 mm, and 21–30 mm) and nodule consistency. Log-rank test statistics were calculated. ResultsThe frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p < 0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] =1.07, 95% confidence interval [CI]: 1.01–1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25–7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35–75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01–5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01–1.13), whereas PAI was no longer significant (p = 0.19). ConclusionsNodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.

Are thyroid nodules with spongiform morphology always benign?

Fine needle aspiration (FNA) biopsy for evaluation of spongiform nodules ≥20mm or observation without FNA was recommended by American Thyroid Association. However, this was a weak recommendation supported by moderate quality evidence. We aimed to assess malignancy risk in spongiform nodules. From January 2015 to June 2016, an experienced endocrinologist performed B-mode greyscale ultrasonography and observed 96 spongiform nodules among 3748 ultrasound procedures. Power Doppler ultrasonography and ultrasound-guided FNA were performed to 96 spongiform nodules. Both colour elastography and strain ratio measurements of dominantly solid areas were performed. All spongiform nodules had benign cytology. Fifty-two (54.2%) nodules were ≥20mm and 44 (45.8%) were smaller than 20mm in maximum diameter. Presence of ultrasonography features related to malignancy was rare; 2% (n=2) microcalcification, 9.4% (n=9) taller than wide shape and 2% (n=2) marked central blood flow were noted. None of the nodules had two or more suspicious features. Ultrasound elastography findings revealed that dominantly solid components of nodules were usually soft as 66.7% had an elasticity score 1 according to colour scale and mean strain ratio was 1.39±0.99. Follow-up with ultrasonography seems to be an efficacious method even for spongiform nodules larger than 2cm. Determination of soft appearance according to colour map on ultrasound elastography and low strain ratio values of dominantly solid areas may be useful to avoid unnecessary biopsies.

Predictors of spontaneous ureteral stone passage in the presence of an indwelling ureteral stent.

Patients presenting acutely with obstructing stones often have a ureteral stent placed as a temporizing solution. Ureteroscopy is then commonly performed in a staged fashion, but occasionally the stone is found to have passed. We aimed to identify the frequency and predictors of ureteral stone passage with a stent in place. Records were reviewed to identify patients who had a stent placed for a single ureteral stone. Subsequent ureteroscopy or CT scan was used to ascertain stone passage. Effect of age, gender, BMI, stone diameter, alpha blocker use, urinary tract infection, hydronephrosis, and stent duration on stone passage was assessed. Inclusion and exclusion criteria were met in 209 patients. Mean maximum stone diameter was 6.5 ± 2.5mm. Passage rates for stones < 3mm, 3-4.9mm, 5-6.9mm, and ≥ 7mm were 50%, 13%, 10%, and 0%, respectively. The overall rate of passage was 8%. Stone passage was associated with smaller maximum stone diameter, more distal stone location, and longer duration of stent before ureteroscopy/CT on univariate analysis (p < 0.01). Stone diameter and stent duration remained significantly associated on multivariable analysis (p = 0.001 and p = 0.05, respectively). Our findings suggest ureteral stone passage with a concurrent ureteral stent is not a rare event as it occurred in 14% of stones less then 7mm in maximum diameter. Stone size and duration of stent before ureteroscopy or CT were found to be independent predictors of passage. Select patients with small ureteral stones who have been stented should be considered for a trial of urine straining or repeat imaging before subsequent ureteroscopy.