Postsurgical Findings Research Articles

Can Nomograms Predict Preoperative Axillary Lymph Node Metastasis in Patients With Breast Cancer to Guide Second Look Ultrasonography?

The low sensitivity of ultrasonography (US) for diagnosing axillary lymph node metastasis in patients with breast cancer has led to the development of multiple tools in an attempt to increase preoperative sensitivity, including second-look US. We compared axillary lymph node metastasis predictor scores with postsurgical findings, using the Memorial Sloan Kettering Cancer Center (MSKCC; New York, NY) and Evidencio (www.evidencio.com) nomograms: 2 freely available online predictor tools. We retrospectively evaluated 450 patients with breast cancer and analyzed data from 194 patients. Sonograms were evaluated to measure lymph node cortical thickness, transverse diameter, and hilum status. Patients were divided into 3 groups: namely 0, 1, and 2 based on the number of postoperative positive nodes (0, 1 and ≥2, respectively). One-way analysis of variance was used to analyze the differences in mean scores across the 3 nodal groups for both nomograms. P < .05 was considered statistically significant. There were significant differences in mean scores across the 3 nodal groups when using MSKCC (P < .001) as well as Evidencio (P < .001). However, there was an overlap of scores across the 3 groups; thus, mutually exclusive values were not obtained. A strong positive correlation was found between MSKCC and Evidencio (P < 0.001). Tumor size and the presence of lymphovascular invasion were significantly associated with axillary nodal disease (P < .001; P = .003, respectively). The use of nomograms to predict axillary nodal involvement in patients with breast cancer can guide discussions, but in their present state, these scores cannot guide clinical decisions or direct second-look US of axilla.

Imaging of postoperative shoulder instability

Postoperative imaging in shoulder instability is still a challenge for radiologists due to various postsurgical anatomical findings that could be considered pathologic in treated shoulder. For this reason is very important a deep knowledge about surgical procedures, anatomical changes after surgery and the appropriate diagnostic imaging modalities to work up the symptomatic postoperative shoulder. Postoperative imaging options include use conventional radiography, magnetic resonance imaging (MRI), MRI arthrography, computed tomography (CT) and CT arthrography. The purpose of our review is to explain the different surgical procedures and to describe postoperative changes detected with radiological imaging.

Clinicopathologic correlates of postoperative N1 or N2 nodal upstaging in non-small cell lung cancer.

Clinical and pathologic determinations of lymph node staging are critical in the treatment of lung cancer. However, up- or downstaging of nodal status frequently is necessitated by postsurgical findings. This study was conducted to evaluate clinicopathologic features that impact nodal upstaging in patients staged primarily via positron emission tomography/computed tomography (PET/CT) and chest CT prior to surgery. Between years 2011 and 2014, 634 patients underwent surgical treatment for non-small cell lung cancer (NSCLC) at our institution. Excluding 37 patients (given induction chemotherapy), 103 patients pathologically staged as N1 or N2 NSCLC. Nodal upstaging patients were classified into group A and non-upstaging patients into group B. We compared clinical characteristics and pathological results of group A with group B. Ultimately, 59 patients (57.3%) were assigned to group A and 44 patients (42.7%) to group B. Patients in group A (vs. group B) were significantly younger (61.6 vs. 68.4 years; P<0.001) and more often were female (47.5% vs. 15.9%; P=0.001), with shorter smoking histories (12.2 vs. 28.8 pack years; P<0.001) and lower maximum standardized uptake values (SUVmax) (7.3 vs. 10.4; P=0.001). Most upstaged (group A) tumors (50/59, 84.7%) were adenocarcinomas, displaying micropapillary (MPC; n=36) and lepidic (n=35) component positivity with significantly greater frequency (both, P<0.001); and the frequency of epidermal growth factor receptor (EGFR) mutation (n=36) was significantly greater in this subset (P=0.001). Multivariate analysis (logistic regression) indicated a significant correlation between MPC positivity and nodal upstaging (P=0.013). In patients upstaged postoperatively to N1 or N2 stage of NSCLC, occult lymph node metastasis and MPC positivity were significantly related.

A retrospective comparison of preoperative MR staging and post-surgical pathology findings in patients with locally advanced rectal cancer treated with neoadjuvant chemotherapy.

A retrospective comparison of preoperative MR staging and post-surgical pathology findings in patients with locally advanced rectal cancer treated with neoadjuvant chemotherapy.

Cardiac magnetic resonance radiofrequency tissue tagging for diagnosis of constrictive pericarditis: A proof of concept study

ObjectiveInvasive cardiac catheterization is the venerable “gold standard” for diagnosing constrictive pericarditis. However, its sensitivity and specificity vary dramatically from center to center. Given the ability to unequivocally define segments of the pericardium with the heart via radiofrequency tissue tagging, we hypothesize that cardiac magnetic resonance has the capability to be the new gold standard. MethodsAll patients who were referred for cardiac magnetic resonance evaluation of constrictive pericarditis underwent cardiac magnetic resonance radiofrequency tissue tagging to define visceral-parietal pericardial adherence to determine constriction. This was then compared with intraoperative surgical findings. Likewise, all preoperative cardiac catheterization testing was reviewed in a blinded manner. ResultsA total of 120 patients were referred for clinical suspicion of constrictive pericarditis. Thirty-nine patients were defined as constrictive pericarditis positive solely via radiofrequency tissue-tagging cardiac magnetic resonance, of whom 21 were positive, 4 were negative, and 1 was equivocal for constrictive pericarditis, as defined by cardiac catheterization. Of these patients, 16 underwent pericardiectomy and were surgically confirmed. There was 100% agreement between cardiac magnetic resonance–defined constrictive pericarditis positivity and postsurgical findings. No patients were misclassified by cardiac magnetic resonance. In regard to the remaining constrictive pericarditis–positive patients defined by cardiac magnetic resonance, 10 were treated medically, declined, were ineligible for surgery, or were lost to follow-up. Long-term follow-up of those who were constrictive pericarditis negative by cardiac magnetic resonance showed no early or late crossover to the surgery arm. ConclusionsCardiac magnetic resonance via radiofrequency tissue tagging offers a unique, efficient, and effective manner of defining clinically and surgically relevant constrictive pericarditis. Specifically, no patient who was identified with constriction via cardiac magnetic resonance underwent inappropriate sternotomy. However, catheterization had substantial and unacceptable false-positive and false-negative rates with important clinical ramifications.

High-Resolution Magnetic Resonance Imaging Can Reliably Detect Orbital Tumor Recurrence after Enucleation in Children with Retinoblastoma

Orbital tumor recurrence is a rare but serious complication in children with retinoblastoma, leading to a high risk of metastasis and death. Therefore, we assume that these recurrences have to be detected and treated as early as possible. Preliminary studies used magnetic resonance imaging (MRI) to evaluate postsurgical findings in the orbit. In this study, we assessed the diagnostic accuracy of high-resolution MRI to detect orbital tumor recurrence in children with retinoblastoma in a large study cohort. Consecutive retrospective study (2007-2013) assessing MRI findings after enucleation. A total of 103 MRI examinations of 55 orbits (50 children, 27 male/23 female, mean age 16.3±12.4 months) with a median time of 8 months (range, 0-93) after enucleation for retinoblastoma. High-resolution MRI using orbital surface coils was performed on 1.5 Tesla MRI systems to assess abnormal orbital findings. Five European experts in retinoblastoma imaging evaluated the MRI examinations regarding the presence of abnormal orbital gadolinium enhancement and judged them as "definitive tumor," "suspicious of tumor," "postsurgical condition/scar formation," or "without pathologic findings." The findings were correlated to histopathology (if available), MRI, and clinical follow-up. Abnormal orbital enhancement was a common finding after enucleation (100% in the first 3 months after enucleation, 64.3% >3 years after enucleation). All histopathologically confirmed tumor recurrences (3 of 55 orbits, 5.5%) were correctly judged as "definitive tumor" in MRI. Two orbits from 2 children rated as "suspicious of tumor" received intravenous chemotherapy without histopathologic confirmation; further follow-up (67 and 47 months) revealed no sign of tumor recurrence. In 90.2%, no tumor was suspected on MRI, which was clinically confirmed during follow-up (median follow-up after enucleation, 45 months; range, 8-126). High-resolution MRI with orbital surface coils may reliably distinguish between common postsurgical contrast enhancement and orbital tumor recurrence, and therefore may be a useful tool to evaluate orbital tumor recurrence after enucleation in children with retinoblastoma. We recommend high-resolution MRI as a potential screening tool for the orbit in children with retinoblastoma to exclude tumor recurrence, especially in high-risk patients within the critical first 2 years after enucleation.

Postsurgical imaging of the oral cavity and oropharynx: what radiologists need to know.

The oral cavity and oropharynx are common locations of neoplastic lesions; neoplasms at these sites are often treated with surgery. The goal of this surgical treatment is to achieve tumor control while preserving, whenever possible, the function of local structures. The procedure used depends largely on the location and extension of the tumor and the disease stage. Follow-up evaluation of patients is done with computed tomography (CT) and magnetic resonance (MR) imaging. The ability to interpret characteristic features at CT and MR imaging is particularly important because normal anatomic structures are altered in specific patterns according to the distinct surgical technique applied. Anatomic changes resulting from the most commonly performed procedures (eg, glossectomy, pelvectomy, and mandibulectomy) will be presented with CT and MR images, multiplanar reconstructions, and schematic illustrations. Understanding of postsurgical CT and MR imaging findings is important to avoid misinterpretation and confusion. Familiarity with the typical postsurgical imaging appearance of the oral cavity and oropharynx is crucial for differentiating normal postsurgical changes from persistent or recurrent disease and for diagnosis of associated second primary malignancies. Knowledge of postsurgical findings is essential for analysis of the oral cavity and oropharynx and allows early diagnosis of tumor recurrence or typical complications after surgical reconstruction.

CT and MRI of aortic coarctation: pre- and postsurgical findings.

OBJECTIVE. The purpose of this article is to summarize the roles of CT and MRI in the diagnosis and follow-up of patients with aortic coarctation. CONCLUSION. Aortic coarctation is a common congenital heart disease accounting for approximately 6-8% of congenital heart defects. Despite its deceptively simple anatomic presentation, it is a complex medical problem with several associated anatomic and physiologic abnormalities. CT and MRI may provide very accurate information of the coarctation anatomy and other associated cardiac abnormalities.

ECG-gated MDCT after aortic and mitral valve surgery.

The purpose of this article is to review the utility of ECG-gated MDCT in evaluating postsurgical findings in aortic and mitral valves. Normal and pathologic findings after aortic and mitral valve corrective surgery are shown in correlation with the findings of the traditionally used imaging modalities echocardiography and fluoroscopy to assist in accurate noninvasive anatomic and dynamic evaluation of postsurgical valvular abnormalities. Because of its superior spatial and adequate temporal resolution, ECG-gated MDCT has emerged as a robust diagnostic tool in the evaluation and treatment of patients with postsurgical valvular abnormalities.

Hysterosalpingography: an imaging Atlas with cross-sectional correlation.

Hysterosalpingography (HSG) provides a unique combination of both fallopian tube and uterine cavity evaluation. A comprehensive understanding of both HSG and correlative cross-sectional imaging findings are essential radiologic skills. This article will review the spectrum of technical artifacts, anatomic variants, congenital uterine anomalies, uterine and tubal pathology, and postsurgical findings as they appear on HSG. Additionally, correlation with MR and ultrasound images is provided. This review article serves as a reference for residents new to HSG as well as staff who perform and interpret HSG infrequently.

Clinical review: Thyroid cancer mimics on surveillance neck sonography.

Sonography of the neck is a critical tool in monitoring patients after near-total thyroidectomy for differentiated thyroid cancer. Sonography has proven to be among the most sensitive imaging techniques for the detection of recurrent or residual cancer in the thyroidectomy bed and metastatic cervical lymph nodes. It is important for the sonologist to be familiar with normal postsurgical findings and other disease processes that may imitate malignant lesions. We describe the typical sonographic appearance of benign lesions that can resemble recurrent thyroid cancer.

Pitfalls in shoulder MRI: part 2--biceps tendon, bursae and cysts, incidental and postsurgical findings, and artifacts.

The purpose of this article is to review frequently encountered pitfalls as they pertain to the biceps tendon, bursae and cysts around the shoulder, incidental findings, postsurgical findings, and frequently encountered imaging artifacts. Imaging pitfalls in and around the shoulder are not limited to normal anatomy and anatomic variants. Radiologists must be cognizant of the vast variability of structures in the shoulder and of the incidental and postsurgical findings and artifacts affecting them.

Sa1369 Biomarker Assessment From EUS Guided Biopsy Predicts Survival Outcomes and Surgical Treatment in Pancreatic Carcinoma

to assessment of esophageal function was 8±7 years. None of the patients had a history of dysphagia or esophageal function testing prior to surgery. The bariatric procedures commonly found in patients with symptoms were Roux-en-Y Gastric Bypass (RYGB) [10 patients], LAGB [5 patients], and sleeve gastrectomy [3 patients]. Common complaints at presentation were dysphagia (8), GERD (6), chest pain (3) and abdominal pain (1). Results of HRM are provided in table 1. The most frequently seen abnormality was Ineffective Esophageal Motility (IEM) and hypertensive LES. Of the 18 patients, two patients had opioid induced esophageal dysmotility. LAGB had the most variable esophageal motor findings, which resolved with deflation of the balloon. Patients with RYGB and sleeve gastrectomy responded to medical management, except for one sleeve gastrectomy patient that underwent revision to RYGB for symptom control. Conclusion: Bariatric surgery has implications not only on the distal, but proximal gut transit and motility. The skewed male prominence in this study is not clearly understood. Our data is limited by the lack of pre-surgical HRM studies to compare post surgical findings. These results have important implications for clinical care, and support the use of HRM in the care management plan of bariatric surgical patients. Table 1: Results of HRM (description) and response to therapy

Gastric Cancer: The Role of Diffusion Weighted Imaging in the Preoperative Staging

Purpose: Evaluate the role of diffusion-weighted-imaging (DWI) in the diagnosis and staging of gastric carcinoma. Materials and methods: A total of 31 patients with gastric adenocarcinoma, which underwent preoperative staging with 3Tesla Magnetic Resonance Imaging (MRI), were enrolled. Two radiologists evaluated the tumor staging in DWI. Results were compared to postsurgical pathologic findings. Results: The T factor accuracy of conventional MRI and DWI was 73% and 80% respectively; while the N staging accuracy of conventional MRI and DWI was 80% and 93%, respectively. Conclusion: DWI and apparent diffusion coefficient (ADC) values showed to be useful in preoperative staging of gastric cancer.

Great Auricular Nerve Preservation During Parotidectomy for Benign Tumors

The great auricular nerve, the largest sensory branch of the cervical plexus, arises from the third cervical nerve (C3) with irregular contribution from the C2. The first part of its course is deep to the sternocleidomastoid muscle. In few years, many experiences by different authors concerning the issue of great auricular nerve integrity during parotidectomy were published in the literature. The aims of our article were to report our experience with 78 consecutive patients who underwent standard superficial, subtotal, or total parotidectomy for benign tumors and to illustrate postsurgical findings regarding the sensibility of the pinna and mandibular angle as subjectively reported in the early postsurgical period and after 3, 6, and 12 months from surgery.

Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: Imaging Appearances of the Normal Flap and Common Complications

The purpose of this essay is to illustrate the normal imaging appearance of deep inferior epigastric perforator (DIEP) flap breast reconstruction and common postoperative complications. Familiarity with the anatomy and normal imaging appearance of a DIEP flap reconstruction will help the breast imager recognize normal postsurgical findings and common postoperative complications.

Complex Syndactyly: Aesthetic and Objective Outcomes

Outcome data after the treatment of complex syndactyly are lacking. The purpose of this investigation was to critically analyze and report our results after surgical reconstruction of complex syndactyly. We included 13 patients and 21 hands (25 webspaces) in this retrospective call-back investigation. There were 17 middle/ring finger and 8 ring/little finger complex syndactylies, each with a defined, isolated osseous bridge between the distal phalanges. We excluded complicated and syndrome-associated syndactylies. Patients returned for clinical examination and subjective assessment at an average of 9 years (range, 2-27 y) after the most recent surgery. Of 21 hands, 6 had undergone a revision surgery. The Vancouver Scar Scale scores averaged 3 (range, 0-6), web creep averaged 1.5 (range, 0-3), and total active motion averaged 148° for the affected fingers. In the middle/ring finger syndactylies, the middle finger was most commonly supinated (average, 13°) and ulnarly deviated (average, 9°), and the ring finger was either supinated or pronated and radially deviated (average, 13°). In the ring/little finger syndactylies, the ring finger was most commonly supinated (average, 8°) without deviation, and the little finger was most commonly pronated (average, 8°) and radially deviated (average, 24°). There was a notable nail wall deformity in most fingers. Surgeon visual analog scale scores (range, 0-10, where lower scores are better) averaged 2.8 (range, 0.8-5.0). Patient visual analog scale scores were 0.4 (range, 0-3) for pain, 1.9 (range, 0-10) for appearance, and 1.1 (range, 0-3) for function. Complex syndactyly reconstruction is challenging, and common postsurgical findings include rotational and angular deformity and nail deformity. When deformity was present, the fingers typically rotated away from and deviated toward the site of the previous complex syndactyly. We describe how we have altered our approach based on these findings. Therapeutic IV.

Soft and hard tissue changes after bimaxillary surgery in Japanese class III asymmetric patients

Objectives:To assess the effects of bimaxillary surgery on Class III subjects with mandibular asymmetry, and to compare the effects of the type of surgery performed in the mandible on the facial profile especially in the presence of facial asymmetry.Materials and Methods:Thirty-six patients in whom imbalance between the maxilla and the mandible were corrected by Le Fort I osteotomy combined with bilateral intraoral vertical ramus osteotomy (BIVRO group, n=9), bilateral sagittal split ramus osteotomy (BSSRO group, n=14), or a combination of intraoral vertical ramus osteotomy (IVRO) and sagittal split ramus osteotomy (SSRO) (IVRO + SSRO group, n=13). Cephalograms were taken before surgery (T1), and 1 year after surgery (T2). Hard and soft-tissue changes were compared.Results:The postsurgical findings showed that greater mandibular backward displacement and greater upper lip forward movement were more pronounced among BIVRO group when compared with BSSRO group. Upper lip relation to E-line showed greater improvement in BIVRO group than BSSRO and IVRO + SSRO groups. The ratios of corresponding mandibular soft to hard tissue movements were higher than that of maxillary movements and were more pronounced in IVRO + SSRO and BSSRO groups when compared with BIVRO group.Conclusion:IVRO surgical technique appears to be more effective in positioning the mandible more posteriorly and improving upper and lower lips position and competence.

Clinical features of ovarian large-cell neuroendocrine carcinoma: Four case reports and review of the literature

The objective of the present study was to present 4 recently encountered ovarian large-cell neuroendocrine carcinoma (LCNEC) cases, and to evaluate their clinicopathological features in the context of the previously reported 29 LCNEC cases. First, we described the clinical features of 4 recently encountered cases. Routine H&E staining and immunohistochemistry for CD56, synaptophysin and chromogranin A were performed on sections of both the LCNEC and epithelial carcinoma components. Clinical data for the total of 33 LCNEC cases were summarized, and the Kaplan-Meier survival curve was estimated. Our cases were observed in women aged 42-81 years. One case is clinically classified as FIGO stage IV with multiple metastases, and the others are classified as FIGO stages Ic, IIc and IIIb by post-surgical findings. Pathological features, assessed by H&E staining, were similar to lung LCNEC, and at least one neuroendocrine marker was positive staining in both LCNEC and the epithelial component. One case was pure type LCNEC and the others were mixed carcinoma. Paclitaxel/carboplatin chemotherapy was performed for all cases and 3 of the 4 treatments were effective. The prognoses of our cases were as follows: 1 in stage Ic died from the disease after only 2 months, but the others survived, with or without recurrence, for 32-64 months, whereas the total 5-year survival of the 33 LCNEC cases was 34.9%. In summary, our 3 LCNEC cases revealed ordinary chemo-sensitivity, resulting in a better prognosis than those previously described, apart from 1 case which exhibited aggressive behavior. For the future, a retrospective survey to elucidate the prognostic factors and prospective clinical studies to evaluate the efficacy of treatment modalities of ovarian LCNEC are necessary, particularly for aggressive LCNEC cases.

Doxorubicin for prevention of epineurial fibrosis in a rat sciatic nerve model: outcome based on gross postsurgical, histopathological, and ultrastructural findings

Epineural fibrosis may complicate peripheral nerve surgeries and currently is considered as one of the main factors responsible for failed surgeries. The authors investigated the postoperative antiscarring effects of topically applied doxorubicin (DXR) on rat sciatic nerves. The sciatic nerves were dissected from the surrounding tissue and exposed bilaterally in 20 Wistar albino adult male rats. Abrasion trauma was produced on the exposed surface of the biceps femoris muscle in the vicinity of the sciatic nerves and their main branches in all animals. In the DXR Group, cottonoid pads soaked with DXR (0.5 mg/ml) were placed around the nerves for 5 minutes, whereas cotton pads soaked with saline (0.9% NaCl) were applied to nerves of animals in the Control Group for the same duration. Twelve weeks after the procedure, all of the rats were killed and the sciatic nerves were examined. Epineural adhesions were evaluated histopathologically and ultrastructurally. Additionally, quantitative histological parameters, the scar tissue formation index and the scar density, were calculated in histological evaluation. Gross postsurgical evaluation as well as histopathological and electron microscopic examination of involved nerve segments showed significantly less epineurial adhesions in the DXR Group than in the Control Group. Quantitative analysis of the epineurium revealed a statistically significant reduction in the density and amount of epineural scarring in specimens from the DXR Group than in those from the Control Group. The results of gross postsurgical anatomical evaluation and histopathological and ultrastructural studies suggested that topical application of DXR effectively reduced epineural scar formation on rat sciatic nerves. These promising findings merit further experimental and clinical studies to determine the efficacy and safe applicability of DXR in human subjects.