Preoperative MRI Research Articles

SURG-06. FRAMELESS STEREOTACTIC INTRACRANIAL CATHETER PLACEMENT FOR DELIVERY OF INTRATUMORAL CELLULAR THERAPIES

Abstract BACKGROUND As the leading disease-related cause of death in children, pediatric brain tumors, and in particular diffuse midline glioma, require novel treatment approaches. Cellular-based therapies offer promise, but challenges still exist in defining their optimal delivery route. Emerging data from our group suggest there may be a role for intratumoral injection in treatment algorithms. We here describe a surgical workflow for intratumoral injection of cellular therapies that utilizes existing and widely used neurosurgical technologies that can be incorporated into future clinical trials. METHODS Infusion target and catheter trajectory was planned using standard pre-operative MRI. Components from an FDA-approved frameless stereotactic intracranial biopsy system were chosen such that they would accept and guide an FDA-approved rigid intracranial catheter system intended for MR-guided procedures. Following catheter insertion, an intraoperative CT was used to determine accuracy of catheter placement by merging the image with the pre-operative MRI. RESULTS The proposed system was tested in a simulated fashion using a phantom cranial model registered to an accompanying brain MRI. The stereotactic biopsy mount was affixed to the skull at the planned entry site for a posterior fossa approach to the pons. Catheter insertion depth was determined using the stereotactic system and the catheter was inserted to this depth through the biopsy mount. Intraoperative CT confirmed the catheter tip location which correlated with the planned infusion target with sub-millimetric accuracy. CONCLUSION Our proposed intratumoral delivery method using frameless stereotaxy shows promise for use in future clinical trials that require intratumoral delivery of cellular therapies. Utilizing FDA-approved devices allows for quick integration into protocols and their wide-spread use makes the approach generalizable. This approach also eliminates the need for MR-guided procedures which can increase cost and require significant hospital resources to perform. Future work will be aimed at streamlining the intraoperative workflow.

HGG-31. GENOMIC CORRELATIONS WITH HEMORRHAGE RISK IN PEDIATRIC PATIENTS WITH DIFFUSE HEMISPHERIC GLIOMA

Abstract BACKGROUND Pediatric diffuse hemispheric glioma (DHG) is a histone-mutated (H3.3G34R/V) high-grade glioma with poor prognosis. Clinical observation and previous reports have identified that a subset of patients present with tumor-associated hemorrhage. Here, we present our findings from radiological review of these patients and determine genomic risk factors predictive for hemorrhage risk in this cohort. METHODS Data was abstracted through the Children’s Brain Tumor Network (CBTN) and EGAS00001004301. Transcriptomic and genomic analyses were completed in R 4.3.1 using edgeR, msigdbr, and xCell. Presence of blood products was determined on preoperative MRI by a board certified pediatric neuroradiologist. RESULTS 48 samples were available across cohorts with transcriptomic or genomic data. 10 samples (21%) had pre-operative imaging and transcriptomic data available. Initial analysis determined that 6 samples (60%) had acute/chronic hemorrhage based on radiological review. Samples with hemorrhage had increased levels of VEGFA (LFC: 3.45, p=2E-07) and CA9 (LFC: 5.97, p=8E-05) expression on the transcriptomic level suggesting that patients with high expression of these markers (AngioHi) had increased risk of hemorrhage compared to patients with low expression of these markers (AngioLo). AngioHi patients had notably higher levels of IL8 (LFC: 3.56, p=0.01) and increased macrophage populations. Genomic information was available for 15 samples (31%, 7 AngioHi, 8 AngioLo). PTEN alterations (n=4, 57%), FBXW7 alterations (n= 2, 29%), or PDGFRa driver alterations (n= 3, 43%) were found in the AngioHi cohort while none of these alterations were identified in the AngioLo cohort. Notably, at least one of these mutations was seen in all cases in the AngioHi cohort. CONCLUSIONS These findings identify potential mutational alterations predictive for tumor-associated hemorrhage in pediatric DHG. Current work is being completed to further characterize how these mutations impact vascular remodeling for patients with DHG and may offer targeted therapeutic opportunities.

Optimal debulking surgery in ovarian cancer patients: MRI may predict the necessity of rectosigmoid resection

ObjectivesTo determine whether MRI can predict the necessity of rectosigmoid resection (RR) for optimal debulking surgery (ODS) in ovarian cancer (OC) patients and to compare the predictive accuracy of pre- and post-neoadjuvant chemotherapy (NACT) MRI.MethodsThe MRI of 82 OC were retrospectively analyzed, including six bowel signs (length, transverse axis, thickness, circumference, muscularis involvement, and submucosal edema) and four para-intestinal signs (vaginal, parametrial, ureteral, and sacro-recto-genital septum involvement). The parameters reflecting the degree of muscularis involvement were measured. Patients were divided into non-RR and RR groups based on the operation and postoperative outcomes. The independent predictors of the need for RR were identified by multivariate logistic regression analysis.ResultsImaging for 82 patients was evaluated (67 without and 15 with NACT). Submucosal edema and muscularis involvement (OR 13.33 and 8.40, respectively) were independent predictors of the need for RR, with sensitivities of 83.3% and 94.4% and specificities of 93.9% and 81.6%, respectively. Among the parameters reflecting the degree of muscularis involvement, circumference ≥ 3/12 had the highest prediction accuracy, increasing the specificity from 81.6% for muscularis involvement only to 98.0%, with only a slight decrease in sensitivity (from 94.4% to 88.9%). The predictive sensitivities of pre-NACT and post-NACT MRI were 100.0% and 12.5%, respectively, and the specificities were 85.7% and 100.0%, respectively.ConclusionsMRI analysis of rectosigmoid muscularis involvement and its circumference can help predict the necessity of RR in OC patients, and pre-NACT MRI may be more suitable for evaluation.Critical relevance statementWe analyzed preoperative pelvic MRI in OC patients. Our findings suggest that MRI has predictive potential for identifying patients who require RR to achieve ODS.Key PointsThe need for RR must be determined to optimize treatment for OC patients.Muscularis involvement circumference ≥ 3/12 could help predict RR.Pre-NACT MRI may be superior to post-NACT MRI in predicting RR.Graphical

IMG-20. IDENTIFICATION OF PRE-OPERATIVE IMAGING FEATURES ASSOCIATED WITH COGNITIVE IMPAIRMENT IN CHILDREN WITH BRAIN TUMOURS USING A LANGUAGE MODELLING SYSTEM COMBINED WITH MACHINE LEARNING ANALYSIS

Abstract BACKGROUND Cognitive impairments caused by paediatric brain tumours negatively impact future quality-of-life. Impairments of processing speed and working memory are important contributors to challenges these children encounter in education. Inconsistent image acquisition and poor imaging quality can restrict advanced radiomic analysis in historical datasets. We developed and refined a language modelling human image-analysis support system, passing data to specific machine learning techniques that can utilise datasets with many data points in a limited population. METHODS Medical records of children treated for brain tumours with surgery and radiotherapy in Manchester between 2000-2020 were reviewed with imaging accessible from 2006-2020. Pre-operative MRI scans were reviewed for 52 patients along with their most recent processing speed and/or working memory test scores. 274 radiological variables analysing tumour features and damage to brain structures were reported per patient using a standardised reporting tool. Univariate analysis was performed using Linear Regression with time-to-test analysed as a covariate. Multivariate analysis used Elastic Net Regression. RESULTS Univariate analysis revealed risk factors for slower processing speed included midline shift, tumour in the corpus callosum, right temporal periventricular white matter oedema, diffusion changes in the left frontal lobe or amygdala and FLAIR changes in the left caudate nucleus (p<0.005). Risk factors for impaired working memory included midline shift, cortical tumour location, left periventricular white matter oedema and diffusion or FLAIR changes in the left frontal lobe (p<0.005). Despite the limited population size and review of only pre-operative features, multivariate analysis produced multiple predictive models able to outperform chance when predicting processing speed and working memory outcomes. CONCLUSIONS This study provides evidence that a radiological language modelling approach can be utilised for outcome prediction. It identified imaging features predictive of cognitive impairments prior to surgery and radiotherapy. Further work is needed to assess inter-observer variability and validate these findings.

LI-RADS Category Can Be a Post-Surgical Prognostic Factor for Intrahepatic Cholangiocarcinoma in Patients with Liver Cirrhosis or Chronic Hepatitis B

<b><i>Introduction:</i></b> The Liver Imaging Reporting and Data System (LI-RADS) categorization has been proposed as a potential prognostic indicator for primary liver neoplasms in patients with liver cirrhosis or chronic hepatitis B. This multicenter study aimed to determine whether LI-RADS categorization can offer additional post-surgical prognostic value for intrahepatic cholangiocarcinoma (ICCA) when used in conjunction with the American Joint Committee on Cancer (AJCC) guidelines. <b><i>Methods:</i></b> Patients with high risk for hepatocellular carcinoma, surgically confirmed ICCAs, and available preoperative MRI were enrolled. LI-RADS categorization of ICCAs was performed using MRI features, and multivariate analyses were conducted incorporating LI-RADS category, AJCC staging, and clinicopathologic factors to evaluate their predictive value for postoperative recurrence-free survival (RFS) and overall survival (OS). In patients with early recurrence (<2 years), the percentages of AJCC stage I and LR-M or LR tumor-in-vein (TIV) were calculated, respectively. <b><i>Results:</i></b> Among the 166 ICCAs analyzed, 13.3% (22/166) were classified as LR-4/5, 77.7% (129/166) as LR-M, and 9.0% (15/166) as LR TIV. Classifications according to the 8th AJCC guidelines for patients with available post-surgical pathologic data and follow-up imaging were 40.6% (63/155) stage I tumors, 23.9% (37/155) stage II, and 35.5% (55/155) stage III. Multivariate analysis revealed that LI-RADS category (LR-M or LR-TIV) was a significant factor for predicting both RFS (hazard ratio [HR] = 2.86, <i>p</i> = 0.02) and OS (HR = 3.18, <i>p</i> = 0.03). Additionally, AJCC staging (II or III) was a significant factor for RFS (HR = 3.90, <i>p</i> < 0.001) and OS (HR = 3.29, <i>p</i> < 0.001), male sex was a significant factor for RFS (HR = 1.89, <i>p</i> = 0.006) and OS (HR = 2.23, <i>p</i> = 0.002), and positive resection margin was a significant factor for OS (HR = 1.91, <i>p</i> = 0.03). Among the 80 patients with early recurrence, 97.5% displayed LR-M or LR-TIV features, while 11.3% were AJCC stage I patients. <b><i>Conclusion:</i></b> The MRI-based preoperative LI-RADS categorization of ICCA provides additional post-surgical prognostic value beyond the AJCC guidelines, with significant implications for both RFS and OS.

3D-visualization of segmented contacts of directional deep brain stimulation electrodes via registration and fusion of CT and FDCT

Objectives3D-visualization of the segmented contacts of directional deep brain stimulation (DBS) electrodes is desirable since knowledge about the position of every segmented contact could shorten the timespan for electrode programming. CT cannot yield images fitting that purpose whereas highly resolved flat detector computed tomography (FDCT) can accurately image the inner structure of the electrode. This study aims to demonstrate the applicability of image fusion of highly resolved FDCT and CT to produce highly resolved images that preserve anatomical context for subsequent fusion to preoperative MRI for eventually displaying segmented contactswithin anatomical context in future studies.Material and methodsRetrospectively collected datasets from 15 patients who underwent bilateral directional DBS electrode implantation were used. Subsequently, after image analysis, a semi-automated 3D-registration of CT and highly resolved FDCT followed by image fusion was performed. The registration accuracy was assessed by computing the target registration error.ResultsOur work demonstrated the feasibility of highly resolved FDCT to visualize segmented electrode contacts in 3D. Semiautomatic image registration to CT was successfully implemented in all cases. Qualitative evaluation by two experts revealed good alignment regarding intracranial osseous structures. Additionally, the average for the mean of the target registration error over all patients, based on the assessments of two raters, was computed to be 4.16 mm.ConclusionOur work demonstrated the applicability of image fusion of highly resolved FDCT to CT for a potential workflow regarding subsequent fusion to MRI in the future to put the electrodes in an anatomical context.

Preoperative diffusion tensor imaging: Fiber-trajectory-distribution-based tractography to identify facial nerve in vestibular schwannoma.

Tractography of the facial nerve based on diffusion MRI is instrumental before surgery for the resection of vestibular schwannoma, but no excellent methods usable for the suppression of motion and image noise have been proposed. The aim of this study was to effectively suppress noise and provide accurate facial nerve reconstruction by extend a fiber trajectory distribution function based on the fourth-order streamline differential equations. Preoperative MRI from 33 patients with vestibular schwannoma who underwent surgical resection were utilized in this study. First, T1WI and T2WI were used to obtain mask images and regions of interest. Second, probabilistic tractography was employed to obtain the fibers representing the approximate facial nerve pathway, and these fibers were subsequently translated into orientation information for each voxel. Last, the voxel orientation information and the peaks of the fiber orientation distribution were combined to generate a fiber trajectory distribution function, which was used to parameterize the anatomical information. The parameters were determined by minimizing the cost between the trajectory of fibers and the estimated directions. Qualitative and visual analyses were used to compare facial nerve reconstruction with intraoperative recordings. Compared with other methods (SD_Stream, iFOD1, iFOD2, unscented Kalman filter, parallel transport tractography), the fiber-trajectory-distribution-based tractography provided the most accurate facial nerve reconstructions. The fiber-trajectory-distribution-based tractography can effectively suppress the effect of noise. It is a more valuable aid for surgeons before vestibular schwannoma resection, which may ultimately improve the postsurgical patient's outcome.

Navigated intraoperative ultrasound in pediatric brain tumors

PurposeThe aim of this study was to evaluate the diagnostic value and accuracy of navigated intraoperative ultrasound (iUS) in pediatric oncological neurosurgery as compared to intraoperative magnetic resonance imaging (iMRI).MethodsA total of 24 pediatric patients undergoing tumor debulking surgery with iUS, iMRI, and neuronavigation were included in this study. Prospective acquisition of iUS images was done at two time points during the surgical procedure: (1) before resection for tumor visualization and (2) after resection for residual tumor assessment. Dice similarity coefficients (DSC), Hausdorff distances 95th percentiles (HD95) and volume differences, sensitivity, and specificity were calculated for iUS segmentations as compared to iMRI.ResultsA high correlation (R = 0.99) was found for volume estimation as measured on iUS and iMRI before resection. A good spatial accuracy was demonstrated with a median DSC of 0.72 (IQR 0.14) and a median HD95 percentile of 4.98 mm (IQR 2.22 mm). The assessment after resection demonstrated a sensitivity of 100% and a specificity of 84.6% for residual tumor detection with navigated iUS. A moderate accuracy was observed with a median DSC of 0.58 (IQR 0.27) and a median HD95 of 5.84 mm (IQR 4.04 mm) for residual tumor volumes.ConclusionWe found that iUS measurements of tumor volume before resection correlate well with those obtained from preoperative MRI. The accuracy of residual tumor detection was reliable as compared to iMRI, indicating the suitability of iUS for directing the surgeon’s attention to areas suspect for residual tumor. Therefore, iUS is considered as a valuable addition to the neurosurgical armamentarium.Trial registration number and datePMCLAB2023.476, February 12th 2024.

Dose optimization of second window indocyanine green in meningioma patients

ObjectiveSurgery remains the first line treatment for meningiomas and can benefit from fluorescence-guided surgical techniques such as second-window indocyanine green (SWIG). In the current study, we compared the use of the standard SWIG dose of 5.0 mg/kg relative to 2.5 mg/kg indocyanine green (ICG) in meningioma patients. MethodsPatients were prospectively enrolled in an IRB-approved study of SWIG and received either the standard dose of 5.0 mg/kg or a reduced dose of 2.5 mg/kg of ICG around 24 h prior to their surgery. Intraoperative near-infrared fluorescence imaging was performed with exo- and endoscopic systems. Signal-to-background ratio (SBR) was calculated to quantify fluorescence and was compared between 5.0 mg/kg and 2.5 mg/kg ICG. All patients received pre-operative MRI and, in select cases, the pre-operative MRI was correlated to intraoperative fluorescence imaging. Results/DiscussionIn the current study, we found no significant difference in the SBR of meningiomas in patients that were administered with either 5.0 mg/kg or 2.5 mg/kg ICG. However, in five patients that received the standard-dose SWIG regimen of 5.0 mg/kg ICG we observed dose-related fluorescence quenching − referred to as “inversion” − that interfered with tumor visualization during fluorescence-guided surgery (FGS). When correlated to pre-operative MRI, a similar rim pattern was observed around the primary tumor on T2 FLAIR, which, in retrospect, could be used as a predictor for inversion during FGS in meningioma patients receiving standard-dose ICG. ConclusionThis study demonstrated that a reduced ICG dose was as effective as standard-dose SWIG in meningioma patients. We therefore recommend to adjust the standard ICG dose for meningioma patients to 2.5 mg/kg particularly when rim enhancement is observed on pre-operative T2 FLAIR.

Enhancing Preoperative Assessment of Endometrial Cancer: The Role of Diffusion-Weighted Magnetic Resonance Imaging in Evaluating Myometrial Invasion.

Endometrial cancer (EC) is the most common gynecological malignancy. Accurate preoperative staging is essential for guiding treatment. The depth of myometrial invasion is a key prognostic factor. This prospective study aimed to evaluate the added benefit of diffusion-weighted imaging (DWI) compared to T2-weighted imaging (T2WI) and dynamic contrast-enhanced MRI (DCE-MRI) for the preoperative assessment of myometrial invasion in EC. The aim of this prospective study was to evaluate the added benefit of DWI in the preoperative assessment of myometrial invasion in EC, in comparison with T2WI and DCE-MRI. The objectives were to assess the imaging characteristics of endometrial carcinoma on T2WI, DCE, and DW MR, to assess the depth of myometrial invasion and overall stage in EC patients, to compare the diagnostic performance of DCE-MRI with that of DW-MRI combined with T2WI, to describe how MR imaging findings can be combined with tumor histologic features and grading to guide treatment planning, and to evaluate the pitfalls and limitations of DCE and DW MR in the assessment of EC. Thirty-one patients with histologically confirmed EC underwent preoperative pelvic MRI on a 1.5T scanner. T2WI, DWI (b-values 0, 1000 s/mm2), and DCE-MRI were performed. Two radiologists independently assessed myometrial invasion on T2WI, T2WI + DWI, and T2WI + DCE-MRI. Histopathology after hysterectomy was the reference standard. Diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each MRI protocol, with separate analyses for superficial (<50%) and deep (≥50%) myometrial invasions. The accuracy for assessing superficial invasion was 61.3% for T2WI, 87.1% for T2WI + DWI, and 87.1% for T2WI + DCE-MRI. For deep invasion, accuracy was 64.5% for T2WI, 90.3% for T2WI + DWI, and 90.3% for T2WI + DCE-MRI. Sensitivity, specificity, PPV, and NPV for T2WI + DWI and T2WI + DCE-MRI were high and comparable (88.9-91.7%) for both superficial and deep invasions. T2WI had markedly lower sensitivity and specificity. The differences between T2WI and the functional MRI protocols were statistically significant (p < 0.01). DWI and DCE-MRI significantly improve the diagnostic performance of MRI for the preoperative assessment of myometrial invasion depth in EC compared to T2WI alone. DWI + T2WI and DCE-MRI + T2WI demonstrate comparable high accuracy. DWI may be preferable since it is faster and avoids contrast administration.

Impact of pre-operative abdominal MRI on survival for patients with resected pancreatic carcinoma: a population-based study

This study determined the impact of pre-operative abdominal MRI on all-cause mortality for patients with resected PDAC. All adult (≥18 years) PDAC patients who underwent pancreatectomy between January 2011 and December 2022 in Ontario, Canada, were identified for this population-based cohort study (ICD-O-3 codes: C250, C251, C252, C253, C257, C258). Patient demographics, comorbidities, PDAC stage, medical and surgical management, and survival data were sourced from multiple linked provincial administrative databases at ICES. All-cause mortality was compared between patients with and without a pre-operative abdominal MRI after controlling for multiple covariates. A cohort of 4579 patients consisted of 2432 men (53.1%) and 2147 women (46.9%) with a mean age of 65.2 years (standard deviation: 11.2 years); 2998 (65.5%) died while 1581 (34.5%) survived. Median follow-up duration post-resection was 22.4 months (interquartile range: 10.8-48.8 months), and median survival post-pancreatectomy was 25.9 months (95% confidence interval [95% CI]: 24.8, 27.5). Patients who underwent a pre-operative abdominal MRI had a median survival of 33.1 months (95% CI: 30.7, 37.2) compared to 21.1 months (95% CI: 19.8, 22.6) for all others. A total of 2354/4579 (51.4%) patients underwent a pre-operative abdominal MRI, which was associated with a 17.2% (95% CI: 11.0, 23.1) decrease in the rate of all-cause mortality, with an adjusted hazard ratio (aHR) of 0.828 (95% CI: 0.769, 0.890). Pre-operative abdominal MRI was associated with improved overall survival for PDAC patients who underwent pancreatectomy, possibly due to better detection of liver metastases than CT. Northern Ontario Academic Medicine Association (NOAMA) Clinical Innovation Fund.

Resection of Secreting Right Carotid Body Paraganglioma: 2-Dimensional Operative Video

Secreting carotid body paragangliomas are very rare entities that account for less than 1% of all tumors of the head and neck region. 1-3 These vascular lesions splay the internal and external carotid arteries as they enlarge and cause increased catecholamine production in affected individuals. Surgical resection is definitive treatment, but preoperative embolization of the tumor can decrease its vascular supply and aid in surgery. Patients undergoing treatment require preoperative administration of alpha and beta adrenergic blockade to avoid intraoperative and postoperative complications. In this case, a 49-year-old woman presented with a growing neck mass compatible with a carotid body tumor. Preoperative MRI demonstrated a lesion splaying the external and internal carotid arteries. Angiogram demonstrated a vascular tumor, which was embolized before surgery. The patient consented to the procedure and the publication of her case and images. The University of Utah does not require Institutional Review Board approval for the presentation of a single case. This step-by-step video illustrates the surgical resection of her secreting right carotid body paraganglioma. Skull base neurosurgeons must understand the anatomy of vessels and nerves of the neck to safely and successfully resect such tumors.

Assessing the predictive capability of machine learning models in determining clinical outcomes for patients with cervical spondylotic myelopathy treated with laminectomy and posterior spinal fusion

BackgroundCervical spondylotic myelopathy (CSM) is a prevalent degenerative condition resulting from spinal cord compression and injury. Laminectomy with posterior spinal fusion (LPSF) is a commonly employed treatment approach for CSM patients. This study aimed to assess the effectiveness of machine learning models (MLMs) in predicting clinical outcomes in CSM patients undergoing LPSF.MethodsA retrospective analysis was conducted on 329 CSM patients who underwent LPSF at our institution from Jul 2017 to Jul 2023. Neurological outcomes were evaluated using the modified Japanese Orthopaedic Association (mJOA) scale preoperatively and at the final follow-up. Patients were categorized into two groups based on clinical outcomes: the favorable group (recovery rates ≥ 52.8%) and the unfavorable group (recovery rates < 52.8%). Potential predictors for poor clinical outcomes were compared between the groups. Four MLMs—random forest (RF), logistic regression (LR), support vector machine (SVM), and k-nearest neighborhood (k-NN)—were utilized to predict clinical outcome. RF model was also employed to identify factors associated with poor clinical outcome.ResultsOut of the 329 patients, 185 were male (56.2%) and 144 were female (43.4%), with an average follow-up period of 17.86 ± 1.74 months. Among them, 267 patients (81.2%) had favorable clinical outcomes, while 62 patients (18.8%) did not achieve favorable results. Analysis using binary logistic regression indicated that age, preoperative mJOA scale, and symptom duration (p < 0.05) were independent predictors of unfavorable clinical outcomes. All models performed satisfactorily, with RF achieving the highest accuracy of 0.922. RF also displayed superior sensitivity and specificity (sensitivity = 0.851, specificity = 0.944). The Area under the Curve (AUC) values for RF, Logistic LR, SVM, and k-NN were 0.905, 0.827, 0.851, and 0.883, respectively. The RF model identified preoperative mJOA scale, age, symptom duration, and MRI signal changes as the most significant variables associated with poor clinical outcomes in descending order.ConclusionsThis study highlighted the effectiveness of machine learning models in predicting the clinical outcomes of CSM patients undergoing LPSF. These models have the potential to forecast clinical outcomes in this patient population, providing valuable prognostic insights for preoperative counseling and postoperative management.

Multiparameter MRI-based radiomics nomogram for preoperative prediction of brain invasion in atypical meningioma:a multicentre study

ObjectiveTo develop a nomogram based on tumor and peritumoral edema (PE) radiomics features extracted from preoperative multiparameter MRI for predicting brain invasion (BI) in atypical meningioma (AM).MethodsIn this retrospective study, according to the 2021 WHO classification criteria, a total of 469 patients with pathologically confirmed AM from three medical centres were enrolled and divided into training (n = 273), internal validation (n = 117) and external validation (n = 79) cohorts. BI was diagnosed based on the histopathological examination. Preoperative contrast-enhanced T1-weighted MR images (T1C) and T2-weighted MR images (T2) for extracting meningioma features and T2-fluid attenuated inversion recovery (FLAIR) sequences for extracting meningioma and PE features were obtained. The multiple logistic regression was applied to develop separate multiparameter radiomics models for comparison. A nomogram was developed by combining radiomics features and clinical risk factors, and the clinical usefulness of the nomogram was verified using decision curve analysis.ResultsAmong the clinical factors, PE volume and PE/tumor volume ratio are the risk of BI in AM. The combined nomogram based on multiparameter MRI radiomics features of meningioma and PE and clinical indicators achieved the best performance in predicting BI in AM, with area under the curve values of 0.862 (95% CI, 0.819–0.905) in the training cohort, 0.834 (95% CI, 0.780–0.908) in the internal validation cohort and 0.867 (95% CI, 0.785–0.950) in the external validation cohort, respectively.ConclusionsThe nomogram based on tumor and PE radiomics features extracted from preoperative multiparameter MRI and clinical factors can predict the risk of BI in patients with AM.

Updated endometrial cancer FIGO staging: the role of MRI in determining newly included histopathological criteria.

Endometrial cancer (EC) is among the prevalent malignancies in gynecology, showing an increasing occurrence and mortality rate. The updated 2023 FIGO staging integrates both histopathological and molecular analyses, which significantly impact the prognosis and treatment approaches. This research aims to examine the effectiveness of MRI in identifying essential histopathological tumor features, including histological subtype, grade, and lymphovascular space invasion. A total of 106 patients diagnosed with EC from February 2018 to December 2023 underwent preoperative pelvic MRI. Surgical procedures followed ESMO guidelines, with histopathological assessments using FIGO 2009 criteria. Two radiologists independently evaluated MRI images, measuring maximum tumor size, minimum tumor ADC value (using a free-hand ROI technique), and ADC tumor/myometrium ratio. MRI findings were compared with histopathological data. Peritoneal implant presence and tumor size exhibited significant differences between endometrioid adenocarcinoma (EAC) and non-endometrioid endometrial carcinoma (NEEC), with p values of < 0.001 and 0.003, respectively. Significant differences in age, tumor size, ADC tumor, and ADC tumor/myometrium between low-grade and high-grade tumors were observed, with p values of < 0.001, 0.004, 0.006, and 0.011, respectively. Increased tumor size, reduced ADC tumor, ADC tumor/myometrium, and pelvic peritoneal implant presence were significantly associated with LVSI, with p values of < 0.001, 0.001, 0.002, and 0.001, respectively. The AUC values for tumor size, ADC tumor, and ADC tumor/myometrium were 0.842, 0.781 and 0.747, respectively, in distinguishing between low and high-grade endometrial tumors. Similarly, obtained AUC values for predicting LVSI were 0.836, 0.719, and 0.696, respectively. Our study emphasizes MRI's role in predicting tumor characteristics such as histological subtype, grade, and LVSI based on updated FIGO criteria. By highlighting the potential of MRI, this research contributes to our comprehension of improving diagnostic and clinical management for EC. Further multicenter studies are warranted to validate these findings and establish MRI's role in EC management.

Loose Seton Technique in the Management of Complex High Anal Fistula: Enhancing Outcomes with Magnetic Resonance Imaging

Background: Complex high anal fistulas challenge treatment efforts, necessitating innovative approaches that balance healing with sphincter preservation. Methods and Results: In a prospective study at Tikrit Teaching Hospital, 39 patients with complex high anal fistulas underwent treatment with loose silicone setons, guided by preoperative MRI mapping. The efficacy of this method was evaluated through follow-up visits at 1, 3, and 6 months, focusing on fistula healing, recurrence rates, continence preservation (assessed by the Wexner Continence Score), and patient satisfaction. Complete healing was achieved in 31 patients (79.5%), with a recurrence rate of 7.7%. There was a significant improvement in continence, with the mean Wexner score reducing from 3.5 to 1.2 (P&lt;0.001). Moreover, 85% of patients expressed satisfaction with their treatment outcomes. Conclusion: The combined use of loose silicone setons and MRI mapping presents an effective, satisfactory method for managing complex high anal fistulas. This technique ensures high healing rates, significantly preserves sphincter function, and achieves high patient satisfaction.

Evaluation of colon cancer prognostic factors by CT and MRI: an up-to-date review.

Colorectal cancer (CRC) is a significant global health concern. Prognostication of CRC traditionally relies on the Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC) TNM staging classifications, yet clinical outcomes often vary independently of stage. Despite similarities, rectal and colon cancers are distinct in their diagnostic methodologies and treatments, with MRI and CT scans primarily used for staging rectal and colon cancers, respectively. This paper examines the challenges in accurately assessing prognostic factors of colon cancer such as primary tumor extramural extension, retroperitoneal surgical margin (RSM) involvement, extramural vessel invasion (EMVI), and lymph node metastases through preoperative CT and MRI. It highlights the importance of these factors in risk stratification, treatment decisions, and surgical planning for colon cancer patients. Advancements in imaging techniques are crucial for improving clinical management and optimizing patient outcomes, underscoring the necessity for ongoing research to refine diagnostic methods and incorporate novel findings into practice.

Predictors of SOZ localization, subsequent surgical intervention, and seizure outcomes in iEEG.

A third of the patients who undergo intracranial EEG (iEEG) for seizure-onset zone (SOZ) localization do not proceed to resective surgery for epilepsy, and over half of those who do continue to have seizures following treatment. To better identify candidates who are more likely to see benefits from undergoing iEEG, we investigated preoperative and iEEG peri-operative features associated with the localization of a putative SOZ, undergoing subsequent surgical treatment, and seizure outcomes. We conducted a retrospective cohort study of consecutive patients who underwent iEEG from 2001 to 2022 at two institutions. Outcomes included SOZ identification, proceeding to surgical treatment (resection vs. neuromodulation), and subsequent seizure freedom. We identified 329 unique patients who were followed for a median of 3.9 (IQR:7) years, with a minimum of 2-year follow-up for seizure outcomes analyses. Multivariate analysis identified lateralized and lobar localization on scalp EEG (OR 3.8, p = 0.001) to be associated with SOZ localization. Patients with unilateral localization on scalp EEG (OR 3.0, p = 0.003), unilateral preimplantation hypothesis (OR 3.1, p = 0.001), and lesional preoperative MRI (OR 2.1, p = 0.033) were more likely to undergo resection than neuromodulation. Similarly, a unilateral pre-implantation hypothesis (OR 2.6, p < 0.001) favored seizure freedom, whereas prior neuromodulation (OR 0.3, p = 0.013) decreased the odds. Larger number of preoperative anti-seizure medications (ASMs) did not influence seizure freedom rates but did decrease favorable (Engel I, II) seizure outcomes (OR 0.7, p = 0.026). Non-invasive localization data prior to iEEG are associated with subsequent resection and seizure freedom, independent of iEEG localization. Factors predictive of SOZ localization are not necessarily predictive of post-operative seizure freedom.

Effects of preoperative breast MRI on surgical management in women aged 40 years and younger with breast cancer.

e13656 Background: Evaluating the use of preoperative breast MRI on the management of breast cancer can help guide surgical decision making for young female patients newly diagnosed with breast cancer. Methods: A retrospective chart review of the George Washington University database between January 2015 and December 2020 identified 125 women age 40 or younger diagnosed with breast cancer. Of the 125 women, 23 were excluded from the study as they were lost to follow up due to care transfers. The management impact of pre-operative MRI was examined and variables collected include age, race, family history, genetic predisposition, breast density, method of detection, initial imaging findings, initial biopsy results, preoperative MRI findings, additional biopsies, additional biopsy results, and surgery type. Results: Patient ages ranged from 22 to 40 (mean 34.5), 69 (67.6%) had a family history of breast cancer, 81 (79.4%) had dense breasts (30 extremely dense and 51 heterogeneously dense), and 82 (80.4%) had the cancer detected due to clinical symptoms with the remaining during surveillance due to high risk. Of all women included, 55 (53.9%) had additional findings on MRI warranting biopsy of which 25 (45.5%) were biopsy proven cancer. 39 (39.4%) patients had lumpectomy and 59 (59.6%) had mastectomy. 1 (0.01%) patient did not undergo surgery due to widespread metastasis. The use of preoperative MRI identified additional carcinoma in 25 (24.5%) out of 102 patients. 24 (96%) in the ipsilateral breast, and 1 (4%) in the contralateral breast. Conclusions: Overall, this data indicates that the use of preoperative MRI for the treatment of breast cancer in young patients increases the detection of occult breast cancer prior to definitive therapy in 24.5% of patients, critically important information for optimal management. We recommend that all young women with newly diagnosed breast cancer undergo pre-operative MRI to further optimize patient care.

Relationship between facet joint osteoarthritis and lumbar paraspinal muscle atrophy: a cross-sectional study.

The paraspinal muscles play an essential role in the stabilization of the lumbar spine. Lumbar paraspinal muscle atrophy has been linked to chronic back pain and degenerative processes within the spinal motion segment. However, the relationship between the different paraspinal muscle groups and facet joint osteoarthritis (FJOA) has not been fully explored. In this cross-sectional study, the authors analyzed adult patients who underwent lumbar spinal surgery between December 2014 and March 2023 for degenerative spinal conditions and had preoperative MRI and CT scans. The fatty infiltration (FI) and functional cross-sectional area (fCSA) of the psoas, erector spinae, and multifidus muscles were assessed on axial T2-weighted MR images at the level of the upper endplate of L4 based on established studies and calculated using custom-made software. Intervertebral disc degeneration at each lumbar level was evaluated using the Pfirrmann grading system. The grades from each level were summed to report the cumulative lumbar Pfirrmann grade. Weishaupt classification (0-3) was used to assess FJOA at all lumbar levels (L1 to S1) on preoperative CT scans. The total lumbar FJOA score was determined by adding the Weishaupt grades of both sides at all 5 levels. Correlation and linear regression analyses were conducted to assess the relationship between FJOA and paraspinal muscle parameters. A total of 225 patients (49.7% female) with a median age of 61 (IQR 54-70) years and a median BMI of 28.3 (IQR 25.1-33.1) kg/m2 were included. After adjustment for age, sex, BMI, and the cumulative lumbar Pfirrmann grade, only multifidus muscle fCSA (estimate -4.69, 95% CI -6.91 to -2.46; p < 0.001) and FI (estimate 0.64, 95% CI 0.33-0.94; p < 0.001) were independently predicted by the total FJOA score. A similar relation was seen with individual Weishaupt grades of each lumbar level after controlling for age, sex, BMI, and the Pfirrmann grade of the corresponding level. Atrophy of the multifidus muscle is significantly associated with FJOA in the lumbar spine. The absence of such correlation for the erector spinae and psoas muscles highlights the unique link between multifidus muscle quality and the degeneration of the spinal motion segment. Further research is necessary to establish the causal link and the clinical implications of these findings.