Precise Preoperative Diagnosis Research Articles

Mixed reality combined with surgical navigation technology assisted in parapharyngeal space tumors surgery: a clinical study

Objective: To assess the feasibility and application of mixed reality combined with surgical navigation technology in parapharyngeal space tumor surgery, and to provide a reference for the development and promotion of this technology. Methods: In this study, retrospective data collection was conducted on 16 patients with parapharyngeal space tumors who were treated at the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology from June 2020 to June 2023. The patient's age was (39.6±17.8) years, with 4 males and 12 females. Mixed reality combined with surgical navigation technology was utilized to assist physicians in the treatment of these patients. Mixed reality combined with surgical navigation technology was used to assist physicians in treatment of these patients. The application steps included acquisition of image data, processing of image data [three-dimensional (3D) reconstruction, image fusion, and virtual surgical design], development of surgical navigation plan, connection of mixed reality and navigation system, automatic registration and intraoperative guidance and validation. In the preoperative plan, landmark points were placed on the virtual tumor and surrounding important structures reconstructed using digital software, serving to guide the localization of crucial anatomical structures. Intraoperative positioning deviation, surgical time, intraoperative blood loss, and postoperative complications were recorded and analyzed to evaluate the clinical application effectiveness of mixed reality combined with surgical navigation technology. Results: With the assistance of mixed reality combined with surgical navigation technology, 16 patients successfully underwent tumor resection. All patients were accurately diagnosed preoperatively by 3D reconstruction and image fusion technology, and a comprehensive preoperative plan was formulated; intraoperatively, mixed reality combined with surgical navigation technology was utilized for the localization of important structures. The average localization deviation of 38 landmark points during the operation were (4.43±1.96) mm, with 62% (26/42) of the points having a deviation of ≥0 and<5 mm. The average duration of the operation was (149.6±53.9) min and the blood loss was 70 (45, 150) ml. The average postoperative follow-up was 16 months, and five patients experienced postoperative complications involving facial paralysis, hoarseness, and choking. Conclusions: Mixed reality combined with surgical navigation technology can achieve the three-dimensional visualization of oral and maxillofacial anatomical structures to achieve precise preoperative diagnosis. During surgery, the technology can real-time display the relationship between soft tissue tumors and the surrounding important anatomical structures, guide surgical operation, and enhance the safety of surgery.

Clinically Available and Reproducible Prediction Models for IDH and CDKN2A/B Gene Status in Adult-type Diffuse Gliomas

PurposeIsocitrate dehydrogenase (IDH) and cyclin-dependent kinase inhibitor (CDKN) 2A/B status holds important prognostic value in diffuse gliomas. We aimed to construct prediction models using clinically available and reproducible characteristics for predicting IDH-mutant and CDKN2A/B homozygous deletion in adult-type diffuse glioma patients. Materials and MethodsThis retrospective, two-center study analysed 272 patients with adult-type diffuse glioma (230 for primary cohort and 42 for external validation cohort). Two radiologists independently assessed the patients’ images according to the Visually AcceSAble Rembrandt Images (VASARI) feature set. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to optimise variable selection. Multivariable logistic regression analysis was used to develop the prediction models. Calibration plots, receiver operating characteristic (ROC) curves, and decision curve analysis (DCA) were used to validate the models. Nomograms were developed visually based on the prediction models. ResultsThe interobserver agreement between the two radiologists for VASARI features was excellent (κ range, 0.833~1). For the IDH-mutant prediction model, the area under the curves (AUCs) were 0.88-0.96 in the internal and external validation sets, For the CDKN2A/B homozygous deletion model, the AUCs were 0.80-0.86 in the internal and external validation sets. The decision curves show that both prediction models had good net benefits. ConclusionsThe prediction models which basing on VASARI and clinical features provided a reliable and clinically meaningful preoperative prediction for IDH and CDKN2A/B status in diffuse glioma patients. These findings provide a foundation for precise preoperative non-invasive diagnosis and personalized treatment approaches for adult-type diffuse glioma patients.

Cyto-Histological Profile of MicroRNAs as Diagnostic Biomarkers in Differentiated Thyroid Carcinomas.

The repertoire of microRNAs (miRNAs) in thyroid carcinomas starts to be elucidated. Among differentiated thyroid carcinomas (DTCs), papillary thyroid carcinoma (PTC) is the most frequent. The assessment of miRNAs expression may contribute to refine the pre-surgical diagnosis in order to obtain a personalized and more effective treatment for patients. This study aims to evaluate (1) the miRNAs in a series of DTCs, and their association with the presence of selected genetic mutations in order to improve diagnosis and predict the biologic behavior of DTC/PTC. (2) The reliability of molecular tests in Ultrasound-guided Fine Needle Aspiration Cytology (US-FNAC) for a more precise preoperative diagnosis. This series includes 176 samples (98 cytology and 78 histology samples) obtained from 106 patients submitted to surgery, including 13 benign lesions (controls) and 93 DTCs (cases). The microRNA expression was assessed for miR-146b, miR-221, miR-222, and miR-15a through quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR). The results were analyzed by the 2-ΔΔCT method, using miR16 as an endogenous control. Regarding PTC diagnosis, the discriminative ability of miRNAs expression was assessed by the area under the Receiver Operating Characteristic Curve (AUC). In PTCs, the association of miRNAs expression, clinicopathological features, and genetic mutations (BRAF, RAS, and TERTp) was evaluated. All the analyzed miRNAs presented a tendency to be overexpressed in DTCs/PTCs when compared with benign lesions, both in cytology and histology samples. In cytology, miRNAs expression levels were higher in malignant tumors than in benign tumors. In histology, the discriminative abilities regarding PTC diagnosis were as follows: miR-146b (AUC 0.94, 95% CI 0.87-1), miR-221 (AUC 0.79, 95% CI 0.68-0.9), miR-222 (AUC 0.76, 95% CI 0.63-0.89), and miR-15a (AUC 0.85, 95% CI 0.74-0.97). miR-146b showed 89% sensitivity (se) and 87% specificity (sp); miR-221 se = 68.4, sp = 90; miR-222 se = 73, sp = 70; and mi-R15a se = 72, sp = 80. MicroRNAs were associated with worst-prognosis clinicopathological characteristics in PTCs (p < 0.05), particularly for miR-222. Our data reveal a significant association between higher expression levels of miR-146b, miR-221, and miR-222 in the presence of the BRAF mutation (p < 0.001) and miR-146b (p = 0.016) and miR-221 (p = 0.010) with the RAS mutation, suggesting an interplay of these mutations with miRNAs expression. Despite this study having a relatively small sample size, overexpression of miRNAs in cytology may contribute to a more precise preoperative diagnosis. The miRNAs presented a good discriminative ability in PTC diagnosis. The association between the miRNAs expression profile and genetic alterations can be advantageous for an accurate diagnosis of DTCs/PTCs in FNAC.

Laparoscopic Tumorectomy for an Unusual Pelvic Retroperitoneal Leiomyoma: A Case Report

Leiomyomas are benign tumors, mostly located in the uterus. The pelvic localization is quite rare, and it is associated with unusual growth patterns. It is important to make an adequate differential diagnosis between malignant and benign retroperitoneal neoplasm because treatment is different. When it is not possible to have a precise preoperative diagnosis, a laparoscopic or laparotomy surgical tumorectomy is often required. To obtain a certain diagnosis, the goal of surgery is ensuring the complete excision of neoplasms and preservation of urination, defecation, and sexual function. We report a rare case of a 58-year-old woman who underwent a laparoscopic tumorectomy for a pelvic retroperitoneal leiomyoma. The patient reported occasional episodes of dull pain in the pelvic region. Pelvic contrast CT scan and magnetic resonance imaging (MRI) showed a retroperitoneal solid mass in contiguity with the posterior wall of the uterine body-isthmus, to be referred to as a pedunculated uterine fibroma strictly posteriorly adherent to the sigma. She first underwent to explorative laparoscopy by a gynecologist who did not find any uterine mass. The patient was subsequently admitted to the department of general surgery and has done a second operative laparoscopy which highlighted the presence of an extra-peritoneal para-rectal mass which was completely excised. The histological examination of tumor indicated that it was a leiomyoma. The postoperative course was uneventful, and the patient was discharged in III post-operative day (POD).

A Case of Gastric Leiomyosarcoma Completely Resected by Endoscopic Submucosal Dissection after a Precise Preoperative Diagnosis.

A 68-year-old woman was diagnosed with leiomyosarcoma (LMS) based on preoperative biopsy of the gastric body. As tumor invasion confined to the submucosa with no breaking of the submucosal layer was confirmed on endoscopic ultrasonography (EUS), the patient underwent endoscopic submucosal dissection (ESD) for gastric LMS, resulting in complete tumor resection. No apparent recurrence was observed in the 2.5 years after treatment. This is an extremely rare case of gastric LMS that underwent ESD after a precise preoperative diagnosis, with no signs of recurrence after treatment. ESD may be an acceptable option for gastric LMS when EUS findings allow this treatment method.

Does Direct MRI Tenography Improve the Diagnostic Performance of Low-Field MRI to Identify Artificially Created Soft-Tissue Lesions within the Equine Cadaveric Digital Flexor Tendon Sheath?

Tenosynovitis of the digital flexor tendon sheath (DFTS) is diagnosed using ultrasonography and contrast tenography. Nevertheless, making a precise preoperative diagnosis is challenging. This study aimed to determine and compare the sensitivity and specificity of low-field MRI and MRI tenography (MRIt) to detect artificially created soft-tissue lesions in the DFTS. In 21 DFTSs, 118 lesions were made tenoscopically in the superficial digital flexor tendon (SDFT), deep digital flexor tendon (DDFT), manica flexoria (MF) and proximal scutum. MRI and MRI, following intrathecal gadolinium administration (MRIt), were performed. The sensitivity and specificity of MRI and MRIt were calculated and compared. Proximal scutum lesions were less frequently identified by MRI (Sensitivity 38%, specificity 96%) compared to MRIt (Sensitivity: 50%, p = 0.80; specificity: 96%, p = 1). This was similar for SDFT lesions (Sensitivity: 39% versus 54%, p = 0.72; specificity: 93% versus 96%, p = 1). MRI detected DDFT lesions (sensitivity 34%; specificity 100%) better than MRIt (sensitivity 32%, p = 0.77; specificity 98%, p = 1). This was similar for MF lesions (MRI sensitivity 61%; specificity 100% vs. MRIt sensitivity 50%, p = 0.68; specificity 96%, p = 1). Lesion size was significantly associated with MRI or MRIt diagnosis (p = 0.001). The intrathecal administration of gadolinium did not significantly improve the ability of low-field MRI to diagnose artificial DFTS tendon lesions. Small lesion length was a significant discriminating factor for lesion detection. MRI and MRIt specificity were high, thus being helpful in diagnosing an intact structure.

Establishment of a Prediction Model Based on Preoperative MRI Radiomics for Diffuse Astrocytic Glioma, IDH-Wildtype, with Molecular Features of Glioblastoma.

In 2021, the WHO central nervous system (CNS) tumor classification criteria added the diagnosis of diffuse astrocytic glioma, IDH wild-type, with molecular features of glioblastoma, WHO grade 4 (DAG-G). DAG-G may exhibit the aggressiveness and malignancy of glioblastoma (GBM) despite the lower histological grade, and thus a precise preoperative diagnosis can help neurosurgeons develop more refined individualized treatment plans. This study aimed to establish a predictive model for the non-invasive identification of DAG-G based on preoperative MRI radiomics. Patients with pathologically confirmed glioma in Huashan Hospital, Fudan University, between September 2019 and July 2021 were retrospectively analyzed. Furthermore, two external validation datasets from Wuhan Union Hospital and Xuzhou Cancer Hospital were also utilized to verify the reliability and accuracy of the prediction model. Two regions of interest (ROI) were delineated on the preoperative MRI images of the patients using the semi-automatic tool ITK-SNAP (version 4.0.0), which were named the maximum anomaly region (ROI1) and the tumor region (ROI2), and Pyradiomics 3.0 was applied for feature extraction. Feature selection was performed using a least absolute shrinkage and selection operator (LASSO) filter and a Spearman correlation coefficient. Six classifiers, including Gauss naive Bayes (GNB), K-nearest neighbors (KNN), Random forest (RF), Adaptive boosting (AB), and Support vector machine (SVM) with linear kernel and multilayer perceptron (MLP), were used to build the prediction models, and the prediction performance of the six classifiers was evaluated by fivefold cross-validation. Moreover, the performance of prediction models was evaluated using area under the curve (AUC), precision (PRE), and other metrics. According to the inclusion and exclusion criteria, 172 patients with grade 2-3 astrocytoma were finally included in the study, and a total of 44 patients met the diagnosis of DAG-G. In the prediction task of DAG-G, the average AUC of GNB classifier was 0.74 ± 0.07, that of KNN classifier was 0.89 ± 0.04, that of RF classifier was 0.96 ± 0.03, that of AB classifier was 0.97 ± 0.02, that of SVM classifier was 0.88 ± 0.05, and that of MLP classifier was 0.91 ± 0.03, among which, AB classifier achieved the best prediction performance. In addition, the AB classifier achieved AUCs of 0.91 and 0.89 in two external validation datasets obtained from Wuhan Union Hospital and Xuzhou Cancer Hospital, respectively. The prediction model constructed based on preoperative MRI radiomics established in this study can basically realize the prospective, non-invasive, and accurate diagnosis of DAG-G, which is of great significance to help further optimize treatment plans for such patients, including expanding the extent of surgery and actively administering radiotherapy, targeted therapy, or other treatments after surgery, to fundamentally maximize the prognosis of patients.

The sinuous, wave-like intratumoral-wall sign is a sensitive and specific radiological biomarker for oligodendrogliomas.

The purpose of this study was to investigate the clinical utility of the sinuous, wave-like intratumoral-wall (SWITW) sign on T2WI in diagnosing isocitrate dehydrogenase (IDH) mutant and 1p/19q codeleted (IDHmut-Codel) oligodendrogliomas, for which a relatively conservative resection strategy might be sufficient due to a better response to chemoradiotherapy and favorable prognosis. Imaging data from consecutive adult patients with diffuse lower-grade gliomas (LGGs, histological grades 2-3) in Beijing Tiantan Hospital (December 1, 2013, to October 31, 2021, BTH set, n = 711) and the Cancer Imaging Archive (TCIA) LGGs set (n = 117) were used to develop and validate our findings. Two independent observers assessed the SWITW sign and some well-reported discriminative radiological features to establish a practical diagnostic strategy. The SWITW sign showed satisfying sensitivity (0.684 and 0.722 for BTH and TCIA sets) and specificity (0.938 and 0.914 for BTH and TCIA sets) in defining IDHmut-Codels, and the interobserver agreement was substantial (κ 0.718 and 0.756 for BTH and TCIA sets). Compared to calcification, the SWITW sign improved the sensitivity by 0.28 (0.404 to 0.684) in the BTH set, and 81.0% (277/342) of IDHmut-Codel cases demonstrated SWITW and/ or calcification positivity. Combining the SWITW sign, calcification, low ADC values, and other discriminative features, we established a concise and reliable diagnostic protocol for IDHmut-Codels. The SWITW sign was a sensitive and specific imaging biomarker for IDHmut-Codels. The integrated protocol provided an explicable, efficient, and reproducible method for precise preoperative diagnosis, which was essential to guide individualized surgical plan-making. • The SWITW sign was a sensitive and specific imaging biomarker for IDHmut-Codel oligodendrogliomas. • The SWITW sign was more sensitive than calcification and an integrated strategy could improve diagnostic sensitivity for IDHmut-Codel oligodendrogliomas. • Combining SWITW, calcification, low ADC values, and other discriminative features could make a precise preoperative diagnosis for IDHmut-Codel oligodendrogliomas.

A Case of Vagal Nerve Schwannoma: A Rare Case Report

Schwannomas are rare, benign tumors that originate from Schwann cells, which are cells that provide support and insulation for nerve fibers. With the exception of the olfactory and the optic nerves, they may emanate from any of the body's peripheral, cranial, or autonomic nerves. This tumor often manifests as a solitary, slowly developing, asymptomatic neck lump with a slight probability of malignant transformation. The initial workup necessitates computed tomography with a contrast medium or magnetic resonance imaging. A precise pre-operative diagnosis may be challenging, as investigations such as Fine Needle Aspiration Cytology (FNAC) have a low specificity. Schwannomas arising from the carotid triangle and involving the Vagus nerve are very rare, but they can cause significant morbidity if left untreated. The treatment of choice is to surgically excise the tumor, with recurrences being rare. Here, we report a case of Schwannoma presented at our hospital which was treated by the surgical excision of the lesion.

Diagnostic Validity and Reliability of Low-Dose Prospective ECG-Triggering Cardiac CT in Preoperative Assessment of Complex Congenital Heart Diseases (CHDs).

For the precise preoperative evaluation of complex congenital heart diseases (CHDs) with reduced radiation dose exposure, we assessed the diagnostic validity and reliability of low-dose prospective ECG-gated cardiac CT (CCT). Forty-two individuals with complex CHDs who underwent preoperative CCT as part of a prospective study were included. Each CCT image was examined independently by two radiologists. The primary reference for assessing the diagnostic validity of the CCT was the post-operative data. Infants and neonates were the most common age group suffering from complex CHDs. The mean volume of the CT dose index was 1.44 ± 0.47 mGy, the mean value of the dose-length product was 14.13 ± 5.4 mGy*cm, and the mean value of the effective radiation dose was 0.58 ± 0.13 mSv. The sensitivity, specificity, PPV, NPV, and accuracy of the low-dose prospective ECG-gated CCT for identifying complex CHDs were 95.6%, 98%, 97%, 97%, and 97% for reader 1 and 92.6%, 97%, 95.5%, 95.1%, and 95.2% for reader 2, respectively. The overall inter-reader agreement for interpreting the cardiac CCTs was good (κ = 0.74). According to the results of our investigation, low-dose prospective ECG-gated CCT is a useful and trustworthy method for assessing coronary arteries and making a precise preoperative diagnosis of complex CHDs.

Unilateral cleft nose deformities at adulthood

Secondary rhinoplasty is a challenging procedure, requiring a precise preoperative diagnosis of nasal deformities before correcting them. As there is currently no accepted outcome measurement tool available to assess unilateral cleft lip and palate (UCLP) nose sequelae before secondary rhinoplasty. The goal of this retrospective study is to identify the nose deformities and rate them in an evaluation scale that allows collecting and analyzing cleft nose data. Our retrospective cohort is composed of 29 patients with UCLP, who underwent secondary rhinoplasty between 2010 and 2021 in a cleft center, with a mean age of 23years old. Evaluation of deformities is made from preoperative two-dimensional photography. The assessment photographic tool is a custom-designed scale of 16 items. A binary scoring system is used by two experts to assess nasolabial deformities. The most encountered sequelaes are the alar foot displacement (93%), the enlarged tip (90%) and the nostril horizontalization (86%). The inter-examiner ICC for total rating was calculated at 0.911 and indicated a strong level of reliability that was highly significant (P<0.05). The simplicity, reliability and reproducibility of the proposed assessment system could be interesting for clinicians, in order to diagnose the nasal deformities before surgery, but also to assess postoperative success of a secondary rhinoplasty and thus to compare several surgical techniques.

Правосторонняя гемиколэктомия с гастропанкреатодуоденальной резекцией en bloc у пациентки 84 лет (клинический случай)

INTRODUCTION: Among the malignant neoplasms, colorectal cancer ranks third in the morbidity worldwide. Tumors of the right half of the colon are often symptomatic, which is an indication for extended and combined resections. Invasion into the neighboring tissues and organs indicates aggressiveness of the tumor biology, however, it is not always associated with the remote metastasizing process. Previously, invasion into the duodenum and/or pancreas was considered to be a non-resectable case, and as a rule, such patients underwent explorative laparotomy and were prescribed supporting medicinal therapy. However, recently some publications appeared on performing multivisceral resections in locally advanced cancer of the right half of the ascending colon with positive long-term results. In the given clinical case, a successful experience of radical surgical intervention in an elderly patient with locally advanced cancer with destruction and invasion into the duodenum is presented. CONCLUSION: Compliance with the oncological principles at each stage of the operation, precise preoperative diagnosis and preparation of the patient for surgical intervention can have a favorable outcome in the process of further treatment and survival of the patient.

Paraganglioma of the urinary bladder initially diagnosed as gastrointestinal stromal tumor requiring combined resection of the rectum: a case report

BackgroundParaganglioma of the urinary bladder (Pub) is rare and presents with clinical symptoms caused by catecholamine production and release. The typical symptoms of Pub are hypertension, macroscopic hematuria, and a hypertensive crisis during micturition. The average size of detected Pubs is approximately 3 cm. Herein, we report a case of a large Pub in which the symptoms were masked by oral medication, precise preoperative diagnosis was difficult, and intraoperative confirmation of tumoral adhesion to the rectum resulted in hypertensive attacks during surgery.Case presentationA 64-year-old Japanese male with a history of hypertension and arrhythmia controlled with oral medication presented with a large tumor in the pelvic region, detected on examination for weight loss, with no clinical symptoms. Computed tomography and magnetic resonance imaging revealed a tumor measuring 77 mm in diameter in the posterior wall of the urinary bladder. The border with the rectum was unclear, and the tumor showed heterogeneous enhancement in the solid part with an enhancing hypodense lesion. Cystoscopy revealed compression of the bladder trigone by external masses; however, no tumor was visible in the lumen. Endoscopic ultrasonography-guided fine-needle aspiration revealed CD34-positive spindle-shaped cells in the fibrous tissue, suggestive of a mesenchymal neoplasm. The tumor was suspected to be a gastrointestinal stromal tumor, and surgery was performed. After laparotomy, we suspected that the tumor had invaded the rectum, and total cystectomy and anterior resection of the rectum were performed. Histologically, the tumor cells had granular or clear amphophilic cytoplasm with an oval nucleus and nests of cells delimited by connective tissue and vascular septations. Immunohistochemically, the tumor was positive for chromogranin A, CD56, and synaptophysin, and a diagnosis of paraganglioma of the urinary bladder was confirmed. There was no tumor recurrence at the 7-month follow-up.ConclusionThis case highlights the importance of careful examination of pelvic tumors, including endocrine testing, for detecting paraganglioma of the urinary bladder in patients with a history of hypertension or arrhythmia.

Clinical Characteristics, Treatment, and Prognosis of Patients with Obstructive Jaundice in Tertiary Care Facilities: A Prospective Study

Background: Obstructive jaundice can have a number of reasons, but choledocholithias is the most frequent. Obstructive jaundice patients frequently complain of pruritus, jaundice, pale faeces, dark urine, and yellow skin and eyes. Today, because to improvements in imaging technology over the years, a precise pre-operative diagnosis is nearly always attainable. The study's goals were to examine the clinical characteristics and treatment of patients with obstructive jaundice. Methods: Patients with obstructive jaundice who were admitted to the Department of Hepatology at SCB Medical College, Cuttack, Odisha, were the subject of the current hospital-based prospective interventional study. Patients of age greater than 12 years of either sex were studied during the study period of two years after providing written consent. Results: The mean age of the 50 patients was 51.10 years, with 29 (58%) female and 21 (42%) male patients. 19 (38%) of the patients had malignant obstructive jaundice, while 31 (62%) had benign causes. The most frequent symptoms and signs of obstructive jaundice were abdominal pain (100%) and icterus (100%) respectively. The most frequent cancer was cholangiocarcinoma (Ca) of the head of pancreas (Ca) of 2009 (18%), followed by cholangiocarcinoma of the distal common bile duct (CBD) of 2004 (08%), and hilar cholangiocarcinoma of 2003 (06%). The most frequent benign cause was choledocholithiasis 25 (50%) followed by benign stricture of common bile duct 03 (06%). Conclusion: One of the frequent reasons of surgically treatable jaundice is obstructive jaundice. Its cause is diverse, and the right imaging is typically required for diagnosis. As delayed diagnosis may result in permanent pathological alterations that increase morbidity and death, proper diagnosis and treatment are essential.

Pyloric adenomatous carcinoma of the gallbladder following laparoscopic cholecystectomy: A case report.

IntroductionAdenoma and intra-adenoma carcinoma of the gallbladder are relatively rare diseases, and the World Health Organization classification reports a frequency of 0.3% for gallbladder adenomas. Precise preoperative diagnosis of gallbladder cancer, especially in the early stages, is challenging. Herein, we report a case of pyloric adenomatous carcinoma of the gallbladder, diagnosed by laparoscopic cholecystectomy and pathology, along with a literature review. This case was reported in accordance with the SCARE 2020 Guideline (Ref).Presentation of caseA 62-year-old woman was diagnosed with a 4-mm polypoid lesion in the gallbladder during a medical examination. The patient was followed-up by ultrasonography (US) once a year and was referred to our department because of an increase in size. Carcinoembryonic antigen and carbohydrate antigen 19-9 levels were within normal limits. Abdominal ultrasonography revealed a pedunculated polypoid lesion in the body of the gallbladder measuring 8 mm. Computed tomography demonstrated that the whole tumor was enhanced in the early phase without significant lymph node enlargement. Magnetic resonance cholangiopancreatography demonstrated a type Ip polypoid lesion located in the body of the gallbladder without pancreaticobiliary junctional abnormalities. Endoscopic ultrasound detected a superficial nodular-type Ip polypoid lesion in the gallbladder body with a parenchyma-like internal echogenic pattern.DiscussionBased on these findings, the patient was diagnosed with gallbladder adenoma, and laparoscopic cholecystectomy was performed. Histopathological examination revealed the tumor was a papillary growth of atypical high columnar epithelial cells. The final diagnosis was pyloric adenoma with high-grade dysplasia and intra-adenoma carcinoma. The patient is currently undergoing outpatient follow-up without recurrence for 1 year.ConclusionEarly gallbladder carcinoma with adenoma should be considered in patients with small gallbladder polypoid lesions. Considering the surgical stress of cholecystectomy and the malignant potential of gallbladder cancer, preceding surgery would be acceptable.

Four cases of IgG4-related pancreatitis preoperatively diagnosed as malignancy

IgG4-related pancreatitis is known to be difficult to distinguish from pancreatic or bile duct cancer. Though endoscopic ultrasound-fine needle aspiration is useful for diagnosis, it is not easy to completely rule out malignancy. Four cases IgG4-related pancreatitis who underwent resection were enrolled at our institute from 2000 to 2019 in the study. Preoperative diagnoses of two cases were bile duct cancer and the two others were pancreatic cancer. Preoperative diagnosis was made by dynamic images of CT, MRI, ERCP, and/or subsequent cytology. These examinations couldn't rule out malignancy because biliary cytology demonstrated positive in one case and class Ⅲ in another one. As a result, the resections were performed under the enough informed consent. In all four cases, the histological diagnoses were IgG4-related pancreatitis. Fortunately, all patients discharged on foot. If precise preoperative diagnosis of IgG4-related pancreatitis could be made, conservative therapy such as steroid administration might have been taken. The combination of CA 19-9 and IgG4 is considered to be useful for distinguishing patients with autoimmune pancreatitis from those with cancer. But, when malignancy such as pancreatic or bile duct cancer couldn't be ruled out, serious consequence after overlooking the possibility of malignancy should be considered. Therefore, resection could be an option for treatment under the surgeons who are familiar with such a difficult operation. Precise diagnostic method and throughout recognition seemed to be essential for IgG4-related pancreatitis.

GCT-45. YOLK SAC TUMOR IN THE CEREBELLAR VERMIS - A CASE REPORT

Yolk sac tumor (YST) is a non-germinomatous malignant germ cell tumor in a young child. It usually arises along a midline axis, mostly pineal region or suprasellar compartment, and it is exceedingly rare to locate in a cerebellar vermis. In the present report, we describe a case of a pure YST located in the cerebellar vermis and review the previous literature. A three-year-old boy visited a local clinic for gait disturbance and frequent vomiting. Gadolinium-enhanced magnetic resonance imaging (MRI) showed a homogeneously-enhanced mass with a cystic component in his cerebellar vermis, and it resulted in hydrocephalus. By its location and his age, our pre-operative diagnosis was a medulloblastoma, and we performed a total resection of the tumor with ventricular drainage. Unexpectedly, the histological investigation revealed it to be a YST. We confirmed that the serum levels of α-fetoprotein (AFP) had elevated at 3176.4 ng/ml in his preserved sample, obtained before the surgery, and it was consistent with the pathological diagnosis. He is receiving chemotherapy consisting of ifosfamide, cisplatin, and etoposide, followed by radiation therapy. In this case, pre-operative MRI revealed that the tumor did not grow into the IVth ventricle in spite of midline location, which was not typical for medulloblastoma. Of note, serum AFP levels had increased, and they might contribute to a precise pre-operative diagnosis and be able to propose an alternative treatment plan, such as neoadjuvant chemotherapy to reduce surgical risk. As a conclusion, a YST should be considered even if it locates in a cerebellar vermis.

"Repair of common atrioventricular junction in isolation and when associated with other congenital heart defects".

Management of atrioventricular septal defects has grown leaps and bounds since the first correction of this malformation. Main reasons considered for the improvement are good understanding of lesion anatomy, precise preoperative diagnosis including imaging, progress in surgical technique, myocardial protection, and post-operative care. In this article we review the anatomy, pathophysiology, clinical features, associations, diagnosis, surgical therapy, complications, and results of atrioventricular septal defects.

Three-dimensional visualization combined with indocyanine green fluorescence imaging in diagnosis and treatment of primary hepatocellular carcinoma

To explore the value of three-dimensional visualization technology (3DVT) combined with indocyanine green (ICG) fluorescence imaging in the diagnosis and treatment of primary hepatocellular carcinoma (HCC). We retrospectively analyzed the clinical data of 154 patients with HCC admitted to the Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University between January, 2016 and November, 2018. In 57 of the patients (3DVT group), preoperative CT and Gd-EOB-DTPA-enhanced MRI were performed and 3D visualization and surgical planning was carried out before the operation; intraoperative ICG florescence imaging was performed for real-time detection of the tumor location and demarcation, intrahepatic satellite lesions and metastases. According to the intraoperative fluorescent signals and 3D visualization-based surgical planning, the final surgical plan was determined. In the other 97 patients (control group), conventional surgical assessment and surgical resection of the tumor was carried out. The preoperative imaging findings, intraoperative tumor detection, postoperative laboratory results, pathological reports, and follow-up data of the patients were analyzed. In 3DVT group, 63 and 70 lesions were detected by preoperative CT and MRI, respectively; compared with CT examination, intraoperative ICG florescence imaging revealed additional 17 lesions, among which 10 were pathologically confirmed as HCC and 7 as cirrhosis nodules. The median volume of bleeding was 300 mL in 3DVT group, significantly less than that in the control group (400 mL; Z=2.291, P=0.022). In both groups, serious complications or perioperative death occurred in none of the patients. The incidence of postoperative complications was significantly lowed in 3DVT group than in the control group [21% (12/57) vs 48.4% (47/97); χ2=11.406, P=0.001]. The overall disease-free survival rate at 2 years after the operation was significantly higher in 3DVT group than in the control group (74.9% vs 28.9%, P=0.022). 3DVT combined with ICG fluorescence imaging allows precise preoperative diagnosis, surgical planning and implementation, intraoperative detection of small liver cancers and precise navigation for HCC treatment, thereby helping to reduce postoperative complications and improve the disease-free survival rate of the patients.

Identification of new genes of pleomorphic adenoma.

Pleomorphic adenoma is the most common salivary gland neoplasm with a variety of histologic appearances. Due to this diversity, precise preoperative diagnosis through fine needle aspiration cytology is difficult.This study sought to identify the differentially expressed genes in pleomorphic adenoma to aid precise diagnosis and clarify the mechanism of tumorigenesis.Suppressive subtractive hybridization was performed on pleomorphic adenoma tissues and the corresponding normal salivary gland tissues to screen of the differential expression of genes in pleomorphic adenoma.Four known genes (microfibrillar associated protein 4 [MFAP4], dystonin [DST], solute carrier family 35 [SLC35], and potassium channel tetramerization domain containing 15 [KCTD15]) were differentially expressed in the tumors compared with the genes in normal tissues. The expression profiles were further confirmed in 15 pleomorphic adenoma and corresponding normal salivary gland tissues by quantitative real-time reverse transcription-polymerase chain reaction.MFAP4, DST, SLC35, and KCTD15 gene expression could be potential biomarkers of pleomorphic adenoma for precise diagnosis.