Preoperative Contrast-enhanced Computed Tomography Scans Research Articles

Unilateral maxillary swelling: a varied spectrum

<p class="abstract"><strong>Background:</strong> Diverse disease entities may present with mass in the maxilla and include benign conditions and malignant tumours. A detailed evaluation including preoperative imaging is essential to plan approach to management of isolated maxillary sinus lesions optimally.</p><p class="abstract"><strong>Methods:</strong> We did a retrospective chart review of 14 patients with isolated maxillary swelling and involvement of maxillary sinus who presented to the Department of ENT in a tertiary care hospital over a period of 4 years. A detailed history and examination were done and investigations including contrast enhanced CT scan of the nose and paranasal sinuses was done in all patients. </p><p class="abstract"><strong>Results:</strong> A total of 14 patients were included in this study. 7 were male and 7 were female. The mean age of the patients was 52.6, the age group of patients varied from 6 to 77 years. In our series we had patients with benign lesions like dentigerous cyst, fibro-osseous lesions, mucocele, radicular cyst, aspergilloma, and mucormycosis. Malignant cases included Adenoid cystic carcinoma, Low grade myofibroblastic sarcoma, Diffuse B cell lymphoma and undifferentiated carcinoma. All patients were treated surgically, they underwent a combined endoscopic and Caldwell Luc approach.</p><p class="abstract"><strong>Conclusions:</strong> In patients with unilateral maxillary swelling, a systematic approach to diagnosis with preoperative contrast enhanced CT scan is essential with a high index of suspicion. Trans nasal endoscopic approach with sinus surgery is the preferred approach for these lesions, however, in cases of jaw cysts and odontogenic cysts extending laterally it can be combined with a Caldwel-Luc approach.</p>

Using Aorta-Lesion-Attenuation Difference on Preoperative Contrast-enhanced Computed Tomography Scan to Differentiate Between Malignant and Benign Renal Tumors

ObjectiveTo evaluate the ability of Aorta-Lesion-Attenuation Difference (ALAD) to differentiate malignant renal tumors from renal oncocytomas. MethodsA retrospective review of preoperative computed tomography (CT) scans and surgical pathology was performed on patients undergoing partial nephrectomy for small, solid renal masses. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice on preoperative CT scan. The discriminative ability of ALAD to differentiate malignant pathology from oncocytoma was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using receiver operating characteristic analysis. ResultsA total of 227 preoperative CT scans and corresponding pathology reports were reviewed. ALAD values were calculated during the excretory and nephrographic phases. Nephrographic ALAD was able to differentiate malignant pathology from oncocytoma using a HU threshold of 24 with a sensitivity of 84%, specificity of 86%, PPV of 98%, and NPV of 33%. The AUC for malignant pathology vs oncocytoma was 0.86 (95% confidence intervals 0.77-0.96). Nephrographic ALAD was able to differentiate chromophobe renal cell carcinoma (RCC) from oncocytoma using a HU threshold of 24 with a sensitivity of 100%, specificity of 86%, PPV of 75%, and NPV of 100%. The AUC for chromophobe RCC vs oncocytoma was 0.98 (95% confidence intervals 0.91-1.00). ConclusionALAD discriminates well between chromophobe RCC and oncocytoma, which may aid in the management of patients with indeterminate diagnoses of oncocytic neoplasm on diagnostic needle biopsy. Further validation of ALAD will be necessary prior to routine use in clinical practice.

Minimally invasive aortic valve replacement through a right anterolateral mini-thoracotomy for the treatment of octogenarians with aortic valve stenosis.

Because of concerns about the high risk of perioperative complications, the feasibility of minimally invasive aortic valve replacement (MIAVR) for elderly patients remains controversial. Here, we review our results of MIAVR in octogenarians with aortic valve stenosis (AS). Between October 2012 and December 2017, 110 patients with AS underwent MIAVR via a right anterolateral mini-thoracotomy; 41 patients were octogenarian (Group O). The perioperative outcomes of these patients were compared with those of the 69 patients who were less than 80years of age (Group Y). A preoperative contrast-enhanced computed tomography (CT) scan was performed in all patients to guide the patient selection and aid the decision regarding cannulation sites. Among all cases of isolated aortic valve replacement, MIAVR accounted for 47% cases during this study period. The mean age of Group O was 83.6 ± 2.9years, with a maximum age of 89. In Group O, there were no in-hospital deaths or morbidity, including stroke. The rate of blood transfusion was significantly higher in Group O than in Group Y (P = 0.01). However, there was no significant difference in ventilation time, the length of intensive care unit stay, the length of hospital stay, or in the rates of cumulative survival and freedom from valve-related complications. With careful patient selection and a perfusion strategy based on preoperative CT scan, equivalent outcomes of MIAVR were even achieved in octogenarians.

Calcification score versus arterial stenosis grading: comparison of two CT-based methods for risk assessment of anastomotic leakage after esophagectomy and gastric pull-up.

PurposeAnastomotic leakage is a major surgical complication following esophagectomy and gastric pull-up. Specific risk factors such as celiac trunk (TC) stenosis and high calcification score of the aorta have been identified, but no data are available on their relative prognostic values. This retrospective study aimed to compare and evaluate calcification score versus stenosis quantification with regards to prognostic impact on anastomotic leakage.Patients and methodsPreoperative contrast-enhanced computed tomography scans of 164 consecutive patients with primary esophageal cancer were evaluated by two radiologists to apply a calcification score (0–3 scale) assessing the aorta, the celiac axis and the right and left postceliac arteries. Concurrently, the presence and degree of stenosis of TC and superior mesenteric artery were recorded for stenosis quantification.ResultsAnastomotic leakage was noted in 14/164 patients and 12/14 showed stenosis of TC (n=11). The presence of TC stenosis was found to have a significant impact on anastomotic healing (p=0.004). The odds ratio for the prediction of anastomotic leakage by the degree of stenosis was 1.04 (95% CI, 1.02–1.07). Ten of 14 patients had aortic calcification scores of 1 or 2, but calcification scores of the aorta, the celiac axis and the right and left postceliac arteries did not correlate with the corresponding TC stenosis values and showed no influence on patient outcome as defined by the occurrence of anastomotic insufficiency (p=0.565, 0.855, 0.518 and 1.000, respectively). Inter-reader reliability of computed tomography analysis and absolute agreement on calcium scoring was mostly over 90%. No significant differences in preoperative comorbidities and patient characteristics were found between those with and without anastomotic leakage.ConclusionMeasurement of TC stenosis in preoperative contrast-enhanced computed tomography scans proved to be more reliable than calcification scores in predicting anastomotic leakage and should, therefore, be used in the risk assessment of patients undergoing esophagectomy and gastric pull-up.

Using aorta lesion attenuation difference (ALAD) on preoperative contrast-enhanced CT scan to differentiate between malignant and benign renal tumors.

606 Background: To evaluate the ability of Aorta−Lesion−Attenuation−Difference (ALAD) to differentiate malignant renal tumors from renal oncocytomas. Methods: A retrospective review of preoperative CT scans and surgical pathology from robotic assisted partial nephrectomy specimens obtained by a single surgeon was performed. ALAD was calculated by measuring the difference in Hounsfield units (HU) between the aorta and the lesion of interest on the same image slice in the nephrographic phase on preoperative CT scan. The discriminative ability of ALAD to differentiate malignant pathology from oncocytoma was evaluated by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under curve (AUC) using ROC analysis. Results: A total of 218 preoperative CT scans and corresponding pathology reports were reviewed. Pathology review revealed 22 oncocytomas (10.1%), 11 chromophobe RCC (5%), 37 papillary RCC (17%), and 148 clear cell RCC (67.9%). ALAD was able to differentiate malignant pathology from oncocytoma using a HU threshold of 24 with a sensitivity of 84%, specificity of 86%, PPV of 98%, and NPV of 33%. The AUC for malignant pathology versus oncocytoma was 0.86 (95% CI 0.77−0.96). Subgroup analysis showed that ALAD was able to differentiate chromophobe RCC from oncocytoma using a HU threshold of 24 with a sensitivity of 100%, specificity of 86%, PPV of 75%, and a NPV of 100%. The AUC for chromophobe RCC versus oncocytoma was 0.98 (95% CI 0.91−1.00). Conclusions: ALAD measurements based upon preoperative CT scans provide good discrimination between malignant renal tumors and oncocytomas, potentially decreasing the need for biopsy in certain patients. ALAD also discriminates well between chromophobe RCC and oncocytoma, which may aid in the management of patients with indeterminate diagnoses of oncocytic neoplasm on biopsy. Further validation of ALAD will be necessary prior to routine use in clinical practice.

New simple image overlay system using a tablet PC for pinpoint identification of the appropriate site for anastomosis in peripheral arterial reconstruction.

To evaluate the accuracy and utility of a new image overlay system using a tablet PC for patients undergoing peripheral arterial reconstruction. Eleven limbs treated with distal bypass surgery were studied. Three-dimensional images obtained by processing a preoperative contrast-enhanced computed tomography scan were superimposed onto the back-camera images of a tablet PC. We used this system to pinpoint a planned distal anastomotic site preoperatively and to make a precise incision directly above it during surgery. We used a branch artery near the distal anastomotic site as a reference point and the accuracy of the system was validated by comparing its results with the intraoperative findings. The precision of the system was also compared with that of a preoperative ultrasonographic examination. Both the image overlay system and ultrasonography (US) accurately identified the target branch artery in all except one limb. In that limb, which had a very small reference branch artery, preoperative US wrongly identified another branch, whereas the image overlay system located the target branch with an error of 10mm. Our image overlay system was easy to use and allowed us to precisely identify a target artery preoperatively. Therefore, this system could be helpful for pinpointing the most accurate incision site during surgery.

Size and Volumetric Growth Kinetics of Renal Masses in Patients With Renal Cell Carcinoma

To examine radiological growth patterns as an indicator of renal tumor aggressiveness, we studied about the growth kinetics of small renal mass (SRM, ≤4 cm) and possible associated factors for high Fuhrman nuclear grade (≥3). From January 1999 to May 2013, 112 cases (111 patients) diagnosed as renal cell carcinoma after surgical treatment were reviewed retrospectively. Patients who had at least two preoperative contrast-enhanced computed tomography scans more than 6 months apart were included. The mean age was 59 years and mean computed tomography follow-up duration was 20 months. Median tumor size and tumor volume at diagnosis were 1.45 cm and 1.80 cm(3), respectively. Median linear growth rate (LGR) was 0.28 cm/year. Median volumetric growth rate was 0.75 cm(3)/year and median volume doubling time was 1.41 years. Tumor growth rate was not different to histologic type (P = .271). High LGR was a significant factor associated with high Fuhrman grade in multivariate analysis (odds ratio 3.877, 95% confidence interval 1.715-8.765). Volumetric growth rate (P <.001) and volume doubling time (P = .004) were positive correlation with initial mass size, but not LGR (P = .764). In our growth kinetics study, generally small renal mass grew slowly. High LGR could be a risk factor for high-grade tumor (Fuhrman grade ≥3).

Primary Small Bowel Adenocarcinoma the Rare Cause of Anemia – A Case Report

Small bowel adenocarcinoma is a very rare disease. Diagnosis is often delayed due to its rarity and nonspecific early symptoms. New diagnostic tools such as CT, NMR, capsule endoscopy and small bowel endoscopy may facilitate its diagnosis. We reported a primary ileum adenocarcinoma clinically presented as chronic fatigue and anemia with occult gastrointestinal (GI) bleeding, complicated with concurrent gastritis and colon polyp. The exploratory laparotomy was required to arrive at diagnosis. Preoperative contrast enhanced CT scan and NMR enterography revealed involved lymph nodes with no clear findings indicating the nature or origin of the lesion.

Significance of preoperative radiographic pancreatic density in predicting pancreatic fistula after surgery for pancreatic neuroendocrine tumors

BackgroundPostoperative pancreatic fistula remains the most severe and worrisome complication after surgery. Predictive preoperative assessment remains challenging. The authors examine the role of pancreatic computed tomography density in predicting postoperative pancreatic fistula after surgery for pancreatic neuroendocrine tumors. MethodsA single institutional retrospective review of pancreatic surgery for neuroendocrine tumors between 1998 and 2010 was conducted. Preoperative contrast-enhanced computed tomography scans were reviewed, with mean region of interest measurements of pancreatic parenchymal density obtained from 10-mm thick axial computed tomography images. ResultsA total of 119 patients were identified: 59 with enucleations and 60 with resections. Decreased preoperative pancreatic density was significantly associated with an increased grade of postoperative pancreatic fistula (P < .01). Subgroup analyses revealed that decreased gland density was associated with increased grade of postoperative pancreatic fistula in the resection (P < .01) but not in the enucleation group (P = .34). ConclusionsA significant association between postoperative pancreatic fistula grade and preoperative pancreatic computed tomography density is observed in patients undergoing resection for pancreatic neuroendocrine tumors.

Patency of the contralateral internal iliac artery in aortouni-iliac endografting

This study determined the outcome of the contralateral internal iliac artery (IIA) in patients undergoing aortouni-iliac (AUI) endovascular abdominal aortic aneurysm repair (EVAR) with a femorofemoral bypass. This retrospective study evaluated 131 consecutive patients undergoing AUI EVAR with femorofemoral bypass at the McGill University Health Center from October 2001 to November 2010. One hundred patients with preoperatively patent contralateral IIA met inclusion criteria for the study. Preoperative demographics and preoperative and postoperative contrast-enhanced computed tomography (CT) scans with multiplanar reconstruction were reviewed for all patients. The last available postoperative CT imaging for all patients was identified and evaluated for contralateral IIA patency. Patency in preoperative and postoperative CT scans was defined as contrast enhancement of the IIA in continuity with the external iliac artery and absence of >50% stenosis at the origin of the IIA. Clinical outcome focused on postoperative pelvic ischemia and reported symptoms of buttock claudication. Mean age at the time of operation was 77.6± 6.7years, and 78% were male. Mean clinical follow-up was 29.2months after surgery, and mean follow-up of imaging with intravenous contrast was 30.6months. The last imaging follow-up showed 67 patients (67%) had a patent contralateral IIA and that the IIAs in 33 patients (33%) were occluded (25 [76%]) or stenotic (8 [24%]). Of the patients with IIA occlusion, 80% (20 of 25) were occluded on the first postoperative imaging (median, 8.5days). Buttock claudication was reported in 18% (6 of 33 patients) with an occluded IIA compared with only 3% (2 of 67 patients) of patients with a patent contralateral IIA on final imaging follow-up (18% vs 3%; P= .014). There were no observed cases of buttock necrosis, spinal ischemia, or colonic ischemia. Our findings suggest that AUI EVAR with femorofemoral bypass is associated with a significant incidence of contralateral IIA malperfusion on postoperative CT imaging. Occlusion appears to occur early in the postoperative period in most patients, and patient-reported buttock claudication is observed significantly more frequently in patients with an occluded IIA compared with those with a patent IIA. More serious pelvic ischemic complications were not seen in this series. Further study is required to determine whether modification of the procedure can prevent contralateral IIA occlusion and the development of buttock claudication.

Accuracy of computed tomography to predict extracapsular spread in p16-positive squamous cell carcinoma.

To determine the accuracy of pretreatment, contrast-enhanced computed tomography (CT) in the diagnosis of extracapsular spread (ECS) in cervical lymph node metastases from p16-positive head-and-neck squamous cell carcinoma (HNSCC). Retrospective observational study. Sixty-five (n = 65) patients diagnosed between 2004 and 2013 with p16-positive HNSCC and with cervical lymph node metastases measuring at least 1 centimeter in diameter on pathological assessment were included. All patients underwent primary surgical treatment. Subjects' preoperative contrast-enhanced neck CT scans were independently assigned a score for the likelihood of ECS (5-point scale) by two board-certified neuroradiologists. Receiver-operating characteristic curves were generated, and optimal sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for each radiologist. On histological analysis, the majority of patients (58%; 38/65) were found to have ECS, and 29% (19/65) of patients had ≥ three metastatic lymph nodes. For radiologist 1, PPV and NPV for ECS detection were 72% (95% confidence interval (CI), 53%-87%) and 53% (95% CI, 36%-70%), respectively. For radiologist 2, PPV and NPV for ECS detection were 82% (95% CI, 60 %-95%) and 53% (95% CI, 38%-69%), respectively. CT is not a reliable method for determining the presence of ECS in p16-positive HNSCC patients.

Difficult airway after late postoperative bleeding in a case of total thyroidectomy, tracheal resection and reconstruction.

Difficult airway after late postoperative bleeding in a case of total thyroidectomy, tracheal resection and reconstruction.

In vivo imaging of cellular proliferation in renal cell carcinoma using 18F-fluorothymidine PET.

The ability to measure cellular proliferation non-invasively in renal cell carcinoma may allow prediction of tumour aggressiveness and response to therapy. The aim of this study was to evaluate the uptake of 18F-fluorothymidine (FLT) PET in renal cell carcinoma (RCC), and to compare this to 18F-fluorodeoxyglucose (FDG), and to an immunohistochemical measure of cellular proliferation (Ki-67). Twenty seven patients (16 male, 11 females; age 42-77) with newly diagnosed renal cell carcinoma suitable for resection were prospectively enrolled. All patients had preoperative FLT and FDG PET scans. Visual identification of tumour using FLT PET compared to normal kidney was facilitated by the use of a pre-operative contrast enhanced CT scan. After surgery tumour was taken for histologic analysis and immunohistochemical staining by Ki-67. The SUVmax (maximum standardized uptake value) mean±SD for FLT in tumour was 2.59±1.27, compared to normal kidney (2.47±0.34). The mean SUVmax for FDG in tumour was similar to FLT (2.60±1.08). There was a significant correlation between FLT uptake and the immunohistochemical marker Ki-67 (r=0.72, P<0.0001) in RCC. Ki-67 proliferative index was mean ± SD of 13.3%±9.2 (range 2.2% - 36.3%). There is detectable uptake of FLT in primary renal cell carcinoma, which correlates with cellular proliferation as assessed by Ki-67 labelling index. This finding has relevance to the use of FLT PET in molecular imaging studies of renal cell carcinoma biology.

Hepatic steatosis is associated with surgical-site infection after hepatic and colorectal surgery

Obesity and increased visceral fat deposits are important risk factors for surgical-site infection (SSI). Interestingly, a potential role of hepatic steatosis on complications after extrahepatic surgery remains unknown. The aim of the present study was to investigate the impact of hepatic steatosis on SSI in patients that underwent open abdominal surgery. A total of 231 patients that underwent either liver (n = 116) or colorectal (n = 115) resection and received preoperative contrast-enhanced computed tomography scans were retrospectively investigated. Signal attenuation of the liver parenchyma was measured on computed tomography scans to assess hepatic steatosis. More SSIs (including types 1, 2, and 3) were found in the group with hepatic steatosis (56/118 [47.5%]) compared with the control group (30/113 [26.6%]; P = .001). Patients with hepatic steatosis showed greater median body mass index than patients without hepatic steatosis (26.6 kg/m(2) [range 16.8-47.0 kg/m(2)] vs 23.2 kg/m(2) [15.9-32.7 kg/m(2)]; P < .001). Patients with hepatic steatosis experienced longer median operation times (297 minutes [52-708 minutes] vs 240 minutes [80-600 minutes]; P = .003). In a multivariate analysis, hepatic steatosis was identified as an independent risk factor for SSI in patients undergoing hepatic (odds ratio 10.33 [95% confidence interval 1.19-89.76]; P = .03) or colorectal (odds ratio 6.67 [95% confidence interval 1.12-39.33]; P = .04) operation. Hepatic steatosis is associated with SSI after hepatic and colorectal operation.

Computed tomography to detect accessory spleens before laparoscopic splenectomy: is it necessary?

Some one-fifth of patients may have accessory spleens (AcS) and require their removal at the time of splenectomy to achieve and maintain hematological response. The purpose of this study was to evaluate the benefit of computed tomography (CT) in patients undergoing laparoscopic splenectomy (LS). All patients who required splenectomy were offered LS and underwent preoperative contrast-enhanced CT scan to detect and locate AcS. The surgeon was not blinded to the result of the CT scan. Patients were followed up to determine if there was recurrent disease. Between 2000 and 2007, 58 consecutive patients (31 men) were referred for splenectomy and all underwent LS. Preoperative CT scan detected 11 AcS in 11 patients (19%), of which 9 were confirmed during LS; the remaining 2 patients suffered with ITP preoperatively and had a good hematologic response to LS. At LS, 14 AcS were found in 13 patients (22%), of which 4 patients had negative preoperative CT scan; those additional AcS were readily found and were located close to the lower pole or hilum of the spleen. All removed AcS were confirmed histologically. In one patient who had LS and removal of AcS for ITP a further AcS within the tail of the pancreas was detected 1 year postoperatively on CT after thrombocytopenia relapsed. The sensitivity and specificity of CT scan for the detection of AcS were 60% and 95.6%, and the corresponding values for laparoscopy were 93.3% and 100%, respectively. Pairwise comparison of the ROC curves identified laparoscopy to be associated with a significantly higher area under the curve compared with CT scan (0.967 vs. 0.673; P = 0.004). Accessory spleens can be readily detected at laparoscopy in the vicinity of the spleen; preoperative CT scan for their detection and localization may not be necessary.

SYNCHRONOUS DOUBLE CANCER OF THE LARGE INTESTINE AND KIDEY-REPORT OF THREE CASES-

Patient 1, a 70-year-old man, was seen at the hospital because of blood stool and was found having rectal cancer at close examination. Preoperative contrast enhanced CT scan of the abdomen revealed left renal cancer. Low anterior resection of the rectum and a left nephrectomy were simultaneously performed. Patient 2, a 63-year-old woman, was seen at the hospital because of tarry stool. Close exploration revealed cancer of the ascending colon. Abdominal contrast enhanced CT scan before operation revealed a left renal cancer. Right hemicolectomy and a left nephrectomy were performed on an one-step approach. Patient 3, a 59-year-old woman, was seen at the hospital because a stool examination was positive to the guaiac test. Close exploration revealed cecal cancer. Abdominal contrast enhanced CT scan before surgery revealed right renal cancer. Right hemicolectomy and a right nephrectomy were performed on an one-step approach. We experienced three cases of synchronous colorectal cancer and renal cancer in which renal cancer was detected by preoperative contrast enhanced CT scan of the abdomen for the colorectal cancer and both cancers were successfully treated by simultaneous operation.

The contrast-enhanced CT scan and the radionuclide brain scan: parallel mechanisms of action in the detection of supratentorial astrocytomas.

The preoperative contrast-enhanced CT scan and the radionuclide brain scan of 70 patients with surgically verified supratentorial astrocytomas were evaluated and compared. The results indicate parallel mechanisms of action of contrast enhancement and radionuclide uptake. These diagnostic modalities apparently mirror the integrity of the blood-brain barrier (BBB) and therefore are useful in assessing the degree of malignancy of supratentorial gliomas. However, lesions with an intact BBB will be missed with RN imaging. These lesions and/or the associated mass effect will be detected with contrast-enhanced computed tomography. Our findings firmly establish contrast-enhanced CT as the primary investigate tool in the suspected brain tumor.