Preoperative Cross-sectional Imaging Research Articles

Extent of macroscopic vascular invasion predicts distant metastasis in primary leiomyosarcoma of the inferior vena cava.

In retroperitoneal leiomyosarcoma (RP LMS), the predominant issue is distant metastasis (DM). We sought to determine variables associated with this outcome and disease-specific death (DSD). Data were retrospectively collected on patients with primary RP LMS treated at a high-volume center from 2002 to 2023. For inferior vena cava (IVC)-origin tumors, the extent of macroscopic vascular invasion was re-assessed on each resection specimen and correlated with preoperative cross-sectional imaging. Crude cumulative incidences were estimated for DM and DSD and univariable and multivariable models were performed. Among 157 study patients, median tumor size was 11.0 cm and 96.2% of cases were intermediate or high grade. All patients underwent complete resection, 56.7% received chemotherapy (43.9% neoadjuvant) and 14.6% received radiation therapy. Only tumor size and grade and not site of tumor origin (e.g., IVC vs. other) were associated with DM and DSD (p < 0.05). Among 64 patients with IVC-origin tumors, a novel 3-tier classification was devised based on the level of intimal disruption, which was associated with both DM (p = 0.007) and DSD (0.002). In primary RP LMS, only tumor size and grade are predictive of DM and DSD. In IVC-origin tumors, the extent of macroscopic vascular invasion is also strongly predictive of these outcomes.

THE INCIDENCE OF ADDITIONAL HERNIA DEFECTS IN A DIASTATIC LINEA ALBA, NOT REPORTED ON PRE-OPERATIVE CT IMAGING

Abstract Aim Patients with ventral primary or incisional hernias with significant recti diastasis are frequently refered to abdominal wall reconstruction (AWR) services. We audited the rate of incidental intra-operative ventral defects related to diastatic linea alba. Method A retrospective analysis of a prospectively maintained database was carried out from March 2023 to January 2024. All patients who underwent AWR using a minimally invasive approach (MIS) were included. Data on the following variables were collected: sex, age (years), BMI (kg/m2), length of hospital stay (LOS, days), operative time (hours), and ventral defects. Results 27 patients underwent MIS AWR (22 robotic; 8 laparoscopic). Male to female ratio was 16:11. Median age was 58 years (IQR 48–66) and BMI 36 kg/m2 (IQR 32–37). All patients underwent eTEP retro-rectus Rives-Stoppa + diastasis plication using macroporous polypropylene non-absorbable synthetic mesh. Median operating time was 3.3 hours (IQR 3.1–3.5) and LOS was 2 days (IQR 1–2). 1 (3%) patient had laparoscopic converted to open procedure due to bowel involvement. 13 (48%) of patients had extra defects associated with diastatic linea alba which were not visualized in pre-operative cross-sectional imagining. Conclusion When compared to a local repair, the MIS AWR approach in patients with ventral hernias and significant diastasis is justified when considering the high likelihood of synchronous linea alba defects and therefore a risk for future recurrence. These extra defects are rarely detected on pre-operative cross-sectional images. In addition, the plication of diastasis during AWR allows surgeons to recreate a more functional linea alba.

Total Knee Arthroplasty in Patients Who Have Skeletal Dysplasia: A Center’s Experience With a Mean 9-Year Follow-Up

BackgroundTotal knee arthroplasty (TKA) in patients who have skeletal dysplasia (SD) is a technically challenging surgery due to deformity, joint contracture, and associated comorbidities. Patients presenting with this condition have traditionally been treated with conservative measures, leading to poor outcomes. The aim of this study was to follow-up on patients who had SD following TKA, specifically with regards to clinical outcomes. MethodsA total of 31 knees (22 patients) with SD that had undergone TKA in our institution were included in our study. The mean follow-up from index surgery was 110.3 months (range: 20 to 291). The type of dysplasia, implant used, and clinical outcomes with patient-reported outcome measures are presented. ResultsThere were 8 patients (36.3%) who had a diagnosis of achondroplasia, followed by multiple epiphyseal dysplasia (31.8%) and spondyloepiphyseal dysplasia (22.7%). There were 14 men and 8 women who had a mean age of 51 years (range: 28 to 73). Custom implants were required in 12 cases (38.7%), custom jigs were used in 6 cases (19.4%), and robotic-assisted surgery was used in 2 (6.5%) TKAs. Hinged prostheses were used in 17 cases (54.8%), posterior-stabilized in 9 (29.0%), and cruciate-retaining implants in 5 (16.1%). There was 1 patient who sustained an intraoperative medial tibial plateau fracture treated with concomitant open reduction and internal fixation. There was 1 revision that occurred during the follow-up period with a patella resurfacing for continued anterior knee pain. Postoperatively, Oxford Knee Scores improved on average by 12.2 points. The 10-year and 20-year all-cause revision-free survival was 96.8, respectively. ConclusionsDespite the technical challenges and complexity associated with this unique patient cohort, we demonstrated excellent implant survivorship and clinical outcomes post-TKA with mid-term to long-term follow-up of more than 20 years. We recommend preoperative cross-sectional imaging for precise planning and implant templating with multidisciplinary team decision-making. Despite our results, functional outcomes remain inferior to primary arthroplasty within the general population, although we still recommend this treatment modality to appropriately counseled patients. Level of EvidenceIII.

Radiologic Occult Metastases in Pancreatic Cancer: Analysis of Risk Factors and Survival Outcomes in the Age of Contemporary Neoadjuvant Multi-agent Chemotherapy.

Radiologic occult metastatic disease (ROMD) in patients with pancreatic ductal adenocarcinoma (PDAC) who undergo contemporary neoadjuvant chemotherapy (NAC) has not been well studied. This study sought to analyze the incidence, risk factors, and oncologic outcomes for patients who underwent the NAC approach for PDAC. A retrospective review analyzed a prospectively maintained database of patients who had potentially resectable PDAC treated with NAC and were offered pancreatectomy at our institution from 2011 to 2022. Multivariable regression analysis was performed to assess risk factors associated with ROMD. Kaplan-Meier curves with log-rank analyses were generated to estimate time-to-event end points. The study enrolled 366 patients. Upfront and borderline resectable anatomic staging comprised 80% of the cohort, whereas 20% had locally advanced disease. The most common NAC regimen was FOLFIRINOX (n = 274, 75%). For 55 patients (15%) who harbored ROMD, the most common site was liver-only metastases (n = 33, 60%). The independent risk factors for ROMD were increasing CA19-9 levels during NAC (odds ratio [OR], 7.01; confidence interval [CI], 1.97-24.96; p = 0.008), indeterminate liver lesions (OR, 2.19; CI, 1.09-4.39; p = 0.028), and enlarged para-aortic lymph nodes (OR, 6.87; CI, 2.07-22.74; p = 0.002) on preoperative cross-sectional imaging. Receipt of palliative chemotherapy (p < 0.001) and eventual formal pancreatectomy (p = 0.04) were associated with survival benefit in the log-rank analysis. The median overall survival (OS) of the patients with ROMD was nearly 15 months from the initial diagnosis, with radiologic evidence of metastases occurring after a median of 2 months. Radiologic occult metastatic disease remains a clinical challenge associated with poor outcomes for patients who have PDAC treated with multi-agent NAC.

Early Complications of Planned Resection Versus Unplanned Excision of Sarcomas in the Distal Upper Extremity

Unplanned excisions are defined as excisions of malignant tumors performed without preoperative cross-sectional imaging or diagnostic biopsy, frequently resulting in residual disease and re-excision secondary to positive surgical margins. The purpose of this study was to compare the relative morbidity of planned versus unplanned upper-extremity sarcoma excisions. A single tertiary referral hospital pathology database was queried from January 2015 through 2022 for primary upper-extremity sarcomas (forearm, wrist, hand, and finger). Demographics, tumor features, survival characteristics, and outcomes were retrospectively reviewed. Forty-two upper-extremity sarcoma patients were identified, two-thirds of whom had unplanned excisions. Those with unplanned excisions were more likely to be female (relative risk [RR]: 1.9; P= .002), undergo initial excision at a nonsarcoma center (RR: 14.0; P < .001), have masses distal to the forearm (RR: 1.6; P= .02), and have smaller masses (4.8 vs 7.4 cm, P= .03). 71.4% of tumors were high grade, and 60.7% less than 5 cm in size.Unplanned excisions had positive margins in 96.4% of cases and were more likely to undergo re-excision (odds ratio [OR]: 20.0; P= .001), more total resections (2.7 vs 1.4, P= .009), sacrifice of neurovascular structures (OR: 6.1; P= .04), adjuvant radiation therapy (OR: 4.5; P= .05), adjuvant systemic therapy (OR: 10.9; P= .03), or experience a complication (OR: 17.6; P= .002) at an average of 38.0 months of follow-up.Nearly half of all unplanned excision patients developed a local recurrence or metastatic disease. Six patients required an amputation versus one in the planned cohort (P= .17), and 26.5% of patients died at an average of 32.5 months from presentation. Distal upper-extremity sarcoma excisions are frequently unplanned, with high rates of morbidity compared with planned excisions. Surgeons should have a low threshold for cross-sectional imaging and core needle biopsy of atypical lesions, irrespective of size, with referral to a sarcoma center. Prognostic IV.

Which factors are associated with a successful outcome following total hip arthroplasty in patients with early radiographic osteoarthritis?

It is unclear which factors are associated with a successful total hip arthroplasty (THA) in patients with early radiographic osteoarthritis (OA). 70 patients with early OA (Kellgren and Lawrence [KL] grades 0-2) who underwent THA were compared with 200 patients with advanced OA (KL grades 3-4). Outcomes were Oxford Hip Scores (OHS), EQ-5D and EQ-VAS scores; compared preoperatively with 1 year postoperatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THA (postoperative OHS ⩾42). The early OA group were significantly younger (61 vs. 66 years; [p = 0.0035). There were no significant differences in BMI, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% vs. 50.4%; p < 0.0001) and improvement in EQ-5D (0.151 vs. 0.002; p < 0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, 16/70 (22.9%) patients had a 'successful' THA. Patients who had a 'successful' THA were significantly more likely to have subchondral cysts on CT/MRI (91.7% vs. 57.7%; p = 0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% vs. 38.2%; p = 0.0353). The combination of cysts and joint space width <1 mm was associated with a PoPC of 68%. THA in patients with early OA (KL grades 0-2) on plain radiographs should be indicated with caution. We advocate preoperative cross-sectional imaging in these patients. In the absence of cysts on CT/MRI, a THA seems unlikely to provide a satisfactory outcome.

Scapulothoracic orientation has a significant influence on the clinical outcome after reverse total shoulder arthroplasty

BackgroundComputer simulation has indicated a significant effect of scapulothoracic orientation and posture on range of motion (ROM) after reverse total shoulder arthroplasty (RTSA). We analyzed this putative effect on the clinical and radiological outcome post-RTSA. MethodsWe retrospectively assessed 2-year follow-up data of RTSA patients treated at our clinic between 2008 and 2019. Patients were categorized into posture types A, B, and C based on an established method using scapular internal rotation on preoperative cross-sectional imaging. We compared differences in clinical ROM, pain, Subjective Shoulder Value, Constant Score, Shoulder Pain and Disability Index (SPADI), quality of life (EQ5D5L utility index) and radiological outcomes between posture types using linear regression analyses. ResultsOf 681 included patients, 225 had type A posture, 326 type B and 130 type C. Baseline group characteristics were comparable, although the type C group had a higher proportion of females (60% [A]; 64% [B]; 80% [C]) with lower abduction strength (0.7 kg [A]; 0.6 kg [B]; 0.3 kg [C]) and a slightly higher proportion with a Grammont design RTSA (41% [A]; 48% [B]; 54% [C]). There were significant adjusted differences in mean (±standard deviation) active flexion (A: 137±21°; B: 136±20°; C: 131±19°) and passive flexion (A: 140±19°; B: 138±19°; C: 134±18°), active (A: 127±26°; B: 125±26°; C: 117±27°) and passive abduction (A: 129±24°; B: 128±25°; C: 121±25°), SPADI (A: 81±18; B: 79±20; C: 73±23) and pain (A: 1.2±1.7; B: 1.6±2.2; C: 1.8±2.4) between posture types at 2 years (p≤0.035). A higher distalization shoulder angle was associated with better abduction in type C patients (p=0.016). Type C patients showed a trend towards a higher complication rate (3.9% vs 1.1% [A]; 3.2% [B]) (p=0.067). ConclusionsType C posture influences the 2-year clinical outcome of RTSA patients in terms of worse flexion, abduction, SPADI and pain. Scapulothoracic orientation and posture should be considered during the patient selection process, preoperative planning and implantation of a RTSA.

Surgical Margins in Musculoskeletal Sarcoma.

» Negative margin resection of musculoskeletal sarcomas is associated with reduced risk of local recurrence.» There is limited evidence to support an absolute margin width of soft tissue or bone that correlates with reduced risk of local recurrence.» Factors intrinsic to the tumor, including histologic subtype, grade, growth pattern and neurovascular involvement impact margin status and local recurrence, and should be considered when evaluating a patient's individual risk after positive margins.» Appropriate use of adjuvant therapy, critical analysis of preoperative advanced cross-sectional imaging, and the involvement of a multidisciplinary team are essential to obtain negative margins when resecting sarcomas.

Intraoperative contrast-enhanced ultrasound has an outcome-relevant impact on surgery of primary and metastatic liver lesions

Abstract Purpose Complete resection of the affected tissue remains the best curative treatment option for liver-derived tumors and colorectal liver metastases. In addition to preoperative cross-sectional imaging, contrast-enhanced intraoperative ultrasound (CE-IOUS) plays a crucial role in the detection and localization of all liver lesions. However, its exact role is unclear. This study was designed to evaluate the clinical and oncological impact of using CE-IOUS in the surgical treatment of these diseases. Materials and Methods Over the three-year study period, 206 patients with primary liver tumors and hepatic metastases were enrolled in this prospective, monocentric study to evaluate the impact of CE-IOUS in liver surgery. Secondary outcomes included comparing the sensitivity and specificity of CE-IOUS with existing preoperative imaging modalities and identifying preoperative parameters that could predict a strategic impact of CE-IOUS. In addition, the oncological significance of CE-IOUS was evaluated using a case-cohort design with a minimum follow-up of 18 months. Results CE-IOUS findings led to a change in surgical strategy in 34% of cases (n=70/206). The accuracy in cases with a major change could be confirmed histopathologically in 71.4% of cases (n=25/35). The impact could not be predicted using parameters assumed to be clinically relevant. An oncological benefit of a CE-IOUS adapted surgical approach was demonstrated in patients suffering from HCC and colorectal liver metastases. Conclusion CE-IOUS may significantly increase R0 resection rates and should therefore be used routinely as an additional staging method, especially in complex liver surgery.

Growth kinetics of venous tumor thrombus in patients with renal cell carcinoma

Some patients with renal cell carcinoma (RCC) present with venous tumor thrombus (VTT). The extent of the VTT is related to survival, so prompt surgical care is recommended. However, studies evaluating the natural history of VTT in patients with RCC are rare. We sought to evaluate the growth kinetics of VTT in patients with RCC using preoperative cross-sectional images. We identified patients who underwent radical nephrectomy and venous tumor thrombectomy at our institution from 01/2009 to 02/2022. We included those with a minimum of 2 adequate preoperative imaging studies (contrast-enhanced Computerized Tomography (CT), noncontrast Magnetic resonance imaging (MRI), or contrast-enhanced MRI), at least 14 days apart. We measured VTT in each study to calculate growth rate, and evaluated predictors of faster growth (demographics, histology, laterality, tumor diameter, and staging). To assess the relation between clinical variables and VTT growth, we used the Wilcoxon Rank-Sum, Kruskal-Wallis, and Spearman correlation tests. A total of 30 patients were included in the analysis. The median time interval between studies was 33 days. Patients were mostly Caucasian and Males (90% and 70%, respectively). Most patients underwent a CT scan as their initial imaging study (66%), followed with an MRI as second study (73%). The mean venous tumor thrombus growth rate was 0.3 mm/d (standard deviation of 0.5mm), and only rhabdoid/sarcomatoid differentiation showed an association with tumor thrombus growth rate (0.3 vs. 0.63 mm/d, P = 0.038). To the best of our knowledge, this is the first study evaluating the natural growth rate of venous tumor thrombus in patients with renal cell carcinoma. We found that tumor thrombi grew an average of 0.3 mm/d (1.0 cm/month) and that those with sarcomatoid and/or rhabdoid differentiation grew faster (0.63 mm/d). Further studies are needed to validate these results and provide a better understanding of tumor thrombus kinetics.

Transduodenal Sphincteroplasty: A Visual Case Study

BackgroundSphincter of Oddi dysfunction is a challenging and rare clinical entity resulting in pancreatobiliary pain and stasis of bile and pancreatic juice. This problem was classically treated with surgical therapy, but as classification of the disease has changed and newer methods of endoscopic evaluation and therapy have evolved, operative transduodenal sphincteroplasty is now generally reserved as a final therapeutic option for these patients. In this video and manuscript, we describe our approach to operative transduodenal sphincteroplasty in a patient with type I Sphincter of Oddi dysfunction. MethodsA 50-year-old female with history of Roux-en-Y gastric bypass presented with episodic right-upper-quadrant and epigastric abdominal pain with associated documented elevations in liver chemistries. Preoperative cross-sectional imaging demonstrated dilation of her common bile duct. After multidisciplinary discussion, the decision was made to pursue operative transduodenal sphincteroplasty. ResultsAll key operative steps of the transduodenal sphincteroplasty are demonstrated in the embedded video. Key operative steps include laparotomy, generous Kocher maneuver, and duodenotomy over the ampulla, allowing access for sequential biliary and pancreatic sphincterotomies and sphincteroplasties with absorbable suture. The duodenotomy and abdominal fascia are then closed. Our patient underwent sequential diet advancement and was discharged to home on postoperative day five. At clinic follow-up, pancreatobiliary-type pain had resolved. ConclusionThe embedded video demonstrates a case of operative transduodenal sphincteroplasty, which can provide durable results in appropriate patient populations.

Current Management of Basal Cell Carcinoma

For the management of basal cell carcinoma, the primary performance of a risk stratification, which is decisive for the further diagnostic and therapeutic steps, is becoming increasingly important.Various non-invasive methods are available to confirm the clinical diagnosis. Histological confirmation of the diagnosis is recommended in unclear cases. In poorly displaced lesions, preoperative cross-sectional imaging of the tumor area should be performed to exclude osseous infiltration.The gold standard in treatment remains surgery, which should be performed by means of micrographically controlled surgery if possible. In addition, there are other therapeutic methods such as radiotherapy or a number of topical therapy options (photodynamic therapy, cryotherapy or application of 5-fluorouracil or imiquimod), which can be used in certain cases. Also for advanced or metastatic basal cell carcinoma, effective drugs are available in the form of the hedgehog inhibitors, for which there is now several years of application experience with regard to efficacy and handling of adverse events. With the PD-1 inhibitor cemiplimab, a further therapeutic option for non-operable or metastatic tumors has been available since June 2021.The most important preventive measure is consistent textile or chemical UV protection in already affected individuals. In addition, nicotinamide and celecoxib can be used orally for prevention. For follow-up, the current S2k guideline recommends regular self-monitoring and standardized medical check-ups.

Lesion-based indicators predict long-term outcomes of pheochromocytoma and paraganglioma- SIZEPASS.

We seek a simple and reliable tool to predict malignant behavior of pheochromocytoma and paraganglioma (PPGL). This single-center prospective cohort study assessed size of primary PPGLs on preoperative cross-sectional imaging and prospectively scored specimens using the Pheochromocytoma of the Adrenal Gland Scaled Score (PASS). Multiplication of PASS points with maximum lesion diameter (in mm) yielded the SIZEPASS criterion. Local recurrence, metastasis or death from disease were surrogates defining malignancy. 76 consecutive PPGL patients, whereof 58 with pheochromocytoma and 51 female, were diagnosed at a mean age of 52.0 ± 15.2 years. 11 lesions (14.5%) exhibited malignant features at a median follow-up (FU) of 49 months (range 4-172 mo). Median FU of the remaining cohort was 139 months (range 120-226 mo). SIZEPASS classified malignancy with an area under the curve (AUC) of 0.97 (95%CI 0.93-1.01; p<0.0001). Across PPGL, SIZEPASS >1000 outperformed all known predictors of malignancy, with sensitivity 91%, specificity 94%, and accuracy 93%, and an odds ratio of 72 fold (95%CI 9-571; P<0.001). It retained an accuracy >90% in cohorts defined by location (adrenal, extra-adrenal) or mutation status. The SIZEPASS>1000 criterion is a lesion-based, clinically available, simple and effective tool to predict malignant behavior of PPGLs independently of age, sex, location or mutation status.

WHICH FACTORS PREDICT A SUCCESSFUL OUTCOME FOLLOWING TOTAL HIP ARTHROPLASTY IN PATIENTS WITH EARLY RADIOLOGICAL OSTEOARTHRITIS?

It is unclear whether patients with early radiographic osteoarthritis (OA) but severe hip symptoms benefit from total hip replacement (THR). We aimed to assess which factors were associated with successful THR in this patient group.From a consecutive series of 1,935 patients undergoing THR we identified 70 (3.6%) patients with early OA (Kellgren and Lawrence (KL) grades 0-2). These were compared with 200 patients with advanced OA (KL grades 3–4). Outcomes were Oxford Hip Scores (OHS), EQ5D and EQ-VAS scores; compared pre-operatively with one year post-operatively. We investigated which clinical and radiographic (plain x-ray, CT, MRI) features predicted successful THR in the early OA group. Success was defined as reaching a postoperative OHS≥42.The early OA group were significantly younger (61 vs 66 years; P=0.0035). There were no significant differences in body mass index, ASA grade or gender. After adjusting for confounders, the advanced OA group had a significantly greater percentage of possible change (PoPC) in OHS (75.8% versus 50.4%; P&lt;0.0001) and improvement in EQ5D (0.151 versus 0.002; P&lt;0.0001). There were no significant differences in complication, revision or readmission rates. In the early OA group, we identified 16/70 (22.9%) patients who had a ‘successful’ THR. Of those with early OA, 38 patients had pre-operative CT or MRI scans. Patients who had a ‘successful’ THR were significantly more likely to have subchondral cysts on CT/MRI (91.7% versus 57.7%; P=0.0362). The presence of cysts on CT/MRI was associated with a significantly greater PoPC in OHS (61.6% versus 38.2%; P=0.0353). The combination of cysts and joint space width (JSW) &lt;1mm was associated with a PoPC of 68%. Plain radiographs were found to significantly underestimate the narrowest JSW compared to CT/MRI (2.4mm versus 1.0mm; P&lt;0.0001).We advise caution in performing THRs in patients with early OA (KL grades 0-2) on plain radiographs. We advocate pre-operative cross-sectional imaging (CT or MRI) in these patients. In the absence of cysts on cross-sectional imaging, a THR seems unlikely to provide a satisfactory outcome.

Surgical outcomes of resected cystic neoplasms of pancreas: Experience from a tertiary care centre in India.

Cystic neoplasms of the pancreas form a rare heterogeneous group of pancreatic tumors with variable clinical and diagnostic characteristics. Its incidence has increased in recent years due to improvements in cross-sectional imaging methods and awareness amongst surgeons. This study aimed to study the demographic, clinical, imaging, and histopathologic characteristics, incidence of malignancy and outcome of surgical resection of pancreatic cystic neoplasms. Retrospective analysis of 91 patients who underwent surgical resection for cystic neoplasm of the pancreas between 2006 to 2017 at a tertiary care institute was done. There was a female preponderance in the study with a mean age of 47.2 years. Abdominal pain (46.1%) and jaundice (23.1%) were the most common symptoms. Computed tomography and endoultrasound (EUS) were the most commonly used imaging methods in the study and demonstrated good surgical correlation. Pancreaticoduodenectomy (37.1%) was the most commonly performed procedure followed by distal pancreaticosplenectomy (31.8%). Of the lesions, 9.8% were found malignant. Solid pseudopapillary epithelial neoplasm (SPEN) (37.3%) was the most common neoplasm followed by serous (21.9%), intraductal papillary mucinous neoplasm (IPMN) (15.3%) and mucinous neoplasm (14.3%). Preoperative radiological diagnostic correlation was found to be 75-100% implying the importance of imaging in cystic neoplasms of the pancreas. Morbidity and mortality in the study group were 28.5% and 2.1%, respectively. Pancreatic cystic neoplasms were mostly benign with female preponderance and presented in the younger age group with prevalence of SPEN higher than IPMN in our subcontinent. These can be reliably diagnosed on preoperative cross-sectional imaging, and surgical resection is associated with favourable outcome and acceptable morbidity.

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

A NOVEL TECHNIQUE FOR MANAGEMENT OF A CRITICALLY-SIZED BONE DEFECT IN THE OPEN PROXIMAL TIBIAL FRACTURE: EMPLOYING THE CAPANNA TECHNIQUE IN TRAUMA

Correlation of Computed Tomography, Pathological Findings, and Clinical Outcomes for Appendicoliths in Appendicitis.

To correlate preoperative imaging of fecaliths with what is seen in surgical specimens. Early studies considered radiological findings of appendicoliths as a contraindication for nonoperative treatment of appendicitis. There is no standard definition for what is labeled as an appendicolith radiologically and little is known about the pathological correlates of these lesions. A single center, retrospective study of a consecutive series of adult patients who underwent appendectomy for acute appendicitis from March 2021 to February 2022 was performed. The primary outcome was concordance between preoperative cross-sectional imaging description of appendicolith with postoperative gross pathology description. Images were retrospectively reviewed by an independent radiologist, and the presence and characteristics of appendicoliths and appendices were examined. Of 88 cases of appendicitis, 86 were diagnosed preoperatively by computed tomography (CT) imaging. Appendicoliths were seen either on CT or pathology in 45 (51%) patients. Of these 45 patients, a total of 38 (84%) were identified radiographically, and 28 (62%) were identified on pathology. Of the 38 appendicoliths diagnosed on preoperative imaging, only 21 (55%) were confirmed pathologically. Additionally, of the 28 appendicoliths observed on pathology, only 21 (75%) were identified preoperatively on imaging. There was no appendiceal obstruction in 10 of the 40 cases (25%) in which retrospective radiological review identified appendicoliths. Discrepancies were observed between CT and pathology findings of appendicoliths. Not all appendicoliths seem to cause appendicitis. Because the presence of appendicolith influences the treatment decisions, there is a need to standardize their radiological diagnosis and better understand their pathophysiology.

Predictive role of radiomics features extracted from preoperative cross-sectional imaging of pancreatic ductal adenocarcinoma in detecting lymph node metastasis: a systemic review and meta-analysis.

Lymph node metastases are associated with poor clinical outcomes in pancreatic ductal adenocarcinoma (PDAC). In preoperative imaging, conventional diagnostic modalities do not provide the desired accuracy in diagnosing lymph node metastasis. The current review aims to determine the pooled diagnostic profile of studies examining the role of radiomics features in detecting lymph node metastasis in PDAC. PubMed, Google Scholar, and Embase databases were searched for relevant articles. The quality of the studies was examined using the Radiomics Quality Score and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tools. Pooled results for sensitivity, specificity, likelihood, and odds ratios with the corresponding 95% confidence intervals (CIs) were calculated using a random-effect model (DerSimonian-Liard method). No significant publication bias was detected among the studies included in this meta-analysis. The pooled sensitivity of the validation datasets included in the study was 77.4% (72.7%, 81.5%) and pooled specificity was 72.4% (63.8, 79.6%). The diagnostic odds ratio of the validation datasets was 9.6 (6.0, 15.2). No statistically significant heterogeneity was detected for sensitivity and odds ratio (P values of 0.3 and 0.08, respectively). However, there was significant heterogeneity concerning specificity (P = 0.003). The pretest probability of having lymph node metastasis in the pooled databases was 52% and a positive post-test probability was 76% after the radiomics features were used, showing a net benefit of 24%. Classifiers trained on radiomics features extracted from preoperative images can improve the sensitivity and specificity of conventional cross-sectional imaging in detecting lymph node metastasis in PDAC.

The role of imaging and sentinel lymph node biopsy in patients with T3b-T4b melanoma with clinically negative disease.

Previous studies demonstrate minimal utility of pre-operative imaging for low-risk melanoma; however, imaging may be more critical for patients with high-risk disease. Our study evaluates the impact of peri-operative cross-sectional imaging in patients with T3b-T4b melanoma. Patients with T3b-T4b melanoma who underwent wide local excision were identified from a single institution (1/1/2005 - 12/31/2020). Cross-sectional imaging was defined as body CT, PET and/or MRI in the perioperative period, with the following findings: in-transit or nodal disease, metastatic disease, incidental cancer, or other. Propensity scores were created for the odds of undergoing pre-operative imaging. Recurrence free survival was analyzed using the Kaplan-Meier method and log-rank test. A total of 209 patients were identified with a median age of 65 (IQR 54-76), of which the majority were male (65.1%), with nodular melanoma (39.7%) and T4b disease (47.9%). Overall, 55.0% underwent pre-operative imaging. There were no differences in imaging findings between the pre- and post-operative cohorts. After propensity-score matching, there was no difference in recurrence free survival. Sentinel node biopsy was performed in 77.5% patients, with 47.5% resulting in a positive result. Pre-operative cross-sectional imaging does not impact the management of patients with high-risk melanoma. Careful consideration of imaging use is critical in the management of these patients and highlights the importance of sentinel node biopsy for stratification and decision making.

Predicting Visual Outcome Following Surgery in Patients with Idiopathic Epiretinal Membrane Using A Novel Convolutional Neural Network.

To develop a deep convolutional neural network (CNN) that enables the prediction of postoperative visual outcomes following epiretinal membrane (ERM) surgery based on preoperative optical coherence tomography (OCT) images and clinical parameters to refine surgical decision-making. A total of 529 patients with idiopathic ERM who underwent standard vitrectomy with ERM peeling surgery by two surgeons between January 1, 2014, and June 1, 2020, were enrolled. The newly developed Heterogeneous Data Fusion Net (HDF-Net) was introduced to predict postoperative visual acuity (VA) outcomes (improvement ≥ 2 lines in Snellen chart or not) 12 months after surgery based on preoperative cross-sectional OCT images and clinical factors, including age, sex, and preoperative VA. The predictive accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of the CNN model were evaluated. The developed model demonstrated an overall accuracy for visual outcome prediction of 88.68% (95% CI, 79.0%-95.7%) with an AUC of 97.8% (95% CI, 86.8%-98.0%), sensitivity of 87.0% (95% CI, 67.9%-95.5%), specificity of 92.9% (95% CI, 77.4%-98.0%), precision of 0.909, recall of 0.870, and F1 score of 0.889. The heatmaps identified the critical area for prediction as the ellipsoid zone of photoreceptors and the superficial retina which was subjected to tangential traction of the proliferative membrane. The novel HDF-Net demonstrated high accuracy in the automated prediction of visual outcomes after weighing and leveraging multiple clinical parameters, including OCT images. This approach may be helpful in establishing personalized therapeutic strategies for ERM management.