Preoperative Radiological Imaging Research Articles

Para-aortic Lymph Node Dissection for Colorectal Cancer: Predicting Pathologic Lymph Node Positivity and Optimizing Outcomes.

In colorectal cancer, the presence of para-aortic lymph nodes (PALN) indicates extraregional disease. Appropriately selecting patients for whom PALN dissection will provide oncologic benefit remains challenging. This study identified factors to predict survival among patients undergoing PALN dissection for colorectal cancer. An institutional database was queried for patients who underwent curative-intent resection of clinically positive PALN for colorectal cancer between 2007 and 2020. Preoperative radiologic images were reviewed, and patients who did and did not have positive PALN on final pathology were compared. Survival analysis was performed to evaluate the impact of pathologically positive PALN on recurrence-free (RFS) and overall survival (OS). Of 74 patients who underwent PALN dissection, 51 had PALN metastasis at the time of primary tumor diagnosis, whereas 23 had metachronous PALN disease. Preoperative chemotherapy ± radiotherapy was given in 60 cases (81.1%), and 28 (37.8%) had pathologically positive PALN. Independent factors associated with positive PALN pathology included metachronous PALN disease and pretreatment and posttreatment radiographically abnormal PALN. On multivariable analysis, pathologically positive PALN was significantly associated with decreased RFS (hazard ratio 3.90) and OS (HR 4.49). Among patients with pathologically positive PALN, well/moderately differentiated histology was associated with better OS, and metachronous disease trended toward an association with better OS. Pathologically positive PALN are associated with poorer RFS and OS after PALN dissection for colorectal cancer. Clinicopathologic factors may predict pathologic PALN positivity. Curative-intent surgery may provide benefit, especially in patients with well-to-moderately differentiated primary tumors and possibly metachronous PALN disease.

Robotic-Assisted Minimally Invasive Direct Coronary Artery Bypass Grafting: A Surgical Technique.

In recent years, there has been a growing interest in robotic-assisted coronary artery revascularization in Europe. Two different types of surgery can be performed using a robotic platform: RA-MIDCAB, in which the mammary artery is harvested endoscopically with robotic assistance and off-pump bypass graft is achieved under direct vision through mini thoracotomy, and TE-CAB, completely robotically performed. We started the robotic cardiac surgery program for mitral valve disease in our hospital, Humanitas Gavazzeni (Bergamo, Italy), in 2019; and in 2021, we addressed our experience with RA-MIDCAB. After a learning curve period, we have developed our technique to optimize the benefits offered by the robotic platform, tailoring strategy to individual patients, based on preoperative radiological images.

Clinical outcomes of open Latarjet-Patte procedures performed for recurrent anterior shoulder instability with primary bone loss versus failed arthroscopic Bankart repair.

This study compares the outcomes of Latarjet-Patte procedures (LPs) performed for primary glenohumeral instability in the setting of critical bone loss (LP-BL) versus salvage surgery performed after a failed arthroscopic Bankart repair (LP-FB). LP's performed by senior author from 2017 to 2021 were separated into cohorts by LP indication. Data abstracted from electronic medical records included demographic information, preoperative clinical scores, radiological imaging, and complications. Postoperative clinical outcome scores collected after a 2-year minimum follow-up included: patient-reported outcomes measurement information system (PROMIS) upper extremity (UE), PROMIS pain interference, PROMIS pain intensity, American Shoulder and Elbow Surgeons (ASES), and visual analog scale pain scores. A total of 47 patients (LP-BL: n=29, LP-FB: n=18) with a mean age of 29 years (range, 15-58 years) were included in this study. Both cohorts achieved good upper extremity functionality without significant differences as indicated by mean PROMIS UE (LP-BL: 52.6±10.0 vs. LP-FB: 54.6±7.6, P=0.442) and ASES score (LP-BL: 89.9±15.7 vs. LP-FB: 91.5±14.4, P=0.712). However, the LP-FB cohort reported lower levels of pain (LP-FB: 0.5±1.1 vs. LP-BL: 1.9±2.7, P=0.020) at their latest follow-up. There were no significant differences in complication rates including re-dislocation between cohorts (LP-BL: 2/29 [6.9%] vs. LP-FB: 2/18 [11.1%], P=0.629). When performed after failed Bankart repair, the LP results in similar postoperative functional outcomes and similar rates of complications and re-dislocations when compared to the primary indication of recurrent glenohumeral instability in the setting of critical bone loss. Level of evidence: III.

CtDNA predicts clinical T1a to pathological T3a upstaging after partial nephrectomy.

Most patients diagnosed with clear cell renal cell carcinoma (ccRCC) are also detected with small and organ-confined tumors, and the majority of these are classified as clinical tumor stage 1a (cT1a). A considerable proportion of patients with cT1 RCC shows tumor upstaging to pathological stage 3a (pT3a), and these patients have worse oncological outcomes. The role of circulating tumor DNA (ctDNA) in RCC has been limited to monitoring treatment response and resistance. Therefore, the present study aimed to evaluate the potential of ctDNA in predicting pT3a upstaging in cT1a ccRCC. We sequenced plasma samples preoperatively collected from 48 patients who had undergone partial nephrectomy for cT1a ccRCC using data from a prospective cohort RCC. The ctDNA were profiled and compared with clinicopathological ccRCC features to predict pT3a upstaging. Associations between ctDNA, tumor complexity, and pT3a upstaging were evaluated. Tumor complexity was assessed using the anatomical classification system. Univariate analysis used chi-squared and Student's t-tests; multivariate analysis considered significant factors from univariate analyses. Of the 48 patients with cT1a ccRCC, 12 (25%) were upstaged to pT3a, with ctDNA detected in 10 (20.8%), predominantly in patients with renal sinus fat invasion (SFI; n = 8). Among the pT3a group, ctDNA was detected in 75%, contrasting with only 2.8% in patients with pT1a (1/36). Detection of ctDNA was the only significant preoperative predictor of pT3a upstaging, especially in SFI. This study is the first to suggest ctDNA as a preoperative predictor of pT3a RCC upstaging from cT1a based on preoperative radiological images.

Glenoid lateralization in reverse shoulder arthroplasty: metal vs. bone offset in different implant designs

BackgroundHigher bone or metal glenoid offset in reverse shoulder arthroplasty reduces scapular notching, improves range of motion, and reduces postoperative instability. This retrospective multicenter study compared two implant designs to evaluate the short-term clinical and radiologic results of bone increased offset (BIO-RSA) and metal increased offset (MIO-RSA) in reverse shoulder. We hypothesized no difference between groups. MethodsThis study analyzed n=62 BIO-RSA and n=90 MIO-RSA cases with a mean follow-up of FUBIO-RSA=29.7±6.0 months (range 24-49 months) and FUMIO-RSA=24.0±1.1 months (range 22-28 months). A 145 onlay humeral stem was utilized in BIO-RSA cases while a 135 semi-inlay humeral stem was implanted in all MIO-RSA cases. Preoperative and postoperative radiologic imaging was reviewed to identify signs of scapular notching. Additionally, lateralization was evaluated according to Erickson et al. The Constant score, Subjective Shoulder Value, and range of motion were evaluated during the baseline and follow-up consultations and the findings of both groups were subsequently compared. ResultsScapular notching was observed in 7.0% (n=8) of MIO-RSA cases and 8.1% (n=5) of BIO-RSA cases (p=0.801). MIO-group had a higher lateralization angle (p=0.020) and the BIO-group a higher distalization angle (p=0.005). At baseline, mean Constant score in the MIO-RSA group was higher than in the BIO-RSA group (p<0.001) and it significantly increased to 67.8±12.1P (MIO-RSA) and 69.5±12.3P (BIO-RSA) to a similar level (p=0.399). Range of motion improved in both groups with no significant difference between both groups at follow-up. ConclusionBIO- and MIO- RSA in two distinct implant designs provide comparable short-term outcomes with a similar increase in shoulder function with notable variations in the lateralization and distalization angles between both implants. Scapular notching was rarely seen and unaffected by the method of glenoid lateralization. Follow-up investigations of both techniques are necessary to complement and track changes in the long-term outcome.

Pubic Tubercle Osteochondroma

Background: The commonest benign bone tumors, osteochondromas, which can be solitary or multiple involving the metaphyseal region of long bones, rarely present in the axial skeleton, such as pelvic girdle, which warrants surgical excision in case of symptoms arising out of pressure effects.&#x0D; Case Report: In this study, we are herewith reporting an unusual case of pubic tubercle osteochondroma, which is solitary and pedunculated in a 37-year-old woman. She has had the swelling for the past 15 years, which was asymptomatic except for mild hydroureteronephrosis, which was an incidental diagnosis; however, we managed the patient with surgical excision of the tumor with elaborate preoperative radiological imaging using both X-ray and computed tomography (CT) scan. Histopathological examination confirmed the diagnosis of osteochondroma.&#x0D; Conclusion: Asymptomatic pelvic osteochondroma should be considered in patients with incidental swelling in the groin region, especially women who may be reluctant to seek medical attention due to social stigma.

Never too young for a salivary gland carcinoma ex-pleomorphic adenoma

BackgroundCarcinoma ex-pleomorphic adenoma (CXPA) can either arise primarily as a de novo or from the malignant transformation of a benign pleomorphic adenoma (PA). CXPA mostly occurs in adults aged 50 to 70 years; hence, the occurrence of CXPA in younger ages is not common.Case presentationWe report a 27-year-old female who had a history of submandibulectomy for pleomorphic adenoma, and presented with recurrent left submandibular swelling for 4 months. The mass was rapidly increasing in size and was associated with occasional throbbing pain. Examination showed a multilobulated, firm left submandibular swelling with no overlying skin changes. FNAC was performed twice, by conventional and ultrasound-guided techniques, and both concluded as benign salivary gland tumours. CT scan and MRI revealed a well-demarcated tumour with an area of necrosis within, with no obvious invasion into surrounding soft tissue and no significant lymphadenopathy. Having high suspicion of a malignant transformation, the tumour was resected with a concurrent modified radical neck dissection. The histopathological examination confirmed a carcinoma ex-pleomorphic adenoma with the myoepithelial malignant component. The patient subsequently received adjuvant radiotherapy. This case demonstrated that CXPA, although rare, can occur in young adults. Pre-operative FNAC and radiological imaging may mimic a pleomorphic adenoma.ConclusionThe presence of recurrent tumours with rapid growth should alarm the clinician about a possible malignant transformation of a benign parotid tumour.

A novel index to predict postoperative hypocalcemia in primary hyperparathyroidism.

Vitamin D (Vit D) deficiency is common in patients with hyperparathyroidism, but the importance of replacement before surgery is controversial. It can be predicted that hypocalcemia risk will be higher in patients with high bone turnover. In this study, the effect of preoperative ALP/Vit D ratio on postoperative hypocalcemia was investigated. Among the primary hyperparathyroidism cases who were operated between 2015 and 2022, 158 patients with complete data were included in the study. Preoperative laboratory results, radiological images, and pathology reports of the patients were evaluated retrospectively. The cross-sectional value of the ALP/Vit D value predicting hypocalcemia was calculated. The effect of these parameters on postoperative hypocalcemia was investigated. The mean age of our patients was 54 (21-81years). When factors affecting postoperative hypocalcemia were evaluated by univariable analysis, Vit D deficiency and insufficiency (p < 0.001), ALP (p < 0.001), ALP/Vit D ratio (p < 0.001), and T score (p = 0.026) found to be factors affecting postoperative hypocalcemia. In multivariate analysis, the ALP/Vit D ratio was found to be an independent variable in predicting hypocalcemia. It was found that hypocalcemia was 45 times more common in patients with ALP/Vit D > 6.34 (p < 0.001). ALP/Vit D ratio predicts patients who will develop postoperative hypocalcemia with 87.2% sensitivity and 87.1% specificity. Vit D deficiency increases the risk of postoperative hypocalcemia, but it is not sufficient alone to predict it. The risk increases more in patients with high bone turnover. The preoperative ALP/Vit D ratio is the strongest predictor of postoperative hypocalcemia risk.

Clinical, Diagnostic, and Treatment Characteristics of Orbital Liposarcoma

PurposeTo clarify the clinical, diagnostic and treatment characteristics of orbital liposarcoma. DesignRetrospective observational case series. MethodsReview of electronic medical records, histopathology, radiological images and follow-up information of 21 patients with orbital liposarcoma. ResultsThe predominant clinical manifestation of this disease was painless exophthalmos. The most frequently encountered pathological types were well-differentiated and myxoid liposarcoma. Preoperative radiological images from 15 patients showed that orbital liposarcoma initially developed in extraocular muscle in 9 patients. Furthermore, all well-differentiated liposarcomas exhibited the radiographic characteristics of irregular and ill-defined adipose tissue, whereas only 12.5% of myxoid liposarcomas had the imaging characteristics. For the patients who exclusively underwent surgery, all cases with subtotal excisions experienced recurrence, 63.6% of marginal excisions recurred and 50% of wide excisions resulted in recurrence. However, none of the patients who underwent marginal excisions or wide excisions combined with adjuvant radiotherapy exhibited recurrence. The analysis of MRI findings in three patients who underwent neoadjuvant radiotherapy revealed that the tumor size remained stable in a patient with well-differentiated liposarcoma, while another patient with the same type of tumor exhibited a gradual increase in size. Conversely, a patient with myxoid liposarcoma experienced a significant reduction in tumor size following neoadjuvant radiotherapy. ConclusionOrbital liposarcoma demonstrated a propensity for developing in the extraocular muscle. The radiological images of well-differentiated liposarcomas were characterized by irregular and ill-defined adipose tissue. Surgery combined with radiotherapy demonstrates potential in reducing recurrence rates. Notably, orbital myxoid liposarcoma exhibited greater sensitivity to radiotherapy compared to well-differentiated liposarcoma.

Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy

BackgroundThe standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures. MethodsPatients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation. ResultsThe mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450). ConclusionThe mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.

Neurosensory Deficits of the Mandibular Nerve Following Extraction of Impacted Lower Third Molars-A Retrospective Study.

Neurosensory deficits are one of the major complications after impacted lower third molar extraction leading to an impaired patient's quality of life. This study aimed to evaluate the incidence of neurosensory deficits after lower third molar extraction and compare it radiologically to the corresponding position of the inferior alveolar nerve. In a retrospective study, all patients who underwent impacted lower third molar extraction between January and December 2019 were compiled. Therefore, clinical data as well as preoperative radiological imaging were assessed. In total, 418 patients who underwent lower third molar extractions (n = 555) were included in this study. Of these, 33 (5.9%) had short-term (i.e., within the initial 7 postoperative days) and 12 (1.3%) long-term (i.e., persisting after 12 months) neurosensory deficits documented. The inferior alveolar nerve position in relation to the tooth roots showed apical position in 27%, buccal position in 30.8%, lingual position in 35.4%, and interradicular position in 6.9%. A statistically significant increased incidence of neurosensory deficits occurs when the inferior alveolar nerve is directly positioned lingually to the tooth roots (p = 0.01).

Status Quo of Surgical Navigation

Surgical navigation, also referred to as computer-assisted or image-guided surgery, is a technique that employs a variety of methods - such as 3D imaging, tracking systems, specialised software, and robotics to support surgeons during surgical interventions. These emerging technologies aim not only to enhance the accuracy and precision of surgical procedures, but also to enable less invasive approaches, with the objective of reducing complications and improving operative outcomes for patients. By harnessing the integration of emerging digital technologies, surgical navigation holds the promise of assisting complex procedures across various medical disciplines. In recent years, the field of surgical navigation has witnessed significant advances. Abdominal surgical navigation, particularly endoscopy, laparoscopic, and robot-assisted surgery, is currently undergoing a phase of rapid evolution. Emphases include image-guided navigation, instrument tracking, and the potential integration of augmented and mixed reality (AR, MR). This article will comprehensively delve into the latest developments in surgical navigation, spanning state-of-the-art intraoperative technologies like hyperspectral and fluorescent imaging, to the integration of preoperative radiological imaging within the intraoperative setting.

Re-sleeve gastrectomy is a safe and sensible intervention in selected patients: retrospective cohort study.

Sleeve gastrectomy is a good treatment intervention to control the metabolic syndrome in patients with obesity worldwide. However, weight regain is of great concern and would usually necessitate a reintervention. In recent years, re-sleeve gastrectomy (ReSG) has been proposed to treat weight regain in the context of a large residual stomach. Our objective was to analyze the long-term results and safety profile of this intervention in a large case series. From September 2010 to March 2021, a retrospective cohort study in a tertiary nonuniversity hospital was performed. Seventy-nine patients received a ReSG by laparoscopy. Preoperative radiologic imaging showed a dilation of the gastric pouch exceeding 250cc in all cases. A total of 79 patients (87% females) with a mean age of 44.8 years old and a mean BMI of 40.0kg/m 2 were enrolled in the study. The mean follow-up was 44.8 months. The ReSG indication was insufficient weight loss in 37 patients (46.8%) and weight regain in 39 patients (53.2%). The authors noticed a 10.1% complications rate: gastric stenosis (5.1%), bleeding (2.5%), and incisional site hernia in 2.5%, with no death. There was no gastric fistula detected. The mean BMI decreased to 33.1kg/m 2 after ReSG (a decrease of 6.9kg/m 2 ). After insufficient weight loss or weight regain following sleeve gastrectomy and in the presence of localized or global gastric tube dilation, ReSG seems to be a good treatment choice and a safe procedure.

Correlation of Lumbar Spine Fat Thickness and Surgical Site Infection in Degenerative Lumbar Spine Surgery

Introduction: Surgical site infection (SSI) is a serious and common complication following any surgery. Patientsundergoing lumbar surgery have a higher risk for SSI. Therefore, it is essential to accurately identifythe risk factors of SSIs to prevent them. There is an insufficient number of studies internationally andonly one to our knowledge nationally that studied the correlation between lumbar fat thickness andSSI in patients undergoing lumbar spine surgery. Our aim was to identify the correlation betweenlumbar fat thickness and SSI and determine its predictive value compared to other risk factors inpredicting the incidence of SSI.&#x0D; Methods: This retrospective cohort study involved all patients aged 18 and above who underwent primary elective degenerative lumbar spine surgery in National Guard Health Affairs (NGHA) from 2016 to 2020 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. All trauma and oncology cases, patients with previous spine surgery, non-instrumented cases, and emergency cases without preoperative radiological images were excluded. The pre-operative and post-operative measurements were assessed using the sagittal MRI images on the T1 view to measure the fat length of the lumbar spine from L2 to S1. Two observers evaluated the films, and the average measurement was documented for each level.&#x0D; Results: 151 patients were included in our study, four of whom developed SSI. When comparing the demographics of both groups, BMI was found to be a significant variable between both groups, with a P-value of 0.013. However, there was no significance regarding age, gender, DM, HTN, steroid use, and level of stay for each group. Furthermore, there was no significance in all vertebrae levels except for L4 fat thickness, which was significantly higher in the SSI group with a P value of 0.0264.&#x0D; Conclusion: Surgical site infection (SSI) is a serious and common complication following any surgical operation. Patients undergoing lumbar surgery have a higher risk for SSI. In this study, we concluded that an increased L4 fat thickness was a significant predictor of SSI.

Cardiac hydatidosis complicated by vascular involvement: a case report

BackgroundHydatid disease is a parasitic infection which is endemic in multiple regions across the globe including Indian subcontinent. Although it commonly affects the liver and other solid organs, isolated involvement of the heart is relatively uncommon. Cardiac hydatidosis can be confidently diagnosed on echocardiography, but cross-sectional imaging by computed tomography (CT) or magnetic resonance imaging (MRI) provides accurate information about its location, extent, and multiplicity. Multiple case studies of cardiac hydatid disease have been reported in the literature. However, cardiac hydatidosis with extension into pulmonary vasculature has not been reported commonly. This case report highlights this rare association, with stress upon the altered surgical management.Case presentationA 50-year-old patient presented with atypical chest pain to the cardiology department of a tertiary care hospital where he underwent multiple blood tests as well as electrocardiography (ECG) and echocardiography as part of the routine examination. Echocardiography revealed a large, multicystic mass invading the posterolateral wall of left ventricle (LV) with no internal vascularity and was provisionally diagnosed as hydatid disease. Subsequent CT study confirmed a large multicystic lesion with the presence of another smaller lesion invading the left atrial appendage (LAA). In order to evaluate the vascular and mediastinal invasion, cardiac MRI was then performed which revealed invasion of right pulmonary artery (PA), right superior pulmonary vein (PV) as well as compression of superior vena cava (SVC) by the smaller lesion. A final diagnosis of cardiac hydatidosis with invasion into right PA and right superior PV was made. Treatment plan for the patient changed, who then underwent an additional reconstruction of right PA and right superior PV after cyst removal.ConclusionsCardiac hydatid disease is a rare but potentially lethal condition, which tends to show slow growth and local invasion. The diversity of findings in such rare cases makes individual surgical approach extremely valuable with preoperative radiological imaging becoming indispensable for correct localization and appropriate planning. Our case report highlights rare association of cardiac hydatidosis with invasion of both pulmonary artery and vein, which eventually altered the surgical management of patient.

WTP2.3 Incidence of intrathyroid parathyroid adenoma - last 9 years in a teaching hospital

Abstract Aim The incidence of intrathyroid parathyroid adenoma (iTPA) is estimated to be 0.7-5.7% of hyperparathyroidism cases. Thyroid lobectomies may be performed when an adenoma cannot be clearly identified and isolated. We aimed to review the incidence of iTPA and outcomes after surgery within our practice. Methods We retrospectively reviewed consecutive parathyroidectomies performed by two experienced upper gastrointestinal surgeons (VS and PT) in a teaching hospital between April 2013 and December 2022. Preoperative radiological imaging was reviewed, and cases of iTPAs were diagnosed intraoperatively and on histopathology. These were further evaluated to review the outcomes after surgery. Results Total of 211 parathyroidectomy surgeries were performed, 11 (5.2%) of which were found to be iTPAs. These were confirmed on histopathology. Median age of patient cohort was 57±13 years. Patients were predominantly female (n=10, 90.9%). None underwent previous neck exploration. There was radiological (SPECT and Ultrasound) suspicion of iTPAs in 3 (1.4%) cases; peri-operative decision was made to explore for iTPA in the remaining 8 cases. 9/11 (81.8%) patients had hemithyroidectomy performed; in the remaining two cases, adenoma was successfully isolated from thyroid tissue and resected. Preoperative methylene blue infusion was utilised in all cases, of which uptake was evident in 8 (72.7%) cases. Calcium normalised in all patients postoperatively and none required further neck exploration. Conclusion Our 9-year series of parathyroid surgery revealed 5.2% incidence of iTPA, the majority of which was diagnosed intraoperatively. Diagnosis of iTPA should be considered if there is suspicion on radiological imaging and where no obvious adenoma is identified after full neck exploration.

A case report of bilateral benign Ovarian Fibrothecoma coincidental with ascites: an unconventional co-occurrence.

We present the case of a 54-year-old female who presented complaining only of a slow progressive increase in the abdominal contour associated with vague abdominal pain. Our preoperative radiological imaging revealed multiple ovarian and uterine masses. Surgical intervention in the form of a hysterectomy with bilateral salpingo-oophorectomy was achieved. Histopathological analysis revealed bilateral benign ovarian fibrothecoma with benign uterine leiomyomas. The patient underwent an uneventful postoperative recovery. Ovarian Fibrothecoma is a rare gynecological pathology. The uniqueness of our case stems from the rarity of its bilateral occurrence and in rare occasions, their occurrence is accompanied by ascites. This kind of co-occurrence should be differentiated from other rare presentations, such as Meigs Syndrome. Therefore, documentation is necessary to circumvent misdiagnoses and to abate the resulting patient morbidity. To further highlight the value of our case, it is to the best of our knowledge, the first documented case of this pathology from our country.

Enhancing Mural Nodules in the Main Pancreatic Duct of Main and Mixed Types of Intraductal Papillary Mucinous Neoplasms: Does Size Matter in Malignancy Risk?

Most guidelines recommend surgical resection of all main duct (MD) and mixed-type (MT) intraductal papillary mucinous neoplasms (IPMNs) in suitable patients. However, there is little evidence regarding the malignancy risk of enhancing mural nodules (EMNs) that are present only in the main pancreatic duct (MPD) in patients with MD- and MT-IPMNs. Therefore, this study aimed to identify the clinical and morphological features associated with malignancy in MD- and MT-IPMNs with EMNs only in the MPD. We retrospectively enrolled 50 patients with MD- and MT-IPMNs with EMNs only in the MPD on contrast-enhanced magnetic resonance imaging. We evaluated the clinical characteristics and preoperative radiologic imaging results of MPD morphology and EMN size and analyzed the risk factors associated with malignancy. Histological findings of EMNs were low-grade dysplasia (38%), malignant lesions (62%), high-grade dysplasia (34%), and invasive carcinoma (28%). On the receiver operating characteristic curve, the cutoff value of EMN size on magnetic resonance imaging for best predicting malignancy was 5 mm (sensitivity, 93.5%; specificity, 52.6%; area under the curve, 0.753). Multivariate analysis showed that only EMN >5 mm (odds ratio, 27.69; confidence interval, 2.75 to 278.73; p=0.050) was an independent risk factor for malignancy. EMNs of >5 mm are associated with malignancy in patients with MD- and MT-IPMNs with EMNs that are present only in the MPD, in accordance with the international consensus guidelines.

Preoperative imaging of clinically relevant intrathoracic abnormalities in pectus excavatum patients.

Preoperative radiological imaging in pectus excavatum sometimes coincidentally yields additional intrathoracic abnormalities. In the context of a larger research project investigating replacement of CT scans by 3D-surface scanning as routine preoperative work-up for pectus excavatum, this study aims to quantify the incidence of clinically relevant intrathoracic abnormalities found incidentally using conventional CT in pectus excavatum patients. A single-center retrospective cohort study was conducted including pectus excavatum patients, receiving CT between 2012 and 2021 as part of their preoperative evaluation. Radiology reports were reviewed for additional intrathoracic abnormalities and scored into three subclasses: non-clinically relevant, potentially clinically relevant or clinically relevant findings. Also, two-view plain chest radiographs reports, if available, were evaluated for those patients with a clinically relevant finding. Subgroup analysis was performed to compare adolescents and adults. In total, 382 patients were included, of whom 117 were adolescents. Although in 41 patients (11%) an additional intrathoracic abnormality was found, only two patients (0.5%) presented with a clinically relevant abnormality requiring additional diagnostics, postponing surgical correction. In only one of the two patients, plain chest radiographs were available, which did not show the abnormality. Subgroup analyses revealed no differences in (potentially) clinically relevant abnormalities between adolescents and adults. The prevalence of clinically relevant intrathoracic abnormalities in pectus excavatum patients was low, supporting the notion that CT and plain radiographs can be safely replaced by 3D-surface scanning in the preoperative work-up for pectus excavatum repair.

Atypically Located Hydatid Cyst Cases: Four Unusual Case Reports

Hydatid cysts are frequently located in liver (65-70%) and lungs (25%). The disease is usually asymptomatic when located in the extrahepatic regions. Sometimes, diagnosis can be established by observing germinative membrane, rockwater, or daughter vesicles during the operation.. A 41-year-old female patient applied with the complaint of intermittent left inguinal pain. Echinococcus Indirect Hemagglutination (IHA) test was positive. In the ultrasonographic examination, a hypoechoic area was observed in the posteromedial of the left femoral head.. A 56-year-old female patient, applied with the complaints of intermittent nausea, vomiting, and epigastric pain. She had a history of surgery for liver hydatid cyst 15 years ago and for lung hydatid cyst 10 years ago. IHA test of the patient was positive. The lesion involving septation and accompanied by calcifications around the cyst was reported as a hydatid cyst at dynamic CT for pancreas and upper abdominal MRI. A 22-year-old female patient applied with perianal pain complaint. Drainage was planned for the patient who had a pre-diagnosis of perianal abscess. Tissues similar to the hydatid cyst membrane were excised together with purulent fluid. The patient was diagnosed with hydatid cyst after the pathology result was reported “as compatible with hydatid cyst”. A 32-year-old female patient had a non-metabolic adrenal subcapsular cyst (hydatid cyst?) in the right adrenal gland on ultrasonography performed for abdominal pain. In abdominal tomography, a “cystic mass compatible with hydatid cyst located in the adrenal gland in the upper pole of the right kidney” was reported. IHA test of the patient was negative. Hydatid cysts located in the perianal region and muscles have been reported as atypical localizations in the literature, and some of them were diagnosed as a result of preoperative clinical evaluation and radiological imaging. Some were diagnosed as a result of pathological examination after the operation. Surgical treatment is an option in suitable cases, and the definitive diagnosis can be established by pathology. Consequently, it should be considered that cystic lesions detected in the patients living in endemic regions can be extrahepatic hydatid cyst that is localized in different anatomical regions.