Previous CT Scan Research Articles

Instrumental Diagnosis of Placenta Accreta and Obstetric and Perinatal Outcomes: Literature Review and Observational Study.

Placenta accreta (PA) is a condition where the placenta is pathologically adherent to the uterus due to a defect in the basal decidua with myometrium invasion by chorionic villi and is classified based on the depth of myometrial invasion by histology. However, ultrasound and magnetic resonance imaging have excellent accuracy. In this study, we investigated clinical benefits of early instrumental diagnosis of PA, especially in reducing maternal-fetal complications and improving perinatal outcomes. We also evaluated diagnostic accuracy of ultrasound and magnetic resonance imaging on placental invasiveness assessment. In this review and observational retrospective study, risk factors of PA were collected, and pregnant women underwent third-trimester ultrasound and magnetic resonance imaging (MRI) to evaluate the degree of infiltration. Imaging results compared to histological findings and surgical evaluation. A total of 38 patients were diagnosed with at the University Hospital "San Giovanni di Dio and Ruggi d'Aragona", Salerno, Italy, by second-trimester ultrasound with high sensitivity (100%) and accuracy (86%). Moreover, 37 of them performed MRI and 60.5% were diagnosed with Accreta, 7.9% increta, 10.5% percreta, and 21.1% not accrue with high sensitivity (100%), specificity (88.9%), and accuracy (97.4%). Histological assay confirmed MRI findings in 96.7% of cases. Risk factors of PA were age >35 years and previous CT scans. In unborn babies, mean 1-min Apgar was 4.3 (range, 3-6), and mean 5-min Apgar was 7.13 (range, 7-9). MRI could be a not-invasive, specific, sensitive, and accurate diagnostic tool for assessing the degree of infiltration in PA, and could guide clinical decisions, such as delivery plan, thus reducing perioperative and fetal complications.

Rectal duplication cyst presenting with change in bowel habits and rectal bleeding: A case report and literature review

We present a rare case of rectal duplication cyst (RDC) in an adult patient who presented with chronic fluctuating bowel habits and rectal bleeding. A faecal immunochemical test (FIT) and a faecal Calprotectin level showed negative results, and no previous abdomen-pelvis CT scan or MRI was identified. A Colonoscopy was performed, showing a benign rectal lesion causing colonic intraluminal compression leading to rectal ulceration and prolapse, and solitary rectal ulcer syndrome was suspected. A Transanal Minimally Invasive surgery (TAMIS) was performed to excise the lesion, with histopathology findings consistent with a rectal duplication cyst. The patient had no intraoperative complications and made an uneventful recovery. A systematic literature review showed 30 30 adult Rectal supplication cyst case reports. In conclusion, The most common presentation of RDC is anal pain and rectal bleeding. The diagnosis of RDC is challenging, and it requires Surgical resection to confirm the diagnosis.

WITHDRAWN: Are glenoid retroversion, humeral subluxation and Walch classification associated with a muscle imbalance

IntroductionThe etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior to posterior rotator cuff muscle and deltoid volumes as a function of humeral subluxation and glenoid morphology when analyzed as continuous variable in arthritic shoulders. MethodsThree hundred and thirty-three (273 arthritic and 60 healthy controls) CT scans of shoulders were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intra-muscular fat was then measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus + teres minor (AP ratio) and the ratio between the anterior and posterior deltoid (APdeltoid) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version/ humeral subluxation/glenoid type in the Walch classification. ResultsWithin the arthritic cohort, no statistically significant difference was found between the AP ratio between A and type B glenoids (1.09 ± 0.22 versus 1.03 ± 0.16 p=0.09), between A and D type glenoids (1.09 ± 0.22 versus 1.12 ± 0.27, p=0.77) nor between the A and C type glenoids (1.09 ± 0.22 versus 1.10 ± 0.19, p=1). No correlation was found between AP ratio and glenoid version/humeral subluxation (rho =-0.0360, p=0.55; rho = 0.076; p=0.21). The APdeltoid ratio of type A glenoids was significantly greater than that of type B glenoids (0.48 ± 0.15 versus 0.35 ± 0.16, p< 0.01), and type C glenoids (0.48 ± 0.15 versus 0.21±0.10, p < 0.01) but not significantly different from the APdeltoid ratio of type D glenoids (0.48 ± 0.15 versus 0.64 ± 0.34, p=1). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between APdeltoid ratio and glenoid version/humeral subluxation (rho=0.55, p<0.01; rho=-0.61, p<0.01). ConclusionAs opposed to previous two-dimensional CT scan studies, we did not find any correlation between AP muscle volume ratio and glenoid parameters in arthritic shoulders. Therefore, rotator cuff muscle imbalance does not seem to be associated with posterior humeral subluxation leading to posterior glenoid erosion and subsequent retroversion characteristic of Walch B glenoids. However, our results could suggest that a larger posterior deltoid pulls the humerus posteriorly into posterior subluxation, but this requires further evaluation as the deltoid follows the humerus possibly leading to secondary asymmetry between the anterior and the posterior deltoid.

A case report of a rare mesenteric lesion

In a 82-year-old man with cardiovascular comorbidities underwent an abdominal CT scan, showing an incidental 9 centimeters cystic mesenteric lesion. An additional Magnetic Resonance Imaging (MRI) described a not-enhanced cystic lesion, with septa, developed in the mesenteric root with a mass effect without any sign of bowel invasion (Figure 1). This lesion was not observed in a previous abdominal CT scan. A cystic peritoneal mesothelium was suspected. A surgical treatment was thus indicated. Because of the location at the mesenteric root, an open approach was performed, revealing a cystic mesenteric multi-loculated lesion, with white liquid contain (Figure 2). A bowel resection of proximal jejunum (45 centimeters) was performed with an handsewn end-to-end anastomosis. Pathological analysis identified a cystic mesenteric lymphangioma without any criteria of malignity.

HT TEMNOGRAPHY INTHEEARLY DIAGNOSIS OF BRAIN LESIONS DUE TO ISCHEMIC OR HEMORRHAGIC SROKE

Background and aim: The efficacy of treatment in brain stroke is strictly time-dependent, and the development of rapid and non-invasive neurodiagnostic tools for the identification of brain lesions is crucial. Here we assess sensitivity, specificity, accuracy and safety of a new technology, the TESHT temnograph, in the identification of brain lesions in comparison to traditional CT and MRI scans. The temnograph is based on microwave emissions and requires the use of a light headset, representing a significant advancement in non-invasiveness and cost-effectiveness of neuroimaging diagnostics. Methods: Ninety-eight nursing home patients (48M, 50F, age:30-85) with ischemic or hemorraghic stroke and a recent MRI and/or TC scan underwent a TESHT scan. The accuracy, specificity, sensitivity of brain lesions identification was compared between the 3 scans. Results: In relation to the previous CT or MRI scans, TESHT showed 100% sensitivity, specificity and accuracy in the detection of prior and recent brain lesions. Moreover, the absolute safety of the tool was confirmed (100%), with no adverse events reported either by patients or technicians. Conclusions: The TESHT temnograph appears to be a highly promising tool for the faster and less invasive diagnosis of brain lesions secondary to stroke, compared to traditional neuroimaging tools such as MRI and CT. Its accuracy, sensitivity and specificity in diagnosis indicates TESHT as a significant advancement in neuroimaging technology, allowing earlier and safer diagnosis in of cerebrovascular diseases.

Increased 18F-FAPI-04 Uptake in Vertebral Hemangioma.

A 54-year-old man with a history of colectomy for colorectal cancer and subsequent liver metastasectomy underwent 18F-FDG PET/CT and 18F-FAPI-04 PET/CT scans to evaluate possible hepatic metastasis revealed by contrast-enhanced MRI. Both studies showed similarly increased uptake in liver metastases, and 18F-FDG detected a metastatic lung nodule. Furthermore, the images showed an incidental finding of increased uptake of 18F-FAPI-04 in the L3 vertebral, which was not 18F-FDG-avid. A review of the patient's previous CT and MRI scans suggests vertebral hemangioma.

FRI042 Worsening Shortness Of Breath After A Mild Case Of Covid-19

Abstract Disclosure: K. Qureshi: None. T.S. Krause: None. K. Vidlock: None. This case demonstrates a complication of COVID 19 that may be more common than we know and overlooked. A 34-year-old female presents to the Emergency Department with worsening shortness of breath and tachycardia for 3 days. Her symptoms are worse with ambulation. She feels dizzy and lightheaded. The patient had COVID-19 about two weeks ago and received monoclonal antibodies. The patient has a history of “drenching” night sweats and unintentional weight loss. She denies fever and cough. The patient is eating and drinking normally with no abdominal pain, nausea, or rash. No changes in bowel movements. The patient’s past medical history consists of ADHD, Anxiety, Neuropathy, and Insomnia. The patient takes Adderall, amitriptyline (ELAVIL), fluocinonide (LIDEX). The patient’s family history consists of an aunt who has autoimmune disease and a maternal grandfather who has Non-Hodgkin's Lymphoma. She works as a medical assistant in a family medicine clinic. Patient underwent a CTA which displayed a new anterior mediastinal mass measuring 4.6 x 2.6 x 3.2 cm which was not shown on a previous CT scan 11 months prior. She was referred to a thoracic surgeon for mediastinoscopy, which couldn’t be performed due to location not adjacent to trachea. A PET scan showed mildly FDG-avid soft tissue density in the anterior mediastinum. Four months later, the patient had a CT scan which showed a modest decrease in size measuring 2.1 x 2.5 cm. The thymus is important in maturation of T cells and is replaced with fat through aging. The thymus plays an important immunological role in defending against pathogens and cancer by maturing and releasing T cells. Thymic hyperplasia is a response that has been displayed in autoimmune diseases such as Myasthenia Gravis. Thymic rebound hyperplasia is seen more often in children, typically after chemotherapy treatment but not seen in adults. Rebound hyperplasia occurs less often with viral illness. There have been a limited number of cases seen with COVID-19. An observational study of 87 participants suggested that rebound thymic hyperplasia may be a positive predictive factor due to the benefit of T-cell lymphocyte production. The presence of thymic hyperplasia on CT scan in COVID patients correlated with a better prognosis in a retrospective study of 325 COVID patients that had a CT scan. This patient will require repeated imaging and follow up. The long-term consequences of this finding are unknown and this patient has a history of night sweats which preceded the COVID course. Presentation: Friday, June 16, 2023

Two Birds with One Stone: Hepatocellular Carcinoma and Small Cell Lung Cancer Imaged with [18F]Fluorocholine Positron Emission Tomography/Computed Tomography.

We describe the case of a 67-year-old male patient with a moderately differentiated hepatocellular carcinoma (HCC) of the right liver lobe who underwent [18F]fluorocholine positron emission tomography/computed tomography (PET/CT) for staging due to a suspicious lung lesion at previous CT scan. [18F]fluorocholine PET/CT showed increased radiopharmaceutical uptake in a liver lesion corresponding to the known HCC. Furthermore, a right pulmonary hilar lesion suspicious for metastatic spread of HCC showed increased radiopharmaceutical uptake. Surprisingly, the histological assessment of the thoracic lesion demonstrated the presence of small cell lung cancer (SCLC). The patient underwent treatment with radiation therapy and chemotherapy for the SCLC and selective internal radiation therapy (SIRT) for the HCC. The patient died after one year due to progressive SCLC. This case demonstrates that coexisting tumors showing increased cell membrane turnover, including SCLC, can be detected by [18F]fluorocholine PET/CT. In our case, [18F]fluorocholine PET/CT findings influenced the patient management in terms of histological verification and different treatment of the detected lesions.

A Case of Tracheoesophageal Fistula in a Non-metastatic Site During Lenvatinib Treatment for Hepatocellular Carcinoma.

We report a case of tracheo-esophageal fistula at a non-metastatic site during lenvatinib treatment of hepatocellular carcinoma with multiple bone metastases. A 58-year-old male patient was diagnosed with hepatocellular carcinoma with multiple bone metastases and was treated with atezolizumab-bevacizumab. However, as the bone metastasis progressed, palliative radiation therapy was administered to the third thoracic vertebra, and lenvatinib was administered as a second-line treatment. The patient was hospitalized for aspiration pneumonia five months later. Chest computed tomography and bronchoscopy revealed a 5 cm tracheoesophageal fistula located 3 cm cranial to the carina. We diagnosed a benign tracheoesophageal fistula due to lenvatinib because his previous CT scan showed no metastases at the site of the fistula, and we performed esophageal bypass surgery 4 weeks after discontinuation of the lenvatinib. To the best of our knowledge, this is the first case report of tracheoesophageal fistula at a nonmetastatic site during lenvatinib treatment for hepatocellular carcinoma.

Pleuroparenchymal Fibroelastosis-like Lesions in Clinical Practice: A Rare Entity? Review of a Radiological Database.

Background: Pleuroparenchymal Fibroelastosis (PPFE) is a rare disease that consists of elastofibrosis that involves the pleura and subpleural lung parenchyma; it is an unusual pulmonary disease with unique clinical, radiological and pathological characteristics. According to recent studies, PPFE may not be a definite disease but a form of chronic lung injury. The aim of this retrospective study is to determine the incidence and to evaluate the distribution, severity and progression of this radiological entity on high-resolution CT (HRCT) exams of the chest, performed in routine clinical practice. In total, 1514 HRCT exams performed in the period January 2016-June 2018 were analyzed. For each exam, the presence of PPFE was evaluated and a quantitative score was assigned (from 0 to 7 points, based on the maximum depth of fibrotic involvement of the parenchyma). When available, two exams with a time interval of at least 6 months were compared for each patient in order to evaluate progression (defined as the increase in the disease score). Patients were divided into different groups according to exposure and their associated diseases. Statistical analysis was performed by using the Wilcoxon test and Kruskal-Wallis test. Results: PPFE was detected in 174 out of 1514 patients (11.6%), with a mean score of 6.1 ± 3.9 (range 1-14). In 106 out of 174 patients (60.9%), a previous CT scan was available and an evolution of PPFE was detected in 19 of these (11.5%). Among these 19 patients with worsening PPFE, 4 had isolated PPFE that was associated with chronic exposure or connective tissue disorders, and the other 15 had an associated lung disease and/or a chronic exposure. In this group, it was found that the ventral segments of the upper lobes, fissures and apical segments of the lower lobes had a greater statistically significant involvement in the progression of the disease compared to the non-progressive group. In 16 of 174 patients (9.2%, 7 of which belonged to the radiological progression group) a biopsy through video-assisted thoracoscopic surgery or apicoectomy confirmed PPFE. Conclusion: PPFE-like lesions are not uncommon on HRCT exams in routine clinical practice, and are frequently found in patients with different forms of chronic lung injury. Further studies are necessary to explain why the disease progresses in some cases, while in most, it remains stationary over time.

Two-year multidisciplinary follow-up of COVID-19 patients requiring invasive and noninvasive respiratory support.

COVID-19 patients frequently develop respiratory failure requiring mechanical ventilation. Data on long-term survival of patients who had severe COVID-19 are insufficient. We assessed and compared two-year survival, CT imaging, quality of life, and functional recovery of COVID-19 ARDS patients requiring respiratory support with invasive (IMV) versus noninvasive ventilation (NIV). Patients with COVID-19 pneumonia admitted up to May 28th, 2020, who required IMV or NIV, and survived to hospital discharge were enrolled. Patients were contacted two years after discharge to assess vital status, functional, psychological, and cognitive outcomes using validated scales. Patients with persistent respiratory symptoms or high burden of residual lung damage at previous CT scan received a two-year chest CT scan. Out of 61 IMV survivors, 98% were alive at two-year follow-up, and 52 completed the questionnaire. Out of 82 survivors receiving NIV only, 94% were alive at two years, and 47 completed the questionnaire. We found no major differences between invasively and noninvasively ventilated patients, with overall acceptable functional recovery. Among the 99 patients completing the questionnaire, 23 have more than moderate exertional dyspnea. Chest CT scans showed that 4 patients (all received IMV) had fibrotic-like changes. Patients who received mechanical ventilation due to COVID-19 and were discharged from hospital had a 96% survival rate at the two-year follow-up. There was no difference in overall recovery and quality of life between patients who did and did not require IMV, although respiratory morbidity remains high.

A RARE PRESENTATION OF DELAYED EPISTAXIS: POST TRAUMATIC INTERNAL CAROTID ARTERY PSEUDOANEURYSM AT A TERTIARY CARE CENTRE IN EASTERN NEPAL

Epistaxis is a common ENT emergency. Various causes are mucosal trauma, anticoagulants and bleeding disorders. Vascular causes and trauma accounts for less than 5% causes. A 25-year-old man presented to emergency with intractable epistaxis. He had sustained road traffic accident 5 months back. His previous CT scan showed multiple facial bones fracture along with sinuses (frontal, maxillary and sphenoid sinus on right para clinoid area) fracture. Initial CT angiography showed no vascular defects. The latest episode of epistaxis was massive and he underwent nasal endoscopy and packing of nose. Pulsatile sphenoidal polyp was visualized, along with transmitted pulsations in the sphenoid sinus on the right side. Subsequent Magnetic Resonance Angiography (MRA) showed a 12x4 mm pseudoaneurysm of clinoidal portion of Internal Carotid Artery on the right side. Post-traumatic Pseudoaneurysm of the Internal Carotid Artery may be the differential diagnosis in traumatic epistaxis, especially the delayed type. If pseudoaneurysm is suspected, CT or MRI angiography should be performed immediately.

The role of repeated imaging in detecting complications in the post-operative period following pancreaticoduodenectomy: Serial CT imaging post-pancreaticoduodenectomy.

Post-pancreaticoduodenectomy haemorrhage is a potentially life-threatening complication. Delay in the detection and subsequent management of complications contribute significantly to post-operative mortality and morbidity associated with pancreaticoduodenectomy. All patients undergoing pancreaticoduodenectomy at an Australian-based tertiary referral center between 2017 and 2022 were reviewed retrospectively. We identified those patients who suffered a post-pancreaticoduodenectomy haemorrhage and further analysed those patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeated CT imaging performed within 24 h of their previous CT scan. A total of 232 pancreaticoduodenectomies were identified for analysis during the study period, of which 23 patients (9.9%) suffered a post-pancreaticoduodenectomy haemorrhage. We present four patients who had their post-pancreaticoduodenectomy haemorrhage identified on repeat CT scan in the setting of a recent (within 24 h) CT scan which showed no evidence of active haemorrhage or pseudoaneurysm formation. All patients received prompt and definitive endovascular management through stent insertion or coil embolization resulting in successful cessation of bleeding. Three patients made an uncomplicated recovery thereafter. Unfortunately, one patient died as a complication of the bleed despite early and definitive endovascular intervention. Our study highlights the importance of having a low threshold for repeated CT imaging in the post-pancreaticoduodenectomy setting, particularly when there remains a high index of suspicion clinically for a post-operative complication, even in the context of previous benign imaging. Given the complexity of pancreaticoduodenectomy, we believe early detection with liberal imaging allows the best chance at successfully managing the morbidity and mortality associated in the post-pancreaticoduodenectomy setting.

Revised indications for head CT in elderly patients with minor traumatic injuries: A retrospective analysis

PurposeThe purpose of this study was to assess the performance of a decision-tree for head-CT indication in elderly patients presenting minor traumatic injuries Materials and MethodsA single-centre retrospective study was performed and analyses were based on emergency CT scans of all patients aged 65 and over who experienced minor head trauma due to falls. The primary judgement criteria was the diagnosis of a traumatic intracranial haemorrhagic lesion (tICH) depicted on the CT scan. Focal neurological deficit and history of tICH on a previous CT scan were used to create the decision-tree. ResultsA total of 1001 patients were included. Ninety-five (9.5%) had tICH on the CT scan. Of these patients, 42 (46.1%) had an abnormal Glasgow Coma Scale, 30 (31.6%) a focal neurological deficit and 13 (13.7%) a history of tICH on a previous CT scan. The presence of at least one of these 3 risk factors was associated with the occurrence of tICH (p <0.001). The decision-tree developed from these risk factors allowed the appropriate classification of 63 of 95 patients (66.3%) with tICH. Undetected haemorrhagic lesions in patients with no clinical severity criteria evolved favourably. The decision-tree correctly identified 97% of patients without any tICH on the CT. ConclusionSystematic head CT for elderly patients presenting minor head trauma could be irrelevant. A decision-tree based on objective clinical severity criteria for the indication of head CT could detect the majority of tICH requiring surgical intervention. Prospective randomized studies are mandatory to confirm these hypotheses.

OC-024 MINIMALLY INVASIVE TREATMENT OF COMPLEX INCISIONAL/VENTRAL HERNIAS USING BOTULINUM TOXIN COMBINED WITH ROBOTIC SURGERY: ROBOTOX PROTOCOL

Abstract Introduction Incisional/ventral hernia repair has changed in the last 20 years. Posterior component separation like TAR (transversus abdominis muscle release) has increased as a revolutionary technique. On the other hand, the use of botulinum toxin (BT) has allowed better closure defect with no tension. We present a preliminary original protocol named ROBOTOX for complex incisional /ventral hernia repair that combined BT and robotic surgery to minimize the TAR procedure. Material and methods BT (Dysport®) was administered in patients with a complex incisional hernia repair and a transverse defect ≧8cm one month before robotic surgery. Demographic variables (age, sex, BMI), EHS classification, need of TAR, size transverse defect, postoperative complications and recurrence were studied. All patients had a previous CT scan. Results Five patients were included in ROBOTOX protocol, 3 men and 2 women with a median age of 63±8, median BMI of 32±3. Four patients had a M3W3 and one a L3 W2 hernia. Median size defect of 11,2±2. Three of them only needed Rives technique, one a unilateral TAR and one a 5 cm dissection of bilateral TAR. At the moment, with a FU of 6±2 months, no recurrences have been reported. Conclusions Robotic surgery combined with BT would allow a downstaging treatment in patients with complex incisional/ventral hernias. A major cases and long term follow up is needed to better conclusions.

S1828 Recurrent Pancreatitis Secondary to Adderall Use With Pancreatic Ascites: A Sight Typically Unseen

Introduction: Pancreatic ascites is a rare disease with a prevalence of 3.5% resulting from pancreatic duct injury. While small ascites resolves spontaneously, large volume, persistent ascites can cause significant morbidity and mortality. We present a case of pancreatic ascites in a patient with recurrent pancreatitis from Adderall use. Case Description/Methods: 38-year-old female with attention deficit hyperactive disorder (ADHD), remote alcohol use, and recurrent pancreatitis complicated by pseudocyst and ascites presented with acute on chronic epigastric pain. Her last reported alcohol use was 2 years ago. Home medications included Adderall (amphetamine and dextroamphetamine) and benzodiazepines. Physical examination revealed normal vital signs, severe cachexia and peripheral edema. Abdomen was distended with epigastric tenderness. Pertinent labs included hemoglobin of 10.8g/dl, calcium 7.6mg/dl, albumin 1.7g/dl and a lipase of 462U/l. Bilirubin, transaminases, alkaline phosphatase and INR were normal. Quantitative immunoglobulins, IgG4, triglycerides and thyroid stimulating hormone were within normal limits. Blood alcohol and phosphatidylethanol (PETH) levels were negative. Previous CT scan demonstrated pancreatic head cyst (4.6cm), stable pseudocysts in the head and body, peripancreatic inflammation and large abdominal ascites. MRCP this admission revealed pancreatic head fluid collection decreased in size (2.3cm), consistent with walled off necrosis (Figure). Diagnostic paracentesis was significant for: WBC 93 cells/mm3, PMN 25%, RBC 2050 cells/mm3, protein 1.9g/dl, lactate dehydrogenase 102U/L, amylase 1496U/L and a serum ascites-albumin gradient (SAAG) < 1.1. An endoscopic retrograde cholangiopancreatography (ERCP) was pursued due to suspicion for pancreatic ascites which showed abrupt cut off of the pancreatic duct in the head, without filling of the pancreatic duct in the body or tail likely due to stricture. A pancreatic stent was placed into the ventral pancreatic duct to maintain patency with plan for endoscopic ultrasound examination (EUS) to exclude obstructive pathology. Discussion: Pancreatic ascites is often seen with recurrent pancreatitis commonly of alcoholic etiology. Our patient had recurrent pancreatitis and ascites due to chronic adderall use. While pancreatitis from adderall use is rare, presentation with ascites can pose a diagnostic challenge. Hence, clinicians should familiarize themselves with early diagnosis and endoscopic management which improves prognosis in this rare disease.Figure 1.: MRCP images revealing large volume ascites (red arrow), walled off necrosis in the pancreatic head (yellow arrow) and peripancreatic inflammation (blue arrow).

Accounting for radiation exposure from previous CT exams while deciding on the next exam: What do referring clinicians think?

PurposeTo obtain clinicians’ views of the need to account for radiation exposure from previous CT scans and the advisability of a regulatory mechanism to control the number of CT scans for an individual patient. MethodsA convenience survey was conducted by emailing a link to a three-question electronic survey to clinicians in many countries, mostly through radiology and radiation protection contacts. Results505 responses were received from 24 countries. 293 respondents (58%) understand that current regulations do not limit the number of CT scans that can be prescribed for a single patient in a year. When asked whether there should be a regulation to limit the number of CT scans that can be prescribed for a single patient in one year, only a small fraction (143, 28%) answered ‘No’, 182 (36%) answered ‘Maybe’ and 166 (33%) answered ‘Yes’. Most respondents (337; 67%) think that radiation risk should form part of the consideration when deciding whether to request a CT exam. A minority (138; 27%) think the decision should be based only on the medical indication for the CT exam. Comparison among the 4 countries (South Korea, Hungary, USA and Canada) with the largest number of respondents indicated wide variations in responses. ConclusionsA majority of the surveyed clinicians consider radiation risk, in addition to clinical factors, when prescribing CT exams. Most respondents are in favor of, or would consider, regulation to control the number of CT scans that could be performed on a patient annually.

P036 A rare case of new onset large vessel vasculitis/aortitis, in a patient with Jak2 positive myelofibrosis

Abstract Background/Aims Large vessel vasculitis refers to inflammation of the wall of the aorta or its main branches; it can be primary (giant cell and Takayasu arteritis) or secondary to infections or autoimmune diseases. We are reporting a rare case of aortitis co-existed with Jak2 positive myelofibrosis. Methods In June 2017, a 57-year-old man who was previously fit and well presented to haematology clinic with tiredness, weight loss, night sweat for the preceding 3 months. Investigations showed pancytopenia and bone marrow biopsy showed dysplasia and grade3 myelofibrosis. He was diagnosed with JAK2 positive myelofibrosis with myelodysplasia and was commenced on ruxolitinib. Three months later, he was admitted with fever and other constitutional symptoms but no evidence of active synovitis or vasculitic skin lesions or temporal arteritis. Investigations showed CRP of more than 200mg/l, HB: 41g/l, WBC: 38.4 x109/l, Neutrophil 18.2 x109/l, Blasts: 1.73 x109/l and Platelet: 68 x109/l; Total protein:creatinine ratio: 30.4 mg/mmol, whereas anti CCP, ANA, ANCA, T-spot test and Syphilis antibody were all negative. Blood cultures were negative. CT-chest abdomen and pelvis showed splenomegaly and subtle fat haziness in the mediastinum adjoining the distal aortic arch with new onset (compared to a previous CT scan) mild thickening of distal aortic arch and descending aorta. Cardiac MRI confirmed active aortitis and PET-CT scan showed focal increased uptake within the arch of the aorta. He was diagnosed with aortitis and cellulitis of the left arm and foot and commenced on antibiotics and prednisolone 40mg. After one month, the patient was doing well, with significant improvement of symptoms and inflammatory markers (CRP: 7mg/l). Prednisolone was tapered and stopped after one year, as there was no evidence of flare up of vasculitis. Results In the literature, there are only few reported cases linking haematological malignancies to different forms of vasculitis. In one case, aortitis was reported as a manifestation of myelodysplastic syndrome whereas the coexistence of aortitis with chronic myeloid leukemia and chronic myelomonocytic leukemia was reported in 2 separate cases raising the possibility of coincidental or paraneoplastic phenomenon. Vasculitic skin ulcers preceded the appearance of myelofibrosis in another case report. In the above case, aortitis can also be related to the chemotherapeutic agents; leukocytoclastic vasculitis was possibly induced by ruxolitinib in a case report. Moreover, bacterial Infection, as a common cause of aortitis can still be the cause here. Conclusion Early recognition of coexistent disorders in patients with haematological malignancies is crucial for successful management. However, it can prove a challenge as malignancy, vasculitis and infection share common clinical features and investigations. Vasculitis can be primary or secondary to a wide variety of disorders, and further research is required to confirm the relation between myelofibrosis and aortitis. Disclosure Z. Alkutobi: None. A. Ugwoke: None. A. Nandagudi: None.

Management of incidentally detected small anterior mediastinal nodules: Which way to go?

ObjectivesWith increasing use of CT screening for lung cancers, there is a tendency toward increased detection of asymptomatic small anterior mediastinal nodules (SAMNs). In face of high rate of non-therapeutic surgery in these patients, workup and follow-up strategy for such lesions remains to be established. Materials and MethodsThis is a real-world study in patients with SAMNs (baseline diameter ≤ 3 cm) during 2013–2018. Interval growth of the nodules was reviewed. Accuracy of preoperative diagnosis was evaluated, and tumor doubling time (TDT) was calculated in resected tumors. ResultsA total of 419 patients were entered into the study, among them 91 received surgery. Eighty-four patients (92.3%) turned out to have thymic tumors, with a non-therapeutic surgery rate of only 6.6%. For 73 patients receiving both CT and MRI examinations, the sensitivity for diagnosing thymic tumors by CT alone was merely 72.1%, which was significantly improved to 97.1% (p < 0.001) when MRI was incorporated. Among 38 thymic tumor patients who had previous CT scan before surgery, significant difference in median TDT was seen between low-grade tumors and intermediate-/high-grade tumors (23.8 vs. 10.1 months, p = 0.021). Of the 328 patients not receiving surgery, 269 (82.0%) were diagnosed of having benign cysts by CT + MRI, followed by 24 (7.3%) lymph nodes, 22 (6.7%) thymic hyperplasia, and 13 (4%) thymic tumors. During follow-up (median 33 months), 319 (97.3%) lesions remained unchanged. ConclusionThe majority of incidentally detected SAMNs remain stable during long-term follow-up. Incorporating MRI with CT scan is helpful in differentiating benign cysts from small thymic tumors, thus avoiding non-therapeutic intervention. Follow-up is safe and warranted upon first detection when high-grade malignancies could be ruled out by careful imaging studies.

COVID-19 Pneumonia and Lung Cancer: A Challenge for the RadiologistReview of the Main Radiological Features, Differential Diagnosis and Overlapping Pathologies.

The COVID-19 pneumonia pandemic represents the most severe health emergency of the 21st century and has been monopolizing health systems’ economic and human resources world-wide. Cancer patients have been suffering from the health systems’ COVID-19 priority management with evidence of late diagnosis leading to patients’ poor prognosis and late medical treatment. The radiologist plays a pivotal role as CT represents a non-invasive radiological technique which may help to identify possible overlap and differential diagnosis between COVID-19 pneumonia and lung cancer, which represents the most frequent cancer histology in COVID-19 patients. Our aims are: to present the main CT features of COVID-19 pneumonia; to provide the main differential diagnosis with lung cancer, chemotherapy-, immunotherapy-, and radiotherapy-induced lung disease; and to suggest practical tips and key radiological elements to identify possible overlap between COVID-19 pneumonia and lung cancer. Despite similarities or overlapping findings, the combination of clinics and some specific radiological findings, which are also identified by comparison with previous and follow-up CT scans, may guide differential diagnosis. It is crucial to search for typical COVID-19 pneumonia phase progression and typical radiological features on HRTC. The evidence of atypical findings such as lymphadenopathies and mediastinal and vessel invasion, as well as the absence of response to therapy, should arouse the suspicion of lung cancer and require contrast administration. Ground-glass areas and/or consolidations bound to radiotherapy fields or pneumonitis arising during and after oncological therapy should always arouse the suspicion of radiation-induced lung disease and chemo/immunotherapy-induced lung disease. The radiological elements we suggest for COVID-19 and lung cancer differential diagnosis may be used to develop AI protocols to guarantee an early and proper diagnosis and treatment to improve patients’ quality of life and life expectancy.