Routine Surveillance Imaging Research Articles

Baseline Diameter Does Not Predict Growth Rate in a Presurgical Ascending Thoracic Aortic Aneurysm Population.

Patients with ascending thoracic aortic aneurysm are recommended to undergo routine imaging surveillance. Although maximal diameter is the primary metric of disease severity, recent American College of Cardiology/American Heart Association guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk. As diameter increases, it is assumed that aortic growth rate accelerates because of increased wall tension; however, this relationship is poorly studied. We aim to investigate the relationship between ascending thoracic aortic aneurysm diameter and growth rate using vascular deformation mapping, a validated technique for 3-dimensional growth mapping with submillimeter accuracy. We retrospectively identified adult patients with ascending aortic dilation (≥4.0 cm) and serial gated computed tomography angiograms separated by ≥2 years, excluding confirmed heritable thoracic aortic disease. Ascending growth rate was defined as 90th percentile radial wall deformation by vascular deformation mapping. Maximal diameter measurements were derived from the baseline computed tomography angiogram, and aortic length and body size-adjusted indexes were calculated. Among 258 included patients (63.2% men; age of 63 years [interquartile range, 55-69 years]), mean±SD baseline diameter was 46.3±3.6 mm and median growth rate was 0.21 mm/year (interquartile range, 0.13-0.38 mm/year). No correlation was noted between growth rate and baseline diameter (r=0.02, P=0.74) or other aortic size metrics. On multivariate analysis, age was independently predictive of growth rate (β=-0.007, P=0.021), alongside weight (β=0.003, P=0.016) and the presence of moderate or severe aortic valve insufficiency (β=0.146, P=0.049). Maximal aortic diameter is not predictive of aortic growth rate, in this contemporary cohort of patients with sizes under current surgical thresholds (<55 mm).

6477 Surprise Finding For A Thyroid Nodule: Metastatic Renal Cell Carcinoma

Abstract Disclosure: A. Xu: None. E. Hsu: None. Introduction: A patient with an incidental and asymptomatic thyroid nodule underwent fine needle aspiration biopsy (FNA) after the nodule increased in size. Without a definite pathology after three FNA attempts, thyroidectomy was performed, where pathology found metastatic renal cell carcinoma (RCC). Clinical Case: A 64 year old woman had a past medical history of obesity, type 2 diabetes, RCC (stage I: pT1bN0M0) treated with right radical nephrectomy five years prior and thought to be in remission, remote smoking history smoking, and coronary artery disease with coronary artery bypass graft (CABG) two months prior, on anticoagulation. The patient reported a distant history of right thyroid lobectomy over a decade prior for unclear reasons, but she was adamant that the pathology was benign. Two years prior to presentation, CT chest done for RCC surveillance had detected a left thyroid nodule. Ultrasound at the time revealed a 3.6 x 1.9 x 2.3 cm solid, isoechoic nodule in the upper left lobe, which was not taller than wide, and had smooth margins and no echogenic foci. A repeat ultrasound at the time of presentation showed interval growth of the nodule, now measuring 4.3 x 2.1 x 2.9 cm. FNA was unsatisfactory, yielding predominantly blood. Patient felt well and had no compressive neck symptoms. We opted to wait two months and repeat FNA, which resulted as atypia of undetermined significance - Bethesda category III (AUS). We recommended completion thyroidectomy, but patient preferred to avoid surgery. We decided to wait two months and repeat FNA with molecular testing. This third FNA resulted AUS again; however, due to non-medical reasons, molecular testing was not performed. Another ultrasound showed slight growth of the nodule, 5.1 x 2.9 x 2.0 cm, which appeared hypoechoic now, but was still not taller than wide, with smooth margins and no echogenic foci. Completion thyroidectomy was performed, with pathology showing metastatic clear cell renal cell carcinoma. Immunostains were positive for carbonic anhydrase and renal cell carcinoma marker and negative for TTF-1. Whole-body PET-CT showed no hypermetabolic foci, and a repeat PET-CT one year later still showed no evidence of metastatic disease. Other than a hospitalization for COVID-19, patient is doing well and asymptomatic now over a year after her thyroidectomy. Oncology will continue routine surveillance imaging for her metastatic renal cell carcinoma thought to be in remission. Clinical Lessons: This case of metastatic renal cell carcinoma to the thyroid adds to the small body of literature showing the thyroid as a possible site of RCC metastasis. The long time interval between initial RCC presentation and metastasis to the thyroid makes this diagnosis more difficult; however, clinicians should be aware of the possibility, making thyroidectomy a stronger option in cases where FNA cytology is indeterminate. Presentation: 6/2/2024

6477 Surprise Finding for a Thyroid Nodule: Metastatic Renal Cell Carcinoma

Abstract Disclosure: A. Xu: None. E. Hsu: None. Introduction: A patient with an incidental and asymptomatic thyroid nodule underwent fine needle aspiration biopsy (FNA) after the nodule increased in size. Without a definite pathology after three FNA attempts, thyroidectomy was performed, where pathology found metastatic renal cell carcinoma (RCC). Clinical Case: A 64 year old woman had a past medical history of obesity, type 2 diabetes, RCC (stage I: pT1bN0M0) treated with right radical nephrectomy five years prior and thought to be in remission, remote smoking history smoking, and coronary artery disease with coronary artery bypass graft (CABG) two months prior, on anticoagulation. The patient reported a distant history of right thyroid lobectomy over a decade prior for unclear reasons, but she was adamant that the pathology was benign. Two years prior to presentation, CT chest done for RCC surveillance had detected a left thyroid nodule. Ultrasound at the time revealed a 3.6 x 1.9 x 2.3 cm solid, isoechoic nodule in the upper left lobe, which was not taller than wide, and had smooth margins and no echogenic foci. A repeat ultrasound at the time of presentation showed interval growth of the nodule, now measuring 4.3 x 2.1 x 2.9 cm. FNA was unsatisfactory, yielding predominantly blood. Patient felt well and had no compressive neck symptoms. We opted to wait two months and repeat FNA, which resulted as atypia of undetermined significance - Bethesda category III (AUS). We recommended completion thyroidectomy, but patient preferred to avoid surgery. We decided to wait two months and repeat FNA with molecular testing. This third FNA resulted AUS again; however, due to non-medical reasons, molecular testing was not performed. Another ultrasound showed slight growth of the nodule, 5.1 x 2.9 x 2.0 cm, which appeared hypoechoic now, but was still not taller than wide, with smooth margins and no echogenic foci. Completion thyroidectomy was performed, with pathology showing metastatic clear cell renal cell carcinoma. Immunostains were positive for carbonic anhydrase and renal cell carcinoma marker and negative for TTF-1. Whole-body PET-CT showed no hypermetabolic foci, and a repeat PET-CT one year later still showed no evidence of metastatic disease. Other than a hospitalization for COVID-19, patient is doing well and asymptomatic now over a year after her thyroidectomy. Oncology will continue routine surveillance imaging for her metastatic renal cell carcinoma thought to be in remission. Clinical Lessons: This case of metastatic renal cell carcinoma to the thyroid adds to the small body of literature showing the thyroid as a possible site of RCC metastasis. The long time interval between initial RCC presentation and metastasis to the thyroid makes this diagnosis more difficult; however, clinicians should be aware of the possibility, making thyroidectomy a stronger option in cases where FNA cytology is indeterminate. Presentation: 6/2/2024

EP.04E.01 Use of Routine Brain Imaging Surveillance after Definitive Treatment for Early-Stage Non-Small Cell Lung Cancer

EP.04E.01 Use of Routine Brain Imaging Surveillance after Definitive Treatment for Early-Stage Non-Small Cell Lung Cancer

Patients at Greatest Risk of Missing Initial 1-Year Follow-Up After Pituitary Adenoma Resection

Routine evaluation and surveillance imaging after pituitary adenoma (PA) endoscopic endonasal transsphenoidal resection (EETS) is a neurosurgical practice to identify tumor recurrence. This study aims to identify social and clinical factors that may contribute to patients missing their initial 1-year follow-up appointment and provide guidance for targeted education to improve patient adherence with postoperative treatment plans, ultimately reducing unknown adenoma recurrence. The authors performed a single-center retrospective review of patients who underwent EETS for PAs from 2007 to 2023. Patients were analyzed for sociodemographic factors, presenting symptoms, time to surgery, surgical outcomes, and adherence to postoperative follow-up visits at 1 year after surgery. A total of 256 patients with PAs treated by EETS met inclusion criteria; 218 (85%) of these patients attended 1-year follow-up, and 38 (15%) missed this visit. Twenty-nine (76%) individuals who missed their 1-year follow up were men (P=0.006). Divorced/widowed/separated patients were 2 times more likely to miss their follow-up compared with their married counterparts (P=0.008). Additional significant risk factors included older age, as the mean age for patients who missed their 1-year appointment was 60.1 years compared with 54.7 years (P=0.028). Patients with visual field deficits at initial presentation were also less likely to follow-up at 1 year (P=0.03). Risk factors of missed 1-year follow-up appointments after PA resection include male sex, divorced/widowed/separated marital status, older age, and the presence of visual deficits at initial presentation. Increased education efforts can be selectively aimed at these at-risk patient cohorts to improve patient compliance and reduce consequences of undetected tumor recurrence.

Routine Surveillance of Upper Urinary Tract Imaging for Diagnosing Upper Urinary Tract Urothelial Cancer Recurrence in Patients with Nonmuscle Invasive Bladder Cancer.

Although routine surveillance imaging to examine upper urinary tract urothelial cancer recurrence during follow-up of nonmuscle invasive bladder cancer is recommended, its necessity remains invalidated. A single-institute long-term follow-up cohort study to evaluate the clinical impact of routine surveillance imaging and identify risk factors for upper urinary tract urothelial cancer recurrence after nonmuscle invasive bladder cancer treatment was conducted. A retrospective chart review of 864 patients with primary nonmuscle invasive bladder cancer who underwent initial transurethral resection of bladder tumor between 1980 and 2020 was conducted. The opportunities to diagnose its recurrence were examined. Moreover, oncological outcomes included upper urinary tract urothelial cancer recurrence-free survival and overall survival. Of 864 patients, 19 (2.2%) experienced upper urinary tract urothelial cancer recurrence. Among 19 patients, recurrence was detected through routine imaging in 12 (63.2%), cystoscopy in 2 (10.5%), urine cytology in 2 (10.5%), and presence of gross hematuria in 1 (5.3%). All patients had high- or highest-risk NMIBC at diagnosis of primary nonmuscle invasive bladder cancer. On multivariate Fine-Gray proportional regression analyses, a tumor size of ≥30 mm and carcinoma in situ were independently associated with short upper urinary tract urothelial cancer recurrence-free survival (P=0.040 and 0.0089, respectively). Most patients experiencing upper urinary tract urothelial cancer recurrence were diagnosed by routine surveillance imaging, suggesting its clinical importance, especially for patients with nonmuscle invasive bladder cancer accompanied by a tumor size of ≥30 mm and carcinoma in situ.

Society of Surgical Oncology Breast Disease Site Working Group Statement on Contralateral Mastectomy: Indications, Outcomes, and Risks.

Rates of contralateral mastectomy (CM) among patients with unilateral breast cancer have been increasing in the United States. In this Society of Surgical Oncology position statement, we review the literature addressing the indications, risks, and benefits of CM since the society's 2017 statement. We held a virtual meeting to outline key topics and then conducted a literature search using PubMed to identify relevant articles. We reviewed the articles and made recommendations based on group consensus. Patients consider CM for many reasons, including concerns regarding the risk of contralateral breast cancer (CBC), desire for improved cosmesis and symmetry, and preferences to avoid ongoing screening, whereas surgeons primarily consider CBC risk when making a recommendation for CM. For patients with a high risk of CBC, CM reduces the risk of new breast cancer, however it is not known to convey an overall survival benefit. Studies evaluating patient satisfaction with CM and reconstruction have yielded mixed results. Imaging with mammography within 12 months before CM is recommended, but routine preoperative breast magnetic resonance imaging is not; there is also no evidence to support routine postmastectomy imaging surveillance. Because the likelihood of identifying an occult malignancy during CM is low, routine sentinel lymph node surgery is not recommended. Data on the rates of postoperative complications are conflicting, and such complications may not be directly related to CM. Adjuvant therapy delays due to complications have not been reported. Surgeons can reduce CM rates by encouraging shared decision making and informed discussions incorporating patient preferences.

Abstract 16982: Baseline Diameter Does Not Predict Growth Rate in Ascending Thoracic Aortic Aneurysm

Introduction: Patients with ascending thoracic aortic aneurysm (aTAA) are recommended to undergo routine imaging surveillance. While maximal diameter is the primary metric of disease severity, recent AHA/ACC guidelines emphasize the importance of aortic growth in determining surgical candidacy and risk of complications. Increasing diameter is often assumed to confer higher aortic growth rate (GR) due to increased wall tension; however, this relationship is poorly studied. Goal: To investigate the relationship between aTAA diameter and GR using Vascular Deformation Mapping (VDM), a validated technique for 3D growth mapping with sub-millimeter accuracy. Methods: We identified 122 patients with ascending aortic dilation (≥4.0 cm) and serial gated CT angiograms (CTA) with an interval of ≥2 years. Ascending GR was defined as the 90th percentile of wall deformation (radial direction) by VDM, normalized by interval (mm/y). Maximal diameter measurements were taken from the baseline CTA report. Aortic height index (AHI, cm/m) and aortic cross-sectional area/height ratio (CSAH, cm^2/m) were calculated. Ascending aortic length (AL, mm) was measured from the annulus to the origin of the innominate artery. Results: 122 patients (60.7% male, mean age 62.8 ± 10.9 y, 0% connective tissue disease) showed a mean baseline diameter of 44.7 ± 3.7 mm and mean GR of 0.30 ± 0.44 mm/y. No correlation was noted between GR and baseline diameter (r= -0.02, p= 0.86), AHI (r= -0.06, p= 0.54), CSAH (r= -0.04, p= 0.70), or AL (r= 0.08, p= 0.41). Diameter was modestly correlated with GR (r = 0.65, CI 95%: 0.11-0.89, p = 0.02) among the small subgroup with diameter ≥50mm (n=12). GR was not significantly correlated to age (r= -0.13, p= 0.17) and did not differ by sex (p= 0.91) or hypertension (p= 0.51). No demographic or anatomic variables were predictive of GR on multivariable analysis. Conclusions: Maximal aortic diameter is not predictive of aortic GR, especially at sizes under surgical thresholds (&lt;50 mm).

S1220 Costs Associated With Routine Post-Procedural Surveillance Imaging After Peroral Endoscopic Myotomy: A Quality Initiative

S1220 Costs Associated With Routine Post-Procedural Surveillance Imaging After Peroral Endoscopic Myotomy: A Quality Initiative

SP5.3 The risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury: A meta-analysis and meta-regression analysis

Abstract Aims To determine the risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury. Methods We performed a systematic review and meta-analysis in compliance with PRISMA statement standards. A search of electronic information sources was conducted to identify all studies reporting the risk of hepatic pseudoaneurysm after liver trauma. The JBI assessment tool was used to assess the risk of bias of the included studies. Random-effects models were applied to calculate pooled outcome data. Results A total of 2030 patients from six studies were included. Based on the American Association for the Surgery of Trauma classification system, 21% had grade I injury; 33% grade II injury; 28% grade III injury; 12% grade IV injury; 5% grade V injury. The pooled risk of hepatic pseudoaneurysm was 1.8% (95% CI 1.1-2.5%). The risk was 0.4% (0-1.2%) in patients with grade I injury, 0.7% (0-1.7%) in patients with grade II injury; 1.5% (0.4-2.7%) in patients with grade III injury; 4.6% (1.4-7.7%) in patients with grade IV injury; 10.6% (1.8-22.9%) in patients with grade V injury. The average time between liver injury and detection of hepatic pseudoaneurysm was 6 days (1-10). Conclusions The risk of hepatic pseudoaneurysm after liver trauma increases as the severity of liver injury increases. Hepatic pseudoaneurysms are rare after grade I or grade II injuries, and increasingly common after grades III, IV and V injuries. We do not hesitate to recommend routine surveillance imaging in patients with grade III to V injuries.

TIPS-10 FEASIBILITY OF A MULTI-MODALITY CENTRAL NERVOUS SYSTEM SCREENING EVALUATION IN HER2+ BREASTCANCER PATIENTS

Abstract BACKGROUND Breast cancer is the most common cancer in the world and the second most common to metastasize to the central nervous system (CNS). CNS-metastases are the most common type of brain tumor and have a rising incidence. They are associated with neurologic morbidity and mortality and remain a major clinical challenge. Survival withCNS-metastases is short with a median survival in the order of months. The incidence of CNS-metastases is 5.1% in breast cancer however true prevalence is not known; at autopsy this incidence ranges between 20-40%. One contributing factor towards the development of CNS-metastases in breast cancer is HER2-positivity. Between 25%-48% of patients with HER2-positive metastatic breast cancer develop CNS-metastases. Currently, routine CNS surveillance imaging is not recommended, however guidelines suggest having a low threshold for evaluation with imaging and/or cerebrospinal fluid (CSF) analysis because of the high rate of CNS-metastases. The clinical relevance of occult CNS-metastases, survival after identification of occult CNS-metastases and the importance of earlier initiation of CNS therapy are unknown. Existing treatment strategies for CNS-metastases rely on a combinatorial approach of chemotherapy, radiotherapy and/or surgery which typically affords limited disease control. This trial seeks to study if surveillance imaging and CSF analysis are feasible as early disease detection mechanisms. METHODS This is a two-cohort study to establish feasibility of multi-modality CNS surveillance. Patients with HER2+ metastatic breast cancer patients (with no known CNS-metastases) who are either Stage IV (Cohort A) or Stage II/III are eligible (Cohort B). On study, patients will undergo MRI Brain and CSF analysis at 6 monthly intervals. CSF analysis includes cytology, circulating tumor cells and cell-free DNA analysis. We plan to enroll 20 patients (10 onto each cohort). 1 of 20 patients have enrolled. This is the first multi-modality screening feasibility study for patients HER2-positive breast cancer.

The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance.

Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.

O150 The risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury: a meta-analysis and meta-regression analysis

Abstract Introduction A systematic review and meta-analysis was conducted to determine the risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury. Methods We performed a systematic review and meta-analysis in compliance with PRISMA statement standards. A search of electronic information sources was conducted to identify all studies reporting the incidence of hepatic pseudoaneurysm after liver trauma. The JBI assessment tool was used to assess the risk of bias. Random-effects models were applied to calculate pooled outcome data. Results A total of 2030 patients from six studies were included. Based on the American Association for the Surgery of Trauma classification system, 21% had grade I injury; 33% grade II injury; 28% grade III injury; 12% grade IV injury; 5% grade V injury. The pooled risk of hepatic pseudoaneurysm was 1.8% (95% CI 1.1-2.5%). The risk was 0.4% (0-1.2%) in patients with grade I injury, 0.7% (0-1.7%) in patients with grade II injury; 1.5% (0.4-2.7%) in patients with grade III injury; 4.6% (1.4-7.7%) in patients with grade IV injury; 10.6% (1.8-22.9%) in patients with grade V injury. The average time between liver injury and detection of hepatic pseudoaneurysm was 6 days (1-10). Conclusion The risk of hepatic pseudoaneurysm after liver trauma increases as the severity of liver injury increases. Hepatic pseudoaneurysms are rare after grade I or grade II injuries, and increasingly common after grades III, IV and V injuries. We do not hesitate to recommend routine surveillance imaging in patients with grade III to V injuries.

Abstract LB146: Imaging surveillance practice patterns among older adults with stage I/II non-small cell lung cancer

Abstract Background: Following completion of curative-intent treatment, patients with non-small cell lung cancer (NSCLC) are recommended to undergo routine imaging surveillance to detect potential cancer recurrence. We aimed to evaluate adherence to guideline recommended imaging surveillance and factors associated with either adherence or non-adherence. Methods: We utilized data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare Program for the years 2003-2016. Participants were included if they were diagnosed with stage I/II NSCLC, survived for more than 2 years following completion of treatment, between the ages of 65-85, and received either surgical resection or stereotactic body radiotherapy (SBRT) as their primary treatment. Participants were considered to have received guideline-recommended imaging surveillance if there was record of receiving at least one computed tomography (CT) or chest x-ray (CXR) during the following four time windows following completion of curative intent treatment: 90-270 days, 360-450 days, 540-630 days, and 720-810 days. Logistic regression analysis was used to evaluate whether race/ethnicity, sex, age group, treatment type, stage of disease, histology, insurance status, marital status, and comorbidity burden were associated with adherence to guideline-recommended imaging surveillance. All analyses were performed using SAS 9.4. Results: A total of 14,296 NSCLC patients were included in the present analysis. Most participants were male (57.9%) and Non-Hispanic (NH) white (85.8%). Notably, only 21.9% of patients received guideline-recommended imaging surveillance during the entire 2-year follow-up period. When evaluating adherence within the first year of follow up only, 51.1% of participants met adherence criteria. Factors associated with receipt of guideline-recommended surveillance during the 2-year surveillance period include being married (OR: 1.17; 95% CI:1.06-1.29), receipt of neoadjuvant systemic therapy (OR: 1.76, 95% CI: 1.12-2.76), and a Charlson comorbidity score of &amp;gt;=3 (OR: 1.17, 95% CI: 1.03-1.33). Factors associated with not receiving guideline-recommended imaging surveillance included NH Black race (OR: 0.73, 95% CI: 0.59-0.91) and receipt of adjuvant systemic therapy (OR: 0.68, 95% CI:0.57-0.81), adjuvant radiotherapy (OR: 0.50, 95% CI: 0.40-0.61), or SBRT only (OR: 0.74, 95% CI: 0.63-0.87). Conclusion: Adherence to guideline-recommended imaging surveillance is low in this population. Strategies to increase compliance to imaging surveillance, particularly among NH black populations, are needed. Citation Format: Meghann Wheeler, Shama Karanth, Danting Yang, Caretia Washington, Livingstone Aduse-Poku, Hyung-Suk (Alex) Yoon, Jiang Bian, Yi Guo, Dejana Braithwaite. Imaging surveillance practice patterns among older adults with stage I/II non-small cell lung cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr LB146.

Incidence of Rib Fracture following Treatment with Proton Therapy for Breast Cancer.

To determine the rib fracture rate in a cohort of patients with breast cancer treated with proton therapy. From a prospective database, we identified 225 patients treated with proton therapy between 2012 and 2020 (223 women; 2 men). Clinical and dosimetric data were extracted, the cumulative incidence method assessed rib fracture rate, and Fine-Gray tests assessed prognostic significance of select variables. In-field rib fracture was defined as a fracture that occurred in a rib located within the 10% isodose line. Out-of-field rib fracture was defined as a fracture occurring in a rib location outside of the 10% isodose line. Of the patients, 74% had left-sided breast cancer; 5%, bilateral; and 21%, right-sided. Dual-energy x-ray absorptiometry scans showed normality in 20%, osteopenia in 34%, and osteoporosis in 6% (test not performed in 40%). Additionally, 57% received an aromatase inhibitor. Target volumes were breast ± internal mammary nodes (IMNs) (16%), breast and comprehensive regional lymphatics (32%), chest wall ± IMNs (1%), and chest wall/comprehensive regional lymphatics (51%). Passive-scattered proton therapy was used for 41% of patients, 58% underwent pencil-beam scanning (PBS), and 1% underwent a combination (passive scattering/PBS), with 85% of patients receiving a boost. Median follow-up was 3.1 years, with 97% having >12-month follow-up. The 3-year cumulative in-field rib fracture incidence was 3.7%. Eight patients developed in-field rib fractures (1 symptomatic, 7 imaging identified) for a 0.4% symptomatic rib fracture rate. Median time from radiation completion to rib fracture identification was 1.8 years (fractures were identified within 2.2 years for 7 of 8 patients). No variables were associated with rib fracture on univariate analysis. Three fractures developed outside the radiation field (0.9% cumulative incidence of out-of-field rib fracture). In this series of patients with breast cancer treated with proton therapy, the 3-year rib fracture rates remain low (in-field 3.7%; symptomatic 0.4%). As in photon therapy, the asymptomatic rate may be underestimated owing to a lack of routine surveillance imaging. However, patients experiencing symptomatic rib fractures after proton therapy for breast cancer are rare.

Multimodality imaging evaluation of arteriovenous fistulas and grafts: a clinical practice review.

Arteriovenous fistulas (AVFs) and grafts (AVGs) are the preferred forms of vascular access for hemodialysis in patients with severe renal dysfunction. Multimodality imaging plays an important role in the pre-procedural evaluation of these patients. Ultrasound is often used for pre-procedural vascular mapping in preparation for the creation of an AVF or AVG. Pre-procedural mapping includes a comprehensive evaluation of the arterial and venous vasculature including evaluation of vessel diameter, stenosis, course, presence of collateral veins, wall thickness and wall abnormalities. Computed tomography (CT), magnetic resonance imaging (MRI) or catheter angiography are used when sonography is not available or when further characterization of sonographic abnormalities is required. Following the procedure, routine surveillance imaging is not recommended. If there are any clinical concerns or if physical examination is inconclusive, further evaluation with ultrasound is warranted. Ultrasound allows for assessment of vascular access site maturation by evaluating the time-averaged blood flow and helping characterize the outflow vein in the case of an AVF. CT and MRI can play a complementary role to ultrasound. Vascular access site complications include non-maturation, aneurysm, pseudoaneurysm, thrombosis, stenosis, steal phenomena or occlusion typically of the outflow vein, infection, bleeding and rarely angiosarcoma. In this article, we review the role of multimodality imaging in the pre- and post-procedural evaluation of patients with AVF and AVG. Additionally, novel technologies of vascular access site creation using endovascular techniques and upcoming non-invasive imaging techniques for evaluation of AVFs and AVGs are discussed.

The risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury: a meta-analysis and meta-regression analysis.

To determine the risk of hepatic pseudoaneurysm after liver trauma in relation to the severity of liver injury. We performed a systematic review and meta-analysis in compliance with PRISMA statement standards (Registration Number: CRD42022328834). A search of electronic information sources was conducted to identify all studies reporting the risk of hepatic pseudoaneurysm after liver trauma. The JBI assessment tool was used to assess the risk of bias of the included studies. Random-effects models were applied to calculate pooled outcome data. A total of 2030 patients from six studies were included. Based on the American Association for the Surgery of Trauma classification system, 21% had grade I injury; 33% grade II injury; 28% grade III injury; 12% grade IV injury and 5% grade V injury. The pooled risk of hepatic pseudoaneurysm was 1.8% (95% CI 1.1-2.5%). The risk was 0.4% (0-1.2%) in patients with grade I injury, 0.7% (0-1.7%) in patients with grade II injury; 1.5% (0.4-2.7%) in patients with grade III injury; 4.6% (1.4-7.7%) in patients with grade IV injury and 10.6% (1.8-22.9%) in patients with grade V injury. The average time between liver injury and detection of hepatic pseudoaneurysm was 6 days(95% CI 1-10) CONCLUSIONS: The risk of hepatic pseudoaneurysm after liver trauma increases as the severity of liver injury increases. Hepatic pseudoaneurysms are rare after grade I or grade II injuries, and increasingly common after grades III, IV and V injuries. We recommend routine surveillance imaging in patients with grade III to V injuries.

Should we reduce routine surveillance imaging in pediatric germ cell tumors?

This paper retrospectively investigated the site and the detection method of relapses in children and adolescents with malignant germ cell tumors enrolled in the TCGM-AIEOP-2004 Study and subsequently developed a relapse, in order to evaluate a possible reduction in radiological exposure during follow-up. Including all malignant cases, serum tumor markers identified a relapse in more than 70% and, according to the selection criteria published by Children Oncology Group in 2018, in more than 90% of cases. These results confirm the importance of serum tumor markers as a relapse detection method, with possible reduction of radiology exams in specific subgroups.

Current diagnosis and management of cardiac melanoma: a case series and review

Malignant melanoma is believed to have the highest rate of cardiac metastasis of any cancer based on autopsy studies, but descriptions of clinical findings, diagnosis, and treatment remain lacking. In particular, the use of immunotherapy has been only sparingly described. We present eight cases of malignant melanoma treated at our institution. Four patients displayed symptoms, three were diagnosed on routine surveillance imaging, and one was diagnosed postmortem. Locations of cardiac tumors varied with all four chambers and septum involved between the cases. Six patients underwent genetic profiling: two patients had a CDKN2A variant detected in their cardiac tumor, one patient had a BRAF mutation, and one patient had an NRAS mutation. Six patients underwent immunotherapy with either anti-PD-1 and/or anti-CTLA-4 therapy. This report highlights the importance of considering cardiac melanoma in surveillance imaging and the use of immunotherapy for management.

Yield of Surveillance Imaging After Mastectomy With or Without Reconstruction for Patients With Prior Breast Cancer

A discrepancy on current guidelines and clinical practice exists regarding routine imaging surveillance after mastectomy, mainly regarding the lack of adequate evidence for imaging in this setting. To investigate the usefulness of imaging surveillance in terms of cancer detection and interval cancer rates after mastectomy with or without reconstruction for patients with prior breast cancer. A comprehensive literature search was conducted in 3 electronic databases-PubMed, ISI Web of Science, and Scopus-without year restriction. References from relevant reviews and eligible studies were also manually searched. Eligible studies were defined as those conducting surveillance imaging (mammography, ultrasonography, or magnetic resonance imaging [MRI]) of patients with prior breast cancer after mastectomy with or without reconstruction that presented adequate data to calculate cancer detection rates for each surveillance method. Independent data extraction by 2 investigators with consensus on discrepant results was performed. A quality assessment of studies was performed using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) template. The generalized linear mixed model framework with both fixed-effects and random-effects models was used to meta-analyze the proportion of cases across studies including 3 variables: surveillance method, reconstruction after mastectomy, and surveillance measure. Three outcome measures were calculated for each eligible study and each surveillance imaging method within studies: overall cancer detection (defined as ipsilateral cancer, both palpable and nonpalpable) rate per 1000 examinations, clinically occult (nonpalpable) cancer detection rate per 1000 examinations, and interval cancer rate per 1000 examinations. In total, 16 studies were eligible for the meta-analysis. The pooled overall cancer detection rates per 1000 examinations were 1.86 (95% CI, 1.05-3.30) for mammography, 2.66 (95% CI, 1.48-4.76) for ultrasonography, and 5.17 (95% CI, 1.49-17.75) for MRI. For mastectomy without reconstruction, the rate of clinically occult (nonpalpable) cancer per 1000 examinations (2.96; 95% CI, 1.38-6.32) and the interval cancer rate per 1000 examinations (3.73; 95% CI, 0.84-3.98) were lower than the overall cancer detection rate (including both palpable and nonpalpable lesions) per 1000 examinations (6.41; 95% CI, 3.09-13.25) across all imaging modalities. The interval cancer rate per 1000 examinations for mastectomy with reconstruction (3.73; 95% CI, 0.41-2.73) was comparable to the pooled cancer detection rate per 1000 examinations (4.73; 95% CI, 2.32-9.63) across all imaging modalities. In all clinical scenarios and imaging modalities, lower rates of clinically occult cancer compared with cancer detection rates were observed. Lower detection rates of clinically occult-compared with overall-cancer across all 3 imaging modalities challenge the use of imaging surveillance after mastectomy, with or without reconstruction. Findings suggest that imaging surveillance in this context is unnecessary in clinical practice, at least until further studies demonstrate otherwise. Future studies should consider using the clinically occult cancer detection rate as a more clinically relevant measure in this setting.