Serial CT Scans Research Articles

Association of clinical and radiographic findings with the outcomes of 93 patients with COVID-19 in Wuhan, China

Rationale: To retrospectively analyze serial chest CT and clinical features in patients with coronavirus disease 2019 (COVID-19) for the assessment of temporal changes and to investigate how the changes differ in survivors and nonsurvivors.Methods: The consecutive records of 93 patients with confirmed COVID-19 who were admitted to Wuhan Union Hospital from January 10, 2020, to February 22, 2020, were retrospectively reviewed. A series of chest CT findings and clinical data were collected and analyzed. The serial chest CT scans were scored on a semiquantitative basis according to the extent of pulmonary abnormalities. Chest CT scores in different periods (0 - 5 days, 6 - 10 days, 11 - 15 days, 16 - 20 days, and > 20 days) since symptom onset were compared between survivors and nonsurvivors, and the temporal trend of the radiographic-clinical features was analyzed.Results: The final cohort consisted of 93 patients: 68 survivors and 25 nonsurvivors. Nonsurvivors were significantly older than survivors. For both survivors and nonsurvivors, the chest CT scores were not different in the first period (0 - 5 days) but diverged afterwards. The mortality rate of COVID-19 monotonously increased with chest CT scores, which positively correlated with the neutrophil-to-lymphocyte ratio, neutrophil percentage, D-dimer level, lactate dehydrogenase level and erythrocyte sedimentation rate, while negatively correlated with the lymphocyte percentage and lymphocyte count.Conclusions: Chest CT scores correlate well with risk factors for mortality over periods, thus they may be used as a prognostic indicator in COVID-19. While higher chest CT scores are associated with a higher mortality rate, CT images taken at least 6 days since symptom onset may contain more prognostic information than images taken at an earlier period.

Assessing Changes in Airflow and Energy Loss in a Progressive Tracheal Compression Before and After Surgical Correction

The energy needed to drive airflow through the trachea normally constitutes a minor component of the work of breathing. However, with progressive tracheal compression, patient subjective symptoms can include severe breathing difficulties. Many patients suffer multiple respiratory co-morbidities and so it is important to assess compression effects when evaluating the need for surgery. This work describes the use of computational prediction to determine airflow resistance in compressed tracheal geometries reconstructed from a series of CT scans. Using energy flux analysis, the regions that contribute the most to airway resistance during inhalation are identified. The principal such region is where flow emerging from the zone of maximum constriction undergoes breakup and turbulent mixing. Secondary regions are also found below the tongue base and around the glottis, with overall airway resistance scaling nearly quadratically with flow rate. Since the anatomical extent of the imaged airway varied between scans—as commonly occurs with clinical data and when assessing reported differences between research studies—the effect of sub-glottic inflow truncation is considered. Analysis shows truncation alters the location of jet breakup and weakly influences the pattern of pressure recovery. Tests also show that placing a simple artificial glottis in the inflow to a truncated model can replicate patterns of energy loss in more extensive models, suggesting a means to assess sensitivity to domain truncation in tracheal airflow simulations.

First-in-Human Assessment of Feasibility and Safety of Multiplexed Genetic Engineering of Autologous T Cells Expressing NY-ESO -1 TCR and CRISPR/Cas9 Gene Edited to Eliminate Endogenous TCR and PD-1 (NYCE T cells) in Advanced Multiple Myeloma (MM) and Sarcoma

Stadtmauer: Celgene: Consultancy; Takeda: Consultancy; Janssen: Consultancy; Amgen: Consultancy; Novartis: Consultancy, Research Funding; Tmunity: Research Funding; Abbvie: Research Funding. Cohen:Poseida Therapeutics, Inc.: Research Funding. Lacey:Novartis: Patents & Royalties: Patents related to CAR T cell biomarkers; Tmunity: Research Funding; Novartis: Research Funding. Melenhorst:Incyte: Research Funding; Novartis: Research Funding, Speakers Bureau; Parker Institute for Cancer Immunotherapy: Research Funding; Genentech: Speakers Bureau; Stand Up to Cancer: Research Funding; IASO Biotherapeutics, Co: Consultancy; Simcere of America, Inc: Consultancy; Shanghai Unicar Therapy, Co: Consultancy; Colorado Clinical and Translational Sciences Institute: Membership on an entity's Board of Directors or advisory committees; National Institutes of Health: Research Funding. Fraietta:Tmunity: Research Funding; Cabaletta: Research Funding; LEK Consulting: Consultancy. Mangan:amgen: Speakers Bureau; takeda: Speakers Bureau; celgene: Speakers Bureau; janssen: Speakers Bureau. Lancaster:novartis: Research Funding. Suhoski:novartis: Research Funding. Fesnak:Novartis: Research Funding. Young:novartis: Research Funding. Chew:tmunity: Other: Scientific Founder, Research Funding; novartis: Research Funding. Zhao:Tmunity: Membership on an entity's Board of Directors or advisory committees, Research Funding; novartis: Research Funding. Hwang:Novartis: Research Funding; Tmunity: Research Funding. Hexner:novartis: Research Funding. June:Novartis: Research Funding; Tmunity: Other: scientific founder, for which he has founders stock but no income, Patents & Royalties.

Decision curve analysis apropos of choice of preferable treatment positioning during breast irradiation

BackgroundRadiotherapy is a standard treatment option for breast cancer, but it may lead to significant late morbidity, including radiation heart damage. Breast irradiation performed individually in the supine or prone position may aid in minimizing the irradiation dose to the heart and LAD coronary artery. A series of CT scans and therapy plans are needed in both positions for the ‘gold standard’ decision on the preferable treatment position. This method is expensive with respect to technology and physician workload.Our ultimate goal is to develop a predictive tool to identify the preferable treatment position using easily measurable patient characteristics. In this article, we describe the details of how model building and consequently validation of the best model are done.MethodsDifferent models were used: both logistic regression and multiple linear regressions were used to estimate the LAD mean dose difference (the difference between the mean dose to the LAD in the supine position versus prone position); predicted dose differences were analysed compared to the ‘gold standard’ values, and the best model was selected accordingly. The final model was checked by random cross-validation. In addition to generally used measures (ROC and Brier score), decision curves were employed to evaluate the performance of the models.ResultsROC analysis demonstrated that none of the predictors alone was satisfactory. Multiple logistic regression models and the linear regression model lead to high values of net benefit for a wide range of threshold probabilities. Multiple linear regression seemed to be the most useful model. We also present the results of the random cross-validation for this model (i.e. sensitivity of 80.7% and specificity of 87.5%).ConclusionsDecision curves proved to be useful to evaluate our models. Our results indicate that any of the models could be implemented in clinical practice, but the linear regression model is the most useful model to facilitate the radiation treatment decision. In addition, it is in use in everyday practice in the Department of Oncotherapy, University of Szeged, Hungary.

3012 Lessons Learned from Ten Litigated Cases of Genitourinary and Gastrointestinal Fistulas Post Benign Gynecological Surgeries: A Multi-Center Case Series

Study Objective We aim to summarize all litigated cases of vesicovaginal, colovaginal and ureteric-vaginal fistulas from benign gynecological surgeries in Canada between 1997 to 2017. We outline the initial post-operative presentation, course of treatment and recovery, clinical and legal outcomes associated with each case. Design Retrospective case series of 10 genitourinary, gastrointestinal and enterocutaneous fistulas occurring post gynecological surgeries for benign indications. Setting Eight secondary and tertiary hospitals across Canada. Patients or Participants Ten women aged 18 years or older receiving laparoscopic, vaginal or open surgeries to treat benign gynecological conditions. Interventions Benign gynecological procedures including laparoscopic-assisted vaginal (1 case), vaginal (1 case) and open abdominal hysterectomies (3 cases), laparoscopic ovarian cystectomy (2 cases), laparoscopic cautery of endometriosis (2 cases) and operative hysteroscopy (1 case). Measurements and Main Results Median age at time of initial operation was 43 (range 39-55). The most common post-op presentation was fever, abdominal pain and tachycardia between post-op days (POD) 4-10. A bladder, small bowel or rectal injury was found on imaging at the time of presentation for 9 out of 10 cases, with one case diagnosed five weeks post op on outpatient serial CT scans. All patients required a laparotomy with involvement from a general surgeon or urologist, and five patients received second and third look laparotomies and bowel resections. 7 patients required ICU observation post-op. In all cases, the fistulas manifested as delayed presentations for unrecognized intra-operative bladder, bowel or ureteric injuries. One patient had ongoing fistulous drainage per vaginal at the time of case settlement. Most litigated cases were dismissed. Conclusion GU and GI fistulas are rare but morbid entities, which most often manifest after missed bladder or bowel injuries, post benign gynecological surgeries. Early detection and recognition of GI and GU injuries may be key for secondary prevention of fistula formation.

1710P - Impact of immunotherapy and targeted therapy on tumour growth rate in sarcoma

BackgroundWith increasing use of immunotherapy and targeted treatments in oncology, it is essential to understand the biological effects of these therapies on tumor kinetics. This retrospective review aims to identify hyperprogressive disease (HPD) occurrence in sarcoma patients treated with immunotherapy or targeted therapy, and its effect on overall survival. MethodsWe performed a retrospective review of advanced sarcoma patients enrolled in immunotherapy or targeted therapy clinical trials at the Princess Margaret Cancer Centre, Toronto. Tumor growth rate (TGR) was assessed for each patient based on serial CT scans at pre-baseline, baseline and on-treatment timepoints. TGR was calculated using a published formula (Champiat et al. 2017), and the ratio between reference and experimental groups was then calculated. The predictive accuracy of HPD was assessed using Cox proportional hazards analysis both as a continuous variable and using a cut-off for TGR ratio percentage of more than 50%. Statistical significance was defined as p<0.05. ResultsWe identified 146 patients who were treated with immunotherapy, targeted therapy, or combination chemotherapy and targeted therapy between July 26, 2013, and August 7, 2018. 106 patients met the eligibility criteria. 20 patients received immunotherapy, 86 patients received targeted or combination chemotherapy and targeted therapy. Three patients from the immunotherapy group had HPD (15%), and two patients from the non-immunotherapy group had HPD (2.3%). The hazard ratio for the patients with TGR ratio percentage of≥50%(HPD) was 9.34 (95% CI 3.38-25.84, p=< 0.001). The median survival in all patients with HPD vs non-HPD was 3.9 months (95% CI 2.5-5.2 months) vs 16.1 months (95 % CI 13-19.2 months). There was no interaction between HPD and receipt of immunotherapy vs other therapy. ConclusionsThere is a correlation between TGR and clinical outcomes in patients with sarcoma treated with immunotherapy or targeted therapy. HPD is associated with worse survival outcomes and may serve as a useful tool in the assessment of treatment futility during patient therapy. Legal entity responsible for the studyAbdul Razak Ryan Albiruni. FundingHas not received any funding. DisclosureE. Amir: Speaker Bureau / Expert testimony: Genentech/Roche; Honoraria (self): Apobiologix ; Advisory / Consultancy: Agendia; Advisory / Consultancy: Myriad Genetics. A.R.R. Albiruni: Honoraria (self): Boehringer Ingelheim ; Advisory / Consultancy: Lilly; Advisory / Consultancy: Merck; Advisory / Consultancy: Boehringer Ingelheim; Research grant / Funding (self): CASI Pharmaceuticals; Research grant / Funding (self): Lilly; Research grant / Funding (self): Novartis; Research grant / Funding (self): Deciphera; Research grant / Funding (self): Karyopharm Therapeutics; Research grant / Funding (self): Pfizer; Research grant / Funding (self): Roche/Genentech; Research grant / Funding (self): Boston Biomedical; Research grant / Funding (self): Bristol-Myers Squibb; Research grant / Funding (self): MedImmune; Research grant / Funding (self): Amgen; Research grant / Funding (self): GlaxoSmithKline; Research grant / Funding (self): Blueprint Medicines; Research grant / Funding (self): Merck; Research grant / Funding (self): AbbVie; Research grant / Funding (self): Adaptimmune. All other authors have declared no conflicts of interest.

P1.17-29 8-year Experience of Navigational Bronchoscopy for Preoperative Localization of Subcentimeter Lung Nodules in a Small Community Hospital

With the advent of lung cancer screening, CT imaging has led to the identification of sub-centimeter nodules that are challenging to localize for both diagnosis and resection. The traditional approaches are problematic because biopsies often have poor diagnostic yield, resulting in repeat attempts at tissue collection, delay in time to treatment, and increased cost. Electromagnetic navigation bronchoscopy (ENB) is a newer technology that allows greater precision in preoperative localization of nodules to obtain tissue for diagnosis and fiducial marker placement. Our institution has adopted a practice that combines simultaneous ENB for nodule localization and video-assisted thoracoscopic surgery (VATS) for resection with single anesthetic administration and operating room team. We aimed to evaluate changes in time to treatment, time to surgery, and length of stay. Retrospective review of all patients who underwent nodule localization and VATS or robotic-assisted VATS (RATS) between (May 2011- March 2019). ENB localization was performed with transbronchial injection of ICG and/or placement of gold fiducial markers. A total of 72 patients underwent VATS or RATS. During the first two years of the study period, ENB was performed with portable C-arm fluoroscopic guidance with diagnostic yield of 48%. Surgery was performed on average 29.7 days (4-190 days) after ENB (3 patients had non-diagnostic bronchoscopy and were followed with serial CT scans that resulted in >100 days until surgery). In August 2017 utilization of Cone Beam CT scan began during ENB, which resulted in reduction in time to surgery to average of 20.1 days (1-39 days). After persistent low diagnostic yield with bronchoscopy and demand for expedient diagnosis, in February 2018, ENB and surgical resection were performed simultaneously with single anesthetic administration and OR team. Furthermore, in December 2018 utilization of daVinci Xi robot began for RATS with ICG injection during ENB for intraoperative localization of nodules. The hospital length of stay (LOS) and time to treatment (from the initial identification of a lung nodule to surgery) for Super D bronchoscopy group (SDB) (n=36) is 5.7/63.8 days, SDB-with cone beam technology (n=8) is 4.5/62.8 days, respectively. Transition to simultaneous resection (n=28) resulted in 100% diagnostic yield, further decrease of both hospital LOS and time to treatment, to 3.6 days and 43.7 days, respectively. Our data demonstrates that intraoperative ENB lung lesion localization with simultaneous VATS/RATS resection results in decreased hospital length of stay, reduced time to treatment, and 100% diagnostic yield. Both metrics significantly impact patient satisfaction and healthcare costs.

849PD - Preliminary results of a phase I/II dose-escalation study of fractionated dose 177Lu-PSMA-617 for progressive metastatic castration resistant prostate cancer (mCRPC)

BackgroundPSMA is overexpressed in PC with limited expression in other organs. PC is radiosensitive with dose-response. Dose-fractionation allows delivery of higher total dose per cycle, may result in less radioresistance due to repopulation compared with doses 6-12 wks apart. Initial Ph I safety results of the dose-escalation portion of this study [ESMO 2018] were without DLT at all dose levels. MethodsEntry criteria: progressive mCRPC following at least 1 potent AR-targeted agent (e.g. abi/enza) and taxane (or unfit/refuse chemo) without limit of # prior therapies, adequate organ function, ECOG performance status 0-2. No preselection for PSMA expression. Treatment was a single cycle of fractionated dose 177Lu-PSMA-617 on D1 and D15. In the Ph I dose-escalation cohort, men received 7.4 to 22 GBq. In Ph II, a Simon 2 stage design enrolled pts at the 22.2 GBq dose level. Pre- and post-treatment 68Ga-PSMA11 PET/CT and post-treatment 177Lu-PSMA-617 imaging was performed in addition to standard serial CT and bone scans. Cellsearch CTC count at baseline and 12 wks. Results44 men (29 in Ph I, 15 in Ph II; total 21 at 22.2 GBq) with median age 69 (range 55-91), median PSA 182.97 (range 0.89-5541) were treated. 93% with bone, 45% nodal, 18% lung, 9% liver, 9% other visceral metastases. 55% with at least 1 prior chemo regimen, 52% >1 prior potent AR therapy, 27% with Ra223, 30% sip-T, 5% 177Lu-J591; 66% Halabi poor risk, 30% intermed risk. With follow up ongoing, 61% with >50% PSA decline (71.4% at 22.2 GBq), median overall survival 16 months (95% CI 11-NR). Of 26 with paired CTC counts, 57.7% decreased, 7.7% stable, 34.6% increased; 34.6% converted from detectable to undetectable at 12 weeks). 61.4% with all grade xerostomia, 29.5% fatigue, 25% thrombocytopenia, 25% anemia, 25% pain, 15.5% nausea. While not required for eligibility, all pts had some PSMA uptake in at least 1 site on PSMA PET, with 2.2% highest lesion SUV < liver SUV, 4.5% 1-2.5x, 13.6% 2.5-5x, and 79.5% highest lesion SUV > 5x liver. ConclusionsA single fractionated cycle of up to 22.2 GBq of 177Lu-PSMA-617 is safe, with encouraging early efficacy signals, even without selection for PSMA expression by imaging. A trend for dose-response was observed. Clinical trial identificationNCT03042468. Legal entity responsible for the studyWell Cornell Medicine. FundingWeill Cornell Medicine, Prostate Cancer Foundation, US Department of Defense, US National Institutes of Health, Endocyte. DisclosureS.T. Tagawa: Advisory / Consultancy, Research grant / Funding (institution): Endocyte. H. Beltran: Advisory / Consultancy: Endocyte. S. Vallabhajosula: Research grant / Funding (institution): Endocyte; Full / Part-time employment: NCM USA. O. Sartor: Research grant / Funding (institution): Endocyte. All other authors have declared no conflicts of interest.

133P - Evaluating lung ct density changes among patients with extensive stage small cell lung cancer (ES-SCLC) treated with thoracic radiotherapy (TRT) alone or TRT followed by combined ipilimumab (IPI) and nivolumab (NIVO)

BackgroundRadiation induced CT changes may be apparent following completion of TRT. We sought to quantify differences in radiation-associated densities on serial CT scans of patients with ES-SCLC treated with TRT alone versus TRT followed by combined IPI and NIVO. MethodsBetween 2016 and 2018, patients at a single institution with ES-SCLC who achieved stable disease or better following initial treatment with platinum doublet chemotherapy were offered TRT and prescribed a total dose of 30Gy in 10 fractions targeting initially involved thoracic tumor sites. Combined IPI 3mg/kg and NIVO 1mg/kg was administered every 3 weeks for up to 4 doses. We evaluated an irradiated region of interest (ROI) within the lungs and a volume of lung (outside the Planning Target Volume) receiving > 20Gy. Within the ROI, we calculated the Hounsfield unit (HU) mean for each patient prior to therapy and at subsequent follow-up CT thorax at least 60 days and closest to 120 days after commencing TRT. To quantify CT density change, we measured the difference in HU mean within the irradiated ROI before and after treatment. ResultsSeventeen patients enrolled on NCT03043599 received TRT followed by combined IPI/NIVO. Two additional patients received the same treatment off protocol. Eleven patients received TRT alone (no IPI/NIVO). The average increase in HU mean within 20Gy irradiated ROI before and after treatment was 9% (max 59%, min -19%) across the study cohort (n=30). CTCAE grade 3 or higher pulmonary toxicity (N=8 of 30) was significantly associated with increased CT density change within the ROI (mean 28% vs 2%, p=0.001). Treatment with TRT and IPI/NIVO (N=19 of 30) demonstrated a trend towards increased mean CT density change within the ROI compared to patients treated with TRT alone (mean 13% vs. 0%, p=0.1). ConclusionsQuantifying CT density change within irradiated lung parenchyma may offer a novel approach to predict radiation associated pulmonary toxicities. Measuring density changes across patient cohorts receiving TRT with novel systemic therapies may help to identify combined treatment strategies likely to be associated with diminished risk of toxicity. Legal entity responsible for the studyThe authors. FundingBristol-Myers Squibb. DisclosureS. Kim: Research grant / Funding (institution): Bristol-Myers Squibb. S.A. Rosenberg: Advisory / Consultancy: Novocure. J.E. Gray: Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): AstraZeneca; Honoraria (self), Advisory / Consultancy: Celgene; Honoraria (self), Advisory / Consultancy: Takeda; Honoraria (self), Advisory / Consultancy: Janssen; Honoraria (self), Advisory / Consultancy, Research grant / Funding (institution): Genentech; Honoraria (self), Advisory / Consultancy: Eli Lilly; Honoraria (self), Advisory / Consultancy: Triptych Health Partners. S.J. Antonia: Advisory / Consultancy: Bristol-Myers Squibb; Advisory / Consultancy, Research grant / Funding (institution): Novartis; Advisory / Consultancy: Merck; Advisory / Consultancy: CBMG; Advisory / Consultancy: Boehringer Ingelheim; Advisory / Consultancy: AstraZeneca/MedImmune; Advisory / Consultancy: Memgen; Advisory / Consultancy: FLX Bio; Advisory / Consultancy: Nektar; Advisory / Consultancy: Venn. B. Perez: Advisory / Consultancy: Bristol-Myers Squibb; Advisory / Consultancy: AstraZeneca. All other authors have declared no conflicts of interest.

Is sub-mSv CT for evaluation of non-specific findings in bone scintigraphy of oncological patients feasible?

Background Hybrid SPECT/CT systems allow the shortening of lead time for investigation of cancer patients, since a complementary CT for radiological characterization of focally increased isotope uptake of unclear origin in bone scintigraphy can be performed simultaneously. The use of low-dose CT (sub-mSv CT) reduces radiation dose compared to standard-dose CT and facilitates the application of complementary CT. Purpose To test the feasibility of sub-mSv CT for the characterization of non-specific findings in the bone scintigraphy of oncological patients. Material and Methods Nineteen oncological patients with a total of 50 findings of unclear origin on bone scintigraphy which required further correlation with morphologic data were included in the study. Each patient underwent two CT scan series consecutively: one low-dose CT and one standard-dose CT. The CT studies were randomized and each finding was rated by four blinded experienced radiologists. A shift in ratings between standard-dose and low-dose images were assessed using the Stuart–Maxwell chi-squared test. Inter-observer agreement and intra-observer agreement was assessed using Light’s kappa and Cohen’s kappa, respectively. Results The mean effective dose of low-dose CT scans was 0.8 mSv compared to 4.2 mSv for the standard-dose CT scans. No statistically significant shift in ratings was observed ( P = 0.62). There was no statistically significant difference in the inter-observer agreements: the values for the standard-dose and low-dose groups were 0.68 (95% confidence interval [CI] 0.57–0.79) and 0.60 (95% CI 0.47–0.72), respectively. Conclusion These results indicate that sub-mSv CT for characterization of non-specific findings in bone scintigraphy of oncological patients is feasible.

Measurement of Cervical Regression and Optimizing Brachytherapy Schedule Concurrently with External Beam Radiation Therapy in Cervical Carcinoma.

IntroductionThis study aimed to measure cervical regression during external beam radiation therapy (EBRT) and optimize the scheduling of brachytherapy concurrently with EBRT.MethodsFifty consecutive patients with carcinoma of the cervix stage IIA to IIIB received concurrent chemoradiotherapy with weekly Cisplatin 40 mg/m2. Cervical regression was evaluated using serial CT scans obtained before and during concurrent chemoradiotherapy (on the third, fourth, and fifth weeks). High dose rate brachytherapy was introduced after 30Gy of EBRT. A total of 25.5Gy in three fractions were delivered during the third, fourth, and fifth weeks of EBRT. Cervical volumes were recorded from the CT scan for cervical regression.ResultsThe mean cervical volume at baseline (i.e., before the start of treatment) was 85.53 cubic centimetres (cc). The mean cervical volumes at the end of the third, fourth, and fifth week were 28.95cc, 24.92cc, and 21.80cc, respectively. The mean cervical regression from baseline to the end of the third, fourth, and fifth week was 60%, 65%, and 69%, respectively. The time for 50% cervical regression was calculated to be 18 days and occurred around 27Gy of EBRT.ConclusionMore than 50% of cervical regressions occur at the end of the third week (i.e., after delivery of 30Gy of EBRT), so it is optimal to introduce brachytherapy at the end of the third week. A conventional point-based plan can cover the high-risk clinical target volume (HRCTV) if the volume is <25cc, but an HRCTV >25cc may be well covered with optimization or a combination of intracavitary and interstitial brachytherapy.

Machine Learning Techniques for the Segmentation of Tomographic Image Data of Functional Materials

In this paper, various kinds of applications are presented, in which tomographic image data depicting microstructures of materials are semantically segmented by combining machine learning methods and conventional image processing steps. The main focus of this paper is the grain-wise segmentation of time-resolved CT data of an AlCu specimen which was obtained in between several Ostwald ripening steps. The poorly visible grain boundaries in 3D CT data were enhanced using convolutional neural networks (CNNs). The CNN architectures considered in this paper are a 2D U-Net, a multichannel 2D U-Net and a 3D U-Net where the latter was trained at a lower resolution due to memory limitations. For training the CNNs, information was derived from 3D X-ray diffraction (3DXRD) measurements. The grain boundary images enhanced by the CNNs were then segmented using a marker-based watershed algorithm with an additional postprocessing step for reducing oversegmentation. The segmentation results obtained by this procedure were quantitatively compared to information derived by the 3DXRD measurements. A quantitative comparison between segmentation results indicates that the 3D U-Net performs best among the considered U-Net architectures. Additionally, a scenario, in which ground truth data is only available in one time step, is considered. Therefore, a CNN was trained only with CT and 3DXRD data from the last measured time step. The trained network and the image processing steps were then applied to the entire series of CT scans. The resulting segmentations exhibited a similar quality compared to those obtained by the network which was trained with the entire series of CT scans.

Arthroscopic bone grafting with percutaneous fixation in treating scaphoid nonunion

Objective To analyze the clinical effects of arthroscopic autologous bone grafting and percutaneous fixation in treating scaphoid nonunion. Methods From May 2013 to August 2017, a total of 25 cases of patients including 20 males and 5 females with unilateral scaphoid fractures and nonunion were reviewed, with mean age of 35.80±2.41 years (18-65 years). The duration from injury to treatment was averaged 11.70±1.90 months (5-18 months). All of the cases sustained waist and proximal end fractures. X-ray and CT scan showed sclerosis and bone resorption without any callus at the fracture sites. However, there were no serious deformities and wrist arthritis. The patients suffered pain and weakness at the radial side of the wrist. The type of the fractures were Slade-Geissler's III-VI, including grade III 4 cases, grade IV 13 cases, grade V 7 cases and grade VI 1 case. The patients were treated with arthroscopic debridement of the sclerotic bone, autologous bone grafting, percutaneous screw (9 cases) or K-wires fixation (16 cases) and immobilization by plaster for 3 weeks after operation, followed by functional rehabilitation training. Bone union was assessed by serial plain radiographs and CT scan regularly. The functional effects were evaluated by comparing the modified Mayo wrist score with the visual analogue scale (VAS) for pain, range of motion (ROM) and the grip strength, which were measured before operation and at 18 months after operation. Results All cases were followed up. Bone union was achieved in all of 25 nonunion. The average radiological union duration was 10.24±2.10 weeks (6-20 weeks). The average VAS score decreased from 6.75±1.10 preoperatively to 1.33±0.21. The mean ROM of wrist was improved to 168.48°±12.41° (92.90% of that of the normal side), compared to that of 135.24°±17.47° preoperatively (79.80% of that of the normal side). The mean grip strength showed improvement from an average of 35.68±3.81 kg (80.46% of that of normal side) preoperatively to 48.75±4.42 kg (90.65% of that of normal side). The average modified Mayo wrist score improved from 61.52±6.32 preoperatively to 85.88±8.37. Conclusion Arthroscopic autologous bone grafting with percutaneous cannulated screw and K-wires fixation is an effective and minimally invasive treatment for scaphoid nonunion, which could protect the blood supply of the fracture sites, decrease the surgical complications, promote bone healing and lead to a faster recovery. Key words: Arthroscopy; Bone transplantation; Scaphoid bone; Fractures, ununited; Fracture fixation, internal

Drug-related pneumonitis during everolimus therapy in patients with metastatic breast cancer: Incidence, radiographic findings, and correlation with clinical outcome.

e12519 Background: Everolimus (EVE) in combination with endocrine therapy are approved for the treatment of HR+/HER2- metastatic breast cancers (MBC) patients. mTOR inhibitor-associated pneumonitis is one of the most worrying and common adverse drug events leading to treatment discontinuation. We investigated the incidence of drug-related pneumonitis (DRP) during EVE therapy in MBC patients and characterize radiographic patterns and clinical impact of pneumonitis. Methods: We retrospectively reviewed the data of MBC patients treated with EVE in Fudan University Shanghai Cancer Center from June 2013 to June 2017, who had baseline and at least one follow-up chest CT available for review (NCT 03730428). Serial chest CT scans were reviewed for abnormalities suspicious for DRP by an independent review of two radiologists. Log rank and Cox proportional hazards regression analysis were used for the time-to-event analysis. Results: DRP was radiographically detected in 45/86 patients (52.3%). Over 80% of DRP occurred in the first 4 months of treatment (cumulative risk 52.3%). Most patients with DRP were asymptomatic (n = 31, 68.9%). Among 14 patients with clinical manifestation, common symptoms included cough, fever and shortness of breath. DRP mostly distributed in bilateral lower lobes. Ground glass opacities and reticular opacities were seen in most of the cases. Elderly patients (OR 1.09, p = 0.002) and patients with baseline pneumonitis (OR 3.96, p = 0.023) are more likely to develop DRP. Patients who developed DRP had significantly longer progression free survival (median 6.8 vs 4.1 months, p = 0.024) and overall survival (OS, median 42.8 vs 21.3 months, p = 0.016). DRP was a predictor of improved OS by multivariate Cox analysis (HR 0.49, 95%CI 0.25-0.97, p = 0.040). Conclusions: DRP was noted in half of the MBC patients treated with EVE. Our preliminary data suggested that DRP would be a predictor for better outcome, which should be further investigated. Given the incidence and outcomes of patients with DRP, close monitoring, prompt diagnoses and appropriate treatment for DRP are critical for the preservation of patients’ quality of life and achievement of maximal treatment outcomes.

Process improvement for follow-up radiology report recommendations of lung nodules

In the modern healthcare system, there are still wide gaps of communication of imaging results to physician and patient stakeholders and tracking of whether follow-up has occurred. Patients are also...

ORBITAL ABSCESS FOLLOWING A CLOSED FACIAL INJURY IN A YOUNG ADULT

Background: Orbital abscess formation is one of the uncommon complications that occur following facial trauma. . We report a rare presentation of orbital abscess in a young adult with post closed facial fracture. Materials and Methods: a case report Result: A 19-year old man who sustained head injury and facial bones fractures without any external adnexal wounds from a road traffic accident. He developed left periorbital haematoma and decrease vision after 3 days of trauma. He was suspected to have left optic neuropathy and empirically treated with corticosteroids. However, his left vision deteriorated and developed progressive proptosis within 3 days. Serial CT scan showed new formation of left subperiosteal and intraconal abscess. Endoscopic orbital decompression and drainage of the abscess was performed. Post operatively, his vision and the proptosis improved. Orbital abscess post closed facial fracture is an unusual complication. Conclusion: High index of suspicion is necessary to diagnose this unusual presentation. Prompt treatment is essential to save the vision. Keywords: Orbital abscess, optic neuropathy, facial trauma, orbital decompression

Effect of cyclical intermittent hypoxia on Ad5CMVCre induced solitary lung cancer progression and spontaneous metastases in the KrasG12D+; p53fl/fl; myristolated p110fl/fl ROSA-gfp mouse.

BackgroundEpidemiological data suggests that obstructive sleep apnea (OSA) is associated with increased cancer incidence and mortality. We investigate the effects of cyclical intermittent hypoxia (CIH), akin to the underlying pathophysiology of OSA, on lung cancer progression and metastatic profile in a mouse model.MethodsIntrathoracic injection of Ad5CMVCre virus into a genetically engineered mouse (GEM) KrasG12D+/-; p53fl/fl; myristolated-p110αfl/fl-ROSA-gfp was utilized to induce a solitary lung cancer. Male mice were then exposed to either CIH or Sham for 40–41 days until harvest. To monitor malignant progression, serial micro CT scans with respiratory gating (no contrast) was performed. To detect spontaneous metastases in distant organs, H&E and immunohistochemistry were performed.ResultsEighty-eight percent of injected Ad5CMVCre virus was recovered from left lung tissue, indicating reliable and accurate injections. Serial micro CT demonstrated that CIH increases primary lung tumor volume progression compared to Sham on days 33 (p = 0.004) and 40 (p<0.001) post-injection. In addition, CIH increases variability in tumor volume on day 19 (p<0.0001), day 26 (p<0.0001), day 33 (p = 0.025) and day 40 (p = 0.004). Finally, metastases are frequently detected in heart, mediastinal lymph nodes, and right lung using H&E and immunohistochemistry.ConclusionsUsing a GEM mouse model of metastatic lung cancer, we report that male mice with solitary lung cancer have accelerated malignant progression and increased variability in tumor growth when exposed to cyclical intermittent hypoxia. Our results indicate that cyclical intermittent hypoxia is a pathogenic factor in non-small cell lung cancer that promotes the more rapid growth of developing tumors.

Abstract TP400: Intravenous Glibenclamide Reduces Water Uptake and Mass Effect in Large Hemispheric Infarction (GAMES-RP Study)

Introduction: Prior studies have shown a linear relationship between CT-derived density and brain water uptake. We sought to determine whether intravenous (IV) glibenclamide (glyburide; BIIB093) would reduce water uptake and mass effect on serial CT scans from patients enrolled in the phase 2 GAMES-RP trial. Methods: Non-contrast CT scans performed between admission and day 7 (n=263) were analyzed in patients in the GAMES-RP modified intention-to-treat sample. Midline shift (MLS) was measured at the level of maximal lateral displacement of the septum pellucidum. CT-derived radiodensity was measured in pre-defined regions of interest (ROI) within the infarct. The same ROIs were mirrored to the contralateral hemisphere. The change in CT radiodensity (change in water uptake) was averaged among gray and white matter regions separately, and across both regions together. Repeated measures mixed effects models were used to assess the effect of IV glibenclamide on MLS or CT-measured water uptake. Results: There was a median of 3 CT scans [IQR 2-5] per patient during the first 7 days after stroke. Greater change in water uptake was associated with more MLS (β=0.17, 95% CI 0.15 to 0.20, p &lt;0.0001). Using repeated measures models, treatment with IV glibenclamide was associated with reduced water uptake (β= -2.25, 95% CI -4.37 to -0.13, p =0.037) and reduced MLS (β= -1.78, 95% CI -2.87 to -0.67, p =0.002), and adjusted for time. Treatment with IV glibenclamide reduced both gray and white matter water uptake independently. In mediation analysis, gray matter edema (β=0.10, 95% CI 0.05 to 0.16, p &lt;0.001) mediated a greater proportion of MLS when compared to white matter (β=0.02, 95% CI -0.03 to 0.08, p =0.427). Conclusions: IV glibenclamide reduced water uptake and MLS after large hemispheric infarction. A phase 3 study is underway to determine whether IV glibenclamide treatment improves clinical outcome.

Case report: hepatic inflammatory myofibroblastic tumour mimicking hepatocellular carcinoma post allogenic stem cell transplant for acute myeloid leukaemia

A 26-year-old female was found to have a solitary hepatic lesion on investigation of deranged liver function tests following allogeneic stem cell transplant (ASCT) for acute myeloid leukaemia (AML). Serial triple phase CT scans revealed growth of the lesion over months. Subsequent core biopsy revealed a diagnosis of fibro-lamellar hepatocellular carcinoma (HCC), a surprising diagnosis in a young patient without cirrhosis or other risk factors. Surgical resection with curative intent was undertaken, a risky anaesthetic endeavour in the setting of co-existing severe pulmonary graft versus host disease. Post-operative histo-pathological analysis of the resected specimen revised the diagnosis from HCC to anaplastic lymphoma kinase (ALK) positive inflammatory myofibroblastic tumour (IMFT), with bizarre reactive atypia in infiltrated hepatocytes at the periphery of the lesion. This is an exceedingly rare mesenchymal neoplasm with indolent behaviour that exhibits an extremely favourable prognosis with surgical resection. Without definitive surgical resection, pathological vigilance and careful histological re-evaluation the treatment plan and prognosis would have been drastically altered. AML, ASCT and previous chemotherapy/radiotherapy have all been associated with the development of these rare benign neoplasms. Given the capacity of IMTs to mimic malignancy, awareness of this histological entity and adequate specimen sample are essential in preventing future misdiagnoses.

Left atrial appendage closure. Monocentric registry of the first 100 cases: Indications, peri-operative anticoagulation strategies, complications and follow-up

According to the French National Authority for Health, percutaneous left atrial appendage closure (LAAC) is recommended for patients with a high risk of stroke (CHA2DS2-VASC ≥ 4) and contraindicated to long-term anticoagulation (AC) due to high bleeding risks. The aim of our monocentric registry was to evaluate our experience after the first 100 procedures. A total of 100 patients were prospectively included from Sept 2013 to Sept 2017. We analyzed data from the procedures considering indications, procedural complications, postoperative antithrombotic treatment and midterm outcome. Procedures took place in a hybrid room under general anesthesia and TEE guidance with 5000UI IV heparin before transseptal puncture. Follow-up was assessed by serial TEE and/or CT scan. Over 4 years, 100 patients underwent LAAC and followed over 27 ± 14 months. Mean age was 74.7 ± 7.8 years (77 M, 23 F) with mean CHA2DS2-VASC 4.6 ± 1.3 and HAS-BLED 2.5 ± 0.9. A total of 84 patients had a history of severe hemorrhage (54% of intracranial and 27% gastrointestinal). A subgroup of 22 patients had a CHA2DS2-VASC score < 4 but had a high bleeding risk. Indications for LAAC were in agreement with ESC guidelines in 96, HAS in 78 and FDA in 40 patients. A total of 40 Watchman™ and 58 ACP™/Amulet™ devices were implanted with 13 post-LAAC complications (6 puncture site, 2 failed implantations with Watchman, 2 pericardial effusions, 1 tamponade and 2 hemorrhages not requiring transfusion). Aspirin as the only antiplatelet therapy (APT) was the major postoperative strategy (74%). No treatment was prescribed in 3. Mean hospital stay was 2 nights. During follow-up we observed 2 asymptomatic device thrombus, 2 intracranial bleeds, 3 ischemic strokes i.e. 0.75%/pt-year and 6% periprosthetic leak. LAAC is a safe and efficient strategy. Management of APT/AC post-LAAC is not yet well defined and should be studied further. Patients with CHA2DS2-VASC < 4 but very high bleeding risk may be an indication for LAAC.