Short-axis Dimension Research Articles

[18F]FAPI adds value to [18F]FDG PET/CT for diagnosing lymph node metastases in stage I-IIIA non-small cell lung cancer: a prospective study

BackgroundThis study investigates the value of fluorine 18 ([18F])-labeled fibroblast activation protein inhibitor (FAPI) for lymph node (LN) metastases in patients with stage I-IIIA non-small cell lung cancer (NSCLC).MethodsFrom November 2021 to October 2022, 53 patients with stage I-IIIA NSCLC who underwent radical resection were prospectively included. [18F]-fluorodeoxyglucose (FDG) and [18F]FAPI examinations were performed within one week. LN staging was validated using surgical and pathological findings. [18F]FDG and [18F]FAPI uptake was compared using the Wilcoxon signed-ranks test. Furthermore, the diagnostic value of nodal groups was investigated.ResultsIn 53 patients (median age, 64 years, range: 31–76 years), the specificity of [18F]FAPI for detecting LN metastasis was significantly higher than that of [18F]FDG (P < 0.001). High LN risk category, greater LN short-axis dimension(≥ 1.0 cm), absence of LN calcification or high-attenuation, and higher LN FDG SUVmax (≥ 10.1) were risk factors for LN metastasis(P < 0.05). The concurrence of these four risk factors accurately predicted LN metastases (Positive Predictive Value [PPV] 100%), whereas the presence of one to three risk factors was unable to accurately discriminate the nature of LNs (PPV 21.7%). Adding [18F]FAPI in this circumstance improved the diagnostic value. LNs with an [18F]FAPI SUVmax<6.2 were diagnosed as benign (Negative Predictive Value 93.8%), and LNs with an [18F]FAPI SUVmax≥6.2 without calcification or high-attenuation were diagnosed as LN metastasis (PPV 87.5%). Ultimately, the integration of [18F]FDG and [18F]FAPI PET/CT resulted in the highest accuracy for N stage (83.0%) and clinical decision revisions for 29 patients.ConclusionIn patients with stage I-IIIA NSCLC, [18F]FAPI contributed additional valuable information to reduce LN diagnostic uncertainties after [18F]FDG PET/CT. Integrating [18F]FDG and [18F]FAPI PET/CT resulted in more precise clinical decisions.Trial registrationThe Chinese Clinical Trial Registry: ChiCTR2100044944 (Registered: 1 April 2021, https://www.chictr.org.cn/showprojEN.html?proj=123995).

Prognostic impact of suspicious extraabdominal lymph nodes on patient survival in advanced ovarian cancer.

To evaluate the clinical impact of suspicious extra-abdominal lymph nodes (EALNs) identified preoperatively on CT and/or PET/CT images in advanced ovarian cancer. A retrospective study was conducted with 122 patients diagnosed with stage III or IV ovarian cancer with preoperative CT and/or PET/CT images from 2006 to 2022. Imaging studies were evaluated for the presence, size and location of suspicious EALNs. Suspicious lymph node enlargement was defined by a cut-off ≥5mm short-axis dimension on CT and/or lesions with maximum standardized uptake values of ≥2.5 on PET/CT. This study only included patients who did not have their EALNs surgically removed. A total 109 patients met the inclusion criteria; 36 (33%) had suspicious EALNs and were categorized as "node-positive". The median overall survival (OS) was 45.73 months for the "node-positive" and 46.50 months for the "node-negative" patients (HR 1.17, 95% CI 0.68-2.00, p = 0.579). In multivariate analysis, after adjusting for other variables selected by process of backward elimination using a significance level of p<0.20, suspicious EALNs still showed no clinical significance on OS (aHR 1.20, 95% CI 0.67-2.13, p = 0.537) as well as progression-free survival (aHR 1.43, 95% CI 0.85-2.41, p = 0.174). Old age (aHR 2.23, 95% CI 1.28-3.89, p = 0.005) and platinum resistance (aHR 1.92, 95% CI 1.10-3.36, p = 0.023) affects adversely on OS. Suspicious EALNs did not worsen the prognosis of patients with advanced ovarian cancer. However, its impact on survival is not yet clarified. Further investigation is required to assess the clinical significance of suspicious EALNs on preoperative imaging studies.

Timing of Surgery for Asymptomatic Primary Mitral Regurgitation: Possible Value of Early, Serial Measurements of Left Ventricular Sphericity.

Asymptomatic primary mitral regurgitation due to myxomatous degeneration of the mitral valve leaflets may remain so for long periods, even as left ventricular function progresses to a decompensated stage. During the early compensated stage, the ventricle's initial response to the volume overload is an asymmetric increase in the diastolic short axis dimension, accomplished by a diastolic shift of the interventricular septum into the right ventricular cavity, creating a more spherical left ventricular diastolic shape, increasing diastolic filling and stroke volume. Early valve repair is recommended to reduce postoperative left ventricular dysfunction. Early serial measurements of left ventricular sphericity index [LV-Si]. during the compensated stage of mitral regurgitation might identify subtle changes in left ventricular shape and assist in determining the optimal earliest timing for surgical intervention.

Prophylactic Para-Aortic Extended Field Irradiation with Concurrent Chemotherapy for FIGO Stage IIIC1 Cervical Cancer Using Intensity Modulated Radiotherapy Technique: Acute Toxicity and Dosimetric Assessment

To evaluate the efficacy of P - PART with concurrent chemotherapy in LACC with the use of intensity modulated radiotherapy technique (IMRT). Our Primary endpoint was to assess acute toxicities and secondary endpoint was to assess loco-regional control (LRC), disease free-survival (DFS), para-aortic recurrence free survival (PA-RFS). A total of 30 patients of squamous cell carcinoma of cervix with stage IIIC1 (FIGO-2018) were recruited in this prospective, single arm interventional phase II study between January 2021 to September 2022. 18FDG-PET CT was performed and those with positive PALN were excluded. IMRT was used to deliver a dose of 50 Gy in 25 fractions to whole pelvis and PALN chain below renal hilum till aortic bifurcation received 45 Gy in 25 fractions. Concurrent cisplatin was administered weekly at 40 mg/m2 during radiation. On completion of external beam radiotherapy, high dose rate intracavitary brachytherapy was given at 7 Gy per fraction in 3 fractions prescribed to HR-CTV. Acute toxicities were assessed using CTCAE version 5.0. Median age was 50 years (37-66 years). All patients had completed treatment as per protocol. All patients had positive pelvic nodes with the maximum nodal short axis dimension of 14 mm (10-18 mm). All patients had positive internal iliac group of LNs, only 2(6.6%) patients had positive common iliac group of Ln. Median number of concurrent cisplatin cycles given were 5 (3-5 cycle). Median overall treatment time was 56 days (52-63 days) and median follow up was 15 months (3-22 month). Median cumulative dose to HR-CTV was 84.3Gy (Range:79.2-86.9Gy). Cumulative median EQD2 to 2cc of bladder and rectum were 69.11Gy (Range:59.17 - 80.07 Gy) and 64.6 Gy (Range: 60.1-66.3Gy) respectively. 7(23.3%) patients having grade 3 diarrhea and 2(6.67%) patients had grade 3 anemia while no significant genitourinary or other toxicities were noted. Patient characteristics, dosimetric data are described in Table-1. All patients underwent clinical and radiological assessment at the time of last follow up with one (3.33%) patient experiencing local failure at 9 months of follow up, hence crude LRC rate is 96.6%, DFS is 13.5 months (5-22 months) and PA-RFS is 16 months (8-23 months) till last date of follow up. Prophylactic EFRT with concurrent chemotherapy using IMRT technique yielded excellent short term clinical outcomes with acceptable toxicity profiles. Longer follow up will elucidate late toxicity and long-term clinical outcomes.

Fetal Echocardiographic Z Score Pilot Project: Study Design and Impact of Gestational Age and Variable Type on Reproducibility of Measurements Within and Across Investigators

Fetal echocardiography is widely available, but normative data are not robust. In this pilot study, the authors evaluated (1) the feasibility of prespecified measurements in a normal fetal echocardiogram to inform study design and (2) measurement variability to assign thresholds of clinical significance and guide analyses in larger fetal echocardiographic Z score initiatives. Images from predefined gestational age groups (16-20, >20-24, >24-28, and >28-32weeks) were retrospectively analyzed. Fetal echocardiography expert raters attended online group training and then independently analyzed 73 fetal studies (18 per age group) in a fully crossed design of 53 variables; each observer repeated measures for 12 fetuses. Kruskal-Wallis tests were used to compare measurements across centers and age groups. Coefficients of variation (CoVs) were calculated at the subject level for each measurement as the ratio of SD to mean. Intraclass correlation coefficients were used to show inter- and intrarater reliabilities. Cohen's d>0.8 was used to define clinically important differences. Measurements were plotted against gestational age, biparietal diameter, and femur length. Expert raters completed each set of measurements in a mean of 23±9 min/fetus. Missingness ranged from 0% to 29%. CoVs were similar across age groups for all variables (P<.05) except ductus arteriosus mean velocity and left ventricular ejection time, which were both higher at older gestational age. CoVs were >15% for right ventricular systolic and diastolic widths despite fair to good repeatability (intraclass correlation coefficient>0.5); ductal velocities and two-dimensional measures, left ventricular short-axis dimensions, and isovolumic times all had high CoVs and high interobserver variability despite good to excellent intraobserver agreement (intraclass correlation coefficient>0.6). CoVs did not improve when ratios (e.g., tricuspid/mitral annulus) were used instead of linear measurements. Overall, 27 variables had acceptable inter- and intraobserver repeatability, while 14 had excessive variability between readers despite good intraobserver agreement. There is considerable variability in fetal echocardiographic quantification in clinical practice that may affect the design of multicenter fetal echocardiographic Z score studies, and not all measurements may be feasible for standard normalization. As missingness was substantial, a prospective design will be needed. Data from this pilot study may aid in the calculation of sample sizes and inform thresholds for distinguishing clinically significant from statistically significant effects.

Relationships Between Systemic Inflammatory Markers and 18F-FDG PET/CT Imaging and Clinical Findings in Pulmonary Sarcoidosis.

Background and aim Sarcoidosis is a multisystem inflammatory disease of unknown aetiology. This study aimed to evaluate the relationship between systemic inflammatory parameters, the systemic immune-inflammation index (SII) and the lymphocyte-to-monocyte ratio (LMR), and disease stage, clinical findings, and 18F-fluoro-2-deoxy-D-glucose (18F-FDG) tomography/computed tomography (PET/CT) uptake. Materials and methods Our study included 73 patients. The general characteristics, radiological features, spirometric tests, PET/CT findings, and laboratory parameters of the patients were recorded. Results Relapse and parenchymal fibrosis were not associated with metabolic parameters, such as LMR and SII. Serum angiotensin-converting enzyme (ACE) levels were lower in the relapsed group than in the non-relapse group. However, the patients' PET/CT images indicated that 18F-FDG parenchym maximum standard uptake value (SUV max), lymph node SUV max, lymph node short axis dimension, SII, and LMR were similar between all patients, relapsed or not. Conclusion Although found to be significant in other inflammatory diseases, we found that SII and LMR alone did not indicate disease prognosis in sarcoidosis due to the small number of patients and the lack of homogeneity between the groups in our study. The usefulness of these markers for clinical use should be investigated by studies that include those with extrapulmonary sarcoidosis, and that calculate these markers at the time of disease diagnosis and during the post-treatment period.

Role of Diffusion-Weighted Magnetic Resonance Imaging for Characterization of Mediastinal Lymphadenopathy.

To assess the diagnostic performance of diffusion-weighted (DW) magnetic resonance imaging (MRI) in the characterization of mediastinal lymph nodes and compare them with morphological parameters. A total of 43 untreated patients with mediastinal lymphadenopathy underwent DW and T2 weighted MRI followed by pathological examination in the period from January 2015 to June 2016. The presence of diffusion restriction, apparent diffusion coefficient (ADC) value, short axis dimensions (SAD), and T2 heterogeneous signal intensity of the lymph nodes were evaluated using receiver operating characteristic curve (ROC) and forward step-wise multivariate logistic regression analysis. The ADC of malignant lymphadenopathy was significantly lower (0.873 ± 0.109 × 10-3 mm2/s) than that of benign lymphadenopathy (1.663 ± 0.311 × 10-3 mm2/s) (p = 0.001). When an ADC of 1.0955 × 10-3 mm2/s was used as a threshold value for differentiating malignant from benign nodes, the best results were obtained with a sensitivity of 94%, a specificity of 96%, and an area under the curve (AUC) of 0.996. A model combining the other three MRI criteria showed less sensitivity (88.9%) and specificity (92%) compared to the ADC-only model. The ADC was the strongest independent predictor of malignancy. The addition of other parameters failed to show any increase in sensitivity and specificity.

First-Principles Study on Interlayer Spacing and Structure Stability of NiAl-Layered Double Hydroxides.

Interlayer spacing and structure stability of layered double hydroxides (LDHs) on their application performance in adsorption, ion exchange, catalysis, carrier, and energy storage is important. The effect of different interlayer anions on the interlayer spacing and structure stability of LDHs has been less studied, but it is of great significance. Therefore, based on density functional theory (DFT), the computational model with 10 kinds of anions intercalated Ni3Al-A-LDHs (A = Cl-, Br-, I-, OH-, NO3 -, CO3 2-, SO4 2-, HCOO-, C6H5SO3 -, C12H25SO3 -) and four Ni R Al-Cl-LDH models with different Ni2+/Al3+ ratios (R = 2, 3, 5, 8) were constructed to calculate and analyze interlayer spacing, structural stability, and their influence factors. It was found that the interlayer spacing order of Ni3Al-A-LDHs intercalated with different anions is OH- < CO3 2- < Cl- < Br- < I- < HCOO- < SO4 2- < NO3 - < C6H5SO3 - < C12H25SO3 -. The hydrogen bond network between the base layer and the interlayer anions affects the arrangement structure of the interlayer anions, which affects the interlayer spacing. For interlayer monatomic anions Cl-, Br-, and I- and the anion of comparable size in each direction SO4 2-, the interlayer spacing is positively correlated with the interlayer anion diameter. The larger difference between the long-axis and short-axis dimensions of the polyatomic anions results in the long axis of the anion being perpendicular to the basal layer, increasing interlayer spacing. The long-chain anion C12H25SO3 - intercalation system exhibits the largest layer spacing of 24.262 Å. As R value increases from 2 to 8, the interlayer spacing of Ni R Al-Cl-LDHs gradually increases from 7.964 to 8.124 Å. The binding energy order between the interlayer anion and basal layer is CO3 2- > SO4 2- > OH- > Cl- > Br- > I- > HCOO- > NO3 - > C12H25SO3 - > C6H5SO3 -. The smaller the interlayer spacing, the higher the binding energy and the stronger the structural stability of LDHs. The factors affecting structural stability mainly include the bond length and bond angle of the hydrogen bond and the charge interaction between the basal layer and interlayer anion. In the CO3 2- intercalated system, the hydrogen bond length exhibits the shortest of 1.95 Å and the largest bond angle of 163.68°. The density of states and energy band analysis show that the higher the number of charges carried by the anion, the stronger its ability to provide electrons to the basal layer.

Fetal growth of left-sided structures and postnatal surgical outcome in borderline left heart varies by cardiac phenotype.

There are two borderline left-heart phenotypes in the fetus: (1) severe aortic stenosis (AS), which is associated with a 'short, fat', globular left ventricle (LV), LV systolic dysfunction and LV growth arrest; and (2) severe left-heart hypoplasia (LHH), which is associated with a 'long, skinny' LV, laminar flow across hypoplastic mitral and aortic valves and arch hypoplasia. Both phenotypes may be counseled for possible single-ventricle palliation. We aimed to compare the rates of left-sided cardiac structure growth and Z-score change over gestation and to describe the postnatal outcomes associated with these two phenotypes. We hypothesized that the left-sided structures would grow faster in fetuses with LHH compared to those with AS, and that those with LHH would be more likely to achieve biventricular circulation. This was a retrospective cohort study using data collected in an institutional cardiology database between April 2001 and April 2018. We included fetuses with severe AS or severe LHH, and with at least two fetal echocardiograms. Inclusion criteria for the AS group included: aortic-annulus Z-score < -2.0, severe AS, depressed LV function, retrograde systolic flow in the aortic arch and endocardial fibroelastosis. Inclusion criteria for the LHH group included: aortic-annulus Z-score < -2.0, hypoplastic but apex-forming LV, normal LV function and retrograde systolic flow in the aortic arch. Exclusion criteria were: abnormal cardiac connections, other forms of structural congenital heart disease, cardiomyopathy, history of fetal aortic valvuloplasty and participation in a maternal hyperoxygenation study. Measurements and respective Z-scores for the aortic-valve annulus, mitral-valve annulus, LV long- and short-axis dimensions, along with aortic-arch measurements, were collected longitudinally for each fetus and plotted over time for both cohorts. Mean slopes of change in dimension and Z-scores over gestation were calculated and compared between the two groups using mixed generalized linear regression accounting for repeated measures. A subanalysis was performed, matching six fetuses from each group for initial aortic-annulus Z-score and gestational age, due to the significant differences in these two variables between the original cohorts. In total, 53 fetuses with 158 echocardiograms were included. In the AS cohort, there were 20 (38%) fetuses with 65 echocardiograms, and in the LHH cohort there were 33 (62%) fetuses with 93 echocardiograms. On the first echocardiogram, LHH fetuses had a later gestational age and a larger aortic-annulus diameter. The rate of aortic-annulus growth was greater in the LHH group compared with the AS group (mean ± SD, 0.15 ± 0.01 mm/week for LHH vs 0.07 ± 0.01 mm/week for AS (P < 0.001)). While the LHH group had a decrease in aortic-annulus Z-score over time, this was at a slower rate than the decrease in the AS group (mean ± SD, -0.04 ± 0.02/week for LHH vs -0.13 ± 0.02/week for AS (P < 0.001)). A similar pattern was seen for the mitral-valve and LV short-axis-dimension Z-scores. Subanalysis of six fetuses from each group matched for initial aortic-annulus Z-score and gestational age demonstrated similar findings, with the LHH group Z-scores decreasing at a slower rate than those in the AS group. Fifty-two of the 53 fetuses were liveborn, one LHH fetus dying in utero. Of the 20 liveborn in the AS cohort, 15 (75%) infants underwent single-ventricle palliation, two (10%) underwent biventricular repair and three (15%) died prior to intervention. Of the 32 liveborn in the LHH cohort, three (9.4%) underwent single-ventricle palliation, 28 (87.5%) achieved biventricular circulation, of which six required no surgery, and one (3.1%) died prior to intervention. The left-sided cardiac structures grow at a faster rate in fetuses with severe LHH than they do in fetuses with severe AS, and the Z-scores decrease at a slower rate in fetuses with severe LHH than they do in those with severe AS. The majority of infants in the LHH group did not undergo single-ventricle palliation. This information can be useful in counseling families on the expected growth potential of the fetus's aortic valve, mitral valve and LV, depending on the cardiac phenotype. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Abstract 10723: Fetal Echocardiographic Assessment of Right Ventricular and Tricuspid Valve Function in Hypoplastic Left Heart Syndrome: Correlation with Postnatal Outcomes

Introduction: Hypoplastic left heart syndrome (HLHS) carries significant morbidity and mortality. Transthoracic echocardiogram (echo) assessment of right ventricular (RV) function and tricuspid regurgitation (TR) correlate with HLHS outcomes. There are limited reports on RV function and TR in fetal HLHS and postnatal outcomes. We aim to correlate RV function and TR on fetal-echo (F-echo) with transplant-free survival (survival), hospital length of stay after initial surgery (LOS), and timing of Glenn (BDG) in HLHS patients. Methods: Imaging and clinical data of fetuses diagnosed with HLHS between February 2014 and September 2020 at our institution were retrospectively reviewed. Measurements of RV myocardial performance index (MPI) and fractional area change (FAC) were made on initial F-echo. The RV shortening fraction (SF), presence/degree of TR, and RV size by diastolic short-axis dimension were recorded. Postnatal outcomes included survival, LOS and age at BDG. Early BDG was a repair at &lt;4 months. Mann-Whitney U test correlated F-echo measures and postnatal outcomes. Results: F-echo was available in 69 subjects; 22 excluded for termination/fetal demise, 9 for genetic syndromes, resulting in 38 subjects. Mean age at initial F-echo was 31.4±0.9wks, 11 referred &gt;30 weeks from regional cardiologists (adjusted mean age 23.1±0.4wks). Subject age at time of review ranged from 7 months to 6.5 years. Eight subjects died (median age 2 months) and 3 required transplant (median age 8 months). F-echo RV MPI was significantly higher (0.372±0.09;p=0.005) and RV FAC was significantly lower (43%±6.4%;p=0.016) in HLHS non-survivors versus survivors. Fetal RV size and presence of TR were not significantly different. Subjects with initial LOS &gt;30 days were more likely to have fetal TR (p&lt;0.001) and RV dilation (p=0.019), but no significant RV MPI and FAC difference. No fetal measures correlated with need for an early BDG. Conclusion: F-echo evaluation of RV MPI and FAC in HLHS correlates with transplant-free survival. Presence of fetal TR and RV dilation correlate with a longer LOS. F-echo measures of RV function and TR function may inform prenatal counseling and postnatal outcomes for fetal HLHS.

Initial Institutional Experience with 18F-Fluciclovine PET-CT in Biochemical Recurrence of Prostate Cancer.

18F-fluciclovine (fluciclovine) is an amino acid analog approved by the Food and Drug Administration for use as a radiotracer in positron emission tomography (PET) in men with biochemical recurrence of suspected prostate cancer. The purpose of this study was to investigate the initial institutional experience with 18F-fluciclovine in the evaluation of prostate cancer with biochemical recurrence. This study was a retrospective review of 135 patients who underwent 18F-fluciclovine PET-computed tomography (PET-CT) at a single institution from August 2018 through January 2020. Prognostic information, including prostate-specific level antigen (PSA) at the time of diagnosis, initial risk, initial Gleason score, and initial stage, was reviewed as well as the PSA level at the time of the scan. The images were reviewed by two radiologists with fellowship training in nuclear medicine and additional training to interpret the fluciclovine studies. A minority of studies were reviewed by a third fellowship-trained radiologist under the guidance of the two nuclear medicine-trained radiologists. In cases with abnormal radiopharmaceutical uptake in lymph nodes, the short-axis dimension of the lymph node or largest lymph node with abnormal uptake was noted. If CT or bone scan was performed within 4 months of the 18F-fluciclovine PET-CT, findings on the alternate imaging were compared with the results of the 18F-fluciclovine PET-CT. Our institutional positivity rate was 75.6%, with 64 (67.4%) patients with metastatic disease and 71 (52.6%) patients with local recurrence detected by fluciclovine. As expected, the rate of positive examinations increased with increasing PSA values measured at the time of imaging (P < 0.001). Of the 54 patients with nodal disease, 35 had nonpathologically enlarged lymph nodes measuring <1 cm in maximum short-axis dimension. In more than half of the patients in this study, with conventional imaging, fluciclovine either discovered otherwise undetectable metastatic disease or suggested the presence of local recurrence. Our single-institution experience with 18F-fluciclovine PET-CT has the largest number of patients to date in the literature and demonstrates the ability of fluciclovine to help guide clinical management in the detection of early recurrent disease.

COVID‐19 associated Kikuchi‐Fujimoto disease

We discuss the case of a 17-year-old male who presented with painful lymphadenopathy, fevers, weight loss, anorexia and a history of preceding anosmia. Histological features on lymph node biopsy were in-keeping with Kikuchi-Fujimoto disease (KFD). We later confirmed SARS-CoV-2 (COVID-19) infection on antibody testing. This case describes an atypical presentation of COVID-19 in a young patient and highlights an association between the virus and this rare disease.

Inter-twin differences in fetal echocardiographic findings are associated with decreased dual twin survival in twin-twin transfusion syndrome

Objective To determine if inter-twin differences in fetal echocardiographic findings are associated with fetal survival in monochorionic pregnancies complicated by twin-to-twin transfusion syndrome (TTTS). Methods This study included women who underwent laser surgery for TTTS between 2012 and 2018 at a single institution. Echocardiographic cardiac parameters in the donor and recipient twins were compared using Z-scores and regression analyses (adjusted for confounding variables) to determine whether any measurable inter-twin differences were associated with neonatal survival at birth. Results are expressed as (Odds ratio [95% confidence interval], p-value). Results Fetal echocardiography and delivery information was available in 124 TTTS cases. Dual live-birth occurred in 72% and at least one live-birth was seen in 89% of cases. Sixty-four percent (51/79) of recipient twins had evidence of cardiac dysfunction compared to 10% (8/79) of the donor twins (p < .01). In the logistic regression, inter-twin differences in left ventricle short axis dimension (0.62[0.44–0.87], p < .01), aortic valve diameter (0.67[0.45–0.99], p = .047), peak systolic velocity across the pulmonary artery (PA-PSV) (0.09[0.01–0.53], p < .01) and mitral valve diameter (0.56[0.38–0.84], p < .01) were associated with lower dual twin survival at birth. Conclusion Inter-twin differences in left cardiac geometry and function are associated with decreased survival at delivery in TTTS.

Neck as mediastinal extension: Diagnosis of sarcoidosis by core biopsy of cervical lymph nodes.

Sarcoidosis is a multi-system granulomatous disease. The diagnostic procedures for histological confirmation are invasive and a less invasive approach to diagnostic pathway is warranted. The utility of diagnostic value of neck ultrasound was retrospectively evaluated. A histological diagnosis was made by ultrasound-guided head and neck core biopsy to confirm clinically and radiologically suspected sarcoidosis. Twenty-five patients were referred for sonographic evaluation of the head and neck after CT scan in an attempt to avoid the use of more invasive tests. These patients had mediastinal adenopathy, but not clinically apparent neck nodes. Where no cervical lymph node suitable for biopsy was seen, parotid glands were biopsied if deemed abnormal. A diagnosis of sarcoidosis was made in all cases where a core biopsy of cervical lymph nodes was attempted. The cervical lymph nodesin this cohort were not particularly enlarged, short-axis dimensions being less than 10mm in majority, and they did not have any sonographic appearances to mark them as pathological. Nevertheless histological examination revealed non-caseating granulomas in all cases. In further two cases, where no neck nodes were seen, a histological diagnosis of sarcoidosis was made from biopsy of diffusely abnormal parotid glands. Given the clear advantages of cervical diagnosis in terms of invasiveness and economy compared to mediastinal alternatives, it is suggested that where the expertise for core biopsy of normal-sized cervical lymph nodes is readily available, the technique may be considered as a first-line investigation for the diagnosis of sarcoidosis.

Fluid distribution in ankle tendon sheaths in healthy volunteers: MRI findings

To assess normal distribution of fluid in the tendon sheaths of the ankle. 21 healthy volunteers were evaluated. Bilateral ankle MRI was performed on a 3T unit with PD-weighted images with fat saturation. The images were interpreted by two radiologists separately, and the short-axis dimension of fluid amount was measured. Bland-Altman plots and correlation plots were used to assess consistency between readers. There were 13 men and 8 women. The mean age was 24.7years. Fluid in the retromalleolar part of the peroneus longus was seen in three ankles of three volunteers and in the inframalleolar part in three ankles of three volunteers. Fluid in the retromalleolar part of the peroneus brevis was seen in four ankles of three volunteers and in the inframalleolar part in three ankles of two volunteers. Fluid in the retromalleolar part of the tibialis posterior was seen in 37 ankles of 20 volunteers and in the inframalleolar part in 38 ankles of 21 volunteers Fluid in the retromalleolar part of the flexor digitorum was seen in 14 ankles of eight volunteers and in the inframalleolar part in 11 ankles of eight volunteers Fluid in the retromalleolar part of the flexor hallucis longus was seen in 23 ankles of 16 volunteers and in the inframalleolar part in 17 ankles of 11 volunteers. Fluid is common in the retro- and inframalleolar parts of the medial tendons. Fluid is virtually absent in the peroneal tendons and anterior tendon sheaths in normal volunteers.

Stereotactic Radiosurgery and Intensity Modulated Radiotherapy for Treatment of Paragangliomas: A Tertiary Medical Center’s 17 Year Experience

Stereotactic radiosurgery (SRS) and intensity modulated radiotherapy (IMRT) are alternative therapies to surgery in the treatment of paragangliomas (PG). We hypothesized that SRS and IMRT could achieve adequate local control (LC) and symptom (sx) control in the treatment of PG with minimal associated toxicity in both upfront and salvage settings. We retrospectively evaluated 31 tumors in 30 non-metastatic patients (pts) treated with linear accelerator (LINAC) based SRS or IMRT at our institution between 2000-2017 for local tumor control and risk of secondary malignancy in an IRB approved study. SRS vs. IMRT was chosen based on PG size and location. Sx control and toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. PG were measured on MRI at radiation oncology (RO) consultation and at last follow up (f/u). Long axis (LA), short axis (SA), and largest craniocaudal dimensions (CC) were compared. LC was defined as no increase in LA, SA, or CC ≥ 3 mm and no salvage therapy by last f/u. Median f/u was 4.16 years. 6 pts were treated for residual disease status post (s/p) surgery, 6 pts had recurrent disease s/p surgery, and 18 pts (19 PG) received radiotherapy (RT) as primary treatment. Smallest PG dimension ranged 0.72-3.41cm and largest dimension 1.42-5.21 cm. 25 pts received SRS (median largest dimension 2.5cm): 13 in 5 fractions (range 2250-3000 cGy), 3 in 3 fractions (2100-2800 cGy) and 9 in 1 fraction (1400-1800 cGy). 4 pts (one with two PG) received IMRT in 15-27 fractions (range 4500-5400 cGy, average largest dimension 4.17 cm). All pts had tumor-induced neurologic sx’s at RO consultation. 23 pts (76.7%) had improvement in at least one PG-induced sx by last f/u. At last f/u imaging, 30 tumors (93.8%) decreased in at least one dimension, median largest decrease 3.6 mm (range 0-17.6 mm). No tumors increased ≥ 3mm and no pts required salvage therapy (100% LC), developed metastatic disease, or developed secondary malignancy with combined 132.43 years of f/u. No SRS pts experienced acute Gr ≥3 toxicity. IMRT toxicity included Gr 3 hearing loss in one patient with baseline hearing decline, and 1 pt with Gr 3 mucositis and skin rash. SRS and IMRT are safe and effective alternatives to surgical resection of paragangliomas with high LC rates, minimal acute and late complications, notable improvement of baseline symptoms, and without occurrence of any secondary malignancy or treatment failures requiring re-intervention. Radiotherapy was equally effective as primary treatment, after subtotal resection, or after progression s/p surgery.

An updated European Organisation for Research and Treatment of Cancer (EORTC) protocol for pathological evaluation of sentinel lymph nodes for melanoma

The sentinel lymph node (SLN) biopsy is a highly accurate staging procedure and the most important prognostic factor in melanoma patients. The European Organisation for Research and Treatment of Cancer (EORTC) Melanoma Group aimed to design an updated evolved SLN protocol for the histopathological workup and reporting. We herein recommend extending the distance between steps according to the short axis dimension of the lymph node and optimise both conventional sectioning and staining procedures including immunohistochemistry. We also provide guidance on the description of the spatial localisation of melanoma deposits in a SLN. The histopathological features to be reported include the following: presence or absence of the metastasis, the intranodal location of the metastasis (subcapsular, parenchymal, combined, extensive confluent and extensive multifocal), the number of the metastatic deposits (1, 2–5, 6–10, 11–20 and >20), the maximum dimension of the largest metastasis (indicating its site) and the presence of extracapsular extension and of naevus cells. This updated EORTC protocol is expected to clarify and simplify the existing procedures, ensuring a reasonable workload for the laboratory and for the pathologists resulting in cost saving with no loss, and possible increase, in accuracy.

Improved co-registration of ex-vivo and in-vivo cardiovascular magnetic resonance images using heart-specific flexible 3D printed acrylic scaffold combined with non-rigid registration

BackgroundEx-vivo cardiovascular magnetic resonance (CMR) imaging has played an important role in the validation of in-vivo CMR characterization of pathological processes. However, comparison between in-vivo and ex-vivo imaging remains challenging due to shape changes occurring between the two states, which may be non-uniform across the diseased heart. A novel two-step process to facilitate registration between ex-vivo and in-vivo CMR was developed and evaluated in a porcine model of chronic myocardial infarction (MI).MethodsSeven weeks after ischemia-reperfusion MI, 12 swine underwent in-vivo CMR imaging with late gadolinium enhancement followed by ex-vivo CMR 1 week later. Five animals comprised the control group, in which ex-vivo imaging was undertaken without any support in the LV cavity, 7 animals comprised the experimental group, in which a two-step registration optimization process was undertaken. The first step involved a heart specific flexible 3D printed scaffold generated from in-vivo CMR, which was used to maintain left ventricular (LV) shape during ex-vivo imaging. In the second step, a non-rigid co-registration algorithm was applied to align in-vivo and ex-vivo data. Tissue dimension changes between in-vivo and ex-vivo imaging were compared between the experimental and control group. In the experimental group, tissue compartment volumes and thickness were compared between in-vivo and ex-vivo data before and after non-rigid registration. The effectiveness of the alignment was assessed quantitatively using the DICE similarity coefficient.ResultsLV cavity volume changed more in the control group (ratio of cavity volume between ex-vivo and in-vivo imaging in control and experimental group 0.14 vs 0.56, p < 0.0001) and there was a significantly greater change in the short axis dimensions in the control group (ratio of short axis dimensions in control and experimental group 0.38 vs 0.79, p < 0.001). In the experimental group, prior to non-rigid co-registration the LV cavity contracted isotropically in the ex-vivo condition by less than 20% in each dimension. There was a significant proportional change in tissue thickness in the healthy myocardium (change = 29 ± 21%), but not in dense scar (change = − 2 ± 2%, p = 0.034). Following the non-rigid co-registration step of the process, the DICE similarity coefficients for the myocardium, LV cavity and scar were 0.93 (±0.02), 0.89 (±0.01) and 0.77 (±0.07) respectively and the myocardial tissue and LV cavity volumes had a ratio of 1.03 and 1.00 respectively.ConclusionsThe pattern of the morphological changes seen between the in-vivo and the ex-vivo LV differs between scar and healthy myocardium. A 3D printed flexible scaffold based on the in-vivo shape of the LV cavity is an effective strategy to minimize morphological changes in the ex-vivo LV. The subsequent non-rigid registration step further improved the co-registration and local comparison between in-vivo and ex-vivo data.

The correlation between the coaptation\xa0height of mitral valve and mitral regurgitation after mitral valve repair

BackgroundTo investigate the association between the coaptation height of mitral valve and mitral regurgitation after mitral valve repair.MethodsFrom Sep 2014 to Jun 2015, 20 patients underwent mitral valve valvuloplasty for mitral regurgitation were included. Ring annuloplasty was performed in all cases. Mitral valve short-axis dimension (MVd), coaptation height (CH), Left ventricular ejection fraction (LVEF) were measured by the transesophageal echocardiography before the operation in operation room and 3 months and 12 months after the operation by the transthoracic echocardiography. A degree from 0 to 4 was used to measure the degree of mitral regurgitation.ResultsThere were 14 patients with 0, 3 patients with 1, 3 patients with 2 of mitral regurgitation 12 months after the operation. CH (3.53 ± 1.91 mm) increased significantly at 3 months (5.05 ± 1.09 mm) and 12 months after operation (5.22 ± 1.15 mm) (p < 0.05). MVd and LVEF were not significantly changed after mitral valve repair. Furthermore, CH after resuscitation have a statistically significant negative correlation with the degree of mitral regurgitation 12 months after operation.ConclusionThe mitral valve repair with mitral valve ring induce the morphologic change of the mitral valve structure. The increase of CH after mitral valve repair may be one of the main factors in regulation of mitral regurgitation.

CT-Based Nodal Radiomic Features and Outcome in Head and Neck Squamous Cell Carcinoma

Non-invasive radiomic biomarkers involve high-throughput extraction of imaging data and may provide important complementary information. We investigated the association between pretreatment nodal radiomic features and clinical outcome for head neck cancer (HNC). After institutional review board approval, patients with lymph node positive head and neck squamous cell carcinoma treated with definitive radiotherapy were retrospectively reviewed. Lymph node delineation for radiation planning was based on computed tomography (CT), and 39 intensity and shape based first order radiomics features were extracted from nodal volumes. Loco-regional control (LRC), disease free survival (DFS) and overall survival (OS) were estimated by a Cox proportional hazard regression univariate analysis (UVA). Association between radiomic features and known p16 status were also analyzed by Wilcoxon rank sum test. A total of 44 patients were identified with a median follow-up of 12 months. Primary sites consisted of oropharynx (n=41) and oral cavity (n=3), 27 (61%) of which 27 (66%) were p16 positive. Median radiation dose was 68 Gy (range 54-70 Gy). The majority of patients received concurrent chemotherapy (n=36, 73%). No radiomic features were associated with p16 status (all p>0.1). The 2-year actuarial LRC, DFS and OS were 84%, 84% and 94%, respectively. On UVA, radiomic features with a trending association to LRC included sphericity (p=0.055), eccentricity (p=0.07), spherical disproportion (p=0.068), convexity (p=0.072), and long-axis dimension (p=0.091), of which, sphericity (p=0.082) and convexity (p=0.072) also showed a trending association with DFS. The radiomics features significantly associated with DFS were surface area [HR 1.02 (95% CI: 1-1.04); p=0.02], long-axis [HR 1.02 (95% CI: 1-1.04); p=0.03], and short-axis dimension [HR 1.09 (95% CI: 1.01-1.18); p=0.04]. Other features with a trending association with DFS were volume (p=0.057), kurtosis (p=0.09), and TGV (p=0.09). No radiomic features predicted for OS on UVA. This study identified certain lymph node radiomic features may be prognostic for DFS in HNC. Further work is required to improve the power and resolution of these features, with the goal towards identifying novel predictive tools to aid in personalized radiotherapy.