Suspicious Imaging Research Articles

Double-headed small-bowel capsule endoscopy: Real-world experience from a multi-centre British study

IntroductionCapsule endoscopy (CE) is well established the investigation of small-bowel (SB) pathology. We compared the use of double-headed (DH) capsules, to conventional single-headed (SH), in a real-world patient cohort in the first multicentre British study. MethodsOver 9 months, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent DH CE instead of conventional SH using MiroCamⓇ MC2000 as per local protocols. One head (L/R) was chosen at random and reported by an expert reviewer. The DH recordings, anonymised and randomised, reported by another expert or re-read after a 4-week interval. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between SH and DH examinations. Results211 CEs were performed. 7 failed to reach the SB; 204 analysed. Indications were: SB bleeding (n = 94); ?SB inflammation or reassessment of known inflammatory bowel disease (IBD) (n = 84); ?SB neoplasia including suspicious radiological imaging (n = 15); and, others e.g. ?celiac disease (n = 11). For SB bleeding: 27/94 (28.7%) examinations reported differences between SH and DH readings. In 17 (18.1%) the findings were clinically significant. SH CE missed angiectasias (5 pts), SB inflammation (7 pts), oesophagitis (2 pts) and SB masses (2 pts). In 1 patient, the extent of angiectasias seen was greater on the DH reading. For IBD: findings differed in 30/84 (35.7%) of CEs; 11 (13.1%) were clinically significant. In 5, signs of active inflammation were missed by the SH reading. In 6, assessment of extent/severity differed. For?SB neoplasia findings differed in 2/15 (13.3%) of examinations. Both were clinically significant. For others: 1/11 (9.1%) examinations differed; however, not deemed clinically significant. Overall, use of DH CE impacted the diagnosis in 30/204 (14.7%). ConclusionsThe use of DH CE provides more information with the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of DH CE in SB assessment should be considered.

Can autoantibody tests enhance lung cancer screening?-an evaluation of EarlyCDT®-Lung in context of the German Lung Cancer Screening Intervention Trial (LUSI).

BackgroundTumor-associated autoantibodies are considered promising markers for early lung cancer detection; so far, however, their capacity to detect cancer has been tested mostly in a clinical context, but not in population screening settings. This study evaluates the early detection accuracy, in terms of sensitivity and specificity, of EarlyCDT®-Lung—a test panel of seven tumor-associated autoantibodies optimized for lung cancer detection—using blood samples originally collected as part of the German Lung Cancer Screening Intervention Trial.MethodsThe EarlyCDT®-Lung test was performed for all participants with lung cancer detected via low-dose computed tomography and with available blood samples taken at detection, and for 180 retrospectively selected cancer-free participants at the end of follow-up: 90 randomly selected from among all cancer-free participants (baseline controls) and 90 randomly selected from among cancer-free participants with suspicious imaging findings (suspicious nodules controls). Sensitivity and specificity of lung cancer detection were estimated in the case group and the two control groups, respectively.ResultsIn the case group, the test panel showed a sensitivity of only 13.0% (95% CI: 4.9–26.3%). Specificity was estimated at 88.9% (95% CI: 80.5–94.5%) in the baseline control group, and 91.1% (95% CI: 83.2–96.1%) among controls presenting CT-detected nodules.ConclusionsThe test panel showed insufficient sensitivity for detecting lung cancer at an equally early stage as with low-dose computed tomography screening.

Updated experience of a tertiary pandemic center on 533 pregnant women with COVID-19 infection: A prospective cohort study from Turkey.

ObjectiveTo investigate the clinical course and impact of coronavirus disease 2019 (COVID‐19) infection on pregnant women.MethodsA prospective cohort study was conducted on pregnant women with confirmed COVID‐19 infection. Demographic features, clinical characteristics, and perinatal outcomes were prospectively evaluated.ResultsOf the 533 cases, 161 (30.2%) had co‐morbidities and 165 (30.9%) were asymptomatic. Cough (n = 178, 33.4%) and myalgia (n = 168, 31.5%) were the leading symptoms. In total, 261 patients (48.9%) received COVID‐19 therapy, 509 (95.5%) had mild disease, 7 (1.3%) were admitted to the intensive care unit (ICU), and invasive mechanical ventilation was necessary in 2 (0.4%) patients. Maternal mortality was observed in 2 (0.4%) cases. Of the patients, 297 (55.7%) were hospitalized, 39 (7.3%) had suspicious radiologic imaging findings, 66 (12.4) had pregnancy complications (preterm delivery [n =22, 4.1%] and miscarriage [n =12, 2.2%] were the most common pregnancy complications), 131 births occurred, and the cesarean section rate was 66.4%. All neonates were negative for COVID‐19. The rate of admission to the neonatal ICU was 9.9%. One specimen of breast milk was positive for the infection.ConclusionThe course of COVID‐19 was mild in the majority of cases. However, increased rates of pregnancy complications and cesarean delivery were observed.

Clinical Application of 7T Magnetic Resonance Imaging in Patients with Focal Cortical Dysplasia IIa and Epilepsy

Background: Focal cortical dysplasia (FCD) is one of the most important pathogenic findings in patients with extratemporal lobe epilepsy. Magnetic resonance imaging (MRI)-negative is the most important negative factor to predict postoperative seizure freedom; however, FCD-I and part of FCD-IIa are MRI-negative on routine MRI. Objectives: To explore the diagnostic values of 7T MRI and its new scan sequences in epilepsy patients with FCD-IIa. Methods: To include patients with focal seizure and suspicious focal abnormal imaging on 3T MRI during preoperative evaluation and perform a 7T MRI scan with white matter-suppressed (WMS) and gray-white matter tissue border enhancement (GWBE) sequences, resective epilepsy surgery, and postoperative pathological finding of FCD-IIa. The preoperative qualitative and localization significance of 7T MRI and 3T MRI in lesions with FCD-IIa was compared, and then, the imaging characteristics of lesions with FCD-IIa on 7T MRI were analyzed. Results: Ten cases were enrolled in this study. Seven tesla MRI presented high spatial resolutions and a high signal-to-noise ratio. WMS and GWBE could selectively suppress the signal of special tissue and improved the possibility of FCD findings. FCD-IIa showed abnormal thickness of gray matter and a blurring border and was hypointense on 7T MRI compared with 3T MRI. Seven patients showed improvement in the qualitative diagnosis strength grade of FCD, and 6 subjects showed improvement in the localization strength grade of the lesion border after careful reading of the 7T MR images. Significant differences were found in the qualitative diagnosis of FCD (p < 0.05) and localization of the lesion border (p < 0.05) between the neuroimaging diagnoses based on 3T MRI and the findings based on 7T MRI. Conclusion: 7T MRI with WMS and GWBE sequences shows application value in the preoperative imaging diagnosis of lesions with FCD-IIa in epilepsy patients.

Pseudoangiomatous stromal hyperplasia: overview and clinical management

: Pseudoangiomatous stromal hyperplasia (PASH) is a benign mesenchymal lesion of the breast characterized by dense collagenous stroma forming “pseudoangiomatous” capillary-like spaces lined by slender spindle cells. A rare condition overall, PASH is most common in premenopausal women, though cases have been described at ages ranging from 14 to 86, and in men, usually associated with gynecomastia. While the exact etiology is unknown, PASH is considered hormonally responsive, with myofibroblastic proliferation leading to stromal hyperplasia. It may present as a palpable mass or an incidental imaging finding. The usual appearance on mammography and ultrasound is that of a well-circumscribed mass which must be differentiated from other benign and malignant lesions such as fibroadenoma, phyllodes tumor, and myofibroblastoma; histologically it must be distinguished from angiosarcoma. Core needle biopsy is indicated for diagnosis and must be concordant with imaging and clinical findings. PASH lesions should be surgically excised if enlarging, associated with symptoms, suspicious imaging findings are present, or other lesions are synchronously diagnosed that warrant removal; otherwise, observation with clinical and imaging follow-up can be considered. Progression and recurrence, each reported at rates of approximately 15–20%, indicate change in management and/or additional surgical intervention. PASH is not associated with an increased risk of breast cancer and prognosis is generally favorable.

Incorporation of a Machine Learning Algorithm With Object Detection Within the Thyroid Imaging Reporting and Data System Improves the Diagnosis of Genetic Risk.

BackgroundThe role of next generation sequencing (NGS) for identifying high risk mutations in thyroid nodules following fine needle aspiration (FNA) biopsy continues to grow. However, ultrasound diagnosis even using the American College of Radiology’s Thyroid Imaging Reporting and Data System (TI-RADS) has limited ability to stratify genetic risk. The purpose of this study was to incorporate an artificial intelligence (AI) algorithm of thyroid ultrasound with object detection within the TI-RADS scoring system to improve prediction of genetic risk in these nodules.MethodsTwo hundred fifty-two nodules from 249 patients that underwent ultrasound imaging and ultrasound-guided FNA with NGS with or without resection were retrospectively selected for this study. A machine learning program (Google AutoML) was employed for both automated nodule identification and risk stratification. Two hundred one nodules were used for model training and 51 reserved for testing. Three blinded radiologists scored the images of the test set nodules using TI-RADS and assigned each nodule as high or low risk based on the presence of highly suspicious imaging features on TI-RADS (very hypoechoic, taller-than-wide, extra-thyroidal extension, punctate echogenic foci). Subsequently, the TI-RADS classification was modified to incorporate AI for T4 nodules while treating T1-3 as low risk and T5 as high risk. All diagnostic predictions were compared to the presence of a high-risk mutation and pathology when available.ResultsThe AI algorithm correctly located all nodules in the test dataset (100% object detection). The model predicted the malignancy risk with a sensitivity of 73.9%, specificity of 70.8%, positive predictive value (PPV) of 70.8%, negative predictive value (NPV) of 73.9% and accuracy of 72.4% during the testing. The radiologists performed with a sensitivity of 52.1 ± 4.4%, specificity of 65.2 ± 6.4%, PPV of 59.1 ± 3.5%, NPV of 58.7 ± 1.8%, and accuracy of 58.8 ± 2.5% when using TI-RADS and sensitivity of 53.6 ± 17.6% (p=0.87), specificity of 83.3 ± 7.2% (p=0.06), PPV of 75.7 ± 8.5% (p=0.13), NPV of 66.0 ± 8.8% (p=0.31), and accuracy of 68.7 ± 7.4% (p=0.21) when using AI-modified TI-RADS.ConclusionsIncorporation of AI into TI-RADS improved radiologist performance and showed better malignancy risk prediction than AI alone when classifying thyroid nodules. Employing AI in existing thyroid nodule classification systems may help more accurately identifying high-risk nodules.

P005 - Do all patients with suspicious prostate cancer need multiparametric magnetic resonance imaging before prostate biopsy?

P005 - Do all patients with suspicious prostate cancer need multiparametric magnetic resonance imaging before prostate biopsy?

Antibiotic Prophylaxis for the Prevention of Infectious Complications following Prostate Biopsy: A Systematic Review and Meta-Analysis.

Infectious complications following prostate biopsy are increasing and fluoroquinolone prophylaxis has recently been banned by the European Commission. In this systematic review we summarize the evidence for different antibiotic prophylaxis regimens. We searched MEDLINE®, Embase® and Cochrane Database for randomized controlled trials (inception to October 2019) assessing antimicrobial interventions in prostate biopsy. Primary outcome was infectious complications. Exclusion criteria were simultaneous interfering interventions. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used to assess the certainty of evidence. Protocol was registered with PROSPERO (CRD42015026354). Overall 59 randomized controlled trials (14,153 participants) and 7 different antimicrobial interventions were included. Antibiotic prophylaxis reduced infectious complications compared to no prophylaxis (RR 0.56, 95% CI 0.40-0.77, p=0.0005, I2=15%, participants 1,753, studies 11). A short-term prophylaxis (single shot to 3 days) was inferior to a long-term prophylaxis (1 to 7 days) with fluoroquinolone (RR 1.89, 95% CI 1.37-2.61, p=0.0001, I2=0%, participants 3,999, studies 17). Fosfomycin trometamol was an alternative to fluoroquinolone with reduced rates of infectious complications (RR 0.49, 95 CI 0.27-0.87, p=0.02, I2=54%, participants 1,239, studies 3). Empiric prophylaxis was inferior to targeted prophylaxis (RR 1.81, 95% CI 1.28-2.55, p=0.0008, I2=48%, participants 1,511, studies 6). Standard prophylaxis was inferior to augmented prophylaxis (using multiple rather than single agent) using a fixed model (RR 2.10, 95% CI 1.53-2.88, p <0.0001, I2=71%, participants 2,597, studies 9), but not using a random model (p=0.07). No difference was observed in infectious complications based on route or timing of antimicrobial prophylaxis. The certainty of evidence was rated as low/very low. In countries where fluoroquinolones are allowed as antibiotic prophylaxis, a minimum of a full 1-day administration as well as targeted therapy in case of fluoroquinolone resistance is recommended. In countries with a ban on fluoroquinolones, fosfomycin is a good alternative, as is augmented prophylaxis, although no established standard combination exists to date.

Incidentally discovered COVID-19 in low-suspicion patients-a threat to front line health care workers.

PurposeThe COVID-19 pandemic has been responsible for thousands of deaths worldwide. Testing remains at a premium, and criteria for testing remains reserved for those with lower respiratory infection symptoms and/or a known high-risk exposure. The role of imaging in COVID-19 is rapidly evolving; however, few algorithms include imaging criteria, and it is unclear what should be done in low-suspicion patients with positive imaging findings.MethodsFrom 03/01/2020–03/20/2020, a retrospective review of all patients with suspected COVID-19 on imaging was performed. Imaging was interpreted by a board-certified, fellowship-trained radiologist. Patients were excluded if COVID-19 infection was suspected at the time of presentation, was the reason for imaging, or if any lower respiratory symptoms were present.ResultsEight patients with suspected COVID-19 infection on imaging were encountered. Seven patients received testing due to suspicious imaging findings with subsequent lab-confirmed COVID-19. No patients endorsed prior exposure to COVID-19 or recent international travel. COVID-19 was suggested in six patients incidentally on abdominal CT and two on chest radiography. At the time of presentation, no patients were febrile, and seven endorsed gastrointestinal symptoms. Five COVID-19 patients eventually developed respiratory symptoms and required intubation. Two patients expired during the admission.ConclusionsPatients with imaging findings suspicious for COVID-19 warrant prompt reverse transcription polymerase chain reaction (RT-PCR) testing even in low clinical suspicion cases. The prevalence of disease in the population may be underestimated by the current paradigm of RT-PCR testing with the current clinical criteria of lower respiratory symptoms and exposure risk.

OR32-06 Opportunistic Assessment of Pituitary Gland with Routine MRI and PET/CT Can Guide in Earlier and Increased Identification of Hypophysitis in Patients Treated with Combination Checkpoint Inhibitors

Background: Hypophysitis is one of the commonly reported adverse events related to immune checkpoint inhibitors (ICI), and the incidence is expected to rise with increased use of combined programmed cell death protein 1 (PD1) and cytotoxic T lymphocyte associated protein 4 (CTLA4) blockade. The clinical diagnosis can be delayed due to non-specific symptoms. At our centre, subjects undergo periodic imaging to assess tumour response to ICI. We reviewed whether neuroimaging studies can guide us in the diagnosis of hypophysitis and whether early changes can be detected before the onset of the clinical syndrome. Methods: We retrospectively reviewed the medical charts, biochemistry, structural brain imaging and whole-body positron emission tomography (PET) with specific reference to hypophysitis in 162 patients treated with combination ICI at a tertiary melanoma referral centre. Suspected cases were identified based on meeting one or more of the following criteria: 1) A documented diagnosis of hypophysitis or pituitary dysfunction found on chart review, 2) A relative change in pituitary size or appearance from baseline on neuroimaging studies, or 3) An increase in pituitary maximum standardized uptake value (SUVmax) greater than 25% from baseline on 18F-FDG PET. Results: 58/162 patients (36%) met criteria for suspected hypophysitis. Only 4 patients were identified on routine screening of early morning cortisol. 14 patients presented with symptoms leading to biochemical work up. A further 40 patients were found to have suspicious imaging changes, 13 of which went on to receive a formal diagnosis of hypophysitis. Of the remaining 27 patients, 23 were receiving high dose glucocorticoids for concomitant immune related adverse events at the time of the abnormal imaging study.Conclusion: We report the highest incidence to date of suspected hypophysitis in cohort of patients treated with combination ICI. This study highlights the important role of structural and functional neuroimaging in the early recognition of hypophysitis. Imaging may also play a role when the clinical syndrome is masked by concurrent glucocorticoid use.

MP81-10 RISK STRATIFICATION FOR EQUIVOCAL PI-RADS 3 RESULTS: CAN MICRO-ULTRASOUND HELP DETERMINE WHICH MEN TO BIOPSY?

You have accessJournal of UrologyProstate Cancer: Detection & Screening VIII (MP81)1 Apr 2020MP81-10 RISK STRATIFICATION FOR EQUIVOCAL PI-RADS 3 RESULTS: CAN MICRO-ULTRASOUND HELP DETERMINE WHICH MEN TO BIOPSY? Georg Salomon*, Giovanni Lughezzani, Hannes Cash, Laura Wiemer, Robin Heckmann, Sebastian Hofbauer, Ander Astobieta, Andrea Sánchez, Frédéric Staerman, Laurent Lopez, Richard Gaston, Thierry Piéchaud, Gregg Eure, Eric Klein, Robert Abouassaly, and Sangeet Ghai Georg Salomon*Georg Salomon* More articles by this author , Giovanni LughezzaniGiovanni Lughezzani More articles by this author , Hannes CashHannes Cash More articles by this author , Laura WiemerLaura Wiemer More articles by this author , Robin HeckmannRobin Heckmann More articles by this author , Sebastian HofbauerSebastian Hofbauer More articles by this author , Ander AstobietaAnder Astobieta More articles by this author , Andrea SánchezAndrea Sánchez More articles by this author , Frédéric StaermanFrédéric Staerman More articles by this author , Laurent LopezLaurent Lopez More articles by this author , Richard GastonRichard Gaston More articles by this author , Thierry PiéchaudThierry Piéchaud More articles by this author , Gregg EureGregg Eure More articles by this author , Eric KleinEric Klein More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , and Sangeet GhaiSangeet Ghai More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000973.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Reducing unnecessary prostate biopsy procedures is an important clinical goal to reduce pain and anxiety for the patient, as well as the risk of infection and overtreatment. Multiparametric (mpMRI) has been proposed as an effective strategy to reduce the need for a prostate biopsy both in the initial and in the repeat biopsy setting. However, indeterminate or equivocal findings at mpMRI can pose a diagnostic challenge. We aimed to determine whether micro-ultrasound could help to further stratify the need for a prostate biopsy in patients with PIRADS 3 lesion at mpMRI. METHODS: This study was based on a retrospective series of patients presenting with at least one PI-RADS 3 lesion at mpMRI at one of 7 international sites. All patients were imaged with micro-ultrasound using the ExactVu™ (Exact Imaging, Markham, Canada) system, and the presence of suspicious lesions was determined and graded according to the PRI-MUS™ (Prostate risk identification using micro-ultrasound)1 protocol. Maximum PRI-MUS score for each subject was used to determine whether the case was non-suspicious on micro-ultrasound (PRI-MUS 1 or 2), equivocal (PRI-MUS 3), or suspicious (PRI-MUS 4 or 5). All patients with a suspicious (PRI-MUS >2) lesion were subjected to a micro-ultrasound guided targeted biopsy. In addition, mpMRI targeted biopsies on PI-RADS 3 lesions were also obtained either with a cognitive or with a fusion biopsy technique according to each center protocol. RESULTS: 144 subjects were included. Overall prostate cancer detection rate for PI-RADS 3 subjects was 48% (69/144), while 20% (29/144) of patients were diagnosed with a clinically significant prostate cancer defined as a ISUP Grade Group (GG) > 1 tumor. PRI-MUS was able to provide significant risk stratification in this population, with non-suspicious micro-ultrasound imaging reducing the risk of finding GG>1 cancer by more than half to 5% (1/19). Equivocal micro-ultrasound provided little additional information with a GG>1 detection rate of 14% (5/35), while suspicious micro-ultrasound imaging resulted in a significant 17% relative increase in GG>1 detection rate to 26% (29/90, p=0.02). CONCLUSIONS: Micro-ultrasound imaging and PRI-MUS protocol findings appear to provide useful additional information in the case of equivocal mpMRI results. When combined with other clinical risk indicators such as PSA, PSA density and family history, it may be possible to better advise patients on the necessity of a biopsy using this data. Source of Funding: None. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1240-e1240 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Georg Salomon* More articles by this author Giovanni Lughezzani More articles by this author Hannes Cash More articles by this author Laura Wiemer More articles by this author Robin Heckmann More articles by this author Sebastian Hofbauer More articles by this author Ander Astobieta More articles by this author Andrea Sánchez More articles by this author Frédéric Staerman More articles by this author Laurent Lopez More articles by this author Richard Gaston More articles by this author Thierry Piéchaud More articles by this author Gregg Eure More articles by this author Eric Klein More articles by this author Robert Abouassaly More articles by this author Sangeet Ghai More articles by this author Expand All Advertisement PDF downloadLoading ...

Fetal Ultrasound and Magnetic Resonance Imaging Findings in Suspected Septo‐Optic Dysplasia

To investigate prenatal imaging findings supporting a diagnosis of suspected septo-optic dysplasia (SOD) by fetal ultrasound (US), magnetic resonance imaging (MRI), or both. A retrospective review identified 11 patients with SOD: 9 had a clinical diagnosis of SOD postnatally, and 2 were terminated on the basis of suspicious prenatal imaging. Prenatal and neonatal imaging of the cavum septi pellucidi (CSP), frontal horns (FHs), and lateral ventricles was evaluated. The appearance of the CSP varied on US and MRI. Complete ("fused") FHs or partial absence of the CSP was reported in 6 of 11 patients by fetal US and 7 of 8 patients by fetal MRI. The diagnosis of SOD was prospectively suspected prenatally in 6 of 11 and in an additional 5 of 11 cases retrospectively. Fetal MRI incorrectly initially reported normal morphologic abnormalities for 2 cases with partial absence of the CSP, whereas US accurately identified the morphologic abnormalities in 1 of these cases before MRI. Imaging features were first suggested at anatomic US (4 patients) and follow-up prenatal US (2 patients). Neonatal imaging was concordant in all 9 live births: 5 completely absent CSP, 3 partially absent CSP, and 1 completely present CSP. Clinical manifestations included optic nerve hypoplasia (9 of 9), panhypopituitarism (5 of 9), and neurodevelopmental delays. Primary imaging features of SOD are "continuous" FHs with complete or partial absence of the CSP. Septo-optic dysplasia can be suspected in utero and can appear isolated but has substantial associated central nervous system anomalies identified on fetal MRI or after birth. Partial absence of the CSP can be a prenatal sign of suspected SOD, although fetal MRI lacked the spatial resolution to identify it accurately in all cases.

Abstract P6-02-05: Clumped vs non-clumped internal enhancement patterns in linear non-mass enhancement on breast MRI

Abstract Purpose To compare positive predictive values (PPVs) of clumped versus non-clumped (homogenous and heterogenous) internal enhancement on MRI detected linear non-mass enhancement (NME) on MRI-guided vacuum assisted breast biopsy (MRI-VABB). Materials and Methods With IRB approval, radiology reports were retrospectively reviewed of 598 lesions undergoing 9-gauge MRI-VABB from January 2015 to April 2018 for lesions showing linear NME, recording clumped and non-clumped internal enhancement. We reviewed the electronic medical records for MRI-guided VABB pathology, any follow up surgery and imaging and/or clinical follow-up &amp;gt;1 year (mean 1.7 years). The X2 test was performed for univariate analysis. Results There were 120/598 (20%) linear NME MRI-VABB lesions with clumped (52/120, 43%) vs non-clumped (68/120, 57%) internal enhancement, average size 1.8 cm (range 0.3-7.6 cm). On MRI-VABB, cancer was identified in 22/120 (18%) lesions, ductal carcinoma in situ (DCIS) was found in 18/22 (82%) and invasive cancer (3 IDC, 1 ILC) in 4 (18%). 31/120 (26%) were high-risk lesions with 3/31 (10%) high-risk lesions upgraded to DCIS at surgery, which comprising a total of 25/120 (21%) malignancies. Malignancy was found in 12/52 (23%) clumped lesions and in 13/68 (19%) of non-clumped lesions that showed heterogenous (5/13, 38%) or homogenous (8/13, 62%) internal enhancement. The PPV of linear NME with clumped internal enhancement (23.1%; 95% CI, 11.6-34.6) was not significantly different from the PPV of non-clumped linear NME (19.1%; 95% CI, 9.8-28.4) (p=0.597). The PPV of linear NME lesions &amp;lt;1cm (33.3%; 95% CI, 11.5-55.1) was not significantly different from the PPV of lesions ≥1cm (18.6%; 95% CI, 11.1-26.2) (p=0.157). 53/120 (44%) NME lesions were operated upon. Of the remaining 67 NME not operated upon, 2 benign findings were lost to follow up, and 65 (64 benign, 1 high-risk) showed no suspicious imaging and/or clinical features on follow up. Conclusion Linear NME showed malignancy in 21% of our series. Linear NME with clumped or non-clumped internal enhancement patterns, regardless of lesion size, should undergo MRI-VABB in appropriate clinical settings. Citation Format: Shu-Tian Chen, James Covelli, Satoko Okamoto, Bruce Daniel, Wendy DeMartini, Debra Ikeda. Clumped vs non-clumped internal enhancement patterns in linear non-mass enhancement on breast MRI [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-02-05.

Pre-diagnosis Multidisciplinary Tumor Board and Time to Staging in Lung Cancer: The Case Western MetroHealth Experience.

IntroductionNational guidelines support the discussion of cancer patients by multidisciplinary tumor boards (MTB). We researched whether early pre-diagnosis multidisciplinary tumor board discussions are associated with shorter times to staging in lung cancer.MethodsWe reviewed our institution’s lung cancer and MTB registries to retrospectively study if an early discussion at pre-diagnostic MTB (pd-MTB) influenced the timeliness of diagnostic evaluation. Over 14 months, 161 consecutive patients with a diagnosis of lung cancer were included. Fifty-five patients were presented at pd-MTB while 106 (controls) patients were not. The primary outcome was the difference in the time interval from suspicious imaging (Ix) to completion of staging (Sx). Outcomes were adjusted for key confounders with a multiple regression analysis.ResultsFor stages I, II, and III lung cancer, where time to therapy matters, early discussion of patients with nodules suspicious for malignancy at pd-MTB was associated with no time delays when compared to patients who were not discussed in pd-MTB. The mean time intervals for imaging to staging (with standard deviations) are 65 days in controls (sd = 42.67) and 75 days (sd = 58.27) in tumor board cases (p=0.39). Adjusting for confounders with a multiple regression analysis among all stages revealed a similar lack of difference in time intervals to diagnosis, staging, and therapy.ConclusionOur stage I-III lung cancer cases (pd-MTB) completed staging in a timely manner, similar to controls (no pd-MTB). The severity of illness at presentation and the availability of diagnostic services and others likely influence the results. Our manuscript shares important numerical data on timelines during cancer diagnosis and treatment. Using this data, prospective registries examining the process workflow may help standardize cancer quality goals and maximize referrals from primary-care/specialty providers. The key findings in our study create a paradigm for future studies to create and achieve “door-to-balloon” time targets for lung cancer care (akin to cardiac care) across different styles of tumor boards.

Conventional culture diagnostics vs. multiplex PCR for the detection of causative agents of vascular graft infections - results of a single centre observational pilot study.

Background: Timely diagnosis of vascular graft infections is of major importance in vascular surgery. The detection of causative microorganisms is needed for specific medical treatment, but conventional culture is often slow, insensitive and inconclusive due to antibiotic pre-treatment. Detection of bacterial DNA by polymerase chain reaction (PCR) might bypass these problems. We hypothesised that multiplex PCR (mPCR) is feasible, fast and sensitive to detect causative microorganisms in vascular graft infections. Patients and methods: We performed a pilot observational prospective study comparing conventional culture and a commercial mPCR. Inclusion criteria were: confirmed graft infection, suspicious imaging, clinical suspicion, anastomotic aneurysm and repeated graft occlusion. Diagnostic methods were performed using identical samples. Time to result, microorganisms and antibiotic resistance in both groups were compared using Student's t-test or nonparametric tests. Results: 22 samples from 13 patients were assessed and 11 samples were negative for bacteria. Some showed multiple germs. In total, we found 15 different organisms. 13 samples matched, 9 had non-concordant results. Out of the mismatches 3 microorganisms identified in PCR were not detected by culture. Time to result with PCR was shorter (median 5h vs. 72h, p<0.001) than with culture. No resistance genes were detected by mPCR, but conventional culture allowed susceptibility testing and revealed resistance in 5 samples. Conclusions: mPCR seems to be a feasible and quick tool to detect causes of vascular graft infections within 24h and might be helpful in antibiotic pre-treated patients. The detection of antibiotic resistance with mPCR needs improvement for clinical practice.

SCIENTIFIC PROGRAM OF 37TH WORLD CONGRESS OF ENDOUROLOGY PROGRAM BOOK

SCIENTIFIC PROGRAM OF 37TH WORLD CONGRESS OF ENDOUROLOGY PROGRAM BOOK

2220 Incidental Finding of Hepatocellular Neoplasms in Non-Cirrhotic Patients: A Case Series

INTRODUCTION: About 20% of hepatocellular cancers (HCC) arise in the absence of cirrhosis, such as in the setting of glycogen storage disease (GSD) and anabolic steroid use. Non-cirrhotic HCC tends to have a lower male predominance, bimodal age distribution, and lower prevalence of hepatitis B, C, and alcohol abuse. There is a larger tumor burden at time of HCC diagnosis but a higher amenability to hepatic resection given preserved liver function and better overall survival than cirrhotic patients. CASE DESCRIPTION/METHODS: Case 1 A 16-year-old male presented after a motor vehicle accident for evaluation of traumatic injuries. He was a body-builder who used anabolic steroids. Physical exam showed a palpable liver edge. Labs were unremarkable. Computed tomography scan of the abdomen showed an incidentally discovered mass in the right hepatic lobe. Magnetic resonance imaging (MRI) of the abdomen showed a 15.1 × 15.0 × 10.8 cm right hepatic lobe mass concerning for a hepatic neoplasm. He underwent partial hepatectomy. Resected surgical specimen showed a β-catenin activated well-differentiated hepatocellular carcinoma. Case 2 A 26-year-old man with GSD type 1a was evaluated for iron-deficiency anemia. Physical exam showed tachycardia, conjunctival pallor, and palpable liver edge. Labs were notable for hemoglobin of 12.6 gm/dL, platelet count of 529 × 103/µL, alanine aminotransferase 92 U/L, and aspartate aminotransferase 82 U/L. MRI of the abdomen showed multiple large arterially enhancing liver masses within the right and left hepatic lobes. The largest lesion within the right lobe of the liver measured 20.2 × 17.7 × 13.5 cm. Endoscopic ultrasound showed a large right heterogenous hepatic lobe lesion, appearing malignant which underwent fine needle aspiration. Pathology was consistent with β-catenin activated hepatocellular neoplasm. The patient is scheduled for a right hepatectomy with possible living donor liver transplantation given the large and multifocal nature of his liver masses. DISCUSSION: There are four different phenotypes of hepatocellular adenomas; the β-catenin subtype has the highest malignant potential. Anemia in GSD appears to be related to large hepatic adenoma formation and warrants imaging of the abdomen to evaluate for a bleed or growth of the lesions. No effective imaging tool or biomarker separates hepatocellular adenoma from HCC, so it is important to keep a low threshold to biopsy a hepatic adenoma with suspicious imaging features.

Does lipofilling after oncologic breast surgery increase the amount of suspicious imaging and required biopsies?-A systematic meta-analysis.

The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings. We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast. Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8months (range 6-50months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%. Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

AB012. Surgical management of malignant pleural mesothelioma

: The clinical suspicion of mesothelioma should be aroused when a patient presenting with a unilateral pleural effusion and pleural thickening gives a history of asbestos exposure. This maybe as a direct exposure whilst working with the substance or indirectly via environmental exposure. In most a thoracic CT is useful leading to an image guided pleural biopsy (if predominantly pleural thickening) or pleural aspiration (if predominantly effusion) to exclude adenocarcinoma. Effusion control can be achieved together with a definitive histological diagnosis by video assisted thoracoscopy (VATS), which does not necessarily need general anaesthesia. If the lung expands on effusion drainage then talc pleurodesis should be performed after biopsy; if the lung is entrapped then an indwelling pleural catheter should be inserted. If the patient is to proceed to further radical treatment then in general they should have similar cardiorespiratory reserve to withstand a lobectomy for lung cancer. Anaemia, leucocytosis and thrombocythaemia are poor prognostic indicators as is severe weight loss. It may be difficult to measure dynamic and static lung volumes due to the disease itself but differential lung perfusion imaging and echocardiographic assessment of ventricular function are useful, particularly if pneumonectomy is proposed. Since radical surgery should always be considered as part of multimodality therapy then the patient should have adequate renal function. The diagnostic biopsy must be sufficient for the tumour cell type to be identified. In most specialist centres pure sarcomatoid malignant pleural mesothelioma (MPM) precludes radical surgery. For biphasic disease the position is less clear and the proportion of sarcomatoid: epithelioid may be considered. The objective of radical surgery is to achieve macroscopic complete resection (MCR) which means leaving no visible residual tumour or a R2 resection. Therefore, CT is used to exclude T4 disease (in conjunction with MRI) and CTPET may be used to investigate potential peritoneal M1 disease. Tumour thickness and volume on CT and avidity on CTPET may all be used to predict prognosis. As not all nodal stations can be sampled preoperatively then N1 disease is a relative contraindication to resection. Endoscopic ultrasound or mediastinoscopy can be used to exclude contralateral N3 disease. Where indicated by suspicious imaging, contralateral video assisted thoracoscopy or laparoscopy may be needed to exclude M1 disease. Currently we offer radical surgery in patients with N1 disease (providing MCR can be achieved) within the MARS2 trial but we await the results in order to inform future practice. In those with an entrapped lung after drainage a debulking VATS visceral decortication (partial pleurectomy) may be considered. This may improve survival but is intended to improve quality of life by improving dyspnoea and removing the need for drainage. Whilst MCR of the pleura is the objective this may require resection of the lung parenchyma due to visceral pleural invasion. Wedge resection is often performed; lobectomy rarely and pneumonectomy is almost never required. Pleurectomy/decortication (PD) is the ideal outcome but in many cases an extended PD (EPD) is required due to pleural invasion of the muscle of the diaphragm. Every effort should be made to separate the diaphragmatic pleura from muscle but clearance should not be compromised nor should a potentially damaged and dysfunctional muscle be preserved. Total visceral pleurectomy is another potential area where clearance may be compromised as early disease is difficult to dissect from the underlying parenchyma. We advocate total pleurectomy since microscopic invasion may be present in macroscopically normal pleura and intraoperative frozen section analysis is unreliable. A systematic lymph node dissection is always performed to insure accurate staging. Together with the stations dissected in lung cancer, nodes in the internal mammary chain, pericardial, diaphragmatic and posterior intercostal nodes should be sampled. How radical surgery best fits into multimodality therapy remains to be determined. Radical hemithorax irradiation is promoted in the SMART protocol and attempts are being made to develop lung sparing protocols. The timing of systemic chemotherapy is still undetermined. Neoadjuvant chemotherapy does ensure that the patient receives all of the prescribed cycles since the recovery from radical surgery can compromise patient fitness and the ability to tolerate chemotherapy. However, as the response rates are under 50%, there is a risk that tumour progression may lead to unresectability. The use of intrapleural cytotoxic chemotherapy after radical resection has many proponents but is not universally used and lacks high grade supportive evidence. The MARS2 trial in the UK of EPD + chemotherapy vs. chemotherapy alone should complete the recruitment target of 326 patients by early 2020 and therefore report in 2022. Until then we should concentrate on standardizing the surgical technique and how we report intraoperative results and completeness of resection.

Size threshold for follow-up of postmenopausal adnexal cysts: 1cm versus 3cm.

To assess 3cm size threshold for follow-up of simple cysts in postmenopausal women. Radiology information system was retrospectively queried for "US pelvis complete" over 8years in women > 50years, with keywords ovarian cyst, adnexal cyst, ovarian mass, cystic mass, cystic neoplasm, ovarian neoplasm, and ovarian mass. Premenopausal women were excluded. Cysts, were classified as ≤ 1cm, 1-3cm, 3-5cm, and ≥ 7cm. Largest cysts on each ovary was recorded. EMR and imaging archives were reviewed for assessing size, stability duration, and surgical records. Descriptive statistics and confidence interval were performed. 4388 patients met the initial search criteria. 919 cysts in 896 women (age: 50-91years, mean: 61.5years) were identified. We found 162 cysts ≤ 1cm, 352 1-3cm, 296 3-7cm , and 51 ≥ 7cm cysts. 127 patients with 1-3cm cysts had no follow-up. Final analysis of 225 1-3cm cysts included 203 ovarian and 22 paraovarian cysts (average size = 1.95cm (1.1-3.0cm)). 103 ovarian cysts had less than 2years, and 100 cysts had more than 2years follow-up. All except one ovarian cyst were stable for the entire duration of their follow-up (Mean duration of follow-up 5.4years) (0.3%, 95% CI 0.0-0.05). 40 cysts resolved. One simple cyst increased in size (followed over 3.25years) without suspicious imaging features and benign on surgery. 1-3cm cysts represented the most common size range (> 40%) in postmenopausal women, majority of which are stable over follow-up with benign outcome. 3cm size threshold is appropriate for simple cyst follow-up in postmenopausal women.