Using texture analysis in the development of a potential radiomic signature for early identification of hepatic metastasis in colorectal cancer.

Background: Radiomics allows information not readily available to the naked eye to be extracted from high resolution imaging modalities such as CT. Identifying that a cancer has already metastasised at the time of presentation through a radiomic signature will affect the treatment pathway. The ability to recognise the existence of metastases earlier will have a significant impact on the survival outcomes. Aim: To create a novel radiomic signature using textural analysis in the evaluation of synchronous liver metastases in colorectal cancer. Methods: CT images at baseline and subsequent surveillance over a 5-year period of patients with colorectal cancer were processed using textural analysis software. Comparison was made between those patients who developed liver metastases and those that remained disease free to detect differences in the 'texture' of the liver. Results: A total of 24 patients were divided into two matched groups for comparison. Significant differences between the two groups scores when using the textural analysis programme were found on coarse filtration (p = 0.044). Patients that went on to develop metastases an average of 18 months after presentation had higher levels of hepatic heterogeneity on CT. Conclusion: This initial study demonstrates the potential of using a textural analysis programme to build a radiomic signature to predict the development of hepatic metastases in rectal cancer patients otherwise thought to have clear staging CT scans at time of presentation.

Furthering Precision in Sentinel Node Navigational Surgery for Oral Cancer: a Novel Triple Targeting System.

To describe an innovative sentinel lymph node (SLN) guidance approach using a radionuclide tracer, 3D augmented reality-guided imaging, and near infrared (NIR) fluorescence over-lay imaging with hand-held probes to optimize accuracy, efficiency, and precise navigation for sentinel node (SN) localization in head and neck cancer. In a cT1N0M0 squamous cell carcinoma of the tongue, pre-operative radionuclide lymphoscintigraphy was performed with a sentinel node-specific radiolabeled tracer. Intraoperatively, a 3D hand-held augmented reality (AR) scanning SPECT probe assessed concordance of the SN with pre-operative SPECT-CT images. The real-time optical video was linked to the SPECT-CT images for added precision. Final guidance to the SN was performed using ICG fluorescence imaging. Dynamic and SPECT-CT showed bilateral lymphatic drainage from the tumor. The 3D hand-held AR SPECT probe SN localization was concordant with pre-operative imaging. The optical video successfully demonstrated the lymphatic drainage in real-time through a unique overlay fluorescence image. The ICG localized to the same nodes identified by both the SPECT-CT and hand-held SPECT images. The use of dual radiation and fluorescence tracers improved SN detection, especially for SN close to the injection site. The hand-held probes allowed the surgeon to dissect continuously, without needing to change tools. The combination of augmented reality, nuclear medicine, and over-lay fluorescence imaging allowed greater accuracy for matching the preoperative imaging with intraoperative identification and precisely guiding the dissection. This method uniquely permitted the surgeon to efficiently dissect the SN with accurate visualization and optimal precision.

Colorectal cancer surgery in the very elderly patient: a systematic review of laparoscopic versus open colorectal resection.

INTRODUCTION: Colorectal cancer is the second most common cause of death from neoplastic disease in men and third in women of all ages. Globally, life expectancy is increasing, and consequently, an increasing number of operations are being performed on more elderly patients with the trend set to continue. Elderly patients are more likely to have cardiovascular and pulmonary comorbidities that are associated with increased peri-operative risk. They further tend to present with more locally advanced disease, more likely to obstruct or have disseminated disease. The aim of this review was to investigate the feasibility of laparoscopic colorectal resection in very elderly patients, and whether there are benefits over open surgery for colorectal cancer. METHODS: A systematic literature search was performed on Medline, Pubmed, Embase and Google Scholar. All comparative studies evaluating patients undergoing laparoscopic versus open surgery for colorectal cancer in the patients population over 85 were included. The primary outcomes were 30-day mortality and 30-day overall morbidity. Secondary outcomes were operating time, time to oral diet, number of retrieved lymph nodes, blood loss and 5-year survival. RESULTS: The search provided 1507 citations. Sixty-nine articles were retrieved for full text analysis, and only six retrospective studies met the inclusion criteria. Overall mortality for elective laparoscopic resection was 2.92% and morbidity 23%. No single study showed a significant difference between laparoscopic and open surgery for morbidity or mortality, but pooled data analysis demonstrated reduced morbidity in the laparoscopic group (p = 0.032). Patients undergoing laparoscopic surgery are more likely to have a shorter hospital stay and a shorter time to oral diet. CONCLUSION: Elective laparoscopic resection for colorectal cancer in the over 85 age group is feasible and safe and offers similar advantages over open surgery to those demonstrated in patients of younger ages.

Mentored Trainees have Similar Short-Term Outcomes to a Consultant Trainer Following Laparoscopic Colorectal Resection.

BACKGROUND: Laparoscopic colorectal surgery has a long learning curve. Using a modular-based training programme may shorten this. Concerns with laparoscopic surgery have been oncological compromise and poor surgical outcomes when training more junior surgeons. This study aimed to compare operative and oncological outcomes between trainees undergoing a mentored training programme and a consultant trainer. METHODS: A prospective study of all elective laparoscopic colorectal resections was undertaken in a single institution. Operative and oncological outcomes were recorded. All trainees were mentored by a National Laparoscopic Trainer (Lapco), and results between trainer and trainees compared. RESULTS: Three hundred cases were included, with 198 (66%) performed for cancer. The trainer undertook 199 (66%) of operations, whilst trainees performed 101 (34%). Anterior resection was the commonest operation (n = 124, 41%). There were no differences between trainer and trainees for the majority of surgical outcomes, including blood loss (p = 0.598), conversion to open (p = 0.113), anastomotic leak (p = 0.263), readmission (p = 1.000) and death rates (p = 0.549). Only length of stay (p = 0.034), stoma formation (p < 0.01) and operative duration (p = 0.007) were higher in the trainer cohort, reflecting the more complex cases undertaken. Overall, there were no significant differences in both short- and longer-term oncology outcomes according to the grade of operating surgeon, including lymph nodes in specimen, circumferential resection margin and 1- and 2-year radiological recurrence. CONCLUSION: When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.

An unusual case of abdominal distension: pneumoperitoneum secondary to pneumomediastinum in a patient with chronic obstructive pulmonary disease.

A 68-year-old lady with end-stage chronic obstructive pulmonary disease presented with vomiting and abdominal pain. On examination her abdomen was grossly distended, diffusely tender and hyper-resonant. Imaging showed dilated loops of bowel and free air in the abdomen with no intestinal perforation. The free abdominal air had come down from the thorax by dissecting down around the oesophagus. A pneumomediastinum was present in her chest, secondary to her extensive emphysematous disease. She was treated conservatively and her pneumomediastinum resolved several weeks later, with subsequent resumption of intestinal motility and return to premorbid function. Surgical intervention would not have helped her condition.

Measurement of frontal lobe functional activation and related systemic effects: a near-infrared spectroscopy investigation.

Near-infrared spectroscopy (NIRS) has been used to measure changes in cerebral oxy- and deoxy- haemoglobin (delta[HbO2], delta[HHb]) in response to functional activation. It has been previously reported that during functional activation of the motor cortex heart rate increases. The aim of this study was to investigate systemic changes during functional activation of the frontal cortex. The responses to anagram presentations with varying difficulty (4-Letters and 7-Letters) over a 6 minute period were recorded. A Hamamatsu NIRO 200 NIRS system recorded delta[HbO2] and delta[HHb] using the modified Beer Lambert law (MBL) and tissue oxygenation index (TOI) employing spatial resolved spectroscopy (SRS) over the left and right frontal hemisphere. Mean blood pressure (MBP) and heart rate (HR) were measured continuously. Nine young healthy volunteers (mean age 23) were included in the analysis. Significant task related changes were observed in both the NIRS and systemic signals during the anagram solving with increases in [HbO2] and [HHb] accompanied by changes in MBP and HR. The [HbO2] and [HHb] signals measured over the frontal region were found to have a varying association with the MBP signal across different volunteers. The effect of these systemic changes on measured NIRS signals must be considered