Cost-effective Solution for Maxillofacial Reconstruction Surgery with Virtual Surgical Planning and 3D Printed Cutting Guides Reduces Operative Time.

Background: This study aimed to explore a low-cost solution for virtual surgical planning/3D printed surgical guides in a training hospital, assessing the impact on intraoperative time and bleeding. Material and Methods: We included a total of 13 patients. 8 who underwent maxillofacial reconstruction surgery with fibula-free flap utilizing virtual surgical planning/3D printed guides (VP/SG), and 5 using conventional surgery (CS) from 2017 to 2020. The surgical time, bleeding, length of hospital stay, and comorbidities were collected and compared in two groups. We recorded the average cost for the complete surgical planning and 3D printed guides. We applied a qualitative survey to the surgeons involved in the surgical procedures. Results The mean surgical time in the VP/SG group was 8.16 ± 2.7, compared to the CS group 12.5 ± 3.8, showing a 4.34 hours difference with statistical significance (p = 0.033). Patients from the CS group had a higher bleeding volume of 921 ± 467.6 mL VS 760 ± 633.8 mL in the VP/SG group. The average cost for the complete surgical planning and 3D printed guides was 914.44 ± 46.39 USD. All the surgeons who answered the survey preferred to perform the procedure utilizing the virtual planning/3D printed guides. Conclusions Virtual planning and 3D printed surgical guides have the potential to reduce operation time in maxillofacial reconstruction.

Contexte : Cette étude visait à explorer une solution peu coûteuse pour la planification chirurgicale virtuelle/l'impression 3D de guides chirurgicaux dans un hôpital d'enseignement, en évaluant leur impact sur le temps peropératoire et le saignement. Matériel et méthodes : Nous avons inclus un total de 13 patients; 8 patients ont subi une chirurgie de reconstruction faciale avec lambeau libre de péroné (fibula) utilisant une planification chirurgicale virtuelle/des guides imprimés en 3D (VP/SG) et 5 patients ont subi une chirurgie conventionnelle (CS) entre 2017 et 2020. Le temps opératoire, le saignement, la durée de l'hospitalisation et les comorbidités ont été consignés et comparés entre les deux groupes. Nous avons enregistré le coût moyen pour la planification chirurgicale complète et les guides imprimés en 3D. Nous avons appliqué une enquête qualitative aux chirurgiens impliqués dans les procédures chirurgicales. Résultats : Le temps opératoire moyen dans le groupe VP/SG a été de 8,16 ± 2,7, comparativement à 12,5 ± 3,8 dans le groupe CS, soit une différence de 4,4 heures avec une signification statistique (P = 0033). Des patients du groupe CS ont perdu un plus grand volume de sang que les patients du groupe VP/SG (respectivement, 921 ± 467.6 mL contre 760 ± 633.8 mL). Le coût moyen de la planification chirurgicale complète et des guides imprimés en 3D a été de 914,44 ± 46,39 US$. Tous les chirurgiens ayant répondu à l'enquête ont préféré utiliser la planification virtuelle/les guides imprimés en 3D pour la réalisation de la procédure. Conclusions : La planification virtuelle et les guides chirurgicaux imprimés en 3D ont le potentiel de réduire les temps opératoires pour la reconstruction maxillo-faciale.

Development and Evaluation of An In-House Lumbar Puncture Simulator for First-Year Resident Lumbar Puncture Procedure Learning.

INTRODUCTION: Lumbar puncture (LP) is a common invasive technique considered an essential learning milestone for anesthesiologists due to its application in spinal anesthesia. We aimed to develop an in-house LP simulator, test its effectiveness in learning the steps to perform an LP and analyze its impact on the first-year residents' self-confidence at our hospital. METHODS:  We used 3D printing and silicone casting to create an LP simulator based on a lumbar spine computed tomography (CT). We divided 12 first-year anesthesiology residents into control and experimental groups. The control group received traditional training, while the experimental group practiced with the simulator for three months. We used a procedure checklist and a Likert scale survey to evaluate their procedural knowledge and self-confidence at baseline, three, and six months. Eighteen months later, we evaluated their LP performance skills. RESULTS: Both groups showed a significant improvement in their knowledge scores over time. After three months, the experimental group had a higher median knowledge score (10 (10 - 10) median (min-max)) than the control group (9 (8 - 9.5) median (min-max)) (p = 0.03). While there were no apparent differences in median self-confidence scores between the groups at any time point, the experimental group had a significant increase in their self-confidence for performing an unassisted LP, with a median score of 1/5 (1 - 2.3) at baseline and 5/5 (4.8 - 5) after six months (p = 0.006). In contrast, the control group's self-confidence scores decreased from 4/5 (3 - 4) after three months to 3/5 (2 - 5) after six months. The evaluation of performance skills did not yield statistically significant results. CONCLUSION: Our study demonstrates that an in-house LP simulator is an effective and practical approach for first-year anesthesiology residents to learn the LP procedure. This approach could be particularly useful in settings with limited resources and a lack of sufficient patients to practice on, as it provides an opportunity for faster learning and increased self-confidence.

Clinical-radiomic model in advanced kidney cancer predicts response to tyrosine kinase inhibitors.

Renal cancer has a global incidence and mortality of 2.2 and 1.8%, respectively. Up to 30% of these patients are intrinsically resistant to tyrosine kinase inhibitors (TKI). The National Comprehensive Cancer Network guidelines do not include any predictive factors regarding response to systemic therapy with TKI in recurrent and advanced diseases. The present study aimed to explore whether a model based on radiomics could predict treatment response in patients with advanced kidney cancer treated with TKIs. The current study included 62 patients with advanced kidney cancer (stages 3 and 4) that underwent a CT scan in the arterial phase from March 2016 to November 2020. Texture analysis was run on the largest cross-sectional area of the primary tumor from each CT scan. A total of three different models were built from radiomics features and clinical data to analyze them by logistic regression and determine whether they correlated with the response to TKI. A receiver operating characteristic curve analysis was performed in each model to calculate the area under the curve (AUC) and the 95% confidence interval (CI). Significant radiomics features and clinical variables were identified and then a clinical model was created (AUC=0.90; sensitivity 75%; specificity 82.35%; CI 95%, 0.78-1.00), a radiomic model (AUC=0.66; sensitivity 16.67%; specificity 89.47%, CI 95%, 0.45-0.87) and a combined model (AUC=0.94; sensitivity 83.33%; specificity 94.12%; CI 95%, 0.84-1.00). Overall, models based on clinical data and radiomics could anticipate response to systemic therapy with TKI in patients with advanced kidney cancer.

Oxaliplatin related multiple focal nodular hyperplasia mimicking metastasis from a gastric cancer.

INTRODUCTION: The FOLFOX6 scheme is a combination drug chemotherapy that contains calcium leucovorin (folinic acid), fluorouracil, and oxaliplatin, the chronic use of chemotherapy with oxaliplatin can progress to focal nodular hyperplasia (FNH), which is a benign hepatic lesion. CASE REPORT: We present a case of a 26- year-old female diagnosed with an ovarian mixed germ cell tumor with extension to the peritoneum, treated with 12 cycles in 9 months with neoadjuvant chemotherapy FOLFOX 6 scheme and oophorectomy. A three-year follow-up CT showed three nodular and hypervascular hepatic lesions suspicious of metastatic disease; an MRI with liver-specific contrast confirmed the diagnosis of FNH. MANAGEMENT AND OUTCOME: The patient continued her follow-up without other treatment and metastatic disease. DISCUSSION: While most multiple liver lesions in a patient with cancer will be suspicious of metastasis, a careful drug history should be obtained, as an oxaliplatin-related side effect to develop FNH has been reported. MRI with liver-specific contrast has a positive predictive value of 95% because of the biliary excretion through OATP1B3 transporter, expressed in functional hepatocytes and overexpressed in some liver tumors such as FNH, so it should be performed when FNH is suspected.

3D-printed anatomical models of the cystic duct and its variants, a low-cost solution for an in-house built simulator for laparoscopic surgery training.

OBJECTIVES: To explore a method to create affordable anatomical models of the biliary tree that are adequate for training laparoscopic cholecystectomy with an in-house built simulator. METHODS: We used a fused deposition modeling 3D printer to create molds of Acrylonitrile Butadiene Styrene (ABS) from Digital Imaging and Communication on Medicine (DICOM) images, and the molds were filled with silicone rubber. Thirteen surgeons with 4-5-year experience in the procedure evaluated the molds using a low-cost in-house built simulator utilizing a 5-point Likert-type scale. RESULTS: Molds produced through this method had a consistent anatomical appearance and overall realism that evaluators agreed or definitely agreed (4.5/5). Evaluators agreed on recommending the mold for resident surgical training. CONCLUSIONS: 3D-printed molds created through this method can be applied to create affordable high-quality educational anatomical models of the biliary tree for training laparoscopic cholecystectomy.

Recurrent renal cell carcinoma to the breast and thigh soft tissues. A case report and review of the literature.

The breast seldom harbors secondary malignant lesions and is rarer for the kidney to be the origin of the metastatic lesion. Keen Imaging analysis, as well as a high index of suspicion, are critical to differentiate a primary tumor from a metastatic lesion. We describe an unusual case of a recurrent RCC presenting as metastatic lesions to the breast and soft tissue of the right thigh in a 51-year-old patient referred to our breast-imaging unit 10 months after therapeutic surgery. An adequate and close follow-up accompanied by a thorough physical exam and appropriate imaging methods is essential to identify these types of cases.

Radiomics Texture Features in Advanced Colorectal Cancer: Correlation with BRAF Mutation and 5-year Overall Survival.

Purpose: To explore the potential of radiomics texture features as potential biomarkers to enable detection of the presence of BRAF mutation and prediction of 5-year overall survival (OS) in stage IV colorectal cancer (CRC). Materials and Methods: In this retrospective study, a total of 145 patients (mean age, 61 years ± 14 [standard deviation {SD}]; 68 female patients and 77 male patients) with stage IV CRC who underwent molecular profiling and pretreatment contrast material-enhanced CT scans between 2004 and 2018 were included. Tumor radiomics texture features, including the mean, the SD, the mean value of positive pixels (MPP), skewness, kurtosis, and entropy, were extracted from regions of interest on CT images after applying three Laplacian-of-Gaussian filters known as spatial scaling factors (SSFs) (SSF = 2, fine; SSF = 4, medium; SSF = 6, coarse) by using specialized software; values of these parameters were also obtained without filtration (SSF = 0). The Wilcoxon rank sum test was used to assess differences between mutated versus wild-type BRAF tumors. Associations between radiomics texture features and 5-year OS were determined by using Kaplan-Meier estimators using the log-rank test and multivariate Cox proportional-hazards regression analysis. Results: The SDs and MPPs of radiomic texture features were significantly lower in BRAF mutant tumors than in wild-type BRAF tumors at SSFs of 0, 4, and 6 (P = .006, P = .007, and P = .005, respectively). Patients with skewness less than or equal to -0.75 at an SSF of 0 and a mean of greater than or equal to 17.76 at an SSF of 2 showed better 5-year OS (hazard ratio [HR], 0.53 [95% confidence interval {CI}: 0.29, 0.94]; HR, 0.40 [95% CI: 0.22, 0.71]; log-rank P = .025 and P = .002, respectively). Tumor location (right colon vs left colon vs rectum) had no significant impact on the clinical outcome (log-rank P = .53). Conclusion: Radiomics texture features can serve as potential biomarkers for determining BRAF mutation status and as predictors of 5-year OS in patients with advanced-stage CRC.Keywords: Abdomen/GI, CT, Comparative Studies, Large BowelSupplemental material is available for this article.© RSNA, 2020.

Main Pancreatic Duct to Parenchymal Thickness Ratio at Preoperative Imaging is Associated with Overall Survival in Upfront Resected Pancreatic Cancer.

BACKGROUND: Pancreatic cancer induces parenchymal atrophy and duct dilation. The aim of this study was to evaluate whether these radiologic modifications are associated with outcomes. METHODS: Upfront pancreaticoduodenectomy patients with available preoperative contrast enhanced CT scan imaging were retrospectively analyzed. Thickness of the pancreas, size of the main pancreatic duct (MPD), and distance of the tumor from the ampulla were assessed. A training cohort was selected, including short- (3-12 months following surgery) and long-term (≥ 36 months) survivors. Identified survival determinants were validated in the overall cohort. RESULTS: Two-hundred-sixteen patients were analyzed. In the training cohort (N = 118), 68 patients (57.6%) were in the short-term and 50 (42.4%) in the long-term survival group. The short-term survival group had significantly higher CA 19-9 levels (p = 0.027), larger tumors (32.6 ± 12.1 mm vs. 26.5 ± 11.6 mm, p = 0.007), poorer differentiation (p = 0.003), higher rate of R < 1 mm resections (54% vs. 32%, p = 0.008), and reduced receipt of adjuvant chemotherapy (p = 0.020). The MPD-to-pancreatic thickness ratio was significantly lower in the short-term survivors (3.6 ± 6.2 vs. 8.2 ± 12.0, p = 0.016). In the entire cohort, an MPD-to-pancreatic thickness ratio ≥ 3.5 was associated with improved OS [median 33.0 months IQR (19.7-48.1) versus 17 months IQR (14.8-19.2), p = 0.004], and confirmed by a Cox-proportional hazards model independently associated with OS (HR = 0.58; p = 0.009), together with tumor size (HR = 1.02; p =0.012), R1/R2 status (HR = 1.53; p = 0.029), and receipt of adjuvant treatment (HR = 0.61; p = 0.021). CONCLUSIONS: High MPD-to-pancreatic thickness ratio was associated with improved long-term survival in pancreaticoduodenectomy for cancer. Whether these features are related to tumor chronicity, indolent biology, or local growth over metastasis remains to be determined.

Acute appendicitis in Amyand's hernia: ultrasound findings and histopathology correlation. A case report.

Amyand's hernia is an uncommon form of inguinal hernia. It represents <1% of all hernias and its complication with appendicitis is still rarer with 0.1-0.13% being reported. A 78-year-old woman was taken to the emergency room with pain in the right groin. The patient was assessed by ultrasound with the clinical suspicion of an inguinal hernia. We present the ultrasonographic features of appendicitis within an inguinal hernia sac. A tubular image that terminated in a blind-ended tip in the longitudinal plane and a target image on the cross-sectional plane were consistent with the sonographically demonstrated appendix. The diagnosis of Amyand's hernia is difficult in the clinical setting. The patient is frequently referred to surgery with the diagnosis of an incarcerated hernia. Ultrasound is a good imaging modality that detects and characterizes this uncommon condition.

Low-keV and Low-kVp CT for Positive Oral Contrast Media in Patients with Cancer: A Randomized Clinical Trial.

Background Substantial gain in the attenuation of iodine on low-kVp and dual-energy CT processed low-keV virtual monochromatic images provides an opportunity for customization of positive oral contrast media administration. Purpose To perform an intrapatient comparison of bowel labeling, opacification, and taste preference with iodinated oral contrast medium (ICM) in standard (sICM) and 25%-reduced (rICM) concentrations at low tube voltage (100 kVp) or on low-energy (50-70 keV) virtual monochromatic images compared with barium-based oral contrast medium (BCM) at 120 kVp. Materials and Methods In this prospective clinical trial, 200 adults (97 men, 103 women; mean age, 63 years ± 13 [standard deviation]) who weighed less than 113 kg and who were undergoing oncologic surveillance (from April 2017 to July 2018) and who had previously undergone 120-kVp abdominopelvic CT with BCM randomly received sICM (7.2 g iodine) or rICM (5.4 g iodine) and underwent 100-kVp CT or dual-energy CT (80/140 kVp) scans to be in one of four groups (n = 50 each): sICM/100 kVp, rICM/100 kVp, sICM/dual-energy CT, and rICM/dual-energy CT. Qualitative analysis was performed for image quality (with a five-point scale), extent of bowel labeling, and homogeneity of opacification (with a four-point scale). Intraluminal attenuation of opacified small bowel was measured. A post-CT patient survey was performed to indicate contrast medium preference, taste of ICM (with a five-point scale), and adverse effects. Data were analyzed with analogs of analysis of variance. Results All CT studies were of diagnostic image quality (3.4 ± 0.3), with no difference in the degree of bowel opacification between sICM and rICM (P > .05). Compared with BCM/120 kVp (282 HU ± 73), mean attenuation was 78% higher with sICM/100 kVp (459 HU ± 282) and 26%-121% higher at sICM/50-65 keV (50 keV = 626 HU ± 285; 65 keV = 356 HU ± 171). With rICM, attenuation was 46% higher for 100 kVp (385 HU ± 215) and 19%-108% higher for 50-65 keV (50 keV = 567 HU ± 270; 65 keV = 325 HU ± 156) compared with BCM (P < .05). A total of 171 of 200 study participants preferred ICM to BCM, with no taste differences between sICM and rICM (3.9 ± 0.6). Fifteen participants had diarrhea with BCM, but none had diarrhea with ICM. Conclusion A 25%-reduced concentration of iodinated oral contrast medium resulted in acceptable bowel labeling while yielding substantially higher luminal attenuation at low-kVp and low-keV CT examinations with improved preference in patients undergoing treatment for cancer. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Laghi in this issue.

Diabetes mellitus in intraductal papillary mucinous neoplasm of the pancreas is associated with high-grade dysplasia and invasive carcinoma.

BACKGROUND: While the association between Diabetes Mellitus (DM) and pancreatic ductal adenocarcinoma is well recognized, its importance in intraductal papillary mucinous neoplasm of the pancreas (IPMN) is not well-defined. We sought to examine the associations of DM with degree of dysplasia and morphological subtypes in IPMN. METHODS: In 454 patients with resected IPMN, we evaluated associations of DM with high-grade dysplasia (HGD), invasive carcinoma, precursor epithelial subtype (gastric, intestinal, oncocytic, pancreatobiliary), and histological type of invasive carcinomas (tubular, colloid, oncocytic) using logistic regression. We performed multivariate analyses adjusting for worrisome features and high-risk stigmata of malignancy in a subset of 289 patients with annotated radiological characteristics. RESULTS: The prevalence of DM in our study was 34%. DM was significantly associated with HGD (OR 2.02, 95% CI 1.02-4.01, P = 0.045) and invasive carcinoma (OR 2.05, 95% CI 1.08-3.87, P = 0.027) after adjusting for worrisome features. Compared to patients without DM, those with recent-onset DM (≤5 years before surgery) had 6.9-fold (95% CI 2.38-19.92, P < 0.001) higher risk of invasive carcinoma. DM was associated with increased likelihood of intestinal-type precursor epithelium (OR 1.63, 95% CI 1.07-2.47, P = 0.022) and colloid carcinomas (OR 2.46, 95% CI 1.01-5.99, P = 0.047) CONCLUSION: Preoperative DM was associated with significantly higher risk of HGD and invasive carcinoma in resected IPMN, and risk of invasive carcinoma was highest in patients with recent-onset DM. Patients with DM were more likely to harbor intestinal-type IPMN and colloid carcinomas. Our findings suggest that a diagnosis of DM in patients with IPMN may warrant more aggressive surveillance.

An age- and gender-related three-dimensional analysis of rotator cuff transverse force couple volume ratio in 304 shoulders.

PURPOSE: The rotator cuff transverse force couple (RCTFC) is fundamental in the shoulder biomechanics, as the balance of its muscle components (the subscapularis relative to the infraspinatus and teres minor) provides stability to the joint. The chronic progression of rotator cuff tears usually present alterations in muscle volume, along with atrophy and compensatory hypertrophy, which can be determined using imaging techniques. The aim of this study was to quantify RCTFC muscle volume in a large sample taking into account the age and gender of the participants involved. METHODS: An observational, retrospective, cross-sectional, descriptive and comparative study was conducted, evaluating thoracic computed tomography scans from 152 patients (304 shoulders) of indistinct gender, with ages ranging between 18 and 85 years. The RCTFC muscle volume was quantified with an oblique/multiplanar segmentation technique. Measuring time was also documented. RESULTS: We observed that muscle volume decreases among the different age (p < 0.04) and gender (p < 0.001) groups. However, the RCTFC volume ratio remained constant at 1.02 ± 0.18 without significant differences throughout all age and gender groups evaluated (p > 0.298). CONCLUSION: The decrease in the RCTFC muscle volume is proportional during the different stages of life, maintaining a constant ratio between its components (physiological RCTFC muscle atrophy). The time-saving segmentation method and volume ratio formula proposed in this study contribute to the management and understanding of rotator cuff tear/pathology.

Efficacy of computed tomography for the prediction of colectomy and mortality in patients with clostridium difficile infection.

AIM: To develop a CT predictor scale for the need for colectomy and to evaluate predictors of all-cause mortality within 30 days after diagnosis ofC. difficile infection (CDI). METHODS: We conducted a retrospective study of adult hospitalized patients whounderwent abdominal CT within 72 h of diagnosis of CDI. RESULTS: Presence of abnormal wall thickening in caecum (OR 8.0; CI 1.37-46.81; p = 0.021), transverse colon (OR 6.7; CI 1.15-35.60; p = 0.034), sigmoid colon (OR 12.6; CI 1.37-115.97; p = 0.025), pancolitis (OR 7.0; CI 1.36-36.01; p = 0.02) and bowel dilation (OR 16.5; CI 2.41-112.83; p = 0.004) predicted colectomy. With these values, a five parameter radiological scale from 0 to 24 was developed (sensitivity and NPV of 100%, cut-off of 6). Furthermore, wall thickening of caecum (OR 6.2; CI 1.06-35.57; p = 0.043), ascending colon (OR 12.0; CI 1.29-111.32; p = 0.029), descending colon (OR 17.0; CI 1.81-160.05; p = 0.013) and sigmoid (OR 10.2; CI 1.10-94.10; p = 0.041) independently predicted mortality within 30 days of CDI diagnosis. CONCLUSION: We designed a CT scale to predict colectomy, able to rule out the development of fulminant colitis and the need for surgical procedure. Patients with wall thickening of the caecum, ascending, descending or sigmoid colon were more likely to die within 30 days of CDI diagnosis.