Correlation of Preoperative Radiological Factors with Histological Involvement of Thyroid Gland in Laryngeal Carcinomas.

Total laryngectomy is the primary treatment for locally advanced laryngeal carcinomas. However, routine thyroid removal (total or hemithyroidectomy) during this procedure is controversial, as the incidence of thyroid gland involvement varies and may lead to lifelong thyroid supplementation, increasing postoperative morbidity. The lack of a consensus on managing the thyroid gland in laryngeal carcinoma cases necessitates improved evaluation techniques, with radiology playing a crucial role in this aspect. Understanding the correlation between radiological factors and histopathological involvement of the thyroid gland can aid in formulating appropriate management strategies during total laryngectomy. To study the correlation of preoperative radiological factors with histopathological involvement of thyroid gland in laryngeal carcinomas. This was a retrospective study which included 57 patients who underwent total laryngectomy for squamous cell carcinoma of larynx. The pre-operative CT findings such as involvement of thyroid cartilage, cricoid cartilage, paraglottic space, anterior commissure, subglottis and thyroid gland along with transglottic extension of tumor were correlated with post-operative histopathological thyroid gland involvement. Cricoid cartilage erosion and thyroid gland involvement in CT scans individually exhibited positive likelihood ratios of 2.58 and 3.23, respectively, demonstrating a reasonable agreement with histopathological findings. The specificity of cricoid cartilage and thyroid gland involvement was also higher with values of 76.4% and 81%, respectively. Moreover, combining thyroid and cricoid cartilage erosion in CT scans as a predictive parameter for thyroid gland involvement resulted in a better likelihood ratio of 8.23 and a fair agreement with histopathological findings. We conclude that cricoid cartilage erosion and thyroid gland involvement in pre-operative CECT can be taken as a preoperative indicator for intraoperative decision on thyroidectomy.

Radiological parameters to predict pancreatic texture: Current evidence and future perspectives.

Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management, thereby minimizing postoperative morbidity. Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease. However, radiological evaluation of pancreatic texture, an important determinant of pancreatic fistula, has not been widely used to predict the risk of postoperative pancreatic fistula. Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture. Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies. With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies, elastography is emerging as a promising tool for predicting pancreatic texture. Also, recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function. Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis, facilitating early intervention. The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences. However, multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.

Evaluation of Acoustic Radiation Force Impulse Imaging in Differentiating Benign and Malignant Cervical Lymphadenopathy.

Background: The aim of this study was to assess the diagnostic role of acoustic radiation force impulse imaging (ARFI) in differentiating benign and malignant cervical nodes. Methods: This was a diagnostic accuracy cross-sectional study. All patients who underwent ultrasound-guided fine-needle aspiration cytology (FNAC) of cervical nodes were included. Patients without FNAC/biopsy and patients in whom cervical nodes were cystic or completely necrotic were excluded. FNAC was used as reference investigation to predict the diagnostic accuracy. In all cases, FNAC was carried out after the B-mode, color Doppler and the ARFI imaging. In patients with multiple cervical lymph nodes, the most suspicious node based on grayscale findings was chosen for ARFI. ARFI included Virtual Touch imaging (VTI), area ratio (AR), and shear wave velocity (SWV) for each node, and the results were compared with FNAC/biopsy. Results: The final analysis included 166 patients. Dark VTI elastograms had sensitivity and specificity of 86.2% and 72.1%, respectively, in identifying malignant nodes. Sensitivity and specificity of AR were 71.3% and 82.3%, respectively, for a cutoff of 1.155. Median SWV of benign and malignant nodes was 1.9 [95% confidence interval (CI), 1.56-2.55] m/s and 6.7 (95% CI, 2.87-9.10) m/s, respectively. SWV >2.68 m/s helped in identifying malignant nodes with 81% specificity, 81.6% sensitivity, and 81.3% accuracy. ARFI was found to be inaccurate in tuberculous and lymphomatous nodes. Conclusion: Malignant nodes had significantly darker elastograms, higher AR and SWV compared to benign nodes, and SWV was the most accurate parameter. ARFI accurately identifies malignant nodes, hence could potentially avoid unwarranted biopsy.

Liver Abnormalities in Systemic Lupus Erythematosus: A Prospective Observational Study.

Objectives In this study, we aimed to examine and analyze liver abnormalities among patients with systemic lupus erythematosus (SLE), including both newly diagnosed patients and those being followed up, as well as the prevalence of lupus hepatitis. Methods This was a prospective observational study. Clinical data, liver function tests (LFTs), and the findings from the ultrasonography of the abdomen among the patients were prospectively recorded and evaluated. Results Overall, 28 of the total 135 (20.7%) patients had liver abnormalities, including biochemical and those detected via ultrasonography. Ten patients had transaminitis, defined as aspartate aminotransferase (AST) or alanine aminotransferase (ALT) levels >2 times the upper limit of normal (ULN). Nine patients had elevated alkaline phosphatase (ALP) or gamma-glutamyl transferase (GGT) of >2 times ULN. In three patients, transaminitis was due to anti-tubercular therapy (ATT)-induced hepatitis; in seven (5.2%), no specific cause for transaminitis could be identified, and hence they were classified as cases of lupus hepatitis. On comparing clinical features between patients with (n=7) and without lupus hepatitis (n=128), the condition was more prevalent in newly diagnosed SLE patients compared to those who had been on follow-up [six (85.7%) vs. 30 (23.6%), p=0.002]. All seven patients with lupus hepatitis had complete resolution of the transaminitis on follow-ups. However, one patient who had received ATT (isoniazid, rifampicin, ethambutol, and pyrazinamide) died. Ultrasonography showed fatty liver in seven patients and chronic liver disease in one patient. Conclusion In this study, transaminitis due to lupus hepatitis was seen in newly diagnosed lupus patients and was not associated with disease activity. Before diagnosing lupus hepatitis, drug-induced liver disease has to be ruled out, and if persistent LFT abnormalities are present, further workup is suggested to rule out overlap with primary biliary cirrhosis and/or autoimmune hepatitis.

Acute kidney injury in patients hospitalized with febrile urinary tract infections: A prospective observational study.

BACKGROUND: Febrile urinary tract infection (fUTI) can be associated with acute kidney injury (AKI). We aimed to study the risk factors for AKI, its pathophysiological categories, and the role of urinary neutrophil gelatinase-associated lipocalin (uNGAL) in differentiating these categories in patients hospitalized with fUTI. MATERIALS AND METHODS: We prospectively studied patients with fUTI admitted to the Department of Medicine of a tertiary care hospital in southern India from January 2017 to December 2018. Clinical evaluation, renal imaging, and estimation of fractional excretion of sodium (FeNa) and uNGAL were done at baseline. AKI was defined as ≥ 0.3 mg/dL rise in serum creatinine (SCr) within 48 hours during hospital stay (KDIGO criterion) or discharge SCr value 0.5 mg/dL or less compared to peak SCr after admission. RESULTS: We studied 100 patients. Their mean age was 52 (± 14) years; 45 were men. In all, 52 had AKI: pre-renal in 11 (21%), intrinsic renal in 24 (47%), post-renal in 16 (31%), and missing data 1 patient. uNGAL levels were significantly higher in the AKI group compared to the no-AKI group (median [IQR] 91.1 [13.2 - 188] vs. 264.9 [115.2 - 355.2] ng/mL; p < 0.001). On multivariable analysis, male sex (adjusted odds ratio, aOR [95% CI] 2.8 [1.09 - 7.14]), hypertension (4.12 [1.24 - 13.7]) and hydroureteronephrosis (7.82 [1.55 - 39.4]) were independently associated with AKI. There was an increasing trend of uNGAL across the three categories of AKI (pre-renal 106.1 [14.6 - 261.7] ng/mL, intrinsic renal 210.8 [8.5 - 353.8] ng/mL, and post-renal 335.5 [269.2 - 692.8] ng/mL; p = 0.001). Patients with pre-renal AKI had significantly lower levels of uNGAL compared to the other two categories combined (106.1 [14.6 - 261.7] vs. 284.6 [179 - 434.4] ng/mL; p = 0.016). CONCLUSION: Hospitalized fUTI patients should be evaluated for AKI, and obstructive uropathy should be ruled out in those with AKI. uNGAL levels may help in differentiating the pre-renal type of AKI from the other two categories.

Association of plasma docetaxel levels with ABCB1 gene polymorphisms and tumour response in locally advanced breast cancer patients of South India on neo-adjuvant chemotherapy.

BACKGROUND: Genetic factors could be attributed to the variability in docetaxel plasma levels and its subsequent therapeutic response. The objectives of this study were to assess the effect of ABCB1 gene polymorphisms [SNPs rs1045642 (C3435T) and rs1128503 (C1236T)] on docetaxel plasma levels and also to analyze the influence of docetaxel plasma levels on tumour response in the ethnically distinct South Indian population. METHODS: 104 locally advanced breast cancer (LABC) patients on docetaxel-based neo-adjuvant chemotherapy (NACT) were included. The plasma docetaxel levels were estimated using the validated reverse phase liquid chromatography with mass spectrometry (LC-MS/MS). DNA was extracted (phenol-chloroform extraction method) and the real-time PCR system using validated TaqMan® SNP genotyping assay method was used for genotyping. Tumour response was assessed by RECIST criteria based on the MRI images. RESULTS: Patients with "CT/TT" genotype of the SNP C1236T had a C0/Ct ratio of 1.6 times higher than those with "CC" genotype (13.5 ± 6.5 vs 8.3 ± 3.1, p = 0.002). Though not significant, patients with "CT/TT" genotype had greater initial plasma concentration (C0) and area under the plasma concentration-time curve (AUC0-t). Conversely, the SNP C3435T was not associated with the plasma docetaxel levels. Furthermore, the C0 and normalized C0 were found to be higher in tumour responders compared to non-responders (p < 0.05). CONCLUSIONS: The plasma levels of docetaxel were significantly influenced by the SNP C1236T of ABCB1 gene coding for the MDR1 transporter (P-glycoprotein). The plasma levels of docetaxel were also found to influence its therapeutic effect.

Evaluation of B-Mode and Color Doppler Ultrasound in the Diagnosis of Malignant Cervical Lymphadenopathy.

Background B-mode ultrasound (BMUS) and color doppler ultrasound (CDUS) could be valuable in evaluating cervical lymphadenopathy compared to palpation. This study aimed at evaluating the efficacy of BMUS and CDUS in differentiating cervical lymph nodes into benign and malignant nature.  Methodology In this cross-sectional analytical study, a total of 166 patients, who were referred for US-guided fine-needle aspiration cytology (FNAC) of cervical nodes, were included. Patients with cystic/ necrotic cervical nodes or without FNAC/biopsy report were excluded. All study patients underwent BMUS and CDUS, followed by the reference investigation of FNAC/biopsy for analysis. In BMUS, short-axis diameter (SAD), short-axis/long-axis diameter ratio (S/L), presence or absence of echogenic hilum and well defined or ill-defined borders were analyzed. In CDUS, the vascular pattern of a cervical node was categorized as hilar, peripheral or mixed. In cases with multiple cervical lymph nodes, the node having the most suspicious features on the greyscale US was chosen. The results were compared with the final FNAC/biopsy reports. Results A total of 166 patients were analyzed in this study. The cut-off point of SAD and S/L ratio for the cervical lymph nodes was 1.28cm and 0.595. The S/L ratio was the best BMUS parameter with a sensitivity of 75%, the specificity of 81%, and an accuracy of 79%. Loss of echogenic hilum was the most sensitive parameter in this study with a sensitivity of 95.4% and an accuracy of 79.5%. The presence of ill-defined margins was significantly higher in the malignant nodes than the benign nodes with a p-value <0.001. The presence of peripheral/mixed vascularity was higher in the malignant nodes than the benign nodes with a p-value <0.001. Conclusions Malignant nodes had significantly higher SAD, higher S/L ratio, loss of echogenic hilum, presence of ill-defined margins and peripheral/mixed vascularity compared to benign nodes. The loss of echogenic hilum was the most accurate and sensitive parameter, while the S/L ratio was found to be the most specific BMUS parameter in the detection of malignant nodes. BMUS and CDUS identify malignant nodes and also helps in guiding FNAC/biopsy.

Diagnostic role of shear wave elastography for differentiating benign and malignant breast masses.

BACKGROUND: Use of B-mode ultrasound (US) may not obviate the need for diagnosis by histopathology, which is an invasive technique and remains the gold standard. These limitations are being overcome with the advent of shear wave elastography (SWE). OBJECTIVES: To assess the diagnostic role of SWE parameters and combined SWE and B-mode US in diagnosing malignant breast lesions. METHOD: This cross-sectional study included all patients with a breast mass on clinical examination. A B-mode US with a Breast Imaging Reporting and Data System (BI-RADS) assessment and SWE evaluation (distance ratio [DR], area ratio [AR] and shear wave velocity [SWV]) in the lesion and healthy breast tissue of all recruited patients was performed. Cut-offs for SWE parameters were derived by receiver operating characteristic (ROC) analysis. The diagnostic performance of the B-mode US, the SWE parameters and the combined imaging in diagnosing malignancy was assessed. RESULTS: This study included a total of 175 breast masses. The median values of the SWE parameters were significantly higher (p < 0.001) in the malignant breast masses (DR, 1.29 vs. 1.03; AR, 1.69 vs. 1.06; and SWV, 9.1 metre per second [m/s] vs. 2.1 m/s). The ROC cut-off for malignancy was derived at 1.135 m/s, 1.18 m/s and 3.18 m/s, respectively, for DR, AR and SWV. The area under the ROC curve was highest for the DR (0.930), whilst this value was 0.914 and 0.901 for the SWV and AR, respectively. Amongst the respective sensitivities and specificities of the B-mode US (90.6% and 90%), SWE (97.6% and 61.1%), SWE (excluding AR) (96.5% and 77.8%) and combined imaging (100% and 72.2%), the highest sensitivity was noted for the combined method. CONCLUSION: All the SWE parameters were significantly higher in the malignant breast masses, compared to the benign lesions. On combining SWE and B-mode US, there was a significant increase in sensitivity but a decrease in specificity.

Influence of ABCB1 C3435T and C1236T gene polymorphisms on tumour response to docetaxel-based neo-adjuvant chemotherapy in locally advanced breast cancer patients of South India.

WHAT IS KNOWN AND OBJECTIVE: Variable response to docetaxel-based neo-adjuvant chemotherapy (NACT) in breast cancer patients had been reported. Genetic polymorphisms in the ABCB1 gene coding for the efflux transporter MDR1 (P-glycoprotein, P-gp) could result in altered tumour response. Hence, this study was proposed to assess the effect of single nucleotide polymorphisms (SNPs) of ABCB1 gene on tumour response in locally advanced breast cancer patients (LABC) of South India who have a distinct genetic makeup. METHODS: Out of 162 LABC patients recruited, 129 patients were included for the final analysis. DNA was extracted by "phenol-chloroform extraction method" from the WBCs, and genotyping for SNPs rs1045642 (C3435T) and rs1128503 (C1236T) in ABCB1 gene was performed with real-time PCR system using validated TaqMan® SNP genotyping assay method. Tumour response was assessed by RECIST criteria based on the MRIs taken before and after completion of four cycles of docetaxel therapy. RESULTS AND DISCUSSION: A total of 102 (79.1%) patients were found to be responders and 27 (20.9%) patients were found to be non-responders to docetaxel therapy. Patients with "CT/TT" genotypes (response rate: 83.3%) of ABCB1 (C1236T) gene showed better tumour response than those with "CC" genotype (response rate: 16.6%) [OR = 2.94 (CI: 1.15-7.52); P = 0.03]. However, on performing binary logistic regression, neither the studied SNPs nor the non-genetic factors like age, BMI, postmenopausal status, laterality of the tumour, ER status, PR status and Her-2/neu status were found to be associated with tumour response to docetaxel (P > 0.05). WHAT IS NEW AND CONCLUSION: The tumour response to docetaxel was significantly influenced by the SNP C1236T of ABCB1 gene coding for the P-gp. However, when adjusted for other non-genetic factors, neither of the ABCB1 variants were found to be associated with tumour response to docetaxel-based NACT in LABC patients of South India.

An evaluation of the finger flexion, Hoffman's and plantar reflexes as markers of cervical spinal cord compression - A comparative clinical study.

OBJECTIVES: This study aimed at determining the frequency of abnormal finger flexion, Hoffman's and extensor plantar (Babinski) response in healthy adults and to determine the sensitivity and specificity of these tests as markers of spinal cord compression in symptomatic patients. METHODS: Patients attending the neurosurgery clinic with neck related complaints formed the case group. The control group consisted of consenting patient attenders and volunteers drawn from the students and faculty of our institute. All subjects underwent examination of the finger flexion, Hoffman's and plantar reflexes and an MRI as per standard protocol. The frequency of the reflexes in the control group, sensitivity and specificity of the reflexes to detect cord compression in the case group were computed. RESULTS: The frequency of the reflexes in healthy controls were finger flexion - 1%, Hoffman's - 0.3% and Babinski sign - 0%. None of the controls with positive reflexes had any abnormality on MR imaging. A combination of the three reflexes had a sensitivity of 91.7%, specificity of 87.5%, PPV of 95.7% and NPV of 77.8% in detecting spinal cord compression. CONCLUSIONS: A combination of finger flexion, Hoffman's and plantar reflexes could be used effectively as a marker of spinal cord compression in symptomatic individuals. They cannot, however, be depended on as screening tests in asymptomatic individuals.

Gossypiboma presenting as coloduodenal fistula--report of a rare case with review of literature.

The term gossypiboma is used to describe a mass of cotton matrix left behind in a body cavity intraoperatively. The most common site reported is the abdominal cavity. It can present with abscess, intestinal obstruction, malabsorption, gastrointestinal hemorrhage, and fistulas. A 37-year-old woman presented with pain in the right hypochondrium for 2 months following open cholecystectomy. As she did not improve with proton pump inhibitors, an esophagogastroduodenoscopy (EGD) was done, which showed a possible gauze piece stained with bile in the first part of the duodenum. Contrast-enhanced computed tomography (CECT) of the abdomen revealed an abnormal fistulous communication of the first part of duodenum with proximal transverse colon, with a hypodense, mottled lesion within the lumen of the proximal transverse colon plugging the fistula, suggestive of a gossypiboma. Excision of the coloduodenal fistula, primary duodenal repair, and feeding jejunostomy was done. The patient recovered well and is now tolerating normal diet. Coloduodenal fistula is usually caused by Crohn's disease, malignancy, right-sided diverticulitis, and gall stone disease. Isolated coloduodenal fistula due to gossypiboma has not been reported in the literature so far to the best of our knowledge. We report this case of coloduodenal fistula secondary to gossypiboma for its rarity and diagnostic challenge.

Appearances of the circumcaval ureter on excretory urography and MR urography: A single-center case series.

OBJECTIVES: To describe Magnetic Resonance Urography (MRU) appearances of the circumcaval ureter, a rare congenital cause of hydronephrosis. MATERIALS AND METHODS: Seven cases of circumcaval ureter, suspected on intravenous urography (IVU), underwent subsequent static MRU using heavily T2-weighted sequences. RESULTS: The various appearances of circumcaval ureter on IVU and MRU were studied and compared. The circumcaval portion of the ureter was especially well seen on axial MRU sections, though this portion was routinely not visualized on IVU. In one case with a ureteric calculus, MRU also depicted a circumcaval course of the ureter, thus providing a complete diagnosis. In yet another case, where a circumcaval ureter was suspected on IVU, MRU proved the actual cause of ureteric obstruction to be a crossing vessel. CONCLUSION: Static MRU using heavily T2-weighted coronal and axial sequences can make or exclude the diagnosis of circumcaval ureter unequivocally.

The role of static magnetic resonance urography in the evaluation of obstructive uropathy.

OBJECTIVE: To assess the diagnostic accuracy of static magnetic resonance urography (MRU) in hydronephrosis and to compare parameters of hydronephrosis in MRU with intravenous urography (IVU). MATERIALS AND METHODS: Sixty-nine patients were included in this study of which 55 patients with a total of 63 hydronephrotic units underwent both IVU and MRU. MRU was performed on a 1.5 T scanner using heavily T2-weighted sequences. The level, grade, and cause of obstruction on each modality were interpreted by 2 radiologists. These were compared with the final diagnosis based on other appropriate modalities including imaging, intraoperative and histopathologic diagnosis. RESULTS: The sensitivity and specificity MRU in detecting hydronephrosis were 95% and 100%, respectively. In determining the level of obstruction, the strength of agreement between IVU and MRU using kappa statistics was κ = 0.66, which corresponds to a good level of agreement. The Spearman correlation coefficient for the grade of hydronephrosis on MRU and IVU was 0.92 (95% confidence interval 0.86-0.95), with a P value of < .0001. The correct diagnosis was made in 89.2% of the cases by IVU and in 93.8% of the cases by MRU. CONCLUSION: Along with a high sensitivity and specificity in detecting the presence, level, and grade of hydronephrosis, MRU without contrast also shows a good agreement with IVU. Static MRU can reliably replace IVU when the latter is contraindicated or technically difficult.

Kartagener syndrome associated with mesangioproliferative glomerulonephritis.

An 11-year-old girl with clinical features of Kartagener syndrome presented with signs of acute glomerulonephritis. Blood urea and creatinine were mildly elevated and anti-streptolysin O and C3 levels were normal. Renal biopsy demonstrated mesangial proliferation and direct immunofluorescence showed IgM and C3 deposits. This appears to be the first report of Kartagener syndrome in association with mesangioproliferative glomerulonephritis. The literature is reviewed and the possible mechanisms for this association are discussed.