Pneumomediastinum in late pregnancy: a case report and review of the literature.

BACKGROUND: Pneumomediastium is a rare complication of pregnancy or labor. METHODS: Here, we report our findings in a case report (gravid 5, para 2, gestational age 33 + 4 weeks) and narratively review the current literature on pneumomediastinum in pregnancy or labor. RESULTS: Our case is the first case that experienced pneumomediastinum after relatively limited exposure to barotrauma in the current pregnancy. Other reports describe pneumomediastinum after hyperemesis gravidarum or during labor. Treatment is usually conservatively due to the trauma mechanism of barotrauma to the alveoli. CONCLUSION: Physicians should be aware of the possibility of pneumomediastinum in pregnant women with acute thoracic pain in cases of (previous) hyperemesis gravidarum or during labor.

Test-Retest Data for the Assessment of Breast MRI Radiomic Feature Repeatability.

BACKGROUND: Radiomic features extracted from breast MRI have potential for diagnostic, prognostic, and predictive purposes. However, before they can be used as biomarkers in clinical decision support systems, features need to be repeatable and reproducible. OBJECTIVE: Identify repeatable radiomics features within breast tissue on prospectively collected MRI exams through multiple test-retest measurements. STUDY TYPE: Prospective. POPULATION: 11 healthy female volunteers. FIELD STRENGTH/SEQUENCE: 1.5 T; MRI exams, comprising T2-weighted turbo spin-echo (T2W) sequence, native T1-weighted turbo gradient-echo (T1W) sequence, diffusion-weighted imaging (DWI) sequence using b-values 0/150/800, and corresponding derived ADC maps. ASSESSMENT: 18 MRI exams (three test-retest settings, repeated on 2 days) per healthy volunteer were examined on an identical scanner using a fixed clinical breast protocol. For each scan, 91 features were extracted from the 3D manually segmented right breast using Pyradiomics, before and after image preprocessing. Image preprocessing consisted of 1) bias field correction (BFC); 2) z-score normalization with and without BFC; 3) grayscale discretization using 32 and 64 bins with and without BFC; and 4) z-score normalization + grayscale discretization using 32 and 64 bins with and without BFC. STATISTICAL TESTS: Features' repeatability was assessed using concordance correlation coefficient(CCC) for each pair, i.e. each MRI was compared to each of the remaining 17 MRI with a cut-off value of CCC > 0.90. RESULTS: Images without preprocessing produced the highest number of repeatable features for both T1W sequence and ADC maps with 15 of 91 (16.5%) and 8 of 91 (8.8%) repeatable features, respectively. Preprocessed images produced between 4 of 91 (4.4%) and 14 of 91 (15.4%), and 6 of 91 (6.6%) and 7 of 91 (7.7%) repeatable features, respectively for T1W and ADC maps. Z-score normalization produced highest number of repeatable features, 26 of 91 (28.6%) in T2W sequences, in these images, no preprocessing produced 11 of 91 (12.1%) repeatable features. DATA CONCLUSION: Radiomic features extracted from T1W, T2W sequences and ADC maps from breast MRI exams showed a varying number of repeatable features, depending on the sequence. Effects of different preprocessing procedures on repeatability of features were different for each sequence. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 1.

Risk of Positive Sentinel Lymph Node After Neoadjuvant Systemic Therapy in Clinically Node-Negative Breast Cancer: Implications for Postmastectomy Radiation Therapy and Immediate Breast Reconstruction.

BACKGROUND: Residual axillary lymph node involvement after neoadjuvant systemic therapy (NST) is the determining factor for postmastectomy radiation therapy (PMRT). Preoperative identification of patients needing PMRT is essential to enable shared decision-making when choosing the optimal timing of breast reconstruction. We determined the risk of positive sentinel lymph node (SLN) after NST in clinically node-negative (cN0) breast cancer. METHODS: All cT1-3N0 patients treated with NST followed by mastectomy and SLNB between 2010 and 2016 were identified from the Netherlands Cancer Registry. Rate of positive SLN for different breast cancer subtypes was determined. Logistic regression analysis was performed to determine correlated clinicopathological variables with positive SLN. RESULTS: In total 788 patients were included, of whom 25.0% (197/788) had positive SLN. cT1-3N0 ER+HER2+, cT1-3N0 ER-HER2+ , and cT1-2N0 triple-negative patients had the lowest rate of positive SLN: 7.2-11.5%, 0-6.3%, and 2.9-6.2%, respectively. cT1-3N0 ER+HER2- and cT3N0 triple-negative patients had the highest rate of positive SLN: 23.8-41.7% and 30.4%, respectively. Multivariable regression analysis showed that cT2 (odds ratio [OR] 1.93; 95% confidence interval [CI] 1.01-3.96), cT3 (OR 2.56; 95% CI 1.30-5.38), grade 3 (OR 0.44; 95% CI 0.21-0.91), and ER+HER2- subtype (OR 3.94; 95% CI 1.77-8.74) were correlated with positive SLN. CONCLUSIONS: In cT1-3N0 ER+HER2+, cT1-3N0 ER-HER2+, and cT1-2N0 triple-negative patients treated with NST, immediate reconstruction can be considered an acceptable option due to low risk of positive SLN. In cT1-3N0 ER+HER2- and cT3N0 triple-negative patients treated with NST, risks and benefits of immediate reconstruction should be discussed with patients due to the relatively high risk of positive SLN.

Are PROMs sufficient to record late outcome of breast cancer patients treated with radiotherapy? A comparison between patient and clinician reported outcome through an outpatient clinic after 10years of follow up.

AIM: To investigate whether breast cancer patients' visits to an outpatient clinic for late outcome (OCLO) can be replaced by patient reported outcome measures (PROMs), by comparing late toxicity scored at the OCLO with PROMs. METHODS: All breast cancer patients treated in our institute with adjuvant radiotherapy 10-11years ago were invited to visit the OCLO, and for filling out PROM-questionnaires. Concordance rate between PROMs and OCLO-reported outcome and the percentage of patients with ≥2 degrees difference in toxicity level between patient and clinician was assessed. RESULTS: 686 of 1029 patients were still alive. 249 patients visited the OCLO, and 341 patients returned a questionnaire. At a group level, patients reported higher toxicity rates than clinicians. The mean concordance for individual patients was 58% between patient and clinician reported outcome. In 2.8%, the clinician reported ≥2 degrees higher toxicity than the patients did, whereas in 6.8% patients reported ≥2 degrees higher toxicity. CONCLUSION: PROMs do not underestimate late side-effects at a group level. In spite of the low concordance rate, PROMS can be used to identify patients who experience a heavy burden of side-effects, requiring specific attention. Therefore, patients can be spared a visit to the OCLO.

Modern multidisciplinary treatment of rectal cancer based on staging with magnetic resonance imaging leads to excellent local control, but distant control remains a challenge.

AIM: The purpose of this multicenter cohort study was to evaluate whether a differentiated treatment of primary rectal cancer based on magnetic resonance imaging (MRI) can reduce the number of incomplete resections and local recurrences and improve recurrence-free and overall survival. METHODS: From February 2003 until January 2008, 296 patients with rectal cancer underwent preoperative MRI using a lymph node specific contrast agent to predict circumferential resection margin (CRM), T- and N-stage. Based on expert reading of the MRI, patients were stratified in: (a) low risk for local recurrence (CRM>2mm and N0 status), (b) intermediate risk and (c) high risk (close/involved CRM, N2 status or distal tumours). Mainly based on this MRI risk assessment patients were treated with (a) surgery only (TME or local excision), (b) preoperative 5 × 5 Gy+TME and (c) a long course of chemoradiation therapy followed by surgery after a 6-8 week interval. RESULTS: Overall 228 patients underwent treatment with curative intent: 49 with surgery only, 86 with 5 × 5 Gy and surgery and 93 with chemoradiation and surgery. The number of complete resections (margin>1mm) was 218 (95.6%). At a median follow-up of 41 months the three-year local recurrence rate, disease-free survival rate and overall survival rate is 2.2%, 80% and 84.5%, respectively. CONCLUSION: With a differentiated multimodality treatment based on dedicated preoperative MR imaging, local recurrence is no longer the main problem in rectal cancer treatment. The new challenges are early diagnosis and treatment, reducing morbidity of treatment and preferably prevention of metastatic disease.

Location of involved mesorectal and extramesorectal lymph nodes in patients with primary rectal cancer: preoperative assessment with MR imaging.

AIM: The purpose of this study is to evaluate the location of involved mesorectal and extramesorectal lymph nodes as depicted on preoperative MRI. Preoperative availability of this information might be useful for the surgeon as well as the radiation therapist and medical oncologist for optimal treatment strategy: type and extent of neoadjuvant treatment as well as extent of surgical resection. METHODS: Forty-one patients with biopsy-proven rectal cancer were included. All patients underwent preoperative MRI using USPIO (lymph node specific contrast agent). Location of all mesorectal and extramesorectal nodes visible on MRI was recorded, as well as USPIO prediction on nodal status. Lesion-by-lesion analysis using histology after surgery was performed for patients who did not receive long course chemoradiation therapy. RESULTS: There were 438 nodes visible, 94 of which were malignant. Most nodes are located in the laterodorsal part of the mesorectum, with no difference in distribution between positive and negative nodes. In relation to height of tumor, the majority of positive nodes are located at tumor height or above. There were significantly more negative nodes (9.6%) located below tumor height as compared to positive nodes (2.1%). There were 40 extramesorectal nodes, in 16 patients, 5 of which were positive in 4 patients. All patients had distal rectal cancer. CONCLUSION: In conclusion, positive mesorectal nodes are located in the laterodorsal part of the mesorectum, at tumor height or above. Positive nodes distal to the tumor are rare, and occur in patients with more proximal nodal metastases. Positive extramesorectal nodes mainly occur in patients with distal rectal cancer with nodal metastases in the mesorectum.

Imaging for predicting the risk factors--the circumferential resection margin and nodal disease--of local recurrence in rectal cancer: a meta-analysis.

The aim of the present study was to conduct a meta-analysis of English literature on the accuracy of preoperative imaging in predicting the two most important risk factors for local recurrence in rectal cancer, the circumferential resection margin (CRM) and the nodal status (N-status). Articles published between 1985 and August 2004 that report on the diagnostic accuracy of endoluminal ultrasound (EUS), computed tomography (CT), or magnetic resonance imaging (MRI) in the evaluation of lymph node involvement were included. A similar search was done for the assessment of the circumferential resection margin in rectal cancer in the period from January 1985 till January 2005. The inclusion criteria were as follows: (1) more than 20 patients with histologically proven rectal cancer were included, (2) histology was used as the gold standard, and (3) results were given in a 2 x 2 contingency table or this table could otherwise be extracted from the article by two independent readers. Based on the results summary receiver operating characteristic (ROC) curves were constructed. Only 7 articles matching inclusion criteria were found concerning the CRM. The meta-analysis shows that MRI is rather accurate in diagnosing a close or involved CRM. For nodal status 84 articles could be included. The diagnostic odds ratio of EUS is estimated at 8.83. For MRI and CT, the diagnostic odds ratio are 6.53 and 5.86, respectively. The results show that EUS is slightly, but not significantly, better than MRI or CT for identification of nodal disease. There is no significant difference between the different modalities with respect to staging nodal status. At present, MRI is the only modality that predicts the circumferential resection margin with good accuracy, making it a good tool to identify high and low risk patients. Predicting the N-status remains a problem for the radiologist for every modality, although considering the new developments in MR imaging, this may change in the near future.