Loco-regional staging accuracy in oesophageal cancer-How good are we in the modern era?

INTRODUCTION: Accuracy of locoregional staging in patients with oesophageal cancer is critical in determining operability and the need for neoadjuvant treatment. Imaging technology has advanced significantly in recent years but it is not known whether this translates to improved staging accuracy. This study investigates staging accuracy in relation to CT, EUS, PET-CT and final pre-operative stage. It specifically addresses the accuracy of staging with respect to the threshold for administering neoadjuvant therapies. MATERIALS AND METHODS: Pre-operative staging according to CT, EUS, PET-CT and final pre-operative stage were compared to the postoperative histological staging in 133 patients undergoing potentially curative surgery (without neoadjuvant therapy) for oesophageal cancer between January 2010 and January 2015. T and N stage accuracies were reported separately for each imaging modality. Patients were also divided into two groups depending on whether the final pre-operative stage was below (≤T2, N0, early tumours) or above (≥T3 and/or ≥N1, locally advanced tumours) the threshold for offering neoadjuvant therapy. Accuracy of pre-operative staging was then analysed with respect to identification of patients below/above this threshold. The additional benefit offered by EUS for this purpose was investigated. RESULTS: T stage accuracies were 72.6%, 76.7% and 79.3% for CT, EUS and final pre-operative stage respectively. N stage accuracies were 75.6%, 77.2%, 74.5% and 78.6% for CT, EUS, PET-CT and final pre-operative stage respectively. Staging accuracy with respect to threshold for neoadjuvant treatment showed 62.0% early tumours were correctly staged and 80.5% advanced tumours were correctly staged. Whether or not patients underwent EUS did not affect the staging accuracy with respect to neoadjuvant treatment threshold. CONCLUSIONS: Staging accuracy with respect to the threshold for treatment with neoadjuvant therapy is poor, leading to potential over/under treatment. Predicting individual response to neoadjuvant therapy would provide a better way to determine which patients should receive this additional treatment.

Budd-Chiari syndrome due to right hepatic lobe herniation: CT image findings of two rare clinical conditions.

Hepatic herniation is a rare clinical condition. Most commonly it is associated with congenital diaphragmatic herniation or acquired through blunt diaphragmatic trauma. We present a case of a right hepatic lobe incisional hernia in a 75-year-old female who underwent partial right-sided nephrectomy 52 years previously. Evidence of partial Budd-Chiari syndrome was seen on CT scan that was presumed to be as a result of traction of the herniated liver. As far as we are aware this is the first case of a right-sided hepatic hernia with evidence of partial Budd-Chiari syndrome. The patient was treated conservatively with anticoagulation and analgesia.

Imaging features of therapeutic drug-induced musculoskeletal abnormalities.

Increasing use of a wide variety of therapeutic drugs with known musculoskeletal side-effect profiles necessitates a rigorous understanding and approach when evaluating imaging features suggestive of drug-induced musculoskeletal abnormalities. The etiology of such abnormalities is diverse, and the clinical and imaging manifestations may be nonspecific. The recognition of adverse effects depends, first, on the physician's vigilant review of clinical information for relevant drug history and indicative signs, and second, on the radiologist's ability to detect musculoskeletal changes consistent with known potential effects of specific drugs. Musculoskeletal abnormalities induced by therapeutic drugs may be broadly categorized as embryopathic, juvenile, or postmaturation. Embryopathic skeletal abnormalities result from the teratogenic effects of drugs administered to pregnant women (eg, thalidomide, anticonvulsants). Other therapeutic agents characteristically lead to abnormalities during postnatal skeletal maturation (eg, high-dose vitamins or prostaglandin) either because they are used exclusively in children or because they have idiosyncratic effects on immature musculoskeletal structures. Many drugs (eg, statins) may have musculoskeletal side effects that, although independent of the stage of skeletal maturation, are most often seen in adults or elderly people because they are commonly prescribed for people in these age groups. Drug-induced musculoskeletal abnormalities may be further characterized according to the predominant skeletal manifestations as osteomalacic, proliferative, or osteoporotic and according to the involvement of soft tissues as musculotendinous or chondral.

Pictorial review: computed tomography features of cardiovascular emergencies and associated imminent decompensation.

Multi-detector computed tomography (MDCT) scanner is available in most hospitals and is increasingly being used as the first line imaging in trauma and suspected cardiovascular emergencies, such as acute coronary syndrome, pulmonary artery thrombo-embolism, abdominal aortic aneurysm and acute haemorrhage (Ryan et al. Clin Radiol 60:599-607, 2005). A significant number of these patients are haemodynamically unstable and can rapidly progress into shock and death. Recognition of computed tomography (CT) signs of imminent cardiovascular decompensation will alert the clinical radiologist to the presence of shock. In this review, the imaging findings of cardiovascular emergencies in both acute traumatic and non-traumatic settings with associated signs of imminent decompensation will be described and illustrated.

Assistance of colorectal stent insertion by sphincterotome.

PURPOSE: Palliation of patients with unresectable colorectal carcinoma is an effective treatment and technical failure is undesirable. Insertion of colorectal stent using a combined radiologic and colonoscopic technique may be technically limited by the ability to negotiate tortuous bends, particularly if the bowel is fixed. METHODS: We used a through scope sphincterotome, which improved the ability to traverse difficult strictures. RESULTS: We have used the technique in four cases as a last resort. This resulted in a technical success in all four cases (100 percent). CONCLUSIONS: Sphincterotome is a useful adjunct in stenting difficult colorectal tumor strictures.

Dissecting intramural haematoma of the oesophagus.

Dissecting intramural haematoma of the oesophagus (DIHO) is a rare condition, which has an excellent prognosis when managed conservatively. Awareness of this condition is vital to guide subsequent investigations and avoid inappropriate treatment or unnecessary surgical intervention. We describe an unusual case of massive DIHO causing left atrial compression presenting with pericarditic electrocardiographic changes and document the utility of endoscopic ultrasound/computed tomography to make the diagnosis.

Minimizing postcolonoscopy abdominal pain by using CO(2) insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO(2) delivery system.

BACKGROUND: Abdominal pain after colonoscopy is a common, distressing symptom resulting from bowel distension by insufflated gas. CO(2), unlike air, is rapidly cleared from the colon by passive absorption. A commercially available CO(2) delivery system has only recently become available. The effects of CO(2) and air insufflation on residual bowel gas and postprocedure pain were compared. METHODS: One hundred patients were randomized to undergo colonoscopy with insufflation of air (n = 51) or CO(2) (n = 49) by means of a regulator; 97 patients completed the study. Patients with active GI bleeding, inflammatory bowel disease, or previous colectomy were excluded. Pain scores (ordinal scale: 0 = none, to 5 = extreme) were recorded immediately after colonoscopy and at 1, 6, and 24 hours. Residual colonic gas was evaluated on abdominal radiographs at 1 hour. RESULTS: Residual colonic gas and postprocedural pain at 1 and 6 hours were significantly less in the CO(2) group. 71% of patients insufflated with room air had colonic distension in excess of 6 cm versus 4% for those in the CO(2) group. 94% of patients insufflated with CO(2) had minimal colonic gas versus 2% in whom air was used (p < 0.0001). Of patients insufflated with air, 45% and 31% had pain at, respectively, 1 hour and 6 hours, versus 7% and 9%, respectively, for those insufflated with CO(2) (respectively, p < 0.0001 and p < O.02). No complications resulted from use of the CO(2) delivery system. CONCLUSIONS: Insufflation of CO(2) rather than air significantly reduces abdominal pain and bowel distension after colonoscopy. CO(2) may be insufflated safely and effectively with the new CO(2) delivery system.