Combined direct hysteroscopic and real-time ultrasound guidance facilitating safe insertion of intra-uterine brachytherapy applicator for locally advanced cervical cancer with significant endocervical stenosis: A novel collaborative approach.

Locally advanced cervical cancer is treated with combined chemoradiation (CCRT) - with the radiotherapy component comprising delivery of both external beam (EBRT) and intra-uterine brachytherapy (IUBT). Following initial pelvic and tumour irradiation via EBRT, secondary tissue fibrosis can obliterate the vagina and / or endocervical canal. 30-88% of women will develop some degree of stenosis, with complete stenosis reported in up to 11% of patients - making accessing the uterine cavity to insert brachytherapy applicators challenging and high risk (Bran et al., 2006). This can result in inadvertent uterine perforation, occurring in 2-10% of cases (Irvin et al., 2002); with subsequent abandonment of both the procedure and proceeding to IUBT to complete treatment. Omission of IUBT confers an at least 10% reduction in overall survival (Karlsson et al., 2017). Whilst ultrasound-guided insertion has been previously described (Van Dyk et al., 2021), we present a surgical video demonstrating a novel technique. We instead utilise a combination of both real-time ultrasound and direct hysteroscopic guidance to achieve successful IUBT applicator insertion following CCRT in a patient with stage IIa1 SCC cervix and previous failed insertion attempt due to complete stenosis of the endocervical canal. We demonstrate how post-radiation changes can be safely navigated - avoiding morbidity from procedural complications and ensuring successful outcome. Our case supports a collaborative approach to complex gynaecological cancer cases; with the combined skills of the oncology, radiology and surgical teams maximising patient safety - and optimising oncological treatment. Use of portable hand-held hysteroscopic devices would increase the feasibility of replicating our described technique in brachytherapy suites, mitigating need for theatre capacity; with MDT discussion central to the planning and staffing of cases.

What are the implications of radiologically abnormal cardiophrenic lymph nodes in advanced ovarian cancer? An analysis of tumour burden, surgical complexity, same-site recurrence and overall survival.

INTRODUCTION: Our paper evaluates the relationship between radiologically abnormal cardiophrenic lymph nodes (CPLN) in advanced ovarian cancer and pattern of disease distribution, tumour burden, surgical complexity, rates of cytoreduction and same-site recurrence. Impact of suspicious CPLN and CPLN dissection on overall survival also determined. MATERIALS AND METHODS: Retrospective review of index CT imaging for 151 consecutive patients treated for stage III/IV ovarian malignancy in a large UK cancer centre to identify radiologically abnormal CPLN. Corresponding surgical, histo-pathological and survival data analysed. RESULTS: 42.6% of patients had radiologically 'positive' CPLN on index CT. Radiological identification of CPLN involvement demonstrated a sensitivity of 82% within our centre. Patients with cardiophrenic lymphadenopathy on pre-operative CT had significantly more co-existing ascites (p = 0.003), omental (p = 0.01) and diaphragmatic disease (p < 0.0001). At primary debulking (PDS), suspicious CPLN were associated with significantly higher surgical complexity scores, without feasibility of complete cytoreduction being impacted. Cardiophrenic involvement at initial diagnosis was associated with same-site relapse at recurrence (p = 0.001). No significant difference in overall survival was demonstrated according to CPLN status following either PDS or delayed debulking (DDS). CPLN dissection did not improve patient outcomes. CONCLUSION: Radiological identification of abnormal CPLN is reliable. Suspicious CPLN appear to represent a surrogate marker of tumour volume - in particular, heralding upper abdominal disease - and should prompt anticipation of high complexity surgery and referral to an appropriate centre. Patients with prior CPLN involvement are more likely to develop same-site recurrence at relapse. Our survival data suggests cardiophrenic LN disease does not worsen patient prognosis and that the therapeutic benefit of CPLN dissection remains unclear.

Non-invasive assessment of liver fibrosis using ARFI with pathological correlation, a prospective study.

INTRODUCTION: ARFI is a new technique that uses acoustic push pulse to generate tissue displacement resulting in shear wave propagation, can be used to measure elasticity of tissue. We aim to assess feasibility of ARFI as a non-invasive method to measure liver fibrosis compared to histological fibrosis scores and to compare our results with the published pooled-meta-analysis cut off values. MATERIAL AND METHODS: Prospective study to compare median velocities of ARFI shear wave measurements (Virtual Touch Imaging™ ACUSON S2000, Siemens, Mountain View CA) with Batts and Ludwig liver fibrosis scoring system F0-F4. RESULTS: 70 patients (mean = 49 years) were included. Etiologies were chronic hepatitis C (n = 43), chronic hepatitis B (n = 7) and others (n = 20). Median ARFI values (m/sec) for fibrosis stages and inflammatory stages measured were F0: 1.52, 1.42; F1: 1.50, 1.37; F3: 2.36, 2.41 and F4: 2.61. Areas under the curve for grade 3 = 0.875, stage 3 = 0.867; grade 2 = 0.4, stage 2 = 0.3.Using the cut-off ARFI value of 1.34 m/s for F ≥ 2 suggested in the meta-analysis, we found sensitivity of detecting true F ≥ 2 is 68%, specificity 66%, PPV 74% and NPV 59%. For F ≥ 3 using the cut-off ARFI value of 1.55 m/s, we found sensitivity of 95%, specificity 86%, PPV 74% and NPV 98%. No stage 4 was compared due to insufficient cases. CONCLUSION: ARFI has strong correlation with higher fibrosis scores compared to lower. When compared to the pooled meta-analysis cut off values, the sensitivity and specificity for detecting true F ≥ 3 are higher than that of F ≥ 2.

Extranodal lymphoma from head to toe: part 1, the head and spine.

OBJECTIVE: Lymphoma can affect virtually every tissue in the body, producing a variety of imaging appearances. In this article, the extranodal manifestations of lymphoma in the head and spine are illustrated and the imaging features that aid in diagnosis are reviewed. CONCLUSION: Knowledge of the imaging appearances of extranodal lymphoma can aid in the differential diagnosis of mass lesions encountered in tissues throughout the body on different imaging modalities.

Extranodal lymphoma from head to toe: part 2, the trunk and extremities.

OBJECTIVE: Lymphoma can affect virtually every tissue in the body, producing a variety of imaging appearances. In this article, the extranodal manifestations of this disease in the trunk and extremities are illustrated and the imaging features that aid in the diagnosis are reviewed. CONCLUSION: Knowledge of the imaging appearances of extranodal lymphoma can aid the differential diagnosis of mass lesions encountered in tissues throughout the body on different imaging modalities.

Rectal cancer: incidence of pulmonary metastases on thoracic CT and correlation with T staging.

PURPOSE: The aim of the study was to evaluate the incidence of pulmonary metastases detected on thoracic computed tomography in patients with rectal cancer and assess the association between the incidence of pulmonary metastases and the stage of the rectal tumor. MATERIALS AND METHODS: Fifty-six consecutive patients who were diagnosed with rectal cancer over a 22-month period were included in the study. These patients had local tumor staging with a pelvic magnetic resonance imaging and staging computed tomographic scan of the chest and upper abdomen immediately after the magnetic resonance imaging. Two radiologists retrospectively reviewed all the thoracic imaging performed on these patients for the presence of metastases. The presence of a parenchymal lung nodule (greater than or equal to 1 cm if single and 0.5 cm if multiple) with a soft tissue component without calcification on lung and mediastinal window settings was considered positive for the presence of metastasis. All other patients were considered as not having any lung metastases. RESULTS: Of the 56 patients, 10 (17.9%) had evidence of pulmonary metastases on computed tomography. Of the 56 patients, there were 3 patients with stage T1, 24 with T2, 26 with T3, and 3 with stage T4 tumors. Of these 10 patients, 1 had a stage T2 tumor, 7 had T3, and 2 had stage T4 tumors. Statistical analysis using exact logistic regression showed the odds of getting lung metastases is an increasing function of tumor grade. CONCLUSIONS: There is a high incidence of lung metastases in patients with rectal cancer, and thoracic computed tomographic scanning should be performed as part of a staging protocol in all patients before any form of treatment is planned. There is a higher incidence of lung metastases with higher T stage.

The complications of repeat median sternotomy in paediatrics: six-months follow-up of consecutive cases.

Repeat median sternotomy in paediatrics though associated with increased perioperative risks, yet the incidence of injury to the underlying structures during sternal re-entry is poorly quantified. We reviewed 108 patients undergoing repeat sternotomies (group-I) and a control group of 516 patients undergoing first time sternotomy (group-II) over six years with six-months follow-up. Overall mean age was 17 months (range 1 day-16 years). Uncontrollable bleeding was encountered in 4 patients (3.7%), non-fatal cardiac laceration in 10 (9.2%), minor injuries to aorta in 7 (6.4%) and right atrium in 8 (7.4%) in Group-I. Forty-one times (38%) pericardial sac was closed and 55 times (51%) artificial materials (Dacron/Gortex) were used in initial procedures. The incidence of injuries during sternal re-entry was significantly lower in those patients where pericardial sac was closed initially (P<0.001). Hospital mortality was 3.7% in Group-I and 2.7% in Group-II, however, overall survival was 95% (group-I) and 97% (group-II) at 6 months' follow-up. Complete heart block, neurological problems and persistence of shunts being the most common reported morbidities in both groups. In conclusion, low incidence of morbidity and mortality in repeat median sternotomy is possible with careful surgical approach. The closure of pericardial sac in initial procedure provides many potential and practical advantages with regard to lesser trauma to underlying structures.