Nodal staging in the rectal cancer follow-up MRI after chemoradiotherapy: use of morphology, size, and diffusion criteria.

AIM: To analyse changes in post-neoadjuvant follow-up magnetic resonance imaging (MRI) staging accuracy for malignant adenopathies in rectal cancer, by comparing size criteria with morphological criteria using high-resolution T2-weighted sequences, as well as variations when adding diffusion-weighted imaging. METHODS AND MATERIALS: The present study was a cross-sectional study of a database including 46 1.5-T MRI examinations (2011-2016) from patients with biopsy-proven rectal cancer and chemoradiotherapy treatment before surgery. All cases were reviewed by three radiologists individually, who were blinded to any clinical information. The radiologists were experienced in rectal cancer (3-6 years) and evaluated the presence of malignant nodes in each patient. Malignancy was determined using morphological, size (5 mm), and diffusion criteria separately, as well as morphology plus diffusion. Each case was assessed four times: (1) evaluation of morphological criteria; (2) size criteria; (3) evaluation only using diffusion (b-values 50, 400, and 800); and (4) diffusion plus morphological criteria. Histological staging of surgical specimens was the reference standard. Statistical analysis included accuracy (area under the receiver operating characteristic [ROC] curve [AUC]), sensitivity, specificity, and positive/negative predictive values (PPV/NPV) for each radiologist, and group agreement (Fleiss' kappa). RESULTS: Mean values using morphological criteria were: AUC 0.78, sensitivity 77.7%, specificity 73.8%, PPV 66.1%, NPV 85.2%. Using size criterion: AUC 0.75, sensitivity 62.9%, specificity 83.2%, PPV 74.1%, NPV 80%. Added diffusion yielded no improvement, and yielded worse results by itself. CONCLUSIONS: Although morphological criteria showed better results in accuracy, sensitivity, and NPV, size criterion yielded the best specificity and PPV. Adding diffusion did not demonstrate a clear advantage over the criteria by themselves. Thus, mixed size-morphology criteria could have the greatest diagnostic value for follow-up N-staging.

¿Están indicadas las pruebas de imagen urgentes en el manejo de la pancreatitis aguda? / Are urgent imaging tests indicated in the management of acute pancreatitis?

La pancreatitis aguda es una urgencia frecuente dentro de la patología abdominal. Se acepta que para su diagnóstico se requieren dos de tres condiciones: presentación clínica típica, datos característicos analíticos y/o en pruebas de imagen. Probablemente, por razones de eficiencia y frecuencia, los dos primeros puntos son los más habitualmente usados. Sin embargo, la necesidad de estudios radiológicos es en ocasiones una fuente de conflicto. Por ello, decidimos realizar una revisión de la evidencia actual en cuanto a la indicación de realización de pruebas de imagen de forma urgente para el manejo de la pancreatitis aguda (AU)

Acute pancreatitis is a common emergency within abdominal disease. It is accepted that two of three conditions must be fulfilled for its diagnosis: characteristic clinical presentation, characteristic laboratory findings, and/or characteristic diagnostic imaging findings. The first two conditions are the most often used, probably for reasons of efficiency and frequency. Nevertheless, the need for imaging studies is sometimes a source of conflict. For this reason, we decided to review the current evidence regarding the indication of urgent imaging tests in the management of acute pancreatitis (AU)

[Are urgent imaging tests indicated in the management of acute pancreatitis?]. / ¿Están indicadas las pruebas de imagen urgentes en el manejo de la pancreatitis aguda?

Acute pancreatitis is a common emergency within abdominal disease. It is accepted that two of three conditions must be fulfilled for its diagnosis: characteristic clinical presentation, characteristic laboratory findings, and/or characteristic diagnostic imaging findings. The first two conditions are the most often used, probably for reasons of efficiency and frequency. Nevertheless, the need for imaging studies is sometimes a source of conflict. For this reason, we decided to review the current evidence regarding the indication of urgent imaging tests in the management of acute pancreatitis.

¿Ha llegado el momento de buscar la escala de Wells 4.0? / Is time to search the Wells Score 4.0?

Antecedentes: El modelo de Wells para la trombosis venosa profunda presenta problemas para su implementación en las áreas de urgencias hospitalarias debido, fundamentalmente, a la complejidad de su aplicación. Objetivo: Evaluar si la inclusión del dímero D como un predictor podría repercutir en una simplificación de dicho modelo. Pacientes y métodos: Sobre una base de datos retrospectiva de pacientes estudiados por trombosis venosa profunda se aplicó un modelo de regresión logística en el que se incluyeron los 10 predictores del modelo de Wells y el resultado del dímero D. El diagnóstico se realizó con una ecografía de compresión con señal Doppler. El dímero D se determinó mediante una técnica cuantitativa de látex, una técnica de inmunofiltración o una técnica turbidimétrica. Resultados: Se estudiaron 577 pacientes (mujeres: 54,1%) con una edad media de 66,7 (14,2) años y un porcentaje de trombosis venosa profunda del 25,1%. Solo 4 variables resultaron independientes, construyéndose un modelo ponderado con una mayor capacidad predictiva (área bajo la curva) que el modelo original (0,844 vs. 0,751, p < 0,001). Ambos modelos mostraron una seguridad aceptable, con una tasa de fracasos similar (0,8% vs. 1%). El modelo simplificado permitió seleccionar a un mayor porcentaje de pacientes en los que podría no haberse realizado la prueba de imagen (20,6% vs. 15,8%, p = 0,039). Conclusiones: La introducción del dímero D en un modelo de regresión permite simplificar el modelo de Wells y mantener su misma eficacia y seguridad, lo que podría mejorar su implementación en las áreas de urgencias hospitalarias (AU)

Background: Wells score for deep vein thrombosis presents problems for implementation in the hospital emergencies, mainly due to the complexity of its enforcement. Objective: To assess whether the inclusion of D-dimer as a predictor might lead to a simplification of this clinical decision rule. Patients and methods: A database of deep vein thrombosis patients was studied by logistic regression model in which the 10 predictors in the Wells score and the dimer D were included. The diagnosis was made with compression ultrasonography with Doppler signal. D-dimer was determined by a quantitative method of latex, a technique immunofiltration or a turbidimetric technique. Results: 577 patients (54.1% women) were studied, with a mean age of 66.7 (14.2) years. 25.1% were diagnosed with deep vein thrombosis. Only four variables were independent, building a weighted model with greater predictive ability (area under the curve) than the original model (0.844 vs. 0.751, p<0.001). Both models showed an acceptable safety, with a similar rate of failure (0.8% vs. 1%). The simplified model allowed to select a higher percentage of patients who could have benefited from the non performance of the imaging test (20.6% vs. 15.8%, p=0.039). Conclusions: The introduction of D-dimer in a regression model simplifies the Wells score and maintain the same efficacy and safety, which could improve its implementation in the hospital emergencies (AU)

Is time to search the Wells Score 4.0? / ¿Ha llegado el momento de buscar la escala de Wells 4.0?

BACKGROUND: Wells score for deep vein thrombosis presents problems for implementation in the hospital emergencies, mainly due to the complexity of its enforcement. OBJECTIVE: To assess whether the inclusion of D-dimer as a predictor might lead to a simplification of this clinical decision rule. PATIENTS AND METHODS: A database of deep vein thrombosis patients was studied by logistic regression model in which the 10 predictors in the Wells score and the dimer D were included. The diagnosis was made with compression ultrasonography with Doppler signal. D-dimer was determined by a quantitative method of latex, a technique immunofiltration or a turbidimetric technique. RESULTS: 577 patients (54.1% women) were studied, with a mean age of 66.7 (14.2) years. 25.1% were diagnosed with deep vein thrombosis. Only four variables were independent, building a weighted model with greater predictive ability (area under the curve) than the original model (0.844 vs. 0.751, p<0.001). Both models showed an acceptable safety, with a similar rate of failure (0.8% vs. 1%). The simplified model allowed to select a higher percentage of patients who could have benefited from the non performance of the imaging test (20.6% vs. 15.8%, p=0.039). CONCLUSIONS: The introduction of D-dimer in a regression model simplifies the Wells score and maintain the same efficacy and safety, which could improve its implementation in the hospital emergencies.

Solución del caso 33. Interrupción proximal unilateral de la arteria pulmonar izquierda / Solution to case 33. Unilateral proximal interruption of the left pulmonary artery

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