Adipose tissue density on CT as a prognostic factor in patients with cancer: a systematic review.

BACKGROUND: Predicting oncologic outcomes is essential for optimizing the treatment for patients with cancer. This review examines the feasibility of using Computed Tomography (CT) images of fat density as a prognostic factor in patients with cancer. METHODS: A systematic literature search was performed in PubMed, Embase and Cochrane up to March 2020. All studies that mentioned using subcutaneous or visceral adipose tissue (SAT and VAT, respectively) CT characteristics as a prognostic factor for patients with cancer were included. The primary endpoints were any disease-related outcomes in patients with cancer. RESULTS: After screening 1043 studies, ten studies reporting a total of 23 - ten for SAT and thirteen for VAT - comparisons on survival, tumor recurrence and postsurgical infection were included. All ten studies included different types of malignancy: six localized, two metastatic disease, and two both. Five different anatomic landmarks were used to uniformly measure fat density on CT: lumbar (L)4 (n = 4), L3 (n = 2), L4-L5 intervertebral space (n = 2), L5-S1 intervertebral space (n = 1), and the abdomen (n = 1). Overall, six of ten SAT comparisons (60%) and six of thirteen VAT comparisons (46%) reported a significant (p < .05) association of increased SAT or VAT density with an adverse outcome. All remaining nonsignificant comparisons, except one, deviated in the same direction of being predictive for adverse outcomes but failed to reach significance. The median hazard ratio (HR) for the nine SAT and thirteen VAT associations where HRs were given were 1.45 (95% confidence interval [CI] 1.01-1.97) and 1.90 (95% CI 1.12-2.74), respectively. The binomial sign test and Fisher's method both reported a significant association between both SAT and VAT and adverse outcomes. CONCLUSION: This review may support the feasibility of using SAT or VAT on CT as a prognostic tool for patients with cancer in predicting adverse outcomes such as survival and tumor recurrence. Future research should standardize radiologic protocol in prospective homogeneous series of patients on each cancer diagnosis group in order to establish accurate parameters to help physicians use CT scan defined characteristics in clinical practice.

Evaluation of offline analysis of archived three-dimensional volume datasets in the diagnosis of fetal brain abnormalities.

OBJECTIVE: To retrospectively evaluate the reliability of offline manipulation of archived three-dimensional (3D) ultrasound volumes in the assessment of the normal fetal brain and the diagnosis of fetal brain abnormalities. METHODS: Seventy-nine 3D volume datasets, archived at the time of scanning, from women attending a tertiary center, were analyzed. They comprised 52 cases with brain abnormalities and 27 normal controls. Postnatal magnetic resonance imaging or postmortem examination confirmed the final diagnosis in all cases with brain anomalies. Offline analysis of the 79 anonymized 3D volume datasets was carried out by three fetal medicine experts, examiner one (E1), examiner two (E2) and examiner three (E3), using 4D View software. The experts were blinded to any prior diagnosis or history. Data were collected on a specially designed data sheet and entered into a specialized database for analysis. Results were compared between examiners, with the initial two-dimensional (2D) diagnosis and with the final definitive diagnosis by calculation of percentage agreement and kappa coefficients. RESULTS: Of the 52 cases with brain anomalies, the correct diagnosis was reached in 88.5% (46/52), 98.1% (51/52) and 92.3% (48/52) of cases on analysis of the 3D volumes by E1, E2 and E3, respectively, whereas only 82.7% (43/52) of cases were correctly diagnosed on the initial 2D examination when compared with the definitive diagnosis. Fetuses without brain anomalies were identified as such by the three experts with 100% agreement. There was good agreement between the initial 2D examination and the analysis of 3D volumes by each of the experts: 86.1% for E1 (κ = 0.7), 89.9% for E2 (κ = 0.79) and 88.6% for E3 (κ = 0.76). CONCLUSIONS: 3D volume datasets are an appropriate and reliable format for storing data from examination of the fetal brain. Offline analysis of 3D datasets is a reliable method that can be used to help in the assessment of brain anomalies and could be a useful adjunct to realtime 2D ultrasonography.

Prenatal diagnosis of fetal abdominal lymphangioma by ultrasonography.

We present a case of abdominal lymphangioma in a fetus together with a review of the literature. Diagnosis was made at 20 weeks' gestation by antenatal ultrasonography. In keeping with other reports, the lesion was located on the left and serial ultrasonography demonstrated rapid growth with extension into the lower extremity.

Persistent right umbilical vein in a fetus with Noonan's syndrome: a case report.

We present a case of persistent right umbilical vein with Noonan's syndrome. Persistence of the right umbilical vein with no intrahepatic portion is an uncommon finding with a review of the literature revealing only five other cases. In these cases drainage was directly into the right atrium, inferior vena cava (IVC) or IVC via the iliac vein. Of the reported cases Noonan's syndrome was confirmed in one case and suspected in a second. This report represents a third case of persistent right umbilical vein with confirmed Noonan's syndrome.

Myocardial motion imaging: a new application of power color flow and frequency-based color flow Doppler in fetal echocardiography.

OBJECTIVE: Myocardial motion imaging is a new way of looking at the fetal heart using power color flow and frequency-based color flow Doppler to demonstrate heart wall movement in color. This study set out to assess the value of myocardial motion imaging in fetal echocardiography in a routine clinical setting. DESIGN: In our hospital, all patients at high risk of carrying a fetus with a cardiac abnormality are offered detailed ultrasound scanning, including fetal echocardiography, at 20 weeks' gestation. A prospective study was carried out over a 2-month period and, in addition to conventional fetal echocardiography, myocardial motion imaging was also carried out on all patients, by means of both power color flow and frequency-based color flow Doppler ultrasound. RESULTS: Myocardial motion imaging demonstrated fetal heart wall movement in 26 of the 27 patients. Myocardial motion imaging using power color flow gave a global view of fetal heart wall movement, demonstrating both atrial and ventricular contraction simultaneously. Myocardial motion imaging using frequency-based color flow Doppler demonstrated atrial and ventricular contractions separately. In addition, as the direction of fetal heart wall motion can be color coded, atrial contractions, ventricular relaxation and ventricular contraction were demonstrated, providing a functional assessment of fetal heart wall movement. Two cases of cardiac abnormality were also studied, one case of hypoplastic left heart syndrome and one case of atrioventricular septal defect. In both cases functional information was obtained using myocardial motion imaging, and the technique also highlighted the anatomical defect. CONCLUSIONS: Myocardial motion imaging produces both a global view of fetal cardiac anatomy and a functional assessment of individual chamber contraction in the normal and abnormal heart. It may prove to be a useful adjunct to conventional color flow Doppler assessment of the fetal heart.

Antenatally detected urinary tract abnormalities: changing incidence and management.

UNLABELLED: To define the incidence of urinary tract abnormalities detected by antenatal ultrasound and assess changes in postnatal management we conducted a retrospective survey using data bases of the nephro-urology unit, obstetric ultrasound and perinatal pathology departments. The birth population (105,542) of the two Nottingham teaching hospitals between January 1984 and December 1993 was divided into two 5-year cohorts, 1984-1988 and 1989-1993. Detailed fetal scanning at 18-20 weeks gestation was introduced in 1989. During this 10-year period, 201 abnormalities of the urinary tract were noted with a 2:1 male to female ratio. The incidence of abnormalities in the first 5 years was 1 in 964 compared to 1 in 364 in the last 5 years. There was a significant increase in the number detected before 20 weeks gestation (12% in 1984-1988 compared to 62% in 1989-1993). Despite the increased incidence of abnormalities detected, the termination rate remained static between the two 5-year cohorts. Only 3 fetuses had intra-uterine intervention and 173 were live-born. Eight infants subsequently died in association with other major congenital abnormalities. The incidence of transient abnormalities (antenatal dilatation with no abnormality noted on postnatal ultrasound) increased from 6% in 1984-1988 to 18% in the 1989-1993 cohort. A more conservative approach to postnatal management is reflected by 71% of infants having operations between 1984 and 1988 compared to 35% in 1989-1993. CONCLUSION: The advent of detailed fetal scanning at 18-20 weeks gestation has significantly increased the detection rate of urinary tract abnormalities with no significant increase in pregnancy termination rates. The need for antenatal intervention is a rare event and most problems can be managed conservatively both pre- and postnatally.

A comparison of power colour flow with frequency based colour flow Doppler in fetal echocardiography.

In this study a direct comparison was made between power colour flow and frequency based colour flow Doppler in the visualization of the ventricular septum and the pulmonary veins of the fetal heart at 18 to 20 weeks. A total of 16 cases were scanned using both power colour flow and frequency based colour flow Doppler. The entire ventricular septum was visualized in all cases using power colour, but in only two cases using frequency based colour Doppler. However, frequency based colour Doppler was capable of identifying part of the ventricular septum in 14 cases. In the assessment of the pulmonary veins, power colour demonstrated both right and left pulmonary veins clearly in 12 cases. There were no cases in which both the right and left pulmonary veins were demonstrated using frequency based colour Doppler.

Mitigating the effects of halofuginone on skin strength by feeding L-proline to broiler chickens.

Two experiments were conducted to determine whether supplemental levels of L-proline in the diets of broiler chickens would mitigate the skin weakening effect caused by continuous feeding of the anticoccidial halofuginone. In Experiment 1, tensile strength and collagen levels in thigh apteria skin were determined at 21 and 42 d of age in male broilers fed 0, .5, and 1% L-proline with either halofuginone (3 mg/kg) or salinomycin (61 mg/kg). In Experiment 2, the same measurements were made on female broilers receiving diets containing halofuginone and supplemented with 0, .5, or 1% L-proline, 1% L-proline through 21 d of age, or 1% L-glutamic acid through 21 d of age, or a diet containing high L-proline feedstuffs (corn gluten meal and ring dried blood meal). In Experiment 1, dermis thickness of thigh apteria was measured in the males at Day 21. Skin strength was increased in male and female broilers fed halofuginone with addition of .5 and 1% L-proline, respectively, at 21 and 42 d of age. Continuous incorporation of synthetic L-proline into diets was shown to improve skin strength in females, whereas diets formulated to contain high levels of L-proline from feedstuffs, 21-d feeding of L-proline, or L-glutamic acid did not increase skin strength.

Outcome of antenatally detected cystic dysplastic kidney disease.

Forty four fetuses with multicystic dysplastic kidney (MCDK) disease recognised on antenatal ultrasound were studied prospectively. In nine aborted fetuses and in five who died in the neonatal period the MCDK disease was bilateral or there were associated lethal abnormalities or syndromes. All surviving infants had unilateral disease and in six (20%) there was significant reflux into the normal contralateral kidney. Since 1988 the management of unilateral MCDK disease has been conservative with no child developing sepsis, hypertension, or malignancy. Serial ultrasound examinations suggest that MCDK lesions involute with time and conservative rather than operative management is favoured.

Dietary and environmental factors affecting skin strength in broiler chickens.

Two experiments were conducted to evaluate dietary and environmental factors involved in skin tensile strength of commercial broilers. In Experiment 1 the effect of added dietary fat (4 or 7%), environmental temperature (25 or 20.5 C after 21 d), and anticoccidial drug (halofuginone or salinomycin fed continuously) were examined factorially using male and female chicks. Skin tensile strength was measured at 21, 35, and 40 d of age. Thickness of the dermal layers was measured from skin taken at Day 35. In Experiment 2, the effect of added dietary fat (0 or 7%), environmental temperature (25 or 18.5 C after 21 d), and anticoccidial drug (halofuginone or salinomycin) were examined factorially using female chicks. Skin strength and collagen content of the skin were measured at 21, 38, and 42 d of age. Skin tensile strength increased with age in both experiments, but female skin strength was subject to periodic decline. Males had significantly strong skin than females. Levels of added fat or environmental temperature did not affect skin strength in either experiment. Continuous feeding of halofuginone significantly (P < .0001) decreased skin strength compared with that of birds fed salinomycin in both experiments. Halofuginone reduced skin strength in females more than males (25 and 9%, respectively). Dermis thickness was correspondingly reduced in the birds consuming halofuginone. In Experiment 2, soluble collagen contents were reduced at all ages in birds consuming halofuginone; insoluble collagen was significantly decreased at 21 d of age. Birds with weakened skin exhibited increased incidence of skin tears during slaughter in a commercial processing plant (P < or = .0043). These results suggest that halofuginone interferes with collagen synthesis, causing decreased collagen formation and reduced skin strength. Neither added dietary fat nor ambient temperature were involved.

Effect of halofuginone on broiler skin strength when used in a shuttle anticoccidial program.

Continuous feeding of the anticoccidial halofuginone to broilers is associated with reduced skin tensile strength and increased skin tearing during processing. The possible mitigating effect of shuttle administration of halofuginone and salinomycin to female broilers was evaluated. Halofuginone or salinomycin were included in the starter and grower diets in all four possible combinations, with anticoccidial omitted from the finisher diets. Starter, grower, and finisher diets were fed to broilers through 3, 6, and 7 wk of age, respectively. Skin strength of pullets fed a diet based on milo and corn (NW) vs a diet based on corn was also compared in a factorial arrangement. Two further treatments were also included: 1) halofuginone-only NW diet supplemented with 2,500 ppm ascorbic acid from 0 to 7 wk; and 2) NW diet reared on wire floor without anticoccidial treatment. Skin tensile strength was determined at 3, 6, and 7 wk of age. Dietary composition had no effect upon skin strength or BW of broilers. Addition of ascorbic acid to the diet containing halofuginone anticoccidial did not improve skin strength. Continuous feeding of halofuginone reduced skin strength whereas withholding anticoccidial and continuous feeding of salinomycin resulted in high skin strength. When halofuginone was used in shuttle feeding programs with salinomycin, there were no differences in skin strength at 7 wk of age compared to birds that were continuously treated with salinomycin. These results suggest halofuginone may be used in a shuttle program either during the starter or grower phase without adverse affect on skin tensile strength at slaughter.

The outcome of fetal ventriculomegaly.

Over a 5 year period 38 cases of fetal ventriculomegaly were diagnosed at Queen's Medical Centre, Nottingham. There were 12 cases of spina bifida and all patients opted for a termination of pregnancy. There were 15 cases of isolated ventriculomegaly comprising seven cases of aqueduct stenosis, four abnormalities of the corpus callosum, one cavum septum pellucidum cyst, one case of porencephaly and two cases of mild lateral ventricular dilatation. The fetuses in this group had a relatively good outcome with five babies showing normal development, three with mild development delay and one with moderate developmental delay. There was one stillbirth and five patients opted for a termination of pregnancy. Associated abnormalities were seen in seven cases and these carried a poor prognosis with one fetus stillborn, one neonatal death, and three patients opted for a termination of pregnancy. Two babies were liveborn, one has severe developmental delay and the other one is normal. The four remaining cases included two Dandy Walker syndrome, one brain tumour and one case of subdural haemorrhage. There were three terminations of pregnancy and one stillbirth in this group. The outcome of fetal ventriculomegaly depends on the presence of associated abnormalities which carry a poor prognosis. It also depends on the timing of the diagnosis as most patients will opt for a termination of pregnancy if the diagnosis is made before 24 weeks gestation. A review of the literature reveals that, excluding terminations, fetuses with isolated ventriculomegaly have an 80% chance of survival and a 50% chance of normal development.

The facial profile in the diagnosis of fetal abnormalities.

In order to assess the significance of fetal facial anomalies detected by ultrasound, a 4 year review was made of all detailed antenatal scans performed in our department. Anomalies were detected in 24 fetuses. All findings were subsequently confirmed. Micrognathia was the most common finding, 38% of these had an abnormal karyotype, and 45% had a recognized skeletal dysplasia. Facial clefting was also commonly seen, both in isolation and associated with other abnormalities. When associated with other abnormalities, 40% of cases with facial clefting had a chromosomal abnormality indicating a need for karyotype analysis in these patients. Other anomalies detected included cebocephaly, hypotelorism, frontal bossing, exophthalmos and hypertelorism. We feel that visualization of the fetal face is an essential part of the assessment of intracranial abnormalities and is valuable in any situation where a chromosomal abnormality or a skeletal dysplasia is suspected.

The ultrasound markers of chromosomal disease: a retrospective study.

Over a 3 year period 37 pregnancies were complicated by a chromosomal abnormality. In the two cases of trisomy 13, holoprosencephaly, facial clefting, polydactyly and growth retardation were seen. In the seven cases of trisomy 18, abnormalities of the extremities, face and heart were common. Growth retardation and diaphragmatic hernia were also demonstrated. In the 21 cases of Down's syndrome the main abnormalities were cardiac, duodenal atresia and subtle digital anomalies. The two fetuses with triploidy showed a large hydropic placenta and holoprosencephaly respectively, and all five cases of Turner's syndrome demonstrated a cystic hygroma two of which were associated with hydrops. From the antenatal scans major anomalies were detected in 18 fetuses, however, chromosomal disease was suspected in only 15 cases. This was in part owing to a high false negative rate for cardiac anomalies (14 cases) in both routine and detailed scans. Owing to the diversity of anomalies present in chromosomal disease full assessment of the fetus is recommended with particular attention to the fetal heart, face, hands and feet. Specific anomalies are suggested for karyotype.

The Dandy-Walker syndrome: the value of antenatal diagnosis.

The Dandy-Walker syndrome can be accurately diagnosed in utero by sonographic demonstration of characteristic morphologic changes in the fetal posterior fossa. Three cases of Dandy-Walker syndrome are described. The associated intracranial and extracranial anomalies are reviewed, and the value of antenatal diagnosis is discussed.

Is a short femur length a useful ultrasound marker for Down's syndrome?

To assess the significance of a short femur in the antenatal diagnosis of Down's syndrome a retrospective analysis was made of all Down's syndrome fetuses diagnosed over a 3 year period. 11 fetuses were found to have had a biparietal diameter and femur length measurement taken between 15 and 24 weeks gestation. Normal graphs were plotted for femur length against gestational age, femur length against biparietal diameter and biparietal diameter/femur length against gestational age. When the Down's syndrome measurements were plotted on the normal graphs there were four abnormal measurements. These four measurements, however, represented two fetuses both of which demonstrated other abnormalities, one cystic hygroma and one duodenal atresia with choroid plexus cysts. We do not feel that the femur length measurement is useful in the antenatal diagnosis of Down's syndrome.

Case report: in utero diagnosis of a vein of Galen aneurysm using colour flow Doppler.

We report the ante-natal diagnosis of a vein of Galen aneurysm using colour flow Doppler at 33 weeks gestation. Ultrasound demonstrated a midline, tubular, echo-free structure superior to the thalamus extending posteriorly. Venous flow was demonstrated within the structure using colour flow Doppler. The diagnosis was confirmed by post-natal sonography. We believe this to be the first ante-natal diagnosis of this condition using colour flow Doppler.