Albert S. C. Low

Evaluation of the Sendai and 2012 International Consensus Guidelines based on cross-sectional imaging findings performed for the initial triage of mucinous cystic lesions of the pancreas: a single institution experience with 114 surgically treated patients

BACKGROUND The Sendai Consensus Guidelines (SCG) were formulated in 2006 to guide the management of mucinous cystic lesions of the pancreas (CLPs) and were updated in 2012 (International Consensus Guidelines, ICG 2012). This study aims to evaluate the clinical utility of the ICG 2012 with the SCG based on initial cross-sectional imaging findings. METHODS One hundred fourteen patients with mucinous CLPs were reviewed and classified according to the ICG 2012 as high risk (HR(ICG2012)), worrisome (W(ICG2012)), and low risk (LR(ICG2012)), and according to the SCG as high risk (HR(SCG)) and low risk (LR(SCG)). RESULTS On univariate analysis, the presence of symptoms, obstructive jaundice, elevated serum carcinoembryonic antigen (CEA)/carbohydrate antigen (CA)19-9, solid component, main pancreatic duct ≥ 10 mm, and main pancreatic duct ≥ 5 mm was associated with high grade dysplasia/invasive carcinoma in all mucinous CLPs. Increasing number of HR(SCG) or HR(ICG2012) features was associated with a significantly increased likelihood of malignancy. The positive predictive value of HR(SCG) and HR(ICG2012) for high grade dysplasia/invasive carcinoma was 46% and 62.5% respectively. The negative predictive value of both LR(SCG) and LR(ICG2012) was 100%. CONCLUSION Both the guidelines were useful in the initial cross-sectional imaging evaluation of mucinous CLPs. The ICG 2012 guidelines were superior to the SCG guidelines.

SIRveNIB: Selective Internal Radiation Therapy Versus Sorafenib in Asia-Pacific Patients With Hepatocellular Carcinoma

Purpose Selective internal radiation therapy or radioembolization (RE) shows efficacy in unresectable hepatocellular carcinoma (HCC) limited to the liver. This study compared the safety and efficacy of RE and sorafenib in patients with locally advanced HCC. Patients and Methods SIRveNIB (selective internal radiation therapy v sorafenib), an open-label, investigator-initiated, phase III trial, compared yttrium-90 (90Y) resin microspheres RE with sorafenib 800 mg/d in patients with locally advanced HCC in a two-tailed study designed for superiority/detriment. Patients were randomly assigned 1:1 and stratified by center and presence of portal vein thrombosis. Primary end point was overall survival (OS). Efficacy analyses were performed in the intention-to-treat population and safety analyses in the treated population. Results A total of 360 patients were randomly assigned (RE, 182; sorafenib, 178) from 11 countries in the Asia-Pacific region. In the RE and sorafenib groups, 28.6% and 9.0%, respectively, failed to receive assigned therapy without significant cross-over to either group. Median OS was 8.8 and 10.0 months with RE and sorafenib, respectively (hazard ratio, 1.1; 95% CI, 0.9 to 1.4; P = .36). A total of 1,468 treatment-emergent adverse events (AEs) were reported (RE, 437; sorafenib, 1,031). Significantly fewer patients in the RE than sorafenib group had grade ≥ 3 AEs (36 of 130 [27.7%]) v 82 of 162 [50.6%]; P < .001). The most common grade ≥ 3 AEs were ascites (five of 130 [3.8%] v four of 162 [2.5%] patients), abdominal pain (three [2.3%] v two [1.2%] patients), anemia (zero v four [2.5%] patients), and radiation hepatitis (two [1.5%] v zero [0%] patients). Fewer patients in the RE group (27 of 130 [20.8%]) than in the sorafenib group (57 of 162 [35.2%]) had serious AEs. Conclusion In patients with locally advanced HCC, OS did not differ significantly between RE and sorafenib. The improved toxicity profile of RE may inform treatment choice in selected patients.

A comparative study of dynamic contrast-enhanced MRI parameters as biomarkers for anti-angiogenic drug therapy

The aim of the present study was to compare three tracer kinetics methods for the analysis of dynamic contrast‐enhanced (DCE) MRI data, namely the generalized kinetics model, the distributed‐parameter model and the initial area under the tumor tracer curve (IAUC) method, in a Phase I study of an anti‐angiogenic drug ABT ‐869; and to explore their utility as biomarkers. Twenty‐eight patients with a range of tumors formed the study population. DCE MRI performed at baseline and 2 weeks post‐treatment was analyzed using all three methods, yielding percentage changes for various tracer kinetics parameters. Correlation analyzes were performed between these parameters and in relation to drug exposure. The association of these parameters with time‐to‐progression was examined using receiver‐operating characteristic and Kaplan–Meier curves. Significant correlation with drug exposure was found for the following parameters: normalized IAUC (IAUCnorm), fractional interstitial volume ve, fractional intravascular volume v1 and permeability PS. However, only ve and PS were effective in predicting late progression. A decrease in ve of more than 1.7% and a decrease in PS of more than 25.1% observed at 2 weeks post‐treatment could be associated with late progression. All three tracer kinetics methods have biomarker potential for assessing the effects of anti‐angiogenic therapy. Copyright

Are preoperative blood neutrophil‐to‐lymphocyte and platelet‐to‐lymphocyte ratios useful in predicting malignancy in surgically‐treated mucin‐producing pancreatic cystic neoplasms?

The aim of this study was to determine if neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) were predictive of malignancy in mucin‐producing pancreatic cystic neoplasms (MpPCN).Introduction The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN). Methods One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively. Results High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories. Conclusions PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms. J. Surg. Oncol. 2015; 112:366–371.

Delayed diagnosis of intermittent mesenteroaxial volvulus of the stomach by computed tomography: a case report

IntroductionGastric volvulus is a rare condition. Presenting acutely, mesenteroaxial gastric volvulus has characteristic symptoms and may be easily detected with upper gastrointestinal contrast studies. In contrast, subacute, intermittent cases present with intermittent vague symptoms from episodic twisting and untwisting. Imaging in these cases is only useful if performed in the symptomatic interval.Case presentationWe describe a patient with a long history of intermittent chest and epigastric pain. An earlier barium meal was not diagnostic. Diagnosis was finally secured during the current admission by a combination of (1) serum investigations, (2) endoscopy, and finally (3) computed tomography.ConclusionNon-specific and misleading symptoms and signs may delay the diagnosis of intermittent, subacute volvulus. Imaging studies performed in the well interval may be non-diagnostic. Elevated creatine kinase and aldolase of a non-cardiac cause and endoscopic findings of ischaemic ulceration and difficulty in negotiating the pylorus may raise the suspicion of gastric volvulus. In this case, abdominal computed tomography with spatial reconstruction was crucial in securing the final diagnosis.

Difficulties with Prenatal Diagnosis of the Walker-Warburg Syndrome

We describe a postnatally diagnosed case of Walker-Warburg syndrome – a form of congenital muscular dystrophy with lissencephaly and eye abnormalities. We reviewed the literature to highlight its clinico-radiological diagnostic features and discuss the difficulties encountered with prenatal diagnosis, especially in cases with no positive family history. An increased awareness of this rare but lethal condition, and a high index of suspicion during routine antenatal ultrasound, could prompt further advanced fetal ultrasonography and magnetic resonance imaging, and aid in timely prenatal diagnosis, management, and counseling.

Enterolith formation in the roux limb hepaticojejunostomy

Enterolith in the Roux limb of Roux-en-Y hepaticojejunostomy is rare. We report a case of a Roux loop enterolith presenting with recurrent cholangitis. Cholescintigraphy and magnetic resonance imaging aided in the preoperative diagnosis. Intraoperatively, a large enterolith was extracted distal to the biliodigestive anastomosis. A kink of the small bowel was also noted distal to the stone. The mechanism for enterolith formation in the Roux loop is discussed.

Systematic review of the clinical utility and validity of the Sendai and Fukuoka Consensus Guidelines for the management of intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND This systematic review was performed to assess the clinical utility of the Sendai Consensus Guidelines (SCG) and Fukuoka Consensus Guidelines (FCG) for intraductal papillary mucinous neoplasm (IPMN). METHODS A computerized search of PubMed was performed to identify all the studies which evaluated the SCG and FCG in surgically resected, histologically confirmed IPMNs. RESULTS Ten studies evaluating the FCG, 8 evaluating the SCG and 4 evaluating both guidelines were included. In 14 studies evaluating the FCG, out of a total of 2498 neoplasms, 849 were malignant and 1649 were benign neoplasms. Pooled analysis showed that 751 of 1801 (42%) FCG+ve neoplasms were malignant and 599 neoplasms of 697 (86%) FCG-ve neoplasms were benign. PPV of the high risk and worrisome risk groups were 465/986 (47%) and 239/520 (46%) respectively. In 12 studies evaluating the SCG, 1234 neoplasms were analyzed of which 388 (31%) were malignant and 846 (69%) were benign. Pooled analysis demonstrated that 265 of 802 (33%) SCG+ve neoplasms were malignant and 238 of 266 SCG-ve (90%) neoplasms were benign. CONCLUSION The FCG had a higher positive predictive value (PPV) compared to the SCG. However, the negative predictive value (NPV) of the FCG was slightly lower than that of the SCG. Malignant and even invasive IPMN may be missed according to both guidelines.

Prospective study to determine early hypertrophy of the contra-lateral liver lobe after unilobar, Yttrium-90, selective internal radiation therapy in patients with hepatocellular carcinoma

Background: Liver resection is a major curative option in patients presenting with hepatocellular carcinoma. An inadequate functional liver remnant is a major limiting factor precluding liver resection. In recent years, hypertrophy of the functional liver remnant after selective internal radiation therapy hypertrophy has been observed, but the degree of hypertrophy in the early postselective internal radiation therapy period has not been well studied. Methods: We conducted a prospective study on patients undergoing unilobar, Yttrium‐90 selective internal radiation therapy for hepatocellular carcinoma to evaluate early hypertrophy at 4–6 weeks and 8–12 weeks after selective internal radiation therapy. Results: In the study, 24 eligible patients were recruited and had serial volumetric measurements performed. The median age was 66 years (38–75 years). All patients were either Child‐Pugh Class A or B, and 6/24 patients had documented, clinically relevant portal hypertension; 15 of the 24 patients were hepatitis B positive. At 4–6 weeks, modest hypertrophy was seen (median 3%; range −12 to 42%) and this increased at 8–12 weeks (median 9%; range −12 to 179%). No preprocedural factors predictive of hypertrophy were identified. Conclusion: Hypertrophy of the functional liver remnant after selective internal radiation therapy with Yttrium‐90 occurred in a subset of patients but was modest and unpredictable in the early stages. Selective internal radiation therapy cannot be recommended as a standard treatment modality to induce early hypertrophy for patients with hepatocellular carcinoma. (Surgery 2017;160:XXX‐XXX.)

Case of an adult tubular sigmoid duplication with associated vascular and urological abnormality

Gastrointestinal duplication is an uncommon congenital condition that usually presents in the paediatric population and found most frequently in the small bowel. Adult colonic duplications are even rarer, and often masquerade as a variety of conditions making diagnosis and management difficult. We report a unique case of tubular sigmoid duplication in an adult male with bilateral triplication of pelvi-calyceal systems who presented with recurrent urinary tract infection, necrotizing scrotal abscesses and incidental rectal mass on digital rectal examination. This is the first reported case with an associated vascular anomaly. Computed tomography (CT) scan identified the distal sigmoid colonic segment to have dual lumens running in parallel. The distended medial colonic lumen was fecal-laden, with a blind-ending distal end compressing the rectum which corresponded to the anterior rectal mass palpated (Fig. 1a,b). Colonoscopy was not performed because of the expected difficulty with the impacted faeces in the duplicated colonic segment. Interestingly, there was an associated anomalous vascular anatomy (Fig. 1c) of an absent right common iliac artery and a persistent single aberrant umbilical artery, otherwise called a patent impar umbilical artery (IUA), which reconstituted with a slender right-sided artery from proximal abdominal aorta to form the right external iliac artery. The IUA was the larger left ‘branch’ of the aorta, which included a large crossover artery coursing extra-peritoneally. The slender rightsided aortic ‘branch’ was actually the distal aorta. Open anterior resection was offered for the duplicated colon because this limb could not be evaluated in the future for malignant change and the pelvic mass is a contributory factor for the recurrent urinary tract infection in the patient. During the lower midline incision, the crossover artery from the left was carefully identified and