Alexis M. Cahalane

Which is the best current guideline for the diagnosis and management of cystic pancreatic neoplasms? An appraisal using evidence-based practice methods.

Background and aimCystic pancreatic neoplasms (CPNs) are an increasingly diagnosed entity. Their heterogeneity poses complex diagnostic and management challenges. Despite frequently encountering these entities, particularly in the context of the increased imaging of patients in modern medicine, doctors have to rely on incomplete and ambiguous published literature. The aim of this project was to review the guidelines relating to CPNs using evidence-based practice (EBP) methods.MethodsA search of both the primary and secondary literature was performed. Five sets of guidelines were identified which were then methodologically appraised by the AGREE II instrument, a validated and widely utilised tool for guideline development assessment.ResultsThe 2014 ‘Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms’ were found to be the most methodologically sound guidelines, on the basis of both the overall score and average weighted domain score.ConclusionsThe current best guidelines were identified. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument can be used for retrospective review of published guidelines or as a roadmap for guideline-writing groups. All guidelines found were methodologically limited. Further longitudinal/prospective studies are required to improve the level of evidence.Key Points• Cystic pancreatic neoplasms (CPNs) are an increasingly encountered entity in modern medicine.• Clinical uncertainty remains with regard to optimal diagnostic and management strategies.• The Italian consensus guidelines for cystic pancreatic neoplasms are currently the best guidelines.

Acute Pancreatitis Secondary to Gestational Hypertriglyceridaemia

Gestational hypertriglyceridaemia is a rare cause of acute pancreatitis. Its pathophysiology is incompletely understood. Severity scoring and effective management remain challenging. We report a case of acute pancreatitis secondary to gestational hypertriglyceridaemia. We describe the use of computed tomography to provide an alternative determination of severity, as well as plasmapheresis as a means of treating the condition.

Bronchopleural Cutaneous Fistula after Pulmonary Radiofrequency Ablation: Treatment with Low-Adherent Paraffin Gauze Dressing

useful during chemoembolization procedures but has been difficult to incorporate into clinical workflow. C-arm CT using flat panel detectors can produce three-dimensional images using the same angiographic unit as used for DSA (3,4), simplifying the process. The advantages of C-arm CT are of particular importance in patients with lesions in the watershed regions, where identifying multiple tumor-supplying vessels and assessing completeness of lipiodol uptake are difficult using projectional imaging alone. Although use of C-arm CT can increase the single-procedure radiation dose to the patient, complete treatment of a tumor may allow avoidance of subsequent procedures, resulting in a net decrease in radiation and nephrotoxic contrast medium exposure (5). In conclusion, the use of C-arm CT during superselective chemoembolization can provide critical information, especially for tumors in watershed territories served by a bilobar segmental supply. Evaluation of completeness of lipiodol uptake can trigger interrogation of additional vessels if indicated, increasing the operator’s confidence of definitive treatment.

MRI and multiple sclerosis—the evolving role of MRI in the diagnosis and management of MS: a clinician’s perspective

The diagnosis of multiple sclerosis (MS) is based on a history consistent with demyelination of the central nervous system and corresponding physical signs on examination. However, this diagnosis is supported radiologically using magnetic resonance imaging (MRI). At present, MRI serves as the most reliable and widely available biomarker for the practising clinician to measure disease activity and treatment response in MS. As MRI remains central to both the diagnosis and management of MS, this paper provides proposed guidelines for its use in routine clinical practice.

MRI and multiple sclerosis––the evolving role of MRI in the diagnosis and management of MS: the radiologist’s perspective

Magnetic resonance imaging (MRI) plays an integral role in the management of multiple sclerosis (MS), from both diagnostic and therapeutic perspectives. This 2-part review aims to detail the evolving and expanding role of MRI for both radiologists and neurologists. In this article, we discuss the diagnostic criteria for MS relevant to radiologists, as well as its varying imaging manifestations. The role of MRI in therapeutic modification and complications are discussed.

The Diagnostic Accuracy of Contrast-Enhanced CT of the Neck for the Investigation of Sialolithiasis

BACKGROUND AND PURPOSE: Sialolithiasis is a common benign pathology affecting the salivary glands but it is unclear if contrast-enhanced CT, which is commonly used for investigation of head and neck pathology, can identify calculi as accurately as noncontrast CT. The aim of this study was to assess the diagnostic accuracy of contrast-enhanced CT of the neck in the diagnosis of sialolithiasis compared with noncontrast CT of the neck used as the criterion standard. MATERIALS AND METHODS: This was a retrospective, case-control study of 92 consecutive cases in 90 patients who underwent both noncontrast CT of the neck and contrast-enhanced CT of the neck in 2 tertiary referral centers from January 2011 to December 2015 for investigation of sialolithiasis. Axial 3-mm-section images were assessed by a fellowship-trained diagnostic neuroradiologist and diagnostic neuroradiology fellow in consensus. Blinded assessment of the contrast-enhanced CT of the neck was performed first, followed by noncontrast CT of the neck after a 2-week interval. The presence or absence of a stone and stone location and size were documented. Statistical analysis was undertaken to assess the agreement between CT protocols and calculate the sensitivity and specificity of contrast-enhanced CT of the neck. RESULTS: Fifty calculi were identified on noncontrast CT of the neck in 31 cases; and 48 calculi, in 31 cases on contrast-enhanced CT of the neck. No calculi were identified in the remaining 61 cases. The sensitivity and specificity of contrast-enhanced CT of the neck in the detection of sialolithiasis was 96% (95% CI, 86.3%–99.5%) and 100% (95% CI, 94.1%–100%), respectively. The positive predictive value of contrast-enhanced CT of the neck was 100% (95% CI, 92.6%–100%), and the negative predictive value was 96.8% (95% CI, 89%–99.6%). The accuracy of contrast-enhanced CT of the neck in diagnosing the presence or absence of salivary calculi was 98%. CONCLUSIONS: Contrast-enhanced CT of the neck is accurate in the detection of sialolithiasis, with no difference in diagnostic accuracy compared with noncontrast CT of the neck.

Radical Resection of a Late-Relapsed Testicular Germ Cell Tumour: Hepatectomy, Cavotomy, and Thrombectomy

Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.