Allen Young

Long-term outcomes of aortic root operations for Marfan syndrome: A comparison of Bentall versus aortic valve-sparing procedures

OBJECTIVESnProphylactic aortic root replacement improves survival in patients with Marfan syndrome with aortic root aneurysms, but the optimal procedure remains undefined.nnnMETHODSnAdult patients with Marfan syndrome who had Bentall or aortic valve-sparing root replacement (VSRR) procedures between 1997 and 2013 were identified. Comprehensive follow-up information was obtained from hospital charts and telephone contact.nnnRESULTSnOne hundred sixty-five adult patients with Marfan syndrome (aged > 20 years) had either VSRR (n = 98; 69 reimplantation, 29 remodeling) or Bentall (n = 67) procedures. Patients undergoing Bentall procedure were older (median, 37 vs 36 years; P = .03), had larger median preoperative sinus diameter (5.5 cm vs 5.0 cm; P = .003), more aortic dissections (25.4% vs 4.1%; P < .001), higher incidence of moderate or severe aortic insufficiency (49.3% vs 14.4%; P < .001) and more urgent or emergent operations (24.6% vs 3.3%; P < .001). There were no hospital deaths and 9 late deaths in more than 17 years of follow-up (median, 7.8 deaths). Ten-year survival was 90.5% in patients undergoing Bentall procedure and 96.3% in patients undergoing VSRR (P = .10). Multivariable analysis revealed that VSRR was associated with fewer thromboembolic or hemorrhagic events (hazard ratio, 0.16; 95% confidence interval, 0.03-0.85; P = .03). There was no independent difference in long-term survival, freedom from reoperation, or freedom from endocarditis between the 2 procedures.nnnCONCLUSIONSnAfter prophylactic root replacement in patients with Marfan syndrome, patients undergoing Bentall and valve-sparing procedures have similar late survival, freedom from root reoperation, and freedom from endocarditis. However, valve-sparing procedures result in significantly fewer thromboembolic and hemorrhagic events.

Bilateral internal thoracic artery grafting: Does graft configuration affect outcome?

BACKGROUNDnDespite evidence that bilateral internal thoracic arteries (ITAs) improve long-term survival after coronary artery bypass grafting (CABG), uptake of this technique remains low. We directly compared bilateral ITA graft configurations and examined long-term outcomes.nnnMETHODSnWe reviewed 762 patients who underwent CABG using bilateral ITA grafts at our institution between 1997 and 2014. The outcomes were mortality and a composite revascularization end point defined as need for percutaneous coronary intervention or repeat CABG. Adjusted subgroup analyses were performed using propensity score-adjusted Cox proportional hazards modeling.nnnRESULTSnThe cohort was divided into 4 groups: in situ (left ITA [LITA] anastomosed to the left anterior descending artery [LAD] with in situ right ITA [RITA] anastomosed to the left coronary circulation [239 patients]); in situ LITA-LAD and in situ RITA-right coronary circulation (239 patients); in situ RITA-LAD with in situ LITA-left coronary circulation (185 patients); and in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (99 patients). Over a median follow-up of 1128xa0days, there were 47 deaths, 58 late percutaneous coronary interventions, and 7 repeat CABG procedures. Unadjusted Kaplan-Meier analysis revealed a difference in need for repeat revascularization among the 4 groups (log rank Pxa0=xa0.049). However, after statistical adjustment, graft configuration was not an independent predictor of repeat revascularization or death.nnnCONCLUSIONSnBilateral ITA graft configuration has no independent effect on need for repeat revascularization or long-term survival. Therefore, the simplest technique, determined by individual patient characteristics, should be selected.

Spondylodiscitis associated with button battery ingestion: Prompt evaluation with MRI

Spondylodiscitis is a rare complication of unwitnessed button battery ingestion in children. We report a case of a 20-month-old girl who presented to the emergency room 2 weeks after endoscopic removal of unwitnessed, impacted esophageal battery. Delayed presentation of spondylodiscitis after foreign body removal is related to local injury, pressure necrosis, and perforation. The bilaminar shape of an unknown ingested foreign body should alert the treating physician that it might be a battery rather than a coin. Prompt evaluation with magnetic resonance imaging is essential to prevent neurological deficit and/or spinal deformities.

Combining Prostate Health Index density, magnetic resonance imaging and prior negative biopsy status to improve the detection of clinically significant prostate cancer

To determine the performance of Prostate Health Index (PHI) density (PHID) combined with MRI and prior negative biopsy (PNB) status for the diagnosis of clinically significant prostate cancer (PCa).

Dynamic Contrast Enhanced Magnetic Resonance Imaging Improves Classification of Prostate Lesions: A Study of Pathological Outcomes on Targeted Prostate Biopsy

Purpose: PI‐RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion‐weighted imaging score 3 peripheral zone lesions as PI‐RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. Materials and Methods: We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging‐transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion‐weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1—diffusion‐weighted imaging score 3/nonenhancing/PI‐RADS score 3, group 2—diffusion‐weighted imaging score 3/enhancing/PI‐RADS score 4 or group 3—diffusion‐weighted imaging score 4/PI‐RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. Results: We identified a total of 389 peripheral zone diffusion‐weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Conclusions: Diffusion‐weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1‐weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.

Sensitivity of susceptibility-weighted imaging in detecting developmental venous anomalies and associated cavernomas and microhemorrhages in children

PurposeDevelopmental venous anomalies (DVA) are common neuroimaging abnormalities that are traditionally diagnosed by contrast-enhanced T1-weighted images as the gold standard. We aimed to evaluate the sensitivity of SWI in detecting DVA and associated cavernous malformations (CM) and microhemorrhages in children in order to determine if SWI may replace contrast-enhanced MRI sequences.MethodsContrast-enhanced T1-weighted images were used as diagnostic gold standard for DVA. The presence of DVA was qualitatively assessed on axial SWI and T2-weighted images by an experienced pediatric neuroradiologist. In addition, the presence of CM and microhemorrhages was evaluated on SWI and contrast-enhanced T1-weighted images.ResultsFifty-seven children with DVA (34 males, mean age at neuroimaging 11.2xa0years, range 1xa0month to 17.9xa0years) were included in this study. Forty-nine out of 57 DVA were identified on SWI (sensitivity of 86%) and 16 out of 57 DVA were detected on T2-weighted images (sensitivity of 28.1%). General anesthesia-related changes in brain hemodynamics and oxygenation were most likely responsible for the majority of SWI false negative. CM were detected in 12 patients on axial SWI, but only in six on contrast-enhanced T1-weighted images. Associated microhemorrhages could be identified in four patients on both axial SWI and contrast-enhanced T1-weighted images, although more numerous and conspicuous on SWI.ConclusionSWI can identify DVA and associated cavernous malformations and microhemorrhages with high sensitivity, obviating the need for contrast-enhanced MRI sequences.

Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

Objectives The aim of this study was to assess the positive surgical margin (PSM) and nerve sparing (NS) rates in patients who underwent prostate MRI (pMRI) prior to radical prostatectomy (RP) and compare them with matched, nonimaged control RP patients. Methods We identified 204 men who underwent preoperative pelvic MRI (pelMRI), of whom 176 (86.3%) underwent pMRIs, within 60 days of RP, and compared them (1:1) with a nonim-aged control group matched by surgeon, age, race, body mass index (BMI), prostate-specific antigen (PSA), pathological Gleason score, prostate specimen weight, and RP year. Results The rates of nonfocal extracapsular extension (nfECE) on RP pathology in the MRI and control groups were similar. PSM rates were lower in the MRI group (13.7% vs 19.3%; P=0.14), but the difference did not meet statistical significance; this was also the case in patients with nfECE on RP pathology (27.7% vs 39.5%; P=0.3). NS rates were similar between groups. In the MRI group, 54 (26.5%) patients had an MRI suspicious for nfECE; their PSM rate (20.4%) was higher than that of patients with an MRI not suspicious for nfECE (11.3%; P=0.11), but the difference lacked statistical significance; the former group had significantly lower rates of NS. Limitations of the study include sample power and nonuniform heeding of MRI results by each surgeon. Conclusion MRI did not significantly decrease the rates of PSM, including in the subset of patients with nfECE on final pathology. Even wider resection may be necessary in patients with MRIs suggesting locally-advanced disease. Studies with greater power are needed.

Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter?

Objective We sought to evaluate computed tomography (CT) imaging as a predictor of adrenal tumor pathology. Methods A retrospective review was conducted of patients who underwent unilateral adrenalectomy for an adrenal mass between January 2005 and July 2015. Tumors were classified as benign, indeterminate, or malignant based on preoperative CT findings. Results Of 697 patients who underwent unilateral adrenalectomy, 216 met the inclusion criteria. Pathology was benign in 88.4%, indeterminate in 2.3%, and malignant in 9.3%, with a median tumor diameter of 2.7 cm (interquartile range, 1.7–4.1 cm) and 9.5 cm (interquartile range, 7.1–12 cm) in the benign and malignant groups, respectively (P < 0.001). Of the tumors with benign features on CT, 100% (143/143) had benign final pathology. Conclusions Imaging characteristics of adrenal tumors on CT scan predict benign pathology 100% of the time. Regardless of size, when interpreted as benign on CT scan, laparoscopic adrenalectomy, if technically feasible, should be the technique used when surgery is offered, or close surveillance may be a safe alternative.

Dynamic Contrast Enhanced MRI Improves Classification of Prostate Lesions: A Study of Pathologic Outcomes on Targeted Prostate Biopsy

Purpose: PI‐RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion‐weighted imaging score 3 peripheral zone lesions as PI‐RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. Materials and Methods: We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging‐transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion‐weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1—diffusion‐weighted imaging score 3/nonenhancing/PI‐RADS score 3, group 2—diffusion‐weighted imaging score 3/enhancing/PI‐RADS score 4 or group 3—diffusion‐weighted imaging score 4/PI‐RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. Results: We identified a total of 389 peripheral zone diffusion‐weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Conclusions: Diffusion‐weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1‐weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.

Adult UrologyOncology: Prostate/Testis/Penis/UrethraDynamic Contrast Enhanced Magnetic Resonance Imaging Improves Classification of Prostate Lesions: A Study of Pathological Outcomes on Targeted Prostate Biopsy

Purpose: PI‐RADS™, version 2 stipulates that dynamic contrast enhanced imaging should be used to classify diffusion‐weighted imaging score 3 peripheral zone lesions as PI‐RADS score 3 (dynamic contrast enhanced imaging negative or nonenhancing) or 4 (dynamic contrast enhanced imaging positive or enhancing). However, to our knowledge it is unknown whether dynamic contrast enhanced imaging separates lesions into clinically meaningful pathological groups. We examined whether dynamic contrast enhanced imaging would improve the detection of clinically significant cancer. Materials and Methods: We identified patients without a prior diagnosis of prostate cancer who underwent multiparametric magnetic resonance imaging‐transrectal ultrasound fusion targeted biopsy of peripheral zone lesions with a diffusion‐weighted imaging score of 3 or 4. Each lesion was grouped into 1 of 3 classifications, including group 1—diffusion‐weighted imaging score 3/nonenhancing/PI‐RADS score 3, group 2—diffusion‐weighted imaging score 3/enhancing/PI‐RADS score 4 or group 3—diffusion‐weighted imaging score 4/PI‐RADS score 4. We measured the rate of grade group 2 or greater pathology detected for each lesion group with subgroup analyses in patients with vs without prior negative systematic biopsy. Results: We identified a total of 389 peripheral zone diffusion‐weighted imaging score 3 or 4 lesions in 290 patients. The rate of grade group 2 or greater cancer on biopsy for group 1, 2 and 3 lesions was 8.9%, 21% and 36.5%, respectively (p <0.03). The rate of grade group 2 or greater pathology was higher in group 2 than group 1 lesions in patients with prior negative systematic prostate biopsy (28% vs 5.0%, p <0.001) but not in those without such a biopsy (16% vs 12%, p = 0.5). Group 3 lesions had a higher rate of grade group 2 or greater cancer than group 2 lesions in the biopsy naïve subgroup (46% vs 16%, p = 0.001). However, the rates were similar in patients with prior negative systematic prostate biopsy (27% vs 28%, p = 0.9). Conclusions: Diffusion‐weighted imaging score 3 peripheral zone lesions were more likely to be clinically significant cancer (grade group 2 or greater) if they were dynamic contrast enhanced T1‐weighted imaging positive. That was most apparent in patients with a prior negative systematic prostate biopsy. In such patients including a dynamic contrast enhanced sequence in multiparametric magnetic resonance imaging allowed for optimal lesion risk stratification.