Bhanusupriya Somarouthu

Segmental arterial mediolysis: clinical and imaging features at presentation and during follow-up.

PURPOSE To review clinical and imaging features at presentation and during follow-up of patients with a suspected diagnosis of segmental arterial mediolysis (SAM). MATERIALS AND METHODS All cases of SAM diagnosed at a single institution from 2000 to 2010 were included. Diagnosis was based on characteristic radiologic features in the absence of other plausible diagnoses. Medical records were reviewed for demographics, presenting symptoms, and laboratory and imaging findings at presentation and during follow-up. RESULTS Fourteen patients (nine men; mean age, 53 y ± 15) were diagnosed with SAM. Initial presentation included abdominal or flank pain (n = 8) and chest pain, headache, stroke, or suprapubic fullness (n = 1 each). Two patients were asymptomatic. Inflammatory markers were negative in all cases. Imaging at presentation revealed involvement of celiac (n = 7), common hepatic (n = 3), splenic (n = 2), superior mesenteric (n = 5), renal (n = 5), and iliac (n = 2) arteries and the abdominal aorta (n = 1). Imaging demonstrated arterial dissections (n = 10), fusiform aneurysms (n = 6), arterial wall thickening (n = 2), and artery occlusion (n = 1). Clinical follow-up was available in 13 patients (median, 25 mo). Symptoms improved (n = 4), resolved (n = 3), or remained stable (n = 2), and four patients experienced new symptoms. Follow-up imaging, available in 10 patients at a median of 33 months, demonstrated new dissections, aneurysms, or arterial occlusions in five patients, including carotid artery dissection in three. Imaging findings remained stable (n = 3), improved (n = 1), or resolved (n = 1). CONCLUSIONS SAM affects middle-aged and elderly patients. Visceral artery dissections and aneurysms are common. The disease progresses in nearly half the patients. Serial follow-up with computed tomographic angiography and/or magnetic resonance angiography may be necessary to monitor disease progression.

Multimodality imaging features, metastatic pattern and clinical outcome in adult extraskeletal Ewing sarcoma: experience in 26 patients

OBJECTIVE To describe the multimodality imaging features, metastatic pattern and clinical outcome in adult extraskeletal Ewing sarcoma (EES). METHODS In this institutional review board-approved, health insurance portability and accountability act-compliant retrospective study, we included 26 patients (17 females and 9 males; mean age, 36 years; range, 18-85 years) with pathologically confirmed EES seen at our institute between 1999 and 2011, who had imaging of primary tumour. Imaging of primary tumour in all 26 patients and follow-up imaging in 23 was reviewed by two radiologists in consensus. Clinical data were extracted from electronic medical records. RESULTS The most common primary sites were the torso (n = 13), extremities (n = 10) and head and neck (HN) region (n = 3). The mean tumour size was 9 cm (range, 3-22 cm); tumours of the torso were larger than those of other areas (p > 0.05). Compared with the skeletal muscle, tumours were isodense on CT (21/21), hypointense (n = 5) to isointense (n = 14) on T1 weighted image, hyperintense on T2 weighted image (19/19) and were fluorine-18 fludeoxyglucose ((18)F-FDG)-avid [10/10; mean maximum standardized uptake value of 7 (range, 3-11)]. Necrosis (15/26), haemorrhage (5/26) and adjacent organ invasion (14/26) were present without calcification. Median follow-up was 16 months. 5 patients had local recurrence (torso, 3; extremity, 1; and HN, 1). Metastases developed in 11 patients (torso, 7; extremities, 3; and HN, 1; p > 0.05); 8 at presentation, most commonly to lung (9/11), peritoneum (4/11), muscles (4/11) and lymph nodes (4/11). Nine patients (torso, 7; extremity, 1; and HN, 1) died (10 months median survival) (p > 0.05). CONCLUSION Adult EESs are large tumours, which frequently invade adjacent organs and metastasize to the lung. EESs of the torso are larger, have more frequent metastases and poorer outcomes. ADVANCES IN KNOWLEDGE Adult EESs of the torso have poor outcomes compared with other EESs.

Stent-Assisted Coil Embolization of an Intraparenchymal Renal Artery Aneurysm in a Patient With Neurofibromatosis

True renal artery aneurysms are rare. They are generally asymptomatic, however, a few may present with hypertension, rupture, or renal dysfunction secondary to distal embolization. Indications for intervention include aneurysm of ≥2.0 cm in diameter, renovascular hypertension, enlarging aneurysm, associated dissection /rupture, and aneurysms in women of child-bearing age/ pregnancy. Endovascular therapy through coil embolization or stent graft exclusion is the recommended management. Coil embolization of the first and second order branch aneurysms is often associated with distal parenchymal loss and current stent graft technology prohibits use of these endoprostheses in the branch renal arteries. In this report, we describe successful stent-assisted coil embolization of an intraparenchymal aneurysm while preserving the distal parenchyma in a young woman with Neurofibromatosis type 1.

Long-term safety and effectiveness of inferior vena cava filters in patients with stroke

Purpose To assess the long-term safety and clinical effectiveness of inferior vena cava (IVC) filters in patients with stroke. Method and materials In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study, we reviewed the clinical data of patients who had stroke and were treated with an IVC filter from 2002 to 2009. The demographics, clinical data, indications for IVC filter, procedural complications, symptomatic post-filter pulmonary embolism (PE) and deep vein thrombosis (DVT), caval occlusion and incidental, imaging-evident filter-related complications were recorded. Safety was assessed through occurrence of filter-related complications during placement and follow-up. Effectiveness was assessed through occurrence of post-filter fatal and non-fatal PE. Results During this period, 371 patients (224 male; mean age 67.5 years) with stroke received an IVC filter. The stroke was hemorrhagic in 28%, ischemic in 20%, associated with intracranial malignancy in 21% and trauma in 31%. 235 (63%) patients (PE in 159) had venous thromboembolism on imaging. The indications for IVC filter included contraindication to anticoagulation in 251 (68%), prophylaxis in 83 (22%), added protection in 22 (6%) and complication or failure of anticoagulation in 15 (4%). There was one procedural complication. During a follow-up of 1.74±2.36 years, 180 (49%) patients died, three due to post-filter PE and the remainder all due to primary disease. Symptomatic post-filter PE and DVT occurred at a frequency of 15% (54/371) and 16% (60/371), respectively. Of these, 15 (4%) had imaging-proven PE. Three (0.8%) succumbed to post-filter PE. Imaging-proven new or recurrent DVT occurred in 6% and 8%, respectively. Symptomatic caval occlusion was seen in five (5/371, 1.3%). Conclusion IVC filters have an acceptable safety profile in stroke patients. In our cohort, they were effective in preventing life-threatening PE.

Diagnosing deep vein thrombosis.

Abstract In this article, we discuss the approach for diagnosing deep vein thrombosis (DVT) in different patient populations. Clinical features and probability assessment guide further diagnostic tests. D-dimer testing is used as screening test; however, duplex ultrasound remains the primary confirmatory test. Computed tomography and magnetic resonance imaging are used only in select patient populations, such as when ultrasound results are equivocal, in patients suspected of central venous DVT, or as a part of combined protocol for diagnosis of pulmonary embolism. Contrast phlebography and plethysmography do not have much of a role during routine diagnosis of DVT.

Image-Guided Ovarian Mass Biopsy: Efficacy and Safety

PURPOSE Image-guided needle biopsy represents a minimally invasive method for pathologic diagnosis of a mass. This study evaluates the diagnostic yield, accuracy, and safety of ovarian mass biopsy with combined core and fine-needle technique. MATERIALS AND METHODS Medical records of all women at least 18 years of age, referred from gynecologic oncology, who underwent image-guided ovarian mass biopsy from 2001 through 2011 were reviewed. Among 27 patients, ultrasound guidance was used in 13 (48%), six transabdominal and seven transvaginal; computed tomography guidance was used in 14 (52%), nine transabdominal and five transgluteal. Biopsy indications were suspected metastasis (n = 15; 56%), suspected ovarian cancer to be treated with neoadjuvant chemotherapy (n = 10; 37%), and relative contraindication to surgery (n = 2; 7%). Mean maximum lesion dimension was 9.9 cm (range, 2-23 cm), with solid composition in nine (33%), cystic in six (22%), and mixed in 12 (44%). Biopsy pathologic findings were compared versus those of the surgical specimen or, for masses that were not resected, versus the stability of benign masses and response to chemotherapy of malignant masses on follow-up. RESULTS All biopsies yielded a diagnosis. No biopsy-related complications were noted. Eleven patients (41%) did not undergo lesion resection and were followed for an average of 28.8 months (range, 0.3-118.4 mo). In no patient did malignancy develop during clinical follow-up after a benign biopsy diagnosis. Sensitivity and specificity for diagnosis of malignancy were 100% ± 0 (19 of 19) and 88% ± 26 (seven of eight), respectively, for cancer detection. In nine patients (33%) with final pathologic diagnosis of epithelial ovarian cancer, tumor seeding was not observed during a mean follow-up of 44.6 months (range, 1.3-110.2 mo). CONCLUSIONS Image-guided ovarian mass core needle biopsy results in a pathologic diagnosis of benign and malignant masses with high yield, accuracy, and safety.

Advanced High-Grade Serous Ovarian Cancer: Frequency and Timing of Thoracic Metastases and the Implications for Chest Imaging Follow-up

PURPOSE To study the frequency, timing, and associations of thoracic metastases in advanced (stage III and IV) high-grade serous ovarian cancer (HGSC) to help optimize the use of cross-sectional chest imaging. MATERIALS AND METHODS This institutional review board-approved retrospective study with waived informed consent included 186 consecutive patients with pathologically proven advanced HGSC after primary cytoreduction (mean age ± standard deviation, 60 years ± 9.7) who underwent imaging at our tertiary cancer institution from January 2012 to December 2012 with at least 1 year of follow-up, unless there was thoracic metastasis or death. Electronic medical records and all available imaging studies were reviewed to record patient and tumor characteristics, frequency and timing of abdominal and thoracic metastases, and visibility of the first thoracoabdominal metastasis on abdominal images. Patient and tumor characteristics associated with thoracic metastases were studied by using univariate and multivariate Cox proportional analysis. RESULTS After median follow-up of 57 months (interquartile range [IQR], 38-93), 175 patients (94%) developed metastatic disease; each had abdominal disease, and 76 (41%) had thoracic metastases. The first thoracoabdominal metastasis was visible on abdominal images in all 175 patients. The thoracic metastasis-free interval was longer than the abdominal disease-free interval (median, 85 months [IQR, 28-131] vs 14 months [IQR, 7-27], respectively; P < .0001). Presence of disease on abdominal images (hazard ratio, 2.56; 95% confidence interval: 1.35, 4.76) was the only factor independently associated with thoracic metastases. CONCLUSION Thoracic metastases in advanced HGSC rarely occur before abdominal disease, and first thoracoabdominal metastases are invariably visible on abdominal images. Therefore, cross-sectional chest imaging may be deferred until development of abdominal disease, with minimal risk of missing thoracic metastases.

Effects of a music intervention on patients undergoing cerebral angiography: a pilot study

Purpose To test the effect of a music intervention on procedural anxiety, stress response and medication requirements in participants with a cerebral aneurysm or arteriovenous malformation (AVM) undergoing cerebral angiography. Method and materials A prospective pilot study was conducted using an experimental two group pre-test, post-test design. 48 participants were randomly assigned to a control group (standard care) or experimental group (standard care plus self-selected music via overhead stereo system). The stress response was measured by heart rate (HR) and systolic blood pressure (SBP) at baseline, and during and following the procedure. Anxiety was measured by the State Trait Anxiety Inventory for Adults (STAI) before and after the procedure, and total medications administered periprocedurally were recorded. Results 24 participants in each group were enrolled. R-ANCOVA revealed non-significant findings for HR (F=1.4; p=0.27; power=0.38) and SBP (F=2.1; p=0.10; power=0.57). The ANCOVA for anxiety revealed significantly lower STAI scores in the control group (F=3.8; p=0.003) compared with the experimental group. Independent t test analysis for the total doses of fentanyl and midazolam were found to be F=0.08, p=0.78 and F=0.38, p=0.54, respectively. Conclusion A music intervention on participants with a brain aneurysm or AVM undergoing cerebral angiography did not have a statistically significant impact on reducing the stress response, anxiety or medication requirements. Interestingly, participants in the control group had significantly less anxiety after their angiogram than did participants in the experimental group. This pilot study sets the stage for future research to further examine these findings.

Magnetic resonance imaging for hypertrophic cardiomyopathy update.

Objectives Hypertrophic cardiomyopathy (HCM) is a genetic disease of the myocardium. Although many patients remain asymptomatic, sudden cardiac death could be the first manifestation of HCM. Magnetic resonance imaging (MRI) plays an important role in the diagnosis and management of this disease. Methods The epidemiology, pathophysiology, and diagnosis of HCM will be briefly reviewed. This is followed by a discussion on the role of cardiac MRI, recommended protocol, typical imaging findings of HCM, and advanced MRI techniques. Conclusions Although MRI is not intended to be a first-line tool for the assessment of HCM, MRI does provide valuable information to aid the management of patients either at risk of or diagnosed with HCM.

Immune-related tumour response assessment criteria: a comprehensive review

Growing emphasis on precision medicine in oncology has led to increasing use of targeted therapies that encompass a spectrum of drug classes including angiogenesis inhibitors, immune modulators, signal transduction inhibitors, DNA damage modulators, hormonal agents etc. Immune therapeutic drugs constitute a unique group among the novel therapeutic agents that are transforming cancer treatment, and their use is rising. The imaging manifestations in patients on immune therapies appear to be distinct from those typically seen with conventional cytotoxic therapies. Patients on immune therapies may demonstrate a delayed response, transient tumour enlargement followed by shrinkage, stable size, or initial appearance of new lesions followed by stability or response. These newer patterns of response to treatment have rendered conventional criteria such as World Health Organization and response evaluation criteria in solid tumours suboptimal in monitoring changes in tumour burden. As a consequence, newer imaging response criteria such as immune-related response evaluation criteria in solid tumours and immune-related response criteria are being implemented in many trials to effectively monitor patients on immune therapies. In this review, we discuss the traditional and new imaging response criteria for evaluation of solid tumours, review the outcomes of various articles which compared traditional criteria with the new immune-related criteria and discuss pseudo-progression and immune-related adverse events.