Z.C. Traill

Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study

Summary Background Public objection to autopsy has led to a search for minimally invasive alternatives. Imaging has potential, but its accuracy is unknown. We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in a large series of adult deaths. Methods This study was undertaken at two UK centres in Manchester and Oxford between April, 2006, and November, 2008. We used whole-body CT and MRI followed by full autopsy to investigate a series of adult deaths that were reported to the coroner. CT and MRI scans were reported independently, each by two radiologists who were masked to the autopsy findings. All four radiologists then produced a consensus report based on both techniques, recorded their confidence in cause of death, and identified whether autopsy was needed. Findings We assessed 182 unselected cases. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26–40) for CT, 43% (36–50) for MRI, and 30% (24–37) for the consensus radiology report; 10% (3–17) lower for CT than for MRI. Radiologists indicated that autopsy was not needed in 62 (34%; 95% CI 28–41) of 182 cases for CT reports, 76 (42%; 35–49) of 182 cases for MRI reports, and 88 (48%; 41–56) of 182 cases for consensus reports. Of these cases, the major discrepancy rate compared with autopsy was 16% (95% CI 9–27), 21% (13–32), and 16% (10–25), respectively, which is significantly lower (p<0·0001) than for cases with no definite cause of death. The most common imaging errors in identification of cause of death were ischaemic heart disease (n=27), pulmonary embolism (11), pneumonia (13), and intra-abdominal lesions (16). Interpretation We found that, compared with traditional autopsy, CT was a more accurate imaging technique than MRI for providing a cause of death. The error rate when radiologists provided a confident cause of death was similar to that for clinical death certificates, and could therefore be acceptable for medicolegal purposes. However, common causes of sudden death are frequently missed on CT and MRI, and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy. Funding Policy Research Programme, Department of Health, UK.

Ultrasound detection of pneumothorax

OBJECTIVE To determine the accuracy of ultrasound in the detection of pneumothorax. METHODS Prospective blinded study comparing ultrasound, CT and radiographic findings in 29 patients following 41 CT-guided lung biopsies. Ultrasound examination of the chest was limited to the biopsy needle entry site. RESULTS Thirteen patients developed a post-biopsy pneumothorax demonstrated by CT. Seven of these were detected by ultrasound and six were visible on erect chest radiographs. Six of the 13 pneumothoraces were not detected by ultrasound, but five of these were loculated away from the biopsy needle entry site and were therefore in areas not examined during the limited ultrasound examination. There were no false-positive diagnoses of pneumothorax using ultrasound. The positive predictive value for ultrasound was 100% and the negative predictive value was 82%. CONCLUSION In this patient group, ultrasound was more sensitive than erect chest radiography in the detection of pneumothorax. Both have a specificity of 100%. This study suggests that ultrasound may prove valuable in pneumothorax detection when rapid conventional radiography is not possible or practical, and in circumstances where ultrasound is readily available, such as during ultrasound-guided interventional procedures.

Air-trapping in extrinsic allergic alveolitis on computed tomography

AIM To document the phenomenon and distribution of air-trapping on computed tomography in patients with sub-acute extrinsic allergic alveolitis (EAA). PATIENTS AND METHODS A retrospective analysis of high resolution CT scans was performed on 20 patients with proven EAA. All patients had inspiratory scans and 12 patients had expiratory scans. These were assessed for the presence and distribution of: air-trapping, ground-glass opacification and nodularity. RESULTS Areas of decreased attenuation consistent with small airways disease was demonstrated in 15/20 patients on inspiratory scans, and confirmed to be areas of air-trapping in 11/12 patients on expiratory scans. Additional areas of air-trapping were identified in 5/11 patients on expiratory scans. 18/20 patients had found-glass opacification and 14/20 patients demonstrated a nodular patter. CONCLUSION Air-trapping is a common finding in sub-acute extrinsic allergic alveolitis on CT and its detection is enhanced by performing expiratory scans.

Diagnosis of coronary artery disease using minimally invasive autopsy: evaluation of a novel method of post-mortem coronary CT angiography

Diagnosis of coronary artery disease using minimally invasive autopsy: evaluation of a novel method of post-mortem coronary CT angiography I.S.D. Roberts *, R.E. Benamore , C. Peebles , C. Roobottom, Z.C. Traill b Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK Department of Radiology, Churchill Hospital, Oxford, UK Department of Radiology, Southampton General Hospital, Southampton, UK d Peninsula Medical School, University of Plymouth, Plymouth, UK

Brain imaging in neonatal hypoglycaemia

Magnetic resonance imaging studies in two cases of neonatal hypoglycaemia showed cortical and white matter cerebral damage that was most obvious in the occipital lobes. Both cases showed oedema in the parieto-occipital cortex and underlying white matter in the acute phase, with profound atrophy of these regions in the chronic phase.  These findings support those of pathological studies which suggest that hypoglycaemia induces cerebral damage by a mechanism separate from the effects of cerebral hypoxia–ischaemia caused by secondary seizures.

State-of-the-art approaches to detecting early bone metastasis in prostate cancer.

Normal bone biology involves interactions between several cell types and their mediators to control bone remodelling in the dynamic skeleton. Bone remodelling is a balanced process of bone synthesis and resorption (osteoblastic and osteoclastic activity). Osteoblasts, derived from mesenchymal stem cells, form bone over ≈ 3 months by producing collagen and bone proteins, and causing the mineralization of bone matrix. Osteoclasts, cells originally from monocyte/macrophage precursors, break down bone over a 3-week period by releasing acid, collagenases and proteases to dissolve the organic and mineral content of bone [8].

Minimally invasive autopsy employing post-mortem CT and targeted coronary angiography: evaluation of its application to a routine Coronial service

Post‐mortem imaging is a potential alternative to traditional medicolegal autopsy. We investigate the reduction in number of invasive autopsies required by use of post‐mortem CT ± coronary angiography.

High risk medicolegal autopsies: is a full postmortem examination necessary?

Aims Aiming to reduce the numbers of high risk autopsies, we use a minimally invasive approach. HIV/hepatitis C virus (HCV)-positive coronial referrals, mainly intravenous drug abusers, have full autopsy only if external examination, toxicology and/or postmortem CT scan do not provide the cause of death. In this study, we review and validate this protocol. Methods and results 62 HIV/HCV-positive subjects were investigated. All had external examination, 59 toxicology and 24 CT. In 42/62, this minimally invasive approach provided a cause of death. Invasive autopsy was required in 20/62, CT/toxicology being inconclusive, giving a potential rather than definite cause of death. Autopsy findings provided the cause of death in 6/20; in the remainder, a negative autopsy allowed more weight to be given to toxicological results previously regarded as inconclusive. In order to validate selection of cases for invasive autopsy using history, external examination and toxicology, a separate group of 57 non-infectious full autopsies were analysed. These were consecutive cases in which there was a history that suggested drug abuse. A review pathologist, provided only with clinical summary, external findings and toxicology, formulated a cause of death. This formulation was compared with the original cause of death, based on full autopsy. The review pathologist correctly identified a drug-related death or requirement for full autopsy in 56/57 cases. In one case, diagnosed as cocaine toxicity by the review pathologist, autopsy additionally revealed subarachnoid haemorrhage and Berry aneurysm. Conclusions These findings support the use of minimally invasive techniques in high risk autopsies, which result in a two-thirds reduction in full postmortems.

Value of Supraregional Multidisciplinary Review for the Contemporary Management of Testicular Tumors

&NA; The importance of specialist histopathology review in determining the tumor prognostic factors required to guide contemporary testicular cancer management is unknown. In a large series from a tertiary center, we found that expert review altered the pathology reports in 27.7% of cases, with a predicted effect on treatment for 6.5% of patients. Thus, specialist histopathology review is essential for the delivery of personalized testicular cancer care. Purpose: Testicular cancers are an uncommon and highly curable group of tumors that are typically managed by specialist multidisciplinary teams (MDTs). Although recent guidelines have emphasized the importance of tumor prognostic factors in predicting recurrence and personalizing therapy in early‐stage disease, the role of central pathology review in determining these factors is unclear. Patients and Methods: We compared the referral histopathology reports with those obtained after expert central review for all cases reviewed by the UK Thames Valley Cancer Network testicular tumor MDT from August 2004 to September 2012. For cases in which the findings differed, we recorded the effect of the alteration on the estimates of patient prognosis and predicted clinical management using international (European Society of Medical Oncology [ESMO]) and local guidelines. Results: The histopathology reports were altered after central review in 129 of 465 cases (27.7%) referred to the testicular tumor MDT during the study period. These resulted in changes in the estimation of prognosis for 42 patients (9.0% total), with a predicted affect on management according to the ESMO guidelines in 30 cases (6.5%). These proportions were broadly similar for both seminoma and nonseminoma, although the reasons for the discrepancies differed between the 2 (principally errors in categorization of rete testis invasion in seminoma and of lymphovascular invasion in nonseminoma). Changes to the tumor type were uncommon (2 cases). Conclusion: Central MDT review results in frequent, clinically relevant alterations to testicular tumor histopathology reports for testicular tumors. The results of our study demonstrate the importance of specialist MDTs to inform patient‐centered care and ensure best practice in the management of these uncommon cancers.

Changing Practice Evaluation—Stage 1 Seminoma: Outcomes With Adjuvant Treatment Versus Surveillance: Risk Factors for Recurrence and Optimizing Follow-up Protocols—Experience From a Supraregional Center

&NA; Stage 1 seminomas treated by orchiectomy (501 cases) were analyzed to identify the risk factors for recurrence and methods of relapse detection. Rete testis invasion and, more strongly, stromal rete testis invasion increased the risk of relapse. Most recurrences were identified within 2 years of surgery by routine surveillance computed tomography scans. Background: Stage 1 seminoma is frequently cured by radical orchiectomy; however, the management strategies after this diagnosis vary in terms of the use of adjuvant treatment and the nature of the follow‐up protocols. We analyzed stage 1 seminomas treated in the Thames Valley Cancer Network for outcomes to determine whether any factors are predictive of recurrence. We also studied relapses to determine the optimal follow‐up schedule and protocol. Materials and Methods: Data were obtained from centers within the Thames Valley Cancer Network for a 12‐year period from 2004 to 2016. We identified 501 patients with stage 1 seminoma. Results: Relapses occurred in 6.2% of the patients receiving adjuvant treatment and 6.1% of those who did not. The only statistically significant predictive factor identified for relapse was rete testis invasion, and the risk was greater when only stromal rete invasion was included, rather than pagetoid as well. A trend was seen toward an increased risk with increased tumor size, but the difference was not statistically significant. Recurrences developed within the first 2 years after surgery in nearly 75% of cases and were identified through surveillance computed tomography scans in 54.8% of the patients. All relapses were treated curatively. Conclusion: Active surveillance leads to excellent outcomes for stage 1 seminoma; however, adjuvant treatment should be reserved for those with high‐risk disease. Follow‐up schedules should include computed tomography imaging during the first 3 years, long‐term measurement of tumor markers, and mechanisms for patients to be seen promptly should symptoms of tumor recurrence occur.