RESUMEN
Hypodense volumes (HDV) in mediastinal masses can be visualized in a computed tomography scan in Hodgkin lymphoma. We analyzed staging CT scans of 1178 patients with mediastinal involvement from the EuroNet-PHL-C1 trial and explored correlations of HDV with patient characteristics, mediastinal tumor volume and progression-free survival. HDV occurred in 350 of 1178 patients (29.7%), typically in larger mediastinal volumes. There were different patterns in appearance with single lesions found in 243 patients (69.4%), multiple lesions in 107 patients (30.6%). Well delineated lesions were found in 248 cases (70.1%), diffuse lesions were seen in 102 cases (29.1%). Clinically, B symptoms occurred more often in patients with HDV (47.7% compared to 35.0% without HDV (p = 0.039)) and patients with HDV tended to be in higher risk groups. Inadequate overall early-18F-FDG-PET-response was strongly correlated with the occurrence of hypodense lesions (p < 0.001). Patients with total HDV > 40 ml (n = 80) had a 5 year PFS of 79.6% compared to 89.7% (p = 0.01) in patients with HDV < 40 ml or no HDV. This difference in PFS is not caused by treatment group alone. HDV is a common phenomenon in HL with mediastinal involvement.
Asunto(s)
Enfermedad de Hodgkin , Neoplasias del Mediastino , Humanos , Masculino , Femenino , Enfermedad de Hodgkin/patología , Enfermedad de Hodgkin/diagnóstico por imagen , Adulto , Neoplasias del Mediastino/patología , Neoplasias del Mediastino/diagnóstico por imagen , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Adulto Joven , Anciano , Adolescente , Mediastino/patología , Mediastino/diagnóstico por imagen , Fluorodesoxiglucosa F18 , Tomografía de Emisión de Positrones , Supervivencia sin ProgresiónRESUMEN
BACKGROUND: Disseminated pulmonary involvement in pediatric Hodgkin lymphoma (pHL) is indicative of Ann Arbor stage IV disease. During staging, it is necessary to assess for coexistence of non-malignant lung lesions due to infection representing background noise to avoid erroneously upstaging with therapy intensification. OBJECTIVE: This study attempts to describe new lung lesions detected on interim staging computed tomography (CT) scans after two cycles of vincristine, etoposide, prednisolone, doxorubicin in a prospective clinical trial. Based on the hypothesis that these new lung lesions are not part of the underlying malignancy but are epiphenomena, the aim is to analyze their size, number, and pattern to help distinguish true lung metastases from benign lung lesions on initial staging. MATERIALS AND METHODS: A retrospective analysis of the EuroNet-PHL-C1 trial re-evaluated the staging and interim lung CT scans of 1,300 pediatric patients with HL. Newly developed lung lesions during chemotherapy were classified according to the current Fleischner glossary of terms for thoracic imaging. Patients with new lung lesions found at early response assessment (ERA) were additionally assessed and compared to response seen in hilar and mediastinal lymph nodes. RESULTS: Of 1,300 patients at ERA, 119 (9.2%) had new pulmonary lesions not originally detectable at diagnosis. The phenomenon occurred regardless of initial lung involvement or whether a patient relapsed. In the latter group, new lung lesions on ERA regressed by the time of relapse staging. New lung lesions on ERA in patients without relapse were detected in 102 (7.8%) patients. Pulmonary nodules were recorded in 72 (5.5%) patients, the majority (97%) being<10 mm. Consolidations, ground-glass opacities, and parenchymal bands were less common. CONCLUSION: New nodules on interim staging are common, mostly measure less than 10 mm in diameter and usually require no further action because they are most likely non-malignant. Since it must be assumed that benign and malignant lung lesions coexist on initial staging, this benign background noise needs to be distinguished from lung metastases to avoid upstaging to stage IV disease. Raising the cut-off size for lung nodules to ≥ 10 mm might achieve the reduction of overtreatment but needs to be further evaluated with survival data. In contrast to the staging criteria of EuroNet-PHL-C1 and C2, our data suggest that the number of lesions present at initial staging may be less important.
Asunto(s)
Enfermedad de Hodgkin , Neoplasias Pulmonares , Estadificación de Neoplasias , Tomografía Computarizada por Rayos X , Humanos , Masculino , Femenino , Enfermedad de Hodgkin/diagnóstico por imagen , Enfermedad de Hodgkin/patología , Enfermedad de Hodgkin/tratamiento farmacológico , Niño , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/patología , Adolescente , Tomografía Computarizada por Rayos X/métodos , Estudios Retrospectivos , Prevalencia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Estudios Prospectivos , Preescolar , Doxorrubicina/uso terapéutico , Etopósido/uso terapéutico , Etopósido/administración & dosificación , Vincristina/uso terapéuticoRESUMEN
BACKGROUND AND OBJECTIVES: Taking a medical history is a core competence of the diagnostic process. At the beginning of their study medical students need to learn and practice the necessary techniques, initially focusing on good structuring and completeness. For this purpose, an interactive software system (ViPATalk) was developed in which the student can train to pose questions to virtual patient avatars in free conversation. At the end, the student receives feedback on the completeness of the questioning and an explanation of the essential items. The use of this software was compared to the traditional format of student role play in a randomized trial. METHODS: The central component of ViPATalk is a chatbot based on the AI language AIML, which generates an appropriate answer based on keywords in the student's question. To enable a realistic use, the student can enter the question via microphone (speech-to-text) and the answer generated by the chatbot is presented as a short video sequence, where the avatar is generated from a real image. Here, the transition between the sequences is seamless, resulting in a continuous movement of the avatar during the conversation. RESULTS: The learning success by practicing with ViPATalk was tested in an anamnestic interview with actors as simulated patients. The completeness of the conversation was evaluated with regard to numerous aspects and also certain behaviors during the conversation. These results were compared with those after practicing using peer role play. CONCLUSIONS: It was found that practicing with ViPATalk was mostly equivalent to the students' role play. In the subsequent survey of the students, the wish was expressed that the ViPATalk software should also be used as an online tool for self-study and that there should be more cases for practicing.
Asunto(s)
Educación de Pregrado en Medicina , Estudiantes de Medicina , Humanos , Avatar , Educación de Pregrado en Medicina/métodos , Programas Informáticos , AprendizajeRESUMEN
OBJECTIVE: To investigate the feasibility and image quality of high-pitch CT pulmonary angiography (CTPA) with reduced iodine volume in normal weight patients. METHODS: In total, 81 normal weight patients undergoing CTPA for suspected pulmonary arterial embolism were retrospectively included: 41 in high-pitch mode with 20 mL of contrast medium (CM); and 40 with normal pitch and 50 mL of CM. Subjective image quality was assessed and rated on a 3-point scale. For objective image quality, attenuation and noise values were measured in all pulmonary arteries from the trunk to segmental level. Contrast-to-noise ratio (CNR) was calculated. Radiation dose estimations were recorded. RESULTS: There were no statistically significant differences in patient and scan demographics between high-pitch and standard CTPA. Subjective image quality was rated good to excellent in over 90% of all exams with no significant group differences (p = 0.32). Median contrast opacification was lower in high-pitch CTPA (283.18 [216.06-368.67] HU, 386.81 [320.57-526.12] HU; p = 0.0001). CNR reached a minimum of eight in all segmented arteries, but was lower in high-pitch CTPA (8.79 [5.82-12.42], 11.01 [9.19-17.90]; p = 0.005). Median effective dose of high-pitch CTPA was lower (1.04 [0.72-1.27] mSv/mGy·cm; 1.49 [1.07-2.05] mSv/mGy·cm; p < 0.0001). CONCLUSION: High-pitch CTPA using ultra-low contrast volume (20 mL) rendered diagnostic images for the detection of pulmonary arterial embolism in most instances. Compared to standard CTPA, the high-pitch CTPA exams with drastically reduced contrast medium volume had also concomitantly reduced radiation exposure. However, objective image quality of high-pitch CTPA was worse, though likely still within acceptable limits for confident diagnosis. CLINICAL RELEVANCE: This study provides valuable insights on the performance of a high-pitch dual-source CTPA protocol, offering potential benefits in reducing contrast medium and radiation dose while maintaining sufficient image quality for accurate diagnosis in patients suspected of pulmonary embolism. KEY POINTS: ⢠High-pitch CT pulmonary angiography (CTPA) with ultra-low volume of contrast medium and reduced radiation dose renders diagnostic examinations with comparable subjective image quality to standard CTPA in most patients. ⢠Objective image quality of high-pitch CTPA is reduced compared to standard CTPA, but contrast opacification and contrast-to-noise ratio remain above diagnostic thresholds. ⢠Challenges of high-pitch CTPA may potentially be encountered in patients with severe heart failure or when performing a Valsalva maneuver during the examination.
Asunto(s)
Hipertensión Pulmonar , Embolia Pulmonar , Humanos , Estudios Retrospectivos , Embolia Pulmonar/diagnóstico por imagen , Arteria Pulmonar/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Angiografía/métodos , Dosis de Radiación , Angiografía por Tomografía Computarizada/métodos , Medios de ContrasteRESUMEN
BACKGROUND: Rebound thymic hyperplasia (RTH) is a common phenomenon caused by stress factors such as chemotherapy (CTX) or radiotherapy, with an incidence between 44% and 67.7% in pediatric lymphoma. Misinterpretation of RTH and thymic lymphoma relapse (LR) may lead to unnecessary diagnostic procedures including invasive biopsies or treatment intensification. The aim of this study was to identify parameters that differentiate between RTH and thymic LR in the anterior mediastinum. METHODS: After completion of CTX, we analyzed computed tomographies (CTs) and magnetic resonance images (MRIs) of 291 patients with classical Hodgkin lymphoma (CHL) and adequate imaging available from the European Network for Pediatric Hodgkin lymphoma C1 trial. In all patients with biopsy-proven LR, an additional fluorodeoxyglucose (FDG)-positron emission tomography (PET)-CT was assessed. Structure and morphologic configuration in addition to calcifications and presence of multiple masses in the thymic region and signs of extrathymic LR were evaluated. RESULTS: After CTX, a significant volume increase of new or growing masses in the thymic space occurred in 133 of 291 patients. Without biopsy, only 98 patients could be identified as RTH or LR. No single finding related to thymic regrowth allowed differentiation between RTH and LR. However, the vast majority of cases with thymic LR presented with additional increasing tumor masses (33/34). All RTH patients (64/64) presented with isolated thymic growth. CONCLUSION: Isolated thymic LR is very uncommon. CHL relapse should be suspected when increasing tumor masses are present in distant sites outside of the thymic area. Conversely, if regrowth of lymphoma in other sites can be excluded, isolated thymic mass after CTX likely represents RTH.
Asunto(s)
Enfermedad de Hodgkin , Linfoma , Hiperplasia del Timo , Neoplasias del Timo , Humanos , Niño , Enfermedad de Hodgkin/diagnóstico por imagen , Enfermedad de Hodgkin/tratamiento farmacológico , Enfermedad de Hodgkin/complicaciones , Hiperplasia del Timo/diagnóstico por imagen , Hiperplasia del Timo/etiología , Recurrencia Local de Neoplasia/diagnóstico por imagen , Recurrencia Local de Neoplasia/tratamiento farmacológico , Linfoma/tratamiento farmacológico , Tomografía Computarizada por Rayos X , Tomografía de Emisión de Positrones/métodos , Neoplasias del Timo/diagnóstico por imagen , Neoplasias del Timo/tratamiento farmacológico , Neoplasias del Timo/complicaciones , Fluorodesoxiglucosa F18/uso terapéutico , RadiofármacosRESUMEN
During the COVID-19 pandemic the third section of the medical examination could be performed on simulation patients and simulators. Their use is also beneficial in forensic medicine, as a higher level of standardization and comparability of examination performance is achieved, and the use of real corpses is often not justifiable for medicolegal reasons. This case reports on the advantages and disadvantages of a simulation in the state examination in which a death certificate was to be completely filled out on the basis of an external postmortem examination on the simulator and an external anamnesis.
RESUMEN
During the COVID-19 pandemic, the third section of the medical examination could be performed with simulation patients. Simulations enable standardized examinations of medical competency according to the educational objectives of the national learning objectives catalogue. The evaluation of student's medical response to child abuse and neglect seems to be an appropriate opportunity to increase attention of prospective physicians for potential child abuse. The presented case reports the simulation of a pediatric nonaccidental trauma.