Shear-Wave Elastography of Benign versus Malignant Musculoskeletal Soft-Tissue Masses: Comparison with Conventional US and MRI.

Purpose To examine if shear-wave elastography (SWE) improves the accuracy of diagnosing soft-tissue masses as benign or malignant compared with US alone or in combination with MRI. Materials and Methods Two hundred six consecutive adult participants (mean age, 57.7 years; range, 18-91 years), including 89 men (median age, 56.0 years; range, 21-91 years) and 117 women (median age, 59.1 years; range, 18-88 years), who were referred for biopsy of a soft-tissue mass were prospectively recruited from December 2015 through March 2017. Participants underwent B-mode US, MRI, and SWE prior to biopsy. Three musculoskeletal radiologists independently reviewed US images alone, followed by US and MRI images together, and classified lesions as benign, probably benign, probably malignant, or malignant. For SWE, the area under the receiver operating characteristic (ROC) curve (AUC) was calculated for transverse shear-wave velocity (SWV). Multivariable logistic regression was used to investigate the association between SWE and malignancy alongside individual demographic and imaging variables. Results At histologic examination, 79 of 206 (38%) participants had malignant lesions. SWV showed good diagnostic accuracy for lesions classified as benign or probably benign by US alone (AUC = 0.87 [95% confidence interval {CI}: 0.79, 0.95]). SWV did not provide substantive diagnostic information for lesions classified as probably malignant or malignant, whether the classification was made with or without MRI. However, multivariable modeling indicated that diagnostic accuracy may vary by lesion position (interaction P = .02; superficial, odds ratio [OR] = 17.7 [95% CI: 1.50, 207], P = .02; deep/mixed, OR = 0.24 [95% CI: 0.07, 0.86], P = .03) and participant age (interaction P = .01; eg, age 43 years, OR = 0.72 [95% CI: 0.15, 3.5], P = .69; age 72 years, OR = 0.08 [95% CI: 0.02, 0.37], P = .001). Conclusion Shear-wave elastography can increase accuracy of soft-tissue lesion diagnosis in conjunction with US. However, a single cut-off may not be universally applicable with diagnostic accuracy that is affected by lesion position and patient age. © RSNA, 2018 Online supplemental material is available for this article.

Postoperative Imaging of Sarcomas.

OBJECTIVE: The purpose of this article is to assist radiologists in developing an organized, systematic approach to imaging interpretation in the care of patients who have been surgically treated for sarcoma. CONCLUSION: Postoperative imaging interpretation of sarcoma can be complex and requires an organized, systematic approach that includes review of the patient's clinical and surgical history and pretreatment images to gain context for differentiating recurrence from time-dependent posttreatment changes.

Necrotising pneumonia caused by non-PVL Staphylococcus aureus with 2-year follow-up.

Necrotising pneumonia (NP) is a rare but life-threatening complication of pulmonary infection. It is characterised by progressive necrosis of lung parenchyma with cavitating foci evident upon radiological investigation. This article reports the case of a 52-year-old woman, immunocompetent healthcare professional presenting to Accident and Emergency with NP and Staphylococcus aureus septicaemia. The cavitating lesion was not identified on initial chest X-ray leading to a delay in antimicrobial optimisation. However, the patient went on to achieve a full symptomatic recovery in 1 month and complete radiological recovery at 2-year follow-up. Long-term prognosis for adult cases of NP currently remains undocumented. This case serves as the first piece of published evidence documenting full physiological and radiological recovery following appropriate treatment of NP in an immunocompetent adult patient.

Use of transabdominal ultrasound-guided transjugular portal vein puncture on radiation dose in transjugular intrahepatic portosystemic shunt formation.

PURPOSE: Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose. METHODS: We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded. RESULTS: Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy. CONCLUSION: Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.

Ipsilateral Dual-Site, Same-Sitting Percutaneous Lung Biopsy: A Feasibility Study.

PURPOSE: Patients with thoracic malignancies often have more than one site of pulmonary, nodal or pleural disease within one hemithorax. In addition, large heterogeneous lesions may comprise distinct, mixed pathological entities. Histological analysis of these lesions can alter tumour staging and treatment options. We investigated the feasibility, safety and benefit of performing image-guided percutaneous lung biopsy (PLB) of two lesions in the same hemithorax at a single sitting. MATERIALS AND METHODS: Ten consecutive outpatients with two or more potential disease foci within the same hemithorax were analysed over a 15-month period. The mean age of the patients was 66 years (range 46-81 years). Patients underwent CT-guided coaxial 20G   core biopsy of both lesions, with separate coaxial punctures for each lesion. Patients were managed as per established local institution ambulatory lung biopsy protocol using small-calibre Heimlich-valve chest drain (HVCD) to treat significant post-PLB pneumothorax in an outpatient setting. Data regarding lesion characteristics, diagnoses and complications were recorded. RESULTS: All 10 patients (n = 20 biopsies, 100% technical success) received informative histological diagnosis on both lesions. This altered management in all cases. Although a high rate of pneumothorax occurred (60%; 6/10), only two of these patients required treatment with HVCD. No other significant complications occurred in those patients with small asymptomatic pneumothoraces or those that required HVCD placement. CONCLUSIONS: Dual-site lung biopsy, performed as a single procedure, is potentially a safe and effective technique for diagnosing patients with multiple thoracic lesions, and can provide useful staging information to guide patient management.

Analysis of the quality of information obtained about uterine artery embolization from the internet.

PURPOSE: The Internet is widely used by patients to source health care-related information. We sought to analyse the quality of information available on the Internet about uterine artery embolization (UAE). MATERIALS AND METHODS: We searched three major search engines for the phrase "uterine artery embolization" and compiled the top 50 results from each engine. After excluding repeated sites, scientific articles, and links to documents, the remaining 50 sites were assessed using the LIDA instrument, which scores sites across the domains of accessibility, usability, and reliability. The Fleisch reading ease score (FRES) was calculated for each of the sites. Finally, we checked the country of origin and the presence of certification by the Health On the Net Foundation (HONcode) as well as their effect on LIDA and FRES scores. RESULTS: The following mean scores were obtained: accessibility 48/60 (80%), usability 42/54 (77%), reliability 20/51 (39%), total LIDA 110/165 (67%), and FRES 42/100 (42%). Nine sites had HONcode certification, and this was associated with significantly greater (p < 0.05) reliability and total LIDA and FRES scores. When comparing sites between United Kingdom and United States, there was marked variation in the quality of results obtained when searching for information on UAE (p < 0.05). CONCLUSION: In general, sites were well designed and easy to use. However, many scored poorly on the reliability of their information either because they were produced in a non-evidence-based way or because they lacking currency. It is important that patients are guided to reputable, location-specific sources of information online, especially because prominent search engine rank does not guarantee reliability of information.

Cancer recurrence after surgery: direct and indirect effects of anesthetic agents.

Surgery is of paramount importance in the management of solid tumors as definitive resection can be totally curative. Nonetheless, metastatic recurrence after surgery remains a major cause of morbidity and mortality. Interest in the impact of the perioperative period on cancer recurrence is now growing rapidly, with recent research suggesting that some anesthetics or anesthetic techniques may influence the pathophysiology of postoperative metastatic spread. Our review examines the most widely postulated mechanisms for this, including the impact of anesthesia on neuroendocrine and immune function. We also consider evidence for a direct impact on tumor cell signaling pathways based on findings from organ protection research. These studies have demonstrated that certain volatile anaesthetics confer cytoprotective properties to exposed cells and lead to significant upregulation of Hypoxia Inducible Factor-1α (HIF-1α). This ubiquitous transcription factor exerts many effects in cancer: its activity has been linked with more aggressive phenotypes and poorer clinical prognosis. It is proposed that such an upregulation of HIFs in tumor cells by these anesthetics may contribute to a tumor's recurrence by stimulating cytoprotective or protumorigenic behavior in residual cells. Conversely, other anesthetic agents appear to downregulate HIFs or cause negligible effect and thus may prove more suitable for use in cancer surgery. As anesthetic drugs are given at a point of potentially high vulnerability in terms of dissemination and establishment of metastases, there is an urgent need to determine the most appropriate anesthetic strategy for surgical oncology so that the optimal techniques are used to maximize long-term survival.

Does prophylactic inhaled nitric oxide reduce morbidity and mortality after lung transplantation?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was does prophylactic inhaled nitric oxide (NO) reduce morbidity and mortality after lung transplantation? Altogether 232 papers were found using the reported search, of which six represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Primary graft dysfunction and failure are serious complications in the first few days following lung transplantation. These phenomena are characterised by bilateral infiltrates on chest radiographs, reduced lung compliance and increased FiO(2) requirements and alveolar-arterial gradients; thus necessitating prolonged mechanical ventilation and often leading to significant mortality. The process known as ischaemic-reperfusion injury is thought to underlie primary graft failure. The studies conducted examining the role of inhaled NO in preventing morbidity and mortality after orthotropic lung transplant tend to focus on potential reductions in the incidence of ischaemic-reperfusion injury as the determinant of clinical outcomes. The majority of these are unfortunately non-randomised and/or uncontrolled studies. All the studies discussed, including the two prospective randomised controlled trials, suffer from small sample sizes. Nonetheless, despite their limitations, there are currently, no randomised controlled studies that demonstrate a reduction in morbidity [time to extubation, length of intensive care unit (ICU) or hospital stay] or mortality. As such it is difficult to currently, recommend the routine use of prophylactic inhaled NO in lung transplant surgery. Further studies may outline a benefit in certain types of surgeries, e.g. single-lung transplants or double-lung requiring cardiopulmonary bypass.

Does use of intraoperative cell-salvage delay recovery in patients undergoing elective abdominal aortic surgery?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed was whether the use of intraoperative cell-salvage (ICS) leads to negative outcomes in patients undergoing elective abdominal aortic surgery? Altogether 305 papers were found using the reported search, of which 10 were judged to represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. None of the 10 papers included in the analysis demonstrated that ICS use led to significantly higher incidence of cardiac or septic postoperative complications. Similarly, length of intensive treatment unit (ITU) or hospital stay and mortality in elective abdominal aortic surgery were not adversely affected. Indeed two trials actually show a significantly shorter hospital stay after ICS use, one a shorter ITU stay and another suggests lower rates of chest sepsis. Based on these papers, we concluded that the use of ICS does not cause increased morbidity or mortality when compared to standard practise of transfusion of allogenic blood, and may actually improve some clinical outcomes. As abdominal aortic surgery inevitably causes significant intraoperative blood loss, in the range of 661-3755 ml as described in the papers detailed in this review, ICS is a useful and safe strategy to minimise use of allogenic blood.