A case report: Ruptured aneurysm with a wide neck treated by flow diverter stent and coil embolization.

Diagnosis and endovascular treatment for ruptured wide neck aneurysms are challenges in clinics, particularly in developing countries. In the present study, we described a clinical case with a ruptured wide neck aneurysm in Vietnam treated by flow diverter stent and coil embolization. A 77-year-old- female patient had a right droopy eyelid for 2 months. The patient was admitted to hospital on the second day after being presented with a sudden-severe headache. Cerebral computed tomography (CT) and magnetic resonance imaging (MRI) were taken on the second day and fifth day after the onset of the headache. The results showed an aneurysm in the right internal carotid artery but no potential subarachnoid hemorrhage (SAH) was displayed. An uncoagulated blood was found in cerebrospinal fluid indicated by a lumbar puncture test. Digital subtraction angiography provided images with one wide-neck right internal carotid aneurysm. The patient was treated by flow diverter stent and coil embolization and the dual antiplatelet therapy with ticagrelor and aspirin at home. After 45 days, the patient did not face with any complication, no neurological symptoms, and the aneurysm was partially thrombosed indicated by MRI images. These results suggested that a lumbar puncture should be analyzed on the patient with brain aneurysm appeared a sudden severe headache and even no potential SAH on brain MRI or CT was found. The combination of flow diverter stent and coil embolization to treat cases with ruptured wide necked aneurysms should be considered in the future.

Does computer-assisted navigation improve baseplate screw configuration in reverse shoulder arthroplasty? A systematic review and meta-analysis of comparative studies.

Introduction: Navigation technologies have improved accuracy and precision in positioning glenoid components during shoulder arthroplasty. The influence of navigation on baseplate screw placement has not been independently investigated. This study aimed to evaluate and synthesize the best scientific evidence on the influence of intraoperative navigation on the length and number of screws for primary baseplate fixation in reverse total shoulder arthroplasty procedures. Methods: In August 2022, PubMed, Scopus, and Embase databases were accessed. We analyzed the screw purchase length, the number of screws required for the fixation of the baseplate, and the proportion of cases fixed with two screws in all clinical trials, comparing navigation to standard instrumentation for reverse shoulder arthroplasty. Following an evaluation of the heterogeneity of the studies, DerSimonian-Laird random-effects models were utilized to merge data from separate studies. Results: The systematic search revealed a total of 2034 articles. After excluding duplicates and irrelevant studies, 633 shoulder arthroplasties from 6 trials were included in the analysis. The pooled mean difference in screw purchase length was 5.839 mm (95 %CI 4.496 to 7. 182) in favor of navigation (P < .001). In addition, significant differences were also found in the number of screws per case (- 0.547, 95 %CI -0.890 to -0.203, P = .002) and in the proportion of cases fixed with two screws (Odds Ratio 3.182 95 %CI 1.057 to 9.579, P = .040) in favor of the navigation group. Conclusions: Intraoperative navigation improves the baseplate screw placement, allowing for a greater screw purchase length and fewer screws to achieve primary fixation of the glenoid component during reverse shoulder arthroplasty. It is unclear whether these improvements will increase the longevity of the prosthesis or the clinical outcomes of the patients.

Postpartum pyomyoma due to Mycoplasma hominis: A case report.

Pyomyoma is a rare condition that causes fever and abdominal pain associated with pregnancy, especially in the postpartum period. An appropriate diagnosis and early medical intervention are required to prevent serious complications. A 38-year-old primigravida with uterine fibroids had fever from the 11th day after cesarean section. The fever did not resolve despite repeated daily administration of broad-spectrum ß-lactam antibiotics for 2 weeks. Although the physical examination did not show any lower abdominal pain, a pelvic magnetic resonance scan revealed degenerative fibroids, and myomectomy was performed. Yellow-greenish odorless pus inside the uterus was detected, and Mycoplasma hominis was detected in the pus culture. Mycoplasma species are resistant to broad-spectrum penicillin antibiotics and can cause pyomyoma. Pyomyomas may not cause uterine tenderness, and the causative organism may be difficult to identify; therefore, additional imaging studies should be considered.

Acute acalculous cholecystitis and cardiovascular disease, which came first? After two hundred years still the classic chicken and eggs debate: A review of literature.

The existence of a close association between disease of the biliary tract and disease of the heart is known from the mists of time. Acute acalculous cholecystitis (AAC) can be defined as an acute necro inflammatory disease of the gallbladder in the absence of cholelithiasis. AAC is a challenging diagnosis. The atypical clinical onset associated to a paucity and similarity of symptoms and to laboratory data mimicking cardiovascular disease (CVD) often results in under and misdiagnosed cases. Moreover, AAC has commonly a fulminant course compared to calculous cholecystitis and it is often associated with gangrene, perforation and empyema as well as considerable morbidity and mortality (up 50%). Early diagnosis is crucial to a prompt treatment in order to avoid complications and to increase survivability. Even today, although scientific evidence dating two hundred years has shown a close association between AAC and CVD, due to the lack of RCT, there is still a lot of confusion regarding the relationship and consequently the clinical management AAC and CVD. In addition, emergency physicians are not always familiar with transient ECG changes with AAC. The aim of this review was to provide evidence regarding epidemiology, pathophysiology, clinical presentation and treatment of the complex association between AAC and CVD. Our main findings indicate that AAC should be suspected after each general disease leading to hypoperfusion such as cardiovascular diseases or cerebrovascular diseases or major heart or aortic surgery. ECG changes in absence of significant laboratory data for IMA (Acute myocardial infarction) could be related to a misdiagnosed AAC. US - Ultrasonography-plays a key role in the early diagnosis and also in the follow up of AAC. Cholecystostomy and cholecystectomy as unique or sequential represent the two prevailing treatment options for AAC.

Bacillus Cereus bacteremia complicated by brain abscess in a severely immunocompromised patient: Addressing importance of early recognition and challenges in diagnosis.

Bacillus cereus (B. cereus) is a known cause of a food poisoning in the general population. However, it can cause life-threatening sepsis and shock in severely immunocompromised patients with hematologic malignancies, which frequently lead to central nervous system (CNS) infections associated with high mortality and morbidity. In this case report, we describe a patient with a newly diagnosed acute myeloid leukemia that underwent induction chemotherapy and developed B. cereus infection that was associated with septic shock and brain abscesses. Definitive diagnosis of multiple brain abscesses was not manifested with routine microbiological investigation but required the use of 16S ribosomal (rRNA) gene polymerase chain reaction (PCR) sequencing of the resected brain lesion. The patient was eventually treated with 8-week course of intravenous vancomycin and high-dose ciprofloxacin which led to a full recovery. This report highlights the significant risk posed by B. cereus infection in neutropenic patients, the use of 16S rRNA PCR sequencing test for definitive diagnosis and use of combination therapy for successful treatment of B. Cereus CNS infection.

Evaluation of image-guided and surface-guided radiotherapy for breast cancer patients treated in deep inspiration breath-hold: A single institution experience.

INTRODUCTION: Nowadays, deep inspiratory breath-hold is a common technique to reduce heart dose in left-sided breast radiotherapy. This study evaluates the evolution of the breath-hold technique in our institute, from portal imaging during dose delivery to continuous monitoring with surface-guided radiotherapy (SGRT). MATERIALS AND METHODS: Setup data and portal imaging results were analyzed for 98 patients treated before 2014, and SGRT data for 228 patients treated between 2018 and 2020. For the pre-SGRT group, systematic and random setup errors were calculated for different correction protocols. Residual errors and reproducibility of breath-holds were evaluated for both groups. The benefit of using SGRT for initial positioning was evaluated for another cohort of 47 patients. RESULTS: Online correction reduced the population mean error from 3.9 mm (no corrections) to 1.4 mm. Despite online setup correction, deviations greater than 3 mm were observed in about 10% and 20% of the treatment beams in ventral-dorsal and cranial-caudal directions, respectively. However, these percentages were much smaller than with offline protocols or no corrections. Mean absolute differences between breath-holds within a fraction were smaller in the SGRT-group (1.69 mm) than in the pre-SGRT-group (2.10 mm), and further improved with addition of visual feedback (1.30 mm). SGRT for positioning did not improve setup accuracy, but slightly reduced the time for imaging and setup correction, allowing completion within 3.5 min for 95% of fractions. CONCLUSION: For accurate radiotherapy breast treatments using deep inspiration breath-hold, daily imaging and correction is required. SGRT provides accurate information on patient positioning during treatment and improves patient compliance with visual feedback.

Dose-volume predictors of post-radiation primary hypothyroidism in head and neck cancer: A systematic review.

BACKGROUND AND PURPOSE: This systematic review aims to identify radiation dose-volume predictors of primary hypothyroidism after radiotherapy in patients with head and neck cancer (HNC). MATERIALS AND METHODS: We performed a systematic literature search of Medline, EMBASE and Web of Science from database inception to July 1, 2021 for articles that discuss radiation dose-volume predictors of post-radiation primary hypothyroidism in patients with HNC. Data on the incidence, clinical risk factors and radiation dose-volume parameters were extracted. A meta-analysis was performed using the random-effects model to estimate the pooled odds ratio (OR) of thyroid volume as a predictor of the risk of post-radiation hypothyroidism, adjusted for thyroid radiation dosimetry. RESULTS: Our search identified 29 observational studies involving 4,530 patients. With median follow-up durations ranging from 1.0 to 5.3 years, the average crude incidence of post-radiation primary hypothyroidism was 41.4 % (range, 10 %-57 %). Multiple radiation dose-volume parameters were associated with post-radiation primary hypothyroidism, including the thyroid mean dose (Dmean), minimum dose, V25, V30, V35, V45, V50, V30-60, VS45 and VS60. Thyroid Dmean and V50 were the most frequently proposed dosimetric predictors. The pooled adjusted OR of thyroid volume on the risk of post-radiation primary hypothyroidism was 0.89 (95 % confidence interval, 0.85-0.93; p < 0.001) per 1 cc increment. CONCLUSION: Post-radiation primary hypothyroidism is a common late complication after radiotherapy for HNC. Minimizing inadvertent exposure of the thyroid gland to radiation is crucial to prevent this late complication. Radiation dose-volume constraints individualized for thyroid volume should be considered in HNC radiotherapy planning.

Nomogram of Combining CT-Based Body Composition Analyses and Prognostic Inflammation Score: Prediction of Survival in Advanced Epithelial Ovarian Cancer Patients.

PURPOSE: To investigate the value of body composition changes measured by quantitative computer tomography (QCT) in evaluating the prognosis of advanced epithelial ovarian cancer (AEOC) patients who underwent primary debulking surgery (PDS) and adjuvant platinum-based chemotherapy, and constructed a nomogram model for predicting survival in combination with prognostic inflammation score (PIS). METHOD: Fifty-seven patients with AEOC between 2012 and 2016 were retrospectively enrolled. Pre- and post-treatment CT images were used to analyze the body composition biomarkers. The subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), cross-sectional area of paraspinal skeletal muscle area (PMA), skeletal muscle density (SMD), body mineral density (BMD) were measured from two sets of CT images. RESULTS: In multivariate analyses, VFA gain, PMA loss, BMD loss, and PIS were independent risk factors of overall survival (OS) (HR = 3.7, 3.0, 2.8, 1.9, respectively, all p < 0.05). Receiver operating characteristic (ROC) curves showed that the prognostic model combining body composition changes (BCC) and PIS had the highest predictive performance (area under the curve = 0.890). The concordance index (C-index) of the prognostic nomogram was 0.779 (95% CI, 0.673-0.886). Decision curve analysis (DCA) demonstrated the prognostic nomogram had a great distinguishing performance. CONCLUSION: CT-based body composition analyses and PIS were associated with poor OS for AEOC patients who underwent PDS and adjuvant platinum-based chemotherapy. The prognostic nomogram with a combination of BCC and PIS was dependable in predicting survival for AEOC patients during treatment.

The role of early diagnosis of emphysematous cystitis: A case report and literature review.

Emphysematous cystitis (EC) is a rare entity caused by bacteria, which produce gas filled cysts in the bladder wall. We present a case of EC in a 72-year-old woman admitted to Vascular Surgery Department because of diabetic foot syndrome. During the hospital stay, the patient's general condition deteriorated. CT established EC diagnosis. Surgical treatment was inevitable. Salvage cystectomy was performed. Despite macroscopic removal of necrotic tissues, the condition of the patient didn't improve, 75 days past diagnosis of EC she died due to the multi-organ failure. Prompt diagnosis provided by imaging plays a key role in the treatment of EC.

First-in-Man Simultaneous Aortic and Mitral Valve Transcatheter Implantation Using Patient-Customized Prostheses.

Valve disease in the presence of porcelain aorta and severe peripheral artery disease challenge physicians in choosing the appropriate therapy. We used a total transcatheter approach, simultaneously implanting a dedicated mitral and aortic valve prosthesis treating a patient with mitral and aortic valve disease at an extremely high surgical risk. (Level of Difficulty: Advanced.).

Acute Autonomic Neuropathy as a Rare Cause of Severe Arterial Hypertension in a Child.

A 7-year-old boy was admitted to the Pediatric Cardiology Department with blood pressure of 160/120 mmHg accompanied by burning pain in his hands and feet and tachycardia, followed by a seizure attack for the first time in his life, which presented shortly after admission. The child underwent a widespread diagnostic process - including laboratory tests and imaging - showing inconclusive results. Acute autonomic neuropathy was eventually diagnosed and successfully treated with intravenous immunoglobulin. The described case illustrates the need for a careful and open-minded approach to patients with hypertension.

Frequency and spectrum of incidental findings when using chest CT as a primary triage tool for COVID-19.

PURPOSE: To determine the prevalence and spectrum of incidental findings (IFs) identified in patients undergoing chest CT as a primary triage tool for COVID-19. METHODS: In this study 232 patients were triaged in our COVID-19 Screening Unit by means of a chest CT (March 25-April 23, 2020). Original radiology reports were evaluated retrospectively for the description of IFs, which were defined as any finding in the report not related to the purpose of the scan. Documented IFs were categorized according to clinical relevance into minor and potentially significant IFs and according to anatomical location into pulmonary, mediastinal, cardiovascular, breast, upper abdominal and skeletal categories. IFs were reported as frequencies and percentages; descriptive statistics were used. RESULTS: In total 197 IFs were detected in 126 patients (54 % of the participants). Patients with IFs were on average older (54.0 years old, SD 16.6) than patients without IFs (44.8 years old, SD 14.6, P < 0.05). In total 60 potentially significant IFs were detected in 53 patients (23 % of the participants). Most often reported were coronary artery calcifications (n = 23, 38 % of total potentially significant IFs/ 10 % of the total study population), suspicious breast nodules (n = 7, 12 % of total potentially significant IFs/ 3% of the total study population) and pulmonary nodules (n = 7, 12 % of total potentially significant IFs/ 3% of the total study population). CONCLUSION: A considerable number of IFs were detected by using chest CT as a primary triage tool for COVID-19, of which a substantial percentage (23 %) is potentially clinically relevant.

Operator independent reliability of direct augmented reality navigated pedicle screw placement and rod bending.

BACKGROUND: AR based navigation of spine surgeries may not only provide accurate surgical execution but also operator independency by compensating for potential skill deficits. "Direct" AR-navigation, namely superposing trajectories on anatomy directly, have not been investigated regarding their accuracy and operator's dependence.Purpose of this study was to prove operator independent reliability and accuracy of both AR assisted pedicle screw navigation and AR assisted rod bending in a cadaver setting. METHODS: Two experienced spine surgeons and two biomedical engineers (laymen) performed independently from each other pedicle screw instrumentations from L1-L5 in a total of eight lumbar cadaver specimens (20 screws/operator) using a fluoroscopy-free AR based navigation method. Screw fitting rods from L1 to S2-Ala-Ileum were bent bilaterally using an AR based rod bending navigation method (4 rods/operator). Outcome measures were pedicle perforations, accuracy compared to preoperative plan, registration time, navigation time, total rod bending time and operator's satisfaction for these procedures. RESULTS: 97.5% of all screws were safely placed (<2 mm perforation), overall mean deviation from planned trajectory was 6.8±3.9°, deviation from planned entry point was 4±2.7 mm, registration time per vertebra was 2:25 min (00:56 to 10:00 min), navigation time per screw was 1:07 min (00:15 to 12:43 min) rod bending time per rod was 4:22 min (02:07 to 10:39 min), operator's satisfaction with AR based screw and rod navigation was 5.38±0.67 (1 to 6, 6 being the best rate). Comparison of surgeons and laymen revealed significant difference in navigation time (1:01 min; 00:15 to 3:00 min vs. 01:37 min; 00:23 to 12:43 min; p = 0.004, respectively) but not in pedicle perforation rate. CONCLUSIONS: Direct AR based screw and rod navigation using a surface digitization registration technique is reliable and independent of surgical experience. The accuracy of pedicle screw insertion in the lumbar spine is comparable with the current standard techniques.

Long-term Outcomes with Carvedilol versus Propranolol in Patients with Index Variceal Bleed: 6-year Follow-up Study.

AIMS AND BACKGROUND: There is limited information on comparison of clinical outcomes with carvedilol for secondary prophylaxis following acute variceal bleed (AVB) when compared with propranolol. We report long-term clinical and safety outcomes of a randomised controlled trial comparing carvedilol with propranolol with respect to reduction in hepatic venous pressure gradient (HVPG) in patients after AVB. METHODS: We conducted a post-hoc analysis of patients recruited in an open-label randomized controlled trial comparing carvedilol and propranolol following AVB, and estimated long-term rates of rebleed, survival, additional decompensation events and safety outcomes. Rebleed and other decompensations were compared using competing risks analysis, taking death as competing event, and survival was compared using Kaplan-Meier analysis. RESULTS: Forty-eight patients (25 taking carvedilol; 23 propranolol) were followed up for 6 years from randomization. More number of patients on carvedilol had HVPG response when compared with those taking propranolol (72%- carvedilol versus 47.8% propranolol, p = 0.047). Comparable 1-year and 3-year rates of rebleed (16.0% and 24.0% for carvedilol versus 8.9% and 36.7% for propranolol; p = 0.457) and survival (94.7% and 89.0% for carvedilol versus 100.0% and 79.8% for propranolol; p = 0.76) were obtained. New/worsening ascites was more common in those receiving propranolol (69.5% vs 40%; p = 0.04). Other clinical decompensations and complications of liver disease occurred at comparable rates between two groups. Drug-related adverse-events were similar in both groups. CONCLUSION: Despite higher degree of HVPG response, long-term clinical, survival and safety outcomes in carvedilol are similar to those of propranolol in patients with decompensated cirrhosis after index variceal bleed with the exception of ascites that developed less frequently in patients with carvedilol.

Co-existent abdominoperitoneal tuberculosis with endometrial cancer: A diagnostic and surgical challenge.

The presence of abdominoperitoneal tuberculosis (APTB) complicates the diagnosis, staging and management of endometrial cancer. Lymph node involvement in APTB may mimic metastatic lymphadenopathy in patients with endometrial cancer. To our knowledge, there have only been 2 previous case reports on this topic. We will describe 3 cases of endometrial cancer co-existing with APTB. The 1st case is a 57-year-old female who underwent elective total laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLHBSO) and bilateral pelvic lymph node dissection (PLND). The final diagnosis is Stage 3C1 endometrial endometroid carcinoma with mucinous differentiation. The 2nd case is a 70-year-old female with who underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) and PLND. The final diagnosis is a Stage 1A endometrioid adenocarcinoma. The 3rd case is a 63-year-old female who underwent TAHBSO and PLND and the final diagnosis was a mixed high-grade serous (90%) and endometrioid (10%) carcinoma of the endometrium. In these cases, the importance of surgical staging is emphasised to accurately stage endometrial cancer. Moreover, thorough peri-operative optimisations by a multi-disciplinary team are essential to improve the outcomes of surgery.

Diagnosing Covid-19 chest x-rays with a lightweight truncated DenseNet with partial layer freezing and feature fusion.

Due to the unforeseen turn of events, our world has undergone another global pandemic from a highly contagious novel coronavirus named COVID-19. The novel virus inflames the lungs similarly to Pneumonia, making it challenging to diagnose. Currently, the common standard to diagnose the virus's presence from an individual is using a molecular real-time Reverse-Transcription Polymerase Chain Reaction (rRT-PCR) test from fluids acquired through nasal swabs. Such a test is difficult to acquire in most underdeveloped countries with a few experts that can perform the test. As a substitute, the widely available Chest X-Ray (CXR) became an alternative to rule out the virus. However, such a method does not come easy as the virus still possesses unknown characteristics that even experienced radiologists and other medical experts find difficult to diagnose through CXRs. Several studies have recently used computer-aided methods to automate and improve such diagnosis of CXRs through Artificial Intelligence (AI) based on computer vision and Deep Convolutional Neural Networks (DCNN), which some require heavy processing costs and other tedious methods to produce. Therefore, this work proposed the Fused-DenseNet-Tiny, a lightweight DCNN model based on a densely connected neural network (DenseNet) truncated and concatenated. The model trained to learn CXR features based on transfer learning, partial layer freezing, and feature fusion. Upon evaluation, the proposed model achieved a remarkable 97.99 % accuracy, with only 1.2 million parameters and a shorter end-to-end structure. It has also shown better performance than some existing studies and other massive state-of-the-art models that diagnosed COVID-19 from CXRs.

Dosimetric analysis of Deep Inspiratory Breath-hold technique (DIBH) in left-sided breast cancer radiotherapy and evaluation of pre-treatment predictors of cardiac doses for guiding patient selection for DIBH.

INTRODUCTION: The risk of radiotherapy-associated cardiovascular disease has been a concern for decades in breast cancer survivors. The objective of our study is to evaluate the dosimetric benefit of Deep Inspiratory Breath-hold technique (DIBH) on organs-at-risk (OAR) sparing in left-sided breast cancer radiotherapy and to find out pre-treatment predictors of cardiac doses for guiding patient selection for DIBH. MATERIAL AND METHODS: Pre-radiotherapy planning CT scans were done in Free Breathing (FB) and in DIBH [using Active Breathing Coordinator system (ABC™)] in 31 left sided breast cancer patients. 3DCRT plans were generated for both scans. Comparison of anatomical and dosimetric variables were done using paired t test and correlation was evaluated using Pearson correlation. Linear regression was used to get independent predictors of cardiac sparing and Receiver Operating Characteristic (ROC) curve analysis was done to find out the specific threshold of the predictors. RESULTS: There was a 39.15% reduction in mean heart dose in DIBH compared to FB (2.4 Gy vs 4.01 Gy) (p < 0.001), 19% reduction in maximum Left Anterior Descending (LAD) dose and a 9.9% reduction in ipsilateral lung mean dose (p = 0.036) with DIBH. A significant correlation was observed between reduction in Heart Volume in Field (HVIF) and Maximum Heart Depth (MHD) with reduction in mean heart dose. Reduction in HVIF (ΔHVIF) independently predicted cardiac sparing. CONCLUSION: DIBH leads to significant reduction in OAR doses and is suggested for all patients of left-sided breast cancer undergoing radiotherapy. However, HVIF and MHD predicted for cardiac sparing and threshold criteria of ΔHVIF and ΔMHD may be used by centres with high workload to select patients for DIBH.

N-butyl cyanoacrylate embolization of a traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery.

We report a case of combined traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal artery, which presented clinically 1 year after initial head trauma. A 39-year-old male presented with seizure activity after a closed head injury from a fall. He was hospitalized for multiple intraparenchymal hemorrhages and ultimately discharged 2 weeks later without neurologic deficits. One year later, he presented with a new right anterior temporal intraparenchymal hemorrhage after a syncopal event. Selective angiography of the right external carotid artery demonstrated a chronic appearing traumatic laceration of the proximal middle meningeal artery with a 6 × 10 mm pseudoaneurysm and a single fistula with venous varix draining into the lateral pterygoid veins. The pseudoaneurysm and arteriovenous fistula were successfully embolized with n-butyl cyanoacrylate.

Primary recurrent orbital schwannoma treated with surgical excision and Mitomycin-C.

PURPOSE: Primary orbital schwannoma (POS) is a slow growing, benign encapsulated peripheral nerve sheath tumor that occurs infrequently within the orbit. Recurrence of POS is extremely rare. Previous speculations for reasons of recurrence include incomplete excision and tumor seeding. OBSERVATIONS: We present the fifth case reported in the literature to date of POS that had 2 episodes of recurrences within 8 years after diagnosis, in which rapid and insidious relapses were observed after initial surgical resection. This is also the first reported recurrent POS in which topical Mitomycin-C (MMC) has been employed during surgical excision with an aim to prevent further recurrences. CONCLUSIONS: AND IMPORTANCE: Whilst complete surgical excision remained the standard for management for most POS, when there are multiple recurrences and in cases where total excision is not possible, addition of topical MMC may be an option that may bring about tumour regression as demonstrated in our case.

Auto-segmentations by convolutional neural network in cervical and anorectal cancer with clinical structure sets as the ground truth.

BACKGROUND: It is time-consuming for oncologists to delineate volumes for radiotherapy treatment in computer tomography (CT) images. Automatic delineation based on image processing exists, but with varied accuracy and moderate time savings. Using convolutional neural network (CNN), delineations of volumes are faster and more accurate. We have used CTs with the annotated structure sets to train and evaluate a CNN. MATERIAL AND METHODS: The CNN is a standard segmentation network modified to minimize memory usage. We used CTs and structure sets from 75 cervical cancers and 191 anorectal cancers receiving radiation therapy at Skåne University Hospital 2014-2018. Five structures were investigated: left/right femoral heads, bladder, bowel bag, and clinical target volume of lymph nodes (CTVNs). Dice score and mean surface distance (MSD) (mm) evaluated accuracy, and one oncologist qualitatively evaluated auto-segmentations. RESULTS: Median Dice/MSD scores for anorectal cancer: 0.91-0.92/1.93-1.86 femoral heads, 0.94/2.07 bladder, and 0.83/6.80 bowel bag. Median Dice scores for cervical cancer were 0.93-0.94/1.42-1.49 femoral heads, 0.84/3.51 bladder, 0.88/5.80 bowel bag, and 0.82/3.89 CTVNs. With qualitative evaluation, performance on femoral heads and bladder auto-segmentations was mostly excellent, but CTVN auto-segmentations were not acceptable to a larger extent. DISCUSSION: It is possible to train a CNN with high overlap using structure sets as ground truth. Manually delineated pelvic volumes from structure sets do not always strictly follow volume boundaries and are sometimes inaccurately defined, which leads to similar inaccuracies in the CNN output. More data that is consistently annotated is needed to achieve higher CNN accuracy and to enable future clinical implementation.