The Impact of Computed Tomography Measurements of Sarcopenia on Postoperative and Oncologic Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a treatment option for peritoneal metastases (PM) but is associated with significant postoperative morbidity. The aim of this study was to determine the prognostic value of computed tomographic (CT)-measured sarcopenia on postoperative outcomes and survival in patients undergoing CRS-HIPEC for PM from various origins. A retrospective cohort study was conducted between 2012 and 2020. Three-hundred and twelve patients (mean age 57.6 ± 10.3, 34.3% male) were included, of which 88 (28.2%) were sarcopenic. PM from a colorectal origin was the most common in both groups. The proportion of major postoperative complications (Clavien-Dindo ≥ III) was not higher in the sarcopenic group (15.9% in sarcopenic patients vs. 23.2% in nonsarcopenic patients, p = 0.17). The mean Comprehensive Complication Index scores, HIPEC-related toxicities, length of hospital stay, and duration of parenteral nutrition were comparable regardless of sarcopenia status. In the multivariate logistic regression analysis of severe complications, only peritoneal carcinomatosis index reached statistical significance (OR, 1.05; 95% CI, 1.01 to 1.08, p = 0.007). Sarcopenia did not impact origin-specific overall survival on Cox regression analysis. Sarcopenia was not associated with worse rates of postoperative severe complications or worse survival rates. Future prospective studies are required before considering sarcopenia as part of preoperative risk assessment.

Malakoplakia of the colon following renal transplantation in a 73 year old woman: report of a case presenting as intestinal perforation.

BACKGROUND: Malakoplakia is a chronic inflammatory disease characterized by tissue infiltrates of large granular macrophages containing distinctive intracytoplasmic inclusions termed Michaelis-Gutmann (MG) bodies. The genitourinary system is the most commonly involved site, followed by the gastrointestinal tract. Malakoplakia may occur as a complication of primary or secondary immunosuppression and, therefore, renal transplant recipients are at risk. The graft itself or extra-renal sites may be involved. Regarding the latter, six cases of colorectal malakoplakia have been reported following renal transplantation, with all but one patient experiencing significant morbidity. We describe a further example of colorectal malakoplakia following renal transplantation. The other previously reported cases are reviewed. CASE PRESENTATION: A 72 year old female presented with left lower quadrant abdominal pain and vaginal bleeding. She had received a cadaveric renal transplant for chronic renal failure ten months previously. Abdomino-pelvic computerized tomography (CT) scanning demonstrated two lesions in the mesocolon: the first adjacent to the descending colon and the second involving the sigmoid colon. A diagnosis of sub-acute perforated diverticulitis with two phlegmons was proposed. The sigmoid lesion was resected. The descending colon lesion was treated by creation of a cutaneous fistula. Microscopy of the sigmoid lesion showed the typical features of malakoplakia. She was discharged on sulfamethoxazole-trimethoprim. Nine months later, no longer receiving antibiotic therapy, the patient reported lower left quadrant discomfort. CT scanning showed para-rectal and pelvic abdominal masses with cutaneous and intestinal fistulas. Treatment with tazobactam-piperacillin was begun and sulfamethoxazole-trimethoprim was reinstated, with subsequent slow clinical improvement. Subsequent abdominal CT scans have shown persistence of the lesions. CONCLUSIONS: Physicians caring for renal transplant recipients should be aware of colorectal malakoplakia as a rare but serious complication. The onset may be within months or as long as a decade or more following transplantation. The clinical presentation is varied, nonspecific, and will likely suggest more common diseases. Although radiologic imaging is also nonspecific, awareness of malakoplakia is of importance to radiologists when formulating the differential diagnosis of mass lesions of the colorectum in this clinical setting. Definitive diagnosis remains dependent on pathologic examination of a biopsy or surgical resection specimen.

Collagenous colitis presenting as spontaneous perforation in an 80 year old woman: Report of a Case.

BACKGROUND: Perforation of the colon occurring during or shortly following colonoscopy or barium enema is a rare complication of collagenous colitis (CC). "Spontaneous" perforation in CC, in which no instigating factor is identified, is even less common, with only five cases reported to date. We report herein an additional case of spontaneous perforation in previously undiagnosed CC and review the clinical and pathological features of previously reported cases. CASE PRESENTATION: An 80 year old woman presented to the emergency department with abdominal pain preceded by approximately one month of frequent non-bloody diarrhea. Abdominal CT showed parietal thickening of the colon at the splenic flexure with pneumatosis and signs of perforation. Segmental resection was performed. Pathologic examination showed the microscopic findings typical of CC complicated by several deep ulcers and perforation. One day following discharge from hospital abdominal pain and frequent non-bloody diarrhea recurred. The patient was managed conservatively and treated with oral budesonide with resulting resolution of symptoms. CONCLUSIONS: Spontaneous perforation is a rare and serious complication of CC. All patients to date have been female. In contrast to procedure-related perforation, which favors the right colon, spontaneous perforation in CC has in all cases involved the left colon. Knowledge of spontaneous perforation as a potential complication of previously undiagnosed CC may be helpful in the evaluation and management of patients presenting with colonic perforation, especially those with risk factors for CC.

An unusual initial presentation of lupus nephritis as a renal mass.

Lupus nephritis is a frequent manifestation of systemic lupus erythematous. Lupus nephritis usually presents with abnormal urinalysis, proteinuria, and/or renal insufficiency. We report a case of a 48-year-old woman who underwent partial nephrectomy for a fortuitously discovered solid enhancing left kidney mass. No neoplastic cells were found in the biopsy specimen; however, the pathology findings were compatible with immune complex glomerulonephritis with a predominantly membranous distribution, a pattern suggestive of lupus nephritis. The mass effect was apparently due to a dense interstitial lymphocytic infiltrate resulting in a pseudotumor. Further investigation revealed microscopic hematuria with a normal kidney function and no significant proteinuria. Antinuclear antibodies were negative, although anti-DNA and anti-SSA/Rho antibodies were positive. A diagnosis of probable silent lupus nephritis was made and the patient was followed up without immunosuppressive treatment. After two years of follow-up, she did not progress to overt disease. To our knowledge, this represents the first case of lupus nephritis with an initial presentation as a renal mass.

Reproducibility of abdominal aortic aneurysm diameter measurement and growth evaluation on axial and multiplanar computed tomography reformations.

PURPOSE: To compare different methods measuring abdominal aortic aneurysm (AAA) maximal diameter (Dmax) and its progression on multidetector computed tomography (MDCT) scan. MATERIALS AND METHODS: Forty AAA patients with two MDCT scans acquired at different times (baseline and follow-up) were included. Three observers measured AAA diameters by seven different methods: on axial images (anteroposterior, transverse, maximal, and short-axis views) and on multiplanar reformation (MPR) images (coronal, sagittal, and orthogonal views). Diameter measurement and progression were compared over time for the seven methods. Reproducibility of measurement methods was assessed by intraclass correlation coefficient (ICC) and Bland-Altman analysis. RESULTS: Dmax, as measured on axial slices at baseline and follow-up (FU) MDCTs, was greater than that measured using the orthogonal method (p = 0.046 for baseline and 0.028 for FU), whereas Dmax measured with the orthogonal method was greater those using all other measurement methods (p-value range: <0.0001-0.03) but anteroposterior diameter (p = 0.18 baseline and 0.10 FU). The greatest interobserver ICCs were obtained for the orthogonal and transverse methods (0.972) at baseline and for the orthogonal and sagittal MPR images at FU (0.973 and 0.977). Interobserver ICC of the orthogonal method to document AAA progression was greater (ICC = 0.833) than measurements taken on axial images (ICC = 0.662-0.780) and single-plane MPR images (0.772-0.817). CONCLUSION: AAA Dmax measured on MDCT axial slices overestimates aneurysm size. Diameter as measured by the orthogonal method is more reproducible, especially to document AAA progression.

Breast abscesses: evidence-based algorithms for diagnosis, management, and follow-up.

Radiologists who regularly perform breast ultrasonography will likely encounter patients with breast abscesses. Although the traditional approach of surgical incision and drainage is no longer the recommended treatment, there are no clear guidelines for management of this clinical condition. Breast abscesses that develop in the puerperal period generally have a better course than nonpuerperal abscesses, which tend to be associated with longer treatment times and a higher rate of recurrence. The available literature on treatment of breast abscesses is imperfect, with no clear consensus on drainage, antibiotic therapy, and follow-up. By synthesizing the data available from studies published in the past 20 years, an evidence-based algorithm for management of breast abscesses has been developed. The proposed algorithm is easy to follow and has been validated by a multidisciplinary team approach and applied successfully during the past 2 years. Breast abscesses are a challenging clinical condition, and radiologists have a pivotal role in evaluation and follow-up of these lesions.

Clinical validation of a software for quantitative follow-up of abdominal aortic aneurysm maximal diameter and growth by CT angiography.

PURPOSE: To compare the reproducibility and accuracy of abdominal aortic aneurysm (AAA) maximal diameter (D-max) measurements using segmentation software, with manual measurement on double-oblique MPR as a reference standard. MATERIALS AND METHODS: The local Ethics Committee approved this study and waived informed consent. Forty patients (33 men, 7 women; mean age, 72 years, range, 49-86 years) had previously undergone two CT angiography (CTA) studies within 16 ± 8 months for follow-up of AAA ≥ 35 mm without previous treatment. The 80 studies were segmented twice using the software to calculate reproducibility of automatic D-max calculation on 3D models. Three radiologists reviewed the 80 studies and manually measured D-max on double-oblique MPR projections. Intra-observer and inter-observer reproducibility were calculated by intraclass correlation coefficient (ICC). Systematic errors were evaluated by linear regression and Bland-Altman analyses. Differences in D-max growth were analyzed with a paired Student's t-test. RESULTS: The ICC for intra-observer reproducibility of D-max measurement was 0.992 (≥ 0.987) for the software and 0.985 (≥ 0.974) and 0.969 (≥ 0.948) for two radiologists. Inter-observer reproducibility was 0.979 (0.954-0.984) for the three radiologists. Mean absolute difference between semi-automated and manual D-max measurements was estimated at 1.1 ± 0.9 mm and never exceeded 5mm. CONCLUSION: Semi-automated software measurement of AAA D-max is reproducible, accurate, and requires minimal operator intervention.

Failure of uterine fibroid embolization.

OBJECTIVE: To assess the outcomes of patients who underwent uterine fibroid embolization (UFE) and to evaluate factors associated with failure of UFE. DESIGN: Retrospective study. SETTING: University teaching hospital. PATIENT(S): Two hundred thirty-three consecutive patients who underwent UFE from November 1997 to February 2004. INTERVENTION(S): Uterine fibroid embolizations were performed by three interventional radiologists using 355-500-mu polyvinyl alcohol particles. MAIN OUTCOME MEASURE(S): Hysterectomy rate, myomectomy rate, and repeat UFE rate. RESULT(S): With a mean follow-up of 13 months, a total of 22 patients underwent surgery after UFE (9.4%); 16 had hysterectomies (6.9%), and 6 had myomectomies (2.6%). This included 3 patients who underwent repeat UFE and subsequently required surgical intervention. The mean (+/- SEM) time interval between UFE and subsequent treatment was 12.5 +/- 2.0 months. Among patients who required surgery, 13 (59.1%) presented with recurrent menorrhagia, and 5 (22.7%) complained of persistent abdominal pain. Histopathologic examination revealed concomitant findings of adenomyosis in 25% of hysterectomy specimens. Patients who failed UFE were more likely to have had a previous myomectomy (13% vs. 2.4%) and significant reduction in the uterine size 6 months after UFE (57.1% vs. 25.2%). CONCLUSION(S): The overall failure rate of UFE is 9.4%. Failure is mainly due to persistent menorrhagia and abdominal pain. Shrinkage of the uterus after UFE does not necessarily correlate with long-term success of UFE.