68Ga-DOTATATE PET/CT: How is it reliable in imaging of cases having clinical suspicion of insulinomas?

PURPOSE: This retrospective study evaluates the value of 68Ga-DOTATATE PET/CT in the diagnosis and localization of insulinomas, whether sporadic, malignant or MEN-1 associated insulinoma. METHOD: The study included 43 patients, having clinical (symptomatic hypoglycemia) and/or laboratory suspicion of having insulinoma (72 h fasting test with serum insulin ≥18 pmol/L), with available pre-operative 68Ga-DOTATATE PET/CT and CE-CT, and diagnosed with insulinoma confirmed by post-operative histopathology. Preoperative imaging was retrospectively analyzed by two radiologists who were blinded to the final diagnosis and to the results of other imaging modalities. Histopathology of specimen was considered the reference standard, and head-to-head comparison of preoperative CE-CT and PET imaging findings. Findings were classified as true positive (TP), true negative (TN), false positive (FP), and false negative (FN) for each modality. Based on these results, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CE-CT, and 68Ga-DOTATATE PET/CT for the detection of insulinoma were calculated. RESULTS: 43 patients (N = 43 patients, L = 56 lesions), out of these, 37 patients had benign sporadic insulinoma (N = 37, L = 42), only 3 patients had malignant sporadic insulinoma (N = 2, L = 9), and 3 patients had MEN-1 syndrome associated insulinoma (N = 3, L = 5). There was no significant statistical difference in sensitivity (P = 0.3058) and PPV (P = 0.5533) for insulinoma localization in the overall cohort with 68Ga-DOTATATE PET/CT (87.5 %, 90.74 %) compared to CE-CT (80.36 %, 93.75 %). CONCLUSION: 68Ga-DOTATATE PET/CT is a non-invasive imaging modality that can identify most insulinomas. Still, it offers limited additional information when the tumor is localized by other anatomic imaging studies, so should be used as an adjunct when imaging studies fail to localize the tumor in insulinoma patients, especially when minimally invasive surgical is intended.

Incidence of incidental positron emission tomography and computed tomography signs of COVID-19 in asymptomatic cancer patients in Egypt.

Background: COVID-19 was first reported in Egypt on 14 February 2020 and continues to be a major threat to public health. Aims: We studied the incidence of incidental positron emission tomography/computed tomography (PET/CT) signs of COVID-19 in asymptomatic cancer patients and compared this with the number of reported COVID-19 cases during the same period. Methods: We included all cancer patients who underwent PET/CT at Misr Radiology Center, Cairo, between 2 May and 7 August 2020. Results: There were 479 patients who underwent PET/CT primarily for follow-up, and 66 (13.78%) of them showed radiological signs of COVID-19, with the peak incidence in weeks 7-8 of the study. This coincided and strongly correlated with the peak incidence of COVID-19 in Egypt (Pearson's correlation coefficient test = 0.943). Conclusion: The incidence of incidental PET/CT signs of COVID-19 was in accordance with the officially reported incidence of COVID-19 in Egypt between 2 May and 7 August 2020. These results could be helpful for implementing and adjusting public health and social measures during the COVID-19 pandemic.

Incidental radiological findings suggestive of COVID-19 in asymptomatic patients.

Despite routine screening of patients for coronavirus disease 2019 (COVID-19) symptoms and signs at hospital entrances, patients may slip between the cracks and be incidentally discovered to have lung findings that could indicate COVID-19 infection on imaging obtained for other reasons. Multiple case reports and case series have been published to identify the pattern of this highly infectious disease. This article addresses the radiographic findings in different imaging modalities that may be incidentally seen in asymptomatic patients who carry COVID-19. In general, findings of COVID-19 infection may appear in computed tomography (CT), magnetic resonance imaging, positron emission tomography-CT, ultrasound, or plain X-rays that show lung or only apical or basal cuts. The identification of these characteristics by radiologists and clinicians is crucial because this would help in the early recognition of cases so that a rapid treatment protocol can be established, the immediate isolation to reduce community transmission, and the organization of close monitoring. Thus, it is important to both the patient and the physician that these findings are highlighted and reported.

Clinical characteristics and outcome of invasive fungal sinusitis in children with hematological malignancies.

Invasive fungal sinusitis (IFS) is a rare disease that requires careful attention and prompts management due to its high mortality among pediatric patients with hematological malignancies. This is a retrospective analysis of pediatric patients with hematological malignancies treated at Children's Cancer Hospital Egypt 57 357 (CCHE) through the period from 2008 till 2016 with proven IFS. Thirty-four patients were diagnosed with IFS. Five (15%) patients had an invasive rhino-cerebral fungal disease. Mucorales were isolated in 50% (n = 17) patients, Aspergillus in 38% (n = 13) patients, and mixed fungal in 12% (n = 4) patients. Sinuses were the only localized site in (45%). Extra-nasal spread was reported in 20 patients; Sino-pulmonary in 35% (n = 12), sino-cerebral in 15% (n = 5), and sino-orbital in 5% (n = 2) patients. Combined antifungal therapy with surgical debridement was done in 59% of patients with a better outcome when compared to those who received only medical antifungal treatment (P = .01). The overall mortality rate at week 12 was 35% (n = 12), and IFS attributable mortality was 20% (n = 7). IFS with cerebral extension carried the highest mortality rate for both 12-week all-cause (P = .04) and fungal-attributable (P = .01) mortality. Pediatric patients with hematologic malignancies are susceptible to invasive fungal sinusitis (IFS). Surgical debridement, combined with antifungal therapy, improves outcomes among those patients. IFS patients with cerebral extension had a higher risk of mortality. LAY SUMMARY: We studied the characteristics of invasive fungal sinusitis in children with hematological malignancies. Mucormycosis was the most common cause. Surgical debridement, combined with anti-fungal therapy, improves outcomes. Patients with rhino-cerebral fungal disease had a higher risk of mortality.

Prognostic significance of the ratio of surgically resected to radiologically detected lung nodules in patients with metastatic osteosarcoma.

The factors that affect the prognosis of patients' metastatic osteosarcoma are still poorly understood. In this study, we investigated a new prognostic factor, the ratio of surgically resected to radiologically detected osteosarcoma lung nodules (SR/RD), which may have predictive value. PATIENTS AND METHODS: Data from patients with metastatic osteosarcoma who underwent metastasectomy between January 2009 and December 2020, in a single center, were reviewed. The relationships between survival and the SR/RD ratio, timing of lung metastases, number of nodules, laterality, and presence of tumor necrosis at first metastasectomy were investigated. RESULTS: Among the 125 metastatic osteosarcoma patients, 80 patients had an SR/RD ratio ≤1. The median duration of follow-up was 72 months, ranging from 6 to 118 months. The five-year overall survival (OS) and postmetastasectomy event-free survival (EFS) for all patients were 36.5% and 18.1%, respectively. The five-year OS of patients with a low SR/RD ratio was 49.6% and that of patients with a high SR/RD ratio was 11.8 (P = 0.001). The two-year postmetastasectomy EFS rates of the high and low ratio groups were 24.1% and 9.4%, respectively (P = 0.001). The SR/RD ratio, number of nodules, and tumor necrosis had significant effects on OS and postmetastasectomy EFS in univariate analysis. A Cox proportional hazard model demonstrated that tumor necrosis and an SR/RD ratio >1 were associated with OS (HR = 1.8 and 2.01) and postmetastasectomy EFS (HR = 1,69 and 1.97). CONCLUSIONS: A high SR/RD ratio of greater than 1 and poor tumor necrosis were significantly associated with poor survival among patients with metastatic osteosarcoma who had lung metastasectomy. The high SR/RD ratio may be a surrogate outcome for incomplete metastatic tumor resection.

Operative management and outcomes in children with pheochromocytoma.

OBJECTIVE: This study aimed to evaluate management and prognosis in children with pheochromocytoma who were treated at an Egyptian tertiary center. METHODS: The authors conducted an 8-year retrospective analysis for 17 patients who were presented from January 2013 to January 2021. Clinical criteria, operative details, and follow-up data were assessed. Overall (OS) and event-free survival (EFS) were estimated by the Kaplan-Meier method. An event was assigned with the occurrence of recurrence or metachronous disease, or death. RESULTS: Median age at diagnosis was 14 years (range: 6-17.5 years). Ten patients (58.8%) were males and seven (41.2%) were females. Hypertension-related symptoms were the main presentations in 15 patients (88%). None of the included children underwent genetic testing. Sixteen patients (94%) had unilateral tumors (right side: 12), whereas only one was presented with bilateral masses. The median tumor size was 7 cm (range: 4-9 cm). Metastatic workup did not reveal any metastatic lesions. All patients underwent open adrenalectomy, and clinical manifestations were completely resolved after surgery. Adjuvant therapy was not administered to any patient. There were no deaths or relapses at a median follow-up time of 40 months, whilst two children had metachronous disease after primary resection. Both were managed by adrenal-sparing surgery, and they achieved a second complete remission thereafter. Five-year OS and EFS were 100% and 88%, respectively. CONCLUSIONS: Complete surgical resection achieves excellent clinical and survival outcomes for pheochromocytoma in children. Meticulous, long-term follow-up is imperative for early detection of metachronous disease to facilitate adrenal-sparing surgery. Genetic assessment for patients and their families is essential; however, it was not available at our institution.

Ultrasound Elastography in the Diagnosis of Malignant Cervical Lymphadenopathy in Children: Can It Replace Surgical Biopsy?

INTRODUCTION: We aimed to assess the accuracy of ultrasound elastography in detecting pediatric malignant cervical lymph nodes, and if this modality can obviate the need for surgical biopsies. MATERIAL AND METHODS: A prospective study from September 2017 to September 2020 included 64 children with persistent cervical lymphadenopathy. Patients were evaluated by meticulous history and physical assessment. B-mode ultrasound, color Doppler, and sonoelastography were conducted thereafter. Elastography scans were classified into five patterns, and patterns from 3 to 5 were considered as malignancies. All children underwent open biopsies followed by pathological examination. Results of tissue diagnosis were compared with patterns of elastography to determine its accuracy. RESULTS: Twenty-eight patients (43.8%) had malignant nodes and the remaining 36 (56.2%) were due to benign causes. Elastography patterns of 1 and 2 were documented in 30 patients, and all of them were diagnosed as benign lesions. Patterns of 3 to 5 were demonstrated in 34 patients. Out of them, 28 were confirmed as malignancies, while 6 children were of benign nature (false positive). Ultrasound elastography achieved sensitivity and specificity of 100 and 85.7%, respectively, and an overall accuracy of 90.6% in the differentiation between malignant and benign entities. The overall accuracy of B-mode and color Doppler were 75 and 82.2%, respectively. CONCLUSION: Elastography is a useful tool that should be added to ultrasound modalities during the diagnosis of pediatric cervical lymphadenopathy. Surgical biopsy in eligible patients is imperative to commence proper therapy or to discharge the child. Despite favorable results of elastography, it cannot replace surgical biopsy or change its indications.

Surgical Resection of Hepatoblastoma: Factors Affecting Local Recurrence.

INTRODUCTION: This study aimed to investigate potential factors contributing to local recurrence after surgical resection of hepatoblastoma (HB). MATERIALS AND METHODS: This retrospective study involving all patients with HB who underwent nontransplant surgery at our tertiary center between July 2007 and July 2018. Data were analyzed regarding microscopic surgical resection margin, tumor multifocality and extracapsular tumor extension in correlation with local recurrence. These relations were assessed by logistic regression. RESULTS: The study included 133 patients with a median age of 1.3 years (range: 0.5-12.8 years). They were classified into 99 cases (74.44%) standard risk and 34 cases (25.56%) high risk. Delayed surgical resection was adopted in all patients. Follow-up to July 2019 revealed that 23 patients (23/133, 17.3%) developed local recurrence, whereas the remaining 110 were locally disease free. Microscopic positive margin (R1) was detected in 29 patients, 8 of them had local recurrence (p = 0.097). Regarding tumor multifocality, there were 12 patients who had multifocal lesions, 3 of them developed local recurrence (p = 0.459). Forty-four patients had extracapsular tumor extension in their pathological reports, 12 of them had local recurrence (p = 0.032). CONCLUSION: Extracapsular tumor extension was a significant prognostic factor of local recurrence after surgical resection of HB. R1 margin does not necessarily require a second resection, and it could achieve accepted results when combined with adjuvant platinum-based chemotherapy. However, patients who are not eligible for surgical resection must be transferred for primary transplantation to obtain favorable outcome.

Surgery in perforated pediatric intestinal lymphoma.

BACKGROUND: Perforation is the most common surgical complication in pediatric intestinal lymphoma. During operation, many surgical decisions are debatable. AIM: To assess the outcome of surgical management of perforated pediatric intestinal lymphoma. PATIENTS AND METHODS: This is a retrospective analysis of all pediatric patients (<18 years old) with intestinal lymphoma treated in our hospital between July 2007 and June 2017. Risk factors for perforation, type of management and outcome in cases of intestinal perforation were analyzed. RESULTS: The study included 240 patients with intestinal lymphoma. Perforation developed in 16 patients (6.7%) with a median age of 5.3 (range: 2.8-15.7) years. Most of the patients (92.5%) had Burkitt lymphoma. The ileum was the most common site of perforation (n = 10). Perforation occurred at presentation (n = 2), during induction (n = 10), during maintenance chemotherapy (n = 2), or at relapse (n = 2). Primary resection anastomosis was done in 12 patients. The resected specimen showed a viable tumor in ten patients. Wound infection (25%) and dehiscence (12.5%) were the most common postoperative complications. The 5-year overall and event-free survivals of patients with perforation were 78.6% and 71.4%, respectively, compared with 85.5% and 81.2% in non-perforated patients; the difference was not significant (p = 0.374 and p = 0.270, respectively). CONCLUSION: Perforation is not an adverse prognostic factor for survival in pediatric intestinal lymphoma patients. Primary resection anastomosis seems to be a safe option if complete tumor resection is feasible.

Ultrasound-guided venous access: "Wire-loaded puncture" technique for paediatric cancer patients.

Ultrasound-guided venous access is becoming a standard technique in many centers worldwide. In small veins and in the pediatric population, successful venous puncture is sometimes followed by resistance in passing the wire. The needle seems to miss the small vein during syringe dismounting, wire mounting and wire advancement through the needle. This work describes a "wire-loaded puncture" technique as a solution for this problem. PATIENTS AND METHODS: Paediatric cancer patients who needed venous access for different indications were included in the study. The wire-loaded technique is described in detail, with special emphasis on the pitfalls of needle guidance under ultrasound in the "out of plane" technique. One-hundred and thirty-nine (139) procedures were initially included using different ultrasound and different access sets. Different operators have participated in the work. Data of patients were retrospectively collected. RESULTS: One-hundred and thirty-nine (139) paediatric cancer patients were initially included in the study. After exclusion of patients with inaccurate data registration, the number of patients decreased to 132. The most common primary pathology was leukemia, 47 cases (33.8%), and Porta-cath was the most commonly used catheter in 70 (50.3%) cases. The right internal jugular vein (IJV) was the most commonly used vein for access in 111 (79.8%) cases. The access was feasible in 130 out of 132 cases from a single puncture. No procedure related complications were recorded. CONCLUSION: The "wire-loaded puncture" technique is a useful technique, particularly in small veins overcoming the relatively common problem of "resisting wire" after a successful vein entry. The technique has a reasonable learning curve and has shown to be reproducible by different operators, machines and venous access sets. A high resolution ultrasound machine is recommended.