Whole and cortical kidney volume predict 5-year post-nephrectomy eGFR in Indian living kidney donors.

AIM: To study the additional utility of pre-nephrectomy whole and cortical kidney volumes (WKV, CKV) in predicting long-term post-nephrectomy kidney function in Indian living kidney donors (LKDs). METHODS: This retrospective cohort study included all LKDs who underwent nephrectomy between 1 January 2006 and 31 December 2015 at our centre, had pre-nephrectomy height, weight and computed tomography (CT) angiography with arterial and nephrographic phase documented, and 5-year post-nephrectomy creatinine values measured. Correlation between body surface area (BSA) adjusted pre-nephrectomy total CKV, WKV and pre-nephrectomy CKD EPI eGFR; BSA-adjusted remnant pre-nephrectomy CKV (rCKV), WKV (rWKV) and 5-year post-nephrectomy CKD EPI creatinine eGFR (5yeGFRCr ); predictors of 5yeGFRCr < 70% of pre-nephrectomy CKD EPI creatinine eGFR (pre-eGFRCr ), and an equation to predict 5yeGFRCr from pre-nephrectomy variables were calculated. RESULTS: A total of 196 LKDs (74% female, mean age 41.7 ± 11.0 years) were included in the study. Total WKV showed higher correlation with pre-nephrectomy eGFR than CKV, the highest with CKD EPI cystatin eGFR. Remnant WKV showed higher correlation than rCKV with post-nephrectomy eGFRCr and this increased over time. Older age, lower rWKV or rCKV, higher BSA, and higher pre-eGFRCr identified LKDs with 5yeGFRCr < 70% of pre-eGFRCr , with rCKV identifying a higher proportion (4.5%) of such LKDs. A model including rWKV or rCKV predicted 5yeGFRCr better than one including age, gender, BSA and pre-eGFRCr alone. CONCLUSION: Inclusion of pre-nephrectomy remnant CKV and WKV into models for 5yeGFRCr and sub-optimal post-nephrectomy adaptation in Indian LKDs improves their accuracy. CKD EPI cystatin eGFR correlates better with functional renal mass.

Prognostic significance of MR identified EMVI, tumour deposits, mesorectal nodes and pelvic side wall disease in locally advanced rectal cancer.

AIM: To study the prognostic significance of MRI identified tumour deposits (TD), extramural vascular invasion (EMVI), lymph node metastases (LNM) and pelvic sidewall (PSW) disease in rectal cancer. METHODS: This IRB approved study was conducted on patients with stage IIA-IIIC rectal adenocarcinoma treated with neoadjuvant long course chemoradiotherapy (LCCRT) and total mesorectal excision (TME) type of surgery between 2012-2018. A radiologist blinded to outcome reviewed staging and restaging magnetic resonance imaging (MRI) for TD, EMVI, LNM and PSW. The agreement between four radiologists was studied and we obtained outcome data from a prospectively maintained database. The prognostic significance of imaging findings was assessed. RESULTS: A total of 297 (186 males) patients with a mean age of 47.3 (SD14.4) years were included in the study. The majority had T3 (n = 206) or T4 (n = 59) stage disease. The mean duration of follow-up was 49.3 ± 25 months (6.6-101 months). 5-year overall (OS) and disease-free survival (DFS) was 84% and 74%, respectively. Staging and restaging MRI had EMVI in 49.5% and 31.3%; TD in 47.5% and 31.6%; LNM in 61.1% and 38.1% and PSW in 11.4% and 6.1%. OS was adversely affected by EMVI, TD and PSW with the adjusted HR (aHR) of 3.32, 3.31, 3.27 for staging MRI and 2.99, 3.1, 2.81 for restaging MRI, respectively, p < 0.05. DFS was affected by EMVI (aHR = 1.85, 2.33) and TD (aHR = 1.83, 2.19), p < 0.05. Persistence of these findings after LCCRT led to worst outcome. Intra- and interobserver agreement for EMVI, TD and LN was 0.789, 0.734, 0.406 and 0.449, 0.354, 0.376, respectively, p < 0.001. CONCLUSIONS: MRI identified that TD, EMVI and PSW disease are independent poor prognostic indicators in rectal cancer patients. Interobserver agreement for these findings was moderate to fair.

Safety and utility of kidney biopsy in patients with estimated glomerular filtration rate < 30 ml/min/1.73 m2.

AIM: Kidney biopsy (KBx) is the gold standard for evaluation of kidney disease, but is associated with a higher risk of complications in patients with reduced glomerular filtration rate (GFR). We studied the safety and utility of KBx in patients with eGFR <30 ml/min/1.73 m2 . METHODS: Consecutive adult patients with eGFR <30 ml/min/1.73 m2 , who were planned for a KBx and consented to participate were prospectively enrolled. Patients with solitary/transplant kidney or acute kidney injury were excluded. Haemoglobin was checked on the day of KBx and repeated 18-24 h later along with a screening ultrasound. Post-KBx complications were noted and their risk-factors analysed. The utility of the KBx was graded as effecting significant, some, or no change to subsequent management. RESULTS: Of the 126 patients included, 75% were male, 27.7% were diabetic, and the median eGFR was 13.5 ml/min/1.73m2 . Major complications occurred in 5.6%. Peri-renal haematomas were detected in 37.3%, and haematomas ≥2 cm were significantly more frequent in those with eGFR <15 ml/min/1.73 m2 (29.2% vs. 13%, p = .032). Dialysis was a risk factor, while pre KBx blood transfusion, diabetes and higher serum albumin were protective against any complication. KBx was more likely to make a significant difference in management in those with eGFR 15-29 ml/min/1.73m2 (44.1% vs. 11.1%, p < .001). Increasing age, lower serum creatinine and albumin were independently associated with KBx utility. CONCLUSION: KBx is relatively safe in severe kidney disease but its risk to benefit balance needs to be carefully considered when eGFR is <15 ml/min/1.73m2 .

Does MRI help in the pre - operative evaluation of pelvic fracture urethral distraction defect? - A pilot study.

OBJECTIVES: To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)? MATERIALS AND METHODS: In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome. RESULTS: Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome. Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20). CONCLUSIONS: MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED. Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.

Enteric duplication in children: Experience from a tertiary center in South India.

BACKGROUND: Enteric duplications (EDs) are rare aberrations of the embryonic gut. This study was undertaken to define the clinical characteristics and management challenges of this unusual entity in the Indian population. MATERIALS AND METHODS: Hospital records of 35 children with 38 ED operated between 2003 and 2014 were analyzed and followed up. RESULTS: The median age at presentation was 285 days (range 1-day to 16 years) with male preponderance (71%). Small bowel duplications were the most common (44%), and thoracoabdominal duplications were seen in 8% children compared to 2% in the literature. The median duration of symptoms was 18 days (interquartile range [IQR] 3-210 days). Associated anomalies were seen in 49% children with vertebral and spinal anomalies being the most common. Ultrasonogram (US) was done in 83% children and had a sensitivity of 55%. In the presence of a gastrointestinal bleed, Technetium(99m) pertechnetate scintigraphy scan had a positive predictive value of 80%. Thirty-five lesions were completely removed. Mucosectomy was done in two children, and one total colonic duplication was left in situ after providing adequate internal drainage. There was no postoperative mortality. The follow-up was possible in 66% children. CONCLUSIONS: EDs are uncommon and have varied, nonspecific symptoms. Thoracoabdominal duplications are more common in the Indian population. The US is a good screening tool but requires a high index of suspicion where complete excision is not possible; the provision of adequate internal drainage is an acceptable alternative. The long-term prognosis of children with ED depends on the extent of physiological disturbance due to associated anomalies.

Risk score for malignancy in patients with suspicious gallbladder lesions: Retrospective analysis of 175 cases.

BACKGROUND: Among cancers, carcinoma gallbladder has one of the most dismal prognosis. Early lesions are difficult to biopsy because of proximity to luminal structures and risk of biliary peritonitis. However, early surgery offers the only chance of a complete cure. Utilizing a risk score would allow characterization of the risk of malignancy and early referral to an oncology centre thereby resulting in better outcomes for patients with carcinoma gallbladder. METHODS: The aim of this study was to develop a risk score for carcinoma in patients with suspicious gallbladder lesions based on clinical presentation and imaging. All patients with suspicious gallbladder lesions on radiological imaging who underwent surgery were analyzed. Patients were considered for scoring if the ultrasound showed the gallbladder wall thickening (more than 4 mm) and computed tomography scan showed operable disease. Statistical analysis was done to derive a score for malignancy. RESULTS: Total 175 patients underwent an operation for suspicious gallbladder lesions from January 2005 to December 2014. The factors analyzed were clinical biochemical and imaging findings. Of these, 71 were benign on the final histopathology and 104 were malignant. The score was constructed with the following variables: female sex, high total bilirubin (≥ 1 mg/dL), presence of a mass, focal location of the lesion, presence of gallbladder stones and nodal involvement in the hepatoduodenal region on imaging. A model score and modified score were obtained. In this modified score, score of more than 8 out of 20 predicted malignancy with a sensitivity of 78% and specificity of 70.4%. Receiver operating characteristic (ROC) curve constructed with these variables had an area under curve of 0.828. There was no statistically significant difference between the model score and the modified score. CONCLUSIONS: A pre-operative risk score was obtained for carcinoma gallbladder, which needs to be validated prospectively in future.

Predicting Positive Radial Margin on Restaging MRI of Patients with Low Rectal Cancer: Can We Do Better?

Objective The aim of this study was to characterize the tissue involving the margin and study if this information will affect margin prediction on restaging magnetic resonance imaging (MRI) in low rectal adenocarcinoma (LRC) patients treated with neoadjuvant long-course chemoradiotherapy (LCCRT). Methods In this retrospective study of nonmetastatic LRC (distal margin <5 cm from the anal verge) treated with LCCRT followed by surgery, a radiologist blinded to outcome reread the restaging MRI and documented if the radial margin was involved by tumor, fibrosis, or mucin reaction using T2 high-resolution (HR) and diffusion-weighted imaging (DWI). The diagnostic performance of tumor-involving margin on restaging MRI was assessed using surgical histopathology as a reference. Interobserver agreement between three independent radiologists was assessed in a subset. Results We included 133 patients (80 males and 53 females) with a mean (range) age of 44.7 (21-86) years and 82% of them had well or moderately differentiated adenocarcinoma. Baseline MRI showed T3 ( n = 58) or T4 ( n = 60) disease in 89% of the patients. The pathological margin was positive in 21% ( n = 28) cases. In restaging MRI, the circumferential resection margin (CRM) ≤1 mm in 75.1% ( n = 100) cases and MRI predicted tumor, fibrosis, and mucin reaction at the margin in 60, 34, and 6%, respectively, and histopathology showed tumor cells in 33, 14.7, and 16.6% of them, respectively. LRC with tumor-involving margin and bad response (MR tumor regression grade [mr-TRG] 3-5) on restaging MRI had fourfold increased risk of positive pathological circumferential resection margin (pCRM). There was moderate and fair inter-reader agreement for the tissue type involving the CRM ( κ = 0.471) and mr-TRG ( κ = 0.266), p < 0.05. The use of both distance criteria and tumor-involving margins improved the diagnostic accuracy for margin prediction from 39 to 66% on restaging MRI. Conclusions Margin prediction on restaging MRI can be improved by characterizing the tissue type involving the margin in low rectal cancer patients. The inter-reader agreement was moderate for determining the tissue type.

Validation of Deauville Score for Response Evaluation in Hodgkin's Lymphoma.

Context: Positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) for treatment monitoring in patients with lymphoma is one of the most well-developed clinical applications. Deauville five-point score (DS) is recommended for response assessment in international guidelines. DS gives the threshold for adequate or inadequate response to be adapted according to the clinical context or research question. Aims: We aimed to validate DS in Hodgkin's lymphoma (HL) by retrospectively assigning this score to F-18 FDG PET-computed tomography (CT) studies done before 2016 and analyzing its concordance with the line of management. The secondary aim was to assess the reproducibility of DS in the interpretation of PET-CT scans. Subjects and Methods: A total of 100 eligible consecutive patients underwent F-18 FDG PET-CT scans between January 2014 and December 2015. Their interim, end of treatment, and follow-up PET scans were retrospectively visually analyzed and assigned DS by three nuclear medicine physicians. Concordance was defined as agreement between the DS assigned and the line of treatment. Interobserver variability was calculated using weighted Kappa and presented with 95% confidence interval. Results: Among 212 scans assigned DS, 165 scans showed agreement between the DS and line of treatment. Of these, 95.2% of scans scored DS 1-3 were kept on following or the same treatment plan was continued and patients did well. Among the scans that showed discordance, 24 scans scored DS 4/5 were continued on the same treatment regimen and the next assessment showed disease progression. Conclusions: Our study confirmed that DS is a useful tool to aid in reporting F-18 FDG PET-CT in the management of HL with good positive and negative predictive values. This study also demonstrated good interobserver agreement.

Analysis of discordant PET and CT findings in 18F-FDG PET-CT scans in the management of oncology patients.

BACKGROUND: Discordant findings are often noted between PET-CT and CT images of 18F-FDG PET-CT scans and cause ambiguity in image interpretation. This study aimed at determining the significance of these findings in the management of oncology patients. CONTEXT: Discordant findings are often noted between PET-CT and CT images of 18F-FDG PET-CT scans and cause ambiguity in image interpretation. AIM: This study aimed at determining the significance of these findings in the management of oncology patients. METHODS: This was an observational, descriptive study. Hence, retrospective analysis of all discordant findings in oncology patients undergoing a PETCT imaging between Jan 2013 and Jan 2016 was done. Those patients who had a follow-up period of minimum 1 year in either of the following forms - repeat PETCT imaging, other radiological imaging, clinical, or histopathological evidence were included. From all the discordant lesions, the sensitivity, specificity, positive predictive, negative predictive value, and accuracy of both PET-CT and CT modalities were determined. RESULTS: Of 348 discordant lesions, 16.7% was noted in soft tissues, 25% in viscera, 28.7% in lungs, 14.1% in lymph nodes, and 15.5% in bones. At the end of follow-up, 15.2% lesions were PET true positive, 57.5% PET true negative, 10.1% CT true positive lesions, 13.8% CT true negative, and 3.4% were inconclusive. CONCLUSION: 18F-FDG PET-CT is superior to CT imaging and should be considered as the first-line imaging modality in oncology patients.

MRI of Recurrent Fistula-in-Ano: Is it Different from Treatment-Naïve Fistula-in-Ano and How Does it Correlate with Anal Sphincter Morphology?

Objectives The main aim of this study was to compare magnetic resonance imaging (MRI) findings of recurrent and treatment-naïve fistula-in-ano and to correlate imaging findings with anal sphincter morphology in recurrent fistula-in-ano. Methods This is a retrospective study of adult patients who underwent MRI for suspected fistula-in-ano in 2018. After excluding patients with alternative diagnosis, patients were stratified into recurrent ( n = 103) and treatment-naïve ( n = 106) fistula-in-ano groups. Two blinded radiologists reread MRI scans in consensus for fistula characteristics and anal sphincter morphology. We compared imaging features of recurrent and treatment-naïve fistula-in-ano, assessed the incidence of anal sphincter scarring among patients with recurrent fistula-in-ano, and studied its association with fistula features. Results Two-hundred nine patients (187 males) with mean age of 40.6 (standard deviation: 12.2) years were included. Trans-sphincteric, inter-sphincteric, extra-sphincteric, and supra-sphincteric fistula-in-ano were seen in 63.6, 33, 2.9, and 0.5%, respectively. There were secondary tracts, supralevator extension, and secondary cause for fistula in 49.3, 12.9, and 14.8%, respectively. There was no difference between the fistula features of recurrent and treatment-naïve fistula-in-ano, except for significantly fewer external openings among recurrent fistula-in-ano ( p = 0.005). Among patients with recurrent fistula-in-ano, MRI detected anal sphincter defect/scarring was seen in 53.4% ( n = 55) and was significantly associated with posterior fistula-in-ano ( p = 0.031), collections and/or supralevator extension ( p = 0.010), and secondary tracts ( p = 0.015). Conclusion Fistula features of recurrent and treatment-naïve patients were mostly similar. There was high incidence (53.4%) of MRI-identified anal sphincter scarring/defect among recurrent fistula-in-ano, which was significantly associated with posterior fistula, collections, supra or translevator extension, and secondary tracts. Key Points MRI-identified anal sphincter scarring is very common among patients with recurrent fistula-in-ano and seen in more than half of them.There was significantly higher incidence of sphincter scarring among patients who had posterior fistula, collections, supralevator/translevator extension, and secondary tracts.

Total Neoadjuvant Therapy (TNT) with Full Dose Concurrent Chemotherapy in Locally Advanced Rectal Adenocarcinoma Including Signet Ring and Mucinous Cancers.

PURPOSE: Total neoadjuvant therapy (TNT) with pre-operative chemotherapy and chemoradiotherapy results in improved survival and is becoming the new standard of care in locally advanced rectal cancer (LARC). We describe our experience with TNT consisting of induction chemotherapy followed by chemoradiotherapy using full dose 5FU without oxaliplatin. METHODS: Adults with biopsy-proven, newly diagnosed LARC with high-risk characteristics on pelvic MRI (T4a or T4b, extramural vascular invasion, N2, mesorectal fascia involvement, enlargement/tumor deposits on lateral lymph nodes) were included. The TNT protocol comprised of six biweekly courses of modified FOLFOX6 followed by pelvic RT with four concurrent cycles of biweekly 5-FU 2600 mg/m2 + LV 200 mg/m2 without oxaliplatin to complete 20 uninterrupted weeks of full dose 5FU. Surgery was planned 11-13 weeks after completing chemoradiotherapy. RESULTS: Eighty-four LARC patients, including 26% with signet-ring cell carcinoma, with high-risk MRI characteristics were treated with the TNT protocol with a 96% completion rate. Significant (> grade 3) toxicities included neutropenia (23.8%), diarrhea (14.2%) anemia (10.7%), and two deaths. The median DFS at 2 years was 22.5 months with better survival noted for those who underwent surgery or had cCR (with NOM) compared to those who did not undergo surgery (due to progression, inadequate regression, or patient preference despite residual disease) -mDFS 27.7 months versus 11.4 months, p = < 0.0001 and mOS 29.2 months versus 15 months p = < 0.0001. CONCLUSION: The hybrid TNT regimen was administered without significant dose delays or interruptions. Toxicity was manageable but with two treatment-related deaths. Ability to undergo surgery after TNT predicted for improved DFS and OS.

Is MDCT an accurate tool to differentiate between benign and malignant etiology in diffuse peritoneal disease?

PURPOSE: There is often considerable overlap of imaging findings in benign and malignant peritoneal diseases. We evaluated patients with diffuse peritoneal disease, to assess the diagnostic value of MDCT in predicting benign or malignant etiology in patients with unknown etiology, by analyzing the various patterns of involvement, particularly tuberculosis (TB) vs malignancy. METHODS: One hundred and thirty-six patients with diffuse peritoneal disease who had abdominal CT and subsequently underwent omental biopsies were included in the study. Peritoneal, mesenteric and omental involvement by disease was evaluated on CT using specific parameters. The presence of lymphadenopathy, ascites, scalloping of organs, involvement of liver and spleen, were also compared between benign and malignant conditions using histopathology as the gold standard. RESULTS: In 136 patients, 72 benign and 64 malignant pathologies were classified as per histopathology. Higher age (p < 0.001), increasing omental thickness (mean 25.2 mm, p = 0.004), omental caking (p < 0.001), > 10 mm mesenteric/peritoneal nodules (p < 0.03), visceral scalloping (p = 0.001), free ascites (p = 0.003), serosal involvement (p = 0.004) and bilateral pleural effusion (p = 0.02) were associated with malignant etiology. Mesenteric thickening/stranding (p = 0.02), mesenteric adenopathy (p < 0.001), necrotic nodes (p = 0.02), splenomegaly (p = < 0.001) and higher attenuation (> 20HU) of ascitic fluid (p < 0.001) were associated with benign etiology. The presence of mesenteric thickening or stranding (p = 0.01), splenomegaly (p = 0.02), higher ascitic fluid attenuation > 20HU (p = < 0.01), mesenteric adenopathy (p < 0.01), necrotic nodes (p = 0.03) favored tuberculosis. CT had diagnostic accuracy (79.3, 86.7%), sensitivity (79.2, 74.6%) and specificity (79.4, 97%) for observers 1 and 2, respectively (Kappa 0.713). CONCLUSION: Contrast-enhanced MDCT has good sensitivity, specificity and accuracy in differentiating benign and malignant etiologies of diffuse peritoneal disease. Multiple common parameters can be used to differentiate between tuberculous peritonitis and peritoneal carcinomatosis.

Growing Teratoma Syndrome-A Clinicoradiological Series.

Context Growing teratoma syndrome (GTS) is a rare entity seen following chemotherapy for metastatic nonseminomatous germ cell tumors, characterized by increase in size of the metastatic deposits, with normal serum tumor markers. Aims In this article, we aim to describe the various clinicoradiological presentations of GTS treated at our center. Design All patients who satisfied the GTS criteria from 2001 to 2019 were included. Characteristic imaging appearances along with sites of primary lesion and metastatic disease, stage and risk stratification at diagnosis, details of chemotherapy, details of surgical treatment and histopathology, levels of tumor markers, serum ß-human chorionic gonadotropin, lactate dehydrogenase, and alpha fetoprotein levels at baseline and at the end of all chemotherapy were analyzed. Results The significant radiological findings observed were an increase in the fat and cystic components and appearance of coarse calcifications within the lesions. Majority of the cases were male patients (87.5%) with testicular primaries and GTS transformation in nodal metastases being the most common occurrence (75%). All eight cases (100%) showed an increase in size and cystic component, whereas four out of eight cases (50%) had presence of internal septations and internal calcification. Conclusion Early recognition of this entity and clinical decision making through serial radiological imaging are of utmost importance as these growing deposits are resistant to chemotherapy and radiotherapy, with complete surgical excision being the only curative and definitive treatment option.

MDT stage migration in MRI of significant rectal polyps and early rectal cancers.

PURPOSE: To audit the diagnostic accuracy of MRI for staging early and polyp rectal cancers with the purpose of identifying scope for service improvement. METHODS: This is an IRB approved retrospective study of patients who underwent staging MRI for rectal growths followed by upfront TME type surgery or local excision without neoadjuvant therapy between 2018 and 2021. MR-T-stage was compared with surgical histopathology. The degree of stage migration in the multidisciplinary team meetings (MDT) was assessed and training needs were identified. RESULTS: 53 patients (32 males) with a mean (SD) age of 56.7 (13.6) years with 54 rectal lesions and underwent trans-anal excision (n = 18) or upfront surgery (n = 35) were included. Pathology showed < / = pT1 stage in n = 18 and > / = pT2 stage in n = 36. Radio-pathological concordance rate was 38.9% and 74.1%, respectively, for primary reports and MDT reads, respectively, and during MDT, the rates improved by 44.5% and 30.5% for < / = pT1 and > / = pT2 stages ,respectively. The overall T-stage migration rate at MDT was 44.6% (25/54) and the migration rate was higher (61.1%) for < / = pT1 stage lesions. The best sensitivity, specificity, PPV, NPV and accuracy of MRI for T-staging was 83.3%, 91.6%, 83.3%, 91.6% and 88.8%, respectively. CONCLUSION: Radio-pathological correlation for MRI T-stage is excellent for MDT reads by experienced radiologists. MDT reads lead to significant down-staging of T-stage in polyp and early rectal cancer thereby improving radio-path correlation.

Comparison of Magnetic Resonance Enterography Global Score (MEGS) with indices of Crohn's disease activity in South Asian population.

PURPOSE: Assessment of disease activity in Crohn's helps predict important clinical outcomes. Among the various modalities available to assess disease activity, magnetic resonance enterography (MRE) is considered a safe and reliable imaging option. Various MRE-based scoring systems have been developed to measure disease activity, one of which being the MRE global score (MEGS). We aimed to correlate MEGS with some of the important indices of Crohn's disease activity. METHODOLOGY: Crohn's disease patients referred for MRE were included in the study. Along with demographic profile and relevant investigations, MRE parameters related to MEGS were also assessed. RESULT: A total of 47 patients were recruited for the study. Their median age was 34 years (range 18-68 years), and male:female ratio was 16:31. There was modest positive correlation between MEGS and faecal calprotectin (r = 0.3, p = 0.04), CRP level (r = 0.34, p = 0.02) and Harvey Bradshaw index (r = 0.3, p = 0.043), respectively. However, there was strong correlation between segmental MEGS and Simple Endoscopic Score in those with terminal ileal disease (r = 0.81, p < 0.001). Mural thickness was the only MRE parameter that correlated with active disease (OR - 1.35, 95% CI 1.01, 1.81, p = 0.041) on multivariate analysis. There was moderate inter-observer agreement (Lin's r = 0.78, p < 0.001). CONCLUSION: MEGS showed modest correlation with indices of Crohn's disease activity which corroborates the complementary role of MRE in management of such patients.

Gallbladder reporting and data system (GB-RADS) for risk stratification of gallbladder wall thickening on ultrasonography: an international expert consensus.

The Gallbladder Reporting and Data System (GB-RADS) ultrasound (US) risk stratification is proposed to improve consistency in US interpretations, reporting, and assessment of risk of malignancy in gallbladder wall thickening in non-acute setting. It was developed based on a systematic review of the literature and the consensus of an international multidisciplinary committee comprising expert radiologists, gastroenterologists, gastrointestinal surgeons, surgical oncologists, medical oncologists, and pathologists using modified Delphi method. For risk stratification, the GB-RADS system recommends six categories (GB-RADS 0-5) of gallbladder wall thickening with gradually increasing risk of malignancy. GB-RADS is based on gallbladder wall features on US including symmetry and extent (focal vs. circumferential) of involvement, layered appearance, intramural features (including intramural cysts and echogenic foci), and interface with the liver. GB-RADS represents the first collaborative effort at risk stratifying the gallbladder wall thickening. This concept is in line with the other US-based risk stratification systems which have been shown to increase the accuracy of detection of malignant lesions and improve management.

Barium Defecating Proctography and Dynamic Magnetic Resonance Proctography: Their Role and Patient's Perception.

OBJECTIVES: The objectives of the study were to compare the imaging findings and patient's perception of barium defecating proctography and dynamic magnetic resonance (MR) proctography in patients with pelvic floor disorders. MATERIAL AND METHODS: This is a prospective study conducted on patients with pelvic floor disorders who consented to undergo both barium proctography and dynamic MR proctography. Imaging findings of both the procedures were compared. Inter-observer agreement (IOA) for key imaging features was assessed. Patient's perception of these procedures was assessed using a short questionnaire and a visual analog scale. RESULTS: Forty patients (M: F =19:21) with a mean age of 43.65 years and range of 21-75 years were included for final analysis. Mean patient experience score was significantly better for MR imaging (MRI) (p < 0.001). However, patients perceived significantly higher difficulty in rectal evacuation during MRI studies (p = 0.003). While significantly higher number of rectoceles (p = 0.014) were diagnosed on MRI, a greater number of pelvic floor descent (p = 0.02) and intra-rectal intussusception (p = 0.011) were diagnosed on barium proctography. The IOA for barium proctography was substantial for identifying rectoceles, rectal prolapse and for determining M line, p < 0.001. There was excellent IOA for MRI interpretation of cystoceles, peritoneoceles, and uterine prolapse and substantial to excellent IOA for determining anal canal length and anorectal angle, p < 0.001. The mean study time for the barium and MRI study was 12 minutes and 15 minutes, respectively. CONCLUSION: Barium proctography was more sensitive than MRI for detecting pelvic floor descent and intrarectal intussusception. Although patients perceived better rectal emptying with barium proctography, the overall patient experience was better for dynamic MRI proctography.

Imaging Manifestations of Accessory Cavitated Uterine Mass-A Rare Mullerian Anomaly.

Context Accessory cavitated uterine mass (ACUM) is an uncommon and under-recognized entity with distinct imaging characteristics and causing significant patient distress. Differentiating it from its other clinical and radiological differentials is therefore extremely important and prevents delay in surgical management which is the treatment of choice. Aims The aim of the study is to describe the MRI appearance of the surgically and pathologically proven ACUM cases from our institution in the last 2 years. Settings and Design This is a retrospective study in a tertiary care hospital in South India. Methods and Material We reviewed the clinical presentations and imaging findings of seven surgically proven cases of ACUM qualifying the proposed diagnostic criteria. Results All patients presented with chronic pelvic pain, dysmenorrhea, and prolonged post-menstrual pain. MRI in all seven cases showed an intramural, noncommunicating, and cavitating lesion near the uterine cornua with internal contents similar to that of endometrioma. Although the cavity was lined by endometrium in all the cases (proven in pathology), it was well appreciable on MRI in only five cases. The rest of the uterine myometrium and main endometrial cavity were normal with no features of adenomyosis. Conclusion MRI is a reliable diagnostic tool for accurate diagnosis of ACUM, and more importantly, in distinguishing it from other causes of chronic pelvic pain like adenomyosis and endometriosis and other imaging differentials like adenomyoma, noncommunicating uterine horn, and degenerating leiomyoma.

Paraneoplastic Autoimmune Multiorgan Syndrome: A Retrospective Study from a Tertiary Care Center in South India.

BACKGROUND: Paraneoplastic autoimmune multiorgan syndrome (PAMS), first described as paraneoplastic pemphigus (PNP) is a heterogeneous autoimmune syndrome with a diverse spectrum of clinical and immunopathological features associated with an internal neoplasm. MATERIALS AND METHODS: The details of the patients diagnosed with PAMS/PNP from an Indian tertiary center between January 2010 to December 2019 were retrieved from the hospital database. The clinical manifestations, histopathological features, immunofluorescence findings, and other relevant clinical details were obtained. RESULTS: There were eight patients (4 males, 4 females) with PAMS, age ranging from 8 to 46 years (mean 31 years), of whom two were 8-year-old children. The mucocutaneous manifestations were polymorphic and all had recalcitrant oral mucosal involvement. The most common mucosal presentation was pemphigus-like (5/8), and the cutaneous presentation was lichen planus-like (5/8). Castleman's disease (5/8) was the commonest neoplasm followed by thymoma (2/8). Interface dermatitis was seen in all biopsies and three different patterns of direct immunofluorescence were seen, which were intercellular "fish-net" fluorescence in the epidermis (2/8), granular/linear deposition along the basement membrane (4/8) and a combination of both patterns (1/8). Indirect immunofluorescence done on rat bladder in 3 patients showed intercellular "fish-net" fluorescence. Desmoglein levels were not elevated in any of our patients. The follow-up period ranged from 1 to 112.5 months (mean, 23.6 months) with a mortality rate of 12.5%. CONCLUSION: In our study, Castleman's disease was the most common associated malignancy, and the mucocutaneous and histopathological findings were heterogeneous. Timely diagnosis and early intervention improved the outcome in our patients.