Hypovascular pancreas head adenocarcinoma: CT texture analysis for assessment of resection margin status and high-risk features.

OBJECTIVES: To determine if CT texture analysis features are associated with hypovascular pancreas head adenocarcinoma (PHA) postoperative margin status, nodal status, grade, lymphovascular invasion (LVI), and perineural invasion (PNI). METHODS: This Research Ethics Board-approved retrospective cohort study included 131 consecutive patients with resected PHA. Tumors were segmented on preoperative contrast-enhanced CT. Tumor diameter and texture analysis features including mean, minimum and maximum Hounsfield units, standard deviation, skewness, kurtosis, and entropy and gray-level co-occurrence matrix (GLCM) features correlation and dissimilarity were extracted. Two-sample t test and logistic regression were used to compare parameters for prediction of margin status, nodal status, grade, LVI, and PNI. Diagnostic accuracy was assessed using receiver operating characteristic curves and Youden method was used to establish cutpoints. RESULTS: Margin status was associated with GLCM correlation (p = 0.012) and dissimilarity (p = 0.003); nodal status was associated with standard deviation (p = 0.026) and entropy (p = 0.031); grade was associated with kurtosis (p = 0.031); LVI was associated with standard deviation (p = 0.047), entropy (p = 0.026), and GLCM correlation (p = 0.033) and dissimilarity (p = 0.011). No associations were found for PNI (p > 0.05). Logistic regression yielded an area under the curve of 0.70 for nodal disease, 0.70 for LVI, 0.68 for grade, and 0.65 for margin status. Optimal sensitivity/specificity was as follows: nodal disease 73%/72%, LVI 72%/65%, grade 55%/83%, and margin status 63%/66%. CONCLUSIONS: CT texture analysis features demonstrate fair diagnostic accuracy for assessment of hypovascular PHA nodal disease, LVI, grade, and postoperative margin status. Additional research is rapidly needed to identify these high-risk features with better accuracy. KEY POINTS: • CT texture analysis features are associated with pancreas head adenocarcinoma postoperative margin status which may help inform treatment decisions as a negative resection margin is required for cure. • CT texture analysis features are associated with pancreas head adenocarcinoma nodal disease, a poor prognostic feature. • Indicators of more aggressive pancreas head adenocarcinoma biology including tumor grade and LVI can be diagnosed using CT texture analysis with fair accuracy.

Degree of Conjugate Gaze Deviation on CT Predicts Proximal Vessel Occlusion and May Expedite Endovascular Therapy.

PURPOSE: Recent trials have demonstrated superior outcomes with combination IV-tPA and endovascular therapy (EVT) within 6 hours of symptom onset in patients with proximal vessel occlusion (ICA, M1, or proximal M1/M2) compared to IV-tPA alone. The current standard of diagnosis for consideration of EVT is CT angiogram (CTA). Unfortunately, not all hospitals are equipped with CTA, and the decision to transfer to tertiary centers is often based on nonenhanced CT. Ipsilateral conjugate gaze deviation (CGD) is associated with worse outcomes and larger infarcts in acute ischemic stroke. We predicted that the more proximal the occlusion, the higher the degree of CGD. MATERIALS AND METHODS: Over a period of 12 months, 182 consecutive patients with acute ischemic stroke treated at our institution were prospectively analyzed. Stroke locations were categorized based on CTA. Average degree of CGD was measured. Patient demographics, ASPECTS, collateral score, National Institutes of Health Stroke Scale, modified Rankin Scale, TICI score, length-of-stay, and mortality were collected. The median follow-up was 30 days. RESULTS: Out of ninety one of 182 patients with (+) CGD, 82 (90%) patients had ICA or middle cerebral artery (MCA) territory infarcts. The median was 25.0° in those with proximal occlusion and 13.7° in those with distal MCA occlusion (P < .001). A higher degree of CGD is positively correlated with proximity of vessel occlusion (correlation coefficient 0.2; P < .05). A cut-off greater than 20.25° (area under the curve = .76) showed a sensitivity of 64.0% and specificity 84.2%. CONCLUSIONS: Measuring degree of CGD may help in early identification of proximal vessel occlusions and expedite transfer for clot retrieval.

Radiographic horizontal gaze deviation in the setting of acute PICA territory ischemia: A potential mimic of large vessel occlusion.

PURPOSE: Horizontal gaze deviation (HGD) is a predictor of acute large vessel occlusion (LVO) and helps to expedite the triage of patients to CTA and endovascular-capable sites. Patients with acute cerebellar ischemia, particularly involving the PICA territory, can also exhibit HGD. MATERIALS AND METHODS: We reviewed 2260 CTA stroke assessment cases between January 2016 and May 2020. Forty-six patients with CTA-proven acute PICA occlusions were identified and compared with 114 patients with acute LVO (ICA, M1, and M1/2). Both clinical and radiographic HGD were examined. The degree of radiographic HGD was measured for each patient. Site of ischemia was confirmed on subsequent MRI. RESULTS: Of the 46 patients with acute PICA occlusions, 20 (43.5%) patients had radiographic (+) HGD with either ipsilateral or contralateral gaze deviation, 6 of whom (13.0%) displayed clinical HGD. Of the 114 patients with LVO (control group), 72 (63.2%) patients had radiographic (+) HGD, all ipsilateral, 49 of whom (68.0%) displayed clinical HGD. The mean degree of HGD between PICA and LVO were 30.0° vs. 22.9°, respectively, p < 0.001; AUC = 0.68. CONCLUSION: Patients with acute PICA occlusion can exhibit either ipsilateral or contralateral HGD and a higher degree of HGD than LVO occlusion on NECT. In hyperacute stroke, the presence of radiographic HGD > 30° in the absence of ischemic changes in the MCA territory should prompt clinicians to closely evaluate for features of early ischemic changes in the cerebellar hemispheres that suggest acute PICA occlusion.

Magnetic Resonance Elastography to Assess Fibrosis in Kidney Allografts.

BACKGROUND AND OBJECTIVES: Fibrosis is a major cause of kidney allograft injury. Currently, the only means of assessing allograft fibrosis is by biopsy, an invasive procedure that samples <1% of the kidney. We examined whether magnetic resonance elastography, an imaging-based measure of organ stiffness, could noninvasively estimate allograft fibrosis and predict progression of allograft dysfunction. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Kidney allograft recipients >1 year post-transplant undergoing an allograft biopsy first underwent free-breathing, flow-compensated magnetic resonance elastography on a 3.0-T magnetic resonance imaging scanner. Each patient had serial eGFR measurements after the elastography scan for a follow-up period of up to 1 year. The mean stiffness value of the kidney allograft was compared with both the histopathologic Banff fibrosis score and the rate of eGFR change during the follow-up period. RESULTS: Sixteen patients who underwent magnetic resonance elastography and biopsy were studied (mean age: 54±9 years old). Whole-kidney mean stiffness ranged between 3.5 and 7.3 kPa. Whole-kidney stiffness correlated with biopsy-derived Banff fibrosis score (Spearman rho =0.67; P<0.01). Stiffness was heterogeneously distributed within each kidney, providing a possible explanation for the lack of a stronger stiffness-fibrosis correlation. We also found negative correlations between whole-kidney stiffness and both baseline eGFR (Spearman rho =-0.65; P<0.01) and eGFR change over time (Spearman rho =-0.70; P<0.01). Irrespective of the baseline eGFR, increased kidney stiffness was associated with a greater eGFR decline (regression r2=0.48; P=0.03). CONCLUSIONS: Given the limitations of allograft biopsy, our pilot study suggests the potential for magnetic resonance elastography as a novel noninvasive measure of whole-allograft fibrosis burden that may predict future changes in kidney function. Future studies exploring the utility and accuracy of magnetic resonance elastography are needed.

Impact of cytogenetics in patients with relapsed or refractory multiple myeloma treated with bortezomib: Adverse effect of 1q21 gains.

We investigated the influence of genetic risk factors on the clinical response to bortezomib in 85 relapsed/refractory multiple myeloma (MM) patients. Interphase cytoplasmic fluorescence in situ hybridization (cIg-FISH) detected del(13q), del(17p), del(1p21), t(4;14), and 1q21 gain in 38%, 22%, 26%, 18% and 39% of evaluable cases. Forty-nine patients (49%) responded to bortezomib with median progression free (PFS) and overall survivals (OS) of 5.0 and 12.6 months, respectively. Patients with 1q21 gain had a significantly shorter OS (5.3 months vs. 24.6 months, p=0.0006) and PFS (2.3 months vs. 7.3 months, p=0.003) than patients without such abnormality. There was no significant difference in response rate, response duration, PFS or OS for any of the other genetic risk factors tested. Multivariate analysis confirmed that 1q21 gain is an independent risk factor for PFS (p=0.03) and OS (p=0.009) of bortezomib-treated relapsed/refractory myeloma.