The role of multimodality imaging in the selection and management of patients treated with cytoreductive surgery and HIPEC.

Cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) is the mainstay of potentially curative surgical treatment for malignancies that have spread to peritoneal surfaces. This surgical procedure is however associated with high morbidity and appropriate patient selection and planning is therefore essential. Available multimodality imaging techniques include CT with oral and intravenous contrast, MRI including use of dedicated peritoneal protocol and FDG-PET/CT. These used with the correct technique, read by specialist radiologists and discussed under the auspices of a dedicated multidisciplinary team, can help to improve outcomes. We demonstrate that imaging not only provides information about peritoneal disease burden but more importantly want to shift the reader's focus to disease distribution. Our examples highlight how imaging helps avoid futile surgery by identifying patients with disease in unfavourable sites and show the strength and limitations of the various imaging modalities. We share how MR imaging can help identify multifocal and often occult sites including widespread miliary disease. Our examples provide a comprehensive overview demonstrating how imaging can help plan surgery by identifying patients who may need splenic vaccinations, counselling for stoma, egg harvesting and input from surgeons with other specialist expertise greatly increasing likelihood of achieving complete cytoreduction.

Wall maturation in necrotic collections in acute pancreatitis: a computed tomography based evaluation.

Aim: To systematically investigate the timing of encapsulation of necrotic collections in acute necrotizing pancreatitis (ANP) using contrast-enhanced computed tomography (CECT). Methods: This retrospective study comprised consecutive patients of ANP who underwent CECT of the abdomen between the second and fourth weeks of illness. Number and site of collections and presence and completeness of the wall (defined as a thin smooth enhancing rim more than 1 mm in thickness) were documented. Results: A total of 195 patients of ANP were included. Seven hundred seventy-three collections were evaluated in 284 CECT scans. The most common site of the collection was anterior pararenal space (n=290, 37.5%). The mean maximum dimension of the collection was 8.1 cm (range, 3.1-16 cm). Two hundred twentytwo (28.7%) collections had a complete wall. The mean interval to complete wall maturation was 18 days (range, 8-28). Overall, 13.3%, 37.1%, and 56.2% of the collections showed complete encapsulation in the second, third, and fourth weeks, respectively. Conclusions: Our study suggests that a significant proportion of necrotic collections show complete encapsulation within 4 weeks of the onset of ANP.

Clinico-pathological predictors of clinical complete response in rectal cancer.

PURPOSE: Prediction of clinical complete response in rectal cancer before neoadjuvant chemo-radiotherapy treatment enables treatment selection. Patients predicted to have complete response could have chemo-radiotherapy, and others could have additional doublet chemotherapy at this stage of their treatment to improve their overall outcome. This work investigates the role of clinical variables in predicting clinical complete response. METHOD: Using the UK-based OnCoRe database (2008 to 2019), we performed a propensity-score matched study of 322 patients who received neoadjuvant chemoradiotherapy. We collected pre-treatment clinic-pathological, inflammatory and radiotherapy-related characteristics. We determined the odds for the occurrence of cCR using conditional logistic regression models. We derived the post-model Area under the Curve (AUC) as an indicator of discrimination performance and stated a priori that an AUC of 0.75 or greater was required for potential clinical utility. RESULTS: Pre-treatment tumour diameter, mrT-stage, haemoglobin, alkaline phosphate and total radiotherapy depths were associated with cCR on univariable and multivariable analysis. Additionally, neutrophil to lymphocyte ratio (NLR), neutrophil-monocyte to lymphocyte ratio (NMLR), lymphocyte count and albumin were all significantly associated with cCR on multivariable analysis. A nomogram using the above parameters was developed with a resulting ROC AUC of 0.75. CONCLUSION: We identified routine clinic-pathological, inflammatory and radiotherapy-related variables which are independently associated with cCR. A nomogram was developed to predict cCR. The performance characteristics from this model were on the prior clinical utility threshold. Additional research is required to develop more associated variables to better select patients with rectal cancer undergoing chemoradiotherapy who may benefit from pursuing a W&W strategy.

Variability of contrast enhancement of pancreas on computed tomography in patients with acute pancreatitis and isolated extrapancreatic necrosis.

BACKGROUND AND STUDY AIM: To evaluate the variability in the enhancement of pancreas on computed tomography (CT) in patients with acute pancreatitis (AP) and isolated extrapancreatic necrosis (EPN) and to investigate whether it affects the extrapancreatic findings and patient outcomes. PATIENTS AND METHODS: This retrospective study comprised of consecutive patients with isolated EPN evaluated between April 2017 and April 2019. A radiologist measured the pancreatic attenuation values (PAV) of head, body, and tail on a contrast enhanced CT. Using a cut-off PAV of 100HU, patients were divided into two groups. The extrapancreatic CT findings and outcome parameters were compared between the two groups. RESULTS: Thirty patients (mean age, 42.13 years, 17 males) with isolated EPN were evaluated. The mean PAV in the head, body, and tail was 83.13 HU (range, 59-161), 84.17 HU (range, 60-160), and 82.23 HU (range, 53-137). The overall mean PAV was 83.12 HU (range, 58-152). There were six patients with overall mean PAV≥100 HU. The group with PAV≥100 HU had a higher number of patients with infected necrosis (66.6% vs. 14.2%, P=0.018). PAV had a significant association with length of hospitalization (P=0.045). CONCLUSION: There is significant variability in the pancreatic enhancement on CT among patients with AP and isolated EPN. Patients with PAV≥100 HU had a significantly longer hospital stay. This, however, may be related to a greater number of patients with infected necrosis in this group.

Role of computed tomography in prediction of gastrointestinal fistula in patients with acute pancreatitis.

AIM: To identify computed tomography (CT) features that predict gastrointestinal fistula (GIF) in patients with acute pancreatitis (AP). METHODS: This retrospective study comprised consecutive patients with AP and GIF from June 2017 to June 2018. The diagnosis of GIF was based on upper gastrointestinal endoscopy, colonoscopy or surgery. A cohort of 19 matched patients from a prospective database of AP served as control group. Measures of severity, and clinical outcome were evaluated. CT parameters were compared between the groups to assess the features that could predict the development of GIF. RESULTS: There was no difference between the two groups in terms of disease etiology, severity, drainage, and mortality. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of bowel wall thickening (P=0.005), maximum thickness of the bowel wall (P=0.007), presence of air foci in extra pancreatic necrosis/ collection (P=0.013), discontinuity of the bowel wall (P=0.046) and the displacement/ compression of bowel by fluid collection (P=0.014). On multivariate analysis, all the above-mentioned CT findings except discontinuity of bowel wall were found to be statistically significant. CONCLUSION: CT is helpful in predicting GIF in patients with AP.

Short-term efficacy of recombinant human GH therapy in cured acromegaly patients with GH deficiency: a single-center experience.

The effectiveness and short-term safety of recombinant human GH (r-hGH) in acromegaly patients with GH deficiency (GHD) after treatment are not well established. The study includes ten subjects with acromegaly who had GHD treated with r-hGH for 6 months. Control groups consisted of ten age-, gender-, and BMI-matched healthy subjects and ten active acromegaly patients who were treatment naïve. Body composition, quality of life (QoL), muscle strength, lipid profile, and cardiovascular risk factors were assessed in all subjects at baseline, and the same parameters were reassessed after 6 months of therapy with r-hGH in acromegaly with GHD. Repeat magnetic resonance imaging of the sella was performed in treated subjects. Optical colonoscopy was done and biopsies were taken from multiple sites for proliferation indices (Ki67). The median duration of GHD was 17.8 months and dose of r-hGH administered was 5.7±1.5 µg/kg per day. There was improvement in bone mineral content (P=0.01), bone mineral density (P=0.04), muscle strength (P<0.001), total cholesterol (P=0.003), high-density cholesterol (P<0.001), and QoL - score (P=0.005), and reduction in low-density cholesterol (P=0.003) and triglyceride (P=0.004) after treatment. There was no change in lean body mass, total body fat, hsCRP, lipoprotein (a), and fibrinogen levels. There was a modest increase in plasminogen activator inhibitor 1 (P=0.002), but it was lower compared with healthy controls and treatment naïve acromegalics (P=0.007). Six month-r-hGH therapy improves body composition, atherogenic lipid profile, QoL, and muscle strength in GHD patients who had acromegaly. Long-term prospective studies are needed to evaluate the effect of r-hGH therapy in these patients.

Spectrum of imaging findings on MDCT enterography in patients with small bowel tuberculosis.

Abdominal tuberculosis (TB) is the sixth most common extrapulmonary site of involvement. The sites of involvement in abdominal tuberculosis, in descending order of frequency, are lymph nodes, genitourinary tract, peritoneal cavity, and gastrointestinal tract. The radiological armamentarium for evaluating tuberculosis of the small bowel (SBTB) includes barium studies (small bowel follow-through, SBFT), CT (multidetector CT, CT enterography, and CT enteroclysis), ultrasound (sonoenteroclysis), and magnetic resonance imaging (MRI; enterography and enteroclysis). In this review, we illustrate the abnormalities at MDCT enterography in 20 consecutive patients with SB TB and also describe extraluminal findings in these patients. MDCT enterography allows non-invasive good-quality assessment of well-distended bowel loops and the adjacent soft tissues. It displays the thickness and enhancement of the entire bowel wall in all three planes and allows examination of all bowel loops, especially the ileal loops, which are mostly superimposed. The terminal ileum and ileocaecal junction are the most common sites of small bowel involvement in intestinal TB. The most common abnormality is short-segment strictures with symmetrical concentric mural thickening and homogeneous mural enhancement. Other findings include lymphadenopathy, ascites, enteroliths, peritoneal thickening, and enhancement. In conclusion, MDCT enterography is a comprehensive technique for the evaluation of SB TB.

Patterns of recurrence of gastrointestinal stromal tumour (GIST) following complete resection: implications for follow-up.

AIM: To determine the frequency, time course and sites of recurrence following surgical resection of gastrointestinal stromal tumours (GIST) and to evaluate the performance of a risk-based surveillance protocol in detection of recurrence. METHODS: Eighty-one patients on surveillance following complete resection of GIST were included. Patients were stratified into risk groups according to accepted histopathological criteria. Computed tomography (CT) examinations were retrospectively reviewed to determine rates, sites and imaging characteristics of recurrence and to assess compliance with the local follow-up protocol. RESULTS: The median time of follow-up was 41 months. Nineteen patients suffered recurrence, all of whom were in the high-risk group. Fifty-eight percent of relapses occurred within 1 year and 84% within 3 years. Even within the high-risk group, patients with relapse had significantly larger (mean 15 versus 10.4 cm, p < 0.05) and more mitotically active primary tumours (mean 33.7 versus 5.6 mitoses per 50 high-power fields; p < 0.05) than those with no relapse. Relapse was to the liver in 12 cases (63%) and to the omentum and mesentery in nine cases (47%), and was asymptomatic in three-quarters of patients. CONCLUSIONS: The high incidence of GIST recurrence in the high-risk group in the first 3 years after surgery supports the use of intensive imaging surveillance in this period. Relapse is often asymptomatic and commonly occurs to the liver, omentum and mesentery. Stratification by tumour factors may enable improved tailoring of surveillance protocols within the high-risk group in the future.

High prevalence of human papillomavirus in esophageal squamous cell carcinoma: a study in paired samples.

Esophageal squamous cell carcinoma (ESCC) is one of the common cancers with a poor prognosis. Incidences of human papillomavirus (HPV) infection range from 0 to 67% in different parts of the world. It has been frequently associated with high-risk HPV genotypes 16 and 18. The present study analyzes the prevalence of HPV infection in ESCC tumor and adjoining mucosa. Fresh tissue samples were obtained from ESCC tumor (group I) and adjoining mucosa (group II). Aliquots of DNA extracts were used. There were 23 patients with paired samples, 19 (83%) were male. HPV was positive in 20/23 (87%). Mean age of HPV positive in group I was 56.63 ± 6.96 and in group II 54.31 ± 7.13 years (P > 0.05). Majority had more than one viral type. HPV52 was the most common observed in 14 (61%) males and two (9%) females. Other common viruses were HPV55, 39, and 59. Smoking had a significant association with viral positivity. p63 and p16 oncoproteins correlated with degree of tumor differentiation but not with viral status. We documented high prevalence of high-risk HPV in ESCC. Our observations support the concept of persistent infection by an oncogenic HPV in cancer development. Our study highlights importance of documenting viral genotype in a defined geographic area.

Effect of biotherapeutics on antitoxin IgG in experimentally induced Clostridium difficile infection.

PURPOSE: Recurrent diarrhoea after successful treatment of primary Clostridium difficile associated disease (CDAD) occurs due to bowel flora alterations and failure to mount an effective antibody response. Apart from antibiotics, risk factors include immunosuppressive and acid-suppressive drug administration. Biotherapeutics such as probiotic and epidermal growth factor (EGF) may offer potential effective therapy for CDAD. MATERIALS AND METHODS: The effect of biotherapeutics in mounting an antibody response against C. difficile toxins was studied in BALB/c mice challenged with C. difficile after pre-treatment with ampicillin, lansoprazole or cyclosporin. Sera from sacrificed animals were estimated for antitoxin IgG by enzyme linked immunosorbent assay. RESULTS: Antitoxin IgG was significantly higher (P<0.05) in C. difficile challenged groups compared to unchallenged controls, but insignificant (P>0.05) in animals in which C. difficile was given after pre-treatment with cyclosporin compared to those without any pre-treatment, or pre-treatment with antibiotic or lansoprazole. In inter-subgroup comparisons also significant anomaly in production of antitoxin IgG was found. The antitoxin IgG levels were raised in animals administered C. difficile after pre-treatment with ampicillin, but lower in animals administered cyclosporin. High levels of antitoxin IgG were also found in the serum samples of animals receiving lansoprazole and C. difficile. CONCLUSIONS: Probiotics showed their beneficial effect by boosting the immune response as seen by production of antitoxin IgG. Oral administration of EGF did not affect the immune response to C. difficile toxins as significant increase was not observed in the serum antitoxin IgG levels in any of the groups investigated.

Colonic neoplasia in acromegaly: increased proliferation or deceased apoptosis?

Patients with acromegaly have higher prevalence of colorectal neoplasms. The pathogenetic mechanism is still unclear and may be related to sustained increase in serum GH-IGF1. We aimed to evaluate the proliferative and apoptotic markers in samples of colonic mucosa obtained during screening colonoscopic biopsy from patients with acromegaly and study their relationship to serum IGF-1 and GH levels. The study subjects included 32 patients with acromegaly (4 female), 10 healthy controls (irritable bowel syndrome) and 10 positive controls (non-acromegalic colonic adenocarcinoma). Patients with acromegaly were divided into two groups, active disease (AD) and disease in remission (AR). Two biopsies each were obtained during colonoscopy from the right colon, transverse colon and rectosigmoid region. All the polyps were biopsied and subjected to histopathological examination. Immunohistochemistry for proliferation marker (Ki-67) and apoptotic markers (caspase-3 and TdT-Mediated dUTP Nick-End Labeling (TUNEL) was carried out in the histopathological samples. Indices of proliferation were significantly different in patients with acromegaly as compared to healthy controls. The mean Ki-67 positivity was 45.1 ± 17.7% in AD and 45.6 ± 23.1% in AR, as compared to 10 ± 5% in healthy controls. While none of the healthy controls had Ki-67 positivity beyond the lower third of crypts, among patients with acromegaly 12/32 (37.5%) had mid-third positivity (P = 0.000) and 15/32 (46.8%) had full length of crypt positively (P = 0.00). Immunostaining for caspase-3 was negative in patients with acromegaly and healthy controls. TUNEL was strongly positive in patients with colonic adenocarcinoma but not in healthy controls and patients with acromegaly. IGF-1 levels were higher in those with Ki-67 positivity in the superficial mucosa. Patients with acromegaly have increased proliferation of colonic epithelial cells. Elevated levels of serum IGF1 are associated with increase proliferation in the superficial crypt cells.

Benign gastric outlet obstruction--spectrum and management.

Intrinsic or extrinsic obstruction of the pyloric channel or duodenum either by benign or malignant diseases leads to gastric outlet obstruction. With improvement in science and technology, the spectrum of gastric outlet obstruction has changed from peptic ulcer disease to corrosives and malignant diseases. Newer investigations like computerized tomography and endoscopy have supplemented the previous clinical tests like saline load test and barium series. Improvised treatment modalities like endoscopic balloon dilatation and endoscopic incision have circumvented the use of surgery which was the gold standard for management of gastric outlet obstruction. Newer modalities like biodegradable stents have an upcoming role in the management.