Effect of Alvarado Score on the Negative Predictive Value of Nondiagnostic Ultrasound for Acute Appendicitis.

Background: The purposes of this study were to calculate the negative predictive value (NPV) of nondiagnostic ultrasound (US) in patients with suspected appendicitis and to identify the clinical factors that were associated with the nondiagnostic US. Methods: We conducted a retrospective review of 412 patients who had graded-compression appendiceal US performed during January 2017 and December 2017. The NPV of the nondiagnostic US in combination with clinical parameters was calculated. Multivariate regression analysis was used to determine the independent predictors for the nondiagnostic US. Results: The US exam was nondiagnostic in 64.8% of the patients, giving an NPV of 70.8%. The NPV of nondiagnostic US increased to 96.2% in patients who had an Alvarado score of <5. The patients who did not have migratory pain, did not have leukocytosis, and had a pain score of <7 were more likely to have a nondiagnostic US study (P < 0.001). Conclusion: Alvarado score had an inverse effect on the NPV of nondiagnostic appendiceal US. Patients who had nondiagnostic US and Alvarado score of <5 were very unlikely to have appendicitis. Active clinical observation or re-evaluation rather than immediate computed tomography may be a safe alternative approach in these low-risk patients. However, the Alvarado score itself was not a predictive factor of nondiagnostic US. The absence of migratory pain, absence of leukocytosis, and low pain score were the independent predictors of nondiagnostic appendiceal US.

Evaluation and external validation of minor lymphatic pelvic pathway for distant metastases in cervical cancer patients treated with concurrent chemoradiotherapy.

To evaluate and validate the minor lymphatic pathway for distant metastases in cervical cancer. This is a retrospective cohort of cervical cancer patients underwent curative concurrent chemoradiotherapy. We used original dataset from 1 university hospital and validation dataset from 3 university hospitals. Lymphadenopathy status in CT imaging was reviewed by radiologist in either the obturator and external iliac nodes (major pathway) or the internal iliac and presacral nodes (minor pathway). We then used Cox regression to adjust for all potential confounders, including paraaortic nodes, T stage, histology, age, total treatment time, total number of nodes, total short axis of nodes. 397 and 384 patients were in the original and validation datasets (median follow-up period, 59.5 month's). The minor pathway was independent prognostic factor in multivariable analysis [HR=2.64; 95%CI=1.07-6.55; P = 0.036] and [HR=14.84; 95%CI=3.15-70.01; P= 0.001] in original and validation datasets, respectively. Whereas, the major pathway was statistically non-significant. Further validation showed that the minor pathway had the highest HR for distant metastases with both the EMBRACE (HR=6.05; 95% CI=1.30-28.08; P = 0.022) and the FIGO 2018 (HR=7.43; 95% CI=2.94-18.78; P<0.001) in the original dataset. A similar result was found with the validation dataset: EMBRACE, HR=30.91; 95% CI=2.78-343.62; P = 0.005; and FIGO 2018, HR=42.41; 95% CI=8.83-203.60; P<0.001.This is the first clinical study to validate that the minor lymphatic pathway was predominantly associated with distant metastases in cervical cancer. This finding should be validated in larger cohort to further integrate in standard staging for prediction of distant metastases.

Development and validation of a prognostic prediction model including the minor lymphatic pathway for distant metastases in cervical cancer patients.

To develop and validate a prognostic model, including the minor lymphatic pathway (internal iliac and presacral nodes). STUDY DESIGN: Retrospective cohort. PARTICIPANTS: Locally advanced cervical cancer underwent concurrent chemoradiotherapy. SAMPLE SIZE: 397 and 384 patients in the development and validation data set. PREDICTORS: Our new nodal staging system with the minor lymphatic pathway. OUTCOME: Distant metastases. STATISTICAL ANALYSIS: Cox regression; net reclassification improvement (NRI) and decision curve analysis (DCA). Our new nodal system was the strongest predictor. The predictors in the final model were new nodal system, tumor stage, adenocarcinoma, initial hemoglobin, tumor size and age. The nodal system and the pretreatment model had concordance indices of 0.661 and 0.708, respectively, with good calibration curves. Compared to the OUTBACK eligibility criteria, the nodal system showed NRI for both cases (22%) and controls (16%). The pretreatment model showed NRI for cases (31%) and controls (18%). DCA in both models showed threshold probability of 15% and 12%, respectively, when compared with 24% in OUTBACK eligibility criteria. Our new nodal staging system and the pretreatment model could differentiate between high-risk and low-risk patients, thus facilitating decisions to provide more aggressive treatment to prevent distant metastases.

Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction.

BACKGROUND: Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes. METHODS: We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications. RESULTS: Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2. CONCLUSION: Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia.

Predictive models for lymph node metastases in patients with testicular germ cell tumors.

PURPOSE: To develop predictive models for lymph node (LN) metastasis in testicular germ cell tumors. MATERIALS AND METHODS: 291 patients with testicular germ cell tumors were included, which were divided into seminomatous and nonseminomatous groups. For screening the risk factors for LN metastasis, the tumor-related characteristics (including histopathological information and tumor markers) alpha fetoprotein and the lymph node-related features on CT were compared between metastatic cases and nonmetastatic cases. Two logistic regression models were built for each histological group, one depending on all tumor- and lymph node-related risk factors (Model 1) and another only on tumor-related factors (Model 2). Receivers operating characteristic curves were used to evaluate the predictive abilities of these models. RESULTS: 117 positive nodes/regions were identified in 68 patients, including 51 metastases and 17 occult metastases. Based on the selected independent risk factors, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of Models 1 and 2 in seminomatous and nonseminomatous groups were (95.5%, 95.3%, 95.3%, 77.8%, and 99.2%), (63.6%, 83.6%, 80.7%, 40.0%, and 93.0%), (93.5%, 94.7%, 94.3%, 89.6%, and 96.8%), and (89.1%, 44.2%, 58.9%, 43.6%, and 89.4%), respectively. CONCLUSION: Two predictive models for each seminomatous and nonseminomatous testicular tumor were established based on lymph node- and tumor-related risk factors. In patients with tumor and lymph node-related risk factors, regular CT surveillance is likely sufficient for predicting LN status, while in the patients without any tumor and lymph node-related risk factors a long interval-time CT follow-up should be considered. Additionally, right side tumors tend to involve contralateral LNs compared to left side ones. Positive inguinal LNs more frequently occur in patients with a history of groin surgery.

Tuberculosis--the great mimicker.

Tuberculosis is an immense health problem in the developing world, and it remains a health care challenge in the developed world. It can affect virtually any organ system in the body. Diagnosis of tuberculosis is often difficult. Many patients with tuberculosis present with nonspecific symptoms, negative purified protein derivative skin test result, and negative findings on culture specimens. Cross-sectional imaging with ultrasound, multidetector computed tomography, and magnetic resonance imaging plays an important role in the diagnosis of tuberculosis. Tuberculosis demonstrates a variety of radiologic features depending on the organ involved and can mimic a number of other disease entities. Cross-sectional imaging alone is insufficient in reaching a conclusive diagnosis. Tuberculosis is a great mimicker as its radiologic manifestations can simulate numerous other diseases across the body systems. However, recognition and understanding of the common and uncommon radiologic manifestations of tuberculosis should alert considering tuberculosis in the high-risk population and correct clinical setting to enable appropriate treatment.

Magnetic resonance imaging of pelvic metastases in male patients.

Magnetic resonance (MR) imaging offers a noninvasive tool for diagnosis of primary and metastatic pelvic tumors. The diagnosis of a pelvic metastatic lesion implies an adverse prognosis and dictates the management strategies. Knowledge of normal MR imaging anatomy of the pelvis and the signal characteristics of normal and abnormal structures is essential for accurate interpretation of pelvic MR imaging. This article reviews imaging manifestations of nodal, visceral, and musculoskeletal metastatic lesions of the pelvis along with current and evolving MR imaging techniques.

Ultrasound surveillance for hepatocellular carcinoma of at-risk patients in Ramathibodi Hospital.

BACKGROUND: Surveillance for hepatocellular carcinoma (HCC) is recommended for patients at risk of developing HCC. However the pattern of surveillance in clinical practice is unclear. OBJECTIVE: To assess the adherence of surveillance program in the detection of HCC and to determine the prevalence of HCC in the at-risk patients who were on surveillance in Ramathibodi Hospital. MATERIAL AND METHOD: Retrospective descriptive study of at-risk patients, who were followed in the liver clinic at Ramathibodi Hospital between January 1, 2007 and December 31, 2012. Clinical data were collected from electronic medical records and radiologic data were extractedfrom the radiology database (PACS). The US findings of focal liver lesion were analyzed for number size, location, and echogenicity. When focal liver lesions suggestive of HCC were detected on ultrasonography, dynamic contrast enhanced CT or AMRI was used to diagnose HCC. On CT/MRI, focal lesions were considered to be HCC when hypervascularity in the arterial phase and washout in the portal venous or delayed phase was found RESULTS: Nine hundred seven patients with risk(s) for HCC underwent ultrasound surveillance. The mean number of ultrasound examinations per patient was 4.7±2.2 scans during the course offollow-up. The mean total adherence time was 37.0±17.1 months. The median time interval between each ultrasound examination was 8.4 months (range: 1.1-63.0 months). Focal liver lesions were detected in 161 of 907patients (17.8%). No new focal liver lesion was detected at less than 3-month interval. The majority of patients were evaluatedfurther by MRI (n = 99; 62.3%) or by CT scan (n = 33; 20.8%). Theperiod prevalence of HCC in patients who received US surveillance was 3.5% (32 patients in 907patients). Most ofpatients with HCC were male (71.9%) and the major risk factor was chronic hepatitis B (50.0%). Twenty-one of 32 patients (65.6%) had normal serum AFP levels. Most HCC's (75.0%) were detected at 8-month interval. The cumulative percentage of HCC's detected at 6-month and 12-month surveillance intervals were 11.1% and 70.4%, respectively. The median tumor size was 22.5 mm, ranging from 12-134 mm. At the time ofHCC diagnosis, eight patients (25.0%) had HCC within BCLC very early stage (by size criteria) and 19 patients (59.4%) were in BCLC early stage. CONCLUSION: Although there were irregular surveillance intervals in our clinical practice, the overall adherence ofpatients to surveillance was acceptable, with the period prevalence of HCC 3.5% and the majority discovered in the early stage.