The 'Starburst' Sign: A Novel Description of PET Images in Carcinoma of Unknown Primary.

BACKGROUND/AIM: Carcinoma of unknown primary (CUP) poses a formidable diagnostic challenge, characterised by high mortality rates and an elusive primary tumour site. While Positron emission tomography (PET) scans are routinely employed in the initial evaluation of CUP patients, identifying the primary tumour remains an ongoing struggle. In light of this, the aim of this case report is to introduce a novel radiological description, termed the 'Starburst' sign, derived from distinctive PET scan appearances associated with CUP. CASE REPORT: In this report, we present the case of a 47-year-old female patient who presented with abdominal symptoms. Upon investigation, extensive peritoneal disease was observed, yet the primary tumour source remained unidentified. Despite further diagnostic efforts, including a normal gastroscopy, a PET scan was able to confirm the presence of high-volume metastatic disease, without an identifiable primary tumour. Palliative treatment was initiated, but unfortunately, the patient's condition deteriorated rapidly, leading to her demise. CONCLUSION: The 'Starburst' sign, a unique radiological description of CUP in PET scans, has significant potential in advancing our understanding of the disease. It provides a visual analogy to a dying star, aiding comprehension of complex pathophysiology and implications of metastatic lesions. The introduction of the 'Starburst' sign benefits patients and healthcare professionals, enhancing education, assessment, and treatment of CUP. This novel description contributes to knowledge in the field and can impact clinical management.

Comparison of Proportion of Elevated Carcinoembryonic Antigen Levels in Patients With Appendiceal and Colorectal Adenocarcinoma: A Systematic Review and Meta-analysis.

BACKGROUND/AIM: The proportion of patients with liver metastases in patients with appendiceal versus colorectal adenocarcinomas was 3.1 percent and 24 percent, respectively, in our peritonectomy centre. From our internal analyses, carcinoembryonic antigen (CEA) was potentially involved. A hypothesis was proposed regarding the natural progression of appendiceal adenocarcinoma. To support this, a systematic review and meta-analysis were performed to examine whether there was a difference in the proportion of patients with an elevated CEA in appendiceal versus colorectal adenocarcinoma patients in the current literature. MATERIALS AND METHODS: Medline (PubMed), EMBASE (Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature, Clinicaltrials.gov, Web of Science, and Google Scholar were searched. All studies involving patients with appendiceal and/or colorectal adenocarcinoma were eligible. Data were analysed by grouping appendiceal and colorectal adenocarcinoma in separate meta-analyses, and then comparing their weighted proportions of elevated CEA. Principal summary measures were weighted proportions of patients with elevated CEA. RESULTS: From the initial identification of 1,928 articles, 136 articles were included in the final synthesis. Ninety-two articles were included in the meta-analysis. Proportions of appendiceal and colorectal adenocarcinoma with elevated CEA were 56% (95%CI=47-65%) and 42% (95%CI=38-46%), respectively (p=0.0001). CONCLUSION: Patients with appendiceal adenocarcinoma had a higher proportion of CEA than those with colorectal adenocarcinoma. Future studies should focus on the several aspects of CEA presented in patients with appendiceal adenocarcinoma. This could provide treatments for patients with colorectal adenocarcinoma by preventing the development of liver metastases.

Development and validation of a multivariable prediction model in open abdomen patients for entero-atmospheric fistula.

BACKGROUND: Laparostomy or Open Abdomen (OA) has matured into an effective strategy in the management of abdominal catastrophe. Single prognostic factors have been identified in a previous systematic review regarding entero-atmospheric fistula (EAF). Unfortunately, no prognostic multivariable model for EAF exist. The aim was to develop and validate a multivariable prediction model from a retrospective cohort study involving three hospital's databases. METHODS: Fifty-seven variables were evaluated to develop a multivariable model. Univariate and multivariable logistic regression analyses were performed for on a developmental data set from two hospitals. Receiver operator characteristics analysis with area under the curve (AUC) and 95% confidence intervals (CI) were performed on the developmental data set (internal validation) as well as on an additional validation data set from another hospital (external validation). RESULTS: Five-hundred and forty-eight patients managed with an OA. Two variables remained in the multivariable prediction model for EAF. The AUC for EAF on internal validation were 0.74 (95% CI: 0.58-0.86) and 0.79 (95% CI: 0.67-0.92) on external validation. CONCLUSIONS: A multivariable prediction model for EAF was externally validated and an easy-to-use probability nomogram was constructed using the two predictor variables. LEVEL OF EVIDENCE: III; prognostic.

Dilemma of mucosal appendicitis: a clinico-pathological entity? A retrospective cohort study.

BACKGROUND: The presence of mucosal inflammation within appendicectomy specimens is poorly described in the literature, and there is debate regarding the clinical significance of this histological finding. The aim of this study is to correlate clinical and radiological data with histologically confirmed acute mucosal appendicitis (MA). METHODS: A retrospective cohort study was performed to identify all patients who underwent appendicectomy over 5 years at Caboolture Hospital. Data were collected in regards to clinical Alvarado score, pathological specimen findings, radiological findings and coincidental conditions, and comparison made between MA and negative appendicectomy groups. RESULTS: A total of 1347 appendicectomy specimens and data were reviewed. Of these, 219 (16%) specimens were microscopically confirmed to have acute mucosal inflammation, 150 (68%) were females. Median age was 19 ± 14 years. A total of 243 (18%) were histologically negative. There was a statistically significant difference in mean Alvarado score in the MA group (5.0 ± 1.9 versus 4.3 ± 1.8, P = 0.0002). Patients with MA are more likely to report migratory pain (48.4 versus 31.4%, P = 0.0001) and rebound tenderness (24.9 versus 14.6%, P = 0.002). Computed tomography and ultrasound scans were negative in 74.1 and 72.6%, respectively, in patients with MA. More MA patients benefited from appendicectomy compared with the negative appendicectomy group (82 versus 63%, P = <0.0001). CONCLUSION: There is a subgroup of patients with MA who are young females with have low Alvarado scores, have non-diagnostic imaging, and may represent almost one-fifth of appendicectomy specimens. This study supports the probability that MA is a pathological entity.

Treatments and other prognostic factors in the management of the open abdomen: A systematic review.

BACKGROUND: The open abdomen (OA) is an important approach for managing intra-abdominal catastrophes and continues to be the standard of care. Despite this, challenges remain with it associated with a high incidence of complications and poor outcomes. The objective of this article is to perform a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify prognostic factors in OA patients in regard to definitive fascial closure (DFC), mortality and intra-abdominal complications. METHODS: An electronic database search was conducted involving Medline, Excerpta Medica, Central Register of Controlled Trials, Cumulative Index to Nursing, and Allied Health Literature and Clinicaltrials.gov. All studies that described prognostic factors in regard to the above outcomes in OA patients were eligible for inclusion. Data collected were synthesized by each outcome of interest and assessed for methodological quality. RESULTS: Thirty-one studies were included in the final synthesis. Enteral nutrition, organ dysfunction, local and systemic infection, number of reexplorations, worsening Injury Severity Score, and the development of a fistula appeared to significantly delay DFC. Age and Adult Physiology And Chronic Health Evaluation version II score were predictors for in-hospital mortality. Failed DFC, large bowel resection and >5 to 10 L of intravenous fluids in <48 hours were predictors of enteroatmospheric fistula. The source of infection (small bowel as opposed to colon) was a predictor for ventral hernia. Large bowel resection, >5 to 10 and >10 L of intravenous fluids in <48 hours were predictors of intra-abdominal abscess. Fascial closure on (or after) day 5 and having a bowel anastomosis were predictors for anastomotic leak. Overall methodological quality was of a moderate level. LIMITATIONS: Overall methodological quality, high number of retrospective studies, low reporting of prognostic factors and the multitude of factors potentially affecting patient outcome that were not analyzed. CONCLUSION: Careful selection and management of OA patients will avoid prolonged treatment and facilitate early DFC. Future research should focus on the development of a prognostic model. LEVEL OF EVIDENCE: Systematic review, level III.