Radiological Differential Diagnoses Based on Cardiovascular and Thoracic Imaging Patterns: Perspectives of Four Large Language Models.

Background Differential diagnosis in radiology is a critical aspect of clinical decision-making. Radiologists in the early stages may find difficulties in listing the differential diagnosis from image patterns. In this context, the emergence of large language models (LLMs) has introduced new opportunities as these models have the capacity to access and contextualize extensive information from text-based input. Objective The objective of this study was to explore the utility of four LLMs-ChatGPT3.5, Google Bard, Microsoft Bing, and Perplexity-in providing most important differential diagnoses of cardiovascular and thoracic imaging patterns. Methods We selected 15 unique cardiovascular ( n = 5) and thoracic ( n = 10) imaging patterns. We asked each model to generate top 5 most important differential diagnoses for every pattern. Concurrently, a panel of two cardiothoracic radiologists independently identified top 5 differentials for each case and came to consensus when discrepancies occurred. We checked the concordance and acceptance of LLM-generated differentials with the consensus differential diagnosis. Categorical variables were compared by binomial, chi-squared, or Fisher's exact test. Results A total of 15 cases with five differentials generated a total of 75 items to analyze. The highest level of concordance was observed for diagnoses provided by Perplexity (66.67%), followed by ChatGPT (65.33%) and Bing (62.67%). The lowest score was for Bard with 45.33% of concordance with expert consensus. The acceptance rate was highest for Perplexity (90.67%), followed by Bing (89.33%) and ChatGPT (85.33%). The lowest acceptance rate was for Bard (69.33%). Conclusion Four LLMs-ChatGPT3.5, Google Bard, Microsoft Bing, and Perplexity-generated differential diagnoses had high level of acceptance but relatively lower concordance. There were significant differences in acceptance and concordance among the LLMs. Hence, it is important to carefully select the suitable model for usage in patient care or in medical education.

A Comparative Study of Acute Invasive Fungal Sinusitis During the First and Second Waves of the COVID-19 Pandemic.

We aimed to compare the demography, clinical profile, histopathology, fungal culture, radiology, surgery performed, medical therapy and outcomes of patients with acute invasive fungal sinusitis seen during the first and second waves of the COVID-19 pandemic by retrospectively reviewing their case records. Of 238 patients, 43(18.1%) presented during the first wave and 195(81.9%) during the second wave. Patients seen during the first wave were older (p = 0.04) and more likely to have visual impairment (p = 0.004), frozen eye (p = 0.012), altered sensorium (p = 0.007) and stage 3 disease (p = 0.03). Those seen during the second wave were more often COVID-19 positive and had newly diagnosed diabetes mellitus (p = 0.04)and stage 1 disease (p = 0.03). Most patients had a positive culture for Rhizopus species during both waves. Histopathology showed broad aseptate hyphae in all patients but angioinvasion was seen more often during the first wave (p = 0.04). The majority of patients were treated with endoscopic+/- open debridement followed by intravenous amphotericin B and oral posaconazole. While the overall survival rate was similar (first wave 65.1%; second wave 79%; p = 0.106), mortality after discharge was greater during the first wave (11.6% vs 1.5%; p = 0.001). Mortality was higher in patients with stage 3 disease (p = 0.003). Significant differences in clinical presentation, histopathology, radiological stage of disease and post-discharge survival were noted between the two waves of the COVID-19 pandemic, the causes for which were multi-factorial.

Tracheobronchopathia Osteochondroplastica - to Biopsy or not to Biopsy? A Relook at The Rare Disease.

BACKGROUND: Tracheobronchopathia osteochondroplastica (TPO) is a rare idiopathic disease involving the tracheobronchial tree. It is mostly an incidental finding with non-specific clinical manifestations. It has typical bronchoscopic, radiological features and biopsy is usually considered non-essential. The study aimed to determine whether biopsy makes a difference in the management of patients. METHODS: All patients diagnosed with TPO in our institution over 15 years (2005 to 2020) were included in this study. Their medical records, chest computed tomography (CT), and bronchoscopy reports were retrospectively reviewed, and data were analysed. All the CT images were reviewed by a senior chest radiologist. RESULTS: From the 20,000 bronchoscopies and 260,000 CT thorax images obtained, 28 cases were diagnosed as TPO based on either bronchoscopy or radiology or both. Among the 19 cases diagnosed through bronchoscopy, 16 underwent a biopsy. In addition to TPO features, biopsy showed additional diagnoses in 6 cases. In 9 cases, TPO was not initially diagnosed by CT but by bronchoscopy. In 8 patients, TPO was diagnosed incidentally on CT performed for other reasons. On follow-up with the treatment of underlying/co-existing concomitant aetiologies, clinical improvement was noted in all patients. None of them progressed to respiratory failure or airway obstruction until the last follow-up. CONCLUSION: Among patients who underwent bronchoscopic biopsy of TPO lesions, 38% had biopsy results showing an alternative aetiology, which led to changes in the treatment plan for all these patients. Hence, a bronchoscopic biopsy of TPO lesions should be performed to rule out other aetiologies.

UDHAVI Community Support During India's Second COVID-19 Wave: A Descriptive Study on a Tertiary Care Center's Pandemic Response Helpline.

BACKGROUND: In April 2021, during the peak of the second wave of the COVID-19 pandemic in India, hospitals overflowed with COVID-19 patients, and people hesitated to seek necessary care due to fear of contracting the disease. The UDHAVI helpline was set up by a tertiary care hospital in Vellore with the help of district administration, nongovernmental organizations, and various supporting agencies to provide general information, medical advice, counseling, and logistics support to the community. METHODS: This is a retrospective study of all the phone calls made to the UDHAVI helpline between mid-May and mid-June 2021 during the second wave of the COVID-19 pandemic. The calls were electronically captured as part of the process, and the information was subsequently retrieved and analyzed. RESULTS: In all, 677 calls were received. The lines for general information, medical advice, counseling, and logistics support received 168 (25%), 377 (56%), 15 (2%), and 117 (17%) calls, respectively. Home care kits, oxygen concentrators, and food were delivered by volunteers from local nongovernmental organizations and hospitals. CONCLUSION: We believe the details of our experience would be useful in the preparedness and mobilization of resources in the event of any public health emergency. As a result of this initiative, we propose an integrated partnership model for emergency response to any pandemic situation.

Multi-centre radiomics for prediction of recurrence following radical radiotherapy for head and neck cancers: Consequences of feature selection, machine learning classifiers and batch-effect harmonization.

Background and purpose: Radiomics models trained with limited single institution data are often not reproducible and generalisable. We developed radiomics models that predict loco-regional recurrence within two years of radiotherapy with private and public datasets and their combinations, to simulate small and multi-institutional studies and study the responsiveness of the models to feature selection, machine learning algorithms, centre-effect harmonization and increased dataset sizes. Materials and methods: 562 patients histologically confirmed and treated for locally advanced head-and-neck cancer (LA-HNC) from two public and two private datasets; one private dataset exclusively reserved for validation. Clinical contours of primary tumours were not recontoured and were used for Pyradiomics based feature extraction. ComBat harmonization was applied, and LASSO-Logistic Regression (LR) and Support Vector Machine (SVM) models were built. 95% confidence interval (CI) of 1000 bootstrapped area-under-the-Receiver-operating-curves (AUC) provided predictive performance. Responsiveness of the models' performance to the choice of feature selection methods, ComBat harmonization, machine learning classifier, single and pooled data was evaluated. Results: LASSO and SelectKBest selected 14 and 16 features, respectively; three were overlapping. Without ComBat, the LR and SVM models for three institutional data showed AUCs (CI) of 0.513 (0.481-0.559) and 0.632 (0.586-0.665), respectively. Performances following ComBat revealed AUCs of 0.559 (0.536-0.590) and 0.662 (0.606-0.690), respectively. Compared to single cohort AUCs (0.562-0.629), SVM models from pooled data performed significantly better at AUC = 0.680. Conclusions: Multi-institutional retrospective data accentuates the existing variabilities that affect radiomics. Carefully designed prospective, multi-institutional studies and data sharing are necessary for clinically relevant head-and-neck cancer prognostication models.

Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis.

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

Diagnostic Value of Connective Tissue Disease Related CT Signs in Usual Interstitial Pneumonia Pattern of Interstitial Lung Disease.

Purpose Usual interstitial pneumonia (UIP) pattern of interstitial lung disease (ILD) can have varied etiology, with connective tissue disease (CTD) being a common known cause. The anterior upper lobe (AUL) sign, exuberant honeycombing (EHC), and straight edge (SE) sign are recently described computed tomography (CT) signs in CTD-related UIP. We test the diagnostic value of these CT signs for CTD in patients with UIP and compare the incidence of these signs between CTD-related UIP and non-CTD-related UIP. We also evaluated the interobserver agreement in detection of these CT signs. Methods Retrospective study of all patients who had UIP pattern of ILD on CT thorax done from January 1, 2016 to January 31, 2019, was grouped into two: non-CTD-related UIP or CTD-related UIP. CT thorax was reviewed for the presence of these signs-AUL, SE, and EHC. The diagnostic values of these signs in diagnosing CTD-related UIP was assessed. For assessment of interobserver agreement, another radiologist reviewed a subset of 30 randomly selected cases and looked for the presence of these signs. Results Of the 156 patients included, 76 had CTD. The incidence of CT signs were significantly higher in CTD-related UIP. The specificities of AUL, EHC, and SE were 82.5, 75, and 85%, respectively. The EHC sign had highest sensitivity of 48.7%. Inclusion of more than one sign increased the specificity of diagnosis of CTD-related UIP; however, the sensitivity decreases. There was excellent interobserver agreement (0.81-0.87) for each of these signs. Conclusion The presence of SE, AUL, and EHC signs in cases with UIP pattern are specific imaging markers to diagnose underlying CTD; however, due to its low sensitivity, the absence of these signs cannot exclude the same. Because of its excellent interobserver agreement, these signs are reliable in the evaluation of CTD-related ILD.

Utility of Mid-treatment DWI in Selecting Pathological Responders to Neoadjuvant Chemoradiotherapy in Locally Advanced Esophageal Cancer.

PURPOSE: Pathological complete response correlates with better clinical outcomes in locally advanced esophageal cancer (LA-EC). However, there is lack of prognostic markers to identify patients in the current setting of neoadjuvant chemoradiotherapy (NACRT) followed by surgery. This study evaluates the utility of mid-treatment diffusion-weighted imaging (DWI) in identifying pathological responders of NACRT. METHODS: Twenty-four patients with LA-EC on NACRT were prospectively recruited and underwent three MRI (baseline, mid-treatment, end-of-RT) scans. DWI-derived apparent diffusion coefficient (ADC) mean and minimum were used as a surrogate to evaluate the treatment response, and its correlation to pathological response was assessed. RESULTS: Mid-treatment ADC mean was significantly higher among patients with pathological response compared to non-responders (p = 0.011). ADC difference (ΔADC) between baseline and mid-treatment correlated with tumor response (p = 0.007). ADC at other time points did not correlate to pathological response. CONCLUSION: In this study, mid-treatment ADC values show potential to be a surrogate for tumor response in NACRT. However, larger trials are required to establish DW-MRI as a definite biomarker for tumor response.

Chronic Granulomatous Invasive Fungal Sinusitis in Patients With Immunocompetence: A Review.

OBJECTIVE: We aimed to study the literature on chronic granulomatous invasive fungal sinusitis to elucidate the changing trends in the management of the disease. DATA SOURCES: Using specific keywords, we searched the PubMed, PubMed Central, and Scopus databases over the past 50 years, which yielded 938 articles in the English language. REVIEW METHODS: Scrutiny of 147 relevant articles revealed 15 homogenous case series (255 cases of histologically proven chronic granulomatous fungal sinusitis alone) and 8 heterogeneous case series (patients with other types of fungal sinusitis included), which were analyzed in detail (all with >5 cases each). CONCLUSIONS: The disease typically affected middle-aged adults with immunocompetence. Most reports were from Sudan, India, and Saudi Arabia. A slowly progressive orbital, cheek, or palatal mass with proptosis (88.2%) or sinonasal symptoms (39.2%) was typical. Ethmoid (57.2%) and maxillary (51.4%) sinuses were chiefly affected with intracranial extension in 35.1%. Aspergillus flavus (64%) was the most frequent isolate reported. Endoscopic excision (78.8%) followed by azole therapy was the preferred treatment in recent reports. Orbital exenteration and craniotomy were infrequently performed. Complete resolution or improvement was reported in 91.3% of patients. Mortality ranged from 5.9% to 22.2%. There is a trend in the literature toward less radical and disfiguring surgery and preferential use of azoles, with good outcomes even in advanced cases. IMPLICATIONS FOR PRACTICE: Chronic granulomatous fungal sinusitis should be diagnosed on the basis of well-defined histopathologic features. A combination of endoscopic sinus surgery and azole therapy usually yields good outcomes.

Congenital Nasal Pyriform Aperture Stenosis: Same CT Dimensions, Varied Scenarios.

Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of neonatal respiratory distress. We report a case series of four infants with similar radiological dimensions but while two needed surgery, two could be managed conservatively. The clinical presentation of the child and the response to conservative treatment, rather than the radiological dimensions were the main predictors for surgical intervention.

Feasibility, safety and oncological outcomes of minimally invasive oesophagectomy following neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma - Experience from a tertiary care centre.

Background: Neoadjuvant chemoradiotherapy (nCRT) has improved the resectability and survival of operable oesophageal squamous cell carcinoma (OSCC). We aimed to study if nCRT for OSCC makes minimally invasive oesophagectomy (MIO) technically more challenging and if the peri-operative and oncological outcomes are acceptable for MIO following nCRT. Materials and Methods: A retrospective review of patients with OSCC (cT1-2N1-2, cT3-4aN0-2) treated with nCRT and MIO between 2013 and 2019 was performed. The operative details including the technical difficulty in tumour dissection and lymphadenectomy, the post-operative complications and oncological outcomes were studied. Results: Seventy-five patients (male:female - 50:25; mean [range] age - 55.49 ± 8.43 [22-72] years; stage II - 34.7%; stage III - 37.3%; stage IVA - 28.0%) were enrolled. The concurrent chemotherapy course was completed by 25.3% of patients and the most common reason limiting the completion of chemotherapy was neutropaenia (66.0%). A thoraco-laparoscopic (n = 60) or hybrid (n = 15) McKeown's oesophagectomy with a two-field lymphadenectomy was performed. The increased surgical difficulty was reported in 41 (54.7%) patients, particularly for mid-thoracic tumours and tumours exhibiting incomplete response. The 30-day overall and major complication rate was 48.0% and 20.0%, respectively, and there was no mortality. The rate of R0 resection, pathological complete response and median lymph nodal yield were 93.3%, 48% and 8 (range: 1-25), respectively. The mean overall survival (OS) was 62.2 months (95% confidence interval [CI]: 52.6-71.8) and recurrence-free survival (RFS) was 53.5 months (95% CI: 43.5-63.5). The 1-, 2- and 3-year OS and RFS were 89.5%, 78.8% and 64.4% and 71.1%, 61.3% and 56.6%, respectively. Conclusion: Minimally invasive McKeown's oesophagectomy is feasible and safe in patients with OSCC receiving nCRT. The radiation component of nCRT increases the degree of operative difficulty, especially in relation to the supracarinal dissection and lymphadenectomy. However, this drawback did not adversely affect the short-term surgical or the long-term oncological outcomes.

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.

Can epicardial and pericardial adipose tissue volume predict the presence and severity of coronary artery disease?

Purpose: Excessive accumulation of free fatty acids in the coronary arteries can lead to coronary artery disease (CAD). Quantification of epicardial adipose tissue (EAT) and pericardial adipose tissue (PAT) is beneficial to understand its relationship with CAD, hypertension (HT), and diabetes. Material and methods: This retrospective study included 54 patients who underwent CT coronary angiogram using a multidetector row CT scanner. The EAT and PAT volumes from cardiac images were quantified using Image J software. The severity of CAD was graded using the CAD-RADS score. Results: Twenty-nine patients had no CAD, 21 patients had significant CAD, and 4 patients had insignificant CAD. Out of 21 patients with significant CAD, 14 had involvement of multiple coronary arteries. The EAT and PAT volumes were higher in patients with HT, DM, CAD-present group and significant-CAD-present group, but this was not statistically significant except the PAT volume with respect to diabetes. Significant correlation was found between EAT volume and calcium score (p = 0.035) and between EAT volume and total cholesterol level (p = 0.017). Significant differences in the EAT volumes were found in different CAD-RADS categories in the right coronary artery (RCA). From the threshold values, it was observed that CAD can develop in LAD even at lower of EAT and PAT volumes. Conclusions: Quantification of EAT and PAT volumes is beneficial in understanding its relationship with the presence and severity of coronary artery disease and its risk factors.

Etiopathology and Prevalence of Pulsatile Tinnitus in a Tertiary Care Referral Hospital.

The diverse etiopathogenesis of pulsatile tinnitus (PT) makes it a difficult condition to diagnose and treat. To describe the clinical features, investigations and diagnosis of patients presenting with pulsatile tinnitus (PT). Retrospective chart review in an otology unit of a tertiary care referral centre. All medical records of patients who had a complaint of pulsatile tinnitus during the period 1st January 2014-1st May 2020 were included in the study. Data regarding history, characteristics of tinnitus, examination findings, investigations and diagnosis were collected and analyzed. Sixty-four patients with complaints of PT presented to our clinic during this time period and were included in the study giving a prevalence of 0.09%. Definite diagnosis was made in 62 (96.8%) cases with a detailed history, clinical examination and tailored investigations. Pathologies diagnosed were paraganglioma (25%), superior semicircular canal dehiscence (20.3%), anterior inferior cerebellar artery loop (7.8%), sigmoid sinus wall dehiscence (10.9%), sigmoid sinus diverticulum (6.25%), jugular bulb anomalies (7.8%) and hyperpneumatised petrous apex (3.1%) among others. Rare causes encountered were IgG4 disease, far advanced otosclerosis, vestibular aqueduct dehiscence and idiopathic intracranial hypertension. Pulsatile tinnitus is a rare complaint in the Otology clinic. Almost all cases of PT can be diagnosed correctly and appropriate treatment initiated with a logical approach to investigations.

Framework for Machine Learning of CT and PET Radiomics to Predict Local Failure after Radiotherapy in Locally Advanced Head and Neck Cancers.

CONTEXT: Cancer Radiomics is an emerging field in medical imaging and refers to the process of converting routine radiological images that are typically qualitatively interpreted to quantifiable descriptions of the tumor phenotypes and when combined with statistical analytics can improve the accuracy of clinical outcome prediction models. However, to understand the radiomic features and their correlation to molecular changes in the tumor, first, there is a need for the development of robust image analysis methods, software tools and statistical prediction models which is often limited in low- and middle-income countries (LMIC). AIMS: The aim is to build a framework for machine learning of radiomic features of planning computed tomography (CT) and positron emission tomography (PET) using open source radiomics and data analytics platforms to make it widely accessible to clinical groups. The framework is tested in a small cohort to predict local disease failure following radiation treatment for head-and-neck cancer (HNC). The predictors were also compared with the existing Aerts HNC radiomics signature. SETTINGS AND DESIGN: Retrospective analysis of patients with locally advanced HNC between 2017 and 2018 and 31 patients with both pre- and post-radiation CT and evaluation PET were selected. SUBJECTS AND METHODS: Tumor volumes were delineated on baseline PET using the semi-automatic adaptive-threshold algorithm and propagated to CT; PyRadiomics features (total of 110 under shape/intensity/texture classes) were extracted. Two feature-selection methods were tested for model stability. Models were built based on least absolute shrinkage and selection operator-logistic and Ridge regression of the top pretreatment radiomic features and compared to Aerts' HNC-signature. Average model performance across all internal validation test folds was summarized by the area under the receiver operator curve (ROC). RESULTS: Both feature selection methods selected CT features MCC (GLCM), SumEntropy (GLCM) and Sphericity (Shape) that could predict the binary failure status in the cross-validated group and achieved an AUC >0.7. However, models using Aerts' signature features (Energy, Compactness, GLRLM-GrayLevelNonUniformity and GrayLevelNonUniformity-HLH wavelet) could not achieve a clear separation between outcomes (AUC = 0.51-0.54). CONCLUSIONS: Radiomics pipeline included open-source workflows which makes it adoptable in LMIC countries. Additional independent validation of data is crucial for the implementation of radiomic models for clinical risk stratification.

Meet the Lacrimal Sac: Endoscopic Surgeons' Road Map.

Knowledge of lateral nasal wall landmarks in relation to lacrimal apparatus is essential for successful endoscopic dacryocystorhinostomy. This descriptive study of right and left sagittally sectioned ten adult cadaver head specimens was done measuring various lateral nasal wall anatomical landmarks including lacrimal apparatus with digital calipers. Maxillary line was identified in 75%, majority overlapping lacrimal sac. Genu of middle turbinate was at or posterior to nasolacrimal duct. Mean distance of superior end of sac was 8.88 mm above axilla, between its anterior edge and axilla was 10.58 mm and its length was 11.72 mm. Considering above measurements, 'Rule of 10' can be applied for nasal mucosal incision. A "Three Tier Approach" to overcome mucosal (nasal), bony (lacrimal and frontal process of maxilla) and mucosal (sac) boundaries exposes lacrimal sac up to its inferior limit ensuring successful endonasal endoscopic dacryocystorhinostomy.

Primary mediastinal germ cell tumours: real world experience in the low middle income (LMIC) setting.

PURPOSE: Primary mediastinal germ cell tumours (PMGCTs) are rare; with limited data available about their outcomes and optimal treatment in the low middle income countries setting. We studied the clinical profile of patients with PMGCT treated at our centre in order to estimate their survival outcomes and to identify prognostic factors affecting the same. PATIENTS AND METHODS: Fifty-seven patients with PMGCTs treated between April 2001 and June 2019 were included. Baseline characteristics, details of first line chemotherapy, response rates, toxicity and surgical outcomes were noted. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. RESULTS: Among 57 male patients (seminoma = 20 and nonseminomatous = 37), the median follow-up was 10 months (range: 1-120 months). For mediastinal seminoma, 9 (45%) and 11 (55%) patients had good and intermediate risk disease, respectively. Nineteen patients (95%) received BEP (Bleomycin, etoposide and cisplatin) chemotherapy. 94.7% had partial responses and median event-free survival was not reached. All patients were alive and disease free at 2 years. For primary mediastinal nonseminomatous germ cell tumours (PMNSGCTs), all patients were poor risk. Thirty-four (91.8%) received BEP/EP chemotherapy as first line. Responses were PRM+ (partial response with elevated markers) in 7 (20.5%) and PRM- in 12 (35.2%). The incidence of febrile neutropenia was 50% and 55.8% in seminole and PMNSGCT, respectively. The median OS was 9.06 months and median PFS was 4.63 months for PMNSGCT. The proportion of patients alive at 1 year and 2 years were 35% and 24.3%, respectively. CONCLUSION: Primary mediastinal seminomas are rarer and have better survival outcomes. Treatment of PMNSGCT is still a challenge and is associated with poorer survival outcomes.

Computed tomography chest in COVID-19: When & why?

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.

Mycophenolate in scleroderma-associated interstitial lung disease: Real-world data from rheumatology and pulmonology clinics in South Asia.

Introduction: There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic sclerosis-related interstitial lung disease. Aim: To study the efficacy of mycophenolate mofetil/ mycophenolate sodium in systemic sclerosis-related interstitial lung disease. Methods: In this single-centre study, clinical, laboratory and imaging details of consecutive patients with systemic sclerosis-related interstitial lung disease receiving mycophenolate mofetil/mycophenolate sodium from rheumatology and pulmonology clinics between January 2008 and March 2017 were retrospectively retrieved. The change in percentage of predicted normal forced vital capacity at last follow-up visit as compared with baseline was studied. In addition, high-resolution computed tomography scans at baseline and 2-year follow-up visit were scored as either stable/improved or worsened by experienced thoracic radiologists blinded to the clinical details of patients. Results: Altogether, 88 patients (85.2% females) with mean age (SD) of 33.8 years (± 11.3) and median (interquartile range) duration of disease since non-Raynaud's symptoms of 36 months (13.5-60) were studied. Diffuse systemic sclerosis comprised 85.2% of them. The mean baseline forced vital capacity was 61.2 ± 17.9% and median scores for ground glass opacities and fibrosis in high-resolution computed tomography were 0.5 (0-1.3) and 1 (0-1.3), respectively. At a median follow-up duration of 30 months (interquartile range = 16.5-49), the percentage of forced vital capacity improved by 1.8% (-3.82 to 9.07) as compared with baseline visit (p = 0.02). In the 2-year follow-up, the ground glass opacity and fibrosis scores in high-resolution computed tomography improved in 17.3% and 7.7% of patients and stabilized in 63.5% and 78.8% patients, respectively. Conclusion: Mycophenolate mofetil/mycophenolate sodium was efficacious in improving /stabilizing forced vital capacity irrespective of the baseline high-resolution computed tomography lung scores in our patients with systemic sclerosis-related interstitial lung disease during the ⩾ 2-year follow-up period.

Patterns of Recurrence in Locally Advanced Resectable Oesophageal Carcinoma: Retrospective Review from a Tertiary Cancer Centre in South India.

PURPOSE: The study aims to analyse patterns of recurrence following neoadjuvant treatment and surgery in carcinoma oesophagus with an intent to postulate optimal nodal radiation. METHODOLOGY: A retrospective review of patients who presented to our centre within a 5-year period (2014-2018), with recurrence following sequential neoadjuvant treatment and radical surgery, was conducted in this single-institution study. The patterns of recurrence and duration of disease-free survival were analysed. RESULTS: Twenty-one patients (14 men, 7 women) presented with recurrence, of which 13, 7, and 1 patient(s) had received NACT, NACTRT, or both, respectively. Six patients who did not receive neoadjuvant radiotherapy received adjuvant RT. Among the 10 patients who had nodal recurrence after RT (either neoadjuvant or adjuvant), 6 and 4 patients had in-field and out-of-field nodal recurrences, respectively-the latter were equally distributed within 5 cm and outside 5 cm of the PTV margin. CONCLUSION: Among the patients who presented with recurrence, more than half had not received neoadjuvant RT (treated in the 'pre-CROSS era' or due to long-segment disease), reasserting the therapeutic superiority of NACTRT. Increased regularity of recurrences in the draining nodal region was not noted in this study, but large-scale, prospective, randomised head-to-head comparative trials to determine optimal nodal irradiation in carcinoma oesophagus are required.