Search

Acute pancreatitis is a frequent entity encountered by radiologists. In 2012, the Atlanta criteria were revised to help radiologists use a common nomenclature when describing acute pancreatitis and its complications. One delayed complication of acute necrotizing pancreatitis in walled-off necrosis, a collection seen at least 4 weeks after an episode of acute pancreatic necrosis and/or acute peripancreatic necrosis. Multiple treatments have been adapted in the setting of walled-off necrosis, including endoscopic cystogastrostomy. The focus of this article is to familiarize the radiologist with the imaging appearance of this procedure as well as, review the outcomes and potential complications of endoscopic cystogastrostomy.

Purpose: Gender-nonconforming patients are at higher risk for medical problems that require prompt medical and mental health intervention. Barriers to healthcare for transgender individuals have been well characterized in the literature, but not in low resource settings. The purpose of this paper is to present the barriers encountered when bringing healthcare to transgender children, adolescents, and adults in a medically underserved, predominantly Hispanic area of the United States. Methods: In this medically underserved area on the U.S.-Mexico border, there is a severe shortage of medical expertise for transgender individuals at both the primary- and specialty-care levels. Further, given the mainly Hispanic population, there is an additional culturally based barrier to obtaining medical care for transgender patients. Results: It is important for academic centers in these regions to collaborate to overcome these barriers through a multidisciplinary approach that includes providing education for medical students and physicians in training and identifying medical providers who are able and willing to provide transgender-competent care adapted to local culture and gender norms. Conclusion: In this manuscript, we will describe the efforts of various groups to address the needs of the transgender community in the region., Competing Interests: No competing financial interests exist.

Purpose: Enhanced recovery after surgery (ERAS) pathways are increasingly implemented. Goal directed fluid therapy (GDFT) is a core component of ERAS pathways that limit excessive volume administration and is associated with increased use of intraoperative vasopressors. Vasopressor effects on anastomotic healing and pancreatic fistula are inconclusive. We hypothesized that intraoperative vasopressor use in an ERAS GDFT algorithm would not increase risk of pancreatic fistulas. Methods: We reviewed all adult patients undergoing pancreatectomy at an academic institution from January 2013 to February 2016, before and after implementation of an ERAS pathway in July 2014. Retrospective chart review was performed. Log-binomial regression, weighted by stabilized inverse probability-of-treatment weights, estimated effect of ERAS and intraoperative vasopressors on fistula risk. Results: One hundred thirty two patients met inclusion criteria: 74 (56.1%) in the ERAS cohort. No significant differences in overall leak risk (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.38-2.09) were observed between the ERAS and pre-ERAS cohorts. Similarly, vasopressor infusions, independent of ERAS pathway, did not significantly increase the risk of anastomotic leaks (RR 1.19, 95% CI 0.52-2.72). Conclusions: Increased use of vasopressor infusions as part of an ERAS pathway for pancreatic surgery is not associated with an increase in the risk of clinically significant pancreatic fistulas., Competing Interests: No competing financial interests exist.

Primary synovial chondromatosis is a benign neoplastic process, occurring mostly in large joints, more rarely in tendon sheaths, and extremely uncommonly in bursae. We describe a patient with primary synovial chondromatosis arising in the fourth intermetatarsal bursa. Knowledge of the bursal anatomy of the forefoot, and of characteristic imaging findings and the pathogenesis of synovial chondromatosis, is essential in including this uncommon entity in the differential when occurring in unusual locations.

Tumor mitotic rate (TMR) is a known prognostic variable in thin melanoma patients. Its significance in stage II melanoma patients is yet to be demonstrated. Retrospective analysis of a prospective melanoma database from 9/1997 to 7/2015 was performed. All stage II melanoma, with documented TMR, and six months of follow-up were included. We evaluated the association of clinicopathologic variables, TMR, as a continuous and categorical variable with recurrence-free survival (RFS) and overall survival (OS) using Cox proportional hazards modeling. We used a statistical model, X-tile, to develop optimal categorizations of TMR. A total of 265 patient characteristics are included in this study. Recurrences occurred in 82 (30.9%) patients, including 5 local, 41 regional, and 36 distant patients. In multivariate model, ulceration, Breslow, and continuous TMR were associated with worse RFS\OS. Continuous TMR demonstrated worse RFS (hazards ratio [HR] 1.02 (1.00-1.05)) and OS (HR 1.02 (1.00-1.04)), whereas dichotomized TMR (≥1 vs <1) was not significant. TMR >10.4 mitoses/mm2 has a 5-year RFS\OS of 27.2 and 44.3 per cent, respectively, compared with 57.4 and 71.4 per cent, respectively, for TMR <3.2 mitoses/mm2. Continuous TMR predicts incidence of recurrence in stage II melanoma. We propose a new categorization method developed by statistical modeling for optimal stratification that may guide surveillance for this disparate patient population.

Introduction: A multidisciplinary approach in the management of complex malignancies is becoming more common, and likewise, adopting such an approach to the care of patients with locally advanced esophageal is recommended in order to optimize clinical outcomes., Methods: In this review, we discuss both the surgical and medical oncology perspectives in the management of patients with locally advanced esophageal cancer. We review the data supporting the current standard-of-care approach, namely trimodality therapy with neoadjuvant chemo-radiotherapy followed by surgery. Other aspects of managing these patients including the control of dysphagia and pain as well as nutritional support are discussed. Finally, we review data that support the importance of incorporating a multidisciplinary streamlined approach in the management of these patients., Results: Rather than having patients see each provider separately, a multidisciplinary approach to esophageal cancer allows for the seamless flow of communication and proactive management of the patient's symptoms. These benefits include increasing the likelihood of evidence-based decision making, shorter time to treatment, and increased patient quality of life, all of which can result in improved patient outcomes., Conclusion: The use of a multidisciplinary team can lead to a more accurate staging paradigm and thereby, better management decisions that translate to improved clinical outcomes. Therefore, optimizing the multidisciplinary approach for the care of patients with locally advanced esophageal cancer is essential for successful and individualized patient care.

This article discusses the current National Comprehensive Cancer Network guidelines and other available Western and Eastern guidelines for the surveillance of gastric cancer following surgical resection. It reviews the literature assessing the utility of intensive surveillance strategies for gastric cancer, which fails to show an improvement in survival. The unique issues relating to follow-up of early gastric cancer and after endoscopic resection of early gastric cancer are discussed. This article also reviews the available modalities for follow-up. In addition, it briefly discusses the advancements in treatment of recurrent and metastatic disease and the implications for gastric cancer survival and surveillance strategies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Spontaneous rupture of a uterine artery in pregnancy is associated with a high rate of mortality. Although uterine artery rupture has been associated with postpartum hemorrhage, it is rarely found during pregnancy. Unfortunately, clinical signs and symptoms are usually vague and nonspecific. We report a case of a 36-year-old woman at 20 weeks gestation presenting with abdominal pain who was found to have a spontaneous uterine artery rupture. To our knowledge, this is the first case report demonstrating imaging findings in a patient with this condition. Our patient underwent successful ligation of the uterine vessel with preservation of both mother and fetus. We will discuss possible etiologies of uterine artery rupture during pregnancy, associated imaging findings, and management options.

Renal cell carcinoma (RCC) accounts for 3% of all cancers in adults. The indications for Radiofrequency Ablation (RFA) for renal carcinomas include T1a (tumor 4 cm or less, limited to the kidney), elderly patients, renal impairment, comorbidities, poor surgical candidate, and multiple bilateral renal masses. We retrospectively reviewed medical records, specifically investigating the indications, complications and outcomes of RFA and nephrectomy for treatment of RCC in a tertiary medical center with a predominantly Hispanic patient population. Forty-nine patients with RCC were evaluated. Nine patients had RFA, 9 had partial nephrectomy and 31 had radical nephrectomy. All patients among the 3 groups had stage T1N0M0 RCC at diagnosis. Tumor recurrence was observed in 2 (22%) patients that had RFA, one (11%) patient that had partial nephrectomy and no patients that had radical nephrectomy. One patient had recurrence of the tumor at the opposite kidney pole from the initial RFA site 4 years later. This particular patient did not have any tumor recurrence at the site of the initial RFA. A second RFA was performed on the recurrent tumor with no recurrence upon subsequent follow up visits. The second patient had recurrence of the RCC on 1 year follow that was discovered to be sarcomatoid RCC, which is an aggressive type with a poor prognosis. Our results support the clinical utility of RFA in patients with stage T1 RCC who are poor surgical candidates or those with reduced renal function. The clinical utility of RFA as an equally effective approach when compared to partial nephrectomy in patients with stage T1 RCC that meet strict indications for the procedure. The treatment choice should be individualized and based on the characteristics of the renal tumor such as size, location and histological type of RCC. We conclude that RFA presents a safe treatment choice for patients with RCC if long term follow up is maintained.

Neoadjuvant therapy is an under-utilized regimen for the treatment of metastatic melanoma. The use of this approach has been increasing in other tumor types. Neoadjuvant therapy may reduce occult circulating tumor cell burden in the face of bulky disease and afford a real time evaluation of treatment effectiveness. Neoadjuvant approach can also provide preoperative histologic and molecular analysis of treated tissue that may guide the postoperative treatment planning in patients with resectable metastatic melanoma lesions. The putative benefits of better margin control and clearance of occult systemic disease would theoretically improve surgical outcome. With the advent of effective agents against metastatic melanoma, this common approach to the treatment of rectal cancer, metastatic colon cancer, and breast cancer should also be evaluated as a viable treatment strategy for advanced stage melanoma.

Endovascular repair is increasingly considered a less-invasive alternative to open repair of abdominal aortic aneurysm. However, there are still many potential complications of endovascular repair, including endoleaks, graft migration, thrombosis, and fistula formation. Endoleak is the most common complication for which these patients undergo long-term imaging surveillance. Most centers acquire computed tomographic (CT) data before contrast administration and during an arterial and delayed phase of aortic enhancement after the administration of intravenous contrast material to optimize detection of endoleaks. Although this technique works well, the downside is significant patient radiation exposure. Although the carcinogenic risk of ionizing radiation because of CT exposure is low, it has been linked to an increase in the lifelong risk of developing fatal cancers. Furthermore, this risk is cumulative and increases with multiple radiation exposure, as is true in surveillance after endovascular repair. As a result, considerable research is being performed to optimize CT protocols in an effort to decrease radiation dose. One such approach is to image these patients with recently introduced dual source dual-energy CT system. Using this technique, virtual noncontrast data may be generated from a postcontrast acquisition which may obviate the routine acquisition of noncontrast acquisition, thus decreasing radiation dose. In this article, we discuss the role of dual energy CT imaging in evaluation of patients after endovascular repair of abdominal aortic aneurysm., (Copyright 2010 Elsevier Inc. All rights reserved.)

The pelvic cake kidney in which there is complete fusion of both kidneys into a single renal parenchymal mass has been described as the rarest of renal fusion anomalies. Pelvic cake kidney most commonly drains via 2 separate ureters, with fewer than 10 reports demonstrating a cake kidney drained by a single ureter. We present the first ever reported case of a pelvic cake kidney drained by a single ureter in association with a unicornuate uterus. These findings were identified in a young female patient who underwent pelvic magnetic resonance imaging for pelvic pain., (Copyright 2010 Elsevier Inc. All rights reserved.)

Poor availability of reference standards for designer drugs, metabolites, and new substances prevents toxicology laboratories from rapidly responding to the changing analytical challenges of drug abuse. A novel screening approach comprising determination of accurate masses of sample components and comparison of these with databases of theoretical monoisotopic masses is described. Using liquid chromatography-time-of-flight mass spectrometry (LC-TOFMS), a routine mass search window of 20-30 ppm was applied to urine samples. The ultimate reference technique, liquid chromatography-Fourier transform mass spectrometry (LC-FTMS), was capable of confirming the findings within a 3 ppm mass accuracy. Using a target database of 7640 compounds, the number of potential elemental formulas ranged from one to three with LC-TOFMS, and it was always one with LC-FTMS. In contrast to ordinary techniques requiring primary reference standards, the formula-based databases can be updated instantly with fresh numeric data from scientific literature and authority sources.

A novel approach was used to analyze street drugs in seized material without primary reference standards. Identification was performed by liquid chromatography/time-of-flight mass spectrometry (LC/TOFMS), essentially based on accurate mass determination using a target library of 735 exact monoisotopic masses. Quantification was carried out by liquid chromatography/chemiluminescence nitrogen detection (LC/CLND) with a single secondary standard (caffeine), utilizing the detector's equimolar response to nitrogen. Sample preparation comprised dilution, first with methanol and further with the LC mobile phase. Altogether 21 seized drug samples were analyzed blind by the present method, and results were compared to accredited reference methods utilizing identification by gas chromatography/mass spectrometry and quantification by gas chromatography or liquid chromatography. The 31 drug findings by LC/TOFMS comprised 19 different drugs-of-abuse, byproducts, and adulterants, including amphetamine and tryptamine designer drugs, with one unresolved pair of compounds having an identical mass. By the reference methods, 27 findings could be confirmed, and among the four unconfirmed findings, only 1 apparent false positive was found. In the quantitative analysis of 11 amphetamine, heroin, and cocaine findings, mean relative difference between the results of LC/CLND and the reference methods was 11% (range 4.2-21%), without any observable bias. Mean relative standard deviation for three parallel LC/CLND results was 6%. Results suggest that the present combination of LC/TOFMS and LC/CLND offers a simple solution for the analysis of scheduled and designer drugs in seized material, independent of the availability of primary reference standards.

Objective: Our purpose was to determine the clinical significance of polyps missed on CT colonography using histologic analysis and the natural history of colorectal polyps and to propose guidelines for follow-up colon surveillance based on CT colonographic findings. SUBJECTS AND METHODS. One hundred eighty-six men (age range, 40-87 years; mean, 62.3 years) underwent CT colonography immediately before conventional colonoscopy. All polyps detected on CT colonography were measured and imaged, and their segmental location was documented. All polyps detected on colonoscopy were measured, photographed, biopsied, and histologically analyzed. Results of CT colonography and conventional colonoscopy were compared with the final pathology reports. Conventional colonoscopy was used as the gold standard unless CT colonography showed a lesion measuring 10 mm or more that was not detected on conventional colonoscopy and had characteristics of a polyp. In these cases, follow-up conventional colonoscopy was offered., Results: One hundred ninety-one polyps were detected on conventional colonoscopy. CT colonography prospectively detected 53 polyps. Histologic analysis of the polyps not detected on CT colonography showed that of those 5 mm or smaller, 58.1% were not adenomas, and of those measuring 6-9 mm, 42.8% were not adenomas. Both missed polyps at CT colonography of 10 mm or more were adenomas. Of the 22 polyps measuring 10 mm or more, three were not detected on conventional colonoscopy. Of these three, CT colonography showed a lesion having characteristics of a polyp, follow-up endoscopy confirmed the presence of the lesion, and histologic analysis showed a villous adenoma, a tubulovillous adenoma, and a tubular adenoma., Conclusion: If CT colonography shows no abnormality, follow-up screening in 5 years is recommended. If CT colonography detects a lesion smaller than 5 mm, follow-up imaging in 3-5 years is recommended. If CT colonography detects a lesion measuring 6 mm or more, endoscopy and polypectomy should be offered unless contraindicated.

Purpose: To determine the frequency with which polyps change positions with respect to the bowel surface and the cause of this movement., Materials and Methods: From December 2001 to March 2003, 113 patients underwent computed tomographic (CT) colonography prior to colonoscopy. For all confirmed polyps that were 5 mm and larger, images obtained with CT colonography were retrospectively analyzed by one author to determine if the polyp was present on both data sets or on only one data set. Retrospective evaluation of these polyps for ventral or dorsal location within the colonic lumen was performed for data sets obtained with patients in the prone and the supine position. The data sets were further reviewed by another author to determine the cause of positional change, when present., Results: Twenty-six patients had a total of 49 histologically proved colorectal polyps that were 5 mm and larger. Eight of 49 colorectal polyps were depicted only on images obtained with the patient in the supine or prone position. Of the remaining 41 polyps that were depicted on images obtained with the patient in the supine and the prone position, 11 moved from a dorsal to a ventral location or vice versa relative to the colonic surface when the patient changed position. Five of these polyps were pedunculated on a stalk. Six were sessile; two were located in the sigmoid colon, two in the transverse colon, one in the ascending colon, and one in the cecum. In these cases, polyp mobility was related to positional changes of the colon in the mesentery, as opposed to true mobility of the polyp., Conclusion: In this series, 27% of polyps moved from a ventral location to a dorsal location relative to the colonic surface when the patient was turned from the supine to the prone position; thus, polyps appeared to be mobile. Thus, a mobile filling defect cannot be assumed to be residual fecal material at CT colonography., (Copyright RSNA, 2004)

FRS2alpha and FRS2beta, two members of the FRS2 family of docking proteins, become tyrosine phosphorylated in response to fibroblast growth factor (FGF) or nerve growth factor (NGF) stimulation. Tyrosine phosphorylated FRS2alpha serves as a platform for the recruitment of multiple signaling proteins for activation of the Ras-mitogen-activated protein (MAP) kinase signaling cascade. We report that Frs2alpha and Frs2beta have distinct spatio-temporal expression patterns in mouse embryos. We further show that FRS2beta can compensate for the loss of FRS2alpha for activation of MAP kinase when expressed in fibroblasts from Frs2alpha(-/-) mouse embryos. We propose that the FRS2 family proteins have distinct roles in vivo through activation of common signaling proteins including MAP kinase.

An analytical procedure was evaluated for the comprehensive toxicological screening of drugs, metabolites, and pesticides in 1-mL urine samples by TurboIon spray liquid chromatography/time-of-flight mass spectrometry (LC/TOFMS) in the positive ionization mode and continuous mass measurement. The substance database consisted of exact monoisotopic masses for 637 compounds, of which an LC retention time was available for 392. A macroprogram was refined for extracting the data into a legible report, utilizing metabolic patterns and preset identification criteria. These criteria included +/-30 ppm mass tolerance, a +/-0.2-min window for absolute retention time, if available, and a minimum area count of 500. The limit of detection, determined for 90 compounds, was <0.1 mg/L for 73% of the compounds studied and >1.0 mg/L for 6% of the compounds. For method comparisons, 50 successive autopsy urine samples were analyzed by this method, and the results confirmed by gas chromatography/mass spectrometry (GC/MS). Findings for parent drugs were consistent with both methods; in addition, LC/TOFMS regularly revealed apparently correct findings for metabolites not shown by GC/MS. Mean and median mass accuracy by LC/TOFMS was 7.6 and 5.4 ppm, respectively. The procedure proved well-suited for tentative identification without reference substances. The few false positives emphasized the fact that all three parameters, exact mass, retention time, and metabolite pattern, are required for unequivocal identification.