## Σάββατο, 24 Μαρτίου 2018

### Dose escalation for prostate stereotactic ablative radiotherapy (SABR): Late outcomes from two prospective clinical trials

Publication date: Available online 24 March 2018
Author(s): Yasir Alayed, Patrick Cheung, Geordi Pang, Alexandre Mamedov, Laura D'Alimonte, Andrea Deabreu, Kristina Commisso, Angela Commisso, Liang Zhang, Harvey C. Quon, Hima Bindu Musunuru, Joelle Helou, D. Andrew Loblaw
PurposeOptimal prostate SABR dose-fractionation is unknown. This study compares long-term outcomes from two prospective trials.MethodsStudy1 patients had low-risk PCa and received 35 Gy/5. Study2 patients had low/intermediate-risk PCa and received 40 Gy/5. Biochemical failure (BF) was defined as nadir + 2.Results114 patients were included (study1, n = 84; study2, n = 30). Median follow-up was 9.6 years and 6.9 years. Median nPSA was 0.4 and 0.1 ng/ml. Nine patients had BF (8 in study1, 1 in study2); two were managed with ADT and four had local salvage. The BF rate was 2.5% and 12.8% at 5 and 10 years for study1 and 3.3% at 5 years for study 2. BF probability was 0% if PSA <0.4 at 4 years, and 20.5% at 10 years if PSA ≥0.4 (p = 0.02). Nine patients died, none of PCa. No patient has metastases or castrate-resistance. At 10 years, OS and CSS were 90.4% (p = 0.25) and 100%.ConclusionsDose-escalated prostate SABR was associated with lower nPSAs but no difference in BF, OS, CSS or MFS. PSA <0.4 at 4 years was a predictor of biochemical control. Half of patients with BF were successfully salvaged. Given that this is a favorable-risk cohort, longer follow-up will be needed to see if the lower nPSA translates into lower BF rates.

### Purpose

The phenomenon of futile recanalization, defined as lack of clinical benefit despite angiographic recanalization, is an important limitation of endovascular treatment for acute ischemic stroke. We aim to characterize the occurrence and predictors of futile recanalization in the endovascular arm of the Interventional Management of Stroke (IMS) III trial.

### Methods

Patients with near complete or complete recanalization (TICI grades 2b and 3) were divided according to functional outcome at 3 months into "meaningful recanalization," defined as mRS score 0–2, and "futile recanalization," mRS score 3–6. Multivariate analysis was performed to identify predictors of futile recanalization.

### Results

Futile recanalization was observed in 61 (47%) of 130. Compared to meaningful recanalization group, the futile recanalization group had higher proportion of women (62.3 vs. 43.5%; p = 0.032), higher incidence of diabetes mellitus (29.5 vs. 8.7%; p = 0.004) and coronary artery disease (27.9 vs. 13%; p = 0.05), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (median [range] 19 [11–31] vs. 15 [8–26], p < 0.001), higher baseline serum glucose (7.6 ± 2.6 vs. 6.7 ± 1.7 mmol/L; p = 0.039), and longer onset-to-start of endovascular treatment time (265.8 ± 48.3 vs. 239.2 ± 47.7 min; p = 0.007). In multivariate analysis, NIHSS (OR 1.3; 95% CI 1.1–1.4), female gender (OR 3.0; 95% CI 1.1–8.2), and onset-to-start of endovascular treatment time (OR 1.2; 95% CI 1.1–1.3) were independent predictors of futile recanalization.

### Conclusion

In IMS III, futile recanalization was common. Delay in endovascular treatment is the only modifiable risk factor. Additional strategies for non-modifiable risk factors—female gender and high NIHSS—need to be identified.

### Purpose

The phenomenon of futile recanalization, defined as lack of clinical benefit despite angiographic recanalization, is an important limitation of endovascular treatment for acute ischemic stroke. We aim to characterize the occurrence and predictors of futile recanalization in the endovascular arm of the Interventional Management of Stroke (IMS) III trial.

### Methods

Patients with near complete or complete recanalization (TICI grades 2b and 3) were divided according to functional outcome at 3 months into "meaningful recanalization," defined as mRS score 0–2, and "futile recanalization," mRS score 3–6. Multivariate analysis was performed to identify predictors of futile recanalization.

### Results

Futile recanalization was observed in 61 (47%) of 130. Compared to meaningful recanalization group, the futile recanalization group had higher proportion of women (62.3 vs. 43.5%; p = 0.032), higher incidence of diabetes mellitus (29.5 vs. 8.7%; p = 0.004) and coronary artery disease (27.9 vs. 13%; p = 0.05), higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (median [range] 19 [11–31] vs. 15 [8–26], p < 0.001), higher baseline serum glucose (7.6 ± 2.6 vs. 6.7 ± 1.7 mmol/L; p = 0.039), and longer onset-to-start of endovascular treatment time (265.8 ± 48.3 vs. 239.2 ± 47.7 min; p = 0.007). In multivariate analysis, NIHSS (OR 1.3; 95% CI 1.1–1.4), female gender (OR 3.0; 95% CI 1.1–8.2), and onset-to-start of endovascular treatment time (OR 1.2; 95% CI 1.1–1.3) were independent predictors of futile recanalization.

### Conclusion

In IMS III, futile recanalization was common. Delay in endovascular treatment is the only modifiable risk factor. Additional strategies for non-modifiable risk factors—female gender and high NIHSS—need to be identified.

### Management update of potentially premalignant oral epithelial lesions

Publication date: Available online 23 March 2018
Source:Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
The term oral potentially malignant disorders (OPMD) previously defined at the World Health Organisation (W.H.O) workshop in 2005 has now been redefined as potentially premalignant oral epithelial lesions (PPOELs). It is important to differentiate PPOEL's which are a broad term to define a wide variety of clinical lesions from oral epithelial dysplasia which should be reserved specifically for lesions with biopsy proven foci of dysplasia. Unfortunately, the nomenclature is not consistent and many times both terms PPOEL and dysplasia are used interchangeably which adds to confusion in the literature. PPOEL's encompass lesions that include leukoplakia, erythroplakia, erythroleukoplakia, lichen planus, and submucosal fibrosis. The World Health Organization (W.H.O). definition of a histologically proven oral premalignant lesion that is associated with a significantly increased risk of malignant transformation. The primary goal of management of dysplasia includes the prevention, early detection and treatment prior to malignant transformation. The aim of this paper is to inform the clinician about management of PPOELs.

### Factors Influencing Confidence in Diagnostic Ratings and Retreatment Recommendations in Coiled Aneurysms.

Factors Influencing Confidence in Diagnostic Ratings and Retreatment Recommendations in Coiled Aneurysms.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Ernst M, Kriston L, Groth M, Frölich AM, Fiehler J, Buhk JH

Abstract
BACKGROUND AND PURPOSE: Angiographic occlusion and retreatment of coiled aneurysms are commonly used as surrogate end points in clinical trials. We aimed to evaluate the influence of aneurysm, patient, and rater characteristics on the confidence of visual evaluation of aneurysm coiling and retreatment decisions.
MATERIALS AND METHODS: Twenty-six participants of the Advanced Course in Endovascular Interventional Neuroradiology of the European Society of Neuroradiology were asked to evaluate digital subtraction angiography examinations of patients who had undergone endovascular coiling, by determining the grade of aneurysm occlusion, the change between immediate postprocedural and follow-up angiograms, their level of confidence, the technical difficulty of retreatment, and the best therapeutic approach. The experience, knowledge, and skills of each participant were assessed. The influence of rater and case characteristics on indicated confidence in diagnostic ratings and retreatment recommendations was analyzed.
RESULTS: Interrater reliability was moderate regarding the assessment of aneurysm occlusion grade (intraclass correlation coefficient = 0.581) and substantial regarding change (intraclass correlation coefficient = 0.776). Overall confidence in the diagnostic rating was high (median, "very certain"). Confidence was statistically significantly higher in cases that were generally rated as "worse." The odds of recommending retreatment were significantly higher in cases that were generally rated with higher mean confidence.
CONCLUSIONS: Although overall confidence in the diagnostic rating was high, our study confirms the suboptimal interrater reliability of visual assessment of aneurysm occlusion as well as retreatment recommendations, rendering both questionable as primary outcome measures. Besides recurrence status, recommendation of retreatment is significantly influenced by patient age, aneurysm neck width, and characteristics of the therapist.

PMID: 29567657 [PubMed - as supplied by publisher]

### Cerebellar Growth Impairment Characterizes School-Aged Children Born Preterm without Perinatal Brain Lesions.

Cerebellar Growth Impairment Characterizes School-Aged Children Born Preterm without Perinatal Brain Lesions.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Pieterman K, White TJ, van den Bosch GE, Niessen WJ, Reiss IKM, Tibboel D, Hoebeek FE, Dudink J

Abstract
BACKGROUND AND PURPOSE: Infants born preterm are commonly diagnosed with structural brain lesions known to affect long-term neurodevelopment negatively. Yet, the effects of preterm birth on brain development in the absence of intracranial lesions remain to be studied in detail. In this study, we aim to quantify long term consequences of preterm birth on brain development in this specific group.
MATERIALS AND METHODS: Neonatal cranial sonography and follow-up T1-weighted MR imaging and DTI were performed to evaluate whether the anatomic characteristics of the cerebrum and cerebellum in a cohort of school-aged children (6-12 years of age) were related to gestational age at birth in children free of brain lesions in the perinatal period.
RESULTS: In the cohort consisting of 36 preterm (28-37 weeks' gestational age) and 66 term-born infants, T1-weighted MR imaging and DTI at 6-12 years revealed a reduction of cerebellar white matter volume (β = 0.387, P < .001), altered fractional anisotropy of cerebellar white matter (β = -0.236, P = .02), and a reduction of cerebellar gray and white matter surface area (β = 0.337, P < .001; β = 0.375, P < .001, respectively) in relation to birth age. Such relations were not observed for the cerebral cortex or white matter volume, surface area, or diffusion quantities.
CONCLUSIONS: The results of our study show that perinatal influences that are not primarily neurologic are still able to disturb long-term neurodevelopment, particularly of the developing cerebellum. Including the cerebellum in future neuroprotective strategies seems therefore essential.

PMID: 29567656 [PubMed - as supplied by publisher]

### 3D Deep Learning Angiography (3D-DLA) from C-arm Conebeam CT.

3D Deep Learning Angiography (3D-DLA) from C-arm Conebeam CT.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Montoya JC, Li Y, Strother C, Chen GH

Abstract
BACKGROUND AND PURPOSE: Deep learning is a branch of artificial intelligence that has demonstrated unprecedented performance in many medical imaging applications. Our purpose was to develop a deep learning angiography method to generate 3D cerebral angiograms from a single contrast-enhanced C-arm conebeam CT acquisition in order to reduce image artifacts and radiation dose.
MATERIALS AND METHODS: A set of 105 3D rotational angiography examinations were randomly selected from an internal data base. All were acquired using a clinical system in conjunction with a standard injection protocol. More than 150 million labeled voxels from 35 subjects were used for training. A deep convolutional neural network was trained to classify each image voxel into 3 tissue types (vasculature, bone, and soft tissue). The trained deep learning angiography model was then applied for tissue classification into a validation cohort of 8 subjects and a final testing cohort of the remaining 62 subjects. The final vasculature tissue class was used to generate the 3D deep learning angiography images. To quantify the generalization error of the trained model, we calculated the accuracy, sensitivity, precision, and Dice similarity coefficients for vasculature classification in relevant anatomy. The 3D deep learning angiography and clinical 3D rotational angiography images were subjected to a qualitative assessment for the presence of intersweep motion artifacts.
RESULTS: Vasculature classification accuracy and 95% CI in the testing dataset were 98.7% (98.3%-99.1%). No residual signal from osseous structures was observed for any 3D deep learning angiography testing cases except for small regions in the otic capsule and nasal cavity compared with 37% (23/62) of the 3D rotational angiographies.
CONCLUSIONS: Deep learning angiography accurately recreated the vascular anatomy of the 3D rotational angiography reconstructions without a mask. Deep learning angiography reduced misregistration artifacts induced by intersweep motion, and it reduced radiation exposure required to obtain clinically useful 3D rotational angiography.

PMID: 29567655 [PubMed - as supplied by publisher]

### Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis.

Endovascular Management of Acute Stroke in the Elderly: A Systematic Review and Meta-Analysis.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Hilditch CA, Nicholson P, Murad MH, Rabinstein A, Schaafsma J, Pikula A, Krings T, Pereira VM, Agid R, Brinjikji W

Abstract
BACKGROUND: Acute ischemic stroke occurs more frequently, presents with more severe symptoms, and has worse outcomes in elderly patients. The safety and efficacy of endovascular therapy for acute stroke in this age group has not been fully established.
PURPOSE: We present the results of a systematic review and meta-analysis examining clinical, procedural, and radiologic outcomes of endovascular therapy for acute stroke in patients older than 80 years of age.
DATA SOURCES: We searched PubMed, MEDLINE, and EMBASE from 1992 to week 35 of 2017 for studies evaluating endovascular therapy for acute stroke in the elderly.
STUDY SELECTION: Two independent reviewers selected studies and abstracted data. The primary end point was good functional outcome at 3 months defined as modified Rankin Scale score of ≤2.
DATA ANALYSIS: Data were analyzed using random-effects meta-analysis.
DATA SYNTHESIS: Seventeen studies reporting on 860 patients were included. The rate of good functional outcome at 3 months was 27% (95% CI, 21%-32%). Mortality at 3 months was 34% (95% CI, 23%-44%). Successful recanalization was achieved in 78% of patients (95% CI, 72%-85%). Procedure-related complications occurred in 11% (95% CI, 4%-17%). The incidence of intracranial hemorrhage was 24% (95% CI, 15%-32%), and for symptomatic intracranial hemorrhage, it was 8% (95% CI, 5%-10%). The mean time to groin was 251 minutes (95% CI, 224-278 minutes). Procedure time was 99 minutes (95% CI, 67-131 minutes).
LIMITATIONS: I2 values were above 50% for all outcomes, indicating substantial heterogeneity.
CONCLUSIONS: Good functional recovery in octogenarians treated with endovascular therapy for acute stroke can be achieved in a high proportion of patients despite the higher incidence of comorbidity in this cohort. Outcomes are inferior to those reported for younger patients; however, endovascular therapy can allow at least 1 in 4 patients older than 80 years of age to regain independent function at 3 months. More research is required to improve patient selection in the elderly, but age should not be a discriminator when deciding to offer endovascular therapy for patients with acute stroke.

PMID: 29567654 [PubMed - as supplied by publisher]

### Diagnosing Early Ischemic Changes with the Latest-Generation Flat Detector CT: A Comparative Study with Multidetector CT.

Diagnosing Early Ischemic Changes with the Latest-Generation Flat Detector CT: A Comparative Study with Multidetector CT.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Maier IL, Leyhe JR, Tsogkas I, Behme D, Schregel K, Knauth M, Schnieder M, Liman J, Psychogios MN

Abstract
BACKGROUND AND PURPOSE: One-stop management of mechanical thrombectomy-eligible patients with large-vessel occlusion represents an innovative approach in acute stroke treatment. This approach reduces door-to-reperfusion times by omitting multidetector CT, using flat detector CT as pre-mechanical thrombectomy imaging. The purpose of this study was to compare the diagnostic performance of the latest-generation flat detector CT with multidetector CT.
MATERIALS AND METHODS: Prospectively derived data from patients with ischemic stroke with large-vessel occlusion and mechanical thrombectomy were analyzed in this monocentric study. All included patients underwent multidetector CT before referral to our comprehensive stroke center and flat detector CT in the angiography suite before mechanical thrombectomy. Diagnosis of early ischemic signs, quantified by the ASPECTS, was compared between modalities using cross tables, the Pearson correlation, and Bland-Altman plots. The predictive value of multidetector CT- and flat detector CT-derived ASPECTS for functional outcome was investigated using area under the receiver operating characteristic curve analysis.
RESULTS: Of 25 patients, 24 (96%) had flat detector CT with sufficient diagnostic quality. Median multidetector CT and flat detector CT ASPECTSs were 7 (interquartile range, 5.5-9 and 4.25-8, respectively) with a mean period of 143.6 ± 49.5 minutes between both modalities. The overall sensitivity was 85.1% and specificity was 83.1% for flat detector CT ASPECTS compared with multidetector CT ASPECTS as the reference technique. Multidetector CT and flat detector CT ASPECTS were strongly correlated (r = 0.849, P < .001) and moderately predicted functional outcome (area under the receiver operating characteristic curve, 0.738; P = .007 and .715; P = .069, respectively).
CONCLUSIONS: Determination of ASPECTS on flat detector CT is feasible, showing no significant difference compared with multidetector CT ASPECTS and a similar predictive value for functional outcome. Our findings support the use of flat detector CT for emergency stroke imaging before mechanical thrombectomy to reduce door-to-groin time.

PMID: 29567653 [PubMed - as supplied by publisher]

### Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access.

Transforaminal Lumbar Puncture: An Alternative Technique in Patients with Challenging Access.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Nascene DR, Ozutemiz C, Estby H, McKinney AM, Rykken JB

Abstract
Interlaminar lumbar puncture and cervical puncture may not be ideal in all circumstances. Recently, we have used a transforaminal approach in selected situations. Between May 2016 and December 2017, twenty-six transforaminal lumbar punctures were performed in 9 patients (25 CT-guided, 1 fluoroscopy-guided). Seven had spinal muscular atrophy and were referred for intrathecal nusinersen administration. In 2, CT myelography was performed via transforaminal lumbar puncture. The lumbar posterior elements were completely fused in 8, and there was an overlying abscess in 1. The L1-2 level was used in 2; the L2-3 level, in 10; the L3-4 level, in 12; and the L4-5 level, in 2 procedures. Post-lumbar puncture headache was observed on 4 occasions, which resolved without blood patching. One patient felt heat and pain at the injection site that resolved spontaneously within hours. One patient had radicular pain that resolved with conservative treatment. Transforaminal lumbar puncture may become an effective alternative to classic interlaminar lumbar puncture or cervical puncture.

PMID: 29567652 [PubMed - as supplied by publisher]

### Brain MRI Characteristics of Patients with Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Their Associations with 2-Year Clinical Outcome.

Brain MRI Characteristics of Patients with Anti-N-Methyl-D-Aspartate Receptor Encephalitis and Their Associations with 2-Year Clinical Outcome.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Zhang T, Duan Y, Ye J, Xu W, Shu N, Wang C, Li K, Liu Y

Abstract
BACKGROUND AND PURPOSE: Anti-N-methyl-D-aspertate receptor encephalitis is an autoimmune-mediated disease without specific brain MRI features. Our aim was to investigate the brain MR imaging characteristics of anti-N-methyl-D-aspartate receptor encephalitis and their associations with clinical outcome at a 2-year follow-up.
MATERIALS AND METHODS: We enrolled 53 patients with anti-N-methyl-D-aspartate receptor encephalitis and performed 2-year follow-up. Brain MRIs were acquired for all patients at the onset phase. The brain MR imaging manifestations were classified into 4 types: type 1: normal MR imaging findings; type 2: only hippocampal lesions; type 3: lesions not involving the hippocampus; and type 4: lesions in both the hippocampus and other brain areas. The modified Rankin Scale score at 2-year follow-up was assessed, and the association between the mRS and onset brain MR imaging characteristics was evaluated.
RESULTS: Twenty-eight (28/53, 53%) patients had normal MR imaging findings (type 1), and the others (25/53, 47%) had abnormal MRI findings: type 2: 7 patients (13%); type 3: seven patients (13%); and type 4: eleven patients (21%). Normal brain MRI findings were more common in female patients (P = .02). Psychiatric and behavioral abnormalities were more common in adults (P = .015), and autonomic symptoms (P = .025) were more common in pediatric patients. The presence of hippocampal lesions (P = .008, OR = 9.584; 95% CI, 1.803-50.931) and relapse (P = .043, OR = 0.111; 95% CI, 0.013-0.930) was associated with poor outcome.
CONCLUSIONS: Normal brain MRI findings were observed in half of the patients. Lesions in the hippocampus were the most common MR imaging abnormal finding. The presence of hippocampal lesions is the main MR imaging predictor for poor prognosis in patients with anti-N-methyl-D-aspartate receptor encephalitis.

PMID: 29567651 [PubMed - as supplied by publisher]

### The New Low-Profile WEB 17 System for Treatment of Intracranial Aneurysms: First Clinical Experiences.

The New Low-Profile WEB 17 System for Treatment of Intracranial Aneurysms: First Clinical Experiences.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: van Rooij SBT, Peluso JP, Sluzewski M, Kortman HG, van Rooij WJ

Abstract
BACKGROUND AND PURPOSE: The Woven EndoBridge (WEB) is an intrasaccular flow diverter intended to treat wide-neck aneurysms. The latest generation WEBs needed a 0.021-inch microcatheter in the small sizes. Recently, a lower profile range of WEBs compliant with a 0.017-inch microcatheter (WEB 17) has been introduced. We present the first clinical results of treatment of both ruptured and unruptured aneurysms with the WEB 17.
MATERIALS AND METHODS: Between December 2016 and September 2017, forty-six aneurysms in 40 patients were treated with the WEB 17. No supporting stents or balloons were used. Twenty-five aneurysms were ruptured (54%). There were 6 men and 34 women (mean age, 62 years; median, 63 years; range, 46-87 years). The mean aneurysm size was 4.9 mm (median, 5 mm; range, 2-7 mm).
RESULTS: There were 2 thromboembolic procedural complications without clinical sequelae and no ruptures. The overall permanent procedural complication rate was 0% (0 of 40; 97.5% CI, 0%-10.4%). Imaging follow-up at 3 months was available in 33 patients with 39 aneurysms (97.5% of 40 eligible aneurysms). In 1 aneurysm, the detached WEB was undersized and the remnant was additionally treated with coils after 1 week. This same aneurysm reopened at 3 months and was again treated with a second WEB. One other aneurysm showed persistent WEB filling at 3 months. Complete occlusion was achieved in 28 of 39 aneurysms (72%), and 9 aneurysms (23%) showed a neck remnant.
CONCLUSIONS: The WEB 17 is safe and effective for both ruptured and unruptured aneurysms. The WEB 17 is a valuable addition to the existing WEB size range, especially for very small aneurysms.

PMID: 29567650 [PubMed - as supplied by publisher]

### Triage in the Angiography Suite for Mechanical Thrombectomy in Acute Ischemic Stroke: Not Such a Good Idea.

Triage in the Angiography Suite for Mechanical Thrombectomy in Acute Ischemic Stroke: Not Such a Good Idea.

AJNR Am J Neuroradiol. 2018 Mar 22;:

Authors: Clarençon F, Rosso C, Degos V, Shotar E, Rolla-Bigliani C, Samson Y, Alamowitch S, Sourour NA

PMID: 29567649 [PubMed - as supplied by publisher]

### Age greater than 60 years portends a worse prognosis in patients with papillary thyroid cancer: should there be three age categories for staging?

Age greater than 60 years portends a worse prognosis in patients with papillary thyroid cancer: should there be three age categories for staging?

BMC Cancer. 2018 Mar 22;18(1):316

Authors: Kauffmann RM, Hamner JB, Ituarte PHG, Yim JH

Abstract
BACKGROUND: Age is an important prognostic factor in papillary thyroid cancer (PTC), with better survival observed in patients < 45 years of age, regardless of stage. Although the impact of increasing age on PTC-related survival is well-known, previous studies have focused on survival relative to age 45 years only. As the number of patients entering their 7th decade of life increases, PTC-related survival in this demographic becomes increasingly important. Survival in patients ≥ 60 years specifically compared to other groups has not previously been examined. We sought to determine whether age ≥ 60 years is an adverse prognostic factor for disease-specific survival and recurrence in patients with PTC.
METHODS: The California Cancer Registry database was linked to inpatient and ambulatory patient records from the Office of Statewide Health Planning and Development for the years 2000-2011. This linked database was queried for patients diagnosed with papillary thyroid cancer and treated with surgery. We then identified prognostic factors related to both 5-year and 10-year disease-specific survival and disease-free survival in patients ≤ 45, 45-59, and ≥ 60 years. Multivariable Cox proportional hazard models were created to test the effect of age ≥ 60 on disease-specific and disease-free survival, controlling for clinical, treatment, and demographic factors.
RESULTS: The final cohort included 15,675 patients. Of the group, 46.3% were between 18 and 44 years of age, 33.6% were 45-59 years, and 20.1% were ≥ 60. Univariate analysis showed that compared to other groups, patients ≥ 60 were more likely to be male (p < 0.001), present with tumors > 5 cm (p < 0.001), more likely to have metastatic disease (p < 0.001), less likely to receive radioactive iodine (p < 0.001), and more likely to receive external beam radiation therapy (p < 0.001). In multivariable Cox proportional hazards models for 5 and 10-year disease-free survival, age ≥ 60 was associated with higher risk of disease at 5 and 10-years (HR 2.3 and 1.9 respectively, p < 0.001). Similar results were observed for 5 and 10-year disease-specific survival (HR 38.0 and 30.0 respectively, p < 0.001) after controlling for gender, race, co-morbidity, stage, surgical procedure, radioactive iodine, insurance, and hospital volume.
CONCLUSIONS: Patients ≥ 60 years of age have worse DSS and DFS after a diagnosis of PTC, across all stages of disease. Given that patients over the age of 45 years have progressively worse survival as they age, these data support having three age groups, 18-44 years of age, 45-59 years, and ≥ 60 as an independent predictor of survival and recurrence to current staging guidelines.

PMID: 29566662 [PubMed - in process]

### Abstracts from the 9th International Symposium of Clinical and Applied Anatomy (ISCAA), September 9-12, 2017 Innsbruck, Austria.

Abstracts from the 9th International Symposium of Clinical and Applied Anatomy (ISCAA), September 9-12, 2017 Innsbruck, Austria.

Surg Radiol Anat. 2018 Mar 22;:

Authors:

PMID: 29568971 [PubMed - as supplied by publisher]

### Breast Lesions Detected via Molecular Breast Imaging

Publication date: Available online 23 March 2018
Author(s): Jason G. Ching, Rachel F. Brem
Rationale and ObjectivesTo evaluate correlations between molecular breast imaging (MBI) descriptor characteristics and positive predictive value (PPV) in detecting breast cancer.Materials and MethodsA retrospective review was performed on 193 suspicious findings from 153 women (31–81 years) with positive MBI examinations. We assessed associations between (i) lesion pattern (mass vs. nonmass) and PPV; (ii) lesion pattern and suspected likelihood of cancer (low vs. moderate vs. high); (iii) background parenchymal uptake (BPU) (homogeneous vs. heterogeneous) and PPV; (iv) breast density (dense vs. non-dense) and PPV; and (v) BPU and density.ResultsOne hundred ten of 153 patients were diagnosed with malignancy or high-risk pathology (PPV1 = 71.9%), and 130/193 biopsies resulted in malignant or high-risk lesions (PPV3 = 67.4%). Biopsies of mass vs. nonmass findings had comparable PPV3 (71.7% vs. 61.3%; P = .0717). Mass findings were correlated with higher suspicion for cancer than nonmass findings (P < .001). There was no significant difference in PPV3 when comparing biopsies from homogeneous vs. heterogeneous BPU (72.5% vs. 60.7%; P = .103). No association was found between patients' BPU and diagnosed cancer or high-risk lesions (P = .513). Biopsies from nondense breasts demonstrated higher PPV3 than biopsies from dense breasts (85.4% vs. 60.6%; P = .0025); patients with nondense breasts were more likely to be diagnosed with cancer or high-risk pathology (PPV1 = 87.8% vs. 66.0%; P = .00844). Dense breasts had a greater association with heterogeneous BPU (P = .0844).ConclusionNeither variability in mass or nonmass positive MBI findings, nor variability in BPU on MBI were significant determinants for the probability of malignancy. Dense breasts were associated with lower predictability and heterogeneous BPU on MBI.

### Designing a Curriculum for Professionalism and Ethics Within Radiology

Publication date: Available online 23 March 2018
Author(s): Aine Marie Kelly, Patricia B. Mullan
Although professionalism and ethics represent required competencies, they are more challenging than other competencies to design a curriculum for and teach. Reasons include variability in agreed definitions of professionalism within medicine and radiology. This competency is also framed differently whether as roles, duties, actions, skills, behavior, beliefs, and attitudes.Standardizing a curriculum in professionalism is difficult because each learner's (medical student/resident) professional experiences and interactions will be unique. Professionalism is intertwined throughout all (sub) specialties and areas and its teaching cannot occur in isolation as a standalone curriculum. In the past, professionalism was not emphasized enough or at all, with global (or no) assessments, with the potential effect of trainees not valuing it.Although we can teach it formally in the classroom and informally in small groups, much of professionalism is witnessed and learned as "hidden curricula". The formal, informal, and hidden curricula often contradict each other creating confusion, disillusion, and cynicism in trainees.The corporatization of medicine pressurizes us to increase efficiency (throughput) with less focus on aspects of professionalism that add value, creating a disjoint between what we do in practice and preach to trainees. Progressively, expectations for our curriculum include providing evidence for the impacts of our efforts on patient outcomes.Generational differences in the perception of professionalism and the increasingly diverse and multicultural society in which we live affects our interpretation of professionalism, which can add to confusion and misunderstanding.The objectives of this article are to outline challenges facing curriculum design in professionalism and to make suggestions to help educators avoid or overcome them.

### Tailoring CT Dose to Patient Size

Publication date: Available online 23 March 2018
Author(s): Yan Klosterkemper, Elisabeth Appel, Christoph Thomas, Oliver T. Bethge, Joel Aissa, Patric Kröpil, Gerald Antoch, Johannes Boos
Rationale and ObjectivesTo use an automatic computed tomography (CT) dose monitoring system to analyze the institutional chest and abdominopelvic CT dose data as regards the updated 2017 American College of Radiology (ACR) diagnostic reference levels (DRLs) based on water-equivalent diameter (Dw) and size-specific dose estimates (SSDE) to detect patient-size subgroups in which CT dose can be optimized.Materials and MethodsAll chest CT examinations performed between July 2016 and April 2017 with and without contrast material, CT of the pulmonary arteries, and abdominopelvic CT with and without contrast material were included in this retrospective study. Dw and SSDE were automatically calculated for all scans using a previously validated in-house developed Matlab software and stored into our CT dose monitoring system. CT dose data were analyzed as regards the updated ACR DRLs (size groups: 21–25 cm, 25–29 cm, 29–33 cm, 33–37 cm, 37–41 cm). SSDE and volumetric computed tomography dose index (CTDIvol) were used as CT dose parameter.ResultsOverall, 30,002 CT examinations were performed in the study period, 3860 of which were included in the analysis (mean age 62.1 ± 16.4 years, Dw 29.0 ± 3.3 cm; n = 577 chest CT without contrast material, n = 628 chest CT with contrast material, n = 346 CT of chest pulmonary, n = 563 abdominopelvic CT without contrast material, n = 1746 abdominopelvic CT with contrast material). Mean SSDE and CTDIvol relative to the updated DRLs were 43.3 ± 26.4 and 45.1 ± 27.9% for noncontrast chest CT, 52.3 ± 23.1 and 52.0 ± 23.1% for contrast-enhanced chest CT, 68.8 ± 29.5 and 70.0 ± 31.0% for CT of pulmonary arteries, 41.9 ± 29.2 and 43.3 ± 31.3% for noncontrast abdominopelvic CT, and 56.8 ± 22.2 and 58.8 ± 24.4% for contrast-enhanced abdominopelvic CT. Lowest dose compared to the DRLs was found for the Dw group of 21–25 cm in noncontrast abdominopelvic CT (SSDE 30.4 ± 21.8%, CTDIvol 30.8 ± 21.4%). Solely the group of patients with a Dw of 37–41 cm undergoing noncontrast abdominopelvic CT exceeded the ACR DRL (SSDE 100.3 ± 59.0%, CTDIvol 107.1 ± 63.5%).ConclusionsOn average, mean SSDE and CTDIvol of our institutional chest and abdominopelvic CT protocols were lower than the updated 2017 ACR DRLs. Size-specific subgroup analysis revealed a wide variability of SSDE and CTDIvol across CT protocols and patient size groups with a transgression of DRLs in noncontrast abdominopelvic CT of large patients (Dw 37–41 cm).

### Recognition of Neonatal Lymphatic Flow Disorder

Publication date: Available online 23 March 2018
Author(s): David M. Biko, Jordan A. Johnstone, Yoav Dori, Teresa Victoria, Edward R. Oliver, Maxim Itkin
Rationale and ObjectivesThis study aimed to describe prenatal and postnatal imaging features and outcomes of neonates with neonatal lymphatic disorders (NLDs).Materials and MethodsAn institutional review board-approved search of the radiology database for patients with NLD identified five patients. Inclusion criteria include prenatal imaging (fetal magnetic resonance [MR] imaging and ultrasound) and postnatal three-dimensional T2 Sampling Perfection with Application optimized Contrasts using different flip angle Evolution (SPACE) and dynamic contrast-enhanced MR lymphangiography within 6 months of life. Chart review was undertaken to evaluate morbidity and mortality.ResultsPrenatal finding of "nutmeg lung" or fetal pulmonary lymphatic disorder was identified in all five patients on fetal MR imaging, and in four of five patients on fetal ultrasound. Postnatal dynamic contrast-enhanced MR lymphangiography demonstrated abnormal lymphatic flow to the lungs in four of five patients, but absent in the single patient with coexisting hypoplastic left heart syndrome (HLHS). Dermal backflow was seen in one patient, also the only patient with prenatal body wall edema. Three patients with lymphatic flow to the lungs only were classified as neonatal chylothorax. The patient with dermal backflow and perfusion to the lungs was diagnosed with central lymphatic flow disorder (CLFD). The HLHS patient with normal lymphatic perfusion maintained the HLHS diagnosis. Of the five patients, the patient with CLFD and the one with HLHS expired because of respiratory distress.ConclusionsNLDs can be recognized on prenatal and postnatal imaging and may be primary, as in neonatal chylothorax or CLFD, or secondary. In this small series, "nutmeg lung" was present in all patients. Prenatal imaging demonstrates that body wall edema may correlate with postnatal dermal backflow, which, in our small cohort, carried a poor prognosis.

### Observer Variability in Breast Cancer Diagnosis between Countries with and without Breast Screening

Publication date: Available online 23 March 2018
Author(s): Delgermaa Demchig, Claudia Mello-Thoms, Warwick Lee, Khulan Khurelsukh, Asai Ramish, Patrick Brennan

### The impact of chemotherapeutic treatment on the oral microbiota of patients with cancer: a systematic review.

The impact of chemotherapeutic treatment on the oral microbiota of patients with cancer: a systematic review.

Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Feb 21;:

Authors: Villafuerte KRV, Martinez CJH, Dantas FT, Carrara HHA, Dos Reis FJC, Palioto DB

Abstract
OBJECTIVE: Chemotherapy is a type of systemic treatment that inhibits neoplastic cells (cancer cells), produces immunosuppression, and may lead to changes in the oral mucosa and, consequently, in the oral microbiota. The aim of this systematic review was to analyze, in the scientific literature, evidence of the impact of chemotherapy on the oral microbiota.
STUDY DESIGN: The authors conducted a search in PubMed/MEDLINE, Scientific Electronic Library Online (SciELO), LILACS, ScienceDirect, Web of Science, and Cochrane Library; to identify studies that discussed change in the oral microbiota of patients with during chemotherapy. Articles published in English until July 2017 were included. The quality of a study was assessed by using the Ottawa-Newcastle scale.
RESULTS: Of 5252 articles potentially relevant to this review, 17 were included in this study. Of the 17 studies included, 16 had used culture techniques, and 1 had used genetic sequencing. The most frequently observed bacteria were aerobic gram-negative (Klebsiella spp., Escherichia coli, Enterobacter, Pseudomonas spp.), anaerobic gram-negative (Veillonella spp., Capnocytophaga), and gram-positive bacteria (Streptococcus spp., Staphylococcus spp.).
CONCLUSIONS: During chemotherapy, patients with cancer present a more complex oral microbiota under favorable conditions for their development during immunosuppression, and these may be responsible for different serious local or systemic pathologies.

PMID: 29566996 [PubMed - as supplied by publisher]

### Objective

Quantitative assessment of surgical skills is an important aspect of surgical training; however, the proposed metrics are sometimes difficult to interpret and may not capture the stylistic characteristics that define expertise. This study proposes a methodology for evaluating the surgical skill, based on metrics associated with stylistic adjectives, and evaluates the ability of this method to differentiate expertise levels.

### Methods

We recruited subjects from different expertise levels to perform training tasks on a surgical simulator. A lexicon of contrasting adjective pairs, based on important skills for robotic surgery, inspired by the global evaluative assessment of robotic skills tool, was developed. To validate the use of stylistic adjectives for surgical skill assessment, posture videos of the subjects performing the task, as well as videos of the task were rated by crowd-workers. Metrics associated with each adjective were found using kinematic and physiological measurements through correlation with the crowd-sourced adjective assignment ratings. To evaluate the chosen metrics' ability in distinguishing expertise levels, two classifiers were trained and tested using these metrics.

### Results

Crowd-assignment ratings for all adjectives were significantly correlated with expertise levels. The results indicate that naive Bayes classifier performs the best, with an accuracy of $$89\pm 12$$ , $$94\pm 8$$ , $$95\pm 7$$ , and $$100\pm 0\%$$ when classifying into four, three, and two levels of expertise, respectively.

### Conclusion

The proposed method is effective at mapping understandable adjectives of expertise to the stylistic movements and physiological response of trainees.