Publications

A rudimentary horn is a type of congenital uterine anomaly associated with a unicornuate uterus. Rudimentary horn pregnancies (RHPs) are extremely rare and the majority of cases result in second trimester rupture necessitating emergent laparotomy with associated high maternal morbidity and delivery of a previable fetus. We report the case of a 33-year-old G5P0131 female who presented at 15 weeks and 4 days gestational age with pelvic and back pain and imaging favoring an abdominal pregnancy. The patient underwent an exploratory laparotomy with left salpingectomy and excision of an unruptured extrauterine pregnancy that was confirmed to be an RHP on pathologic examination. Postsurgery review of the imaging demonstrated several features consistent with the diagnosis of an RHP that were not initially identified. Furthermore, the patient's medical and surgical histories were notable for several risk factors associated with congenital uterine anomalies that should have heightened the clinical suspicion for an RHP. This case emphasizes how increased familiarity with the risk factors and imaging findings associated with rudimentary horns and RHPs may lead to an earlier and more accurate diagnosis, more timely and appropriate treatment, and ultimately a reduction in maternal and fetal morbidity and mortality.

BACKGROUND: Clinical use of cardiovascular magnetic resonance (CMR), reference tool for cardiac function and myocardial tissue assessment, is frequently limited by long acquisition times. This study aimed to compare conventional "standard protocol" (ASSET bSSFP cine plus 2D single-segment PSIR LGE) with novel "fast protocol" incorporating deep-learning reconstruction (Sonic DL bSSFP cine and 2D multisegment PSIR LGE with AIR Recon DL), focusing on image quality, functional measurements, myocardial characterisation, and overall scan duration.

METHODS AND RESULTS: One-hundred consecutive patients with known or suspected myocardial disease underwent both protocols. Participants were predominantly male (78%), mean age 52 ± 16 years, mean BMI 25.0 ± 4.3 kg/m2. Clinical indications included arrhythmias (26%), hypertrophic cardiomyopathy (19%), and coronary artery disease (13%). Cine image quality was comparable between ASSET bSSFP and Sonic DL bSSFP (Likert score 4.59 vs 4.56, p = 0.682), with no differences in ventricular size, function, or left ventricle mass. However, Sonic DL cine markedly shortened acquisition time for long-axis and short-axis stacks (38 vs 61 s and 125 vs 227 s respectively, both p < 0.001). Similarly, 2D-MS PS LGE preserved diagnostic quality (Likert score 4.60 vs 4.51) while reducing acquisition time for long-axis and short-axis stacks (25 vs 77 s and 78 vs 302 s respectively, both p < 0.001). The "fast" protocol reduced total scan time by nearly 60%, enabling comprehensive CMR completion in under 10 min.

CONCLUSIONS: A deep learning-based "fast" CMR protocol significantly reduces scan time without compromising volumetric accuracy or image quality, resulting a feasible option for routine clinical practice.

BACKGROUND: While varices and variceal bleeds are well-known and feared complications of advanced cirrhosis and portal hypertension, omental variceal bleed are a rare sequala even in patients with known esophageal or gastric varices. While rare, omental varices pose a risk for hemoperitoneum if ruptured, which is a life-threatening complication with high mortality rates despite surgical intervention.

CASE SUMMARY: This report reviews the case of a patient 36-year-old female with alcohol related cirrhosis decompensated by ascites, but no history of varices admitted for hemorrhagic shock from spontaneous rupture of omental varices requiring emergency surgery. She underwent the first documented successful orthotopic liver transplantation the same admission.

CONCLUSION: This case report and literature review stresses the importance of early consideration and identification of intraabdominal variceal sources in cirrhotic patients with refractory shock.

PURPOSE: To evaluate safety, hypertrophy, and kinetic growth rate (KGR) of future liver remnant following yttrium-90 radiation lobectomy (RL-90Y) in liver cancer using resin microspheres.

MATERIALS AND METHODS: This was a retrospective, single-center study. Patients with primary liver cancer who underwent RL-90Y transarterial radioembolization (TARE) from November 2015 to December 2022 were reviewed. Twenty-eight patients (68% with HCC and 36% with iCCA) were included. The right lobe was treated in 18 of 28 patients (64%). Single-compartment dosimetry model was used. Total liver parenchymal volume (TLPV), treated parenchymal volume, and future liver remnant volume (FLRV) were recorded at baseline and after treatment at 0-4 months (T1) and >4 months (T2). Hypertrophy, FLRV/TLPV ratio, and KGR were calculated. Treatment response was categorized by modified Response Evaluation Criteria in Solid Tumors (RECIST) for hepatocellular carcinoma (HCC) and RECIST for intrahepatic cholangiocarcinoma (iCCA). Primary outcomes included safety profile, hypertrophy, and KGR. Secondary outcomes included disease response and proportion of patients bridged to surgery.

RESULTS: The hypertrophy and KGR at T1 were 16% (interquartile range [IQR], 4%-28%) and 1.5% per week (IQR, 0.6%-2.3%) with increase in FLRV (P < .001) and FLRV/TLPV ratio (P < .001). KGR was higher at T1 than at T2 (1.3% vs 0.6%, P = .034). Treatment response (n = 27) was complete, partial, stable, and progressive in 53%, 24%, 6%, and 18% for HCC and 0%, 20%, 50%, and 30% for iCCA. Seven patients (25%) were bridged to resection at 2.5 months (IQR, 1.9-4.7 months). No differences were noted in atrophy, hypertrophy, and KGR at both time points (T1 and T2) when stratified on type of cancer, cirrhosis, portal vein thrombosis, or prescribed tumor dose.

CONCLUSIONS: RL-90Y TARE using single-compartment dosimetry with resin microspheres can safely be performed in patients with primary liver cancer with KGR of 1.5% per week.

BACKGROUND: EUS and MRCP are considered equivalent for pancreatic cancer screening. ASGE guidelines suggest that the choice between these modalities should be based upon patient preferences, however, there is limited data to help guide clinicians.

METHODS: All consecutive patients undergoing pancreatic cancer screening who had undergone both EUS and MRCP between 2021 and 2024 were identified. We also selected a comparison cohort of patients undergoing pancreatic cyst surveillance. A survey to elicit patient preferences and experience regarding physical discomfort, anxiety, dread, convenience, reassurance and cancer worry was administered to both groups.

RESULTS: Of 150 pancreatic cancer screening patients approached, 74 % agreed to participate. We compared mean response scores between EUS and MRCP and found patients favored EUS: less claustrophobia(p = 0.001), less dread(p = 0.02), more reassurance(p = 0.01), and more likely to recommend to family(p = 0.059). While 41.4 % reported no overall preference, 33.3 % preferred EUS and 25.2 % MRCP. Of 70/150(47 %) pancreatic cyst surveillance patients who responded, no difference in anxiety, dread or reassurance was noted between EUS and MRCP, but patients reported more claustrophobia with MRCP(p = 0.001). However, patients were more likely to recommend MRCP to family(p = 0.055). While 36.8 % reported no overall preference, 44.1 % preferred MRCP and 19.1 % EUS. Higher levels of cancer worry were reported by screening than cyst surveillance patients, but both groups reported that this rarely interfered with daily activities.

CONCLUSIONS: Almost 60 % of patients prefer one screening modality over the other, with a trend towards screening patients favoring EUS and cyst surveillance patients MRCP. These findings support a patient-centered individualized approach to pancreatic cancer screening.

BACKGROUND: Lymphatic anatomy has primarily been described in cadaveric dissections. Mapping of the upper extremity superficial lymphatic system with indocyanine green (ICG) lymphography provides functional insights and detail to major anatomic variations.

METHODS: Healthy female volunteers underwent lymphatic mapping of the upper extremities with ICG lymphography. ICG was injected in six standard sites in the hand/wrist and upper arm. Major anatomic variations of four main forearm pathways and connectivity to four upper arm pathways were described.

RESULTS: 90 arms of 45 volunteers were included. The posterior radial channel predominantly courses in the dorsal forearm (98%). The posterior ulnar forearm pathway courses in the dorsal forearm in the majority of arms (70%). The anterior radial and anterior ulnar forearm channels exclusively course in the volar forearm (100%). The posterior radial pathway connects to the bicipital (80%), lateral (48%), medial (9%), and tricipital (7%) upper am pathways. The posterior ulnar pathway connects to the lateral (54%), tricipital (51%), medial (21%), and bicipital (14%) upper arm pathways. The anterior radial pathway connects to the medial (50%) and bicipital (60%) pathways. The anterior ulnar pathway connects to the medial (54%) and bicipital (59%) pathways.

CONCLUSIONS: Upper extremity lymphatic drainage to the lateral and tricipital pathways is enabled exclusively by the dorsal forearm channels suggesting their importance in BCRL risk. Variations of upper extremity lymphatic anatomy are relevant to the risk, prevention, and treatment of breast cancer-related lymphedema risk and warrant further study.

Adult, symptomatic Chiari malformation Type I (CMI) is a painful, often debilitating, neurological condition which is defined by the herniation, or extension, of the cerebellar tonsils below the skull. Research has shown that Chiari patients on average exhibit a number of anatomical variations, or morphometric differences, from healthy controls in the cranio-vertebral region; however the potential contribution of these differences to CMI's pathophysiology is not clear. This case-control study looked at nine representative morphometric measures (MM) in 432 adult, female CMI subjects and 148 adult, female controls. Each measure was dichotomized at three increasing distances from the control mean to represent exposures in an odds ratio analysis with CMI as the outcome. In addition, logistic regression modeling was used to determine the overall predictive ability of the MMs. Finally, disease severity was compared across three CMI subgroups with varying degrees of morphometric severity. We found that a reduced fastigium height demonstrated the largest increase in both crude and adjusted odds ratios at every level with an exposure-response pattern. Logistic regression correctly identified 87% of the CMI subjects as CMI based on the MMs. On average, CMI subjects had more than 3 MMs that were at least one standard deviation from the control mean, but there was no association between morphological and disease severity. These results suggest that further studies into anatomical variations such as fastigium height in CMI patients are warranted.

Interventional oncology has gained a lot of traction as an attractive alternative treatment for various musculoskeletal tumours by offering minimally invasive image-guided therapies. In this domain, thermal ablation is increasingly being used malignant tumours, including bone metastatic disease. Thermal ablation therapies such as radiofrequency ablation, microwave ablation, cryoablation and high intensity focused ultrasound therapy achieve excellent local tumour control and pain palliation, whilst structural stability is ensured through the combination with bone augmentation techniques such as standard or reinforced osteoplasty. Many factors are affecting the results including the biology of the disease the treatment intent (curative or palliative) as well as the potential for complications, like thermal injury to surrounding tissues, highlight the need for meticulous procedural planning. This review highlights the pathophysiology, the current repertoire of thermal ablation techniques, clinical outcomes and the future directions for the treatment of metastatic bone disease.