Adamo, Daniel

Radiologists play a key role in the management of renal masses, and it is important to understand the nonsurgical treatment options for solid renal masses, typical imaging findings after treatment, common complications, and methods to avoid pitfalls.

AbstractBackgroundComputed tomography (CT) is routinely used to guide cryoablation procedures. Notably, CT‐guidance provides 3D localization of cryoprobes and can be used to delineate frozen tissue during ablation. However, metal‐induced artifacts from ablation probes can make accurate probe placement challenging and degrade the ice ball conspicuity, which in combination could lead to undertreatment of potentially curable lesions.PurposeIn this work, we propose an image‐based neural network (CNN) model for metal artifact reduction for CT‐guided interventional procedures.MethodsAn image domain metal artifact simulation framework was developed and validated for deep‐learning‐based metal artifact reduction for interventional oncology (MARIO). CT scans were acquired for 19 different cryoablation probe configurations. The probe configurations varied in the number of probes and the relative orientations. A combination of intensity thresholding and masking based on maximum intensity projections (MIPs) was used to segment both the probes only and probes + artifact in each phantom image. Each of the probe and probe + artifact images were then inserted into 19 unique patient exams, in the image domain, to simulate metal artifact appearance for CT‐guided interventional oncology procedures. The resulting 361 pairs of simulated image volumes were partitioned into disjoint training and test datasets of 304 and 57 volumes, respectively. From the training partition, 116 600 image patches with a shape of 128 × 128 × 5 pixels were randomly extracted to be used for training data. The input images consisted of a superposition of the patient and probe + artifact images. The target images consisted of a superposition of the patient and probe only images. This dataset was used to optimize a U‐Net type model. The trained model was then applied to 50 independent, previously unseen CT images obtained during renal cryoablations. Three board‐certified radiologists with experience in CT‐guided ablations performed a blinded review of the MARIO images. A total of 100 images (50 original, 50 MARIO processed) were assessed across different aspects of image quality on a 4‐point likert‐type item. Statistical analyses were performed using Wilcoxon signed‐rank test for paired samples.ResultsReader scores were significantly higher for MARIO processed images compared to the original images across all metrics (all p < 0.001). The average scores of the overall image quality, iceball conspicuity, overall metal artifact, needle tip visualization, target region confidence, and worst metal artifact, needle tip visualization, iceball conspicuity, and target region confidence improved by 34.91%, 36.29%, 39.94%, 34.17%, 35.13%, and 45.70%, respectively.ConclusionsThe proposed method of image‐based metal artifact simulation can be used to train a MARIO algorithm to effectively reduce probe‐related metal artifacts in CT‐guided cryoablation procedures.

AbstractIntroduction/PurposePercutaneous core‐needle biopsy of the testicle has been shown to be a safe and effective method of obtaining tissue for histological analysis and can be considered in specific clinical scenarios. While the use of spermatic cord block has been shown to be effective in pain relief in the emergent setting and as an anaesthetic option for inguinal surgery, its use in percutaneous core‐needle biopsy has not been well described. Through this case series, we present our experience and technique of ultrasound‐guided percutaneous core‐needle biopsy using spermatic cord block in the setting of indeterminant testicular masses.MethodsOur departmental biopsy database was reviewed to identify patients who underwent percutaneous core‐needle biopsy of the testicle from March 2010 to July 2022 and who also received spermatic cord block during the procedure.ResultsThree patients were identified who met the search criteria. All three patients presented for the evaluation of indeterminant testicular mass and had a known non‐testicular primary cancer diagnosis at the time of biopsy. All three biopsies were performed using a combination of spermatic cord block, moderate sedation, and local anaesthetic. Biopsies were obtained using an 18‐gauge spring‐loaded device with 4‐5 core samples obtained during each procedure. All biopsies were well tolerated without significant pain or post‐procedure complications.DiscussionUltrasound‐guided percutaneous core‐needle testicular biopsy using spermatic cord block is a safe and effective option in sampling indeterminate testicular masses while maintaining patient comfort.ConclusionThe inclusion of a spermatic cord block in combination with local anaesthetic and moderate sedation has become standard practice in our institution, as we believe this maximises patient comfort and safety resulting in a better patient experience.

AbstractObjectiveThe objective of this study was to evaluate the role of adrenal venous sampling (AVS) in guiding the management of patients with corticotropin (ACTH)‐independent glucocorticoid secretory autonomy and bilateral adrenal masses.Design and PatientsA cohort with 25 patients underwent AVS and surgical management.MeasurementsCortisol was measured from the adrenal veins (AVs) and inferior vena cava (IVC). AV/IVC cortisol ratio and cortisol lateralization ratio (CLR) (dominant AV cortisol concentration divided by the nondominant AV cortisol concentration) were calculated. Posthoc receiver‐operating characteristic curves were generated to determine the specificity of revised AV/IVC cortisol ratio and CLR in differentiating unilateral from bilateral disease.ResultsPatients underwent unilateral (n = 21) or bilateral (n = 4) adrenalectomy. The mean AV/IVC cortisol ratio for unilateral adrenalectomy was 12.1 ± 9.6 (dominant) and 4.7 ± 3.8 (contralateral) with a mean CLR of 3.6 ± 3.5. The mean AV/IVC cortisol ratio for bilateral adrenalectomy was 7.5 ± 2.1, with a mean CLR of 1.1 ± 0.6. At a mean follow‐up of 22 months, one patient who underwent unilateral adrenalectomy for the predicted bilateral disease developed recurrent mild autonomous cortisol secretion. Posthoc analyses demonstrated a specificity of 95%–100% for unilateral disease with AV/IVC cortisol ratio >9 for one side, <2.0 for the opposite side and a CLR > 2.3. The specificity was 80%–90% for bilateral disease with AV/IVC cortisol ratio >5.1 bilaterally and a CLR < 1.1.ConclusionsAmong patients with bilateral adrenal masses and ACTH‐independent autonomous cortisol secretion, AVS can distinguish between unilateral and bilateral disease with high specificity and may guide surgical management.

Abstract Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting (P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.