Inter- and Intra-Observer Variability and the Effect of Experience in Cine-MRI for Adhesion Detection

Cine-MRI for adhesion detection is a promising novel modality that can help the large group of patients developing pain after abdominal surgery. Few studies into its diagnostic accuracy are available, and none address observer variability. This retrospective study explores the inter- and intra-observer variability, diagnostic accuracy, and the effect of experience. A total of 15 observers with a variety of experience reviewed 61 sagittal cine-MRI slices, placing box annotations with a confidence score at locations suspect for adhesions. Five observers reviewed the slices again one year later. Inter- and intra-observer variability are quantified using Fleiss’ (inter) and Cohen’s (intra) κ and percentage agreement. Diagnostic accuracy is quantified with receiver operating characteristic (ROC) analysis based on a consensus standard. Inter-observer Fleiss’ κ values range from 0.04 to 0.34, showing poor to fair agreement. High general and cine-MRI experience led to significantly (p < 0.001) better agreement among observers. The intra-observer results show Cohen’s κ values between 0.37 and 0.53 for all observers, except one with a low κ of −0.11. Group AUC scores lie between 0.66 and 0.72, with individual observers reaching 0.78. This study confirms that cine-MRI can diagnose adhesions, with respect to a radiologist consensus panel and shows that experience improves reading cine-MRI. Observers without specific experience adapt to this modality quickly after a short online tutorial. Observer agreement is fair at best and area under the receiver operating characteristic curve (AUC) scores leave room for improvement. Consistently interpreting this novel modality needs further research, for instance, by developing reporting guidelines or artificial intelligence-based methods

How to define a positive circumferential resection margin in t3 adenocarcinoma of the esophagus

A positive circumferential resection margin (CRM) is associated with poor survival after esophagectomy for cancer. The Royal College of Pathologists (RCP) defines a CRM when tumor is found <1 mm of the lateral margin whereas the College of American Pathologists (CAP) defines CRM when tumor cells are located at the lateral margin. This study evaluates the clinical prognostic significance of CRM on overall survival (OS) and disease-free survival (DFS) in patients who underwent esophagectomy for T3 esophageal adenocarcinoma. Analysis included 132 patients. CRM was found in 26 cases (19.7%) corresponding to CAP criteria versus 89 cases (67.4%) corresponding to RCP criteria. Median OS using RCP criteria was 16.4 (95%CI, 8.5-24.2) months for CRM patients versus 21.0 (95%CI 16.3-25.6) months in CRM patients (P=0.144). With CAP criteria, median OS in CRM and CRM patients was 9.4 (95%CI, 7.6-11.2) months versus 21.6 (95%CI, 18.9-24.3) months, respectively (P=0.000). Median DFS using RCP criteria was 18.0 (95%CI, 11.5-24.6) months for CRM patients versus 11.0 (95%CI, 8.1-14.0) months for CRM patients (P=0.257). Applying the CAP criteria, median DFS in CRM and CRM patients was 16.3 (95%CI, 10.6-22.0) months versus 7.0 (95%CI, 6.3-7.8) months, respectively (P=0.000). Effects of a CRM according to CAP criteria remained significant after multivariate testing [OS: hazard ratio (HR), 2.43; 95%CI, 1.52-3.90; DFS: HR, 2.09; 95%CI, 1.32-3.30]. Only with the CAP criteria, CRM is an independent prognostic factor for survival and recurrence in patients with T3 adenocarcinoma of the esophagus. The circumferential margin should only be considered positive (ie, R1) if the tumor is found at the inked lateral margin of resection in accordance with the CAP criteri

Through-Plane Movement at Multiple Aortic Levels on Dynamic Computed Tomography Angiography Is Limited in Patients With an Abdominal Aortic Aneurysm

PURPOSE: To analyze the movement of the aorta in the craniocaudal direction (through-plane movement) during the cardiac cycle at several levels to determine any potential impact on endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: For this study, 30 patients (median age 73.0 years; 27 men) with an infrarenal AAA were randomly selected from a prospectively maintained EVAR database. All patients had undergone preoperative electrocardiogram-gated computed tomography angiography consisting of 8 phases. After semiautomatic segmentation, a 3-dimensional location probe was placed in the center of the aorta (center point) on the orthogonal slices at 12 different levels along the aorta and iliac arteries for all 8 phases. Movement of the center point during the cardiac cycle was analyzed for each level. Values are given as the median and interquartile range (IQR). RESULTS: The median through-plane movement of all levels was 3.0 mm (IQR 2.8-3.2) and appeared to be lower in the region of the celiac and renal arteries: 2.6 mm (IQR 1.7-3.1) at 3 cm proximal to the most distal renal artery and 2.4 mm (IQR 1.9-2.9) at 1 cm distal to the most distal renal artery, respectively. The thoracic part of the aorta showed the largest through-plane motion: 4.1 mm (IQR 2.7-4.6). CONCLUSION: This study quantifies aortic through-plane motion in the craniocaudal direction. Since through-plane movement appears to be limited, findings of previous studies investigating pulsatile in-plane distension seem to be representative for aortic distension

Through-Plane Movement at Multiple Aortic Levels on Dynamic Computed Tomography Angiography Is Limited in Patients With an Abdominal Aortic Aneurysm

PURPOSE: To analyze the movement of the aorta in the craniocaudal direction (through-plane movement) during the cardiac cycle at several levels to determine any potential impact on endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA). METHODS: For this study, 30 patients (median age 73.0 years; 27 men) with an infrarenal AAA were randomly selected from a prospectively maintained EVAR database. All patients had undergone preoperative electrocardiogram-gated computed tomography angiography consisting of 8 phases. After semiautomatic segmentation, a 3-dimensional location probe was placed in the center of the aorta (center point) on the orthogonal slices at 12 different levels along the aorta and iliac arteries for all 8 phases. Movement of the center point during the cardiac cycle was analyzed for each level. Values are given as the median and interquartile range (IQR). RESULTS: The median through-plane movement of all levels was 3.0 mm (IQR 2.8-3.2) and appeared to be lower in the region of the celiac and renal arteries: 2.6 mm (IQR 1.7-3.1) at 3 cm proximal to the most distal renal artery and 2.4 mm (IQR 1.9-2.9) at 1 cm distal to the most distal renal artery, respectively. The thoracic part of the aorta showed the largest through-plane motion: 4.1 mm (IQR 2.7-4.6). CONCLUSION: This study quantifies aortic through-plane motion in the craniocaudal direction. Since through-plane movement appears to be limited, findings of previous studies investigating pulsatile in-plane distension seem to be representative for aortic distension

Results of endovascular repair of infrarenal aortic aneurysms using the Endurant stent graft

Objective Recent reports showed that the Endurant stent graft (Medtronic Cardiovascular, Santa Rosa, Calif) is safe and effective for endovascular repair of abdominal aortic aneurysms (AAAs). However, due to its relatively recent introduction, only short-term follow-up data are available. This study presents the 4-year results using this device. Methods All clinical data, including detailed anatomic information of the first 100 consecutive patients treated with the Endurant stent graft for an infrarenal AAA in three Dutch high-volume hospitals, were prospectively collected. Computed tomography angiography was routinely performed before the procedure, ≤1 month, and at 1 year post-endovascular aneurysm repair. Thereafter, the imaging modality during yearly follow-up was individualized (duplex ultrasound imaging or computed tomography angiography). Patients were classified as within or outside the instructions for use (IFU) for analysis. Study end points were primary clinical success, overall and AAA-related mortality, and sac morphology changes and endoleak during follow-up. Estimates were obtained using Kaplan-Meier plots. Results The study included 100 consecutive patients (88 men) with a median age of 74 years (interquartile range [IQR], 67-79 years) and median AAA diameter of 58 mm (IQR, 55-65 mm), between December 2007 and March 2009. Twenty patients (20%) were treated outside the IFU (18, outside proximal neck IFU, one outside iliac IFU, and one outside both IFUs). Median follow-up was 48 months (IQR, 36-53 months), and no patients were lost. One contained rupture was observed after 1.5 months due to graft infection. No patients had graft migration. Two type Ia endoleaks, 5 type Ib endoleaks, and 15 type II endoleaks were found. Primary clinical success was 97%, 90%, 84% and 77% at 1, 2, 3, and 4 years, respectively. Primary clinical success was comparable for patients treated within or outside IFU (P =.20), although both patients outside iliac IFU needed a secondary iliac intervention. Over time, maximum aneurysm diameter decreased ≥5 mm, remained stable, and increased ≥5 mm in 58%, 32%, and 10% of the patients, respectively. All-cause mortality was 20% at 4 years, with a 3% AAA-related mortality. Conclusions The 4-year follow-up data of the Endurant stent graft for AAA treatment shows its use results in a low AAA-related mortality with adequate prevention of rupture or aneurysm growth. Although patients with very challenging anatomy were treated in our series, primary clinical success rates were comparable for patients treated within and outside the IFU. However, both patients outside the iliac IFU needed a secondary iliac intervention. The knowledge of the present results may aid in improving outcomes in the future. Copyrigh

Sildenafil enhances systolic adaptation, but does not prevent diastolic dysfunction, in the pressure-loaded right ventricle

Right ventricular (RV) failure due to pressure or volume overload is a major risk factor for early mortality in congenital heart disease and pulmonary hypertension, but currently treatments are lacking. We aimed to demonstrate that the phosphodiesterase 5A inhibitor sildenafil can prevent adverse remodelling and improve function in chronic abnormal RV overload, independent from effects on the pulmonary vasculature. In rat models of either pressure or volume overload, we performed pressurevolume studies to measure haemodynamic effects and voluntary exercise testing as clinical outcome after 4 weeks of sildenafil (or vehicle) administration. In the pressure-loaded right ventricle, sildenafil enhanced contractility [end-systolic elastance (mmHg/mL) 247 68 vs.155 71, sildenafil vs. vehicle, P 0.05], prevented RV dilatation [end-diastolic volume (L) 733 50 vs. 874 39, P 0.05], reduced wall stress [peak wall stress (mmHg) 323 46 vs. 492 62, P 0.05], and partially preserved exercise tolerance [running distance () 33 15 vs. 62 12, P 0.05]. Protein kinase A was not activated by sildenafil and thus did not mediate the observed effects. In contrast, protein kinase G-1 was activated by sildenafil, but hypertrophy was not inhibited. Importantly, sildenafil did not prevent diastolic dysfunction, whereas RV fibrosis appeared to be increased in sildenafil-treated rats. In the volume-loaded right ventricle, sildenafil treatment did not show any beneficial effects. We demonstrate sildenafil to have beneficial, afterload-independent effects on the pressure-loaded right ventricle, but not on the volume-loaded right ventricle. These results indicate that sildenafil may offer a specific treatment for the pressure-loaded right ventricle, although persistent diastolic dysfunction and RV fibrosis could be of concern