Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients' quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas.

Abdominal Emergencies in Cancer Patients

Abdominal emergencies in cancer patients encompass a wide spectrum of oncologic conditions caused directly by malignancies, paraneoplastic syndromes, reactions to the chemotherapy or often represent the first clinical manifestation of an unknown malignancy. Not rarely, clinical symptoms are the tip of an iceberg. In this scenario, the radiologist is asked to exclude the cause responsible for the patient's symptoms, to suggest the best way to manage and to rule out the underlying malignancy. In this article, we discuss some of the most common abdominal oncological emergencies that may be encountered in an emergency department.

Imaging of central nervous system emergencies in oncology

Central nervous system (CNS) may be predisposed to devastating complications in cancer patients which may add to morbidity and mortality in this group. Majority of the complications are vascular in nature due to the altered coagulation profile and pro-inflammatory state in these patients. However, there are a host of other conditions which may affect the clinical course of these patients including metabolic and toxic encephalopathies, infections, and paraneoplastic syndromes. Moreover, multimodality management of these patients, which is often used in majority of the cancers, exposes them to treatment related complications. This pictorial review aims to enlighten the reader regarding the various complications affecting the CNS as seen at our tertiary cancer care institute. We aim to highlight the emergent nature of these complications and the need to identify them quickly and accurately on imaging which helps to institute early appropriate management and prevents further morbidity and mortality.

Surgical complications of oncological treatments: A narrative review

Gastrointestinal complications are common in patients undergoing various forms of cancer treatments, including chemotherapy, radiation therapy, and molecular-targeted therapies. Surgical complications of oncologic therapies can occur in the upper gastrointestinal tract, small bowel, colon, and rectum. The mechanisms of action of these therapies are different. Chemotherapy includes cytotoxic drugs, which block the activity of cancer cells by targeting intracellular DNA, RNA, or proteins. Gastrointestinal symptoms are very common during chemotherapy, due to a direct effect on the intestinal mucosa resulting in edema, inflammation, ulceration, and stricture. Serious adverse events have been described as complications of molecular targeted therapies, including bowel perforation, bleeding, and pneumatosis intestinalis, which may require surgical evaluation. Radiotherapy is a local anti-cancer therapy, which uses ionizing radiation to cause inhibition of cell division and ultimately lead to cell death. Complications related to radiotherapy can be both acute and chronic. Ablative therapies, including radiofrequency, laser, microwave, cryoablation, and chemical ablation with acetic acid or ethanol, can cause thermal or chemical injuries to the nearby structures. Treatment of the different gastrointestinal complications should be tailored to the individual patient and based on the underlying pathophysiology of the complication. Furthermore, it is important to know the stage and prognosis of the disease, and a multidisciplinary approach is necessary to personalize the surgical treatment. The purpose of this narrative review is to describe complications related to different oncologic therapies that may require surgical interventions.

Role of artificial intelligence in oncologic emergencies: a narrative review

Oncologic emergencies are a wide spectrum of oncologic conditions caused directly by malignancies or their treatment. Oncologic emergencies may be classified according to the underlying physiopathology in metabolic, hematologic, and structural conditions. In the latter, radiologists have a pivotal role, through an accurate diagnosis useful to provide optimal patient care. Structural conditions may involve the central nervous system, thorax, or abdomen, and emergency radiologists have to know the characteristics imaging findings of each one of them. The number of oncologic emergencies is growing due to the increased incidence of malignancies in the general population and also to the improved survival of these patients thanks to the advances in cancer treatment. Artificial intelligence (AI) could be a solution to assist emergency radiologists with this rapidly increasing workload. To our knowledge, AI applications in the setting of the oncologic emergency are mostly underexplored, probably due to the relatively low number of oncologic emergencies and the difficulty in training algorithms. However, cancer emergencies are defined by the cause and not by a specific pattern of radiological symptoms and signs. Therefore, it can be expected that AI algorithms developed for the detection of these emergencies in the non-oncological field can be transferred to the clinical setting of oncologic emergency. In this review, a craniocaudal approach was followed and central nervous system, thoracic, and abdominal oncologic emergencies have been addressed regarding the AI applications reported in literature. Among the central nervous system emergencies, AI applications have been reported for brain herniation and spinal cord compression. In the thoracic district the addressed emergencies were pulmonary embolism, cardiac tamponade and pneumothorax. Pneumothorax was the most frequently described application for AI, to improve sensibility and to reduce the time-to-diagnosis. Finally, regarding abdominal emergencies, AI applications for abdominal hemorrhage, intestinal obstruction, intestinal perforation, and intestinal intussusception have been described.

Multimodality imaging workup of classical Hodgkin lymphoma in an 8-month-old child

The incidence of Hodgkin lymphoma (HL) varies by age, most commonly affecting 15-19-year-olds. Cases in children less than 3 years old are exceedingly rare. We report a case of classical HL in an 8-month-old male; the youngest case reported thus far in the literature to our knowledge. Furthermore, while lymphadenopathy is a salient feature of HL, it was absent in our patient, who presented with immunodeficiency and delays in achieving neurologic milestones. A thorough radiologic workup demonstrated bilateral paravertebral masses, collapse of the T3 vertebrae, and severe spinal cord compression. Involvement of the lung, liver, and spleen was also noted. Histopathological evaluation of the paravertebral mass revealed a diagnosis of classical HL. Various non-neoplastic and malignant disorders, such as tuberculosis, Langerhans cell histiocytosis, leukemia, and neuroblastoma, amongst others, could be included in the differential diagnosis of our patient. Using an Illustrative case report, we review the multimodality imaging workup of Hodgkin lymphoma.

Urgent and unexpected findings in oncology and hematology patients: A practical approach to imaging

Urgent and unexpected findings are very common in oncology and haematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumours and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.

Non-Hodgkin Lymphoma Imaging Spectrum in Children, Adolescents, and Young Adults

In children, adolescents, and young adults (CAYA), non-Hodgkin lymphoma (NHL) is characterized by various age-related dissimilarities in tumor aggressiveness, prevailing pathologic subtypes, and imaging features, as well as potentially different treatment outcomes. Understanding the imaging spectrum of NHL in CAYA with particular attention to children and adolescents is critical for radiologists to support the clinical decision making by the treating physicians and other health care practitioners. The authors discuss the currently performed imaging modalities including radiography, US, CT, MRI, and PET in the diagnosis, staging, and assessment of the treatment response. Familiarity with diagnostic imaging challenges during image acquisition, processing, and interpretation is required when managing patients with NHL. The authors describe potentially problematic and life-threatening scenarios that require prompt management. Moreover, the authors address the unprecedented urge to understand the imaging patterns of possible treatment-related complications of the therapeutic agents used in NHL clinical trials and in practice. Online supplemental material is available for this article. ^©RSNA, 2022.

Tumor mass in the lung with superior vena cava syndrome

Group of symptoms due to vena cava superior obstruction is named superior vena cava syndrome. A 65-year-old female, long-standing smoker was presented with a two-week history of dry cough and facial swelling. The patient noticed a palpable mass on the right side of the neck. Computer tomography scan with contrast showed extensive, irregular, non-homogenous consolidation in the right upper lobe, involving the right hilus, surrounding the aortic arch, supra aortic branches and pleural effusion at the right side of the body. Also, ultrasound examination of supra clavicular space showed enlarged pathologic hypoehogenic lymph node without an echogenic hilum. Ultrasound guided fine needle biopsy of lymph node was performed, and cytopathology findings showed metastatic lesion from primary microcellular lung cancer, IIIC stadium, cT4N3M0. Venous angioplasty was performed showing stenosis in the superior vena cava. After balloon dilatation, the stent was placed at the site of stenosis. The patient received chemio- and radiotherapy and survival time was seven months. Superior vena cava syndrome is an urgent clinical condition, and lung cancer is the leading cause of this syndrome. Computer tomography imaging findings and endovascular stent placement are important for detection and management of the superior vena cava thrombosis.

Urgent and unexpected findings in oncology and hematology patients: a practical approach to imaging

Urgent and unexpected findings are very common in oncology and hematology patients. This article reviews the most important points included in the European Society of Radiology's guidelines and proposes a practical approach to reporting and communicating these findings more efficiently. This approach is explained with illustrative examples. Radiologists can provide added value in the management of these findings by helping referring clinicians reach the best decisions. To this end, it is essential to know the imaging manifestations of the most common findings that must be reported urgently, such as the specific toxicity of different treatments, the complications of tumors and catheters, infections, and thrombosis. Moreover, it is crucial to consider the individual patient's treatment, risk factors, clinical situation, and immune status.

CT for Evaluation of Hemoptysis

Hemoptysis, which is defined as expectoration of blood from the alveoli or airways of the lower respiratory tract, is an alarming clinical symptom with an extensive differential diagnosis. CT has emerged as an important noninvasive tool in the evaluation of patients with hemoptysis, and the authors present a systematic but flexible approach to CT interpretation. The first step in this approach involves identifying findings of parenchymal and airway hemorrhage. The second step is aimed at determining the mechanism of hemoptysis and whether a specific vascular supply can be implicated. Hemoptysis can have primary vascular and secondary vascular causes. Primary vascular mechanisms include chronic systemic vascular hypertrophy, focally damaged vessels, a dysplastic lung parenchyma with systemic arterial supply, arteriovenous malformations and fistulas, and bleeding at the capillary level. Evaluating vascular mechanisms of hemoptysis at CT also entails determining if a specific vascular source can be implicated. Although the bronchial arteries are responsible for most cases of hemoptysis, nonbronchial systemic arteries and the pulmonary arteries are important potential sources of hemoptysis that must be recognized. Secondary vascular mechanisms of hemoptysis include processes that directly destroy the lung parenchyma and processes that directly invade the airway. Understanding and employing this approach allow the diagnostic radiologist to interpret CT examinations accurately in patients with hemoptysis and provide information that is best suited to directing subsequent treatment. ^©RSNA, 2021.

Increased Intracranial Pressure: The Use of an Individualized Ladder Approach

OBJECTIVE

This paper provides a review of current knowledge on intracranial pressure (ICP) dynamics, assessment, and diagnostic considerations, and presents a ladder approach to the management of the neuro-oncological emergency increased ICP.

DATA SOURCE

Review of recent literature from PubMed.

CONCLUSION

Increased ICP can rapidly escalate into a catastrophic event. Prompt initiation of an individualized ladder approach to clinical management enabled by early recognition of symptoms and application of diagnostic tools have been shown to improve outcomes in patients suffering from this neuro-oncological emergency.

IMPLICATIONS FOR NURSING PRACTICE

The care of cancer patients with increased ICP can be very challenging. When increased ICP in patients with cancer is evident or strongly suspected, nurses need to initiate a prompt and effective care plan that includes intensive monitoring of symptoms and continuous assessment of the patient's neurological condition that will guide diagnostic and treatment decisions. Nurses must continue to recognize the importance of utilizing best available evidence to support a collaborative interdisciplinary clinical plan of care.

Imaging of acute abdomen in cancer patients

The pattern of disease causing acute abdominal pain has changed over last few decades, some of this has been attributed to intraabdominal cancers. The most common acute abdominal complaints in cancer patients are related to the gastrointestinal system. Abdominal emergencies in cancer patients can result from the underlying malignancy itself, cancer therapy and/or result from the standard pathologies causing acute abdomen in otherwise healthy population. Therapy-related or disease-related immunosuppression or high dose analgesics often blunt many of the findings which are usually expected in non-cancer general population. This complicates the clinical picture rendering the clinical exam less reliable in many cancer patients, and resulting in different pathologies which clinicians and the radiologists should remain aware of. This article focuses on imaging illustrations with differential diagnosis for various emergency scenarios related to acute abdomen specifically in oncologic settings.

Diagnostic accuracy of MR, CT, and ECT in the differentiation of neoplastic from nonneoplastic spine lesions

AIM

To provide guidance for appropriate imaging examinations for diagnosing spinal tumors or tumor-like lesions.

METHODS

A total of 121 patients with suspected spinal tumors were included this retrospective study. Each patient underwent ≥2 imaging examinations, including computerized tomography (CT), magnetic resonance (MR), and/or emission computed tomography (ECT). All patients were diagnosed by pathology after core needle or surgical biopsies. The results were compared with those of pathological examinations using paired chi-squared tests, and compared with each other. Statistical indicators that tested the consistency of the results included McNemar's and kappa coefficients, as well as receiver operating characteristic curves.

RESULTS

The differences among MR, CT, ECT, and pathology were not significant. The kappa coefficient of MR, CT, and ECT was 46.1%, 36.0%, and 55.9%, respectively. The area under the curve of ECT, MR, and CT scans was 0.809, 0.705, and 0.704, respectively; and the differences among them were significant (P < .05). Post hoc multiple comparisons showed no significant differences among imaging examinations in terms of sensitivity, specificity, misdiagnosis rate, and coincidence rate (P > .05). However, significant differences were noted in the kappa coefficient and missed diagnosis rate (P < .05).

CONCLUSIONS

Although ECT was the most accurate imaging method, its high cost and large radiation dosage limit its widespread application. Furthermore, MR verified spinal tumors more effectively; however, CT excluded them more efficiently. In summary, when all factors are considered, MR is still the optimal modality for the diagnosis of spinal tumors, especially during the initial screening.

Reducing emergency department (ED) computed tomography (CT) utilization in women treated for gynecologic cancers

OBJECTIVES

The objective of this quality improvement (QI) project was to decrease the rate of low-value computed tomography (CT) imaging in established gynecologic oncology patients presenting to the emergency department (ED).

METHODS

This was a cohort study with a before and after design that evaluated implementation of a QI project designed to decrease CT utilization in established gynecologic oncology patients in the ED. The pre-intervention cohort included patients admitted through the ED from 4/1/17 to 5/31/18, while the post-intervention cohort was from 6/1/18 to 5/31/19. The intervention included gynecologic oncology consultation before CT on patients who had imaging within the prior 3 weeks. Details regarding CT, ED length of stay (LOS), and oncologic history were abstracted. The value of CT was determined by consensus from 2 reviewers. Prospective data monitoring evaluated for patient safety.

RESULTS

Prior to intervention, there were 129 unique ED encounters in gynecologic oncology patients leading to admission. CT scans were performed in 101 (78.3%) encounters, 57.7% of which were deemed to be of low-value. Following implementation, the CT utilization rate decreased significantly from median monthly rate of 75.2% to 49.1% (p < 0.00001), and the ED LOS decreased from 8.1 to 6.9 h (p = 0.0102). The number of CT scans deemed to be low-value in the post-intervention group decreased to 2 (3.8%).

CONCLUSIONS

Implementation of an early consultation policy and imaging guidelines led to a significant decrease in unnecessary CT utilization and shorter ED LOS in gynecologic oncology patients presenting to the ED.

Asymptomatic azygos vein overflow in a young patient with primary mediastinal seminoma

The azygos system is the most important pathway for decompression of the superior vena cava (SVC) when a blood flow obstruction to the right atrium is present. Thoracic and mediastinal malignancies, mainly lung cancers, are responsible for 60%–85% of superior vena cava syndrome (SVCS) cases. An uncommon origin of SVCS is primary malignant mediastinal germ cell tumor (PMMGCT) which represent 1%–4% of all mediastinal tumors and can be divided into two broad groups: seminomas and nonseminomatous germ cell tumors (NSGCTs). Primary mediastinal seminomas clinical presentation is often nonspecific, even if the majority of patients present with superior vena cava involvement. Here, we present the radiologic features of asymptomatic azygos system overflow in a patient with primary mediastinal seminoma.

Non-aortic vascular findings on chest CT angiogram: including arch vessels and bronchial arteries

CT angiogram (CTA) has become the modality of choice for imaging of thoracic vascular pathologies, involving the aorta and the pulmonary arteries. Apart from showing exquisite details of these large arteries, pathologies and anatomic variants of their branches can also be studied to a great extent. The major branches of aortic arch can be affected by a wide variety of pathologies ranging from atherosclerosis to trauma and vasculitis. Bronchial arteries in spite of supplying only 1% of lung parenchyma can become hypertrophied in various congenital and acquired conditions, becoming an important source of collateral circulation as well as a source for life threatening hemoptysis. CT also plays an important role in diagnosis of vascular compression at the thoracic outlet. With advances in CT technology, the acquisition, interpretation and clinical applications of CT angiography will continue to grow in the years to come.

Blood finds a way: pictorial review of thoracic collateral vessels

In the healthy patient, blood returns to the heart via classic venous pathways. Obstruction of any one of these pathways will result in blood flow finding new collateral pathways to return to the heart. Although significant anatomic variation exists and multiple collateral vessels are often present in the same patient, it is a general rule that the collateral pathways formed are a function of the site of venous blockage. Therefore, knowledge of typical collateral vessel systems can provide insight in localizing venous obstruction and characterizing its severity and chronicity. In addition, knowledge of collateral anatomy can be essential in interventional procedural and/or surgical planning, especially when placing catheters in patients with venous blockage. In this pictorial review, we provide a systematic approach to understanding collateral pathways in patients with venous obstruction in the upper body.

Imaging of Oncologic Emergencies

Oncologic emergencies can be either the result of the primary tumor, its metastasis, a paraneoplastic syndrome or reaction to the chemotherapy. Imaging plays a crucial role in ensuring a prompt diagnosis as well as assisting in the therapeutic management. In this article, we discuss the common thoracic and abdominal oncological emergencies that may be encountered in an emergency department.

CT Imaging of Emergent Renal Conditions

The kidneys are paired intra-abdominal organs which provide essential functions and maintain homeostasis throughout the human body. Numerous disease processes affect the kidneys and cause acute renal dysfunction or other potentially catastrophic complications. These conditions can be broadly categorized into obstructive, infectious, hemorrhagic, traumatic, and vascular diseases. Imaging plays a vital role in the work-up and diagnosis of acute and emergent renal conditions. Evaluation of emergent renal conditions with a focus on CT imaging is discussed.

Imaging manifestations of Behcet's disease: Key considerations and major features

Behcet's disease is an autoimmune disease most commonly seen in the Middle East. Although primarily known with painful oral and genital ulcers, it can lead to vasculitis. Therefore, several associated complications such as thrombotic syndromes, aneurysmal arterial disease may arise. In many cases, it might be difficult to make the diagnosis purely based on clinical grounds; however, imaging plays an important role for both diagnosis and assessment of the disease's complications. We provide a comprehensive review of the most notable imaging findings of Behcet's disease.

Transcatheter Arterial Chemoembolization with Spherical Embolic Agent in Patients with Pulmonary or Mediastinal Metastases from Breast Cancer

PURPOSE

To evaluate safety and feasibility of transcatheter arterial chemoembolization with superabsorbent polymer microspheres (SAP-MS) for patients with pulmonary or mediastinal metastasis from breast cancer.

METHODS

Between November 2002 and January 2015, 14 patients with 29 unresectable pulmonary or mediastinal breast cancer metastases underwent transcatheter arterial chemoembolization using SAP-MS (50-100 μm) after injection of a combination of 2-4 types of anticancer drugs (eg, cisplatin [30 mg] + fluorouracil [500 mg], or epirubicin [40 mg] + mitomycin C [4 mg] + fluorouracil [500 mg]). As a primary endpoint, local tumor response and adverse events were evaluated 1 month after the first transcatheter arterial chemoembolization, according to Response Evaluation Criteria In Solid Tumors Version 1.1 and Common Terminology Criteria for Adverse Events Version 4 criteria. Transcatheter arterial chemoembolization was repeated as needed. Overall survival was analyzed as a secondary endpoint.

RESULTS

Response rate was 28.6% (partial response, 4 patients; stable disease, 10 patients). Median progression rate was -12.7%. No cases of hematologic toxicity of grade 3 or higher were observed. A grade 3 maculopapular rash was observed in 1 patient. After the first transcatheter arterial chemoembolization sessions, 63 additional transcatheter arterial chemoembolization sessions were performed (average, 5.5 sessions per patient; range, 2-10 sessions). The median overall survival time after the first session was 29 months, and the 5-year survival rate was 49.5%.

CONCLUSIONS

Transcatheter arterial chemoembolization with SAP-MS is a well-tolerated and feasible palliative treatment option for patients with pulmonary or mediastinal metastasis from breast cancer.

Outcomes in Critically Ill Patients with Cancer-Related Complications

INTRODUCTION

Cancer patients are at risk for severe complications related to the underlying malignancy or its treatment and, therefore, usually require admission to intensive care units (ICU). Here, we evaluated the clinical characteristics and outcomes in this subgroup of patients.

MATERIALS AND METHODS

Secondary analysis of two prospective cohorts of cancer patients admitted to ICUs. We used multivariable logistic regression to identify variables associated with hospital mortality.

RESULTS

Out of 2,028 patients, 456 (23%) had cancer-related complications. Compared to those without cancer-related complications, they more frequently had worse performance status (PS) (57% vs 36% with PS≥2), active malignancy (95% vs 58%), need for vasopressors (45% vs 34%), mechanical ventilation (70% vs 51%) and dialysis (12% vs 8%) (P<0.001 for all analyses). ICU (47% vs. 27%) and hospital (63% vs. 38%) mortality rates were also higher in patients with cancer-related complications (P<0.001). Chemo/radiation therapy-induced toxicity (6%), venous thromboembolism (5%), respiratory failure (4%), gastrointestinal involvement (3%) and vena cava syndrome (VCS) (2%) were the most frequent cancer-related complications. In multivariable analysis, the presence of cancer-related complications per se was not associated with mortality [odds ratio (OR) = 1.25 (95% confidence interval, 0.94-1.66), P = 0.131]. However, among the individual cancer-related complications, VCS [OR = 3.79 (1.11-12.92), P = 0.033], gastrointestinal involvement [OR = 3.05 (1.57-5.91), P = <0.001] and respiratory failure [OR = 1.96(1.04-3.71), P = 0.038] were independently associated with in-hospital mortality.

CONCLUSIONS

The prognostic impact of cancer-related complications was variable. Although some complications were associated with worse outcomes, the presence of an acute cancer-related complication per se should not guide decisions to admit a patient to ICU.

Role of computed tomography at a cancer center emergency department

To evaluate the imaging methods used at the emergency department (ED) of a cancer center, with emphasis on computed tomography (CT). A descriptive, retrospective, single-center study was conducted by reviewing imaging exams and medical records, after approval of the institution's Ethics Review Board. The demographic data, cancer history, and imaging exam requested were evaluated for all patients and the indications and results of head, chest, and abdominopelvic CT scans were also evaluated. During the study period, there were 8710 visits to the ED, and 5999 imaging studies were requested in 3788 patients (43.5 % of total of visits). One thousand eight hundred twenty-nine CT exams were used in 1121 visits (12.9 % of total of visits). The mean age of patients was 57.7 years and most patients (93.2 %) had a known primary tumor. The most common indications for abdominopelvic CT were non-oncologic emergencies (26.7 %) and postoperative complications (19.2 %), and the results were negative in 36.6 %, positive for clinical suspicion in 49.0 %, and incidental positive in 14.5 %. The most frequent indication for chest CT was suspected pulmonary embolism (34.4 %); however, only 11.1 % confirmed the diagnosis. The results of head TC were negative in 72.9 % and the indications that had more positive findings were suspected metastasis (32.1 %) and focal neurological sign/altered level of consciousness (24.5 %). CT plays an important role in driving the cancer patients visiting the ED. However, the high rate of negative or discordant results causes a concern for the inadvertent and excessive use of this imaging modality.

Bronchial arteries: anatomy, function, hypertrophy, and anomalies

The two main sources of blood supply to the lungs and their supporting structures are the pulmonary and bronchial arteries. The bronchial arteries account for 1% of the cardiac output but can be recruited to provide additional systemic circulation to the lungs in various acquired and congenital thoracic disorders. An understanding of bronchial artery anatomy and function is important in the identification of bronchial artery dilatation and anomalies and the formulation of an appropriate differential diagnosis. Visualization of dilated bronchial arteries at imaging should alert the radiologist to obstructive disorders that affect the pulmonary circulation and prompt the exclusion of diseases that produce or are associated with pulmonary artery obstruction, including chronic infectious and/or inflammatory processes, chronic thromboembolic disease, and congenital anomalies of the thorax (eg, proximal interruption of the pulmonary artery). Conotruncal abnormalities, such as pulmonary atresia with ventricular septal defect, are associated with systemic pulmonary supply provided by aortic branches known as major aortopulmonary collaterals, which originate in the region of the bronchial arteries. Bronchial artery malformation is a rare left-to-right or left-to-left shunt characterized by an anomalous connection between a bronchial artery and a pulmonary artery or a pulmonary vein, respectively. Bronchial artery interventions can be used successfully in the treatment of hemoptysis, with a low risk of adverse events. Multidetector computed tomography helps provide a vascular road map for the interventional radiologist before bronchial artery embolization.

Current management of surgical oncologic emergencies

Objectives

For some oncologic emergencies, surgical interventions are necessary for dissolution or temporary relieve. In the absence of guidelines, the most optimal method for decision making would be in a multidisciplinary cancer conference (MCC). In an acute setting, the opportunity for multidisciplinary discussion is often not available. In this study, the management and short term outcome of patients after surgical oncologic emergency consultation was analyzed.

Method

A prospective registration and follow up of adult patients with surgical oncologic emergencies between 01-11-2013 and 30-04-2014. The follow up period was 30 days.

Results

In total, 207 patients with surgical oncologic emergencies were included. Postoperative wound infections, malignant obstruction, and clinical deterioration due to progressive disease were the most frequent conditions for surgical oncologic emergency consultation. During the follow up period, 40% of patients underwent surgery. The median number of involved medical specialties was two. Only 30% of all patients were discussed in a MCC within 30 days after emergency consultation, and only 41% of the patients who underwent surgery were discussed in a MCC. For 79% of these patients, the surgical procedure was performed before the MCC. Mortality within 30 days was 13%.

Conclusion

In most cases, surgery occurred without discussing the patient in a MCC, regardless of the fact that multiple medical specialties were involved in the treatment process. There is a need for prognostic aids and acute oncology pathways with structural multidisciplinary management. These will provide in faster institution of the most appropriate personalized cancer care, and prevent unnecessary investigations or invasive therapy.

Beyond PET/CT in Hodgkin lymphoma: a comprehensive review of the role of imaging at initial presentation, during follow-up and for assessment of treatment-related complications

Objective

The purpose of this article is to provide a comprehensive review of the role of imaging modalities other than PET/CT in the management of Hodgkin lymphoma (HL). PET/CT is the imaging modality of choice in the management of Hodgkin’s lymphoma (HL). However, imaging modalities other than PET/CT such as plain radiographs, ultrasound, CT, MRI and nuclear imaging can help in various stages of clinical management of HL, including the initial workup and post-treatment surveillance. Both CT and MRI help in detecting recurrences, treatment-related pulmonary, cardiovascular and abdominal complications as well as second malignancies. Familiarity with expected post-treatment changes and complications on surveillance images can help radiologists guide patient management. The purpose of this article is to provide a comprehensive review of the role of imaging modalities other than PET/CT in the management of Hodgkin lymphoma (HL).

Main Messages

• Surveillance of HL patients is usually performed with plain radiographs and CT.

• Follow-up imaging can depict normal post-treatment changes or treatment-related complications.

• Imaging is important for the timely detection of second malignancies in HL patients.

BWH emergency radiology--surgical correlation: small-bowel GI stromal tumor perforation

We present the radiological and intraoperative correlation of a large necrotic gastrointestinal stromal tumor (GIST) with features of a tumor-bowel fistula and perforation in a 49-year-old woman presenting to the emergency department with a 4-day history of worsening abdominal pain, vomiting, and diarrhea. The patient underwent urgent exploratory laparotomy for partial resection of the small bowel, with primary anastomosis. The purpose of this article is to emphasize the importance for emergency radiologists to be familiar with this entity and its possible complications to help guide the surgeons in the patient's management.

Mortality in emergency surgical oncology

PURPOSE

Cancer patients can experience problems related to their disease or treatment. This study evaluated reasons for presentation at the emergency room (ER) and outcome of surgical oncology patients.

METHODS

A retrospective chart review for all surgical oncology patients who presented at the ER of the UMCG for surgical consultation between October 1, 2012, and March 31, 2013.

RESULTS

A total of 200 cancer patients visited the ER for surgical consultation: 53.5 % with complications of (previous) cancer treatment, 25.5 % with symptoms caused by malignant disease, and 21.0 % with symptoms not related to cancer or cancer treatment. The 30-day mortality rate for patients with progressive disease was 25.5 %, and overall mortality rate was 62.8 %. The most frequent reason for ER presentation was intestinal obstruction (26.5 %), of which 41.5 % was malignant. Most cancer patients (59.5 %) did not undergo surgery during follow-up. The 30-day mortality for these patients was 14.3 % and overall mortality was 37.8 %. Most patients who died within the first 30 days after ER presentation had not undergone any surgery after presentation (89.5 %).

CONCLUSIONS

There is great variation in mortality rates for cancer patients presenting at the ER for surgical consultation. The mortality in this study was greatest for patients with progressive disease (30-day mortality 25.5 % and overall mortality 62.8 %), and the majority of patients who died within 30 days (89.5 %) had not undergone surgery after ER presentation. Surgery should only be performed in the acute setting when essential and when the expected outcome is favorable for the patient.

Surgical emergencies in oncology

An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result of the malignant disease or its treatment. Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into medical or surgical. The literature was reviewed to construct a summary of potential surgical emergencies in oncology that any surgeon can be confronted with in daily practice, and to offer insight into the current approach for these wide ranged emergencies. Cancer patients can experience symptoms of obstruction of different structures and various causes. Obstruction of the gastrointestinal tract is the most frequent condition seen in surgical practice. Further surgical emergencies include infections due to immune deficiency, perforation of the gastrointestinal tract, bleeding events, and pathological fractures. For the institution of the appropriate treatment for any emergency, it is important to determine the underlying cause, since emergencies can be either benign or malignant of origin. Some emergencies are well managed with conservative or non-invasive treatment, whereas others require emergency surgery. The patient's performance status, cancer stage and prognosis, type and severity of the emergency, and the patient's wishes regarding invasiveness of treatment are essential during the decision making process for optimal management.

Imaging acute complications in cancer patients: what should be evaluated in the emergency setting?

Increased incidence world-wide of cancer and increased survival has also resulted in physicians seeing more complications in patients with cancer. In many cases, complications are the first manifestations of the disease. They may be insidious and develop over a period of months, or acute and manifest within minutes to days. Imaging examinations play an essential role in evaluating cancer and its complications. Plain radiography and ultrasonography (US) are generally performed initially in an urgent situation due to their wide availability, low cost, and minimal or no radiation exposure. However, depending on a patient's symptoms, evaluation with cross-sectional imaging methods such as computed tomography (CT) and magnetic resonance imaging (MRI) is often necessary. In this review article, we discuss some of the most important acute noninfectious oncological complications for which imaging methods play an essential role in diagnosis.