Recurrent Chordoma Resection in the Advanced Multimodality Image Guided Operating Suite: 2-Dimensional Operative Video

Recurrent skull base chordomas are challenging lesions. They already had maximum radiation, and in the absence of any effective medical treatment, surgical resection is the only treatment.1,2 Surgery on recurrent previously radiated chordomas, however, carries much higher risk and the likelihood of subtotal resection. Maximizing tumor resection allows longer tumor control.3-5 The Advanced Multimodality Image Guided Operating Suite developed at the Brigham and Women's Hospital, Harvard Medical School, with the support of the National Institutes of Health, provides an optimal environment to manage these tumors. It offers the capability to obtain and integrate multiple modalities during surgery, including magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), endoscopy, ultrasound, fluoroscopy, and the ability to perform emergent endovascular procedures.5-7 The patient is a 39-yr-old male, presenting after 19 yr follow-up of a surgical resection and proton beam treatment for a skull base chordoma. He developed progressive ophthalmoplegia due to recurrence of his chordoma at the right petrous apex and cavernous sinus. Preoperative angiography demonstrated narrowing of the petrous segment of the right carotid artery suspect of radiation-induced angiopathy. The presence of radiation-induced angiopathy increases the risk of intraoperative carotid rupture, and the availability of endovascular intervention in the operative suite added favorable preparedness to deal with such complications if they happen. Given the clinical and radiological progression, surgical intervention was carried out through the prior zygomatic approach with the goal of performing maximum resection.8 The patient had an uneventful postoperative course and remained stable until he had a second recurrence 4 yr later. The patient consented to the procedure.

Real-Time High-Resolution MRI Endoscopy at up to 10 Frames per Second

Objective. Atherosclerosis is a leading cause of mortality and morbidity. Optical endoscopy, ultrasound, and X-ray offer minimally invasive imaging assessments but have limited sensitivity for characterizing disease and therapeutic response. Magnetic resonance imaging (MRI) endoscopy is a newer idea employing tiny catheter-mounted detectors connected to the MRI scanner. It can see through vessel walls and provide soft-tissue sensitivity, but its slow imaging speed limits practical applications. Our goal is high-resolution MRI endoscopy with real-time imaging speeds comparable to existing modalities. Methods. Intravascular (3 mm) transmit-receive MRI endoscopes were fabricated for highly undersampled radial-projection MRI in a clinical 3-tesla MRI scanner. Iterative nonlinear reconstruction was accelerated using graphics processor units connected via a single ethernet cable to achieve true real-time endoscopy visualization at the scanner. MRI endoscopy was performed at 6-10 frames/sec and 200-300 μm resolution in human arterial specimens and porcine vessels ex vivo and in vivo and compared with fully sampled 0.3 frames/sec and three-dimensional reference scans using mutual information (MI) and structural similarity (3-SSIM) indices. Results. High-speed MRI endoscopy at 6-10 frames/sec was consistent with fully sampled MRI endoscopy and histology, with feasibility demonstrated in vivo in a large animal model. A 20-30-fold speed-up vs. 0.3 frames/sec reference scans came at a cost of ~7% in MI and ~45% in 3-SSIM, with reduced motion sensitivity. Conclusion. High-resolution MRI endoscopy can now be performed at frame rates comparable to those of X-ray and optical endoscopy and could provide an alternative to existing modalities, with MRI’s advantages of soft-tissue sensitivity and lack of ionizing radiation.

Solitary tracheal B-cell lymphoma in an adult alpaca (Vicugna pacos)

Background This report describes a case of solitary tracheal lymphoma in a 14-year-old alpaca mare. Case presentation The alpaca was referred for dyspnea and inspiratory noise. The clinical examination included complete blood cell count, blood chemistry, endoscopy, ultrasound, radiographs, and computed tomography (CT). A solitary tracheal intraluminal and juxtatracheal lymphoma was diagnosed by fine needle aspiration (FNA). The owner requested euthanasia due to the uncertain prognosis. At postmortem examination, the presence of solitary lymphoma without involvement of other organs was confirmed. Immunohistochemical analysis confirmed a B-cell origin. Conclusions Although multicentric lymphoma is the most commonly described neoplasia affecting South American camelids (SAC), solitary forms of the disease may occur.

Pilot Study to Assess the Use of Ultrasound in Evaluating the Abnormal Pediatric Airway

In this study, we sought to explore the feasibility of using ultrasonography to evaluate airway anomalies in awake children with previous airway reconstruction. For the month of December 2018, we reviewed the medical records of patients aged <18 years old with prior airway reconstruction who had an outpatient appointment and a microlaryngoscopy and bronchoscopy within 24 hours of each other. Four patients met inclusion criteria and were enrolled. Sonographic airway images and measurements were obtained during the outpatient appointment and compared with those obtained during endoscopy. Ultrasound identified extraluminal stents and glottic, subglottic, and tracheal pathology. Subglottic measurements obtained sonographically were within 0.1 to 0.5 mm of the outer diameter of the appropriate endotracheal tubes. Ultrasound did not visualize tracheotomy tubes or posterolateral pathology. Our findings lay the foundation for expanding the role of ultrasound in pediatric airway assessment, keeping in mind its apparent inability to visualize posterolateral airway pathology.

ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS OF GASTROINTESTINAL SUBMUCOSAL TUMORS AT HUE UNIVERSIY OF MEDICINE AND PHARMACY HOSPITAL

Background: Diagnosis of gastrointestinal submucosal tumors (SMT) is still a challenge in clinical practice and data about gastrointestinal submucosal tumors in our country was very limited. This study aimed to assess some characteristics of gastrointestinal submucosal tumors. Patients and Methods: cross–sectional study; 195 patients having gastrointestinal submucosal tumors diagnosed by endoscopic ultrasound at Hue University of Medicine and Pharmacy Hospital were enrolled from October 2013 to December 2018. Cutting biopsy or EUS- FNA in case necessary. Results: The mean age of patients was 48.92 ± 15.23. The prevalence was nearly equal in men and women with 48.2% and 51.8%, respectively. According to location, submucosal tumors were 45.6% in the stomach, 35.9% in the esophagus and 2.6% in the colon and rectum. According to etiology, the submucosal cyst was found in 23.6%, the leiomyoma was 22.1%, the Brunner’s gland was 1% and the unknown submucosal tumors was 19.5%. 58.1% of the leiomyoma and 67.4% of the submucosal cyst were found in the esophagus. 76% of the GIST, 83.3% of the ectopic pancreas and 64.7% of the lipoma were found in stomach. Conclusions: Based on endoscopy ultrasound, the most common locations of SMT were stomach and esophagus; the most common SMT were submucosal cyst and leiomyoma. Key words: Submucosal tumor (SMT), Endoscopic ultrasound (EUS)

Comparison of clinical and pathologic staging in esophageal cancer.

31 Background: Randomized trials have demonstrated improved disease-free survival for more advanced esophageal cancer treated with neoadjuvant chemo radiation (NCXRT). However, accurately treating a patient relies on the accuracy of pre-treatment T and N staging with endoscopy ultrasound and cross-sectional imaging, which is unknown, and can lead to over or under-treatment. Therefore, the objective of this study is to compare the clinical and pathologic staging in patients with early esophageal cancer that would be impacted by inaccurate clinical staging. Methods: Primary, non-metastatic esophageal cancer patients who had upfront esophagectomy without neoadjuvant CXRT between 2004 and 2013 were identified in the National Cancer database. The Kappa index was used to determine patient and tumor characteristics that effected concordance between clinical and pathologic T and N staging (p > 0.05 shows discordance). Results: Of 1810, 43 % of clinical T2 tumors were upstaged compared to 38% of T1 and 13% of clinical T2 were downstaged. Clinically positive N1 disease had the greatest concordance (91%) between clinical and pathologically staging, compared to clinical N0, where 57% were upstaged. Some patient groups significantly impacted the concordance rates of staging. T-Stage was less accurate (more discordant) in females (68%, kappa 0.41, p = 0.057) and Blacks (59%, kappa 0.023, p = 0.069) whereas overall N-stage was more discordant in Hispanics (83%, kappa, 0.67, p = 0.165). Conclusions: Accurate staging for esophageal adenocarcinoma can significantly impact the course of treatment. Upfront surgical resection of clinical T1 lesions and node negative tumors are at risk for under-treatment due to poor concordance with pathological stage, which may lead to decreased survival compared to a regimen of NCXRT. Clinicians should be aware of patient and tumor characteristics that increase the likelihood of discordance between clinical and pathologic staging when discussing treatment options for patients with esophageal cancer.

ENDOSCOPIC ULTRASOUND IN DIAGNOSIS OF GASTROINTESTINAL AND PANCREATICOBILIARY DISEASES

Background and aims: Data about endoscopic ultrasound in our country was still limited. This study aimed to evaluate the efficacy and safety of endoscopy ultrasound for diagnosis of gastrointestinal and pancreaticobiliary diseases. Patients and methods: A cross - sectional study was conducted on 1176 patients undergoing endoscopy ultrasound to diagnose gastrointestinal- pancreaticobiliary diseases. Results: Study on a total of 1176 patients indicated for endoscopic ultrasound. We have some following results: Gastrointestinal diseases. The submucosal tumor was about 55,74% and gastrointestinal cancer was 44.26%. The local of submucosal tumor: 52.93% with gastric subepithelial lesions, 33.46% oesophageal, 11.67% duodenum and 1.94% from the colorectal. The esophagus cancer was 37.27%, colorectal cancer was 36.27%, gastric cancer was 24.01% and duodenum cancer was 2.45%. Pancreaticobiliary diseases: The common bile duct stone was 68.89%, Biliary tract dilation of unknown cause was 9.64%, vater tumor was 9.42%, cholangioma was 7.89%, billiary diseases was caused by paradise and billiary cyst was 1.97%. Pancreas diseases: 43.25% with chronic pancreatitis, 31.66% pancreas cancer, 17.76% acute pancreatitis and 7.33% pancreas cyst. EUS-FNA for pancreas cancer was about 80% and IPMN was 20%. Complication of hypoxia found in 0.34% and only 1 case of immediate bleeding after EUS-FNA. Conclusions: Endoscopic ultrasound is a highly effective and relatively safe method of diagnosis for gastrointestinal- pancreaticobiliary diseases. Key words: endoscopic ultrasound, gastrointestinal and pancreaticobiliary diseases