Determine Cumulative Radiation Dose and Lifetime Cancer Risk in Marfan Syndrome Patients Who Underwent Computed Tomography Angiography of the Aorta in Northeast Thailand: A 5-Year Retrospective Cohort Study

Objective: To evaluate computed tomography angiography (CTA) data focusing on radiation dose parameters in Thais with Marfan syndrome (MFS) and estimate the distribution of cumulative radiation exposure from CTA surveillance and the risk of cancers. Methods: Between 1st January 2015 and 31st December 2020, we retrospectively evaluated the cumulative CTA radiation doses of MFS patients who underwent CTA at Khon Kaen University Hospital, a leading teaching hospital and advanced tertiary care institution in northeastern Thailand. We utilized the Radiation Risk Assessment Tool (RadRAT) established at the National Cancer Institute in Bethesda, Maryland, to evaluate the risk of cancer-related CTA radiation. Results: The study recruited 29 adult MFS patients who had CTA of the aorta during a 5-year study period with 89 CTA studies. The mean cumulative CTDI vol is 21.5 ± 14.68 mGy, mean cumulative DLP is 682.2 ± 466.7 mGy.cm, the mean baseline future risk for all cancer is 26,134 ± 7601 per 100,000, and the excess lifetime risk for all cancer is 2080.3 ± 1330 per 100,000. The excess lifetime risk of radiation-induced cancer associated with the CTA surveillance study is significantly lower than the risk of aortic dissection or rupture and lower than the baseline future cancer risk. Conclusions: We attempted to quantify the radiation-induced cancer risk from CTA surveillance imaging performed for MFS patients in this study, with all patients receiving a low-risk cumulative radiation dose (less than 1 Gy) and all patients having a low excessive lifetime risk of cancer as a result of CTA. The risk–benefit decision must be made at the point of care, and it entails balancing the benefits of surveillance imaging in anticipating rupture and providing practical, safe treatment, therefore avoiding morbidity and mortality.

Concepts in Musculoskeletal Bone and Soft Tissue Biopsy

Imaging-guided needle biopsy of musculoskeletal lesions is a high-yield and low-risk procedure that can be used for definitive characterization of indeterminate bone and soft tissue lesions. Familiarity with the preprocedural, technical, and postprocedural steps is vital for the appropriate management of these cases. Biopsy request triage requires an awareness of definitively benign conditions and other tumor mimics. A complete clinical, laboratory, and imaging work-up is essential for procedural planning and determining pathologic concordance. Consultation with an orthopaedic oncologist is a requisite step to ensure maximizing biopsy yield and to avoid interference with any future limb-sparing surgical intervention. Knowledge of the equipment, pertinent medications, and appropriate biopsy technique can minimize the risk of periprocedural complications. Finally, the radiologist may be required to discuss the concordance of histopathology with preprocedure imaging, perform repeat image-guided biopsy, and carefully interpret sarcoma surveillance imaging examinations.

A Conservative Approach to a Large Mycotic Pulmonary Pseudoaneurysm

Pulmonary mycotic pseudoaneurysm is a rare complication of bacteremia with high associated mortality. We present a case of a large proximal pulmonary artery pseudoaneurysm as a result of methicillin-sensitive Staphylococcus aureus bacteremia, originating from a tunneled dialysis catheter infection. This case was ultimately managed conservatively with surveillance imaging and a prolonged intravenous antibiotic course, rather than with surgical or interventional management. To our knowledge, this is the first reported case of a mycotic pulmonary pseudoaneurysm due to septic embolization of an infected superior vena cava thrombus.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Cost Evaluation Study of Management and Surveillance, and Review of the Recent USA and UK Guidelines

Introduction Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell lymphoma associated with textured breast implants, recently recognized by the revised WHO Classification. Recommended management for BIA-ALCL involves a multidisciplinary team (MDT) approach with breast surgery, haemato-oncology, pathology, radiology and oncoplastic input. Definitive management for the 'effusion-only' subset is surgical implant and capsule removal; systemic therapy is reserved for 'mass-forming' and 'advanced-disease' cohorts. Overall prognosis is excellent with the vast majority achieving remission. Although the diagnostic and treatment paradigm is established, post treatment surveillance and follow-up guidance varies widely (globally); over-utilisation of imaging tests compromises the patient pathway, impacts limited health-care resources and is associated financial burdens on patients and providers. Recently, newly published consensus guidelines (UK MHRA and USA NCCN clarify follow-up and surveillance imaging (Table 1). The aim of this study was to review our BIA-ALCL specialist centre institutional practise; to quantify the direct economic cost (EC) of imaging surveillance and indirect EC of outpatient clinic (OPC) assessment compared EC if recent guidelines were followed. The secondary aim is to highlight and raise awareness of the latest international guidance to promote the standardisation of practise. Methods A retrospective analysis of a prospectively maintained patient database between July 2015 to October 2019 was conducted, with Institutional Review Board Approval. Data collection included patient demographics, tumour subset, treatment, clinical and imaging surveillance. Follow-up and imaging undertaken for symptomatic concerns / non-BIA-ALCL related pathology was excluded. Imaging costs were calculated using UK NHS tariffs. Results Eleven patients were treated for BIA-ALCL during the study period, with a median age of 49 at diagnosis (range 30-82years). Patients were diagnosed with: effusion-only (n=7), effusion and mass (n=2), mass-only (n=2) subtypes, at a median time of eleven years from implant insertion (IQR 8-12). All patients underwent explantation and en-bloc capsulectomy, with 1 patient required neo-adjuvant (CHOP, Brentuximab) and 1 adjuvant (CHOP) therapy (CHOP. Surveillance with imaging and OPC detected no disease recurrence to date (overall median follow-up 38 months, IQR 12-47). Post treatment episodes of surveillance imaging or follow-up related to patient symptoms were excluded. 8 patients underwent surveillance imaging at our institute (Table 2). Total cost of imaging was £10,396 ($14,396) with a median cost of £1,953 ($2,705) per patient [IQR £526-2029 ($728-2,810)]. 7 patients had completed at least 24 months follow-up since surgery during the study period (Table 3), with 3 patients having not yet completed their follow-up period of two years. Of those with completed follow-up, the median OPC follow-up per patient was 48 months (IQR 38-52), median number of OPC was 7 (IQR 6-11) and the median cost of clinic review was £982 (IQR 804-1395). The surplus cost per patient compared with recommended follow-up was £118 ($164) [IQR £0-531 ($0-738)]. Conclusions Our data shows the variable BIA-ALCL surveillance practise pattern and the associated additional direct and indirect EC of unnecessary asymptomatic surveillance imaging, with an excessive number of follow-up OPC and period of clinical follow-up after complete remission. With no recurrence detected in our patient cohort to date, this data supports the new UK and updated USA NCCN Guidelines (extrapolated from data in other NHLs, and analogous to principles of the ASH Choosing Wisely Campaign) that routine post-treatment surveillance imaging should not be performed in BIA-ALCL patients. Routine asymptomatic post-treatment surveillance imaging is clinically unnecessary and potentially leads to a 'Cascade Effect' of further tests, with increased radiation exposure, excess costs and impact on limited health-care resources. We also support open-access follow-up for patients in remission, to reduce unnecessary follow up appointments. With UK and USA guidelines now available for BIA-ALCL, we support training and education of health-care professionals, global consensus guidelines and a registry, for this rare however increasingly recognised new entity. Figure 1 Figure 1. Disclosures Iyengar: Takeda: Membership on an entity's Board of Directors or advisory committees, Other: conference support, Speakers Bureau; Gilead: Membership on an entity's Board of Directors or advisory committees, Other: conference support, Speakers Bureau; Beigene: Membership on an entity's Board of Directors or advisory committees; Abbvie: Other: conference support; Janssen: Other: conference support, Speakers Bureau. Nicholson: Pfizer: Consultancy; Kite, a Gilead Company: Other: Conference fees, Speakers Bureau; BMS/Celgene: Consultancy; Novartis: Consultancy, Other: Conference fees. El-Sharkawi: Kyowa Kirin: Other: Ad boards; Beigene: Other: Ad boards; ASTEX: Other: Ad boards; Novartis: Other: Travel Support; Takeda: Honoraria; Roche: Honoraria; Janssen: Honoraria, Other: Ad boards; AstraZeneca: Honoraria, Other: Ad boards; AbbVie: Honoraria, Other: Travel Support, Ad boards. Tasoulis: BMJ: Consultancy, Membership on an entity's Board of Directors or advisory committees. Cunningham: Roche: Research Funding; Clovis Oncology: Research Funding; Celgene: Research Funding; Eli Lilly: Research Funding; Bayer: Research Funding; OVIBIO: Membership on an entity's Board of Directors or advisory committees; 4SC: Research Funding; AstraZeneca: Research Funding; MedImmune: Research Funding.