CorRECTreatment: a web-based decision support tool for rectal cancer treatment that uses the analytic hierarchy process and decision tree

BACKGROUND

The selection of appropriate rectal cancer treatment is a complex multi-criteria decision making process, in which clinical decision support systems might be used to assist and enrich physicians' decision making.

OBJECTIVE

The objective of the study was to develop a web-based clinical decision support tool for physicians in the selection of potentially beneficial treatment options for patients with rectal cancer.

METHODS

The updated decision model contained 8 and 10 criteria in the first and second steps respectively. The decision support model, developed in our previous study by combining the Analytic Hierarchy Process (AHP) method which determines the priority of criteria and decision tree that formed using these priorities, was updated and applied to 388 patients data collected retrospectively. Later, a web-based decision support tool named corRECTreatment was developed. The compatibility of the treatment recommendations by the expert opinion and the decision support tool was examined for its consistency. Two surgeons were requested to recommend a treatment and an overall survival value for the treatment among 20 different cases that we selected and turned into a scenario among the most common and rare treatment options in the patient data set.

RESULTS

In the AHP analyses of the criteria, it was found that the matrices, generated for both decision steps, were consistent (consistency ratio<0.1). Depending on the decisions of experts, the consistency value for the most frequent cases was found to be 80% for the first decision step and 100% for the second decision step. Similarly, for rare cases consistency was 50% for the first decision step and 80% for the second decision step.

CONCLUSIONS

The decision model and corRECTreatment, developed by applying these on real patient data, are expected to provide potential users with decision support in rectal cancer treatment processes and facilitate them in making projections about treatment options.

Hypoglycemia induced by long-acting somatostatin analogues in a patient with nonfunctional neuroendocrine tumor

Somatostatin and its long-acting analogues are effective in symptom control in patients with functional neuroendocrine tumors; they are also able to control tumor growth. Somatostatin analogues are safe and generally well tolerated. In some cases they may cause serious complications. Somatostatin analogues are potent inhibitors of growth hormone (GH) and glucagon secretion. They cause impairment of hepatic glucose output and delay in intestinal absorption of carbohydrates. Patients with huge tumor mass and multiple liver metastases have increased risk of tumor-induced hypoglycemia. In these patients, long-acting octreotide may trigger serious hypoglycemia. The patients whose glucose control is dependent on counter-regulatory hormones should be monitored for the possibility of hypoglycemia. Herein, we present a patient with severe and prolonged hypoglycemia after long-acting octreotide treatment.

CT findings of non-functioning neuroendocrine pancreatic tumors

Neuroendocrine tumors are rare neoplasms of the pancreas, representing 0.5% of all pancreatic tumors. Approximately, one-third of neuroendocrine tumors are hormonally inactive and called non-functioning neuroendocrine tumors. As these tumors remain clinically silent in their course of growth, they may attain great sizes without causing apparent clinical findings and commonly present in advanced stage. We report three cases of non-functioning neuroendocrine tumors with large sizes and discuss the radiological findings.

Lipoma of the pancreas: MRI findings

Lipomas of the pancreas are very rare. Focal fatty infiltration of the pancreas is an entity that should be differentiated from a pancreatic lipoma. In this report the MRI findings of an incidentally found pancreatic lipoma are presented and the role of MRI in the differentiation of pancreatic lipoma and focal fatty infiltration of the pancreas is discussed.

A new method for the evaluation of erectile dysfunction: sildenafil plus Doppler ultrasonography

PURPOSE

Of the various methods of hemodynamic studies performed to evaluate erectile dysfunction penile color Doppler ultrasound is currently considered the best. However, intracavernous injection is invasive and has adverse effects, such as prolonged erection. We evaluated whether sildenafil may be used as a substitute for intracavernous agents when assessing impotence on color Doppler ultrasound.

MATERIALS AND METHODS

A total of 42 patients with erectile dysfunction underwent color Doppler ultrasound before and after intracavernous injection of 60 mg. papaverine with genital and audiovisual sexual stimulation. Peak flow and end diastolic velocity were measured in the recorded waveforms obtained 0, 1, 5, 10 and 20 minutes after injection. The patients also underwent color Doppler ultrasound after a 50 mg. oral dose of sildenafil with genital and audiovisual sexual stimulation not before 3 days after the papaverine study. The same parameters were measured at 30, 45, 60, 75 and 90 minutes, and compared with the values obtained after papaverine injection.

RESULTS

Mean peak flow velocity significantly increased after oral sildenafil starting at 30 minutes and achieving a maximum value at 60 minutes. There were no significant differences in the 2 methods in mean peak velocity 1, 5, 10 and 20 minutes after papaverine injection, and 30, 45, 60, 75 and 90 minutes after oral sildenafil administration. Penile color Doppler ultrasound with intracavernous papaverine injection is accepted as the gold standard but color Doppler ultrasound with sildenafil has 90% sensitivity and 100% selectivity for demonstrating arterial insufficiency. Due to prolonged erection 5 patients (11.9%) in the papaverine group required pharmacological detumescence by intracavernous injection. No adverse effects of sildenafil were observed.

CONCLUSIONS

Sildenafil administration achieved increased peak flow velocity comparable to that after intracavernous papaverine injection. With no prolonged erection sildenafil emerges as a safer alternative compared to more invasive intracavernous injection.

Color doppler sonography in the follow-up of giant glutealaneurysm embolization

False aneurysm of the gluteal artery is uncommon and may develop secondary to penetrating gluteal injury or pelvic trauma. The use of color Doppler sonography may allow the initial diagnosis of gluteal pseudoaneurysms and provide information about the success of the interventional radiological procedures. In this study, color Doppler sonographic examination demonstrated the failure of the endovascular treatment of a giant superior gluteal artery pseudoaneurysm. The second intervention of super-selective coil embolization provided optimal thrombosis and eliminated the need for open surgery.

Pancreatic adenocarcinoma: detection and staging with dynamic MR imaging

OBJECTIVE

To compare the efficacy of dynamic contrast-enhanced MR imaging and spin-echo T1-weighted with and without fat-saturated MR imaging in the detection and staging of pancreatic adenocarcinoma.

METHODS AND MATERIAL

Spin-echo T1-weighted, fat-saturated T1-weighted and dynamic breath-hold 2D-FLASH MR imaging were performed in 25 patients with pancreatic adenocarcinoma. MR images were analysed by calculating the CNR between tumor and normal portion of the pancreas. The CNRs calculated at each sequences were compared. A total of 16 out of 25 patients underwent surgery. Preoperative staging according to TNM classification was also done in patients undergoing surgery.

RESULTS

The CNR was significantly different (P<0.05) in the arterial phase of dynamic MR images. The accuracy of 'T' staging was 75% for SE T1-W, fat-saturated T1-W and arterial phase of dynamic MR images.

CONCLUSION

The CNRs between pancreatic carcinoma and normal pancreas is significantly higher in dynamic MR sequences than the SE T1-W, fat-saturated T1-W sequences. However, the accuracy of tumor staging according to TNM is equivocal to SE T1-W and fat-saturated T1-W images.

The prediction of papaverine induced priapism by color Doppler sonography

PURPOSE

We identified color Doppler sonography findings that are useful for predicting priapism in patients after the intracavernous injection of diagnostic papaverine.

MATERIALS AND METHODS

We evaluated 72 men with erectile dysfunction by color Doppler sonography after the diagnostic injection of papaverine. Cavernous artery waveforms were recorded, and peak systolic and diastolic velocity of the recorded waveforms was measured. In cases of priapism color Doppler sonography findings were retrospectively evaluated to identify any finding that would predict priapism.

RESULTS

Priapism was observed in 8 of the 72 patients (11.1%). In 6 of 8 priapism cases there was no blood flow in the cavernous artery during or after adequate erection, including after minutes 5, 10 and 20 in 3, 1 and 2, respectively. This absence of encoding was not relieved even after all stimuli were removed. In 2 patients who later presented with complaints of priapism the Doppler study was completed normally and all parameters were acquired without any cessation of blood flow in the cavernous artery. The persistent disappearance of color and pulse encoding in the cavernous artery predicted priapism with 75% sensitivity, 100% specificity, a positive and negative predictive value of 100% and 96.9%, respectively, and 97% accuracy.

CONCLUSIONS

The persistence of absent blood flow in the cavernous artery even after the elimination of all stimuli during penile color Doppler ultrasound is a reliable predictor of priapism. The finding is accurate enough to initiate treatment for priapism to avoid further delay.

Splenic vascular malformations and portal hypertension in hereditary hemorrhagic telangiectasia: sonographic findings

Hereditary hemorrhagic telangiectasia, or Osler-Rendu-Weber disease, is an autosomal dominant disorder in which a variety of vascular dysplasias occur throughout the organ systems. We report the gray-scale and color Doppler sonographic findings in a case of hereditary hemorrhagic telangiectasia. Gray-scale sonographic examination revealed massive splenomegaly, multiple dilated intrasplenic vascular structures (some with adjacent punctate calcifications), an aneurysmal dilatation of the splenic vein, dilated intrahepatic portal branches, and marked atrophy of the right hepatic lobe. Color Doppler sonography showed dilatation of the truncus coeliacus and high-velocity flow in the splenic artery. There were significant aliasing in the splenic hilum and an abnormal, arterialized flow in intrasplenic branches of the splenic vein. The splenic vein was massively enlarged with increased flow velocity and contained an isolated aneurysmal dilatation in the hilum. There were multiple serpiginous retroperitoneal collateral vessels, and the left gastric vein was dilated with hepatofugal flow. The patient had portal hypertension that developed secondary to the increased portal flow.

Multiple coarctation of the pulmonary artery

Pulmonary artery coarctation is a rare congenital anomaly characterized by single or multiple stenoses of the pulmonary arteries and their branches. There are only a few reports describing the radiological film of this entity. In this paper we report the case of a 68 year-old woman who presented with dyspnea. The scintigraphic, examination of the lungs gave the misleading impression of pulmonary embolism, and only angiography and magnetic resonance imaging established the correct diagnosis of multiple coarctations of the pulmonary artery.

Aneurysmal dilatation of the paraumbilical vein in an infant

The paraumbilical veins are one of the most common collateral pathways developing in portal hypertension. Aneurysmal dilatation of a patent paraumbilical vein is a very unusual finding. We report the first infant case of a paraumbilical vein aneurysm and its Doppler ultrasound findings.

Can magnetic resonance imaging predict the success of parturition in oxytocin-induced pregnant women?

The aim of this study was to assess whether magnetic resonance imaging could predict the outcome of attempted vaginal delivery in a group of pregnant women whose parturition had to be induced by oxytocin. The signal intensity and morphology alterations in the cervix of 21 full-term pregnant women were analyzed before the induction of parturition. T2-weighted gradient echo sequences were utilized and signal intensity in the cervix was measured from the anterior and posterior lips of the cervix. An index indicating the brightness range of the cervix was formulated to overcome the effects of the individual intensity changes. Imaging features including the signal intensity and the evidence of effacement were correlated with the actual type of delivery performed. Images were also assessed visually by two independent radiologists. Statistical analysis of brightness indexes that were considered to have a predictive value as an indicator for possible delivery was not significant. However, visually assessed signal intensity of the cervix correlated strongly with the type of delivery. Effacement itself was the most reliable parameter in predicting the progress of the delivery. In conclusion, MR imaging seems to be useful for predicting normal parturition in full-term pregnant women who need oxytocin induction. However, the presence of effacement seems to be a more reliable and practical parameter that will be preferred in that prediction.

Differentiation of recurrent rectal cancer and scarring with dynamic MR imaging

The accuracy of dynamic contrast enhanced magnetic resonance (MR) imaging in the differentiation of malignant and benign pelvic lesions during follow-up of patients with treated colorectal tumours was evaluated prospectively. 19 patients (11 men, 8 women; age range 35-70 years; mean 57 years) with suspected local recurrence of colorectal malignancy were evaluated with MR imaging. Dynamic MR imaging with axial Turbo-FLASH gradient echo imaging and bolus injection of contrast medium was performed. Dynamic images, each consisting of one slice in the same location, were acquired at 5, 10, 15, 20 and 30 s, and at 1, 2, 3, 4, 5 and 10 min. The maximum change in signal intensity (Emax), the acceleration rate of the time-intensity curve (TIC) and the ratio of the signal intensity of the lesions to the signal intensity of the iliac artery (SIL/SIA) were used as the enhancement parameters. The TIC and SIL/SIA ratio at 60 s were found to be valuable in the differential diagnosis; Emax had no significance in differentiating benign and malignant lesions. Sensitivity was 83% for each calculated parameter. SIL/SIA has the highest specificity and accuracy among the parameters.

Subclavian artery aneurysm with oesophagoarterial fistula

Aneurysms of the subclavian artery are rare. Fistula formation between the subclavian artery and the oesophagus has been described in aberrant subclavian artery and oesophageal foreign body. However, a fistula between a non-aberrant subclavian artery aneurysm and the oesophagus has not been previously reported. In this report, an unusual case of subclavian artery aneurysm with a fistula to the oesophagus causing intractable haematemesis is presented with the angiographic findings.

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents

The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38-77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34-125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments.

Asymptomatic ureteral varices: detection by Doppler sonography

Retroperitoneal ectatic or varicose veins may cause ureteral extrinsic pressure defects. Doppler sonography may be helpful in the characterization of these vascular lesions. We report the sonographic findings in a case of asymptomatic idiopathic left ureteral varices.

Inflammatory fibroid polyp presenting with intestinal invagination: sonographic and correlative imaging findings

We report a case of a large inflammatory fibroid polyp of the small bowel presenting with intussusception in a 22-year-old man. Sonography demonstrated a solid, mobile, homogeneous, echogenic mass surrounded by the typical mural layers of an invaginated ileum. CT demonstrated a well-defined intraluminal solid mass with an attenuation of 17 HU. The pathologic diagnosis after segmental ileal resection was ileal inflammatory fibroid polyp.

Subcapsular hemorrhage of adult Wilms' tumor

Wilms' tumor is a rare malignancy of kidney in adults. It usually cannot be differentiated from other renal masses preoperatively. This is a presentation of a case of adult Wilms' tumor who developed spontaneous hemorrhage during radiological evaluation. As tumor rupture can change the stage of the tumor and alter the prognosis of the patient, urgent work-up and treatment is advised.

Bilateral epididymal Candida abscesses: sonographic findings and sonographically guided fine-needle aspiration

We report the case of a 67-year-old diabetic man who presented 2 months after transurethral prostate surgery with impaired consciousness, urinary incontinence, and recurrent urinary tract infections that did not respond to antibiotic treatment. Sonographic findings suggested abscess formation (enlarged, heterogeneous epididymides and a central hypoechoic area in the head of the left epididymis). Aspirates obtained from sonographically guided needle biopsy were purulent. Staining showed budding yeast forms, and Candida albicans grew in culture. Systemic candidiasis was diagnosed. The patient underwent bilateral epididymo-orchiectomy, and pathologic analysis of resected specimens showed bilateral epididymal necrosis and disseminated abscess formation.

Influence of dietary protein and sex on walking ability and bone parameters of broilers

1. The study was conducted to investigate the effect of dietary protein on the walking ability and bone parameters of broilers reared under summer temperatures which ranged from 26 degrees to 32 degrees C (+/- 2 degrees C). 2. Three different dietary protein combinations were used. The diets (per kg) were: low protein with 205 g crude protein and 12.94 MJ ME, 184 g crude protein and 12.75 MJ ME; medium protein with 219 g crude protein and 12.99 MJ ME, 201 g crude protein and 12.87 MJ ME; and high protein with 238 g crude protein and 12.99 MJ ME, 216 g crude protein and 12.96 MJ ME from 0 to 4 and 4 to 7 weeks of age, respectively. Body weights of birds were recorded and birds' walking ability (gait scoring) were scored for each bird, according to 3 categories (completely normal to immobile, at 4 and 7 weeks). Tibia parameters and tibia plateau angles were also determined at 7 weeks. 3. Birds fed on the low protein were lighter than those fed on the medium or high protein diets. At 7 weeks, birds with poor walking ability weighted 149 g less than birds with no walking difficulty. 4. Bone parameters were not affected by dietary protein, sex or gait score. There was a significantly positive correlation between bone strength and radiographic density. Bone strength was also significantly correlated with bone weight and length.

Retroperitoneal fibrosis mimicking a rectal tumor: report of a case

PURPOSE

The study contained herein was undertaken to report an original case of retroperitoneal fibrosis that resembled a rectal tumor both symptomatically and radiologically.

METHOD

Reported is a case of retrorectal fibrosis with a brief literature review of the topic.

RESULT

Although many forms of retroperitoneal fibrosis have been reported, extension below the pelvic rim is very unusual. Compression of the rectum and right ureter, with constipation as a chief complaint, made this case presentation unusual. Although computerized tomographic findings and needle biopsies supported the diagnosis of retroperitoneal fibrosis, an exploratory laparotomy was necessary to rule out a malignancy and to release the ureter.

CONCLUSION

A fibrotic mass involving the retrorectal region may mimic a rectal tumor. To reach a final diagnosis, an exploratory laparotomy may be necessary, despite sophisticated evaluation techniques, because it is difficult to differentiate whether the mass is malignant.

Magnetic resonance imaging evaluation of incision healing after cesarean sections

The purpose of this study was to examine the healing period of incision scar in myometrial wall and the normal pelvis after cesarean sections by means of MRI. In this study 17 voluntary women were examined after their first delivery with cesarean section in the early postpartum period (first 5 days), and following this, three more times in 3-month intervals. The MRI examinations were performed on a 1.0-T system (Magnetom, Siemens, Erlangen, Germany), and sagittal T1-weighted (550/17 TR/TE) and T2-weighted (2000/80 TR/TE) spin-echo (SE) images of the pelvis were obtained. During follow-up examinations incision scar tissues lost their signals within the first 3 months on both SE sequences, and little alteration was observed in the subsequent tests. Zonal anatomy of the uterus reappeared completely 6 months after cesarean sections. The time for the involution of the uterus was independent of the zonal anatomy recovery, and the maximum involution was inspected within the first 3 months. In conclusion, the maturation time of myometrial scar tissue in uncomplicated cesarean sections, which can be evaluated by the signal alterations in MRI, is approximately 3 months, whereas the complete involution and the recovery of the zonal anatomy need at least 6 months.

Diagnostic value of magnetic resonance imaging in gynaecology

In this study 23 patients with various gynaecological pathologies were evaluated. Ultrasonography and magnetic resonance imaging were performed in all cases, but only 14 were evaluated with computed tomography. On the basis of ultrasonography, 4 patients were labelled as having malignant ovarian tumours, however, this diagnosis was confirmed by magnetic resonance imaging in only 1 of the 4. Magnetic resonance imaging also determined the correct diagnosis in a patient with endometrioma whereas computed tomography showed only a simple cyst, and ultrasonography diagnosed a subserous myoma. Tumour was demonstrated by magnetic resonance imaging in 2 patients with cervical carcinoma although computed tomography and ultrasonography had previously shown no tumour mass in these patients. It was concluded that magnetic resonance imaging is much superior to computed tomography and ultrasonography in gynaecological diagnosis. This advantage results from the correct detection of the contents of ovarian cysts, the number and localization of uterine leiomyomas in T2 scans, invasion of uterine malignancies and differential diagnosis of subserous uterine leiomyomas from ovarian tumours.

The Hajdu-Cheney syndrome: a case report and review of the literature

Hajdu-Cheney syndrome which is also known as type VI idiopathic osteolysis is a rare disease transmitted autosomal dominantly. In this syndrome, osteolysis involves primarily the terminal phalanges. We describe here a 18-year-old boy with typical clinical and radiological signs of Hajdu-Cheney syndrome.