ABSTRACT Objective To address technical limitations of histotripsy in treating hepatic tumours larger than 3 cm by developing a mathematical framework to optimize treatment coverage while minimizing unsafe overlap. Methodology A theoretical model was constructed using sphere packing and covering principles to estimate the number of smaller treatment zones required to cover a larger tumour volume and applied to a clinical case of a 6 × 6 cm hepatic tumour. Volume ratios were calculated and adjusted using random close packing density (~64%). Results Our model predicted 2.16–4.94 treatment zones for a 6 cm tumour; three overlapping treatments were performed to ensure adequate coverage. Our model suggests that the number of required treatments may increase exponentially with tumour size. Conclusions This framework provides a practical tool for preoperative planning. As tumour size increases, challenges include prolonged procedures, increased anaesthesia exposure and greater resource utilization, especially for tumours exceeding 7 cm. Overlapping treatments may increase risks such as acute kidney injury and vascular thrombosis, necessitating careful patient selection and thorough risk–benefit discussion. Importantly, safety‐limited overlap makes untreated voids within tumours mathematically unavoidable. Thus, our model should not be interpreted as achieving curative intent but can be interpreted as a method for palliative debulking.
ABSTRACT Background Acute cholecystitis is a common surgical condition, most frequently caused by gallstones. Ultrasound is recommended as the first‐line imaging modality, while CT and MRCP are reserved for inconclusive cases or suspected complications. Increasing use of CT in Denmark raises concerns regarding unnecessary radiation exposure. This study evaluated the use of radiological imaging modalities in patients with acute cholecystitis at a Danish regional hospital, including an audit of CT scan justification. Materials and Methods The study population consisted of patients admitted with acute cholecystitis at a Danish regional hospital between March 2019 and February 2023. This retrospective quality assurance study assessed annual incidence, and a random sample of 200 patients was analysed for clinical characteristics and use of imaging modalities. Two independent surgeons evaluated whether CT as the initial imaging modality was justified; disagreements were resolved by consensus. Results Ultrasound was used as the first imaging modality in 54% of patients and as the sole modality in 37%. Overall, 69% of patients underwent only one imaging modality. MRCP was most frequently used as the final modality (40.3%). Murphy's sign was undocumented in 49.2% of cases. Ultrasound was more frequently selected as the initial modality when Murphy's sign was positive (74%) compared with negative (48%) or undocumented (42%). In the CT audit, 16.1% of CT scans were deemed unjustified. Conclusion Ultrasound remains the primary first‐line imaging modality in acute cholecystitis, and documentation of Murphy's sign significantly influences imaging selection. Systematic assessment and documentation of Murphy's sign may improve imaging appropriateness and reduce unnecessary CT use. Notably, approximately one‐sixth of CT scans were unjustified.
ABSTRACT Objective To audit the impact of palliative mastectomy with axillary dissection (PMAD) on the prognosis of patients with de novo stage IV breast cancer in the Pok Oi Hospital (POH), Hong Kong. Methodology We retrospectively reviewed 5377 patients with breast cancer treated in POH between January 2010 and October 2025 and identified 68 patients with de novo stage IV disease who underwent PMAD after systemic therapy. Progression‐free survival (PFS) and overall survival (OS) were estimated by the Kaplan–Meier method and compared by the log‐rank test. Results Median age was 55 years (IQR 48–59 years); 30 patients (44.1%) were premenopausal. Median follow‐up was 31 months (IQR 15–70 months). Common metastatic sites were bone (57.4%), distant lymph nodes (32.4%), liver (22.1%), lung (20.6%), and brain (2.9%). Median OS was 52 months and median PFS was 21 months. Five‐year PFS and OS rates were 31.4% and 47.4%, respectively. Patients with negative margins had a better median PFS than those with positive margins (21 vs. 5 months, p = 0.030, HR 3.188, 95% CI: 1.117–9.100). Patients with negative margins had a better median OS than those with positive margins (52 vs. 13 months, p = 0.013, HR 3.793, 95% CI: 1.319–10.909). Patients with oligometastasis had a trend of better median PFS and OS than those with multiple metastases, although there was no statistical significance (p = 0.141, HR 1.640, 95% CI: 0.849–3.169 and p = 0.055, HR 2.051, 95% CI: 0.986–4.264, respectively). Conclusions PMAD should not be adopted universally for de novo stage IV breast cancer but may be considered selectively—particularly for patients with oligometastasis. Multidisciplinary team collaboration is essential to integrate surgery within individualized, multimodal care plans.
ABSTRACT Amyand's hernia is a rare subtype of inguinal hernia characterized by the presence of the vermiform appendix within the hernia sac. The estimated incidence of Amyand's hernia with concurrent appendicitis is only 0.1% of all cases. A 66‐year‐old male presented with a 5‐day history of right groin swelling, erythema and burning sensation, but without abdominal pain. Laboratory investigations revealed leukocytosis and elevated C‐reactive protein. CT imaging suggested an Amyand's hernia with appendicitis. Emergency surgery via a lower midline laparotomy revealed a perforated appendix and purulent material within the hernia sac. Appendectomy and abdominal lavage were performed. Due to gross inflammation, hernia repair was deferred. An additional inguinal incision was made to evacuate the abscess. This case highlights the diagnostic and treatment challenges of Amyand's hernia, particularly in the absence of classic signs of appendicitis. Timely imaging and individualized surgical management are crucial to optimize outcomes.
