Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise

PURPOSE

To compare the diagnostic characteristics of routine-read (RR), structured-reported read (SR), and structured expert-read pelvic (SER) MRI for staging of pelvic endometriosis in a tertiary care academic center.

METHODS

Of 530 patients with endometriosis (2013-2018), 59/530 (11.1%) were staged surgically and underwent pelvic MRI. Radiology reports were considered RR; MRI studies were independently reassessed by SR and SER. Involvement was recorded by compartment [anterior (AC), middle (MC), posterior (PC), adnexal (AX), and other (OC)]. Diagnostic discrepancy between review methods was assessed with McNemar's test. Interobserver agreement was assessed using Cohen's unweighted kappa.

RESULTS

Of 295 compartments in 59 women (mean age = 38.8 years; range 20-69), 147/295 (49.8%) had confirmed endometriosis. Overall sensitivity: RR = 42.9%; SR = 86.4%; SER = 74.2%. SR's increased sensitivity was significant for PC (p < 0.001), MC (p < 0.001), AC (p = 0.001), AX (p = 0.038). Higher sensitivity by SER was significant for PC (p < 0.001), MC (p = 0.004) and AC (p < 0.001), but not AX (p > 0.05). Overall specificity: RR = 95.3%; SR = 45.9%; SER = 81.8%. SER specificity was no different than RR for PC or AX (p > 0.5). RR sensitivity relied heavily on detection of AX involvement, whereas SR and SER showed additional sites of disease while maintaining comparable specificity for SER. Overall agreement between SR and SER was fair [k = 0.342 (95% CI 0.25, 0.44)].

CONCLUSIONS

Even at a tertiary care academic center, SER outperforms both SR and RR in the assessment of pelvic endometriosis. Although lack of expertise may negatively impact specificity, use of structured reporting is significantly more sensitive than RR. Therefore, its use can be of assistance in surgical planning and patient counseling.

Incidental finding of a supradiaphragmatic caudate lobe on cross-sectional imaging: An exceedingly rare entity

Intrathoracic accessory lobes of the liver are exceedingly rare and usually found incidentally in asymptomatic patients. Its diagnosis poses a real challenge for radiologists due to its rarity, location and rounded solid mass appearance. Herein, we describe the case of a supradiaphragmatic caudate lobe of the liver in a 43-year-old African American woman presenting to the hospital for evaluation of an inferior vena cava (IVC) thrombus with CT. Final diagnosis was achieved by MRI using intravenous contrast material, showing a 4.7 cm by 2.7 cm oval shaped mass, with similar signal intensity to the main liver on all sequences. Appropriate diagnosis of this intrathoracic mass is important to negate the need for unnecessary procedures and set a proper follow up after clinical diagnosis.

Differentiation of pancreatic head ductal adenocarcinoma from inflammatory pancreatic pseudomass by MR cholangio-pancreatography: utility of the duct-interrupted, corona, and attraction signs

PURPOSE

To determine sensitivity and specificity of the "duct-interrupted," "corona," and "attraction" signs on MR cholangio-pancreatography (MRCP) in distinguishing pancreatic head ductal adenocarcinoma (PDAC) from inflammatory pancreatic pseudomass (IPP).

MATERIALS AND METHODS

This study included 53 adults (33 men and 20 women, mean age, 55 years; range, 17-87 years) with a pancreatic head mass who underwent MRCP. Three blinded radiologists independently reviewed each MRCP exam and three signs were assessed: (1) the "duct-interrupted" sign, deemed positive for PDAC if the duct within the mass demonstrated complete interruption with upstream dilation; (2) the "corona" sign, considered positive for PDAC if dilated side-branches were located exclusively outside the mass; and (3) the "attraction" sign, deemed positive for IPP if the dilated common bile duct showed attraction and angulation towards the mass. Sensitivity, specificity, and positive and negative predictive values of the signs were calculated, as well as interobserver agreement.

RESULTS

Out of 53 masses, 17 (32%) were PDAC and 36 (68%) were IPP. Sensitivity, specificity, and positive and negative predictive values of the "duct-interrupted" sign to differentiate between PDAC from IPP for the three readers were 29-53%, 89-95%, 56-82% and 73-81%, respectively (κ = 0.41); for the "corona" sign, they were 29-53%, 81-100%, 56-100%, and 75-78%, respectively (κ = 0.4), and for the "attraction" sign, they were 20-25%, 71-82%, 64-75%, and 31-34%, respectively (κ = 0.54).

CONCLUSION

The "duct-interrupted" and "corona" MRCP signs have high specificity for diagnosing PDAC, while the "attraction" sign has good specificity for identifying IPP.

Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning

OBJECTIVE

To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons.

MATERIALS AND METHODS

In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning.

RESULTS

Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports.

CONCLUSION

Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.

Synchronous granular cell tumors of the pancreas and cecum

Granular cell tumors (GCT) are rare and typically benign. Diagnosis is challenging due to nonspecific imaging characteristics and symptomatology. Herein, we report a combination of pancreatic/cecal GCTs in a 43-year-old man. Contrast enhanced MDCT demonstrated a 1.5 cm well-defined homogeneous intraluminal cecal mass and a 1.6 cm slightly hypervascular pancreatic body mass. On MRI, the pancreatic mass showed increased enhancement on post-gadolinium delayed sequences. Diagnosis was confirmed by excisional pathology (S100 and CD68, PAS-D positive). Radiologists, gastroenterologists, and surgeons should ponder the possibility of GCTs in the differential diagnosis of any small, pancreatic or cecal well-defined tumor.

Surgical Practical Skills Learning Curriculum: Implementation and Interns' Confidence Perceptions

OBJECTIVE

To provide an overview of the practical skills learning curriculum and assess its effects over time on the surgical interns' perceptions of their technical skills, patient management, administrative tasks, and knowledge.

DESIGN

An 84-hour practical skills curriculum composed of didactic, simulation, and practical sessions was implemented during the 2015 to 2016 academic year for general surgery interns. Totally, 40% of the sessions were held during orientation, whereas the remainder sessions were held throughout the academic year. Interns' perceptions of their technical skills, administrative tasks, patient management, and knowledge were assessed by the practical skills curriculum residents' perception survey at various time points during their intern year (baseline, midpoint, and final). Interns were also asked to fill out an evaluation survey at the completion of each session to obtain feedback on the curriculum.

SETTING

General Surgery Residency program at a tertiary care academic institution.

PARTICIPANTS

20 General Surgery categorical and preliminary interns.

RESULTS

Significant differences were found over time in interns' perceptions on their technical skills, patient management, administrative tasks, and knowledge (p < 0.001 for all). The results were also statistically significant when accounting for a prior boot camp course in medical school, intern status (categorical or preliminary), and gender (p < 0.05 for all). Differences in interns' perceptions occurred both from baseline to midpoint, and from midpoint to final time point evaluations (p < 0.001 for all). Prior surgical boot camp in medical school status, intern status (categorical vs. preliminary), and gender did not differ in the interns' baseline perceptions of their technical skills, patient management, administrative tasks, and knowledge (p > 0.05 for all).

CONCLUSIONS

Implementation of a Practical Skills Curriculum in surgical internships can improve interns' confidence perception on their technical skills, patient management skills, administrative tasks, and knowledge.

Applicability of current NCCN Guidelines for pancreatic adenocarcinoma resectability: analysis and pitfalls

PURPOSE

To test the applicability of National Comprehensive Cancer Network (NCCN v 3.2017) resectability criteria for pancreatic ductal adenocarcinoma (PDAC) in clinical practice, at a high-volume tertiary referral center.

MATERIALS AND METHODS

102 consecutive patients (53 female; mean age 66.2 years, range 34-90 years) with biopsy proven, non-metastatic PDAC were evaluated by our multidisciplinary pancreatic cancer program between July 2013 and February 2016. Retrospective review of staging pancreatic CT angiography was performed, and radiographic features were categorized as conforming to or non-conforming to existing v 3.2017 definitions.

RESULTS

Among 102 patients, 10 (10%) had CTA evidence of vascular involvement that did not conform to existing NCCN Guidelines. Six new scenarios of vascular involvement were identified. The remaining 92 patients presented with resectable (n = 20 [22%]), borderline resectable (n = 42 [45.6%]), or unresectable (n = 30 [33%]) PDAC. Approximately half (n = 21 [51%]) of borderline resectable patients' tumors demonstrated isolated venous involvement, whereas 39% had both arterial and venous involvement. A minority (11%) demonstrated only major arterial involvement. Assignment to unresectable status reflected both arterial and venous involvement (11, 37%), arterial involvement only (10, 33%) patients, and unreconstructible venous involvement in 9 (30%).

CONCLUSION

In our experience, current NCCN resectability guidelines for PDAC do not accurately classify vascular involvement identified in approximately 10% of patients. Revision of the current guidelines could be helpful to clinical practice.