Imaging Concordance With Vein Sampling for Primary Aldosteronism: A Cohort Study and Literature Review

INTRODUCTION

Adrenal venous sampling (AVS) is used to distinguish unilateral from bilateral aldosterone hypersecretion as a cause of primary aldosteronism (PA). Unilateral disease is treated with adrenalectomy and bilateral hypersecretion managed medically.

METHODS

We performed a single institution retrospective cohort study of adult patients undergoing adrenalectomy for PA from July 2013 to June 2022. Concordance of imaging findings with AVS was evaluated. Statistical analysis was performed with Mann-Whitney U and chi-squared Fisher's exact. Literature review performed via triple method search strategy.

RESULTS

Twenty-one patients underwent AVS and adrenalectomy for PA. Two patients did not have imaging findings and 19 were localized with an adenoma. For patients with image localization, AVS was concordant in nine, discordant in four, and nondiagnostic in six. For patients with discordant findings, age range was 35.8 to 72.4 y compared with concordant patient age range of 49.8 to 71.7 y. Overall discordance between imaging results and AVS was 40%. The aldosterone level was associated with concordance with a median of 52 ng/dL compared with 26 ng/dL if discordant (P = 0.002). There was a significant reduction in antihypertensive medications for the entire cohort from a median of three medications (interquartile range 2-4) to 1 medication (interquartile range 1-2), P < 0.001.

CONCLUSIONS

In this cohort, 40% of patients with selective AVS had discordant imaging and AVS results. Aldosterone level was associated with concordance. Hypertension was significantly improved with a median decrease of two antihypertensives. Our results support performance of AVS on all candidates for adrenalectomy for PA.

Cross-sectional imaging: current status and future potential in adult celiac disease

Celiac disease (CD), triggered by exposure to gluten in genetically susceptible individuals, is an immune-mediated small bowel disease affecting about 1% of the population worldwide. But the prevalence of CD varies with age, sex, and location. A strict gluten-free diet remains the primary treatment for CD, currently. Most of patients with CD respond well to gluten-free diet with good prognosis, while some patients fail to get symptomatic relief or histological remission (e.g., nonresponsive or refractory CD). Because of heterogeneous clinical appearance, the diagnosis of CD is difficult. Moreover, malignant complications and poor outcomes accompanied with refractory CD present great challenges in disease management. Over the past three decades, cross-sectional imaging techniques (computed tomography [CT] and magnetic resonance imaging [MRI]) play an important role in small bowel inflammatory and neoplastic diseases. Compared with endoscopic techniques, cross-sectional imaging permits clearly presentation of both intraluminal and extraluminal abnormalities. It provides vascular and functional information, thus improving the possibility as diagnostic and follow-up tool. The value of cross-sectional imaging for patients with suspected or confirmed CD has been gradually demonstrated. Studies revealed that certain features suggested by cross-sectional imaging could help to establish the early diagnosis of CD. Besides, the potential contributions of cross-sectional imaging may lie in the evaluation of disease activity and severity, which helps guiding management strategies. The purpose of this review is to provide current overviews and future directions of cross-sectional imaging in adult CD, thus facilitating the understanding and application in clinical practice. CLINICAL RELEVANCE STATEMENT: In this review, we systematically summarized the existing knowledge of cross-sectional imaging in adult CD and analyzed their possible roles in clinical practice, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. KEY POINTS: • Regarding a condition described as "celiac iceberg", celiac disease remains underdiagnosed and undertreated. • Cross-sectional imaging is helpful in clinical management of celiac disease, including disease diagnosis, complication identification, treatment evaluation, and prognostic prediction. • Cross-sectional imaging should be considered as the valuable examination in patients suspected from celiac disease.

Integrated FDG-PET/CT contribution over cross-sectional imaging in recurrence or progression of pancreaticobiliary neoplasms

PURPOSE

We aim to compare FDG-PET/CT and cross-sectional imaging (contrastenhanced CT/MRI) diagnostic abilities in detecting recurrence/progression of pancreaticobiliary system tumors and to reveal the clinical impact of integrated FDGPET/CT to CT/MRI on patient management.

MATERIALS AND METHODS

FDG-PET/CT and CT/MRI scans of 70 patients from initiation of treatment until proven recurrence/progression were retrospectively evaluated. FDGPET/CT and contrast-enhanced CT/MRI accuracy, sensitivity, specificity, PPV and NPV are compared in terms of overall recurrence/progression diagnosis and sitespecific concern; local disease, local lymph node, and distant organ metastasis. The impact of integrated FDG-PET/CT on patient management is scrutinized.

RESULTS

CT/MRI has higher sensitivity than FDG-PET/CT in detecting loco-regional involvement (90% vs 76.7% P: 0.152), local lymph node metastasis (88.9% vs 77.8%, P: 0.380) and distant organ metastasis (96.5% vs 80.7%; P: 0.006) in tumor recurrence/progression. In overall diagnosis, CT/MRI is more sensitive and accurate but less specific than FDG-PET/CT (92.3% vs 87.7%; 87.1% vs 84.2%; 40% vs 20%, respectively). In 8% (6/70) of patients FDG-PET/CT had a major impact on patient management.

CONCLUSION

FDG-PET/CT and cross-sectional imaging have different advantages and shortcomings. In recurrence/progression, recognition of early changes is more feasible by CT/MRI. However, inconsistency of morphologic and metabolic findings is important reason of cross-sectional imaging failure. FDG-PET/CT is superior in showing extraabdominal metastases, but missing small-volume lesions and misinterpreting inflammatory changes are still a problem lowering its sensitivity. Nevertheless FDGPET/CT is good option for guiding undetermined imaging findings or clinic-radiologic mismatch.

Re-thinking the value of cross-sectional torso imaging for ground-level fall patients with altered mental status: Outcomes from a level 1 trauma center

INTRODUCTION

Patients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR).

METHODS

Single-institution retrospective cohort study of GLF patients (≤1 m) with and without AMS (GCS <15, blood alcohol level >150 mg/dL, intubation prior to hospital evaluation), 2015-2019. Traumatic injury identification on CTT was evaluated in the context of normal/abnormal torso PE (based on provider documentation) and normal CXR/PXR.

RESULTS

1195 patients met inclusion criteria; 344 had AMS, of which 129 (37.5 %) underwent CTT. A further 851 patients had normal mental status, of which 180 (21.2 %) underwent CTT. Patients with a normal PE with AMS (N = 79) and without AMS (N = 38) had a similar rate of new injury discovery on CTT (6.3% vs. 7.9 %, p = 1.00). Negative PE had a negative predictive value (NPV) for identification of a new, acute traumatic injury of 92.4 % (95 % CI: 0.84-0.96) in patients with AMS while normal PE, CXR, and PXR had a NPV of 96.0 % (95 % CI: 0.80-0.99). Among patients with CTT, patients with AMS had a significantly lower rate of acute traumatic injury on CTT compared to alert patients (26.4 % vs. 48.9 %, p < 0.001). On multivariate analysis, AMS was not positively associated with likelihood of identifying acute traumatic injury on CTT.

CONCLUSIONS

In patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.

Point-of-Care Intestinal Ultrasound in Pediatric Inflammatory Bowel Disease

PURPOSE OF REVIEW

Intestinal ultrasound (IUS) is an emerging non-invasive point-of-care tool utilized by pediatric gastroenterologists for accurately detecting and monitoring inflammatory bowel disease (IBD) activity. In this article, we reviewed the evidence supporting and technique to perform IUS for children with IBD.

RECENT FINDINGS

IUS technique can visualize the colon from the distal sigmoid until the cecum and the terminal ileum without the need for bowel preparation, fasting, or sedation in children with IBD. IUS has been shown to be accurate to endoscopy in children with ulcerative colitis and Crohn's disease. IUS may be the most accurate biomarker to follow as a marker of treatment response that is predictive of endoscopic outcomes in children with IBD. Multiple studies have demonstrated that IUS can be performed at the point-of-care for IBD activity assessment in children. Recent studies have demonstrated the accuracy of IUS to endoscopy and magnetic resonance enterography with an ability to be repeated as a monitor of treatment response for tight control monitoring.

Is cross-sectional imaging necessary for fractures of the distal lower leg in children and adolescents: results of a nationwide survey

PURPOSE

In childhood and adolescence, cross-sectional imaging, most commonly computed tomography (CT), is often performed for advanced diagnosis of joint injuries of the distal lower leg and upper ankle. Due to radiation exposure, the need for CT remains controversial, as these injuries follow stereotypies and usually have a similar course. Alternatively, the performance of magnetic resonance imaging (MRI) is also discussed. Since radiation sensitivity at this young age is much higher than in adults, an effort must be to minimize radiation exposure according to as low as reasonably achievable (ALARA) principles. The aim of this survey is to evaluate the current procedure in Germany in the diagnosis of pediatric injuries of the distal lower leg and upper ankle.

METHODS

For data collection, a survey entitled "CT in fractures of the ankle joint in childhood and adolescence: subject of the survey are injuries between 8 and 15 years of age" of the Section of Pediatric Traumatology in the German Association of Trauma Surgery was sent to all members via the distribution list of the German Society of Orthopedics and Traumatology and the distribution list of the German Society of Pediatric Surgery in a period from September 20, 2022-December 21, 2022. The survey included a total of 21 questions. Target groups were trauma and pediatric surgeons and orthopedic surgeons working in the hospital and in practice.

RESULTS

A total of 525 participants took part in the survey: ultrasound diagnostics are used by almost 25% and the Ottawa Ankle Rules by over 50% always or in most cases. A conventional x-ray is always or most often used by over 90%. CT imaging is rarely used by 88.57%, mainly for surgical planning or analysis of fracture progression. 69.9% report that their radiology department uses a pediatric protocol for CT exams; 25.71% do not know if this is the case. MRI imaging is also used infrequently by 89.33%, mostly to identify associated injuries. Overall, CT imaging is chosen by 55.62% and MRI imaging by 35.24% as the sectional imaging modality for suspected fractures; 95.05% consider sectional imaging useful for a triplane fracture, 59.24% for a two-plane fracture, 41.71% for a Salter-Harris type III/IV injury, and 8% for a Salter-Harris type I/II injury.

CONCLUSION

The survey showed that the conventional X-ray is still the gold standard. Interestingly, more than half of the respondents regularly use the Ottawa Ankle Rules, and diagnostics using ultrasound are also used by almost a quarter. Awareness of radiation protection in children exists, although a quarter of all participants do not know the extent to which their radiology department has a specific pediatric protocol for CT imaging. Cross-sectional imaging is performed on a regular basis. Regarding the actual extent of imaging, there is a clear divergence between theory and practice.

[Computed tomography versus magnetic resonance imaging : Pros and cons in axial spondyloarthritis]

The diagnosis of axial spondyloarthritis depends on direct visualization of the sacroiliitis in addition to clinical assessment and determination of the histocompatibility antigen HLA-B27. While the value of conventional radiographic images has meanwhile been described in many studies as insufficient to diagnose the disease at an early stage, magnetic resonance imaging and also computed tomography now offer the possibility to visualize findings, such as bone marrow edema, erosion, fat metaplasia, backfill and ankylosis. Thus, it is necessary to decide which procedure should be used and when. Furthermore, both cross-sectional imaging techniques are currently undergoing major changes, and technical advancements are making great strides every year. This article provides an overview of which future technologies will be included in the rheumatological diagnostics of the sacroiliac joints. This overview also illustrates which standard methods are established in the diagnostics of axial spondyloarthritis and how they are used.

Multimodality imaging findings of infected endometriomas: "T1 signal reversal" as a potential diagnostic sign?

Endometrioma superinfection is a rare clinical entity that may cause diagnostic confusion and can be complicated by rupture, peritonitis, sepsis, and even death. Therefore, early diagnosis is crucial for appropriate patient management. Since clinical findings can be mild or nonspecific, radiological imaging is frequently used for diagnostic purposes. From a radiological perspective, it can be challenging to distinguish the presence of infection in an endometrioma. Complex cyst structure, wall thickening, increased peripheral vascularization, nondependent air bubbles, and surrounding inflammatory changes have been reported as potential US and CT findings suggestive of superinfection. On the other hand, there is a gap in the literature regarding MRI findings. To the best of our knowledge, this is the first case report in the literature to discuss MRI findings and temporal evolution of infected endometriomas. In this case report, we aim to present a patient with bilateral infected endometriomas at different stages, and to discuss the multimodality imaging findings, focusing specifically on the MRI. We defined 2 new MRI findings that may indicate the presence of superinfection in the early period. The first one was the "T1 signal reversal" seen in bilateral endometriomas. The second one, "progressive disappearance of T2 shading," was observed only in the right-sided lesion. These nonenhancing signal changes accompanied by increased lesion sizes during MRI follow-up were thought to represent a transition from blood to pus, and the percutaneous drainage of the right-sided endometrioma microbiologically confirmed our suspicion. In conclusion, MRI can be helpful in the early diagnosis of infected endometrioma due to its high soft tissue resolution. Percutaneous treatment may contribute to patient management as an alternative to surgical drainage.

Extracardiac Findings on Cardiac Magnetic Resonance: A Children's Hospital Experience

Cardiac magnetic resonance (CMR) incorporates a field of view that has the potential to capture clinically relevant extracardiac findings (ECF); however, there has been minimal investigation of ECF prevalence in children's hospitals, where the patient population varies in age and diagnosis. We retrospectively reviewed consecutive, clinically indicated, CMR studies performed at a tertiary care children's hospital during a 1-year period from January 1 to December 31, 2019. ECFs were classified as significant or non-significant based on whether they were described in the final impression of the CMR report. A total of 851 distinct patients had a CMR study during the 1-year period. Mean age was 19.5 (range 0.2; 74.2) years. A total of 254 ECFs were present in 158 of the 851 studies (18.6%) with 9.8% of all studies having significant ECFs. A total of 40.2% of ECFs were previously unknown and 9.1% (23/254) of ECFs included further recommendations (2.1% of all studies). ECFs were most often found in the chest (48%) or abdomen/pelvis (46%). Three patients were incidentally found to have malignancy (renal cell, thyroid, and hepatocellular carcinoma). Comparing studies with significant ECFs to the group without, CMR indications for biventricular CHD (43% vs 31%, p = 0.036), single ventricle CHD (12% vs 3.9%, p = 0.002), and aortopathy/vasculopathy (16% vs 7.6%, p = 0.020) were more common. The odds of significant ECF increased with increasing age (OR 1.82, 95% CI 1.10-3.01) and increased most notably between ages 14 to 33 years old. Recognition of the high percentage of ECFs remains important for timely diagnosis of these incidental findings.

Infarcts and ischemia in the abdomen: an imaging perspective with an emphasis on cross-sectional imaging findings

Infarcts and ischemia of abdominal organs may present with acute abdominal pain, and early diagnosis is crucial to prevent morbidity and mortality. Unfortunately, some of these patients present in poor clinical conditions to the emergency department, and imaging specialists are crucial for optimal outcomes. Although the radiological diagnosis of abdominal infarcts is often straightforward, it is vital to use the appropriate imaging modalities and correct imaging techniques for their detection. Additionally, some non-infarct-related abdominal pathologies may mimic infarcts, cause diagnostic confusion, and result in delayed diagnosis or misdiagnosis. In this article, we aimed to outline the general imaging approach, present cross-sectional imaging findings of infarcts and ischemia in several abdominal organs, including but not limited to, liver, spleen, kidneys, adrenals, omentum, and intestinal segments with relevant vascular anatomy, discuss possible differential diagnoses and emphasize important clinical/radiological clues that may assist radiologists in the diagnostic process.

3D Visualisation of the Spine

The 3D visualisation of the spine is thought of from multiple viewpoints. Firstly, radiological imaging is considered, with plain radiography, CT and MRI imaging discussed in detail with relevant applications to spinal surgery.3D printing can be used in spinal surgery with multiple applications including education, pre-operative planning for complex cases and making patient-specific guides and implants. The rapidly growing field of intraoperative navigation and robotics have been discussed, in addition to their benefits and limitations within spinal surgery, as well as some technical tips.An understanding of relevant anatomy and biomechanics is necessary for any surgeon, and so this chapter describes the key concepts to be familiar with, particularly the spinal motion segment and the different methods for classifying spinal injuries and how that relates to stability. The concepts discussed have been brought together by applying this knowledge to some interesting clinical cases. They highlight the importance of 3D visualisation of the spine, which must be considered throughout the decision-making process when managing patients. Spinal surgeons use multiple imaging modalities, knowledge of anatomy and biomechanics, as well as considering the need for navigation in more complex cases, all on a daily basis. With the advancement of technology available for 3D visualisation of the spine, we will be able to improve patient outcomes even further in the future.

Evaluation of different imaging modalities for axillary lymph node staging in breast cancer patients to provide a personalized and optimized therapy algorithm

PURPOSE

The reliable detection of tumor-infiltrated axillary lymph nodes for breast cancer [BC] patients plays a decisive role in further therapy. We aimed to find out whether cross-sectional imaging techniques could improve sensitivity for pretherapeutic axillary staging in nodal-positive BC patients compared to conventional imaging such as mammography and sonography.

METHODS

Data for breast cancer patients with tumor-infiltrated axillary lymph nodes having received surgery between 2014 and 2020 were included in this study. All examinations (sonography, mammography, computed tomography [CT] and magnetic resonance imaging [MRI]) were interpreted by board-certified specialists in radiology. The sensitivity of different imaging modalities was calculated, and binary logistic regression analyses were performed to detect variables influencing the detection of positive lymph nodes.

RESULTS

All included 382 breast cancer patients had received conventional imaging, while 52.61% of the patients had received cross-sectional imaging. The sensitivity of the combination of all imaging modalities was 68.89%. The combination of MRI and CT showed 63.83% and the combination of sonography and mammography showed 36.11% sensitivity.

CONCLUSION

We could demonstrate that cross-sectional imaging can improve the sensitivity of the detection of tumor-infiltrated axillary lymph nodes in breast cancer patients. Only the safe detection of these lymph nodes at the time of diagnosis enables the evaluation of the response to neoadjuvant therapy, thereby allowing access to prognosis and improving new post-neoadjuvant therapies.

Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size

Introduction/background

Adrenal incidentalomas (AIs) are masses > 1 cm found incidentally during radiographic imaging. They are present in up to 4.4% of patients undergoing CT scan, and incidence is increasing with usage and sensitivity of cross-sectional imaging. Most result in diagnosis of adrenal cortical adenoma, questioning guidelines recommending removal of all AIs with negative functional workup. This retrospective study analyzes histological outcome based on size of non-functional adrenal masses.

Material and methods

10 years of data was analyzed from two academic institutions. Exclusion criteria included patients with positive functional workups, those who underwent adrenalectomy during nephrectomy, < 18 years, and incomplete records. AI radiologic and histologic size, histologic outcome, laterality, imaging modality, gender, and age were collected. T-test was used for comparison of continuous variables, and the two-sided Fisher’s exact or chi-square test were used to determine differences for categorical variables. Univariate analysis of each independent variable was performed using simple logistic regression.

Results

73 adrenalectomies met the above inclusion criteria. 60 were detected on CT scan, 12 on MRI, and one on ultrasound. Eight of 73 cases resulted in malignant pathology, 3 of which were adrenocortical carcinoma (ACC). Each ACC measured > 6 cm, with mean radiologic and pathologic sizes of 11.2 cm and 11.3 cm. Both radiologic and pathologic size were significant predictors of malignancy (p = 0.008 and 0.011).

Conclusions

Our results question the generally-accepted 4 cm cutoff for excision of metabolically-silent AIs. They suggest a 6 cm threshold would suffice to avoid removal of benign lesions while maintaining sensitivity for ACC.

Updated systematic review and meta-analysis on diagnostic issues and the prognostic impact of myosteatosis: A new paradigm beyond sarcopenia

Myosteatosis, which is excessive fat infiltration in the skeletal muscle, is now considered a distinct disease from sarcopenia. Advances in imaging technique have made muscle parameters an evaluable biomarker, and many studies have proved association between myosteatosis and aging or disease process. However, the diagnosis and clinical impact of myosteatosis have not been well established. Thus, we aim to provide a systematic summary with a qualitive review of 73 eligible studies regarding these issues. First, the most widely used modality to diagnose myosteatosis is abdominal computed tomography, based on evaluation of the muscle radiodensity of the total abdominal muscle area predominantly at the L3 vertebral level. However, there was significant heterogeneity in the diagnostic methods and cutoff values used to diagnose myosteatosis (32 different cutoff values among 73 studies). Second, the clinical impact of myosteatosis on prognosis was very straightforward, and most studies have shown a negative impact of myosteatosis on overall survival and complications related to underlying diseases. However, the mechanism of the myosteatosis on mortality has not been explored well, and metabolic dysfunction (i.e. insulin resistance, systemic inflammation) would be a possible explanation. Providing systemic review of current issues can elucidate future directions for developing standardized diagnosis and management of myosteatosis.

The Growing Role for Semantic Segmentation in Urology

As the quantity and quality of cross-sectional imaging data increase, it is important to be able to make efficient use of the information. Semantic segmentation is an emerging technology that promises to improve the speed, reproducibility, and accuracy of analysis of medical imaging, and to allow visualization methods that were previously impossible. Manual image segmentation often requires expert knowledge and is both time- and cost-prohibitive in many clinical situations. However, automated methods, especially those using deep learning, show promise in alleviating this burden to make segmentation a standard tool for clinical intervention in the future. It is therefore important for clinicians to have a functional understanding of what segmentation is and to be aware of its uses. Here we include a number of examples of ways in which semantic segmentation has been put into practice in urology. PATIENT SUMMARY: This mini-review highlights the growing role of segmentation methods for medical images in urology to inform clinical practice. Segmentation methods show promise in improving the reliability of diagnosis and aiding in visualization, which may become a tool for patient education.

Cross-sectional imaging features of unusual adrenal lesions: a radiopathological correlation

The detection rates of adrenal masses are increasing with the common and widespread use of cross-sectional imaging. Adrenal adenomas, myelolipomas, metastases, pheochromocytomas, and adrenocortical tumors are well-known and relatively common adrenal tumors. However, there are many less-known neoplastic and nonneoplastic adrenal diseases that might affect the adrenal glands in addition to these common lesions. These rare entities include, but are not limited to, hydatid cysts, congenital adrenal hyperplasia, Wolman disease, adrenal tuberculosis, primary adrenal lymphoma. This article aims to present imaging findings of these unusual lesions in accordance with their pathologic characteristics. We think that the simultaneous presentation of the pathological findings with the imaging features may facilitate the learning process and may potentially enhance the recognition of these entities.

EUS is accurate in characterizing pancreatic cystic lesions; a prospective comparison with cross-sectional imaging in resected cases

Background

Imaging modalities for characterizing pancreatic cystic lesions (PCLs) is a known uncertainty. The aim of this prospective study was to compare the diagnostic performance of endoscopic ultrasound morphology, cytology and cyst fluid carcinoembryonic antigen (EUS-FNA-CEA) with cross-sectional imaging in resected PCLs.

Methods

The cross-sectional imaging and EUS-FNA-CEA results were collected in an academic tertiary referral centre using histology of the surgical specimen as the diagnostic standard.

Results

Of 289 patients undergoing evaluation for PCL with cross-sectional imaging and EUS-FNA between February 2007 and March 2017, 58 underwent surgical resection providing a final diagnosis of the PCLs: 45 mucinous, 5 serous, 1 pseudocyst, 2 endocrine, 2 solid pseudopapillary neoplasms and 3 other. EUS-FNA-CEA was more accurate than cross-sectional imaging in diagnosing mucinous PCLs (95% vs. 83%, p = 0.04). Ninety-two percent of the PCLs with high-grade dysplasia or adenocarcinoma were smaller than 3 cm in diameter. The sensitivity of EUS-FNA-CEA and cross-sectional imaging for detecting PCLs with high-grade dysplasia or adenocarcinoma were 33% and 5% (p = 0.03), respectively. However, there was no difference in accuracy between the modalities (62% vs. 66%, p = 0.79). The sensitivity for detecting pancreatic adenocarcinomas only was 64% for EUS-FNA-CEA and 9% for cross-sectional imaging (p = 0.03). Overall, EUS-FNA-CEA provided a correct diagnosis in more patients with PCLs than cross-sectional imaging (72% vs. 50%, p = 0.01).

Conclusions

EUS-FNA-CEA is accurate and should be considered a complementary test in the diagnosis of PCLs. However, the detection of PCLs with high-grade dysplasia or adenocarcinoma needs to be improved. Cyst size does not seem to be a reliable predictor of high-grade dysplasia or adenocarcinoma.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08166-3) contains supplementary material, which is available to authorized users.

Accuracy of various criteria for lymph node staging in ductal adenocarcinoma of the pancreatic head by computed tomography and magnetic resonance imaging

BACKGROUND

Lymph node staging of ductal adenocarcinoma of the pancreatic head (PDAC) by cross-sectional imaging is limited. The aim of this study was to determine the diagnostic accuracy of expanded criteria in nodal staging in PDAC patients.

METHODS

Sixty-six patients with histologically confirmed PDAC that underwent primary surgery were included in this retrospective IRB-approved study. Cross-sectional imaging studies (CT and/or MRI) were evaluated by a radiologist blinded to histopathology. Number and size of lymph nodes were measured (short-axis diameter) and characterized in terms of expanded morphological criteria of border contour (spiculated, lobulated, and indistinct) and texture (homogeneous or inhomogeneous). Sensitivities and specificities were calculated with histopathology as a reference standard.

RESULTS

Forty-eight of 66 patients (80%) had histologically confirmed lymph node metastases (pN+). Sensitivity, specificity, and Youden's Index for the criterion "size" were 44.2%, 82.4%, and 0.27; for "inhomogeneous signal intensity" 25.6%, 94.1%, and 0.20; and for "border contour" 62.7%, 52.9%, and 0.16, respectively. There was a significant association between the number of visible lymph nodes on preoperative CT and lymph node involvement (pN+, p = 0.031).

CONCLUSION

Lymph node staging in PDAC is mainly limited due to low sensitivity for detection of metastatic disease. Using expanded morphological criteria instead of size did not improve regional nodal staging due to sensitivity remaining low. Combining specific criteria yields improved sensitivity with specificity and PPV remaining high.

Characteristics and outcomes of acute colitis diagnosed on cross-sectional imaging presenting via the emergency department in an Irish academic medical centre

BACKGROUND AND AIMS

A significant proportion of patients presenting to the Emergency Department with gastrointestinal symptoms that result in cross-sectional imaging receive a radiological diagnosis of colitis. We aimed to review the characteristics, outcomes, and final diagnoses of new emergency department presentations with colitis diagnosed on cross-sectional imaging.

METHODS

A radiology database was interrogated to identify patients admitted from the Emergency Department of St James's Hospital whose cross-sectional imaging demonstrated colitis. Baseline demographic data, information on inpatient investigations, final diagnoses, and outcomes were recorded. Adverse outcomes were defined as a requirement for surgery, intensive care unit (ICU) stay, or mortality RESULTS: A total of 118 patients, 67% female, were identified with a median age of 64 years (range 16.9-101.2). Median (range) admission duration was 10 days (1-241). Final colitis diagnoses were infectious (28%), undefined (27%), reactive (18%), inflammatory bowel disease (11%), ischaemic (9%), chemotherapy-associated (3%), diverticular (3%), and medication-associated (1%). Colonic perforation, colectomy, and mortality occurred in 1%, 5%, and 13% of the cohort respectively. On univariate analysis, low haemoglobin, low albumin, high lactate, and male gender were associated with adverse outcomes with the following odds ratios (OR) and 95% confidence intervals (95%CI) were low haemoglobin 1.49 [1.15-1.92] P = 0.002, low albumin 1.16 [1.07-1.25] P = 0.0002, lactate 1.65 [1.13-2.42] P = 0.009, and male gender 3.09 [1.23-7.77] P = 0.019. On multivariate analysis, male gender was associated with adverse outcomes.

CONCLUSION

Patients presenting to the Emergency Department with a colitis, requiring an abdominal CT are a heterogenous group with a proportion having concomitant intra-abdominal pathology resulting in critical illness. Hence their is a significant morbidity and mortality observed in this cohort which should not be extrapolated to a general population of patients presenting with colitis. In this cohort of patients, anaemia, hypoalbuminaemia, and elevated lactate in patients presenting to the ED with acute colitis are significantly associated with adverse outcomes. Early recognition of these prognostic factors may identify the cohort of patients who are best managed in a high-dependency setting.

Imaging guidelines for acute pancreatitis: when and when not to image

In patients with acute pancreatitis (AP), diagnostic imaging is performed for various reasons, including the detection of the etiology (e.g., biliary obstruction caused by gallstones), diagnosis of pancreatitis in an unclear clinical setting, assessment of the severity of the process, and evaluation of its complications. In spite of the potential benefits of these imaging studies in the setting of AP, especially economic consequences but also medical risks are associated with diagnostic imaging, including increase of the effective radiation dose received by patients with AP and rising health care costs, frequently without impact on management. The rising incidence of acute pancreatitis in the Western world is escalating its financial burden with national health care expenses of over 2.5 billion dollars annually. Despite evidence-based national recommendations on utilization of diagnostic imaging in patients with AP, unnecessary imaging studies are still frequently performed, especially in the early hospital course. The purpose of this article is, therefore, to review the imaging guidelines for acute pancreatitis with regards to when and when not to image, with the aim to minimize inappropriate utilization.

The role of preoperative computerized tomography (CT) scan of the pelvis and groin in the management of clinically early staged vulva squamous cell carcinoma

INTRODUCTION

Vulvar squamous cell carcinoma (VSCC) commonly metastasises through groin lymphatics. However, the use of pre-operative imaging in detecting inguinal nodal metastasis before staging surgery or to triage patients for sentinel node biopsy remains unclear. Here, we investigated if pre-operative CT scan, the imaging choice in our cancer centre, influences the overall course of VSCC management in those patients without clinical evidence of groin lymphadenopathy.

METHOD

The study comprised of a prospective cohort of 225 patients with VSCC who underwent staging surgery within a regional tertiary gynaecological cancer centre. Comprehensive information of the cohort's demography, clinicopathological variables and outcome data were collected and analysed. Findings of pre-operative imaging were compared with histological findings of inguinal lymph nodes following groin lymphadenectomy. Statistical analyses were performed using SPSS V24.

RESULTS

Pre-operative CT scan was performed on 116 (56.6%) patients. The sensitivity and specificity of cross-sectional imaging in detecting groin lymphatic metastasis were 59.1% and 77.8%, respectively; while the positive (PPV) and negative predictive value (NPV) were 61.9% and 75.7%, respectively. In patients who had sentinel inguinal nodes biopsy, the sensitivity, specificity, PPV and NPV of CT scan in detecting inguinal node metastasis were 30.0%, 85.7%, 33.3% and 83.7%, respectively. There was no difference in disease-free and overall survival in those who received pre-operative imaging when compared to those who did not.

CONCLUSION

Pre-operative CT scan may be omitted in early stage VSCC prior to surgical staging as it does not affect overall management and surgical outcomes.

Necrotising fasciitis of the breast: A rare but deadly disease

INTRODUCTION

Necrotising fasciitis is a rare but deadly bacterial infection causing soft tissue and fascial necrosis. It is associated with a mortality rate of 25%. It is characterised by; erythematous skin, which turns dusky blue before haemorrhagic bullae develop; localised pain; and inflammation. It is most commonly found in the extremities, the abdomen or the perineum but is rarely seen in the breast.

CASE PRESENTATION

We describe a 54-year-old lady who presented with breast erythema and raised inflammatory markers. Initially treated as cellulitis, however when her symptoms did not improve and despite IV antibiotics her bloods worsened, a CT scan was performed which showed a large volume of interstitial soft tissue gas with diffuse fat stranding, consistent with necrotising fasciitis. Debridement of her breast alongside the use of sensitive antibiotics and ITU support led to a satisfactory outcome.

DISCUSSION

We discuss how an early diagnosis can be made by the recognition of a triad of symptoms common in necrotising fasciitis, and how optimal management can be achieved with the incorporation of imaging to successfully identify the condition and allow targeted debridement of the areas of necrotising fasciitis.

CONCLUSION

A high index of suspicion should be held if pain is disproportionate to the signs or sepsis is present. To aid an early diagnosis, imaging of the breast should be performed early to avoid delay in treatment.

[PET/MRI]

CLINICAL/METHODICAL ISSUE

Magnet resonance imaging (MRI) is an excellent anatomical reference method for the combination with positron emission tomography (PET). But MRI does not produce data, which can be directly used for attenuation correction of PET data, potentially compromising quantitative accuracy of PET.

STANDARD RADIOLOGICAL METHODS

Hybrid-positron emission tomography/computed tomography (PET/CT) is an established standard diagnostic tool, particularly for staging and restaging in oncology. Attenuation correction of PET data is performed with a µMAP derived from low-dose-CT, considered as a robust method.

METHODICAL INNOVATIONS

Using standardized MRI-sequences, tissue classes are segmented and attenuation maps are obtained, based on empirical density values. In addition, new reconstruction algorithms and the possibility to acquire PET and MRI simultaneously with MRI-based motion correction are available. These advances have improved image quality and quantitative accuracy of the PET-data in PET/MRI.

PERFORMANCE

In numerous oncological studies PET/CT and PET/MR were rated as equal in their diagnostic performance. The combination of functional-metabolic PET and multiparametric MRI with excellent soft tissue contrast complement each other with regard to their diagnostic information in numerous tumor entities.

PRACTICAL RECOMMENDATIONS

The standard diagnostic workup for lung cancer is currently still based on PET/CT. In numerous tumor entities, the combination of PET/MRI can provide additional diagnostic information.

Optical and Cross-Sectional Imaging Technologies for Bladder Cancer

Optical and cross-sectional imaging plays critical roles in bladder cancer diagnostics. White light cystoscopy remains the cornerstone for the management of non-muscle-invasive bladder cancer. In the last decade, significant technological improvements have been introduced for optical imaging to address the known shortcomings of white light cystoscopy. Enhanced cystoscopy modalities such as blue light cystoscopy and narrowband imaging survey a large area of the urothelium and provide contrast enhancement to detect additional lesions and decrease cancer recurrence. However, higher false-positive rates accompany the gain of sensitivity. Optical biopsy technologies, including confocal laser endomicroscopy and optical coherence tomography, provide cellular resolutions combined with subsurface imaging, thereby enabling optical-based cancer characterization, and may lead to real-time cancer grading and staging. Coupling of fluorescently labeled binding agents with optical imaging devices may translate into high molecular specificity, thus enabling visualization and characterization of biological processes at the molecular level. For cross-sectional imaging, upper urinary tract evaluation and assessment potential extravesical tumor extension and metastases are currently the primary roles, particularly for management of muscle-invasive bladder cancer. Multi-parametric MRI, including dynamic gadolinium-enhanced and diffusion-weighted sequences, has been investigated for primary bladder tumor detection. Ultrasmall superparamagnetic particles of iron oxide (USPIO) are a new class of contrast agents that increased the accuracy of lymph node imaging. Combination of multi-parametric MRI with positron emission tomography is on the horizon to improve accuracy rates for primary tumor diagnostics as well as lymph node evaluation. As these high-resolution optical and cross-sectional technologies emerge and develop, judicious assessment and validation await for their clinical integration toward improving the overall management of bladder cancer.

Differences in the imaging of Crohn's disease patients between North America and Europe: are we ready to bridge the divide?

The emphasis of treatment in Crohn's disease has evolved from a reactive model to "treat-to-target" approaches. Cross-sectional imaging has rapidly evolved in parallel, with a growing evidence base supporting its abilities for diagnosis, monitoring and prognostication. Whilst there are differences in emphasis between Europe and North America, particularly around the type of imaging modalities and patterns of multidisciplinary care, there is increasing convergence. This perspective piece provides an overview of the evolving role of cross-sectional imaging in Crohn's disease, discusses practice differences between North America and Europe and provides suggestions on areas for future collaboration and research priorities.

[Magnetic resonance imaging and active cardiac implants]

The combination of magnetic resonance imaging (MRI) and active cardiac implants, such as pacemakers and implantable cardioverter defibrillators (ICD) has been a challenge for electrophysiologists and imaging for many years. Diagnostic and therapeutic possibilities on the one hand and technical hazards on the other hand highlight the need for improvements and algorithms that enable a safe approach to these challenges. The advent of so-called MRI conditional implants provides safe procedures for at least some of the patients with an implant and the need for MRI. Recently published data encourage clinicians not to completely excluded an imaging modality as promising as MRI in clinically urgent cases in the presence of conventional implants. The interdisciplinary consensus paper of the German Society of Cardiology and the German Society of Radiology provides recommendations for these situations. This review article discusses these recommendations and provides an overview of the most recent publications with a focus on the long-term course of device parameters.

Visualization of the fat planes between the pancreas and the adjacent organs and blood vessels using multi-detector computed tomography

PURPOSE

To explore individual variations in visibility of the fat planes between the pancreatic parenchyma and adjacent organs and blood vessels using the multi-detector-computed tomography (MDCT).

METHODS

Abdominal contrast-enhanced MDCT examinations of 520 consecutive adult individuals were retrospectively analysed by exploring the presence of visible fat planes between the healthy pancreas and the following surrounding structures: stomach, descending duodenum (D2), splenic, portal, superior mesenteric vein (SV, PV, SMV), inferior vena cava (IVC), and coeliac trunk, common hepatic and superior mesenteric artery (CT, HA and SMA). Spearman's rank correlation coefficient (r_S) was used to assess the correlation of individual gender, age, body mass and BMI, and visible fat planes towards particular surrounding structures.

RESULTS

Fat planes between the pancreatic parenchyma and surrounding structures was visible as follows: stomach in 76%, D2 11.7%, SV 51.5%, PV 0%, SMV 28.8%, IVC 80.8%, CT 99.4%, HA 90.4% and SMA in 100% participants. The presence of visible fat planes significantly correlated (p < 0.001) with body mass for stomach (r_S = 0.367), D2 (r_S = 0.247), SV (r_S = 0.355), SMV (r_S = 0.384) and IVC (r_S = 0.259); BMI for stomach (r_S = 0.292), SV (r_S = 0.248), SMV (r_S = 0.290) and IVC (r_S = 0.216); age for D2 (r_S = 0.363), SV (r_S = 0.276) and SMV (r_S = 0.409); and male gender for stomach (r_S = 0.160) and SV (r_S = 0.198).

CONCLUSION

Fat planes around the pancreatic parenchyma in the MDCT scan was almost always visible towards the adjacent magistral visceral arteries and IVC, always invisible towards the PV, and variably visible towards the SV, SMV, stomach and duodenum depending on the individual body mass, BMI, age and gender.

Kienböck's disease: Role of cross-sectional imaging in treatment choice and patient follow-up

The management of Kienböck's disease is complex and constantly evolving in parallel with progress in the understanding of the pathophysiological mechanisms of this condition. Cross-sectional imaging techniques have an essential role in the diagnosis and prognostic assessment of this disease. CT allows the optimal study of the morpho-structure of lunate bone. MRI makes it possible to study bone marrow viability. As for CT arthrography, it allows to evaluate accurately articular cartilage of the different carpal joints. The evaluation of these different aspects of Kienböck's disease is essential for optimal treatment selection. Cross-sectional imaging also has an interest in post-treatment follow-up, by having a prognostic value and allowing the identification of post-operative complications. The purpose of this article is to review the contribution of cross-sectional imaging in the assessment of Kienböck's disease before and after treatment according to the most common surgical procedures. Pathophysiological mechanisms, predisposing factors, the different classifications and their interests will be discussed.

Imaging of Odontogenic Infections

Odontogenic infections represent a common clinical problem in patients of all ages. The presence of teeth enables the direct spread of inflammatory products from dental caries, trauma, and/or periodontal disease into the maxilla and mandible. The radiographic changes seen depend on the type and duration of the inflammatory process and host body response. Imaging plays a central role in identifying the source of infection and the extent of the disease spread and in detecting any complications. Many different imaging modalities can be used. The radiographic features associated with acute and chronic inflammatory processes are discussed.

Creating diagnostic criteria for perforated appendicitis using cross-sectional imaging

INTRODUCTION

Preoperative determination of perforated versus acute appendicitis can be difficult. We compared CT and MRI performance in diagnosing perforated appendicitis, and created diagnostic criteria.

METHODS

We retrospectively reviewed all pediatric patients who underwent appendectomy within one day of CT or MRI between 1/1/2013 and 1/16/2016. True diagnosis was determined by pathology report. Findings on CT/MRI were grouped into "hard" findings (abscess, pneumoperitoneum, extruded fecalith, appendiceal wall with visible hole) and "soft" findings (extensive/diffuse inflammation/free fluid, phlegmon). Correlation of white blood cell count (WBC), temperature, peritoneal signs, and symptom duration >72 h with perforation was assessed using logistic regression. Significant correlates were incorporated in clinical criteria.

RESULTS

135 patients underwent appendectomy after CT/MRI. Fifty patients underwent MRI and 85 CT. Using hard and/or soft findings, MRI was 86.7% sensitive and 74.3% specific, compared to 68.4% (p = 0.19) and 92.4% (p = 0.025) for CT. WBC > 15, temperature >38.0 °C, and peritoneal signs predicted perforation. Diagnostic accuracy of MRI was highest using imaging findings alone. Accuracy of CT was improved by mandating at least one of the previous three clinical correlates, resulting in 68.4% sensitivity and 93.9% specificity.

CONCLUSIONS

MRI trended toward more sensitive and CT was more specific for complicated appendicitis. CT specificity is improved by our algorithm.

Tumor response assessment: comparison between unstructured free text reporting in routine clinical workflow and computer-aided evaluation based on RECIST 1.1 criteria

PURPOSE

Standardized computer-aided tumor response assessment is common in clinical trials. In contrast, unstructured free text reporting (UFTR) is common in daily routine. Therefore, this study aimed to discern and quantify differences between UFTR and computer-aided standardized tumor response evaluation based on RECIST 1.1 criteria (RECIST), serving as gold standard, in clinical workflow.

METHODS

One-hundred consecutive patients with cancer eligible for RECIST 1.1 evaluation, who received five follow-up CTs of the trunk, were retrospectively included. All UFTRs were assigned to RECIST response categories [complete response, partial response (PR), stable disease (SD), progressive disease (PD)]. All CTs were re-evaluated using dedicated software (mint lesion™) applying RECIST 1.1. The accordance in tumor response ratings was analyzed using Cohen's kappa.

RESULTS

At the first follow-up, 47 cases were rated differently with an SD underrepresentation and a PR and PD overrepresentation in UFTR. In the subsequent follow-ups, categorical differences were seen in 38, 44, 37, and 44%. Accordance between UFTR and RECIST was fair to moderate (Cohen's kappa: 0.356, 0.477, 0.390, 0.475, 0.376; always p < 0.001). Differences were mainly caused by the rating of even small tumor burden changes as PD or PR in UFTR or by comparison to the most recent prior CT scan in UFTR instead of comparison to nadir or baseline.

CONCLUSIONS

Significant differences in tumor response ratings were detected comparing UFTR and computer-aided standardized evaluation based on RECIST 1.1. Thus, standardized reporting should be implemented in daily routine workflow.

Value of cross-sectional imaging in assessing active Crohn's disease before stoma reversal

BACKGROUND

There are currently no guidelines on the need to assess disease activity before stoma reversal in Crohn's disease (CD). We sought to determine the value of cross-sectional imaging for detecting active CD before stoma reversal.

METHODS

38 CD patients underwent cross-sectional imaging before stoma reversal. CD activity was blindly evaluated by an independent radiologist. Postoperative outcomes were recorded.

RESULTS

Before stoma reversal, cross-sectional imaging identified active CD in 20 of the 38 study participants (52.6%). In 9 out of 10 tested patients, radiologic and endoscopic assessments gave concordant findings with regard to CD recurrence before stoma reversal. Stoma reversal was delayed in half of the patients with active CD and in none of the patients without active CD. Before stoma reversal, tumor necrosis factor alpha antagonists or immunosuppressants were initiated in 45% of the patients with active CD and 5.6% of the patients without active CD. In the year following stoma reversal, the recurrence rate (in a radiologic assessment) was higher in patients with active CD than in patients without active CD (75.0% vs. 30.8%, respectively; p=0.04).

CONCLUSION

Cross-sectional imaging revealed postoperative recurrence in about a quarter of patients before stoma reversal; this finding may influence the postoperative treatment strategy and outcomes.

Medical Therapies for Stricturing Crohn's Disease: Efficacy and Cross-Sectional Imaging Predictors of Therapeutic Failure

BACKGROUND

Medical therapy efficacy remains controversial in stricturing Crohn's disease. Cross-sectional imaging, especially magnetic resonance imaging, has been suggested as very helpful to guide therapeutic decision making.

AIM

To assess efficacy and predictors of therapeutic failure in patients receiving medical treatments for stricturing Crohn's disease.

METHODS

In this retrospective study, therapeutic failure was defined as symptomatic stricture leading to surgical or endoscopic therapeutics, hospitalization, treatment discontinuation or additional therapy and short-term clinical response as clinical improvement assessed by two physicians. The 55 cross-sectional imaging examinations (33 magnetic resonance imaging and 22 CT scan) before starting medical therapy were analyzed independently by two radiologists. Results were expressed as hazard ratio (HR) or odds ratio (OR) with 95% confidence intervals (95% CI).

RESULTS

Among 84 patients, therapeutic failure rate within 60 months was 66.6%. In multivariate analysis, Crohn's disease diagnosis after 40 years old (HR 3.9, 95% CI [1.37-11.2], p = 0.011), small stricture luminal diameter (HR 1.34, 95% CI [1.01-1.80], p = 0.046), increased stricture wall thickness (HR 1.23, 95% CI [1.04-1.46], p = 0.013) and fistula with abscess (HR 5.63, 95% CI [1.64-19.35], p = 0.006) were associated with therapeutic failure, while anti-TNF combotherapy (HR 0.17, 95% CI [0.40-0.71], p = 0.015) prevented it. Considering 108 therapeutic sequences, the short-term clinical response rate was 65.7%. In multivariate analysis, male gender (OR 0.15, 95% CI [0.03-0.64], p = 0.011), fistula with abscess (OR 0.09, 95% CI [0.01-0.77], p = 0.028) and comb sign (OR 0.23, 95% CI [0.005-0.97], p = 0.047) were associated with short-term clinical failure.

CONCLUSION

Anti-TNF combotherapy seemed to prevent therapeutic failure, and cross-sectional imaging should be systematically performed to help medical management in stricturing Crohn's disease.

Personalized medicine: Enhancing our understanding of pediatric growth with analytic morphomics

BACKGROUND/PURPOSE

Analytic morphomics is being used to identify 3-D biologic measures with superior clinical utility and risk stratification over traditional factors such as age, height, and weight. The purpose of this study is to define age and gender specific Pediatric Reference Analytic Morphomics Population (PRAMP™) growth charts.

METHODS

This retrospective study population contains 2591 individual CT scans of a normative reference population of males and females (1-20years old). Growth curves were constructed at the 5th, 25th, 50th, 75th, and 95th quantiles for morphomic variables, including psoas muscle area, trabecular bone density, and visceral fat area by age and gender.

RESULTS

Total psoas muscle area increases over time until late adolescence. Trabecular bone density remains stable until adolescence, decreases during adolescence, and increases in young adulthood. Visceral fat area increases over time with greater variation between the 5th and 95th percentile with increasing age.

CONCLUSIONS

The PRAMP™ data have been used to construct age- and sex-specific reference growth curves. This may be used to better define "abnormal" in efforts to create unique risk-categorization algorithms specific to particular clinical and global health investigations.

LEVEL OF EVIDENCE

Level II.

Quality Initiative Program in Its Sixth Year: Has It Become Part of Our Radiology Culture?

PURPOSE

The study sought to determine if the Quality Initiative Program (QUIP) has become part of the radiology culture at our institution.

METHODS

After Research Ethics approval, QUIPs from January 2009 to December 2014 were assessed. We evaluated the response rates of radiologists receiving QUIPs to ensure they reviewed them. We performed a survey of radiologists and trainees to gain feedback regarding their perception of QUIPs in February 2014 and in June 2015.

RESULTS

Response rates of radiologists receiving a QUIP improved, with 76% response rate in 2014 up from 66% in the first year and 42% in the second year. Based on the 2015 survey including radiologists and trainees, 75% agreed that QUIPs were educational, compared with 67% 16 months earlier. Fifty percent of respondents had changed their overall practice of reporting based on feedback from the QUIP in 2015 compared with 32% in 2014. In both surveys, 100% of respondents indicated that QUIPs have not been used against them for any disciplinary measure (or other negatively perceived action). When asked if there was a perceived decrease in stigma felt when a QUIP was received, 71% agreed or were neutral and 28% disagreed.

CONCLUSIONS

The QUIP is educational to radiologists and trainees, leading to positive changes in clinical practice. The majority accepts this program but there is still a stigma felt when a QUIP is received, particularly among residents. Nevertheless, we feel that QUIP has been integrated into our radiology culture and, hopefully, imminent transition to commercial quality software will be smooth.

Factors associated with surgery in patients with intra-abdominal fistulizing Crohn's disease

AIM

To characterize radiological and clinical factors associated with subsequent surgical intervention in Crohn’s disease (CD) patients with intra-abdominal fistulae.

METHODS

From a cohort of 1244 CD patients seen over an eight year period (2006 to 2014), 126 patients were identified as having intra-abdominal fistulae, and included in the study. Baseline patient information was collected from the medical records. Imaging studies were assessed for: anatomic type and number of fistulae; diameter of the inflammatory conglomerate; length of diseased bowel; presence of a stricture with pre-stenotic dilatation; presence of an abscess; lymphadenopathy; and the degree of bowel enhancement. Multivariate analysis for the prediction of abdominal surgery was calculated via Generalized Linear Models.

RESULTS

In total, there were 193 fistulae in 132 patients, the majority (52%) being entero-enteric. Fifty-nine (47%) patients underwent surgery within one year of the imaging study, of which 36 (29%) underwent surgery within one month. Radiologic features that were associated with subsequent surgery included: multiple fistulae (P = 0.009), presence of stricture (P = 0.02), and an entero-vesical fistula (P = 0.01). Evidence of an abscess, lymphadenopathy, or intense bowel enhancement as well as C-reactive protein levels was not associated with an increased rate of surgery. Patients who were treated after the imaging study with combination immunomodulatory and anti-TNF therapy had significantly lower rates of surgery (P = 0.01). In the multivariate analysis, presence of a stricture [RR 4.5 (1.23-16.3), P = 0.02] was the only factor that increased surgery rate.

CONCLUSION

A bowel stricture is the only factor predicting an increased rate of surgery. Radiological parameters may guide in selecting treatment options in patients with fistulizing CD.

Imaging of Cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common primary hepatobiliary tumour, and it is increasing in incidence. Imaging characteristics, behaviour, and therapeutic strategies in CC differ significantly, depending on the morphology and location of the tumour. In cross-sectional imaging, CCs can be classified according to the growth pattern (mass-forming, periductal infiltrating, intraductal) and the location (intrahepatic, perihilar, extrahepatic/distal). The prognosis of CC is unfavourable and surgical resection is the only curative treatment option; thus, early diagnosis (also in recurrent disease) and accurate staging including the evaluation of lymph node involvement and vascular infiltration is crucial. However, the diagnostic evaluation of CC is challenging due to the heterogeneous nature of the tumour. Diagnostic modalities used in the imaging of CC include transabdominal ultrasound, endosonography, computed tomography, magnetic resonance imaging with cholangiopancreatography, and hybrid imaging such as positron emission tomography/computed tomography. In this review, the potential of cross-sectional imaging modalities in primary staging, treatment monitoring, and detection of recurrent disease will be discussed.

Cardiac-gated computed tomography angiography in three alpacas with complex congenital heart disease

BACKGROUND

The prevalence of congenital heart disease is higher in camelids than in other domestic species and complex defects, often involving the great vessels, are more frequently encountered in llamas and alpacas than in other species. Some of these complex defects can be difficult to accurately characterize via echocardiography, the most commonly used diagnostic imaging technique to evaluate the heart in veterinary patients. Contrast-enhanced, electrocardiogram (ECG)-gated computed tomography (CT) has proven utility for the evaluation of human patients with certain congenital heart defects, including those with conotruncal septation defects and other abnormalities involving the formation of the great vessels.

METHODS

Three alpaca crias, 4 days, 5 weeks and 14 months of age were clinically evaluated and subjected to a complete color-flow Doppler echocardiogram and a contrast-enhanced ECG-gated CT.

RESULTS

These alpacas exhibited a variety of clinical findings including lethargy, failure to thrive, exercise intolerance, heart murmur, and/or respiratory difficulty. All three crias were subsequently diagnosed with complex cardiac defects including pulmonary atresia with a ventricular septal defect (VSD), a truncus arteriosus with a large VSD, and a double outlet right ventricle with a large VSD and aortic hypoplasia. In each case, the diagnosis was confirmed by postmortem examination.

CONCLUSION

Color flow echocardiographic evaluation identified all of the intra-cardiac lesions and associated flow anomalies but contrast-enhanced ECG-gated CT permitted more accurate assessment of the morphology of the extracardiac structures and permitted a more precise determination of the exact nature and anatomy of the great vessels.

Follow-up after gastrectomy for cancer: the Charter Scaligero Consensus Conference

PURPOSE

Presently, there is no scientific evidence supporting a definite role for follow-up after gastrectomy for cancer, and clinical practices are quite different around the globe. The aim of this consensus conference was to present an ideal prototype of follow-up after gastrectomy for cancer, based on shared experiences and taking into account the need to rationalize the diagnostic course without losing the possibility of detecting local recurrence at a potentially curable stage.

METHODS

On June 19-22, 2013 in Verona (Italy), during the 10th International Gastric Cancer Congress (IGCC) of the International Gastric Cancer Association, a consensus meeting was held, concluding a 6-month, Web-based, consensus conference entitled "Rationale of oncological follow-up after gastrectomy for cancer."

RESULTS

Forty-eight experts, with a geographical distribution reflecting different health cultures worldwide, participated in the consensus conference, and 39 attended the consensus meeting. Six statements were finally approved, displayed in a plenary session and signed by the vast majority of the 10th IGCC participants. These statements are attached as an annex to the Charter Scaligero on Gastric Cancer.

CONCLUSION

After gastrectomy for cancer, oncological follow-up should be offered to patients; it should be tailored to the stage of the disease, mainly based on cross-sectional imaging, and should be discontinued after 5 years.

Cross-sectional imaging of thoracic and abdominal complications of cerebrospinal fluid shunt catheters

This study aims to review the imaging findings of distal (thoracic and abdominal) complications related to ventriculo-peritoneal (VP), ventriculo-pleural (VPL), and ventriculo-atrial (VA) cerebrospinal fluid (CSF) shunt catheter placement. Institution review board-approved single-center study of patients with thoracic and abdominal CSF catheter-related complications on cross-sectional imaging examinations over a 14-year period was performed. Clinical presentation, patient demographics, prior medical history, and subsequent surgical treatment were recorded. The presence or absence of CSF catheter-related infection and/or acute hydrocephalus on cross-sectional imaging was also recorded. There were 81 distal CSF catheter-related complications identified on 47 thoracic or abdominal imaging examinations in 30 patients (age 5-80 years, mean 39.3 years), most often on CT (CT = 42, MRI = 1, US = 4). Complications included 38 intraperitoneal and 11 extraperitoneal fluid collections. Extraperitoneal collections included nine abdominal wall subcutaneous (SC) pseudocysts associated with shunt migration and obesity, an intrapleural pseudocyst, and a breast pseudocyst. There were also two large VPL-related pleural effusions, a fractured catheter in the SC tissues, and a large VA shunt thrombus within the right atrium. Ten patients (33.3 %) had culture-positive infection from CSF or shunt catheter samples. Ten patients (33.3 %) had features of temporally related acute or worsening hydrocephalus on neuroimaging. In four of these patients, the detection of thoracic and abdominal complications on CT preceded and predicted the findings of acute hydrocephalus on cranial imaging. Thoracic and abdominal complications of CSF shunts, as can be identified on CT, include shunt infection and/or obstruction, may be both multiple and recurrent, and may be predictive of concurrent acute intracranial problems.

Traumatic and non-traumatic adrenal emergencies

Multiple traumatic and non-traumatic adrenal emergencies are occasionally encountered during the cross-sectional imaging of emergency department patients. Traumatic adrenal hematomas are markers of severe polytrauma, and can be easily overlooked due to multiple concomitant injuries. Patients with non-traumatic adrenal emergencies usually present to an emergency department with a non-specific clinical picture. The detection and management of adrenal emergencies is based on cross-sectional imaging. Adrenal hemorrhage, adrenal infection, or rupture of adrenal neoplasm require immediate detection to avoid dire consequences. More often however, adrenal emergencies are detected incidentally in patients being investigated for non-specific acute abdominal pain. A high index of suspicion is required for the establishment of timely diagnosis and to avert potentially life-threatening complications. We describe cross-sectional imaging findings in patients with traumatic and non-traumatic adrenal hemorrhage, adrenal infarctions, adrenal infections, and complications of adrenal masses.

The growth rate of "clinically significant" renal cancer

Surveillance studies of enhancing renal masses report on a mean tumor growth rate of about 0.3 cm/year. In most of these studies however, only small tumors in elderly patients were followed. In the current report, we attempt to evaluate the growth rate of “clinically significant” renal carcinomas defined as tumors that were treated immediately upon diagnosis. 46 patients (mean age 64 years SD 11 years) were treated for renal carcinoma. All had a cross-sectional imaging studies performed 6–60 months prior to diagnosis of kidney cancer demonstrating no tumor. Tumor growth rate was calculated by dividing tumor’s largest diameter by the time interval between the normal kidney imaging and diagnosis of renal cancer. Mean tumor diameter was 4.5 cm (SD 2.4 cm). Mean time period from the normal imaging to diagnosis of renal cancer was 33.6 months (SD 18 months). According to the proposed model, the average growth rate of “clinically significant” renal carcinomas was 2.13 cm/year (SD 1.45, range 0.2–6.5 cm/year). Tumor growth rate correlated inversely with patient’s age (p = 0.007). Patient gender or Fuhrman’s grade did not correlate however. The growth rate of “clinically significant” renal cancer appears to be higher than the rate reported in surveillance trials. Renal tumors tend to grow faster in young patients. As such, variable growth rate should be taken into account when considering active surveillance in young patients and when designing trials for evaluation of anti-cancer agents.

The effects of changes in utilization and technological advancements of cross-sectional imaging on radiologist workload

RATIONALE AND OBJECTIVES

To examine the effect of changes in utilization and advances in cross-sectional imaging on radiologists' workload.

MATERIALS AND METHODS

All computed tomography (CT) and magnetic resonance imaging (MRI) examinations performed at a single institution between 1999 and 2010 were identified and associated with the total number of images for each examination. Annual trends in institutional numbers of interpreted examinations and images were translated to changes in daily workload for the individual radiologist by normalizing to the number of dedicated daily CT and MRI work assignments, assuming a 255-day/8-hour work day schedule. Temporal changes in institutional and individual workload were assessed by Sen's slope analysis (Q = median slope) and Mann-Kendall test (Z = Z statistic).

RESULTS

From 1999 to 2010, a total of 1,517,149 cross-sectional imaging studies (CT = 994,471; MRI = 522,678) comprising 539,210,581 images (CT = 339,830,947; MRI = 199,379,634) were evaluated at our institution. Total annual cross-sectional studies steadily increased from 84,409 in 1999 to 147,336 in 2010, representing a twofold increase in workload (Q = 6465/year, Z = 4.2, P < .0001). Concomitantly, the number of annual departmental cross-sectional images interpreted increased from 9,294,140 in 1990 to 94,271,551 in 2010, representing a 10-fold increase (Q = 8707876/year, Z = 4.5, P < .0001). Adjusting for staffing changes, the number of images requiring interpretation per minute of every workday per staff radiologist increased from 2.9 in 1999 to 16.1 in 2010 (Q = 1.7/year, Z = 4.3, P < .0001).

CONCLUSIONS

Imaging volumes have grown at a disproportionate rate to imaging utilization increases at our institution. The average radiologist interpreting CT or MRI examinations must now interpret one image every 3-4 seconds in an 8-hour workday to meet workload demands.

Small bowel imaging of inflammatory bowel disease

The study of the small bowel (SB) has always been challenging both for clinicians and radiologist. It is a long and tortuous tube that can be affected by various pathologies whose signs and symptoms are usually non specific and can mimic other acute abdominal disorders. For these reasons, imaging plays a central role in the diagnosis of the different pathological conditions that can occur. They are important also in the management and follow up of chronic diseases. We expose and evaluate all the radiological methods that are now available for the study of the SB with particular emphasis on the technological improvement of cross-sectional imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI). These techniques have, infact, highly improved in terms of execution times (fast acquisitions images), patients discomfort and radiation dose, for CT, with consequent reduced biological risks. Moreover, the new post-processing options with multiplanar reconstruction and isotropic images have made significant changes in the evaluation of the exams. Especially MRI scans have been improved by the advent of new sequences, such as diffusion weighted imaging and cine-MRI, parallel imaging and breath-hold sequences and can provide excellent soft-tissue contrast without the use of ionizing radiations.

Management of Incidental Pancreatic Cystic Lesions

BACKGROUND

Pancreatic cystic lesions (PCL) are common. They are increasingly detected as an incidental finding of transabdominal ultrasound or cross-sectional imaging. In contrast to other parenchymal organs, dysontogenetic pancreatic cysts are extremely rare. In symptomatic patients the most frequent PCL are acute and chronic pseudocysts. The majority of incidental cystic lesions, however, are neoplasias which have different risks of malignancy.

METHODS

PubMed was searched for studies, reviews, meta-analyses, and guidelines using the following key words: ('pancreatic cystic lesions' OR 'cystic pancreatic lesions' OR 'intraductal papillary mucinous neoplasia' OR 'mucinous cystic neoplasia' OR 'pancreatic cyst' OR 'pancreatic pseudocyst') AND (management OR treatment OR outcome OR prognosis OR diagnosis OR imaging OR 'endoscopic ultrasound' EUS-FNA OR EUS OR 'endoscopic ultrasonography' OR CT OR MRI). Retrieved papers were reviewed with regard to the diagnostic and therapeutic management of incidental PCL.

RESULTS

In addition to clinical criteria, transabdominal ultrasonography including contrast-enhanced ultrasonography, cross-sectional radiological imaging, and endoscopic ultrasound (EUS) are used for diagnostic characterization and risk assessment. EUS plays an outstanding role in differential diagnosis and prognostic characterization of incidental PCL. In a single examination it is possible to perform high-resolution morphological description, perfusion imaging, as well as fine-needle aspiration of cyst content, cyst wall, and solid components. An international consensus guideline has defined worrisome and high-risk criteria for the risk assessment of mucinous pancreatic cysts, which are mainly based on the results of EUS and cross-sectional imaging. Nevertheless, despite diagnostic progress and guideline recommendations, differential diagnosis and management decisions remain difficult. This review will discuss problems in and approaches to the diagnosis of incidental PCL.

CONCLUSION

An evidence-based algorithm for the diagnosis of incidental PCL is proposed.

Choice of diagnostic and therapeutic imaging in periodontics and implantology

Imaging forms an integral component for diagnosis of dental and in specific periodontal diseases. To date, intra-oral radiographic techniques are the main non-invasive diagnostic aids for the detection and assessment of internal changes in mineralized periodontal tissues like alveolar bone. These analog radiographic techniques suffer from inherent limitations like: Two dimensional projection, magnification, distortion, superimposition and misrepresentation of anatomic structures. The evolution of novel imaging modalities, namely cone beam computed tomography, tuned aperture CT empowered dental researchers to visualize the periodontium three dimensionally. This improves interpretation of structural and biophysical changes, ensures densitometric assessments of dentoalveolar structures including variations in alveolar bone density, and peri-implant bone healing more precisely. This detailed review, highlights current leading edge concepts, envisions a wide range of imaging modalities which pave the way for better understanding and early intervention of periodontal diseases.

Cross-sectional imaging work-up of adrenal masses

Advances in medical imaging with current cross-section modalities enable non-invasive characterization of adrenal lesions. Computed tomography (CT) provides characterization with its non-contrast and wash-out features. Magnetic resonance imaging (MRI) is helpful in further characterization using chemical shift imaging (CSI) and MR spectroscopy. For differentiating between benign and malignant masses, positron emission tomography (PET) imaging is useful with its qualitative analysis, as well as its ability to detect the presence of extra-adrenal metastases in cancer patients. The work-up for an indeterminate adrenal mass includes evaluation with a non-contrast CT. If a lesion is less than 10 Hounsfield Units on a non-contrast CT, it is a benign lipid-rich adenoma and no further work-up is required. For the indeterminate adrenal masses, a lipid-poor adenoma can be differentiated from a metastasis utilizing CT wash-out features. Also, MRI is beneficial with CSI and MR spectroscopy. If a mass remains indeterminate, PET imaging may be of use, in which benign lesions demonstrate low or no fluorodeoxyglucose activity. In the few cases in which adrenal lesions remain indeterminate, surgical sampling such as percutaneous biopsy can be performed.

PET/CT in Gynecologic Cancer: Present Applications and Future Prospects-A Clinician's Perspective

This article briefly reviews the epidemiology, diagnosis, and treatment of the common gynecologic malignancies, with an emphasis on the shortcomings of current clinical practice. The persistent need to achieve early diagnosis, adjust proper treatment, enhance surveillance, and improve the outcome of these patients has led to the development of new diagnostic modalities. Novel tools such as 18F-fluorodeoxyglucose PET/CT should aim at enhancing the clinician's ability to make critical decisions in treating difficult scenarios.