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May 2017 Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ May 2017
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    • “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”


      Interpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • “It is postulated that when analyzing a radiologic study, there is rapid identi cation of abnormalities using peripheral vision with subsequent scrutiny utilizing central vision. Radiologists compare this “gist” impression with information contained in long-term memory that forms the viewer’s cognitive schema (or expectations) of what information is in an image. This rapid response is shown when a radiologist identifies subtle abnormalities on mammography and chest radiography in only 250 ms.”

      
Interpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • “Differences in attentional processing explain the variations in search patterns between experts and novices. Expert radiologists know where to look for nodules, which limits inspection of many irrelevant areas. Other regions may not be scrutinized because they lack concerning preattentive attributes.”
I

      nterpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”


      Interpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • “A long-recognized method to reduce error in interpretation is to have “ films interpreted independently by two readers”. Double reading is not practiced consistently in the United States because it is time-consuming and the second read is not reimbursed. Because of the time commitment and lack of financial compensation, double reading should be reserved for complex cases in which a second opinion will provide a substantial benefit. Furthermore, the process must be rapid, and mechanisms to reconcile discrepancies between readers should be clearly defined.”

      
Interpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • “Computer-aided detection (CAD) refers to pattern recognition software that ags suspicious features on an image in an attempt to decrease false-negative readings.The radiologist reviews the examination and the CAD-marked areas of concern before issuing a final .CAD systems do not mark all actionable findings; therefore, the absence of a CAD mark on a finding should not preclude evaluation. In addition, current CAD systems generate more false findings than true findings. The radiologist must determine whether a CAD mark warrants further. The difficulty in discriminating between true- and 
false-positive marks is the biggest current challenge in CAD software. CAD is currently used and studied most widely in mammography but is also used in chest imaging and other modalities.”


      Interpretive Error in Radiology 
Waite S et al.
 AJR 2017; 208:739–749
    • Skeletal bone age assessment is a common clinical practice to investigate endocrinology, genetic and growth disorders in children. It is generally performed by radiological examination of the left hand by using either the Greulich and Pyle (G&P) method or the Tanner-Whitehouse (TW) one. However, both clinical procedures show several limitations, from the examination effort of radiologists to (most importantly) significant intra- and inter-operator variability. To address these problems, several automated approaches (especially relying on the TW method) have been proposed; nevertheless, none of them has been proved able to generalize to different races, age ranges and genders. In this paper, we propose and test several deep learning approaches to assess skeletal bone age automatically; the results showed an average discrepancy between manual and automatic evaluation of about 0.8 years, which is state-of-the-art performance.

      
Deep learning for automated skeletal bone age assessment in X-ray images.
Spampinato C  et al.
Med Image Anal. 2017 Feb;36:41-51

    • “In this paper, we propose and test several deep learning approaches to assess skeletal bone age automatically; the results showed an average discrepancy between manual and automatic evaluation of about 0.8 years, which is state-of-the-art performance. Furthermore, this is the first automated skeletal bone age assessment work tested on a public dataset and for all age ranges, races and genders, for which the source code is available, thus representing an exhaustive baseline for future research in the field. Beside the specific application scenario, this paper aims at providing answers to more general questions about deep learning on medical images: from the comparison between deep-learned features and manually-crafted ones, to the usage of deep-learning methods trained on general imagery for medical problems, to how to train a CNN with few images.”

      
Deep learning for automated skeletal bone age assessment in X-ray images.
Contrast

    • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”


      Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
    • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”


      Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
    • ”Utilizing a BMI threshold of 25 for adult men, and 30 for adult women, to administer oral contrast for abdominal and pelvic CT scan in ED patients appears to be a reasonable solution to facilitate shorter ED stays, while maintaining the diagnostic quality of CT scans, and reducing the need for repeat examination. While ED time constraints have certainly modified our current practice, taking action based on priorities has provided a reasonable approach based on demographics of our patient population.”


      Oral contrast administration for abdominal and pelvic CT scan in emergency setting: is there a happy medium?
Sokhandon, F. 
Abdom Radiol (2017) 42: 784. doi:10.1007/s00261-016-0969-3
Kidney

    • “Fat retention in the bladder after partial nephrectomy can be observed using CT, although it is relatively rare. It is clinically asymptomatic and disappears spontaneously in most cases.”


      CT detection of fat retention in the bladder after partial nephrectomy
 Kazaoka, J., Kusakabe, M., Ottomo, T. et al. 
Abdom Radiol (2017). doi:10.1007/s00261-017-1117-4
    • Fat Retention in the Bladder: Causes
      • Chyluria
      • Transurethral inlection of oil or lubricants
      • Iatrogenic
      • Filariasis
      • s/p Partial Nephrectomy
    • “Partial nephrectomy is clearly indicated in the guidelines as the standard operative procedure for small renal cell carcinoma, and it shows no difference in long-term cancer control when compared with radical nephrectomy . In a previous study investigating the complications associated with partial nephrectomy and radical nephrectomy, the number of complications associated with the genitourinary system (mostly urinary leakage) was significantly higher in the partial nephrectomy group, although there was no significant difference in the overall incidence of complications between the two groups. Other than urinary leakage, perinephric abscess, acute renal failure, retroperitoneal hemorrhage, and pseudoaneurysm formation are the known complications of partial nephrectomy.”


      CT detection of fat retention in the bladder after partial nephrectomy
 Kazaoka, J., Kusakabe, M., Ottomo, T. et al. 
Abdom Radiol (2017). doi:10.1007/s00261-017-1117-4
    • Partial Nephrectomy: Complications
      • urinary leakage
      • perinephric abscess
      • acute renal failure
      • retroperitoneal hemorrhage
      • pseudoaneurysm formation
      • chyluria
    • “Although renal infarcts are common after FEVAR, the clinical relevance of these events appears to be limited, with less than one-quarter of patients with renal infarcts experiencing a decline in renal function.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890 



    • “Renal ischemia remains a known compli- cation of FEVAR, with clinical studies showing variable rates of renal impairment after FEVAR of juxtarenal abdominal aortic aneurysms. Studies show that 11– 35% of patients experience a transient increase in serum creatinine levels (defined as a > 30% increase in serum creatinine level), and 0–4% of patients require temporary or permanent dialysis.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

    • “Our data show a gradual mild increase in baseline serum creatinine level in all patients undergoing FEVAR, regardless of whether the patient had a renal infarct. This nding mirrors a recent study from France , which found an increase in serum creatinine level during the first week after FEVAR.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

    • “Although the presence of renal infarct af- ter FEVAR is relatively common in our pa- tient population, it seems to carry little clini- cal relevance. This information is useful to interpreting radiologists when determining the urgency to report such findings, as well as when explaining the clinical relevance to referring clinicians and to patients undergo- ing FEVAR.” 


      Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

    • “Fat retention in the bladder was found in 5 patients (5.4%) after partial nephrectomy, but was not observed in any patients after total nephrectomy. No fat retention was seen immediately after partial nephrectomy (4–8 days), but occurred 2–15 months after the surgery. Subsequently, intravesical fat retention disappeared in 3 patients (8, 24, and 16 months later), and it persisted from 19–22 months after surgery in the remaining 2 patients. Collecting system repair occurred in 25 patients (27%) with partial nephrectomy. There was no statistically significant association between fat retention in the bladder and intraoperative collecting system repair (p = 0.12). The association with intravesical fat retention was not significant for either tumor size, distance to the collecting system, or the R.E.N.A.L. Nephrometry Score.”


      CT detection of fat retention in the bladder after partial nephrectomy
 Kazaoka, J., Kusakabe, M., Ottomo, T. et al. 
Abdom Radiol (2017). doi:10.1007/s00261-017-1117-4
    • Renal Cell Carcinoma: Factoids
      • RCC accounts for 85% of renal cancers
      • 210,000 new cases of RCC are diagnosed yearly
      • Clear cell accounts for 70-80% of RCCs, followed by papillary which is 14-17% and chromophobe RCC accounts for 4-8%
      • Clear cell is most likely to metastasize
      • Oncocytomas account gfot up too 4% of lesions
    • “Homogeneous simple renal cysts can have mean attenuation values of up to 30 HU, as determined by contrast-enhanced CT, whereas homogeneous RCCs have mean attenuation values as low as 42 HU, with no overlap occurring between the two groups. These data suggest that further evaluation of a homogeneous renal mass with a mean attenua- tion value of 30 HU or less on a contrast-enhanced CT scan likely is unwarranted.”


      Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
    • “A total of 116 heterogeneous renal cell carcinomas (RCCs) (99 clear cell, four papillary, four oncocytic, seven chromophobe, and two unclassi ed RCCs), 13 homogeneous RCCs (10 papillary, two oncocytic, and one chromophobe RCC), and 24 cysts (all of which were homogeneous) were evaluated. All homogeneous RCCs had mean attenuation values of more than 42 HU, whereas renal cysts had mean attenuation values of up to 30 HU (p < 0.001). Two readers qualitatively and identically categorized all RCCs as homogeneous or heterogeneous (κ = 1.0; p < 0.001).”


      Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
    • “In most cases, simple renal cysts can be easily diagnosed and dismissed as benign. In general, simple renal cysts have simple uid attenuation (0– 20 HU), are homogeneous, have a hairline thin smooth wall or an imperceptible wall, and do not enhance after administration of a contrast agent.”


      Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
    • “A study of more than 11,000 simple renal cysts evaluated with unenhanced CT sup- ported the use of unenhanced CT as long as the mass is homogeneous in attenuation, has an attenuation value between –10 and 20 HU, 
has a hairline thin wall, and does not contain septa, nodules, or calcification.”

      
Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
    • “The present study shows that homoge- neous simple renal cysts can have a mean attenuation value of up to 30 HU on contrast- enhanced CT, whereas homogeneous RCCs have a mean attenuation value as low as 42 HU, and there was no overlap noted between these two groups.”


      Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
    • “In conclusion, the present study shows that homogeneous simple renal cysts can have a mean attenuation value of up to 30 HU on contrast-enhanced CT, whereas homogeneous RCCs can have a mean attenuation value as low as 42 HU, with no overlap occurring between these two groups. Simple renal cysts may have a mean attenuation value of greater than 20 HU on contrast-enhanced CT and are currently considered to be incompletely characterized, and the data in the present study suggest that if a homogeneous renal mass has a mean attenuation value of 30 HU or less, further evaluation likely is not warranted.”


      Differentiating Renal Neoplasms From Simple Cysts on Contrast- Enhanced CT on the Basis of Attenuation and Homogeneity 
Agochukwu N et al
AJR 2017; 208:801–804
Liver

    • “The liver is the largest organ in the adult human body, weighing approximately 1.5 kg. It is divided into eight independent segments on the basis of the fact that each segment has a separate vascular inflow and outflow. The hepatic inflow consists of the hepatic artery and portal vein in the center of each hepatic segment, and the outflow consists of the hepatic veins in the periphery of the segment. The portal vein, which supplies 75% of the blood supply to the liver, provides deoxygenated blood that has drained from the spleen, pancreas, and gastrointestinal tract. The hepatic artery, a branch of the celiac artery, supplies 25% of the blood to the liver and provides the liver with oxygenated blood.”

      
A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “The portal vein and hepatic artery each divide into right and left lobar branches, which further divide into segmental, then lobular branches. The smallest portal vein and hepatic artery branches are located at the corners of hepatic lobules. The hexagonal hepatic lobules represent the small microscopic units of the liver. Each lobule is formed of radiating hepatocytes and many specialized capillaries, known as sinusoids. In the sinusoids, the blood is processed by hepatocytes, which can absorb or release nutrients and metabolize toxic chemicals. Deoxygenated blood flows out of the lobules through the central veins (located at the center of each lobule) to, in order, the hepatic veins, IVC, and right atrium.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “Portal vein thrombosis can be seen with many conditions, including cirrhosis, abdominal tumors, intraabdominal inflammatory processes such as Crohn disease, diverticulitis and appendicitis, hypercoagulable states, and trauma . Recently, portal vein thrombosis was found to be associated with metabolic syndrome, especially with central abdominal obesity. A thrombus may be either bland or tumoral, with venous invasion from adjacent malignancies.”

      
A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “Transient hepatic attenuation differences (THADs) and THIDs refer to perfusional changes usually resulting from portal venous occlusion, with THAD being seen at CT and THID at MR imaging. These perfusional changes generally appear as segmental wedge-shaped areas of enhancement during the arterial phase, which become isoattenuating/isointense during the portal venous phase. This results from an increase in hepatic arterial inflow in response to decreased portal venous flow, resulting in relative hyperenhancement during arterial-phase imaging. Causes of THAD and THID include bland and tumor thrombi, extrinsic compression (such as from adjacent tumors), surgical ligation, flow diversion from shunts or anomalous blood supply, and inflammation of the biliary ducts or adjacent organs.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “A portal venous aneurysm, or varix, is a localized fusiform or saccular dilatation of the portal vein measuring greater than 2 cm in diameter. This cutoff was derived from a sonographic study by Doust and Pearce in which no portal vein measured more than 1.5 cm in diameter in patients with healthy livers, or more than 1.9 cm in patients with cirrhotic livers. Intrahepatic portal veins are considered to be aneurysmal when there is a diameter of greater than 0.7 cm in a patient with a healthy liver and 0.85 cm in a patient with a cirrhotic liver. The extrahepatic portal vein is the most commonly involved vein in the portal venous system to form aneurysms, followed by the splenomesenteric venous confluence, intrahepatic portal vein, splenic vein, superior mesenteric vein, and inferior mesenteric vein. Although a portal venous aneurysm is often incidentally discovered during imaging, the most common presentation is abdominal pain . Complications of aneurysms include thrombosis, compression of the biliary tree or duodenum, and rupture.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “The most common cause of portal venous gas is bowel ischemia, which can result from arterial or venous mesenteric thrombosis, hypoperfusion, aortic dissection, embolic disease, or intestinal obstruction. Bowel distention and intra-abdominal sepsis have also been implicated as sources of portal venous gas . At CT, portal venous gas appears as linear branches of air coursing in the expected location of the portal venous system to the periphery of the liver . The feature of peripheral branching air at CT helps differentiate portal venous gas from pneumobilia, which typically is more central. The sonographic appearance of portal venous gas is multiple tiny high-amplitude transient intraluminal echogenic foci, resulting in characteristic high-amplitude spikes at Doppler spectral analysis. The air bubbles in the portal vein are strong acoustic reflectors, which cause blooming of the color flow in the portal vein and are noted to move during real-time imagings.”

      
A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • Portal Vein Thrombosis: Causes
      • cirrhosis
      • abdominal tumors
      • intraabdominal inflammatory processes such as Crohn disease, diverticulitis and appendicitis
      • hypercoagulable states
      • trauma
    • Portal Venous Air: Causes
      • bowel ischemia, which can result from arterial or venous mesenteric thrombosis, hypoperfusion, aortic • dissection, embolic disease, or intestinal obstruction
      • bowel distention
      • intra-abdominal sepsis
    • “Gallstone ileus (GI) represents a small percentage (0.4–5%) of a range of causes of mechanical intestinal bowel obstruction. It predominantly affects the elderly patient population; 25% are adults over 65 years old. It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1. Cases of GI have been reported in as young as 13 years old up to the oldest of 91 years old. Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30%. This is mainly due to the patient’s demographics and delayed diagnosis or misdiagnosis.”


      Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
    • Gallstone Ileus: Facts
      • It predominantly affects the elderly patient population; 25% are adults over 65 years old.
      • It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1.
      • Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30% [
    • “Mirizzi syndrome refers to hepatic duct obstruction due to extrinsic compression by impacted stone in the neck of gallbladder or cystic duct. As a natural sequel of disease, the stone can erode into adjacent gastrointestinal tract, forming cholecystoenteric fistula such as cholecystoduodenal, cholecysto-gastric, or cholecysto-colonic fistula. The fistula thus provides an exit route for the gallstones leading to the development of GI.”


      Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
    • “Bouveret’s syndrome is another subtype of GI, which is gastric outlet obstruction secondary to impaction of gallstone in the pylorus or proximal duodenum. Its occurrence is rare comprising only 1–3% of all cases of GI. It occurs as a result of large gallstone eroding through the gallbladder into the duodenum causing gastroduodenal obstruction and cholecystoduodenal fistulation. Other reported sites of impacted stone are around the gallbladder fossa and stomach. The size of the gallstone is slightly larger than the classic GI, measuring about 4.5 cm.”


      Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
    • Primary Liver Tumors: Facts
    • Hepatoma: Frequency
    • Hepatoma: SEER Data
    • Hepatoma: SEER Data
    • Hepatoma: Facts
    • “Recurrence of HCC reduces survival rates in patients treated with surgery, and one of the most relevant risk factors for tumour recurrence is microvascular invasion (mVI). The identification of mVI on preoperative examinations could improve surgical planning's and techniques so as to reduce the risk of tumour recurrence. During our study, we have revised 101 CT examinations of the liver performed on patients diagnosed with solitary HCC who had surgical treatment and pathological analysis of the specimens for mVI in order to detect CT signs which could be reliable in mVI prediction. On CT examinations, the tumours were evaluated for margins, capsule, size, contrast enhancement, halo sign and Thad. From our statistical analysis, we found out that irregularity in tumour margins and defects in peritumoural capsule are the most significant characteristics predicting mVI in HCC. Every report on CT examinations performed on surgical candidate patients should include suggestions about mVI probability in order to tailor procedures, reduce tumour recurrence risk and improve survival rates.”


      Vascular microinvasion from hepatocellular carcinoma: CT findings and pathologic correlation for the best therapeutic strategies.
Reginelli A et al.
Med Oncol. 2017 May;34(5):93

    • “Recurrence of HCC reduces survival rates in patients treated with surgery, and one of the most relevant risk factors for tumour recurrence is microvascular invasion (mVI). The identification of mVI on preoperative examinations could improve surgical planning's and techniques so as to reduce the risk of tumour recurrence. During our study, we have revised 101 CT examinations of the liver performed on patients diagnosed with solitary HCC who had surgical treatment and pathological analysis of the specimens for mVI in order to detect CT signs which could be reliable in mVI prediction. On CT examinations, the tumours were evaluated for margins, capsule, size, contrast enhancement, halo sign and Thad. From our statistical analysis, we found out that irregularity in tumour margins and defects in peritumoural capsule are the most significant characteristics predicting mVI in HCC.”


      Vascular microinvasion from hepatocellular carcinoma: CT findings and pathologic correlation for the best therapeutic strategies.
Reginelli A et al.
Med Oncol. 2017 May;34(5):93

Musculoskeletal

    • Sclerotic Metastases to the Spine: Differential Diagnosis
      • Prostate cancer
      • Breast cancer
      • Carcinoid tumor and other neuroendocrine tumors
      • Mucinous adenocarcinoma of the GI tract
      • Lymphoma
      • Neuroblastoma
Pancreas

    • “Lymphoepithelial cyst (LEC) of the pancreas is a rare, non-neoplastic lesion composed of keratinizing squamous epithelial cells and lymphoid tissue. Prospective diagnosis of LEC remains challenging due to paucity of data in the literature, its non-specific imaging, and the presence of cytologic features that overlap with other cystic pancreatic lesions. Preoperative diagnosis of LEC is of considerable interest since it can spare the patient an unnecessary operation.”


      Lymphoepithelial cyst of pancreas: spectrum of radiological findings with pathologic correlation
 Borhani, A.A., Fasanella, K.E., Iranpour, N. et al. Abdom Radiol (2017) 42: 877. doi:10.1007/s00261-016-0932-3
    • “Round shape, mild complexity, and exophytic location in pancreatic body and tail can be suggestive of LECs. These features however are not specific and may be seen with other cystic pancreatic lesions. CT findings should be used in conjunction with EUS, cytology, and tumor marker studies to secure the diagnosis of LEC.”


      Lymphoepithelial cyst of pancreas: spectrum of radiological findings with pathologic correlation
 Borhani, A.A., Fasanella, K.E., Iranpour, N. et al. Abdom Radiol (2017) 42: 877. doi:10.1007/s00261-016-0932-3
    • PURPOSE: To compare diagnostic performance for prediction of malignant potential in IPMNs between EUS, contrast-enhanced CT and MRI.

      CONCLUSION: Diagnostic performance of contrast-enhanced CT, MRI, and EUS for predicting malignant IPMNs was comparable with each modalities without significant difference.

      
Diagnostic performance and imaging features for predicting the malignant potential of intraductal papillary mucinous neoplasm of the pancreas: a comparison of EUS, contrast-enhanced CT and MRI.
Choi SY et al.
Abdom Radiol  2017 Jan 31. doi: 10.1007/s00261-017-1053-3. [Epub ahead of print]

    • RESULTS: Diagnostic performance of contrast-enhanced CT (AUC = 0.792 in R1, 0.830 in R2), MRI (AUC = 0.742 in R1, 0.776 in R2), and EUS (AUC = 0.733) for predicting malignant IPMNs were comparable without significant difference (p > 0.05). In multivariable analysis, enhancing solid component in contrast-enhanced CT and MRI and mural nodule in EUS (OR 1.8 in CT, 1.36 in MRI, 1.47 in EUS), MPD diameter ≥ 10 mm (OR 1.3 in CT, 1.4 in MRI, 1.66 in EUS), MPD diameter of 5-9 mm (OR 1.23 in CT, 1.31 in MRI), and thickened septa or wall (OR 1.3 in CT and MRI) were significant variables (p < 0.05). Interobserver agreement of thickened cyst septa or wall (k = 0.579-0.617) and abrupt caliber change of MPD (k = 0.689-0.788) was lower than other variables (k > 0.80).


      Diagnostic performance and imaging features for predicting the malignant potential of intraductal papillary mucinous neoplasm of the pancreas: a comparison of EUS, contrast-enhanced CT and MRI.
Choi SY et al.
Abdom Radiol  2017 Jan 31. doi: 10.1007/s00261-017-1053-3. [Epub ahead of print]

    • Solid and Papillary Epithelial  Neoplasm (SPEN): Demographics
      • Age range usually teens to late twenties
      • Females in the 2nd and 3rd decade with a mean age of 27 but a range of 8-72 years old
      • Female to male ration nearly 10-1
      • Clinical presentation commonly vague abdominal pain
      • It is most often a benign neoplasm, but 10–15% of the cases are malignant.
      • Long term outcome good with surgery and 5 year survival 95-100%
    • Solid and Papillary Epithelial  Neoplasm (SPEN): CT Findings
      • Average size is 5 cm but range is 1-10 cm
      • Cystic and Solid Mass with capsule common
      • Calcifications may be extensive especially around the border of the lesion
      • Calcifications present in up to one third of cases
      • Average size is 5 cm but range is 1-10 cm
      • Lesion location more common in the tail of the pancreas
    • Solid and Papillary Epithelial  Neoplasm (SPEN): Differential Diagnosis
      • Cystic Pancreatic Masses
            • Serous Cystadenoma (SC)
            • Mucinous Cystic Neoplasm (MCN)
            • Intraductal Papillary Mucinous Neoplasm (IPMN)
            • Cystic Neuroendocrine Neoplasms
      SPEN



      SC



      MCN





Practice Management

    • “In my field of marketing, stories are often more important than hard facts because a brand or company’s stories shape its reality. I believe a company’s destiny follows its story. Companies that want to increase their market share and change their destiny need to begin by sharing their story, and the story must be carefully crafted to instill in the viewer a sense of the character of the business, not just the product they sell.”


      The Power of Stories in Brands, Business, and Life 
Anna Griffin, BS, Madison B. Johnson, Elliot K. Fishman, MD, 
Karen M. Horton, MD, Pamela T. Johnson
JACR Volume 14, Issue 4, April 2017, Pages 573–574.
    • “A company’s story is not just a vehicle to sell its product, but can also be used to humanize the customer’s relationship with the organization. Some marketing campaigns have focused on sharing the personality of the company’s employees, which transforms the customer’s view of the company from a corporation to a consortium of talented, engaging individuals. The company is personalized by introducing the people who drive its operations as people rather than “divisions.” .

      ”
The Power of Stories in Brands, Business, and Life 
Anna Griffin, BS, Madison B. Johnson, Elliot K. Fishman, MD, 
Karen M. Horton, MD, Pamela T. Johnson
JACR Volume 14, Issue 4, April 2017, Pages 573–574.
    • “A radiology practice’s success hinges on attracting the best staff and providers. Recruitment campaigns should create marketing materials that incorporate images and video to best convey the character and the mission of the organization. People want to be part of organizations that have an important mission .”

      
The Power of Stories in Brands, Business, and Life 
Anna Griffin, BS, Madison B. Johnson, Elliot K. Fishman, MD, 
Karen M. Horton, MD, Pamela T. Johnson
JACR Volume 14, Issue 4, April 2017, Pages 573–574.
    • “Similarly, residency and fellowship training programs can engage medical student applicants with online video clips designed to illustrate the resident culture. One of the most common metrics that students describe in their decision-making process is “whether I feel like it’s a good fit.” Web-based resources that tell the story of life within a department can be very effective in the competitive recruitment arena. Additionally, telling the story of how other successful trainees have gone on to become leaders in the field is a powerful draw, because it could become the applicant’s story.”

      
The Power of Stories in Brands, Business, and Life 
Anna Griffin, BS, Madison B. Johnson, Elliot K. Fishman, MD, 
Karen M. Horton, MD, Pamela T. Johnson
JACR Volume 14, Issue 4, April 2017, Pages 573–574.
Small Bowel

    • “For both GIST and NET, the mean attenuation values of the tumors were significantly higher than those of adenocarcinoma and lymphoma in both the arterial and enteric phases (all p-values < 0.05). The mean attenuation value of GIST was significantly higher than that of metastases in both the arterial (p = 0.041) and enteric phases (p = 0.000199). The mean attenuation value of NET was significantly higher than that of metastases in the enteric phase (p = 0.000199).”


      Small bowel neoplasms: enhancement patterns and differentiation using post-contrast multiphasic multidetector CT
 Shinya, T., Inai, R., Tanaka, T. et al. 
Abdom Radiol (2017) 42: 794. doi:10.1007/s00261-016-0945-y 

    • “The use of multiphasic threshold levels led to an improvement in diagnostic accuracy; GIST could be discriminated from adenocarcinoma with an accuracy of 82.76%, GIST could be discriminated from lymphoma with an accuracy of 87.50%, and NET from adenocarcinoma with an accuracy of 92.00%.”


      Small bowel neoplasms: enhancement patterns and differentiation using post-contrast multiphasic multidetector CT
 Shinya, T., Inai, R., Tanaka, T. et al. 
Abdom Radiol (2017) 42: 794. doi:10.1007/s00261-016-0945-y 

    • “In conclusion, the mean CT attenuation values could potentially be useful to discriminate between the small bowel neoplasms with acceptable diagnostic capacities, using individual monophasic and multiphasic threshold levels on post-contrast multiphasic MDCT, particularly in the arterial phase, for the four primary small bowel neoplasms in this study. The results of our study suggest that there may be a consistent relationship between the enhancement pattern on post-contrast multiphasic MDCT and the histologic findings and that the multiphasic dynamic enhancement data could be a robust tool for the discrimination of small bowel neoplasms.”


      Small bowel neoplasms: enhancement patterns and differentiation using post-contrast multiphasic multidetector CT
 Shinya, T., Inai, R., Tanaka, T. et al. 
Abdom Radiol (2017) 42: 794. doi:10.1007/s00261-016-0945-y
    • “In summary, the Radiology department at NYU-Langone Medical Center has, through dialogue with our Emergency Medicine section, reaffirmed the benefits of oral contrast utilization for CT scanning of ED patients. We have found that stocking the oral contrast in the ED and allowing a 45-min period for oral contrast administration coordinated with obtaining clinical and laboratory information facilitate radiologic diagnosis with a high level of confidence and accuracy. As stated by JRD Tata, it is insistence on relentless attention to detail and insistence on highest standards of quality and performance that are the keys to productivity and efficiency, most certainly not through cutting corners.”


      Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
    • ”Utilizing a BMI threshold of 25 for adult men, and 30 for adult women, to administer oral contrast for abdominal and pelvic CT scan in ED patients appears to be a reasonable solution to facilitate shorter ED stays, while maintaining the diagnostic quality of CT scans, and reducing the need for repeat examination. While ED time constraints have certainly modified our current practice, taking action based on priorities has provided a reasonable approach based on demographics of our patient population.”


      Oral contrast administration for abdominal and pelvic CT scan in emergency setting: is there a happy medium?
Sokhandon, F. 
Abdom Radiol (2017) 42: 784. doi:10.1007/s00261-016-0969-3
    • “Gallstone ileus (GI) represents a small percentage (0.4–5%) of a range of causes of mechanical intestinal bowel obstruction. It predominantly affects the elderly patient population; 25% are adults over 65 years old. It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1. Cases of GI have been reported in as young as 13 years old up to the oldest of 91 years old. Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30%. This is mainly due to the patient’s demographics and delayed diagnosis or misdiagnosis.”


      Pictorial review: the pearls and pitfalls of the
 radiological manifestations of gallstone ileus
 Chuah, P.S., Curtis, J., Misra, N. et al. Abdom Radiol (2017) 42: 1169. doi:10.1007/s00261-016-0996-0
    • Gallstone Ileus: Facts
      • It predominantly affects the elderly patient population; 25% are adults over 65 years old.
      • It affects more commonly in the elderly female with an average age of 65–75 years and female–male ratio of 4–7:1.
      • Despite the rare incidence, it carries a mortality and morbidity rate of around 7–30% [
    • “Our Emergency physicians do not see that oral contrast administration for CT hampers operational efficiency; in fact, they have expressed gratitude to our department for care in diagnosis. They have stated that delays in patient turnaround are more frequently related to overall demand on the scanner and not to the oral contrast consumption period. They are all acutely aware of the serious consequences of missed or incorrect diagnoses (either leading to inappropriate hospital admission or discharge), and will always choose good medical care over time slashing, corner cutting methods that impress the dashboard monitors perhaps at the expense of excellence in patient care.”


      Oral contrast utilization for abdominal/pelvic CT scanning in today’s emergency room setting
 Megibow A.J. 
Abdom Radiol (2017) 42: 781. doi:10.1007/s00261-016-0941-2
Vascular

    • “The liver is the largest organ in the adult human body, weighing approximately 1.5 kg. It is divided into eight independent segments on the basis of the fact that each segment has a separate vascular inflow and outflow. The hepatic inflow consists of the hepatic artery and portal vein in the center of each hepatic segment, and the outflow consists of the hepatic veins in the periphery of the segment. The portal vein, which supplies 75% of the blood supply to the liver, provides deoxygenated blood that has drained from the spleen, pancreas, and gastrointestinal tract. The hepatic artery, a branch of the celiac artery, supplies 25% of the blood to the liver and provides the liver with oxygenated blood.”

      
A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “The portal vein and hepatic artery each divide into right and left lobar branches, which further divide into segmental, then lobular branches. The smallest portal vein and hepatic artery branches are located at the corners of hepatic lobules. The hexagonal hepatic lobules represent the small microscopic units of the liver. Each lobule is formed of radiating hepatocytes and many specialized capillaries, known as sinusoids. In the sinusoids, the blood is processed by hepatocytes, which can absorb or release nutrients and metabolize toxic chemicals. Deoxygenated blood flows out of the lobules through the central veins (located at the center of each lobule) to, in order, the hepatic veins, IVC, and right atrium.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “Portal vein thrombosis can be seen with many conditions, including cirrhosis, abdominal tumors, intraabdominal inflammatory processes such as Crohn disease, diverticulitis and appendicitis, hypercoagulable states, and trauma . Recently, portal vein thrombosis was found to be associated with metabolic syndrome, especially with central abdominal obesity. A thrombus may be either bland or tumoral, with venous invasion from adjacent malignancies.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “Transient hepatic attenuation differences (THADs) and THIDs refer to perfusional changes usually resulting from portal venous occlusion, with THAD being seen at CT and THID at MR imaging. These perfusional changes generally appear as segmental wedge-shaped areas of enhancement during the arterial phase, which become isoattenuating/isointense during the portal venous phase. This results from an increase in hepatic arterial inflow in response to decreased portal venous flow, resulting in relative hyperenhancement during arterial-phase imaging. Causes of THAD and THID include bland and tumor thrombi, extrinsic compression (such as from adjacent tumors), surgical ligation, flow diversion from shunts or anomalous blood supply, and inflammation of the biliary ducts or adjacent organs.”

      
A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “A portal venous aneurysm, or varix, is a localized fusiform or saccular dilatation of the portal vein measuring greater than 2 cm in diameter. This cutoff was derived from a sonographic study by Doust and Pearce in which no portal vein measured more than 1.5 cm in diameter in patients with healthy livers, or more than 1.9 cm in patients with cirrhotic livers. Intrahepatic portal veins are considered to be aneurysmal when there is a diameter of greater than 0.7 cm in a patient with a healthy liver and 0.85 cm in a patient with a cirrhotic liver. The extrahepatic portal vein is the most commonly involved vein in the portal venous system to form aneurysms, followed by the splenomesenteric venous confluence, intrahepatic portal vein, splenic vein, superior mesenteric vein, and inferior mesenteric vein. Although a portal venous aneurysm is often incidentally discovered during imaging, the most common presentation is abdominal pain . Complications of aneurysms include thrombosis, compression of the biliary tree or duodenum, and rupture.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “The most common cause of portal venous gas is bowel ischemia, which can result from arterial or venous mesenteric thrombosis, hypoperfusion, aortic dissection, embolic disease, or intestinal obstruction. Bowel distention and intra-abdominal sepsis have also been implicated as sources of portal venous gas . At CT, portal venous gas appears as linear branches of air coursing in the expected location of the portal venous system to the periphery of the liver . The feature of peripheral branching air at CT helps differentiate portal venous gas from pneumobilia, which typically is more central. The sonographic appearance of portal venous gas is multiple tiny high-amplitude transient intraluminal echogenic foci, resulting in characteristic high-amplitude spikes at Doppler spectral analysis. The air bubbles in the portal vein are strong acoustic reflectors, which cause blooming of the color flow in the portal vein and are noted to move during real-time imagings.”


      A Comprehensive Approach to Hepatic Vascular Disease
Khaled M. Elsayes et al.
RadioGraphics (in press)
    • “Some classic signs may help in this tough mission, including the Draped Aorta sign. It refers to posterior aortic bulging and consequent loss of the interface between the aortic posterior wall and/or when the aneurism wall closely follows the contour of the adjacent vertebral bodies and psoas muscle. This sign may also be associated with vertebral erosions and is indicative of impending AAA rupture.”


      The draped aorta sign of impending aortic aneurysm rupture
 Fonseca, E.K.U.N., e Castro, A..A., Tames, A..V.C. et al. Abdom Radiol (2017). doi:10.1007/s00261-017-1114-7
    • “Although renal infarcts are common after FEVAR, the clinical relevance of these events appears to be limited, with less than one-quarter of patients with renal infarcts experiencing a decline in renal function.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890 



    • “Renal ischemia remains a known compli- cation of FEVAR, with clinical studies showing variable rates of renal impairment after FEVAR of juxtarenal abdominal aortic aneurysms. Studies show that 11– 35% of patients experience a transient increase in serum creatinine levels (defined as a > 30% increase in serum creatinine level), and 0–4% of patients require temporary or permanent dialysis.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

    • “Our data show a gradual mild increase in baseline serum creatinine level in all patients undergoing FEVAR, regardless of whether the patient had a renal infarct. This nding mirrors a recent study from France , which found an increase in serum creatinine level during the first week after FEVAR.” 


      Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

    • “Although the presence of renal infarct af- ter FEVAR is relatively common in our pa- tient population, it seems to carry little clini- cal relevance. This information is useful to interpreting radiologists when determining the urgency to report such findings, as well as when explaining the clinical relevance to referring clinicians and to patients undergo- ing FEVAR.”

      
Incidence and Clinical Significance of Renal Infarct After Fenestrated Endovascular Aortic Aneurysm Repair 
Burke LMB et al.
AJR 2017; 208:885–890

© 1999-2017 Elliot K. Fishman, MD, FACR. All rights reserved.