Imaging Pearls ❯ July 2024
|
-- OR -- |
|
3D and Workflow
- “We performed cinematic rendering of a PET/CT performed with the PSMA-targeted radiotracer 18F-DCFPyL of a woman with oligometastatic clear cell renal cell carcinoma. The patient had radiotracer uptake in a discrete lesion in the left breast, which was highly conspicuous on the rendered images. In this case, the use of cinematic rendering allowed for the rapid identification and precise anatomical localization of the patient's site of disease. Although demonstrative of the potential of this reconstructive method for visualizing PET/CT data, further efforts are needed to define the role of cinematic rendering in clinical practice.”
Cinematic rendering of 18F-DCFPyL PET/CT fusion data in a patient with metastatic clear cell renal cell carcinoma.
Rowe SP, Krueger S, Gorin MA, Fishman EK.
BJUI Compass. 2024 Feb 4;5(6):548-550. doi: 10.1002/bco2.324. PMID: 38873347; PMCID: PMC11168768. - “When working with fused dataset, such as CT in combination with position emission tomography (PET), the task of cinematic rendering is more complex, as there is nothing intrinsic to distinguish between the two image types within the visualization. To solve this, our group recently developed a method to includeinternal lighting for PET data so that it has a visually distinctsignature from that of the CT data. This approach allows bothdatasets to be displayed as a combined rendering and provides aglobal overview of both abnormal PET uptake and its anatomic location.”
Cinematic rendering of 18F-DCFPyL PET/CT fusion data in a patient with metastatic clear cell renal cell carcinoma.
Rowe SP, Krueger S, Gorin MA, Fishman EK.
BJUI Compass. 2024 Feb 4;5(6):548-550. doi: 10.1002/bco2.324. PMID: 38873347; PMCID: PMC11168768. 
Cinematic rendering of 18F‐DCFPyL PET/CT fusion data in a patient with metastatic clear cell renal cell carcinoma
BJUI Compass, Volume: 5, Issue: 6, Pages: 548-550, First published: 04 February 2024, DOI: (10.1002/bco2.324)
Adrenal
- “Given the frequency with which adrenal nodules are identified, it is important to determine the optimal strategy for subsequent management. This study, along with others, suggests that adrenal-protocol CT may not be the best diagnostic test for homogeneous and heterogeneous nodules despite the current American College of Radiology recommendations. Recent clinical practice guidelines from the European Society of Endocrinology highlight the value of unenhanced attenuation as the best method for initial assessment. If a heterogeneous adrenal nodule is not diagnosed as an adenoma on unenhanced CT, the next step is uncertain but may be referral for endocrinology and biochemical workup rather than a reflexive recommendation for adrenal-protocol CT.”
Editorial Comment: CT With Adrenal-Washout Protocol Is Not Useful for Heterogeneous Nodules
Daniel I. Glazer
AJR 2024; 222:e2431086 - BACKGROUND. CT with adrenal-washout protocol (hereafter, adrenal-protocol CT) is commonly performed to distinguish adrenal adenomas from other adrenal tumors. However, the technique’s utility among heterogeneous nodules is not well established, and the optimal method for placing ROIs in heterogeneous nodules is not clearly defined.
OBJECTIVE. The purpose of our study was to determine the diagnostic performance of adrenal-protocol CT to distinguish adenomas from nonadenomas among heterogeneous adrenal nodules and to compare this performance among different methods for ROI placement.
Performance of CT With Adrenal-Washout Protocol in Heterogeneous Adrenal Nodules: A Multiinstitutional Study
Michael T. Corwin et al.
AJR 2024; 222:e2330769 - RESULTS. The nodules comprised 82 adenomas and 82 nonadenomas (36 pheochromocytomas, 20 metastases, 12 adrenocortical carcinomas, and 14 nodules with other pathologies). The mean nodule size was 4.5 Å} 2.8 (SD) cm (range, 1.6–23.0 cm). Unenhanced CT attenuation of 10 HU or less exhibited sensitivity and specificity for adenoma of 22.0% and 96.3% for standard-ROI, 11.0% and 98.8% for high-ROI, 58.5% and 84.1% for low-ROI, and 30.5% and 97.6% for average-ROI methods. Adrenal-protocol CT overall (unenhanced attenuation ≤ 10 HU or absolute washout of ≥ 60%) exhibited sensitivity and specificity for adenoma of 57.3% and 84.1% for the standard-ROI method, 63.4% and 51.2% for the high-ROI method, 68.3% and 62.2% for the low-ROI method, and 59.8% and 85.4% for the average-ROI method.
CONCLUSION. Adrenal-protocol CT has poor diagnostic performance for distinguishing adenomas from nonadenomas among heterogeneous adrenal nodules regardless of the method used for ROI placement.
CLINICAL IMPACT. Adrenal-protocol CT has limited utility in the evaluation of heterogeneous adrenal nodules.
Performance of CT With Adrenal-Washout Protocol in Heterogeneous Adrenal Nodules: A Multiinstitutional Study
Michael T. Corwin et al.
AJR 2024; 222:e2330769
Deep Learning
- “We found that experience-based radiologist characteristics, including years of experience, subspecialty in thoracic radiology and experience with AI tools, did not serve as reliable predictors of treatment effect, in terms of both calibration performance and discriminationperformance. These findings challenge the associations between experience-based radiologist characteristics and the treatment effect of AI assistance reported in previous research. The observed variability could be attributed to our larger and more diverse sample size, encompassing 140 radiologists with varying skill levels, experiences and preferences. Additionally, our study’s inclusion of a wide range of diagnostic tasks enables a robust examination of the complex factors influencing the treatment effect. Furthermore, the performance characteristics and quality of the specific AI system may play an important role, highlighting the need for developers to consider these factors when deploying AI assistance. To optimize the implementation of AI assistance, a comprehensive assessment of multiple factors, including the clinical task, patient population and AI system, is essential.”
Heterogeneity and predictors of the effects of AI assistance on radiologists
Feiyang Yu et al.
Nature Medicine | Volume 30 | March 2024 | 837–849 - “In conclusion, our study underscores the need for individualized approaches that are aware of clinician heterogeneity, high-quality AI models and comprehensive assessments of multiple factors to optimize the implementation of AI assistance in clinical medicine. Collaboration between clinicians and AI developers, focusing on personalized strategies and continuous improvement of AI models, will be essential for achieving the full potential of clinician–AI collaboration in healthcare.”
Heterogeneity and predictors of the effects of AI assistance on radiologists
Feiyang Yu et al.
Nature Medicine | Volume 30 | March 2024 | 837–849 - “Artificial Intelligence (AI) has emerged as a transformative force within medical imaging, making significant strides within emergency radiology. Presently, there is a strong reliance on radiologists to accurately diagnose and characterize foreign bodies in a timely fashion, a task that can be readily augmented with AI tools. This article will first explore the most common clinical scenarios involving foreign bodies, such as retained surgical instruments, open and penetrating injuries, catheter and tube malposition, and foreign body ingestion and aspiration. By initially exploring the existing imaging techniques employed for diagnosing these conditions, the potential role of AI in detecting non-biological materials can be better elucidated. Yet, the heterogeneous nature of foreign bodies and limited data availability complicates the development of computer-aided detection models. Despite these challenges, integrating AI can potentially decrease radiologist workload, enhance diagnostic accuracy, and improve patient outcomes.”
Artificial intelligence in the detection of non‑biological materials
Liesl Eibschutz et al.
Emergency Radiology (2024) 31:391–403 - “Many authors note that the risk of this complication decreases if institutions follow the recommended perioperative and postoperative checklists and guidelines. Yet over 80% of operations noted to have RSB reported correct counts at the end of the case. As most RSB have standardized shapes and sizes, computer-aided detection (CAD) systems can be highly effective for identification.”
Artificial intelligence in the detection of non‑biological materials
Liesl Eibschutz et al.
Emergency Radiology (2024) 31:391–403 - “Despite AI’s enormous potential in foreign body detection, current applications have thus far been in research settings, often training and validating models on devised images such as those with cadavers or fusion images. Before the widespread deployment of AI systems, these models must be trialed on natural datasets to ensure real-world clinical utility and performance. Though significant legal hurdles surrounding liability and tort law remain that may limit AI’s potential use, the ongoing advancements in the field augment its clinical utility and potential.”
Artificial intelligence in the detection of non‑biological materials
Liesl Eibschutz et al.
Emergency Radiology (2024) 31:391–403 - “Despite these challenges, the advancements in AI technology, coupled with collective efforts to obtain diverse and comprehensive datasets, offer a promising trajectory for the future of medical imaging in foreign body analysis. Further, the integration of AI in clinical practice has the potential to alleviate radiologist workload, enhance their efficiency, and reduce diagnostic errors. As the field of medical imaging continues to progress, the collaboration between AI and radiology may ultimately enhance diagnostic precision and patient care.”
Artificial intelligence in the detection of non‑biological materials
Liesl Eibschutz et al.
Emergency Radiology (2024) 31:391–403
- “I could help address urgent global health priorities, but the realization of this potential is contingent upon having data that represent those people, diseases, and geographies. Unfortunately, the current health data landscape does not reflect this. Evidence across health datasets (including in ophthalmology, dermatology, and radiology) has consistently highlighted that publicly accessible health data are heavily skewed toward just a few countries and exclude much of the world. In this issue of NEJM AI, we publish an article by Wu et al. demonstrating that this problem similarly exists in clinical text datasets, a topic of increasing importance as health care applications of large language models grow rapidly. In this article, we see 192 publicly available clinical text datasets originating from 14 countries and covering nine languages, yet they leave out Africa and Oceania entirely.”
A Global Health Data Divide
Xiaoxuan Liu et al.
NEJM AI 2024; 1 (6) - Accepting that global inequality and inequitable health care access are in equal parts pernicious and persistent, what needs to change if AI is to be part of the solution? Improving the availability of health care data that appropriately represent the individuals most in need must be a core priority. Having a diverse pool of health data globally is critical for fostering a research, development, and innovation ecosystem that is able to support a range of use cases. Moreover, investment is needed in both infrastructure and digital literacy to empower countries and their citizens, ensuring that data collection and AI development are focused on the most important use cases. We cannot afford to ignore the message emerging consistently from multiple reviews of available health datasets: that thereis a substantial global health data divide. Addressing this problem will be challenging, but this is essential to enabling AI health technologies that help those who need it most.
A Global Health Data Divide
Xiaoxuan Liu et al.
NEJM AI 2024; 1 (6)
- ”But the richness of medical images imperceptible to human eyes does not stop at the chest x-ray. For digital eyes, a chest CT encodes data for coronary artery disease risk with imputation of coronary calcium scores. One AI model has shown its superiority compared with radiologists for detecting pancreatic cancer from either chest CT or abdominal CT scans. Research is also assessing whether AI models and abdominal CTs can detect diabetes and predict cardiovascular risk. Beyond CT scans, mammography has information about risk of heart disease via presence of breast artery calcification.”
AI-enabled opportunistic medical scan interpretation.
Topol EJ.
Lancet. 2024 May 11;403(10439):1842. doi: 10.1016/S0140-6736(24)00924-3. PMID: 38735291. - ”Machine digital eyes can glean far more information from a scan than human experts can readily detect or accurately decipher. It may not be long before a chest x-ray report comes back with your risk of heart attack and stroke over the next decade, your coronary calcium score, your heart ejection fraction, the presence of leaky valve, and whether you have type 2 diabetes. Developments in artificial intelligence (AI) make this scenario likely in the coming years. This advance is an unanticipated, opportunistic output of deep learning AI.”
AI-enabled opportunistic medical scan interpretation.
Topol EJ.
Lancet. 2024 May 11;403(10439):1842. doi: 10.1016/S0140-6736(24)00924-3. PMID: 38735291. - ”The tip-off for much of this research came initially from use of AI tools with retinal images. Using AI, risks for some diseases that ophthalmologists cannot see—eg, risk of Parkinson’s disease, Alzheimer’s disease, hepatobiliary disease, kidney disease, heart attack, or stroke—became apparent. Similarly, what cardiologists cannot detect from an electrocardiogram—eg, risk of atrial fibrillation, heart attack, stroke, diabetes, kidney disease, anaemia, and filling pressure of the left heart—have been reported with AI models. Yet up to this point little has been implemented in the clinic to make use of such opportunistic outputs of medical images.”
AI-enabled opportunistic medical scan interpretation.
Topol EJ.
Lancet. 2024 May 11;403(10439):1842. doi: 10.1016/S0140-6736(24)00924-3. PMID: 38735291. - ”Despite this progress, a cautionary note is needed about AI-enabled opportunistic medical scan interpretation. A major concern is that the bonus outputs of medical images will be wrong, leading to unnecessary further evaluations, costs, and unwarranted patient anxiety. Before exploiting the unexpected windfall of information from medical scans, researchers need to fine-tune foundation AI models and rigorously prospectively assess the AI performance in diverse populations and settings. But looking ahead, there is great potential for what might be in store for AI’s medical discernibility. A prodigious amount of medical information is not currently being harnessed, much of which could be informative to patients and reduce the costs of additional medical imaging and missed diagnoses.”
AI-enabled opportunistic medical scan interpretation.
Topol EJ.
Lancet. 2024 May 11;403(10439):1842. doi: 10.1016/S0140-6736(24)00924-3. PMID: 38735291.
- “AI-enabled clinical services (see the Figure for examples) have the potential to simultaneously lower health care spending and improve health outcomes. They may reduce the time and effort devoted to diagnosing disease, which can be associated with improved health outcomes, increased productivity, and lowered labor costs. For example, Viz LVO (Viz.ai) reviews computed tomography angiography to triage patients with suspected stroke. All may also replace more invasive and expensive diagnostic tests, potentially reducing treatment complications, diagnostic spending, and subsequent treatment costs. For example, Heart Flow Analysis (HeartFlow) is advertised as a replacement for invasive and expensive tests to manage coronary artery disease. Moreover, AI-enabled services may allow less specialized physicians to make diagnoses that would otherwise require more specialized physicians; for example, Luminetics Core (Digital Diagnostics) can be used by primary care clinicians to test for diabetic retinopathy. Although cost offsets from AI-enabled clinical services are anticipated, they are not guaranteed, in part because AI-enabled services may increase use.”
How Should Medicare Pay for Artificial Intelligence?
Zink A et al.
JAMA Intern Med. 2024 May 28. doi: 10.1001/jamainternmed.2024.1648. Online ahead of print. - “Currently, CMS payment for AI-enabled services is determined by existing rules for reimbursing new technologie that rely on 1 of 3 payment pathways: (1) bundling the new technology with an existing service without an initial payment adjustment and adjusting the service price over time, (2) bundling with an existing service but including a transitional add-on payment for use of the new technology (until a new price for the service that reflects the AI-enabled component can be established), or (3) paying as a separately payable service. Existing methods for establishing new technology payment to clinicians, including for AI-enabled clinical services, rely on the price set by the firm (which likely reflects monopoly pricing power and CMS treatment of this price as a cost to the clinician) rather than the true cost to the firm of providing the service.”
How Should Medicare Pay for Artificial Intelligence?
Zink A et al.
JAMA Intern Med. 2024 May 28. doi: 10.1001/jamainternmed.2024.1648. Online ahead of print. - “An associated complication is that when the price charged by AI firms is high,CMS is likely to use the separately payable pathway, which is the most generous to clinicians.8This incentivizes AI firms to set ahigher price. In the extreme, if CMS fees cover the full price charged by AI firms, the equilibrium price charged to clinicians would have no limit. This is why transitional new technology reimbursement is typically a fraction of the price charged to clinicians. Competition can also keep prices down, but the market for US Food and Drug Administration– approved AI services within certain clinical settings has been uncompetitive to date despite AI firms not being subject to the same exclusivity restrictions as the pharmaceutical industry.”
How Should Medicare Pay for Artificial Intelligence?
Zink A et al.
JAMA Intern Med. 2024 May 28. doi: 10.1001/jamainternmed.2024.1648. Online ahead of print. - “Because AI has the potential to improve productivity and quality within the health care system,CMSmust promote its development and diffusion. However, it is important that high prices for AI-enabled clinical services are not locked in for perpetuity. Striking this balance is important and may vary on a case-by-case basis, but should be possible with close attention to how AI is associated with workflows and the quality of clinical services.”
How Should Medicare Pay for Artificial Intelligence?
Zink A et al.
JAMA Intern Med. 2024 May 28. doi: 10.1001/jamainternmed.2024.1648. Online ahead of print.
Medical Artificial Intelligence and Human Values.
Yu KH, Healey E, Leong TY, Kohane IS, Manrai AK.
N Engl J Med. 2024 May 30;390(20):1895-1904- “Such human values pertain broadly to the principles, standards, and preferences that reflect human goals and guide human behaviors. As we review here, LLMs and new foundation models, as technically impressive as they are, are only the latest incarnation in a long line of probabilistic models that have been integrated into medical decision making, which have all required that their creators and implementers make value judgments.”
Medical Artificial Intelligence and Human Values.
Yu KH, Healey E, Leong TY, Kohane IS, Manrai AK.
N Engl J Med. 2024 May 30;390(20):1895-1904 - Medical Artificial Intelligence and Human Values
- As large language models and other artificial intelligence models are used more in medicine, ethical dilemmas can arise depending on how the model was trained. A user must understand how human decisions and values can shape model outputs. Medical decision analysis offers lessons on measuring human values.
- A large language model will respond differently depending on the exact way a query is worded and how the model was directed by its makers and users. Caution is advised when considering the use of model output in decision making. - “Although we do not foresee physicians dramatically altering diagnostic practice using decision analysis in the era of LLMs, the core principle of utility elicitation offers lessons on aligning AI models for medicine. These lessons include the fundamental incompatibility of utilities from competing parties, the importance of how information is presented, and the benefits of enumerating and measuring both probabilities and utilities even when uncertainty remains in both.”
Medical Artificial Intelligence and Human Values.
Yu KH, Healey E, Leong TY, Kohane IS, Manrai AK.
N Engl J Med. 2024 May 30;390(20):1895-1904 - “AI governance teams can also help provide oversight, and agencies worldwidn are grappling with how to regulate AI models, a challenge that will become more complex with foundation models and models that can reason over multiple data types. Finally, considerations of the values of individual patients may cause physicians to ignore or override AI recommendations; the liability implications remain an active focus by legal scholars. As medical AI becomes more integrated into care, recognizing and mitigating the risks associated with dataset shift will be paramount in aligning AI outputswith human values.”
Medical Artificial Intelligence and Human Values.
Yu KH, Healey E, Leong TY, Kohane IS, Manrai AK.
N Engl J Med. 2024 May 30;390(20):1895-1904 - “At every stage of training and deploying an AI model, human values enter. AI models are far from immune to the shifts and discrepancies of values across individual patients and societies. Past utilities may no longer be relevant or even reflect pernicious societal biases. Our shared responsibility is to ensure that the AI models we deploy accurately and explicitly reflect patient values and goals. As noted by Pauker and Kassirer in the Journal more than three decades ago in reviewing progress in medical decision analysis, “the threat to physicians of a mathematical approach to medical decision making simply has not materialized.” Similarly, rather than replacing physicians, AI has made the consideration of values, as reflected by the guidance of a thoughtful physician, more essential than ever.”
Medical Artificial Intelligence and Human Values.
Yu KH, Healey E, Leong TY, Kohane IS, Manrai AK.
N Engl J Med. 2024 May 30;390(20):1895-1904
- “Pancreatic surveillance can detect early-stage pancreatic cancer and achieve long-term survival, but currently involves annual endoscopic ultrasound and MRI/MRCP, and is recommended only for individuals who meet familial/genetic risk criteria. To improve upon current approaches to pancreatic cancer early detection and to expand access, more accurate, inexpensive, and safe biomarkers are needed, but finding them has remained elusive. Newer approaches to early detection, such as using gene tests to personalize biomarker interpretation, and the increasing application of artificial intelligence approaches to integrate complex biomarker data, offer promise that clinically useful biomarkers for early pancreatic cancer detection are on the horizon.”
The role of biomarkers in the early detection of pancreatic cancer
Michael Goggins
Fam Cancer. 2024 Apr 25. doi: 10.1007/s10689-024-00381-4. Online ahead of print. - “After decades of effort and many challenges associated with discovering suitable biomarkers that could improve the early detection of pancreatic cancer, there are signs of progress. The detection of early-stage pancreatic cancer, particularly Stage I disease is associated with long-term survival. Using a tumor marker gene test that accounts for common gene variants that influence the level of CA19-9 and DUPAN-2 significantly improves diagnostic accuracy. Machine learning approaches offer the possibility of yielding greater information from biomarkers, particularly imaging based biomarkers which remain the main diagnostic tools for pancreatic surveillance and the evaluation of suspected pancreatic cancer.”
The role of biomarkers in the early detection of pancreatic cancer
Michael Goggins
Fam Cancer. 2024 Apr 25. doi: 10.1007/s10689-024-00381-4. Online ahead of print. - Results: Fifty-one patients (16.1%) achieved a 5-y RFS. A tumor size ≤23 mm, the absence of serosal invasion on computed tomography (CT), and Neutrophil-to- Lymphocyte Ratio <1.0, were significantly associated with the 5-y RFS in model 1. A Prognostic Nutritional Index ≥58 and the absence of serosal invasion and extrapancreatic nerve plexus invasion on CT were significantly associated with 5-y RFS in model 2. Only six (11.8%, model 1) and four (7.8%, model 2) patients had all three prognostic factors, and their 5-y RFS rates were 83.3% and 100%, respectively.
Conclusions: A modest number of patients who underwent upfront surgery achieved 5-yRFS, but only ~10% of them could be identified preoperatively. Based on these results, almost all R-PC patients are forced to undergo neoadjuvant treatment in daily practice.
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura1 | Teiichi Sugiura1 | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11.
Esophagus
- “Atrioesophageal fistula (AEF) after atrial fibrillation ablation is the most serious and feared complication. AEF is difficult to diagnose, and delays in diagnosis are common. Highly variable symptoms usually do not start to appear for 1 week or longer postprocedure, and when they appear, the patient often presents to a community hospital staffed by providers with little knowledge of AEF . Postablation esophageal perforation can present with variations including true AEF, pericardioesophageal fistula, and mediastinal-esophageal fistula. True AEF usually has a precursor esophageal lesion, which is often neglected or confused with pericarditis, a more common complication associated with atrial fibrillation ablation. Esophageal lesions eventually ulcerate and may progress into a direct connection between esophagus and left atrium, causing air embolism with stroke, sepsis, and sometimes esophageal bleeding. AEF is rare but is often fatal, especially if not treated, with mortality rates ranging from 40% to 100%.”
Recognition, Management, and Prevention of Atrioesophageal Fistula
Catanzaro JN, Assis FR, Verma A, Tandri H, Tilz RR, Spragg DD, Calkins H, Fishman EK, Deneke T..
JACC Clin Electrophysiol. 2024 Apr 13:S2405-500X(24)00165-8. doi: 10.1016/j.jacep.2024.02.022. Epub ahead of print. PMID: 38703161. 
Recognition, Management, and Prevention of Atrioesophageal Fistula
Catanzaro JN, Assis FR, Verma A, Tandri H, Tilz RR, Spragg DD, Calkins H, Fishman EK, Deneke T..
JACC Clin Electrophysiol. 2024 Apr 13:S2405-500X(24)00165-8. doi: 10.1016/j.jacep.2024.02.022. Epub ahead of print. PMID: 38703161.
Kidney
- “Patient age (46.4 +/- 11.1 years vs. 58.6 +/- 16.0 years), tumor calcification (1/19 vs. 18/56), stalk (0/19 vs. 10/56), internal vessels (15/19 vs. 19/56) and the enlarged adjacent supplying artery (14/19 vs. 10/56) were significantly different between BPG and bladder cancer (P < 0.05). The CT value in the corticomedullary phase (92.4 +/- 16.6 HU vs. 64.0 +/- 14.5 HU) and the contrast-enhanced value in the corticomedullary phase (54.5 +/- 17.4 HU vs. 28.5 +/- 12.8 HU) were significantly greater in BPG patients than in bladder cancer patients (P < 0.001), with corresponding area under the curve values of 0.930 and 0.912, respectively. The optimal cutoff values were 83.2 HU and 38.5 HU, respectively. A CT value > 83.2 HU in thecorticomedullary phase and a contrast-enhanced CT value > 38.5 HU in the corticomedullary phase were used to indicate BPG with sensitivities of 78.9% and 89.5%, respectively, and specificities of 94.6% and 75.0%, respectively.”
Contrast‑enhanced CT in the differential diagnosis of bladder cancer and paraganglioma
Jiu‑ping Liang et al.
Abdominal Radiology (2024) 49:1584–1592 - “Bladder paraganglioma (BPG) is an extremely rare tumor that accounts for only 0.06% of all bladder tumors and 1% of extra-adrenal pheochromocytomas. BPGs are chromaffin cell tumors that arise from the sympathetic innervation of the bladder wall. The most common symptoms include headache, micturition-related palpitations and dizziness, paroxysmal hypertension, and intermittent painless gross hematuria. Most paragangliomas are nonhypersecretory, which makes accurate diagnosis challenging. Silent BPG must be distinguished from bladder cancer because BPG may lead to hypertensive crisis and post-micturition syncope. If BPG can be diagnosed preoperatively, vital organ signs are closely monitored to prevent perioperative complications such as hypertensive crisis.”
Contrast‑enhanced CT in the differential diagnosis of bladder cancer and paraganglioma
Jiu‑ping Liang et al.
Abdominal Radiology (2024) 49:1584–1592 - “The area under the curve (AUC) for the CT value in the corticomedullary phase was 0.930 (0.868–0.991), and the optimal cutoff value was 83.2 HU. In the corticomedullary phase, a CT value > 83.2 HU indicated BPG, while a CT value < 83.2 HU indicated bladder cancer. The corresponding sensitivity, specificity and Youden index were 78.9%, 94.6% and 0.735, respectively. The area under the curve (AUC) for contrast-enhanced imaging in the corticomedullary phase was 0.912 (0.844–0.980), and the optimal cutoff value was 38.5 HU. A contrast-enhanced value > 38.5 HU indicated a BPG, and a value < 38.5 HU indicated bladder cancer. The corresponding sensitivity, specificity and Youden index were 89.5%, 75.0% and 0.645, respectively.”
Contrast‑enhanced CT in the differential diagnosis of bladder cancer and paraganglioma
Jiu‑ping Liang et al.
Abdominal Radiology (2024) 49:1584–1592
- “Page kidney or Page phenomenon is an uncommon, potentially reversible form of secondary arterial hypertension, related to excessive activation of the renin/angiotensin hormonal cascade, that can be induced by extrinsic compression of the kidney by subcapsular hematoma, or other perirenal process. Page kidney can be suggested on imaging by the presence of renal contour deformation, and moreover any asymmetrically impaired renal function can manifest on CECT or MRI as a delayed enhancement relative to the normal kidney (“delayed nephrogram”) or abnormal contrast retention on subsequent non-enhanced scans.”
What can go wrong when doing right? A pictorial review of iatrogenic genitourinary complications.
Chahine R, Mendiratta-Lala M, Consul N, et al.
Abdom Radiol (NY). 2024 Jun 4. doi: 10.1007/s00261-024-04384-8. Epub ahead of print. PMID: 38832944. - BCG is an immunotherapy treatment option for noninvasive multifocal bladder cancer, often used following transurethral resection of bladder tumors (TURBT). It involves instillation of Mycobacterium bovis (M. bovis) into the bladder to induce a localized inflammatory reaction that can lead to tumor shrinkage. This treatment can be complicated chronic cystitis, manifested on CT and MRI as diffuse urinary bladder thickening with perivesicular fat stranding, as well as bladder contractures, ulcerations, and hematuria. BCG may also lead to reactivated infection in nearby or distant organs, resulting in epidydimo-orchitis, balanitis, pyelonephritis, aortitis, osteomyelitis, or pulmonary infection.
What can go wrong when doing right? A pictorial review of iatrogenic genitourinary complications.
Chahine R, Mendiratta-Lala M, Consul N, et al.
Abdom Radiol (NY). 2024 Jun 4. doi: 10.1007/s00261-024-04384-8. Epub ahead of print.
- “Severe hemorrhage complicates approximately 2% of percutaneous nephrostomy tube (PCN) placements, resulting from vascular shearing and focal wall disruption. Arterial injury may specifically lead to formation of a pseudoaneurysm, which is a contained arterial rupture lacking coverage from all three layers of the vascular wall. In a periprocedural setting, this can result from instrumentation extension beyond the confines of the renal collecting system into or near the adjacent vasculature. On contrast-enhanced CT or MRI, it appears as a rounded region of focal contrast enhancement that mirrors the arterial blood pool, which may be either intraparenchymal or extra-parenchymal. A characteristic “yin-yang” sign can be seen on color Doppler ultrasound, with a to-and-fro waveform on spectral Doppler, due to swirling blood inside the pseudoaneurysm. Unlike a true aneurysm, a pseudoaneurysm of any size typically requires treatment given high risk for rupture and life-threatening bleeding. A ruptured pseudoaneurysm may also show active arterial bleeding (with progressive extravascular contrast pooling) or renal hematoma on multiphasic CT, which is discussed further below.”
What can go wrong when doing right? A pictorial review of iatrogenic genitourinary complications.
Chahine R, Mendiratta-Lala M, Consul N, et al.
Abdom Radiol (NY). 2024 Jun 4. doi: 10.1007/s00261-024-04384-8. Epub ahead of print. PMID: 38832944.
- “Left renal vein (LRV) entrapment is termed nutcracker phenomenon (NCP) when asymptomatic and nutcracker syndrome (NCS) when symptomatic. The term ‘nutcracker’ is attributed to de Scheppers (1972), although Grant reported the first anatomical description (1937). A bimodal peak in the 2nd decade and 3rd to 4th decades with a female preponderance is recognized. In anterior NCS, the LRV is compressed between the SMA and aorta in the aorto-mesenteric space. In posterior NCS (20%), a circumaortic or retroaortic LRV is compressed between the aorta and the spine Predisposing factors include renal ptosis, hyperacute SMA to aorta angulation, and a high LRV course. Clinical findings include hematuria (most commonly), left flank or abdominal pain, proteinuria, orthostatic intolerance, and fatigue.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “May-Thurner (MT) syndrome refers to compression of the left common iliac vein (LCIV) between the right common iliac artery (RCIA) and the lumbar spine (typically at the L5 vertebra level). Virchow (1851) reported a link between this anatomic variation and an increased incidence of left leg deep venous thrombosis (DVT). May and Thurner (1957), for which MT syndrome is eponymously named, discovered MT anatomy with intraluminal venous spurs in 22% of 430 cadavers. These spurs are secondary to chronic pulsations and mechanical stress by the RCIA resulting in venous endothelial damage and intimal fibrosis. There is a female-to-male ratio of 5:1 with most patients being in the 2nd to 5th decade Females are disproportionately affected due to their more accentuated lumbar lordosis leading to reduced pelvic space. MT anatomy predisposes to venous hypertension and recurrent left limb DVT, with MT accounting for 2–5% of all DVTs. Most patients (70%) with MT anatomy are asymptomatic.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “MT anatomy is associated with three morphological appearances as originally described by Jeon et al. on CT venography including (a) focal extrinsic compression, (b) diffuse atrophy, and (c) cord-like obliteration. In (a), there is focal extrinsic compression of the LCIV by the crossing RCIA. In (b), there is a contiguous stenotic segment of the LCIV between the compression site superiorly and the internal and external iliac bifurcation distally. In (c), the contiguous stenotic segment of the LCIV becomes more profoundly narrowed and diffusely thread-like. These morphologic appearances presumably represent a continuum of vessel alterations over time. CT/MR can confirm MT anatomy, assess the degree of obstruction, and evaluate for DVT, pulmonary emboli, and other abnormalities such as dilated retroperitoneal or pudendal venous collaterals, and lower limb edema from venous congestion. Thin collimationand multiplanar reconstructions improve the conspicuity of findings and anatomical relationships.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “Crossing vessels (CVs), first described by Wadsworth (1983), are a potential extrinsic cause of ureteropelvic junction obstruction (UPJO). CVs are commonly renal arteries or veins located at the ureteric transition point, with the lower pole anterior segmental artery or vein most frequently implicated. In UPJO, CVs are found in 45–51% of adults and older children, and in 6–11% of younger children. A histopathology study of 178 patients showed that chronic inflammation was more common in UPJs related to CVs than UPJs from intrinsic etiologies (e.g., a congenitally stenotic or aperistaltic proximal ureter that typicallymanifests as antenatal hydronephrosis). Intermittentobstruction is characteristic with symptoms including abdominal pain, hematuria, vomiting, and infection.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761
Pancreas
- “Pancreatic surveillance can detect early-stage pancreatic cancer and achieve long-term survival, but currently involves annual endoscopic ultrasound and MRI/MRCP, and is recommended only for individuals who meet familial/genetic risk criteria. To improve upon current approaches to pancreatic cancer early detection and to expand access, more accurate, inexpensive, and safe biomarkers are needed, but finding them has remained elusive. Newer approaches to early detection, such as using gene tests to personalize biomarker interpretation, and the increasing application of artificial intelligence approaches to integrate complex biomarker data, offer promise that clinically useful biomarkers for early pancreatic cancer detection are on the horizon.”
The role of biomarkers in the early detection of pancreatic cancer
Michael Goggins
Fam Cancer. 2024 Apr 25. doi: 10.1007/s10689-024-00381-4. Online ahead of print. - “After decades of effort and many challenges associated with discovering suitable biomarkers that could improve the early detection of pancreatic cancer, there are signs of progress. The detection of early-stage pancreatic cancer, particularly Stage I disease is associated with long-term survival. Using a tumor marker gene test that accounts for common gene variants that influence the level of CA19-9 and DUPAN-2 significantly improves diagnostic accuracy. Machine learning approaches offer the possibility of yielding greater information from biomarkers, particularly imaging based biomarkers which remain the main diagnostic tools for pancreatic surveillance and the evaluation of suspected pancreatic cancer.”
The role of biomarkers in the early detection of pancreatic cancer
Michael Goggins
Fam Cancer. 2024 Apr 25. doi: 10.1007/s10689-024-00381-4. Online ahead of print. - Results: Fifty-one patients (16.1%) achieved a 5-y RFS. A tumor size ≤23 mm, the absence of serosal invasion on computed tomography (CT), and Neutrophil-to- Lymphocyte Ratio <1.0, were significantly associated with the 5-y RFS in model 1. A Prognostic Nutritional Index ≥58 and the absence of serosal invasion and extrapancreatic nerve plexus invasion on CT were significantly associated with 5-y RFS in model 2. Only six (11.8%, model 1) and four (7.8%, model 2) patients had all three prognostic factors, and their 5-y RFS rates were 83.3% and 100%, respectively.
Conclusions: A modest number of patients who underwent upfront surgery achieved 5-yRFS, but only ~10% of them could be identified preoperatively. Based on these results, almost all R-PC patients are forced to undergo neoadjuvant treatment in daily practice.
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura1 | Teiichi Sugiura1 | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11.
- ”Groove pancreatitis is a rare form of chronic pancreatitis that affects the ‘groove’ between the head of the pancreas, the duodenum, and the common bile duct. The exact cause is unknown, but long-term alcohol abuse and smoking are frequently observed in patients with this condition. Ectopic pancreas has been associated with groove pancreatitis when heterotopic pancreatic tissue is located between the medial duodenal wall and the head of the pancreas. When ectopic pancreas manifests symptoms, the clinical presentation can be severe, requiring surgical intervention.”
Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review
Gary Amseian . Juan‑Ramon Ayuso
Abdominal Radiology (2024) 49:1734–1746 - “Pancreatic congenital anomalies are frequent and result from alterations in the processes involved in glandular embryology, with the most frequent variants resulting from abnormalities in fusion and duct formation. While most of these anomalies are asymptomatic, they can mimic pathological conditions and predispose individuals to specific pancreatic or peripancreatic pathologies. Their correct diagnosis is critical to avoid unnecessary investigations or invasive procedures and to provide adequate treatment when they manifest clinically. Furthermore, it is essential to consider these anomalies when planning pancreatic and peripancreatic surgeries to prevent potential surgical complications. Distinguishing pancreatic congenital anomalies from their main radiological pitfalls is a challenge for the radiologist, for which findings from computed tomography and magnetic resonance are essential.”
Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review
Gary Amseian , Juan‑Ramon Ayuso
Abdominal Radiology (2024) 49:1734–1746
- “The upper gastrointestinal tract is the most common location, with gastric and duodenal involvement reported at frequencies of 24–38% and 9–36%, respectively. But it has been identified in other locations, such as the jejunum, liver, gallbladder, colon, appendix, spleen, mesentery, retroperitoneum, female reproductive system, mediastinum, and lungs . Gastric and duodenal ectopic pancreas is most frequently found in the submucosa along the greater curvature of the antrum and in the proximal duodenum, typically with an endophytic growth pattern. The first 50 cm of the jejunum is the third most frequent location, estimated in 0.5–35% of cases. They are also typically located in the submucosa although exophytic growth patterns are more common .”
Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review
Gary Amseian . Juan‑Ramon Ayuso
Abdominal Radiology (2024) 49:1734–1746 - “Submucosal heterotopic pancreas can be easily misidentified as gastrointestinal stromal tumors (GIST). Unlike GISTs, which often exhibit exophytic or mixed growth patterns, globular contours, and a well-defined border, ectopic pancreas usually presents with an endoluminal pattern, flat contours, and poorly defined borders, in addition to the previously described characteristics.”
Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review
Gary Amseian . Juan‑Ramon Ayuso
Abdominal Radiology (2024) 49:1734–1746 - “Most cases of ectopic pancreas are asymptomatic and are identified incidentally on pathological specimens or during autopsies. However, it can manifest clinically with symptoms resulting from mass effect, such as obstruction or intussusception, as well as underlying pathologies, including ulceration, bleeding, and acute or chronic pancreatitis. Ectopic pancreas is susceptible to the same pathological conditions that affect the normal pancreas. For instance, there have been reported cases of ectopic insulinomas in patients presenting with hypoglycemia. Cystic degeneration and, on rare occasions, malignant transformation can also occur.”
Pancreatic congenital anomalies and their features on CT and MR imaging: a pictorial review
Gary Amseian . Juan‑Ramon Ayuso
Abdominal Radiology (2024) 49:1734–1746
- “Pancreatic cystic neoplasms are lesions comprised of cystic components that show different biological behaviors, epidemiology, clinical manifestations, imaging features, and malignant potential and management. Benign cystic neoplasms include serous cystic neoplasms (SCAs). Other pancreatic cystic lesions have malignant potential, such as intraductal papillary mucinous neoplasms and mucinous cystic neoplasms. SCAs can be divided into microcystic (classic appearance),honeycomb, oligocystic/macrocystic, and solid patterns based on imaging appearance. They are usually solitary but may be multiple in von Hippel–Lindau disease, which may depict disseminated involvement. The variable appearances of SCAs can mimic other types of pancreatic cystic lesions, and cross-sectional imaging plays an important role in their differential diagnosis. Endoscopic ultrasonography has helped in improving diagnostic accuracy of pancreatic cystic lesions by guiding tissue sampling (biopsy) or cyst fluid analysis. Immunohistochemistry and newer techniques such as radiomics have shown improved performance for preoperatively discriminating SCAs and their mimickers.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “While frequently found incidentally and usually asymptomatic, larger lesions (>4 cm) can cause non- specific symptoms, including abdominal pain, palpable abdominal mass, and rarely jaundice. Most lesions (60%) occur in the pancreatic body and tail, with the remaining 40% seenin the pancreatic head and uncinate process. SCAs show a predilection for middle-aged and older women and are less commonly seen in males. In contrast, mucinous cystic neoplasms are almost exclusively seen in females and contain ovarian stroma. SCAs are sub-classified by the 2019 World Health Organization (WHO) Digestive System Tumor Classification as microcystic serous cystadenoma, oligocystic/macrocystic serous cystadenoma, solid serous adenoma, Von Hippel–Lindau (VHL) syndrome-associated serous cystic neoplasm, and mixed serous-neuroendocrine neoplasm. While SCAs are overwhelmingly considered benign lesions and clinically managed as such, a few rare cases have been reported in the literature that have undergone malignant degeneration. One study consisting of 2622 cases reported only three cases of serous cystadenocarcinomas.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “VHL-associated serous cystic neoplasm (WHO classification) present with lesions that are indiscernible at histology from sporadically occurring serous cystic tumors . VHL is a multi-tumor inherited autosomal dominant disease . VHL is caused by mutations in the VHL tumor suppressor gene and is characterized by the presence of hemangioblastoma of the central nervous system and retina, adrenal pheochromocytoma, renal cell carcinoma (RCC), pancreatic neuroendocrine tumors and cysts, cystadenomas, and mixed tumors, and other organ involvement. In VHL disease, almost 7.6% of patients may have pancreatic manifestations alone, while 11.5% of patients show combined lesions. In VHL patients, serous cystic neoplasms can be focal or replace the pancreas diffusely. Most commonly, these lesions show the classical microcystic cystadenoma appearance or the oligocystic/macrocystic variant features. Solid pancreatic tumors occur in <20% of VHL patients, mostly PNETs, however, some benign pancreatic cysts that are microcysts can be organized architecturally in such a dense manner that they can mimic PNETs on imaging, though this is rare.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “The oligocystic/macrocystic pattern accounts for less than 10% of cases of SCAs. This variant may be a single unilocular cyst or a lesion comprised of several larger (>2 cm) Unlike the microcystic variant, the oligocystic/macrocystic form does not have a central scar but does show external lobulations like microcystic SCAs. These lesions also occur more frequently in the pancreatic head. If the lesion is large enough, these patients may present with jaundice or common bile duct obstruction. The differential diagnosis for oligocystic/macrocystic SCA includes solid pseudopapillary tumor, pseudocyst, and mucinous cystic neoplasm. The external lobulations of SCAs can aid in distinguishing between mucinous cystic neoplasms and IPMNs. Dilatation of the pancreatic duct is only seen in rare cases cysts than seen with the microcystic variant.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “The solid variant is an extremely rare type of SCAs and is also known as solid serous adenoma. This variant has variable definitions in the literature with some authors basing their definition on a microscopic appearance, while others use a solid radiologic appearance for diagnosis. Solid variant SCAs are formed by cells that resemble those from other forms of SCA but do not contain cystic spaces in histopathology . This is in distinction to other variants of SCAs that can have a solid appearance on imaging but demonstrate cystic spaces on histopathology. On imaging, the solid variant is difficult to distinguish from other solid pancreatic lesions such as pancreatic neuroendocrine tumors or other solid lesions such as metastatic renal cell carcinoma.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “Chu et al. demonstrated equivalent performance between their radiomics-based model and an experienced radiologist in the accurate classification of several pancreatic cystic lesions (SCAs, MCNs, SPNs, and NETs) with an AUC of 0.94 for the AI-based approach and 0.895 for the radiologist. The documented imaging features were size and location of pancreatic cysts and presence of calcifications or pancreatic duct dilatation (>3 mm in diameter). A total of 488 radiomics features from the segmented three-dimensional (3D) volume of the cystic lesion were extracted based on venous phase images. Although more validation is still needed, the ability of AI to accurately characterize pancreatic cystic lesions can potentially improve the selection of patients with high-risk lesions who would benefit from surgical intervention, while separating out those who can be managed more conservatively.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “SCAs are associated with somatic or germline VHL gene mutations on chromosome 3p25. In addition, the presence of VHL mutation with TP53 or TERT promoter mutations corresponds with interval growth in size in SCAs. The presence of a VHL mutation combined with the lack of a KRAS, GNAS, or RNF43 mutations (commonly identified in mucinous cystic neoplasms and pancreatic ductal adenocarcinoma) have a sensitivity of 71–100% and specificity of 91–100% for accurately preoperatively detecting SCA. SCAs also lack CTNNB1 mutations that are specific for solid pseudopapillary neoplasm (SPN).’
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press) - “Benign squamoid cyst of pancreatic duct is a rare cystic lesion of the pancreas first described in 2007. These cysts are the result of unilocular cystic dilatation of pancreatic ducts and have variable linings (from attenuated, flat, non-stratified squamous, to transitional, to mucosaltype stratified squamous epithelium without a cornified layer or parakeratosis). These lesions are typically relatively small cysts, with a median size of 1.5 cm. These lesions are difficult to distinguish from other pancreatic cystic lesions and most cases of benign squamoid cyst of pancreatic duct are proven after surgical resection. However, the presence of squamous epithelium in cytologic samples obtained by EUS may suggest this entity and help avoid unnecessary resection.”
Imaging of pancreatic serous cystadenoma and common imitators
Camila Lopes Vendrami · Nancy A. Hammond · David J. Escobar
Abdominal Radiology 2024 (in press)
- “Lymph node metastasis is one of the strongest prognostic factors for poor prognosis. However, CT findings in the absence of lymph node metastasis were not found to be a predictor of the 5-y RFS due to its low negative predictive value. In contrast, its positive predictive value was high (93.2%). Therefore, the presence of lymph node metastasis on CT findings is accurate and generally used to predict poor prognosis in patients. Recently, Bian et al reported that an automated preoperative artificial intelligence (AI) algorithm for lymph nodes showed favorable accuracy in predicting lymph node metastasis on CT in patients with PC. In the future, AI may be able to predict patient prognosis even more accurately using preoperative images.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura1 | Teiichi Sugiura1 | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11. - “CA 19-9 is also well known to be associated with early recurrence and poor prognosis; however, we failed to detect it as a predictor of 5-y RFS. In fact, in the current series, the higher the CA 19-9 value, the higher was the rate of early recurrence (data not shown). However, among 166 patients with a preoperative CA 19-9 value <120 U/mL, 130 (78%) experienced recurrence within 5 y after surgery. Given these results, tumor biomarkers, primarily CA 19-9, appear to be useful in predicting early recurrence and survival, but have limited power in predicting long-term RFS.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura | Teiichi Sugiura | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11. - “The present study showed that 16.7% of patients who underwent upfront surgery for R-PC achieved an actual 5-y RFS. To identify long-term recurrence-free survivors, prognostic factors were investigated using actual survival, excluding censoring before the end of observation. In model 1, a tumor size ≤23 mm, absence of radiological serosal invasion, and NLR <1.0 were identified as independent predictors for the 5-y RFS. In model 2, the absence of serosal invasion, absence of PL invasion, and PNI ≥58 were identified. These preoperative predictors focusing on peripancreatic tissue invasion and a nutritional index could identify the groups with an extremely favorable RFS among patients treated with upfront surgery and could be feasible in many centers without specific tests, tools, or additional costs. Patients who fulfill these predictors are likely to achieve 5-y RFS, even if upfront surgery is performed without NATand to be a population that does not require NAT.”
Predictive factors of actual 5-y recurrence-free survival after upfront surgery for resectable pancreatic cancer
Masao Uemura | Teiichi Sugiura | Ryo Ashida1 et al
Ann Gastroenterol Surg. 2024;00:1–11.
Small Bowel
- “Initially, lymph nodes exhibit increased dimensions with homogeneous enhancement, with growth generally self-limiting to 12- 40 mm. Nevertheless, with the progression of the disease, the central part of the lymph node tends to undergo necrotic degeneration, identified at CT as an oval structure with a hypodense central region and peripheral ring enhancement in contrast phases (capsular enhancement). This is the most common presentation but not pathognomonic for caseous necrosis. Following the temporal evolution, the capsule of affected lymph nodes may degenerate, with the fusion of some forming conglomerate nodal masses on CT.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “Abdominal tuberculosis lymphadenopathy differential diagnoses include diseases such as Whipple's disease, pyogenic infections, and malignancies like non-seminomatous germ cell tumors, pancreatic cancer, lymphoma, and metastatic lymph nodes.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “The evaluation of lymph node necrosis in abdominal studies is limited but extensively researched in cervical neoplasms. In a study by Zoumalan et al. the presence of central necrosis in lymph nodes identified in preoperative CT scans was found to be a strong indicator of extracapsular metastatic spread (sensitivity: 95% and specificity: 85%), a finding further supported by histopathological analysis. This central necrosis proved to be a more sensitive indicator of extracapsular spread than the mere lymph node diameter. Moreover, the absence of central necrosis shows a high negative predictive value (98%) for extracapsular dissemination of metastases in the lymph nodes, which can aid in assessing the disease stage presented by the patient and the possibility of a poor outcome.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “Lymphomas can lead to lymphadenopathy in almost every part of the body, most commonly affecting the chest, retroperitoneum, or superficial lymph node chains, with abdominal lymphadenopathies being common. Traditionally, Hodgkin's lymphoma rarely presents with mesenteric lymphadenopathy (less than 8.3%) and has little tendency to form nodal conglomerates. On the other hand, non-Hodgkin's lymphoma involves multiple abdominal lymph node levels with lymph nodes showing increased dimensions with homogeneous soft tissues attenuation on CT scans. Generally, there is no necrosis or central cystic degeneration, but there is a tendency for lymph nodes to fuse and form masses. However, some subtypes of Hodgkin lymphoma have atypical presentations, including nodular sclerosis and mixedcellularity subtypes necrosis which commonly present with necrosis.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “The presence of a small amount of macroscopic fat is not unusual in the hilar region of normal lymph nodes. However, the replacement of lymph nodes with fat is very uncommon and can be found in conditions such as complicated coeliac disease, Crohn's disease, metastatic liposarcomas, Whipple's disease, and chronic lymphocytic leukemia.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “Whipple disease is a systemic bacterial infection caused by the bacterium Tropheryma whipplei. It should be considered when individuals present with a combination of abdominal pain, weight loss, and diarrhea, especially in the context of nonspecific arthritis or arthralgia. Nonetheless, it is not uncommon for the disease to involve the cardiac and central nervous systems, with such manifestations potentially being more clinically noticeable . Classically, the disease has an insidious onset, often taking several years until a definitive diagnosis is made. The conclusive diagnosis relies on histology, involving periodic acid–Schiff (PAS) staining in duodenal biopsies. Lymphadenopathy is observed in approximately 50% of patients, more frequently in the mediastinum (28%) and mesentery (17%). In Whipple disease, lymph nodes exhibit a distinctive feature—a high fat content. Additionally, a thickening of the small bowel wall with moderate dilatation and the absence of normal wall stratification are frequently observed.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “Castleman's disease, also known as angiofollicular lymph node hyperplasia, is a benign condition characterized primarily by excessive lymphocytic proliferation. It seems to result from a chronic low-grade inflammatory process triggered by latent infection with HSV8, leading to hyperplasia of the lymphoid system. Most Castleman disease cases are located in the thorax (70%), followed by the neck (10–15%), and approximately 10–15% occur in the abdominal cavity. The unicentric form is a benign condition typically without symptoms, characterized by a single lymphoid mass mainly found in the mediastinum. On the other hand, the multicentric type involves multiple lymphatic stations and is associated with the presence of type B symptoms and a worse prognosis .”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “Calcifications in lymph nodes often occur as result of past granulomatous infections such as tuberculosis (more frequent) and histoplasmosis (previously described), as well as other diseases such as sarcoidosis, silicosis, amyloidosis, calcifications secondary to the treatment of lymphomas and seminomas, and due to metastatic involvement of tumors such as breast, ovarian, colon, and bladder.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “The prevalence of lymph node calcification in metastatic mucinous tumors varies across different tumor types and anatomical locations. Studies have reported calcification rates ranging from 20 to 80% in metastatic mucinous tumors of the colon and rectum. In metastatic mucinous tumors of the ovary, the prevalence of calcification is lower, ranging from 2 to 10% . According to Ko et al., calcification is more prevalent in mucinous carcinomas compared to non-mucinous colorectal carcinomas (21% versus 5%) and most calcifications are small and punctate.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. - “The evaluation of abdominal lymph nodes is traditionally associated with their size measurement; however, a multitude of information can be derived from cross-sectional imaging methods with a thorough assessment not only of lymph node size but also of their margins, shape, proportions, and primarily evaluation of their attenuation pattern. The presence of necrosis, fat or calcification, can narrow the diagnostic possibilities, which, along with other findings, can define the inflammatory or neoplastic pathology that presents as lymph node disease.”
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622. 
Tips and tricks for a proper radiological assessment of abdominal and pelvic lymph nodes.
Potente ALL, de Borborema CLP, Vieira ICP, et al..
Abdom Radiol (NY). 2024 Jun 6. doi: 10.1007/s00261-024-04390-w. Epub ahead of print. PMID: 38844622.
- “Gastrointestinal stromal tumours (GISTs) are defined as CD117-positive primary, spindled or epithelioid, mesenchymal tumours of the gastrointestinal tract, omentum, or mesentery. While computed tomography (CT) is the recommended imaging modality for GISTs, overlap in imaging features between GISTs and other gastrointestinal tumours often make radiological diagnosis and subsequent selection of the optimal therapeutic approach challenging. Cinematic rendering is a novel CT post-processing technique that generates highly photorealistic anatomic images based on a unique lighting model. The global lighting model produces high degrees of surface detail and shadowing effects that generate depth in the final three-dimensional display. Early studies have shown that cinematic rendering produces high-quality images with enhanced detail by comparison with other three-dimensional visualization techniques. Cinematic rendering shows promise in improving the visualization of enhancement patterns and internal architecture of abdominal lesions, local tumour extension, and global disase burden, which may be helpful for lesion characterization and pretreatment planning.”
Stromal Tumours: A Review of Current Possibilities and Future Developments
Maxime Barat, Anna Pellat, Benoit Terris, Anthony Dohan, Romain Coriat, Elliot K. Fishman , Steven P. Rowe, Linda Chu, and Philippe Soyer
Canadian Association of Radiologists Journal2024, Vol. 75(2) 359–368 - “Cinematic rendering (CR) is a relatively recent technique for visualization of volumetric data that provides photorealistic 3D views from CT data owing to the use of more physical photon effects by comparison with traditional 3D representations. In that regard, the very realistic representation of complex lighting interactions gives more surface detail and enhances the evaluation of spatial relationships by comparison with volume-rendered images. The 3D views provided byCR are advantageous for preoperative planning of a variety of tumours compared to more traditional 3D imaging. To date, CR has been applied to a variety of abdominal conditions including, but not exhaustively, pancreatic, gastric, colonic, hepatic, and splenic diseases. However, the application of CR to GISTs has received little attention to date.”
Stromal Tumours: A Review of Current Possibilities and Future Developments
Maxime Barat, Anna Pellat, Benoit Terris, Anthony Dohan, Romain Coriat, Elliot K. Fishman , Steven P. Rowe, Linda Chu, and Philippe Soyer
Canadian Association of Radiologists Journal2024, Vol. 75(2) 359–368 - “CR visualizations in the workup of GISTs can accentuate the dynamic enhancement pattern through more distinctly highlighting the anatomy of the enhancing portions within the lesion. CR confers the added benefit of dynamic window width and level adjustment, which can aid in delineating cystic or necrotic areas within the tumour . CR helps demonstrate the extraluminal growth and the relationship of GIST to underlying mucosa, overlying serosa, and vessels, which has the potential to further surgical or endoscopic treatment planning. CR is also valuable in detecting or excluding small bowel bleeding from the tumour.”
Stromal Tumours: A Review of Current Possibilities and Future Developments
Maxime Barat, Anna Pellat, Benoit Terris, Anthony Dohan, Romain Coriat, Elliot K. Fishman , Steven P. Rowe, Linda Chu, and Philippe Soyer
Canadian Association of Radiologists Journal2024, Vol. 75(2) 359–368 - “CR offers the potential for comprehensive assessment of GISTs. CR can potentially improve the appreciation of the spatial relationship between the GIST and surrounding organs and delineation of the major vascular supply, which may influence endoscopic or surgical planning. However, this is done at a penalty of additional post-processing. In the future, CR implementation would require a more standardized and user-friendly interface, with the ultimate goal of being entirely automated with the help of artificial intelligence algorithms.”
Stromal Tumours: A Review of Current Possibilities and Future Developments
Maxime Barat, Anna Pellat, Benoit Terris, Anthony Dohan, Romain Coriat, Elliot K. Fishman , Steven P. Rowe, Linda Chu, and Philippe Soyer
Canadian Association of Radiologists Journal2024, Vol. 75(2) 359–368 - “The applications of CR as a post-processing tool in the evaluation of GISTs are growing. CR enhances the subtle texture changes between GIST and adjacent normal gastrointestinal mucosa that may improve tumour detection. The pseudoendoluminal views created from CR simulate an actual endoscopic view that can assist in resection. CR effectively displays the relationship between GIST and the surrounding structures, and can assist in operative planning. Considering the improved image detail of CR and favorable observer perceptions, the technique is gaining wide acceptance in many institutions. The next step should be to investigate how CR can be implemented in the real-life setting and how it can positively influence patient care and outcome. Future studies including large numbers of patients and based on randomized assignment of radiologists and physicians to have and not have access to CR images to estimate the net benefit of CR in terms of diagnostic confidence and patient outcome. Finally, incorporation of CR images in artificial intelligence pipelines should be a future challenge for GIST imaging.”
Stromal Tumours: A Review of Current Possibilities and Future Developments
Maxime Barat, Anna Pellat, Benoit Terris, Anthony Dohan, Romain Coriat, Elliot K. Fishman , Steven P. Rowe, Linda Chu, and Philippe Soyer
Canadian Association of Radiologists Journal2024, Vol. 75(2) 359–368
Stomach
- “Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.”
Value of multidetector computed tomography angiography in severe non‑variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit
Marco Di Serafino et al.
Abdominal Radiology (2024) 49:1385–1396 - “Bleeding location was correctly identified by MDCTA in 61 out of 68 cases (3 esophagus, 27 stomach, 35 duodenum). In 2 cases the bleeding site was falsely identified by MDCTA (FP examinations), whereas MDCTA failure to provide bleeding location was observed in the remnant 3 cases (FN examinations). Only two disagreements in identifying the bleeding site detection were encountered, but consensus between the opinions of the two reviewing radiologists was achieved through a joint review of MDCTA image reconstructions.”
Value of multidetector computed tomography angiography in severe non‑variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit
Marco Di Serafino et al.
Abdominal Radiology (2024) 49:1385–1396 - “The results of our study showed that MDCTA is highly sensitive and accurate for the bleeding status detection in severe NVUGIB patients. Worth mentioning, all patients with active bleeding confirmed by the reference standard were correctly identified by MDCTA, and no FP were observed, resulting in a PPV of 100%. There were 11 FN MDCTA examinations, in which MDCTA was able to show signs of recent bleeding only. In 4 out of 11 FN findings mild oozing bleeding due to gastric heteroplastic lesions (n = 3) and Mallory-Weiss tear (n = 1) was endoscopically observed, probably exceeding the lower limit of 0.3 mL/ min reported for the detection of active GIB by means of MDCTA. In 2 FN examinations, MDCTA performed prior to any diagnostic modality failed to identify active bleeding but correctly identified the underlying NVUGIB etiology (gastroduodenal artery VAPA, n = 1; superior mesenteric artery VAPA, n = 1), addressing proper endovascular treatment.”
Value of multidetector computed tomography angiography in severe non‑variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit
Marco Di Serafino et al.
Abdominal Radiology (2024) 49:1385–1396 - “Although EGD is the mainstay in the diagnosis and treatment of most NVUGIB cases, MDCTA seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute NVUGIB. It may play a crucial role in the management of selected cases of NVUGIB, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of MDCTA in the diagnostic process of acute NVUGIB.”
Value of multidetector computed tomography angiography in severe non‑variceal upper gastrointestinal bleeding: a retrospective study in a referral bleeding unit
Marco Di Serafino et al.
Abdominal Radiology (2024) 49:1385–1396
Vascular
- “Vascular compression syndromes are a diverse group of pathologies that can manifest asymptomatically and incidentally in otherwise healthy individuals or symptomatically with a spectrum of presentations. Due to their relative rarity, these syndromes are often poorly understood and overlooked. Early identification of these syndromes can have a significant impact on subsequent clinical management. This pictorial review provides a concise summary of seven vascular compression syndromes within the abdomen and pelvis including median arcuate ligament (MAL) syndrome, superior mesenteric artery (SMA) syndrome, nutcracker syndrome (NCS), May-Thurner syndrome (MTS), ureteropelvic junction obstruction (UPJO), vascular compression of the ureter, and portal biliopathy. The demographics, pathophysiology, predisposing factors, and expected treatment for each compression syndrome are reviewed.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “The median arcuate ligament (MAL) is a fibrous band that joins the bilateral diaphragmatic crura at the aortic hiatus. Typically located at the L1 vertebra level, the MAL canbe found at the proximal celiac axis (CA) level in 10–24% of patients due to high CA origin or low MAL insertion. It is asymptomatic in 85% with a minority experiencingsymptoms such as post-prandial abdominal pain, nausea, vomiting, diarrhea, and/or weight loss. An abdominal bruit can be present. It is postulated that MAL syndrome from CA compression is due to (1) mesenteric ischemia from restricted blood flow leading to abdominal angina exacerbated by post-prandial demands or (2) celiac plexus irritation leading to pain and splanchnic vasoconstriction. Clinical findings can be vague, insidious, and overlap with other disorders culminating in diagnostic uncertainty, diagnostic delays, and misdiagnosis.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “On CT/MR, findings include (1) focal narrowing of the CA within 5 mm of the ostia associated with poststenotic dilatation, (2) acute angulation between the CA and the aorta on the sagittal projection leading to a J-shaped CA configuration (‘hook sign’) that is worsened on expiration due to upward movement of the CA, and (3) the presence of mesenteric collaterals and aneurysm formation in the collateral circulation. Additionally, CT/MR can exclude other causes of CA compression (e.g., atherosclerotic plaques). The use of dedicated inspiratory and expiratory CT phases has been discussed but has not received universal acceptance.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “Left renal vein (LRV) entrapment is termed nutcracker phenomenon (NCP) when asymptomatic and nutcracker syndrome (NCS) when symptomatic. The term ‘nutcracker’ is attributed to de Scheppers (1972), although Grant reported the first anatomical description (1937). A bimodal peak in the 2nd decade and 3rd to 4th decades with a female preponderance is recognized. In anterior NCS, the LRV is compressed between the SMA and aorta in the aorto-mesenteric space. In posterior NCS (20%), a circumaortic or retroaortic LRV is compressed between the aorta and the spine Predisposing factors include renal ptosis, hyperacute SMA to aorta angulation, and a high LRV course. Clinical findings include hematuria (most commonly), left flank or abdominal pain, proteinuria, orthostatic intolerance, and fatigue. Additionally, LRV entrapment may incite varicosities leading to pelvic discomfort, varicoceles in males, and pelvic congestion syndrome in females. The true prevalence of NCS is unknown due to the absence of uniform diagnostic criteria. However, CT studies suggest that NCP has an incidence of 11–27%.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “May-Thurner (MT) syndrome refers to compression of the left common iliac vein (LCIV) between the right common iliac artery (RCIA) and the lumbar spine (typically at the L5 vertebra level). Virchow (1851) reported a link between this anatomic variation and an increased incidence of left leg deep venous thrombosis (DVT). May and Thurner (1957), for which MT syndrome is eponymously named, discovered MT anatomy with intraluminal venous spurs in 22% of 430 cadavers. These spurs are secondary to chronic pulsations and mechanical stress by the RCIA resulting in venous endothelial damage and intimal fibrosis. There is a female-to-male ratio of 5:1 with most patients being in the 2nd to 5th decade Females are disproportionately affected due to their more accentuated lumbar lordosis leading to reduced pelvic space. MT anatomy predisposes to venous hypertension and recurrent left limb DVT, with MT accounting for 2–5% of all DVTs. Most patients (70%) with MT anatomy are asymptomatic.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “MT anatomy is associated with three morphological appearances as originally described by Jeon et al. on CT venography including (a) focal extrinsic compression, (b) diffuse atrophy, and (c) cord-like obliteration. In (a), there is focal extrinsic compression of the LCIV by the crossing RCIA. In (b), there is a contiguous stenotic segment of the LCIV between the compression site superiorly and the internal and external iliac bifurcation distally. In (c), the contiguous stenotic segment of the LCIV becomes more profoundly narrowed and diffusely thread-like. These morphologic appearances presumably represent a continuum of vessel alterations over time. CT/MR can confirm MT anatomy, assess the degree of obstruction, and evaluate for DVT, pulmonary emboli, and other abnormalities such as dilated retroperitoneal or pudendal venous collaterals, and lower limb edema from venous congestion. Thin collimationand multiplanar reconstructions improve the conspicuity of findings and anatomical relationships.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761 - “Crossing vessels (CVs), first described by Wadsworth (1983), are a potential extrinsic cause of ureteropelvic junction obstruction (UPJO). CVs are commonly renal arteries or veins located at the ureteric transition point, with the lower pole anterior segmental artery or vein most frequently implicated. In UPJO, CVs are found in 45–51% of adults and older children, and in 6–11% of younger children. A histopathology study of 178 patients showed that chronic inflammation was more common in UPJs related to CVs than UPJs from intrinsic etiologies (e.g., a congenitally stenotic or aperistaltic proximal ureter that typicallymanifests as antenatal hydronephrosis). Intermittentobstruction is characteristic with symptoms including abdominal pain, hematuria, vomiting, and infection.”
Vascular compression syndromes in the abdomen and pelvis: a concise pictorial review
Reshma M. Koshy et al.
Abdominal Radiology (2024) 49:1747–1761
- “Atrioesophageal fistula (AEF) after atrial fibrillation ablation is the most serious and feared complication. AEF is difficult to diagnose, and delays in diagnosis are common. Highly variable symptoms usually do not start to appear for 1 week or longer postprocedure, and when they appear, the patient often presents to a community hospital staffed by providers with little knowledge of AEF . Postablation esophageal perforation can present with variations including true AEF, pericardioesophageal fistula, and mediastinal-esophageal fistula. True AEF usually has a precursor esophageal lesion, which is often neglected or confused with pericarditis, a more common complication associated with atrial fibrillation ablation. Esophageal lesions eventually ulcerate and may progress into a direct connection between esophagus and left atrium, causing air embolism with stroke, sepsis, and sometimes esophageal bleeding. AEF is rare but is often fatal, especially if not treated, with mortality rates ranging from 40% to 100%.”
Recognition, Management, and Prevention of Atrioesophageal Fistula
Catanzaro JN, Assis FR, Verma A, Tandri H, Tilz RR, Spragg DD, Calkins H, Fishman EK, Deneke T..
JACC Clin Electrophysiol. 2024 Apr 13:S2405-500X(24)00165-8. doi: 10.1016/j.jacep.2024.02.022. Epub ahead of print. PMID: 38703161.
Recognition, Management, and Prevention of Atrioesophageal Fistula
Catanzaro JN, Assis FR, Verma A, Tandri H, Tilz RR, Spragg DD, Calkins H, Fishman EK, Deneke T..
JACC Clin Electrophysiol. 2024 Apr 13:S2405-500X(24)00165-8. doi: 10.1016/j.jacep.2024.02.022. Epub ahead of print. PMID: 38703161.