Phase I Safety and Feasibility Pilot of Hepatic Artery Infusion Chemotherapy in a Rural Catchment Area Using The Codman Vascular Catheter with The Medtronic SynchroMed II Pump for Intrahepatic Cancers.

BACKGROUND: Discontinuation of the Codman 3000 pump in 2018 left no Food and Drug Administration (FDA)-approved hepatic artery infusion (HAI) device for unresectable colorectal liver metastases (uCLM) and intrahepatic cholangiocarcinoma (uIHC). Historically, HAI has been performed at academic medical centers in large metropolitan areas, which are often inaccessible to rural patients. Consequently, feasibility of dissemination of HAI to rural populations is unknown. PATIENTS AND METHODS: Under an FDA investigational device exemption, we opened the only HAI program in Kentucky and enrolled patients with uCLM and uIHC in a phase I clinical trial. The trial examined the safety of the hybrid Codman catheter/Medtronic SynchroMed II pump (hCMP) combination, defined as successful completion of one cycle of HAI chemotherapy. Rural feasibility was assessed by number of missed pump fills appointments. RESULTS: A total of 21 patients (n = 17 uCLM, n = 4 uIHC) underwent hCMP implantation before accrual was stopped early owing to FDA approval of the Intera 3000 pump. 20/21 (95%) patients met the primary safety endpoint. Serious adverse events (AEs) included a grade 5 coronavirus disease 2019 (COVID-19) infection (n = 1) and a grade 3 catheter erosion into the bowel (n = 1). Biliary sclerosis developed in two patients (9.5%). Median distance to infusion center was 47.6 miles (2-138 miles), and 62% were from Appalachia, yet there were no missed pump fill appointments. The 2-year overall survival was 82.4% (uCLM) and 50% (uIHC). CONCLUSIONS: The hCMP device had an acceptable safety profile. Despite the complexity of starting a new HAI program, early results showed feasibility for HAI delivery in a rural catchment area and comparable outcomes to larger urban-based HAI centers.

Development of CNN models for the enteral feeding tube positioning assessment on a small scale data set.

BACKGROUND: Enteral nutrition through feeding tubes serves as the primary method of nutritional supplementation for patients unable to feed themselves. Plain radiographs are routinely used to confirm the position of the Nasoenteric feeding tubes the following insertion and before the commencement of tube feeds. Convolutional neural networks (CNNs) have shown encouraging results in assisting the tube positioning assessment. However, robust CNNs are often trained using large amounts of manually annotated data, which challenges applying CNNs on enteral feeding tube positioning assessment. METHOD: We build a CNN model for feeding tube positioning assessment by pre-training the model under a weakly supervised fashion on large quantities of radiographs. Since most of the model was pre-trained, a small amount of labeled data is needed when fine-tuning the model for tube positioning assessment. We demonstrate the proposed method using a small dataset with 175 radiographs. RESULT: The experimental result shows that the proposed model improves the area under the receiver operating characteristic curve (AUC) by up to 35.71% , from 0.56 to 0.76, and 14.49% on the accuracy, from 0.69 to 0.79 when compared with the no pre-trained method. The proposed method also has up to 40% less error when estimating its prediction confidence. CONCLUSION: Our evaluation results show that the proposed model has a high prediction accuracy and a more accurate estimated prediction confidence when compared to the no pre-trained model and other baseline models. The proposed method can be potentially used for assessing the enteral tube positioning. It also provides a strong baseline for future studies.

Case 213: primary splenic angiosarcoma.

History A 75-year-old woman with a medical history of gastroesophageal reflux disease and type II diabetes presented to the hospital with a 3-month history of gradually worsening headaches, vague upper abdominal pain, and lower back pain. The patient denied fevers, night sweats, contact with sick individuals, occupational exposure to infection, bleeding, immunodeficiency, intravenous drug use, alcohol or tobacco abuse, history of malignancy, family history of genetic disorders, and international travel. Physical examination revealed a skin-colored mass protruding from the right side of her forehead, but there were no other notable abnormalities. Her diabetes was managed with diet, and the only prescription medication she was taking was esomeprazole. She was not taking anticoagulants. Initial laboratory work-up revealed anemia and profound thrombocytopenia (hemoglobin level, 9.4 g/dL; platelet count, 16 × 10(9)/L); these were refractory to aggressive treatment, including plasmapheresis, immunosuppression with prednisolone, and numerous transfusions. Contrast material-enhanced magnetic resonance (MR) imaging of the head was performed at admission to further evaluate the patient's headache and the mass on the patient's forehead. Ultrasonography (US) of the abdomen was performed to evaluate the cause of abdominal pain. The discovery of liver lesions at US led us to perform contrast-enhanced computed tomography (CT) of the chest, abdomen, and pelvis. Contrast-enhanced MR imaging of the abdomen was performed to narrow the diagnostic considerations for the lesions identified at CT. Bone marrow biopsy revealed no evidence of infectious or neoplastic processes. Endoscopy and colonoscopy were performed; however, they revealed no abnormalities. Further laboratory work-up included extensive testing for parasites, fungi, bacteria, and viruses, including the human immunodeficiency virus (HIV). All of the results were negative. On the 17th day of admission, the patient became acutely unresponsive, her condition deteriorated rapidly, and she died. Unenhanced head CT was performed at the time of the patient's acute decompensation.

MR imaging of penile pathology and prostheses.

Penile MRI is a vital yet underutilized diagnostic tool that provides detailed information crucial for managing various penile pathologies. Due to its infrequent use, many radiology trainees lack confidence in interpreting these exams. This article reviews the anatomy, key technical considerations, and interpretive pearls for penile trauma, Peyronie's disease, priapism, penile neoplasms, prosthesis evaluation, and a few miscellaneous conditions. Through illustrative case examples, this review aims to enhance the understanding and proficiency of radiologists in performing and interpreting penile MRI in these clinical scenarios.

Deep learning versus iterative reconstruction on image quality and dose reduction in abdominal CT: a live animal study.

Objective.While simulated low-dose CT images and phantom studies cannot fully approximate subjective and objective effects of deep learning (DL) denoising on image quality, live animal models may afford this assessment. This study is to investigate the potential of DL in CT dose reduction on image quality compared to iterative reconstruction (IR).Approach.The upper abdomen of a live 4 year old sheep was scanned on a CT scanner at different exposure levels. Images were reconstructed using FBP and ADMIRE with 5 strengths. A modularized DL network with 5 modules was used for image reconstruction via progressive denoising. Radiomic features were extracted from a region over the liver. Concordance correlation coefficient (CCC) was applied to quantify agreement between any two sets of radiomic features. Coefficient of variation was calculated to measure variation in a radiomic feature series. Structural similarity index (SSIM) was used to measure the similarity between any two images. Diagnostic quality, low-contrast detectability, and image texture were qualitatively evaluated by two radiologists. Pearson correlation coefficient was computed across all dose-reconstruction/denoising combinations.Results.A total of 66 image sets, with 405 radiomic features extracted from each, are analyzed. IR and DL can improve diagnostic quality and low-contrast detectability and similarly modulate image texture features. In terms of SSIM, DL has higher potential in preserving image structure. There is strong correlation between SSIM and radiologists' evaluations for diagnostic quality (0.559) and low-contrast detectability (0.635) but moderate correlation for texture (0.313). There is moderate correlation between CCC of radiomic features and radiologists' evaluation for diagnostic quality (0.397), low-contrast detectability (0.417), and texture (0.326), implying that improvement of image features may not relate to improvement of diagnostic quality.Conclusion.DL shows potential to further reduce radiation dose while preserving structural similarity, while IR is favored by radiologists and more predictably alters radiomic features.

CT enterography: principles, trends, and interpretation of findings.

Computed tomographic (CT) enterography is an emerging alternative to traditional fluoroscopy for the assessment of disorders of the small bowel. The greatly improved spatial and temporal resolution provided by multidetector CT scanners, combined with good luminal distention provided by negative oral contrast agents and with good bowel wall visualization, have made CT enterography the main imaging modality not only for investigating proved or suspected inflammatory bowel disease but also for detecting occult gastrointestinal tract bleeding, small bowel neoplasms, and mesenteric ischemia. CT enterography is particularly useful for differentiating between active and fibrotic bowel strictures in patients with Crohn disease, thus enabling selection of the most appropriate treatment (medical management or intervention) for an improved outcome. CT enterography allows excellent visualization of the entire thickness of the bowel wall and depicts extraenteric involvement as well, providing more detailed and comprehensive information about the extent and severity of the disease process.

The augmented role of pancreatic imaging in the era of endoscopic necrosectomy: an illustrative and pictorial review.

Endoscopic cystogastrostomy for mature pancreatic collections has long been recognized. However, FDA approval of newer lumen-apposing metallic stents in 2014 has now brought pancreatic necrosectomy to the endoscopic realm. Endoscopic drainage of Walled-off necrosis and direct endoscopic necrosectomy are technically challenging procedures with higher rates of complications. Collaborative clinical decision making both pre- and post-procedurally between the radiologist, endoscopist, and the surgeon can greatly improve outcomes in necrotizing pancreatitis. Herein, we review the basic pathophysiology that underlies progressive radiographic findings in NP, value of preprocedural imaging, current management algorithms, newer tools, and techniques as well as potential post-procedure complications on imaging follow-up after endoscopic interventions in necrotizing pancreatitis.

Renal Granulomatosis Post Intravesical Bacillus Calmette-Guerin Therapy for Non-muscle-invasive Bladder Cancer.

Intravesical Bacillus Calmette-Guerin (BCG) immunotherapy is a proven, effective treatment for intermediate- and high-risk non-muscle-invasive bladder cancer. Minor side effects are common and expected but systemic effects can occur in <5% of treated patients. We present a rare case of a 49-year-old male that presented with fever and chills after 3 weeks of intravesical BCG therapy post transurethral resection of bladder tumor. New renal lesions were present on contrast-enhanced computed tomography scan which was histologically proven to be necrotizing renal granulomatosis.

Endometriosis revisited: an imaging review of the usual and unusual manifestations with pathological correlation.

The manifestations of endometriosis commonly present a diagnostic challenge to the gynecologist and radiologist. Familiarity with its varied presentations may allow for a more accurate diagnosis. The goal of this review is to the present the imaging spectrum of endometriosis, less common sites of involvement as well as the potential rare complications. Relevant surgical and histopathological correlation is also provided. In addition to clinical evaluation and sonography, MRI is a highly accurate imaging modality in the diagnosis of endometriosis. It possesses a distinctive advantage over other modalities in that it allows a complete survey of the pelvic compartments. The potentially devastating effects of endometriosis include pelvic pain and even infertility. Since standard treatment is surgical, the radiologist needs to be familiar with the various manifestations in order to aid diagnosis for appropriate management.

Radiologist and Sonographer Interpretation Discrepancies for Biliary Sonographic Findings: Our Experience.

PURPOSE: The aim was to determine the discrepancy rate between the preliminary interpretation by sonographers and the final radiology interpretation for biliary sonographic findings. MATERIALS AND METHODS: Institutional review board approval was obtained. Four hundred consecutive right upper quadrant sonographer performed ultrasounds were reviewed retrospectively. Sonographers' worksheets were compared with the final radiology report. For the purposes of this project, only the biliary findings were compared and reviewed. Discrepant findings were reviewed by 5 ultrasound experts, and a majority vote sought to determine truth, sonographer worksheet findings, or radiologist report. The clinical impact of the discrepant findings was also evaluated. RESULTS: Of the 400 scans, there were 338 agreements and 62 discrepancies. The overall discrepancy rate was 15.5%. The most frequently contested discrepancy was the presence or absence of pericholecystic fluid n = 21. Sonographers (S) were deemed correct 8 times and radiologists (R) 13 times, denoted 8/13 (S/R). The overall split was 30/32 (S/R) with radiologists deemed correct 52% of the time and sonographers 48% of the time. Using a 1-sample proportion χ test with Yates' continuity correction, there were no statistically significant discrepancies between the 2 groups. CONCLUSIONS: We observed an interpretation discrepancy rate of 15.5% with radiologists deemed correct slightly more frequently, although this did not meet statistical significance. Clinically impactful discrepant findings (6.5% of all discrepancies) were all correctly called by the radiologists. Both groups bring tremendous value to the ultrasound arena, and continued collaboration should be encouraged. PURPOSE: The aim of this study was to determine the discrepancy rate that exists between the preliminary interpretation by sonographers and the subsequent final radiology interpretation for biliary sonographic findings.

Stone size limits the use of Hounsfield units for prediction of calcium oxalate stone composition.

OBJECTIVE: To evaluate the role of stone size in predicting urinary calculus composition using Hounsfield units on noncontrasted computed tomography (CT) scan. METHODS: A retrospective review was performed for all patients who underwent ureteroscopy or percutaneous nephrolithotomy during a 1-year period, had a stone analysis performed, and had CT imaging available for review. All CT scans were reviewed by a board-certified radiologist. Variables evaluated included age, sex, body mass index, stone size, stone location, Hounsfield units (HUs), and stone composition. RESULTS: We identified a total of 91 patients (41 men and 50 women) with CT imaging and stone analysis available for review. Stone analysis showed 41 calcium oxalate monohydrate (CaOxMH), 13 calcium oxalate dihydrate, 29 calcium phosphate, 5 uric acid, 2 struvite, and 1 cystine stone. Average age was 46 years, and average body mass index was 32 kg/m2. Measured HUs varied significantly with size for CaOxMH and calcium oxalate dihydrate stones (P values <.05), but not for calcium phosphate stones (P = .126). Using a CaOxMH identification value of 700-1000 HUs, 28 of 41 stone compositions (68%) would not have been correctly identified, including all 10 (100%) small (<5 mm) stones, 13 of 22 (59%) medium (5-10 mm) stones, and 5 of 9 large (>10 mm) stones (55%). CONCLUSION: For calcium stones, the ability of CT HUs to predict stone composition was limited, likely due to the mixed stone composition. Within a cohort of CaOxMH stone formers, measured HUs varied linearly with stone size. All stones <5 mm were below thresholds for CaOxMH composition.