Diagnostic accuracy of endoscopy in determining rectal tumor proximity to the peritoneal reflection.

PURPOSE: Treatment of invasive rectal adenocarcinoma is stratified into upfront surgery versus neoadjuvant chemoradiotherapy, in part, based on tumor distance from the anal verge (AV). This study examines the correlation between tumor distance measurements (endoscopic and MRI) and relationship to the anterior peritoneal reflection (aPR) on MRI. METHODS: A single-center retrospective study was performed at a tertiary center accredited by the National Accreditation Program for Rectal Cancer (NAPRC). 162 patients with invasive rectal cancer were seen between October of 2018 and April of 2022. Sensitivity and specificity were determined for MRI and endoscopic measurements in their ability to predict tumor location relative to the aPR. RESULTS: One hundred nineteen patients had tumors endoscopically and radiographically measured from the AV. Pelvic MRI characterized tumors as above (intraperitoneal) or at/straddles/below the aPR (extraperitoneal). True positives were defined as extraperitoneal tumors [Formula: see text] 10 cm. True negatives were defined as intraperitoneal tumors > 10 cm. Endoscopy was 81.9% sensitive and 64.3% specific in predicting tumor location with respect to the aPR. MRI was 86.7% sensitive and 92.9% specific. Utilizing a 12 cm cutoff, sensitivity of both modalities increased (94.3%, 91.4%) but specificity decreased (50%, 64.3%). CONCLUSION: For locally invasive rectal cancers, tumor position relative to the aPR is an important factor in determining the role of neoadjuvant therapy. These results suggest endoscopic tumor measurements do not accurately predict tumor location relative to the aPR, and may lead to incorrect treatment stratification recommendation. When the aPR is not identified, MRI-reported tumor distance may be a better predictor of this relationship.

Low-density Isolated Intraperitoneal Free Fluid in Pediatric Blunt Trauma Is Not Associated With Abdominal Injury.

OBJECTIVES: Isolated intraperitoneal free fluid (IIFF) is defined as intraperitoneal fluid seen on computed tomography (CT) without identifiable injury. In a hemodynamically stable patient, this finding creates a challenge for physicians regarding the next steps in management because the clinical significance of this fluid is not completely understood. We hypothesized that pediatric blunt trauma patients with a finding of simple IIFF on CT would not have clinically significant intraabdominal injury. METHODS: A retrospective review (2009-2018) was conducted of all pediatric blunt trauma patients who underwent CT scan of the abdomen/pelvis at our institution. All patients with scans performed at our institution with the finding of IIFF were included. Scans were reviewed to measure the Hounsfield Units (HU) of the intraabdominal fluid. Groups were stratified into HU > 25 and HU ≤ 25, below accepted cutoffs for acute blood, and clinical outcomes were reviewed. RESULTS: A total of 413 patients had free fluid on CT abdomen/pelvis with 279 (68%) having only the finding of IIFF. The HU was 25 or less in 236 (85%) patients. No patients in the HU ≤ 25 group required operative exploration or had examination findings to indicate they had intraabdominal injury. Four (9%) patients in the HU > 25 required laparotomy (P < 0.0001). No patients in the HU ≤ 25 group required further workup or hospital admission over concern for intraabdominal injury. CONCLUSIONS: Pediatric blunt trauma patients with HU of 25 or less IIFF and a nonperitonitic physical examination did not require operative exploration or further workup for intraabdominal injury. In the absence of other injuries, it is safe to discharge these patients without further workup.

Checklist for a Radiology Information System Go-Live.

This article highlights the experience of a single center institution undergoing a change in radiology information system (RIS) software platforms, transitioning to an electronic medical record-RIS driven workflow. Ten planning and execution topics with recommendations are presented in checklist form from the radiology department perspective. The build process of creating a site specific RIS takes many months, beginning with the organization of a steering committee. On Go-Live, several checklist items are offered to help streamline the troubleshooting process and improve communication throughout the radiology department. The groundwork of the group effort in creating the infrastructure of the build process can continue to be useful beyond Go-Live, as RIS features are continually optimized.

Online Portals: Gateway to Patient-Centered Radiology.

OBJECTIVE: Online portals typically allow access to radiology reports, causing a shift in the communication. This article evaluates the studies available in the literature about patient portals and the use of patient portals in radiology. Patient and physician preferences and the impact on radiology reporting are presented. CONCLUSION: Patient portals provide an opportunity for radiologists to engage with their patients via a new method of communication. Radiologist collaboration with referring physicians is important in providing care in accordance with patient preferences.

Evaluation of the diagnostic value of a venous phase in CT angiography of the extremities in the setting of trauma: is vein imaging in vain?

PURPOSE: This study examined the value of including a venous phase in addition to the initial arterial phase in the CT angiography evaluation of extremity trauma. METHODS: CT studies from 157 patients (average age 38 years, age range 18-89 years, male 83%, female 17%) were obtained for trauma to the upper or lower extremity with both arterial and venous phases and retrospectively reviewed. The detection rate and type of vascular injury were evaluated by using the arterial phase alone and compared to the detection rate when interpreting the arterial and venous phases together. RESULTS: Arterial injury was identified in 35 cases (22%), and venous injury was identified in seven cases (5%). Four cases of discrepant diagnoses were identified between image interpretation of the arterial phase alone and interpretation using both phases, all of which were venous injuries that were visible only on the venous phase. None of the four cases of venous injury required a change in surgical management. Overall, no significant difference in diagnosis between the two methods of image interpretation (arterial phase alone, arterial and venous phases) was discovered (p > 0.125; CI 95%). CONCLUSIONS: The use of a venous phase in the CT angiography evaluation of extremity trauma does not add significant arterial diagnostic or clinical management value despite its potential of increasing the diagnostic detection rate of venous injury.

Pediatric cervical spine marrow T2 hyperintensity: a systematic analysis.

OBJECTIVE: Hyperintense areas of vertebral bone marrow on fluid-sensitive sequences are at times seen on pediatric MRI of the cervical spine in children without suspicious clinical conditions to explain marrow pathology. Although these likely have no clinical significance they may be mistaken for pathology. The purpose of this study is to systematically evaluate the locations and patterns of marrow T2 hyperintensity in the pediatric cervical spine, with respect to age. MATERIALS AND METHODS: At 1.5 T, the C2 through T3 vertebrae of 82 children aged 0-17 years without clinically suspicious marrow abnormality were retrospectively reviewed by two musculoskeletal radiologists, who were blinded to patients' age. The frequency, intensity, and location of the foci of marrow T2 hyperintensity were recorded for each vertebra on a 12-point scoring system and were correlated with the patients' age. RESULTS: Foci of marrow hyperintensity were seen in 46/82 (56.1%) patients and in 241/734 (32.8%) vertebrae. Foci were most common in C4 (42% of patients), C5 (45.7%), and C6 (37.8%). The foci of T2 hyperintensity were more common inferiorly (188 foci) and adjacent to the anterior cortex (123). Analysis revealed no significant correlation between age and marrow score (Spearman = -0.147, P = 0.19), but did find a trend towards increased presence of marrow T2 hyperintensity in the ages of most rapid growth, 8-14 years (81.5% of patients). CONCLUSION: Vertebral body marrow T2 hyperintensity was most common endosteally and in the mid-cervical spine with a slight peak in adolescence. We therefore believe that these pediatric cervical marrow changes may be related to rapid bone growth at the point of maximal kyphotic stress.

Added Value of Dedicated Spine CT to Detect Fracture in Patients with CT Chest, Abdomen, and Pelvis in the Trauma Setting.

PURPOSE: Fractures of the thoracolumbar spine account for up to 90% of spinal fractures, and are associated with significant disability. The advantage of acquiring dedicated spine CT imaging in addition to visceral CT studies of the chest, abdomen and pelvis for detection of spinal fractures has not been definitively established. This retrospective study seeks to determine the contribution of dedicated spine CT in the acute clinical setting. METHODS: Patients who were diagnosed with fractures of the thoracic or lumbar spine at our institution between January 1, 2010 and June 30, 2014 were identified. Additional inclusion criteria included having a CT of the chest and/or abdomen and pelvis followed by a dedicated thoracic or lumbar spine CT within 30 days. Reports were reviewed for accuracy of fracture detection, and missed fractures were retrospectively analyzed on images for detectability. RESULTS: A total of 102 patients met our inclusion criteria for a total of 312 fractures. Of the 312 fractures, 31 (10%) were missed on the initial visceral CT in 18 of the 102 patients. In all but two cases, at least one fracture was identified on the visceral spine CT. There were no cases in which the newly identified fractures changed patient management. CONCLUSION: All fractures requiring surgical intervention were identified on the visceral CT. A dedicated spine CT does detect additional spine fractures but does not clearly alter patient management.

Non-visualization of the ovary on CT or ultrasound in the ED setting: utility of immediate follow-up imaging.

PURPOSE: In the setting of female patients in the ED receiving both a CT scan and ultrasound of the pelvis, we compared the studies to assess the diagnostic value of non-visualization of the ovary in predicting the absence of ovarian disease. METHODS: A retrospective review of the electronic medical record identified adult female non-pregnant patients who received both a CT abdomen and pelvis and a transabdominal and transvaginal pelvic ultrasound within a 48-h period through the emergency department. The imaging studies were blindly reviewed to evaluate the ovaries on each CT and US independently. Ovaries were characterized as normal, non-visualized, or abnormal requiring follow-up. All cases of non-visualized ovaries were compared to the appearance on the corresponding exam for each patient, and assessed for agreement (normal or non-visualized) or disagreement (abnormal). Subsequently, the electronic medical record was used as a reference standard to assess the presence or absence of ovarian pathology over the subsequent ninety days. Statistical analysis was performed utilizing a McNemar test with a 95% confidence interval. RESULTS: A total of 181 patients were included in the study (age range 18-75). Of these, 36 patients had non-visualization of one ovary (21 patients) or both ovaries (15 patients) on either study. On CT, 18 ovaries were non-visualized, with no cases of disagreement on ultrasound or subsequent short-term follow-up (NPV 100%). On ultrasound, 39 ovaries were non-visualized, with three of these adnexae appearing abnormal on CT (NPV 92%): one with an enlarged ovary and two with hydrosalpinx. No ovarian abnormalities were evident on chart follow-up. Significant correlation of agreement between normal and non-visualized pairs on CT and US was observed (p = 0.025, McNemar). There was a combined NPV of 94% regardless of modality for the absence of ovarian pathology in the case of non-visualization. The most common abnormal imaging findings associated with non-visualized ovaries were uterine fibroids and hemoperitoneum. CONCLUSION: The absence of detection of the ovary on pelvic US or CT is highly predictive of the lack of ovarian abnormality on short-term follow-up, and does not typically require additional imaging to exclude ovarian disease.