Ultrasound is superior to palpation for thyroid cancer detection in high-risk childhood cancer and BMT survivors.

PURPOSE: Thyroid cancer is a common subsequent malignant neoplasm in childhood cancer survivors (CCS). Patients who received radiotherapy (RT) to the head, neck, upper thorax, or total body irradiation (TBI) are considered to be at risk for subsequent thyroid cancer. Current Children's Oncology Group screening guidelines recommend annual neck palpation. Our objective was to determine if ultrasound (US) is more sensitive and specific than palpation to detect thyroid cancer in high-risk CCS and bone marrow transplant (BMT) survivors. METHODS: Electronic medical records of patients followed in a longitudinal survivorship clinic from January 1, 2010 to December 31, 2017 were reviewed. Inclusion criteria included history of RT to the head, neck, upper thorax, or TBI for primary therapy or preparation for BMT prior to the age of 20 years. RESULTS: Two hundred and twenty-five patients had documented palpation and 144 (64%) also had US evaluation. Mean radiation dose was 28.6 Gy. Sixteen of 225 patients (7.1%) developed a subsequent thyroid cancer at a mean of 9.7 years from the completion of RT. Sensitivity of US was 100% compared with 12.5% for palpation. US demonstrated higher accuracy, with a receiver operating characteristic (ROC) area under the curve (AUC) of 0.87 versus 0.56 for palpation (P < 0.0001). CONCLUSION: Routine screening with US was more sensitive than palpation for detection of subsequent thyroid cancer after high-risk RT in CCS and BMT survivors. Screening US may lead to earlier detection of thyroid cancer in this population. Earlier diagnosis has the potential to decrease operative complexity, and earlier definitive therapy reduces the likelihood of metastatic disease.

Dynamic ultrasound in the evaluation of patients with suspected slipping rib syndrome.

OBJECTIVE: Slipping rib syndrome (SRS) affects adolescents and young adults. Dynamic ultrasound plays a potential and likely significant role; however, limited data exist describing the protocol and techniques available. It is our intent to describe the development of a reproducible protocol for imaging in patients with SRS. MATERIALS AND METHODS: Retrospective review of suspected SRS patients from March 2017 to April 2018. A total of 46 patients were evaluated. Focused history and imaging was performed at the site of pain. Images of the ribs were obtained in the parasagittal plane at rest and with dynamic maneuvers. Dynamic maneuvers included Valsalva, crunch, rib push maneuver, and any provocative movement that elicited pain. Imaging was compared with records from the pediatric surgeon specializing in slipping ribs. Statistical analysis was performed. RESULTS: Thirty-six of the 46 patients had a diagnosis of SRS, and had an average age of 17 years. Thirty-one patients were female, 15 were male. Thirty-one out of 46 (67%) were athletes. Average BMI was 22.6. Dynamic ultrasound correctly detected SRS in 89% of patients (32 out of 36) and correctly detected the absence in 100% (10 out of 10). Push maneuver had the highest sensitivity (87%; 0.70, 0.96) followed by morphology (68%; 0.51, 0.81) and crunch maneuver (54%; 0.37, 0.71). Valsalva was the least sensitive (13%; 0.04, 0.29). CONCLUSION: Dynamic ultrasound of the ribs, particularly with crunch and push maneuvers, is an effective and reproducible tool for diagnosing SRS. Valsalva plays a limited role. In addition to diagnosing SRS, ultrasound can give the surgeon morphological data and information on additional ribs at risk, thereby assisting in surgical planning.

Magnetic resonance imaging of the pediatric mediastinum.

The mediastinum, the central anatomical space of the thorax, is divided by anatomical landmarks but not by physical boundaries. The mediastinum is a conduit, a space through which cranial nerves, important nerve branches, the sympathetic chain, vascular structures, and visceral structures, the trachea and esophagus pass. This arrangement allows contiguous extension or communication of disease along facial planes and through potential spaces to and from the head and neck or cervical spine, to and from the superior mediastinum, between superior and inferior mediastinal levels, and between inferior mediastinal spaces into the intra- and retroperitoneal spaces. Magnetic resonance imaging (MRI) of the mediastinum in children poses technical challenges, in particular cardiac and respiratory motion, and diagnostic challenges, including a broad range of tissue types and possible diagnoses. In this paper we review mediastinal anatomy, MRI sequences and protocol choices and include a short discussion of features and MRI findings of some of the congenital and acquired pathologies that are most often encountered in the pediatric mediastinum.

Pigmented villonodular synovitis of the flexor hallucis longus tendon: A rare cause of leg pain in a 12-year-old girl.

Pigmented villonodular synovitis is an uncommon benign neoplastic proliferation associated with the synovium, bursa, or tendon sheaths; most commonly occurring in the third to fourth decade of life. It is rare in children and may be painful or painless. Magnetic resonance imaging is the diagnostic study of choice. In this report, the radiologic, ultrasound, and magnetic resonance imaging findings of pigmented villonodular synovitis of the flexor hallucis longus in a 12-year-old girl are discussed. We briefly review the surgical findings as well. To our knowledge, this is the first case report that simultaneously synthesizes the imaging findings of 3 diagnostic imaging modalities for optimal visualization and is the youngest reported case of pigmented villonodular synovitis of the flexor hallucis longus tendon.

Performance of ACR TI-RADS and the Bethesda System in Predicting Risk of Malignancy in Thyroid Nodules at a Large Children's Hospital and a Comprehensive Review of the Pediatric Literature.

While thyroid nodules are less common in children than in adults, they are more frequently malignant. However, pediatric data are scarce regarding the performance characteristics of imaging and cytopathology classification systems validated to predict the risk of malignancy (ROM) in adults and select those patients who require fine-needle aspiration (FNA) and possibly surgical resection. We retrospectively reviewed the electronic medical records of all patients 18 years of age or younger who underwent thyroid FNA at our institution from 1 July 2015 to 31 May 2022. Based on surgical follow-up from 74 of the 208 FNA cases, we determined the ROM for the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) ultrasound risk stratification system and The Bethesda System for Reporting Thyroid Cytopathology and added our results to those of pediatric cohorts from other institutions already published in the literature. We found the following ROMs for 1458 cases using ACR TI-RADS (TR): TR1. Benign: 2.2%, TR2. Not Suspicious: 9.3%, TR3. Mildly Suspicious: 16.6%, TR4. Moderately Suspicious: 27.0%, and TR5. Highly Suspicious 76.5%; and for 5911 cases using the Bethesda system: Bethesda I. Unsatisfactory: 16.8%, Bethesda II. Benign: 7.2%, Bethesda III: Atypia of Undetermined Significance: 29.6%, Bethesda IV. Follicular Neoplasm: 42.3%, Bethesda V. Suspicious for Malignancy: 90.8%, and Bethesda VI. Malignant: 98.8%. We conclude that ACR TI-RADS levels imply higher ROMs for the pediatric population than the corresponding suggested ROMs for adults, and, in order to avoid missing malignancies, we should consider modifying or altogether abandoning size cutoffs for recommending FNA in children and adolescents whose thyroid glands are smaller than those of adults. The Bethesda categories also imply higher ROMs for pediatric patients compared to adults.

Spondyloepiphyseal dysplasia congenita: Use of complementary 3D reconstruction imaging for preoperative planning.

We present a case of spondyloepiphyseal dysplasia congenita (SEDC), a rare autosomal dominant genetic disorder that results in short stature and skeletal anomalies. Children with SEDC have disproportionate short-trunked short stature, platyspondyly, coxa vara, and epiphyseal involvement. Those with coxa vara can develop osteoarthritis of the hip early and a valgus hip osteotomy is recommended to preserve hip function and delay progression to osteoarthritis. Surgery is difficult due to the three-dimensional deformity, unossified femoral head, and small patient size. In this case, a patient-specific surgical plan and implant sizing was developed using a composite 3D reconstruction from computed tomography (CT) and magnetic resonance imaging (MRI). The complementary use of both modalities allowed for a complete visualization of the patient's dysplastic femoral head & neck anatomy.

Optimal Visualization of Os Subfibulare Using 3D Water Selective Cartilage Scan (3D_WATSc) MRI Sequencing: A Case Report.

Os subfibulare is an accessory ossicle of the lateral malleolus at the distal end of the fibula. In most instances, os subfibulare is found incidentally on radiographs. While os subfibulare typically remains asymptomatic, some cases may present with ankle pain or instability. To initiate appropriate treatment and maximize patient outcomes, it is crucial to accurately visualize the accessory ossicle. Here, we report a symptomatic case of os subfibulare diagnosed with ankle radiographs and a 3D water selective cartilage scan (3D_WATSc, Ingenia, Philips Healthcare, The Netherlands) magnetic resonance imaging sequence and treated surgically with open ossicle excision and a modified Broström procedure.

Establishing an Online Educational Teaching File on Instagram for an Academic Radiology Department: Proof-of-Concept.

Instagram is a powerful social media platform, which can serve as the ideal educational companion app for a visually rich discipline such as Radiology. Instagram facilitates easy content creation allowing for educators to utilize this resource for easy and rapid dissemination of educational content. The authors describe their experience of creating an online publicly available radiology teaching file on Instagram as a proof-of-concept, to help other individuals and institutions in leveraging social media to create and share quality educational content for current and future trainees.

Incidence estimates and demographics of scaphoid fracture in the U.S. population.

PURPOSE: The epidemiology of scaphoid fracture is based mostly on retrospective analyses of small population centers. The purpose of this study was to determine the incidence of scaphoid fractures in a large national population database. METHODS: The National Electronic Injury Surveillance System (NEISS) is a representative sample of patients that is weighted to provide estimates of various injuries in the United States presenting to emergency rooms. Data on wrist fractures obtained from NEISS were used to estimate the incidence of scaphoid fractures in the United States between 2002 and 2006. We could not distinguish true scaphoid fractures from suspected scaphoid fractures. Demographics, location, mechanism, and sports participation were also recorded. RESULTS: A total of 507 injuries coded as fractures of the scaphoid were identified in the database from 2002 to 2006. According to the methodology of the NEISS sample, this corresponds to an estimated 21,481 scaphoid fractures among 909,309 total wrist fractures nationwide (2.4%) and an estimated incidence of scaphoid fractures of 1.47 fractures per 100,000 person-years (95% confidence interval, 1.31-1.63). CONCLUSIONS: The estimated incidence of scaphoid fractures using U.S. census data is an order of magnitude less than the estimates in prior studies. If the data represent both suspected and true fractures, the incidence of true scaphoid fractures is likely an order of magnitude less than our estimates. Young males and persons between 10 and 19 years of age are at highest risk for scaphoid fracture.

Making the diagnosis of midgut volvulus: Limited abdominal ultrasound has changed our clinical practice.

PURPOSE: To assess the diagnostic accuracy of limited abdominal ultrasound (US) examination for midgut volvulus (MGV) and to evaluate how clinical practice has changed in a free-standing children's hospital leading to the near obsolescence of upper GI (UGI) studies for the diagnosis of MGV. MATERIALS AND METHODS: All patients with suspected MGV who underwent abdominal US during 2016-2017 were identified using keyword search tools in the radiology information system. Retrospective, blinded image review was performed by a certificate of added qualification (CAQ), board certified pediatric radiologist. US images were evaluated for the presence of the superior mesenteric artery (SMA) cutoff sign and twisting of the bowel and mesentery around the SMA (whirlpool sign). The results were compared with the operative reports. RESULTS: 195 US studies were performed from 2016 to 2017. The most common presentations were vomiting (44%), abdominal pain (7%), and suspected malrotation (10%) 195 US studies were reviewed, of which 16 were nondiagnostic. The remaining 179 diagnostic studies showed MGV in 14 patients. Those 14 patients were surgically explored and confirmed to have midgut volvulus. 7 of the 16 nondiagnostic US studies were further evaluated with UGI examination with 1 patient demonstrating malrotation without volvulus, which was confirmed at surgery. 2 had CT exams which were normal. 4 were followed clinically. The remaining 3 patients went to surgery, all of which did not show MGV. There were 164 negative US, none of whom went to surgery. US was diagnostic in 92% of patients and when diagnostic the positive and negative predictive values of US were 100%. CONCLUSION: Limited abdominal US is a highly accurate examination for the diagnosis of midgut volvulus. UGI exposes patients to ionizing radiation and should be reserved for patients in whom US is nondiagnostic or inconclusive. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: Level 3.

Third ventricle choroid plexus papilloma: 2 cases.

The third ventricle is an uncommon location for choroid plexus papillomas. In adults, these tumors most commonly occur in the fourth ventricle. In children, they are more commonly found in the lateral ventricles. When these lesions are discovered in the third ventricle, they are often posteriorly located. Hydrocephalus and macrocephaly are typical sentinel findings. We present 2 cases of this uncommon presentation of third ventricular choroid plexus papilloma.

Congenital venolobar syndrome, pulmonary sequestration, and horseshoe lung in a newborn female.

A 6-day-old female presented to a pediatric cardiologist with tachypnea. A computed tomography angiogram of the chest showed partial anomalous pulmonary venous return, a pulmonary sequestration, and a horseshoe lung. Depicted here are radiographic findings which display this rare combination. This case demonstrates the need for the radiologist to consider additional abnormalities in the setting of anomalous pulmonary venous return.

Opiate leukoencephalopathy in a pediatric patient.

A 17-year-old male presented from an outside facility in acute respiratory failure and profound hypotension. He was found to have classic MRI brain findings of opiate-induced leukoencephalopathy which was corroborated with urine drug screen and history. This entity has been described in the adults but is not as well recognized in the pediatric population. As the opiate epidemic continues to evolve, this case brings heightened awareness of this disorder to pediatric radiologists.

Unique neuroradiological findings in propionic acidemia.

Propionic acidemia is a rare metabolic disorder that affects the catabolism of branched-chain amino acids and oddchain fatty acids. Propionic acidemia is one of the least common organic acidemias. Presented here are manifestations not previously characterized. The first case is an infant with diffuse subcortical diffusion restriction and vermian atrophy. The second case is an adolescent with asymmetric cortical volume loss and contralateral cortical diffusion restriction. These unique brain MRI findings of propionic acidemia may aid the neuroradiologist in guiding genetic testing for occult metabolic disease.