Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases.

OBJECTIVE: The objective of our study was to determine the impact of embedding a pretest probability rule that is required during the computerized physician order-entry (CPOE) process on the appropriateness of CT angiography (CTA) of the pulmonary arteries for the diagnosis of pulmonary embolism (PE) in the emergency department (ED). MATERIALS AND METHODS: Data were obtained from the electronic medical records of all adults who visited the ED from October 17, 2010, through October 17, 2012 (n = 96,507). The primary outcome was the appropriateness of pulmonary CTA. Logistic regression was used to test whether rates of appropriate use, overuse, and underuse of pulmonary CTA improved significantly after the implementation of the decision support tool when controlling for other patient characteristics. RESULTS: Pulmonary CTA was appropriately used in 67.2% of patients with a modified Wells score of ≥ 4, a positive d-dimer test result, or both. CTA was overused in 19.3% of patients and underused in 13.5% of patients. Each additional month after the start of the intervention was associated with a 4-percentage point increase in the odds that the modified Wells score would indicate CTA had been used appropriately (odds ratio [OR] = 1.04; 95% CI, 1.01-1.07) and significantly lowered the odds of overuse of CTA (OR = 0.93; 95% CI, 0.90-0.96) based on the modified Wells score. These changes were not associated with any significant alteration in the level of CTA utilization or the positivity rate. CONCLUSION: The addition of a mandatory field in the CPOE record was associated with a significant improvement in the appropriate ordering of pulmonary CTA but did not change the PE positive rate or CTA utilization. It seems likely that physicians gradually inflated the modified Wells scores in spite of the fact that a threshold modified Wells score was not required to perform pulmonary CTA.

Rib hyperostosis: a benign entity with suspicious imaging features.

Rib hyperostosis has previously been described in conjunction with disorders causing excessive vertebral ossification due to osseous bridging across the costovertebral joint, such as in diffuse idiopathic skeletal hyperostosis. Hyperostosis is believed to be a reactive process due to altered forces across the affected rib as bridging osteophytes decrease mobility at the respective costovertebral joint. The imaging characteristics of rib hyperostosis can be highly suspicious for malignancy. We share 2 cases of biopsy-proven benign rib hyperostosis with imaging across multiple modalities in hopes of increasing awareness of this entity and its imaging characteristics. In the first case, a 62-year-old female without history of malignancy underwent rib biopsy after bone scintigraphy demonstrated intense radiotracer uptake along a posteromedial rib. In the second case, a 66-year-old male with history of recurrent prostate cancer underwent rib biopsy after interval development of intense radiotracer uptake on bone scintigraphy along a posteromedial rib, new compared to 6 months prior. Both cases were seen in the setting of osseous bridging at the respective costovertebral joint. Imaging findings include contiguous radiotracer uptake on bone scintigraphy confined to the rib and respective costovertebral joint, cortical bone thickening with osseous excrescence at the costovertebral joint on radiographic and cross-sectional imaging, and increased osseous edema-like change, postcontrast enhancement, and surrounding soft tissue edema on magnetic resonance imaging. By increasing awareness to these imaging features, we hope to improve diagnostic confidence and decrease unnecessary, expensive, and sometimes invasive workup for future patients.

Endoscopy in the CT Scanner: a Multidisciplinary Approach to Difficult Cases.

Endoscopic interventions have been made safer with the use of fluoroscopy. This technique has limitations in patients with challenging anatomy. The combined use of endoscopy and CT fluoroscopy provides the added precision necessary to accomplish difficult interventions. In this video, we present two cases where endoscopy and CT fluoroscopy were used concurrently. While other publications have demonstrated the use of CT guidance to perform endoscopic interventions, this video also demonstrates the reverse-how endoscopic guidance can be used to make a CT-guided procedure possible. This video demonstrates the enhanced patient care possible when a multidisciplinary approach between interventional radiologists and surgeons is followed.

Image-guided EBUS bronchoscopy system for lung-cancer staging.

The staging of the central-chest lymph nodes is a major step in the management of lung-cancer patients. For this purpose, the physician uses a device that integrates videobronchoscopy and an endobronchial ultrasound (EBUS) probe. To biopsy a lymph node, the physician first uses videobronchoscopy to navigate through the airways and then invokes EBUS to localize and biopsy the node. Unfortunately, this process proves difficult for many physicians, with the choice of biopsy site found by trial and error. We present a complete image-guided EBUS bronchoscopy system tailored to lymph-node staging. The system accepts a patient's 3D chest CT scan, an optional PET scan, and the EBUS bronchoscope's video sources as inputs. System workflow follows two phases: (1) procedure planning and (2) image-guided EBUS bronchoscopy. Procedure planning derives airway guidance routes that facilitate optimal EBUS scanning and nodal biopsy. During the live procedure, the system's graphical display suggests a series of device maneuvers to perform and provides multimodal visual cues for locating suitable biopsy sites. To this end, the system exploits data fusion to drive a multimodal virtual bronchoscope and other visualization tools that lead the physician through the process of device navigation and localization. A retrospective lung-cancer patient study and follow-on prospective patient study, performed within the standard clinical workflow, demonstrate the system's feasibility and functionality. For the prospective study, 60/60 selected lymph nodes (100%) were correctly localized using the system, and 30/33 biopsied nodes (91%) gave adequate tissue samples. Also, the mean procedure time including all user interactions was 6 min 43 s All of these measures improve upon benchmarks reported for other state-of-the-art systems and current practice. Overall, the system enabled safe, efficient EBUS-based localization and biopsy of lymph nodes.

Indications and approach to surgical resection of lung metastases.

Pulmonary metastasectomy is a curative option for selected patients with cancer spread to the lungs. Complete surgical removal of pulmonary metastases can improve survival and is recommended under certain criteria. Specific issues that require consideration in a multidisciplinary setting when planning pulmonary metastasectomy include: adherence to established indications for resection, the surgical strategy including the use of minimally invasive techniques, pulmonary parenchyma preservation, and the role of lymphadenectomy.

Survival outcomes of patients with colorectal liver metastases following hepatic resection or ablation in the era of effective chemotherapy.

The outcome of patients with colorectal liver metastases (CLM) undergoing surgical resection in the era of effective chemotherapy is not widely reported. In addition, factors associated with disease-specific survival (DSS) in a contemporary series of patients are not well defined. Clinical, pathologic, and outcome data for 64 patients with CLM treated by a single surgeon in a multidisciplinary setting from February 2002 to October 2007 were examined. Hepatic resection was combined with radiofrequency ablation (RFA) in 23 (36%) cases. Secondary or tertiary resection was undertaken in 12 (19%) patients. Synchronous CLM were noted in 25 (39%) cases. Neoadjuvant chemotherapy was given to 41 (64%) patients. Following hepatic resection, adjuvant chemotherapy was administered in 52 (81%) cases. There was one (2%) operative mortality. One or more complications were noted in 24 (38%) patients. Median length of hospital stay was 7 (2-7) days. Five-year DSS and overall survival were 72% and 69%, respectively. Bilobar disease (p < 0.001), local tumor extension (p = 0.02), response to neoadjuvant chemotherapy (p = 0.005), preoperative portal vein embolization (p = 0.05), number of hepatic lesions (p = 0.03), positive resection margin (p < 0.001), and node-positive primary disease (p = 0.001) were prognostically significant factors on univariate analysis. On multivariate analysis, bilobar disease (p = 0.02) and local tumor extension (p = 0.02) were the only two independent prognostic factors. We conclude that, in patients with CLM, a multidisciplinary approach encompassing an aggressive surgical policy achieves excellent 5-year survival results with acceptable operative morbidity and mortality. Bilobar disease and local extrahepatic extension of cancer appear to be independent prognostic factors for long-term survival.

Interbronchoscopist variability in endobronchial path selection: a simulation study.

BACKGROUND: Endobronchial path selection is important for the bronchoscopic diagnosis of focal lung lesions. Path selection typically involves mentally reconstructing a three-dimensional path by interpreting a stack of two-dimensional (2D) axial plane CT scan sections. The hypotheses of our study about path selection were as follows: (1) bronchoscopists are inaccurate and overly confident when making endobronchial path selections based on 2D CT scan analysis; and (2) path selection accuracy and confidence improve and become better aligned when bronchoscopists employ path-planning methods based on virtual bronchoscopy (VB). METHODS: Studies of endobronchial path selection comparing three path-planning methods (ie, the standard 2D CT scan analysis and two new VB-based techniques) were performed. The task was to navigate to discrete lesions located between the third-order and fifth-order bronchi of the right upper and middle lobes. Outcome measures were the cumulative accuracy of making four sequential path selection decisions and self-reported confidence (1, least confident; 5, most confident). Both experienced and inexperienced bronchoscopists participated in the studies. RESULTS: In the first study involving a static paper-based tool, the mean (+/- SD) cumulative accuracy was 14 +/- 3% using 2D CT scan analysis (confidence, 3.4 +/- 1.3) and 49 +/- 15% using a VB-based technique (confidence, 4.2 +/- 1.1; p = 0.0001 across all comparisons). For a second study using an interactive computer-based tool, the mean accuracy was 40 +/- 28% using 2D CT scan analysis (confidence, 3.0 +/- 0.3) and 96 +/- 3% using a dynamic VB-based technique (confidence, 4.6 +/- 0.2). Regardless of the experience level of the bronchoscopist, use of the standard 2D CT scan analysis resulted in poor path selection accuracy and misaligned confidence. Use of the VB-based techniques resulted in considerably higher accuracy and better aligned decision confidence. CONCLUSIONS: Endobronchial path selection is a source of error in the bronchoscopy workflow. The use of VB-based path-planning techniques significantly improves path selection accuracy over use of the standard 2D CT scan section analysis in this simulation format.

Combined right nephrectomy and pancreaticoduodenectomy. Indications and outcomes.

CONTEXT: Nephrectomy and pancreaticoduodenctomy are operations often performed for the treatment of malignancy. However, the combination of both procedures is rarely reported. OBJECTIVES: The indications and outcomes of combined right nephrectomy and pancreaticoduodenectomy were assessed. STUDY DESIGN: Patients were identified from a prospective operative database between 2002 and 2008. SETTING: A tertiary care center. PATIENTS: One-hundred and 80 patients undergoing pancreaticoduodenectomy. There were 5 (2.8%) patients treated by combined right nephrectomy and pancreaticoduodenal resection. MAIN OUTCOME MEASURE: Description of these 5 patients. RESULTS: Three patients had retroperitoneal sarcomas adherent to the right kidney and duodenum, one patient had a locally advanced transitional-cell carcinoma and the remaining patient presented with an ampullary malignancy and concurrent right renal tumor All patients underwent en bloc resection with clear margins. Median operating time was 13 hours (range: 9-21 hours). There was no perioperative mortality in this series. Complications were noted in 3 (60%) patients related to pancreaticoduodenal resection and all were managed conservatively without significant clinical impact. Median post-operative hospital stay was 8 days (range: 7-11 days). At a median follow-up of 14 months (range: 3-36 months) all patients were alive without evidence of disease recurrence. CONCLUSION: En bloc right nephrectomy combined with pancreaticoduodenal resection can be performed in selected patients with malignant tumors with acceptable morbidity to achieve clear resection margins.

Modern management of chylous leak following head and neck surgery: a discussion of percutaneous lymphangiography-guided cannulation and embolization of the thoracic duct.

High-output chylous leak beyond 5 to 7 days of conservative medical treatment should be treated promptly to avoid the risk for nutritional and imunologic depletion. Given the effectiveness and low morbidity of this minimally invasive treatment, this is a reasonable first option before surgical repair of thoracic duct leak not responsive to conservative medical treatment.

Evaluating Report Text Variation and Informativeness: Natural Language Processing of CT Chest Imaging for Pulmonary Embolism.

OBJECTIVE: The aim of this study was to quantify the variability of language in free text reports of pulmonary embolus (PE) studies and to gauge the informativeness of free text to predict PE diagnosis using machine learning as proxy for human understanding. MATERIALS AND METHODS: All 1,133 consecutive chest CTs with contrast studies performed under a PE protocol and ordered in the emergency department in 2016 were selected from our departmental electronic workflow system. We used commercial text-mining and predictive analytics software to parse and describe all report text and to generate a suite of machine learning rules that sought to predict the "gold standard" radiological diagnosis of PE. RESULTS: There was extensive variation in the length of Findings section and Impression section texts across the reports, only marginally associated with a positive PE diagnosis. A marked concentration of terms was found: for example, 20 words were used in the Findings section of 93% of the reports, and 896 of 2,296 distinct words were each used in only one report's Impression section. In the validation set, machine learning rules had perfect sensitivity but imperfect specificity, a low positive predictive value of 73%, and a misclassification rate of 3%. CONCLUSION: Use of free text reporting was associated with extensive variability in report length and report terms used. Interpretation of the free text was a difficult machine learning task and suggests potential difficulty for human recipients in fully understanding such reports. These results support the prospective assessment of the impact of a fully structured report template with at least some mandatory discrete fields on ease of use of reports and their understanding.

Imaging of the calcaneus.

The anatomy of the calcaneus is complex with multiple processes and grooves for support of related bony and soft tissue structures. With respect to imaging, the calcaneus and its articulations are a diagnostic challenge to radiologists and clinicians. This article focuses on the use of commonly employed radiologic modalities with respect to the anatomy of the calcaneus and some of the more common and challenging conditions that affect the calcaneus.

Automatic definition of the central-chest lymph-node stations.

PURPOSE: Lung cancer remains the leading cause of cancer death in the United States. Central to the lung-cancer diagnosis and staging process is the assessment of the central-chest lymph nodes. This assessment requires two steps: (1) examination of the lymph-node stations and identification of diagnostically important nodes in a three-dimensional (3D) multidetector computed tomography (MDCT) chest scan; (2) tissue sampling of the identified nodes. We describe a computer-based system for automatically defining the central-chest lymph-node stations in a 3D MDCT chest scan. METHODS: Automated methods first construct a 3D chest model, consisting of the airway tree, aorta, pulmonary artery, and other anatomical structures. Subsequent automated analysis then defines the 3D regional nodal stations, as specified by the internationally standardized TNM lung-cancer staging system. This analysis involves extracting over 140 pertinent anatomical landmarks from structures contained in the 3D chest model. Next, the physician uses data mining tools within the system to interactively select diagnostically important lymph nodes contained in the regional nodal stations. RESULTS: Results from a ground-truth database of unlabeled lymph nodes identified in 32 MDCT scans verify the system's performance. The system automatically defined 3D regional nodal stations that correctly labeled 96% of the database's lymph nodes, with 93% of the stations correctly labeling 100% of their constituent nodes. CONCLUSIONS: The system accurately defines the regional nodal stations in a given high-resolution 3D MDCT chest scan and eases a physician's burden for analyzing a given MDCT scan for lymph-node station assessment. It also shows potential as an aid for preplanning lung-cancer staging procedures.