Diagnostic Yield of Incremental Biopsy Cores and Second Lesion Sampling for In-Gantry MRI-Guided Prostate Biopsy.

BACKGROUND. In-gantry MRI-guided biopsy (MRGB) of the prostate has been shown to be more accurate than other targeted prostate biopsy methods. However, the optimal number of cores to obtain during in-gantry MRGB remains undetermined. OBJECTIVE. The purpose of this study was to assess the diagnostic yield of obtaining an incremental number of cores from the primary lesion and of second lesion sampling during in-gantry MRGB of the prostate. METHODS. This retrospective study included 128 men with 163 prostate lesions who underwent in-gantry MRGB between 2016 and 2019. The men had a total of 163 lesions sampled with two or more cores, 121 lesions sampled with three or more cores, and 52 lesions sampled with four or more cores. A total of 40 men underwent sampling of a second lesion. Upgrade on a given core was defined as a greater International Society of Urological Pathology (ISUP) grade group (GG) relative to the previously obtained cores. Clinically significant prostate cancer (csPCa) was defined as ISUP GG 2 or greater. RESULTS. The frequency of any upgrade was 12.9% (21/163) on core 2 versus 10.7% (13/121) on core 3 (p = .29 relative to core 2) and 1.9% (1/52) on core 4 (p = .03 relative to core 3). The frequency of upgrade to csPCa was 7.4% (12/163) on core 2 versus 4.1% (5/121) on core 3 (p = .13 relative to core 2) and 0% (0/52) on core 4 (p = .07 relative to core 3). The frequency of upgrade on core 2 was higher for anterior lesions (p < .001) and lesions with a higher PI-RADS score (p = .007); the frequency of upgrade on core 3 was higher for apical lesions (p = .01) and lesions with a higher PI-RADS score (p = .01). Sampling of a second lesion resulted in an upgrade in a single patient (2.5%; 1/40); both lesions were PI-RADS category 4 and showed csPCa. CONCLUSION. When performing in-gantry MRGB of the prostate, obtaining three cores from the primary lesion is warranted to optimize csPCa diagnosis. Obtaining a fourth core from the primary lesion or sampling a second lesion has very low yield in upgrading cancer diagnoses. CLINICAL IMPACT. To reduce patient discomfort and procedure times, operators may refrain from obtaining more than three cores or second lesion sampling.

Contrast-Enhanced Ultrasound Guidance for Interventional Procedures.

Since its introduction, contrast-enhanced ultrasound (CEUS) has gained an important role in the diagnosis and management of abdominal and pelvic diseases. Contrast-enhanced ultrasound can improve lesion detection rates as well as success rates of interventional procedures when compared to conventional ultrasound alone. Additionally, CEUS enables the interventionalist to assess the dynamic enhancement of different tissues and lesions, without the adverse effects of contrast-enhanced computed tomography, such as exposure to ionizing radiation and nephrotoxicity from iodinated contrast material. This review article describes the various applications and advantages of the use of CEUS to enhance performance of ultrasound-guided interventions in the abdomen and pelvis.

Real-time MRI-guided percutaneous sclerotherapy of low-flow head and neck lymphatic malformations in the pediatric population - a stepwise approach.

Real-time MRI-guided percutaneous sclerotherapy is a novel and evolving treatment for congenital lymphatic malformations in the head and neck. We elaborate on the specific steps necessary to perform an MRI-guided percutaneous sclerotherapy of lymphatic malformations including pre-procedure patient work-up and preparation, stepwise intraprocedural interventional techniques and post-procedure management. Based on our institutional experience, MRI-guided sclerotherapy with a doxycycline-gadolinium-based mixture as a sclerosant for lymphatic malformations of the head and neck region in children is well tolerated and effective.

Percutaneous CT-Guided Cryoablation of the Salivary Glands in a Porcine Model.

PURPOSE: To evaluate the imaging, histologic changes and safety of computed tomography (CT)-guided cryoablation of the parotid glands in a porcine model. MATERIALS AND METHODS: Unilateral CT-guided parotid gland cryoablation was performed in 5 juvenile miniature pigs. The ablated parotid glands underwent 2 cycles of 10-minute freeze and 5-minute thaw using three 17-g cryoprobes. The animals were monitored daily for complications including pain, frostbite, infection, and sialocele or fistula formation. Follow-up CT was performed at 6 weeks postcryoablation. Pathologic evaluation was performed on 2 of the ablated parotid glands. RESULTS: All cryoablations in 5 right parotid glands, with 3 sites in each gland, were technically successful. No symptoms suggestive of facial nerve damage were observed during 6-week follow-up. One pig developed an infected sialocele, which was treated with percutaneous drainage and oral antibiotic therapy. No CT evidence of sialocele or other abnormality was identified at the 6-week follow-up in all pigs. Histologic evaluation was performed on 2 of the parotid gland specimens, 1 with the treated sialocele, and 1 of the remaining pigs without sialocele. Both glands demonstrated postprocedural intraglandular lymph nodes and reactive changes without evidence of sialocele or abscess on histopathology. CONCLUSIONS: Cryoablation of parotid glands was technically feasible in a porcine model. Only 1 pig developed sialocele, which was successfully treated. Further research is warranted to determine the potential use of salivary gland cryoablation to treat patients with drooling.

Clinical evaluation of CAIPIRINHA: comparison against a GRAPPA standard.

PURPOSE: To evaluate image quality when using a CAIPIRINHA sampling pattern in comparison to a standard GRAPPA sampling pattern in patients undergoing a routine three-dimensional (3D) breathheld liver exam. CAIPIRINHA uses an optimized phase encoding sampling strategy to alter aliasing artifacts in 3D acquisitions to improve parallel imaging reconstruction. MATERIALS AND METHODS: Twenty patient volunteers were scanned using a 3D VIBE acquisition with an acceleration factor of four using a CAIPIRINHA and standard GRAPPA sampling pattern. CAIPIRINHA and GRAPPA images were evaluated by three radiologists in a two alternative forced choice test, and the Wilcoxon signed rank test was performed. RESULTS: The CAIPIRINHA sampling pattern was preferred in an average of 68% of the comparisons, and the Wilcoxon signed rank test showed a significant improvement in CAIPIRINHA images (P = 0.014). This analysis indicates that in the given sample set, CAIPIRINHA preference over the GRAPPA standard was statistically significant. CONCLUSION: This work shows that for an acceleration factor of four, a CAIPIRINHA accelerated VIBE acquisition provides significantly improved image quality in comparison to the current GRAPPA standard. This allows a further reduction in imaging time for similar spatial resolutions, which can reduce long breathhold requirements in abdominal imaging, and may be particularly helpful in patients who cannot provide requisite breathholds with current protocols.

Simultaneous magnetic resonance angiography and perfusion (MRAP) measurement: initial application in lower extremity skeletal muscle.

PURPOSE: To obtain a simultaneous 3D magnetic resonance angiography and perfusion (MRAP) using a single acquisition and to demonstrate MRAP in the lower extremities. A time-resolved contrast-enhanced exam was used in MRAP to simultaneously acquire a contrast-enhanced MR angiography (MRA) and dynamic contrast-enhanced (DCE) perfusion, which currently requires separate acquisitions and thus two contrast doses. MRAP can be used to assess large and small vessels in vascular pathologies such as peripheral arterial disease. MATERIALS AND METHODS: MRAP was performed on 10 volunteers following unilateral plantar flexion exercise (one leg exercised and one rested) on two separate days. Data were acquired after administration of a single dose of contrast agent using an optimized sampling strategy, parallel imaging, and partial-Fourier acquisition to obtain a high spatial resolution, 3D-MRAP frame every 4 seconds. Two radiologists assessed MRAs for image quality, a signal-to-noise ratio (SNR) analysis was performed, and pharmacokinetic modeling yielded perfusion (K(trans) ). RESULTS: MRA images had high SNR and radiologist-assessed diagnostic quality. Mean K(trans) ± standard error were 0.136 ± 0.009, 0.146 ± 0.012, and 0.191 ± 0.012 min(-1) in the resting tibialis anterior, gastrocnemius, and soleus, respectively, which significantly increased with exercise to 0.291 ± 0.018, 0.270 ± 0.019, and 0.338 ± 0.022 min(-1) . Bland-Altman analysis showed good repeatability. CONCLUSION: MRAP provides simultaneous high-resolution MRA and quantitative DCE exams to assess large and small vessels with a single contrast dose. Application in skeletal muscle shows quantitative, repeatable perfusion measurements, and the ability to measure physiological differences.

Pneumodissection: an alternative protective technique for the percutaneous cryoablation of small renal masses.

INTRODUCTION: Percutaneous cryoablation is an emerging treatment option for the small renal mass. It poses a risk of thermal injury to adjacent tissues, limiting its application. We describe pneumodissection, a novel technique for preventing thermal injury during percutaneous cryoablation. MATERIALS AND METHODS: The cases of 4 patients who underwent percutaneous renal cryoablation and pneumodissection were retrospectively reviewed. RESULTS: Pneumodissection mechanically separated four tumors from overlying bowel segments (mean distance 1.2 ± 0.4 cm), permitting successful cryoablation. There were no complications or recurrences with 7.5 months of follow-up. CONCLUSIONS: Pneumodissection is a feasible displacement technique that facilitates percutaneous cryoablation in at-risk patients. Further study is warranted.

Hemostasis effects of direct intraparenchymal injection of platelets and fresh frozen plasma before cutting needle biopsy in an animal model.

PURPOSE: To evaluate the effectiveness of direct intraparenchymal injection of platelets or fresh frozen plasma (FFP) into the needle tract before cutting needle biopsy to decrease postprocedural blood loss in pigs with normal and abnormal hemostasis. MATERIALS AND METHODS: A total of 12 Yorkshire-cross pigs were anesthetized and maintained on a respirator. The pigs were divided into three groups: three with normal hemostasis, five treated with warfarin anticoagulation, and four treated with aspirin. Four types of biopsies were performed in the exposed livers and kidneys with 14-gauge Tru-Cut needles. The first was a standard (ie, control) biopsy, and the other three were performed with 2 mL normal saline solution, porcine FFP, or platelet-rich porcine plasma injected into the planned needle tract. Biopsy was then performed in the same needle tract. Blood loss was measured with gauze sponges. RESULTS: Significantly decreased postbiopsy blood loss was noted after FFP and platelet injection in the livers and kidneys of all groups except the kidney biopsy group after platelet injection in pigs with normal hemostasis. There was no significant difference in blood loss between the control and saline solution control groups in any of the pigs. CONCLUSIONS: Local injection of platelets or FFP significantly decreases postbiopsy blood loss in pigs with impaired hemostasis.

Evolving clinical applications of contrast-enhanced ultrasound (CEUS) in the abdominal aorta.

Ultrasound (US) represents the initial modality in the workup of abdominal aortic pathology based on the plethora of advantages including widespread availability, low cost, safety profile and repeatability. However, US has inherent limitations including limited spatial information of pathologic processes to neighboring structures, lower sensitivity to slow blood flow and aortic luminal irregularities. For evaluation of aortic pathology angiography has long been considered the gold standard. Non-invasive cross-sectional imaging techniques like computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have gradually replaced interventional angiography for the evaluation of aorta, currently being regarded as the diagnostic imaging modalities of choice for diagnosis of virtually every aortic disease. Interventional angiography is currently primarily performed for treatment purposes of aortic pathology. The introduction of microbubbles as ultrasonographic contrast agents has rendered contrast-enhanced ultrasound (CEUS) an evolving valuable complementary technique with markedly increased diagnostic accuracy for certain aortic applications. CEUS is characterized by the potential to be performed in patients with impaired renal function. Due to its superior spatial and temporal resolution, ability for prolonged scanning and dynamic and real-time imaging, it provides clinically significant additional information compared to the standard Duplex US. The purpose of this paper is to discuss the currently available literature regarding abdominal aortic applications of CEUS, briefly elaborate on CEUS technique and safety and present cases in order to illustrate the added value in aortic pathologies. Conditions discussed include abdominal aortic aneurysm (AAA), aneurysm rupture, aneurysm surveillance after endovascular repair, dissection and aortitis.

Real-time MRI-guided percutaneous sclerotherapy treatment of venous low-flow malformations in the head and neck.

Purpose This manuscript describes the technique of real-time MRI-guided sclerotherapy for low-flow venous malformations in the head and neck based on our institutional experience. Materials and methods Ethanolamine oleate is used as the sclerosant and is mixed with gadolinium for visualization during the procedure. The five procedural steps include: (I) an initial tri-plane T2-weighted sequence to visualize the lesion; (II) a T1 FSE or trueFISP sequence to assess needle placement and advancement within the lesion; (III) a tri-plane T1 FLASH sequence to monitor sclerosant injection; (IV) a T1 FSE or VIBE sequence to assess sclerosant coverage of the malformation before needle removal; (V) a post-procedural tri-plane T1 fat-saturated sequence to confirm sclerosant coverage of the lesion. Periprocedural medications typically include steroids, antibiotic prophylaxis, and non-steroidal anti-inflammatory medication. Patients are typically admitted for overnight observation. Conclusion Real-time MRI-guided sclerotherapy for low-flow venous malformations in the head and neck is effective and safe.

Increased carotid intima media thickness and cardiac biomarkers in HIV infected children.

OBJECTIVES: To assess carotid intima media thickness (IMT) and cardiac biomarkers in HIV infected children on antiretroviral therapy (ART). METHODS: This was a single site, cross sectional, controlled observational study. We assessed carotid IMT, homocysteine, high-sensitivity C-reactive protein and myeloperoxidase levels in HIV infected children on stable ART for >or= 6 months. Carotid IMT was reported as internal carotid artery (ICA) and common carotid artery (CCA) thickness; left and right sides were measured separately. Groups were compared using appropriate two-sample tests. RESULTS: Of the 62 subjects enrolled, 31 were HIV positive (50%), 66% were female, and 69% were African-American. Median CD4% was 32% and 26 patients (84%) had HIV-1 RNA< 400 copies/ml. Sixteen patients had been taking protease inhibitors for a median duration of 27 months. None had hypertension or smoked. HIV infected children had higher HOMA-IR, waist-to-hip ratio, cholesterol, triglycerides, myeloperoxidase and lower homocysteine levels. Left and right CCA IMT, and left and right ICA IMT were significantly higher in the HIV infected group. Significant predictors of carotid IMT measurements in uninfected controls were body mass index and homocysteine, but only the duration of ARV therapy was predictive of IMT in the HIV infected group. CONCLUSION: Higher levels of carotid IMT and some cardiac markers were found in ART treated HIV infected children when compared to matched uninfected controls. These results suggest that HIV infected children receiving ART may be at increased risk of cardiovascular disease.

Utility of Doppler ultrasonography for predicting improvement of platelet count after transjugular intrahepatic portosystemic shunt.

OBJECTIVE: Portal pressure gradient (PPG) after transjugular intrahepatic portosystemic shunt (TIPS) <12 mmHg has been reported as the only factor predictive of increase in platelet count. As flow velocities measured on Doppler ultrasound are related to pressure gradient based on the Bernoulli equation, we used this parameter to predict increased platelet count after TIPS placement. METHODS: A total of 161 consecutive patients who underwent TIPS placement entered this retrospective study. The platelet count was measured before, one week after and one month after TIPS placement. Clinically significant thrombocytopenia was defined as platelet count ≤100 000. Pre- and post-TIPS PPGs were measured. The velocity of blood flow in the proximal, mid and distal TIPS stent was measured using Doppler ultrasound, and the difference in the highest and lowest measured velocity was entitled flow velocity gradient (FVG), which was considered normal when ≤100 cm/s. RESULTS: In 121 patients with pre-TIPS thrombocytopenia, the mean platelet count one week and one month after TIPS placement increased 25.7 x 103 and 35.0 x 103 in 90 patients with PPG≤12 mmHg (P=0.028 and P=0.015), while there was no significant change in platelet count in patients with a PPG >12 mmHg (P=0.098 and P=0.075). Platelets increased significantly when FVG≤ 100 cm/s (n=95) vs FVG >100 cm/s (n=26) one week (37.0x103 vs 11.0x103; P = 0.005 vs 0.07) and one month after TIPS placement (17.0x103 vs 5.2x103; P = 0.01 vs 0.21). CONCLUSION: FVG >100 cm/s is not associated with increase in post-TIPS platelet count. On the other hand, findings suggestive of proper TIPS function (FVG ≤100 cm/s and PPG≤ 12 mmHg) predict a significant increase in post-TIPS platelet count.

The Radiologist Is in, but Was it Worth the Wait? Radiology Resident Note Quality in an Outpatient Interventional Radiology Clinic.

Preprocedural evaluation of patients in an interventional radiology (IR) clinic is a complex synthesis of physical examination and imaging findings, and as IR transitions to an independent clinical specialty, such evaluations will become an increasingly critical component of a successful IR practice and quality patient care. Prior research suggests that preprocedural evaluations increased patient's perceived quality of care and may improve procedural technical success rates. Appropriate documentation of a preprocedural evaluation in the medical record is also paramount for an interventional radiologist to add value and function as an effective member of a larger IR service and multidisciplinary health care team. The purpose of this study is to examine the quality of radiology resident notes for patients seen in an outpatient IR clinic at a single academic medical center before and after the adoption of clinic note template with reminders to include platelet count, international normalized ratio, glomerular filtration rate, and plan for periprocedural coagulation status. Before adoption of the template, platelet count, international normalized ratio, glomerular filtration rate and an appropriate plan for periprocedural coagulation status were documented in 72%, 82%, 42%, and 33% of patients, respectively. After adoption of the template, appropriate documentation of platelet count, international normalized ratio, and glomerular filtration rate increased to 96%, and appropriate plan for periprocedural coagulation status was documented in 83% of patients. Patient evaluation and clinical documentation skills may not be adequately practiced during radiology residency, and tools such as templates may help increase documentation quality by radiology residents.

Contrast enhanced ultrasound guided biopsies of liver lesions not visualized on standard B-mode ultrasound-preliminary experience.

BACKGROUND: To assess the technical success of contrast enhanced ultrasound (CEUS) guided biopsies of liver lesions poorly visualized on B-mode ultrasound. METHODS: Patients were selected during the procedure based on the real-time clinical scenario of unsatisfactory B-mode ultrasound lesion visualization and all patients would have otherwise undergone CT guided liver lesion biopsy. A total of 26 patients underwent CEUS guided biopsy and were included in this retrospective analysis. The review of the patients' files included demographic information, lesion characteristics on imaging, procedural details and pathology outcome. Technical success was defined as concordance between the radiological findings, pathology report and clinical follow-up-demonstrating lack of need for re-biopsy or re-biopsy with identical pathological results. Patients with less than 2 months follow-up were excluded from the study. RESULTS: CEUS guided liver biopsy was successful in 23 out of 26 patients (88.5%). The average procedure time was 30.7±12.3 minutes and the average lesion size was 2.2±1.7 cm. The majority of lesions (80.8%) were hypoenhancing on the delayed phase of CEUS. The mean number of samples taken from each lesion per procedure was 3.2 (±1.7). CONCLUSIONS: CEUS guidance biopsies of focal liver lesions (FLL) that were difficult to visualize on B-mode ultrasound demonstrated high success rate and may be an evolving image guidance modality in selected patients to avoid CT guided procedures.

Emergent ultrasound interventions.

The interventionist can perform many emergent procedures with ultrasound guidance, because of its real-time, multiplanar imaging capability and portability. With the use of color Doppler, additional important information, such as aberrant vessels, can be ascertained to help plan needle trajectory. Ultrasound is also useful for nonemergent procedures, such as biopsies. All interventionists are encouraged to be facile with the use of ultrasound.

Percutaneous computed tomography guided cryoablation of the celiac plexus as an alternative treatment for intractable pain caused by pancreatic cancer.

Computed Tomography (CT)-guided percutaneous cryoablation was performed in a 43-year-old patient with intractable epigastric abdominal pain caused by advanced adenocarcinoma of the pancreas and extensive celiac trunk involvement. Initial treatment with celiac plexus nerve neurolysis using local ethanol injection was unsuccessful. A 17-gauge 17-cm cryoablation probe (Galil Medical Inc. Plymouth Meeting, PA) was placed into the expected location of the celiac plexus through a left paraspinal approach under CT guidance and two cycles of freeze-thaw were performed. Patient's pain decreased from 10 of 10 (subjective pain scoring using a visual analog scale; VAS; 0-10) to 3. No post-procedure complication was observed. His pain has remained stable after 6 months of follow up. Percutaneous cryoablation appears to be an effective alternative to neurolytic celiac plexus block for palliative treatment of celiac plexus involvement. Further study with larger number of patients is needed to evaluate the safety and efficacy.

Roux-en-Y gastric bypass for clinically severe obesity: normal appearance and spectrum of complications at imaging.

Surgery currently appears to be the most effective method to curtail the effects of morbid obesity and all of its comorbid conditions. Although the ideal procedure has yet to be devised, Roux-en-Y gastric bypass has proved to be successful for many morbidly obese patients pursuing weight loss and increased health. As the technical aspects of this procedure become less cumbersome and the patient population increases, it is vital for radiologists to be proficient in the specific evaluation of these patients, in order to provide optimal care. Complications can be minimized, managed more efficiently, or prevented with prompt evaluation by the radiologist. It is important to appreciate the patency of both the gastrojejunostomy and the jejunojejunostomy, as well as adequate progression of contrast material before the patient is discharged (preferably 24-72 hours after surgery). Follow-up complications include anastomotic leak, staple-line disruption, stomal stenosis, occlusion of the Roux limb, small-bowel obstruction due to adhesions or internal hernia, and obstruction of the enteroenterostomy leading to acute gastric distention. These complications may be life threatening, since clinical symptoms are often inconclusive. To achieve optimal outcome, therefore, conventional radiographic and computed tomographic studies should not be delayed.