Contrast-enhanced Digital Mammography: A Single-Institution Experience of the First 208 Cases.

Contrast-enhanced digital mammography (CEDM) is the only imaging modality that provides both (a) a high-resolution, low-energy image comparable to that of digital mammography and (b) a contrast-enhanced image similar to that of magnetic resonance imaging. We report the initial 208 CEDM examinations performed for various clinical indications and provide illustrative case examples. Given its success in recent studies and our experience of CEDM primarily as a diagnostic adjunct, CEDM can potentially improve breast cancer detection by combining the low-cost conclusions of screening mammography with the high sensitivity of magnetic resonance imaging.

Factors Contributing to the Success of Ultrasound-Guided Native Renal Biopsy.

OBJECTIVES: The purpose of this study was to evaluate factors contributing to the success of ultrasound-guided native renal biopsy. METHODS: We retrospectively identified patients who had ultrasound-guided native renal biopsy at our institution over a 10-year period. We reviewed the imaging and electronic medical records to collect demographic information and clinical data, including pathologic results. Biopsy samples were categorized and compared on the basis of the number of glomeruli (optimal [≥20] versus suboptimal [<20]) and the pathologist's reported diagnostic confidence (high confidence versus limited confidence). Procedure details, including the operator and the use of the cortical tangential approach, were also obtained. RESULTS: For 282 patients with biopsies using 18-gauge needles, the number of passes made was significantly higher for optimal (P < .001) and high-confidence (P < .001) specimens than for suboptimal and limited-confidence specimens. The cortical tangential approach was used more frequently for optimal (P< .001) and high-confidence (P = .01) specimens than for suboptimal and limited-confidence specimens. Radiologists routinely doing ultrasound-guided procedures of all types had significantly more optimal (P= .01) and high-confidence (P= .001) specimens than radiologists with limited ultrasound experience. The distance to the kidney, cortical thickness, glomerular filtration rate, and body mass index were not significant factors. CONCLUSIONS: The ultrasound-guided procedural experience of the operator, taking more than 1 specimen, and the use of the cortical tangential approach significantly improved the pathologic material obtained during native renal biopsies.

Risk of bleeding after native renal biopsy as a function of preprocedural systolic and diastolic blood pressure.

PURPOSE: To determine the risk of bleeding complications after native renal biopsy as a function of preprocedural blood pressure (BP). MATERIALS AND METHODS: A total of 293 patients (163 men; mean age, 59.1 y) who underwent ultrasound-guided native kidney biopsy at a single institution over a 10-year period were retrospectively identified. Demographic and clinical data were collected, including systolic BP (SBP) and diastolic BP (DBP) at the time of the biopsy and presence and severity of complications. Differences in clinical and demographic data among patients with and without complications were analyzed. RESULTS: Of 293 patients, nine (3.1%) experienced major complications (required transfusion or intervention) and 10 (3.4%) experienced minor complications (pain, hematoma, or hematuria). Patients with SBP greater than 140 mm Hg or DBP greater than 90 mm Hg were 10 times more likely to experience major complications (P < .02) than patients without high BP (odds ratio [OR], 10.6; 95% confidence interval [CI], 1.3-86.0). The odds of complications were particularly increased in patients with SBP greater than 170 mm Hg (OR, 23.3; 95% CI, 2.3-234.4) and were modestly increased in patients with SBP between 141 and 170 mm Hg (OR, 7.11; 95% CI, 0.8-61.7). For DBP, the odds of complications increased with DBP greater than 90 mm Hg (OR, 7.2; 95% CI, 1.9-27.9). CONCLUSIONS: Patients undergoing native renal biopsy who have an SBP greater than 140 mm Hg or DBP greater than 90 mm Hg are at higher risk for bleeding complications. Further research is needed to determine whether medically lowering these patients' BP before kidney biopsy decreases complications.

Prospective Study of Supplemental Screening With Contrast-Enhanced Mammography in Women With Elevated Risk of Breast Cancer: Results of the Prevalence Round.

PURPOSE: Contrast-enhanced mammography (CEM) and magnetic resonance imaging (MRI) have shown similar diagnostic performance in detection of breast cancer. Limited CEM data are available for high-risk breast cancer screening. The purpose of the study was to prospectively investigate the efficacy of supplemental screening CEM in elevated risk patients. MATERIALS AND METHODS: A prospective, single-institution, institutional review board-approved observational study was conducted in asymptomatic elevated risk women age 35 years or older who had a negative conventional two-dimensional digital breast tomosynthesis screening mammography (MG) and no additional supplemental screening within the prior 12 months. RESULTS: Four hundred sixty women were enrolled from February 2019 to April 2021. The median age was 56.8 (range, 35.0-79.2) years; 408 of 460 (88.7%) were mammographically dense. Biopsy revealed benign changes in 22 women (22/37, 59%), high-risk lesions in four women (4/37, 11%), and breast cancer in 11 women (11/37, 30%). Fourteen cancers (10 invasive, tumor size range 4-15 mm, median 9 mm) were diagnosed in 11 women. The overall supplemental cancer detection rate was 23.9 per 1,000 patients, 95% CI (12.0 to 42.4). All cancers were grade 1 or 2, ER+ ERBB2-, and node negative. CEM imaging screening offered high specificity (0.875 [95% CI, 0.844 to 0.906]), high NPV (0.998 [95% CI, 0.993 to 1.000), moderate PPV1 (0.164 [95% CI, 0.076 to 0.253), moderate PPV3 (0.275 [95% CI, 0.137 to 0.413]), and high sensitivity (0.917 [95% CI, 0.760 to 1.000]). At least 1 year of imaging follow-up was available on all patients, and one interval cancer was detected on breast MRI 4 months after negative screening CEM. CONCLUSION: A pilot trial demonstrates a supplemental cancer detection rate of 23.9 per 1,000 in women at an elevated risk for breast cancer. Larger, multi-institutional, multiyear CEM trials in patients at elevated risk are needed for validation.

Performance of an algorithm for diagnosing acute cholecystitis using clinical and sonographic parameters.

PURPOSE: Identify an algorithm using clinical and ultrasound (US) parameters with high diagnostic performance for acute cholecystitis. METHODS: Consecutive emergency department (ED) patients from 4/1/2019 to 12/31/2019 were retrospectively reviewed to record non-US parameters and make US observations. Outcomes were categorized as either: (1) acute cholecystitis; or (2) negative acute cholecystitis. Pivot tables identified parameter combinations either not found with acute cholecystitis or with predictive value for acute cholecystitis to establish the algorithm. US Division radiologists finalized an US report prior to ED disposition without use of the algorithm. Radiologist impression and algorithm prediction for acute cholecystitis were categorized as either (1) acute cholecystitis; (2) negative acute cholecystitis; or (3) inconclusive. RESULTS: Three hundred and sixty-six studies on 357 patients (mean age, 51 yrs ± 20 yrs; 215 women) met the inclusion criteria. 10.9% (40/366) of US studies had acute cholecystitis, 12.6% (46/366) had pathologically identified chronic cholecystitis without acute cholecystitis, and 76.5% (280/366) were negative acute cholecystitis. Algorithm compared to radiologist diagnostic performance was as follows: (1) sensitivity: 90.0% vs. 55.0%, p < 0.001; (2) augmented sensitivity (defined as when inconclusive categorization is considered consistent with acute cholecystitis): 100% vs. 85.0%, p < 0.001; (3) specificity: 93.6% vs. 94.8%, p = 0.50; (4) diagnostic rate (opposite of inconclusive rate): 96.4% vs. 93.2%, p = 0.04; (5) adverse outcome rate: 0.0% vs. 1.6%, p undefined. CONCLUSION: For acute cholecystitis, an algorithm using non-binary ultrasound and clinical assessments had higher sensitivity, higher diagnostic rate, and fewer adverse outcomes, than subspecialty radiologist impressions.

US-guided renal transplant biopsy: efficacy of a cortical tangential approach.

PURPOSE: To describe the cortical tangential approach to ultrasonographically (US) guided renal transplant biopsy and evaluate its efficacy in obtaining sufficient cortical tissue. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was exempted from review by the institutional review board. Informed consent was not required. The number of core biopsy samples, glomeruli, and small arteries obtained during 294 consecutive US-guided renal transplant biopsies in 254 patients (134 men, 120 women; age range, 19-79 years; mean age, 52.2 years) in one department between June 1 and December 31, 2008, were recorded, along with any ensuing complications. Procedural success was assessed according to Banff 97 criteria. RESULTS: There were 1.2 +/- 0.4 (standard deviation) biopsy core samples taken per case by 11 radiologists using the cortical tangential approach. In 290 cases, biopsy results showed 21.7 +/- 10.1 glomeruli and 5.0 +/- 2.8 small arteries. Two hundred seventy-six (95%) cases were adequate or minimal according to Banff 97 assessment criteria. Of the 14 inadequate cases (5%), six were lacking only one glomerulus to achieve minimal status. Only one biopsy core sample was taken in all 14 inadequate cases and in 233 successful cases (success rate, 85%). None of the 43 cases with two or more biopsy core samples taken were inadequate (success rate, 100%). Two patients (0.7%) had a hemorrhagic complication requiring transfusion, and another four patients (1.4%) experienced a minor self-limiting complication. CONCLUSION: The cortical tangential approach can be used by a cohort of radiologists to achieve 95% or higher collective success in obtaining cortical tissue during renal transplant biopsy, with few complications. The success rate is higher, without increased complications, when more than one core specimen is taken.

Accuracy of ultrasound in estimation of prostate weight: comparison of urologists and radiologists.

INTRODUCTION: Measurements of prostate size are obtained to contribute in the diagnosis and follow up of patients with a variety of diseases. Since its introduction, transrectal ultrasonography (TRUS) of the prostate has become the most common method for assessment of prostate volumes. Ultrasonography, in general, has been associated with concerns of operator dependent variability. Herein, we analyze the accuracy of urologists and radiologists performing TRUS. MATERIAL AND METHODS: The accuracy of preoperative TRUS prostate volume estimation was evaluated by comparing it to gross specimen prostate weight following robot-assisted radical prostatectomy (RARP) performed from August 2004 to March 2008 in Mayo Clinic Arizona. A total of 800 RARPs were evaluated retrospectively with 302 patients having a prostate volume measurement with TRUS at our institution followed by RARP being performed within 30 days. The TRUS measurements were divided into two groups: those TRUS measurements performed by urologists (group 1), and those performed by radiologists (group 2). The accuracy of the two groups were compared using a Pearson correlation analysis. RESULTS: The estimated weight by TRUS in the total cohort of patients correlated with the pathological specimen weight at 0.802 with a standard error of 0.90. Group 1 performed a total of 114 ultrasounds with a correlation of 0.835 and a standard error of 1.27. Group 2 performed a total of 188 with a correlation of 0.786 and a standard error of 0.88. CONCLUSIONS: Urologists and radiologists are both consistently within 17%-22% of the estimated prostate specimen weight. Urologists appeared to have a slightly higher accuracy in estimation but a higher range of error for the whole group when compared to radiologists. Transrectal ultrasonography is a reliable technique to estimate prostate weight and accuracy to within 20% of the pathological weight. Urologists and radiologists are essentially equally proficient in estimating prostate weight with TRUS. These findings are particularly important with respect to specialty certification and competency/proficiency evaluation, as health care increasingly moves towards outcomes based reimbursement.

Demonstration of 99mTc-MDP Uptake in a Mobile Urinary Bladder Calculus on SPECT/CT.

We report a large mobile bladder calculus with intense Tc-MDP uptake demonstrated on both whole-body bone scintigraphy and SPECT/CT images in a patient with complicated chronic history of urolithiasis and urinary tract infection. Bone tracer uptake in bladder calculus is a rare phenomenon and might be related to the composition and matrix of calculus, direct exposure to excreted radiotracer, and bacterial colonization on the surface of calculus.

Comparison of Open and Robot Assisted Radical Nephrectomy With Level I and II Inferior Vena Cava Tumor Thrombus: The Mayo Clinic Experience.

OBJECTIVE: To compare the perioperative and oncologic outcomes associated with open radical nephrectomy with tumor thrombus (O-RNTT) vs robot assisted radical nephrectomy with tumor thrombus (RA-RNTT). Renal cell carcinoma with venous tumor thrombus has traditionally been managed through an open surgical approach. The robot assisted approach may offers improved perioperative outcomes compared to open, but there are few studies comparing these 2. METHODS: We analyzed patients with renal cell carcinoma and inferior vena cava tumor thrombus between 1998 and 2018, comparing perioperative and oncologic outcomes of these patients with Level I and Level II thrombus. Cohorts were stratified by surgical approach: O-RNTT vs RA-RNTT. Univariate analysis was conducted using chi-squared test and t tests when appropriate. Kaplan-Meier estimates were used to evaluate survival. RESULTS AND LIMITATION: Twenty-seven patients were in the O-RNTT group, and 24 in the RA-RNTT group. Patients in the RA-RNTT group, compared to the O-RNTT group, demonstrated shorter length of stay (3 vs 7 nights, P = .03), lower estimate blood loss (450 vs 1800 mL, P <.01), and lower transfusion rate (21% vs 82%, P <.01). The RA-RNTT group had 26% fever complications compared to the open (17% vs 43%, P <.01). There was no significant difference in estimated overall survival or recurrence-free survival between the O-RNTT and RA-RNTT groups. CONCLUSION: RA-RNTT produced a shorter length of stay, less transfusions, and a lower rate of complications with no significant difference in overall survival.

Robot Assisted Surgery of the Vena Cava: Perioperative Outcomes, Technique, and Lessons Learned at The Mayo Clinic.

Introduction: This study aims to describe robot assisted surgery of the inferior vena cava (IVC) by assessing techniques utilized, perioperative outcomes, complications, and long-term patency of the IVC. Methods: A retrospective review was performed on all robotic surgeries involving dissection and repair of the IVC at our institution. Patient characteristics, operative reports, and follow-up visits were analyzed. Preoperative and postoperative imaging was independently reviewed by a single radiologist to determine changes in IVC diameter. Complications were analyzed according to early (<30 days) vs late (>30 days). Results: Thirty-four patients underwent robot assisted surgery of the vena cava from 2008 to 2018. Twenty-six cases were performed for urologic malignancy, four were performed for IVC filter explantation, and four renal vein transpositions were performed for nutcracker syndrome. Twenty-four of the 26 patients with urologic malignancy underwent radical nephrectomy with IVC tumor thrombectomy. Three cases were converted to open. Median length of stay was two nights, and mean estimated blood loss (EBL) was 375 mL. There were five complications, ranging from Clavien-Dindo grade II-IIIa, four of which were early complications. No patients required return to the operating room, and there were no perioperative mortalities. IVC diameter was reduced by 41% on axial diameter, with no patients experiencing compromised venous return. Conclusion: Robot assisted surgery offers the advantage of minimally invasive surgery with the ability to apply open surgical principles. In our series, an experienced multidisciplinary team approach yielded low EBL, short length of stay, and low complication rates.

Robot Assisted Radical Cystectomy vs Open Radical Cystectomy: Over 10 years of the Mayo Clinic Experience.

OBJECTIVES: There is scant information about intermediate / long-term comparative outcomes between robot assisted radical cystectomy (RARC) and open radical cystectomy (ORC). The purpose of this study is to present survival and oncological outcomes between bladder cancer patients who undergo RARC vs. ORC with an overall median follow-up of over 5 years. MATERIALS AND METHODS: A query of all patients who underwent radical cystectomy between January, 2007 and January, 2018 at Mayo Clinic Arizona yielded 595 patients. After excluding cystectomy performed for nonmalignant indication, cancer secondary to nonbladder primary, and cancers with grossly metastatic disease at the time of surgery, 481 patients remained. Data was collected on patient demographics, preoperative information, operative details, complications, and follow-up. Statistical analyses were generated using SPSS 22.0. RESULTS: In 481 total patients, 203 (42.2%) underwent RARC and 278 (57.8%) underwent ORC. The median follow-up for the entire cohort was 66 months. The 5-year recurrence-free survival (RFS) was 70.8% vs. 64.7% and the 10-year RFS was 69.6% vs. 62.7% for the RARC vs. ORC, respectively (P = 0.135). The 5-year overall survival (OS) was 58.9% vs. 57.7% and the 10-year OS was 39.9% vs. 45.6% for RARC vs. ORC patients, respectively (P = 0.466). There were no differences in any recurrence patterns, including the incidence of atypical recurrences (1.5% vs. 1.8% [P = 0.786], respectively). A Cox-proportional hazards model was fitted that included independent predictors of RFS and OS. The results revealed no difference in RFS (HR 1.235, 95% CI: 0.832-1.833, P = 0.295) or OS (HR 0.790, 95% CI: 0.550-1.135, P = 0.202) between the respectively. CONCLUSIONS: Recurrence free survival, OS, and recurrence patterns are similar in bladder cancer patients who undergo either RARC or ORC.

Rationale for catheter directed therapy in pulmonary embolism.

Pulmonary embolism (PE) is a widespread health concern associated with major morbidity and mortality. Catheter directed therapy (CDT) has emerged as a treatment option for acute PE adding to the current potential options of systemic thrombolysis or anticoagulation. The purpose of this review is to understand the rationale and indications for CDT in patients with PE. While numerous studies have shown the benefits of systemic thrombolysis compared to standard anticoagulation, these are balanced by the increased risk of major bleeding. With this in mind, CDT has the potential to offer the benefits of systemic thrombolysis and in theory, a reduced risk of bleeding. This article will review current treatment guidelines in both massive and submassive PE evaluating both short and long term benefits. The role of CDT will be highlighted, with an emphasis on efficacy and safety.

Successful coil embolization of circumflex iliac artery pseudoaneurysms following paracentesis.

Abdominal paracentesis complicated by perforation of a penetrating arterial branch is an extremely rare complication. We report 2 patients who presented with abdominal wall pseudoaneurysms following abdominal paracentesis for the evaluation and treatment of their hepatic dysfunction. We subsequently review the treatment modalities and interventions performed in each case.