PADUA and R.E.N.A.L. nephrometry scores correlate with perioperative outcomes of robot-assisted partial nephrectomy: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database.

OBJECTIVES: To evaluate and compare the correlations between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) and R.E.N.A.L. [Radius (tumour size as maximal diameter), Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior (a)/posterior (p) descriptor and the Location relative to the polar line] nephrometry scores and perioperative outcomes and postoperative complications in a multicentre, international series of patients undergoing robot-assisted partial nephrectomy (RAPN) for masses suspicious for renal cell carcinoma (RCC). PATIENTS AND METHODS: We retrospectively evaluated the clinical records of patients who underwent RAPN between 2010 and 2013 for clinical N0M0 renal tumours in four international centres that completed all the data required for the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database. All patients underwent preoperative computed tomography or magnetic resonance imaging to define the clinical stage and anatomical characteristics of the tumours. PADUA and R.E.N.A.L. scores were retrospectively assessed in each centre. Univariate and multivariate analyses were used to evaluate the correlations between age, gender, Charlson comorbidity index, clinical tumour size, PADUA and R.E.N.A.L. complexity group categories and warm ischaemia time (WIT) of >20 min, urinary calyceal system closure, and grade of postoperative complications. RESULTS: Overall, 277 patients were evaluated. The median (interquartile range) tumour size was 33.0 (22.0-43.0) mm. The median PADUA and R.E.N.A.L. scores were eight and seven, respectively; 112 (40.4%), 86 (31.0%) and 79 (28.5%) patients were classified in the low-, intermediate- or high-complexity group according to PADUA score, while 118 (42.5%), 139 (50.1%) and 20 (7.2%) were classified in the low-, intermediate- or high-complexity group according to R.E.N.A.L. score, respectively. Both nephrometry tools significantly correlated with perioperative outcomes at univariate and multivariate analyses. CONCLUSION: A precise stratification of patients before PN is recommended to consider both the potential threats and benefits of nephron-sparing surgery. In our present analysis, both PADUA and R.E.N.A.L. were significantly associated with predicting prolonged WIT and high-grade postoperative complications after RAPN.

Changes in primary breast cancer heterogeneity may augment midtreatment MR imaging assessment of response to neoadjuvant chemotherapy.

PURPOSE: To evaluate whether changes in magnetic resonance (MR) imaging heterogeneity may aid assessment for pathologic complete response (pCR) to neoadjuvant chemotherapy (NACT) in primary breast cancer and to compare pCR with standard Response Evaluation Criteria in Solid Tumors response. MATERIALS AND METHODS: Institutional review board approval, with waiver of informed consent, was obtained for this retrospective analysis of 36 consecutive female patients, with unilateral unifocal primary breast cancer larger than 2 cm in diameter who were receiving sequential anthracycline-taxane NACT between October 2008 and October 2012. T2- and T1-weighted dynamic contrast material-enhanced MR imaging was performed before, at midtreatment (after three cycles), and after NACT. Changes in tumor entropy (irregularity) and uniformity (gray-level distribution) were determined before and after MR image filtration (for different-sized features). Entropy and uniformity for pathologic complete responders and nonresponders were compared by using the Mann-Whitney U test and receiver operating characteristic analysis. RESULTS: With NACT, there was an increase in uniformity and a decrease in entropy on T2-weighted and contrast-enhanced subtracted T1-weighted MR images for all filters (uniformity: 23.45% and 22.62%; entropy: -19.15% and -19.26%, respectively). There were eight complete pathologic responders. An area under the curve of 0.84 for T2-weighted MR imaging entropy and uniformity (P = .004 and .003) and 0.66 for size (P = .183) for pCR was found, giving a sensitivity and specificity of 87.5% and 82.1% for entropy and 87.5% and 78.6% for uniformity compared with 50% and 82.1%, respectively, for tumor size change for association with pCR. CONCLUSION: Tumors become more homogeneous with treatment. An increase in T2-weighted MR imaging uniformity and a decrease in T2-weighted MR imaging entropy following NACT may provide an earlier indication of pCR than tumor size change.

Role of Effective Policy and Screening in Managing Pediatric Nutritional Insecurity as the Most Important Social Determinant of Health Influencing Health Outcomes.

Social Determinants of Health (SDOH) impact nearly half of health outcomes, surpassing the influence of human behavior, clinical care, and the physical environment. SDOH has five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context. Any adversity arising out of these interlinked domains predominantly affects children due to their greater susceptibility, and the adverse outcomes may span generations. Unfavorable SDOH may cause food insecurity, malnutrition, unbalanced gut microbiome, acute and chronic illnesses, inadequate education, unemployment, and lower life expectancy. Systematic screening by health care workers and physicians utilizing currently available tools and questionnaires can identify children susceptible to adverse childhood experiences, but there is a deficiency with respect to streamlined approach and institutional support. Additionally, current ameliorating supplemental food programs fall short of pediatric nutritional requirements. We propose a nutrition-based Surveillance, Screening, Referral, and Reevaluation (SSRR) plan encompassing a holistic approach to SDOH with a core emphasis on food insecurity, coupled with standardizing outcome-based interventions. We also propose more inclusive use of Food Prescription Programs, tailored to individual children's needs, with emphasis on education and access to healthy food.

Centrally infiltrating renal masses on CT: differentiating intrarenal transitional cell carcinoma from centrally located renal cell carcinoma.

OBJECTIVE: The objective of our study was to retrospectively determine the accuracy of CT for differentiating intrarenal transitional cell carcinoma (TCC) from centrally located renal cell carcinoma (RCC) and to define the most discriminating diagnostic CT features. MATERIALS AND METHODS: CT studies of 98 pathologically proven central renal tumors (64 centrally located RCCs and 34 intrarenal TCCs) seen over 5 years at three university hospitals were reviewed by five specialty-trained radiologists who were blinded to the final diagnosis. Multiple CT features and global impression were graded on a 4-point score. The sensitivity and specificity of each feature and of global assessment were calculated and compared using receiver operating characteristic (ROC) analysis. Interobserver agreement (kappa values) was also calculated for each parameter. RESULTS: All five readers recognized intrarenal TCCs with a high diagnostic accuracy (sensitivity, 90%; specificity, 90%; area under ROC curve [AUC], 0.80-0.95 for global assessment) with moderate-to-excellent interobserver agreement (κ = 0.72-1). Six CT features were most diagnostically specific for identifying intrarenal TCCs: tumor centered within the collecting system; focal filling defect in the pelvicalyceal system; preserved renal shape; absence of cystic or necrotic change; homogeneous tumor enhancement; and tumor extension toward the ureteropelvic junction (sensitivity, 68-82%; specificity, 79-89%; AUC, 0.75-0.84). There was moderate-to-good agreement among the readers over all these features (κ = 0.44-0.69). CONCLUSION: Intrarenal TCC can be recognized with a high accuracy on CT; global impression showed the best diagnostic performance. A solid, homogeneously enhancing mass that is centered on the collecting system and extends toward the ureteropelvic junction combined with a focal pelvicalyceal filling defect and preserved renal outline is more likely to be an intrarenal TCC than a centrally located RCC.

Dacryoadenitis and diffuse orbital inflammation: unusual first presentations of Churg-Strauss syndrome.

Churg-Strauss syndrome (CSS) is a rare form of vasculitis involving small-to medium-sized blood vessels. CSS typically affects blood vessels of the lungs, gastrointestinal system, and peripheral nerves, but can also involve the heart, skin and kidneys. Here we present two CSS patients presenting with unusual ocular manifestations. Although ophthalmic complications remain relatively uncommon in vasculitides such as Churg-Strauss syndrome, these conditions should be considered in patients presenting with ocular manifestations and concurrent ear, nose and throat symptoms, arthralgia or with positive ANCA and eosinophilia.

Alveolar proteinosis with hypersensitivity pneumonitis: a new clinical phenotype.

BACKGROUND AND OBJECTIVE: The aim of the present study was to report the features of five patients with concurrent histopathological features of pulmonary alveolar proteinosis (PAP) and hypersensitivity pneumonitis (HP) and their high-resolution CT (HRCT) appearances. METHODS: Patients with histopathological features of both HP and PAP on surgical lung biopsy referred for tertiary review were retrospectively identified. The pathology and HRCT images were semi-quantitatively scored to evaluate the relative contribution to HP and PAP. RESULTS: Five patients had histopathological features of HP and PAP but had varied HRCT appearances. All had imaging features of PAP to a varying degree with two patients also showing characteristics of HP but three patients had ill-defined thickened interlobular septa, not typical of either disease. CONCLUSIONS: We describe the coexistence of PAP and HP in five patients and discuss possible linkages between these two distinct pathologies.

Imaging of uterine malignancies.

This article reviews the role of imaging in malignant neoplasms of the uterine corpus. Endometrial cancer is the most common uterine malignancy, and diagnosis is made by histology. Staging of these tumors remain surgical-pathologic on the 2009 International Federation of Gynecology and Obstetrics staging system. However, imaging is important in treatment planning, with magnetic resonance imaging providing the best staging for the primary tumor; more advanced disease may be evaluated with computed tomography or positron emission tomography-computed tomography. Uterine sarcomas are uncommon and heterogeneous group of malignancies. International Federation of Gynecology and Obstetrics have introduced a new staging system for uterine sarcoma that is also surgical-pathologic. Imaging is used in evaluating these tumors and in defining the extent of disease. Other malignant tumors involving the uterus and discussed here include lymphoma and metastases.

Multimodality Assessment of Cystic Renal Masses.

Renal cysts are a common imaging finding, often incidental. Ultrasound, CT and MRI are the main modalities responsible for renal cyst detection and characterization. These modalities often play a complementary role in modern radiological practice, each of them with strengths and limitations. In view of a recently proposed 'multimodality' update to the historical Bosniak classification, this article provides a general overview of the current imaging approach to renal cysts, and outlines some of the diverse pathologic entities responsible for renal cyst formation.

Comparison of whole body magnetic resonance imaging (WBMRI) to whole body computed tomography (WBCT) or 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) in patients with myeloma: Systematic review of diagnostic performance.

OBJECTIVES: To undertake a systematic review to determine the diagnostic performance of whole body MRI (WBMRI) including diffusion weighted sequences (DWI) compared to whole body computed tomography (WBCT) or 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) in patients with myeloma. METHODS: Two researchers searched the primary literature independently for WBMRI studies of myeloma. Data were extracted focusing on the diagnostic ability of WBMRI versus WBCT and 18F-FDG PET/CT. Meta-analysis was intended. RESULTS: 6 of 2857 articles were eligible that included 147 patients, published from 2008 to 2016. Studies were heterogeneous including both newly diagnosed & relapsed patients. All were single centre studies. Four of the six studies (66.7%) accrued prospectively and 5/6 (83.3%, 3 prospective) included WBMRI and 18F-FDG PET/CT. Three of seven (42.9%) included DWI. The lack of an independent reference standard for individual lesions was noted in 5/6 (83.3%) studies. Studies reported that WBMRI detected more lesions than 18F-FDG PET/CT (sensitivity 68-100% versus 47-100%) but was less specific (specificity 37-83% versus 62-85.7%). No paper assessed impact on management. CONCLUSIONS: Studies were heterogeneous, the majority lacking an independent reference standard. Future prospective trials should address these limitations and assess the impact of WBMRI on management.

Added Value of Contrast-Enhanced T1-Weighted and Diffusion-Weighted Sequences for Characterization of Incidental Findings on Whole Body Magnetic Resonance Imaging in Plasma-Cell Disorders.

BACKGROUND: Whole body magnetic resonance imaging (WBMRI) is currently recommended by guidelines for the assessment of myeloma. This will inevitably result in incidental findings. We aimed to assess the frequency of extraskeletal incidental findings and the added value of contrast-enhanced (CE) T1-weighted (T1-W) and diffusion-weighted (DWI) sequences for their characterization in a single WBMRI examination. PATIENTS AND METHODS: We performed 1.5 T WBMRI in 100 patients (53 female; median age, 65 years) with plasma-cell disorders from January 2014 to July 2017. T2-weighted sequences were reviewed initially for incidental findings, followed by sequential review of T1-W, CE T1-W, and DWI sequences for lesion characterization. Descriptive statistics were undertaken. RESULTS: A total of 348 incidental findings were detected in 97 (97%) of 100 patients; only 38 (10.9%) of 348 findings were indeterminate. T1-W sequences increased diagnostic confidence in the characterization of 12 (31.6%) of 38; CE T1-W sequences in the characterization of 16 (50%) of 32; and DWI increased diagnostic confidence in 21 (55.3%) of 38 compared to the T2-weighted sequence alone. CONCLUSION: Incidental findings are common, but the majority are of no clinical consequence. No additional cancers were noted in our series. DWI and CE T1-W sequences increased diagnostic confidence in 50% of indeterminate findings and may reduce the need for further investigation.

Characterization of Small Renal Tumors With Magnetic Resonance Elastography: A Feasibility Study.

OBJECTIVES: The aim of this study was to explore the feasibility of magnetic resonance elastography (MRE) for characterizing indeterminate small renal tumors (SRTs) as part of a multiparametric magnetic resonance (MR) imaging protocol. MATERIALS AND METHODS: After institutional review board approval and informed consent were obtained, 21 prospective adults (15 men; median age, 55 years; age range, 25-72 years) with SRT were enrolled. Tumors (2-5 cm Ø) were imaged using 3-directional, gradient echo MRE. Viscoelastic parametric maps (shear wave velocity [c] and attenuation [α]) were analyzed by 2 independent radiologists. Interobserver agreement (Bland-Altman statistics and intraclass correlation coefficients) was assessed. Anatomical T2-weighted, dynamic contrast-enhanced (DCE) and diffusion sequences completed the acquisition protocol. Imaging parameters were compared between groups (Mann-Whitney U test). RESULTS: Quality of MRE was good in 18 cases (mean nonlinearity <50%), including 1 papillary renal cell carcinoma and 1 metanephric adenoma. A cohort of 5 oncocytomas and 11 clear-cell renal cell carcinomas (ccRCCs) was analyzed for statistical differences. The MRE viscoelastic parameters were the strongest imaging discriminators: oncocytomas displayed significantly lower shear velocity c (median, 0.77 m/s; interquartile range [IQR], 0.76-0.79) (P = 0.007) and higher shear attenuation α (median, 0.087 mm; IQR, 0.082-0.087) (P = 0.008) than ccRCC (medians, 0.92 m/s and 0.066 mm; IQR, 0.84-0.97 and 0.054-0.074, respectively). T2 signal intensity ratio (tumor/renal cortex) was lower in oncocytomas (P = 0.02). The DCE and diffusion MR parameters overlapped substantially (P ≥ 0.1). Oncocytomas displayed a consistent MRE viscoelastic profile, corresponding to data point clustering in a bidimensional scatter plot. Values for MRE intraclass correlation coefficient were 0.982 for c and 0.984 for α, indicating excellent interobserver agreement. CONCLUSIONS: Magnetic resonance elastography is feasible for SRT characterization; MRE viscoelastic parameters were stronger discriminators between oncocytoma and ccRCC than anatomical, DCE and diffusion MR imaging parameters.