Validation of a Resectability Scoring System for Prediction of Pancreatic Adenocarcinoma Surgical Outcomes.

BACKGROUND: The most used pancreatic cancer (PC) resectability criteria are descriptive in nature or based solely on dichotomous degree of involvement (< 180° or > 180°) of vessels, which allows for a high degree of subjectivity and inconsistency. METHODS: Radiographic measurements of the circumferential degree and length of tumor contact with major peripancreatic vessels were retrospectively obtained from pre-treatment multi-detector computed tomography (MDCT) images from PC patients treated between 2001 and 2015 at two large academic institutions. Arterial and venous scores were calculated for each patient, then tested for a correlation with tumor resection and R0 resection. RESULTS: The analysis included 466 patients. Arterial and venous scores were highly predictive of resection and R0 resection in both the training (n = 294) and validation (n = 172) cohorts. A recursive partitioning tree based on arterial and venous score cutoffs developed with the training cohort was able to stratify patients of the validation cohort into discrete groups with distinct resectability probabilities. A refined recursive partitioning tree composed of three resectability groups was generated, with probabilities of resection and R0 resection of respectively 94 and 73% for group A, 61 and 35% for group B, and 4 and 2% for group C. This resectability scoring system (RSS) was highly prognostic, predicting median overall survival times of 27, 18.9, and 13.5 months respectively for patients in RSS groups A, B, and C (p < 0.001). CONCLUSIONS: The proposed RSS was highly predictive of resection, R0 resection, and prognosis for patients with PC when tested against an external dataset.

Hyperechoic Periappendiceal Fat: Evaluation of Criteria for Improving Specificity in the Sonographic Diagnosis of Appendicitis in Pediatric Patients.

OBJECTIVES: To test the hypothesis that abutting and encasing types of hyperechoic periappendiceal fat are specific sonographic indicators of appendicitis in pediatric patients, including individuals with maximum outer diameters (MODs) of 6 to 8 mm in whom diagnosis by the MOD alone is known to be equivocal. METHODS: Appendiceal sonograms of 271 consecutive pediatric patients were retrospectively evaluated for hyperechoic periappendiceal fat (globular, ≥1.0 cm; categorized as type 0, none; type 1, "abutting," encompassing <180° of the appendiceal circumference; or type 2, "encasing," encompassing 180° or more of the appendiceal circumference) and the MOD. Histopathologic and medical records constituted reference standards. Statistical methods included the binomial distribution, logistic regression, a receiver operating characteristic analysis, and the exact McNemar test. RESULTS: All patients with hyperechoic fat and 105 of 107 patients with appendicitis had MODs of 6 mm or greater. The MOD and fat types 1 and 2 each were significantly associated with appendicitis in the univariable regression. The MOD and fat type 1 were independently associated with appendicitis in multivariable regression (odds ratio, 24.97; P = .034; and odds ratio, 5.35; P < .001, respectively). Specificities of an MOD of 6 to 8 mm and an MOD of 6 mm or greater alone were 89.0% (95% confidence interval, 83.2%-93.4%); these increased to 100.0% each (95% confidence interval, 97.8%-100.0%; P < .001) when combined with fat types 1, 2, and either 1 or 2 as diagnostic criteria, with positive predictive values of 100.0%. CONCLUSIONS: Types 1 and 2 periappendiceal fat are specific indicators of appendicitis, and both improve specificity compared to the MOD. Importantly, they add specificity in diagnosing appendicitis in patients with diagnostically equivocal MODs of 6 to 8 mm.

Diagnostic Performance of Margin Features in Thyroid Nodules in Prediction of Malignancy.

OBJECTIVE: The purpose of this study was to evaluate thyroid nodule margins for specific morphologic features and determine the diagnostic performance of these features in differentiating papillary carcinoma from benign thyroid nodules. MATERIALS AND METHODS: Nodules measuring 1-3 cm in largest diameter that had been evaluated with high-resolution ultrasound (12-18 MHz) and ultrasound-guided biopsy with definitive pathologic diagnosis were analyzed. Three blinded board-certified readers evaluated high-resolution images of each nodule for jagged edges, lobulated borders, and curved borders along their margins. Reader interpretations were correlated with the pathologic diagnosis to determine the diagnostic performance of each feature. A board-certified pathologist analyzed 10 randomly selected nodules with jagged edges by slide review to evaluate for structural correlation with the imaging finding. RESULTS: The diagnostic performance of jagged edges in papillary carcinoma of the thyroid was 67.4% sensitive and 78.3% specific (odds ratio, 7.44; p < 0.001) for malignancy. Jagged edges correlated with infiltrative variant expansion at slide review. Lobulated borders had sensitivity of 76.1% and specificity of 60.9% for papillary carcinoma (odds ratio, 4.95; p = 0.001) for malignancy. Curved borders were not a significant predictor of papillary carcinoma. CONCLUSION: Jagged edges and lobulated borders of thyroid nodule margins are statistically significant predictors of papillary carcinoma of the thyroid. Jagged edges correlate with infiltrative-type expansion and may be useful predictors of more aggressive papillary carcinomas.

Spectral Doppler Waveforms for Diagnosis of Appendicitis: Potential Utility of Point Peak Systolic Velocity and Resistive Index Values.

Purpose To test the hypothesis that appendiceal spectral Doppler waveforms can distinguish patients with and patients without appendicitis. Materials and Methods In this retrospective study, Doppler waveforms were obtained from intramural appendiceal arteries identified with color Doppler imaging in 60% (93 of 155) of consecutive patients whose appendices were visualized at graded compression ultrasonography (US) performed for suspected appendicitis (53 male and 40 female; age, 1-56 years; mean, 14.5 years) over the 5-month period from November 2015 through March 2016. Point, non-angle-corrected peak systolic velocity (PSV) and resistive index (RI) values were compared between patients with and patients without appendicitis by utilizing histopathologically proven appendicitis and 6-week clinical follow-up as diagnostic reference standards. Data were assessed by using the Student t test, exact binomial distribution, two-sample test of proportions, and receiver operating characteristic analysis. Results Among the 93 patients, 36 (38.7%) had proven appendicitis (mean PSV, 19.7 cm/sec; mean RI, 0.69) and 57 patients (61.2%) did not (mean PSV, 7.1 cm/sec, P < .0001; mean RI, 0.50, P < .0001). The area under the receiver operating characteristic curve for the diagnosis of appendicitis was 0.97 (95% confidence interval [CI]: 0.95, 1.00) for PSV and 0.86 (95% CI: 0.78, 0.95; P = .011) for RI. Chosen discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 94.7% and 96.5% with sensitivity of 88.9% and 63.9% (P = .013) and negative predictive value of 93.1% and 80.9% (P = .045), respectively. Original clinical graded compression US interpretations based on established US findings demonstrated specificity of 96.2% and sensitivity of 100.0%. Considering the subset of 20 patients whose maximum outer diameter measured 6-8 mm, the discriminatory criteria of PSV greater than 10 cm/sec and RI greater than 0.65 yielded specificity for appendicitis of 88.9% each, with sensitivity of 100.0% and 63.6% and negative predictive value of 100.0% and 66.6%, respectively. Conclusion In patients with visualized appendices at US, those with appendicitis exhibit significantly higher point PSV and point RI values than do patients without appendicitis and are distinguishable with high specificity by using a PSV greater than 10 cm/sec and an RI greater than 0.65 as diagnostic criteria. © RSNA, 2017.

Cholestyramine as a promising, strong anion exchange resin for direct capture of genetic biomarkers from raw pancreatic fluids.

The ability to capture cell-free DNA from the gastrointestinal tract, in a minimally invasive manner, could enhance our ability to diagnose gastrointestinal disease, or gain a better understanding of the spatial mapping of the intestinal microbiota. We, therefore, sought to identify a class of capture agents that could directly and efficiently sequester genetic material from intestinal fluids. As a particular case study, we examined the ability to capture DNA from pancreatic secretions, for potential application in enabling the sequestration of early, genetic biomarkers of pancreatic disease. We hypothesized that the cholestyramine series of strong cation exchange resins, which are FDA approved for the treatment of high cholesterol, may be capable of capturing DNA from pancreatic secretions. We identified a particular cholestyramine resin, DOWEX 1 × 2 100-200 mesh, which is able to efficiently capture and purify DNA from pancreatic fluid. Using only 200 µL of pancreatic secretions, we are able to recover 247 ± 182 ng of amplifiable human DNA, giving an estimated pancreatic fluid DNA content of 1.23 ± 0.91 ng/µL. To our knowledge, this is the first demonstration of a material that can effectively capture and purify DNA directly from untreated pancreatic fluids. Thus, our approach could hold high utility for the in vivo capture of DNA and disease biomarkers if incorporated into an appropriate sampling device. Biotechnol. Bioeng. 2017;114: 934-938. © 2016 Wiley Periodicals, Inc.

Anatomic Reasons for Failure to Visualize the Appendix With Graded Compression Sonography: Insights From Contemporaneous CT.

OBJECTIVE: The purpose of this study is to identify the anatomic locations of appendixes on CT when graded compression sonography fails to visualize the appendix. MATERIALS AND METHODS: The study included 197 patients with suspected appendicitis whose appendixes were not visualized on graded compression sonography performed with typically used transducers of at least 10 MHz, who underwent CT within 48 hours following graded compression sonography, and who had available either pathologic examination following surgery or 6-week follow-up if surgery was not performed. Appendixes were retrospectively localized using four transverse quadrants (including the posteromedial quadrant) centered on the ileocecal valve and projected vertically, the craniocaudal level relative to the iliac crests, and the depth of the appendix as measured from the surface of the skin. Data were assessed using the Fisher exact test, t test, multinomial test, binomial distribution, ANOVA, and linear regression. RESULTS: Appendixes were most frequently located in the posteromedial quadrant (123 of 197 patients [62.4%]; 95% CI, 55.3-69.2%) at a statistically significantly greater frequency than that expected by chance (p < 0.00001). Appendixes were located above the iliac crests in 19.8% of patients (39/197; 95% CI, 14.5-26.1%) and at depths exceeding the penetration of typical transducers of at least 10 MHz in 19.3% of patients (38/197; 95% CI, 14.0-25.5%). All appendixes (95% CI, 98.1-100.0%) were located within the range of 6-MHz transducers. CONCLUSION: Appendixes that are not visualized on graded compression sonography are most frequently located in the posteromedial quadrant and are often located above the iliac crests or at depths too great for visualization with typically used transducers of at least 10 MHz. Accordingly, when the appendix is not visualized on graded compression sonography, targeted scanning of the posteromedial quadrant and the region above the iliac crests, and scanning with 6-MHz transducers, may enable visualization of the appendix and are recommended additions to scanning protocols.

Imaging Pancreatic Cysts with CT and MRI.

CT and MRI are the imaging modalities of choice to guide the clinical management of incidentally discovered pancreatic cysts. Most of these lesions are mucinous cysts with varying degrees of malignant potential. This article reviews the CT and MRI findings that help differentiate a potentially aggressive lesion that requires EUS or surgery from a lesion of low malignant potential that is appropriate for imaging surveillance. The imaging-based societal guidelines for these cysts are reviewed.

Doppler Ultrasound in Liver Cirrhosis: Correlation of Hepatic Artery and Portal Vein Measurements With Model for End-Stage Liver Disease Score.

OBJECTIVES: To determine whether hepatic arterial and portal venous Doppler ultrasound measurements of the liver in cirrhotic patients correlate with patients' Model for End-Stage Liver Disease (MELD) scores, splenomegaly, or ascites. MATERIALS AND METHODS: Sonographic images and reports were reviewed of 264 patients with hepatic cirrhosis who underwent abdominal ultrasound with Doppler in this internal review board-approved retrospective study. MELD scores were recorded at the time of ultrasound. On gray-scale ultrasound, spleen length was measured and the presence of ascites was noted. Hepatic arterial velocity (HAv) with angle correction, hepatic arterial resistive index, and portal vein velocity with angle correction were measured on Doppler ultrasound. Correlation of hepatic arterial and portal venous Doppler values with MELD score, presence of splenomegaly, and presence of ascites was tested using linear or binary logistic regression analysis. Diagnostic performance of Doppler parameters for high-risk MELD was assessed. RESULTS: The HAv statistically significantly correlated with the MELD score (P = .0001), spleen size (P =.027), and presence of ascites (P =.0001), whereas the hepatic arterial resistive index and portal vein velocity did not correlate with these factors. For MELD scores greater than 19, an HAv greater than 120 cm/s showed accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 74, 42, 90, 67, and 76%, respectively. With an HAv greater than 160 cm/s, the odds ratio for MELD scores greater than 19 was 42.1. CONCLUSIONS: We found a statistically significant correlation with elevated HAv and increasing MELD scores, splenomegaly, and presence of ascites in patients with cirrhotic liver disease; this may be a useful imaging biomarker in the evaluation of patients with cirrhosis.

Sonographic Differentiation of Complicated From Uncomplicated Appendicitis: Implications for Antibiotics-First Therapy.

OBJECTIVES: To evaluate sonographic findings as indicators of complicated versus uncomplicated appendicitis in the setting of known appendicitis, a necessary distinction in deciding whether to proceed with antibiotic therapy or with appendectomy. METHODS: With Institutional Review Board approval and Health Insurance Portability and Accountability Act compliance, appendiceal sonograms of 119 patients with histopathologically proven appendicitis were retrospectively blindly reviewed to determine the presence or absence of the normally echogenic submucosal layer, the presence of mural hyperemia, periappendiceal fluid, appendicoliths, and hyperechoic periappendiceal fat and to determine the maximum outside diameter. Results were compared with the presence of complicated versus uncomplicated appendicitis on histopathologic examination and assessed by both univariate and mulitvariate logistic regression; confidence intervals (CIs) of proportions were assessed by the exact binomial test. RESULTS: Thirty-two (26.9%) of the 119 patients had complicated appendicitis, including 11 with gangrenous appendicitis without perforation and 21 with gangrenous appendicitis and perforation. Loss of the submucosal layer was the only independent significant indicator of complicated appendicitis in multivariate regression (P < .001) and provided sensitivity and specificity values of 100.0% (95% CI, 89.1%-100.0%) and 92.0% (95% CI, 84.1%-96.7%), respectively. CONCLUSIONS: Loss of the normally echogenic submucosal layer was the most useful sonographic finding for discriminating complicated from uncomplicated appendicitis, being the only finding independently and significantly associated with complicated appendicitis and, additionally, providing both high sensitivity and high specificity. This information may help a physician decide whether to proceed with antibiotic therapy or with appendectomy when treating a patient with appendicitis.

Preoperative Multidetector CT Diagnosis of Extrapancreatic Perineural or Duodenal Invasion Is Associated with Reduced Postoperative Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: Preliminary Experience and Implications for Patient Care.

Purpose To test the hypothesis that patients with pancreatic adenocarcinoma who otherwise are viewed to have resectable disease but have preoperative findings of extrapancreatic perineural invasion (EPNI) and/or duodenal invasion at multidetector computed tomography (CT) have reduced postoperative survival after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma (PDAC). Materials and Methods This study was approved by the institutional review board and complied with HIPAA. The authors retrospectively evaluated 76 consecutive patients with PDAC who underwent preoperative multidetector CT and subsequent pancreaticoduodenectomy. Two radiologists blinded to surgical pathology results and clinical outcome evaluated multidetector CT images for evidence of EPNI and duodenal invasion; discrepancies were resolved by consensus. Also determined for each patient were resected lymph node status, tumor size, surgical margin status, time to progression, and time to death. Data were assessed with the Goodman-Kruskal gamma for correlations among indicators and the log-rank test, Kaplan-Meier estimates, and multivariate Cox proportional hazards regression for survival analysis. Results In univariate analysis, duodenal invasion and/or EPNI on preoperativemultidetector CT images was associated with significantly decreased progression-free survival (P < .0001) and overall survival (P = .0013), and the clinical indicators (lymph node status, tumor size, and surgical margin status) as well as duodenal invasion and/or EPNI showed correlation with each other. In multivariate regression that included multidetector CT findings as well as the three traditional clinical indicators, only duodenal invasion and/or EPNI showed significant independent association with reduction in both modes of survival (P < .0001 and P = .014, respectively). Interobserver agreement was substantial with respect to EPNI and duodenal invasion (κ = 0.691 and 0.682, respectively). Conclusion Patients with evidence of EPNI and/or duodenal invasion on preoperative multidetector CT images have significantly reduced survival after pancreaticoduodenectomy for PDAC. © RSNA, 2016.

Lymphoid Hyperplasia of the Appendix: A Potential Pitfall in the Sonographic Diagnosis of Appendicitis.

OBJECTIVE: The objective of this study was to test the hypothesis that thickening of the lamina propria, a finding produced by lymphoid hyperplasia, is significantly associated with false-positive sonographic diagnoses of appendicitis in 6- to 8-mm noncompressible appendixes. MATERIALS AND METHODS: Sonograms of 119 consecutive patients with suspected appendicitis and 6- to 8-mm noncompressible appendixes were retrospectively blindly evaluated for thickening of the lamina propria (short axis thickness ≥ 1 mm). The reference standard for appendicitis was pathologic analysis of resected specimens. Results were compared with the two-tailed Fisher exact test. RESULTS: Thirty-one patients (26.1%) had a thickened lamina propria and 88 (73.9%) did not. Of the 27 pediatric patients with a thickened lamina propria, five (18.5%) had true-positive and 22 (81.5%) had false-positive sonograms for appendicitis; among the 55 pediatric patients without a thickened lamina propria, 27 (49.1%) had true-positive and 28 (50.9%) had false-positive sonograms for appendicitis (p = 0.009). Similar differences in adult patients were not statistically significant. All five pediatric patients with appendicitis and thickened lamina propria also showed two or more findings of periappendiceal fluid, hyperechoic periappendiceal fat, or mural hyperemia on color Doppler examination, compared with two of 22 similar pediatric patients without appendicitis (p < 0.001). CONCLUSION: Lymphoid hyperplasia may result in a noncompressible appendix 6-8 mm in diameter and may be misdiagnosed as appendicitis in pediatric patients. True-positive diagnoses of appendicitis can be accurately identified by the presence of at least two additional findings from the group of periappendiceal fluid, hyperechoic periappendiceal fat, and mural hyperemia. Identifying the characteristic sonographic appearance of lymphoid hyperplasia may help prevent false-positive misdiagnoses of appendicitis.

Color Doppler Imaging of the Appendix: Criteria to Improve Specificity for Appendicitis in the Borderline-Size Appendix.

OBJECTIVES: To test the hypothesis that continuous intramural vascular signal measuring at least 3 mm on color Doppler imaging is highly specific for appendicitis in patients with diagnostically borderline-size appendices. METHODS: Two blinded observers independently reviewed color Doppler images of the appendix in 94 consecutive patients who had undergone sonography for suspected appendicitis and whose appendices were of diagnostically borderline size (6-8 mm maximum outer diameter). Intramural vascular flow on color Doppler images was classified as absent, type 1 (only punctate and dispersed signal), or type 2 (continuous linear or curvilinear signal measuring at least 3.0 mm in long- or short-axis views). Histopathologic examination and clinical follow-up served as reference standards. Proportions were assessed by the exact binomial test. RESULTS: Of the 94 patients, 33 (35.1%) had type 1 flow (of whom 5 [15.2%] had appendicitis); 23 (24.5%) had type 2 flow (of whom 20 [87.0%] had appendicitis); and 38 (40.4%) had absent flow (of whom 10 [26.3%] had appendicitis). The sensitivity, specificity, and odds ratio of type 2 flow as an indicator of appendicitis were 57.1%, 94.9%, and 24.9 (P< .001), respectively; the corresponding values for type 1 flow as an indicator of normal appendices were and 47.5%, 85.7%, and 5.4 (P = .002). CONCLUSIONS: Continuous intramural linear or curvilinear signal measuring at least 3 mm on color Doppler imaging is a highly specific, although relatively insensitive, sign of acute appendicitis in noncompressible appendices of diagnostically borderline size (6-8 mm).

Combining in Vitro Diagnostics with in Vivo Imaging for Earlier Detection of Pancreatic Ductal Adenocarcinoma: Challenges and Solutions.

Pancreatic ductal adenocarcinoma (PDAC) is the fourth-leading cause of cancer-related death in the United States and is associated with a dismal prognosis, particularly when diagnosed at an advanced stage. Overall survival is significantly improved if PDAC is detected at an early stage prior to the onset of symptoms. At present, there is no suitable screening strategy for the general population. Available diagnostic serum markers are not sensitive or specific enough, and clinically available imaging modalities are inadequate for visualizing early-stage lesions. In this article, the role of currently available blood biomarkers and imaging tests for the early detection of PDAC will be reviewed. Also, the emerging biomarkers and molecularly targeted imaging agents being developed to improve the specificity of current imaging modalities for PDAC will be discussed. A strategy incorporating blood biomarkers and molecularly targeted imaging agents could lead to improved screening and earlier detection of PDAC in the future. (©) RSNA, 2015.

MDCT Diagnosis of Perineural Invasion Involving the Celiac Plexus in Intrahepatic Cholangiocarcinoma: Preliminary Observations and Clinical Implications.

OBJECTIVE: The purpose of this study was to test the hypothesis that soft-tissue infiltration along the celiac plexus and delayed enhancement exceeding two-thirds of the tumor area on preoperative MDCT correlate with histologic evidence of perineural invasion in resected intrahepatic cholangiocarcinomas. MATERIALS AND METHODS: Two experienced abdominal radiologists retrospectively reviewed preoperative multiphasic MDCT scans of 20 patients who underwent resection of intrahepatic cholangiocarcinoma, identifying soft-tissue infiltration along the celiac plexus, delayed enhancement exceeding two-thirds of the tumor area, and maximum tumor diameter. Consensus findings were compared with intratumoral perineural invasion in resected intrahepatic cholangiocarcinomas using the Fisher exact test. RESULTS: Six patients had histologic intratumoral perineural invasion, five of whom had soft-tissue infiltration along the celiac plexus on preoperative MDCT, with corresponding 83.3% sensitivity and 92.9% specificity for perineural invasion and significant association between these MDCT and histologic findings (p = 0.002). No patients with histologic perineural invasion had enhancement exceeding two-thirds of the tumor area on MDCT; sensitivity was 0.0% for this finding. Tumor diameter on MDCT was not significantly associated with perineural invasion at histopathology (p = 0.530). CONCLUSION: Soft-tissue infiltration along the celiac plexus on MDCT is an indicator of perineural invasion in patients with intrahepatic cholangiocarcinoma. The data did not confirm an association between delayed enhancement exceeding two-thirds of the tumor area and perineural invasion. Because perineural invasion from intrahepatic cholangiocarcinoma is associated with a very poor prognosis and is generally a contraindication to surgery, the MDCT diagnosis of celiac plexus perineural invasion in patients with intrahepatic cholangiocarcinoma may have important implications for prognosis and treatment planning.

Journal Club: the Alvarado score as a method for reducing the number of CT studies when appendiceal ultrasound fails to visualize the appendix in adults.

OBJECTIVE. The purpose of this article is to evaluate the hypothesis that Alvarado scores of 3 or lower identify adult patients who are unlikely to benefit from CT after appendiceal ultrasound fails to show the appendix and is otherwise normal. MATERIALS AND METHODS. We identified 119 consecutive adults for whom the appendix was not seen on otherwise normal appendiceal sonography performed as the first imaging study for suspected appendicitis, who subsequently underwent CT within 48 hours, and whose data permitted retrospective calculation of admission Alvarado scores. Specific benefits of CT were defined as diagnoses of appendicitis or significant alternative findings, and specific benefits were compared between patients with Alvarado scores of 3 or less and 4 or higher. Significant alternative findings on CT were findings other than appendicitis that were treated with medical or surgical therapy during the admission or that were to be addressed during follow-up care. Diagnostic reference standards were discharge diagnoses, pathologic examinations, and clinical follow-up. RESULTS. No patients (0.0%, 0/49) with Alvarado scores 3 or lower had appendicitis, compared with 17.1% (12/70) of patients with Alvarado scores 4 or higher (p = 0.001), and CT showed neither appendicitis nor significant alternative findings in 85.7% (42/49) versus 58.6% (41/70) of these patients, respectively (p = 0.002). The rates of perforated appendicitis, as well as significant alternative CT findings, did not differ significantly. CONCLUSION. Adults with Alvarado scores 3 or lower who have nonvisualized appendixes and otherwise normal appendiceal sonography are at very low risk for appendicitis or significant alternative findings and therefore are not likely to benefit from CT.

How the radiologist can add value in the evaluation of the pre- and post-surgical pancreas.

Disease involving the pancreas can be a significant diagnostic challenge to the interpreting radiologist. Moreover, the majority of disease processes involving the pancreas carry high significant morbidity and mortality either due to their natural process or related to their treatment options. As such, it is critical for radiologists to not only provide accurate information from imaging to guide patient management, but also deliver that information in a clear manner so as to aid the referring physician. This is no better exemplified than in the case of pre-operative staging for pancreatic adenocarcinoma. Furthermore, with the changing healthcare landscape, it is now more important than ever to ensure that the value of radiology service to other providers is high. In this review, we will discuss how the radiologist can add value to the referring physician by employing novel imaging techniques in the pre-operative evaluation as well as how the information can be conveyed in the most meaningful manner through the use of structured reporting. We will also familiarize the radiologist with the imaging appearance of common complications that occur after pancreatic surgery.

Variable color Doppler sonographic appearances of retained products of conception: radiologic-pathologic correlation.

OBJECT OF STUDY: Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. We hypothesize that variability in sonographic vascularity may be due to histopathologic variation in the placental tissue. MATERIALS, METHODS, AND PROCEDURES: After institutional review board approval, sonographic images and pathologic specimens were retrospectively reviewed in 26 patients with pathologically proven RPOC. Ultrasound (US) images were scored 0-3 for the degree of vascularity by two radiologists blinded to the diagnosis. Corresponding pathologic specimens were evaluated for vascularization of chorionic villi, degree of inflammation, morphology of maternal arteries, chorionic villous preservation, and percentage of clot, membranes, chorionic villi, and decidua/myometrium. Statistical analysis, including multiple linear regression, was performed. RESULTS: RPOC with histologically avascular chorionic villi or those with markedly reduced vascularization had significantly lower US vascularity scores (p = 0.030) than those with chorionic villi showing normal or decreased vascularization. Sonographically avascular RPOC had a significantly lower percentage villi (p = 0.028) and higher percentage of decidua (p = 0.004) than specimens where US showed any Doppler vascularity. Histologic vascularity of villi (p = 0.049) and non-observation of maternal arteries (p = 0.001) were significant predictors of US vascularity scores in multivariate linear regression analysis, while inflammation of villi (p = 0.053) was a marginally significant predictor. SIGNIFICANCE OF THE CONCLUSIONS: Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity. This finding may underlie known differences in clinical outcomes between sonographic vascularity groups.

Sonographic Detection of Extracapsular Extension in Papillary Thyroid Cancer.

OBJECTIVES: To identify and evaluate sonographic features suggestive of extracapsular extension in papillary thyroid cancer. METHODS: Three board-certified radiologists blinded to the final pathologic tumor stage reviewed sonograms of pathologically proven cases of papillary thyroid cancer for the presence of extracapsular extension. The radiologists evaluated the following features: capsular abutment, bulging of the normal thyroid contour, loss of the echogenic capsule, and vascularity extending beyond the capsule. RESULTS: A total of 129 cases of pathologically proven thyroid cancer were identified. Of these, 51 were excluded because of lack of preoperative sonography, and 16 were excluded because of pathologic findings showing anaplastic carcinoma, follicular carcinoma, or microcarcinoma (<10 mm). The final analysis group consisted of 62 patients with papillary thyroid carcinoma, 16 of whom had pathologically proven extracapsular extension. The presence of capsular abutment had 100% sensitivity for detection of extracapsular extension. Conversely, lack of capsular abutment had a 100% negative predictive value (NPV) for excluding extracapsular extension. Contour bulging had 88% sensitivity for detection of extracapsular extension and when absent had an 87% NPV. Loss of the echogenic capsule was the best predictor of the presence of extracapsular extension, with an odds ratio of 10.23 (P = .034). This sonographic finding had 75% sensitivity, 65% specificity, and an 88% NPV. Vascularity beyond the capsule had 89% specificity but sensitivity of only 25%. CONCLUSIONS: Sonographic features of capsular abutment, contour bulging, and loss of the echogenic thyroid capsule have excellent predictive value for excluding or detecting extracapsular extension and may help in biopsy selection, surgical planning, and treatment of patients with papillary thyroid cancer.

Value of Intraoperative Sonography in Pancreatic Surgery.

The utility of intraoperative sonography for pancreatic disease has been well described for detection and evaluation of neoplastic and inflammatory pancreatic disease. Intraoperative sonography can help substantially reduce surgical time as well as decrease potential injury to tissues and major structures. Imaging with sonography literally at the point of care--the surgeon's scalpel--can precisely define the location of pancreatic lesions and their direct relationship with surrounding structures in real time during surgery. This article highlights our experience with intraoperative sonography at multiple institutional sites for both open and laparoscopic surgical procedures. We use intraoperative sonography for a wide range of pancreatic disease to provide accurate localization and staging of disease, provide guidance for enucleation of nonpalpable, nonvisible tumors, and in planning the most direct and least invasive surgical approach, avoiding injury to the pancreatic duct or other vital structures.

Predictors of appendicitis on computed tomography among cases with borderline appendix size.

Confident diagnosis of appendicitis when the appendix is borderline (6 to 7 mm) in size can be challenging. This retrospective study assessed computed tomography (CT) findings that are most predictive of appendicitis when the appendix is borderline in diameter. Three radiologists conducted separate, blind retrospective reviews of 105 contrast-enhanced CTs with borderline appendices. Presence or absence of appendicitis was confirmed by chart review of clinical or surgical outcomes. Logistic regression was used to determine the odds ratio (OR) and the receiver operating characteristic for CT features predictive of appendicitis. Absence of intraluminal air (OR = 5.11, p < 0.001), wall hyperemia (OR = 3.92, p = 0.002), wall thickening (OR = 29.7, p < 0.001), and fat stranding (OR = 3.85, p = 0.003) were significant findings in univariate logistic regression. Using a multivariate model, we found that the absence of intraluminal air (OR = 6.04, p = 0.002) and wall thickening (OR = 24.6, p < 0.001) remained statistically significant and were unaffected by adjustment for gender and pediatric age. The area under the curve was significantly greater for the multivariate model than the initial, clinical CT impressions (p = 0.024). The combination of wall thickening and absence of intraluminal air was 92.6 % (95 % CI 75.7-99.1) sensitive and 82.4 % (95 % CI 65.5-93.2) specific for appendicitis. Wall thickening and the absence of intraluminal air are prominent predictors of appendicitis and, if present together, these features may aid in identifying appendicitis on CT when the appendix is borderline in size.