Radiologists Help Each Other to Improve Efficiency by Decreasing the Time to Look Up a Patient's Relevant Clinical History in the Electronic Medical Record.

The study aims to prove that it takes less time to look up relevant clinical history from an electronic medical record (EMR) if the information is already provided in a specific space in the EMR by a fellow radiologist. Patients with complex oncological and surgical histories need frequent imaging, and every time a radiologist may spend a significant amount of time looking up the same clinical information as their peers. In collaboration with ACMIO and Radiant Epic team, a space labeled "Specialty Comments" was added to the SNAPSHOT of patient's chart in EMR. For our research purpose, the specialty comment was labeled as boxed history as a variable for data analysis. If the history was not provided in that particular space, it was labeled as without boxed history. Inclusion criteria included outpatients with complex oncological histories undergoing CT chest, abdomen, and pelvis with IV contrast. The time to look up history (LUT) was documented in minutes and seconds. Two assistant professors from Abdominal Imaging provided LUT. A total of 85 cases were included in the study, 39 with boxed history and 46 without boxed history. Comparing averages of the individual reader means for history, mean LUT differed by 2.03 min (without boxed history) versus 0.57 min (with boxed history), p < 0.0001. The t-test and the nonparametric Wilcoxon tests for a difference in the population means were highly significant (p < 0.0001). A history directed to radiologist's needs resulted in a statistically significant decrease in time spent by interpreting radiologists to look through the electronic medical records for patients with complex oncological histories. Availability of history pertinent to radiology has wide-ranging advantages, including quality reporting, decrease in turnaround time, reduction in interpretation errors, and radiologists' continued learning. The space for documenting clinical history may be reproduced, or some similar area may be developed by optimizing the electronic medical records.

Ultrasound-guided needle localization of recurrent paratracheal thyroid cancer.

OBJECTIVES: Ultrasound-guided needle localization techniques have been used to direct the resection of targeted axillary lymph nodes in the management of breast cancer. To date, there has been only one other description of this technique as a localization method to direct cancer resection in the neck. We offer further support for the broader application of this technique by reporting its use in the successful identification and resection of recurrent papillary thyroid cancer after a paratracheal node dissection failed to localize the cancer. METHODS: We report a case and discuss the relevant literature regarding ultrasound-guided localization and resection of recurrent well-differentiated thyroid cancer. RESULTS: We were able to achieve successful identification and resection of recurrent papillary thyroid cancer using this technique. CONCLUSIONS: This technique may be useful in the treatment of selected cases of recurrent thyroid cancer to increase the efficacy and safety of surgical resection.

Gadolinium-enhanced fat-suppressed T1-weighted imaging for staging ureteral carcinoma: correlation with histopathology.

OBJECTIVE: The purpose of this study was to retrospectively compare contrast-enhanced fat-suppressed T1-weighted images with histopathologic findings in ureteral carcinoma to develop accurate preoperative MR criteria for T staging. CONCLUSION: Contrast-enhanced fat-suppressed T1-weighted images can be used to distinguish thickened noncarcinomatous ureteral walls, which occur due to the proliferation of fibrous tissue, from ureteral carcinoma because fibrous tissue enhances more intensely on MRI than ureteral carcinoma. We also observed that when ureteral carcinomas had invaded periureteral fat tissue, a disruption or fragmentation of the intensely enhancing ureteral wall was seen. Using the MR criteria for T staging that we developed on the basis of these findings, we were able to accurately determine whether a carcinoma had invaded periureteral fat tissue in all of our patients.

MDCT imaging of the stomach: advances and applications.

The stomach may be involved by a myriad of pathologies ranging from benign aetiologies like inflammation to malignant aetiologies like carcinoma or lymphoma. Multidetector CT (MDCT) of the stomach is the first-line imaging for patients with suspected gastric pathologies. Conventionally, CT imaging had the advantage of simultaneous detection of the mural and extramural disease extent, but advances in MDCT have allowed mucosal assessment by virtual endoscopy (VE). Also, better three-dimensional (3D) post-processing techniques have enabled more robust and accurate pre-operative planning in patients undergoing gastrectomy and even predict the response to surgery for patients undergoing laparoscopic sleeve gastrectomy for weight loss. The ability of CT to obtain stomach volume (for bariatric surgery patients) and 3D VE images depends on various patient and protocol factors that are important for a radiologist to understand. We review the appropriate CT imaging protocol in the patients with suspected gastric pathologies and highlight the imaging pearls of various gastric pathologies on CT and VE.

Maximizing clinical information obtained by CT.

CT scanning is an integral part of the urologist's practice today. It is the most commonly used imaging modality and the one with which urologists are most familiar. CT urography, CT angiography, and 3D reconstruction enable the urologist to perform comprehensive evaluations of patients who have different urologic diseases, using a single imaging modality. It is thus prudent that urologists become familiar with CT applications, to maximize the clinical information available from them.

Technique for ensuring negative surgical margins during laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Obtaining a negative surgical margin during laparoscopic partial nephrectomy (LPN) is paramount to optimizing the oncologic efficacy of the procedure. Limitations of laparoscopy hinder the ability to extrapolate the intraparenchymal tumor extension from the exophytic portion. We developed a technique wherein ultrasound-confirmed needle localization of the deep tumor margin prior to tumor extirpation ensured negative surgical margins. MATERIALS AND METHODS: Our technique was developed and initially tested using an agar-based ultrasound phantom designed to mimic 2-cm exophytic renal tumors. Needle placement was imaged with ultrasonography and subsequently correlated with findings on sectioning of the tumor mimic. Laparoscopic extirpation of the tumor mimic following needle placement was carried out in a pelvic trainer. The technique has subsequently been incorporated into our LPN technique in four patients. RESULTS: Ultrasound-confirmed needle localization of intraparenchymal tumor extension was feasible and reproducible in an ultrasound phantom. Ultrasound findings correlated with gross findings. Needle placement prior to tumor resection helped to ensure negative surgical margins when applied in the pelvic trainer and when used in three patients. In the remaining patient, improper needle placement resulted in a grossly positive deep margin. CONCLUSION: Ultrasound-confirmed needle placement effectively and reproducibly marks the deep margin of small renal tumors in a mimic as well as in vivo. Our needle technique eliminates the guesswork and unreliability associated with mental visualization and extrapolation of tumor extent during LPN.

Tumor grade of clear cell renal cell carcinoma assessed by contrast-enhanced computed tomography.

The purpose of this study was to clarify the association between CT findings and Fuhrman grade of clear cell renal cell carcinoma (ccRCC). The study group consisted of 214 surgically proven ccRCC in 214 patients. Contrast-enhanced CT studies were retrospectively assessed for tumor size, cystic versus solid, calcification, heterogeneity of lesions, percentage of non-enhancing (necrotic) areas, and growth pattern. CT findings and Fuhrman grade were compared. Nineteen of 22 (86.4%) cystic ccRCC were low grade (Fuhrman grades 1-2). There was no significant correlation between tumor size and grade in cystic ccRCC (P = 0.43). In predominantly solid ccRCC, there was significant correlation between tumor size and grade (P < 0.0001). Thirty-eight of 43 (88.4%) infiltrative ccRCC were high grade (Fuhrman grades 3-4). Logistic regression showed tumor size and infiltrative growth were significantly associated with grades 3-4 (P = 0.00083 and P = 0.0059). Cystic ccRCC tends to be low grade. Infiltrative growth and larger tumor size may increase the likelihood of high grade ccRCC.

Safety of ultrasound-guided fine needle aspiration biopsy of neck lesions in patients taking antithrombotic/anticoagulant medications.

We examined records of patients who underwent ultrasound-guided fine needle aspiration biopsy (USGFNAB) of neck lesions to determine whether there was a significantly increased incidence of bleeding complications in patients on antithrombotic and/or anticoagulant (AT/AC) medications compared to patients not receiving AT/AC therapy. Our institutional review board approved this Health Insurance Portability and Accountability Act-compliant retrospective examination of patients' medical data without requiring informed consent. The records of 593 patients (422 women and 171 men ranging from 18 to 91 years of age) who underwent USGFNAB of 788 total neck lesions over an 18-month period were reviewed to determine AT/AC medication used and evidence of USGFNAB-related bleeding complications. Of these, 144 patients (24.3%) were taking one or more AT/AC medications including aspirin, clopidogrel, heparin, and warfarin. The χ2 test was used to assess statistically significant differences in the incidence of USGFNAB-related bleeding complications between patients who were on daily AT/AC medications (test group) and patients who were not (control group). Six USGFNAB-related hematomas (1.0%) occurred. Two hematomas developed in patients on AT/AC medications, and 4 hematomas developed in patients who did not take AT/AC medications (χ = 0.27, df = 1, P = 0.603). This study shows no statistically significant difference in the incidence of hematoma formation after USGFNAB of neck lesions in patients taking AT/AC medications compared to patients not taking AT/AC medications. On the basis of these data, there is no benefit, with regard to incidence of bleeding complications, to discontinuing AT/AC medications in patients undergoing USGFNAB of neck masses.

Laparoscopic renal tumor cryoablation: appropriate application of real-time ultrasonographic monitoring.

BACKGROUND AND PURPOSE: Many authors who report outcomes of laparoscopic cryoablation for renal tumors comment that real-time intracorporeal ultrasonographic monitoring of the ice-ball formation is imperative. In our experience, ultrasonographic monitoring of the ice-ball formation necessitates significantly more mobilization of the kidney, and the images are difficult to interpret because of artifact and the cryoablation effect on the tissue. We report our intermediate outcomes for laparoscopic cryoablation without real-time ultrasonographic monitoring of the ice ball. PATIENTS AND METHODS: Between December 2002 and May 2007, 27 patients underwent laparoscopic renal cryoablation. The cryoablation approach was based on tumor location and surgeon preference. Lesions were identified and overlying fat was excised, without further mobilization. Real-time ultrasonographic measurement and mapping of the renal lesion were performed. All lesions were biopsied before cryoablation. A double 10-minute freeze-thaw cycle was performed. Postoperative follow-up comprised serial imaging at months 1, 3, 6, and 12 and yearly thereafter. RESULTS: Mean patient age was 70.1 years with a mean renal tumor size of 2.2 cm. Sixteen (59.3%) patients had more than three comorbidities and six (22.2%) patients had two comorbidities with at least 1 previous intra-abdominal surgery. An average of four cryoablation probes were used per lesion. The serum creatinine level was 1.3 mg preoperatively and 1.4 mg at last follow-up. At follow-up of 22 months, there were no local recurrences and 1 (3%) metastatic lesion. CONCLUSION: Laparoscopic cryoablation of small renal masses continues to be a safe and effective technique, even without the use of real-time ultrasonographic monitoring of the ice ball.

Evaluation of locally recurrent pelvic malignancy: performance of T2- and diffusion-weighted MRI with image fusion.

PURPOSE: To evaluate the performance of T2- and diffusion-weighted magnetic resonance imaging (MRI) with image fusion for detection of locally recurrent pelvic malignancy. MATERIALS AND METHODS: The study group consisted of 28 patients (27 female, 1 male) who underwent pelvic MRI at 1.5 T after treatment of pelvic malignancy. MR images were reviewed independently by three blinded readers. The performance of the four sequences for detecting local recurrence was evaluated using receiver operating characteristic analysis: T2-weighted fast spin-echo (FSE), diffusion-weighted echo-planar imaging (DWI), dynamic contrast-enhanced (DCE) fat-suppressed T1-weighted spoiled gradient echo (SPGR), and T2-DWI with image fusion, the latter created using OsiriX Medical Imaging Software. RESULTS: Local recurrence was confirmed at biopsy in 16 patients. Twelve patients showed no evidence of recurrence on two consecutive MRI studies. The Az value for T2-DWI with image fusion (0.949) was statistically greater than that for T2-weighted FSE (0.849) (P<0.05). The sensitivity and specificity was 87.5% and 47.2%, respectively, for T2-weighted FSE, 100.0% and 50.0% for DWI, 95.8% and 58.3% for DCE fat-suppressed T1-weighted SPGR, and 93.8% and 72.2% for T2-DWI with image fusion. CONCLUSION: For depicting locally recurrent pelvic malignancy, T2-DWI with image fusion outperforms standard T2-weighted FSE and DWI and is comparable to DCE fat-suppressed T1-weighted SPGR.