Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting.

OBJECTIVES: To update the 2012 ESGAR consensus guidelines on the acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for clinical staging and restaging of rectal cancer. METHODS: Fourteen abdominal imaging experts from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) participated in a consensus meeting, organised according to an adaptation of the RAND-UCLA Appropriateness Method. Two independent (non-voting) Chairs facilitated the meeting. 246 items were scored (comprising 229 items from the previous 2012 consensus and 17 additional items) and classified as 'appropriate' or 'inappropriate' (defined by ≥ 80 % consensus) or uncertain (defined by < 80 % consensus). RESULTS: Consensus was reached for 226 (92 %) of items. From these recommendations regarding hardware, patient preparation, imaging sequences and acquisition, criteria for MR imaging evaluation and reporting structure were constructed. The main additions to the 2012 consensus include recommendations regarding use of diffusion-weighted imaging, criteria for nodal staging and a recommended structured report template. CONCLUSIONS: These updated expert consensus recommendations should be used as clinical guidelines for primary staging and restaging of rectal cancer using MRI. KEY POINTS: • These guidelines present recommendations for staging and reporting of rectal cancer. • The guidelines were constructed through consensus amongst 14 pelvic imaging experts. • Consensus was reached by the experts for 92 % of the 246 items discussed. • Practical guidelines for nodal staging are proposed. • A structured reporting template is presented.

Correction to: Magnetic resonance imaging for clinical management of rectal cancer: Updated recommendations from the 2016 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting.

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What the Radiologist Should Know About Treatment of Peritoneal Malignancy.

OBJECTIVE: The purpose of this article is to discuss the role of the radiologist in the treatment of peritoneal cancer, with focus placed on advanced treatment options and selection of patients with resectable disease for whom complete cytoreduction can be achieved. CONCLUSION: Peritoneal cancers traditionally have been associated with significant morbidity and universal mortality; however, the management of such cancers has evolved substantially. Advanced treatment options, including cytoreductive surgery and intraperitoneal chemotherapy, are associated with significantly improved long-term patient survival. To ensure that patients benefit from aggressive multimodality treatments, the radiologist plays a pivotal role in the multidisciplinary team to ensure careful patient selection, identifying individuals with resectable disease for whom complete cytoreduction can be achieved.

Preoperative imaging of colorectal liver metastases: what the radiologist and the multidisciplinary team need to know.

The management of patients with colorectal liver metastases (CRLM) has transformed over the past 2 decades. Advances in surgical techniques, systemic therapies, and local treatments have resulted in a paradigm shift. Disease that would once have been considered terminal is now frequently treated aggressively with both a disease-free and overall survival benefit. In line with the expanding range of treatment options, there has been an increase in the volume and complexity of imaging required in the management of these patients to ensure optimal patient selection and outcome. The radiologist plays a pivotal role in interpreting these studies, conveying the relevant information and informing the discussion at multidisciplinary team meetings. The purpose of this review is to provide an update for radiologists on the current surgical management of patients with CRLM highlighting specific imaging information that is required by the multidisciplinary team when assessing resectability and/or the need for additional liver-directed therapies.

What is the optimum post treatment surveillance imaging protocol for low-grade appendiceal mucinous neoplasms and pseudomyxoma peritoneii?

Appendiceal mucinous neoplasms are rare and can be associated with the development of disseminated peritoneal disease known as pseudomyxoma peritonei (PMP). Mucinous tumours identified on appendicectomy are therefore followed up to assess for recurrence and the development of PMP. In addition, individuals who initially present with PMP and are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are followed up to assess for recurrence. However, despite the concerted efforts of multiple expert groups, the optimal imaging follow-up protocol is yet to be established. The purpose of this article is to review the available evidence for imaging surveillance in these populations to identify the optimum post-resection imaging follow-up protocol.

Magnetic resonance imaging for the clinical management of rectal cancer patients: recommendations from the 2012 European Society of Gastrointestinal and Abdominal Radiology (ESGAR) consensus meeting.

OBJECTIVES: To develop guidelines describing a standardised approach regarding the acquisition, interpretation and reporting of magnetic resonance imaging (MRI) for clinical staging and restaging of rectal cancer. METHODS: A consensus meeting of 14 abdominal imaging experts from the European Society of Gastrointestinal and Abdominal Radiology (ESGAR) was conducted following the RAND-UCLA Appropriateness Method. Two independent (non-voting) chairs facilitated the meeting. Two hundred and thirty-six items were scored by participants for appropriateness and classified subsequently as appropriate or inappropriate (defined by ≥ 80 % consensus) or uncertain (defined by < 80 % consensus). Items not reaching 80 % consensus were noted. RESULTS: Consensus was reached for 88 % of items: recommendations regarding hardware, patient preparation, imaging sequences, angulation, criteria for MRI assessment and MRI reporting were constructed from these. CONCLUSIONS: These expert consensus recommendations can be used as clinical guidelines for primary staging and restaging of rectal cancer using MRI. KEY POINTS: • These guidelines recommend standardised imaging for staging and restaging of rectal cancer. • The guidelines were constructed through consensus amongst 14 abdominal imaging experts. • Consensus was reached by in 88 % of 236 items discussed.

An abbreviated MRI protocol for surveillance of cystic pancreatic lesions.

PURPOSE: Cystic pancreatic lesions (CPLs) are common and increasingly encountered in clinical radiology practice. The appropriate imaging surveillance strategy for lower-risk CPLs (branch duct-intraductal papillary mucinous neoplasms and indeterminant small cystic lesions) has been a topic of intense study and debate in recent years. MRI is considered the investigation of choice for initial characterisation and follow-up of CPLs. Follow-up intervals for CPLs vary from 6 months to 2 years and surveillance may be lifelong or until the patient is no longer considered fit for potential surgical intervention. This creates a significant burden on MRI resources as a standard protocol pancreatic MRI may have an acquisition time of up to 35-50 min. However, the necessity of contrast-enhanced sequences and diffusion weighted imaging (DWI) for routine follow-up of CPLs has been questioned in recent years. METHODS: We reviewed the available evidence to determine whether an abbreviated MRI (A-MRI) protocol may be safely adopted for surveillance of CPLs, as has been implemented in other clinical scenarios. RESULTS: A number of recent retrospective studies have indicated that an A-MRI, omitting contrast-enhanced and DWI, may be used for CPL surveillance without any suspicious features or cases of malignancy being missed. Although small number of cases may need to be recalled for additional MR sequences based on the A-MRI findings, there is still a significant overall timesaving. CONCLUSION: The best available evidence currently suggests that an A-MRI protocol should be considered for routine surveillance of CPLs. Prospective studies are required to ensure the findings reported in these retrospective case studies are backed up in ongoing clinical practice.

Consensus review of discordant findings maximizes cancer detection rate in double-reader screening mammography: Irish National Breast Screening Program experience.

PURPOSE: To assesses consensus review of discordant screening mammography findings in terms of its sensitivity, safety, and effect on overall performance in the first 6 years of operation of the Irish National Breast Screening Program (NBSP). MATERIALS AND METHODS: Women who participated in the Irish NBSP gave written informed consent for use of their data for auditing purposes. Local ethics committee approval was obtained. The study population consisted of women who participated in the Irish NBSP and underwent initial screening mammography at one of the two screening centers serving the eastern part of Ireland between 2000 and 2005. Independent double reading of mammograms was performed. When the readers disagreed regarding referral, the case was reviewed by a consensus panel. Of the 128 569 screenings performed, 1335 (1%) were discussed by consensus. RESULTS: Of the 1335 cases discussed by consensus, 606 (45.39%) were recalled for further assessment. This resulted in an overall recall rate of 4.41%. In those recalled to assessment, 71 cases of malignant disease were diagnosed (ductal carcinoma in situ, n = 24; invasive cancer, n = 47). The remaining 729 patients were returned to biennial screening. Of these 729 patients, seven had false-negative findings that were identified in the subsequent screening round. Use of the highest reader recall method, in which a patient is recalled if her findings are deemed abnormal by either reader, could potentially increase the cancer detection rate by 0.6 per 1000 women screened but would increase the recall rate by 12.69% and the number of false-positive findings by 15.37%. CONCLUSION: The consensus panel identified 71 (7.33%) of 968 cancers diagnosed. Consensus review substantially reduced the number of cases recalled and was associated with a low false-negative rate.

Extension of hepatic necrosis secondary to current arcing to surgical clips: a potential complication of radiofrequency ablation.

The authors present a case report of a 67-year-old woman who underwent radiofrequency ablation of recurrent hepatic metastases. She was managed 2 years previously with a right hemi-hepatectomy. Subsequent to RF ablation she developed hepatic necrosis extending in a linear fashion to two of the metallic surgical clips at the free edge of the liver, consistent with current arcing.

Impact of full field digital mammography on the classification and mammographic characteristics of interval breast cancers.

OBJECTIVE: Full field digital mammography (FFDM) is increasingly replacing screen film mammography (SFM) in breast screening programs. Interval breast cancers are an issue in all screening programs and the purpose of our study is to assess the impact of FFDM on the classification of interval breast cancers at independent blind review and to compare the mammographic features of interval cancers at FFDM and SFM. MATERIALS AND METHODS: This study included 138 cases of interval breast cancer, 76 following an FFDM screening examination and 62 following screening with SFM. The prior screening mammogram was assessed by each of five consultant breast radiologists who were blinded to the site of subsequent cancer. Subsequent review of the diagnostic mammogram was performed and cases were classified as missed, minimal signs, occult or true interval. Mammographic features of the interval cancer at diagnosis and any abnormality identified on the prior screening mammogram were recorded. RESULTS: The percentages of cancers classified as missed at FFDM and SFM did not differ significantly, 10.5% (8 of 76) at FFDM and 8.1% (5 of 62) at SFM (p=.77). There were significantly less interval cancers presenting as microcalcifications (alone or in association with another abnormality) following screening with FFDM, 16% (12 of 76) than following a SFM examination, 32% (20 of 62) (p=.02). CONCLUSION: Interval breast cancers continue to pose a problem at FFDM. The switch to FFDM has changed the mammographic presentation of interval breast cancer, with less interval cancers presenting in association with microcalcifications.

Virtual colonoscopy.

Computerized tomographic colonography (CT colonography) is a new, non-invasive technique that has been developed over the last few years; it looks at the large bowel in detail. In this chapter we look at how the examination is performed and we consider how the images are displayed. We describe the normal features of the colon, as seen using this technique, as well as the features of common pathological conditions. We will discuss screening for colorectal cancer and the performance of CT colonography; we compare the latter with other procedures currently employed in the screening and diagnosis of colorectal pathology. We consider the difficulties in interpreting these CT colonographic images and look at ways to overcome such difficulties. Finally we discuss future developments of this exciting, new technique.

Informatics in radiology (infoRAD): portable toolkit for providing straightforward access to medical image data.

Computer-aided analysis of medical images usually involves the development of custom software applications that interpret, process, and ultimately display medical image data. The interpretation stage involves decoding the image data and presenting them to the application developer for further processing. A toolkit has been created specifically for interpreting medical image data; it thus acts as a platform for development of medical imaging applications. The toolkit, which is referred to as NeatMed, is intended to reduce development time by eliminating the need for the application developer to deal directly with medical image data. NeatMed was implemented by using Java, a programming language with a range of attractive features including ease of use, extensive support material, and portability. NeatMed was developed specifically for use in a research environment. Straightforward to use and well documented, it is intended as an alternative to commercially available medical imaging toolkits. NeatMed currently provides support for the Digital Imaging and Communications in Medicine and Analyze medical image file formats. Support material including sample source code is available via the Internet; links to related resources are also provided. Most important, NeatMed is freely available and its continuing development is motivated by requests and suggestions from end users.

Cystic duct remnant and the 'post-cholecystectomy syndrome'.

Post-cholecystectomy syndrome refers to a wide spectrum of conditions that pose a challenging diagnostic dilemma. Cystic duct remnant, defined as a residual duct greater than 1 cm in length, may, in the presence of stones, cause post-cholecystectomy syndrome. In this report, 4 patients with post-cholecystectomy syndrome due to cystic duct remnant are described. All underwent laparoscopic cholecystectomy and one was converted to open. The patients presented with pain 10 months to 9 years post-cholecystectomy and investigations demonstrated cystic duct remnant. All patients underwent successful resection with resolution of symptoms. In this era of laparoscopic surgery, where surgery favors a long cystic duct remnant, we should be aware of cystic duct stones as a possible cause of postcholecystectomy syndrome. This report highlights magnetic resonance cholangiopancreatography as the optimal method for evaluating the biliary tract in these cases.

Efficacy of IV Buscopan as a muscle relaxant in CT colonography.

The aim of this study was to examine the efficacy of IV Buscopan as a muscle relaxant in CT colonography in terms of colonic distension and polyp detection, and to determine its particular efficacy in patients with diverticular disease. Seventy-three consecutive patients were randomised to receive IV Buscopan or no muscle relaxant prior to CT colonography. CT colonography was performed using a Siemens Somatom 4-detector multislice CT scanner. The following parameters were recorded: degree of colonic distension using a 4-point scale; diagnostic adequacy of colonic distension; presence or absence of diverticular disease; and presence of colonic polyps. Accuracy of polyp detection was assessed using subsequent conventional colonoscopy as a gold standard. There was no significant difference between the two groups in the number of segments that were deemed to be optimally or adequately distended (p=0.37). Although IV Buscopan did improve distension of certain segments, this effect was not sufficient to improve the number of diagnostically adequate studies in the Buscopan group (p=0.14). In patients with diverticular disease, IV Buscopan did not have any significant effect on segments affected by diverticulosis but was associated with an improvement in distension of more proximal segments. There was no significant difference between the two groups in terms of polyp detection (p=0.34). The addition of prone scanning to supine scanning was found to be the most useful technique for maximising colonic distension. Intravenous Buscopan at CT colonography does not improve the overall adequacy of colonic distension nor the accuracy of polyp detection. In patients with sigmoid diverticular disease IV Buscopan improves distension of more proximal colonic segments and may be useful in selected cases, but our results do not support its routine use for CT colonography.

Colonic surveillance by CT colonography using axial images only.

Patients at increased risk of colon cancer require strict colon surveillance. Our objective was to establish the efficacy of 2D axial CT colonography as a surveillance test when performed in routine clinical practice. Eighty-two patients at increased risk of colon cancer underwent CT colonography followed by conventional colonoscopy on the same morning. CT colonography studies were performed on a four-ring multidetector CT scanner (100 mAs, 120 kVp, 4 x 2.5 collimation) and were interpreted by two radiologists using 2D axial images only. Results were correlated with findings at colonoscopy. Note was made of subsequent histology reports from polypectomy specimens. A total of 52 polyps were detected at colonoscopy. Using 2D axial images alone, with no recourse to 2D multiplanar or 3D views, the sensitivity of CT colonography was 100, 33 and 19% for polyps larger than 9, 6-9 and smaller than 6 mm, respectively. Per-patient specificities were 98.8, 96 and 81.5%, respectively. Twenty-nine percent of polyps smaller than 1 cm were adenomatous and there were no histological features of severe dysplasia. CT colonography is a useful colon surveillance tool for patients at increased risk of colon cancer. It has a high specificity for identifying patients who should proceed to colonoscopy and polypectomy, while allowing further colon examination to be deferred in patients with normal studies. Using 2D axial images only, CT colonography can be performed as part of the daily CT workload, with a very low rate of referral for unnecessary colonoscopy.