A Multicenter Study of Needle Size and Safety for Splenic Biopsy.

Background Splenic biopsy is rarely performed because of the perceived risk of hemorrhagic complications. Purpose To evaluate the safety of large bore (≥18 gauge) image-guided splenic biopsy. Materials and Methods This retrospective study included consecutive adult patients who underwent US- or CT-guided splenic biopsy between March 2001 and March 2022 at eight academic institutions in the United States. Biopsies were performed with needles that were 18 gauge or larger, with a comparison group of biopsies with needles smaller than 18 gauge. The primary outcome was significant bleeding after the procedure, defined by the presence of bleeding at CT performed within 30 days or angiography and/or surgery performed to manage the bleeding. Categorical variables were compared using the χ2 test and medians were compared using the Mann-Whitney test. Results A total of 239 patients (median age, 63 years; IQR, 50-71 years; 116 of 239 [48.5%] female patients) underwent splenic biopsy with an 18-gauge or smaller needle and 139 patients (median age, 58 years [IQR, 49-69 years]; 66 of 139 [47.5%] female patients) underwent biopsy with a needle larger than 18 gauge. Bleeding was detected in 20 of 239 (8.4%) patients in the 18-gauge or smaller group and 11 of 139 (7.9%) in the larger than 18-gauge group. Bleeding was treated in five of 239 (2.1%) patients in the 18-gauge or smaller group and one of 139 (1%) in the larger than 18-gauge group. No deaths related to the biopsy procedure were recorded during the study period. Patients with bleeding after biopsy had smaller lesions compared with patients without bleeding (median, 2.1 cm [IQR, 1.6-5.4 cm] vs 3.5 cm [IQR, 2-6.8 cm], respectively; P = .03). Patients with a history of lymphoma or leukemia showed a lower incidence of bleeding than patients without this history (three of 90 [3%] vs 28 of 288 [9.7%], respectively; P = .05). Conclusion Bleeding after splenic biopsy with a needle 18 gauge or larger was similar to biopsy with a needle smaller than 18 gauge and seen in 8% of procedures overall, with 2% overall requiring treatment. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Grant in this issue.

Safety profile and technical success of narrow window CT-guided percutaneous biopsy with blunt needle approach in the abdomen and pelvis.

OBJECTIVE: To assess success and safety of CT-guided procedures with narrow window access for biopsy. METHODS: Three hundred ninety-six consecutive patients undergoing abdominal or pelvic CT-guided biopsy or fiducial placement between 01/2015 and 12/2018 were included (183 women, mean age 63 ±â€¯14 years). Procedures were classified into "wide window" (width of the needle path between structures > 15 mm) and "narrow window" (≤ 15 mm) based on intraprocedural images. Clinical information, complications, technical and clinical success, and outcomes were collected. The blunt needle approach is preferred by our interventional radiology team for narrow window access. RESULTS: There were 323 (81.5%) wide window procedures and 73 (18.5%) narrow window procedures with blunt needle approach. The median depth for the narrow window group was greater (97 mm, interquartile range (IQR) 82-113 mm) compared to the wide window group (84 mm, IQR 60-106 mm); p = 0.0017. Technical success was reached in 100% (73/73) of the narrow window and 99.7% (322/323) of the wide window procedures. There was no difference in clinical success rate between the two groups (narrow: 86.4%, 57/66; wide: 89.5%, 265/296; p = 0.46). There was no difference in immediate complication rate (narrow: 1.3%, 1/73; wide: 1.2%, 4/323; p = 0.73) or delayed complication rate (narrow: 1.3%, 1/73; wide: 0.6%, 1/323; p = 0.50). CONCLUSION: Narrow window (< 15 mm) access biopsy and fiducial placement with blunt needle approach under CT guidance is safe and successful. CLINICAL RELEVANCE STATEMENT: CT-guided biopsy and fiducial placement can be performed through narrow window access of less than 15 mm utilizing the blunt-tip technique. KEY POINTS: • A narrow window for CT-guided abdominal and pelvic biopsies and fiducial placements was considered when width of the needle path between vital structures was ≤ 15 mm. • Seventy-three biopsies and fiducial placements performed through a narrow window with blunt needle approach had a similar rate of technical and clinical success and complications compared to 323 procedures performed through a wide window approach, with traditional approach (> 15 mm). • This study confirmed the safety of the CT-guided percutaneous procedures through < 15 mm window with blunt-tip technique.

Highest 3-month international normalized ratio (INR): a predictor of bleeding following ultrasound-guided liver biopsy.

OBJECTIVES: To determine whether international normalized ratio (INR), bilirubin, and creatinine predict bleeding risk following percutaneous liver biopsy. METHODS: A total of 870 consecutive patients (age 53 ± 14 years; 53% (459/870) male) undergoing non-targeted, ultrasound-guided, percutaneous liver biopsy at a single tertiary center from 01/2016 to 12/2019 were retrospectively reviewed. Results were analyzed using descriptive statistics and logistic regression models to evaluate the relationship between individual and combined laboratory values, and post-biopsy bleeding risk. Receiver operating characteristic (ROC) curves and area under ROC (AUC) curves were constructed to evaluate predictive ability. RESULTS: Post-biopsy bleeding occurred in 2.0% (17/870) of patients, with 0.8% (7/870) requiring intervention. The highest INR within 3 months preceding biopsy demonstrated the best predictive ability for post-biopsy bleeding and was superior to the most recent INR (AUC = 0.79 vs 0.61, p = 0.003). Total bilirubin is an independent predictor of bleeding (AUC = 0.73) and better than the most recent INR (0.61). Multivariate regression analysis of the highest INR and total bilirubin together yielded no improvement in predictive performance compared to INR alone (0.80 vs 0.79). The MELD score calculated using the highest INR (AUC = 0.79) and most recent INR (AUC = 0.74) were similar in their predictive performance. Creatinine is a poor predictor of bleeding (AUC = 0.61). Threshold analyses demonstrate an INR of > 1.8 to have the highest predictive accuracy for bleeding. CONCLUSION: The highest INR in 3 months preceding ultrasound-guided percutaneous liver biopsy is associated with, and a better predictor for, post-procedural bleeding than the most recent INR and should be considered in patient risk stratification. CLINICAL RELEVANCE STATEMENT: Despite correction of coagulopathic indices, the highest international normalized ratio within the 3 months preceding percutaneous liver biopsy is associated with, and a better predictor for, bleeding and should considered in clinical decision-making and determining biopsy approach. KEY POINTS: • Bleeding occurred in 2% of patients following ultrasound-guided liver biopsy, and was non-trivial in 41% of those patients who needed additional intervention and had an associated 23% 30-day mortality rate. • The highest INR within 3 months preceding biopsy (AUC = 0.79) is a better predictor of bleeding than the most recent INR (AUC = 0.61). • The MELD score is associated with post-procedural bleeding, but with variable predictive performance largely driven by its individual laboratory components.

Routine radiology-pathology concordance evaluation of CT-guided percutaneous lung biopsies increases the number of cancers identified.

BACKGROUND: Routine concordance evaluation between pathology and imaging findings was introduced for CT-guided biopsies. PURPOSE: To analyze malignancy rate in concordant, discordant, and indeterminate non-malignant results of CT-guided lung biopsies. METHODS: Concordance between pathology results and imaging findings of consecutive patients undergoing CT-guided lung biopsy between 7/1/2016 and 9/30/2021 was assessed during routine meetings by procedural radiologists. Concordant was defined as pathology consistent with imaging findings; discordant was used when pathology could not explain imaging findings; indeterminate when pathology could explain imaging findings but there was concern for malignancy. Recommendations for discordant and indeterminate were provided. All the malignant results were concordant. Pathology of repeated biopsy, surgical sample, or follow-up was considered reference standard. RESULTS: Consecutive 828 CT-guided lung biopsies were performed on 795 patients (median age 70 years, IQR 61-77), 423/828 (51%) women. On pathology, 224/828 (27%) were non-malignant. Among the non-malignant, radiology-pathology concordance determined 138/224 (62%) to be concordant with imaging findings, 54/224 (24%) discordant, and 32/224 (14%) indeterminate. When compared to the reference standard, 33/54 (61%) discordant results, 6/30 (20%) indeterminate, and 3/133 (2%) concordant were malignant. The prevalence of malignancy in the three groups was significantly different (p < 0.001). Time to diagnosis was significantly different between patients who reached the diagnosis with imaging follow-up (median 114 days, IQR 69-206) compared to repeat biopsy (33 days, IQR 18-133) (p = 0.01). CONCLUSION: Routine radiology-pathology concordance evaluation of CT-guided lung biopsy correctly identifies patients at high risk for missed diagnosis of malignancy. Repeat biopsy is the fastest method to reach diagnosis. CLINICAL RELEVANCE STATEMENT: A routine radiology-pathology concordance assessment identifies patients with non-malignant CT-guided lung biopsy result who are at greater risk of missed diagnosis of malignancy. KEY POINTS: • A routine radiology-pathology concordance evaluation of CT-guided lung biopsies classified 224 non-malignant results as concordant, discordant, or indeterminate. • The percentage of malignancy on follow-up was significantly different in concordant (2%), discordant (61%), and indeterminate (20%) (p < 0.001). • Time to definitive diagnosis was significantly shorter with repeat biopsy (33 days), compared to imaging follow-up (114 days), p = 0.01.

Moral Distress in Radiology: Frequency, Root Causes, and Countermeasures-Results of a National Survey.

BACKGROUND. A major cause of burnout is moral distress: when one knows the right course of action but institutional constraints make the right course impossible to pursue. OBJECTIVE. The purpose of this study was to assess the frequency and severity with which radiologists experience moral distress and to explore moral distress's root causes and countermeasures. METHODS. This study entailed a national survey that evaluated moral distress in radiology. The survey incorporated the validated Moral Distress Scale for Health Care Professionals, along with additional questions. After the scale was modified for applicability to radiology, respondents were asked to assess 16 clinical scenarios in terms of frequency and severity of moral distress. On May 10, 2022, the survey was sent by e-mail to 425 members of radiology practices included on a national radiology society's quality-and-safety LISTSERV. The Measure of Moral Distress for Health Care Professionals (MMD-HP) score was calculated for each respondent as a summary measure of distress across scenarios (maximum possible score, 256). RESULTS. After 12 surveys with incomplete data were excluded, the final analysis included 93 of 425 respondents (22%). A total of 91 of 93 respondents (98%) experienced at least some moral distress for at least one scenario. A total of 17 of 93 respondents (18%) had left a clinical position due to moral distress; 26 of 93 (28%) had considered leaving a clinical position due to moral distress but did not leave. The mean MMD-HP score was 73 ± 51 (SD) for those who had left, 89 ± 47 for those who had considered leaving but did not leave, and 39 ± 35 for those who had never considered leaving (p < .001). A total of 41 of 85 respondents (48%) thought that the COVID-19 pandemic had influenced their moral distress level. Across respondents, the three scenarios with highest moral distress were related to systemic causes (higher case volume than could be read safely, high case volume preventing teaching residents, and lack of administrative action or support). The countermeasure most commonly selected to alleviate moral distress was educating leadership about sources of moral distress (71%). CONCLUSION. Moral distress is prevalent in radiology, typically relates to systemic causes, and is a reported contributor to radiologists changing jobs. CLINICAL IMPACT. Urgent action by radiology practice leadership is required to address moral distress, as radiologists commonly practice in environments contradictory to their core values as physicians.

Unexplained Acute Distal Pancreatitis: Association With Subsequent Diagnosis of Pancreatic Cancer.

BACKGROUND. Distal pancreatitis is an atypical imaging subtype of acute pancreatitis involving only the pancreatic body and tail, the head being spared. If no cause is identified, suspicion of a small imaging-occult cancer may be warranted. OBJECTIVE. The purpose of this study was to determine the frequency of subsequently diagnosed pancreatic cancer in patients with unexplained acute distal pancreatitis and to compare this frequency to that found in patients with unexplained nondistal pancreatitis. METHODS. This retrospective study included patients who underwent contrast-enhanced CT between January 1, 2019, and December 31, 2020, that showed acute pancreatitis without identifiable explanation. Studies were classified as showing distal or nondistal acute pancreatitis on the basis of consensus. The Fisher exact test was used to compare the frequency of subsequent histologic diagnosis of pancreatic cancer between groups. Negative classification required 6 or more months of imaging follow-up and/or 12 or more months of clinical follow-up. Interreader agreement among seven readers of varying experience was assessed by Fleiss kappa. RESULTS. Among 215 patients with acute pancreatitis, 116 (54%) had no identifiable explanation and formed the study sample. A total of 100 of 116 (86%) patients (59 men, 41 women; mean age, 57 ± 18 [SD] years) had nondistal acute pancreatitis; 16 of 116 (14%) patients (10 men, six women; mean age, 66 ± 14 years) had distal acute pancreatitis. Among patients with nondistal pancreatitis, none were subsequently diagnosed with pancreatic cancer; 62 had sufficient follow-up (median, 2.5 years) to be classified as having negative follow-up for pancreatic cancer. Among patients with distal pancreatitis, nine were subsequently diagnosed with pancreatic cancer (median interval to suspected cancer on subsequent CT, 174 days); five had sufficient follow-up (median, 3.1 years) to be classified as having negative follow-up for pancreatic cancer. The frequency of pancreatic cancer was higher (p < .001) in patients with distal pancreatitis (9/14 [64%; 95% CI, 35-87%]) than in with those with nondistal pancreatitis (0/62 [0%; 95% CI, 0-6%]). Interreader agreement on classification of distal versus nondistal pancreatitis was almost perfect (κ = 0.81). CONCLUSION. Distal pancreatitis without identifiable cause on CT is an uncommon but unique imaging subtype of acute pancreatitis that is associated with a high frequency of pancreatic cancer. CLINICAL IMPACT. In patients with acute distal pancreatitis without identifiable cause, endoscopic ultrasound-guided biopsy should be considered to evaluate for an underlying small cancer.

Quality Improvement Report: Adherence to Follow-up Recommendations for Incidental Abdominal Aneurysms.

The use of national guidelines for the management of incidental radiologic findings remains low. Therefore, improving adherence to and consistency with follow-up recommendations for incidental findings was undertaken in a large academic practice. A gap analysis was performed, and incidental findings of abdominal aneurysms for which reporting management recommendations could be improved were identified. The Kotter change management framework was used, and institution-specific dictation macros were developed and implemented in February 2021 for the management of abdominal aortic aneurysms (AAAs), renal artery aneurysms (RAAs), and splenic artery aneurysms (SAAs). A retrospective medical record review was conducted for February through April in 2019, 2020, and 2021 to assess reporting adherence and imaging and clinical follow-up. Personal feedback was provided to radiologists in July 2021 with repeat data collection in September 2021. A significant increase in the number of correct follow-up recommendations was reported for incidental AAAs and SAAs after implementation of the macro (P < .001). However, there was no significant change for RAAs. Providing personal feedback to radiologists further improved adherence with standard recommendation macros for common findings and dramatically increased adherence for rare findings such as RAAs. New macros resulted in an increase in AAA and SAA imaging follow-up (P < .001). Institution-specific dictation macros were found to improve adherence to reporting recommendations for incidental abdominal aneurysms, with further improvement seen after feedback, which can have a significant effect on clinical follow-up. © RSNA, 2023.

Enhancement Type at Contrast-enhanced Mammography and Association with Malignancy.

Background Despite the increasing use of contrast-enhanced mammography (CEM), there are limited data on the evaluation of findings on recombined images and the association with malignancy. Purpose To determine the rates of malignancy of enhancement findings on CEM images in the presence or absence of low-energy findings using the Breast Imaging Reporting and Data System (BI-RADS) lexicon developed for mammography and MRI. Materials and Methods All diagnostic CEM examinations performed at one academic institution between December 2015 and December 2019 had low-energy and recombined images retrospectively. Data were independently reviewed by three breast imaging radiologists with 5-25 years of experience using the BI-RADS mammography and MRI lexicon. Outcome was determined with pathologic analysis or 1-year imaging or clinical follow-up. The χ2 and Fisher exact tests were used for analysis. Results A total of 371 diagnostic CEM studies were performed in 371 women (mean age, 54 years ± 11[SD]). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of enhancement on CEM images was 95% (104 of 109 [95% CI: 90, 98]), 67% (176 of 262 [95% CI: 61, 73]), 55% (104 of 190 [95% CI: 47, 62]), and 97% (176 of 181 [95% CI: 94, 99]), respectively. Among 190 CEM studies with enhancing findings, enhancing lesions were more likely to be malignant when associated with low-energy findings (26% vs 59%, P < .001). Among enhancement types, mass enhancement composed 71% (99 of 140) of all malignancies with PPV of 63% when associated with low-energy findings. Foci, non-mass enhancement, and mass enhancement without low-energy findings had PPV of 6%, 24%, and 38%, respectively. Neither background parenchymal enhancement nor density was associated with enhancement type (P = .19 and P = .28, respectively). Conclusion Mass enhancement on recombined images using CEM was most commonly associated with malignancy, especially when associated with low-energy findings. Enhancement types were more likely to be benign when not associated with low-energy findings; however, they should still be viewed with suspicion, given the high association with malignancy. © RSNA, 2022 Online supplemental material is available for this article.

Incidence of pancreatic cancer during long-term follow-up in patients with incidental pancreatic cysts smaller than 2 cm.

PURPOSE: To assess the long-term malignancy risk of incidental small pancreatic cysts. MATERIALS AND METHODS: In this HIPAA-compliant, IRB-approved, retrospective, multi-institutional study, the long-term incidence of pancreatic cancer was compared between patients with and without small pancreatic cysts. Patients with incidental pancreatic cysts ≥ 0.5 and < 2.0 cm in maximal diameter, detected on MRI performed between 1999 and 2011, represented the "small pancreatic cyst" group. Patients that underwent MRI between 2005 and 2011 and had no reported pancreatic cysts represented the comparison "no cyst" group. RESULTS: The "small pancreatic cyst" group included 267 patients, ages 63.4 ± 11.8 years, 166/267 (62%) women with a mean follow-up of 8.6 ± 4.3 years, median 9.2 years; the "no cyst" group included 1,459 patients, ages 64.6 ± 12 years, 794/1,459 (54%) women with a mean follow-up of 7.0 ± 4.2 years, median 7.8 (p values 0.12, 0.02, < 0.001, respectively). Two/267 (0.7%) patients developed pancreatic cancer at a separate location from the known cyst in the "small pancreatic cyst" group, with a cancer rate of 0.9 (95% CI 0.1-3.1) cases per 1,000 patient-years. In the "no cyst" cohort, 18/1,459 (1.2%) patients developed pancreatic cancer, with a cancer rate of 1.8 (95% CI 1.2-3.1) cases per 1,000 patient-years (p = 0.6). The all-cause mortality was similar in both groups: 57/267 (21%) vs. 384/1,459 (26%) (p = 0.09). CONCLUSION: The long-term risk of pancreatic malignancy in asymptomatic patients with incidental pancreatic cysts less than 2 cm is 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. These very few pancreatic cancers developed at a separate location from the known cyst. KEY POINTS: • After a median of 9.2 years of follow-up, the risk of pancreatic malignancy in patients with an asymptomatic small pancreatic cyst was 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. • Very few pancreatic cancer cases developed in the location separate from the known pancreatic cyst.

Concordance Assessment of Pathology Results with Imaging Findings after Image-Guided Biopsy.

PURPOSE: To assess the impact of radiology review for discordance between pathology results from computed tomography (CT)-guided biopsies versus imaging findings performed before a biopsy. MATERIALS AND METHODS: In this retrospective review, which is compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board, 926 consecutive CT-guided biopsies performed between January 2015 and December 2017 were included. In total, 453 patients were presented in radiology review meetings (prospective group), and the results were classified as concordant or discordant. Results from the remaining 473 patients not presented at the radiology review meetings were retrospectively classified. Times to reintervention and to definitive diagnosis were obtained for discordant cases; of these, 49 (11%) of the 453 patients were in the prospective group and 55 (12%) of the 473 patients in the retrospective group. RESULTS: Pathology results from CT-guided biopsies were discordant with imaging in 11% (104/926) of the cases, with 57% (59/104) of these cases proving to be malignant. In discordant cases, reintervention with biopsy and surgery yielded a shorter time to definitive diagnosis (28 and 14 days, respectively) than an imaging follow-up (78 days) (P < .001). The median time to diagnosis was 41 days in the prospective group and 56 days in the retrospective group (P = .46). When radiologists evaluated the concordance between pathology and imaging findings and recommended a repeat biopsy for the discordant cases, more biopsies were performed (50% [11/22] vs 13% [4/31]; P = .005). CONCLUSIONS: Eleven percent of CT-guided biopsies yielded pathology results that were discordant with imaging findings, with 57% of these proving to be malignant on further workup.

Ovarian Cystadenomas: Growth Rate and Reliability of Imaging Measurements.

OBJECTIVES: To evaluate the growth rate of benign ovarian cystadenomas and the degree of variability in ultrasound measurements. METHODS: Two independent retrospective cohorts of women found to have benign cystadenomas at surgery were identified. To assess growth rate, ultrasounds on women in a community-based health system were reviewed and the growth rate was determined based on the maximum reported size dimension using a mixed effect model. To assess measurement variability, two radiologists independently measured presurgical adnexal imaging findings for women in a tertiary care referral setting. Interobserver, intra-observer, and intermodality (cine clip versus still images) variability in measurements was determined using correlation coefficients (CC) and Bland-Altman analysis, with the proportion of measurements varying by more than 1 cm calculated. RESULTS: For growth rate assessment, 405 women with 1412 ultrasound examinations were identified. The median growth rate was 0.65 cm/year with mucinous cystadenomas growing faster at 0.83 cm/year compared to 0.51 cm/year for serous cystadenomas (median test P < .0001). To evaluate measurement variability, 75 women were identified with 176 ultrasound studies. The within-subject standard deviations for ultrasound measurements were 0.74 cm for cine clip images and 0.41 cm for static images, with 11% of measurements overall differing by more than 1 cm. CONCLUSIONS: Cystadenomas grow on average 0.65 cm/year, which is similar in magnitude to the inherent error observed in measurement on ultrasound, suggesting that repeat ultrasound at intervals of longer than a year will often be needed to accurately assess growth if a cyst represents a benign cystadenoma.

The Sonographic Appearance of Endometrial Intraepithelial Neoplasia.

OBJECTIVES: To describe the sonographic findings of endometrial intraepithelial neoplasia (EIN), a precursor of endometrial cancer. METHODS: Cases were found by word search of pathology database 1/2013 to 6/2019. One hundred and seventy-eight patients with ultrasound <1 year prior to biopsy were included. Medical records were searched for patient data. Two radiologists blindly classified images. Differences of opinion were decided by clinical report. Univariate and multivariate analyses were performed. RESULTS: Median time between ultrasound and first sampling procedure was 49 days. Median age was 55 (range 28-85) years. Endometrial thickness ranged from 2 to 90 mm. Mean endometrial thickness was 13 ± 6 mm in the noncancer group and 16 ± 11 mm in the cancer group (P = .02). The endometrium was almost always heterogeneous 175/178 (98%). Cysts were almost always multiple (89/109, 82%) and >1 mm (72/109, 66%). Masses were most often >5 mm (56/105, 55%) and ill-defined (41/105, 39%). Vascularity was present in 93/178 examinations (52%) and always associated with cysts and/or mass. There were 92 cancers, 25 with invasion (including 4 with tumor extension into adenomyosis). In 47 cases, the endometrial-myometrial interface was graded as ill-defined, 39 of whom had hysterectomy. There was macroscopic cancer in 11, microscopic cancer in 4, and invasive carcinoma in 12 patients (P for invasive cancer versus other outcomes = .02). Depth of invasion was 5- >95%, with 6 cancers >50%. Multivariate analysis showed thickness, polyps, and type of bleeding as the best set of independent variables for cancer (area under the receiver operating characteristic (ROC) curve [AUC] = .75). Replacing type of bleeding with age or menopausal status had AUC of .73 and .74, respectively. CONCLUSIONS: EIN has a variety of sonographic appearances with thickened endometrium with cysts and masses being common. Ill-definition of the endometrial-myometrial interface is a poor prognostic finding when seen in the absence of adenomyosis.

Yield of pelvic CT in emergency department patients undergoing CT torso for generalized or multiple complaints.

PURPOSE: To evaluate the utility of pelvic computed tomography (CT) in emergency department (ED) patients undergoing chest CT angiogram (CTA) for chest pain or suspected pulmonary embolism (PE) followed by abdominopelvic CT in the same session for additional multisystem or generalized complaints. METHODS: This retrospective study included consecutive adult ED patients from January 2017 to December 2019 who underwent CTA for suspected PE followed by portovenous abdominopelvic CT for multisystem or generalized complaints. Patient demographics, vitals, laboratory values, exam indication, malignancy history, and recent surgery/intervention were recorded. CT reports were reviewed for acute chest, abdomen, and/or pelvic pathology. RESULTS: There were 400 patients with 243 (61%) women and mean age of 59.8 years. Acute pelvic findings were seen in 11% (45/400). In 53% (24/45) of these, pelvic pathology could be diagnosed based on the abdominal portion of the CT. Five percent (21/400) of patients demonstrated isolated acute pelvic findings with 86% of these (18/21) clinically suspected prior to imaging. Acute pelvic pathology was associated with female gender (p = 0.015) and elevated white blood cell count (WBC) (p = 0.03). Specific pelvic CT indications and female gender were significantly associated with (p = 0.02 each) and independent predictors of isolated acute pelvic pathology. CONCLUSION: In ED patients undergoing chest CTA for chest pain or suspected PE combined with abdominopelvic CT, the presence of acute pelvic-related pathology not visualized on abdominal CT is low. For this ED patient cohort, pelvic CT may not be necessary in men with normal WBC and a low pre-imaging clinical suspicion for acute pelvic pathology.

Repeat Evaluation of Lung Shunt Fraction is Unnecessary: A Retrospective Observational Study of Successive Lung Shunt Fractions from Variable Arterial Distributions in Patients Undergoing Radioembolization of Primary and Secondary Liver Tumors.

PURPOSE: To evaluate whether the recalculation of lung shunt fraction (LSF) is necessary prior to next-stage or same lobe repeat radioembolization. MATERIALS AND METHODS: Retrospective chart review was performed for patients who underwent radioembolization between February 2008 and December 2018. Eighty of 312 patients had repeat mapping angiograms and LSF calculations. A total of 160 LSF calculations were made using planar imaging (155, [97%]) and single-photon emission computed tomography (5 [3%]) technetium-99m macroaggregated albumin hepatic arterial injection imaging. The mean patient age was 61.8 years ± 12.7; 69 (86%) patients had metastatic disease and 11 (14%) had hepatocellular carcinoma. RESULTS: Patients had a median LSF of 5% (interquartile range [IQR] 3%-9%) with a median absolute difference of 1.25 (IQR 0.65-3.4) and a median of 76 days (IQR 42.5-120 days) between repeat LSF calculations. There was a median change in LSF of 0.2% between mapping studies (P = .11). There was no statistical significance between the repeat LSFs regardless of the arterial distribution (P = .79) or between tumor types (P = .75). No patients exceeded lung dose limits using actual or predicted prescribed dose amounts. The actual median lung dose was 2.6 Gy (IQR 1.8-4.4 Gy, maximum = 20.5) for the first radioembolization and 2.0 Gy (IQR 1.3-3.7 Gy, maximum = 10.1) for the second radioembolization. CONCLUSIONS: No significant difference in LSF was identified between different time points and arterial distributions within the same patient undergoing repeat radioembolization. In patients who receive well under 30-Gy lung dose for the initial treatment and a 50-Gy cumulative lung dose, repeat radioembolization treatments in the same patient may not require a repeat LSF calculation.

Minimizing Radiation Dose Outliers Through Systematic Analysis, Computed Tomography Technologist Education, and Standardized System Solutions.

OBJECTIVES: The aims of the study were to systematically analyze causes for radiation dose outliers in emergency department noncontrast head computed tomographies (CTs), to develop and implement standardized system solutions, and audit program success for an extended period of time. METHODS: This study was performed in a large, tertiary academic center between January 2015 and September 2017. Four phases of radiation dose data collection with and without prior interventions were performed. Outliers from 5 categories were evaluated for appropriateness in consensus by 2 radiologists and a senior CT technologist. RESULTS: A total of 275 ± 15 CTs per period were included. Fifty-seven inappropriate scanning parameters were found in 24 (9%) of 254 CTs during the first analysis, 27 in 21 (7%) of 290 CTs during the second, 11 in 10 (4%) of 276 during the third assessment (P = 0.006). After a year without additional intervention, the number remained stable (14 in 11/281 CTs, 4%). CONCLUSIONS: Combining a dose reporting system, individual case analysis, staff education, and implementation of systemic solutions lead to sustained radiation exposure improvement.

Implementing radar reflector-guided localization of nonpalpable breast lesions: Feasibility, challenges, outcomes, and lessons learned.

Reflector-guided localization uses a nonradioactive radar implant for wire-free presurgical breast lesion localization. A single-institution retrospective evaluation found lower rates of positive margins and of close margins for reflector-guided localizations compared with wire localizations, resulting in a statistically significant decrease in the re-excision rates (p = 0.015). The two approaches did not show statistically significant difference in localization time and OR time. Technical challenges included particulars inherent in reflector placement, while patient factors included special considerations for reflector placement in the postsurgical breast. Despite novel challenges, we found reflector-guided localization to be accurate and efficient.

Role of C-reactive protein in effective utilization of emergent MRI for spinal infections.

PURPOSE: Emergent spinal MRI is recommended for patients with back pain and red flags for infection. However, many of these studies are negative due to low prevalence of spinal infections. Our purpose was to assess if C-reactive protein (CRP) can be used to guide effective utilization of emergent MRI for spinal infections. METHODS: 316/960 (33%) MRIs performed for infection by the emergency department over 75-month period had CRP levels obtained at presentation, after excluding patients receiving antibiotic or had spinal surgery in < 1 month. An MRI was considered positive when there was imaging evidence of spinal infection confirmed on follow-up by surgery/biopsy/drainage or definitive therapy. A CRP of ≤ 10 mg/L was considered normal and > 100 mg/L as highly elevated. RESULTS: CRP was normal in 95/316 (30%) and abnormal in 221/316 (70%) patients. MRI was positive in 43/316 (13.6%) patients, all of whom had abnormal CRP. CRP (p < 0.001) and intravenous drug use (IVDU; p = 0.002) were independently associated with a positive MRI. Receiver operator characteristic (ROC) analysis showed AUC of 0.76 for CRP, slightly improving with IVDU. Sensitivity, specificity, and negative predictive values for CRP level cut-off: 10 mg/L, 100%, 35%, and 100%, and 100 mg/L, 58%, 70% and 91%, respectively. CONCLUSION: Abnormal CRP, although extremely sensitive, lacks specificity in predicting a positive MRI for spinal infection unless highly elevated. However, a normal CRP (absent recent antibiotic or surgery) makes spinal infection unlikely, and its routine use as a screening test can help reducing utilization of emergent MRI for this purpose.

Dependent lesion positioning at CT-guided lung biopsy to reduce risk of pneumothorax.

OBJECTIVES: To evaluate the impact of patient positioning during CT-guided lung biopsy on patients' outcomes. METHODS: In this retrospective, IRB-approved, HIPAA-compliant study, consecutive CT-guided lung biopsies performed on 5/1/2015-12/26/2017 were included. Correlation between incidence of pneumothorax, chest tube placement, pulmonary bleeding with patient, and procedure characteristics was evaluated. Lesion-trachea-table angle (LTTA) was defined as an angle between the lesion, trachea, and horizontal line parallel to the table. Lesion above trachea has a positive LTTA. Univariate and multivariate logistic regression analysis was performed. RESULTS: A total of 423 biopsies in 409 patients (68 ± 11 years, 231/409, 56% female) were included in the study. Pneumothorax occurred in 83/423 (20%) biopsies with chest tube placed in 11/423 (3%) biopsies. Perilesional bleeding occurred in 194/423 (46%) biopsies and hemoptysis in 20/423 (5%) biopsies. Univariate analysis showed an association of pneumothorax with smaller lesions (p = 0.05), positive LTTA (p = 0.002), and lesions not attached to pleura (p = 0.026) with multivariate analysis showing lesion size and LTTA to be independent risk factors. Univariate analysis showed an association of increased pulmonary bleeding with smaller lesions (p < 0.001), no attachment to the pleura (p < 0.001), needle throw < 16 mm (p = 0.05), and a longer needle path (p < 0.001). Multivariate analysis showed lesion size, a longer needle path, and lesions not attached to the pleura to be independently associated with perilesional bleeding. Risk factors for hemoptysis were longer needle path (p = 0.002), no attachment to the pleura (p = 0.03), and female sex (p = 0.04). CONCLUSIONS: Interventional radiologists can reduce the pneumothorax risk during the CT-guided biopsy by positioning the biopsy site below the trachea. KEY POINTS: • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy results in lower rate of pneumothorax, as compared with the lesion above the trachea. • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy does not affect rate of procedure-associated pulmonary hemorrhage or hemoptysis.

Clinical utility of 2-D anatomic measurements in predicting cough-associated headache in Chiari I malformation.

PURPOSE: Cough-associated headache (CAH) is the most distinctive symptom of patients with Chiari I malformation (CMI) and indicates clinically significant disease. We determined the clinical utility of simple 2D anatomic measurements performed on a PACS workstation by assessing their diagnostic accuracy in predicting CAH in CMI patients. METHODS: Seventy-two consecutive CMI patients (cerebellar tonsillar herniation > 5 mm) with headache seen by neurosurgeons over 6 years were included. Sagittal T1 images were used by two readers to measure: extent of tonsillar herniation, lengths of the clivus and supra-occiput, McRae and pB-C2 lines, as well as clivus-canal, odontoid retroversion, and skull base angles. Neurosurgery notes were reviewed to determine presence of CAH. Mann-Whitney test was used to compare measurements between patients with and without CAH. Predictive accuracy was assessed by receiver operating characteristic (ROC) curve. RESULTS: 47/72 (65.3%) CMI patients reported CAH. Tonsillar herniation with CAH (10.2 mm, 7-14 mm; median, interquartile range) was significantly greater than those without CAH (7.9 mm, 6.3-10.9 mm; p = 0.02). Tonsillar herniation ≥ 10 mm showed sensitivity and specificity of 51% and 68%, and tonsillar herniation > 14 mm showed sensitivity and specificity of 30% and 100%, respectively, for predicting CAH. Other 2D measurements showed no statistically significant differences. CONCLUSIONS: Among the 2D measurements used, only the extent of tonsillar herniation is different between CMI patients with and without CAH. Although CMI is diagnosed with tonsillar herniation of only 5 mm, we found that a much higher extent of herniation is needed to be predictive of CAH.

Asymptomatic Endometrial Thickening of 8 mm or Greater on Postcontrast Computed Tomography in Postmenopausal Women Is a Predictor of Endometrial Cancer.

OBJECTIVES: The aim of this study was to assess the value of opportunistic endometrial thickness measurement on postcontrast computed tomography (CT) as a predictor of endometrial cancer in asymptomatic postmenopausal women. METHODS: For this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective study with waiver of informed consent, our institution's tumor board database was searched for postmenopausal patients, diagnosed with endometrial cancer between August 2003 and December 2016 and who had a postcontrast pelvic CT within 12 months prior to the cancer diagnosis (while they were asymptomatic)-"cancer group." Same number of age-matched patients who had postcontrast pelvic CT constituted the noncancer control group. Endometrial thickness was measured on sagittal postcontrast CT images. RESULTS: After applying exclusion criteria, 22 asymptomatic patients who were diagnosed with endometrial cancer within 1 year after the CT comprised the cancer group, and 22 age-matched patients comprised the control group. Average endometrial thickness was 18.7 ± 14.8 mm (range, 2-70 mm) in the cancer group and 3.6 ± 2.5 mm (range, 1.8-10 mm) in the control group (P < 0.0001). Endometrial thickness 8 mm or greater predicted endometrial cancer with 86% sensitivity and 91% specificity in these asymptomatic patients. Area under the receiver operating characteristic curve for endometrial thickness as a predictor of endometrial cancer was 0.92. CONCLUSIONS: Endometrial thickness 8 mm or greater on sagittal postcontrast CT was shown to have high sensitivity in opportunistic detection of endometrial cancer in asymptomatic postmenopausal women.