Interobserver Agreement for CT and MRI Findings of Chronic Pancreatitis in Children: A Multicenter Ancillary Study Under the INSPPIRE Consortium.

BACKGROUND. Imaging findings represent key criteria for diagnosing chronic pancreatitis in children. Understanding radiologists' agreement for imaging findings is critical to standardizing and optimizing diagnostic criteria. OBJECTIVE. The purpose of this study is to evaluate the interobserver agreement among experienced pediatric radiologists for subjective, quantitative, and semiquantitative imaging findings of chronic pancreatitis in children. METHODS. In this retrospective study, CT or MRI examinations performed in children with chronic pancreatitis were submitted by six sites participating in the INSPPIRE (International Study Group of Pediatric Pancreatitis: In Search for a Cure) Consortium. One pediatric radiologist from each of the six sites reviewed examinations; three of the radiologists independently reviewed all CT examinations, and the other three radiologists independently reviewed all MRI examinations. Reviewers recorded 13 categoric imaging findings of chronic pancreatitis and measured pancreas thickness and pancreatic duct diameter. Agreement was assessed using kappa coefficients for the categoric variables and intraclass correlation coefficients (ICCs) for the continuous variables. RESULTS. A total of 76 CT and 80 MRI examinations performed in 110 children (65 girls and 45 boys; mean age, 11.3 ± 4.6 [SD] years) were reviewed. For CT, kappa coefficients for categoric findings ranged from -0.01 to 0.81, with relatively high kappa coefficients noted for parenchymal calcifications (κ = 0.81), main pancreatic duct dilatation (κ = 0.63), and atrophy (κ = 0.52). ICCs for parenchymal thickness measurements ranged from 0.57 in the pancreas head to 0.80 in the body and tail. The ICC for duct diameter was 0.85. For MRI, kappa coefficients for categoric findings ranged from -0.01 to 0.74, with relatively high kappa coefficients noted for main duct irregularity (κ = 0.74), side branch dilatation (κ = 0.70), number of dilated side branches (κ = 0.65), and main duct dilatation (κ = 0.64); kappa coefficient for atrophy was 0.52. ICCs for parenchymal thickness measurements ranged from 0.53 for the neck and body individually to 0.68 in the tail. ICC for duct diameter was 0.77. CONCLUSION. Interobserver agreement was fair to moderate for most CT and MRI findings of chronic pancreatitis in children. CLINICAL IMPACT. This study highlights challenges for the imaging diagnosis of pediatric chronic pancreatitis. Standardized and/or objective criteria are needed given the importance of imaging in diagnosis.

The radiologist's role in assessing differences of sex development.

When infants are identified with a difference of sex development (DSD), a thoughtful approach to imaging is essential to appropriate clinical management. This review provides a comprehensive guide for radiologists who are tasked with performing this critical assignment. We review the embryologic basis of DSDs, with attention to the imaging findings that can indicate specific diagnoses. We also discuss techniques for optimal imaging, including strategies for identifying the gonads by US, tactics for performing genitograms with fluoroscopy and contrast-enhanced US, and the appropriate utilization of MRI. Finally, we review the clinical data and imaging findings that characterize some of the most common DSDs, including congenital adrenal hyperplasia, complete androgen insensitivity syndrome and gonadal dysgenesis.

A Novel Thoracic Ultrasound Measurement After Congenital Diaphragmatic Hernia Repair Identifies Decreased Diaphragmatic Excursion Associated With Adverse Respiratory and Surgical Outcomes.

Background and Aim: Congenital diaphragmatic hernia (CDH) is a rare defect often associated with pulmonary hypoplasia and abnormal pulmonary vascular development. Even after successful hernia repair, pulmonary disease may persist into adulthood. Impaired diaphragmatic motility may lead to compromised respiratory function long after index repair. This study investigates whether a novel ultrasound measurement, the diaphragmatic excursion ratio, can be a simple and non-invasive method to evaluate routine diaphragmatic motion after CDH repair, and whether it correlates with adverse surgical and respiratory outcomes. Materials and Methods: A cross-sectional study was conducted in consecutive patients who presented at medium-term follow-up visit between December 2017 and December 2018 after CDH repair at single pediatric hospital. Transthoracic ultrasound was performed with craniocaudal diaphragmatic excursion measured bilaterally during routine breathing. Diaphragmatic excursion ratios (diaphragmatic excursion of repaired vs. unrepaired side) were calculated and retrospectively compared with clinical data including demographics, length of stay, respiratory adjuncts, oral feeding, and need for gastrostomy. Results: Thirty-eight patients (median age at ultrasound, 24 months, interquartile range 11-60) were evaluated. Nine patients underwent primary repair, 29 had non-primary repair (internal oblique muscle flap or mesh patch). Patients with a diaphragmatic excursion ratio below the median (0.54) had longer hospital stays (median 77 vs. 28 days, p = 0.0007) more ventilator days (median 16 vs. 9 days, p =0.004), and were more likely to have been discharged on oxygen (68 vs. 16%, p = 0.001). They were also less likely to be exclusively taking oral feeds at 1-year post-surgery (37 vs. 74%, p = 0.02) and more likely to require a gastrostomy tube in the first year of life (74 vs. 21%, p = 0.003). Conclusions: Transthoracic ultrasound after CDH repair is practical method to assess diaphragm motion, and decreased diaphragm excursion ratio is associated with worse respiratory outcomes, a longer length of stay, and dependence on gastrostomy tube feeding within 1 year. Further prospective studies may help validate this novel ultrasound measurement and offer prognostic value.

Contrast-enhanced genitosonography and colosonography: emerging alternatives to fluoroscopy.

Imaging plays a crucial role in evaluating newborns and infants with cloacal and urogenital malformations. Contrast-enhanced genitosonography (ceGS) and contrast-enhanced colosonography (ceCS) are sensitive and radiation-free alternatives to fluoroscopic genitography and colography for diagnosis and surgical planning. These imaging techniques are performed by instilling a US contrast agent into specific body cavities to define the genitourinary and colorectal anatomy. This review article presents the experience with ceGS and ceCS applications in children, focusing on the background, examination technique, and interpretation of imaging findings, as well as strengths and weaknesses compared to conventional techniques.

Monitoring Arteriovenous Malformation Response to Genotype-Targeted Therapy.

Arteriovenous malformations (AVMs) have recently been reported to have a high incidence of somatic KRAS mutations suggesting potential for treatment with mitogen-activated protein kinase inhibitors. In this case report, we describe genotype-targeted treatment of a KRAS mutant metameric AVM in a patient with Cobb syndrome using the mitogen-activated protein kinase inhibitor trametinib. Therapeutic response was monitored with phase-contrast magnetic resonance angiography to quantify AVM arterial inflow as an imaging biomarker. Treatment with trametinib resulted in a substantial decrease in blood flow to the AVM, with a >75% reduction in arterial inflow after 6 months of trametinib therapy.

Parents of Pediatric Radiology Patients Prefer Timely Reporting and Discussing Results with Referring Providers.

RATIONALE AND OBJECTIVES: With the introduction of new communication channels, such as encrypted messaging and online electronic medical record patient portals, there are ever-increasing ways for patients and their families to access their medical information. While patient preferences regarding how they receive the results of their radiology examinations have been assessed in the adult population, there is limited data on parent preferences for pediatric radiology patients. MATERIALS AND METHODS: The aim of this study was to determine how the parents of pediatric radiology patients prefer to receive the results of their child's imaging studies. The study design was an institutional review board-approved anonymous voluntary survey distributed to parents in a pediatric radiology waiting room. RESULTS: Of the current possible ways to receive radiology results, most parents preferred to receive their child's radiology results from the referring doctor (65%). A minority of parents preferred to receive the results from a radiologist in-person (16%) or via the radiology report (16%). In multiple hypothetical scenarios, parents also preferred to receive radiology results from the referring doctor rather than the radiologist, with the single exception being when no subsequent appointment with the referring doctor was planned. When asked to prioritize the most important aspect of receiving radiology test results, most parents prefer having results available quickly (65%). CONCLUSION: This survey suggests that in the pediatric radiology realm, efforts toward timely reporting will likely have a greater impact on patient satisfaction than prioritizing more in-person radiologist-patient communication.

Improved diagnostic confidence and accuracy of pediatric elbow fractures with digital tomosynthesis.

BACKGROUND: Pediatric elbow fractures are common but remain challenging to accurately diagnose. Digital tomosynthesis is a technique that has shown promise in difficult adult fracture patterns but has not been formally studied in the pediatric population. OBJECTIVE: To assess the added value of digital tomosynthesis on the detection and diagnostic confidence of pediatric elbow fractures. MATERIALS AND METHODS: A retrospective study was performed between January 2016 and December 2017 in pediatric patients (≤18 years) to assess the ability of conventional elbow radiographs and digital tomosynthesis to detect elbow fractures. One hundred twenty-one pediatric patients with concern for pediatric elbow trauma (64 males, 57 females; mean age: 8.1 years, range: 1 year to 17 years) were imaged with both conventional elbow radiographs and digital tomosynthesis. Two blinded pediatric radiologists identified fractures and indicated their diagnostic confidence. Observer agreement was assessed with Cohen's Kappa coefficient and a nonparametric Wilcoxon rank sum test was used to compare the degree of diagnostic confidence between standard radiographs alone and standard radiographs with digital tomosynthesis. McNemar's test was used to assess the difference in the rate of fracture detection between the two methods and sensitivity, specificity, precision, accuracy and diagnostic odds ratios were calculated. RESULTS: Compared with standard radiographs alone, standard radiographs with digital tomosynthesis improved inter-rater agreement, sensitivity, specificity, accuracy, precision and the diagnostic odds ratio for fracture detection and increased diagnostic confidence (Rater 1: P=0.01, Rater 2: P=0.003). CONCLUSION: The addition of digital tomosynthesis with conventional elbow radiographs improves diagnostic confidence and performance for the detection of pediatric elbow fractures.

Digital tomosynthesis of the pediatric elbow.

Imaging pediatric elbow trauma in the acute setting remains diagnostically challenging given difficult patient positioning, multiple ossification centers of the pediatric elbow, overlapping structures, and complex joint anatomy. Digital tomosynthesis is a technique where the X-ray source travels across a limited arc angle, obtaining a series of low-dose exposures that are in turn digitally reconstructed to produce high in-plane resolution at a relatively low overall radiation dose. Digital tomosynthesis is now more commonly integrated into standard radiographic machines and offers a new and exciting way to assess the pediatric elbow. In this review article we discuss the clinical applications of digital tomosynthesis in pediatric elbow trauma along with challenges related to technique, patient positioning and artifacts.

Effect of radiologist pregnancy on the performance of pediatric fluoroscopic studies: a survey of Society for Pediatric Radiology members.

BACKGROUND: To our knowledge, the fluoroscopic practice patterns of pregnant diagnostic radiologists have not been documented. OBJECTIVE: To describe the fluoroscopic practice patterns during pregnancy among members of the Society for Pediatric Radiology (SPR) and potential impact on career and professional relationships. MATERIALS AND METHODS: After approval from the SPR, we sent all 1,847 SPR members an email link to an anonymous online survey that queried how pregnancy affects a practicing radiologist who performs fluoroscopy. RESULTS: Of the 398 responses (65% female, 35% male), most female respondents (78%) reported having been pregnant while practicing radiology and the majority (85%) performed fluoroscopy during pregnancy. Most performed fluoroscopy during all three trimesters (first 78%, second 90%, third 87%) and the majority (81%) used double-lead. Forty-six percent indicated that their fluoroscopic responsibilities during pregnancy were stressful. Of those who opted to perform fewer fluoroscopy studies, 20% indicated that it impacted negatively on their career or professional relationships. After witnessing a pregnant co-worker perform fewer fluoroscopic studies, 11% (4% male; 16% female; P<0.05) of respondents observed a subsequent negative impact on the co-worker's career or professional relationships. CONCLUSION: The majority of responding female SPR members had performed fluoroscopy during pregnancy and most performed fluoroscopy during their entire pregnancy with double-lead. Differences between self-reported adversity and observed adversity of performing less fluoroscopy during pregnancy speak to the lack of awareness of the issues, particularly among male colleagues. A clear policy with regard to performing fluoroscopy during pregnancy for all radiologists in every department is necessary.

Value of dedicated small-field-of-view sacroiliac versus large-field-of-view pelvic magnetic resonance imaging for evaluating pediatric sacroiliitis.

BACKGROUND: Optimized MRI parameters can be leveraged to improve signal intensity, accelerate imaging acquisition and increase resolution. Higher-resolution imaging with a small field of view (FOV) has been proposed as standard practice for investigating sacroiliac (SI) joints, but the improvement in disease detection and characterization over pelvic imaging with large FOV has not been established. OBJECTIVE: The purpose of this study was to compare dedicated MR images of the SI joints with survey imaging (large-FOV pelvic MRI) for detecting sacroiliitis. MATERIALS AND METHODS: Fifty-eight pediatric patients suspected of having sacroiliitis underwent dedicated sacroiliac joint and survey pelvic imaging at the same imaging session. We independently evaluated the small- and large-FOV image data sets for presence or absence of sacroiliitis, e.g., bone marrow edema, erosions and synovitis. We used nonparametric statistical tests to compare lesion scores for severity of inflammation. We created test characteristics for the survey pelvic images (low-resolution images of the sacroiliac joints) using dedicated sacroiliac images (small-FOV, high-resolution images) as the gold standard. RESULTS: Dedicated sacroiliac small-FOV MRI detected more sacroiliitis compared to survey pelvic imaging with large FOV (χ2=6.125, P=0.013). Readers detected significantly more features of inflammation on small- compared to large-FOV images, e.g., erosions (P=0.039), synovitis (P=0.009), sclerosis (P=0.017) and osteitis (P=0.001). Test characteristics for pelvic large-FOV imaging were sensitivity=0.76, specificity=1.00, positive predictive value = 1.00 and negative predictive value = 0.75. CONCLUSION: This study provides test characteristics for survey pelvic MRI with lower-resolution large-field-of-view images as a screening tool for detecting sacroiliitis. Pelvic screening studies with large FOV have lower sensitivity, and dedicated sacroiliac MRI with small FOV is superior in detecting sacroiliitis when compared to pelvic screening MRI.

Assessment of quiet T2 weighted PROPELLER sequence in pediatric abdominal imaging.

INTRODUCTION: Elevated acoustic noise during Magnetic Resonance Imaging (MRI) has been associated with patient anxiety and altered cochlear function. Acoustic Reduction Technique (ART) T2 weighted (T2w) periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) has been studied in brain MR but not abdominopelvic imaging. The purpose of our study was to evaluate the image quality and acoustic noise level of ART T2w PROPELLER sequence in comparison with the conventional T2w PROPELLER sequence in pediatric abdomino-pelvic imaging. METHODS: Eleven consecutive pediatric patients undergoing abdomino-pelvic MRI were scanned on a 3 Tesla magnet using standard and ART T2w PROPELLER sequences. After scanning completion, objective sound level measurements were performed with a sound level meter and microphone. Mann-Whitney U test was used for a non-parametric two-tailed statistical analysis of acoustics, image rating and scan time with significance level set to 0.05. Overall inter-rater agreement was calculated using Cohen's kappa coefficient. RESULTS: Eleven pediatric patients (4 females and 7 males) between 26 days and 18 years of age (mean = 10.0, SD = 5.8) were included. ART T2w produced lower levels of acoustic noise than standard technique in a comparison of mean decibel readings from eleven trials of standard and ART T2w (p value = 0.00008). Streak artifacts were rated greater in ART T2w by both raters (p-value = 0.00278 and 0.00252). There was no significant difference in bile duct blurring, respiratory ghosting, pulsation, fat suppression or hepatic parenchymal depiction. CONCLUSION: Presence of additional streaking artifacts should be considered along with the benefit of reduced acoustic noise from ART T2w.

ABVD Without Radiation for Newly Diagnosed Pediatric and Young Adult Patients With Hodgkin Lymphoma: A Single Center Retrospective Analysis of 28 Consecutive Patients.

Hodgkin lymphoma (HL) is the most common malignancy affecting adolescents and young adults. Treatment with a combination of chemotherapy and radiation results in cure rates of >90%. However, radiation therapy causes significant late effects and avoiding radiation entirely for patients who respond to chemotherapy is an accepted strategy. Since 2011, 28 consecutive patients diagnosed with classic HL have been treated with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) for 4 to 6 cycles. Patients who achieved a complete metabolic response (CMR) as assessed by [F] fluorodeoxyglucose positron emission tomography by the end of chemotherapy did not receive radiation. Among the 27 evaluable patients, 26/27 (96.2%) achieved a CMR with ABVD alone with 24/27 (88.9%) having achieved a CMR after 2 cycles. Event-free survival at 5 years is 90.5% and overall survival is 100% with a median follow-up time of 22.4 and 22.1 months, respectively. Treating pediatric and young adult HL patients with ABVD alone results in CMRs in >95% of patients. Patients who were refractory to ABVD or relapsed after treatment eventually achieved remission with a combination of standard and novel salvage therapies. This regimen demonstrates the feasibility of avoiding upfront radiation in newly diagnosed pediatric HL patients.

From Inguinal Hernias to Spermatic Cord Lipomas: Pearls, Pitfalls, and Mimics of Abdominal and Pelvic Hernias.

Abdominal and pelvic hernias may be indolent and detected incidentally, manifest acutely with pain and distress, or cause chronic discomfort. Physical examination findings are often ambiguous and insufficient for optimal triage. Therefore, accurate anatomic delineation and identification of complications are critical for effective treatment planning. Imaging, particularly computed tomography, provides a vital understanding of the hernia's location and size, involved viscera, and severity of associated complications. Reader familiarity with the imaging appearances and anatomic landmarks of hernias is important for correct diagnosis, which may impact preoperative planning and reduce morbidity. This article reviews the appearance of anatomic structures in the abdominal wall and pelvis that are important for diagnosing common and uncommon abdominal and pelvic hernias, and it highlights key imaging features that are helpful for differentiating hernias, mimics, and their complications. Online DICOM image stacks are available for this article . ©RSNA, 2017.

Intussusception: past, present and future.

Intussusception is a common etiology of acute abdominal pain in children. Over the last 70 years, there have been significant changes in how we diagnose and treat intussusception, with a more recent focus on the role of ultrasound. In this article we discuss historical and current approaches to intussusception, with an emphasis on ultrasound as a diagnostic and therapeutic modality.

Assessing 3D T2 FSE sequence for identification of the normal appendix: working toward a single-sequence MR appendicitis protocol.

PURPOSES: To assess the ability of a single isotropic 3D T2 FSE sequence to identify the normal appendix in children with potential implication as alternative second-line modality in pediatric appendicitis. MATERIALS AND METHODS: Retrospective review of MR abdomino-pelvis or pelvis in children from Oct 2014-Dec 2016 was done. Only exams with 3D T2 FSE sequence performed on a single scanner type were selected. Patients with history of post appendectomy, studies in which field of view did not include ileocecal valve, with technical and protocol errors, or with fat-saturated acquisition were excluded. All images were blindly reviewed by three radiologists. The following questions were asked: (1) Is the appendix visualized?, (2) What is the most clearly demonstrable plane?, (3) Where is the appendix located?, (4) Are there any findings indicating appendicitis? Average pairwise percentage and Fleiss Kappa were used to assess the inter-rater agreement on the visualization and location of the appendix. RESULTS: A total of 22 MRI studies were reviewed (F = 13:M = 9, Mean age = 11.45 yrs. [SD = 4.3]). Total MRI scan time was estimated at 6 mins. Readers saw appendix in 72.7-81.8%, and saw with high confidence in 12 cases (54.5%), low confidence in 4-6 case (18.2-27.3%), and did not see in 4-6 cases(18.2-27.3%). The average pairwise percentage agreement was 71.2%. Fleiss Kappa of overall rating of visualization was 0.52 (p < 0.001). Fleiss Kappa of high confidence of visualization was 0.76 (p < 0.001). Reader 1 and reader 2 saw the appendix best on the axial plane. Reader 3 saw the appendix best on the coronal plane. For location, deep pelvis was the most common identified location. The average pairwise percentage agreement was 68.2% and Fleiss Kappa was 0.76 (p < 0.001). There is no findings indicating appendicitis. CONCLUSION: A single 3D T2 FSE sequence had good ability to detect normal appendices and also allowed multiplanar reconstructions, which may use as a single-sequence protocol in cases of suspected appendicitis in children when ultrasound is inconclusive.

Pediatric renal transplant biopsy with ultrasound guidance: the 'core' essentials.

This review provides a comprehensive and practical approach to pediatric percutaneous renal transplant biopsies, highlighting techniques and strategies to optimize adequate sample yield and ensure patient safety. In children with end-stage renal disease, transplantation is the preferred choice of therapy, providing for overall lower long-term morbidity and mortality compared with dialysis. In the ongoing management of renal transplant patients, core tissue sampling via a percutaneous renal biopsy remains the gold standard when transplant dysfunction is suspected. Indications for renal transplant biopsy and techniques/tools for adequate sample yield are discussed. Strategies for common challenges such as poor visualization and renal transplant mobility are addressed. We discuss the clinical signs, techniques and imaging findings for common complications including hematomas, arteriovenous fistulas and pseudoaneurysms. Although the percutaneous renal transplant biopsy procedure is generally safe with rare complications, care must be taken to ensure major complications are promptly recognized and treated. Adequate tissue samples obtained via renal biopsy are imperative to promptly identify transplant rejection to provide valuable information for patient diagnosis, treatment and outcomes. Radiologist and nephrologist attention to proper ultrasound techniques and optimal biopsy tools are critical to ensure tissue adequacy and minimize complications.

Incidental Findings on Pediatric Abdominal Magnetic Resonance Angiography.

RATIONALE AND OBJECTIVES: Abdominal magnetic resonance angiography (MRA) has gained favor in pediatric patients owing to its lack of ionizing radiation and noninvasive nature. Reports exist regarding incidental findings on body MRA in adult patients. However, the incidental findings in pediatric abdominal MRA have not been previously reported. Our study aims to determine the frequencies, characteristics, and categories of incidental findings in pediatric patients undergoing abdominal MRA. MATERIALS AND METHODS: Retrospective study was performed in 78 consecutive contrast-enhanced abdominal MRA of patients between ages 0 and 20 years over a 7-year time period. The presence of incidental vascular and extravascular findings was noted. Reports were categorized in consensus by two radiologists as no incidental finding (group A), normal or normal variants or nonsignificant incidental common findings (group B), or abnormal incidental findings (group C). Group C was reviewed to determine whether additional management was performed. RESULTS: A total of 40 boys and 38 girls (51%:49%) were reported, with a mean age of 12.3 years (standard deviation ±5.6 years, range 7 days to 20 years). Three most common indications for MRA were renal artery stenosis (24.4%), vasculitis (21.8%), and suspected intra-abdominal venous thrombosis (14.1%). We identified a total of 92 incidental findings in 50 of 78 patients; 60 findings in 29 patients in group B, and 32 findings in 21 patients in group C. Atelectasis at the lung bases was the most common incidental finding in group B (14 of 78 patients). The most common findings in group C were ascites, scoliosis, and splenomegaly. There were three abnormal incidental findings that led to causative workup and/or further management (moderate ascites, pericardial and pleural effusion, and venous malformation). The remaining cases with abnormal findings received treatment of their primary conditions only. CONCLUSIONS: Pediatric abdominal MRA revealed a large number of incidental findings. The large majority were findings without clinical significance. Basal lung atelectasis was the most common overall incidental and nonsignificant finding, whereas ascites was the most common abnormal incidental finding. Although not all abnormal incidental findings affected management, appropriate identification and communication of relevant findings would improve patient care.