EUS-guided hepaticogastrostomy versus percutaneous transhepatic biliary drainage after failed ERCP: A propensity score-matched analysis.

Background and study aims Percutaneous transhepatic biliary drainage (PTBD) is the traditional second-line option after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP). Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a viable alternative to PTBD. Our study aimed to compare outcomes of EUS-HG and PTBD for benign and malignant biliary diseases following failed ERCP. Patients and methods This single-center study retrospectively analyzed patients undergoing EUS-HG and PTBD for benign and malignant biliary disorders. A propensity score-matched analysis was performed using age, sex, and Charlson Comorbidity Index. The primary outcome was clinical success, which we defined as a decrease in total bilirubin by ≥ 50% at 2 weeks for malignant disease and resolution of the biliary disorder for benign disease. Results In total, 41 patients underwent EUS-HG and 138 patients underwent PTBD. After propensity score matching in a 1:2 ratio, 32 EUS-HG patients were matched with 64 PTBD. Technical success was achieved in 29 of 32 (91%) for EUS-HG and 63 of 64 (98%) for PTBD ( P =0.11). Clinical success was 100% for EUS-HG and 75% for PTBD ( P =0.0021). EUS-HG was associated with a lower adverse event rate (EUS-HG 13% vs. PTBD 58%, P <0.0001), shorter procedure duration (median 60 vs. 115 minutes, P <0.0001), shorter post-procedure length of stay (median 2 vs. 4 days, P <0.0001), and fewer reinterventions (median 1 vs. 3, P <0.0001). Conclusions Our results suggest that EUS-HG is superior to PTBD in the treatment of benign and malignant biliary disorders after failed ERCP.

A rare radiological presentation of pulmonary metastases from malignant melanoma.

Malignant melanoma is a highly aggressive cancer with metastatic potential to various locations such as the lymph nodes, lungs, liver, brain, and bone. After the lymph nodes, the lungs are the most common site of malignant melanoma metastases. Pulmonary metastases from malignant melanoma commonly presents as solitary or multiple solid nodules, sub-solid nodules or miliary opacities on CT chest. We present a case of pulmonary metastases from malignant melanoma in a 74-year-old man which presented unusually on CT chest as a combination of patterns like "crazy paving," upper lobe predominance with subpleural sparing, and centrilobular micronodules. Video-assisted thoracoscopic surgery, wedge resection and tissue analysis were performed, which confirmed the diagnosis of malignant melanoma metastases, and the patient further underwent PET-CT for staging and surveillance. Patients with pulmonary metastases from malignant melanoma can have atypical imaging findings, therefore radiologists should be aware of these unconventional presentations to avoid any misdiagnoses.

Translating radiology reports into plain language using ChatGPT and GPT-4 with prompt learning: results, limitations, and potential.

The large language model called ChatGPT has drawn extensively attention because of its human-like expression and reasoning abilities. In this study, we investigate the feasibility of using ChatGPT in experiments on translating radiology reports into plain language for patients and healthcare providers so that they are educated for improved healthcare. Radiology reports from 62 low-dose chest computed tomography lung cancer screening scans and 76 brain magnetic resonance imaging metastases screening scans were collected in the first half of February for this study. According to the evaluation by radiologists, ChatGPT can successfully translate radiology reports into plain language with an average score of 4.27 in the five-point system with 0.08 places of information missing and 0.07 places of misinformation. In terms of the suggestions provided by ChatGPT, they are generally relevant such as keeping following-up with doctors and closely monitoring any symptoms, and for about 37% of 138 cases in total ChatGPT offers specific suggestions based on findings in the report. ChatGPT also presents some randomness in its responses with occasionally over-simplified or neglected information, which can be mitigated using a more detailed prompt. Furthermore, ChatGPT results are compared with a newly released large model GPT-4, showing that GPT-4 can significantly improve the quality of translated reports. Our results show that it is feasible to utilize large language models in clinical education, and further efforts are needed to address limitations and maximize their potential.

A Novel Workflow to Create a Checkpoint Inhibitor Pneumonitis Patient Registry.

Background Despite being a groundbreaking cancer therapy, immune checkpoint inhibitors (ICI) can lead to potentially life-threatening toxicity with checkpoint inhibitor pneumonitis (CIP). While treatable, it is easy for clinicians to miss the symptoms of CIP, which can lead to a delay in diagnosis and worsening respiratory function. There is no consensus approach to systematically identifying patients at risk of developing CIP. Thus, we sought to create a workflow that could inform patient selection for ICI therapy based on previously reported risk factors for CIP development. Materials and methods We retrospectively identified 250 patients with lung cancer treated with at least one dose of an ICI over 20 months. Data were collected on comorbidities, cancer type and stage, performance status, ICI cycles, biomarkers, prior curative treatment, diagnostic evaluation, antibiotics, steroids, progression, and survival. A single-blinded radiologist characterized radiographic patterns of suspected CIP cases. Results Among 97 patients who received steroids while admitted to the hospital, 12 (6%) had at least one sign or symptom suggestive of CIP. Chronic obstructive pulmonary disease and non-small cell lung cancer subtypes correlated with suspicion of having CIP. CIP was confirmed in five patients (42%) and ruled out (mimics) in seven (58%). Median times until symptoms were 17 months and one month for confirmed and mimic cases, respectively. The median time to confirm or exclude CIP was 5 ± 4 days. Most suspected cases underwent thoracic imaging, blood cultures, and empiric antibiotics. Radiographic patterns in suspected cases included ground glass opacities, organizing pneumonia, acute interstitial pneumonia/acute respiratory distress syndrome, bronchiolitis, radiation recall pneumonitis, hypersensitivity pneumonitis, and post-radiation fibrotic changes. Conclusions CIP mimics are common in clinical practice; therefore, it is reasonable to empirically treat suspected cases with shorter courses of steroids until diagnostic clarity is achieved. This proof-of-concept study demonstrates that this novel workflow can identify the true incidence of CIP, inform treatment decisions, and lead to the development of implementation studies to improve patient care directly.

Bridging the Communication Gaps: A Prospective Single-Arm Pilot Study Testing the Feasibility of Interdisciplinary Radiotherapy Planning in Locally Advanced Lung Cancer.

RATIONALE AND OBJECTIVES: The treatment of locally advanced lung cancer (LALC) with radiotherapy (RT) can be challenging. Multidisciplinary collaboration between radiologists and radiation oncologists (ROs) may optimize RT planning, reduce uncertainty in follow-up imaging interpretation, and improve outcomes. MATERIALS AND METHODS: In this prospective clinical treatment trial (clinicaltrials.gov NCT04844736), 37 patients receiving definitive RT for LALC, six attending ROs, and three thoracic radiologists were consented and enrolled across four treatment centers. Prior to RT plan finalization, representative computed tomography (CT) slices with overlaid outlines of preliminary irradiation targets were shared with the team of radiologists. The primary endpoint was to assess feasibility of receiving feedback no later than 4 business days of RT simulation on at least 50% of plans. RESULTS: Thirty-seven patients with lung cancer were enrolled, and 35 of 37 RT plans were reviewed. Of the 35 patients reviewed, mean age was 69 years. For 27 of 37 plans (73%), feedback was received within 4 or fewer days (interquartile range 3-4 days). Thirteen of 35 cases (37%) received feedback that the delineated target potentially did not include all sites suspicious for tumor involvement. In total, changes to the RT plan were recommended for over- or undercoverage in 16 of 35 cases (46%) and implemented in all cases. Radiology review resulted in no treatment delays and substantial changes to irradiated volumes: gross tumor volume, -1.9 to +96.1%; planning target volume, -37.5 to +116.5%. CONCLUSION: Interdisciplinary collaborative RT planning using a simplified workflow was feasible, produced no treatment delays, and prompted substantial changes in RT targets.

Evaluation of epiphora by topical contrast-enhanced CT and MR dacryocystography: which one to choose?

BACKGROUND: Our study aims to compare non-invasive imaging such as topical computed tomography dacryocystography (CTD) and topical magnetic resonance dacryocystography (MRD) in patients with epiphora. PURPOSE: To evaluate the practicability of topical contrast media during helical CTD and topical saline during MRD to reveal obstruction in the nasolacrimal drainage system (NLDS). MATERIAL AND METHODS: Twenty participants with nasolacrimal duct obstruction were observed for two years. Ten participants underwent CTD and the other 10 participants underwent MRD. Images were analyzed by two radiologists. Participants were also asked about the level of discomfort of the contrast material versus the saline solution. RESULTS: The NLDS was seen on both CTD and MRD. Very good agreement between the two observers (κ value > 0.81) was seen according to the κ statistics. CTD multiplanar and 3D images allowed for precise diagnosis of the point of obstruction whereas, the MRD did not require any contrast material and showed the point of obstruction. Saline was more comfortable for the patients than topical contrast (P < 0.05). CONCLUSION: Topical CTD and MRD are non-invasive techniques that can visualize the degree and level of obstruction in the NLDS than conventional invasive cannulation dacryocystography. CTD is useful in visualizing the point of obstruction and smaller drainage structures. However, it is a source of ionizing radiation to the lens. The benefit of MRD is that it requires no contrast or radiation; however, it is poor in depicting the bone anatomy and smaller drainage structures. Finally, saline was better tolerated by patients than topical contrast.

The Mediastinal Visceral Space: The Central Pathway for the Spread of Mediastinal Disease.

The connective tissue of the mediastinal visceral space extends from the neck through the chest and into the abdomen. This connective tissue encases the esophagus and tracheobronchial tree and is bounded by the perivisceral fascia. The continuous longitudinal and axial interconnection of the mediastinal visceral space accounts for commonly observed bidirectional pathways of disease through the chest. Disease patterns that seem counterintuitive when viewed through the lens of gross anatomy are more understandable in view of this knowledge. This article illustrates case examples of the spread of gas, fluid, fat and soft tissue mass through the mediastinal visceral space.

Early-stage COVID-19 pandemic observations on pulmonary embolism using nationwide multi-institutional data harvesting.

We introduce a multi-institutional data harvesting (MIDH) method for longitudinal observation of medical imaging utilization and reporting. By tracking both large-scale utilization and clinical imaging results data, the MIDH approach is targeted at measuring surrogates for important disease-related observational quantities over time. To quantitatively investigate its clinical applicability, we performed a retrospective multi-institutional study encompassing 13 healthcare systems throughout the United States before and after the 2020 COVID-19 pandemic. Using repurposed software infrastructure of a commercial AI-based image analysis service, we harvested data on medical imaging service requests and radiology reports for 40,037 computed tomography pulmonary angiograms (CTPA) to evaluate for pulmonary embolism (PE). Specifically, we compared two 70-day observational periods, namely (i) a pre-pandemic control period from 11/25/2019 through 2/2/2020, and (ii) a period during the early COVID-19 pandemic from 3/8/2020 through 5/16/2020. Natural language processing (NLP) on final radiology reports served as the ground truth for identifying positive PE cases, where we found an NLP accuracy of 98% for classifying radiology reports as positive or negative for PE based on a manual review of 2,400 radiology reports. Fewer CTPA exams were performed during the early COVID-19 pandemic than during the pre-pandemic period (9806 vs. 12,106). However, the PE positivity rate was significantly higher (11.6 vs. 9.9%, p < 10-4) with an excess of 92 PE cases during the early COVID-19 outbreak, i.e., ~1.3 daily PE cases more than statistically expected. Our results suggest that MIDH can contribute value as an exploratory tool, aiming at a better understanding of pandemic-related effects on healthcare.

Bronchobiliary fistula: a rare postoperative complication of spilled gallstones from laparoscopic cholecystectomy.

Bronchobiliary fistula (BBF) is defined as the abnormal connection between the biliary system and the bronchial tree, which presents clinically as an irritant cough with bilioptysis. Many conditions can lead to its development. We present a case of an acquired BBF in a 61-year-old man with a significant history of spilled gallstones from a prior laparoscopic cholecystectomy and subsequent presentation of intermittent right upper quadrant pain and recurrent pneumonia. Imaging studies revealed a liver and subdiaphragmatic abscess with right middle lobe pneumonia and a BBF traversing the right hemidiaphragm. The patient was surgically managed by takedown of fistula with drainage of the abscess and removal of spilled gallstone, followed by a resection of the right middle lobe. While previous studies indicate spilled gallstones are benign, this case demonstrates its potential for serious complications. Therefore, early diagnosis and proper management is essential as BBF has a high morbidity and mortality rate.

Rapid Development of Clinically Symptomatic Radiation Recall Pneumonitis Immediately Following COVID-19 Vaccination.

In this report, we present the case of a 66-year-old man who received local consolidation radiotherapy to the right lung and mediastinum for oligometastatic non-small cell lung cancer (NSCLC) following partial response to upfront chemoimmunotherapy. He continued with maintenance immunotherapy and was asymptomatic for eight months after completing radiation therapy. He then developed symptoms consistent with pneumonitis within three to five days of his first administration of the coronavirus disease 2019 (COVID-19) vaccine injection. He reported that these symptoms significantly intensified within three to five days of receiving his second dose of the vaccine. The clinical time frame and radiographic evidence raised suspicion for radiation recall pneumonitis (RRP). Patients undergoing maintenance immunotherapy after prior irradiation may be at increased risk of this phenomenon that may be triggered by the administration of the COVID-19 vaccine.

MRI of common penile pathologies and penile prostheses.

MRI can delineate finer details of penile anatomy and pathology due to inherent higher soft-tissue contrast and spatial resolution. It can characterize inflammation and identify abscesses, localize penile fractures, guide surgical planning in penile fibrosis and Peyronie's disease, and depict components of the penile prosthesis and its complications. MRI is a great investigative tool for penile neoplasms, including locally infiltrative neoplasms where clinical examination is limited, and local staging is crucial for surgical planning.

Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving Approach.

Certain inflammatory pancreatic abnormalities may mimic pancreatic ductal adenocarcinoma at imaging, which precludes accurate preoperative diagnosis and may lead to unnecessary surgery. Inflammatory conditions that may appear masslike include mass-forming chronic pancreatitis, focal autoimmune pancreatitis, and paraduodenal pancreatitis or "groove pancreatitis." In addition, obstructive chronic pancreatitis can mimic an obstructing ampullary mass or main duct intraductal papillary mucinous neoplasm. Secondary imaging features such as the duct-penetrating sign, biliary or main pancreatic duct skip strictures, a capsulelike rim, the pancreatic duct-to-parenchyma ratio, displaced calcifications in patients with chronic calcific pancreatitis, the "double duct" sign, and vessel encasement or displacement can help to suggest the possibility of an inflammatory mass or a neoplastic process. An awareness of the secondary signs that favor a diagnosis of malignant or inflammatory lesions in the pancreas can help the radiologist to perform the differential diagnosis and determine the degree of suspicion for malignancy. Repeat biopsy or surgical resection may be necessary to achieve an accurate diagnosis and prevent unnecessary surgery for inflammatory conditions. Online supplemental material and DICOM image stacks are available for this article. ©RSNA, 2019.

Hepatic complications of oral contraceptive pills and estrogen on MRI: Controversies and update - Adenoma and beyond.

Hepatic complications of oral contraceptive pills and exogenous estrogens include intrahepatic canalicular cholestasis, neoplasm formation and vascular pathologies. While it remains controversial as to whether estrogen plays a role in focal nodular hyperplasia, hemangioma or hamartoma, exposure to oral contraceptive pills and estrogen has a strong association with hepatic adenomas. Four different subgroups of adenomas have been described: Inflammatory, HNF-1α-mutated, ß-catenin-mutated and unclassified. Vascular complications may include Budd-Chiari syndrome, vascular thrombosis, dilated sinusoids and peliosis.

Utility of Magnetic Resonance Imaging Brain Epilepsy Protocol in New-Onset Seizures: How is it Different in Developing Countries?

INTRODUCTION: Magnetic resonance imaging (MRI) is the current imaging tool of choice in the investigation of patients with seizures. The advent of high-resolution MRI with a dedicated seizure protocol has significantly increased the chances of identifying a cause, resulting in a positive clinical impact on the management of these patients. AIMS: The aims of this study were to evaluate the diagnostic efficacy of standard MRI, identify whether there is an increase in the diagnostic yield with the addition of dedicated seizure protocol, and compare the diagnostic yields of MRI and electroencephalogram (EEG) individually and in combination. SUBJECTS AND METHODS: This is a prospective study of 129 consecutive patients who presented with new-onset seizures over an 18-month period. The MRI scans performed on 1.5T were reviewed for their diagnostic yield and their association with abnormal electrical activity on EEG. Chi-square test of significance (P < 0.05) was used to test for the difference in proportion. The correlation between MRI brain and EEG was studied using McNemer test. RESULTS: MRI detected potentially epileptogenic lesions in 59 patients (47%). The frequency of epileptogenic lesions was highest in patients who had focal-onset seizures (81%). The most common lesion type was infection and inflammation (28%), with neurocysticercosis being the most common, followed by mesial temporal sclerosis, ischemia, and tumor. About 37% of epileptogenic lesions were missed by standard protocol, which were detected on a dedicated seizure protocol MRI. The diagnostic yield of EEG was 31%. Abnormal MRI and EEG were concordant in 18% of patients, with EEG being normal in 37% of patients with epileptogenic lesions. CONCLUSIONS: MRI detects epileptogenic lesions in almost one half who presented with new-onset seizures and of these, more than third of them were detected using a "dedicated seizure protocol." While almost 50% with seizures will have a cause identified on MRI, the sensitivity can be substantially improved by utilizing a dedicated seizure protocol.