Differences between genders in colorectal morphology on CT colonography using a quantitative approach: a pilot study.

PURPOSE: To explore quantitative differences between genders in morphologic colonic metrics and determine metric reproducibility. METHODS: Quantitative colonic metrics from 20 male and 20 female CTC datasets were evaluated twice by two readers; all exams were performed after incomplete optical colonoscopy. Intra-/inter-reader reliability was measured with intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC). RESULTS: Women had overall decreased colonic volume, increased tortuosity and compactness and lower sigmoid apex height on CTC compared to men (p<0.0001,all). Quantitative measurements in colonic metrics were highly reproducible (ICC=0.9989 and 0.9970; CCC=0.9945). CONCLUSION: Quantitative morphologic differences between genders can be reproducibility measured.

Detailed quantitative assessment of colonic morphology at CT colonography using novel software: a feasibility and reproducibility study.

The aim of this study was to evaluate feasibility and reproducibility of quantitative assessment of colonic morphology on CT colonography (CTC). CTC datasets from 60 patients with optimal colonic distension were assessed using prototype software. Metrics potentially associated with poor endoscopic performance were calculated for the total colon and each segment including: length, volume, tortuosity (number of high curvature points <90°), and compactness (volume of box containing centerline divided by centerline length). Sigmoid apex height relative to the lumbosacral junction was also measured. Datasets were quantified twice each, and intra-reader reliability was evaluated using concordance correlation coefficient and Bland-Altman plot. Complete quantitative datasets including the five proposed metrics were generated from 58 of 60 (97 %) CTC examinations. The sigmoid and transverse segments were the longest (55.9 and 51.4 cm), had the largest volumes (0.410 and 0.609 L), and were the most tortuous (3.39 and 2.75 high curvature points) and least compact (3347 and 3595 mm2), noting high inter-patient variability for all metrics. Mean height of the sigmoid apex was 6.7 cm, also with high inter-patient variability (SD 6.8 cm). Intra-reader reliability was high for total and segmental lengths and sigmoid apex height (CCC = 0.9991) with excellent repeatability coefficient (CR = 3.0-3.3). There was low percent variance of metrics dependent upon length (median 5 %). Detailed automated quantitative assessment of colonic morphology on routine CTC datasets is feasible and reproducible, requiring minimal reader interaction.

Impact of hysterectomy on three-dimensional rectosigmoid morphology and endoscopy performance: a pilot study.

OBJECTIVES: Assess differences in three-dimensional colonic metrics on CTC in women with or without hysterectomy following incomplete endoscopy to determine if there is a correlation between colonic morphology and incomplete colonoscopy after hysterectomy. METHODS: Quantitative rectosigmoid metrics were derived from CTC datasets of 37 women with hysterectomy and 36 women without hysterectomy who underwent CTC for incomplete endoscopy. Evaluated metrics included colonic length, volume, tortuosity, and compactness and sigmoid apex height relative to the lumbosacral junction. Differences were measured using the Student's t test, and intra-reader reliability was assessed using ICC. The relative risk of incomplete rectosigmoid visualization was determined by reviewing the endoscopy reports. RESULTS: Women with hysterectomy had a lower sigmoid apex height (p = 0.002), as well as increased tortuosity (p = 0.012) and compactness (p = 0.001) and decreased length (p = 0.026) and volume (p = 0.016) of the rectosigmoid. Intra-reader reliability was high for centerline length (ICC = 0.9940) and sigmoid apex height (ICC = 0.9851). The relative risk of incomplete visualization of the rectosigmoid on endoscopy in women with hysterectomy was 2.068 (p = 0.043) compared to women without hysterectomy. CONCLUSION: Our pilot data show reproducible quantitative differences in three-dimensional metrics of the rectosigmoid in women with or without hysterectomy who underwent CTC for incomplete endoscopy and increased relative risk of incomplete endoscopic visualization of the rectosigmoid after hysterectomy. Our findings suggest that women with hysterectomy may benefit from CTC rather than endoscopy as the initial diagnostic test for evaluating the colon.

US-guided Biopsy of Neck Lesions: The Head and Neck Neuroradiologist's Perspective.

Ultrasonographically (US) guided percutaneous biopsy of a neck lesion is a cost-effective, safe, and diagnostically effective procedure without radiation exposure. The benefit of real-time visualization of the needle location allows for instantaneous maneuvering of the needle trajectory for safe and accurate tissue sampling with short procedural time. Effective US-guided biopsy requires technical experience, strong clinical acumen, and skillful biopsy technique. A neuroradiologist's knowledge of head and neck anatomy and pathology allows correlation with cross-sectional imaging and enhances the understanding of US imaging evaluation. Familiarity with a spectrum of neck surgeries and reconstructions and expertise in imaging evaluation of the treated neck are invaluable in accurate identification of the target for biopsy in patients with treatment-related altered anatomy using US guidance. After thyroid nodules, the common adult neck masses are lymphadenopathy, head and neck cancer, salivary neoplasms, nerve sheath tumors, and inflammatory and infectious pseudomasses. Diagnostic expertise in the imaging characteristics of these individual pathologic conditions and their differential diagnoses also play an important role in choosing the biopsy technique and in procuring an adequate sample for diagnosis, including material for ancillary laboratory testing. Using an anatomic zone approach, this article illustrates the practical considerations in patient selection, the methodical analysis of preprocedure cross-sectional imaging and its correlation with real-time US evaluation, general principles for optimizing US instrumentation, and biopsy technique. In skillful hands, the versatility and portability of US make it the valuable modality for histologic sampling of superficial head and neck lesions. Online supplemental material is available for this article.

The accuracy of mobile teleradiology in the evaluation of chest X-rays.

We assessed the diagnostic accuracy of digital photographs of plain film chest X-rays (CXRs) obtained using a mobile phone. The study was a randomized, non-inferiority trial, in which physical plain film CXRs viewed on a light box were compared with digital photographs of plain film CXRs. CXRs were selected from a database of radiology studies to show common pathologies found in Botswana associated with pneumonia, lung carcinoma, tuberculosis, pneumothorax and interstitial disease, as well as normal findings. The pre-selected diagnoses were subsequently verified by a second radiologist. Seven radiologists were randomized to review 75 plain film CXRs on light boxes before viewing 75 digital photographs, or vice versa. Their responses were considered correct if they matched the pre-defined diagnosis. For both modalities, the correct diagnosis was provided in 79% of cases; for plain film CXRs, the correct diagnosis was provided in 82% of cases and for digital photographs the correct diagnosis was provided in 76% of cases. The difference in diagnostic accuracy was -5.7% (95% CI: -10.8% to -0.5%), which confirmed non-inferiority (P<0.001) for the primary outcome of diagnostic accuracy. A subgroup analysis demonstrated non-inferiority for lung carcinoma and pneumonia images, although non-inferiority was not achieved for pneumothorax, tuberculosis, interstitial disease or normal images. The study demonstrates that digital photographs of CXRs obtained via a mobile phone equipped with a digital camera are non-inferior to plain film CXRs.

CT colonography: effect of computer-aided detection of colonic polyps as a second and concurrent reader for general radiologists with moderate experience in CT colonography.

OBJECTIVES: To assess the effectiveness of computer-aided detection (CAD) as a second reader or concurrent reader in helping radiologists who are moderately experienced in computed tomographic colonography (CTC) to detect colorectal polyps. METHODS: Seventy CTC datasets (34 patients: 66 polyps ≥6 mm; 36 patients: no abnormalities) were retrospectively reviewed by seven radiologists with moderate CTC experience. After primary unassisted evaluation, a CAD second read and, after a time interval of ≥4 weeks, a CAD concurrent read were performed. Areas under the receiver operating characteristic (ROC) curve (AUC), along with per-segment, per-polyp and per-patient sensitivities, and also reading times, were calculated for each reader with and without CAD. RESULTS: Of seven readers, 86% and 71% achieved a higher accuracy (segment-level AUC) when using CAD as second and concurrent reader respectively. Average segment-level AUCs with second and concurrent CAD (0.853 and 0.864) were significantly greater (p < 0.0001) than average AUC in the unaided evaluation (0.781). Per-segment, per-polyp, and per-patient sensitivities for polyps ≥6 mm were significantly higher in both CAD reading paradigms compared with unaided evaluation. Second-read CAD reduced readers' average segment and patient specificity by 0.007 and 0.036 (p = 0.005 and 0.011), respectively. CONCLUSIONS: CAD significantly improves the sensitivities of radiologists moderately experienced in CTC for polyp detection, both as second reader and concurrent reader. KEY POINTS: • CAD helps radiologists with moderate CTC experience to detect polyps ≥6 mm. • Second and concurrent read CAD increase the radiologist's sensitivity for detecting polyps ≥6 mm. • Second read CAD slightly decreases specificity compared with an unassisted read. • Concurrent read CAD is significantly more time-efficient than second read CAD.

Bevacizumab-induced perforation of the gastrointestinal tract: clinical and radiographic findings in 11 patients.

AIM: To present the gastrointestinal (GI) complications associated with bevacizumab therapy and their findings on abdominal imaging studies. METHODS: A computerized search identified 11 patients with GI complications of bevacizumab therapy on abdominal CT (n = 11) and fluoroscopic GI contrast studies (n = 4) who met our study criteria (including five patients with ovarian cancer, five with colon cancer, and one with cervical cancer). The medical records and imaging studies were reviewed to determine the clinical and radiographic findings in these patients. RESULTS: All 11 patients had findings of GI perforation on CT, or CT and GI contrast studies. CT revealed a localized extraluminal collection containing gas, fluid, and/or contrast material in eight patients (73%) with focal perforation, and free abdominal air and fluid in three (27%) with free perforation The imaging studies also revealed seven fistulas, including two colovaginal, one rectovaginal, one enterocutaneous, one colocutaneous, one gastrocolic, and one colorectal fistula. Eight (73%) of the 11 patients died within 1 year of the development of GI perforation, and the perforation was felt to be the cause of death in four patients (36%). CONCLUSION: Abdominal CT and fluoroscopic GI contrast studies are useful imaging tests for the diagnosis of potentially life-threatening GI perforation as a complication of bevacizumab therapy. When GI perforation is detected on abdominal imaging studies, treatment with bevacizumab should immediately be discontinued.

Comparison of small bowel follow through and abdominal CT for detecting recurrent Crohn's disease in neoterminal ileum.

PURPOSE: To assess the findings of recurrent Crohn's disease in the neoterminal ileum on small bowel follow through (SBFT) and computed tomography (CT) as well as the overall diagnostic performance of these imaging tests. METHODS: Our radiology database yielded 52 patients with an ileocolic anastomosis for Crohn's disease who underwent SBFT and CT. The images were reviewed to determine the sensitivity, specificity, PPV, and NPV for individual findings of recurrent Crohn's disease in the neoterminal ileum. The overall sensitivity, specificity, PPV, and NPV of these tests for recurrent Crohn's disease were determined by comparing imaging reports to endoscopic and surgical findings in 45 patients (87%) and clinical response to treatment in seven (13%). RESULTS: SBFT had a sensitivity of 90%, specificity of 85%, PPV of 95%, and NPV of 73% for detecting recurrent Crohn's disease, and CT had a sensitivity of 77%, specificity of 69%, PPV of 88%, and NPV of 50%. These tests combined had a sensitivity of 95%, specificity of 69%, PPV of 90%, and NPV of 82%. The most common findings were luminal narrowing, thickened folds, and ulcers (especially aphthoid lesions) on SBFT and bowel wall thickening on CT. CT also revealed extraenteric collections not visualized on SBFT in three patients (8%). CONCLUSIONS: Our experience suggests that SBFT is more sensitive and specific than CT for detecting recurrent Crohn's disease in the neoterminal ileum, mainly because of the ability of barium studies to depict aphthoid lesions not visualized on CT. Conversely, CT is better for detecting extraenteric findings such as abscesses. When combined, these tests have a higher sensitivity for detecting recurrent Crohn's disease than either test alone.

Imaging of the female pelvis through the life cycle.

The appearance of the normal reproductive tract on radiologic images changes dramatically over the female patient's life span, reflecting the influence of hormones on these organs. In female children and adolescents, the appearance of the reproductive tract reflects the stage of sexual maturation. In women of reproductive age, physiologic changes such as those occurring in the corpus luteum are routinely imaged and must be distinguished from pathologic conditions. In the postmenopausal years, as reproductive hormone levels diminish, the endometrium and ovaries undergo progressive involution. Imaging findings that might be considered physiologic in younger women may represent pathologic or even neoplastic changes in postmenopausal women. Although postpartum imaging is typically performed in symptomatic patients, including those with greater than expected vaginal bleeding, suspected obstetric trauma, thromboembolic disease, or infectious complications, clinicians who interpret these radiologic results should be familiar with expected findings in asymptomatic patients after childbirth. Familiarity with the spectrum of ultrasonographic, computed tomographic, and magnetic resonance imaging appearances of the normal female reproductive tract from birth through the postmenopausal years will ultimately help clinicians avoid misinterpreting these normal physiologic changes as pathologic conditions.

saline-infused sonohysterography: tips for achieving greater success.

Saline-infused sonohysterography (SIS) may help improve visualization of the endometrium and endometrial cavity and assess tubal patency. Although most SIS procedures are straightforward, a variety of pitfalls may lead to an unsuccessful procedure or incomplete evaluation. SIS should be scheduled between days 4 and 10 of the patient's menstrual cycle, when the endometrium is at its thinnest, and physiologic changes during the secretory phase are not present. Performing preprocedure imaging serves many purposes, such as depicting hydrosalpinx, causes of uterine and adnexal tenderness, and pelvic inflammatory disease, as well as assessing the size and position of the uterus and the orientation of the cervix. It is important not to presume that fibroids are the cause of bleeding when the endometrium is obscured at preprocedure imaging. Obstacles to a successful procedure include issues related to patient anxiety and discomfort, which may be prevented or minimized at almost every step of the procedure. Inability to obtain access to the cervix is the most common cause of unsuccessful SIS; proper patient positioning in a semi-upright lithotomy position is important. Injection of air during any US-guided procedure may lead to shadowing that obscures the region of interest. Adequate distention of the endometrial cavity is crucial for successful SIS, and optimal positioning of the distended balloon may improve the degree of distention. However, poor distention may be indicative of an underlying pathologic condition. Knowledge of these pitfalls and the strategies to overcome them may prevent premature or unnecessary termination of an otherwise successful study.

ACR appropriateness criteria© ovarian cancer screening.

The majority of women with ovarian cancer have advanced stage disease at the time of diagnosis and a poor 5 year survival rate. Hence, screening has been investigated in the hopes of improving survival by diagnosing ovarian cancer at an earlier stage. Most screening methods thus far have included ultrasound and/or serum tumor markers. However, low prevalence of the disease, high false positive rate of current screening methods, and the probable rapid growth of most ovarian carcinomas from no defined precursor lesion, all contribute to difficulty in screening for ovarian cancer. While screening may be able to detect ovarian cancer at an earlier stage, adequate data is presently lacking on whether screening improves survival. The results of ongoing large clinical trials will be available in a few years and should provide critical information regarding the usefulness of screening. Pending results of those large clinical trials, screening is not currently recommended for women at average risk for ovarian cancer. Screening is most likely to be performed in women with an increased familial risk of ovarian cancer, but patients should be aware that even with this risk factor, there is currently insufficient evidence to know if screening is effective. New screening methods, including new or multiple serum markers and proteomics, are also being investigated.

Spectrum of imaging findings on MRI and CT after uterine artery embolization.

Uterine artery embolization (UAE) is an effective treatment for symptomatic uterine fibroids. Magnetic resonance (MR) imaging is typically employed to evaluate the uterus following UAE for fibroid infarction, size, location change, persistent enhancement, changes in adenomyosis, and uterine necrosis. Variable pattern of calcification on computed tomography (CT) can differentiate embolic particles and fibroid involution. CT following UAE may be requested because of acute pelvic pain or chest discomfort or pyrexia and/or for complications that may require treatment in acute phase. Visualization of gas in uterus and uterine vessels following UAE is an expected finding that should not be misinterpreted as a sign of infection. The MRI and CT appearances vary depending upon the time interval after UAE and success of the procedure. Radiologists should be familiar with the range of post-UAE appearances on MRI and CT to better aid clinicians in correct diagnosis and treatment. The main purpose of this pictorial review is to identify the spectrum of findings on MRI and CT performed after UAE, to illustrate UAE-associated common and uncommon MRI and CT appearances and discuss post-UAE complications that require urgent medical or surgical intervention.

Adenomyosis: sonohysterography with MRI correlation.

OBJECTIVE: The purpose of this study was to describe the sonohysterographic features of adenomyosis with MRI correlation. CONCLUSION: In this study, when the sonohysterographic findings suggested adenomyosis, MRI findings confirmed the diagnosis in 96% of cases. Myometrial cracks are, to our knowledge, a previously undescribed sonohysterographic sign of adenomyosis.

ACR Appropriateness Criteria on acute pelvic pain in the reproductive age group.

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation.

Submucosal fibroids becoming endocavitary following uterine artery embolization: risk assessment by MRI.

OBJECTIVE: The purpose of our study was to assess the relationship between the endometrium and submucosal fibroids before and after uterine artery embolization (UAE). MATERIALS AND METHODS: Contrast-enhanced pelvic 1.5-T MRI was performed in 49 women before and after UAE over a 2-year period. Dominant (largest diameter) fibroids in intramural, submucosal, subserosal, pedunculated subserosal, and endocavitary locations were assessed on pre- (baseline) and postembolization MRI. Size, locations of dominant fibroids relative to endometrium and serosa before and after embolization were compared. The ratio between the largest endometrial interface and the maximum dimension of the dominant submucosal fibroid (interface-dimension ratio) was determined on baseline MRI. The infarction rate for dominant fibroids was estimated after UAE. RESULTS: One hundred forty dominant fibroids were identified on baseline MRI. Forty-nine (35%) were intramural, 39 (28%) were submucosal, 34 (24%) were subserosal, eight (6%) were pedunculated subserosal, and 10 (6%) were endocavitary in location on preembolization MRI. After UAE, of 39 dominant submucosal fibroids, 13 (33%) became endocavitary: complete (n = 4), partial (n = 9) on the basis of European Society of Gynaecological Endoscopy (ESGE) classification. The preembolization mean interface-dimension ratio and mean diameters for dominant fibroids that became endocavitary were significantly greater than for those that did not become endocavitary after embolization (0.65 vs 0.32, p < 0.005; 8 vs 5.4 cm, p < 0.05, respectively). All dominant submucosal fibroids showed 100% infarction after UAE. CONCLUSION: Submucosal fibroids with an interface-dimension ratio of greater than 0.55 are more likely to migrate into the endometrial cavity after UAE. The majority of these are expelled spontaneously without significant symptoms. Rarely, submucosal fibroids greater than 6 cm in size that become endocavitary may cause postprocedural complications requiring further intervention and medical treatment.

CT colonography for incomplete or contraindicated optical colonoscopy in older patients.

OBJECTIVE: Our purpose was to assess the performance of CT colonography (CTC) in patients older than 60 years who were referred because colonoscopy was contraindicated or incomplete. MATERIALS AND METHODS: Over a 2-year period, 61 patients underwent CTC at our institution, 42 of whom (26 women, 16 men) were 60 years old or older (range, 60-87 years; mean age, 71 years). After 24-48 hours of ingesting only clear liquids and after colonic cleansing, fecal tagging, and automated CO2 insufflation, patients were scanned using a 16-MDCT scanner. Images were obtained with the patient in the supine and prone positions and as needed in the right or left decubitus position. Axial 2D and 3D endoluminal views were evaluated on a dedicated workstation. RESULTS: Contraindications to colonoscopy in 12 (29%) of the 42 patients were as follows: anticoagulation (n = 8), increased anesthesia risk (n = 3), and poor tolerance for colonoscopy preparation (n = 1). Incomplete colonoscopy in the other 30 patients (71%) was due to diverticular disease (n = 10), colonic redundancy (n = 10), adhesions (n = 3), residual colonic content (n = 3), sigmoid stricture (n = 1), ventral hernia (n = 1), and unknown cause (n =2). No complications were observed. Optimal distention of the entire colon was achieved in 38 patients (90%). Thirty-nine (93%) of the 42 patients had abnormal findings: diverticular disease (n = 25), one or more polyps (n = 22), a mass lesion (n = 1), a lipoma (n = 1), and inflammatory stricture (n = 1). Extracolonic findings potentially requiring further evaluation or treatment were observed in 26 patients (62%). CONCLUSION: CTC using CO2 insufflation was well tolerated and successful in imaging the entire colon in most of the 42 patients, despite the presence of sigmoid diverticular disease or colonic redundancy.

Adnexal torsion: new clinical and imaging observations by sonography, computed tomography, and magnetic resonance imaging.

OBJECTIVE: The purpose of this study was to review the clinical, imaging, and pathologic findings associated with adnexal torsion. METHODS: A review of surgically proven cases of torsion between 1990 and 2006 included clinical, surgical, and pathologic data and preoperative sonographic, computed tomographic (CT), and magnetic resonance imaging (MRI) studies. Imaging reports were assessed to determine whether a correct preoperative diagnosis was made. Factors related to failure to make a correct diagnosis were evaluated. RESULTS: Fifty-eight cases of torsion were evaluated (patient ages, 12-85 years; 14 postmenopausal). There was a slight right-sided predominance (55%); in most cases (72%), both the ovary and fallopian tube were involved. Common symptoms/signs were pain (91%), leukocytosis (64%), nausea/vomiting (62%), and a palpable mass (41%). Twenty-eight patients (48%) had previous abdominal surgery; in 12 (46%) of these 28, pelvic adhesions were noted. At pathologic examination, underlying adnexal masses were found in 30 cases (52%); they were benign in 26 (87%) of 30 cases. Common imaging findings were an adnexal mass (65% on sonography, 87% on CT, and 75% on MRI), a displaced adnexal mass/enlarged ovary (53% on sonography, 87% on CT, and 75% on MRI), and ascites (53% on sonography, 73% on CT, and 50% on MRI). A correct preoperative diagnosis was made by initial sonography in 15 (71%) of 21 cases versus initial CT in 5 (38%) of 13. A correct imaging diagnosis was made more frequently in premenopausal than in menopausal patients (P = .02) and in patients without an underlying adnexal mass compared with those with a mass (P = .05). CONCLUSIONS: Although CT shows features suggestive of torsion, in our study, the diagnostic value of initial CT was less than that of initial sonography. A correct preoperative diagnosis was made less often with an underlying adnexal mass and in postmenopausal women. Previous surgery and adhesions may be predisposing factors for adnexal torsion.