Evaluating the effect of NPO status on mucosal coating during double contrast barium esophagrams.

INTRODUCTION: Current guidelines for double contrast barium esophagography studies (BAS) suggest that patients should be nil per os (NPO) prior to completing BAS for optimal esophageal coating, although the time required varies between practices and institutions. It is believed that consumption of food or water disrupts the ability for thick barium contrast to properly coat the esophageal mucosa. Exams that are rescheduled for this reason can lead to delays in care, without substantial evidence that NPO status truly affects esophageal mucosal coating for these exams with current barium mixtures. OBJECTIVE: The study aims to identify the necessity, or lack thereof, of standard NPO protocol in patients undergoing BAS, in effort to prevent unnecessary procedural delay. MATERIALS AND METHODS: This study is an IRB-approved HIPAA-compliant study of 370 consecutive adult patients (115 male/255 female, mean age 55) who underwent BAS at our institution from January to June of 2022. Patients were divided into two groups: < 4 h NPO (n = 334), and ≥ 4 h NPO (n = 36). Four abdominal radiologists blinded to NPO interval independently reviewed a random sample of approximately 92 patients (91-94) and graded esophageal coating on a 4-point-scale with 1 being insufficient coating and 4 being optimal coating. RESULTS: No significant statistical difference in mean esophageal coating score was found between the ≥ 4 h NPO cohort (3.04 ± SD 0.78) and the < 4 h NPO cohort (2.97 ± SD 0.70; P = 0.54). Subset analysis of patients who were NPO for < 2 h (n = 9) also showed no significant difference in mean esophageal coating score (3.11 ± SD 0.6; P = 0.92), compared to the standard ≥ 4 NPO status. CONCLUSION: Non-adherence to standard NPO protocol prior to BAS studies did not result in a significant difference in esophageal coating when compared to traditional preprocedural fasting of 4 or more hours.

Stereotactic Body Radiation Therapy Salvage for Lymph Node Recurrent Prostate Cancer in the Era of PSMA PET Imaging.

PURPOSE OF REVIEW: Our understanding of patterns of prostate cancer recurrence after primary treatment of localized disease has significantly evolved since the development of positron emission tomography (PET) agents targeting prostate cancer. Previously, most biochemical recurrences were not associated with imaging correlates when restaging with computed tomography (CT), magnetic resonance imaging (MRI), or bone scintigraphy and, hence, were typically assumed to represent occult metastases. A rising prostate specific antigen (PSA) after previous local therapy prompting a PET scan showing uptake limited to regional lymph nodes is an increasingly common clinical scenario as advanced prostate cancer imaging becomes more widely utilized. The optimal management strategy for patients who have lymph node recurrent prostate cancer is both unclear and evolving, particularly in terms of local and regionally directed therapies. Stereotactic body radiation therapy (SBRT) utilizes ablative radiation doses with steep gradients to achieve local tumor control while sparing nearby normal tissues. SBRT is an attractive therapeutic modality due to its efficacy, favorable toxicity profile, and flexibility to administer elective doses to areas of potential occult involvement. The purpose of this review is to briefly describe how SBRT is being implemented in the era of PSMA PET for the management of solely lymph node recurrent prostate cancer. RECENT FINDINGS: SBRT has been shown to effectively control individual lymph node tumor deposits within the pelvis and retroperitoneum for prostate cancer and is well-tolerated with a favorable toxicity profile. However, a major limitation thus far has been the lack of prospective trials supporting the use of SBRT for oligometastatic nodal recurrent prostate cancer. As further trials are conducted, its exact role in the treatment paradigm of recurrent prostate cancer will be better established. Although PET-guided SBRT appears feasible and potentially beneficial, there is still considerable uncertainty about the use of elective nodal radiotherapy (ENRT) in patients with nodal recurrent oligometastatic prostate cancer. PSMA PET has undoubtedly advanced imaging of recurrent prostate cancer, revealing anatomic correlates for disease recurrence that previously went undetected. At the same time, SBRT continues to be explored in prostate cancer with feasibility, a favorable risk profile, and satisfactory oncologic outcomes. However, much of the existing literature comes from the pre-PSMA PET era and integration of this novel imaging approach has led to greater focus on new and ongoing clinical trials to rigorously evaluate this approach and compare to other established treatment modalities utilized for oligometastatic, nodal recurrence of prostate cancer.

Contemporary Review of Multimodality Imaging of the Prostate Gland.

Tissue changes and the enlargement of the prostate, whether benign or malignant, are among the most common groups of diseases that affect men and can have significant impacts on length and quality of life. The prevalence of benign prostatic hyperplasia (BPH) increases significantly with age and affects nearly all men as they grow older. Other than skin cancers, prostate cancer is the most common cancer among men in the United States. Imaging is an essential component in the diagnosis and management of these conditions. Multiple modalities are available for prostate imaging, including several novel imaging modalities that have changed the landscape of prostate imaging in recent years. This review will cover the data relating to commonly used standard-of-care prostate imaging modalities, advances in newer technologies, and newer standards that impact prostate gland imaging.

PET/MRI for evaluation of patients with pancreatic cancer.

Pancreatic cancers are the third leading cause of cancer-related death in the USA and outcomes remain poor despite improvements in imaging and treatment paradigms. Currently, computed tomography (CT) and magnetic resonance imaging (MRI) are frequently utilized for staging and restaging of these malignancies, but positron emission tomography (PET)/CT can play a role in troubleshooting and improve whole-body staging. PET/MRI is a novel imaging modality that allows for simultaneous acquisition of PET and MRI images, leading to improved image quality and potential increased sensitivity. Early studies suggest that PET/MRI may play a larger role in pancreatic cancer imaging in future. This manuscript will briefly discuss current imaging approaches to pancreatic cancer and outline existing evidence and published data supporting the use of PET/MRI for pancreatic cancers.

Postoperative surveillance of pancreatic ductal adenocarcinoma (PDAC) recurrence: practice pattern on standardized imaging and reporting from the society of abdominal radiology disease focus panel on PDAC.

PURPOSE: Surgical resection is the only potential curative treatment for patients with pancreatic ductal adenocarcinoma (PDAC), but unfortunately most patients recur within 5 years of surgery. This article aims to assess the practice patterns across major academic institutions and develop consensus recommendations for postoperative imaging and interpretation in patients with PDAC. METHODS: The consensus recommendations for postoperative imaging surveillance following PDAC resection were developed using the Delphi method. Members of the Society of Abdominal Radiology (SAR) PDAC Disease Focused Panel (DFP) underwent three rounds of surveys followed by live webinar group discussions to develop consensus recommendations. RESULTS: Significant variations currently exist in the postoperative surveillance of PDAC, even among academic institutions. Differentiating common postoperative inflammatory and fibrotic changes from tumor recurrence remains a diagnostic challenge, and there is no reliable size threshold or growth rate of imaging findings that can provide differentiation. A new liver lesion or peritoneal nodule should be considered suspicious for tumor recurrence, and the imaging features should be interpreted in the appropriate clinical context (e.g., CA 19-9, clinical presentation, pathologic staging). CONCLUSION: Postoperative imaging following PDAC resection is challenging to interpret due to the presence of confounding postoperative inflammatory changes. A standardized reporting template for locoregional findings and report impression may improve communication of relaying risk of recurrence with referring providers, which merits validation in future studies.

Accelerated Fellowships Applicable Across all Subspecialty Areas of Diagnostic Radiology as a Catalyst for Academic Recruitment.

RATIONALE AND OBJECTIVES: To build a sustainable faculty development program based on potential acceleration of all subspecialty fellowships types into the PGY 5 year. MATERIALS AND METHODS: Single center experience in programmatic change to enhance faculty recruitment. Diagnostic Radiology (DR) residents apply to subspecialty fellowships per SCARD Fellowship Embargo Guidelines. Based on projected faculty hiring needs, internal candidates are vetted and agree to enter an accelerated fellowship. The commitment is two years: the PGY5 senior year schedule prioritizes rotations in the subspecialty area while fulfilling requirements of all DR graduates, including call. Accelerated fellows (AF) participate in junior faculty development and concentrated mentoring. A subsequent instructor faculty year within our department is required to ensure professional maturity and provides financial remuneration greater than PGY 6 fellowships. RESULTS: From July 1, 2018, to June 30, 2022, 34 trainees have graduated from our DR program, and 32 have gone through the process of securing fellowships. Over this interval, our DR program has matched 7-9 residents per year. Up to four early specialization positions consisting of 2 Early Specialization in Interventional Radiology (ESIR), and 2 Early Specialization in Nuclear Medicine (ESNM), per year, are available. Over four years of the program, 8 residents participated in standard early specialization opportunities: 5 ESIR, and 3 ESNM. These 8 residents were excluded from consideration for AFs. Two additional residents declined fellowships, leaving 22 seeking standard fellowships for PGY 6 year. 6 (27%) of those were approached as potential AFs; 3 (50%) agreed to and completed the 24-month process. 2 of 3 (67%) continue to serve on faculty after the required instructor year. CONCLUSION: The novel concept of early specialization outside of ESIR and ESNM presents an opportunity to tailor the PGY 5 DR year to increase recruitment to academic faculty positions.

Defining Oligometastatic Disease in the New Era of PSMA-PET Imaging for Primary Staging of Prostate Cancer.

Oligometastatic prostate cancer has traditionally been defined in the literature as a limited number of metastatic lesions (either to soft tissue or bone), typically based on findings seen on CT, MRI, and skeletal scintigraphy. Although definitions have varied among research studies, many important clinical trials have documented effective treatments and prognostication in patients with oligometastatic prostate cancer. In current clinical practice, prostate-specific membrane antigen (PSMA)-PET/CT is increasingly utilized for the initial staging of high-risk patients and, in many cases, detecting metastases that would have otherwise been undetected with conventional staging imaging. Thus, patients with presumed localized and/or oligometastatic prostate cancer undergo stage migration based on more novel molecular imaging. As a result, it is challenging to apply the data from the era before widespread PET utilization to current clinical practice and to relate current trials using PSMA-PET/CT for disease detection to older studies using conventional staging imaging alone. This manuscript aims to review the definition of oligometastatic prostate cancer, summarize important studies utilizing both PSMA-PET/CT and conventional anatomic imaging, discuss the concept of stage migration, and discuss current problems and challenges with the current definition of oligometastatic disease.

Role of molecular imaging in the detection of localized prostate cancer.

Molecular imaging of prostate cancer continues to grow, with recent inclusion of several positron emission tomography (PET) radiotracers into the recent National Comprehensive Cancer Network guidelines and the US Food and Drug Administration approval of prostate-specific membrane antigen (PSMA)-targeted radiotracers. While much of the work for many of these radiotracers is focused on systemic staging and restaging in both newly diagnosed high-risk prostate cancer and biochemically recurrent disease patients, the potential role of molecular imaging for the detection of localized prostate cancer has not yet been fully established. The primary aim of this article will be to present the potential role for molecular imaging in the detection of localized prostate cancer and discuss potential advantages and disadvantages to utilization of both PET/computed tomography (CT) and PET/magnetic resonance imaging (MRI) for this clinical indication of use.

Thromboelastography: a review for radiologists and implications on periprocedural bleeding risk.

Thromboelastography (TEG) and rotational thromboelastometry are emerging technologies that are gaining increasing acceptance in the medical field to evaluate the coagulation status of patients on an individual level by assessing dynamic clot formation. TEG has been proven to reduce blood product use as well as improve patient outcomes in a variety of medical settings, including trauma and surgery due to the expediated nature of the test as well as the ability to determine specific deficiencies present in whole blood that are otherwise undetectable with traditional coagulation studies. Currently, no guidelines or recommendations are in place for the utilization of TEG in interventional or diagnostic radiology although access to TEG has become increasingly common in recent years. This manuscript presents a review of prior literature on the technical aspects of TEG as well as its use in various fields and explains the normal TEG-tracing parameters. Common hemodynamic abnormalities and their effect on the TEG tracing are illustrated, and the appropriate treatments for each abnormality are briefly mentioned. TEG has the potential to be a useful tool for determining the hemodynamic state of patients in both interventional and diagnostic radiology, and further research is needed to determine the value of these tests in the periprocedural setting.

Multimodality Multisystem Imaging of Pregnancy-Related Changes: Featuring Neurologic, Cardiothoracic, Breast, Gynecologic, and Musculoskeletal Issues.

ABSTRACT: Pregnancy and the puerperium are a time of significant physiologic change, and with an average of 4 million births in the United States yearly, radiologists encounter pregnancy-related imaging findings regularly. While many of these findings represent physiologic changes, a significant number represent pathology, making it paramount for radiologists to distinguish between the two. This case-based article reviews imaging findings within the nervous, cardiovascular, pulmonary, breast, gynecologic, musculoskeletal, digestive, hematologic, and integumentary systems throughout pregnancy and the postpartum period.

Pancreatic neuroendocrine neoplasms: a 2022 update for radiologists.

Pancreatic neuroendocrine neoplasms (PaNENs) are a unique group of pancreatic neoplasms with a wide range of clinical presentations and behaviors. Given their heterogeneous appearance and increasing detection on cross-sectional imaging, it is essential that radiologists understand the variable presentation and distinctions PaNENs display compared to other pancreatic neoplasms. Additionally, some of these neoplasms may be hormonally functional, and it is imperative that radiologists be aware of the common clinical presentations of hormonally active PaNENs. Knowledge of PaNEN pathology and treatments may influence which imaging modality is optimal for each patient. Each imaging modality used for PaNENs has distinct advantages and disadvantages, particularly in different treatment settings. Thus, the focus of this manuscript is to provide an update for the radiologist on PaNEN pathology, imaging, and treatments.

Imaging for the Initial Staging and Post-Treatment Surveillance of Penile Squamous Cell Carcinoma.

Although relatively rare in the United States, penile squamous cell carcinoma is encountered worldwide at a higher rate. Initial diagnosis is often made on clinical exam, as almost all of these lesions are externally visible and amenable to biopsy. In distinction to other types of malignancies, penile cancer relies heavily on clinical nodal staging of the inguinal lymph node chains. As with all cancers, imaging plays a role in the initial staging, restaging, and surveillance of these patients. The aim of this manuscript is to highlight the applications, advantages, and limitations of different imaging modalities in the evaluation of penile cancer, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography.

Imaging of Neuroendocrine Neoplasms: Monitoring Treatment Response-AJR Expert Panel Narrative Review.

Neuroendocrine neoplasms (NENs) encompass a broad spectrum of tumors throughout the body and range in biologic behavior from indolent to aggressive. Consequently, a wide spectrum of treatment options are available for NENs, including observation, somatostatin analogues, targeted therapy, chemotherapy, surgical resection, liver-directed therapy (embolization and ablation), and peptide receptor radionuclide therapy. Given the wide variety of tumor behaviors and treatments, precise criteria for treatment response in NENs are lacking. Though conventional anatomic imaging with CT and MRI remains important for NEN response assessment, the use of somatostatin receptor (SSR) PET is increasing and often provides synergistic and complementary information. Additionally, in certain clinical scenarios, a particular imaging strategy may prove superior or inferior to others for the detection of metastatic disease and evaluation of therapy response. A strong need exists to further define appropriate and standardized assessment criteria for tumor response and progression in NEN. This article presents the strengths and weaknesses of individual imaging modalities for evaluating NEN therapy response, including conventional anatomic imaging, SSR PET, FDG PET, dual-tracer PET, and PET/MRI. Ongoing challenges and unmet needs in the use of imaging for NEN response evaluation are explored.

Variability in personal protective equipment in cross-sectional interventional abdominal radiology practices.

PURPOSE: To determine institutional practice requirements for personal protective equipment (PPE) in cross-sectional interventional radiology (CSIR) procedures among a variety of radiology practices in the USA and Canada. METHODS: Members of the Society of Abdominal Radiology (SAR) CSIR Emerging Technology Commission (ETC) were sent an eight-question survey about what PPE they were required to use during common CSIR procedures: paracentesis, thoracentesis, thyroid fine needle aspiration (FNA), superficial lymph node biopsy, deep lymph node biopsy, solid organ biopsy, and ablation. Types of PPE evaluated were sterile gloves, surgical masks, gowns, surgical hats, eye shields, foot covers, and scrubs. RESULTS: 26/38 surveys were completed by respondents at 20/22 (91%) institutions. The most common PPE was sterile gloves, required by 20/20 (100%) institutions for every procedure. The second most common PPE was masks, required by 14/20 (70%) institutions for superficial and deep procedures and 12/12 (100%) institutions for ablation. Scrubs, sterile gowns, eye shields, and surgical hats were required at nearly all institutions for ablation, whereas approximately half of institutions required their use for deep lymph node and solid organ biopsy. Compared with other types of PPE, required mask and eye shield use showed the greatest increase during the SARS-CoV-2 pandemic. CONCLUSION: PPE use during common cross-sectional procedures is widely variable. Given the environmental and financial impact and lack of consensus practice, further studies examining the appropriate level of PPE are needed.

Percutaneous biopsy and drainage of the pancreas.

Percutaneous pancreatic interventions performed by abdominal radiologists play important diagnostic and therapeutic roles in the management of a wide range of pancreatic pathology. While often performed with endoscopy, pancreatic mass biopsy obtained via a percutaneous approach may serve as the only feasible option for diagnosis in patients with post-surgical anatomy, severe cardiopulmonary conditions, or prior non-diagnostic endoscopic attempts. Biopsy of pancreatic transplants are commonly performed percutaneously due to inaccessible location of the allograft by endoscopy, usually in the right lower quadrant or pelvis. Percutaneous drainage of collections in acute pancreatitis is primarily indicated for infection with clinical deterioration and may be performed alone or in combination with endoscopic drainage. Post-surgical pancreatic collections related to pancreatic duct fistula or leak also often warrant therapeutic percutaneous drainage. Knowledge of appropriate indications, strategies of approach, technique, and complications associated with these procedures is critical for a successful clinical practice.

Procedural moderate sedation in patients with opioid addiction and chronic pain: a practical primer for the radiologist.

Opioid use disorder and chronic pain are increasingly commonly encountered in medicine and many patients now are prescribed medications (such as buprenorphine) to help treat these conditions. Many radiologists are unfamiliar with how these medications work and how they impact providing procedural sedation during procedures in the radiology department. The focus of this manuscript is to provide radiologists background and guidance on how these medications interact with medications given for procedural sedation and the appropriate management strategy for patients with opioid use disorder and chronic pain who require procedural sedation.