Comparison of radiation dose and image quality from single-energy and dual-energy CT examinations in the same patients screened for hepatocellular carcinoma.

AIM: To compare radiation dose surrogates [volume CT dose index (CTDIvol), dose-length product (DLP), size-specific dose estimate (SSDE), and effective dose] and image noise in a cohort of patients undergoing hepatocellular carcinoma screening who underwent both single-energy CT (SECT) and dual-energy CT (DECT). MATERIALS AND METHODS: In this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study, 74 adults (mean age 59.5 years) underwent 64 section SECT (120 kVp and weight-based reference mAs) and 128 section dual-source DECT (100/Sn 140 kVp and CTDIvol, adjusted to match the CDTIvol of the SECT protocol) on different occasions. Noise levels were measured in the liver, inferior vena cava (IVC), retroperitoneal (RP) fat, and aorta. Generalized linear models were constructed to compare dose and noise, adjusting for effective diameter. RESULTS: The total DLP (1371.11 mGy-cm, SD = 527.91) and effective dose (20.57 mSv, SD = 7.92) with SECT were significantly higher than the DLP (864.84 mGy-cm, SD = 322.10) and effective dose (12.97 mSv, SD = 4.83) with DECT (p < 0.001). The differences between SECT and DECT increased as the patient's effective diameter increased (p < 0.001). Noise levels in the liver (22.4 versus 21.9 HU), IVC (22.3 versus 23.4 HU), and RP fat (23.5 versus 23 HU) were similar for DECT and SECT (p > 0.05) but were significantly lower in the aorta for DECT (25.3 versus 26.4 HU; p = 0.006). CONCLUSION: DECT imaging of the abdomen can achieve noise levels comparable to those seen with SECT imaging without a dose penalty to patients.

Donor kidney volume and outcomes following live donor kidney transplantation.

Pre-donation kidney volume and function may be crucial factors in determining graft outcomes in kidney transplant recipients. We measured living donor kidney volumes by 3D helical computed tomography scanning and glomerular filtration rate (GFR) by (125)I-iothalamate clearances in 119 donors, and correlated these values with graft function and incidence of acute rejection at 2 years post-transplantation. Kidney volume strongly correlated with GFR (Pearson r= 0.71, p < 0.001). Body size and male gender were independent correlates of larger kidney volumes, and body size and age were predictors of kidney function. The effects of transplanted kidney volume on graft outcome were studied in 104 donor-recipient pairs. A transplanted kidney volume greater than 120 cc/1.73 m(2) was independently associated with better estimated GFR at 2 years post-transplant when compared to recipients of lower transplanted kidney volumes (64 +/- 19 vs. 48 +/- 14 mL/min/1.73 m(2), p < 0.001). Moreover, recipients of lower volumes had a higher incidence of acute cellular rejection (16% vs. 3.7%, p = 0.046). In conclusion, kidney volume strongly correlates with function in living kidney donors and is an independent determinant of post-transplant graft outcome. The findings suggest that (1) transplantation of larger kidneys confers an outcome advantage and (2) larger kidneys should be preferred when selecting from otherwise similar living donors.

Spiral CT scanning technique in the detection of aspiration of LEGO foreign bodies.

BACKGROUND: Radiolucent foreign bodies (FBs) such as plastic objects and toys remain difficult to identify on conventional radiographs of the neck and chest. Children may present with a variety of respiratory complaints, which may or may not be due to a FB. OBJECTIVE: To determine whether radiolucent FBs such as plastic LEGOs and peanuts can be seen in the tracheobronchial tree or esophagus using low-dose spiral CT, and, if visible, to determine the optimal CT imaging technique. MATERIALS AND METHODS: Multiple spiral sequences were performed while varying the CT parameters and the presence and location of FBs in either the trachea or the esophagus first on a neck phantom and then a cadaver. Sequences were rated by three radiologists blinded to the presence of a FB using a single scoring system. RESULTS: The LEGO was well visualized in the trachea by all three readers (both lung and soft-tissue windowing: combined sensitivity 89 %, combined specificity 89 %) and to a lesser extent in the esophagus (combined sensitivity 31 %, combined specificity 100 %). The peanut was not well visualized (combined sensitivity < 35 %). The optimal technique for visualizing the LEGO was 120 kV, 90 mA, 3-mm collimation, 0.75 s/revolution, and 2.0 pitch. This allowed for coverage of the cadaver tracheobronchial tree (approximately 11 cm) in about 18 s. Although statistical power was low for detecting significant differences, all three readers noted higher average confidence ratings with lung windowing among 18 LEGO-in-trachea scans. CONCLUSION: Rapid, low-dose spiral CT may be used to visualize LEGO FBs in the airway or esophagus. Peanuts were not well visualized.

Accuracy and utility of 3-dimensional computed tomography in evaluating donors for adult living related liver transplants.

Three-dimensional (3D) computed tomography (CT) is an imaging technique that renders anatomic detail in 3D images from helical computed tomographic scans. The purpose of this study is to assess 3D CT in the preoperative evaluation of adult living related liver transplant donors. Nine patients underwent right-lobe liver resection for adult living related liver transplants between October 1999 and September 2000. All donors underwent triphasic helical CT of the liver with 3D computed tomographic reconstruction and conventional angiography. The 3D images were correlated with angiography and intraoperative findings. The origin of vessels, relative length of segments, and position of branches were considered for accuracy. The 3D computed tomographic images were compared with angiograms to determine whether angiography could be replaced by 3D CT. 3D CT identified all variations of the hepatic vein confluences and portal vein trifurcations and all hepatic arterial variants. At surgery, the 3D computed tomographic images of hepatic and portal veins were judged to be accurate and helpful in 8 of 9 cases, and images of the hepatic artery, accurate and helpful in 5 of 9 cases. The 3D computed tomographic images of hepatic and portal veins were better than or equivalent to angiograms in nearly all cases. The 3D computed tomographic images of the hepatic artery were better than or equivalent to angiography in 5 of 9 cases. By providing an accurate 3D map of the liver and its vasculature, 3D computed tomographic reconstructions of the hepatic vasculature are a useful adjunct for surgical planning in adult living related liver donors. 3D CT clearly delineates portal and hepatic veins as well as or better than the angiogram and can identify the hepatic artery and its branches well enough to consider replacing angiography, thus reducing cost, inconvenience, and risk to the donor.

Power injection of contrast media using central venous catheters: feasibility, safety, and efficacy.

OBJECTIVE: This study evaluates the feasibility, safety, and efficacy of power-injecting IV contrast media through central venous catheters for CT examinations. SUBJECTS AND METHODS: Two hundred ninety-five CT examinations were performed during an 18-month period in 225 patients with indwelling central venous catheters. Patients were randomized to power injection either through peripheral IV catheter or through central venous catheter. Feasibility was defined as the percentage of patients with contrast material injected successfully through the randomized access route. Safety was evaluated by comparing patients with complications. Efficacy was evaluated by comparing contrast enhancement of the thoracic aorta, pulmonary artery, abdominal aorta, and liver. RESULTS: Two hundred nine patients had randomization data recorded. One hundred three (94%) of 109 patients were successfully injected through their indwelling catheter compared with 42 (42%) of 100 through a peripherally placed IV catheter (p < 0.001). After reassignment for unsuccessful access, 174 patients underwent central venous catheter injection, and 51, peripheral IV catheter injection. No statistically significant difference was noted in the complications between the central venous catheter and peripheral IV catheter groups. Enhancement was greater in the thoracic aorta, pulmonary artery, and liver for the peripheral IV catheter group (p < 0.03). CONCLUSION: Power injection of contrast media through central venous catheters for CT examinations is feasible and safe when set hospital guidelines and injection protocols are followed. This technique provides an acceptable alternative in patients without adequate peripheral IV access when bolus contrast enhancement is desired.

Feasibility of instructing radiology technologists in the performance of gastrointestinal fluoroscopy.

OBJECTIVE: We sought to determine if dedicated gastrointestinal technologists could be trained to properly perform esophagography and double-contrast barium enema examinations. SUBJECTS AND METHODS: Ninety-four patients undergoing double-contrast barium enema examinations and 123 patients undergoing esophagographic examinations were included in the study. The study was conducted over a 4-month period, with examinations performed by eight gastrointestinal technologists, 10 radiology residents, and four staff radiologists. Four random lists were generated for each set of examinations. Each staff gastrointestinal radiologist, who was unaware of who had performed the examination, independently scored the representative radiographs. RESULTS: For the double-contrast barium enema examinations, no statistically significant differences were found between the technologists and residents for amount of barium used, degree of distention, cecal opacification, and quality of spot radiographs. The technologist-performed examinations had a statistically significant lower mean fluoroscopy time (3.2 min, compared with 4.0 min for staff radiologists and 5.7 min for residents). For the esophagrams, no statistically significant differences between technologists and residents were found for single-contrast esophagrams; radiographs of the gastric cardia; assessment of motility, reflux, and transit of a solid bolus; and fluoroscopy time. Double-contrast esophagrams obtained by technologists received a better mean score than did those of the residents. CONCLUSION: Radiology technologists can be trained to perform high-quality esophagography and double-contrast barium enema examinations without an unacceptably high radiation dose.

Prospective, blinded comparison of laparoscopic ultrasonography vs. contrast-enhanced computerized tomography for liver assessment in patients undergoing colorectal carcinoma surgery.

PURPOSE: To prospectively and blindly compare intraoperative laparoscopic ultrasonography to preoperative contrast-enhanced computerized tomography in detecting liver lesions in colorectal cancer patients. Additionally, we compared conventional (open) intraoperative ultrasonography with bimanual liver palpation to contrast-enhanced computerized tomography in a subset of patients. METHODS: From December 1995 to March 1998, 77 consecutive patients underwent curative (n = 63) or palliative (n = 14) resections for colorectal cancer. All patients undergoing curative resections were randomized to either laparoscopic (n = 34) or conventional (n = 29) surgery after informed consent. All patients underwent contrast-enhanced computerized tomography, diagnostic laparoscopy, and laparoscopic ultrasonography before resection. In those patients who had conventional procedures, intraoperative ultrasonography with bimanual liver palpation was also done. All laparoscopic ultrasonography and intraoperative ultrasonography evaluations were performed by one of two radiologists who were blinded to the CT results. All hepatic segments were scanned using a standardized method. The yield of each modality was calculated using the number of lesions identified by each imaging modality divided by the total number of lesions identified. RESULTS: In 43 of the 77 patients, both the laparoscopic ultrasonography and CT scan were negative for any liver lesions. In 34 patients, a total of 130 lesions were detected by laparoscopic ultrasonography, CT, or both. When compared with laparoscopic ultrasonography, intraoperative ultrasonography with bimanual liver palpation identified one additional metastatic lesion and no additional benign lesions. laparoscopic ultrasonography identified two patients with mets who had negative preoperative contrast-enhanced computerized tomography. CONCLUSIONS: Laparoscopic ultrasonography of the liver at the time of primary resection of colorectal cancer yields more lesions than preoperative contrast-enhanced computerized tomography and should be considered for routine use during laparoscopic oncologic colorectal surgery.

Imaging guided biopsies of renal masses.

Percutaneous fine-needle aspiration biopsy can be used for the diagnosis of many abdominal masses. It is safe and accurate, and is often all that is necessary to determine treatment. Fine-needle aspiration biopsy is both accurate and cost-effective, comparing favorably with open surgical biopsy. The use of percutaneous biopsy for the diagnosis of renal masses is now more commonplace as urologists and radiologists become familiar with its indications, contraindications, accuracy and complications.

Preoperative use of 3D volume rendering to demonstrate renal tumors and renal anatomy.

With increased use of computed tomography (CT) and abdominal ultrasonography, the indications for nephron-sparing surgery are also increasing. Triphasic helical CT and three-dimensional (3D) volume rendering can be combined into a single noninvasive test to delineate renal tumors and normal and complex renal anatomy prior to nephron-sparing surgery. This combination technique has proved accurate and very useful for both preoperative and intraoperative planning by demonstrating renal position, tumor location and depth of tumor extension into the kidney, relationship of the tumor to the collecting system, and renal vascular anatomy. Knowledge of the position of the kidney relative to the lower rib cage, iliac crest, and spine helps in planning the initial surgical incision. By depicting tumor location and depth of extension, helical CT with 3D volume rendering helps ensure complete tumor excision and conservation of adjacent normal renal parenchyma. Depiction of the relationship of the tumor to the collecting system helps anticipate further tumor extension and minimize postoperative complications. Identification of normal renal vasculature and anatomic variants can help minimize ischemic injury and intraoperative bleeding. Radiologists should be familiar with current indications for nephron-sparing surgery and understand what information is required prior to surgery.

Triphasic helical CT of the kidneys: contribution of vascular phase scanning in patients before urologic surgery.

OBJECTIVE: The purpose of this study was to evaluate the potential benefits of performing vascular phase scanning of the kidneys in addition to unenhanced and parenchymal phase contrast-enhanced CT in patients being examined for urologic surgery. MATERIALS AND METHODS: Parenchymal and vascular phase images from triphasic renal helical CT of 50 patients were sequentially evaluated in a randomized, retrospective fashion by two independent observers. The number of renal arteries and veins and the presence of vein or collecting system anomalies were recorded for each scan phase along with a subjective 10-point-scale score of the visibility of the vasculature and collecting system. Correlation of these findings was made with surgical or angiographic findings in 67 of the 87 kidneys and was made by consensus review in the remaining 20 kidneys. RESULTS: Accessory renal arteries were seen significantly more often (p < .05, chi-square test) on the vascular phase scans. The subjective scores for the visibility of the renal arteries and renal veins were significantly higher on the vascular phase scans (p < .0001, Wilcoxon's rank sum test). The subjective scores for the visibility of the filling of the collecting system and renal pelvis were significantly higher for the parenchymal phase scans, despite the use of a small contrast bolus before each scan (p < .0001, Wilcoxon's rank sum test). CONCLUSION; Triphasic renal CT better reveals the artery and vein anatomy of the kidney than does parenchymal phase imaging only. Triphasic helical CT is indicated in patients undergoing planning for urologic surgery when vascular anatomy is clinically important.

3-dimensional volume rendered computerized tomography for preoperative evaluation and intraoperative treatment of patients undergoing nephron sparing surgery.

PURPOSE: Computerized tomography (CT) is the diagnostic and staging modality of choice for renal neoplasms. Existing imaging modalities are limited by a 2-dimensional (D) format. Recent advances in computer technology now allow the production of high quality 3-D images from helical CT. Nephron sparing surgery requires a detailed understanding of renal anatomy. Preoperative evaluation must delineate the relationship of the tumor to adjacent normal structures and demonstrate the vascular supply to the tumor for the surgeon to conserve as much normal parenchyma as possible. We propose that helical CT combined with 3-D volume rendering provides all of the information required for preoperative evaluation and intraoperative management of nephron sparing surgery cases. We prospectively evaluated the role of 3-D volume rendering CT in 60 patients undergoing nephron sparing surgery for renal cell carcinoma at the Cleveland Clinic Foundation. MATERIALS AND METHODS: Triphasic spiral CT was performed preoperatively in 60 consecutive patients undergoing nephron sparing surgery for renal neoplasms. A 3 to 5-minute videotape was prepared using volume rendering software which demonstrated the position of the kidney, location and depth of extension of the tumor(s), renal artery(ies) and vein(s), and relationship of the tumor to the collecting system. These videotapes were viewed by a radiologist and urologist in the operating room at surgery, and immediately correlated with surgical findings. Corresponding renal arteriograms of 19 patients were retrospectively compared to 3-D volume rendering CT and operative findings. RESULTS: A total of 97 renal masses were identified in 60 cases evaluated with 3-D volume rendering CT before nephron sparing surgery. There were no complications related to the 3-D protocol and 3-D rendering was successful in all patients. The number and location of lesions identified by 3-D volume rendering CT were accurate in all cases, while enhancement and diagnostic characteristics were consistent with pathological findings in 95 of 97 tumors (98%). Of 77 renal arteries identified at surgery 74 were detected by 3-D volume rendering CT (96%). Helical CT missed 3 small accessory arteries, including 1 in a cross fused ectopic kidney. All major venous branches and anomalies were identified, including 3 circumaortic left renal veins. Of 69 renal veins identified at surgery 64 were detected by 3-D volume rendering CT (93%). All 5 renal veins missed by CT were small, short, duplicated right branches of the main renal vein. Renal fusion and malrotation anomalies were correctly identified in all 4 patients. CONCLUSIONS: The 3-D volume rendering CT accurately depicts the renal parenchymal and vascular anatomy in a format familiar to most surgeons. The data integrate essential information from angiography, venography, excretory urography and conventional 2-D CT into a single imaging modality, and can obviate the need for more invasive imaging. Additionally, the use of videotape in an intraoperative setting provides concise, accurate and immediate 3-D information to the surgeon, and it has become the preferred means of data display for these procedures at our center.

Comparison of two barium suspensions for dedicated small-bowel series.

OBJECTIVE: The in vivo radiographic features of two commercially available formulations of barium used as contrast media in dedicated small-bowel series were compared. SUBJECTS AND METHODS: Fifty-six consecutive outpatients referred for a dedicated small-bowel series were randomly administered either E-Z-Paque or Entrobar. Representative survey radiographs from each examination were randomized and reviewed by six gastrointestinal radiologists from three institutions. Each observer assigned a numeric score (1 = poor, 2 = fair, 3 = good, and 4 = excellent) that rated the quality of the radiograph with respect to these characteristics: definition of fold pattern, translucency, distention, and integrity of the barium column. Statistical analysis was performed for each characteristic using Wilcoxon's two-sample rank sum test. RESULTS: All six observers found a statistically significant difference between the two barium formulations for mean scores for definition of fold pattern and translucency. Mean scores for fold pattern were 3.3, 3.0, 3.2, 3.6, 3.3, and 3.4 for Entrobar and 2.1, 2.3, 2.4, 3.2, 2.6, and 2.7 for E-Z-Paque. Mean scores for translucency were 2.5, 2.7, 2.8, 3.1, 2.7, and 3.3 for Entrobar and 1.6, 1.7, 2.1, 2.3, 1.9, and 2.7 for E-Z-Paque. No statistically significant difference was found for mean score for distention or integrity of the barium column. CONCLUSION: On radiographs, Entrobar was found to have superior characteristics for visualization of fold pattern and translucency but offered no advantages for distention or integrity of the barium column. Improved translucency and definition of fold pattern may translate into improved sensitivity and confidence in diagnosing small-bowel abnormality.

Contemporary diagnosis of retrocaval ureter.

PURPOSE: We describe a noninvasive radiologic evaluation of a retrocaval ureter using currently available technology. MATERIALS AND METHODS: Three-dimensional volume-rendered CT and diuretic renography were performed for evaluation of a possible retrocaval ureter. RESULTS: The 3D CT scan definitively diagnosed the retrocaval ureter, while diuretic renography showed no evidence of clinically significant obstruction. No invasive procedures were required. CONCLUSION: A 3D volume-rendered CT scan in the excretory phase combined with diuretic renography is the radiologic evaluation of choice for patients with a suspected retrocaval ureter, as it is noninvasive yet highly accurate in its anatomic delineation.

Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound scan versus computed tomography scan.

PURPOSE: The purpose of this study was to compare the accuracy of a color duplex ultrasound scan (CDU) to a computerized axial tomography scan (CT) in the diagnosis of endoleaks after stent graft repair of abdominal aortic aneurysms. METHODS: The Endovascular Aneurysm Clinical Trial Core Laboratory records were reviewed from 117 concurrent CDU and CT studies that were performed in 79 patients who were implanted with the Endovascular Technologies stent graft device between December 1995 and January 1997. All of the studies were interpreted by the Core Laboratory as having the presence or the absence of an endoleak or as being indeterminate because of technical factors. Of the 117 videotaped CDU studies available for reexamination, 100 were reassessed for technical adequacy on the basis of the following criteria: a satisfactory imaging of the aneurysm sac and of the stent graft with gray scale, and both color and spectral Doppler scan evaluation for endoleak outside the endograft and within the aneurysm sac. RESULTS: Of the 117 studies, 103 CDUs (88%) and 114 CTs (97%) were recorded as having the presence or the absence of an endoleak and 14 CDUs (12%) and 3 CTs (3%) were indeterminate. For the studies that were recorded to have the presence or the absence of an endoleak, the sensitivity, the specificity, the positive and the negative predictive values, and the accuracy of CDUs as compared with CTs were 97%, 74%, 66%, 98%, and 82%, respectively. Of the 100 CDU videotaped studies available for review, the following results were seen: (1) 93 CDUs had satisfactory B-mode images, (2) 76 had satisfactory color Doppler scan images to evaluate for endoleaks, (3) 55 had color Doppler scan assessment of the entire abdominal aortic aneurysm sac for endoleak, and (4) 27 had spectral Doppler scan waveform confirmation of suspected endoleaks. Only 19 CDU studies (19%) with all 4 criteria for complete assessment of endoleak were performed. CONCLUSION: Although most of the CDU studies were technically suboptimal, the CDUs reliably identified endoleaks with an excellent sensitivity and a negative predictive value as compared with CT scans.

Helical CT and CT angiography for the identification of crossing vessels at the ureteropelvic junction.

In comparison with pyeloplasty, endourologic procedures for the treatment of ureteropelvic junction obstruction offer good success rates with less morbidity and a shorter hospitalization; however, studies have found lower success rates and increased complications in patients with crossing vessels. Conventional diagnostic angiography and intravenous urography have both been used to identify crossing vessels at the UPJ; but, a reliable, less invasive, less costly, and simpler preoperative procedure to identify crossing vessels is needed. Helical CT with CT angiography is a promising noninvasive technique for the identification of crossing vessels at the ureteropelvic junction, which can be used for surgical planning of endourologic treatment of UPJ obstruction.

Comparison of examination times between CT scanners: are the newer scanners faster?

OBJECTIVE: The purpose of this study was to determine if a newer technology helical CT scanner can reduce CT examination times. MATERIALS AND METHODS: Data from 1049 CT examinations were recorded prospectively during a 5-week period. "Room time" was defined as the time each patient spent in the CT room (time patient exited minus time patient entered) and "scanner time" was defined as the time a scanner was dedicated to a specific patient (longer of either time that image processing was complete minus time patient entered room, or total time that patient spent in the scanner room). Data to calculate the room and scanner times were recorded along with the scanner type, examination protocol, and five other covariates. Both times were calculated for the 10 most common examination protocols (n = 769 patients) and compared between the older and newer model CT scanner using analysis of covariance models. The most common protocols were abdomen and pelvis (n = 211); head (n = 146); chest (n = 99); simple sinus (n = 99); and chest, abdomen, and pelvis (n = 68). RESULTS: The mean room and scanner times, adjusted for covariates, were both significantly shorter for the newer scanner (p = .0001). The results for room time were statistically significant for six of the 10 examination protocols (84% of examinations). Likewise, the results for scanner time were statistically significant for four examination protocols (68% of examinations). Examination times were longer for inpatients (p = .0001) and when problems occurred during the examination (p = .0001). Sex and age did not significantly affect examination times (p > .08). CONCLUSION: The newer helical CT scanner we studied significantly reduced the time for many types of examinations.

Timed barium swallow: a simple technique for evaluating esophageal emptying in patients with achalasia.

OBJECTIVE: Our purpose was to define a simple technique for timing a barium swallow by which radiologists can assess esophageal emptying in patients with achalasia before and after minimally invasive therapy. Our purpose was also to determine the best method of quantifying the degree of emptying using this timed technique. MATERIALS AND METHODS: In the barium swallow technique, upright frontal spot films of the esophagus are obtained at 1, 2, and 5 min after ingestion of 100-200 ml of low-density (45% weight in volume) barium sulfate (volume of barium determined by patient tolerance). Forty-two of these barium swallows done by 23 patients with achalasia were retrospectively reviewed. The examination served either as a baseline study or as a 1-month follow-up study after patients had undergone pneumatic dilatation or Clostridium botulinum toxin injection. The spot films were digitized, and a region of interest was drawn around the column of barium by two observers. The change in area seen in the region of interest on the 1- and 5-min films served as the gold standard for percentage of emptying. The spot films were then analyzed by four other observers, each of whom independently, subjectively, and qualitatively estimated the percentage of emptying between the 1- and 5-min spot films. Percentages were divided into quintiles. On a separate occasion, each of these four observers also independently measured the height and width of the barium column on the 1- and 5-min spot films. The product of height times width seen on the 1- and 5-min films became the quantitative estimate for percentage of emptying. RESULTS: We found no statistically significant difference between the percentage of emptying as measured on the digitized images by the two observers and the height-times-width calculations or qualitative emptying percentage as estimated by the four observers. Interobserver agreement for the area evaluated on the digitized films as well as the height-times-width measurements and qualitative estimates of emptying was almost perfect (the correlation coefficients being 0.99, 0.87, and 0.93, respectively). CONCLUSION: The timed barium swallow is a simple and reproducible technique. Both qualitative assessment and estimated change in area based on height-times-width measurements of the barium column are accurate methods of estimating esophageal emptying.

Prospective evaluation of fine needle aspiration of small, solid renal masses: accuracy and morbidity.

OBJECTIVES: To determine the accuracy and clinical utility of fine needle aspiration (FNA) of small, solid renal masses. METHODS: A total of 25 patients with small (less than 5.0 cm), solid, clinically localized renal masses were prospectively identified and evaluated with computed tomography guided FNA with analysis for presence of malignant cells and determination of nuclear grade. The final pathologic findings were used for comparison in each case. All patients had renal cell carcinoma and were managed with radical or partial nephrectomy; 3 had low-grade lesions (Fuhrman's grade 1/4), 2 had high-grade lesions (Fuhrman's grade 4/4), and all other patients had intermediate-grade lesions (Fuhrman's grade 2/4 or 3/4) on final histopathologic assessment. RESULTS: Overall, 10 aspirations yielded diagnostic malignant cells, and 9 were read as rare as rare atypical cells suspicious for malignancy. The remainder were negative (n = 6). Correlation with final nuclear grade was observed in eight instances and discordance in two instances. Subcapsular hematomas were observed at the time of surgery in 10 patients, but in no instance was the operation adversely affected. CONCLUSIONS: The diagnostic yield of FNA of small, solid renal masses appears to be too low to justify the potential morbidity of the procedure.

Spiral noncontrast CT versus combined plain radiography and renal US after extracorporeal shock wave lithotripsy: cost-identification analysis.

PURPOSE: To investigate the costs of spiral computed tomography (CT) versus those of combined plain radiography and renal ultrasound (US) in screening for postprocedural complications after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: Twenty-five adult patients who had undergone ESWL were prospectively examined with spiral CT, renal US, and plain abdominal radiography. Each examination was timed, and direct technical costs were calculated by using a procedural-based cost-accounting system. The combined cost of US and plain radiography was compared with the cost of spiral CT. RESULTS: The average time for spiral CT was 15.3 minutes compared with 37.2 minutes for combined US and plain radiography. The direct technical cost of spiral CT was $36.86 compared with $57.60 for combined US and plain radiography. Average examination times were varied to assess the effect on overall costs. Within reasonable time ranges, combined US and plain radiography cannot be cost equivalent to spiral CT. CONCLUSION: Spiral CT is faster and is associated with less direct technical cost than combined US and plain radiography when used to examine patients after ESWL, given the dependence of this model on time of examination. Further studies are needed to assess the relative accuracy of these alternative approaches.