Experience of a single academic institution with the National Accreditation Program for Rectal Cancer and the resulting improvement in care.

AIM: The American College of Surgeons Committee on Cancer developed the National Accreditation Program for Rectal Cancer (NAPRC) to reduce variations in rectal cancer care, standardize clinical practice and encourage multidisciplinary approaches. The aim of this study was to analyse if accreditation achieved a higher quality of care at one hospital. METHOD: The University of California Davis Medical Center was accredited in 2019. A retrospective review of rectal adenocarcinoma patients was performed between the years 2013 and 2018. Patients presenting from 2013 to 2015 were discussed at a gastrointestinal tumour board while patients in 2018 had an accredited rectal cancer tumour board. Patients from 2016 to 2017 were excluded as the programme was still developing. Compliance to the NAPRC standards was compared between the cohorts. RESULTS: One hundred and thirty patients were evaluated, 88 (68%) in the prerectal tumour board cohort and 42 (32%) in the rectal tumour board cohort. The prerectal tumour board cohort often failed to meet attendance standards. All patients in the rectal tumour board cohort met all criteria. Similarly, clinical service compliance improved in the rectal tumour board cohort for 13 metrics, 10 of which were statistically significant. Although a high proportion of patients in both groups experienced quality surgery, i.e. complete total mesorectal excision and negative margins, the lack of complete pathological reporting in the prerectal tumour board cohort limited analysis. CONCLUSION: Multidisciplinary rectal cancer tumour boards are associated with improved compliance with recommended care by the NAPRC. Patients discussed at a rectal cancer tumour board were more likely to receive appropriate staging, coordinated care and have better clinical documentation.

Sonographic Assessment of Acute Versus Chronic Cholecystitis: An Ultrasound Probability Stratification Model.

OBJECTIVES: What sonographic variables are most predictive for acute cholecystitis? What variables differentiate acute and chronic cholecystitis? METHODS: The surgical pathology database was reviewed to identify adult patients who underwent cholecystectomy for cholecystitis and had a preceding ultrasound of the right upper quadrant within 7 days. A total of 236 patients were included in the study. A comprehensive imaging review was performed to assess for gallstones, gallbladder wall thickening, gallbladder distension, pericholecystic fluid, gallstone mobility, the sonographic Murphy's sign, mural hyperemia, and the common hepatic artery peak systolic velocity. RESULTS: Of 236 patients with a cholecystectomy, 119 had acute cholecystitis and 117 had chronic cholecystitis on surgical pathology. Statistical models were created for prediction. The simple model consists of three sonographic variables and has a sensitivity of 60% and specificity of 83% in predicting acute versus chronic cholecystitis. The most predictive variables for acute cholecystitis were elevated common hepatic artery peak systolic velocity, gallbladder distension, and gallbladder mural abnormalities. If a patient had all three of these findings on their preoperative ultrasound, the patient had a 96% chance of having acute cholecystitis. Two of these variables gave a 73-93% chance of having acute cholecystitis. One of the three variables gave a 40-76% chance of having acute cholecystitis. If the patient had 0 of 3 of the predictor variables, there was a 29% chance of having acute cholecystitis. CONCLUSIONS: Gallbladder distension, gallbladder mural abnormalities, and elevated common hepatic artery peak systolic velocity are the most important sonographic variables in predicting acute versus chronic cholecystitis.

Ultrasound Screening for Transplant Renal Artery Stenosis Risk Stratification Using Standardized Criteria in Structured Reporting: A Validation Study.

OBJECTIVES: To evaluate the effectiveness of templated ultrasound reports using transplant renal artery stenosis (TRAS) risk stratification (RS), particularly with regard to utilization of downstream angiographic studies and angiographic presence of TRAS. METHODS: Ultrasounds with TRAS-RS templated reports from August 2017 to May 2020 were included. Studies were excluded if performed <28 days posttransplant and where TRAS was not clinically considered. A total of 530 ultrasounds met inclusion/exclusion criteria. TRAS-RS criteria were recorded (renal artery velocity ≥300 cm/s, spectral broadening in the renal artery, and intraparenchymal acceleration time ≥0.1 second). Depending on the number of criteria present, recipients were stratified into low (0/3), intermediate (1/3), high (2/3), and very high (3/3) risk for TRAS. Student's t-test was performed to identify whether the TRAS-RS category was associated with 1) performance of angiography to assess for TRAS and 2) angiographic presence of TRAS. RESULTS: Of the 530 ultrasounds, 74 (14%) underwent angiography. Of these, 41 (55%) were positive for TRAS (overall positive rate, 8%). Number of ultrasounds, angiograms, and angiograms positive for TRAS, respectively, in each of the TRAS-RS categories for the 530 cases were: low probability: n = 370 (70% of all studied reports), 7 angiograms (2%), and 0 (0%) positive for TRAS; intermediate: n = 87 (16%), 24 angiograms (28%), and 8 (33%) positive; high: n = 46 (9%), 23 angiograms (50%), and 14 (61%) positive; and very high: n = 27 (5%), 20 angiograms (74%), and 19 (95%) positive. TRAS-RS score was associated with subsequent performance of angiography and positive rate for TRAS (P < .01). CONCLUSION: Implementing a defined ultrasound screening tool with templated reporting for TRAS allowed for effective selection of those requiring an angiogram.

Measuring Rectal Cancer Tumor Height: Concordance Between Clinical Examination and MRI.

BACKGROUND: Rectal cancer is categorized into categories on the basis of tumor height measurements. Tumor height is used to guide initial treatment and determines the eligibility for clinical trials. OBJECTIVE: This study aimed to determine the concordance between tumor heights measured by MRI and by clinical examination. DESIGN: This was an institutional review board-approved retrospective analysis of MRI and the clinical measurements of tumor height. SETTING: This study was conducted at a single university center that was accredited by the Commission on Cancer National Accreditation Program for Rectal Cancer. PATIENTS: Ninety-five patients who were treated between 2015 and 2019 and who had an MRI and clinical evaluation were included. MAIN OUTCOME MEASUREMENTS: The mean difference of tumor height between MRI and clinical examination was calculated. Secondary outcomes were to assess whether position in the rectum, age, BMI, or sex would affect the difference and how the measurements would change eligibility for rectal cancer trials. RESULTS: Tumor height measurement by MRI and clinical examination had a good correlation, with r = 0.89 and p < 0.001. The mean absolute difference of measurement of tumor height was 1.56 cm. Higher tumors had a larger absolute difference between measurements. Body mass index was significantly associated with the difference in measurements. The discordance in measurements led to a change in eligibility for clinical trials for 38.9% of patients. Clinical trial eligibility was not significantly associated with tumor height category, sex, or patient age. LIMITATIONS: This study was conducted at a single center with retrospective methodology. CONCLUSIONS: Although MRI and clinical measurements showed a strong correlation, nearly 40% of our patients had a change in clinical trial eligibility depending on measurement modality. We suggest that trial investigators be consistent in establishing measurement technique as their inclusion criterion. See Video Abstract at http://links.lww.com/DCR/B756. MEDICIN DE LA ALTURA DEL TUMOR DE CNCER DE RECTO CONCORDANCIA ENTRE EL EXAMEN CLNICO Y LA RESONANCIA MAGNTICA: ANTECEDENTES:El cáncer de recto se clasifica en categorías basadas en las mediciones de la altura del tumor. La altura del tumor se usa para guiar el tratamiento inicial y determina la elegibilidad para los ensayos clínicos.OBJETIVO:Determinar la concordancia entre la altura de los tumores medida por resonancia magnética (RMN) y por examen clínico.DISEÑO:Este fue un análisis retrospectivo aprobado por el IRB de la resonancia magnética y las mediciones clínicas de la altura del tumor.AJUSTE:Esto se llevó a cabo en un único centro universitario que fue acreditado por el Programa Nacional de Acreditación del Cáncer de Recto de la Comisión de Cáncer.PACIENTE:Se incluyeron 95 pacientes que fueron atendidos entre 2015 y 2019 y que tuvieron una resonancia magnética y evaluación clínica.PRINCIPALES MEDIDAS DE RESULTADOS:Se calculó la diferencia media de la altura del tumor entre la resonancia magnética y el examen clínico. Los resultados secundarios fueron evaluar si la posición en el recto, la edad, el índice de masa corporal (IMC) o el sexo afectarían la diferencia y cómo las mediciones cambiarían la elegibilidad para los ensayos de cáncer de recto.RESULTADOS:La medición de la altura del tumor por resonancia magnética y el examen clínico tuvo una buena correlación con r = 0,89 y p < 0,001. La diferencia absoluta media de medición de la altura del tumor fue de 1,56 cm. Los tumores más altos tenían una diferencia absoluta más grande entre las mediciones. El IMC se asoció significativamente con la diferencia en las mediciones. La discordancia en las mediciones llevó a un cambio en la elegibilidad para los ensayos clínicos para el 38,9% de los pacientes. La elegibilidad para ensayos clínicos no se asoció significativamente con la categoría de altura del tumor, el sexo o la edad del paciente.LIMITACIONES:Se realizó en un solo centro con metodología retrospectiva.CONCLUSIONES:Aunque la resonancia magnética y las mediciones clínicas mostraron una fuerte correlación, casi el 40% de nuestros pacientes tuvieron un cambio en la elegibilidad para los ensayos clínicos según la modalidad de medición. Sugerimos que los investigadores del ensayo sean coherentes al establecer la técnica de medición como criterio de inclusión. Consulte Video Resumen en http://links.lww.com/DCR/B756.

Clinical Importance of Incidentally Detected Hyperenhancing Liver Observations on Portal Venous Phase Computed Tomography in Patients Without Known Malignancy or Liver Disease.

OBJECTIVE: The aim of the study was to determine the prevalence of clinically important masses among incidental hyperenhancing liver observations on portal venous phase computed tomography (CT) in patients without known malignancy or liver disease. METHODS: Retrospective search of portal venous phase CTs was performed to identify hyperenhancing liver observations in patients without cancer or liver disease. Observations were assigned a morphology of homogeneous, hemangioma, or heterogeneous. The reference standard was pathology (n = 2), liver protocol CT/magnetic resonance imaging (n = 40), follow-up portal venous phase CT for 2 years or more (n = 81), or clinical follow-up for 5 years or more (n = 107). RESULTS: There were no clinically important masses among 83 observations with homogeneous morphology or 110 with hemangioma morphology. There were 2 clinically important masses (1 hepatocellular carcinoma and 1 hepatic adenoma) among 37 (5.4%) heterogeneous morphology observations. CONCLUSIONS: Incidental hyperenhancing liver observations on portal venous phase CT with homogeneous or typical hemangioma morphology in patients without known cancer or liver disease are highly likely benign.

Incidental Pancreatic Cysts on Cross-Sectional Imaging.

Incidental pancreatic cysts are commonly encountered in radiology practice. Although some of these are benign, mucinous varieties have a potential to undergo malignant transformation. Characterization of some incidental pancreatic cysts based on imaging alone is limited, and given that some pancreatic cysts have a malignant potential, various societies have created guidelines for the management and follow-up of incidental pancreatic cysts. This article reviews the imaging findings and work-up of pancreatic cysts and gives an overview of the societal guidelines for the management and follow-up of incidental pancreatic cysts.

Sonographically Diagnosed Urothelial Thickening in Kidney Allografts: A Noninvasive and Clinically Highly Relevant Marker for the Detection of Acute Rejection.

OBJECTIVE. The objective of our study was to investigate the significance of sonographic features in assessing for acute kidney allograft rejection in the modern era. MATERIALS AND METHODS. In this retrospective study, 107 adult patients with a kidney allograft biopsy performed between 2015 and 2018 and diagnostic ultrasound performed within 2 weeks of the biopsy were included. Acute rejection was diagnosed on the basis of biopsy tissue sample results using the Banff criteria. The following ultrasound features were assessed: perfusion, cortical echogenicity, corticomedullary differentiation, urothelial thickening, change in renal length, renal artery velocity, and intraparenchymal arterial resistive index. Subjective measures of perfusion, echogenicity, corticomedullary differentiation, and urothelial thickening were assessed independently and in consensus by three abdominal radiologists; multirater kappa values were calculated for interobserver variability. The Wilcoxon rank sum test and chi-square test were used to evaluate the differences between two groups (rejection vs no rejection) and the sonographic features. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were calculated for sonographic features that are associated with acute rejection. RESULTS. Of the sonographic features, only the presence of urothelial thickening was significantly associated with acute rejection (p < 0.001) and had substantial agreement (κ = 0.61) among readers. Urothelial thickening was highly sensitive (96%; 95% CI, 79-100%) with a high NPV (98%; 95% CI, 86-100%). CONCLUSION. Urothelial thickening on ultrasound is a highly sensitive finding for acute kidney rejection with a high NPV and thus may play a role in sonographic prebiopsy screening. Other historically associated sonographic features seem to play little, if any, role in the screening and assessment for kidney allograft rejection in the modern era.

Effect and Safety of Radiation Therapy Boost to Extramesorectal Lymph Nodes in Rectal Cancer.

PURPOSE: In rectal cancer, the presence of extramesorectal/lateral pelvic lymph node (LPN) is associated with higher risk of locoregional and distant recurrences. LPNs are not typically resected during a standard total mesorectal excision (TME) procedure, and the optimal management for these patients is controversial. We assessed the safety and efficacy of adding a radiation therapy boost to clinically positive LPN during neoadjuvant chemoradiation therapy for rectal cancer. METHODS AND MATERIALS: We analyzed nonmetastatic, lymph node positive rectal adenocarcinoma patients treated with neoadjuvant chemoradiation therapy followed by TME between May 2011 and February 2018. Patients without LPN involvement received external beam radiation therapy (45 Gy in 25 fractions) to the primary tumor and regional draining lymph node basins followed by a boost (5.4 Gy in 3 fractions) to gross disease. Patients with clinically positive LPN that would not be removed during TME received an additional boost (up to a total dose between 54.0 and 59.4 Gy) to the involved LPNs. We compared locoregional control, overall survival, progression-free survival, and treatment-related toxicity between these 2 groups. RESULTS: Fifty-three patients were included in this analysis with median follow-up of 30.6 months for the LPN- group (n = 41) and 19.9 months for the LPN+ group (n = 12). There was no difference in 3-year overall survival (90.04% vs 83.33%, P = .890) and progression-free survival (80.12% vs 80.21%, P = .529) between the 2 groups. We did not observe any LPN recurrences. There were no differences in rates of acute grade 3+ or chronic toxicities. CONCLUSIONS: Despite the well-documented negative prognostic effect of LPN metastasis, we observed promising outcomes for LPN+ patients treated with an additional radiation boost. Our results suggest that radiation therapy boost to clinically involved, unresected LPN is an effective treatment approach with limited toxicity. Additional studies are needed to optimize treatment strategies for this unique patient subset.

Differences in Growth Rate on CT of Adrenal Adenomas and Malignant Adrenal Nodules.

OBJECTIVE. The purpose of this study is to determine the differences in growth rate of adrenal adenomas and malignant adrenal nodules. MATERIALS AND METHODS. This was a retrospective review of adults with an adrenal nodule seen at two different abdominal or chest CT examinations or PET/CT examinations. Patients in the adenoma group were included if they had a CT, MRI, or pathologic diagnosis of an adrenal adenoma. Patients in the malignant group were included if they had a pathologically proven malignant adrenal nodule. Nodule growth was defined as a change in the largest axial diameter greater than or equal to 3 mm. Growth rate was calculated by dividing the change in the longest axial diameter by the time between the first and last imaging examination. RESULTS. There were 105 adenomas and 26 malignant nodules. Of the 105 adenomas, 34 (32.4%; 95% CI, 23.6-42.2%) grew, three (2.9%; 95% CI, 0.6-8.1%) became smaller, and 68 (64.8%; 95% CI, 54.8-73.8%), were unchanged in size. All 26 (100%; 95% CI, 89.1-100%) malignant nodules grew. The mean (± SD) growth rate of adenomas was 1.0 ± 0.67 mm/year (range, 0.3-2.8 mm/year), compared with 58.4 ± 78.5 mm/year (range, 5.8-395.4 mm/year) for malignant nodules (p < 0.001). A growth rate of 3 mm/year distinguished adenomas from malignant nodules with a sensitivity of 100% (95% CI, 86.8-100%) and a specificity of 100% (95% CI, 96.6-100%). CONCLUSION. Approximately one-third of radiologically proven adrenal adenomas grew, all of which grew at a rate less than 3 mm/year. All malignant adrenal nodules grew, and all at a rate greater than 5 mm/year.

Musculoskeletal Imaging Findings of Hematologic Malignancies.

Hematologic malignancies comprise a set of prevalent yet clinically diverse diseases that can affect every organ system. Because blood components originate in bone marrow, it is no surprise that bone marrow is a common location for both primary and metastatic hematologic neoplasms. Findings of hematologic malignancy can be seen with most imaging modalities including radiography, computed tomography (CT), technetium 99m (99mTc) methylene diphosphonate (MDP) bone scanning, fluorine 18 (18F) fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT, and magnetic resonance (MR) imaging. Because of the diversity of imaging appearances and clinical behavior of this spectrum of disease, diagnosis can be challenging, and profound understanding of the underlying pathophysiologic changes and current treatment modalities can be daunting. The appearance of normal bone marrow at MR imaging and FDG PET/CT is also varied due to dynamic compositional changes with normal aging and in response to hematologic demand or treatment, which can lead to false-positive interpretation of imaging studies. In this article, the authors review the normal maturation and imaging appearance of bone marrow. Focusing on lymphoma, leukemia, and multiple myeloma, they present the spectrum of imaging findings of hematologic malignancy affecting the musculoskeletal system and the current imaging tools available to the radiologist. They discuss the imaging findings of posttreatment bone marrow and review commonly used staging systems and consensus recommendations for appropriate imaging for staging, management, and assessment of clinical remission. ©RSNA, 2017.

The clinical content of preconception care: preconception care for men.

Little attention has been given to men's preconception health and health care. This paper reviews the key elements of an approach to optimizing the preconception health status of men. Preconception care for men is important for improving family planning and pregnancy outcomes, enhancing the reproductive health and health behaviors of their female partners, and preparing men for fatherhood. Most importantly, preconception care offers an opportunity, similar to the opportunity it presents for women, for disease prevention and health promotion in men. Currently, no consensus exists on service delivery of preconception care for men--who should provide preconception care to whom, where, when, and how, and there are significant barriers to this care including the organization, financing, training, and demand. Finally, much more research on the content and how to effectively market and implement preconception care for men is needed.