Wall suction-assisted image-guided thoracentesis: a safe alternative to evacuated bottles.

AIM: To compare the safety of evacuated bottle-assisted thoracentesis with wall suction-assisted thoracentesis. MATERIALS AND METHODS: An institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective study of 161 consecutive patients who underwent 191 evacuated bottle-assisted thoracenteses from 1 January 2012 to 30 September 2012, and 188 consecutive patients who underwent 230 wall suction-assisted thoracenteses from 1 January 2013 to 30 September 2013 was conducted. All procedures used imaging guidance. Primary diagnosis, age, gender, total fluid volume removed, and adverse events (AE) up to 30 days post-procedure were recorded and graded using Common Terminology Criteria for Adverse Events 4.0 (CTCAE)2. RESULTS: Overall AE rates were 42.9% (82/191) for the evacuated bottle group and 19.6% (45/230) for the wall suction group (p<0.0001). Grade I AE occurred more commonly in the evacuated bottle group than in the wall suction group, [41.9% (80/191) and 18.3% (42/230)], respectively (p<0.0001). No significant differences were observed in grade 2 [0.5% (1/191) and 0% (0/230), p=0.45] or grade 3 AE [0.5% (1/191) and 1.3% (3/230), p=0.63] between the evacuated bottle and wall suction groups, respectively. No grade 4 or 5 AE occurred. Excluding transient chest pain and cough, there was no statistical difference in overall AE rate between the evacuated bottle and wall suction groups [11% (21/191) and 8.3% (19/230), p=0.4]. CONCLUSION: Image-guided thoracentesis performed with wall suction is safe when compared to evacuated bottles. The use of wall suction, in comparison to evacuated bottles, may decrease the incidence of transient chest pain or cough.

Breath-hold PET/CT-guided tumour ablation under general anaesthesia: accuracy of tumour image registration and projected ablation zone overlap.

AIM: To assess single-breath-hold combined positron-emission tomography/computed tomography (PET/CT) for accuracy of tumour image registration and projected ablation volume overlap in patients undergoing percutaneous PET/CT-guided tumour-ablation procedures under general anaesthesia. MATERIALS AND METHODS: Eight patients underwent 12 PET/CT-guided tumour-ablation procedures to treat 20 tumours in the lung, liver, or adrenal gland. Using breath-hold PET/CT, the centre of the tumour was marked on each PET and CT acquisition by four readers to assess two- (2D) and three-dimensional (3D) spatial misregistration. Overlap of PET and CT projected ablation volumes were compared using the Dice similarity coefficient (DSC). Interobserver differences were assessed with repeated measure analysis of variance (ANOVA). Technical success and local progression rates were noted. RESULTS: Mean tumour 2D PET/CT misregistrations were 1.02 mm (range 0.01-5.02), 1.89 (0.03-7.85), and 3.05 (0-10) in the x, y, and z planes. Mean 3D misregistration was 4.4 mm (0.36-10.74). Mean projected PET/CT ablation volume DSC was 0.72 (±0.19). No significant interobserver differences in 3D misregistration (p=0.73) or DSC (p=0.54) were observed. Technical success of ablations was 100%; one (5.3%) of 19 tumours progressed. CONCLUSION: Accurate spatial registration of tumours and substantial overlap of projected ablation volumes are achievable when comparing PET and CT acquisitions from single-breath-hold PET/CT. The results suggest that tumours visible only at PET could be accurately targeted and ablated using this technique.

PET/CT-guided percutaneous liver mass biopsies and ablations: targeting accuracy of a single 20 s breath-hold PET acquisition.

AIM: To determine whether a single 20 s breath-hold positron-emission tomography (PET) acquisition obtained during combined PET/computed tomography (CT)-guided percutaneous liver biopsy or ablation procedures has the potential to target 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG)-avid liver masses as accurately as up to 180 s breath-hold PET acquisitions. MATERIALS AND METHODS: This retrospective study included 10 adult patients with 13 liver masses who underwent FDG PET/CT-guided percutaneous biopsies (n = 5) or ablations (n = 5). PET was acquired as nine sequential 20 s, monitored, same-level breath-hold frames and CT was acquired in one monitored breath-hold. Twenty, 40, 60, and 180 s PET datasets were reconstructed. Two blinded readers marked tumour centres on randomized PET and CT datasets. Three-dimensional spatial localization differences between PET datasets and either 180 s PET or CT were analysed using multiple regression analyses. Statistical tests were two-sided and p < 0.05 was considered significant. RESULTS: Targeting differences between 20 s PET and 180 s PET ranged from 0.7-20.3 mm (mean 5.3 ± 4.4 mm; median 4.3) and were not statistically different from 40 or 60 s PET (p = 0.74 and 0.91, respectively). Targeting differences between 20 s PET and CT ranged from 1.4-36 mm (mean 9.6 ± 7.1 mm; median 8.2 mm) and were not statistically different from 40, 60, or 180 s PET (p = 0.84, 0.77, and 0.35, respectively). CONCLUSION: Single 20 s breath-hold PET acquisitions from PET/CT-guided percutaneous liver procedures have the potential to target FDG-avid liver masses with equivalent accuracy to 180 s summed, breath-hold PET acquisitions and may facilitate strategies that improve image registration and shorten procedure times.

Attitudes of patients with metastatic breast cancer toward research biopsies.

BACKGROUND: Research studies involving human tissue are increasingly common. However, patients' attitudes toward research biopsies are not well characterized, particularly when the biopsies are carried out outside the context of therapeutic trials. PATIENTS AND METHODS: One hundred sixty patients with metastatic breast cancer (MBC) from two academic (n = 80) and two community (n = 80) hospitals completed a 29-item self-administered survey to evaluate their willingness to consider providing research purposes only biopsies (RPOBs) (as a stand-alone procedure) and additional biopsies (ABs) (additional needle passes at the time of a clinically indicated biopsy). RESULTS: Eighty-two (51%) of 160 patients would consider having RPOBs, of which 42 (53%) and 40 (50%) patients were from academic and community hospitals, respectively. Patients who had more prior biopsies were less likely to consider RPOBs (RR = 0.6, 95% CI: 0.4-1.0, P = 0.03). Of 160 patients, 115 (72%) patients would consider having ABs. Of these, 64 (80%) and 51 (64%) patients from academic and community hospitals, respectively, would consider ABs (RR = 1.2, 95% CI: 1.0-1.5, P = 0.03). CONCLUSIONS: Many patients with MBC in both academic and community settings report willingness to consider undergoing biopsies for research. Further research is needed to understand ethical, logistical and provider-based barriers to broader participation in such studies.

Virtual unenhanced CT images acquired from dual-energy CT urography: accuracy of attenuation values and variation with contrast material phase.

AIM: To determine how representative virtual unenhanced (VNE) images are of true unenhanced (TNE) images when performing computed tomography (CT) urography on a dual-energy CT (DECT) system, and whether the images are affected by the contrast material phase. MATERIALS AND METHODS: In this retrospective, institutional review board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study, TNE were compared with VNE images derived from the nephrographic (VNEn) and excretory (VNEe) phases in 100 consecutive CT urograms. Two readers in consensus measured attenuation values of abdominal organs, fat, and renal lesions (>1 cm). Image noise was correlated with patient thickness. Detectability of renal stones was evaluated. Image quality and acceptability was assessed using a five-point scale. Expected dose saving by removing the TNE phase was calculated. RESULTS: VNE attenuation values of liver, renal parenchyma, and aorta were significantly different to TNE values (p < 0.05); spleen and fat attenuation values showed no significant difference. No significant difference was found between VNEn and VNEe images. Image noise was significantly greater in TNE images (p < 0.0001) and correlated with patient thickness. VNEn and VNEe images had sensitivities of 76.6 and 65.6% for detection of stones, identifying all stones greater than 3 and 4 mm, respectively. Both VNE images received significantly lower image quality scores than TNE images (p < 0.0001); however, the majority of images were deemed acceptable. The mean theoretical dose saving by removing the TNE phase was 35%. CONCLUSION: Although VNE images demonstrate high reader acceptability, accuracy of attenuation values and detection of small stones is limited. The contrast material phase, however, does not affect attenuation values. Further validation of VNE images is recommended prior to clinical implementation.

Gastrointestinal tract wall visualization and distention during abdominal and pelvic multidetector CT with a neutral barium sulphate suspension: comparison with positive barium sulphate suspension and with water.

OBJECTIVE: When examining patients with contrast-enhanced multidetector-row CT, we determined if the stomach and small bowel were visualized and distended better with a neutral barium sulphate suspension than with positive barium sulphate suspension or water. MATERIALS AND METHODS: After obtaining approval from our institutional review board, 156 patients (women: 84; mean age: 54 yrs) with no history of gastrointestinal tract disease were randomized prospectively to receive orally either 900 ml of neutral (0.1% w/v) barium sulphate suspension (n = 53), 900 ml of positive (2.1% w/v) barium sulphate suspension (n = 53), or 900 ml of water (n = 50), prior to undergoing contrast-enhanced abdominal and pelvic multidetector-row CT. Two independent radiologists evaluated the stomach, and small bowel, for luminal distension and wall visualization, using a five point scale. Results were compared using Kruskal-Wallis and Mann-Whitney U tests. RESULTS: The walls of the stomach, and small bowel were visualized better in patients who were administered neutral barium sulphate suspension than those who were administered either positive barium sulphate suspension (p < 0.01) or water (p < 0.01). In patients who received neutral barium sulphate suspension, the stomach and small bowel were distended better compared to patients administered water (p < 0.01); the stomach, duodenum, and ileum were distended better compared to patients administered positive barium sulphate suspension (p < 0.05). CONCLUSIONS: When examining patients with intravenous contrast-enhanced abdominal and pelvic multidetector-row CT, orally administered neutral barium sulphate suspension allows the gastrointestinal tract to be visualized and distended better than either positive barium sulphate suspension, or water.

Noninvasive multidetector computed tomography enterography in patients with small-bowel Crohn's disease: is a 40-second delay better than 70 seconds?

BACKGROUND: Multidetector computed tomography (MDCT) enterography combines neutral enteric contrast with intravenously administered contrast material. The optimal intravenous (IV) contrast material protocol has still not been established. PURPOSE: To determine the optimal delay time to image patients with small-bowel Crohn's disease during MDCT enterography. MATERIAL AND METHODS: After oral administration of 1350 ml of neutral contrast medium, 26 patients with small-bowel Crohn's disease underwent MDCT enterography;scans were obtained 40 s (enteric phase) and 70 s (parenchymal phase) after IV administration of 100 ml of iodinated contrast material. Three radiologists, blinded to clinical and pathological findings, independently and retrospectively evaluated each scan in two separate reading sessions for the presence or absence of CT features of Crohn's disease activity. The interobserver agreement was evaluated, and the efficacy of each phase in detecting active disease in the terminal ileum for each reader was determined. The gold standard was pathology (n=13), endoscopy (n=3), and clinical evaluation (n=10). RESULTS: No statistically significant difference was present between the enteric and the parenchymal phase for each reader in each segment regarding the presence or absence of CT features of Crohn's disease. The interobserver agreement for the presence of five main features of active Crohn's disease in the terminal ileum ranged from poor to excellent.The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for active Crohn's disease in the terminal ileum ranged from 40 to 90%, 88 to 100%, 70 to 94%, 44 to 100%, and 69 to 96%, respectively. There was no statistical difference between the two phases for each reader. CONCLUSION: MDCT enterography in patients with suspected active Crohn's disease can be obtained at either 40 s or 70 s after IV contrast material.

Fatal, complete splenic infarction and hepatic infection due to disseminated Trichosporon beigelii infection: CT findings.

We report on a 56-year-old woman with acute lymphocytic leukemia who presented with right upper quadrant pain, fever, nausea, and vomiting. Laboratory studies confirmed fungemia with Trichosporum beigelii, and contrast-enhanced computed tomography of the abdomen demonstrated numerous low-attenuation liver lesions and a hypodense spleen with capsular enhancement suggestive of complete splenic infarction. Subsequent splenectomy confirmed that the spleen was completely infarcted and infiltrated with Trichosporum. The patient had a difficult postoperative course and died despite aggressive antifungal therapy.

Usual and unusual causes of extrahepatic cholestasis: assessment with magnetic resonance cholangiography and fast MRI.

Cholestasis may result from hepatocellular (intrahepatic) disease or biliary tract (extrahepatic) abnormalities. Etiologies causing extrahepatic cholestasis are extremely diverse and invasive procedures, such as endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC), were previously required to establish the diagnosis. Due to refinements of magnetic resonance imaging (MRI) techniques, the patient with extrahepatic cholestasis currently can be evaluated noninvasively, and the information revealed frequently exceeds the findings obtained by ERCP and PTC. In this essay, we illustrate the classic MR cholangiographic (MRC) and MRI features of a variety of disorders causing extrahepatic cholestasis, including non-neoplastic disorders of the biliary tract (congenital abnormalities, infectious processes, iatrogenic disorders, and postsurgical complications) and neoplastic conditions (e.g., tumors of the pancreas, biliary tree, liver, ampulla, and regional lymph nodes). In most cases, familiarity with the key MRC features in addition to information obtained via cross-sectional MR images provide sufficient information for adequate lesion characterization.

Asymptomatic nonspecific serum hyperamylasemia and hyperlipasemia: spectrum of MRCP findings and clinical implications.

We assessed the magnetic resonance cholangiopancreatographic (MRCP) findings in patients with asymptomatic, mild elevations of serum amylase and lipase levels to determine whether there might be a pathoanatomic cause for these laboratory abnormalities. MRCP was performed in 633 consecutive patients. Of these, 54 (8.5%) images were obtained in patients with asymptomatic serum hyperamylasemia and hyperlipasemia. MRCP was performed on a 1.0-T MR system; breath-hold gradient-recall, half-Fourier acquisition, and rapid acquisition with relaxation enhancement sequences were obtained. Findings were verified by follow-up, biopsy, or surgery. One-sided, large-sample z tests were used to compare the incidence of abnormalities between the study and control groups (579 patients). The pancreas appeared abnormal on MRCP in 31 patients (57%), including the pancreas divisum in 10 patients (18.5%). Other findings included morphologic changes compatible with chronic pancreatitis in nine patients (16.6%) and a healed pancreatic laceration, juxtapapillary duodenal diverticulum, papillary sclerosis, intraductal pancreatic lithiasis, and hemochromatosis in one patient each (1.9%). Small cystic lesions (< 1 cm) within the pancreas were seen in 15 patients (27.8%). In eight patients, these were associated with other abnormalities (pancreas divisum in three patients, chronic pancreatitis in four, and pancreatic laceration in one). No malignancy was diagnosed. The incidences of normal examination (p = 0.01), pancreas divisum (p < 0.005), and a small cystic lesion (p = 0.01) as solitary findings in this subgroup of patients were significantly higher when compared with the remainder of the studied population. Investigation of asymptomatic patients with nonspecific hyperamylasemia and hyperlipasemia by means of MRCP yielded pancreatic findings in more than 50% of these patients. Pancreas divisum was found more often than expected in the general population.

Large retroperitoneal hibernoma in an adult male: CT imaging findings with pathologic correlation.

Hibernoma is a rare benign tumor consisting primarily of brown fatty tissue. It is usually seen in locations where normal brown adipose tissue is found in fetuses and infants such as the periscapular or interscapular region, the neck, the axilla, the thorax, and, more rarely, the retroperitoneum. We report the computed tomographic findings and pathologic features of a large retroperitoneal hibernoma discovered in an adult male. Radiologists and surgeons should be aware that hibernoma should be included in the differential diagnosis of a large fatty retroperitoneal soft tissue tumor.

State-of-the-art imaging of acute pancreatitis.

The purpose of this essay is to focus on the characteristic imaging features, as revealed by a variety of radiological modalities, which allow for an accurate diagnosis and staging of acute pancreatitis. In addition, emphasis will be made on the role of imaging in providing early prognostic information about the outcome of the disease.

Solid and papillary epithelial neoplasm of the pancreas: MR imaging findings.

We present the magnetic resonance imaging (MRI) findings in a young patient with histological proven solid and papillary epithelial neoplasm of the pancreas. Although the appearance of this tumor at MRI can be useful in making a correct preoperative diagnosis, only few cases describing its MRI features have been reported in the radiological literature.

MR imaging-guided prostate biopsy with surgical navigation software: device validation and feasibility.

Magnetic resonance (MR) imaging--guided prostate biopsy in a 0.5-T open imager is described, validated in phantom studies, and performed in two patients. The needles are guided by using fast gradient-recalled echo and T2-weighted fast spin-echo images. Surgical navigation software provided T2-weighted images critical to targeting the peripheral zone and the tumor. MR imaging can be used to guide prostate biopsy.

Primary versus secondary ovarian malignancy: imaging findings of adnexal masses in the Radiology Diagnostic Oncology Group Study.

PURPOSE: To analyze ultrasonographic (US), computed tomographic (CT), and magnetic resonance (MR) imaging features of primary and secondary ovarian malignant neoplasms to determine if there is any significant difference in their appearance. MATERIALS AND METHODS: Analysis of the multi-institutional Radiology Diagnostic Oncology Group data revealed 86 patients with primary ovarian carcinoma and 24 patients with a secondary ovarian neoplasm. Numerous imaging features that had been recorded for the adnexal masses with each imaging modality were reviewed and compared between primary and secondary malignant ovarian neoplasms. RESULTS: Of the imaging features assessed with all three modalities, multilocularity as determined at US (P =.02) or MR imaging (P: =.01) was the only significant feature. At US, 30 (37%) of 81 primary ovarian cancers were multilocular, whereas only three (12%) of 24 metastatic neoplasms were multilocular. At MR imaging, 40 (74%) of 54 primary ovarian cancers were multilocular, whereas only five (36%) of 14 metastatic neoplasms were multilocular. Neither a predominately solid appearance nor bilaterality was significantly different between primary and secondary neoplasms. CONCLUSION: For malignant ovarian masses, multilocularity at MR imaging or US favors the diagnosis of primary ovarian malignancy rather than secondary neoplasm, but it is difficult to accurately distinguish between primary and secondary ovarian malignancies.

Abdominal thrombotic and ischemic manifestations of the antiphospholipid antibody syndrome: CT findings in 42 patients.

PURPOSE: To determine the abdominal computed tomographic (CT) findings in patients with antiphospholipid antibody syndrome (APS). MATERIALS AND METHODS: Retrospective review of medical records from two university medical centers from 1994 through 1997 revealed 215 patients who had a hypercoagulable state attributed to primary or secondary APS. Abdominal CT findings in these patients were reviewed for evidence of large-vessel occlusion or visceral ischemia. RESULTS: In 42 (19.5%) of 215 patients with APS (age range, 32-65 years; mean age, 42 years), abdominal thromboses or ischemic events were detected at CT. Twenty-two (52%) had major vascular thromboses, including those in the inferior vena cava (n = 10), portal and superior mesenteric veins (n = 7), splenic vein (n = 4), and aorta (n = 1). Thirty-six (86%) patients had abdominal visceral ischemia resulting in renal infarction (n = 22), bowel ischemia (n = 13), splenic infarction (n = 6), pancreatitis (n = 3), hepatic infarction (n = 1), and/or hepatic dysfunction with portal hypertension (n = 1). In some patients, more than one abdominal organ and/or vessel was involved. CONCLUSION: Patients who have circulating antiphospholipid antibodies are at risk for major abdominal vascular thromboses and organ infarction. Radiologists must be familiar with this syndrome; they may be the first physicians to suggest the diagnosis on the basis of findings of unusual or recurrent sites of thrombosis, especially in young patients.

Abdominal cross-sectional imaging for inpatients with abnormal liver function test results: yield and usefulness.

BACKGROUND: Abdominal cross-sectional imaging is often performed to evaluate abnormal liver function test (LFT) results in hospitalized patients. However, few data are available regarding the yield and usefulness of imaging inpatients for the indication of abnormal LFT results, the process of requesting abdominal imaging studies, or the response to their findings. METHODS: We retrospectively reviewed abdominal imaging scans that were obtained during a 27-month period. We matched the imaging studies done with the indication of abnormal LFT results; all scans were requested using computerized physician order entry. Reports were coded for interpretation and associated process step results. To determine the usefulness of the imaging studies, a random sample of patient charts with positively coded imaging studies were reviewed. Imaging examinations were considered useful if they provided new diagnostic information and/or changed subsequent patient care. RESULTS: Of 6494 abdominal imaging studies, 856 were performed for the indication of abnormal LFT results and matched to both image reports and laboratory results. Report coding judged 37% of interpretations as clinically significant, including 27% with "positive" (abnormal results and explain the abnormal LFT results) examinations. Among the positive examinations, the most common diagnoses were biliary obstruction (25%), cholecystitis (21%), malignancy (20%), and cirrhosis (14%). Positively coded reports provided new clinical information in 63% of these studies and changed patient care in 42% of cases. Process measures assessed provision of additional information to and from radiologists (69% and 8%, respectively) and the frequency with which the findings of current abdominal imaging studies were compared with those of prior studies (59%). CONCLUSION: Abdominal cross-sectional imaging studies performed on inpatients with abnormal LFT results had a high diagnostic yield and frequently changed patient care.

MR imaging-guided percutaneous cryotherapy of liver tumors: initial experience.

PURPOSE: To describe the cryoablation of liver tumors by using a percutaneous approach and intraprocedural magnetic resonance (MR) imaging monitoring and to assess the feasibility and safety of the procedure. MATERIALS AND METHODS: Fifteen hepatic tumors (mean diameter, 2.9 cm) in 12 patients were treated (18 total cryoablations). Fourteen were metastases and one was a hemangioma; all were proved at biopsy. By using a 0.5-T open MR imaging system, cryoneedles were placed and lesions ablated by using real-time monitoring. Clinical signs and symptoms were assessed and laboratory tests performed. Intraprocedural depictions of iceballs were compared with contrast material-enhanced MR imaging-based estimates of cryonecrosis that were obtained 24 hours after cryoablation. RESULTS: MR imaging-guided percutaneous cryotherapy resulted in no serious complications and no clinically important changes in serum liver enzymes or creatinine or myoglobin levels. Intraprocedural MR imaging demonstrated iceballs as sharply marginated regions of signal loss that expanded and engulfed tumors. The maximal iceball size was 4.9 x 2.2 x 2.2 cm with the use of one cryoneedle and 6.0 x 5.6 x 4.9 cm with three cryoneedles. Intraprocedural iceball depictions correlated well with postprocedural cryonecrosis estimates. CONCLUSION: MR imaging-guided percutaneous cryotherapy of liver tumors is feasible and safe. MR imaging can be used to estimate cryotherapy effects and guide therapy intraprocedurally.