Percutaneous kidney biopsy trends in the Medicare population by specialty from 2011 to 2021: implications for nephrology training requirements and radiology referral patterns.

PURPOSE: To study trends in volume and reimbursement for percutaneous kidney biopsy (PKB) by physicians and advanced practice providers (APPs) for Medicare enrollees from 2011-2021. METHODS: Claims from the Medicare Part B Physician/Supplier Procedure Master File (a national Medicare database) for 2011-2021 were extracted using Current Procedural Terminology codes for PKB. Total volumes were compared by provider specialty. Non-facility reimbursement, work Relative Value Unit (RVU) non-facility practice expense RVU, and malpractice RVU were compared. RESULTS: Between 2011 and 2021, total volume of PKB by physicians and APPs increased from 30,753 to 34,090 (10.9%), with a peak of 37,882 in 2019 prior to the COVID 19 pandemic. Radiology performed the majority of procedures during the study period. Relative share for radiology increased from 67.6% to 81.1% while the relative share for internal medicine/nephrology decreased from 24.3% to 14.3%, accelerating between 2019 and 2020. Volume and relative share for APPs marginally increased (from 0.9% to 1.2%). Non-facility reimbursement decreased from $578.96 in 2010 to $568.76 in 2021 (1.7%), work RVU decreased from 2.63 to 2.38 (9.5%), non-facility practice expense RVU decreased from 14.10 to 13.71 (2.8%), and malpractice RVU decreased from 0.31 to 0.21 (32.3%). CONCLUSION: Volume and total share of PKB performed by radiology increased over the study period. Conversely, internal medicine/nephrology performed fewer kidney biopsies. Despite the expanding role for APPs in other image-guided procedures, very few PKBs were performed by APPs throughout the study period. Reimbursement and RVU for PKB declined over the study period.

Management of Incidentally Detected Gallbladder Polyps: Society of Radiologists in Ultrasound Consensus Conference Recommendations.

Gallbladder polyps (also known as polypoid lesions of the gallbladder) are a common incidental finding. The vast majority of gallbladder polyps smaller than 10 mm are not true neoplastic polyps but are benign cholesterol polyps with no inherent risk of malignancy. In addition, recent studies have shown that the overall risk of gallbladder cancer is not increased in patients with small gallbladder polyps, calling into question the rationale for frequent and prolonged follow-up of these common lesions. In 2021, a Society of Radiologists in Ultrasound, or SRU, consensus conference was convened to provide recommendations for the management of incidentally detected gallbladder polyps at US. See also the editorial by Sidhu and Rafailidis in this issue.

Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018.

PURPOSE: To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image guidance. METHODS: Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS: For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION: A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.

Survey Study on the Experience, Practice Patterns, and Preferences of the Fellows of the Society of Radiologists in Ultrasound for Evaluation and Management of Gallbladder Polyps Detected With Ultrasound.

ABSTRACT: Gallbladder polyps (GPs) are a common incidental finding on ultrasound; however, important differences in recommended management exist among professional society guidelines.An electronic survey was sent to 189 fellows of the Society of Radiologists in Ultrasound. Main outcomes included preferences and current practice patterns for evaluation, management, and surveillance of GPs as well as personal lifetime experience with gallbladder sonography and GPs.A total of 64 subjects (34%) with experience in gallbladder sonography completed the study. The estimated combined total number of gallbladder scans seen by the responders was 3,071,880. None of fellows had ever seen a pedunculated GP <1 cm detected on ultrasound that was proven to be malignant at the time of detection or during subsequent follow-up. All of the fellows used size as a feature to stratify recommendations. The median size threshold currently used by Society of Radiologists in Ultrasound fellows for recommending ultrasound follow-up was 6 mm, and their preferred threshold was 7 mm. The median size threshold for recommending surgical consultation was 10 mm, and the preferred threshold was 10 mm. Wall thickening and shape were considered important factors by 76% and 67% of respondents, respectively.Society of Radiologists in Ultrasound fellows tend to provide recommendations most similar to the American College of Radiology and Canadian Association of Radiology guidelines for management of GPs. Many would prefer guidelines that result in fewer recommendations for follow-up and surgical consultation. Despite a substantial combined experience, this survey did not uncover any case of a small GP that was malignant.

Sonography of liver transplantation.

Orthotopic liver transplant (OLT) is established as the definitive treatment of choice for end stage liver disease. Over the years, refined surgical techniques as well as advancements in organ preservation and immunosuppressive regimens have improved graft and patient survival rates. Imaging has also contributed to improved graft and patient survival. Ultrasound is the initial investigation of choice for evaluation of post-transplant anatomy and for identifying early complications. A thorough knowledge of surgical techniques and normal post-operative appearance of the OLT is needed to accurately identify and characterize graft complications. The objective of this article is to review the sonographic findings of normal liver transplant as well as post-operative complications. Indications and contraindications for OLT as well as different surgical techniques will also be briefly reviewed.

Diagnostic value of MRI-derived liver surface nodularity score for the non-invasive quantification of hepatic fibrosis in non-alcoholic fatty liver disease.

OBJECTIVES: To assess the accuracy of MRI-derived liver surface nodularity (LSN) score for staging of hepatic fibrosis in patients with non-alcoholic fatty liver disease (NAFLD). METHODS: Forty-seven patients with clinicopathological diagnosis of NAFLD who underwent 1.5-T liver MRI within 12 months of liver biopsy were included. Axial non-contrast T1-weighted 3D GRE was used for image analysis. LSN of the left lobe was measured using a custom semiautomated software. Histopathologic analysis (F0-F4) served as the reference standard for staging of fibrosis. Mann-Whitney test and Spearman's correlation coefficient were used to compare LSN scores between different stages of fibrosis and to assess the correlation. Diagnostic performance of LSN score for detection of significant (F2-F4) and advanced (F3-F4) fibrosis was assessed by receiver operating characteristics (ROC) curve. p value of less than 0.05 was considered statistically significant different. RESULTS: Twenty-one subjects had advanced fibrosis. The LSN scores among different stages of fibrosis were significantly different (p < 0.001). The correlation between LSN score and stage of fibrosis was also strong (ρ = 0.71; p < 0.001). The areas under ROC curves for detection of significant and advanced fibrosis were 0.80 (95% CI 0.66-0.95) and 0.86 (95% CI 0.75-0.97), using a threshold of 2.23 and 2.44, respectively. This method showed 81% sensitivity and 88% specificity for detection of advanced fibrosis. CONCLUSION: MR-based LSN score is a promising non-invasive objective tool for detection of advanced fibrosis in patients with NAFLD. KEY POINTS: • Liver surface nodularity (LSN) score is a fast retrospective method for precise quantification of nodularity of liver surface. • MR-based LSN score is a promising non-invasive objective tool to accurately detect different stages of fibrosis in patients with non-alcoholic fatty liver disease (NAFLD).

Assessment of Response to Neoadjuvant Therapy Using CT Texture Analysis in Patients With Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinoma.

OBJECTIVE. The goal of this study was to assess the correlation between CT-derived texture features of pancreatic ductal adenocarcinoma (PDAC) and histologic and biochemical markers of response to neoadjuvant treatment as well as disease-free survival in patients with potentially resectable PDAC. SUBJECTS AND METHODS. Thirty-nine patients completed this prospective study protocol between November 2013 and December 2016. All patients received neoadjuvant chemotherapy, underwent surgical resection, and had histologic grading of tumor response. Similar CT protocol was used for all patients. Pancreatic (late arterial) phase of pre- and posttreatment CT scans were evaluated. Histogram analysis and spatial-band-pass filtration were used to extract textural features. Correlation between textural parameters, histologic response, biochemical response, and genetic mutations was assessed using Mann-Whitney test, chi-square analysis, and multivariate logistic regression. Association with disease-free survival was assessed using Kaplan-Meier method and Cox model. RESULTS. Pretreatment mean positive pixel (MPP) at fine- and medium-level filtration, pretreatment kurtosis at medium-level filtration, changes in kurtosis, and pretreatment tumor SD were statistically different between patients with no or poor histologic response and favorable histologic response (p < 0.05). Changes in skewness and kurtosis at medium-level filtration significantly correlated with biochemical response (p < 0.01). On the basis of multivariate analysis, patients with higher MPP at pretreatment CT were more likely to have favorable histologic response (odds ratio, 1.06; 95% CI, 1.002-1.12). The Cox model for association between textural features and disease-free survival was statistically significant (p = 0.001). CONCLUSION. Textural features extracted from baseline pancreatic phase CT imaging of patients with potentially resectable PDAC and longitudinal changes in tumor heterogeneity can be used as biomarkers for predicting histologic response to neoadjuvant chemotherapy and disease-free survival.

Comparison of 2D Shear Wave Elastography, Transient Elastography, and MR Elastography for the Diagnosis of Fibrosis in Patients With Nonalcoholic Fatty Liver Disease.

OBJECTIVE. The aim of the present study was to compare the diagnostic accuracy of liver stiffness measurements (LSMs) obtained using MR elastography (MRE), transient elastography (TE), and 2D shear wave elastography (SWE) in patients with biopsy-proven nonalcoholic fatty liver disease (NAFLD). SUBJECTS AND METHODS. We prospectively enrolled 62 adult subjects (mean age [± SD], 50 ± 13 years; 58% women; body mass index [weight in kilograms divided by the square of height in meters], 35 ± 7). Two-dimensional SWE, MRE, and TE were performed at a mean of 105 ± 86 days after liver biopsy. The area under the ROC curve (AUROC) values and 95% CIs for the corresponding LSMs (expressed in kilopascals) were calculated, with significant fibrosis (Metavir liver fibrosis score, F2-F4) and advanced fibrosis (F3-F4) used as outcome measures. Pairwise comparisons of AUROC values were conducted using the DeLong test. Statistical significance was set at p < 0.05. RESULTS. For the 62 subjects, valid LSMs were obtained for 57 subjects with the use of 2D SWE, for 59 subjects with TE, for 59 subjects with MRE, and for 54 subjects with all three modalities combined. The AUROC values (95% CIs) of 2D SWE, TE, and MRE for the diagnosis of significant fibrosis were 0.80 (0.67-0.92), 0.77 (0.64-0.89), and 0.85 (0.74-0.95), respectively. The AUROC values (95% CIs) of 2D SWE, TE, and MRE for the diagnosis of advanced fibrosis were 0.89 (0.80-0.98), 0.86 (0.77-0.95), and 0.95 (0.89-1.00), respectively. Pairwise comparisons revealed similar diagnostic accuracy for significant fibrosis (2D SWE vs MRE, p = 0.431; 2D SWE vs TE, p = 0.317; and MRE vs TE, p = 0.052) and advanced fibrosis (2D SWE vs MRE, p = 0.348; 2D SWE vs TE, p = 0.293; and MRE vs TE, p = 0.059). CONCLUSION. For patients with biopsy-proven NAFLD, 2D SWE, MRE and TE exhibited comparable and very good to excellent diagnostic accuracy for advanced fibrosis and comparable but lower accuracy for significant fibrosis.

Comparison of the collection approaches of 2 large thyroid fine-needle aspiration practices reveals differing advantages for cytology and molecular testing adequacy rates.

INTRODUCTION: At our institution, almost all thyroid fine-needle aspiration (FNA) procedures are performed by either Endocrinology or Radiology personnel. In this study, we compared the cytology and molecular adequacy rates of these 2 thyroid FNA practices, which differ on several aspects of specimen procurement. MATERIALS AND METHODS: All thyroid FNA specimens from Endocrinology and Radiology practices between September 2008 and December 2016 were included. Over this time frame, the molecular testing modality transitioned from polymerase chain reaction (PCR)-based (7-gene panel era) to next generation sequencing (NGS)-based (ThyroSeq era). In measuring cytology adequacy, the Bethesda System unsatisfactory rate was determined. Molecular adequacy was categorized as Optimal, Limited Thyroid Epithelial Cells, Limited Nucleic Acids, or Failed. These parameters were compared for the 2 practices. RESULTS: The study cohorts comprised 5810 specimens from Endocrinology and 4597 from Radiology. More Endocrinology specimens were satisfactory for cytology diagnosis than those from Radiology (94.7% versus 90.0%, P < 0.001). For molecular adequacy, fewer Endocrinology specimens were optimal than specimens from Radiology for both the 7-gene panel era (76.2% versus 82.9%, P < 0.001) and the ThyroSeq era (88.1% versus 91.9%, P = 0.049). CONCLUSIONS: The 2 thyroid FNA practices varied inversely in their adequacy rates for cytology and molecular testing. Had one practice been superior for both cytology and molecular adequacy, a recommendation for the method of choice would have been straightforward. However, our results show that optimization of FNA practice for the current practice of thyroid cytology requires further investigation due to the complex nature of specimen procurement.

Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging.

OBJECTIVE. We describe the indications, surgical technique, outcome, and imaging findings in patients with pancreatic ductal adenocarcinoma (PDAC) treated with distal pancreatectomy and celiac artery resection (modified Appleby procedure). CONCLUSION. Distal pancreatectomy and celiac artery resection is a feasible surgery in selected patients with locally advanced PDAC. Knowledge of surgical technique and imaging features may aid radiologists in identifying patients with locally invasive PDAC who might benefit from resection and identifying characteristic distal pancreatectomy and celiac artery resection complications.

Prospective Study of the Impact of Liver Biopsy Core Size on Specimen Adequacy and Procedural Complications.

OBJECTIVE: An American Association for the Study of Liver Diseases (AASLD) consensus document stressed the importance of obtaining sufficient liver biopsy specimens to minimize sampling errors. Many centers continue to use smaller-diameter core systems to minimize perceived complication risks. The objective of this study was to assess the impact of core gauge (18- vs 16-gauge) on specimen adequacy and procedural complications. SUBJECTS AND METHODS: One hundred fifty patients referred for liver biopsy were randomized to undergo 16- or 18-gauge ultrasound (US)-guided core biopsy. Hemorrhage was qualitatively evaluated, and pain was assessed using a 10-point rating scale. The length and number of portal tracts per specimen were assessed. On the basis of the AASLD guidelines, specimen adequacy was defined as 11 or more portal tracts. Differences in pathology metrics and pain scoring were assessed using chi-square and linear regression models. RESULTS: No significant hemorrhage occurred in either group, and there was no difference in postbiopsy pain scores. The mean specimen length obtained with 16-gauge needles was less than that obtained with 18-gauge needles (1.7 vs 1.9 cm, p = 0.03). The mean number of portal tracts obtained with 16-gauge biopsies was greater than obtained with 18-gauge systems (14 vs 13, p = 0.03); 85% of 16-gauge biopsy specimens and 80% of 18-gauge biopsy specimens were adequate on the basis of the AASLD criteria, although this difference was not statistically significant. CONCLUSION: US-guided 18- and 16-gauge core biopsies are similarly safe. A large percentage of 18- or 16-gauge specimens are inadequate when AASLD quality control adequacy thresholds are applied, and specimen adequacy is not significantly affected by biopsy gauge.

Delayed splenic vascular injury after nonoperative management of blunt splenic trauma.

BACKGROUND: Delayed splenic vascular injury (DSVI) is traditionally considered a rare, often clinically occult, harbinger of splenic rupture in patients with splenic trauma that are managed conservatively. The purpose of our study was to assess the incidence of DSVI and associated features in patients admitted with blunt splenic trauma and managed nonoperatively. MATERIALS AND METHODS: A retrospective analysis was conducted over a 4-y time. Patients admitted with blunt splenic trauma, managed no-operatively and with a follow-up contrast-enhanced computed tomography (CT) scan study during admission were included. The CT scans were reviewed for American Association for the Surgery of Trauma splenic injury score, amount of hemoperitoneum, and presence of DSVI. Logistic regression models were used to investigate the risk factors associated with DSVI. RESULTS: A total of 100 patients (60 men and 40 women) constituted the study group. Follow-up CT scan demonstrated a 23% incidence of DSVI. Splenic artery angiography validated DSVI in 15% of the total patient population. Most DSVIs were detected only on arterial phase CT scan imaging. The American Association for the Surgery of Trauma splenic injury score (odds ratio = 1.73; P = 0.045) and the amount of hemoperitoneum (odds ratio = 1.90; P = 0.023) on admission CT scan were associated with the development of DSVI on follow-up CT scan. CONCLUSIONS: DSVI on follow-up CT scan imaging of patients managed nonoperatively after splenic injury is common and associated with splenic injury score assessed on admission CT scan.

Comparison of true unenhanced and virtual unenhanced (VUE) attenuation values in abdominopelvic single-source rapid kilovoltage-switching spectral CT.

OBJECTIVE: To assess the agreement between the true non-contrast (TNC) attenuation values of intra-abdominal structures and attenuation values obtained on virtual-unenhanced (VUE) images based on rapid kVp-switching dual-energy CT. The effects of contrast phase and patient characteristics (e.g., BMI, hematocrit, hemoglobin content) on VUE values were also investigated. METHODS: Ninety four patients who underwent triphasic abdominal CT (liver mass protocol, n = 47; pancreas mass protocol, n = 47) between August 2014 and May 2015 were retrospectively reviewed. Unenhanced series was performed using conventional single-energy mode at 120 kVp. Late arterial and venous phase post-contrast series were obtained utilizing rapid kVp-switching dual-energy CT technique. VUE images were processed off of arterial (VUE-art) and venous (VUE-ven) phase series. Attenuation values of liver, pancreas, kidneys, adrenal glands, muscle, subcutaneous fat, aorta, IVC, and main portal vein were recorded on TNC and VUE sets of images. Attenuation values were compared using univariate linear regression and Student two-tailed paired t test. RESULTS: There was excellent correlation between TNC, VUE-art, and VUE-ven attenuation values across all organs (p < 0.0001). Paired Student t test, however, showed significant difference between TNC and VUE-art attenuation of kidneys, right adrenal gland, paraspinal muscle, and aorta. There was also significant difference between TNC and VUE-ven attenuation of left kidney. Percentage of cases which had >10 HU difference between VUE and TNC for an individual was calculated which ranged between 13% (right kidney) and 42% (right adrenal gland). CONCLUSION: Although the correlation between VUE and TNC attenuation values was excellent and mean difference between TNC and VUE attenuation values was negligible (ranging between -5.94 HU for paraspinal muscles to 6.2 HU in aorta), intra-patient analysis showed a considerable number of cases which had >10 HU difference between VUE and TNC. VUE-ven generally offered a better approximation of TNC values. Further optimization of post-processing algorithms might be necessary before complete replacement of TNC with VUE images.

Hepatic Sinusoidal Dilatation: A Review of Causes With Imaging-Pathologic Correlation.

Hepatic sinusoids are vascular conduits connecting the portal triad with the central vein. Multiple conditions can lead to sinusoidal dilatation and congestion with resultant stasis of blood within the lumen. The altered hemodynamics associated with hepatic sinusoidal dilatation generally result in heterogeneous enhancement of the hepatic parenchyma on contrast-enhanced computed tomography and magnetic resonance imaging, a pattern often described as "mosaic" enhancement. In this article, we review the causes of hepatic sinusoidal dilatation and the imaging manifestations on contrast-enhanced computed tomography and magnetic resonance.

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.

Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

Non-focal liver signal abnormalities on hepatobiliary phase of gadoxetate disodium-enhanced MR imaging: a review and differential diagnosis.

Gadoxetate disodium (Gd-EOB-DTPA) is a linear, non-ionic paramagnetic MR contrast agent with combined extracellular and hepatobiliary properties commonly used for several liver indications. Although gadoxetate disodium is commonly used for detection and characterization of focal lesions, a spectrum of diffuse disease processes can affect the hepatobiliary phase of imaging (i.e., when contrast accumulates within the hepatocytes). Non-focal signal abnormalities during the hepatobiliary phase can be seen with multiple disease processes such as deposition disorders, infiltrating tumors, vascular diseases, and post-treatment changes. The purpose of this paper is to review the different processes which result in non-focal signal alteration during the hepatobiliary phase and to describe imaging patterns that may order a differential diagnosis and facilitate patient management.

Hepatic sarcoidosis in patients presenting with liver dysfunction: imaging appearance, pathological correlation and disease evolution.

OBJECTIVES: We hypothesize that hepatic sarcoidosis is a dynamic process that can lead to cirrhosis and portal hypertension, independent of the course of thoracic disease. Therefore, we assess the imaging appearance and progression of hepatic sarcoidosis in subjects presenting with hepatic dysfunction. METHODS: An IRB-approved, HIPAA-compliant, single-institution retrospective review identified 39 subjects with sarcoidosis-related liver dysfunction. Clinical information was collected. Two abdominal radiologists analyzed baseline and follow-up imaging studies, scoring features of cirrhosis. Chest CT was also analyzed. RESULTS: At presentation, 23 subjects (59.0 %) exhibited >3 cirrhotic features and 15 (38.5 %) >2 findings of portal hypertension. Of subjects with available follow-up, 57.9 % (19 subjects; mean interval 4.7 years) showed worsening of >3 cirrhotic features (Pearson rho = 0.58; p = 0.009). Parenchymal nodules were uncommon (25.6 %), and most regressed. Although 87.2 % of subjects were diagnosed with thoracic sarcoidosis, there was poor correlation between severity of hepatic and chest disease (Pearson rho = 0.30; p = 0.119). A mean of 7.2 years elapsed between diagnosis of pulmonary and liver involvement. CONCLUSION: Sarcoidosis may present as liver dysfunction, cirrhosis or portal hypertension. Sarcoid-related liver disease may progress and can manifest without, alongside or significantly after a diagnosis of pulmonary disease. KEY POINTS: • Patients often present with elevated liver function tests indicating cholestasis. • Patients may present with portal hypertension, and some progress to cirrhosis. • Though biopsy can be considered for focal liver lesions, most will regress. • Extent of intra-abdominal involvement may not correlate with severity of thoracic disease. • Liver disease may manifest alongside, prior to or significantly after initial diagnosis.

Impact of the Multi-Gene ThyroSeq Next-Generation Sequencing Assay on Cancer Diagnosis in Thyroid Nodules with Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance Cytology.

BACKGROUND: Fine-needle aspiration (FNA) cytology is a common approach to evaluate thyroid nodules. It offers definitive diagnosis of a benign or malignant nodule in the majority of cases. However, 10-25% of nodules yield one of three indeterminate cytologic diagnoses, leading to suboptimal management of these patients. Atypia of undetermined significance/follicular lesion of undermined significance (AUS/FLUS) is a common indeterminate diagnosis, with the cancer risk ranging from 6% to 48%. This study assessed whether a multi-gene next-generation sequencing (NGS) assay can offer significant improvement in diagnosis in AUS/FLUS nodules. METHODS: From May 2014 to March 2015, 465 consecutive FNA samples with the cytologic diagnosis of AUS/FLUS underwent prospective molecular testing using the ThyroSeq v2.1 panel. The panel included 14 genes analyzed for point mutations and 42 types of gene fusions occurring in thyroid cancer. In addition, eight genes were assessed for expression in order to evaluate the cell composition of FNA samples. Ninety-eight (21%) of these nodules had definitive surgical (n = 96) or nonsurgical (n = 2) follow-up and were used to determine the assay performance. RESULTS: Among 465 AUS/FLUS nodules, three were found to be composed of parathyroid cells and 462 of thyroid follicular cells. Of the latter, 31 (6.7%) were positive for mutations. The most frequently mutated genes were NRAS and HRAS, and overall point mutations in seven different genes and five types of gene fusions were identified in these nodules. Among 98 nodules with known outcome, histologic analysis revealed 22 (22.5%) cancers. ThyroSeq v2.1 was able to classify 20/22 cancers correctly, showing a sensitivity of 90.9% [confidence interval (CI) 78.8-100], specificity of 92.1% [CI 86.0-98.2], positive predictive value of 76.9% [CI 60.7-93.1], and negative predictive value of 97.2% [CI 78.8-100], with an overall accuracy of 91.8% [CI 86.4-97.3]. CONCLUSIONS: The results of the study demonstrate that the ThyroSeq v2.1 multi-gene NGS panel of molecular markers provides both high sensitivity and high specificity for cancer detection in thyroid nodules with AUS/FLUS cytology, which should allow improved management for these patients.

The cystic duct knot sign: case report with description of a new ultrasound sign of gallbladder torsion.

Gallbladder torsion or volvulus is a rare but potentially lethal entity. We report the imaging findings of gallbladder torsion and describe a potentially novel ultrasound sign for the preoperative diagnosis of torsion. An 87-year-old woman presented with a 4-day history of right upper quadrant pain. An initial right upper quadrant ultrasound exam demonstrated cholelithiasis and findings of acute cholecystitis which included gallbladder distension, wall thickening, trace pericholecystic fluid, and a positive sonographic Murphy's sign. Gallbladder torsion was prospectively diagnosed on the subsequent contrast-enhanced CT scan of the abdomen based upon the abnormal transverse orientation of the gallbladder with the neck directed laterally. Ultrasound images were reviewed and a "knot"-like hyperechoic nodular appearance of the torsed cystic duct close to the gallbladder neck was clearly apparent. Prospective identification of the torsed cystic duct may prompt the ultrasound diagnosis of gallbladder torsion.

Adrenal Imaging Features Predict Malignancy Better than Tumor Size.

INTRODUCTION: In adrenal tumors, size ≥ 4 cm has been an indication for adrenalectomy due to concern for malignancy. We compared mass size to imaging features (ImF) for accuracy in diagnosing adrenal malignancy. METHODS: Data were retrieved for 112 consecutive patients who had adrenalectomy from January 2011 to August 2014. ImF was classified as nonbenign if HU > 10 on unenhanced CT scan or if loss of signal on out-of-phase imaging was absent on chemical-shift MRI. Indications for resection included hormonal hypersecretion, nonbenign ImF, and/or size ≥ 4 cm. RESULTS: Of 113 resected adrenals, 37 % were functional. Histologic malignancy occurred in 18 % (20/113) and included 3 adrenocortical carcinomas (ACC), 1 epithelioid liposarcoma, 1 lymphoma, 1 malignant nerve sheath tumor, and 14 adrenal metastases. Patients with malignancies were older (mean age, 60 ± 13 vs. 51 ± 14 years, p = 0.01). Malignant tumors were larger on preoperative imaging (mean 5.3 ± 3.2 vs. 3.9 ± 2.4 cm, p = 0.03). All 20 malignant masses had nonbenign ImF. In predicting malignancy, the sensitivity, specificity, NPV, and PPV of nonbenign ImF was 100, 57, 100, and 33 %, respectively. Size ≥ 4 cm was less predictive with sensitivity, specificity, NPV, and PPV of 55, 61, 86, and 23 %, respectively. If size ≥ 4 cm had been used as the sole criterion for surgery, 45 % of malignancies (9/20) would have been missed including 8 metastases and an ACC. CONCLUSIONS: In resected adrenal tumors, the presence of nonbenign ImF is more sensitive for malignancy than mass size (100 vs. 55 %) with equivalent specificity. Regardless of mass size, adrenalectomy should be strongly considered when non-benign ImF are present.