Diagnosis of gynecologic malignancy after the treatment of presumed benign fibroid disease with interventional radiology procedures: a retrospective cohort study.

OBJECTIVE: To ascertain the finding of future diagnosis of malignancy in women who undergo nonsurgical treatment for uterine fibroid disease with interventional radiology (IR) procedures. DESIGN: Mixed-methods retrospective cohort study. SETTING: Two tertiary care academic hospitals in Boston, Massachusetts. PATIENT(S): A total of 491 women who underwent radiologic intervention for fibroids between 2006 and 2016. INTERVENTION(S): Uterine artery embolization or high-intensity focused ultrasound ablation. MAIN OUTCOME MEASURE(S): Subsequent surgical interventions and diagnosis of gynecologic malignancy after the IR procedure. RESULT(S): During the study period, 491 women underwent treatment of fibroids with IR procedures; follow-up information was available for 346 cases. The mean age was 45.3 ± 4.8 years, and 69.7% were between the ages of 40 and 49 years. Regarding ethnicity, 58.9% of patients were white, and 26.1% were black. The most common symptoms were abnormal uterine bleeding (87%), pelvic pressure (62.3%), and pelvic pain (60.9%). A total of 106 patients underwent subsequent surgical treatment of fibroids. Of the 346 patients who had follow-up, 4 (1.2%) were diagnosed with leiomyosarcoma after their interventional treatment for fibroids. An additional 2 cases of endometrial adenocarcinoma and 1 case of a premalignant lesion of the endometrium were noted. CONCLUSION(S): The proportion of patients who went on to be diagnosed with leiomyosarcoma after conservative IR treatments appears to be higher than previously reported. A thorough preprocedural workup and patient counseling regarding the possibility of underlying uterine malignancy should be undertaken.

ACR Appropriateness Criteria® Clinically Suspected Adnexal Mass, No Acute Symptoms.

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Influence of Academic Productivity on Gender Disparity in Academic Interventional Radiology.

OBJECTIVE. This study aimed to determine the effect of academic productivity measured using surrogate metrics, including h-index, publication number, and citation number, on the advancement of academic interventional radiology (IR) staff. MATERIALS AND METHODS. Publicly available data on faculty members in IR departments across academic institutions in Canada and the United States were collected. Gender, academic ranking, leadership position (if any), publication number, citation number, years of active research, and h-index were collected for each faculty member, and these data were used to create a prediction equation. RESULTS. Four hundred twenty IR faculty members met the inclusion criteria for this study. Overall, women were the minority, representing 10% of all IR faculty. Women in academic IR attained academic ranks at a rate comparable to that of men, with 59% of women attaining the rank of assistant professor and 32% attaining associate professor, compared with 59% of men at the assistant professor and 25% at the associate professor level. A trend toward lower female representation was present at the full professor level (women, 8%; men, 15%) but this difference did not reach statistical significance. Leadership position by gender as a percentage of their overall representation in the field was also similar between women and men (first-in-command women, 15%; first-in-command men, 15%; second-in-command women, 2%; second-in-command men, 2%). No significant difference was found between women and men in terms of academic achievement metrics, including publication number, citation number, h-index, and years of active research. CONCLUSION. Women in academic IR achieve similar publication metrics as men and attain promotion to higher academic rank and leadership positions equal to their overall representation in the field. However, women remain the minority among academic IR faculty across North America.

ACR Appropriateness Criteria® Staging and Follow-Up of Ovarian Cancer.

In the management of epithelial ovarian cancers, imaging is used for cancer detection and staging, both before and after initial treatment. The decision of whether to pursue initial cytoreductive surgery for ovarian cancer depends in part on accurate staging. Contrast-enhanced CT of the abdomen and pelvis (and chest where indicated) is the current imaging modality of choice for the initial staging evaluation of ovarian cancer. Fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT and MRI may be appropriate for problem-solving purposes, particularly when lesions are present on CT but considered indeterminate. In patients who achieve remission, clinical suspicion for relapse after treatment prompts imaging evaluation for recurrence. Contrast-enhanced CT is the modality of choice to assess the extent of recurrent disease, and fluorine-18-2-fluoro-2-deoxy-d-glucose PET/CT is also usually appropriate, as small metastatic foci may be identified. If imaging or clinical examination confirms a recurrence, the extent of disease and timing of disease recurrence then determines the choice of treatments, including surgery, chemotherapy, and radiation therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Patient Complaints in Image-Guided Interventions: Evaluation of Multifactorial Issues Using a Coding Taxonomy.

OBJECTIVE: The purpose of this article is to classify complaints from patients undergoing image-guided interventions using a coding taxonomy and to test whether single-coded complaints were resolved satisfactorily compared with multifactorial (multiple codes) complaints. MATERIALS AND METHODS: In this retrospective study, patients' complaint narratives between April 1999 and December 2012 were reviewed and categorized according to a three-level taxonomy into domains and codes. Resolutions were categorized as satisfactory or unsatisfactory to the patient and were classified as follows: clarification, apology, manager notification, change of provider, reimbursement, and quality review. Complaints were classified as single coded (only one code identified in the patients' description) and multifactorial (multiple codes identified). Statistical analysis was performed with the Fisher test, with the significance level set at 0.05. A run chart with the distribution of complaints by domains (relationships, management, and clinical) by year was performed. RESULTS: A total of 146 codes were extracted from 71 narratives (2.06 codes/complaint) and were classified into the following domains: clinical (52%; n = 76), management (24%; n = 35), and relationships (24%; n = 35). The most common codes included quality of care, safety, and communication breakdown issues. A run chart found a decline in absolute numbers of complaints over the years in the domains studied. The frequency of satisfactory resolution was 86% for multifactorial versus 81% for single-coded complaints with no statistically significant differences observed (p = 0.72). Over 50% of complaints were resolved by providing clarification to patients (n = 36). CONCLUSION: There were no statistically significant differences between multifactorial and single-coded complaints. Clinical codes and communication breakdown were the most common reasons for patient-reported complaint, with most complaints successfully resolved with clarification.

Mannequin-based Telesimulation: Increasing Access to Simulation-based Education.

A telesimulation platform utilizes communications technology to provide mannequin-based simulation education between learners and instructors located remotely from one another. Specifically, the instructor controls the mannequin and moderates the debriefing remotely. During these sessions, the instructor observes the learners in real time and provides immediate feedback during the debriefing. This platform obviates the need to have instructors, learners, and mannequins in the same place at the same time, potentially allowing simulation-based educational sessions to occur with greater frequency for institutions not located proximate to formal simulation centers. Additionally, the telesimulation platform enables an experienced simulation instructor to observe and directly help new simulation instructors at remote simulation locations. Readily available Web-conferencing, screen-sharing software, microphones, and webcams makes telesimulation possible. Mannequin-based telesimulation is relatively new and not well represented in the literature, but could facilitate systems changes, providing educational experiences to health care professionals in locations not currently benefiting from mannequin-based simulation opportunities. Several research questions need to be addressed in future studies to better develop this educational approach, including technical feasibility, logistic issues, a comparison of telesimulation to other simulation approaches, and assessing limitations of the telesimulation platform.

ACR Appropriateness Criteria® Ovarian Cancer Screening.

There has been much interest in the identification of a successful ovarian cancer screening test, in particular, one that can detect ovarian cancer at an early stage and improve survival. We reviewed the currently available data from randomized and observational trials that examine the role of imaging for ovarian cancer screening in average-risk and high-risk women. We found insufficient evidence to recommend ovarian cancer screening, when considering the imaging modality (pelvic ultrasound) and population (average-risk postmenopausal women) for which there is the greatest available published evidence; randomized controlled trials have not demonstrated a mortality benefit in this setting. Screening high-risk women using pelvic ultrasound may be appropriate in some clinical situations; however, related data are limited because large, randomized trials have not been performed in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pilot Study of a Patient-Centered Radiology Process Model.

PURPOSE: The Radiology Process Model (RPM) was previously described in terms of its conceptual basis and proposed survey items. The current study describes the first pilot application of the RPM in the field and the results of initial psychometric analysis. METHODS: We used an Institutional Review Board-approved pilot RPM survey in 100 patients having outpatient interventional radiology procedures. The 24 survey items had 4 or 5 levels of severity. We assessed for missing data, items that patients found confusing, any suggestions by patients for additional items and clarity of items from patient feedback. Factor analysis was performed and internal consistency measured. Construct validity was assessed by correlation of patient responses to the items as a summated scale with a visual analog scale (VAS) they completed indicating their interventional radiology experience. RESULTS: The visual analog scale and the RPM summated scale were strongly correlated (r = 0.7). Factor analysis showed four factors: interactions with facility and doctors/staff, time-sensitive aspects, pain, and anxiety. The items showed high internal consistency (alpha: 0.86) as a group and approximately 0.7 to 0.9 by the factors. Analysis shows that two items could be deleted (cost and communication between radiologist and referrers). Revision of two items and potential addition of others are discussed. CONCLUSIONS: The RPM shows initial evidence of psychometric validity and internal consistency reliability. Minor changes are anticipated before wider use.

Pulmonary Artery Pseudoaneurysms: Clinical Features and CT Findings.

OBJECTIVE: The purpose of this study was to analyze the clinical and CT features of pulmonary artery pseudoaneurysms (PAPs). MATERIALS AND METHODS: A database search of chest CT examinations performed from January 1, 2000 to December 31, 2014 identified 24 patients with findings consistent with PAPs. A CT finding consistent with a PAP was defined as a focal saccular outpouching of a pulmonary artery. Medical records were reviewed to determine clinical presentations, treatments, and outcomes. CT scans were reviewed by two board-certified fellowship-trained chest radiologists. RESULTS: A total of 35 PAPs were identified in 24 patients. Hemoptysis and shortness of breath were the most common presenting symptoms. The most commonly identified causes of PAPs were infection (33%), neoplasms (13%), and trauma (17%). Of the 35 PAPs, 29 (83%) were located in segmental or subsegmental pulmonary arteries. A solitary PAP was identified in 20 (83%) patients, and multiple PAPs were identified in three patients with endocarditis and one patient with pulmonary metastases. Only three of 35 (9%) PAPs were associated with a ground-glass halo. Endovascular treatment was successfully performed in 12 patients, and only one patient had immediate recurrent hemoptysis after treatment. PAP was clinically suspected by the referring clinicians in only three patients. Sixteen of the 35 (46%) PAPs were not reported on the initial CT studies. CONCLUSION: PAPs showed a strong predilection for the peripheral pulmonary arteries. Multiplicity of PAPs can be seen in the settings of endocarditis and pulmonary metastatic disease. Most PAPs were not associated with a ground-glass halo. PAPs can be lethal but were often not suspected clinically and were underreported by radiologists.

Developing a Patient-Centered Radiology Process Model.

PURPOSE: There has been increasing interest in the process of care that patients experience. To keep step with the rest of medicine, our specialty should be designing metrics that assess the overall experience of patients seeking care in radiology departments. A recent memo from the ACR chair calls for more work in this area. The aim of this study was to develop a patient-centered model for the experience of radiologic care, which may be helpful in addressing this need. METHODS: Using principles of multiattribute utility theory and psychometric theory as well as recent literature, a model was developed for a patient-centered index that could be used in radiology facilities. RESULTS: A model was developed that concisely incorporates patient-centeredness of both radiologists and staff members (communication with patient and referrers, competence, and pain control) as well as patient- and process-related issues such as costs, procedural morbidity, access to care, appointment duration, waiting, timing of appointments, cleanliness of facility, and coordination with clinical services. The overall radiology process model was constructed as a set of nested models, which allow more integrated detail within the domains of patient experience. CONCLUSIONS: This model and others like it may help the ACR develop quality metrics to reasonably quantify the patient experience.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group.

Acute pelvic pain in premenopausal women frequently poses a diagnostic dilemma. These patients may exhibit nonspecific signs and symptoms such as nausea, vomiting and leukocytosis. The cause of pelvic pain includes a myriad of diagnostic possibilities such as obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The choice of the imaging modality is usually determined by a suspected clinical differential diagnosis. Thus the patient should undergo careful evaluation and the suspected differential diagnosis should be narrowed before an optimal imaging modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice, to assess for pelvic pain, when an obstetric or gynecologic etiology is suspected and computed tomography is often more useful when gastrointestinal or genitourinary pathology is thought to be more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies owing to its lack of ionizing radiation.The American College of Radiology Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Prospective analysis of an interprofessional team training program using high-fidelity simulation of contrast reactions.

OBJECTIVE: Successful management of a contrast reaction requires prompt recognition and treatment and effective team dynamics among radiologists, technologists, and nurses. A radiology department implemented a simulation program in which teams of nurses, technologists, and physicians managed simulated contrast reactions. The purpose of this study was to evaluate whether simulation improved the participants' abilities to manage a contrast reaction and work in a team during an emergency. SUBJECTS AND METHODS: Physicians, nurses, and technologists worked in inter-professional teams to manage two high-fidelity simulated adverse contrast reactions. Participants completed surveys before and after the simulation that included knowledge-based questions about the appropriate management of contrast reactions. Surveys also included questions for assessing participants' perceptions of their ability to manage adverse contrast reactions, measured with a 6-point Likert scale. Before and after comparisons were made with the McNemar test with a Bonferroni correction requiring p ≤ 0.003 for significance. For the other analyses, p ≤ 0.05 was considered significant. RESULTS: After completion of the simulation exercises, participants had significant improvement in knowledge (p < 0.001). After the simulation, participants reported significant improvement in their ability to manage an anaphylactoid reaction and their ability to work in a team (p < 0.00001). Participants requested repeat simulation exercises every 6-12 months. CONCLUSION: Simulation exercises improved the self-reported ability of radiology personnel to manage contrast reactions and work in a team during an emergency. Simulation should be incorporated into future educational initiatives to improve patient safety in radiology practices.

Radiologist compliance with institutional guidelines for use of nonroutine communication of diagnostic imaging results.

PURPOSE: The aim of this study was to evaluate radiologist compliance with institutional guidelines for nonroutine communication of diagnostic imaging results. METHODS: From July 2012 through September 2013, 7,401 completed advanced imaging cases were retrospectively reviewed by groups of 3 or more radiologists. The reviewing radiologists were asked to reach consensus on two questions related to nonroutine communication: (1) "Does the report describe a finding which requires nonroutine communication to the patient's physicians?" and if so, (2) "Were the department's guidelines for nonroutine communication followed?" Consensus judgments were aggregated and analyzed on the basis of subspecialty, level of acuity per the guidelines, and type of communication used. RESULTS: Of the 7,401 studies reviewed, 960 (13.0%) were deemed to require nonroutine results communication. The need for nonroutine communication was most frequent with CT (16.6%), followed by MRI (11.1%) and ultrasound (3.4%). For the divisions studied, nonroutine communication was most frequently needed in thoracic (37.9%), followed by neurologic (17.3%), emergency (15.8%), cardiac (13.7%), musculoskeletal (4.4%), and abdominal (0.7%) imaging. Of the cases requiring nonroutine communication, 39 (4%) yielded consensus that the guidelines were not appropriately followed: 21% (n = 8) involved level 1 findings (critical), 41% (n = 16) involved level 2 findings (acute), and 38% (n = 15) involved level 3 findings (nonacute). Failures of communication involving level 1 findings primarily involved neurologic imaging, including 4 cases of new cerebral infarct and 3 cases of new intracranial hemorrhage. CONCLUSIONS: Established guidelines for nonroutine communication are appropriately applied and durable, underscoring the high yield of formalizing and implementing these guidelines across practice settings.

Direct translumbar inferior vena cava ports for long-term central venous access in patients with cancer.

PURPOSE: To evaluate the indications, complications, and long-term results of translumbar port placements to the inferior vena cava for long-term central venous access in a single tertiary center. MATERIALS AND METHODS: This retrospective study included all patients with cancer who underwent translumbar port placement from January 2000 to July 2012; 31 patients (all women) with an average age of 53.1 years ± 11.1 (range, 30-77 y) were included in the study. Of these patients, 26 (81%) had breast cancer, 3 had lung cancer, 1 had ovarian cancer, and 1 had rectal cancer. Indications included central venous occlusion in 9 patients (29%) and bilateral mastectomy and lymph node dissection in 22 patients (71%). RESULTS: All procedures were technically successful. The overall 30-day complication rate was 9.7% (n = 3). Average catheter use was 14.1 months ± 21 (range, 0.75-108 mo). Thirteen (41.9%) ports were removed because they were no longer needed; 4 (12.9%) ports required removal for port malfunction; 12 (38.7%) patients died with their ports still in place; 2 (6.5%) ports remain in use. Three (9.7%) ports required delayed secondary intervention to remain functional. One patient had a systemic infection attributed to the port, resulting in an overall infection rate of 0.08 per 1,000 catheter days. CONCLUSIONS: Translumbar inferior vena cava port placement is a technically feasible and safe alternative method for long-term central venous access.

The role of radical surgery in the management of acquired uterine arteriovenous malformation.

BACKGROUND: Acquired arteriovenous malformations (AVMs) can develop after uterine instrumentation. The increased risks of vascular changes, including abnormal placentation, after repeated cesarean sections are well studied. Herein, we describe a patient with delayed hemorrhage from a uterine AVM, following dilation and curettage for a cesarean scar pregnancy. CASE: A 32-year-old G3P2 presented with a cesarean scar ectopic pregnancy managed with dilation and curettage, which incurred a 1,500-ml blood loss. Within 6 weeks, she returned with 2 episodes of vaginal bleeding. Initial angiography demonstrated a high-flow arteriovenous fistula, which was coiled. Vaginal hemorrhage recurred; repeat angiography demonstrated a large AVM. Gelfoam embolization of the bilateral internal iliac arteries reduced the vascularity of the AVM. The AVM's location, starting at the left lateral apex of the cesarean scar and extending into the parametrium, necessitated a radical hysterectomy. Pathologic examination revealed a placenta percreta extending into the parametrium. CONCLUSION: The prevalence of uterine AVMs has increased with the rise in surgical obstetrics. In patients with a failed prior interventional procedure, surgical management is necessary to prevent life-threatening hemorrhage. The location of the AVM within the abnormal uterine scar tissue requires familiarity with radical pelvic surgical techniques that are normally used in cancer surgery in order to definitively treat this delayed obstetrical complication.

Embolization of angiographically visible type I and II utero-ovarian anastomoses during uterine artery embolization for fibroid tumors: impact on symptom recurrence and permanent amenorrhea.

PURPOSE: To compare the incidences of symptom recurrence and permanent amenorrhea following uterine artery embolization (UAE) for symptomatic fibroid tumors in patients with type I and II utero-ovarian anastomoses (UOAs) with versus without ovarian artery embolization (OAE). MATERIALS AND METHODS: A retrospective, institutional review board-approved study of 99 women who underwent UAE for symptomatic fibroid tumors from April 2005 to October 2010 was conducted to identify patients who had type I or II UOAs at the time of UAE. Based on the embolization technique, patients were categorized into standard (ie, UAE only), combined (ie, UAE and OAE), and control (patients without UOAs who underwent UAE) groups. Data collected included patient characteristics, procedural technique and findings, symptom recurrence, secondary interventions, and permanent amenorrhea. Statistical analysis was performed with the Fisher exact test, with significance reached at P < .05. RESULTS: Twenty patients (20.2%; mean age, 46.9 y ± 6.3) had type I (n = 3) or II (n = 17) UOAs. Thirteen (65%) underwent UAE only (standard group) and seven (35%) underwent UAE and OAE (combined group). There were no significant differences between groups in demographics or in the incidence of permanent amenorrhea after procedures (follow-up, 561 d ± 490). There was a significantly higher incidence of symptom recurrence in the standard group compared with the control group (P = .01), with no differences between combined and control groups (P = 1). CONCLUSIONS: There were no statistical differences in permanent amenorrhea rates in the groups studied, with significantly higher symptom recurrence rates observed when OAE was not performed in the setting of UOA.