Preventing errors in laterality.

An error in laterality is the reporting of a finding that is present on the right side as on the left or vice versa. While different medical and surgical specialties have implemented protocols to help prevent such errors, very few studies have been published that describe these errors in radiology reports and ways to prevent them. We devised a system that allows the radiologist to view reports in a separate window, displayed in a simple font and with all terms of laterality highlighted in separate colors. This allows the radiologist to correlate all detected laterality terms of the report with the images open in PACS and correct them before the report is finalized. The system is monitored every time an error in laterality was detected. The system detected 32 errors in laterality over a 7-month period (rate of 0.0007 %), with CT containing the highest error detection rate of all modalities. Significantly, more errors were detected in male patients compared with female patients. In conclusion, our study demonstrated that with our system, laterality errors can be detected and corrected prior to finalizing reports.

Low correlation between serum thyroglobulin and 131I radioiodine whole body scintigraphy: implication for postoperative disease surveillance in differentiated thyroid cancer.

PURPOSE: To evaluate postoperative serum thyroglobulin (Tg) as a reliable tumor marker in low-risk differentiated thyroid cancer (DTC). METHODS: Two hundred and three patients met the selection criteria of >18 years old; who had undergone total or near total thyroidectomy; had a postoperative Tg, and had undergone 131I pre ablation whole body scan (PA-WBS). The primary endpoint was the correlation between Tg level and functional remnant thyroid tissues. Outcomes were categorized as concordant and discordant. Concordant results were positive Tg (>1 ng/ml) with positive PA-WBS or negative Tg (<1 ng/ml) with negative PA-WBS. Discordant results were negative Tg with a positive PA-WBS or positive Tg with a negative PA-WBS. To increase the sensitivity of Tg detection, we evaluated Tg in patients with high thyroid stimulating hormone (TSH) with serum level >30 mU/l on thyroxine withdrawal protocol. RESULTS: One hundred ten patients (54.1%) had discordant results (p < 0.05) with positive PA-WBS and Tg <1 ng/ml, while 93 patients (45.9%) had concordant results. For concordant results, 88 patients had positive PA-WBS and Tg >1 ng/ml, and 5 patients had negative PA-WBS and Tg <1 ng/ml. There was no patient with Tg >1 ng/ml and negative PA-WBS. There were 74 patients with high TSH (>30 mU/l) on abstention (thyroxine withdrawal protocol). Twenty-four (32.5%) had discordant results (p < 0.001) and 50 (67.5%) had concordant results. CONCLUSION: There is low correlation between postoperative Tg and PA-WBS. The sole use of Tg as a serum biomarker for postoperative disease status may not be reliable.

Single shot lymphoscintigraphy in breast cancer: Effective single tracer sentinel node detection protocol with reduction in procedural pain.

PURPOSE: Variation in protocols for axillary sentinel lymph node (SLN) mapping exists. We strive to evaluate the effectiveness of reduction in number of injections on reducing procedural pain, while maintaining nodal detection. METHODS: Over 7 years, the number of periareolar injections performed was reduced stepwise from 4 to 1. This was analyzed for SLN detection and patients' subjective perceived pain. RESULTS: 828 patients with invasive breast cancer who underwent SLN mapping were included. Laterality of breast injection site included 326 (39.4%) in the right breast, 354 (42.8%) in the left breast and 148 (17.9%) in bilateral breasts. In patients who had 4 injection sites in a unilateral breast (n = 143), the reported pain score was 4.3 ± 2.4. Patients with 3 injections (n = 163), 2 injections (n = 163) and 1 injection (n = 211) in a breast reported pain scores of 3.4 ± 2.4, 3.2 ± 2.2, and 2.9 ± 2.6, respectively. In patients who had bilateral sentinel node procedures, those with 4 injections in each breast for a total of 8 injections (n = 37) reported a pain score of 5.7 ± 2.4. Patients with 3 (n = 51), 2 (n = 31) and 1 (n = 39) injection(s) in each breast reported perceived pain of 4.8 ± 2.8, 3.7 ± 2.7 and 3.5 ± 1.9, respectively. Incremental decreased pain scores were achieved with decreasing number of injections (p < 0.001). Nodal detection was maintained. CONCLUSION: A single periareolar subdermal injection site reduces periprocedural pain while maintaining nodal detection.

Adding value to imaging services: a survey of patient and referring physician preferences for direct radiologic reporting of results.

PURPOSE: To identify preferences of patients and referring physicians for direct patient communication and notification of radiologic study results. METHODS: An anonymous survey was conducted of patients undergoing outpatient radiologic imaging studies and their referring physicians. The voluntary surveys elicited responses regarding preferences on a 5-point Likert scale (Strongly disagree, disagree, neutral, agree and strongly agree), as well as indicated by responding yes or no to specific questions. RESULTS: 368 patients completed the survey. 81.5% of patient responders preferred all results communicated from the radiologist within the same day. 65.9% of patients preferred same day results if normal vs 65.8% if abnormal. 34.5% preferred to wait and review normal results with the referring physician. 41.5% preferred to wait and review abnormal results with the referring physician. It was found that patients were more likely to strongly agree with waiting to review results with the referring physician if the results were abnormal, as opposed to normal (18.5% vs 11.9%, respectively; P < 0.014). 64% of physicians did not want results reviewed with their patients; 87.6% did not want a report sent to the patient by the radiologist, even after report was sent to their office. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety. CONCLUSIONS: 58-82% of patients preferred same day radiologist communication of their results while 55-87.6% of physicians did not prefer same day radiologist communication of results directly with their patients. 66.4% of patients surveyed indicated that waiting for imaging results gives them anxiety.

Treatment of superior vena cava syndrome using AngioJet™ thrombectomy system.

BACKGROUND: Superior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration. CASE PRESENTATION: A 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava. CONCLUSIONS: Acute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient's clinical condition necessitates treatment.

Rare association of progressive congenital extrahepatic portosystemic shunt with development of multifocal hepatocellular carcinoma.

The association between the Abernethy malformation, a rare vascular anomaly in which the portal blood is diverted into the systemic circulation, and development of hepatic tumours is well established. We present a case of multifocal hepatocellular carcinoma (HCC) in the presence of extrahepatic portosystemic shunt with a diminutive portal vein (Type 2 Abernethy malformation). Abdominal ultrasound performed on a 72-year-old female presenting with elevated liver function tests found a 5.6 cm right hepatic lobe mass. Subsequent CT and MRI examinations demonstrated multifocal lesions. A diminutive portal vein was present (transverse diameter of 7 mm) with a large tortuous complex shunt (maximum transverse diameter 2.0 cm) arising at the portal vein bifurcation with branches connecting to the left renal vein and inferior vena cava. Review of a CT examination performed 10 years ago demonstrated a normal-sized portal vein (transverse diameter of 1.5 cm) with a smaller calibre portosystemic shunt (maximum transverse diameter 9 mm). To our knowledge, this is one of the first reports to demonstrate the evolution of progressive portosystemic shunting and the development of HCC.

Elastography-targeted Thyroid Nodule Aspiration: A Novel Approach.

OBJECTIVES: Since 2009, the rate of nondiagnostic (ND) thyroid nodule fine-needle aspiration (FNA) has ranged from 2% to 20%. A ND result can cause further patient morbidity secondary to repeated procedures and delay in diagnosis. The use of real-time strain elastography (RTE) in determining nodule malignant risk has gained considerable focus recently. A less studied area where RTE may prove beneficial is its role in targeting areas for FNA. Our hypothesis is that FNA performed in concurrence with RTE will show a decreased rate of ND results leading to fewer repeated FNA. MATERIALS AND METHODS: The Institutional Review Board approval was obtained. A retrospective review of all thyroid nodule FNA from January 1, 2011, to January 1, 2014, was performed with review of nodule size, presence of microcalcifications, vascularity, solid components, patient age, and gender. Cases were separated based if RTE was done before FNA or not. Pathology reports were reviewed to assess for specimen adequacy. Statistical comparison was performed using SAS analysis software. RESULTS: A total of 221 specimens were reviewed, with RTE performed on 140 cases (63.4%). Both groups were similar in demographics and previously described nodule characteristics. The ND rate when RTE was not performed was 16% (13/68) compared to 10% when RTE was performed (14/126). The difference was not found to be statistically significant, P = 0.205. CONCLUSIONS: The presence of an elastogram failed to demonstrate a significant decrease in ND FNA rates although these results may be secondary to study design. Further evaluation with prospective trials using larger sample size may ultimately detect increased accuracy of RTE-targeted FNA.

Rare Intensely Fluorine-18-fluorodeoxyglucose Avid Large Retropharyngeal Goiter in a Patient with Invasive Breast Carcinoma.

Diffuse increased fluorine-18-fluorodeoxyglucose ((18)F-FDG) avidity on positron emission tomography (PET) scans has been demonstrated in patients with chronic thyroiditis, likely secondary to increased inflammatory cell glucose uptake. A complex association has been demonstrated between breast cancer and thyroid disease, although the mechanism remains elusive. Development of chronic thyroiditis and/or goiter in breast cancer patients has been suggested to convey a more favorable prognosis. Goiter extension is almost exclusively into retrosternal space, with only a handful of cases reported with superior extension into retropharyngeal space. We present a rare case of a diffusely enlarged goiter extending superior and posterior into the retropharyngeal space with an associated intense (18)F-FDG avidity standardized uptake value maximum (SUVmax) of 16.1 in a patient with invasive ductal breast cancer. To our knowledge, this represents the first published case of diffusely (18)F-FDG avid goiter with retropharyngeal extension.

FDG-PET-positive lower-extremity sebaceous-gland carcinoma in a patient with Muir-Torre syndrome.

Sebaceous-gland carcinoma can occur alone or as one of the defining features of the Muir-Torre syndrome. Cases occurring below the head and neck are extremely rare. Here we describe the case of a 70-year-old male with Muir-Torre syndrome who had a recurrent sebaceous-gland carcinoma in the left lower extremity that demonstrated (18)F-FDG avidity. An (18)F-FDG-avid lower-extremity sebaceous-gland carcinoma has not been previously reported.

Effects of varying serum glucose levels on 18F-FDG biodistribution.

OBJECTIVE: Hyperglycemia has been shown to influence fluorine-18 fluorodeoxyglucose ((18)F-FDG) uptake in tumor cells. Therefore, patients are instructed to fast for 6 h, while maintaining serum glucose levels at an acceptable range. The study was performed to evaluate the effect of fasting blood glucose levels on the biodistribution of (18)F-FDG in various tissues including the liver, heart, bone marrow, skeletal muscle, and tumors. MATERIALS AND METHODS: Fingerstick fasting blood glucose is routinely measured on the morning of the procedure. The maximum standardized uptake value (SUV(max)) in the right and left hepatic lobes, left ventricle, sacrum, thigh, and tumor was measured in 229 consecutive patients undergoing (18)F-FDG PET/computed tomography for tumor. Patients were divided into three groups depending on their serum glucose levels: low (<100; n = 53), medium (100-160; n = 149), and high (160-201; n = 27). A retrospective analysis of the relationship between glucose levels and standardized uptake value was performed. RESULTS: There was a statistically significant increase in the average SUV(max) in the right and left hepatic lobes as glucose levels increased (right lobe P=0.00144; left lobe P = 0.03889). Subsequently, pairwise analysis was performed, revealing a statistically significant increase in SUV(max) in the right hepatic lobe between low-glucose and medium-glucose groups and in both hepatic lobes between low and high groups (P < 0.017). No significant difference was observed in any of the other measured tissues. CONCLUSION: This study shows a directly proportional relationship between blood glucose levels and nonpathologic (18)F-FDG biodistribution in the right and left hepatic lobes. The influence of blood glucose on expected biodistribution patterns, particularly in the liver, should be considered during interpretation.