The why, who, how, and what of communicating CT radiation risks to patients and healthcare providers.

Computed tomography (CT) has witnessed tremendous growth in utilization. Despite its immense benefits, there is a growing concern from the general public and the medical community about the detrimental consequences of ionizing radiation from CT. Anxiety from the perceived risks associated with CT can deter referring physicians from ordering clinically indicated CT scans and patients from undergoing medically necessary exams. This article discusses various strategies for educating patients and healthcare providers on the benefits and risks of CT scanning and salient techniques for effective communication.

Electronic Health Record Order Entry-Based Interventions in Response to a Global Iodinated Contrast Media Shortage: Impact on Contrast-Enhanced CT Utilization.

BACKGROUND. Radiology informatics systems and clinical decision support tools in the electronic health record (EHR) can be leveraged to help impact ordering patterns in response to the ongoing global iodinated contrast media shortage. OBJECTIVE. The purpose of our study was to assess the impact of EHR order entry-based interventions, implemented as part of a health system's response to the global contrast media shortage, on contrast-enhanced CT utilization. METHODS. This retrospective study included 79,259 patients who underwent CT at a large multisite health system between April 1, 2022, and July 3, 2022. Two EHR-based interventions were implemented as part of the health system's response to the global contrast media shortage. A first EHR-based intervention on May 10, 2022, entailed creating an alert that appeared in a sidebar after any contrast-enhanced body CT orders, indicating the present shortage and recommending alternate imaging modalities. A second EHR-based intervention on May 16, 2022, required referrers to enter detailed clinical information for all contrast-enhanced body CT orders, which radiologists used when protocoling examinations. Data regarding CT orders and examinations performed were extracted from the electronic data warehouse. RESULTS. During the preintervention, first postintervention, and second postintervention periods, the mean number of patients who underwent contrast-enhanced CT per weekday was 726, 689, and 639, respectively (p for preintervention vs second postintervention periods, < .001). During the three periods, the mean number of patients who underwent CT per weekday was 1350, 1323, and 1314 (p < .001). During the three periods, the mean number of patients who underwent contrast-enhanced body CT per weekday was 561, 532, and 492 (p < .001). During the three periods, the mean number of orders for CT with IV contrast media per weekday was 154, 143, and 131 (p < .001). During the three periods, the mean number of orders for CT without IV contrast media per weekday was 196, 202, and 221 (p < .001). CONCLUSION. EHR order entry-based interventions implemented in response to the global contrast media shortage significantly reduced contrast-enhanced CT utilization in a large health system. CLINICAL IMPACT. The findings indicate the ability to rapidly achieve changes in ordering clinician behavior and subsequent clinical practice using systemwide EHR changes.

PET/MRI and PET/CT Radiomics in Primary Cervical Cancer: A Pilot Study on the Correlation of Pelvic PET, MRI, and CT Derived Image Features.

PURPOSE: To evaluate the correlation of radiomic features in pelvic [2-deoxy-2-18F]fluoro-D-glucose positron emission tomography/magnetic resonance imaging and computed tomography ([18F]FDG PET/MRI and [18F]FDG PET/CT) in patients with primary cervical cancer (CCa). PROCEDURES: Nineteen patients with histologically confirmed primary squamous cell carcinoma of the cervix underwent same-day [18F]FDG PET/MRI and PET/CT. Two nuclear medicine physicians performed a consensus reading in random order. Free-hand regions of interest covering the primary cervical tumors were drawn on PET, contrast-enhanced pelvic CT, and pelvic MR (T2 weighted and ADC) images. Several basic imaging features, standard uptake values (SUVmean, SUVmax, and SUVpeak), total lesion glycolysis (TLG), metabolic tumor volume (MTV), and more advanced texture analysis features were calculated. Pearson's correlation test was used to assess the correlation between each pair of features. Features were compared between local and metastatic tumors, and their role in predicting metastasis was evaluated by receiver operating characteristic curves. RESULTS: For a total of 101 extracted features, 1104/5050 pairs of features showed a significant correlation (ρ ≥ 0.70, p < 0.05). There was a strong correlation between 190/484 PET pairs of features from PET/MRI and PET/CT, 91/418 pairs of CT and PET from PET/CT, 79/418 pairs of T2 and PET from PET/MRI, and 50/418 pairs of ADC and PET from PET/MRI. Significant difference was seen between eight features in local and metastatic tumors including MTV, TLG, and entropy on PET from PET/CT; MTV and TLG on PET from PET/MRI; compactness and entropy on T2; and entropy on ADC images. CONCLUSIONS: We demonstrated strong correlation of many extracted radiomic features between PET/MRI and PET/CT. Eight radiomic features calculated on PET/CT and PET/MRI were significantly different between local and metastatic CCa. This study paves the way for future studies to evaluate the diagnostic and predictive potential of radiomics that could guide clinicians toward personalized patients care.

Consensus Guidelines for the Definition of Time-to-Event End Points in Image-guided Tumor Ablation: Results of the SIO and DATECAN Initiative.

There is currently no consensus regarding preferred clinical outcome measures following image-guided tumor ablation or clear definitions of oncologic end points. This consensus document proposes standardized definitions for a broad range of oncologic outcome measures with recommendations on how to uniformly document, analyze, and report outcomes. The initiative was coordinated by the Society of Interventional Oncology in collaboration with the Definition for the Assessment of Time-to-Event End Points in Cancer Trials, or DATECAN, group. According to predefined criteria, based on experience with clinical trials, an international panel of 62 experts convened. Recommendations were developed using the validated three-step modified Delphi consensus method. Consensus was reached on when to assess outcomes per patient, per session, or per tumor; on starting and ending time and survival time definitions; and on time-to-event end points. Although no consensus was reached on the preferred classification system to report complications, quality of life, and health economics issues, the panel did agree on using the most recent version of a validated patient-reported outcome questionnaire. This article provides a framework of key opinion leader recommendations with the intent to facilitate a clear interpretation of results and standardize worldwide communication. Widespread adoption will improve reproducibility, allow for accurate comparisons, and avoid misinterpretations in the field of interventional oncology research. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Liddell in this issue.

Hybrid imaging of the abdomen and pelvis.

Accurate imaging is crucial for lesion detection in abdominal organs, for the noninvasive characterization of focal and diffuse abnormalities, and for surgical planning. To accomplish these tasks, several imaging modalities such as multidetector computer tomography (MDCT), magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) are used for abdominal imaging, providing important morphological, functional or metabolic information. More recently, PET/MRI has been gaining attention due to the possibility of combining high-resolution imaging with metabolic imaging. PET/MRI is a novel hybrid imaging technology that in the near future might play a pivotal role in the clinical management of oncologic and inflammatory abdominopelvic diseases. Despite the still limited number of published clinical studies, PET/MRI has been proven to be at least equivalent to PET/CT and to standalone MRI in a variety of oncologic disease. Moreover, in selected and focused clinical studies, it has been proven to outperform current standard of care imaging, for example, in evaluating cholangiocarcinomas, liver metastases, untreated and treated rectal cancer. This has also had an impact on therapeuticmanagement in some studies. Therefore in some institutions, including those of the authors, PET/MRI is becoming the new standard imaging modality in staging treatment-naïve intrahepatic massforming cholangiocarcinomas and prior to complicated hepatic surgery.

Abdominal Imaging Findings in COVID-19: Preliminary Observations.

Background Angiotensin-converting enzyme 2, a target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), demonstrates its highest surface expression in the lung, small bowel, and vasculature, suggesting abdominal viscera may be susceptible to injury. Purpose To report abdominal imaging findings in patients with coronavirus disease 2019. Materials and Methods In this retrospective cross-sectional study, patients consecutively admitted to a single quaternary care center from March 27 to April 10, 2020, who tested positive for SARS-CoV-2 were included. Abdominal imaging studies performed in these patients were reviewed, and salient findings were recorded. Medical records were reviewed for clinical data. Univariable analysis and logistic regression were performed. Results A total of 412 patients (average age, 57 years; range, 18 to >90 years; 241 men, 171 women) were evaluated. A total of 224 abdominal imaging studies were performed (radiography, n = 137; US, n = 44; CT, n = 42; MRI, n = 1) in 134 patients (33%). Abdominal imaging was associated with age (odds ratio [OR], 1.03 per year of increase; P = .001) and intensive care unit (ICU) admission (OR, 17.3; P < .001). Bowel-wall abnormalities were seen on 31% of CT images (13 of 42) and were associated with ICU admission (OR, 15.5; P = .01). Bowel findings included pneumatosis or portal venous gas, seen on 20% of CT images obtained in patients in the ICU (four of 20). Surgical correlation (n = 4) revealed unusual yellow discoloration of the bowel (n = 3) and bowel infarction (n = 2). Pathologic findings revealed ischemic enteritis with patchy necrosis and fibrin thrombi in arterioles (n = 2). Right upper quadrant US examinations were mostly performed because of liver laboratory findings (87%, 32 of 37), and 54% (20 of 37) revealed a dilated sludge-filled gallbladder, suggestive of bile stasis. Patients with a cholecystostomy tube placed (n = 4) had negative bacterial cultures. Conclusion Bowel abnormalities and gallbladder bile stasis were common findings on abdominal images of patients with coronavirus disease 2019. Patients who underwent laparotomy often had ischemia, possibly due to small-vessel thrombosis. © RSNA, 2020.

[Hybrid imaging of the abdomen and pelvis. German version]. / Hybridbildgebung bei abdominellen Erkrankungen.

Accurate imaging is crucial for lesion detection in abdominal organs, for the noninvasive characterization of focal and diffuse abnormalities, and for surgical planning. To accomplish these tasks, several imaging modalities such as multidetector computer tomography (MDCT), magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) are used for abdominal imaging, providing important morphological, functional or metabolic information. More recently, PET/MRI has been gaining attention due to the possibility of combining high-resolution imaging with metabolic imaging. PET/MRI is a novel hybrid imaging technology that in the near future might play a pivotal role in the clinical management of oncologic and inflammatory abdominopelvic diseases. Despite the still limited number of published clinical studies, PET/MRI has been proven to be at least equivalent to PET/CT and to stand-alone MRI in a variety of oncologic disease. Moreover, in selected and focused clinical studies, it has been proven to outperform current standard of care imaging, for example, in evaluating cholangiocarcinomas, liver metastases, untreated and treated rectal cancer. This has also had an impact on therapeutic management in some studies. Therefore in some institutions, including those of the authors, PET/MRI is becoming the new standard imaging modality in staging treatment-naïve intrahepatic mass-forming cholangiocarcinomas and prior to complicated hepatic surgery.

Hysterosalpingography in endometriosis: performance and interpretation.

Endometriosis is often seen and sometimes initially diagnosed on hysterosalpingography (HSG), an imaging exam routinely performed on patients with infertility. Here we discuss the role of HSG in the evaluation of patients with infertility with a focus on patients with endometriosis. The HSG technique, including patient preparation as well as potential risks and complications, is detailed. Imaging findings in patients with endometriosis are illustrated and a template for exam reporting is presented. Common imaging pitfalls are described with examples.

Performance of 18F-fluciclovine PET/MR in the evaluation of osseous metastases from castration-resistant prostate cancer.

PURPOSE: 18F-Fluciclovine is indicated for evaluation of suspected prostate cancer (PCa) biochemical recurrence. There are few studies investigating fluciclovine with PET/MR and none evaluated osseous metastases. Our aim was to assess the performance of 18F-fluciclovine PET/MR (fluciclovine-PET/MR) for detecting osseous metastases in patients with castration-resistant prostate cancer (CRPC). We also investigated possible correlations between SUVmax and ADCmean. METHODS: We evaluated 8 patients with CRPC metastatic to bones, some before and some after radium therapy, who underwent 13 fluciclovine-PET/MR studies. We analyzed the performance of radionuclide bone scan (RBS), MR alone, fluciclovine-PET alone, and fluciclovine-PET/MR in detecting osseous metastases. Lesion size, characteristics (early sclerotic, late sclerotic, mixed, lytic), SUVmax, and ADCmean were assessed. The reference standard was a combination of clinical information and correlation with both prior and follow-up imaging. RESULTS: Of 347 metastatic bony lesions in 13 studies, 238/347 (68%) were detected by fluciclovine-PET alone, 286/347 (82%) by RBS, 344/347 (99%) by MR alone, and 347/347 (100%) by fluciclovine-PET/MR. Fluciclovine-PET/MR and MR had the best performance (p < 0.001). There was no statistically significant difference between fluciclovine-PET/MR and MR alone (p = 0.25). Fluciclovine-PET had a lower detection rate especially with late sclerotic lesions (p < 0.001). There was a moderate inverse correlation between lesion SUVmax and ADCmean (r = - 0.49; p < 0.001). CONCLUSIONS: This study suggests that fluciclovine-PET/MR and MR have high sensitivity for detecting osseous metastases in CRPC. Fluciclovine-PET alone underperformed in detecting late sclerotic lesions. The inverse correlation between SUVmax and ADCmean suggests a possible relationship between tumor metabolism and cellularity.

Management implications of fluorodeoxyglucose positron emission tomography/magnetic resonance in untreated intrahepatic cholangiocarcinoma.

PURPOSE: Intrahepatic cholangiocarcinoma (ICC) is associated with a poor prognosis with surgical resection offering the best chance for long-term survival and potential cure. However, in up to 36% of patients who undergo surgery, more extensive disease is found at time of operation requiring cancellation of surgery. PET/MR is a novel hybrid technology that might improve local and whole-body staging in ICC patients, potentially influencing clinical management. This study was aimed to investigate the possible management implications of PET/MR, relative to conventional imaging, in patients affected by untreated intrahepatic cholangiocarcinoma. METHODS: Retrospective review of the clinicopathologic features of 37 patients with iCCC, who underwent PET/MR between September 2015 and August 2018, was performed to investigate the management implications that PET/MR had exerted on the affected patients, relative to conventional imaging. RESULTS: Of the 37 patients enrolled, median age 63.5 years, 20 (54%) were female. The same day PET/CT was performed in 26 patients. All patients were iCCC-treatment-naïve. Conventional imaging obtained as part of routine clinical care demonstrated early-stage resectable disease for 15 patients and advanced stage disease beyond the scope of surgical resection for 22. PET/MR modified the clinical management of 11/37 (29.7%) patients: for 5 patients (13.5%), the operation was cancelled due to identification of additional disease, while 4 "inoperable" patients (10.8%) underwent an operation. An additional 2 patients (5.4%) had a significant change in their operative plan based on PET/MR. CONCLUSIONS: When compared with standard imaging, PET/MR significantly influenced the treatment plan in 29.7% of patients with iCCC. TRIAL REGISTRATION: 2018P001334.

Clinical impact of PET/MR in treated colorectal cancer patients.

PURPOSE: The primary aim of the present study was to evaluate if PET/MR induced management changes versus standard of care imaging (SCI) in treated colorectal cancer patients. The secondary aim was to assess the staging performance of PET/MR and of SCI versus the final oncologic stage. METHODS: Treated CRC patients who underwent PET/MR with 18F-FDG and SCI between January 2016 and October 2018 were enrolled in this retrospective study. Their medical records were evaluated to ascertain if PET/MR had impacted on their clinical management versus SCI. The final oncologic stage, as reported in the electronic medical record, was considered the true stage of disease. RESULTS: A total of 39 patients who underwent 42 PET/MR studies were included, mean age 56.7 years (range 39-75 years), 26 males, and 13 females. PET/MR changed clinical management 15/42 times (35.7%, standard error ± 7.4%); these 15 changes in management were due to upstaging in 9/42 (21.5%) and downstaging in 6/42 (14.2%). The differences in management prompted by SCI versus PET/MR were statistically significant, and PET/MR outperformed SCI (P value < 0.001; odds ratio = 2.8). In relation to the secondary outcome, PET/MR outperformed the SCI in accuracy of oncologic staging (P value = 0.016; odds ratio = 4.6). CONCLUSIONS: PET/MR is a promising imaging tool in the evaluation of treated CRC and might change the management in these patients. However, multicenter prospective studies with larger patient samples are required in order to confirm these preliminary results.

Nationwide, Longitudinal Trends in CT Colonography Utilization: Cross-Sectional Survey Results From the 2010 and 2015 National Health Interview Survey.

PURPOSE: Colon cancer screening reduces deaths from colorectal cancer. Screening rates have plateaued; however, studies have found that giving patients a choice between different screening tests improves adherence. CT colonography is a minimally invasive screening test with high sensitivity for colonic polyps (>1 cm). With increasing insurance coverage of CT colonography nationwide, there are limited estimates of CT colonography utilization over time. Our purpose was to estimate CT colonography utilization over time using nationally representative cross-sectional survey data. METHODS: We utilized 2010 and 2015 National Health Interview Survey cross-sectional data. Participants between ages 50 and 75 without colorectal cancer history were included. Accounting for complex survey design elements, logistic regression analyses evaluated changes in CT colonography utilization over time, adjusted for potential confounders, and stratified by insurance and age. RESULTS: Overall, 21,686 respondents were included (8,965 in 2010, 12,721 in 2015). Reported CT colonography utilization decreased from 1.2% to 0.9% (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.86-0.98). Stratified analyses revealed no changes in utilization in patients with private insurance (P = .35) and in patients younger than 65 (P = .07). Overall awareness of CT colonography decreased from 20.5% to 15.9% (OR 0.93, 95% CI 0.91-0.95). Reported optical colonoscopy utilization increased from 57.9% to 63.6% (OR 1.03, 95% CI 1.02-1.05). CONCLUSION: Despite increasing self-reported utilization of optical colonoscopy from 2010 to 2015, survey results suggest that CT colonography awareness (∼16%) and utilization (∼1%) remain low. Improved public awareness and coverage expansion to Medicare-aged populations will promote improved CT colonography utilization and overall colorectal cancer screening rates.

Effect of androgen deprivation and radiation therapy on MRI fiber tractography in prostate cancer: can we assess treatment response on imaging?

OBJECTIVE: To evaluate quantitative changes in Diffusion Tensor Magnetic Resonance Tractography in prostate cancer following androgen deprivation and radiation therapy. METHODS: 22 patients with elevated PSA and biopsy proven prostate carcinoma who underwent MRI of the prostate at 1.5 T with an endorectal coil were included. Group A) was the study group (n = 11), participants who underwent androgen deprivation and/or radiation therapy and group B) were Gleason-matched control group (n = 11) participants who did not undergo such therapy. Diffusion weighted images were used to generate three-dimensional (3D) map of fiber tracts from DTI. 3D regions of interest (ROI) were drawn over the tumor and healthy prostatic parenchyma in both groups to record tract number and tract density. Tumor region and normal parenchymal tract densities within each group were compared. RESULTS: Mean tract density in the tumor region and normal parenchyma was 2.3 and 3.3 in study group (tract numbers: 116.6 and 170.2 respectively) and 1.6 and 2.7 in the control group respectively (tract numbers: 252.5 and 346.3 respectively). The difference between these values was statistically significant for the control group (p = 0.0018) but not for the study group (p = 0.11). The difference between the tract numbers of tumor and normal parenchyma appears to narrow following therapy. CONCLUSION: The study demonstrated utility in using tractography as a biomarker in prostate cancer patients post treatment. ADVANCES IN KNOWLEDGE: Quantitative DTI fiber tractography is a promising imaging biomarker to quantitatively assess treatment response in the setting of post-androgen deprivation and radiation therapy for prostate cancer.

Diagnostic performance of PET/MR in the evaluation of active inflammation in Crohn disease.

This study investigates the performance of PET/MR versus each sub-modality alone in the assessment of active inflammation in patients with Crohn disease, when compared to surgery as standard of reference. Sensitivity for detecting active inflammation was 91.5% for PET, 80% for MR, and 88% for PET/MR. Specificity for active inflammation was 74% for PET, 87% for MR, and 93% for PET/MR. Diagnostic accuracy was 84% for PET, 83% for MR, and 91% for PET/MR. In conclusion, PET/MR is significantly more accurate than either sub-modality alone and more specific than PET alone in the detection of active inflammation in patients with Crohn disease.

Assessing the Effect of Weight-Based Protocol Modifications to Lower Dose for CT-Guided Hepatic and Renal Tumor Radiofrequency Ablations.

OBJECTIVE: This study assessed radiation dose after CT-guided percutaneous radiofrequency ablations (RFAs) of hepatic and renal tumors and the effect of weight-based CT protocol modification for lowering overall dose in these procedures. MATERIALS AND METHODS: CT-guided RFA for renal and hepatic ablations performed from January 1, 2009, through December 31, 2009, were retrospectively reviewed (90 men and 48 women; age, 42-81 years). The radiation dose was recorded during each of the following steps: planning, performing, and postprocedure. Weight-based protocol modification changes in tube voltage and tube current were then applied to renal and hepatic ablations performed subsequently (18 men and 11 women; age, 48-82 years). Image quality, needle localization, lesion detection, ability to detect complications, and overall operator satisfaction were noted for each case (score, 1-5). Dose reduction after modification was then calculated. RESULTS: Retrospective analysis found a mean (± SD) overall CT dose index (CTDI) for CT-guided RFA to be 16.5 ± 2.3 mGy. After protocol modification, the mean CTDI decreased to 6.63 ± 0.67 mGy, a 59.6% reduction overall; for hepatic ablations, the reduction was 65.96% (p < 0.0001) and the reduction for renal ablations was 38.97% (p = 0.0153). Image quality analysis showed high operator satisfaction (3-5), including adequate needle localization (4-5), lesion visibility (3-5), and high performer confidence (4-5). Higher dose reduction was noted for patients weighing more than 180 lb (82 kg) (p < 0.0001). CONCLUSION: Simple weight-based CT protocol modifications can significantly reduce radiation dose during CT-guided percutaneous ablations in the liver and kidneys without significantly sacrificing image quality.

Imaging guided percutaneous interventions in hepatic dome lesions: Tips and tricks.

Percutaneous hepatic interventions are generally safe given the fact that liver closely abuts the abdominal wall and hence it is easily accessible. However, the superior portion of liver, adjacent to the diaphragm, commonly referred as the "hepatic dome", presents unique challenges for interventionists. Percutaneous access to the hepatic dome may be restricted by anatomical factors and special considerations may be required to avoid injury to the surrounding organs. The purpose of this review article is to discuss certain specific maneuvers and techniques that can enhance the success and safety of interventions in the hepatic dome.

Decision Making: Thermal Ablation Options for Small Renal Masses.

Renal cell carcinoma is a relatively common tumor, with an estimated 63,000 new cases being diagnosed in the United States in 2016. Surgery, be it with partial or total nephrectomy, is considered the mainstay of treatment for many patients. However, those patients with small renal masses, typically less than 3 to 4 cm in size who are deemed unsuitable for surgery, may be suitable for percutaneous thermal ablation. We review the various treatment modalities, including radiofrequency ablation, microwave ablation, and cryoablation; discuss the advantages and disadvantages of each method; and review the latest data concerning the performance of the various ablative modalities compared with each other, and compared with surgery.

Renal Mass and Localized Renal Cancer: AUA Guideline.

PURPOSE: This AUA Guideline focuses on evaluation/counseling and management of adult patients with clinically localized renal masses suspicious for cancer, including solid-enhancing tumors and Bosniak 3/4 complex-cystic lesions. MATERIALS AND METHODS: Systematic review utilized research from the Agency for Healthcare Research and Quality and additional supplementation by the authors and consultant methodologists. Evidence-based statements were based on body of evidence strength Grade A/B/C (Strong/Moderate/Conditional Recommendations, respectively) with additional statements presented as Clinical Principles or Expert Opinions. RESULTS: Great progress has been made since the previous guidelines on management of localized renal masses were released (2009). The current guidelines provide updated, evidence-based recommendations regarding evaluation/counseling of patients with clinically localized renal masses, including the evolving role of renal mass biopsy. Given great variability of clinical, oncologic and functional characteristics, index patients are not utilized and the panel advocates individualized counseling/management. Management options (partial nephrectomy/radical nephrectomy/thermal ablation/active surveillance) are reviewed including recent data about comparative effectiveness and potential morbidities. Oncologic issues are prioritized while recognizing that functional outcomes are of great importance for survivorship for most patients with localized kidney cancer. A more restricted role for radical nephrectomy is recommended following well-defined selection criteria. Priority for partial nephrectomy is recommended for clinical T1a lesions, along with selective use of thermal ablation, particularly for tumors ≤3.0 cm. Important considerations for shared decision-making about active surveillance are explicitly defined. CONCLUSIONS: Several factors should be considered during counseling/management of patients with clinically localized renal masses, including general health/comorbidities, oncologic potential of the mass, pertinent functional issues and relative efficacy/potential morbidities of various management strategies.