Prostate Multiparametric Magnetic Resonance Imaging Program Implementation and Impact: Initial Clinical Experience in a Community Based Health System.

INTRODUCTION: Magnetic resonance imaging of the prostate is increasingly being performed at academic centers but implementation in community based health systems has lagged and literature regarding clinical impact in this setting is limited. We describe our experience developing a community based prostate magnetic resonance imaging program, including the evolution of interpretation and reporting methods, and the resulting clinical impact during a period of more than 5 years (August 2010 to December 2015). METHODS: Data collected for prostate magnetic resonance imaging included demographic, clinical, scanning, pathology and treatment/management information. Suspicion level on prostate magnetic resonance imaging was correlated with pathology results when available. Outcomes were compared across 3 reporting eras, ie early, mid and Prostate Imaging Reporting and Data System, version 2. RESULTS: A total of 537 prostate magnetic resonance images were obtained for diagnosed prostate cancer (60%) or screening (37%). During the study period the number of scans and ordering physicians increased. The proportion of patients with suspected extraprostatic extension (17.5%), lymph node metastasis (6.9%) and bone/other metastasis (4.3%) on prostate magnetic resonance imaging remained relatively constant. When stratified by era, there was a significant increase in low suspicion studies (p = 0.0002) and a trend toward a significant increase in cancer detection at biopsy (p = 0.09), reflecting increased specificity in the Prostate Imaging Reporting and Data System, version 2 era. CONCLUSIONS: While staging information with prostate magnetic resonance imaging was accurate early in the implementation of the program, lesion characterization improved with use of Prostate Imaging Reporting and Data System, version 2 criteria and standardized reporting. Regular multidisciplinary participation in community based prostate magnetic resonance imaging programs may maximize clinical impact.

Regression of massive cardiac rhabdomyoma on everolimus therapy.

Cardiac rhabdomyoma is the primary feature of the genetic disease, tuberous sclerosis complex, the most common cardiac tumor diagnosed in neonates and infants. Spontaneous regression is observed in most cases, but these tumors may cause hemodynamic instability, arrhythmias or other complications. We describe the case of a critically ill neonate, resuscitated after cardiac arrest secondary to massive locally invasive cardiac rhabdomyoma, who was successfully treated with everolimus (mammalian target of rapamycin [mTOR] inhibitor). Rapid tumor regression was observed on echocardiography, but it was unlikely that it was confounded by the natural disease course of regression. The presented case suggests that mTOR inhibitors may play a significant role in the treatment of large cardiac rhabdomyomas in critically ill neonates.

ACR appropriateness criteria® nonischemic myocardial disease with clinical manifestations (ischemic cardiomyopathy already excluded).

Nonischemic myocardial disease or cardiomyopathy can present as arrhythmia, palpitations, heart failure, dyspnea, lower extremity edema, ascites, syncope, and/or chest discomfort and can be classified as either systolic, diastolic, or a combination of both. Echocardiography is the mainstay of evaluating left ventricular function. However, cardiac magnetic resonance imaging (MRI) is now considered the reference standard imaging technique to assess myocardial anatomy, function, and viability. Advanced MRI techniques with delayed myocardial enhancement, especially, can provide information beyond echocardiography for tissue characterization in CM and can assist in determining specific etiology or in narrowing the differential. Often imaging enhancement patterns, signal characteristics, and morphology on MRI can lead to specific diagnoses such as amyloidosis, hypertrophic CM, or iron deposition. Cardiac computed tomography is usually used in excluding coronary artery disease but can also be used in some patients unable to undergo cardiac MRI to assess arrhythmogenic right ventricular dysplasia. Both 18-F-fluoro-2-deoxyglucose positron emission tomography and delayed contrast-enhanced MRI can be used to assess for cardiac sarcoidosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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 in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Surgeon assessment of renal preservation with partial nephrectomy provides information comparable to measurement of volume preservation with 3-dimensional image analysis.

PURPOSE: The strongest predictors of renal function after partial nephrectomy are the preoperative glomerular filtration rate and the amount of preserved parenchyma. Measuring volume preservation by 3-dimensional imaging is accurate but time-consuming. Percent functional volume preservation was designed to replace surgeon assessment of volume preservation with a less labor intensive, objective assessment. We compared volume preservation with 3-dimensional imaging, percent functional volume preservation and surgeon assessment of volume preservation as predictors of renal function after partial nephrectomy. MATERIALS AND METHODS: We calculated volume preservation with 3-dimensional imaging, percent functional volume preservation and surgeon assessment of volume preservation in 41 patients with preoperative and postoperative cross-sectional imaging available. Surgeon assessment was validated internally in another 75 patients. Short-term and long-term renal function was assessed with univariate and multivariate linear regression models. RESULTS: Median parenchymal preservation was 85% (range 37% to 105%) by 3-dimensional imaging, 91% (range 51% to 114%) by percent functional preservation and 88% (range 45% to 99%) by surgeon assessment. Each method strongly correlated with nadir glomerular filtration rate (r(2) = 0.75, 0.65 and 0.78) and latest glomerular filtration rate (r(2) = 0.65, 0.66 and 0.67, respectively, each p <0.0001). Univariate analysis revealed that age, preoperative glomerular filtration rate, renal nephrometry score and each assessment were significant predictors of renal function (p <0.05). On multivariate analysis parenchymal preservation was the strongest predictor (p <0.0001). Models using volume preservation with 3-dimensional imaging, percent functional volume preservation and surgeon assessment of volume preservation were statistically similar in the ability to predict the nadir and latest glomerular filtration rates. In an additional validation cohort surgeon assessment remained strongly correlated with nadir glomerular filtration rate (r(2) = 0.74) and latest glomerular filtration rate (r(2) = 0.73, each p <0.0001). CONCLUSIONS: Surgeon assessment of volume preservation provides a reliable estimate of renal functional preservation with characteristics comparable to those of more time intensive alternatives. We propose that surgeon assessment of volume preservation should be routinely reported to facilitate analysis of partial nephrectomy outcomes.

ACR Appropriateness Criteria chronic chest pain-low to intermediate probability of coronary artery disease.

Chronic chest pain can arise from a variety of etiologies. However, of those potential causes, the most life-threatening include cardiac disease. Chronic cardiac chest pain may be caused either by ischemia or atherosclerotic coronary artery disease or by other cardiac-related etiologies, such as pericardial disease. To consider in patients, especially those who are at low risk for coronary artery disease, are etiologies of chronic noncardiac chest pain. Noncardiac chest pain is most commonly related to gastroesophageal reflux disease or other esophageal diseases. Alternatively, it may be related to costochondritis, arthritic or degenerative diseases, old trauma, primary or metastatic tumors, or pleural disease. Rarely, noncardiac chest pain may be referred pain from organ systems below the diaphragm, such as the gallbladder. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 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 in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria(®) acute nonspecific chest pain-low probability of coronary artery disease.

This document outlines the usefulness of available diagnostic imaging for patients without known coronary artery disease and at low probability for having coronary artery disease who do not present with classic signs, symptoms, or electrocardiographic abnormalities indicating acute coronary syndrome but rather with nonspecific chest pain leading to a differential diagnosis, including pulmonary, gastrointestinal, or musculoskeletal pathologies. A number of imaging modalities are available to evaluate the broad spectrum of possible pathologies in these patients, such as chest radiography, multidetector CT, MRI, ventilation-perfusion scans, cardiac perfusion scintigraphy, transesophageal and transthoracic echocardiography, PET, spine and rib radiography, barium esophageal and upper gastrointestinal studies, and abdominal ultrasound. It is considered appropriate to start the assessment of these patients with a low-cost, low-risk diagnostic test such as a chest x-ray. Contrast-enhanced gated cardiac and ungated thoracic multidetector CT as well as transthoracic echocardiography are also usually considered as appropriate in the evaluation of these patients as a second step if necessary. A number of rest and stress single-photon emission CT myocardial perfusion imaging, ventilation-perfusion scanning, aortic and chest MR angiographic, and more specific x-ray and abdominal examinations may be appropriate as a third layer of testing, whereas MRI of the heart or coronary arteries and invasive testing such as transesophageal echocardiography or selective coronary angiography are not considered appropriate in these patients. Given the low risk of these patients, it is mandated to minimize radiation exposure as much as possible using advanced and appropriate testing protocols. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 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 in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria® chronic chest pain--high probability of coronary artery disease.

Imaging is valuable in determining the presence, extent, and severity of myocardial ischemia and the severity of obstructive coronary lesions in patients with chronic chest pain in the setting of high probability of coronary artery disease. Imaging is critical for defining patients best suited for medical therapy or intervention, and findings can be used to predict long-term prognosis and the likely benefit from various therapeutic options. Chest radiography, radionuclide single photon-emission CT, radionuclide ventriculography, and conventional coronary angiography are the imaging modalities historically used in evaluating suspected chronic myocardial ischemia. Stress echocardiography, PET, cardiac MRI, and multidetector cardiac CT have all been more recently shown to be valuable in the evaluation of ischemic heart disease. Other imaging techniques may be helpful in those patients who do not present with signs classic for angina pectoris or in those patients who do not respond as expected to standard management. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 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 in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria(®) on suspected lower extremity deep vein thrombosis.

Lower extremity deep vein thrombosis (DVT) is a common clinical concern, with an incidence that increases with advanced age. DVT typically begins below the knee but may extend proximally and result in pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT and can be fatal. Although clinical examination and plasma d-dimer blood evaluation can often predict the presence of DVT, imaging remains critical for the diagnostic confirmation and treatment planning of DVT. Patients with above-the-knee or proximal DVT have a high risk for pulmonary embolism and are recommended to receive anticoagulation therapy. On the other hand, patients with below-the-knee or distal DVT rarely experience pulmonary embolism, and anticoagulation therapy in these patients remains controversial. However, one sixth of patients with distal DVT may experience extension of their thrombus above the knee and therefore are recommended to undergo serial imaging assessment at 1 week to exclude proximal DVT extension if anticoagulation therapy is not initiated. Ultrasound is the preferred imaging method for evaluation of patients with newly suspected lower extremity DVT. Magnetic resonance and CT venography can be especially helpful for the evaluation of suspected DVT in the pelvis and thigh. Contrast x-ray venography, the historic gold standard for DVT assessment, is now less commonly performed and primarily reserved for patients with more complex presentations such as those with suspected recurrent acute DVT.

ACR Appropriateness Criteria® on chest pain, suggestive of acute coronary syndrome.

Acute chest pain suggestive of acute coronary syndrome is a frequent complaint in the emergency department. Acute coronary syndromes include myocardial infarction and unstable angina. Being able to establish the diagnosis rapidly and accurately may be lifesaving. A cardiac workup is indicated in this subset of patients in the acute setting, even if there are no ischemic changes on electrocardiography. If the clinical examination and initial cardiac workup suggest that a patient is having myocardial ischemia, the patient will usually be urgently referred for invasive coronary angiography and revascularization. In stable patients without evidence of ST elevation and ongoing myocardial ischemia, an initially conservative approach is sometimes considered. Cardiac risk stratification of this subgroup of patients who are at low and intermediate risk for coronary artery disease is recommended before discharge, and imaging is necessary to exclude ischemia as an etiology. Noninvasive cardiac imaging modalities include chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI. Noncardiac etiologies of chest pain include aortic dissection, aortic aneurysm, pulmonary embolism, pericardial disease, and lung parenchymal disease. Noninvasive cardiac imaging in patients who are at low and intermediate risk for coronary artery disease may improve confidence regarding the safety of discharge from the emergency department. In addition to risk stratification, noncoronary etiologies for chest pain can be established with imaging.

Coronary artery fistulas: CT findings.

Coronary artery fistulas are anomalous terminations of the coronary arteries. Most often, these fistulas are incidentally identified in the adult and pediatric populations. Many patients are asymptomatic; however, an awareness of these fistulas is important because they have been associated with various clinical features, including chest pain or heart failure in young patients. Correct diagnosis of coronary artery fistulas is important, and early surgical correction is indicated because of the high prevalence of late symptoms and complications. Traditionally, conventional angiography has been used for the diagnosis of coronary anomalies. With more frequent use of 64-row multi-detector computed tomography (CT) in chest and cardiac imaging, the number of incidentally found coronary artery fistulas has been increasing. CT angiography and conventional angiography can have additive value in diagnosis of this cardiac anomaly. In every CT study of the heart, special attention should be paid to the courses and terminations of the coronary arteries to detect these potentially fatal anomalies.

ACR appropriateness criteria on recurrent symptoms following lower-extremity angioplasty.

Lower-extremity arteriopathy patients can be managed nonsurgically, but there is no standard algorithm for follow-up. The authors present a consensus on appropriate postangioplasty studies in the setting of claudication or a threatened limb. Physical examination with measurements of the ankle-brachial index should be the first step in patients with recurrent symptoms. When there is high clinical suspicion for a threatened limb, the patient should proceed directly to catheter angiography for possible reintervention. However, in the setting of claudication alone, segmental Doppler pressures and pulse volume recordings are the initial test of choice. Magnetic resonance angiography or ultrasound can be used in conjunction to further characterize lesions with more detail. Computed tomographic angiography may also be used to image lower-extremity vasculature but is limited by the presence of large amounts of vascular calcifications. Novel techniques, including dual-energy computed tomographic angiography and noncontrast magnetic resonance angiography, may provide clinicians with alternative approaches in patients with large amounts of vascular calcifications and renal insufficiency, respectively.

Descending tumor thrombus from renal cell carcinoma metastases with SVC syndrome.

We describe a case of renal cell carcinoma metastases to the thyroid gland invading local veins and extending to the neck veins causing superior vena cava (SVC) syndrome.

Outcome of fetuses with clubfeet diagnosed by prenatal sonography.

OBJECTIVE: To determine the outcome of fetuses with clubfoot diagnosed by prenatal sonography. METHODS: We identified all fetuses scanned at our institution from May 1989 to May 2002 in whom clubfoot was suspected or diagnosed on prenatal sonography. From maternal and neonatal medical records, we collected the following information when available: unilateral or bilateral clubfoot, gestational age at diagnosis, other sonographic findings, and pregnancy outcome, including pathologic reports and neonatal findings at birth. RESULTS: One hundred twenty-one fetuses had prenatal sonographic suspicion or diagnosis of clubfoot. Twenty-two had no follow-up information, and 12 fetuses were terminated with fetal parts that could not be evaluated at pathologic examination, leaving 87 study cases. Outcome information was from neonatal records in 51 and from pathologic reports in 36. The gestational age at diagnosis ranged from 12.3 to 39.2 weeks, with a mean of 22.2 weeks. Forty-two (48%) had unilateral clubfoot, and 45 (52%) had bilateral clubfoot on sonography. The false-positive rate was significantly higher with unilateral clubfoot than bilateral clubfoot (12 [29%] of 42 versus 3 [7%] of 45; P < .05). Other anomalies were more common with bilateral clubfoot than with unilateral clubfoot (34 [76%] of 45 versus 23 [55%] of 42; P < .05), the most common being other musculoskeletal anomalies, neural tube defects, and cardiovascular anomalies. Of fetuses with information about chromosomes, the rates of aneuploidy were similar for unilateral and bilateral clubfoot (5 [28%] of 18 versus 10 [32%] of 31; P > .05). CONCLUSIONS: Fetuses with an antenatal sonographic diagnosis of clubfoot often have other anomalies, aneuploidy, or both. The false-positive rate for diagnosis of clubfoot is higher for unilateral clubfoot than bilateral clubfoot. The rate of associated anomalies is higher with bilateral clubfoot than unilateral clubfoot.