Imaging of Neuroendocrine Neoplasms; Principles of Treatment Strategies. What Referring Clinicians Want to Know.

ABSTRACT: Neuroendocrine neoplasms (NENs) are a diverse group of tumors that express neuroendocrine markers and primarily affect the lungs and digestive system. The incidence of NENs has increased over time due to advancements in imaging and diagnostic techniques. Effective management of NENs requires a multidisciplinary approach, considering factors such as tumor location, grade, stage, symptoms, and imaging findings. Treatment strategies vary depending on the specific subtype of NEN. In this review, we will focus on treatment strategies and therapies including the information relevant to clinicians in order to undertake optimal management and treatment decisions, the implications of different therapies on imaging, and how to ascertain their possible complications and treatment effects.

Efficacy of Whole-Blood Model of Gadolinium-Based Contrast Agent Relaxivity in Predicting Vascular MR Signal Intensity In Vivo.

BACKGROUND: Previous in vitro studies have described sub-linear longitudinal and heightened transverse H2 O relaxivities of gadolinium-based contrast agents (GBCAs) in blood due to their extracellular nature. However, in vivo validation is lacking. PURPOSE: Validate theory describing blood behavior of R1 and R2 * in an animal model. STUDY TYPE: Prospective, animal. ANIMAL MODEL: Seven swine (54-65 kg). FIELD STRENGTH/SEQUENCE: 1.5 T; time-resolved 3D spoiled gradient-recalled echo (SPGR) and quantitative Look-Locker and multi-echo fast field echo sequences. ASSESSMENT: Seven swine were each injected three times with 0.1 mmol/kg intravenous doses of one of three GBCAs: gadoteridol, gadobutrol, and gadobenate dimeglumine. Injections were randomized for rate (1, 2, and 3 mL/s) and order, during which time-resolved aortic 3D SPGR imaging was performed concurrently with aortic blood sampling via an indwelling catheter. Time-varying [GBCA] was measured by mass spectrometry of sampled blood. Predicted signal intensity (SI) was determined from a model incorporating sub-linear R1 and R2 * effects (whole-blood model) and simpler models incorporating linear R1 , with and without R2 * effects. Predicted SIs were compared to measured aortic SI. STATISTICAL TESTS: Linear correlation (coefficient of determination, R2 ) and mean errors were compared across the SI prediction models. RESULTS: There was an excellent correlation between predicted and measured SI across all injections and swine when accounting for the non-linear dependence of R1 and high blood R2 * (regression slopes 0.91-1.04, R2 ≥ 0.91). Simplified models (linear R1 with and without R2 * effects) showed poorer correlation (slopes 0.67-0.85 and 0.54-0.64 respectively, both R2 ≥ 0.89) and higher averaged mean absolute and mean square errors (128.4 and 177.4 vs. 42.0, respectively, and 5506 and 11,419 vs. 699, respectively). DATA CONCLUSION: Incorporating sub-linear R1 and high first-pass R2 * effects in arterial blood models allows accurate SPGR SI prediction in an in vivo animal model, and might be utilized when modeling MR blood SI. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY: Stage 1.

Unexpected extracardiac findings in cardiac computed tomography from neonates to young adults.

BACKGROUND: Modern CT scanners with lower radiation doses have resulted in large numbers of cardiac CTs being performed in children. As seen in adults, pediatric cardiac CT has the potential to demonstrate extracardiac variants and pathology that can occur in conjunction with congenital heart disease (CHD). Prior publications demonstrated a high incidence of extracardiac findings in various locations but the prevalence of urgent unexpected extracardiac findings in children is unknown. OBJECTIVE: The purpose of this study was to describe the incidence, distribution and clinical significance of the extracardiac findings on pediatric cardiac CT at a tertiary referral center. MATERIALS AND METHODS: We reviewed all reports (n = 648) for 554 children through young adults who received a cardiac CT study between Jan. 2, 2018, and March 10, 2020, at our tertiary referral pediatric hospital. We interrogated CT reports for extracardiac findings and categorized them by system (airway, pulmonary, abdomen, malpositioned lines and musculoskeletal). We then subclassified each of these findings by level of clinical importance based upon the need for intervention or treatment into low, medium or high importance. High-importance findings were confirmed with a focused chart review. If a patient had more than one CT with a persistent extracardiac finding, the finding was only counted once. RESULTS: We identified 562 individual extracardiac findings, with one or more extracardiac findings present in 91% of the study population. Extracardiac findings with high clinical importance, requiring urgent attention or intervention, were present in 10% (57/554) of cases. The most common location of extracardiac findings was pulmonary (50%; 280/562), followed by airway (22%; 125/562) and abdomen (9%; 52/562). CONCLUSION: Unexpected highly important extracardiac findings were found in 10% of patients. Therefore, extracardiac structures should be scrutinized for the timely identification of potentially highly important findings.

Solid Pseudopapillary Neoplasm: A Single Institutional Case Series of a Rare Pancreatic Tumor.

Purpose: Solid pseudopapillary neoplasms (SPN) are rare pancreatic cystic neoplasms with low malignant potential that tend to occur in young women. Due to the rarity of this disease, there are few large case series in the literature, and the exact pathophysiology remains unknown. In this article, we aim to share our institutional experience. Methods: Retrospective clinical data collection and analysis was performed on all patients with a diagnosis of SPN at the University of Colorado Hospital and Children's Hospital of Colorado (n = 28). Results: Twenty-eight patients were diagnosed with SPN during the study period. The median age was 21.5 years, and the majority of patients were female (89.3%) and Caucasian (60.7%). Six patients were diagnosed incidentally (21.4%). The majority of tumors were in the pancreatic tail (46.4%), and most underwent distal pancreatectomy (64.3%). The mean tumor size was 5.4 cm, and R0 resection was achieved in 25 patients (89.3%). Ten patients underwent laparoscopic resection (35.7%). The median hospital length of stay was 8.5 days, and postoperative complication rate was 39.3%. Median follow-up was 41 months, with 78.6% of patients alive without evidence of disease, while 2 patients were lost to follow-up. Two patients developed recurrence/metastases, which were resected; both are alive without evidence of disease. Conclusion: SPN are rare pancreatic tumors diagnosed most frequently in young women. Surgical resection is the mainstay of treatment, and outcomes are excellent if complete resection is achieved. Predictors of malignant disease are inconsistent in current literature. Considerations should be made for a minimally invasive approach in patients with SPN. Multidisciplinary clinics may be helpful in the diagnosis, management, and surveillance of pancreatic cystic lesions, with major potential for the advanced practitioner role.

Understanding Patient Experiences, Opinions, and Actions Taken After Viewing Their Own Radiology Images Online: Web-Based Survey.

BACKGROUND: The ability for patients to directly view their radiology images through secure electronic portals is rare in the American health care system. We previously surveyed patients within our health system and found that a large majority wanted to view their own radiology images online, and we have since implemented this new feature. OBJECTIVE: We aim to understand patient experiences, opinions, and actions taken after viewing their own radiology images online. METHODS: We emailed a web-based survey to patients who recently viewed their radiology images via our electronic patient portal. RESULTS: We sent 1825 surveys to patients and received 299 responses (response rate 16.4%). Patients reported a favorable experience (258/299, 86.3% agree) viewing their radiology images online. Patients found value in reading their radiology reports (288/299, 96.3% agree) and viewing their images (267/299, 89.3% agree). Overall, patients felt that accessing and viewing their radiology images online increased their understanding of their medical condition (258/299, 82.9%), made them feel more in control and reassured (237/299, 79.2% and 220/299, 73.6%, respectively), and increased levels of trust (214/299, 71.6%). Only 6.4% (19/299) of the patients indicated concerns with finding errors, 6.4% (19/299) felt that viewing their images online made them worry more, and 7% (21/299) felt confused when viewing their images online. Of patients who viewed their images online, 45.2% (135/299) took no action with their images, 32.8% (98/299) saved a copy for their records, 25.4% (76/299) shared them with their doctor, and 14.7% (44/299) shared them with another doctor for a second opinion. A total of 9 patients (3%) shared their radiology images on Facebook, Instagram, or both, primarily to inform family and friends. Approximately 10.4% (31/299) of the patients had questions about their radiology images after viewing them online, with the majority (20/31, 65%) seeking out a doctor, and far fewer (5/31, 16%) choosing to ask a family member about their images. Finally, respondents viewed their images online using 1 or more devices, including computers, smartphones, tablets, or a combination of these devices. Approximately 26.7% (103/385) of the responses noted technical difficulties, with the highest incidence rate occurring with smartphones. CONCLUSIONS: We report the first known survey results from patients who viewed their own radiology images through a web-based portal. Patients reported high levels of satisfaction and increased levels of trust, autonomy, reassurance, and medical understanding. Only a small minority of patients expressed anxiety or confusion. We suggest that patient access to radiology images, such as patient access to radiology reports, is highly desired by patients and is operationally practical. Other health care institutions should consider offering patients access to their radiology images online in the pursuit of information transparency.

Off Label Use of StarClose for Superior Gluteal Artery Puncture Closure Following Embolisation of an Internal Iliac Artery Type II Endoleak.

INTRODUCTION: Embolisation of type II internal iliac artery endoleaks is challenging given limited options for obtaining transarterial access and for achieving access site haemostasis. REPORT: An 86 year old woman who had undergone endovascular repair for an aorto-iliac aneurysm was found to have serial enlargement of the left common iliac artery portion of the aneurysm observed over a period of two years. At the time of the initial repair, the left internal iliac artery was embolised using coils, and then was covered by extending the iliac limb endoprosthesis into the external iliac artery. However, computed tomography angiography showed recanalisation of the previously coiled left internal iliac artery, thus allowing contrast to flow into the left common iliac aneurysm sac. Given that the internal iliac artery origin was covered and there was no visible collateral pathway, direct puncture of the superior gluteal artery was selected to access the left internal iliac artery in a retrograde fashion. This presented a challenge in terms of achieving haemostasis given the deep position of the arterial access site, which was unlikely to be amenable to manual compression. Off label StarClose was chosen for closure of the superior gluteal arterial access, with successful haemostasis and preserved patency of the vessel. DISCUSSION: Off label StarClose was used successfully to obtain haemostasis after obtaining percutaneous transgluteal access to the superior gluteal artery in order to embolise a type II endoleak arising from the internal iliac artery. Keywords: StarClose; Iliac artery type II endoleak; Arterial closure device; Haemostasis; Superiorgluteal artery.

The Impact of Thiopurine Metabolite Monitoring on the Durability of Thiopurine Monotherapy in Pediatric IBD.

Background: Thiopurine metabolite monitoring to proactively dose optimize to achieve therapeutic levels has not been used consistently, and it is unclear if this would lead to better outcomes. We aimed to compare 6-month outcomes between standard and optimized dosing strategies and define long-term predictors of thiopurine durability. Methods: Two hundred sixteen pediatric IBD patients with at least 2 6-thioguanine nucleotide (6-TGN) levels were grouped for analysis by start dose: >2.5 mg/kg/day AZA (group 1) or <2.5 mg/kg/day (group 2) and further subgrouped depending on whether dosing was optimized to achieve 6-TGN >235 pmol/8 × 108 RBC. The metabolites, 6TGN and 6MMP, were univariate and multivariate analyses tested associations among metabolite levels, laboratory data, and the primary outcome of 6-month steroid-free clinical remission (SFR) (HBI ≤4 for CD; partial Mayo Score [pMS] ≤2 for UC). Thiopurine durability was measured using Kaplan Maier survival analysis. Results: 6-MP, azathioprine, pediatrics, therapeutic drug monitoring, pediatrics were measured a median 59 (43-76) days after initiation of thiopurine. Both dosing strategies led to similar initial 6-TGN levels (group 1 = median 209 [IQR: 155-272] with 25% of patients >235; group 2 = 196 [139-274] with 29% >235). Steroid-free clinical remission was achieved in 74% of the 180 still on thiopurines at 6 months. Start dose was not associated with 6-month SFR-73% in group 1 and 77% in group 2 within those on thiopurines at 6 months (P = 0.61). Fixed- and optimized-dosing subgroups had similar 6-month 6-TGN levels, SFR rate, and percentage 6-TGN > 235. Only 6-TGN level >235 at 6 months predicted thiopurine durability (3 years [1.7-7.7] vs 2.5 years [0.83-5]; log-rank P < 0.001), and this did not retain significant in a multivariate model. Initial dosing strategy, first 6-TGN level, 6-month SFR, 6MMP:6TGN ratio, and delta-MCV did not predict durability. The rate of adverse events was 22%. Conclusions: Steroid-free clinical remission and 6-TGN levels at 6 months were no different between a standardized, fixed dosing strategy and a metabolite-driven, optimized dosing strategy.