Impact of easing COVID-19 safety measures on trauma computed tomography imaging volumes.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has led to substantial disruptions in healthcare staffing and operations. Stay-at-home (SAH) orders and limitations in social gathering implemented in spring 2020 were followed by initial decreases in healthcare and imaging utilization. This study aims to evaluate the impact of subsequent easing of SAH on trauma volumes, demand for, and turnaround times for trauma computed tomography (CT) exams, hypothesizing that after initial decreases, trauma volumes have increased as COVID safety measures have been reduced. METHODS: Patient characteristics, CT imaging volumes, and turnaround time were analyzed for all adult activated emergency department trauma patients requiring CT imaging at a single Level-I trauma center (1/2018-2/2022) located in the sixth most populous county in the USA. Based on COVID safety measures in place in the state of California, three time periods were compared: baseline (PRE, 1/1/2018-3/19/2020), COVID safety measures (COVID, 3/20/2020-1/25/2021), and POST (1/26/2021-2/28/2022). RESULTS: There were 16,984 trauma patients across the study (PRE = 8289, COVID = 3139, POST = 5556). The average daily trauma patient volumes increased significantly in the POST period compared to the PRE and COVID periods (13.9 vs. 10.3 vs. 10.1, p < 0.001), with increases in both blunt (p < 0.001) and penetrating (p = 0.002) trauma. The average daily number of trauma CT examinations performed increased significantly in the POST period compared to the PRE and COVID periods (56.7 vs. 48.3 vs. 47.6, p < 0.001), with significant increases in average turnaround time (47 min vs. 31 and 37, p < 0.001). CONCLUSION: After initial decreases in trauma radiology volumes following stay-at-home orders, subsequent easing of safety measures has coincided with increases in trauma imaging volumes above pre-pandemic levels and longer exam turnaround times.

Targetable IDH1 mutation identified in a rare case of pancreatic serous cystadenocarcinoma but not a series of serous cystadenomas.

Serous cystadenocarcinoma (SCAC) of the pancreas is rare, with only 35 cases reported in the literature. We present a case of SCAC, comparing the clinical presentation, management and molecular features of this case to a series of serous cystadenoma (SCA), which may be a precursor. Compared with SCAs (n = 5), SCAC was larger (11.5 vs median 3.6 cm). The case of SCAC invaded the spleen and exhibited distant metastasis, a requirement for diagnosis since pathologic features are otherwise indistinguishable from SCA. VHL mutations have been reported in about half of SCA in the literature. Accordingly, we identified either somatic or germline VHL mutations in 3 of 5 SCAs (60%), yet no pathogenic mutation was identified in the SCAC. A somatic mutation in IDH1 was found in SCAC only. This has been associated with multiple malignancies, is targetable with the drug ivosidenib and should be studied as a progression factor in SCAC.

Evaluation of Hepatocellular Carcinoma Treatment Response After Locoregional Therapy.

Locoregional therapy (LRT) for hepatocellular carcinoma can be used alone or with other treatment modalities to reduce rates of progression, improve survival, or act as a bridge to cure. As the use of LRT expands, so too has the need for systems to evaluate treatment response, such as the World Health Organization and modified Response Evaluation Criteria In Solid Tumors systems and more recently, the Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA). Early validation results for LI-RADS TRA have been promising, and as research accrues, the TRA is expected to evolve in the near future.

Outcomes of Artificial Intelligence Volumetric Assessment of Kidneys and Renal Tumors for Preoperative Assessment of Nephron-Sparing Interventions.

Background: Renal-cell carcinoma is the most common kidney cancer and the 13th most common cause of cancer death worldwide. Partial nephrectomy and percutaneous ablation, increasingly utilized to treat small renal masses and preserve renal parenchyma, require precise preoperative imaging interpretation. We sought to develop and evaluate a convolutional neural network (CNN), a type of deep learning (DL) artificial intelligence (AI), to act as a surgical planning aid by determining renal tumor and kidney volumes through segmentation on single-phase CT. Materials and Methods: After Institutional Review Board approval, the CT images of 319 patients were retrospectively analyzed. Two distinct CNNs were developed for (1) bounding cube localization of the right and left hemiabdomen and (2) segmentation of the renal parenchyma and tumor within each bounding cube. Training was performed on a randomly selected cohort of 269 patients. CNN performance was evaluated on a separate cohort of 50 patients using Sorensen-Dice coefficients (which measures the spatial overlap between the manually segmented and neural network-derived segmentations) and Pearson correlation coefficients. Experiments were run on a graphics processing unit-optimized workstation with a single NVIDIA GeForce GTX Titan X (12GB, Maxwell Architecture). Results: Median Dice coefficients for kidney and tumor segmentation were 0.970 and 0.816, respectively; Pearson correlation coefficients between CNN-generated and human-annotated estimates for kidney and tumor volume were 0.998 and 0.993 (p < 0.001), respectively. End-to-end trained CNNs were able to perform renal parenchyma and tumor segmentation on a new test case in an average of 5.6 seconds. Conclusions: Initial experience with automated DL AI demonstrates that it is capable of rapidly and accurately segmenting kidneys and renal tumors on single-phase contrast-enhanced CT scans and calculating tumor and renal volumes.

Segmentation of the Prostate Transition Zone and Peripheral Zone on MR Images with Deep Learning.

Purpose To develop a deep learning model to delineate the transition zone (TZ) and peripheral zone (PZ) of the prostate on MR images. Materials and Methods This retrospective study was composed of patients who underwent a multiparametric prostate MRI and an MRI/transrectal US fusion biopsy between January 2013 and May 2016. A board-certified abdominal radiologist manually segmented the prostate, TZ, and PZ on the entire data set. Included accessions were split into 60% training, 20% validation, and 20% test data sets for model development. Three convolutional neural networks with a U-Net architecture were trained for automatic recognition of the prostate organ, TZ, and PZ. Model performance for segmentation was assessed using Dice scores and Pearson correlation coefficients. Results A total of 242 patients were included (242 MR images; 6292 total images). Models for prostate organ segmentation, TZ segmentation, and PZ segmentation were trained and validated. Using the test data set, for prostate organ segmentation, the mean Dice score was 0.940 (interquartile range, 0.930-0.961), and the Pearson correlation coefficient for volume was 0.981 (95% CI: 0.966, 0.989). For TZ segmentation, the mean Dice score was 0.910 (interquartile range, 0.894-0.938), and the Pearson correlation coefficient for volume was 0.992 (95% CI: 0.985, 0.995). For PZ segmentation, the mean Dice score was 0.774 (interquartile range, 0.727-0.832), and the Pearson correlation coefficient for volume was 0.927 (95% CI: 0.870, 0.957). Conclusion Deep learning with an architecture composed of three U-Nets can accurately segment the prostate, TZ, and PZ. Keywords: MRI, Genital/Reproductive, Prostate, Neural Networks Supplemental material is available for this article. © RSNA, 2021.

Effect of shelter-in-place on emergency department radiology volumes during the COVID-19 pandemic.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has led to significant disruptions in the healthcare system including surges of infected patients exceeding local capacity, closures of primary care offices, and delays of non-emergent medical care. Government-initiated measures to decrease healthcare utilization (i.e., "flattening the curve") have included shelter-in-place mandates and social distancing, which have taken effect across most of the USA. We evaluate the immediate impact of the Public Health Messaging and shelter-in-place mandates on Emergency Department (ED) demand for radiology services. METHODS: We analyzed ED radiology volumes from the five University of California health systems during a 2-week time period following the shelter-in-place mandate and compared those volumes with March 2019 and early April 2019 volumes. RESULTS: ED radiology volumes declined from the 2019 baseline by 32 to 40% (p < 0.001) across the five health systems with a total decrease in volumes across all 5 systems by 35% (p < 0.001). Stratifying by subspecialty, the smallest declines were seen in non-trauma thoracic imaging, which decreased 18% (p value < 0.001), while all other non-trauma studies decreased by 48% (p < 0.001). CONCLUSION: Total ED radiology demand may be a marker for public adherence to shelter-in-place mandates, though ED chest radiology demand may increase with an increase in COVID-19 cases.

Postprocedure Intravenous Patient-Controlled Analgesia Compared to Epidural Patient-Controlled Analgesia Use after Uterine Fibroid Embolization: A Clinical Audit.

PURPOSE: Postprocedure epidural analgesia has a proven benefit over intravenous (i.v.) analgesia for pain management, but has not yet been demonstrated for uterine fibroid embolization (UFE). The objectives of this clinical audit were to determine if epidural patient-controlled analgesia (PCA) was beneficial to patient outcome as compared to i.v. PCA in decreasing parenteral opioid requirements and its associated side effects and determine if there is a difference in required oral opioids after the PCA is stopped. MATERIALS AND METHODS: This manuscript audited postprocedural pain management of 51 patients after UFE was performed. 20 patients received an i.v. PCA for post-UFE pain control and 31 received an epidural PCA for post-UFE pain control. Total hydromorphone dose, the frequency of anti-nausea medication use, the frequency of anti-pruritus medication use, and patient pain satisfaction data was collected. RESULTS: Total hydromorphone dose administered to patients post-UFE using epidural PCA was significantly less than patients using an i.v. PCA (P = 0.001). However, the frequency of nausea and pruritus between the two groups did not achieve statistical significance with (P = 0.663) and (P = 0.639) respectively. CONCLUSION: Our clinical audit found that parenteral opioid requirements administered after UFE can be significantly reduced by using epidural PCA instead of i.v. PCA. However, we found no statistically significant difference in medication related side effects or oral opioid use thereafter.

Recognizing the CT Manifestations of Gynecologic Conditions Encountered in the Emergency Department.

Women commonly present to the emergency room with subacute or acute symptoms of gynecologic origin. Although a pelvic exam and ultrasound (US) are the preferred initial diagnostic tools for gynecologic entities, a CT is often the first line imaging modality in the emergency department. We will provide a review of normal uterine enhancement and normal pregnancy related findings, and then familiarize radiologists with the CT appearances of gynecologic entities classically described on ultrasound that may present to the emergency department.

Evaluation of Margin Status of a Breast Lumpectomy Specimen: What the Radiologist Should Know.

Breast Conserving Therapy (BCS) or lumpectomy has been an established treatment option for women with early-stage invasive breast cancers. Surgical margin status has a significant impact on local recurrence. However, there is much complexity in achieving a negative lumpectomy margin. There are multiple risks and predictors of positive surgical margins that the radiologist needs to be familiar with. When working as a member of a multidisciplinary team, it is important to be cognizant of the pathologist's and surgeon's roles in reducing the number of failed breast conserving surgeries. Despite the common use of imaging to help avoid positive surgical margins, it is important to remember the limitations of standard intraoperative specimen radiographs. A negative resection margin is the goal of BCS ensuring decrease of local recurrence, increased cosmesis, and improved long-term survival.

Endometriosis revisited: an imaging review of the usual and unusual manifestations with pathological correlation.

The manifestations of endometriosis commonly present a diagnostic challenge to the gynecologist and radiologist. Familiarity with its varied presentations may allow for a more accurate diagnosis. The goal of this review is to the present the imaging spectrum of endometriosis, less common sites of involvement as well as the potential rare complications. Relevant surgical and histopathological correlation is also provided. In addition to clinical evaluation and sonography, MRI is a highly accurate imaging modality in the diagnosis of endometriosis. It possesses a distinctive advantage over other modalities in that it allows a complete survey of the pelvic compartments. The potentially devastating effects of endometriosis include pelvic pain and even infertility. Since standard treatment is surgical, the radiologist needs to be familiar with the various manifestations in order to aid diagnosis for appropriate management.

Bleeding stomal varices in portal hypertension.

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, to the best of our knowledge, there are no cases in the current literature in which treatment of this entity is performed with a combination of TIPS shunt placement and N-butyl cyanoacrylate variceal embolization.

Renal Granulomatosis Post Intravesical Bacillus Calmette-Guerin Therapy for Non-muscle-invasive Bladder Cancer.

Intravesical Bacillus Calmette-Guerin (BCG) immunotherapy is a proven, effective treatment for intermediate- and high-risk non-muscle-invasive bladder cancer. Minor side effects are common and expected but systemic effects can occur in <5% of treated patients. We present a rare case of a 49-year-old male that presented with fever and chills after 3 weeks of intravesical BCG therapy post transurethral resection of bladder tumor. New renal lesions were present on contrast-enhanced computed tomography scan which was histologically proven to be necrotizing renal granulomatosis.

Primary lung carcinoid metastatic to the breast.

Lung carcinoid tumors account for approximately 2% of lung cancers, with 10% of the tumors represented by the atypical type. While atypical carcinoids are metastatic to intrathoracic lymph nodes in approximately half of the cases on the initial presentation, distant metastases are seen in only 20% of the patients and are found most frequently in bones, liver, adrenal glands, and brain. We present a case of an unusual metastatic disease to the breast in 51-year-old female who developed a new breast mass 2 years after left lower lobectomy due to atypical carcinoid tumor. Atypical pulmonary carcinoid metastases to the breast are exceptionally uncommon, yet they are important considerations for appropriate management, especially with an anamnesis of this neoplasm.