Radiology report turnaround: expectations and solutions.

The ultimate work product of a radiology department is a finalized radiology report. Radiology stakeholders are now demanding faster report turnaround times (RTAT) and anything that delays delivery of the finalized report will undermine the value of a radiology department. Traditional reporting methods are inherently inefficient and the desire to deliver fast RTAT will always be challenged. It is only through the adoption of an integrated radiology information system (RIS)/picture archiving and communication system (PACS) and voice recognition (VR) system that RTAT can consistently meet stakeholder expectations. VR systems also offer the opportunity to create standardized, higher quality reports.

Omental infarct: CT imaging features.

BACKGROUND: The aim of this study is to describe contrast-enhanced computed tomographic (CT) features of acute omental infarction and to study the evolutionary changes on follow-up CT imaging. METHODS: Fifteen cases of omental infarction were evaluated for their initial CT imaging features. The imaging features evaluated included size of the fatty lesion, location, peripheral rim, and relation to colon. CT findings were correlated with etiology, clinical presentation, and leukocytosis. Follow-up CT images were available in eight patients and the imaging features were studied. RESULTS: Eight omental infarcts were of unknown etiology and seven were secondary to abdominal surgery. In 53% of patients (eight of 15), the location of the omental infarct was in the right lower, mid, or upper quadrants. These eight right-side infarcts occurred in six patients with primary omental infarcts. In 13 of 14 patients who underwent CT within 15 days of onset of omental infarct, the margin of the lesion was ill defined. Primary omental (n = 8) infarcts were seen in younger patients (p = 0.02) and were larger on CT (p = 0.02) compared with secondary omental infarcts. CT findings evolved from an ill-defined, heterogeneous fat-density lesion to a well-defined, heterogeneous fat-density lesion with a peripheral hyperdense rim in all six secondary omental infarctions for which acute stage and follow-up CT images were available for interpretation. CONCLUSION: There is a significant difference in the age distribution and CT findings in terms of size of the omental infarction between primary and secondary etiologies. On follow-up CT, secondary omental infarcts progressively shrank and developed a well-defined, hyperdense rim around a fatty core.

A conserved role for retinoid signaling in vertebrate pancreas development.

Retinoic acid (RA) signaling plays critical roles in the regionalization of the central nervous system and mesoderm of all vertebrates that have been examined. However, to date, a role for RA in pancreas and liver development has only been demonstrated for the teleost zebrafish. Here, we demonstrate that RA signaling is required for development of the pancreas but not the liver in the amphibian Xenopus laevis and the avian quail. We disrupted RA signaling in Xenopus tadpoles, using both a pharmacological and a dominant-negative strategy. RA-deficient quail embryos were obtained from hens with a dietary deficiency in vitamin A. In both species we found that pancreas development was dependent on RA signaling. Furthermore, treatment of Xenopus tadpoles with exogenous RA led to an expansion of the pancreatic field. By contrast, liver development was not perturbed by manipulation of RA signaling. Taken together with our previous finding that RA signaling is necessary and sufficient for zebrafish pancreas development, these data support the hypothesis that a critical role for RA signaling in pancreas development is a conserved feature of the vertebrates.

Radiofrequency ablation of renal cell carcinoma.

Small renal cell carcinomas of less than 4 cm diameter have been detected increasingly in asymptomatic patients because of the widespread use of cross-sectional imaging. Radical or partial nephrectomy is generally considered the reference for the treatment of a solitary renal cell carcinoma. However, for those patients who are not candidates for surgery, minimally invasive procedures may be desirable. Although percutaneous radiofrequency ablation for the treatment of renal cell carcinoma is a recent innovation, the results of preliminary clinical series and animal studies are encouraging, and show it to be technically feasible with minimal morbidity. In this article, we review the technique, indications, imaging findings, as well as the results of clinical and animal studies of radiofrequency ablation for the treatment of renal cell carcinoma.

Case report. Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity.

Hepatic portal venous gas has traditionally been associated with a grave prognosis and high mortality. However, with the advent of ultrasound and CT, numerous less serious causes have been associated with this dramatic radiological finding. We present a previously unreported association with colchicine toxicity. The patient ingested a large dose of colchicine and was subsequently found to have portal venous gas on CT. The source of gas was felt to be intestinal gas penetrating through the demonstrated bowel injury. No surgical intervention was deemed necessary and the finding resolved spontaneously.

Intraductal papillary mucinous tumors of the pancreas.

Intraductal papillary mucinous tumor (IPMT) is an uncommon pancreatic neoplasm with characteristic histology and distinctive clinicobiologic behavior. It is characterized by proliferation of ductal epithelium associated with ductal dilatation and variable mucin production. Due to indolent nature of these tumors, IPMTs are frequently missed or misdiagnosed. Prompt recognition and differentiation from other tumors are essential because IPMT has a better prognosis than other pancreatic malignancies. The purpose of this article is to display the radiologic spectrum of IPMT.

Comparison of excretory phase, helical computed tomography with intravenous urography in patients with painless haematuria.

AIM: To compare excretory phase, helical computed tomography (CT) with intravenous (IV) urography for evaluation of the urinary tract in patients with painless haematuria. MATERIALS AND METHODS: Ninety-one out-patients had IV urography followed by helical CT limited to the urinary tract. Both IV urograms and CT images were evaluated for abnormalities of the urinary tract in a blinded, prospective manner. The clinical significance of abnormalities was scored subjectively and receiver operator characteristic curve analysis was performed. RESULTS: In 69 of 91 patients (76%), no cause of haematuria was identified. In 22 of 91 patients (24%), the cause of haematuria was identified as follows: transitional cell cancer of the bladder (n=15), urinary tract stones (n=3), cystitis (n=2), haemorrhagic pyelitis (n=1) and benign ureteral stricture (n=1). With IV urography, there were 15 true-positive, seven false-negative and three false-positive interpretations. With CT, there were 18 true-positive, four false-negative and two false-positive interpretations. There was no significant difference between IV and CT urography for the significance of the positive interpretations (n=0.47). CONCLUSION: Excretory phase CT urography was comparable with IV urography for evaluation of the urinary tract in patients with painless haematuria. However, the study population did not include any upper tract cancers.

Halo sign: useful CT sign for differentiating benign from malignant colonic disease.

AIM: To evaluate the halo sign for accurately distinguishing benign from malignant colonic wall thickening. MATERIALS AND METHODS: Computed tomography (CT) examinations of 92 patients (70 men; 22 women; mean age 57 years) with pathologically proven colonic wall thickening (51 benign and 41 malignant) were retrospectively reviewed in a blinded fashion. The affected segment was assessed for presence of the halo sign, degree and uniformity of thickness and density of the intramural stratum. RESULTS: The halo sign was present in 74.5% (38/51) patients with benign and 7.3% (3/41) patients with malignant bowel disease. The presence of the halo sign was 75.4% sensitive and 92.5% specific for benign bowel wall thickening. All 38 benign halos showed uniform, continuous stratification; only one of three malignant halos met the strict criteria for benign halo. CONCLUSION: The halo sign is a moderately sensitive and highly specific sign for distinguishing benign from malignant bowel wall thickening. However, it is not pathognomonic for benign disease. Detailed analysis of halo characteristics is necessary to improve the usefulness of this finding.

Thorotrast-induced cholangiocarcinoma: case report.

Thorotrast, a contrast medium used extensively before being banned in 1950s, delivers a densely ionizing, high linear energy transfer type of radiation that predisposes to malignancies. We report a case of peripheral cholangiocarcinoma and describe its computed tomographic and magnetic resonance imaging features in a patient who developed it 48 years after exposure to Thorotrast.

State-of-the-art imaging of pancreatic neoplasms.

Pancreatic imaging with multidetector CT allows multiphase acquisition of thin slices in a single breath-hold and is especially valuable in obtaining isotropic three-dimensional reformations that improves our ability to provide accurate pre-operative vascular mapping. Advanced MR technology allows faster imaging of pancreas, thus facilitating MR cholangiopancreatography. Use of tissue-specific MR contrast agents, endoscopic ultrasound and PET in pancreatic imaging has evolved considerably. This review article discusses the role of CT, MR, endoscopic ultrasound and PET imaging in pancreas.

Predictive value of benign percutaneous adrenal biopsies in oncology patients.

PURPOSE: Percutaneous CT guided biopsy is accepted as a safe procedure for the diagnosis of indeterminate adrenal masses in oncologic patients. The purpose of this study was to evaluate the accuracy of a 'negative for tumour' adrenal biopsy in the oncologic patient population by assessing subsequent outcome including clinical course, size and imaging characteristics of the adrenal lesions on follow-up imaging studies and pathological findings at re-biopsy or following adrenal mass resection. MATERIALS AND METHODS: Retrospective analysis of 225 oncological patients (FM, 128;87; age range 33-87 years, mean age 66 years) who had undergone CT guided biopsies of an adrenal mass over a 5-year period was performed. Those patients with a report consistent with 'negative for malignancy' were evaluated by reviewing the medical records for patient demographics, primary malignancy, histology of adrenal tumour, subsequent surgical interventions, repeat adrenal biopsy under image guidance, by open surgery or at autopsy, subsequent abdominal imaging in which the adrenal gland was imaged, and long-term outcome including hospital admissions, or death. RESULTS: Of the 225 CT-guided adrenal biopsies performed, 41 (18%) were negative for neoplasm. The primary neoplasm in these 41 patients included lung cancer (n=32), breast (n=5), renal cell carcinoma (n=2), bladder (n=1), and prostate (n=1). The size of the adrenal lesions ranged from 2.8-5 cm. Of the 41 biopsies, which were negative for tumour; 10 were identified as adenomas and the rest showed benign adrenal cortical cells or hyperplasia on cytopathology and histopathology. Repeat biopsies were obtained in 13/41 (31%) patients; whereas 2/41 (5%) had their adrenal gland analyzed on post mortem examination. None of these 15 repeat evaluations yielded tumour. CONCLUSION: In oncological patients, pathological analysis of tissue samples obtained by CT-guided percutaneous biopsy, suggesting benign aetiology, is reliable and predicts a benign course on long-term follow-up. A negative or benign pathology result for a CT guided percutaneous adrenal biopsy can be regarded as a true negative evaluation in oncological patients with no necessity to repeat the biopsy.

MRI contrast agents for evaluating focal hepatic lesions.

Contrast-enhanced magnetic resonance imaging (MRI) has become an important tool in the detection and characterization of focal hepatic lesions especially when other investigations such as ultrasound (US) and computed tomography (CT) are inconclusive. The purpose of this pictorial review is to briefly summarize the properties of various MRI contrast agents used in hepatic imaging and to highlight their role in evaluation of focal hepatic lesions.

Nonvascular interventional procedures: analysis of a 10-year database containing more than 21,000 cases.

PURPOSE: To analyze all procedures performed during 10 years in a nonvascular interventional practice. MATERIALS AND METHODS: Date, organ location, and type of all 21,324 procedures performed between October 1990 and September 2000 were recorded in a database; also included were patient age and inpatient or outpatient status. Because genitourinary procedures were not included during the first 4 years, nephrostomies were added retrospectively. Yearly interventional caseload was compared with the department caseload and the assignment of new medical record numbers. Trends in individual procedure location and type were analyzed, as well as patient age, inpatient status, daily caseloads, and day of the week when the procedure was performed. RESULTS: Caseloads have increased 10.8% per year, exceeding increases in radiology department and hospital activity. Abdomen, outside of a specific organ, was the most common location; catheter deployment was the most common procedure. Abscess drainage, placement of chest tubes, and nephrostomies have increased, but biliary drainages have decreased. Inpatients outnumbered outpatients in all years except 1995, but the trend was toward an increase in the proportion of outpatients. The average patient was 59.6 years old, with average age diminishing. Friday was the busiest day, but weekend procedures have increased. CONCLUSION: Nonvascular interventional procedures have increased, with more currently being performed on weekends.

Tunneled peritoneal catheter placement under sonographic and fluoroscopic guidance in the palliative treatment of malignant ascites.

OBJECTIVE: We present a treatment for recurrent, symptomatic ascites in patients with malignant disease. This report summarizes our experience with percutaneous tunneled peritoneal catheters in 24 patients. SUBJECTS AND METHODS: Of the 40 consecutive patients who presented with at least four therapeutic paracenteses in a 4-week period, 24 patients underwent the percutaneous tunneled procedure. All had malignant ascites. RESULTS: All 24 patients had successful insertion of a permanent tunneled peritoneal drainage catheter. Eighteen were outpatients and six were inpatients. All patients were relieved of their clinical symptoms, including abdominal distention and dyspnea, and were relieved of lower extremity discomfort. The mean life span after catheter placement was 7.2 weeks. Twenty (83%) of the 24 patients were treated at home with their catheters in place. Three patients experienced minor complications from bacterial peritonitis, which responded to antibiotics. One patient had to have his catheter removed. CONCLUSION: Percutaneous placement of specialized tunneled catheters appears to be a viable and safe technique in patients who have symptomatic ascites that require frequent therapeutic paracentesis for relief of symptoms.

CT colonography with teleradiology: effect of lossy wavelet compression on polyp detection--initial observations.

PURPOSE: To assess the consequences of lossy compression on the diagnostic accuracy of CT colonography for detecting colonic polyps. MATERIALS AND METHODS: Helical CT images of cleansed colonic segments were evaluated. Source images were compressed to 1:1, 10:1, and 20:1 ratios with lossy wavelet compression. Two independent readers blinded to corresponding colonoscopic results analyzed 144 randomly ordered colonic segments in multiplanar and volume-rendered endoscopic views. Sensitivity, specificity, and receiver operating characteristic curves were generated for each compression ratio on the basis of expressed confidence in lesion presence. Similar analyses were performed to assess distention and bowel preparation adequacy and evaluation time required. RESULTS: Results based on video colonoscopy-confirmed lesions revealed 100% (four of four) sensitivity for lesions larger than 10 mm for compression ratios 1:1, 10:1, and 20:1 for both readers; sensitivities for all lesions smaller than 10 mm were 50%-78%, 38%-67%, and 38%-67% for respective ratios for both readers. Differences in diagnostic performance for each reader across ratios were not significant (P =.30-.99, McNemar test). The time required to evaluate and assess bowel preparation and distention adequacy did not change significantly across ratios. CONCLUSION: On the basis of the patient sample, lossy compression of transverse source images to at least a 20:1 ratio did not adversely affect diagnostic performance or evaluation time for CT colonography.

Prevalence of incidental Bochdalek's hernia in a large adult population.

OBJECTIVE: The purpose of this study was to determine the prevalence and characteristics of adult Bochdalek's hernia in a large patient population. MATERIALS AND METHODS: We retrospectively reviewed all abdominal CT scans obtained at our hospital in 1998. Patients in our study were identified through a keyword search of our database for "Bochdalek," "hernia," and "diaphragm." The individual patient studies identified were reviewed in a soft-copy format. We noted the location and side of the body on which the diaphragmatic hernia arose and the contents of the sac. We also performed a chart review for each patient included in the study, noting the patient's sex, age, and symptoms. RESULTS: Incidental Bochdalek's hernia was diagnosed in 22 patients (17 women, five men), which represents an incidence of 0.17% based on 13,138 abdominal CT reports we reviewed. The mean age of the patients was 66.6 years. None of the patients were symptomatic. Sixty-eight percent of the hernias were on the right side of the body, 18% were on the left side, and 14% were bilateral. Seventy-three percent contained only fat or omentum, whereas 27% had solid or enteric organ involvement including the spleen, small intestine, or large intestine. CONCLUSION: Bochdalek's hernia is not rare, and the incidence of Bochdalek's hernias that contain enteric tract is higher than previously reported. This incidence likely represents a conservative estimate because some Bochdalek's hernias may have been overlooked or unreported.

Transvaginal interventional procedures: aspiration, biopsy, and catheter drainage.

Transvaginal ultrasonographically (US) guided procedures are simple and safe and often represent the only means of access to pelvic disease. Aspiration of cystic pelvic masses and core biopsy of solid pelvic masses can be easily performed by using the transvaginal route, an endoluminal US transducer, and a needle guide. Because of concerns about false-negative diagnosis and potential tumor seeding with biopsy of primary ovarian cystic lesions, the indications for transvaginal aspiration and biopsy of ovarian and adnexal lesions are predominantly therapeutic. Similarly, using an endoluminal probe with modification of the guide, one can also perform safe and effective trocar catheter drainage of pelvic abscesses via the transvaginal route. The transvaginal route is ideally suited to pelvic abscess drainage because of the proximity of the vaginal fornices to most pelvic fluid collections. The transvaginal route has the disadvantage of being semisterile; because of the risk of superinfecting previously noninfected pelvic pathologic conditions, the transvaginal approach should be used only for solid lesions or cystic lesions that can be completely aspirated. Familiarity with the transvaginal route of access is crucial for adequate treatment of many gynecologic and nongynecologic pelvic pathologic conditions.