Recognizing the features of Isolated Fallopian Tube Torsion on CT and MRI and interobserver agreement: A cross-sectional study.

PURPOSE: Isolated Fallopian tube torsion (IFTT) is a rare cause of acute pelvic pain in women of reproductive age. Preoperative diagnosis is rarely made, even though an early surgery is necessary to preserve women's fertility. This study aims to identify simple and reproductible imaging features for the diagnosis of IFTT on sectional imaging. METHODS: We conducted a retrospective, cross-sectional study on patients diagnosed with IFTT in our center between January 2008 and December 2021. The CTs and MRIs of 16 patients with surgically proven IFTT were retrospectively and independently reviewed by two radiologists to identify the relevant findings for the diagnosis. RESULTS: The median patient age was 29 years (range: 13-63 years). Only four patients (25 %) had a conservatory treatment. Two patterns of IFTT were identified on CT and MRI. The first pattern (n = 6, 37 %) consisted of a thin-walled hydrosalpinx, U- or C-shaped, with a median diameter of 3 cm. The second pattern (n = 10, 63 %) consisted of an extra-ovarian cyst adjacent to a soft tissue mass containing the twisted tube and vessels. In 15 patients (94 %), the ipsilateral ovary was of normal size. Hematosalpinx was observed in 3 patients with necrosis of the tube on pathological reports (19 %). Interobserver agreement was substantial or good for all criteria. CONCLUSIONS: An association of simple and reproductible features can support the diagnosis of IFTT on sectional imaging in an emergency context: the identification of these features may avoid a delayed surgical treatment, which could otherwise compromise women's fertility.

Development and validation of a composite score to predict severe forms of ischemic colitis.

OBJECTIVE: To develop a simple scoring system in order to predict the risk of severe (death and/or surgery) ischemic colitis METHODS: In this retrospective study, 205 patients diagnosed with ischemic colitis in a tertiary hospital were consecutively included over a 6-year period. The study sample was sequentially divided into a training cohort (n = 103) and a validation cohort (n = 102). In the training cohort, multivariable analysis was used to identify clinical, biological, and CT variables associated with poor outcome and to build a risk scoring system. The discriminative ability of the score (sensitivity, specificity, positive predictive value, negative predictive value) was estimated in the two cohorts to externally validate the score, and a receiver operating characteristic curve was established to estimate the area under the curve of the score. Bootstrapping was used to validate the score internally. RESULTS: In the training cohort, four independent variables were associated with unfavorable outcome: hemodynamic instability (2 pts), involvement of the small bowel (1 pt), paper-thin wall pattern (3 pts), no stratified enhancement pattern (1 pt). The score was used to categorize patients into low risk (score: 0, 1), high risk (score: 2-3), and very high risk (score: 4-7) groups with sensitivity and specificity of 97% and 67%, respectively, and a good discriminating capability, with a C-statistic of 0.94. Internal and external validation showed good discrimination capability (C-statistics of 0.9 and 0.84, respectively). CONCLUSION: A simple risk score can stratify patients into three distinct prognosis groups, which can optimize patient management. CLINICAL TRIAL NUMBER: NCT04662268 KEY POINTS: • Simple scoring system predicting the risk of severe ischemic colitis • First study to include CT findings to the clinical and biological data used to determine a severity score.

Imaging strategies for patients with suspicion of uncomplicated colic pain: diagnostic accuracy and management assessment.

OBJECTIVE: Compare different imaging scenarios in the diagnosis of uncomplicated renal colic due to urolithiasis (URCU). MATERIALS AND METHODS: A total of 206 prospectively included patients had been admitted with suspected URCU and had undergone abdominal plain film (APF), US and unenhanced CT after clinical STONE score evaluation. CT was the reference standard. We assessed sensitivity (Se), specificity (Spe) and Youden index for colic pain diagnosis, percentage of patients managed by urologic treatment with stone identified, percentage of alternative diagnoses (AD) and exposure to radiation, according to single imaging approaches, strategies driven by patient characteristics and conditional imaging strategies after APF and US. RESULTS: One hundred (48.5%) patients had a final diagnosis of URCU and 19 underwent urologic treatment. The conditional strategy, i.e. CT in patients who had no stone identified at US, had a perfect sensitivity and specificity. This enabled diagnosis of all stones requiring urology management while decreasing the number of CT exams by 22%. The strategy whereby CT was used when there was neither direct or indirect APF + US finding of colic pain nor alternative diagnoses in patients with a STONE score ≥ 10 had a sensitivity of 0.95 and a specificity of 0.99, identified 84% of stones managed by urologic treatment and decreased the number of CT examinations by 76%. CONCLUSION: In patients with clinical findings consistent with URCU, the use of ultrasound as first-line imaging modality, with CT restricted to patients with negative US and a STONE score ≥ 10, led to a sensitivity and specificity of above 95%, identified 84% of stones requiring urological management and reduced the number of CT scans needed by fourfold. KEY POINTS: • For diagnosis, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, provides both a sensitivity and specificity superior or equal to 95% and reduces the number of CT scans necessary by fourfold. • For management, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, maintains a 84% stone identification rate in urology-treated patients.

Diagnostic performance of CT signs for predicting adnexal torsion in women presenting with an adnexal mass and abdominal pain: A case-control study.

PURPOSE: To determine which CT findings or combinations of CT findings could accurately identify adnexal torsion in a cohort of women admitted for abdominal pain and presenting with an adnexal mass. MATERIALS AND METHODS: The local institutional review board approved this retrospective case-control study involving adults-the informed consent requirement was waived. Enhanced computed tomography (CT) findings of 32 consecutive adnexal torsion and 32 control patients admitted for abdominal pain and presenting with an adnexal mass were independently reviewed by two radiologists, with consensus by a third one, for all CT findings commonly assessed in adnexal torsion. All twisted and untwisted adnexa were confirmed by surgery. Univariate and multivariate analyses were performed for adnexal torsion prediction. RESULTS: The median patient age was 41 years (interquartile range, 30.5-62 years). Only benign masses were encountered in the torsion group. Five CT features were significantly associated with adnexal torsion: a large ovary with a threshold at 80mm (p=0.005), median or contralateral displacement of the adnexa (p=0.00014), asymmetric wall thickening of the mass (p<0.0001), inter-utero-ovarian mass (p<0.0001) and whirlpool sign (p=0.0006). In the multivariate analysis, only the inter-utero-ovarian mass was independently associated with adnexal torsion (odds ratio=130 (CI95%: 15-infinite), p<0.0001) with an excellent overall diagnostic performance (AUC=0.89; CI95%: 0.81-0.97). It was a sensitive (Se=97%, CI95%: 84-100) and specific feature (Sp=81%, CI95%: 64-93). CONCLUSION: An inter-utero-ovarian mass is an accurate and reliable CT finding for diagnosing adnexal torsion in patients with acute abdominal pain and an adnexal mass.

How to differentiate acute pelvic inflammatory disease from acute appendicitis ? A decision tree based on CT findings.

PURPOSE: To construct a decision tree based on CT findings to differentiate acute pelvic inflammatory disease (PID) from acute appendicitis (AA) in women with lower abdominal pain and inflammatory syndrome. MATERIALS AND METHODS: This retrospective study was approved by our institutional review board and informed consent was waived. Contrast-enhanced CT studies of 109 women with acute PID and 218 age-matched women with AA were retrospectively and independently reviewed by two radiologists to identify CT findings predictive of PID or AA. Surgical and laboratory data were used for the PID and AA reference standard. Appropriate tests were performed to compare PID and AA and a CT decision tree using the classification and regression tree (CART) algorithm was generated. RESULTS: The median patient age was 28 years (interquartile range, 22-39 years). According to the decision tree, an appendiceal diameter ≥ 7 mm was the most discriminating criterion for differentiating acute PID and AA, followed by a left tubal diameter ≥ 10 mm, with a global accuracy of 98.2 % (95 % CI: 96-99.4). CONCLUSION: Appendiceal diameter and left tubal thickening are the most discriminating CT criteria for differentiating acute PID from AA. KEY POINTS: • Appendiceal diameter and marked left tubal thickening allow differentiating PID from AA. • PID should be considered if appendiceal diameter is < 7 mm. • Marked left tubal diameter indicates PID rather than AA when enlarged appendix. • No pathological CT findings were identified in 5 % of PID patients.

Systematic unenhanced CT for acute abdominal symptoms in the elderly patients improves both emergency department diagnosis and prompt clinical management.

OBJECTIVES: To assess the added-value of systematic unenhanced abdominal computed tomography (CT) on emergency department (ED) diagnosis and management accuracy compared to current practice, in elderly patients with non-traumatic acute abdominal symptoms. METHODS: Institutional review board approval and informed consent were obtained. This prospective study included 401 consecutive patients 75 years of age or older, admitted to the ED with acute abdominal symptoms, and investigated by early systematic unenhanced abdominal CT scan. ED diagnosis and intended management before CT, after unenhanced CT, and after contrast CT if requested, were recorded. Diagnosis and management accuracies were evaluated and compared before CT (clinical strategy) and for two conditional strategies (current practice and systematic unenhanced CT). An expert clinical panel assigned a final diagnosis and management after a 3-month follow-up. RESULTS: Systematic unenhanced CT significantly improved the accurate diagnosis (76.8% to 85%, p=1.1x10-6) and management (88.5% to 95.8%, p=2.6x10-6) rates compared to current practice. It allowed diagnosing 30.3% of acute unsuspected pathologies, 3.4% of which were unexpected surgical procedure requirement. CONCLUSIONS: Systematic unenhanced abdominal CT improves ED diagnosis accuracy and appropriate management in elderly patients presenting with acute abdominal symptoms compared to current practice. KEY POINTS: • Systematic unenhanced CT improves significantly diagnosis accuracy compared to current practice. • Systematic unenhanced CT optimizes appropriate hospitalization by increasing the number of discharged patients. • Systematic unenhanced CT allows detection of about one-third of acute unsuspected abdominal conditions. • It should allow boosting emergency department management decision-making confidence in old patients.

Adhesive small-bowel obstruction: value of CT in identifying findings associated with the effectiveness of nonsurgical treatment.

PURPOSE: To identify computed tomographic (CT) findings that are associated with the effectiveness of nonsurgical treatment in patients with adhesive small-bowel obstruction ( SBO small-bowel obstruction ) that was initially treated medically. MATERIALS AND METHODS: The local institutional review board approved this retrospective study; the informed consent requirement was waived. Multi-detector row CT studies in 159 patients (64 women, 95 men; median age, 69 years) with adhesive SBO small-bowel obstruction that was initially treated medically were reviewed retrospectively and independently by two emergency radiologists to identify numerous CT findings that could be associated with the effectiveness of nonsurgical treatment. Results were compared according to the success or failure of nonsurgical treatment. Univariate statistical analyses were performed for qualitative and quantitative data, as appropriate, and each significant parameter was entered in a multivariate logistic regression analysis. The κ statistic and correlation coefficients were used to assess interobserver agreement, as appropriate. RESULTS: Nonsurgical treatment succeeded in 113 patients (71%) and failed in 46 patients (29%). At univariate analysis, an anterior parietal adhesion, a feces sign, and the lack of a beak sign were associated with successful nonsurgical treatment, whereas two beak signs or more, a whirl sign, a C- or U-shaped appearance of the bowel loop, and a high degree of obstruction were associated with nonsurgical treatment failure. At multivariate analysis, fewer than two beak signs and the presence of an anterior parietal adhesion were independent predictors of the effectiveness of nonsurgical treatment, with odds ratios of 0.27 and 0.11, respectively. CONCLUSION: The number of beak signs and the location of the transition zone in relation to the anterior peritoneal layer are independent signs associated with the success or failure of nonsurgical treatment.

Invasive breast carcinoma: influence of prognosis and patient-related factors on kinetic MR imaging characteristics.

PURPOSE: To retrospectively compare the kinetic magnetic resonance (MR) imaging characteristics of invasive breast carcinomas with both prognostic tumoral and patient-related parameters. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by the institutional review board, and informed consent was waived. From January 2008 to January 2011, 273 consecutive women (mean age, 55 years; range, 23-83 years) with invasive breast cancers who had undergone MR imaging were selected. The kinetic curves were retrospectively classified according to the Breast Imaging Reporting and Data System lexicon. Initial enhancement and maximal enhancement percentages, time to peak enhancement, and the signal enhancement ratio were calculated for each lesion. Kinetic characteristics were compared according to tumoral parameters (size, pathologic type, grade, hormone receptor status, and c-erbB-2 status) and patient parameters (menopausal status, personal history of breast carcinoma) by means of univariate and then multivariate analysis by using false-discovery-rate statistics. RESULTS: Lesions in menopausal patients exhibited less suspicious quantitative and qualitative characteristics than lesions in nonmenopausal patients. There was an independent association between the kinetic characteristics and menopausal status, with an odds ratio of 2.94 for the lack of rapid initial contrast material uptake and of 2.38 for the lack of washout in menopausal patients as compared with nonmenopausal patients. The odds ratio was 4.00 for not having rapid initial contrast material uptake in patients with a personal history of ipsilateral breast cancer. CONCLUSION: Kinetic data in invasive breast cancer are associated with the patient's menopausal status, with a typical kinetic pattern of malignancy being less common in menopausal patients.

Journal club: Acute abdominal pain in elderly patients: effect of radiologist awareness of clinicobiologic information on CT accuracy.

OBJECTIVE: The purpose of this study was to assess whether the availability of clinicobiologic findings would affect the diagnostic performance of CT of elderly emergency department patients with nontraumatic acute abdominal pain. MATERIALS AND METHODS: The cases of 333 consecutively registered patients 75 years old or older presenting to the emergency department with acute abdominal pain and who underwent CT were retrospectively reviewed by two radiologists blinded or not to the patient's clinicobiologic results. Diagnostic accuracy was calculated according to the level of correctly classified cases in both the entire cohort and a surgical subgroup and was compared between readings performed with and without knowledge of the clinicobiologic findings. Agreement between each reading and the reference diagnosis and interobserver agreement were assessed with kappa statistics. RESULTS: In both the entire cohort (87.4% vs 85.3%, p = 0.07) and the surgical group (94% vs 91%, p = 0.15), there was no significant difference in CT accuracy between diagnoses made when the radiologist was aware and those made when the radiologist was not aware of the clinicobiologic findings. Agreement between the CT diagnosis and the final diagnosis was excellent whether or not the radiologist was aware of the clinicobiologic findings. CONCLUSION: In the care of elderly patients, CT is accurate for diagnosing the cause of acute abdominal pain, particularly when it is of surgical origin, regardless of the availability of clinical and biologic findings. Thus CT interpretation should not be delayed until complete clinicobiologic data are available, and the images should be quickly transmitted to the emergency physician so that appropriate therapy can be begun.