Structured Reporting in Ultrasound.

Structured reporting of ultrasound examinations can add value throughout the imaging chain. Reports may be created in a more efficient manner, with increased accuracy and clarity. Communication with referring providers and patients may be improved. Patient care can be enhanced through improved adherence with guidelines and local best practices. Radiology departments may benefit from improved billing and quality reporting. Consistent discrete data can enable research and collaborations between institutions. This article will review the multifaceted impact of structuring ultrasound reports.

Sonographic Appearances of Portal Vein Abnormalities.

Portal venous system evaluation is required in many clinical circumstances, as substantial morbidity and mortality can be associated with a spectrum of portal vein abnormalities. Portal venous system pathologies can be congenital or acquired, and the knowledge of their imaging appearances will allow for a confident diagnosis and appropriate treatment options. In addition, a firm understanding of anatomical variants is important for planning surgical procedures and percutaneous interventions of the liver. This article will review various imaging appearances of portal venous systems abnormalities.

Magnetic Resonance-Guided Focused Ultrasound: A Brief Review With Emphasis on the Treatment of Extra-abdominal Desmoid Tumors.

Magnetic resonance-guided focused ultrasound (MRgFUS) utilizes high-intensity focused ultrasound to noninvasively, thermally ablate lesions within the body while sparing the intervening tissues. Magnetic resonance imaging provides treatment planning and guidance, and real-time magnetic resonance thermometry provides continuous monitoring during therapy. Magnetic resonance-guided focused ultrasound is ideally suited for the treatment of extra-abdominal desmoid fibromatosis due to its noninvasiveness, lack of ionizing radiation, low morbidity, and good safety profile. Conventional treatments for these benign tumors, including surgery, radiation, and chemotherapy, can carry significant morbidity. Magnetic resonance-guided focused ultrasound provides a safe and effective alternative treatment in this often-young and otherwise healthy patient population. While there is considerable experience with MRgFUS for treatment of uterine fibroids, painful bone lesions, and essential tremor, there are few reports in the literature of its use for treatment of benign or malignant soft tissue tumors. This article reviews the principles and biologic effects of high-intensity focused ultrasound, provides an overview of the MRgFUS treatment system and use of magnetic resonance thermometry, discusses the use of MRgFUS for the treatment of extra-abdominal desmoid tumors, and provides several case examples.

ACR Appropriateness Criteria® Hematospermia.

Most men with hematospermia or hemospermia (HS) are young (<40 years of age), presenting with transient or episodic HS without other signs or symptoms of disease. The condition is self-limiting in most cases and idiopathic in nature. When a cause can be identified, infections of the urogenital tract are the most common. Imaging does not play a role in this patient population. In older men (>40 years of age), clinical screening for prostate cancer is advised. Furthermore, when HS is persistent or has symptoms, causes include obstruction or stricture at the level of the verumontanum, calcifications or calculi in the prostate, ejaculatory ducts or seminal vesicles, and cysts arising within these structures. Noninvasive imaging, predominantly transrectal ultrasound (TRUS) and MRI, can be used in men of any age with persistent or refractory HS, or other associated symptoms or signs. TRUS is considered as the first-line imaging with MRI used when TRUS is inconclusive or negative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria Staging of Testicular Malignancy.

Testicular cancer represents only 1% of all malignancies occurring in men. However, it is the most frequent malignancy in men between the ages of 20 and 34 years, accounting for 10% to 14% of cancer incidence in that age group. In most instances, the diagnosis of testicular tumors is established with a carefully performed physical examination and scrotal ultrasonography. Tumor markers are useful for determining the presence of residual disease. Cross-sectional imaging studies (CT, MRI) are useful in determining the location of metastases. Chest radiography and CT are used to assess pulmonary disease. Fluorine-18-2-fluoro-2-deoxy-d-glucose (FDG) PET scans have slightly higher sensitivity than CT, but their role in staging testicular cancer has not been determined in a large study. FDG PET may play a role in the follow-up of higher stage seminoma after chemotherapy. Bone scans are useful in the absence of FDG PET scans and should be used when bone metastases are suspected. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (the RAND/UCLA Appropriateness Method and the Grading of Recommendations Assessment, Development, and Evaluation) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The utility of abdominal ultrasound during percutaneous suprapubic catheter placement.

INTRODUCTION: To evaluate the use of ultrasound (US) at the time of percutaneous suprapubic catheter (SPC) placement. US has been recommended as a way to minimize complications, such as bowel injury, during percutaneous SPC placement, yet there is limited data supporting this recommendation. MATERIALS AND METHODS: A retrospective chart review was performed on patients undergoing percutaneous SPC placement from 2002 to 2011. The method of percutaneous SPC placement (cystoscopic and/or ultrasound guidance, blind) was recorded and patients were subdivided into groups based on the use of US. The need to modify the approach based on US findings and complications such as bleeding or bowel injury were noted and compared between groups. RESULTS: A total of 307 percutaneous SPCs were placed: cystoscopy alone was used in 190 (62%) patients, cystoscopy + US in 86 (28%) patients, US alone in 6 (2%) patients, and 25 (8%) patients had the SPC placed blindly. Previous lower abdominal surgery was noted in 41/92 (45%) of patients with and 32/215 (15%) of patients without US usage. US identified intervening loops of bowel in 5/92 cases (5%), all of whom had a history of lower abdominal surgery. The approach was modified in 2/5 and abandoned in 3/5 based on US findings. Postoperative bleeding occurred in 1/215 (0.5%) of patients with and 1/92 (1%) of patients without US usage. No bowel injuries occurred. CONCLUSIONS: While US may not be needed in most patients, particularly when cystoscopy is used, it may help to avoid bowel injury in patients with a history of lower abdominal surgery.

ACR appropriateness criteria jaundice.

A fundamental consideration in the workup of a jaundiced patient is the pretest probability of mechanical obstruction. Ultrasound is the first-line modality to exclude biliary tract obstruction. When mechanical obstruction is present, additional imaging with CT or MRI can clarify etiology, define level of obstruction, stage disease, and guide intervention. When mechanical obstruction is absent, additional imaging can evaluate liver parenchyma for fat and iron deposition and help direct biopsy in cases where underlying parenchymal disease or mass is found. Imaging techniques are reviewed for the following clinical scenarios: (1) the patient with painful jaundice, (2) the patient with painless jaundice, and (3) the patient with a nonmechanical cause for jaundice. 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 where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

ACR Appropriateness Criteria pretreatment staging of colorectal cancer.

Because virtually all patients with colonic cancer will undergo some form of surgical therapy, the role of preoperative imaging is directed at determining the presence or absence of synchronous carcinomas or adenomas and local or distant metastases. In contrast, preoperative staging for rectal carcinoma has significant therapeutic implications and will direct the use of radiation therapy, surgical excision, or chemotherapy. CT of the chest, abdomen, and pelvis is recommended for the initial evaluation for the preoperative assessment of patients with colorectal carcinoma. Although the overall accuracy of CT varies directly with the stage of colorectal carcinoma, CT can accurately assess the presence of metastatic disease. MRI using endorectal coils can accurately assess the depth of bowel wall penetration of rectal carcinomas. Phased-array coils provide additional information about lymph node involvement. Adding diffusion-weighted imaging to conventional MRI yields better diagnostic accuracy than conventional MRI alone. Transrectal ultrasound can distinguish layers within the rectal wall and provides accurate assessment of the depth of tumor penetration and perirectal spread, and PET and PET/CT have been shown to alter therapy in almost one-third of patients with advanced primary rectal cancer. 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® right lower quadrant pain--suspected appendicitis.

The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of "classic" signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. 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.

Presentation, treatment, and outcomes of dural metastases in men with metastatic castrate-resistant prostate cancer: a case series.

PURPOSE: Men with metastatic castrate-resistant prostate cancer (mCRPC) have shown increased survival since the introduction of docetaxel-based chemotherapy in 2004. While bone metastases are common in prostate cancer, cranial dural metastases (DM) are not. We hypothesize that longer survival in patients with mCRPC may increase the incidence of uncommon metastatic sites, including the cranial dura. We describe 10 cases of DM in men with mCRPC and review the relevant literature. MATERIALS AND METHODS: We conducted a retrospective chart review of 10 subjects with mCRPC, diagnosed ante-mortem with DM at our institution between August 1, 2003 and June 1, 2008. Variables analyzed included prognostic factors at prostate cancer diagnosis, number of therapies prior to DM, treatments administered for DM with response achieved, and survival following diagnosis of DM. RESULTS: Median age at prostate cancer diagnosis was 59 years (range, 52-80), with a median Gleason's score of 9 (range, 8-10) and prostate-specific antigen (PSA) of 37 ng/dL (range, 4.9-118). Fifty percent had metastatic disease at initial diagnosis. A median of 5 therapies (range, 1-13) were administered prior to diagnosis of DM, including a median of 1 course of chemotherapy (range, 1-3). Cranial neuropathies were the most common presenting symptoms of DM, and 8 of 10 patients received treatment for their DM, most often radiotherapy. Median survival for this group was 6.17 months (range, < 1-15). CONCLUSIONS: Treatment advances in mCRPC may lead to an increased incidence of previously rare metastatic sites. CNS symptoms in men with mCRPC should prompt evaluation for DM.

ACR Appropriateness Criteria on colorectal cancer screening.

Colorectal cancer remains one of the most common causes of cancer death in this country. This malignancy is ideally suited for screening because the detection and removal of the precursor adenomatous polyp can prevent most colorectal cancers from ever forming. The choice of a test for screening involves consideration of various individual parameters, including patient age and the presence of risk factors for the development of colorectal cancer. Computed tomographic colonography (CTC) has emerged as the leading imaging technique for colorectal cancer screening in average-risk individuals on the basis of the evidence presented in this paper. The double-contrast barium enema is an alternative imaging test that is appropriate particularly when CTC is not available. In 2008, the American Cancer Society guideline for colorectal cancer screening was revised jointly with the US Multi-Society Task Force on Colorectal Cancer and the ACR to include CTC every 5 years as an option for average-risk individuals. Computed tomographic colonography is also the preferred test for colon evaluation after an incomplete colonoscopy. Imaging tests including CTC and the double-contrast barium enema are usually not indicated for colorectal cancer screening in high-risk patients with polyposis syndromes or inflammatory bowel disease. This paper presents the new colorectal cancer imaging test ratings and is the result of evidence-based consensus by the ACR Appropriateness Criteria Expert Panel on Gastrointestinal Imaging.

ACR Appropriateness Criteria on Crohn's disease.

In the past decade, new therapeutic agents have been developed that permit gastroenterologists to treat virtually all forms of Crohn's disease. The success of these treatments depends on an accurate diagnosis of the nature and extent of disease. Fortunately, radiologists now possess a powerful arsenal of imaging techniques to guide the choice of therapy. This article discusses the usefulness of both traditional and newer imaging techniques in the management of Crohn's disease and its various clinical presentations.

Resonance metallic ureteral stents do not successfully treat ureteroenteric strictures.

PURPOSE: To report the outcomes of patients with ureteroenteric strictures after ileal conduit urinary diversion that were managed with Resonance metallic ureteral stents. PATIENTS AND METHODS: Ten ureteroenteric strictures in patients with ileal conduits that were managed with metallic ureteral stenting were retrospectively identified. Charts were examined for patient age, anastomosis type, stricture cause, stricture laterality, complications, and follow-up. RESULTS: Nine of 10 (90%) cases resulted in distal stent migration. Mean time to stent migration was 21 days (range 3-60 d). CONCLUSIONS: Placement of Resonance metallic stents in patients with ileal conduits is ineffective for management of ureteroenteric strictures because of the high rate of distal migration.

Multidetector computerized tomography urography as the primary imaging modality for detecting urinary tract neoplasms in patients with asymptomatic hematuria.

PURPOSE: We determined whether multidetector computerized tomography urography is sensitive and specific for detecting urinary tract neoplasms when used as the primary imaging modality for evaluating patients with hematuria. MATERIALS AND METHODS: A retrospective review was performed of the radiological, urological and pathological records of 468 patients without a history of urinary neoplasms who presented with hematuria. All patients underwent multidetector computerized tomography urography and complete urological evaluation, including cystoscopy. Laboratory urinalysis and cytology were done in 350 and 318 of the 468 patients, respectively. Multivariate logistic regression analysis was performed using the variables multidetector computerized tomography urography diagnosis, worst urine cytology, number of red blood cells per high power field, gross hematuria, age and gender to predict urinary tract neoplasm. RESULTS: A total of 50 urinary neoplasms were diagnosed in 468 patients. Multidetector computerized tomography urography detected 32 of 50 neoplasms for a sensitivity of 64%, specificity of 98%, positive predictive value of 76% and negative predictive value of 96%. There were 10 false-positive and 18 false-negative multidetector computerized tomography urography studies. Multivariate logistic regression showed that abnormal multidetector computerized tomography urography findings, ie neoplasm (p <0.0001), and suspicious or positive urine cytology (p = 0.0009) were significant. Patients with an abnormal multidetector computerized tomography urography diagnosis and suspicious or positive urine cytology had 44 and 47 times greater odds, respectively, of having urinary neoplasms compared to the odds in those with normal examinations. CONCLUSIONS: Multidetector computerized tomography urography is relatively sensitive and highly specific for detecting urinary neoplasms. It may serve as the primary imaging modality to evaluate patients with hematuria. Multidetector computerized tomography urography does not eliminate the role of cystoscopy in the evaluation of hematuria.

Intrahepatic portal hypertension secondary to metastatic carcinoma of the prostate.

While the liver is a common site of metastasis, tumor metastases are not a common cause of portal hypertension. We report a case of a patient with symptomatic portal hypertension due to diffuse metastatic prostate carcinoma infiltration of liver parenchyma that was not appreciated with routine imaging.

Sonographic differentiation of digital tendon rupture from adhesive scarring after primary surgical repair.

PURPOSE: After the surgical repair of finger tendons finger range of motion may be limited by tendon rupture or adhesive scarring. Differentiating tendon rupture from adhesive scarring may be difficult clinically. Digital tendon sonography allows the evaluation of tendon integrity in a dynamic setting. Our objective was to determine if sonography could differentiate tendon rupture from adhesive scarring in patients who have had primary tendon repair. METHODS: A retrospective review was performed of the radiographic, clinical, and surgical records of patients referred for finger sonography over a 2-year period. Twenty-eight digits in 21 patients were evaluated for finger tendon disruption after primary surgical repair. The diagnosis of complete tendon rupture was made when 1 or more of the following was identified: a gap separating the proximal and distal tendon margins, visualization of only the proximal tendon margin, or visualization of only the distal tendon margin. Adhesive scarring was diagnosed if the tendon appeared intact with abnormal peritendinous soft tissue abutting or partially encasing the tendon, with synovial sheath thickening, or with restricted tendon motion during dynamic evaluation. RESULTS: Sonography correctly identified tendon rupture or adhesive scarring in 27 of 28 digits with 1 false-positive case (sensitivity, 100%; specificity, 93%; positive-predictive value, 93%; negative-predictive value, 100%; accuracy, 96%). CONCLUSIONS: Sonography is an accurate modality for differentiating tendon rupture from adhesive scarring in patients with prior surgical tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic, Level I.

Intra-abdominal desmoid tumor following retroperitoneal lymph node dissection for testicular germ cell tumor.

In the testicular cancer post-treatment setting a rapidly growing retroperitoneal mass leads to a differential diagnosis including recurrent germ cell tumor, residual mature teratoma, or sarcomatoid degeneration. We report the case of a 27-year-old man with a large abdominal mass occurring in the setting of a mixed germ cell tumor after radical orchiectomy with primary chemotherapy followed by retroperitoneal lymph node dissection. Surgical excision of this mass followed by pathological review revealed an intra-abdominal desmoid tumor. Fluorescence in situ hybridization (FISH) for isochromosome 12p failed to demonstrate a germ cell tumor origin. This is the fourth such case of an intra-abdominal desmoid tumor after retroperitoneal lymph node dissection for testicular cancer in the urologic literature. This case highlights the need for careful consideration of a desmoid tumor when a rapidly growing spindle cell tumor is encountered in a post-treatment testis cancer patient.

Opacification of the genitourinary collecting system during MDCT urography with enhanced CT digital radiography: nonsaline versus saline bolus.

OBJECTIVE: The purpose of this study was to determine whether a saline bolus during CT urography improves urinary collecting system opacification and whether the addition of enhanced CT digital radiography (CTDR) improves urinary collecting system visualization with or without a saline bolus. MATERIALS AND METHODS: One hundred eight CT urography and enhanced CTDR examinations were reviewed. Fifty-four patients were given a saline bolus during CT urography, and 54 patients underwent CT urography without a saline bolus. Urinary collecting system opacification was evaluated by group (saline vs nonsaline), imaging technique (CT urography alone vs CT urography plus enhanced CTDR), number of enhanced CTDR images, and site of nonopacified urinary segments. Using a multivariate logistic regression model, we determined significance of variables and odds of complete opacification. RESULTS: In the saline group, 248 nonopacified sites were identified on CT urography alone and 95 sites with CT urography plus enhanced CTDR. In the nonsaline group, 185 nonopacified sites were identified on CT urography alone and 59 sites with CT urography plus enhanced CTDR. Combining both groups, 433 nonopacified sites were identified with CT urography alone and 154 sites with CT urography plus enhanced CTDR. Multivariate logistic regression showed significance for group (p = 0.010), imaging method (p < 0.0001), number of enhanced CTDR images (p = 0.048), and site of segment opacification (p < 0.0001). The renal pelvis shows the greatest odds and the distal ureter the lowest odds for complete opacification by group or imaging method. CONCLUSION: The addition of a saline bolus offers no improvement, whereas the addition of enhanced CTDR offers significant improvement in collecting system opacification during CT urography.