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ABSTRACT |
Monday, May 1, 10:00 AM–12:00 PM
Abstracts 013–022
Moderators: Mark E. Lockhart, MD and Gary M. Israel, MD
10:00 AM
Keynote Address: Recent Topics in Genitourinary Trauma from the Radiology Literature
Mark E. Lockhart, MD, University of Alabama at Birmingham, Birmingham, AL
10:20 AM
013. Diagnostic Effectiveness of Pelvic Ultrasound and CT for Acute Pelvic Pain in Nonpregnant Women
Hastreiter D.*; Dubinsky T.; Radiology, University of Washington/Harborview Medical Center, Seattle, WA.
Address correspondence to D. Hastreiter (dhastrei{at}u.washington.edu)
Objective: Recently the healthcare industry has become concerned with perceived over-imaging of patients. The diagnostic effectiveness of first-line cross-sectional imaging for acute pelvic pain in nonpregnant women was assessed in this investigation.
Materials and Methods: The radiology database at Harborview Medical Center was searched from 10/02–10/04 for nonpregnant females presenting to the ER or urgent care clinic for pelvic pain who underwent an abdomen/pelvis CT or pelvic ultrasound (US). The medical records were reviewed for outcomes.
Results: The average age of the 157 patients meeting study criteria was 32 +/- 10. In 71 and 86 cases, respectively, an abdomen/pelvis CT or a pelvic US was performed first. Abnormal findings were described in 70% and 65% of the initial CTs and USs, respectively. The opposite imaging study was performed during the same hospitalization in 21% of patients. Of the 8 US first patients who had subsequent CTs, the CT changed the diagnosis in 3 patients having a negative ultrasound, one requiring emergent surgery for appendicitis. Of the 25 CT first patients who had subsequent USs, US only changed the diagnosis in one case but was felt to better reflect the diagnosis in 5 cases. Imaging findings were diverse and included ovarian cysts, gynecologic masses, appendicitis, and normal studies. The final diagnosis was obtained through CT or US in 80% of cases. MRI provided the final diagnosis in one case of presumed pelvic metastases and another of lumbar epidural abscess. Twenty of the thirty-two cases in which CT or US did not provide the diagnosis were given diagnoses of confirmed or presumed pelvic inflammatory disease (PID) or urinary tract infection (UTI). Surgeries were performed in 21 patients 0–220 days after presentation. In predicting the need for surgery, the sensitivity and positive predictive value for both CT and US were above 0.80. The specificity and negative predictive value were greater than 0.97.
Conclusion: To our knowledge, this is the first study describing the positivity rate of both CT and US for diagnosis of acute pelvic pain in nonpregnant women. Patients referred for urgent imaging had an imaging-detectable abnormality in approximately two-thirds of cases. CT and US were able to provide the final diagnosis in 80% of patients and were valuable in predicting the need for surgery. Pelvic pathology more readily diagnosed by laboratory analysis or clinical history/exam, such as UTIs and uncomplicated PID, may have normal imaging.
014. Postoperative Focal Pelvic Lesions after Inguinal Hernioplasty Using Prosthetic Mesh: CT Findings
Chernyak V.1*; Patlas M.2; Kaul B.1; Milikow D.1; Ricci Z.J.1; Rozenblit A.M.1; 1. Radiology, Montefiore Medical Center, Bronx, NY; 2. Radiology, Hamilton General Hospital, East Hamilton, ON, Canada.
Address correspondence to V. Chernyak (vichka17{at}hotmail.com)
Objective: To investigate frequency and morphology of focal pelvic lesions (FPL) in patients after inguinal hernioplasty with a prosthetic mesh.
Materials and Methods: Consecutive patients who had prosthetic inguinal hernioplasty between 1997 and 2004 and had subsequent pelvic CT were identified using the Medical Records, discharge diagnosis, and Radiology Information System. Pelvic CT of each patient was evaluated by three observers for the presence of a FPL at the internal inguinal ring (IIR). The shape, size and attenuation of the FPL were recorded. The findings were compared with the operative note which included the type of surgical mesh (plug-like or flat) used for the repair.
Results: There were 93 patients, 86 males, with a mean age of 62.4 years (range, 14–89 years), who had 96 hernioplasties, in which a plug-like or flat mesh were used in 71 and 25 cases, respectively. There were 96 CT scans obtained between 1 and 46 months (mean, 15.4 months) after surgery. Indications included evaluation of abdominal, pelvic or flank pain (n = 46), vascular disease (n = 6), staging of newly diagnosed or a known malignancy (n = 28), and miscellaneous (n = 16). An FPL was identified in 69 (71.9%) of 96 cases. FPLs were found in 63 (88.7%) of 71 cases repaired with a plug-like mesh, but in only 6 (24%) of 25 cases repaired with a flat mesh (p < 0.0001). All (100%) FPLs corresponded to the surgical site and were located deep to the IIR, abutting the anterior pelvic wall. FPLs were ovoid or round in 65 (94.2%) and 4 (5.8%) cases, respectively; all (100%) were well-defined. The mean greater diameter of FPL was 2.4 cm (range, 1.3–3.9 cm). FPLs had mean attenuation value of 17 HU (range, –4 to 64 HU) with attenuation of less than 20 HU found in 49 (71.0%) of 69 lesions.
Conclusion: An ovoid or round FPL located at the IIR, with low attenuation on CT is a common postoperative finding in patients after inguinal hernioplasty performed with a plug-like mesh.
015. CT Imaging Findings in Adnexal Torsion
Horn W.L.1*; Menias C.O.2; Bennett G.L.1; 1. Radiology, Women's Imaging Division, New York University Medical Center, New York, NY; 2. Abdominal Imaging Section, Mallinckrodt Institute of Radiology, St. Louis, MO.
Address correspondence to W.L. Horn (hornw01{at}med.nyu.edu)
Objective: To describe the computed tomographic (CT) features of adnexal torsion.
Materials and Methods: The CT scans, clinical and pathologic findings in 20 patients with surgically proven adnexal torsion were retrospectively evaluated. Eighteen scans were performed with oral and IV contrast and 2 without contrast. Imaging features examined included: size, nature, location of adnexal mass, visualization and characterization of the ipsilateral fallopian tube and ovary, uterine location, presence and characterization of ascites and pelvic inflammatory changes.
Results: All patients presented with lower quadrant or flank pain and an adnexal mass at CT. Masses ranged in maximal dimension from 2.5 to 21 cm (mean, 10.1 cm) and were mainly cystic (9), mainly solid (1), mixed cystic and solid (1), mixed lesions containing fat and calcium (7), and cystic and tubular in configuration (2). Findings at pathology showed primary ovarian masses in 17 patients: mature cystic teratoma (7), follicular/ luteal cyst (5), cystadenoma (3), fibroma (1), and strumal carcinoid tumor (1). In one patient there was a paratubal cyst and in 2 patients an infarcted fallopian tube without other findings. At CT, the adnexal mass was located above the level of the uterine fundus in 13 cases and on the side of torsion in 11. The mass was located at the midline or opposite side of the pelvis in 9 cases. The fallopian tube was visualized and thickened in 17 cases. The ipsilateral ovary was not visualized in 13 cases, was normal in 2, enlarged in 2 and enlarged with peripheral follicles in 3. The uterus was deviated to the side of torsion in 9 cases, deviated to the opposite side in 1 and was midline in 9 (one patient had prior hysterectomy). A small to moderate amount of ascites was noted in 17 cases and was hemorrhagic in 3 (greater than 30 HU). Pelvic inflammatory changes were identified in 13 patients.
Conclusion: The most frequent CT findings of adnexal torsion included the presence of an adnexal mass, located above the level of the uterine fundus with associated fallopian tube thickening. Ascites, pelvic inflammatory change and lack of visualization of the ipsilateral ovary were also present in the majority of cases. Adnexal mass location at the midline or opposite side of the pelvis, deviation of the uterus to the side of torsion, and enlargement of the ipsilateral ovary with or without peripheral follicles were less frequently observed.
016. The `Sentinel Clot' Sign: A Useful CT Finding in the Evaluation of Intraperitoneal Bladder Rupture Following Blunt Trauma
Shin S.S.1*; Jeong Y.Y.2; Kang H.K.2; Song S.G.1; Oh H.J.1; Park J.G.1; 1. Diagnostic Radiology, Chonnam National University Hospital, Gwangju, South Korea; 2. Diagnostic Radiology, Chonnam National University Hwasun Hospital, Hwasun, South Korea.
Address correspondence to S.S. Shin (kjradsss{at}dreamwiz.com)
Objective: To evaluate the frequency and relevance of the `sentinel clot' sign on CT in patients with traumatic intraperitoneal bladder rupture.
Materials and Methods: During a recent 27-month period, 74 consecutive
trauma patients (45 men, 29 women; age range, 12-84 years; mean, 50.8 years)
with hematuriawere examined with IV contrast-enhanced CT of the abdomen and
pelvis, followed by retrograde cystography. Diagnosis of intraperitoneal
bladder rupture was confirmed by retrograde cystography and during surgical
exploration. Contrast-enhanced CT scanning was performed by using a helical CT
scanner and a standard trauma protocol at our institution. Two radiologists
retrospectively reviewed all CT images in consensus. The `sentinel clot' sign
was considered to be present when the highest-density clot appeared on and
near to the bladder dome. CT findings, such as sentinel clot sign, pelvic
fracture, traumatic injury to other abdominal viscera, and degree of ascites,
were assessed and statistically analyzed using the two-tailed
2 or Fisher's exact test.
Results: Of the 74 patients, 20 (16 men, 4 women; age range, 30–84 years; mean, 53.7 years) had intraperitoneal bladder rupture. The sentinel clot sign was more frequently found in patients with intraperitoneal bladder rupture (16 patients [80%]) than in patients without intraperitoneal bladder rupture (4 patients [7.4%]) (p < 0.001). Ascites was found in all patients with intraperitoneal bladder rupture, irrespective of associated intraabdominal visceral injury, whereas 19 [35.2%] of the 54 patients without intraperitoneal bladder rupture had ascites (p < 0.001). Pelvic fracture was less frequently found in patients with intraperitoneal bladder rupture (5 patients [25%]) than in patients without intraperitoneal bladder rupture (39 patients [72.2%]) (p < 0.001).
Conclusion: Detection and localization of the `sentinel clot' sign adjacent to the bladder dome may improve the sensitivity and specificity of CT performed before cystography in diagnosing traumatic intraperitoneal bladder rupture, especially when the patients present with hematuria and ascites.
017. Sclerosis of Post Operative Lymphoceles Using Fibrin Sealant
Silas A.M.*; Forauer A.R.; Gemery J.M.; Interventional Radiology, Dartmouth Hitchcock Medical Center, Lebanon, NH.
Address correspondence to A.M. Silas (Anne.M.Silas{at}Hitchcock.ORG)
Objective: To review experience with fibrin-based tissue sealant sclerosis of post surgical lymphoceles at our institution.
Materials and Methods: Fifteen patients who presented with post-surgical lymphoceles were treated with injection of fibrin tissue sealant. Procedures were performed with fluoroscopic and sonographic guidance. All lymphoceles were drained and sclerosed with a mixture of fibrin sealant and gentamicin. No drainage catheter was left in place. Post procedure follow-up consisted of periodic ultrasound evaluations (within 1–4 weeks of therapy) and clinical exams (ongoing).
Results: Twelve male and three female patients (mean age: 52 years). Eleven renal transplant patients with lymphoceles were successfully with one session of sclerosis. Two patients underwent two treatments. Two patients underwent three treatments: 1 renal transplant patient who had also failed sclerotherapy with doxycycline and 1 patient who presented > 6 months after radical prostatectomy. Seven patients undergoing a single treatment experienced complete resolution while the remaining patients had persistent, though asymptomatic, fluid collections, smaller than at original presentation. Sonographic mean follow-up was 252 days (range 8–339); mean clinical follow-up was 327 days (range 105–646). There were no peri-procedural complications.
Conclusion: Fibrin sealant is a safe and effective option in the sclerosis of post-operative lymphoceles.
018. The Use of Diagnostic PET/CT for Radiation Therapy Treatment Planning
Wahab S.H.1*; Mutic S.1; Low D.A.1; Siegel B.A.2; Dehdashti F.2; Grigsby P.W.1; 1. Radiation Oncology, Washington University School of Medicine, St. Louis, MO; 2. Nuclear Medicine, Washington University School of Medicine, St. Louis, MO.
Address correspondence to S.H. Wahab (worldys{at}hotmail.com)
Objective: PET-Guided Radiation Therapy (PGRT) is increasingly being used to define treatment volumes for radiation therapy, typically by fusing diagnostic PET images with treatment planning CT images taken in the radiation oncology department. The hypothesis of this study is that a CT performed at the time of PET/CT will have adequate spatial resolution for treatment planning and will allow more accurate image co-registration of PET and CT by minimizing the variables introduced by patient positioning, organ motion and organ deformation. We report on our early experience implementing a process whereby a diagnostic PET/CT dataset is used for radiation therapy treatment planning.
Materials and Methods: In the radiation oncology department, therapists use room mounted positioning lasers to orient the patient in the treatment position and build a custom immobilization device. A traditional planning CT is taken for back-up redundancy and for study comparison. The patient is then taken to Nuclear Medicine for PET/CT. Therapists again set up the patient in the treatment position using the customized immobilization device, ensuring that the positioning lasers match the appropriate skin marks. An attenuation correction CT scan is taken followed by a higher resolution CT (120–150 mAs, 130 kVp, 3 mm thickness, 2.5 mm spacing, 480 mm FOV) through the region of interest. Whole-body PET is then performed. The PET and high resolution CT datasets are sent by DICOM to a treatment planning system. While PET/CT image datasets are intrinsically co-registered, the planning software requires that they be fused using semi-automated software built into the planning system. The fused PET/CT images are used for all contour delineation and treatment planning.
Results: Ten patients with cervical cancer have been planned for radiation treatment using only co-registered image datasets from a diagnostic PET/CT. High correlation has been observed between the co-registered image datasets. Structures identified on the PET images demonstrate better spatial and volumetric correlation to patient anatomy on the CT taken at the time of PET than to patient anatomy on the traditional planning CT.
Conclusion: The use of diagnostic PET/CT imaging for radiation therapy treatment planning is feasible. The technique may improve the accuracy of PGRT by decreasing PET-to-CT co-registration errors due to variations in patient positioning, organ motion, and organ deformation occurring between the serial imaging studies.
019. Accuracy of Image-guided Percutaneous Renal Mass Biopsy and Impact on Clinical Management
Maturen K.E.1*; Nghiem H.V.2; Higgins E.J.1; Caoili E.M.1; Wolf J.S.3; Wood D.P.3; 1. Radiology, University of Michigan, Ann Arbor, MI; 2. Radiology, William Beaumont Hospital, Royal Oak, MI; 3. Urology, University of Michigan, Ann Arbor, MI.
Address correspondence to K.E. Maturen (kmulder{at}umich.edu)
Objective: To determine the accuracy of imaging guided percutaneous renal mass biopsy and the impact of biopsy results on clinical management.
Materials and Methods: With institutional review board approval, we retrospectively reviewed image-guided renal biopsies performed by the radiology cross-sectional interventional service between February 1999 and July 2005. Patient records, pathology reports, and imaging studies were reviewed. Concordance of biopsy diagnosis and follow-up data was assessed. Impact on clinical management was assessed by two experienced urologists.
Results: 276 renal biopsies were performed during the study period. 123 of these were random biopsies—performed to assess rejection in transplant kidneys or to determine etiology of renal failure in native kidneys—and were excluded. 153 renal mass biopsies were performed in 126 patients (56 female, 70 male; average age 60, range 28–90). Coaxial 18 Ga core needle technique was used in 152 cases, constituting the study population. Repeat biopsies were performed in 27 patients for follow-up after radiofrequency ablation (RFA) (n = 20), second mass (n = 4) or diagnostic dilemma (n = 3). 85 biopsies (56%) demonstrated malignant neoplasm; 61 (40%) benign findings (including 22 (14.5%) benign neoplasms such as oncocytoma, and 39 (25.5%) non-neoplastic results) and 6 (4%) were non-diagnostic. Including non-diagnostic biopsies, sensitivity for malignancy was 97.7% and specificity 100% using imaging stability for > 1 year as confirmation of benignity. However, follow-up data or tissue confirmation was not yet available in 18 benign biopsies and 3 non-diagnostic biopsies. There were no significant procedure-related complications. At least 90 (59%) biopsy results significantly impacted clinical management, when significant impact is defined as change from no therapy to therapy, including surgery, RFA, chemotherapy, or radiation.
Conclusion: Percutaneous image-guided cutting needle biopsy of renal masses is safe and accurate. Tissue diagnosis frequently alters clinical decision making, particularly in the following clinical situations: benign renal mass, locally advanced or metastatic disease from presumed renal malignancy, or extrarenal malignancy. Biopsy may allow a number of unnecessary nephrectomies to be avoided.
020. Impact of Diagnostic Imaging and Interventional Radiology in the Management of Renal Trauma: A Thirty Year Experience
Dunfee B.L.1*; Lucey B.C.1; Varghese J.C.1; Uberoi J.2; Liou L.S.2; Soto J.A.1; 1. Department of Radiology, Boston University Medical Center, Boston, MA; 2. Department of Urology, Boston University Medical Center, Boston, MA.
Address correspondence to B.L. Dunfee (Brian.Dunfee{at}bmc.org)
Objective: To evaluate the impact of diagnostic imaging and interventional radiology in the management of renal and ureteric trauma.
Materials and Methods: A retrospective analysis of the trauma registry at our institutionover the past thirty years from 1975 to 2005 was performed. All patients sustaining documented renal and/or ureteric injury were identified, yielding a total of 145 patients. We documented the injuries, management, and clinical outcome in all cases. Management was classified as surgical or non-surgical, including minimally invasive therapy or conservative management. Minimally invasive therapy included percutaneous nephrostomy tubes, ureteral stenting, percutaneous vascular intervention, and percutaneous urinoma drainage. We compared the rates of each class of management by decade.
Results: Of the 145 patients with documented injuries, 51/145 (35%) underwent nephrectomy, 4/145 (3%) partial nephrectomy, 49/145 (34%) renorrhaphy, and 41/145 (28%) had minimal invasive therapy or conservative management. From 1975 to 1984, 4/23 (17%) had nephrectomy, 2/23 (9%) partial nephrectomy, 17/23 (74%) renorrhaphy, and 0/23 (0%) non-surgical management. From 1985 to 1994, 25/55 (45%) had nephrectomy, 1/55 (2%) partial nephrectomy, 23/55 (42%) renorrhaphy, and 6/55 (11%) non-surgical management. From 1995 to 2004, 22/67 (33%) had nephrectomy, 1/67 (2%) partial nephrectomy, 9/67 (13%) renorrhaphy, and 35/67 (52%) non-surgical management. The number of minimally invasive procedures performed was 0/23 (0%) from 1975 to 1984, 2/55 (4%) from 1985 to 1994, and 8/67 (12%) from 1995 to 2004.
Conclusion: The use of improved quality diagnostic imaging and the advent of minimally invasive therapeutic options has definitively shifted the management of renal and ureteric trauma away from surgical to non-surgical management.
021. Magnetic Resonance-guided Focused Ultrasound Surgery (MRgFUS) with Rapid Interleaved Technique: Initial Experience for the Treatment of Uterine Fibroids
Holland G.A.1*; Hanannel A.2; Briigss M.H.3; Dick A.B.3; Bruno R.3; 1. Radiology, Lahey Clinic, Burlington, MA; 2. Clinical Application, InSightec, Tirat Carmel, Israel; 3. Gynecology, Lahey Clinic, Burlington, MA.
Address correspondence to G.A. Holland (george.a.holland{at}lahey.org)
Objective: MRgFUS is a technique that uses MRI to target, and control the noninvasive ultrasound thermal ablation of uterine fibroids. The purpose of this study was to evaluate a rapid manual interleaved MRgFUS (iMRgFUS) treatment of uterine fibroids that permits treatments to be done in less time or treatment of larger fibroids than the prior reported technique of MRgFUS.
Materials and Methods: 14 pre or perimenopausal adult women with symptomatic fibroids were treated with the rapid iMRgFUS. Enrollment required symptomatic uterine fibroids scoring a minimum of 18 on a symptom severity questionnaire. Gynecological examination and prior MRI confirmed a definitive diagnosis of symptomatic uterine fibroids. Treatments were with conscious sedation on an ExAblate 2000 (InSightec, Tirat Carmel, Israel) integrated into a 1.5 Tesla MR scanner (General Electric Medical Systems, Waukesha, WI). T2 weighted images were performed in 3 cardinal imaging planes (4,000–7,000/95–102 msec TR/TE). The treatment was manually plotted on the FSE images with fibroid(s) divided into 2 to 5 separate non-overlapping regions. The intersonication cooling time was decreased from the default of 90 seconds to the minimum of 45–50 sec's. Each sonication was performed in 14–20 sec's and then monitored with an MR thermal map which are performed with a spoiled gradient echo sequence (TR/TE 27/11–13 msec). The treatments were limited to about 3 hours. Post procedural imaging was performed with dynamically gadolinium enhanced using 3 dimensional spoiled gradient echo images. The research was funded by a grant from InSightec.
Results: iMRgFUS permitted up to 127 sonications in a treatment versus 60–70 sonications with prior technique in a 3-hour treatment. The same sized fibroid could be treated in about 60% of the time as the treatments using the former protocol. There were no serious adverse events in patients treated with the iMRgFUS. All patients had 3 month follow up and 8 patients had 6 month follow up. Twelve of the 14 patients had marked improvements in their symptom scores on the follow up visits. None of the patients treated with iMRgFUS have had alternative forms of treatment to date.
Conclusion: iMRgFUS is an apparently safe method for a more rapid treatment of fibroids. This allows either a shorter duration of a fibroid treatment in 60% of the time previously required or permits the treatment of greater volume of fibroid. Larger studies of iMRgFUS will also need to be tested.
022. Multimodality Imaging of Vascular Extracapsular Extension of Prostate Cancer
Liebeskind M.E.1,2*; 1. 525 Park Avenue, Park Avenue Radiologists, PC, New York, NY; 2. Robert S. Bard, New York, NY.
Address correspondence to M.E. Liebeskind (marc.liebeskind{at}parkavenueradiologists.com)
Objective: Diagnosis and therapy for prostate cancer is problematic given the prevalence of disease, the different biologic behavior of aggressive versus indolent lesions and the difficulty with localization. This study was designed to assess the correlation between dynamic contrast enhanced MRI of the prostate with endorectal sonographic evaluation using power Doppler evaluation. The ability to distinguish vascular prostatic neoplasm from adjacent normal prostatic tissue while staging prostate carcinoma is an advantage of dynamic prostate MRI over MR spectroscopy that allows for correlation with sonography, which is used to guide focused prostate biopsy and may increasingly guide focused therapy. Evaluation with both MRI and sonography was performed to assess for extracapsular extension of disease.
Materials and Methods: 24 patients were evaluated with dynamic contrast enhanced pelvic MRI (Siemens Symphony 1.5 Tesla with phased array body coil) with computer aided diagnostic software (3TP). All patients had correlative endorectal sonography (Kretz Voluson 730 Expert with 6–10 MHz probe) and biopsy-proven prostate carcinoma.
Results: 24 patients with biopsy-proven prostate cancer were evaluated. 12 patients (50%) demonstrated extracapsular extension of disease on both MRI and sonography (1 Gleason 3 + 3, 5 Gleason 3 + 4, 4 Gleason 4 + 4, 2 Gleason 4 + 5). 1 patient with a Gleason 3 + 4 lesion was noted in whom MRI diagnosed extracapsular extension. 1 patient with a Gleason 3 + 4 lesion was noted in whom ultrasound diagnosed extracapsular extension.
Conclusion: The ability to stage extent of disease at the same time as guiding ultrasound focused biopsy and therapy is a significant advantage of dynamic prostate MRI over MR spectroscopy for evaluation of vascular tumors, which has been validated for diagnosis but has no sonographic correlate.
* Will present paper
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