Publications

The purpose of this article is to present algorithms for the diagnostic management of solitary bone lesions incidentally encountered on computed tomography (CT) and magnetic resonance (MRI) in adults. Based on review of the current literature and expert opinion, the Practice Guidelines and Technical Standards Committee of the Society of Skeletal Radiology (SSR) proposes a bone reporting and data system (Bone-RADS) for incidentally encountered solitary bone lesions on CT and MRI with four possible diagnostic management recommendations (Bone-RADS1, leave alone; Bone-RADS2, perform different imaging modality; Bone-RADS3, perform follow-up imaging; Bone-RADS4, biopsy and/or oncologic referral). Two algorithms for CT based on lesion density (lucent or sclerotic/mixed) and two for MRI allow the user to arrive at a specific Bone-RADS management recommendation. Representative cases are provided to illustrate the usability of the algorithms.

OBJECTIVE: We report a series of 355 consecutive patients treated over 9 years in a single institution with intended PDC.

BACKGROUND: Surgery for MPM has shifted from extra-pleural pneumonectomy to PDC with the goal of MCR.

METHODS: Clinical and outcome data were reviewed. Kaplan-Meier estimators and log rank test were used to compare the overall survival, and logistic regression models were used.

RESULTS: MCR was achieved in 304. There were 223 males, median age was 69 and histology was epithelioid in 184. The 30 and 90-day mortality were 3.0% and 4.6%.Most complications were low grade. Prolonged air leak in 141, deep venous thrombosis in 64, Atrial fibrillation in 42, chylothorax in 24, Empyema in 23, pneumonia in 21, Hemothorax in 12 and pulmonary embolus in 8. Median/5-year survival were 20.7 months/17.9% in the intent-to-treat cohort and 23.2months/21.2% in the MCR group. The survivals were best for patients with Tlstage and epithelioid histology (69.8months/54.1%). In a multivariable analysis, factors that were found to be associated with longer patient overall survival included epithelioid histology, T stage, quantitative clinical stage/tumor volume staging, adjuvant chemotherapy, intraoperative heated chemo, female sex, and length of stay shorter than 14 days.

CONCLUSIONS: PDC is feasible with low mortality and is associated with manageable complication rates. 5-year survival of patients undergoing PDC with MCR in multi-modality setting is approaching 25% depending on quantitative and clinical stage, sex and histological subtype and is better than PDC without- MCR.

BACKGROUND AND PURPOSE: Computed tomography angiographies are frequently performed in the emergency department (ED) for the assessment of cervical artery dissection (CeAD) due to the high risk of associated morbidity, but their diagnostic utility is not fully evaluated. We assessed the radiological outcomes and clinical correlates of CTAs performed for suspected CeAD.

MATERIALS AND METHODS: CTAs for all indications (IndicationALL) over a 10-year period were evaluated to identify those with CeAD. A subgroup of CTAs performed for suspected CeAD (IndicationDISSECTION) was identified and further assessed for clinical findings predictive of CeAD. Magnetic resonance angiography/fat-saturated images (MRA/FSI) performed after CTA were also assessed.

RESULTS: Nine-thousand-two-hundred-four CTAs were performed by our ED for IndicationALL of which 850 (9.2%) were for IndicationDISSECTION. CeAD was noted in 1.5% (142/9204) among IndicationALL and in 6.1% (53/850) of IndicationDISSECTION CTAs. The most common radiological findings were mural thrombus and eccentric lumen. In the IndicationDISSECTION group, new headache (OR: 2.5, 95%CI: 1.2-5.7) and partial Horner syndrome (OR: 14.4, 95%CI: 4.2-49.9) predicted carotid dissection and cervical fracture (OR: 5.5, 95%CI: 2.1-14.6) predicted vertebral artery dissections. MRA/FSI confirmed CeAD in all positive cases, but in 2 CTAs read as negative, MRA/FSI was positive for vertebral artery dissection.

CONCLUSION: Although the yield of CTAs for clinically suspected CeAD is low, the paucity of reliable clinical predictors, high risk of morbidity, availability in ED, and comparable performance to MRA/FSI justifies its widespread utilization for initial diagnosis of CeAD.

PURPOSE: MRI is currently the gold standard imaging modality in the diagnosis of lumbar spine discitis/osteomyelitis. However, even with supportive clinical and laboratory data, the accuracy of MRI remains limited by several degenerative and inflammatory mimics, such that it continues to represent a challenge for radiologists. This study reports a new quantitative imaging marker of lumbar paraspinal soft tissue edema which shows significant accuracy for spondylodiscitis.

METHODS: Thirty-five patients with equivocal MRI findings of lumbar discitis/osteomyelitis vs endplate degenerative changes were reviewed over a 24-month period. Patients with a history of surgery, fractures/recent trauma, signs of advanced infection such as abscesses, phlegmon or severe osseous destruction were excluded. Two ABR board certified neuroradiologists who were blinded to the final diagnosis evaluated a new marker; the superior-inferior paraspinal edema ratio (SI-PER). The SI-PER was obtained by measuring the superior-inferior extent of increased signal/edema in the paraspinal soft tissues on the paraspinal inversion recovery images divided by the vertebral body height measured at midpoint. Cases positive for spondylodiscitis were those confirmed by biopsy, aspiration/drainage, surgery, or clinical improvement following antibiotic treatment. The diagnostic sensitivity and specificity of SI-PER were determined by Receiver operating characteristic (ROC) analysis.

RESULTS: In 23/35 (66%) patients, the diagnosis of discitis/osteomyelitis was confirmed. The SI-PER showed a significant association with a positive MRI diagnosis (p = 0.001). Inter-observer correlation for SI-PER was 0.92. ROC analysis showed an area under the curve of 0.84. A SI-PER of 2.5 was 96% sensitive and 75% specific for the diagnosis of discitis/osteomyelitis, with a PPV of 88% and a NPV of 90%.

CONCLUSION: In this study, the superior inferior paraspinal edema ratio (SI-PER), a newly defined MRI marker, was found to have high sensitivity for differentiating spondylodiscitis from endplate degenerative changes on lumbar spine MRI.

Rapid histologic assessment of fresh prostate biopsies may reduce patient anxiety, aid in biopsy sampling, and enable specimen triaging for molecular/genomic analyses and research that could benefit from fresh tissue analysis. Nonlinear microscopy (NLM) is a fluorescence microscopy technique that can produce high-resolution images of freshly excised tissue resembling formalin-fixed paraffin-embedded (FFPE) H&E. NLM enables evaluation of tissue up to  100 µm below the surface, analogous to serial sectioning, but without requiring microtome sectioning. One hundred and seventy biopsies were collected from 63 patients who underwent in-bore MRI or MRI/ultrasound fusion biopsy procedures. Biopsies were stained in acridine orange and sulforhodamine 101, a nuclear and cytoplasmic/stromal fluorescent dye, for 45 s. Genitourinary pathologists evaluated the biopsies using NLM by translating the biopsies in real time to areas of interest and NLM images were recorded. After NLM evaluation, the biopsies were processed for standard FFPE H&E and similarities and differences between NLM and FFPE H&E were investigated. Accuracies of NLM diagnoses and Gleason scores were calculated using FFPE histology as the gold standard. Pathologists achieved a 92.4% sensitivity (85.0-96.9%, 95% confidence intervals) and 100.0% specificity (94.3-100.0%) for detecting carcinoma compared to FFPE histology. The agreement between the Grade Group determined by NLM versus FFPE histology had an unweighted Cohen's Kappa of 0.588. The average NLM evaluation time was 2.10 min per biopsy (3.08 min for the first 20 patients, decreasing to 1.54 min in subsequent patients). Further studies with larger patient populations, larger number of pathologists, and multiple institutions are warranted. NLM is a promising method for future rapid evaluation of prostate needle core biopsies.

See also the editorial by Ronot in this issue. Online supplemental material is available for this article.

BACKGROUND AND PURPOSE: Although the cerebellar tonsils are parasagittal structures, the extent of tonsillar herniation (ETH) in Chiari I malformation (CMI) is currently measured in the midsagittal plane. We measured the ETH of each cerebellar tonsil in the parasagittal plane and assessed their diagnostic utility by comparing them to the midsagittal ETH measurements in predicting cough-associated headache (CAH), an indicator of clinically significant disease in CMI.

METHODS: Eighty-five CMI patients with 3D-MPRAGE images were included. Neurosurgeons determined the presence of CAH. Sagittal images were used to measure ETH in the midsagittal (MS_ETH) and parasagittal planes (by locating tonsillar tips on each side on reformatted coronal images). Given the parasagittal ETH (PS_ETH) asymmetry in the majority of cases, they were considered Smaller_PS_ETH or Larger_PS_ETH. The accuracy of ETH measurements was assessed by the receiver operating characteristic (ROC) curve.

RESULTS: Of 85 patients, 46 reported CAH. ROC analysis showed an area under the curve (AUC) of 0.78 for Smaller_PS_ETH significantly better than 0.65 for MS-ETH in predicting CAH (p = 0.001). An AUC of 0.68 for Larger_PS_ETH was not significantly different from MS_ETH. The sensitivity and specificity of predicting CAH were 87% and 28% for MS_ETH >6 mm versus 90% and 46% for Smaller_PS_ETH >6 mm, and 52% and 67% for MS_ETH >9 mm versus 48% and 87% for Smaller_PS_ETH >9 mm. At ETH >15 mm, no differences were seen between the measurements.

CONCLUSIONS: Diagnostic utility of ETH measurements in detecting clinically significant CMI can be improved by parasagittal measurements of the cerebellar tonsillar herniation.