Amanda S. Corey

Prognostic Accuracy of Computed Tomography Findings for Patients With Laryngeal Cancer Undergoing Laryngectomy

PURPOSE The indications for upfront laryngectomy in the management of laryngeal cancer are a functionless larynx and extralaryngeal extension. Practically, clinicians rely on imaging to predict which patients will have T4 disease. Our goal was to review the accuracy of preoperative computed tomography (CT) scanning in determining the necessity for initial laryngectomy for advanced laryngeal cancer. PATIENTS AND METHODS In total, 107 consecutive untreated laryngectomy specimens with high-quality, preoperative CT imaging interpreted by our neuroradiologists were reviewed. Radiographic findings, including sclerosis, invasion, penetration, extralaryngeal spread, and subglottic extension were correlated with pathologic findings. CT images were not reinterpreted, since our purpose was to assess the original interpretations. RESULTS CT imaging reported 23 cases of thyroid cartilage penetration and 27 cases of extralaryngeal spread. Pathology reported 12 cases of thyroid cartilage invasion, 29 cases of penetration, and 45 cases of extralaryngeal disease. CT imaging identified 17 (59%) of 29 cases of pathologically documented thyroid cartilage penetration and 22 (49%) of 45 cases of pathologically documented extralaryngeal spread. Pathologically proven extralaryngeal spread without thyroid cartilage penetration occurred in 18 (40%) of 45 cases. The positive predictive values for thyroid cartilage penetration and extralaryngeal spread were 74% and 81%. Sclerosis was of limited value in predicting thyroid cartilage invasion or penetration. Cricoid or arytenoid destruction predicted for thyroid cartilage penetration at rates of 57% and 63%. CONCLUSION CT imaging has clear limitations when deciding whether there is thyroid cartilage penetration or extralaryngeal spread of advanced laryngeal cancer. Extralaryngeal spread without thyroid cartilage penetration was more common than expected. Alternate methods of pretreatment assessment are needed.

ACR Appropriateness Criteria Low Back Pain.

Most patients presenting with uncomplicated acute low back pain (LBP) and/or radiculopathy do not require imaging. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags raising suspicion for serious underlying conditions, such as cauda equina syndrome, malignancy, fracture, and infection. Many imaging modalities are available to clinicians and radiologists for evaluating LBP. Application of these modalities depends largely on the working diagnosis, the urgency of the clinical problem, and comorbidities of the patient. When there is concern for fracture of the lumbar spine, multidetector CT is recommended. Those deemed to be interventional candidates, with LBP lasting for > 6 weeks having completed conservative management with persistent radiculopathic symptoms, may seek MRI. Patients with severe or progressive neurologic deficit on presentation and red flags should be evaluated with MRI. 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.

Radiographic Imaging of Human Papillomavirus Related Carcinomas of the Oropharynx

Imaging, especially contrast-enhanced computed tomography (CECT) for anatomy and positron emission tomography (PET) with labeled 18F fluorodeoxyglucose for physiologic detail, is critical for staging carcinomas of the oropharynx. As the incidence of human papillomavirus (HPV) infection and related carcinomas of the tonsil and base of tongue (BOT) increases, experience with CECT and PET for staging HPV+ tumors is growing. No imaging modality, however, can determine whether the tumor is HPV+. There are some unique challenges posed by HPV+ oropharyngeal squamous cell carcinoma (SCC). In most locations of the head and neck, a malignancy enhances more than surrounding normal structures, which facilitates tumor mapping. Unfortunately, normal lymphoid tissue of the oropharynx, in the BOT and palatine tonsillar fossa, enhances on CECT and gadolinium enhanced magnetic resonance imaging in a manner similar to SCC. The primary tumor may be small or even occult at presentation, and easily over-looked on CECT. PET coupled with CECT has made a true “unknown primary” very rare, as the metabolically active tumor is almost always detectable on PET. The nodal metastases, so common with HPV+ SCC, can be truly cystic; and as such, can be misdiagnosed as a second branchial cleft cyst, a congenital benign lesion. These pitfalls, coupled with the complex anatomy of the upper aerodigestive tract, make staging these tumors difficult. In this monograph we describe the anatomy of the oropharynx and review the imaging modalities available for staging. Figures highlight the points raised in the text.

Clinical Decision Support and Acute Low Back Pain: Evidence-Based Order Sets

Low back pain is one of the most common reasons for visits to physicians in the ambulatory care setting. Estimated medical expenditures related to low back pain have increased disproportionately relative to the more modest increase in the prevalence of self-reported low back pain in the past decade. The increase in spine care expenditures has not been associated with improved patient outcomes. Evidence-based order templates presented in this article are designed to assist practitioners through the process of managing patients with acute low back pain. A logical method of choosing, developing, and implementing clinical decision support interventions is presented that is based on the best available scientific evidence. These templates may be reasonably expected to improve patient care, decrease inappropriate imaging utilization, reduce the inappropriate use of steroids and narcotics, and potentially decrease the number of inappropriate invasive procedures.

Implementation of a Novel Surveillance Template for Head and Neck Cancer: Neck Imaging Reporting and Data System (NI-RADS)

BACKGROUND: DESCRIPTION OF THE PROBLEM The recent ACR Intersociety Committee Summer Conference addressed the need to reengineer the radiology enterprise to adhere to the value equation and be “patientcentric, data-driven, and outcomesbased.” The Intersociety Committee advocated for the universal use of report templates and linked management recommendations [1]. The ACR instituted the BI-RADS initiative more than 20 years ago to address interobserver variability in mammography reporting [2]. The standardization of mammography reports improved comprehension of imaging findings, conveyed the level of suspicion, and guided management recommendations [3]. Structured reports are also easier for patients to understand, facilitating direct communication between radiologists and patients. Many patients want increased direct input from radiologists because of their greater expertise in imaging interpretation [4]. Referring physicians are most receptive to direct patient reporting when they have working relationships with radiologists as part of a coordinated health care team [5]. Referring physicians may worry that direct patient reporting might result

ACR Appropriateness Criteria Dementia and Movement Disorders.

Neurodegenerative disease, including dementia, extrapyramidal degeneration, and motor system degeneration, is a growing public health concern and is quickly becoming one of the top health care priorities of developed nations. The primary function of anatomic neuroimaging studies in evaluating patients with dementia or movement disorders is to rule out structural causes that may be reversible. Lack of sensitivity and specificity of many neuroimaging techniques applied to a variety of neurodegenerative disorders has limited the role of neuroimaging in differentiating types of neurodegenerative disorders encountered in everyday practice. Nevertheless, neuroimaging is a valuable research tool and has provided insight into the structure and function of the brain in patients with neurodegenerative disorders. Advanced imaging techniques, such as functional neuroimaging with MRI and MR spectroscopy, hold exciting investigative potential for better understanding of neurodegenerative disorders, but they are not considered routine clinical practice at this time. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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.

Characteristics and Limitations of FDG PET/CT for Imaging of Squamous Cell Carcinoma of the Head and Neck: A Comprehensive Review of Anatomy, Metastatic Pathways, and Image Findings

OBJECTIVE This image-based article illustrates the anatomic regions of squamous cell carcinomas of the head and neck and describes the metastatic pathways in and TNM staging for each region. Both the role and limitations of FDG PET/CT in imaging such cancers are discussed, and cases exemplifying these issues are reported. Also included is a discussion of the use of FDG PET/CT to monitor the response of squamous cell carcinomas of the head and neck to therapy, in addition to a brief comparison of PET/CT with such traditional imaging modalities as CT, MRI, and ultrasound. CONCLUSION Understanding the characteristics of squamous cell carcinoma of the head and neck, as imaged by FDG PET/CT, is crucial for determining treatment strategy, because it helps to avoid incorrect staging and also provides an accurate assessment of treatment response.

Simultaneous typical and extraordinary imaging findings of AIDS-associated cytomegalovirus encephalitis

Encephalitis caused by cytomegalovirus (CMV) is a devastating disease that occurs mostly in profoundly immunocompromised individuals, particularly in the setting of advanced HIV infection or organ transplantation. Imaging findings in AIDS-associated cytomegalovirus encephalitis that have been described range from ventriculitis (more common) to solitary mass lesions (less common). We describe a fatal case of AIDS-associated cytomegalovirus encephalitis that included typical imaging findings but also atypical features with widespread, multifocal lesions demonstrating restricted diffusion on magnetic resonance imaging (MRI). It is likely that these diffusion abnormalities are appreciated due to changes in imaging technology from the pre-highly active antiretroviral therapy era in which the typical imaging findings of CMV encephalitis were first described. The differential diagnosis of widespread, multifocal lesions with restricted diffusion in the setting of AIDS should now include CMV encephalitis.

Pitfalls in the Staging of Cancer of the Oropharyngeal Squamous Cell Carcinoma

The face of oropharyngeal squamous cell carcinoma (OPSCC) is changing. It has a dichotomous nature, with 1 subset of the disease associated with tobacco and alcohol use and the other having proven association with human papilloma virus infection. Imaging plays an important role in the staging and surveillance of OPSCC, and a detailed knowledge of the anatomy and pitfalls is critical. This article will review the detailed anatomy of the oropharynx and epidemiology of OPSS, along with its staging, patterns of spread, and treatment.

ACR Appropriateness Criteria® Cerebrovascular Disease

Diseases of the cerebral vasculature represent a heterogeneous group of ischemic and hemorrhagic etiologies, which often manifest clinically as an acute neurologic deficit also known as stroke or less commonly with symptoms such as headache or seizures. Stroke is the fourth leading cause of death and is a leading cause of serious long-term disability in the United States. Eighty-seven percent of strokes are ischemic, 10% are due to intracerebral hemorrhage, and 3% are secondary to subarachnoid hemorrhage. The past two decades have seen significant developments in the screening, diagnosis, and treatment of ischemic and hemorrhagic causes of stroke with advancements in CT and MRI technology and novel treatment devices and techniques. Multiple different imaging modalities can be used in the evaluation of cerebrovascular disease. The different imaging modalities all have their own niches and their own advantages and disadvantages in the evaluation of cerebrovascular disease. 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.