Carolyn L. Wang

Positron Emission Mammography: Correlation of Estrogen Receptor, Progesterone Receptor, and Human Epidermal Growth Factor Receptor 2 Status and 18F-FDG

OBJECTIVE The study objective was to assess the correlation between (18)F-FDG uptake values on positron emission mammography (PEM), expressed as maximum uptake value and lesion-to-background ratio, and receptor status (i.e., estrogen receptor [ER], progesterone receptor [PR], and human epidermal growth factor receptor 2 [HER2]), tumor histology, and tumor grade. We also evaluated for the correlation between maximum uptake value on PEM and maximum uptake value on a whole-body PET/CT. MATERIALS AND METHODS We retrospectively reviewed our database for patients with newly diagnosed breast cancer who were referred for PEM between June 2007 and September 2009. A subset of patients also underwent a whole-body PET/CT scan. The original pathology reports were reviewed to establish the histologic type, grade, and receptor status. RESULTS The study involved 98 patients with 100 lesions. ER-negative tumors and PR-negative tumors had significantly higher mean lesion-to-background ratio than did their respective receptor-positive tumors (p = 0.02). Triple-negative tumors (i.e., ER-negative, PR-negative, and HER2-negative tumors) had statistically higher mean lesion-to-background ratio than did ER-positive PR-positive HER2-negative tumors (p = 0.04). Infiltrating ductal carcinomas had significantly higher PEM FDG uptake values than did infiltrating lobular carcinomas (p = 0.02-0.04). Breast tumors with higher histologic grade also had significantly higher PEM FDG uptake values than did those with lower grade (p = 0.03 and p < 0.001). A moderately high correlation (0.76-0.79) was seen between whole-body PET/CT and PEM uptake values. CONCLUSION This study shows a correlation between PEM FDG uptake values and the prognostic factors that have been shown to predict breast cancer survival.

Hepatocellular carcinoma in the noncirrhotic liver.

OBJECTIVE Hepatocellular carcinomas (HCCs) that arise in noncirrhotic livers have several histologic and biochemical features that distinguish them from HCCs occurring in the setting of cirrhosis. Because the presentation, management, and prognosis of these entities are distinct, the accurate preoperative characterization of these lesions is of great clinical significance. We review the pathogenesis, imaging appearance, and clinical implications of noncirrhotic HCCs as they pertain to the clinical radiologist. CONCLUSION HCCs that develop in noncirrhotic patients have distinct etiologic, cytogenetic, histopathologic, and clinical features. Despite a larger tumor burden at the time of HCC diagnosis, noncirrhotic patients with HCC have better overall survival and disease-free survival than cirrhotic patients with HCC. Knowledge of the precise clinical and imaging features of this entity and of other diagnostic considerations for the noncirrhotic liver is essential for improved patient care.

Cost analysis and feasibility of high-fidelity simulation based radiology contrast reaction curriculum.

RATIONALE AND OBJECTIVES Radiology residents have variable training in managing acute nonrenal adverse reactions to iodinated contrast media because of their rarity. Preliminary results show positive feedback and knowledge gain with high-fidelity simulation-based training. Financial costs and the time required to implement a high-fidelity simulation curriculum are higher than for a lecture series. The objective of this study was to provide a financial and time cost-benefit analysis for high-fidelity simulation training of acute adverse reactions to iodinated contrast media. MATERIALS AND METHODS Forty-four radiology residents were divided into lecture and simulation groups. Five simulation scenarios were created, with core education content mirrored in the lecture. Lengths of faculty time commitment and resident training were recorded. Financial costs, including manikin and simulation facility rates, were recorded and divided by the number of residents to obtain per resident simulation and lecture costs. A written evaluation of the experience, with Likert-type items and unstructured response items, was conducted. RESULTS Cost per resident for simulation training setup was

Allergic reactions to iodinated contrast media: premedication considerations for patients at risk.

259.76, and

Rate of Contrast Material Extravasations and Allergic-like Reactions: Effect of Extrinsic Warming of Low-Osmolality Iodinated CT Contrast Material to 37°C

203.46 for subsequent years, compared to <

Patient Access to Online Radiology Reports

5 for lecture. Faculty time was 7 academic days for simulation versus 2 days for lecture format. Resident simulation commitment was 3 hours 30 minutes. Time to train technologists to run the simulation was 3 hours. All residents provided positive feedback regarding the simulation curriculum, with mean feedback scores statistically higher than lecture group (P < .05). CONCLUSIONS This study illustrates that financial costs of implementation are low compared to the potential cost of morbidity associated with the life-threatening event of an acute adverse reaction to iodinated contrast media.

(18)F-FDG PET/CT-positive internal mammary lymph nodes: pathologic correlation by ultrasound-guided fine-needle aspiration and assessment of associated risk factors.

The objectives of this article are to review allergy-type reactions to iodinated contrast media and the protocols utilized to prevent or reduce the occurrence of these adverse reactions in high-risk patients. We will begin by discussing the types or classifications of the adverse reactions to iodinated contrast media. We will then discuss reaction mechanisms, identify the patients at highest risk for adverse reactions, and clarify common misperceptions about the risk. Finally, we will discuss the actions of the medications used to help reduce or prevent allergy-type reactions to iodinated contrast media, the protocols used to help reduce or prevent contrast reactions in high-risk patients, and the potential side effects of these medications. We will also discuss the high-risk patient who has received premedication due to a prior index reaction and discuss the risk of having a subsequent reaction, termed “breakthrough reaction.” Identifying patient at high risk for an “allergy-type” reaction to contrast media is an essential task of the radiologist. Prevention of or reduction of the risk of an adverse reaction is critical to patient safety. If an examination can be performed without contrast in a patient at high risk for an allergy-type reaction, it may be appropriate to avoid contrast. However, there are situations where contrast media is necessary, and the radiologist plays a vital role in preventing or mitigating an allergy-type reaction.

Surgical Resection of a Malignant Liver Lesion: What the Surgeon Wants the Radiologist to Know

PURPOSE To retrospectively determine whether extrinsic warming of the low-osmolality contrast material iopamidol to 37°C prior to intravenous administration at computed tomography (CT) affects extravasation and allergic-like reaction rates. MATERIALS AND METHODS The need to obtain informed patient consent was waived for this HIPAA-compliant and institutional review board-approved analysis. All adverse events related to the intravenous administration of iopamidol during CT examinations occurring 200 days before (period 1) and 200 days after (period 2) the cessation of extrinsic contrast material warming (37°C) for intravenous injections of less than 6 mL/sec at Duke University Medical Center (Durham, NC) were retrospectively reviewed. Adverse event rates were compared by using χ2 statistics. RESULTS There were 12,682 injections during period 1 (10,831 injections of iopamidol 300 and 1851 injections of iopamidol 370) and 12,138 injections (10, 064 injections of iopamidol 300 and 2074 injections of iopamidol 370) during period 2. Adverse event rates for iopamidol 300 were not affected by extrinsic warming (extravasation rates: 0.30% [32 of 10,831] in period 1 vs 0.23% [23 of 10,064] in period 2, P=.64; allergic-like reaction rates: 0.39% [42 of 10,831] in period 1 vs 0.46% [46 of 10,064] in period 2, P=.74; overall adverse events: 0.68% [74 of 10,831] in period 1 vs 0.69% [69 of 10,064] in period 2, P=.99). Discontinuation of extrinsic warming was associated with significantly increased extravasation and overall adverse event rates for iopamidol 370 (extravasation rates: 0.27% [five of 1851] vs 0.87% [18 of 2074], P=.05; allergic-like reaction rates: 0.16% [three of 1851] vs 0.39% [eight of 2074], P=.42; overall adverse events: 0.43% [eight of 1851] vs 1.25% [26 of 2074], P=.02). CONCLUSION Extrinsic warming (to 37°C) does not appear to affect adverse event rates for intravenous injections of iopamidol 300 of less than 6 mL/sec but is associated with a significant reduction in extravasation and overall adverse event rates for the more viscous iopamidol 370.

Errors of epinephrine administration during severe allergic-like contrast reactions: lessons learned from a bi-institutional study using high-fidelity simulation testing

RATIONALE AND OBJECTIVES Our objective was to evaluate the frequency with which patients viewed their online radiology reports in relation to clinical and laboratory notes and identify sociodemographic factors associated with report viewing. METHOD AND MATERIALS We conducted a cross-sectional study of 129,419 patients who had online patient portal access in our large health system in 2014. We determined whether patients viewed their radiology reports, laboratory reports, and clinical notes. We also collected patient sociodemographic information including gender, age, primary spoken language, race/ethnicity, and insurance status. We performed multivariate analyses to determine significant associations between viewing of radiology reports and viewing of other types of clinical reports and patient characteristics. RESULTS Of 61,131 patients with at least one radiology report available, 31,308 (51.2%) viewed them. Patients who also viewed laboratory reports or clinical notes were significantly more likely to view their radiology reports (P < 0.001). Women (56.2%), patients 25-39 years old (59.5%), and English speakers (53.6%) were most likely to view radiology reports. In multivariate analysis, Asian-Americans were more likely and African-Americans were less likely to view their radiology reports compared to whites (OR = 1.07 and OR = 0.39, respectively; P < 0.001 for both). Patients with Medicaid were less likely to view radiology reports compared to patients with commercial insurance (OR = 0.38, P < 0.001). CONCLUSION More than half of patients with access to online radiology reports viewed them, with higher viewing rates associated with viewing other types of reports and lower rates associated with characteristics of traditionally underserved patient populations.

A Pregnant Patient With Hypoglycemia

OBJECTIVE Metastatic breast cancer in internal mammary (IM) lymph nodes is associated with a poor prognosis. This study correlates (18)F-FDG PET/CT-positive IM lymph nodes with ultrasound-guided fine-needle aspiration (FNA) cytopathologic results and determines risk factors for IM node positivity on PET/CT. MATERIALS AND METHODS For this retrospective study, a database search was performed to identify patients referred for whole-body (18)F-FDG PET/CT for initial staging or restaging of breast cancer from January 1, 2005, through December 31, 2010. The radiology reports and images were reviewed for patients with (18)F-FDG-avid IM lymph nodes on PET/ CT and correlated with the cytopathologic results from FNA of selected PET/CT-positive IM lymph nodes. The patients with positive IM nodes on PET/CT who underwent PET/CT for initial staging were compared against age-matched and tumor size-matched patients to identify risk factors for IM node positivity on PET/CT. RESULTS One hundred ten of 1259 patients (9%) had an (18)F-FDG-avid IM lymph node on PET/CT. Twenty-five patients underwent ultrasound-guided FNA of a suspicious IM node, and 20 IM lymph nodes (80%) were cytologically proven metastases from the primary breast malignancy. High tumor grade, the presence of lymphovascular invasion (LVI), and triple receptor-negative hormonal receptor status were found to be significant risk factors for IM node positivity on PET/CT (p < 0.05). CONCLUSION Although fewer than 10% of breast cancer patients have positive IM nodes on (18)F-FDG PET/CT performed for initial staging or restaging, a positive IM node indicates a very high likelihood of malignant involvement on ultrasound-guided FNA. The presences of high tumor grade, LVI, or triple receptor-negative status are risk factors for IM node positivity on (18)F-FDG PET/CT.