Cheryl A. Sadow

Bladder cancer detection with CT urography in an Academic Medical Center.

PURPOSE To evaluate the performance characteristics of computed tomographic (CT) urography for the detection of bladder cancer in patients at risk for the disease. MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective HIPAA-compliant review of medical records of 2600 consecutive patients undergoing CT urography. Of these, 838 CT urograms in 779 patients (449 men, mean age of 62 years, range of 27-92 years; 330 women, mean age of 56 years, range of 18-86 years) evaluated for hematuria or a history of urothelial cancer, who had undergone cystoscopy within 6 months of the CT urogram, were included in the study. Clinical reports of CT urograms containing a bladder lesion interpreted as suspicious for malignancy were classified as positive. All others were classified as negative. Cystoscopy reports were classified as positive if a lesion underwent biopsy or was resected or negative if no lesion was detected. Performance characteristics for both CT urography and cystoscopy were determined by using pathologic findings or clinical follow-up as the reference standard. Ninety-five percent confidence intervals were estimated for each test characteristic. RESULTS The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value (NPV) for bladder cancer detection were 79% (117 of 149), 94% (649 of 689), 91% (766 of 838), 75% (117 of 157), and 95% (649 of 681) for CT urography and 95% (142 of 149), 92% (634 of 689), 93% (776 of 838), 72% (142 of 197), and 99% (634 of 641) for cystoscopy. The NPV of CT urography was higher in patients evaluated for hematuria alone (98%, 589 of 603). However, the accuracy of CT urography was considerably lower in patients with a prior urothelial malignancy (78%, 123 of 158). CONCLUSION CT urography is an accurate noninvasive test for detecting bladder cancer in patients at risk for the disease. The high NPV of CT urography in patients with hematuria may obviate cystoscopy in selected patients.

Body CT Scanning in Young Adults: Examination Indications, Patient Outcomes, and Risk of Radiation-induced Cancer

PURPOSE To quantify patient outcome and predicted cancer risk from body computed tomography (CT) in young adults and identify common indications for the imaging examination. MATERIALS AND METHODS This retrospective multicenter study was HIPAA compliant and approved by the institutional review boards of three institutions, with waiver of informed consent. The Research Patient Data Registry containing patient medical and billing records of three university-affiliated hospitals in a single metropolitan area was queried for patients 18-35 years old with a social security record who underwent chest or abdominopelvic CT from 2003 to 2007. Patients were analyzed according to body part imaged and scanning frequency. Mortality status and follow-up interval were recorded. The Biologic Effects of Ionizing Radiation VII method was used to calculate expected cancer incidence and death. Examination indication was determined with associated ICD-9 diagnostic code; 95% confidence intervals for percentages were calculated, and the binomial test was used to compare the difference between percentages. RESULTS In 21 945 patients, 16 851 chest and 24 112 abdominopelvic CT scans were obtained. During the average 5.5-year (± 0.1 [standard deviation]) follow-up, 7.1% (575 of 8057) of chest CT patients and 3.9% (546 of 13 888) of abdominal CT patients had died. In comparison, the predicted risk of dying from CT-induced cancer was 0.1% (five of 8057, P < .01) and 0.1% (eight of 12 472, P < .01), respectively. The most common examination indications were cancer and trauma for chest CT and abdominal pain, trauma, and cancer for abdominopelvic CT. Among patients without a cancer diagnosis in whom only one or two scans were obtained, mortality and predicted risk of radiation-induced cancer death were 3.6% (215 of 5914) and 0.05% (three of 5914, P < .01) for chest CT and 1.9% (219 of 11 291) and 0.1% (six of 11 291, P < .01) for abdominopelvic CT. CONCLUSION Among young adults undergoing body CT, risk of death from underlying morbidity is more than an order of magnitude greater than death from long-term radiation-induced cancer.

Duodenal and other gastrointestinal toxicity in cervical and endometrial cancer treated with extended-field intensity modulated radiation therapy to paraaortic lymph nodes.

PURPOSE To characterize the rates of acute and late duodenal and other gastrointestinal (GI) toxicities among patients treated for cervical and endometrial cancers with extended-field intensity modulated radiation therapy (EF-IMRT) to the paraaortic nodes and to analyze dose-volume relationships of GI toxicities. METHODS AND MATERIALS Fifty-three patients with endometrial or cervical cancer underwent EF-IMRT to the paraaortic nodes, of whom 46 met the inclusion criteria for GI toxicity and 45 for duodenal toxicity analysis. The median prescribed dose to the paraaortic nodes was 54 Gy (range, 41.4-65 Gy). The 4 duodenal segments, whole duodenum, small bowel loops, peritoneum, and peritoneum plus retroperitoneal segments of colon were contoured retrospectively, and dosimetric analysis was performed to identify dose-volume relationships to grade ≥3 acute (<90 day) and late (≥90 day) GI toxicity. RESULTS Only 3/46 patients (6.5%) experienced acute grade ≥3 GI toxicity and 3/46 patients (6.5%) experienced late grade ≥3 GI toxicity. The median dose administered to these 6 patients was 50.4 Gy. One of 12 patients who received 63 to 65 Gy at the level of the renal hilum experienced grade 3 GI toxicity. Dosimetric analysis of patients with and without toxicity revealed no differences between the mean absolute or fractional volumes at any 5-Gy interval between 5 Gy and the maximum dose. None of the patients experienced duodenal toxicity. CONCLUSIONS Treatment of paraaortic nodes with IMRT is associated with low rates of GI toxicities and no duodenal-specific toxicity, including patients treated with concurrent chemotherapy. This technique may allow sufficient dose sparing of the bowel to enable safe dose escalation to at least 65 Gy.

Positive Predictive Value of CT Urography in the Evaluation of Upper Tract Urothelial Cancer

OBJECTIVE The purpose of this study was to determine the positive predictive value of CT urography in the diagnosis of upper tract urothelial malignancies. MATERIALS AND METHODS Retrospective review of the records of patients who underwent 2,602 CT urographic examinations revealed that 81 (3%) examinations of 77 patients had findings suggesting upper tract urothelial cancer. Two radiologists in consensus categorized the findings as large masses (> 5 mm), small masses (≤ 5 mm), or urothelial thickening. The positive predictive value of CT urography was determined with the findings at pathologic examination (n = 42), followup imaging (n = 29), or clinical follow-up alone (n = 5). One patient with insufficient follow-up information was excluded. The effects of age, sex, indication for examination, imaging appearance, and urine cytology were analyzed with the Fishers exact test or Students t test. Multivariate logistic regression analysis was used to generate a model for predicting the probability of the presence of upper tract urothelial cancer in patients with positive CT urographic examinations. RESULTS The positive predictive value of CT urography for upper tract urothelial cancer was 53% (40/76) overall, 83% (29/35) for large masses, 0% (0/17) for small masses, and 46% (11/24) for urothelial thickening. Imaging appearance, urine cytology, and age were significant univariate predictors (p < 0.05) of the presence of upper tract urothelial cancer in patients with positive CT urographic examinations. The independent variables most likely associated with upper tract urothelial cancer were urine cytology (odds ratio, 60.0; 95% CI, 5.5-653.7) and imaging appearance (odds ratio, 24.4; 95% CI, 3.0-201.9) after adjusting for age and clinical indication. CONCLUSION The positive predictive value of CT urography for upper tract urothelial cancer is moderate because benign findings mimic cancer. Positive findings on a CT urogram are more likely to indicate cancer in the setting of large masses or positive urine cytology.

Frequent Body CT Scanning of Young Adults: Indications, Outcomes, and Risk for Radiation-Induced Cancer

PURPOSE The aims of this study were to define the magnitude of frequent body CT scanning of young adults and to determine associated patient diagnoses, examination indications, short-term outcomes, and estimated radiation-induced cancer risk. METHODS Patients aged 18 to 35 years who underwent chest or abdominopelvic CT between 2003 and 2007 at any of 3 hospitals were identified and categorized by total number of scans per body part as rarely (<5), intermediately (>5 and <15), or frequently (>15) scanned. Medical records of the frequently scanned were reviewed. Cumulative radiation exposure, calculated from typical effective doses, was used to estimate cancer risk. Cancer incidence and mortality were estimated using the Biological Effects of Ionizing Radiation method. RESULTS A total of 25,104 patients underwent 45,632 scans, of whom 23,851 (95%) and 70 (0.3%) were rarely and frequently scanned, respectively. Among frequently scanned patients, the most common diagnoses were cancer (19 of 36 [52.8%]) and cystic fibrosis with lung transplantation (11 of 36 [30.5%]) for chest CT and cancer (25 of 34 [73.5%]) for abdominopelvic CT. During the mean 5.4 years (range, 0.9-7.6 years) of follow-up, 46% of frequently scanned patients (32 of 70) died. Of the 47 cancers predicted in the entire cohort, 36 (77%) and 2 (3%) were expected in the rarely and frequently scanned. CONCLUSIONS The majority of CT-induced cancers are predicted to result from sporadic rather than frequent scanning. Frequent scanning confers a significant cancer risk but occurs in severely ill patients, a large proportion of who die before any radiation-induced cancer would be a factor in their health.

PET/CT-guided percutaneous liver mass biopsies and ablations: targeting accuracy of a single 20 s breath-hold PET acquisition.

AIM To determine whether a single 20 s breath-hold positron-emission tomography (PET) acquisition obtained during combined PET/computed tomography (CT)-guided percutaneous liver biopsy or ablation procedures has the potential to target 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG)-avid liver masses as accurately as up to 180 s breath-hold PET acquisitions. MATERIALS AND METHODS This retrospective study included 10 adult patients with 13 liver masses who underwent FDG PET/CT-guided percutaneous biopsies (n = 5) or ablations (n = 5). PET was acquired as nine sequential 20 s, monitored, same-level breath-hold frames and CT was acquired in one monitored breath-hold. Twenty, 40, 60, and 180 s PET datasets were reconstructed. Two blinded readers marked tumour centres on randomized PET and CT datasets. Three-dimensional spatial localization differences between PET datasets and either 180 s PET or CT were analysed using multiple regression analyses. Statistical tests were two-sided and p < 0.05 was considered significant. RESULTS Targeting differences between 20 s PET and 180 s PET ranged from 0.7-20.3 mm (mean 5.3 ± 4.4 mm; median 4.3) and were not statistically different from 40 or 60 s PET (p = 0.74 and 0.91, respectively). Targeting differences between 20 s PET and CT ranged from 1.4-36 mm (mean 9.6 ± 7.1 mm; median 8.2 mm) and were not statistically different from 40, 60, or 180 s PET (p = 0.84, 0.77, and 0.35, respectively). CONCLUSION Single 20 s breath-hold PET acquisitions from PET/CT-guided percutaneous liver procedures have the potential to target FDG-avid liver masses with equivalent accuracy to 180 s summed, breath-hold PET acquisitions and may facilitate strategies that improve image registration and shorten procedure times.

Correlation of Point B and Lymph Node Dose in 3D-Planned High-Dose-Rate Cervical Cancer Brachytherapy

PURPOSE To compare high dose rate (HDR) point B to pelvic lymph node dose using three-dimensional-planned brachytherapy for cervical cancer. METHODS AND MATERIALS Patients with FIGO Stage IB-IIIB cervical cancer received 70 tandem HDR applications using CT-based treatment planning. The obturator, external, and internal iliac lymph nodes (LN) were contoured. Per fraction (PF) and combined fraction (CF) right (R), left (L), and bilateral (Bil) nodal doses were analyzed. Point B dose was compared with LN dose-volume histogram (DVH) parameters by paired t test and Pearson correlation coefficients. RESULTS Mean PF and CF doses to point B were R 1.40 Gy +/- 0.14 (CF: 7 Gy), L 1.43 +/- 0.15 (CF: 7.15 Gy), and Bil 1.41 +/- 0.15 (CF: 7.05 Gy). The correlation coefficients between point B and the D100, D90, D50, D2cc, D1cc, and D0.1cc LN were all less than 0.7. Only the D2cc to the obturator and the D0.1cc to the external iliac nodes were not significantly different from the point B dose. Significant differences between R and L nodal DVHs were seen, likely related to tandem deviation from irregular tumor anatomy. CONCLUSIONS With HDR brachytherapy for cervical cancer, per fraction nodal dose approximates a dose equivalent to teletherapy. Point B is a poor surrogate for dose to specific nodal groups. Three-dimensional defined nodal contours during brachytherapy provide a more accurate reflection of delivered dose and should be part of comprehensive planning of the total dose to the pelvic nodes, particularly when there is evidence of pathologic involvement.

Diagnostic yield of CT urography in the evaluation of young adults with hematuria

OBJECTIVE CT urography is increasingly used as the initial imaging test in patients with hematuria. The aim of our study was to determine the yield of CT urography in young adults with hematuria to see whether single phase unenhanced CT would have been sufficient. MATERIALS AND METHODS We reviewed medical records of consecutive patients undergoing CT urography between March 2000 and July 2009 at our tertiary medical center. Of 5400 CT urograms performed, 375 (6.9%) in 359 patients aged 40 years or younger with hematuria were included in the study. Urographic findings were tabulated according to their clinical significance. CT images were reviewed to see whether contrast-enhanced images were necessary for diagnosis. RESULTS A clinically significant source was found in 83 of 375 examinations (22.1%), including 42 of 142 (29.6%) for gross hematuria, 29 of 181 (16.0%) for microscopic hematuria, and 12 of 52 (23.1%) for hematuria of unspecified subtype. The most common clinically significant findings were renal or ureteral calculi (n = 73 [75.3%]); four malignancies were also detected. Ninety-two (94.8%) of 97 clinically significant findings were evident on unenhanced images. All significant findings that required contrast-enhanced images for diagnosis occurred in patients with predisposing medical conditions. CONCLUSION A clinically significant source of hematuria was detected in 22.1% of CT urograms of young adults. However, an unenhanced CT alone may be sufficient in patients without additional predisposing medical conditions, thereby reducing radiation dose in this radiosensitive population.

Sonographic and Magnetic Resonance Imaging Findings in Uterine Incarceration

We show the sonographic and magnetic resonance imaging features of uterine incarceration. Clinical data and imaging findings were retrospectively reviewed for 8 confirmed cases identified by sonography from 2000 to 2010. Two patients had magnetic resonance imaging. Seven of 8 patients (87.5%) presented with abdominal pain; 4 of 8 (50.0%) also had urinary symptoms. All had a retroverted uterus with an elongated an‐terosuperiorly displaced or poorly visualized cervix on sonography. Magnetic resonance imaging showed similar features, but in both cases, the placental position was misinterpreted because of severe uterine retroversion. Radiologists should be aware of this condition and its imaging features to reduce associated morbidity and mortality.

A prospective feasibility study of radiation and concurrent bevacizumab for recurrent endometrial cancer

OBJECTIVES To determine the toxicity and survival rates in a trial of concurrent bevacizumab and external beam radiation (EB) for patients with recurrent endometrial or ovarian cancer. METHODS Nineteen women with recurrent endometrial (n = 15) or ovarian (n = 4) cancer with gross disease involving the vaginal cuff, and/or pelvic nodes and/or para-aortic nodes, cancer were enrolled between 2008 and 2010. All patients received bevacizumab during radiation. Toxicity was assessed at baseline, weekly during treatment and every 3 months for at least 1 year after treatment. RESULTS All patients completed EB on schedule. For the 15 patients with recurrent endometrial cancer, the 1- and 3-year progression-free survival (PFS was) 80%/67% and overall survival (OS) was 93%/80%. Patients that had a vaginal cuff recurrence alone had a 1- and 3-year PFS of 75%/63% and OS of 100%/75%. Two patients with pelvic node involvement did not recur throughout the entire follow-up period. The 5 patients with para-aortic node involvement had a 1- and 3-year PFS of 80%/60% and OS of 80%/80%. Of the 4 ovarian cancer patients 3 relapsed with 1- and 3-year PFS of 80%/40% and OS of 100%/60%. Toxicities included thrombosis and 1 embolic event in the setting of metastatic disease. No gastrointestinal perforations were noted. CONCLUSIONS Delivering bevacizumab with concurrent radiation provides excellent local tumor control and survival for women with recurrent endometrioid endometrial cancer, particularly those with unresectable nodes. Caution must be used in those at highest risk of developing metastatic disease given the increased risk of thromboembolic events. This regimen may be considered for recurrent gynecologic malignancies in future trials.