Shlomit Goldberg-Stein

Body CT During Pregnancy: Utilization Trends, Examination Indications, and Fetal Radiation Doses

OBJECTIVE The objective of our study was to analyze body CT utilization trends, indications, fetal radiation doses, and scanning parameters associated with high fetal radiation doses (defined as > 30 mGy). MATERIALS AND METHODS A retrospective review of all chest and abdominopelvic CT examinations performed between 1998 and 2005 of patients known to be pregnant was conducted. Demographics, gestational age, examination indication, and scan parameters were recorded. Fetal radiation dose was calculated for those abdominopelvic examinations with direct fetal irradiation. RESULTS From a database of more than 170,000 chest and more than 180,000 abdominopelvic CT examinations, 74 chest and 86 abdominopelvic examinations of pregnant patients were identified. Chest CT use increased on average 75%/y/1,000 deliveries in pregnancy versus 19%/y increase in all patients (p = 0.2700). Abdominopelvic CT utilization increase was on average 22%/y/1,000 deliveries in pregnant patients versus 13%/y increase in all patients (p = 0.1865). The most common indication for chest CT during pregnancy was suspected pulmonary embolism (85%, 63/74) and for abdominopelvic CT, suspected appendicitis (58%, 50/86). The average fetal dose from abdominopelvic CT was 24.8 mGy (range, 6.7-56 mGy); one examination exceeded the 50-mGy threshold for increased risk of childhood cancer. Scanning parameters associated with a dose of more than 30 mGy were a pitch of less than 1 (p = 0.0080) and more than one series acquisition (p = 0.0136). CONCLUSION Growth of CT during pregnancy reflects the trend of increased CT utilization in the general population. Avoiding use of CT in pregnant patients with suspected appendicitis would significantly decrease fetal radiation exposure. Abdominopelvic CT during pregnancy should be carefully planned and monitored so as not to exceed the fetal radiation dose for negligible risk.

Radiation dose management: part 2, estimating fetal radiation risk from CT during pregnancy.

OBJECTIVE The purpose of this article is to review fetal radiation doses and associated risks resulting from CT performed during pregnancy. The scanning parameters that influence dose and the techniques for estimating and reducing dose are explained. CONCLUSION Fetal radiation doses for CT examinations in which the fetus is not directly imaged-for example, head or chest CT-are minimal and need not figure in the risk-benefit analysis to perform the examination. In contrast, radiation dose should be considered with abdominopelvic CT because the fetus is likely to be exposed directly to the scanning beam. Safe implementation of CT in this setting requires an understanding of the factors influencing radiation dose. With this knowledge, when a risk-benefit analysis in a given clinical situation favors imaging using CT, the radiologist need not withhold or delay the examination and can achieve diagnostic-quality images while reducing radiation exposure.

Extranodal Rosai-Dorfman Disease: Clinicopathologic Series of 10 Patients With Radiologic Correlation and Review of the Literature.

OBJECTIVES To describe the radiologic and clinicopathologic features of extranodal Rosai-Dorfman disease (RDD) in our patient population. METHODS Via a data mining engine, we evaluated 13 cases of extranodal RDD in 10 patients treated at our institution from 2000 to 2014. RESULTS There was a marked female predominance (90%) in our series. The most common clinical presentation was a palpable, painless mass, which often simulated a neoplasm. Only two cases occurred in children. Multicentric and recurrent disease were uncommon. Histologically, all cases showed large histiocytes with emperipolesis in a mixed inflammatory background, with areas of dense, storiform collagen fibrosis. Positive S-100 and CD68 with negative CD1a in histiocytes are characteristic. CONCLUSIONS Extranodal RDD is rare and its manifestations varied. It may constitute a clinical and pathologic diagnostic challenge. Clinical suspicion and recognition of its histologic features are necessary for correct diagnosis and avoiding unnecessary treatment. Resection is curative in most cases.

Implementing a Structured Reporting Initiative Using a Collaborative Multistep Approach

PURPOSE To describe the successful implementation of a structured reporting initiative in a large urban academic radiology department. METHODS We describe our process, compromises, and top 10 lessons learned in overhauling traditional reporting practices and comprehensively implementing structured reporting at our institution. To achieve our goals, we took deliberate steps toward consensus building, undertook multistep template refinement, and achieved close collaboration with the technical staff, department coders, and hospital information technologists. Following institutional review board exemption, we audited radiologist compliance by evaluating 100 consecutive cases of 12 common examination types. Fisher exact test was applied to determine significance of association between trainee initial report drafting and template compliance. RESULTS We produced and implemented structured reporting templates for 95% of all departmental computed tomography, magnetic resonance, and ultrasound examinations. Structured templates include specialized reports adhering to the American College of Radiologys Reporting and Data Systems (ACRs RADS) recommendations (eg, Lung-RADS and Li-RADS). We attained 94% radiologist compliance within 2 years, without any financial incentives. CONCLUSIONS We provide a blueprint of how to successfully achieve structured reporting using a collaborative multistep approach.

Implementing a Software Solution across Multiple Ultrasound Vendors to Auto-fill Reports with Measurement Values

Reliable transmission of ultrasound measurements into radiology reports is fraught with potential sources of error. In a conventional workflow, measurements are either written by hand on worksheets and/or dictated from worksheets or the images themselves into the radiology report. Valuable physician time is spent dictating, checking, and editing these values and this process is error-prone. Our approach was to use a transfer-software application to auto-populate measurements, with a goal of achieving >90% utilization rate by both technologists and radiologists. Implementation involved creating measurement fields for each measurement on each ultrasound unit of our multisite academic department. These fields were then mapped in both the transfer-software and the dictation software, to set up a 1:1:1 correspondence for each field. As a result, each measurement acquired by the technologist would automatically populate the radiology report within the dictation software. We created and mapped 128 fields for 39 exam templates. After implementation, technologist utilization rate was 86%-96% and overall radiologist utilization rate was 92%-93%. Radiology resident utilization rate was highest, at 95%-96%. We provide a guide for implementation and lessons learned.

Responses to letters to the editor for “Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes”

Dear Editor, We read with interest the recent Letter to the Editor [1] by Messina and colleagues in which our paper entitled BFluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of shortterm patient outcomes^ [2] was criticized for the use of ionizing radiation in these procedures, concluding Bthe musculoskeletal community should increase the awareness of ionizing radiation risks and try implementing the use of ultrasound in place of fluoroscopy to perform these procedures.^ It may interest our readers to know that we have made operational changes in our environment since writing our manuscript, and we have indeed shifted our practice exclusively to sonographically guided retrocalcaneal bursa injections. Our group has performed >60 retrocalcaneal bursa injections under US guidance over the last 12 months, with great success and no known complications. However, we still firmly believe that in certain clinical environments the fluoroscopically guided technique is useful to know and should be applied when required to provide timely patient care. We share the sentiments of Ouellette and Munk [3] who in the same recent issue of Skeletal Radiology noted that, BIn a perfect world, all musculoskeletal injections that could be effectively done under ultrasound guidance would be done under sonography rather than fluoroscopy because of the lack of ionizing radiation. But the world we live in is not perfect.^ Ouellette goes on to explain that reasonable efforts are required to maintain exposures to ionizing radiation as far below the dose limits as practical. These limits of reason and practicality are recognized in both the wording of the ALARA principle itself and the wording of the directive of the European Atomic Agency [4, 5]. The exceedingly low dose to the appendicular skeleton using our described fluoroscopic approach may be a wise choice for some practitioners from a Bpopulation perspective^ in certain clinical environments. To quote Ouellette again, BDoing all cases under ultrasound is a nice idea in the world of utopia, but in reality this approach my lead to patients suffering on a waiting list^ [3]. We could not agree more. In our current practice, our previous resource limitations are no longer an issue, and patients are scheduled for sonographically guided retrocalcaneal bursa injection within 5–7 days of the order being placed. Of note, we do still make use of our fluoroscopic technique on occasion. Last month we shifted a patient from ultrasound to fluoroscopic guidance because of extensive, thick enthesopathy causing severe shadowing and obscuration of the target retrocalcaneal bursa. As Lopez-Ben and Coumans [6] point out in their letter to the editor regarding our recent article [2], our group has also recently published a survey of post-graduate musculoskeletal ultrasound education demonstrating that only 65% of radiology programs responding to the survey offered dedicated musculoskeletal ultrasound training [7]. In our shift from fluoroscopic guidance to sonographic guidance, not only for retrocalcaneal bursa injections, but also * Shlomit Goldberg-Stein sgoldberg@montefiore.org

FDG PET-CT of Genitourinary and Gynecologic Tumors: Overcoming the Challenges of Evaluating the Abdomen and Pelvis

Introduction 2-Deoxy-2-[ F]-fluoro-D-glucose positron emission tomography (FDG PET) performed concurrently with computed tomography (CT) is central to the care of patients with advanced solid cancers. The combined FDG PET-CT examination (PET-CT) serves to provide comprehensive evaluation of tumor extent in primary treatment planning and plays an important role in accurately detecting recurrent disease during follow-up. Patients with genitourinary and gynecologic malignancies pose a unique challenge in PETCT imaging as most tumor burden, especially at initial presentation, involves the abdomen and pelvis. In this body region, physiological background tracer patterns and imaging artifacts confound interpretation. This article summarizes the performance of PET-CT on patients with genitourinary and gynecologic cancers. We discuss examination performance and image interpretation, highlighting points particularly relevant to abdominopelvic evaluation. Variations in patterns of normal physiological tracer distribution are described. Case examples illustrate potential sources for false-positive and false-negative diagnoses, and techniques for avoiding them.