Vinay Duddalwar

Unsuspected Pulmonary Emboli in Cancer Patients: Clinical Correlates and Relevance

PURPOSE Advances in computed tomography (CT) scanning have led to the detection of unsuspected pulmonary emboli (PE) on routine cancer staging scans. We hypothesized that these patients had signs or symptoms suggestive of PE that may have been overlooked by their health care providers. PATIENTS AND METHODS A retrospective chart review was performed on 59 patients found on routine cancer staging CT scans to have unsuspected PE. Information on patient demographics, malignancy characteristics, risk factors for venous thromboembolism (VTE), and symptoms was recorded. A retrospective case-control analysis was then performed using two age- and stage-matched control patients for each patient who had similar staging CT scans performed during the same period. RESULTS Fifty-two patients with unsuspected PE were identified. Forty-four percent had signs or symptoms commonly associated with PE; when fatigue was included, 75% were symptomatic. Ninety-two control patients were identified for 46 of the case patients. Patients with unsuspected PE were significantly more likely to have had a prior history of VTE (20% v 3%; P = .007). The patients with PE were significantly more likely than control patients to complain of fatigue (54% v 20%; P = .0002) and shortness of breath (22% v 8%; P = .02). There was no difference between the groups in administration of chemotherapy within 30 days, central venous catheter use, or erythropoietin therapy. CONCLUSION Seventy-five percent of patients found to have unsuspected PE on cancer staging CT scans were symptomatic. Fatigue and shortness of breath were significantly more common in patients with unsuspected PE than in control patients.

Outcomes after placement of colorectal stents

Background  Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator.

CT appearances of abdominal tuberculosis

The purpose of this article is to review and illustrate the spectrum of computed tomography (CT) appearances of abdominal tuberculosis. Tuberculosis can affect any organ or tissue in the abdomen, and can be mistaken for other inflammatory or neoplastic conditions. The most common sites of tuberculosis in the abdomen include lymph nodes, genitourinary tract, peritoneal cavity and gastrointestinal tract. The liver, spleen, biliary tract, pancreas and adrenals are rarely affected, but are more likely in HIV-seropositive patients and in miliary tuberculosis. This article should alert the radiologist to consider abdominal tuberculosis in the correct clinical setting to ensure timely diagnosis and enable appropriate treatment.

Abdominal Manifestations of Extranodal Lymphoma: Spectrum of Imaging Findings

OBJECTIVE The purpose of this article is to illustrate the spectrum of appearances of extranodal lymphoma in the abdomen using cross-sectional imaging techniques. CONCLUSION Extranodal lymphoma in the abdomen can mimic other neoplastic or inflammatory conditions. Although a definitive diagnosis is possible only with biopsy, it is important to consider extranodal lymphoma in the presence of certain imaging appearances in the appropriate clinical setting for the correct diagnosis, accurate staging, and optimal management.

Renal Tumor Contact Surface Area: A Novel Parameter for Predicting Complexity and Outcomes of Partial Nephrectomy

BACKGROUND The contact surface area (CSA) of a tumor with adjacent renal parenchyma may determine the complexity and thus the perioperative outcomes of partial nephrectomy (PN). OBJECTIVE We devised a novel imaging parameter, renal tumor CSA, and correlate it with perioperative outcomes in patients undergoing PN. DESIGN, SETTING, AND PARTICIPANTS Of 200 patients undergoing PN for a tumor (January 2010 to August 2011), 162 had renal protocol computed tomography scanning data available. CSA was calculated using image-rendering software (Synapse 3D, Fujifilm), and interobserver variability was determined between three independent observers. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS CSA was correlated to baseline demographics and perioperative outcomes as a continuous and categorical variable using multivariable logistic regression analysis. The ability of CSA to predict adverse perioperative events was compared with demographic factors and nephrometry scoring systems. RESULTS AND LIMITATIONS The mean tumor size was 3.1cm; CSA was 18.3 cm(2). CSA ≥20 cm(2) correlated with adverse tumor characteristics (greater tumor size, volume, and complexity) and perioperative outcomes (more parenchymal volume loss, blood loss, and complications) compared with CSA <20 cm(2). On multivariable logistic regression, CSA independently predicted operative time, complications, hospital stay, and renal functional outcomes. This predictive ability of CSA was superior to the other parameters evaluated. CONCLUSIONS CSA is a novel imaging parameter that quantifies the CSA of renal tumor with adjacent parenchyma. Our preliminary data indicate that CSA correlates with PN outcomes. If validated externally in a larger cohort, CSA could be incorporated into future versions of nephrometry scoring systems. PATIENT SUMMARY In this study we outline the method of calculating the contact surface area (CSA) of renal tumors with the surrounding normal kidney using image-rendering software. We found that CSA correlates with a number of important surgical outcomes including operative time, loss of renal function, and complications.

Contrast-Enhanced Ultrasound of the Liver and Kidney

The clinical use of noncardiac contrast-enhanced ultrasound scan (CEUS) has been steadily gaining momentum. CEUS is a reliable and safe technique with a diverse array of applications. This article reviews the current and potential future clinical applications of CEUS. Emphasis will be placed on evaluating focal lesions with the liver and kidney. Contrast agent composition and mechanism are also briefly reviewed.

Imaging Assessment of Congenital and Acquired Abnormalities of the Portal Venous System

Abnormalities of the portal venous system are a heterogeneous group of conditions that can cause substantial morbidity and mortality and may lead to complications during surgery or percutaneous interventions involving the portal venous system. High-resolution computed tomography, ultrasonography, and magnetic resonance imaging permit a comprehensive, noninvasive evaluation of the portal venous system, enabling the detection of both structural and functional abnormalities. However, an understanding of the embryologic development of the normal portal venous anatomy and anatomic variants is essential to accurately interpret the imaging findings. Knowledge of the characteristic appearances of abnormalities of the portal venous system allows a more confident diagnosis, permitting timely treatment and more informed guidance of surgical procedures and percutaneous interventions, which may lead to an improved outcome.

What the radiologist needs to know about urolithiasis: part 1--pathogenesis, types, assessment, and variant anatomy.

OBJECTIVE This article reviews types of urinary calculi and their imaging appearances, presents direct and secondary imaging findings of urolithiasis, and provides an overview of treatment methods. Pertinent imaging findings that impact clinical management are highlighted. The implications of complex or variant genitourinary anatomy are reviewed. We outline a standard format for the reporting of urolithiasis to facilitate informed clinical management decisions. CONCLUSION Unenhanced CT is the preferred examination for evaluation of urolithiasis because of its availability, ease of performance, and high sensitivity. An awareness of the important imaging findings to report allows appropriate and efficient therapy.

Identifying aggressive prostate cancer foci using a DNA methylation classifier

BackgroundSlow-growing prostate cancer (PC) can be aggressive in a subset of cases. Therefore, prognostic tools to guide clinical decision-making and avoid overtreatment of indolent PC and undertreatment of aggressive disease are urgently needed. PC has a propensity to be multifocal with several different cancerous foci per gland.ResultsHere, we have taken advantage of the multifocal propensity of PC and categorized aggressiveness of individual PC foci based on DNA methylation patterns in primary PC foci and matched lymph node metastases. In a set of 14 patients, we demonstrate that over half of the cases have multiple epigenetically distinct subclones and determine the primary subclone from which the metastatic lesion(s) originated. Furthermore, we develop an aggressiveness classifier consisting of 25 DNA methylation probes to determine aggressive and non-aggressive subclones. Upon validation of the classifier in an independent cohort, the predicted aggressive tumors are significantly associated with the presence of lymph node metastases and invasive tumor stages.ConclusionsOverall, this study provides molecular-based support for determining PC aggressiveness with the potential to impact clinical decision-making, such as targeted biopsy approaches for early diagnosis and active surveillance, in addition to focal therapy.

Contrast-enhanced ultrasound (CEUS) of cystic and solid renal lesions: a review

Incidentally detected renal lesions have traditionally undergone imaging characterization by contrast-enhanced computer tomography (CECT) or magnetic resonance imaging. Contrast-enhanced ultrasound (CEUS) of renal lesions is a relatively novel, but increasingly utilized, diagnostic modality. CEUS has advantages over CECT and MRI including unmatched temporal resolution due to continuous real-time imaging, lack of nephrotoxicity, and potential cost savings. CEUS has been most thoroughly evaluated in workup of complex cystic renal lesions, where it has been proposed as a replacement for CECT. Using CEUS to differentiate benign from malignant solid renal lesions has also been studied, but has proven difficult due to overlapping imaging features. Monitoring minimally invasive treatments of renal masses is an emerging application of CEUS. An additional promising area is quantitative analysis of renal masses using CEUS. This review discusses the scientific literature on renal CEUS, with an emphasis on imaging features differentiating various cystic and solid renal lesions.