Problems in Diagnostic Radiology

Utility of Three Week Follow Up Upper Gastrointestinal Study in Asymptomatic Patients Following Laparoscopic Sleeve Gastrectomy Publication date: Available online 14 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Joshua Knight, Arun Krishnaraj

Determining the Patient Complexity of Head CT Examinations: Implications for Proper Valuation of a Critical Imaging Service Publication date: Available online 10 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Melissa M. Chen, Joshua A. Hirsch, Ryan K. Lee, Danny R. Hughes, Gregory N. Nicola, Andrew B. Rosenkrantz Abstract Purpose The head-CT exam code was recently identified by policy makers as having a potentially overvalued RVU. A critical aspect in determining RVUs is the complexity of patients undergoing the service. This study evaluated the complexity of patients undergoing head-CT. Methods The 2017 Medicare PSPS Master File was used to identify the most common site for performing head-CT examinations. Given the most common location, the 5% Research Identifiable File, was then used to evaluate complexity of patients undergoing head CT on the same day as an ED visit based on the Evaluation & Management (E&M) “level” of these visits (1-least complex to 5-most complex patient) and the ICD-10 diagnosis coding associated with the billed head CT claims. Results 56.1% of head CT examinations were performed in the ED. 70% of non-contrast exams performed in the ED were ordered in the most complex patient encounters (level 5 E&M visits). The most common ICD-10 code for head-CT without IV contrast billed with a level 5 E&M visit was “dizziness and giddiness”, and for head-CT without and with IV contrast was “headache”. Conclusion Head-CT is not only most frequently ordered in the ED, but also during the most complex ED visits, suggesting that the ICD-10 codes associated with such exams do not appropriately reflect patient complexity. The valuation process should also consider the complexity of associated billed patient encounters, as indicated by E&M visit levels.

How Often is the Dynamic Contrast Enhanced Score Needed in PI-RADS Version 2? Publication date: Available online 10 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Albert T. Roh, Richard E. Fan, Geoffrey A. Sonn, Shreyas S. Vasanawala, Pejman Ghanouni, Andreas M. Loening Abstract Background Prostate imaging reporting and data system version 2 (PI-RADS v2) relegates dynamic contrast enhanced (DCE) imaging to a minor role. We sought to determine how often DCE is used in PI-RADS v2 scoring. Materials and Methods We retrospectively reviewed data from 388 patients who underwent prostate magnetic resonance imaging and subsequent biopsy from January 2016 through December 2017. In accordance with PI-RADS v2, DCE was deemed necessary if a peripheral-zone lesion had a diffusion-weighted imaging score of 3, or if a transition-zone lesion had a T2 score of 3 and diffusion-weighted imaging experienced technical failure. Receiver operating characteristic curve analysis assessed the accuracy of prostate-specific antigen density (PSAD) at different threshold values for differentiating lesions that would be equivocal with noncontrast technique. Accuracy of PSAD was compared to DCE using McNemar's test. Results Sixty-nine lesions in 62 patients (16%) required DCE for PI-RADS scoring. Biopsy of 10 (14%) of these lesions showed clinically significant cancer (Gleason score ≥7). In the subgroup of patients with equivocal lesions, those with clinically significant cancer had significantly higher PSADs than those with clinically insignificant lesions (means of 0.18 and 0.13 ng/mL/mL, respectively; P= 0.038). In this subgroup, there was no statistical difference in accuracy in determining clinically significant cancer between a PSAD threshold value of 0.13 and DCE (P= 0.25). Conclusions Only 16% of our patients needed DCE to generate the PI-RADS version 2 score, raising the possibility of limiting the initial screening prostate MRI to a noncontrast exam. PSAD may also be used to further decrease the need for or to replace DCE altogether.

Ensuring Appropriateness of Pediatric Second Opinion Consultations Publication date: Available online 10 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Justin Glavis-Bloom, Unikora Yang, Daniel Nahl, Fariba Goodarzian, Amit Sura ABSTRACT Purpose We sought to evaluate discrepancy rates between outside interpretations, radiology trainee preliminary reports, and subspecialist attending final interpretations for pediatric second opinion consultations on plain film and CT imaging and to evaluate the impact of a process improvement for second opinion consultations. Methods Of a total of 572 requests for second opinion consultations during a one-year preintervention period, we utilized RADPEER to score concurrence of 158 requests which occurred overnight and included outside radiologist interpretations and resident preliminary reports. In consultation with clinician committees, we developed new guidelines for requesting second opinion consultations. We evaluated the impact on the number of consultations for the one-year period following implementation of this process improvement. Results There was concurrence between the outside interpretation and pediatric subspecialist second opinion in 146 of 158 cases (92%). There was concurrence between the radiology resident and pediatric subspecialist second opinion in 145 of 158 cases (92%). During the 1-year period following our process improvement implementation, the total number of second opinion consultations decreased to 185 (from 572, a decrease of 68%) and the number of overnight requests for resident preliminary reports decreased to 11 (from 158, a decrease of 93%). Conclusions There was a high degree of concurrence between interpretations provided by outside radiologists, overnight radiology residents, and attending pediatric radiologists at our institution. Analyzing institutional-specific discrepancy rates is a valuable first step in partnering with clinicians to develop appropriate guidelines for second opinion consultations.

Dedicated Diagnostic Radiology/Radiation Oncology Rounds: Added Value Beyond Traditional Tumor Boards Publication date: Available online 9 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Kimberly G. Kallianos, Bannet N. Muhoozi, Alexander Gottschalk, Sue S. Yom, Jason W. Chan, Travis S. Henry, Brett M. Elicker, Karen G. Ordovas, David M. Naeger Abstract Objectives We aimed to evaluate the impact of collaborative discussion between diagnostic radiologists and radiation oncologists on radiation oncology management for thoracic oncology patients. Methods We reviewed cases presented at multidisciplinary thoracic tumor boards (TTB) (n=122) and diagnostic radiology/radiation oncology rounds (DR/ROR) (n=45). Changes in planned radiation management following imaging discussion were categorized - no change, timing change, and treatment volume change. Phase of care was also classified. In DR/ROR, radiation oncologists were surveyed regarding 1) change in radiation oncology management and 2) change in confidence (both 5-point Likert scales). Results Discussion of imaging with a radiologist changed radiation oncology management in 31.1% of TTB cases and 68.9% of DR/ROR cases (p<0.001). Changes to the timing of initiating radiation therapy occurred with similar frequency in the two settings (31.1% vs 46.7%, p=0.063). Changes to target volume occurred more frequently in DR/ROR, (35.6% vs <1%), p<0.001. Over half of imaging discussions in DR/ROR resulted in at least “moderate” change in radiation oncology management, and the level of confidence held by the radiation oncologists increased following discussion with radiologists in 95.6% of cases. Conclusion Collaborative discussions between radiation oncologists and diagnostic radiologists in a multi-specialty tumor board and in targeted two-specialty rounds are not redundant, but result in different management changes and at different phases of care. Our study emphasizes the importance of consultation with physicians as an area where radiologists can add value, specifically the added benefit of smaller collaborative discussions.

MDCT imaging of acute bladder pathology Publication date: Available online 9 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Dr Benjamin Hirshberg, Dr Matthew Rheinboldt Abstract In this review, we will discuss and illustrate the pathophysiology, presentation, and multidetector CT findings associated with emergent bladder conditions, limiting our discussion to traumatic, infectious, and obstructive etiologies. After reviewing CT cystographic technique, the commonly utilized classification systems for bladder trauma will be presented with illustrative examples of associated typical and more infrequent secondary injuries and complications. Next, the pathogenesis and imaging appearance of both mechanical and neurogenic acute urinary retention will be addressed, including less common though potentially pathognomonic obstructive etiologies including urethral calculi and ectopic ureteroceles. Finally, we will review and illustrate the imaging features of both inflammatory and infectious cystitis, including hemorrhagic and emphysematous variants, as well as the potentially encountered secondary complications.

Intra- and inter-subspecialty variability in lumbar spine MRI interpretation: A multi-reader study comparing musculoskeletal radiologists and neuroradiologists Publication date: Available online 9 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Nityanand Miskin, Glenn C. Gaviola, Raymond Y. Huang, Christine J. Kim, Thomas C. Lee, Kirstin M. Small, Ged G. Wieschhoff, Jacob C. Mandell Background and Purpose The purpose of this study is to assess the differences in degenerative spine MRI reporting between subspecialty-trained attending neuroradiologists and musculoskeletal radiologists at a single institution, academic medical center. Materials and Methods Fifty consecutive outpatient non-contrast lumbar spine examinations were selected from the PACS. Three musculoskeletal radiologists (MSK) and three neuroradiologists (NR) independently reviewed and interpreted the exams at the L4-L5 and L5-S1 levels in the same manner as in clinical practice. The assessment of neural foraminal stenosis (NFS) and spinal canal stenosis (SCS) was converted to a 5-point ordinal scale. The assessment of lateral recess stenosis (LRS) and facet osteoarthritis (FO) was recorded as present/absent. Inter-subspecialty and intra-subspecialty analysis was performed using Cohen's kappa coefficient with a binary matrix of all reader pairs. Results There was moderate inter-subspecialty agreement (k=0.527) for NFS and SCS (k=0.540). Inter-subspecialty agreement was slight for LRS (k=0.0818) and FO (k=0.153). The MSK group demonstrated greater intra-subspecialty agreement in assessment of NFS and SCS compared to the NR group, with non-overlapping confidence intervals. The NR group demonstrated greater nominal intra-subspecialty agreement in the assessment of both LRS and FO, although with non-overlapping confidence intervals. Conclusion There is moderate inter-subspecialty agreement between MSK radiologists and neuroradiologists in reporting the severity of NFS and SCS, although MSK radiologists demonstrated greater intra-subspecialty agreement. There is slight inter-subspecialty agreement for LRS and FO. The demonstration of differences in inter-reader agreement is a crucial first step to attempt to ameliorate these variabilities.

Lumbar Spine MRI: Missed Opportunities for Abdominal Aortic Aneurysm Detection Publication date: Available online 9 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Evan J. Zucker, Anand M. Prabhakar ABSTRACT Purpose The U.S. Preventive Services Task Force (USPSTF) recommends one-time sonographic screening for abdominal aortic aneurysms (AAAs) in male smokers ages 65-75 and other selected individuals in this age group based on risk factors. Patients in this age range are frequent utilizers of lumbar spine MRI, in which the abdominal aorta is typically fully imaged. The purpose of this study was to assess the potential detection rate of AAAs on lumbar spine MRI performed in the USPSTF screening age range with systematic aortic measurement and the frequency with which AAAs are currently reported in practice. Materials and Methods All consecutive lumbar spine MRI exams performed without contrast at a single academic tertiary care center over a one year period (4/1/2016-3/31/2017) in patients ages 65-75 were retrospectively reviewed. Maximal anteroposterior and transverse dimensions of the abdominal aorta were measured using axial T2-weighted images, supplemented with sagittal T2-weighted images if assessment was limited by field-of-view or artifact. The detection rate of AAA, defined as dilation of the aorta to a diameter of ≥3 cm, size of AAAs detected, and frequency with which AAAs were reported, were assessed. Differences in aortic diameters and aneurysm detection rates between genders were compared with the unpaired two-sample t-test. Results 395 lumbar spine MRIs were reviewed, 240 (60.8%) in women and 155 (39.2%) in men, with mean ± standard deviation (SD) age of 70.2 ± 3.2 years. AAAs were detected in 38/395 (9.6%) cases, most (33/38, 86.8%) of which were <4 cm. Of these, only 4 (10.5%) were reported by the interpreting radiologist; 3/4 (75%) corresponded to aneurysms ≥4 cm. Conclusion Lumbar spine MRI performed in the USPSTF AAA screening age range, especially in men, facilitates frequent detection of AAA when the aorta is systematically measured. However, in typical lumbar spine assessment, AAAs are often underreported, particularly for smaller aneurysms.

U.S. Health Disparities – Opportunities for Radiologists Publication date: Available online 2 May 2019 Source: Current Problems in Diagnostic Radiology Author(s): Nadja Kadom

Gastrointestinal Stromal Tumor of the Jejunum With Active Bleeding Demonstrated on Dual-Energy MDCT Angiography: A Case Report Publication date: May–June 2019 Source: Current Problems in Diagnostic Radiology, Volume 48, Issue 3 Author(s): Abdul Razik, Kumble S. Madhusudhan, Abhishek Aggarwal, Rajesh Panwar, Deep N. Srivastava Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract and may occasionally present with acute gastrointestinal bleed (GIB). Multidetector computed tomography (MDCT) angiography is extremely useful in demonstrating the tumor as well as the presence of active hemorrhage, thereby guiding subsequent interventional or surgical management. We report a case of a 38-year-old man who presented with acute-onset melena and compensated shock, whose source of bleed remained elusive on endoscopy. MDCT angiography performed on a dual-energy scanner showed a jejunal tumor with active intraluminal contrast extravasation. The tumor was subsequently resected and the patient did well on follow-up. This was one of the few instances when MDCT angiography demonstrated active bleeding in a GIST and the first such case demonstrated on a dual-energy scanner.