A recent study was conducted to assess the effect of weight-based automatic tube current modulation in children with congenital thoracic cardiovascular disease using conventional angiography, sonography, or surgery as reference standards.

The findings show that automatic tube current modulation combined with low tube voltage settings markedly reduces radiation exposure without significant reduction in image quality.

The Study
68 patients referred to the pediatric radiology department for known or suspected cardiovascular abnormalities over a 2-year period were identified.

Methodology

Overall, 38 patients underwent 64-MDCT and 30 underwent 16-MDCT.

Patients were divided into 3 groups based on tube voltages used corresponding to 80, 100, and 120 kVp. A normality distribution test was used based on age, height, and body weight.

Of those who underwent surgery, postoperative scanning was identified.

Tube voltage was individually adjusted to patient weight.

For those undergoing 64-MDCT, commercially available tube current modulation software was used which obtains monitoring of tissue attenuation and results in real-time adjustment of the base tube current.

Image evaluation was performed on a 3D-enabled workstation. Each data set was assessed for image noise and graded for quality.

To assess diagnostic quality, 2 readers were asked to independently assess the display of relevant vascular structures and to identify cardiovascular defects.

Image quality was graded using multiple previously published criteria, and structures were assessed on a 5-point scale, with 1 corresponding to qualitative unacceptability and 5 to excellent diagnostic quality.

All defects that had been documented on MDCT were correlated to cardiac sonography, conventional angiography, or surgery.

Radiation dose was calculated using CT dose calculation software with variables such as CT dose index (CTDI), dose-length product (DLP), and effective radiation dose equivalent being reported.

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Results
Compared with scanning without automated tube current modulation, the tube current-time product was statistically significantly reduced by 57.8%. CTDI was reduced by 56.3% and DLP by 54.9%. The radiation dose equivalent was reduced by 60.3%.

In comparison with 16-MDCT, 64-MDCT with tube current modulation resulted in a significant reduction in all these variables as well.

Image quality scores and image noise levels were comparable for both CT scanning techniques.

All cardiovascular defects documented on MDCT scans were correlated at cardiac sonography with agreement calculated to be 94.9% and 91.5% for the 2 reviewers.

Using catheter angiography and surgery, agreement was 100%.

Conclusions
Automated tube current modulation combined with low tube voltage resulted in significantly decreased radiation dose while maintaining image quality and diagnostic accuracy.

Reviewer’s Comments
When presented with data from studies such as this, it is surprising that the standard of practice has been to wantonly expose children to unnecessary ionizing radiation without establishing a threshold where study quality would not suffer.

For the time being, the data from a significant cohort such as this should be put into practice at any institution with the same scanning equipment.

Author: Basil Hubbi, MD

Reference:
Herzog C, Mulvihill DM, et al. Pediatric Cardiovascular CT Angiography: Radiation Dose Reduction Using Automatic Anatomic Tube Current Modulation. AJR; 2008; 190 (May): 1232-1240

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A recent study was conducted to evaluate the diagnostic characteristics of sonographic surveillance for detection of metachronous contralateral breast cancer in patients with a history of breast cancer surgery, in order to determine whether sonography in addition to mammography might be justified in terms of time and cost.

The results, published in the American Journal of Roentgenology indicate that while annual screening sonography in addition to mammograhy may be useful for the discovery of metachronous contralateral cancers, the time and cost involved may not be justified.

The Study
Over a 1-year retrospective period, patients who had undergone surgery for biopsy-proven breast malignancy were identified.

Those who had sonographic evaluation in addition to mammographic evaluation were included in the study. Patients had undergone bilateral whole breast sonography in addition to mammography every 6 months for the first 2 years and then annually thereafter. Exclusion criteria included a history of bilateral breast cancer surgery.

Methodology
1256 Asian women (mean age, 50 years) were included in the study. Over the follow-up period, the contralateral breast was classified as a BI-RADS 1 or 2 93.6% of the time. A BI-RADS 3 category was assigned to 3.8%, category 4 to 2.3%, and category 5 to 0.3%.

One radiologist reviewed the reports of the imaging studies and documented the BI-RADS category. The images were not reread.

Those classified as BI-RADS 1 or 2 were considered negative. BI-RADS categorization of 3, 4, or 5 were only included if they were referring to the breast contralateral to the surgical breast.

In other words, the originally reported BI-RADS was re-categorized to assess only the contralateral breast. The final diagnosis of each patient was determined based on tissue diagnosis at a follow-up time of ≥1 year.
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Results
Overall, 46 biopsies were performed. When tissue diagnosis was compared with BI-RADS category, the positive-predictive value (PPV) was 41.0%.

One cancer was missed, resulting in a false-negative rate of 0.06%.Of patients who continued sonographic adjuvant surveillance for >2 years, a 0.4% false-negative rate was revealed.

Two cases of biopsy-proven contralateral metachronous breast cancer were found on sonography and not detected on mammography.

Annual screening sonography may be useful for the discovery of metachronous contralateral cancers.

Reviewer’s Comments
The authors do not comment extensively on the finding that only 2 cancers discovered on sonography were also mammographically occult. For the remaining cases of metachronous cancer, the mammogram was judged to be positive as well.

Although a significant tool for those 2 cases, does it truly justify the time and cost of performing sonographic surveillance in addition to mammographic surveillance in a patient with otherwise no complaints?

On the other hand, those with a history of breast cancer, or any symptoms, might certainly consider having both sonography and mammography to rule out any chance of a false negative.

Author: Basil Hubbi, MD
Reference:
Kim MJ, Kim E-K, et al. Sonographic Surveillance for the Detection of Contralateral Metachronous Breast Cancer in an Asian Population. AJR; 2009; 192 (January): 221-228.

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Diagnosing Necrotizing Enterocolitis in Newborns and Infants

A recent study was conducted to evaluate intraobserver and interobserver agreement when using a 10-point scale of abnormal findings designed to standardize reporting of abdominal radiographs in neonates or infants with suspected necrotizing enterocolitis (NEC).

The study, published in AJR, demonstrates that substantial inter- and intraobserver agreement can be found when radiologists use a 10-point scale to report abnormal findings in children with suspected NEC.

The Study
All patients who underwent anteroposterior and cross-table lateral abdominal radiography for suspected necrotizing enterocolitis over a 1-year period were identified.

Inclusion criteria consisted of age <=2 months at the time of study, frontal and cross-table lateral views obtained, and clinically suspected NEC.

Subjects were selected as sample cases to exemplify the separate classifications of findings as determined on a 10-point scale (the Duke Abdominal Assessment Scale).

The scale was designed so that increasing numbers reflected increasing certainty that a patient had NEC and increasing concern regarding the severity of the patient’s disease, with 0 indicating a normal exam and 10 indicating pneumoperitoneum.

Eighty-eight cases from 49 patients were included in the study for review.

Methodology
The radiographs were reviewed as well as the most recent prior abdominal radiograph by 4 pediatric radiologists who were recruited as study participants. Each participant recorded a single score using the 10-point scale.

Each participant reviewed the cases in the same sequence. The studies were interpreted twice by all participants at least 4 weeks apart to evaluate for intraobserver agreement. Data analysis was performed by a statistician.

Results
The patient mean age in the total study population was 24.9 days. Overall, 47.3% were girls and 52.7% were boys. The 4-weighted kappa values for intraobserver agreement ranged from 0.635 to 0.946 corresponding to substantial intraobserver agreement.

The 24-weighted kappa values for interobserver agreement ranged from 0.574 to 0.898, also corresponding to substantial interobserver agreement. Reader agreement was greatest for a score of 9 and 10, indicating portal venous gas and pneumoperitoneum, respectively.

Agreement was poorest for scores of 4 and 6, indicating separation or focal thickening of bowel loops and possible pneumatosis with other abnormal findings, respectively.

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Conclusions
The investigation served to initiate validation of the Duke Abdominal Assessment Scale by demonstrating consistent substantial intraobserver and interobserver agreement when evaluating radiographs for suspected necrotizing enterocolitis.

Reviewer’s Comments
Although the authors allude to this also, this reviewer feels that this article lacks the correlation with the scoring system to clinical outcomes or change in management that may result depending on the scoring assigned.

They refer to the greatest inter- and intraobserver agreement with portal venous gas and pneumoperitoneum, both signs that often indicate impending surgical treatment.

However, this reviewer wonders how the scale can be helpful when the scoring falls somewhere between 2 and 6.

Thankfully for us, the authors recognize that this is only early data, and follow-up studies will be conducted

Author: Basil Hubbi, MD
Reference:
Coursey CA, Hollingsworth CL, et al. Radiologists’ Agreement When Using a 10-Point Scale to Report Abdominal Radiographic Findings of Necrotizing Enterocolitis in Neonates and Infants. AJR; 2008; 191 (July): 190-197

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A recent study was conducted to assess the mammographic appearance of breast cancer exhibiting a basal phenotype, and to determine whether these features facilitate earlier detection of these tumors, which tend to have a poor prognosis.

Methodology
Over a 12-year period, invasive breast cancers that were recorded in women <=70 years of age were identified.

Those cancers identified on pathology to be of the basal phenotype were noted.

Of those, mammographic features were recorded, including qualification of a mass as well-defined, ill-defined, or spiculated.

Also, architectural distortion, focal asymmetry, or microcalcifications were identified.

If >1 finding was present, the nondominant characteristics were also included in the descriptions.

Five experienced breast imagers, who were blinded to the pathology results, recorded the mammographic features.

The data sets were combined to identify cases where mammographic appearance at screening detection was recorded, and the breast tumor was classified as having basal or nonbasal phenotype.

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Results
356 screening-detected cases of invasive breast cancer with basal phenotype were identified, and 309 had the nonbasal phenotype.

For both types, the dominant mammographic feature was a mass with either ill-defined or spiculated margins.

Basal-phenotype tumors were significantly more likely to appear as ill-defined masses on mammograms.

Nonbasal-phenotype tumors were significantly more likely than basal tumors to exhibit marginal spiculation.

Comedo calcification was seen more frequently with basal tumors as well.

When tumor grade was taken into account, these findings persist, showing that differences in mammographic appearance are not simply due to tumor grade.

Conclusions
In the assessment of characteristics of basal-phenotype breast tumors, these tumors are less likely to have spiculation, more likely to manifest as an ill-defined mass, and more likely to be found in association with comedo calcification.

Breast tumors with basal phenotype have a different mammographic appearance than nonbasal tumors and may explain the good prognostic value of mammographic spiculation.

Reviewer’s Comments
This article is interesting in that it acts to correlate mammographic findings with actual histology, with the idea that basal-phenotype tumors are more aggressive. How will this affect everyday practice?

Regardless of mammographic findings suggesting more aggressive tumors, the lesions will still be subjected to the same algorithm of imaging workup, followed by biopsy, and ultimately surgery and/or neoadjuvant therapy as per true findings at pathology.

Author: Basil Hubbi, MD

Reference:
Luck AA, Evans AJ, et al. Breast Carcinoma With Basal Phenotype: Mammographic Findings. AJR; 2008; 191 (August): 346-351

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A recent study which was conducted to assess whether transperineal sonography is valid and accurate in discriminating different types of imperforate anus in neonates has proved useful in introducing a simple value for separating the high and intermediate type of imperforate anus from the low type, and in diagnosing imperforate anus more accurately.

The Study
Over a 10-year period, infants were examined with transperineal ultrasound after clinically being diagnosed with imperforate anus.

Methodology
On ultrasound, the distal rectal pouch was identified and its distance to the perineum was recorded.

Thereafter, the distance and the type of imperforate anus were confirmed on the basis of surgical findings.

The type of imperforate anus is classified as high, intermediate, or low, depending on the relation of the distal rectum to the puborectalis sling of the levator ani muscle.

High type is defined as a rectum that terminates above the level of the puborectalis.

Intermediate type terminates within the puborectalis.

Low type passes through the levator ani muscle group and through the central puborectalis, terminating below the sling.

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Results
54 patients were included in the study. A final diagnosis of imperforate anus was made for 22 patients.

The mean distance between the distal rectal pouch and the perineum in this group was 10.4 mm. For intermediate imperforate anus, 17 patients were identified. They had a mean pouch-to-perineum distance of 23.6 mm.

For the patients identified as a high imperforate anus, of which there were 17 patients, the mean pouch-to-perineum distance was 25.5 mm.

Conclusions
As can be seen from the results, there was considerable overlap for the pouch-to-perineum distance for those patients diagnosed with intermediate or high imperforate anus. After thorough statistical analysis, the cutoff value for the distance from the distal rectal pouch to the perineum was determined to be 15 mm. This cutoff value yielded a sensitivity estimated to be 100% and a specificity of 86% when diagnosing low imperforate anus. This cutoff value correctly diagnosed 19 of the 22 infants with low imperforate anus, with the remaining 3 infants diagnosed on the findings of anocutaneous fistula. All 34 cases of intermediate or high imperforate anus were correctly classified at sonographic examination using this cutoff value, with no reliable value for separating those diagnosed with high imperforate anus from those with indeterminate type.

Reviewer’s Comments
The study introduces a simple value for separating the high and intermediate type of imperforate anus from the low type.

The authors only briefly touch on the importance of taking into account the presence and type of fistula on clinical grounds, which also aids in diagnosis.

This proved valuable with the 3 infants diagnosed with low imperforate anus based on an anocutaneous fistula–something to keep in mind when putting this data into practice.

Author: Basil Hubbi, MD).

Reference:

Haber, Hans P., Seitz, Guido, et al. Transperineal Sonography for Determination of the Type of Imperforate Anus. AJR 2007; 189:1525-1529

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A recent study was conducted to evaluate intraobserver and interobserver agreement when using a 10-point scale of abnormal findings designed to standardize reporting of abdominal radiographs in neonates or infants with suspected necrotizing enterocolitis (NEC).

The study, published in AJR, demonstrates that substantial inter- and intraobserver agreement can be found when radiologists use a 10-point scale to report abnormal findings in children with suspected NEC.

The Study
All patients who underwent anteroposterior and cross-table lateral abdominal radiography for suspected necrotizing enterocolitis over a 1-year period were identified.

Inclusion criteria consisted of age <=2 months at the time of study, frontal and cross-table lateral views obtained, and clinically suspected NEC.

Subjects were selected as sample cases to exemplify the separate classifications of findings as determined on a 10-point scale (the Duke Abdominal Assessment Scale).

The scale was designed so that increasing numbers reflected increasing certainty that a patient had NEC and increasing concern regarding the severity of the patient’s disease, with 0 indicating a normal exam and 10 indicating pneumoperitoneum.

Eighty-eight cases from 49 patients were included in the study for review.

Methodology
The radiographs were reviewed as well as the most recent prior abdominal radiograph by 4 pediatric radiologists who were recruited as study participants. Each participant recorded a single score using the 10-point scale.

Each participant reviewed the cases in the same sequence. The studies were interpreted twice by all participants at least 4 weeks apart to evaluate for intraobserver agreement. Data analysis was performed by a statistician.

Results
The patient mean age in the total study population was 24.9 days. Overall, 47.3% were girls and 52.7% were boys. The 4-weighted kappa values for intraobserver agreement ranged from 0.635 to 0.946 corresponding to substantial intraobserver agreement.

The 24-weighted kappa values for interobserver agreement ranged from 0.574 to 0.898, also corresponding to substantial interobserver agreement. Reader agreement was greatest for a score of 9 and 10, indicating portal venous gas and pneumoperitoneum, respectively.

Agreement was poorest for scores of 4 and 6, indicating separation or focal thickening of bowel loops and possible pneumatosis with other abnormal findings, respectively.

[text_ad]

Conclusions
The investigation served to initiate validation of the Duke Abdominal Assessment Scale by demonstrating consistent substantial intraobserver and interobserver agreement when evaluating radiographs for suspected necrotizing enterocolitis.

Reviewer’s Comments
Although the authors allude to this also, this reviewer feels that this article lacks the correlation with the scoring system to clinical outcomes or change in management that may result depending on the scoring assigned.

They refer to the greatest inter- and intraobserver agreement with portal venous gas and pneumoperitoneum, both signs that often indicate impending surgical treatment.

However, this reviewer wonders how the scale can be helpful when the scoring falls somewhere between 2 and 6.

Thankfully for us, the authors recognize that this is only early data, and follow-up studies will be conducted

Author: Basil Hubbi, MD
Reference:
Coursey CA, Hollingsworth CL, et al. Radiologists’ Agreement When Using a 10-Point Scale to Report Abdominal Radiographic Findings of Necrotizing Enterocolitis in Neonates and Infants. AJR; 2008; 191 (July): 190-197

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Every professional caregiver has dedicated themselves to a lifetime of learning.

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This invaluable Special Report, Pancreatic Imaging: Current Techniques tells you what you need to know about Magnetic resonance cholangiopancreatography (MRCP) and Endoscopic Retrograde Cholangiopancreatography (ERCP), and how they compare as diagnostic tools.

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• Magnetic resonance cholangiopancreatography (MRCP), what it is and how it works;
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• How MRCP compares with Endoscopic Retrograde Cholangiopancreatography (ERCP) in terms of procedure;
• The pros and cons of MRCP compared with ERCP;
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• How MRCP compares with ERCP in terms of safety;
• How MRCP compares with ERCP in terms of imaging quality;
• How MRCP compared with ERCP in terms of visualization;
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And more….

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P.S. As any diagnostician knows, experience is key in detecting disease. So is keeping up to date with the latest technologies, techniques, and procedures, in the hopes of gaining the best patient outcomes.

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Radiology Daily was launched to help you stay on top of your CME requirements, bringing you the latest news on Emergency Radiology. This is news you can use in your practice to stay on the cutting edge, or even ahead of the curve.

Radiology Daily, from Oakstone Medical Publishing, which produces the landmark Practical Reviews in Radiology, brings you the latest news in the world of radiology from over 40 journals around the globe. These peer-reviewed article abstracts are essential reading for anyone in the field of radiology who wants to keep current with the latest research and findings, and meet their CME requirements at the same time.

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In this invaluable Special Report, Imaging of Acute Stroke: Early Detection Is Key, you will learn about:

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• signs of a hemorraghic infarct;
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• which imaging studies show stroke within the first 24 hours to seven days;
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• contrast enhancement and what it means;
• other things to look for around the MCA sign;
• the significance of the gyriform pattern;
• CT versus MRI in an acute stroke setting;
• stroke imaging controveries to be aware of;
• dealing with artifacts;
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If you’re a practising radiologist, radiology resident or internist, you know how crucial safe and accurate gastrointestinal imaging is.

So, what’s a busy radiologist to do?

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Radiology Daily was launched to help you stay on top of your CME requirements, bringing you the latest news on gastrointestinal imaging. This is news you can use in your practice to stay on the cutting edge, or even ahead of the curve professionally.

Radiology Daily, from Oakstone Medical Publishing, which produces the landmark Practical Reviews in Radiology, brings you the latest news in the world of radiology from over 40 journals around the globe.

The peer-reviewed article abstracts in Practical Reviews in Radiology are essential reading for anyone in the field of radiology who wants to keep current with the latest research and findings, and meet their CME requirements at the same time.

Now you can also get this invaluable free special report, Advantages and Efficacy of Virtual Colonoscopy for Colon Cancer Screening Compared With Conventional Colonoscopy, completely free.

When you download your copy of your free special report, Advantages and Efficacy of Virtual Colonoscopy for Colon Cancer Screening Compared With Conventional Colonoscopy, you’ll also be registered for free Radiology Daily email alerts.

Each time we publish a new article on gastrointestinal imaging, it will be sent to your inbox, to help keep you up to date on the news you need to know in the world of radiology.

To get your free copy of Advantages and Efficacy of Virtual Colonoscopy for Colon Cancer Screening Compared With Conventional Colonoscopy, simply enter your email address in the box, and click on the button below.

We will send you a confirmation email with your download link to get your copy of this free special report.

Then, about once every month, you will receive a new article via email on gastrointestinal imaging.

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Every professional caregiver has dedicated themselves to a lifetime of learning.

You hunger for knowledge…for advanced skills…for tools that promote patient health…

Your goal is always the same:

You want to detect and diagnose disease more quickly and efficiently, in its earliest stages, when treatment is likely to be less difficult and cure is more probable.

This invaluable special report tells you what you need to know about virtual colonscopy, and how it compares with conventional colonoscopy as a diagnostic tool for detecting colon cancer and dealing with polyps before they can ever progress to the cancerous stage.

In this special report you will learn about:

• The statistics on colon cancer;
• Our progress in the fight against colon cancer;
• Our success in treating colon cancer;
• The current state of colon cancer screening;
  • Fecal occult blood test;

• Barium studies;
• Endoscopy;
• Sigmoidoscopy;
• Full colonoscopy;
• Virtual colonoscopy;