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To initiate a peer learning conference for our abdominal radiology division across multiple geographically separated sites and different time zones, and to determine radiologist preference for peer learning versus traditional score-based peer review. We implemented a monthly peer learning videoconference for our abdominal radiology division. Surveys regarding radiologist opinion regarding traditional peer review and the new peer learning conferences were conducted before and after 6 months of conferences. Peer learning conferences were well attended across our multiple sites, with an average of 43 participants per conference. Radiologist opinion regarding peer review was poor, with survey radiologists responding positively to only 1 out of 12 process questions. Opinion regarding peer learning was extremely favorable, with radiologists responding positively to 12 out of the same 12 process questions. After 6 months of peer learning conferences, 87.9% of surveyed radiologists wished to continue them in some fashion, and no one preferred to return to score-based peer review alone. We successfully implemented a peer learning conference for our abdominal radiology division spread out over multiple geographic sites. Our radiologists strongly preferred peer learning conferences over our traditional peer review system for quality control.

Metastatic urothelial carcinoma (mUC) has a poor prognosis with a 5-year survival probability of 4.8%. The mainstay of first-line treatment is platinum-based chemotherapy. Second-line therapy involves immune checkpoint inhibitors or a fibroblast growth factor receptor (FGFR) inhibitor, erdafitinib, for patients harboring selected FGFR alterations. Several additional agents are under development for the treatment of mUC. Recent studies demonstrate that ramucirumab and docetaxel have clinical activity in mUC. We report two patients with metastatic upper tract urothelial cancer (mUTUC) with FGFR alterations who were heavily pretreated with FGFR inhibitors that later showed response to ramucirumab and docetaxel. Preclinical studies indicate that FGF and VEGF pathways work synergistically, which could explain the observations in our patients. Our findings may represent another treatment option for patients with mUC and FGFR alterations who have progressed on multiple lines of therapy.

To initiate a peer learning conference for our abdominal radiology division across multiple geographically separated sites and different time zones, and to determine radiologist preference for peer learning versus traditional score-based peer review.We implemented a monthly peer learning videoconference for our abdominal radiology division. Surveys regarding radiologist opinion regarding traditional peer review and the new peer learning conferences were conducted before and after 6 months of conferences.Peer learning conferences were well attended across our multiple sites, with an average of 43 participants per conference. Radiologist opinion regarding peer review was poor, with survey radiologists responding positively to only 1 out of 12 process questions. Opinion regarding peer learning was extremely favorable, with radiologists responding positively to 12 out of the same 12 process questions. After 6 months of peer learning conferences, 87.9% of surveyed radiologists wished to continue them in some fashion, and no one preferred to return to score-based peer review alone.We successfully implemented a peer learning conference for our abdominal radiology division spread out over multiple geographic sites. Our radiologists strongly preferred peer learning conferences over our traditional peer review system for quality control.

OBJECTIVE. Most peer review programs focus on error detection, numeric scoring, and radiologist-specific error rates. The effectiveness of this method on learning and systematic improvement is uncertain at best. Radiologists have been pushing for a transition from an individually punitive peer review system to a peer-learning model. This national questionnaire of U.S. radiologists aims to assess the current status of peer review and opportunities for improvement. MATERIALS AND METHODS. A 21-question multiple-choice questionnaire was developed and face validity assessed by the ARRS Performance Quality Improvement subcommittee. The questionnaire was e-mailed to 17,695 ARRS members and open for 4 weeks; two e-mail reminders were sent. Response collection was anonymous. Only responses from board-certified, practicing radiologists participating in peer review were analyzed. RESULTS. The response rate was 4.2% (742/17,695), and 73.7% (547/742) met inclusion criteria. Most responders were in private practice (51.7%, 283/547) with a group size of 11-50 radiologists (50.5%) and in an urban setting (61.6%). Significant diversity was noted in peer review systems, with RADPEER used by less than half (45.0%) and cases selected most commonly by commercial software (36.2%) or manually (31.2%). There was no consensus on the number of required peer reviews per month (10-20 cases, 32.1%; > 20 cases, 29.1%; < 10 cases, 21.7%). Less than half (43.7%) did not use peer review for group education. Whereas most (67.7%) were notified of their peer review results individually, 21.5% were not notified at all. Around half were dissatisfied (44.5%) because of insufficient learning (94.0%) and inaccurate representation of their performance improvement (75.5%). Overall, the group discrepancy rates were unknown to most radiologists who participate in peer review (54.3%). Submission bias was the main reason for underreporting of serious discrepancies (49.0%). Most found four peer-learning methods feasible in daily practice: incidental observation, 65.1%; focused practice review, 52.9%; professional auditing, 45.8%; and blinded double reading, 35.4%. CONCLUSION. More than half of participants reported that peer review data are used for educational purposes. However, significant diversity remains in current peer review practice with no agreement on number of required reviews, method of case selection, and oversight of results. Nearly half of the radiologists reported insufficient learning, although most feel a better system would be feasible in daily practice.

Effective and dedicated educators are critical to the preservation and advancement of the practice of radiology. The need for innovative and adaptable educators is increasingly being recognized, with several institutions granting academic promotions through clinician-educator tracks. The implementation of resident “clinician-educator tracks” or “teaching tracks” should better prepare residents aspiring to become academic radiologists focused on teaching. In this work, we describe our experience in the development and implementation of a clinician-educator track for diagnostic radiology residents at our institution.

Diagnostic workup of scrotal lesions should begin with a complete clinical history and physical examination, including analysis of risk factors such as family history of testicular cancer, personal history of tumor in the contralateral testis, and cryptorchidism, followed by imaging. Scrotal ultrasonography (US) with a combination of gray-scale and color Doppler techniques has been the first-line imaging modality for evaluation of testicular and extratesticular lesions because of its low cost, wide availability, and high diagnostic accuracy. However, US has limitations related to operator dependence, the relatively small field of view, and lack of tissue characterization. Magnetic resonance (MR) imaging, because of its superior soft-tissue contrast and multiplanar capabilities, is increasingly being used as a supplemental diagnostic problem-solving tool in cases where scrotal US findings are inconclusive or nondiagnostic. In addition to morphology, lesion location, and tissue characterization (eg, fat, blood products, granulation tissue, and fibrosis), scrotal MR imaging provides important information that can affect surgical planning and improve patient care. MR imaging also is helpful for differentiating testicular and extratesticular lesions, distinguishing between benign and malignant lesions, and evaluating the local extent of disease. This review discusses the anatomy and MR imaging features of testicular and extratesticular neoplastic and nonneoplastic conditions and describes relevant MR imaging techniques. ©RSNA, 2018 Contact information that appeared in the print version of this article was updated in the online version on May 14, 2018.

To determine (1) the sensitivity for detection of small polyps with varying MR slice thicknesses using a resolution phantom; (2) reader confidence in polyp detection; and (3) image acquisition time. A resolution phantom was created using a 3D printer. Polyp morphologies were sessile (height = diameter), flat (height = 1/2 diameter of the base), and pedunculated (stalk length = polyp diameter). Polyp diameters were 5, 7, 10, and 12 mm. Images were acquired with section thicknesses of 5, 3, and 1 mm. Images were independently reviewed by 4 board-certified radiologists who were blinded to phantom design and sequences parameters. Readers recorded maximal polyp diameter and confidence level that a polyp was present on a 1–100 point scale. Image acquisition time was also recorded. All polyps were detected by all 4 readers in the 5-mm-section thickness series. All polyps were detected by 3 readers in the 3- and 1-mm-section thickness series. The fourth reader identified 11/12 polyps in the 3- and 1-mm-section thickness series. Confidence levels were not statistically significantly different for the different section thicknesses (p = 0.28). Increasing the section thickness from 1 to 5 mm decreased image acquisition time from 3 min 54 s to 41 s. Five-millimeter-section thickness was adequate for identification of 5–12 mm polyps regardless of shape. Pending further reduction in acquisition time, this prototype sequence holds promise for segmental imaging of the colon with MR colonography.

Rational and Objectives To evaluate whether addition of nonenhanced computed tomography (NECT) to intravenous contrast-enhanced (CE) abdominal CT improves detection or characterization of hypervascular liver masses. Patients were referred for initial staging or follow-up with known breast, melanoma, neuroendocrine, or thyroid cancer. Material and Methods The literature was searched using the patient, intervention, comparison, and outcome (PICO) method. Retrieved articles were critically appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-based Medicine hierarchy of validity for diagnostic studies. Results One thousand one hundred studies were reviewed; only 11 studies matched the PICO of our study and were appraised. Most of the appraised articles were published in the 1990s using older technology and contrast delivery. The retrieved diagnostic performance for characterization of liver metastases showed sensitivity/specificity of 97%/76% for NECT, 97%/75% for arterial CT, and 98%/76% for portal venous phase CT in patients with breast cancer; sensitivity of 96% (arterial and portal CT) versus 100% (NECT, arterial and portal CT) in patients with melanoma; and sensitivity of 43% (portal CT) versus 17% (NECT) in patients with neuroendocrine tumor. No primary study was found for performance of different CT protocols in patients with thyroid cancer. Available evidence showed radiologists reported more conspicuous liver masses on CECT compared to NECT in patients with breast or neuroendocrine cancer. Conclusions Based on existing evidence, NECT only adds a small incremental value to CECT for detection/characterization of hypervascular liver metastases. Addition of NECT increases patient's exposure to radiation and the number of images available for interpretation.

Purpose The aim of this study was to identify trends and opinions with respect to leadership turnover, leadership responsibilities, and residency requirements. Methods Program directors (PDs) of diagnostic radiology (DR) residency programs were identified via the ACGME and the Fellowship and Residency Electronic Interactive Database, along with a programmatic website search. A web-based survey was e-mailed, with questions concerning lengths of time the current and prior PDs held their positions, residency size, amounts of time spent on and lengths of current and past Program Information Forms, and opinions on how the position has changed and how metrics, outcomes, and documentation may be affecting teaching, resident education, and patient care. Results Thirty-two percent (60 of 186) of US DR residency PDs answered at least 1 of the survey questions. The average length of time the current PDs held their positions was shorter compared with the previous PDs, and it has taken longer and required more pages to complete the current Program Information Forms compared with prior cycles. The majority of respondents felt that the job of PD was harder than 5 years ago and that turnover among PDs is a "current/impending" problem. The majority of respondents felt that time spent on metrics, outcomes, and documentation is taking away from teaching, learning, and taking care of patients. Conclusions Many DR residency PDs have recognized increased administrative burdens in recent years. Some feel that these increased demands may in part have negative effects on resident education and patient care.

Assess the added value of nonenhanced computed tomography (NECT) to contrast-enhanced CT (CECT) of the abdomen for characterization of hypervascular liver metastases and incidental findings. Institutional review board approved, Health Insurance Probability and Accountability Act compliant, retrospective study of patients with melanoma, neuroendocrine tumor, or thyroid cancer. First available triphasic abdomen CT after initial diagnosis was reviewed by 3 radiologists. The 3 most suspicious lesions were characterized on the CECT as benign or malignant and then recharacterized after reviewing the NECT with CECT. Incidental renal and adrenal lesions were characterized similarly. Diagnostic performance of CECT vs its combination with NECT was assessed. Statistical significance level was set at P < 0.05. A total of 81 patients were included (mean age = 55 years; 52% male; 64% with liver lesions; 27% and 11% with incidental renal and adrenal lesions, respectively). Percentage area under the curve and 95% CI of CECT vs combination with NECT for characterization of liver metastases was 98(94–100) vs 99(96–100) for reviewer 1 (P = 0.35), 93(86–100) vs 94(87–100) for reviewer 2 (P = 0.23), and 96(90–100) vs 99(97–100) for reviewer 3 (P = 0.32). Mean difference in area under the curve and 95% CI between 2 protocols for characterization of liver, renal, and adrenal lesions were −0.007(−0.05 to 0.04) (P = 0.63), −0.09(−0.25 to 0.07) (P = 0.22), and −0.01(−0.05 to 0.02) (P = 0.27), respectively. After addition of NECT, confidence level for lesion characterization increased 4%–15% for liver metastases, 18%–59% and 33%–67% for renal and adrenal lesions, respectively. In conclusion, while addition of NECT to CECT improved radiologist' confidence, there was no statistically significant change in characterization of hypervascular liver metastases or incidental renal and adrenal lesions.

Obstructive voiding symptoms are most commonly due to prostatic hyperplasia, but other causes include bladder neck contractures, prostatic carcinomas, neurogenic bladder, and urethral stricture. Symptoms include hesitancy, dribbling, decreased force of stream, and postvoid fullness. Imaging is useful in evaluating the presence and degree of hydronephrosis, estimation of renal function, evaluation of the bladder and prostate, and detection of incidental upper tract malignancies or stones. Various modalities have been used for evaluation of the cause of obstruction. Literature on the indications and usefulness of these radiologic studies for obstructive voiding symptoms in different clinical settings is reviewed.

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited progressive disorder associated with significant pain and discomfort affecting quality of life. This study determined the impact of pain medication use and other clinical, biochemical and genetic characteristics on the physical and mental well being of predialysis ADPKD patients using the Short Form 36 (SF-36) questionnaire.The authors prospectively evaluated ADPKD patients in the Cohort Study, funded by the Polycystic Kidney Disease Foundation. Data on clinical, biochemical, and radiologic variables were collected in patients who were given the Short Form-36 questionnaire. Variables independently associated with the Physical Component Summary (PCS) and the Mental Component Summary (MCS) scores were identified.One hundred fifty-two patients had a mean PCS and MCS of 46.9 +/- 11.3 and 51.0 +/- 9.0, similar to the general population and better than the ESRD population. Eleven (7%) reported pain medication intake within 1 mo of evaluation and demonstrated lower PCS than those not taking pain medications. Patients with GFRor= 80 ml/min/1.73 m(2) had greater PCS than those with GFR80 ml/min/1.73 m(2). Age, BMI, pulse pressure, pain medication use, and education level independently associate with PCS and account for 32% of the variability of the measurement. Pulse pressure correlated with MCS.Predialysis ADPKD patients assess their quality of life similar to the general population. Age, BMI, pulse pressure, pain medication intake, and education level link to their physical well-being.

OBJECTIVE. This commentary deals with the study by Newhouse and colleagues in this issue of the AJR discussing the implications of a lack of a control group in previously published studies on contrast-induced nephropathy (CIN).CONCLUSION. Until more rigorous studies including an appropriate control group address the issue of CIN, our understanding of the actual risk of CIN when administering IV contrast media is limited.

The aim of this study was to evaluate a non-enhanced ultra-low-dose (ULD) abdominal-pelvic multi-detector row computerized tomography (MDCT) to assess patients with acute abdominal pain who would otherwise undergo three-view abdominal X-ray series. Institutional review board approval was obtained with waiver of informed consent. This study was Health Insurance Portability and Accountability Act-compliant. One hundred and sixty-three patients (mean age, 51 years; range, 19-82 years, M/F = 110:53) who underwent ULD MDCT were included in the study. Two subspecialty radiologists independently reviewed the images for abnormal findings and image quality parameters. The effective radiation dose was calculated for each patient and compared to standard-dose computed tomography (CT) scans of 50 matched controls. Findings were confirmed by reviewing the patients' medical records, and statistical analysis was performed. ULD MDCT showed a high sensitivity (100%), specificity (98.5%), and positive predictive value (91.7%) for detection of free air, stones, and intestinal obstruction. For other sources of abdominal pain, the overall sensitivity, specificity, and positive predictive value were 86%, 96%, and 95%, respectively. Mean effective radiation dose from this study was 2.10 mSv (range of 0.67 to 6.64 mSv) with a 78% mean dose reduction compared to standard-dose CT. There was good inter-observer agreement (=0.4 to 0.81). ULD abdominal-pelvic MDCT provides rapid and reasonably accurate diagnostic information in patients with acute abdominal pain at a very low radiation dose.

Purpose Pay-for-performance (P4P) programs have been implemented in many health care markets in the United States. The purpose of this study was to survey faculty members and trainees regarding familiarity with the P4P model and their interest in further education. Methods An eight-question survey designed to explore faculty member and trainee awareness of and attitudes toward P4P was distributed. Data were analyzed using Microsoft Excel. Results One hundred four of 144 questionnaires distributed to faculty members (50 of 70) and trainees (54 of 74) were returned. Sixty-one percent of trainees stated that they had never heard of the P4P model. Seventeen percent of trainees and 26% of attending radiologists were aware that P4P programs have already been instituted. Although 74% of trainees agreed that P4P will influence their reimbursement in the future, only 42% of attending radiologists agreed. A minority of trainees and attending radiologists (35%) felt that P4P improves the quality of care, whereas 42% were neutral. A majority were interested in further education. Conclusion Faculty members and trainees in diagnostic radiology in a university-based program were unfamiliar with the P4P model of reimbursement and were interested in learning more. Additional investigation is needed to ascertain whether this knowledge gap is widespread. This could influence future education about P4P on a national level.

Data from serial renal magnetic resonance imaging of the Consortium of Radiologic Imaging Study of PKD (CRISP) autosomal dominant polycystic kidney disease (PKD) population showed that cystic expansion occurs at a consistent rate per individual, although it is heterogeneous in the population, and that larger kidneys are associated with more rapid disease progression. The significance of gene type to disease progression is analyzed in this study of the CRISP cohort. Gene type was determined in 183 families (219 cases); 156 (85.2%) had PKD1, and 27 (14.8%) had PKD2. PKD1 kidneys were significantly larger, but the rate of cystic growth (PKD1 5.68%/yr; PKD2 4.82%/yr) was not different (P = 0.24). Cyst number increased with age, and more cysts were detected in PKD1 kidneys (P < 0.0001). PKD1 is more severe because more cysts develop earlier, not because they grow faster, implicating the disease gene in cyst initiation but not expansion. These insights will inform the development of targeted therapies in autosomal dominant PKD.

Reduced renal function in patients with simple renal cysts. Background. Sporadic renal cysts not associated with genetic polycystic disorders are common and generally thought to be of no clinical significance. Since multiple cysts frequently develop in end-stage renal disease (ESRD), we tested the hypothesis that cysts that are solitary or few in number are an early mani- festation of reduced renal function. Methods. We evaluated 561 hospitalized patients who un- derwent contrast-enhanced, abdominal computed tomography (CT) and correlated clinical characteristics and parameters of renal function with the presence or absence of renal cysts. Results. Age ranged from 16 to 100 years, mean serum creati- nine concentration was 0.88 mg/dL (range 0.4 to 2.1 mg/dL), and mean estimated creatinine clearance was 94 mL/min/ 1.73 m 2 (range 22 to 218 mL/min/1.73 m 2 ). The presence of cysts was significantly correlated with older age (P < 0.001), higher serum creatinine concentration (P < 0.002), and lower estimated creatinine clearance (P < 0.001). In a multivariate analysis, including age and gender, estimated creatinine clear- ance still correlated with the presence of cysts (P = 0.009). When patients were grouped by age, estimated creatinine clear- ance correlated with cysts in patients

Renal structure in early autosomal-dominant polycystic kidney disease (ADPKD): The Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease (CRISP) cohortBackgroundAutosomal-dominant polycystic kidney disease (ADPKD) is characterized by gradual renal enlargement and cyst growth prior to loss of renal function. Standard radiographic imaging has not provided the resolution and accuracy necessary to detect small changes in renal volume or to reliably measure renal cyst volumes. The Consortium for Radiologic Imaging Studies in Polycystic Kidney Disease (CRISP) is longitudinally observing ADPKD individuals using high-resolution magnetic resonance (MR) imaging to determine if change in renal and cyst volumes can be detected over a short period of time, and if they correlate with decline in renal function early in disease.MethodsStandardization studies were conducted in phantoms and four subjects at each participating clinical center. After, in the full-scale protocol, healthy ADPKD individuals 15 to 45years old with creatinine clearance>70mL/min underwent standardized MR renal imaging, renal iothalamate clearance, comprehensive clinical evaluation, and determination of 24-hour urinary albumin and electrolyte excretion. Stereology was used from T1-weighted images to quantify renal volume, and region-growing thresholding was used from T2-weighted images to determine cyst volume. Renal structures were evaluated in relation to demographic, clinical, and biochemical variables using means/medians, standard deviations, and Pearson correlations.ResultsReliability coefficients for MR renal and cyst volume measurements in phantoms were 99.9% and 89.2%, respectively. In the full-scale protocol, 241 ADPKD individuals (145 women and 96 men) were enrolled. Total renal, cyst, and % cyst volume were significantly greater in each decade group. Hypertensive individuals demonstrated greater renal, cyst, and % cyst volume than normotensive subjects. Age-adjusted renal (r = -0.31, P < 0.0001), cyst (r = -0.36, P < 0.0001), and % cyst volume (r = -0.35, P < 0.0001) were inversely related to glomerular filtration rate (GFR). Age-adjusted renal volume (r = 0.42, P < 0.0001), cystic (r = 0.39, P < 0.0001, and % cyst volume (r = 0.41, P < 0.0001) were related with urinary albumin excretion.ConclusionMR measures of renal and cyst volume are reliable and accurate in patients with ADPKD. ADPKD is characterized by significant cystic involvement that increases with age. Structure (renal and cyst volume) and function (GFR) are inversely related and directly related with the presence of hypertension and urinary albumin excretion in individuals with normal renal function.

We present the first report of an immature teratoma arising from a germ cell testicular cancer invading the duodenum. While other seminomatous and non-seminomatous germ cell tumors are known to metastasize to the duodenum, this is the first such case involving an immature teratoma directly invading the duodenum from a metastatic retroperitoneal mass.

Rationale and Objectives. The interpretation of an abdominal computed tomographic (CT) scan is occasionally inconclusive. In many of these cases, the radiologist suggests an additional imaging test for further confirmation or clarification. The purpose of this study was to evaluate the outcome of self-referral by the radiologist after abdominal CT scanning. Materials and Methods. Reports from 545 consecutive abdominal CT scans were reviewed to track recommendations for additional imaging. In patients who underwent the additional work-up, a determination of the effect of the study was attempted. In patients who did not, explanations were sought. Wording of the recommendations was also recorded. Results. Recommendations were made for additional imaging studies in 105 (19.3%) patients. Of these, 32 (30.5%) were performed and 31 (96.9%) were helpful by confirming malignancy ( n = 5), confirming a benign process ( n = 24), or being therapeutic ( n = 2). In one, no information was added. There were 63 (60.0%) patients who did not undergo the recommended studies. Reasons included “no clinical indication” ( n = 51), alternative study performed ( n = 9), or study previously performed ( n = 3). In eight (7.6%) patients the chart provided insufficient information about whether the patient underwent the study, and in two (1.9%) the chart was unavailable. Wording of the recommendation had no effect on whether the study was performed ( P > .05). Conclusion. Although interpretation of abdominal CT scans leads to recommendations for additional imaging in a minority of cases, these recommendations were infrequently followed. When followe, however, the findings from the recommended studies were usually helpful. Better clinical information is perhaps the best way to reduce self-referral by radiologists.

To evaluate whether addition of nonenhanced computed tomography (NECT) to intravenous contrast-enhanced (CE) abdominal CT improves detection or characterization of hypervascular liver masses. Patients were referred for initial staging or follow-up with known breast, melanoma, neuroendocrine, or thyroid cancer.The literature was searched using the patient, intervention, comparison, and outcome (PICO) method. Retrieved articles were critically appraised and assigned a level of evidence based on the Oxford University Centre for Evidence-based Medicine hierarchy of validity for diagnostic studies.One thousand one hundred studies were reviewed; only 11 studies matched the PICO of our study and were appraised. Most of the appraised articles were published in the 1990s using older technology and contrast delivery. The retrieved diagnostic performance for characterization of liver metastases showed sensitivity/specificity of 97%/76% for NECT, 97%/75% for arterial CT, and 98%/76% for portal venous phase CT in patients with breast cancer; sensitivity of 96% (arterial and portal CT) versus 100% (NECT, arterial and portal CT) in patients with melanoma; and sensitivity of 43% (portal CT) versus 17% (NECT) in patients with neuroendocrine tumor. No primary study was found for performance of different CT protocols in patients with thyroid cancer. Available evidence showed radiologists reported more conspicuous liver masses on CECT compared to NECT in patients with breast or neuroendocrine cancer.Based on existing evidence, NECT only adds a small incremental value to CECT for detection/characterization of hypervascular liver metastases. Addition of NECT increases patient's exposure to radiation and the number of images available for interpretation.

Littoral cell angioma (LCA) is a rare primary vascular tumor of the spleen with a nonspecific clinical presentation. Frequently, it is an incidental finding in individuals undergoing imaging for other disorders and requires pathologic correlation for definitive diagnosis. Here we present a case and a brief overview of the literature.

Renal and adrenal tumors can invade into the inferior vena cava (IVC) in 4%-10% of cases. Consequently, urologists must remain well versed in the anatomy of the IVC. The IVC develops embryologically from the coordinated growth and regression of a series of veins. Occasionally, these veins can persist, creating vena caval abnormalities. A completely duplicated caval system is 1 of these variations. We present a case of renal cell carcinoma with tumor thrombus extending into a duplicated IVC and show how understanding of venous drainage and pertinent imaging can aid with a successful outcome.

Summary Background and objectives The significance of renal parenchymal volume and the factors that influence it are poorly understood. Design, setting, participants, & measurements Renal parenchymal volume (RPV) was measured on contrastenhanced CT scans after exclusion of sinus fat and vessels in 224 healthy subjects evaluated as kidney donors and in a separate cohort of 22 severely obese individuals before and after 6 months of weight loss. GFR was measured by iohexol clearance in 76 of the transplant donors. RPV was correlated with age, GFR, and various anthropometric parameters. Results In potential transplant donors, RPV correlated with body surface area (BSA; r 0.68) and was 7% larger in men but did not vary with age or race. Gender and body size were independent determinants of RPV. RPV correlated well with GFR (r 0.62) and accounted for almost all of the variability in a model of GFR that included age, race, gender, and body surface area. GFR correlated more strongly with RPV than with creatinine-based equations. The same relationship between RPV and BSA was observed in obesity, and RPV decreased with weight loss. Conclusions In healthy adults younger than 65 years, renal parenchymal volume is governed by body size and gender but not age or race and is strongly correlated with GFR. This indicates that renal parenchymal volume varies to meet metabolic demand and is closely linked to renal function. Clin J Am Soc Nephrol 6: 70–76, 2011. doi: 10.2215/CJN.00030110

Nine patients with biopsy-proved hepatocellular carcinoma underwent percutaneous ethanol ablation therapy (PEAT) with computed tomographic (CT) guidance. Twenty-five ablation sessions were performed in nine lesions ranging in size from 1.8 to 6.5 cm. Repeat biopsy was performed in seven of those nine lesions between 1 and 2 months after completion of therapy. CT scans obtained immediately after ablation demonstrated a necrotic area equal in size to the target lesion in five patients; four of those five patients have had negative findings at biopsy and are free of known disease. None of the patients with CT evidence of limited necrosis are currently free of disease. Peripheral nodularity was demonstrated after ablation in three patients at CT; none are free of disease. All four patients in whom there was no peripheral nodularity are free of known disease. Thus, CT evidence of necrosis and lack of nodularity immediately after PEAT are suggestive of absence of disease.

For segmentation and volume measurement of renal cysts and parenchyma from kidney MR images in subjects with autosomal dominant polycystic kidney disease (ADPKD), a semi-automated, multi-spectral anaylsis (MSA) method was developed and applied to T1- and T2-weighted MR images. In this method, renal cysts and parenchyma were characterized and segmented for their characteristic T1 and T2 signal intensity differences. The performance of the MSA segmentation method was tested on ADPKD phantoms and patients. Segmented renal cysts and parenchyma volumes were measured and compared with reference standard measurements by fluid displacement method in the phantoms and stereology and region-based thresholding methods in patients, respectively. As results, renal cysts and parenchyma were segmented successfully with the MSA method. The volume measurements obtained with MSA were in good agreement with the measurements by other segmentation methods for both phantoms and subjects. The MSA method, however, was more time-consuming than the other segmentation methods because it required pre-segmentation, image registration and tissue classification-determination steps.

The objective of this study was to investigate the prevalence of hepatic cysts by age and gender in patients with early autosomal-dominant polycystic kidney disease (ADPKD) and to determine whether hepatic cyst volume is related to renal and renal cyst volumes by using magnetic resonance imaging (MRI). A total of 230 patients with ADPKD (94 men and 136 women) who were aged 15 to 46 yr and had relatively preserved renal function were studied. MRI images of the kidney and liver were obtained to measure renal, renal cyst, and hepatic cyst volumes. These volume measurements and hepatic cyst prevalence were compared in all patients and in subgroups on the basis of gender and age (15 to 24, 25 to 34, and 35 to 46 yr). The overall prevalence of hepatic cysts was 83%; the prevalence was 58, 85, and 94% in the sequential age groups and 85% in women and 79% in men. The prevalence was related directly to renal volume (chi2 = 4.30, P = 0.04) and to renal cyst volume (chi2 = 5.59, P = 0.02). The total hepatic cyst volume was significantly greater in women than in men (a logarithmic transformation mean of 5.27 versus 1.94 ml; P = 0.003). The average hepatic cyst volume was 0.25, 5.75, and 22.78 ml in sequential age groups. Hepatic cysts are evident in 94% of patients who are older than 35 yr and in 55% of individuals who are younger than 25 yr. Hepatic cysts are more prevalent and larger in total cyst volume in women than in men. Hepatic cyst prevalence and aggregate total hepatic cyst volume increased with age.

To study the patients with main pancreatic duct dilation on computed tomography (CT) and thereby to provide the predictive criteria to identify patients at high risk of significant diseases, such as pancreatic cancer, and to avoid unnecessary work up for patients at low risk of such diseases.Patients with dilation of the main pancreatic duct on CT at Emory University Hospital in 2002 were identified by computer search. Clinical course and ultimate diagnosis were obtained in all the identified patients by abstraction of their computer database records.Seventy-seven patients were identified in this study. Chronic pancreatitis and pancreatic cancer were the most common causes of the main pancreatic duct dilation on CT. Although the majority of patients with isolated dilation of the main pancreatic duct (single duct dilation) had chronic pancreatitis, one-third of patients with single duct dilation but without chronic pancreatitis had pancreatic malignancies, whereas most of patients with concomitant biliary duct dilation (double duct dilation) had pancreatic cancer.Patients with pancreatic double duct dilation need extensive work up and careful follow-up since a majority of these patients are ultimately diagnosed with pancreatic cancer. Patients with single duct dilation, especially such patients without any evidence of chronic pancreatitis, also need careful follow-up since the possibility of pancreatic malignancy, including adenocarcinoma and intraductal papillary mucinous tumors, is still high.

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by progressive enlargement of cyst-filled kidneys.In a three-year study, we measured the rates of change in total kidney volume, total cyst volume, and iothalamate clearance in patients with ADPKD. Of a total of 241 patients, in 232 patients without azotemia who were 15 to 46 years old at baseline we used magnetic-resonance imaging to correlate the total kidney volume and total cyst volume with iothalamate clearance. Statistical methods included analysis of variance, Pearson correlation, and multivariate regression analysis.Total kidney volume and total cyst volume increased exponentially, a result consistent with an expansion process dependent on growth. The mean (+/-SD) total kidney volume was 1060+/-642 ml at baseline and increased by a mean of 204+/-246 ml (5.27+/-3.92 percent per year, P0.001) over a three-year period among 214 patients. Total cyst volume increased by 218+/-263 ml (P0.001) during the same period among 210 patients. The baseline total kidney volume predicted the subsequent rate of increase in volume, independently of age. A baseline total kidney volume above 1500 ml in 51 patients was associated with a declining glomerular filtration rate (by 4.33+/-8.07 ml per minute per year, P0.001). Total kidney volume increased more in 135 patients with PKD1 mutations (by 245+/-268 ml) than in 28 patients with PKD2 mutations (by 136+/-100 ml, P=0.03).Kidney enlargement resulting from the expansion of cysts in patients with ADPKD is continuous and quantifiable and is associated with the decline of renal function. Higher rates of kidney enlargement are associated with a more rapid decrease in renal function.

Autosomal-dominant polycystic kidney disease (ADPKD) is characterized by gradual renal enlargement and cyst growth prior to loss of renal function. Standard radiographic imaging has not provided the resolution and accuracy necessary to detect small changes in renal volume or to reliably measure renal cyst volumes. The Consortium for Radiologic Imaging Studies in Polycystic Kidney Disease (CRISP) is longitudinally observing ADPKD individuals using high-resolution magnetic resonance (MR) imaging to determine if change in renal and cyst volumes can be detected over a short period of time, and if they correlate with decline in renal function early in disease.Standardization studies were conducted in phantoms and four subjects at each participating clinical center. After, in the full-scale protocol, healthy ADPKD individuals 15 to 45 years old with creatinine clearance70 mL/min underwent standardized MR renal imaging, renal iothalamate clearance, comprehensive clinical evaluation, and determination of 24-hour urinary albumin and electrolyte excretion. Stereology was used from T1-weighted images to quantify renal volume, and region-growing thresholding was used from T2-weighted images to determine cyst volume. Renal structures were evaluated in relation to demographic, clinical, and biochemical variables using means/medians, standard deviations, and Pearson correlations.Reliability coefficients for MR renal and cyst volume measurements in phantoms were 99.9% and 89.2%, respectively. In the full-scale protocol, 241 ADPKD individuals (145 women and 96 men) were enrolled. Total renal, cyst, and % cyst volume were significantly greater in each decade group. Hypertensive individuals demonstrated greater renal, cyst, and % cyst volume than normotensive subjects. Age-adjusted renal (r = -0.31, P0.0001), cyst (r = -0.36, P0.0001), and % cyst volume (r = -0.35, P0.0001) were inversely related to glomerular filtration rate (GFR). Age-adjusted renal volume (r = 0.42, P0.0001), cystic (r = 0.39, P0.0001, and % cyst volume (r = 0.41, P0.0001) were related with urinary albumin excretion.MR measures of renal and cyst volume are reliable and accurate in patients with ADPKD. ADPKD is characterized by significant cystic involvement that increases with age. Structure (renal and cyst volume) and function (GFR) are inversely related and directly related with the presence of hypertension and urinary albumin excretion in individuals with normal renal function.

Incidental findings of thickened luminal GI organs (LGIO) on CT are not uncommon. However, the significance of these findings is unclear. Because of the lack of scientific data, there are no clinical guidelines for the evaluation of these radiologic abnormalities. Our objective was to determine whether endoscopic evaluation of these findings revealed significant abnormalities.This study evaluated all incidental findings of thickened LGIO in a large medical center from October, 1997 to March, 1999 that were followed by endoscopic examinations.Ninety-six percent of patients with incidental findings of thickening of the sigmoid colon or rectum, 81% of patients with thickening of the distal esophagus, and 13% of patients with thickening of the cecum had significant abnormalities on further endoscopic work up.Although positive pathologic findings are less common in thickening of the cecum than in other LGIO, all of these incidental findings on CT warrant further endoscopic examination.

To determine the percentage of outpatients with elevated serum creatinine levels (/=2.0 mg/dL [177 micromol/L]) and associated reported risk factors for contrast material-induced nephrotoxic reactions (eg, diabetes, renal disease, male, age/= 60 years, chemotherapy) who undergo computed tomography (CT) and to define a true high-risk population.The serum creatinine levels were obtained in a total of 2,034 consecutive outpatients (969 male, 1,065 female) who underwent contrast material-enhanced CT. In addition, selected patient charts were reviewed to determine the presence of risk factors for contrast material-induced nephrotoxic reactions.Only 66 (3.2%) had an elevated serum creatinine level. Risk factors were identified in 64 of the 66 (97%) patients with an elevated serum creatinine level. Renal disease was present in 62 of the 66 (94%) patients. Two of the 66 patients with an elevated creatinine level had no identifiable risk factors, representing 0.1% of the total number of patients.The data suggest that the majority of patients with a serum creatinine level of at least 2.0 mg/dL (177 micromol/L) will be identified by screening for risk factors. Careful patient screening, especially for renal disease, at the time of scheduling could result in considerable savings in terms of radiology man-hours expended and laboratory costs.

e15617 Background: The presence or absence of systemic inflammation has been associated with dramatic changes in prognosis for patients with metastatic renal cell carcinoma (mRCC). In this study we define kinetic inflammatory response (KIR) patterns as changes in the intensity of the systemic inflammatory response (SIR) over time as a result of therapeutic intervention or disease progression with the goal of ascertaining whether such patterns have any clinical utility. Methods: A retrospective, single institution study was conducted at the Winship Cancer Institute of Emory University. Inclusion criteria included treatment with a targeted agent for mRCC of any histology and the concurrent assessment of serum CRP and albumin on a minimum of three occasions at least two weeks apart. The modified Glasgow Prognostic Score (mGPS) was used to quantify the intensity of the SIR at each available time point. Results: A cohort of 55 patients was identified from among 635 patients who were evaluated for kidney cancer during the screening period of January 1, 2005 and June 30, 2011. The SIR was assessed a total of 804 times with a median of 14 time points per patient (range 3 to 49). A total of 113 lines of theapy were administered with a median of 2 per patient (range 1 to 5). KIR patterns were categorized as optimal, suboptimal, relapse, refractory and acquired systemic inflamation. Tandem KIR patterns were also observed. The absence or sustained loss of systemic inflammation was associated with responsiveness to therapy and prolonged overall survival (OS) whereas the persistence or acquisition of systemic inflammation was associated with resistance to therapy and shortened OS. In one instance, active surveillance with biomarkers of systemic inflammation led to the discovery of an occult penile metastasis. Conclusions: KIR pattern recognition provides a simple and inexpensive way for clinicians to monitor interactions between the tumor and the innate immune system with the clinical objective of inducing or maintaining an inflammation free state. Biomarkers of systemic inflammation may prove to be particularly useful for active surveillance of patients with fully resected, locally advanced or mRCC.