Preferred Imaging Modality Research Articles

Management of cryptoglandular fistula-in-ano among gastrointestinal surgeons in the Netherlands

BackgroundManagement of cryptoglandular fistula-in-ano (FIA) can be challenging. Despite Dutch and international guidelines determining optimal therapy is still quite difficult. The aim of this study was to report current practices in the management of cryptoglandular FIA among gastrointestinal surgeons in the Netherlands.MethodsDutch surgeons and residents who are treating FIA regularly were sent a survey invitation by email. The survey was available online from September 19 to December 1 2019. The questionnaire consisted of 28 questions concerning diagnostic and surgical techniques in the treatment of intersphincteric and transsphincteric FIA.ResultsIn total, 147 (43%) surgeons responded and completed the survey. Magnetic resonance imaging was the preferred diagnostic imaging modality (97%) followed by the endo-anal ultrasound (12%). In case of a high FIA, 86% used a non-cutting seton. Most respondents removed a seton between 6 weeks and 3 months (n = 84, 58%). Fistulotomy was the procedure of preference in low transsphincteric (86%) and low intersphincteric FIA (92%). Mucosal advancement flap (MAF) and ligation of intersphincteric fistula tract (LIFT), with 78% and 46%, respectively, were the procedures that were applied most often in high transsphincteric FIA. In high intersphincteric FIA 67% performed a MAF and 33% a fistulotomy. Thirty-three percent of all respondents stated that they habitually closed the internal fistula opening, half of them used a Z-plasty. For debridement of the fistula tract the preferred method was curettage (78%).ConclusionsDutch gastrointestinal surgeons use various techniques in the management of FIA. Novel promising techniques should be investigated adequately in sufficient large trials to increase consensus. A core outcome measurement and a prospective international database would help in comparing results. Until then, treatment should be adjusted to the individual patient, governed by fistula characteristics and patient choice.

The Potential Benefit of Emergency Ultrasound Plus MDCT for The Diagnosis of Major Chest Trauma … A Diagnostic Test Accuracy Study

Background: Multidetector computed tomography (MDCT) has established itselfas the preferred imaging modality for the evaluation of polytrauma patients owning to its significantly better ability in detecting tissue but patients are exposed to great amount of radiation during MDCT examination. Ultrasound has thebenefits of being reliable, dynamic, rapid, noninvasive technique and freed from radiation. Objective: This study aims toascertain the role of transthoracic ultrasound for imaging blunt chest trauma patients and compared its sensitivity, specificity and accuracy to those of MDCT as a gold standard modality. Patients and methods: This study was carried on 57 patients, 54 males (94.7%) and 3 were females (5.3%) and ages ranged from 5 to 60 years. All patients were exposed to major blunt chest trauma with or without associated polytrauma. Results: With MDCT as the gold standard, the most common injury detected by ultrasound (US) was pleural in 89.5% of patients with 96% accuracy, chest wall lesions were found in 80.7% of patients with 95% diagnostic accuracy, parenchymal lesions were found in 64.9% of patients with 91% diagnostic accuracy and mediastinal lesions were detected in 3.5% with 91% diagnostic accuracy. The sensitivity and specificity of ultrasonography varied for detecting thesubsequent pathologies: rib fracture (89% and 100%) subcutaneous emphysema (87% and100 %), hemothorax (94% and 100%), pneumothorax (89% and 100%), hydropneumothorax (81% and 100%), pulmonary contusions (82% and 100%), lung collapse (93% and 100%), lung laceration (100% and 100%) and hemopericardium (100% and100%), respectively. Conclusions: Chest US proved its value for diagnosis of blunt thoracic injuries with acceptable sensitivity and high specificity, particularly for pleural, pericardial and parenchymal lung injuries.

Primary Mediastinal B-Cell Lymphoma: Novel Precision Therapies and Future Directions

Primary mediastinal large B-cell lymphoma (PMBCL) is a distinct clinicopathologic disease from other types of diffuse large B-cell lymphoma (DLBCL) with unique prognostic features and limited availability of clinical data. The current standard treatment for newly diagnosed PMBCL has long been dependent on a dose-intensive, dose-adjusted multi-agent chemotherapy regimen of rituximab plus etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-R-EPOCH). Recent randomized trials have provided evidence that R-CHOP followed by consolidation radiotherapy (RT) is a valuable alternative option to first-line treatment. For recurrent/refractory PMBCL (rrPMBCL), new drugs such as pembrolizumab and CAR-T cell therapy have proven to be effective in a few studies. Positron emission tomography-computed tomography (PET-CT) is the preferred imaging modality of choice for the initial phase of lymphoma treatment and to assess response to treatment. In the future, baseline quantitative PET-CT can be used to predict prognosis in PMBCL. This review focuses on the pathology of PMBCL, underlying molecular basis, treatment options, radiotherapy, targeted therapies, and the potential role of PET-CT to guide treatment choices in this disease.

Recurrent feature fusion learning for multi-modality pet-ct tumor segmentation

Background and objective: [18f]-fluorodeoxyglucose (fdg) positron emission tomography – computed tomography (pet-ct) is now the preferred imaging modality for staging many cancers. Pet images characterize tumoral glucose metabolism while ct depicts the complementary anatomical localization of the tumor. Automatic tumor segmentation is an important step in image analysis in computer aided diagnosis systems. Recently, fully convolutional networks (fcns), with their ability to leverage annotated datasets and extract image feature representations, have become the state-of-the-art in tumor segmentation. There are limited fcn based methods that support multi-modality images and current methods have primarily focused on the fusion of multi-modality image features at various stages, i.e., early-fusion where the multi-modality image features are fused prior to fcn, late-fusion with the resultant features fused and hyper-fusion where multi-modality image features are fused across multiple image feature scales. Early- and late-fusion methods, however, have inherent, limited freedom to fuse complementary multi-modality image features. The hyper-fusion methods learn different image features across different image feature scales that can result in inaccurate segmentations, in particular, in situations where the tumors have heterogeneous textures. Methods: we propose a recurrent fusion network (rfn), which consists of multiple recurrent fusion phases to progressively fuse the complementary multi-modality image features with intermediary segmentation results derived at individual recurrent fusion phases: (1) the recurrent fusion phases iteratively learn the image features and then refine the subsequent segmentation results; and, (2) the intermediary segmentation results allows our method to focus on learning the multi-modality image features around these intermediary segmentation results, which minimize the risk of inconsistent feature learning. Results: we evaluated our method on two pathologically proven non-small cell lung cancer pet-ct datasets. We compared our method to the commonly used fusion methods (early-fusion, late-fusion and hyper-fusion) and the state-of-the-art pet-ct tumor segmentation methods on various network backbones (resnet, densenet and 3d-unet). Our results show that the rfn provides more accurate segmentation compared to the existing methods and is generalizable to different datasets. Conclusions: we show that learning through multiple recurrent fusion phases allows the iterative re-use of multi-modality image features that refines tumor segmentation results. We also identify that our rfn produces consistent segmentation results across different network architectures.

Analysis of Three-Dimensional Ultrasound in Diagnosis of Shoulder and Neck Inflammation and Surrounding Tissue Lesions

Ultrasound imaging technology can not only show neck tear the degree and extent of disease, to help make the correct diagnosis, can also be used to assess shoulder neck inflammation after surgery to repair a shoulder muscle neck tissue integrity and healing. Ultrasound imaging with high-resolution, real-time operation, low cost, etc. gradually become shoulder neck inflammatory disease preferred imaging modality. The sensitivity and specificity for three-dimensional ultrasound imaging of shoulder neck inflammation were 78% and 93% in this study. The full-thickness inflammation sensitivity and specificity were 50% and 95%. The sensitivity and specificity of inflammation were 57% and 87%, respectively. This study shows that the diagnostic accuracy of 3D ultrasound imaging in shoulder and neck inflammation and surrounding tissue lesions is close to that of MRI. Three-dimensional appearance of new technologies such as ultrasound imaging will further improve ultrasound imaging techniques in shoulder neck inflammation application in the diagnosis and treatment assessment.

Outcomes by Race in Breast Cancer Screening With Digital Breast Tomosynthesis Versus Digital Mammography.

Purpose:Digital breast tomosynthesis (DBT) in conjunction with digital mammography (DM) is becoming the preferred imaging modality for breast cancer screening compared with DM alone, on the basis of improved recall rates (RR) and cancer detection rates (CDRs). The aim of this study was to investigate racial differences in the utilization and performance of screening modality.Methods:Retrospective data from 63 US breast imaging facilities from 2015 to 2019 were reviewed. Screening outcomes were linked to cancer registries. RR, CDR per 1,000 examinations, and positive predictive value for recall (cancers/recalled patients) were compared.Results:A total of 385,503 women contributed 542,945 DBT and 261,359 DM screens. A lower proportion of screenings for Black women were performed using DBT plus DM (referred to as DBT) (44% for Black, 48% for other, 63% for Asian, and 61% for White). Non-White women were less likely to undergo more than one mammographic examination. RRs were lower for DBT among all women (8.74 versus 10.06, P < .05) and lower across all races and within age categories. RRs were significantly higher for women with only one mammogram. CDRs were similar or higher in women undergoing DBT compared with DM, overall (4.73 versus 4.60, adjusted P = .0005) and by age and race. Positive predictive value for recall was greater for DBT overall (5.29 versus 4.45, adjusted P < .0001) and by age, race, and screening frequency.Conclusions:All racial groups had improved outcomes with DBT screening, but disparities were observed in DBT utilization. These data suggest that reducing inequities in DBT utilization may improve the effectiveness of breast cancer screening.

Posterior circulation acute stroke prognosis early CT scores in predicting functional outcomes: A meta-analysis.

Patients with posterior circulation acute ischemic stroke exhibit varied clinical presentations and functional outcomes. Whether posterior circulation acute stroke prognosis early computed tomography scores (PC-ASPECTS) predict unfavorable functional outcomes (UFO) for patients treated with different therapeutic regimens is unclear. According to PRISMA guidelines, we performed a systematic search of electronic databases for studies assessing the functional outcomes of posterior circulation acute ischemic stroke using baseline PC-ASPECTS. The following three scales of PC-ASPECTS were retrieved: UFO prediction by using PC-ASPECTS per score decrease, UFO prediction by using binary PC-ASPECTS with a cut-off value, and the difference in PC-ASPECTS between patients with unfavorable and favorable functional outcomes. Moreover, a subgroup analysis was conducted for patients treated with intra-arterial endovascular treatment (IA-EVT) only. Sensitivity analysis with different definition of UFO and image modalities were also conducted. In total, 25 studies were included. In scale 1, PC-ASPECTS significantly predicted UFO (odds ratio [OR]: 1.66 per score decrease, 95% confidence interval [CI]: 1.32-2.07). In scale 2, binary PC-ASPECTS with a cut-off value between 6 and 9 significantly predicted UFO (OR: 3.91, 95% CI: 2.54-6.01). In scale 3, patients with UFO had lower PC-ASPECTS than those with favorable outcomes (standardized mean difference [SMD]: -0.67, 95% CI: -0.8 to -0.55). For patients treated with IA-EVT only, the scales demonstrated consistent results. Sensitivity analysis showed PC-ASPECTS significantly predicted UFO in both definitions of modified Rankin Scale ≥ 3 and ≥ 4, and magnetic resonance imaging was preferred imaging modality for PC-ASPECTS evaluation. Baseline PC-ASPECTS is effective in predicting UFO for patients with posterior circulation acute ischemic stroke treated with different therapeutic regimens.

Cardiac MRI and Myocardial Injury in COVID-19: Diagnosis, Risk Stratification and Prognosis.

Myocardial injury is a common complication of the COVID-19 illness and is associated with a worsened prognosis. Systemic hyperinflammation seen in the advanced stage of COVID-19 likely contributes to myocardial injury. Cardiac magnetic resonance imaging (CMR) is the preferred imaging modality for non-invasive evaluation in acute myocarditis, enabling risk stratification and prognostication. Modified scanning protocols in the pandemic setting reduce risk of exposure while providing critical data regarding cardiac tissue inflammation and fibrosis, chamber remodeling, and contractile function. The growing use of CMR in clinical practice to assess myocardial injury will improve understanding of the acute and chronic sequelae of myocardial inflammation from various pathological etiologies.

The role of MRI in evaluation of cervical carcinoma

ObjectiveTo review the role of MRI in the diagnosis and staging of cervical carcinoma.BackgroundIt is widely accepted that MRI is the preferred imaging modality for detection of cervical carcinoma nowadays; different techniques are needed for early detection of the disease, its correct staging, and treatment.Patients and methodsThis case–control study included 62 patients divided into a case group of 32 patients diagnosed clinically or by transvaginal ultrasound with cervical cancer, confirmed by biopsy, and a control group of 30 patients who had pelvic MRI for other reasons. All patients were assessed by history and review of previous ultrasound reports and underwent pelvic MRI with diffusion-weighted MRI and dynamic contrast-enhanced MRI.ResultsThis study revealed a statistically significant difference between the case and control groups regarding apparent diffusion coefficient (ADC) value (P < 0.001). There was no significant difference in ADC value between different subtypes of cervical cancer. The diagnostic accuracy of ADC in discrimination of patients and control in defining the best cutoff value of ADC (×10–3), which was 1.10, was 99.5%, with sensitivity of 96.6% and specificity of 96.9%.ConclusionDiffusion-weighted imaging is a potentially useful adjunct to conventional MRI in evaluating cervical carcinoma, thus improving overall diagnostic accuracy, tumor staging, prediction of response to therapy, and treatment follow-up. ADC values may vary not only with different imaging parameters but also with different types of MRI systems.

Demystifying Sacral Masses: A Pictorial Review.

The sacrum is a triangular shaped bone made up of five fused vertebral bodies. It is composed of bone, cartilage, marrow elements as well as notochord remnants and is a common site for both benign and malignant (primary and secondary) tumors. Familiarity with the imaging features and clinical presentations of sacral bone tumors could be helpful in narrowing the differential diagnosis. Magnetic resonance imaging and computed tomography are the preferred imaging modalities for evaluating sacral masses. This pictorial review will highlight imaging features of common sacral tumors with pathologic correlation. Additionally, this article will review some critical principles and helpful tips to successfully biopsy these lesions.

Ultrasound of the neonatal hip as a screening tool for DDH: how to screen and differences in screening programs between European countries.

Developmental dysplasia of the hip comprises a broad spectrum of abnormalities in hip development, of variable severity. Besides physical examination, ultrasound is the preferred imaging modality for screening for developmental dysplasia of the hip in children aged younger than six months. The Graf method is the most widely used ultrasound technique for infant hips; a stepwise approach will be shown in this article. Furthermore, the process of dynamic ultrasound imaging will be explained as well as the use of transinguinal ultrasound in infants wearing a spica cast. There is no consensus on the best way to screen for developmental dysplasia of the hip, which is probably the reason why different screening programs exist throughout Europe, as will be discussed in this article. The use of universal versus selective ultrasound remains a controversy, as does the timing. Is it better to perform sonography in all newborn infants like in Germany and Austria? Or should we examine only the infants with clinical hip instability or risk factors (breech position, positive family history), like in the UK and the Netherlands? This article reviews the epidemiology, static and dynamic ultrasound techniques in screening for developmental dysplasia of the hip, and differences in screening programs throughout Europe. Set aside the uncertainties about whom and when to screen, it needs to be emphasized that ultrasound screening for developmental dysplasia of the hip is important, since the disease is initially occult and easier to treat when identified early. In this way, the radiologist can aid in preventing serious disability of the hip.

Cone beam CT - A preferable imaging modality to diagnose stafne’s bone cavity

The Stafne’s bone cavity is a depression of the mandible on the lingual surface. The Stafne defect is normal anatomical variant because of depression created by salivary gland tissue associated with the submandibular gland. Cone Beam Computed Tomography (CBCT) is newer radiological tool for diagnosing maxillofacial diseases and dental implant planning. The Stafne bony cavity is incidental finding in dental radiographs and CBCT. We are reporting five cases of Stafne bone cavity with pictures of CBCT to emphasize the preferable imaging modality for diagnosing Stafne’s bone cavity. Keywords: Stafne bone cavity, Static bone cavity, Stafne cyst, Idiopathic bone cavity.

Gastrointestinal: Recurrent colic and the percutaneous endoscopic gastrojejunostomy.

A 71-year-old lady presented with long-standing colicky epigastric pain and vomiting on a background of advanced Parkinson's disease, treated by third-line medical therapy with duodopa administered by a percutaneous endoscopic gastrojejunostomy (PEG-J) tube. The PEG-J tube provided a steady and constant bioavailability of the drug by overcoming the slow and erratic gastric emptying commonly observed in patients with Parkinson's disease. On examination, the patient was afebrile and hemodynamically stable. She had a soft abdomen with focal epigastric tenderness without peritonism. Her biochemical investigations were unremarkable. Computed tomography scan demonstrated a long segment of thickened small bowel along the PEG-J tubing, with duplicated layers of bowel forming concentric rings consistent with a jejuno-jejunal intussusception (Fig. 1). She underwent a laparotomy demonstrating collapsed proximal loops of jejunum telescoping into distally dilated loops, with a palpable intraluminal mass. Following reduction of the intussusception, a longitudinal enterotomy was performed to deliver a phytobezoar formed over a PEG-J tube knot (Fig. 2). The PEG-J was otherwise well positioned, and no underlying anatomical abnormality was identified. Intussusception is classified according to site of origin: entero-enteric, ileocolic, or colocolic. The vast majority are entero-enteric with jejuno-jejunal intussusceptions being extremely uncommon. Intussusception in adults is almost always due to intraluminal tumors, and rarely are bezoars or PEG-J tubes cited as underlying causes. Unlike children, symptoms in adults are nonspecific, and therefore, abdominal computed tomography is the preferred imaging modality to obtain a diagnosis. Surgery remains the cornerstone of management for adults given the high incidence of intraluminal pathology. Phytobezoars can develop because of a variety of medical pathologies including gastrointestinal motility disorders. Most likely due to her underlying Parkinson's disease, and the rare complication of PEG-J tube knotting, this patient developed a bezoar acting as a lead point causing recurrent intussusception. This case represents an exceedingly rare presentation of a jejunal intussusception secondary to a bezoar forming over a knot in the PEG-J tubing. These images highlight this interesting case, demonstrating the importance of intussusception as a differential diagnosis in patients with nonspecific abdominal complaints, especially those predisposed to gastrointestinal dysmotility, to avoid delays in diagnosis.

Update on COVID-19 Myocarditis.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) gained worldwide attention at the end of 2019 when it was identified to cause severe respiratory distress syndrome. While it primarily affects the respiratory system, we now have evidence that it affects multiple organ systems in the human body. Cardiac manifestations may include myocarditis, life threatening arrhythmias, acute coronary syndrome, systolic heart failure, and cardiogenic shock. Myocarditis is increasingly recognized as a complication of Coronavirus-19 (COVID-19) and may result from direct viral injury or from exaggerated host immune response. The diagnosis is established similar to other etiologies, and is based on detailed history, clinical exam, laboratory findings and non-invasive imaging studies. When available, cardiac MRI is the preferred imaging modality. Endomyocardial biopsy may be performed if the diagnosis remains uncertain. Current management is mainly supportive with the potential addition of interventions recommended for severe COVID-19 disease, such as remdesivir, steroids, and convalescent plasma. In the setting of cardiogenic shock and refractory, life-threatening arrhythmias that persist despite medical therapy, advanced mechanical circulatory support devices should be considered. Ultimately, early recognition and aggressive intervention are key factors in reducing morbidity and mortality. Our management strategy is expected to evolve further as we learn more about COVID-19 disease and the associated cardiac complications.

Groin abscess: A retrospective review of diagnosis and treatment

• Groin abscess is a very rare presentation to the Emergency department. It constitutes less than 0.04% of all Emergency Department presentations. • It is more common in intravenous drug users (IVDU) who inject into the groin. • Pseudoaneurysm is a very rare complication of groin abscesses. • The commonest organisms cultured are streptococcus (A, B or C) and staphylococcus aureus. • Most patients responded to treatment with antibiotics with or without incision and drainage of the abscess. • Asymptomatic deep vein thrombosis is not uncommon in IVDUs with groin abscesses. To determine the incidence, diagnosis and management of adult patients (over the age of 18 years) that presented to our Emergency department with a groin abscess over a 12-month period. Retrospective chart review of all adult patients presenting a large suburban hospital with a provisional diagnosis of groin abscess was undertaken from January 2019 to December 2019. A proforma was used to capture data such as the age, sex, co-morbidities, imaging, profile of micro-organisms and treatment. 39 patients with groin abscess were identified, representing approximately 0.04% of all ED attendances. There were 21 males and 18 females. The age range was from 23 to 73 years (mean age 42). The abscess was located on the left side in 19 patients (49%), 18 (46%) on the right and 2 (5%) were bilateral. The majority of patient (64%) were intravenous drug users. 28 patients had either CT angiography or Ultrasound scan. 37 patients had some form treatment; either I&D or antibiotics. 2 patients were discharged without any treatment. There was no pseudoaneurysm identified. There were 2 cases of incidental DVT. 48% of organism cultured were staphylococcus or streptococcus (A, B or C). Groin abscess is a rare presentation to the Emergency department. It is more common in intravenous drug users (IVDU). The most preferred imaging modality is CT angiography. Pseudoaneurysm is rare. The commonest organisms cultured are streptococcus (A, B or C) and staphylococcus aureus. Most patients responded to treatment with antibiotics with or without incision and drainage of the abscess.

LGG-44. PROGNOSTIC SIGNIFICANCE OF IMAGING CHARACTERISTICS IN PEDIATRIC LOW GRADE GLIOMAS

Pediatric low-grade gliomas (pLGG) account for one third of all central nervous system (CNS) tumors. MRI is the preferred imaging modality for diagnosis and response evaluation. This study aims to evaluate if radiographic characteristics of pLGG at diagnosis are prognostic. Medical records of 700 pLGG patients were reviewed who were seen between 1998- 2019 at our institution. Summary statistics were provided to describe patient demographic and clinical characteristics. 603 patients were not eligible because incomplete records, 97 patients were identified and eligible for the review. There were 45 females and 52 males with the mean age of 6.5 years at diagnosis. Patients were categorized based on contrast enhancement to 2 groups; none/mild versus moderate/high with 65 and 32 patients respectively. 31 patients had infiltrative glioma (32.3%) with more than one lobe involved at diagnosis. Fifteen patients (15.46%) had hydrocephalous at initial diagnosis. 32 patients (32.9%) did not have any treatment and remained stable while 65(67.0%) had either surgery, chemotherapy or radiation or combination. 21 patients had neurofibromatosis type-1(NF-1) with better outcome comparing to non-NF1 as previously reported. No statistically significant difference in outcome was found based on the imaging characteristics at diagnosis including contrast enhancement, hydrocephalus, tumor size, presence of cyst or infiltrative tumors. The 5 years PFS rate for the entire cohort was 47%. Our study results are limited by low patient number, hence collaborative multi-institutional studies are warranted to delineate consensus and investigate prognostic factors to improve the outcome of pLGG.

Role of Computed Tomography Perfusion in Identification of Acute Lacunar Stroke Syndromes.

Lacunar syndromes correlate with a lacunar stroke on imaging in 50% to 60% of cases. Computed tomography perfusion (CTP) is becoming the preferred imaging modality for acute stroke triage. We aimed to estimate the sensitivity, specificity, and predictive values for noncontrast computed tomography and CTP in lacunar syndromes, and for cortical, subcortical, and posterior fossa regions. A retrospective analysis of confirmed ischemic stroke patients who underwent acute CTP and follow-up magnetic resonance imaging between 2010 and 2018 was performed. Brain noncontrast computed tomography and CTP were assessed independently by 2 stroke neurologists. Receiver operating characteristic curve analysis was performed to estimate sensitivity, specificity, and area under the curve (AUC) for the detection of strokes in patients with lacunar syndromes using different CTP maps. We found 106 clinical lacunar syndromes, but on diffusion-weighted imaging, these consisted of 59 lacunar, 33 cortical, and 14 posterior fossa strokes. The discrimination of ischemia identification was very poor using noncontrast computed tomography in all 3 regions, but good for cortical (AUC, 0.82) and poor for subcortical and posterior regions (AUCs, 0.55 and 0.66) using automated core-penumbra maps. The addition of delay time and mean transient time maps substantially increased subcortical (AUC, 0.80) and slightly posterior stroke detection (AUC, 0.69). Analysis of mean transient time and delay time maps in combination with core-penumbra maps improves detection of subcortical and posterior strokes.

Knowledge and perception on the transmission and control of SARS-COV-2 infection among allied radiation medicine professionals in Ghana.

Knowledge and perception on transmission and control of SARS-COV-2 infection are key to preventing outbreak of the disease in healthcare settings and in dealing with the COVID-19 pandemic. This study assessed the level of knowledge on SARS-COV-2 infection prevention, transmission and symptoms of COVID-19, as well as perceptions regarding prevention of SARS-COV-2 infection among allied radiation medicine professionals. Cross-sectional descriptive survey was carried out among 145 radiation medicine professionals in Ghana using facts on COVID-19 as presented on the website of the World Health Organization and data was analyzed based on weighted average indices. Overall, the extent of knowledge among allied radiation medicine professionals on the symptoms of COVID-19, transmission and control of SARS-COV-2 infection in radiation medicine facilities were all adequate, with weighted average indices of 3.8, 4.1 and 4.4 respectively. However, overall perception of the respondents regarding the use of radiation medicine procedures in management of COVID-19 was diverse, with weighted index of 3.5. The facts about COVID-19 that were identified to be most known were shortness of breath being a serious symptom of the disease and fever being a common symptom. The extent of knowledge on the fact that “SARS-COV-2 infection can be transmitted through small droplets from the nose or mouth of an infected person” was almost excellent, with weighted average index of 4.9. Also, the thinking that provision of hand washing and sanitizing facilities is a measure for controlling the infection was almost perfectly shared among the respondents. Computed tomography was perceived by majority of the respondents as the most preferred imaging modality for screening patients for COVID-19. The study shows that some aspects of the awareness of radiation medicine professionals on COVID-19 pandemic are adequate and others need critical improvement to help reduce spread of the disease.

The Role of Whole Body STIR MRI in Assessing First Biochemical Relapse in Patients with Myeloma

Background: Myeloma remains an incurable disease and most patients will relapse. The optimal timing of salvage initiation remains uncertain although there is a trend to treating early biochemical relapse. In the current COVID-19 pandemic, delaying therapy of asymptomatic relapsed patients is also desirable, but avoidance of renal failure and symptomatic bony disease is important. Whole body STIR MRI with diffusion weighted imaging (DWI) has the potential to diagnose bone involvement at a very early, pre-symptomatic stage, before cortical destruction occurs. It may be a useful tool to assess the ability to defer therapy in myeloma patients with asymptomatic biochemical relapse.Methods: We performed a retrospective audit of newly diagnosed patients with symptomatic myeloma, diagnosed between April 2012 and Oct 2019. We studied only patients in first relapse who had achieved PR or better to first-line therapy. Patients were typically monitored with monthly serum protein electrophoresis and free light chain assessments. The preferred imaging modality during the study period was whole body STIR MRI with DWI analysis and additional dedicated spinal sequences. Response and relapse criteria were as defined by the IMWG with the exception that regular urine BJP monitoring was not performed. Rapid biochemical relapse was defined as per Sonneveld (ASH Education Book 2017). The decision to initiate therapy for relapse was at the discretion of the treating hematologist.Results: 125 patients with newly diagnosed symptomatic myeloma who achieved PR or better to first line therapy were identified. Median age at diagnosis was 64yrs (range, 32 to 89yrs) and 72% were male. Immunoglobulin type was IgG (54%), IgA (23%), light chain (22%) and IgD (1%). ISS stage was I (19%), II (60%) and III (21%) and 21% were high risk as defined by the presence of t(4;14), t(14;16) or del17p by bone marrow FISH. Half received autologous stem cell transplantation with bortezomib-based therapy being the commonest induction for both transplant- and non-transplant-eligible populations. Amongst this group with responsive disease, haematological response was CR (38%), VGPR (29%) and PR (33%).75 (60%) of patients have relapsed at a median of 32 months. For patients in CR and VGPR, it took a median of 92 days from the first presence or increase in monoclonal immunoglobulin until IMWG defined relapse criteria were met. At the time of IMWG defined relapse, in terms of assessing need for therapy, the patients clinical status was defined as: rapid biochemical relapse (15%), relapse in a patient with high risk FISH (26%), relapse in a patient with renal failure at diagnosis (15%) and meeting CRAB criteria exclusive of MRI findings (7%), leaving 37% (n=27) in slow biochemical relapse without a definite indication for urgent therapy. MRI was performed as the bone imaging modality in 20 of these 27 slow biochemical relapse patients at a median of 42 days (range, -12 days to 210 days) after IMWG defined relapse: 10 demonstrated new focal bone lesions, 3 no lesions, 4 stable lesions and 3 improved bone lesions. Of these 10 patients with no new MRI detected bone disease, two were treated immediately at physician discretion.Thus, only 8 of 75 relapses were asymptomatic with a normal MRI, had no other indication for urgent therapy and were observed. For this group, the median time to treatment was 96 days (range, 34 to 576 days). Of these 5 had therapy initiated at physician discretion in the absence of clinical deterioration at a median of 78 days post biochemical relapse, one had treatment started 38 days after relapse due to renal deterioration and two were observed for 6 months and 1.4 years prior to the development of progressive focal bone lesions on MRI. None of the 10 patients with slow biochemical relapse and no new focal MRI bone lesions developed symptomatic bone disease within 6 months of that normal MRI.Conclusion: Whole body STIR MRI identifies new focal bone lesions in half of patients with slow biochemical relapse and no other treatment indication, justifying early therapy initiation at biochemical progression. In the setting of the COVID-19 pandemic, whole body STIR MRI with DWI may also be a useful tool to identify patients with slow biochemical relapse who are suitable for careful observation rather than salvage chemotherapy. Only a minority (11% in our study) of relapses, however, are potentially suitable for this approach.DisclosuresMollee:Janssen: Membership on an entity's Board of Directors or advisory committees, Research Funding; Caelum: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Takeda: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; BMS/Celgene: Membership on an entity's Board of Directors or advisory committees.

Pyriform Sinus Fistula in Children: Preferred Imaging Modality and Risk Factors for Diagnostic Delay.

Background: Diagnostic delay of pyriform sinus fistula (PSF) continues to challenge clinicians, and the preferred imaging modality is yet to be verified. The purpose of this study was to investigate the preferred imaging modality for PSF and the possible risk factors for a longer diagnostic delay.Methods: Medical records of patients with a surgically confirmed PSF from 2014 to 2018 were retrospectively evaluated. A comparison of the first esophagography timing with a true-positive (TP) result and that with a false-negative (FN) result was made. Data of computed tomography (CT) performed immediately after esophagography were also analyzed. In addition, the factors related to diagnostic delay were analyzed using multivariate regression models.Results: A total of 147 patients ranging in age from 0 to 16 years (median: 5.2 years) were included. The mean time since the symptom onset of the first esophagography with TP result was significantly longer than that of the examination with FN result (95.18 ± 79.12 vs. 52.59 ± 42.40 days, P = 0.032). When the time since the symptom onset was less than 12 weeks, the false-negative rate (FNR) of the first esophagography was declining dramatically with a longer time interval. Among 18 cases with an FN result of the first esophagography, the fistulous tract was finally identified in seven cases using an immediate CT. The mean of diagnostic delay was 12.28 months. Besides, rural residency was an independent risk factor for a longer diagnostic delay.Conclusion: Joint examination of esophagography and an immediate CT is the preferred imaging modality for the diagnosis of PSF in children. It is inadvisable to perform the first esophagography when the time since the symptom onset is less than 12 weeks. Besides, the rural residency is an independent risk factor for a longer diagnostic delay.