Radiological Cases Research Articles

Cutaneous Squamous Cell Carcinoma Leading to a Broken Heart

SESSION TITLE: Student/Resident Lung Cancer SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: Cardiac metastases have been found in 6-20 % of autopsies of patients with metastatic malignancies (1). Secondary cardiac neoplasms, particularly lymphoma, esophageal, lung, breast cancers and melanoma are the most common (2). We report the case of an immuno-competent 58 year old man with widespread metastatic infiltration of the heart and lungs from primary cutaneous squamous cell carcinoma (cSCC). CASE PRESENTATION: 58 year old male, non-smoker, with history of resected cSCC of the back presented a year later with a new left axillary mass. Biopsy was positive for metastatic SCC. PET-CT demonstrated left metastatic axillary lymph nodes and bilateral lung nodules for which he began cisplatin and cetuximab. He became dyspneic and oxygen dependent, developing small pleural effusions that were negative for malignancy. Echocardiogram showed a hyperdynamic left ventricle without pericardial effusion. CT angiogram of chest was negative for pulmonary embolus however demonstrated progression of bilateral pulmonary nodules and lymphadenopathy. Bronchoscopy was notable for nonobstructive endobronchial lesions in the left mainstem with biopsy revealing SCC. Persistent tachycardia preceded cardiopulmonary arrest without successful resuscitation. Autopsy revealed widely metastatic squamous cell carcinoma involving heart and bilateral lungs. The heart surprisingly revealed numerous foci of metastatic moderately to poorly differentiated squamous cell carcinoma involving the septum, anterior right ventricular wall, posterior left ventricular wall, aortic arch and foci of pericardium. DISCUSSION: Cardiac metastases are clinically more difficult to diagnose pre-mortem due to nonspecific signs and symptoms. The first approach is often echocardiography, but CT and Cardiac MRI may highlight some important imaging findings (3). The prognosis of patients with cardiac metastasis remains dismal with a 5 years survival of 7% reported in the literature (2). CONCLUSIONS: Dermatologic SCC has been documented to have a potentially aggressive and fatal nature in organ transplant recipients due to long-term immunosuppression however our case illustrates this in an immune-competent host. Cardiac metastasis should be considered in patients presenting with cardiac symptoms especially when there is a history of advanced cancer. When cardiac metastases are discovered the prognosis is poor (2). Reference #1: Cheruvu B, Cheruvu P, Boyars M. An unusual case of metastasis to the left side of the heart: a case report. J Med Case Reports. 2011;5:23. doi: 10.1186/1752-1947-5-23 Reference #2: Hunter JM, Reid AL, Stride PJ, Dettrick A. Right ventricular inflow tract obstruction secondary to metastatic cutaneous squamous cell carcinoma. BMJ Case Reports. 2012;2012:bcr2012006556. doi:10.1136/bcr-2012-006556 Reference #3: Villa A, Eshja E, Dallavalle S, Bassi EM, Turco A. Cardiac metastases of melanoma as first manifestation of the disease. Journal of Radiology Case Reports. 2014;8(4):8-15. doi:10.3941/jrcr.v8i4.1700 DISCLOSURE: The following authors have nothing to disclose: Tulip Jhaveri, Kamil Rechache, Christopher Tretter, Carla Lamb No Product/Research Disclosure Information

El caso clínico: vigencia, valores y estrategias para abordar su escritura

The case report is used to communicate the experience acquired by its authors with a patient. Although its relevance has been doubted, the case report deserves to be vindicated and contextualized. We review the case report's historical tradition, recent evolution and current formats. We describe its utility as a scientific tool, a continuing education resource and an aid to diagnosis. We reflect on the teaching potential its writing entails. Finally, we provide strategies to address the writing of a radiological case report.

Immunoglobulin G4-Related Disease (IgG4-RD) Presenting as Sclerosing Cholangitis - A Radiological Case Report

Immunoglobulin G4-Related Disease (IgG4-RD) Presenting as Sclerosing Cholangitis - A Radiological Case Report

The Importance of Precise Imaging in Villonodular Synovitis of the Hip: A Radiology Case Report

The Importance of Precise Imaging in Villonodular Synovitis of the Hip: A Radiology Case Report

Instructions for Radiological Case Reports.

Purpose This paper explains the purpose and structure of a radiological case report and provides guidance for radiologists with respect tothe writing of a well-structured patient case report. Materials and Methods The current literature and the author's experience as a writer were used to create a manual that describes steps for preparing a radiological case report containing all of the important ingredients for effective communication. Results Case reports are the first line of evidence in documenting clinical observations in the literature. A case report should be written succinctly and consists of four structured main sections: introduction, description of the case, discussion and conclusion. Its structure follows the structure of an original research article, whereby the description of the case of the case report corresponds to the materials and methods section of the research article. The introduction provides the subject and merit of the case report with respect to the published literature. The case description presents the case in detail and chronological order to allow for plausibility. The discussion compares the case with the published literature and summarizes the essential features. A case report, like an original article, must provide a justified conclusion. The conclusion should be brief and be applicable to clinical practice. Conclusion The unique quality of the case, proper preparation and a clear conclusion are essential for a case report to be published. Key Points: · Case reports are the first line of evidence in documenting clinical observations in the literature. · The structure of a case report structure follows the structure of an original research article. · The unique quality of the case, proper preparation and a clear conclusion are essential for a case report to be published.. Citation Format · Bannas P. Anleitung zum Schreiben eines radiologischen Fallberichts. Fortschr Röntgenstr 2017; 189: 333 - 337.

Impact of an Interactive Diagnostic Case Simulator on a Medical Student Radiology Rotation.

The objective of our study was to assess the short-term impact of adding an interactive simulator to a medical student radiology clerkship. We hypothesized that transitioning students from passive observers to active participants in the reading room would create an appealing and effective learning experience for the current generation of students. An interactive workstation that provided diagnostic simulations of 84 cases selected to maximize exposure to important diagnoses in musculoskeletal (MSK) radiology was created. From February 2015 through July 2016, 83 students on the radiology elective rotated through MSK: 40 in the traditional observational role and 43 with the MSK simulator. At the end of the rotation, all students completed general radiology and MSK-based competency examinations. The students who used the interactive workstation completed a survey about their experience. MSK competency scores were significantly better for students who rotated with the interactive workstation compared with students in the traditional observational role (mean scores, 71% and 51%, respectively; p < 0.0001). There was no difference in end-of-rotation general competency scores between the groups (mean, 86% and 85%; p = 0.32). Ninety-one percent of students reported the simulator had at least a moderately positive impact on their radiology experience. All students (100%) reported that learning was improved and recommended establishing workstations for other subspecialties. Twenty-one percent of students reported that their experience using the simulator had a positive impact on considering radiology as a career choice. Using a reading room-based diagnostic radiology case simulator improves medical student learning, enables self-directed learning, and improves overall experience on the radiology clerkship, positively impacting consideration of radiology as a career.

Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine.

Purpose Evaluation of clinical impact regarding diagnostic and therapeutic changes influenced by interdisciplinary radiological case presentations. Materials and Methods Prospective evaluation of radiological-gastrointestinal clinical case conferences over a 1-year period at a tertiary care center. We documented the preparation (phase 1) and clinical case conference (phase 2) regarding their impact on the radiology report and further diagnostic work-up and therapy. Results 1067 examinations were evaluated in 69 clinical case conferences including 487 cases. We calculated a mean time of 35.8 minutes per conference with 5.1 minutes per case for preparation. During phase 1, major changes compared to the previous report were found in 1.2 % of cases, and no change was found in 91.4 % of cases. In phase 2 an additional relevant finding was found in 0.6 % of cases, while there was no major change to the reports in 99 % of cases. We recommended further radiological diagnostic workup in 9 % of cases and interventional radiological examination in 2.7 % of cases, while no change was documented in 83.2 %. Further radiological or surgical therapy was recommended in 7 % and 6.8 % of cases, respectively. There was no change in therapy in 78.5 % of cases. Conclusion The analysis of an interdisciplinary radiological case presentation in internal medicine shows that the case discussion with the radiologist results in a change in patient management in 37.3 % of cases (16.8 % diagnosis, 21.5 % therapy). Overall, interdisciplinary radiological clinical case conferences help to improve the management and quality of patient care. Our data support the broad implementation of radiological clinical case conferences. Key Points · The second opinion obtained during the preparation of a radiological case presentation does not change the written report in most cases.. · "Talking radiology" in radiological case presentations results in a significant change in patient management in over ⅓ of all cases.. · In radiological clinical case conferences an experienced radiologist can initiate diagnostic and interventional radiological methods that can be correctly implemented in therapeutic pathways.. · "Talking radiology" improves the quality of therapy and patient care.. Citation Format · Dendl L. M., Teufel A., Schleder S. et al. Analysis of Radiological Case Presentations and their Impact on Therapy and Treatment Concepts in Internal Medicine. Fortschr Röntgenstr 2017; 189: 239 - 246.

Forensic imaging in legal medicine in the Netherlands: Retrospective analysis of over 1700 cases in 15 years' experience

Abstract Introduction Forensic radiology in the living and postmortem is a new horizon in legal medicine for the detection and documentation of forensic evidence and reconstruction of the manner of death. A collaboration was undertaken 15 years ago between the Netherlands Forensic Institute, where all forensic autopsies in the Netherlands are performed, and the department of radiology in the Groene Hart Hospital (GHH). Methods Without exception, all forensic radiological cases performed/interpreted in the GHH between 2000 and 2015 were included in the database. Radiologic imaging was always performed in addition to autopsy or medico-legal investigation. Retrospectively, the corresponding autopsy/forensic reports were studied to obtain case information. Imaging modalities, sex, age, cause and manner of death/trauma were analyzed in both living and postmortem cases. Results A total of 1734 radiology cases was included, of which 82% was post-mortem. Male/female ratio was 2:1, mean age was 36 years (0‐98). Performed imaging modalities were: total body CT: 656, cranial CT: 571, skeletal x-ray: 349, larynx-hyoid x-ray: 327, MRI: 118. Reported preliminary diagnoses were: blunt trauma (battering: 458, blunt objects: 121, transportation accidents: 156, airplane accidents: 34, explosions: 8, falls: 137), penetrating trauma: 199, ballistic trauma: 150, asphyxial deaths (strangulation, suffocation): 305, submersion: 98, fire: 80, diseases: 156, no anatomical cause of death (discovered corpses: 159, exhumed bodies: 27, sudden unexplained death in infancy: 76). Conclusion This annually growing forensic radiological database enables data analysis in pre- and post-mortem cases and has proved to be a useful source for retrospective research and scientific collaboration.

3:00 PMAbstract No. 316 - ▪ FEATURED ABSTRACT Radiation exposure in radial versus femoral artery access in interventional radiology

Radial artery access has slowly been gaining popularity due to reduced complication rates and improved patient comfort compared to femoral artery access. However, studies have demonstrated a substantial increase (up to 100% [1]) in operator radiation exposure for radial access. We implemented a unique radial approach using a mobile lead wall placed between the operator and patient. Operator exposure with this shielded radial approach was compared to a standard femoral approach. Dose data for the principal operator and scrub technologist were measured using the RaySafe i2 staff dosimetry system for 25 interventional radiology cases: 11 radial and 14 femoral artery access. Standard radiation protection including lead aprons, table drapes, and a “floating” acrylic shield were used for all cases. For radial cases, a 1.5 mm lead equivalent mobile wall further protected the operator. For each case, staff doses (in μSv) were normalized by the total fluoroscopy reference point dose (in mGy) in order to account for differences in case complexity. Normalized staff doses were averaged for radial and femoral cases. A t-test was used for statistical significance. Radial and femoral approaches were also simulated by irradiating an anthropomorphic phantom. Dosimeters were placed at typical staff positions both with and without shielding. For each approach, shielding efficacy was determined via the ratio of shielded to unshielded doses. Operator exposure was reduced by 78% for radial access with a mobile lead wall compared to femoral access (0.009 μSv/mGy vs 0.041 μSv/mGy, p=0.03). However, there was no significant difference in radiation exposure for the scrub technologist (0.032 μSv/mGy vs 0.023 μSv/mGy, p=0.42). Phantom data revealed an average dose reduction of 99% for shielded radial cases with the addition of a mobile lead wall, versus 53% for femoral cases utilizing standard shielding. Radial artery access allows the placement of a mobile lead wall between the operator and patient, which can substantially reduce operator exposure compared to femoral access. Interventional radiologists should consider the benefits of radial access to both patients and staff when appropriate.

Honoring our helpers.

This special issue of the Journal of Radiology Case Reports honors the reviewers who donated their time and expertise throughout the year 2015 to the high quality and success of this journal.

Low-Contrast Detail Phantom: Proof of Concept

PurposeTo investigate the concept of filling the air gaps of the conventional contrast detail phantom (CDP) with various concentrations of contrast media, and to develop a variable level of attenuation-level differential phantoms that could be more appropriate for contrast measurements in some radiology cases. MethodsImages were acquired using the digital radiography system of the traditional CDP (Perspex/air hole phantom) and the novel form of CDP where the air holes were replaced with attenuating material. In this study, two different attenuating materials were introduced, water and a 30% concentration of iodine-based contrast medium. Image quality was assessed using automated processing to calculate the image quality factor (IQF)inv. Results and DiscussionPhantom studies indicate that lower contrast levels are obtained when CDP holes are filled with water and a 30% concentration of iodine contrast media than those observed for air/Perspex or traditional CDP. As an example, when a 5-mAs beam is used the IQFinv values are 5.32 in the case of air filling the holes; however, when these holes are filled with water under the same conditions, the value of the IQFinv drops to 2.55, and to 2.83 when 30% of contrast media is used. Other concentrations were also tested. These results indicate that it is possible to extend the contrast scale in these phantoms to include ranges that are more realistic for a patient's body than just air and tissue-equivalent material. ConclusionsThese findings indicate that the proposed extension of the contrast scales allows smaller changes in contrast to be discerned. This is due to the small attenuation differences of the subject materials (e.g, 30% contrast liquid and wax) from the traditional form of CDP (material/air). This suggests that the low form of the CDP may have a useful role in assessing image quality in planar radiology as an evaluation tool to better represent low-subject contrast imaging requirements.

A Vertically Integrated Online Radiology Curriculum Developed as a Cognitive Apprenticeship:: Impact on Student Performance and Learning

The principles of Collins' cognitive apprenticeship model were used to design a radiology curriculum in which medical students practice radiological skills using online case-based modules. The modules are embedded within clinical third-year clerkships, and students are provided with personalized feedback from the instructors. We describe the development of the vertical online radiology curriculum and evaluate its impact on student achievement and learning process using a mixed method approach. The curriculum was developed over a 2-year period. Student participation was voluntary in the first year and mandatory in the second year. For quantitative curriculum evaluation, student metrics for voluntary versus mandatory groups were assessed using independent sample t tests and variable entry method regression analysis. For qualitative analysis, responses from a survey of students about the value of the curriculum were organized into defined themes using consensus coding. Mandatory participation significantly improved (p = .001) the mean radiology examination score (82 %) compared to the voluntary group (73%), suggesting that mandatory participation had a beneficial effect on student performance. Potential preexisting differences in underlying general academic performance were accounted for by including mean basic science grades as the first variable in the regression model. The significant increase in R(2) from .16 to .28 when number of radiology cases completed was added to the original model, and the greater value of the standardized beta for this variable, suggest that the curriculum made a significant contribution to students' radiology examination scores beyond their baseline academic performance. Five dominant themes about curricular characteristics that enhanced student learning and beneficial outcomes emerged from consensus coding. These themes were (1) self-paced design, (2) receiving feedback from faculty, (3) clinical relevance of cases, (4) gaining confidence in interpreting radiological images, and (5) transfer of conceptual knowledge to actual practice. The vertically integrated online radiology curriculum can positively impact student performance and learning process in the context of the cognitive apprenticeship model.

A Platform-Independent Plugin for Navigating Online Radiology Cases.

Software methods that enable navigation of radiology cases on various digital platforms differ between handheld devices and desktop computers. This has resulted in poor compatibility of online radiology teaching files across mobile smartphones, tablets, and desktop computers. A standardized, platform-independent, or "agnostic" approach for presenting online radiology content was produced in this work by leveraging modern hypertext markup language (HTML) and JavaScript web software technology. We describe the design and evaluation of this software, demonstrate its use across multiple viewing platforms, and make it publicly available as a model for future development efforts.

Reconstructive dosimetry for cutaneous radiation syndrome.

According to the International Atomic Energy Agency (IAEA), a relatively significant number of radiological accidents have occurred in recent years mainly because of the practices referred to as potentially high-risk activities, such as radiotherapy, large irradiators and industrial radiography, especially in gammagraphy assays. In some instances, severe injuries have occurred in exposed persons due to high radiation doses. In industrial radiography, 80 cases involving a total of 120 radiation workers, 110 members of the public including 12 deaths have been recorded up to 2014. Radiological accidents in industrial practices in Brazil have mainly resulted in development of cutaneous radiation syndrome (CRS) in hands and fingers. Brazilian data include 5 serious cases related to industrial gammagraphy, affecting 7 radiation workers and 19 members of the public; however, none of them were fatal. Some methods of reconstructive dosimetry have been used to estimate the radiation dose to assist in prescribing medical treatment. The type and development of cutaneous manifestations in the exposed areas of a person is the first achievable gross dose estimation. This review article presents the state-of-the-art reconstructive dosimetry methods enabling estimation of local radiation doses and provides guidelines for medical handling of the exposed individuals. The review also presents the Chilean and Brazilian radiological accident cases to highlight the importance of reconstructive dosimetry.

Common procedures and strategies for anaesthesia in interventional radiology.

This review describes the range of cases now available in the interventional radiology suite and summarizes suggestions for their anaesthetic and perioperative management. The type and complexity of interventional radiology cases being performed increases from year to year. Anaesthesiologists' presence in interventional radiology is increasing in turn, due to increasingly ill patients and intricate procedures requiring more than local anaesthesia for well tolerated completion. The literature available describing this is largely written by radiologists, with little attention paid to anaesthetic considerations. Cases in interventional radiology are complex in terms of the logistics of working in an unfamiliar area, frequency of patient comorbidity and unfamiliar procedures. Ensuring familiarity with the variety of interventional radiology procedures and their periprocedure requirements can increase anaesthesiologists' comfort in interventional radiology.

Radiological Case: Cystic adventitial disease

Radiological Case: Cystic adventitial disease

Radiological Case: Perched facet

Radiological Case: Perched facet

Imaging findings of adiposis dolorosa vs. massive localized lymphedema.

Adiposis dolorosa (Dercum's disease) is a condition of benign, painful subcutaneous lipomatous lesions associated with weakness, endocrine and lipid abnormalities, and mental disturbances. There is little information documenting the cross-sectional imaging findings that differentiate it from lipomatous and neoplastic soft tissue masses, or massive localized lymphedema. The purpose of this study was to provide a radiological case series of adiposis dolorosa. A 10-year retrospective review of the picture archiving and communications system was performed. Two musculoskeletal radiologists reviewed images to confirm and document imaging features, location, size, and patient demographics. Medical records were reviewed to characterize patients into three groups: one group met at least three of the four criteria of Dercum's syndrome, the second group met less than three criteria, and the third group had clinical diagnosis of cellulitis of the lower extremity. Seventeen cases (25 masses) of adiposis dolorosa were found, nine cases of which met at least three criteria of Dercum's syndrome. All cases in the first two groups demonstrated skin thickening and lymphedema of subcutaneous fat, which was fluid attenuation on CT and low or intermediate T1-weighted and high STIR/T2-weighted MR signal. Two cases with pathology showed mild fatty infiltration with fibrous septa, and the third case showed massive localized lymphedema. The third group of ten cellulitis patients demonstrated non-mass-like subcutaneous edema with similar CT attenuation and MR signal characteristics to the first two groups, but differed by the presence of post-contrast enhancement and non-mass-like appearance in 90%. Imaging findings of adiposis dolorosa and massive localized lymphedema overlap, as do the symptoms and pathological features. Due to the mass-like engorgement of the soft tissues and pain, patients will often undergo imaging to exclude neoplasm or infection. Knowledge of these conditions and the characteristic imaging findings is important to prevent unnecessary biopsy and misdiagnosis.

Radiological Case: Orbital pseudotumor with cavernous sinus and sellar extension

Radiological Case: Orbital pseudotumor with cavernous sinus and sellar extension

1:54 PM, Abstract No. 282 - Evaluation of the efficacy of an interactive interventional radiology case based electronic tablet application on the academic development of radiology residents

1:54 PM, Abstract No. 282 - Evaluation of the efficacy of an interactive interventional radiology case based electronic tablet application on the academic development of radiology residents