Radiology Pathology Research Articles

PathBot: A Radiology-Pathology Correlation Dashboard.

Pathology is considered the "gold standard" of diagnostic medicine. The importance of radiology-pathology correlation is seen in interdepartmental patient conferences such as "tumor boards" and by the tradition of radiology resident immersion in a radiologic-pathology course at the American Institute of Radiologic Pathology. In practice, consistent pathology follow-up can be difficult due to time constraints and cumbersome electronic medical records. We present a radiology-pathology correlation dashboard that presents radiologists with pathology reports matched to their dictations, for both diagnostic imaging and image-guided procedures. In creating our dashboard, we utilized the RadLex ontology and National Center for Biomedical Ontology (NCBO) Annotator to identify anatomic concepts in pathology reports that could subsequently be mapped to relevant radiology reports, providing an automated method to match related radiology and pathology reports. Radiology-pathology matches are presented to the radiologist on a web-based dashboard. We found that our algorithm was highly specific in detecting matches. Our sensitivity was slightly lower than expected and could be attributed to missing anatomy concepts in the RadLex ontology, as well as limitations in our parent term hierarchical mapping and synonym recognition algorithms. By automating radiology-pathology correlation and presenting matches in a user-friendly dashboard format, we hope to encourage pathology follow-up in clinical radiology practice for purposes of self-education and to augment peer review. We also hope to provide a tool to facilitate the production of quality teaching files, lectures, and publications. Diagnostic images have a richer educational value when they are backed up by the gold standard of pathology.

Pre-oncall key conditions training for first-year radiology registrars.

The Royal Australian and New Zealand College of Radiology (RANZCR) recognised the importance of experience in on-call and emergency radiology for first-year registrars by introducing 'Key conditions in Year 1 training'. This list of common radiological pathologies can help to focus preparations for new registrars as they prepare for after-hours duties. The Royal Brisbane and Women's Hospital (RBWH) implemented a 12-week formal training programme, based on this curriculum, for new registrars prior to commencing after-hours work. Its impact was assessed by an image recognition and interpretation examination that was administered to registrars before and after training. Examination results revealed that the prescribed training programme significantly increased both the rate and accuracy of reporting, and that improvements in speed were not at the expense of accuracy. Furthermore, it showed that a 12-week training programme was able to improve novice radiology registrars' ability to detect radiological abnormalities above that of experienced emergency department clinicians. Performances of consultant radiologists were used as a 'gold standard' control. This research demonstrates the value of a formal training programme in preparing registrars for extended after-hours reporting duties and contributing to important departmental service provision.

Cocoon Syndrome: A Rare Entity

Sclerosing encapsulating peritonitis (SEP) is an uncommon condition characterized by the encasement of small bowel due to a thick fibrotic coverage. This entity is usually related to several diseases, highlighting among them the peritoneal dialysis, and less frequent is the primary or idiopathic peritoneal sclerosis or cocoon syndrome. SEP is clinically variable, depending on the severity and duration of the disease, the underlying causes and the patient’s immune status. The most common presentation is intestinal obstruction. It is rarely presented as a complication such as enterocutaneous fistulas, intestinal necrosis and malnutrition. Intestinal perforation is quite uncommon in patients with SEP. We present a case of cocoon syndrome in a 67-year-old man and describe his clinical onset, radiology and anatomical pathology findings. J Curr Surg. 2017;7(4):69-71 doi: https://doi.org/10.14740/jcs334e

Viral and Prion Infections of the Central Nervous System: Radiologic-Pathologic Correlation: From the Radiologic Pathology Archives.

Viral infections of the central nervous system (CNS) range in clinical severity, with the most severe proving fatal within a matter of days. Some of the more than 100 different viruses known to affect the brain and spinal cord are neurotropic with a predilection for producing CNS infection. The host response to viral infection of the CNS is responsible for the pathophysiology and imaging findings seen in affected patients. Viral CNS infections can take the form of meningitis, encephalitis, encephalomyelitis, or, when involving the spinal cord and nerve roots, encephalomyeloradiculitis. In 1982, an infectious particle termed a prion that lacked nucleic acid and therefore was not a virus was reported to produce the fatal neurodegenerative disease Creutzfeldt-Jakob disease and related disorders. These prion diseases produce characteristic neuroimaging findings that are distinct from those seen in most viral infections. The clinical and imaging findings associated with viral CNS infection are often nonspecific, with microbiologic analysis of cerebrospinal fluid the most useful single test allowing for diagnosis of a specific viral infection. This review details the spectrum of viral CNS infections and uses case material from the archives of the American Institute for Radiologic Pathology, with a focus on the specific clinical characteristics and magnetic resonance imaging features seen in these infections. Where possible, the imaging features that allow distinction of these infections from other CNS inflammatory conditions are highlighted.

Adjacent Segment Pathology: Progressive Disease Course or a Product of Iatrogenic Fusion?

Cervical spine clinical adjacent segment pathology (CASP) has a reported 3% annual incidence and 26% ten-year prevalence. Its pathophysiology remains controversial, whether due to mechanical stress of a fusion segment on adjacent levels or due to patient propensity to develop progressive degenerative change. We investigate this relationship by comparing prevalence of CASP in traumatic and spondylotic patient cohorts. A retrospective review of traumatic cervical spine fusion cases performed by the local group of neurosurgeons from 2004-2008 was completed. Surgery for CASP and presence of radiological adjacent segment pathology (RASP) were identified by telephone and electronic medical record (EMR) review, and compared to those in patients having elective cervical fusion for degenerative disease. There was a higher proportion of males (50/100 vs. 37/46, p0.05). Mean follow-up times were different (6.4 years in the trauma group, 7.1 years in the degenerative group; p<0.01), although this was not thought to be clinically significant. The degenerative group was found to have a significantly higher reoperation rate for CASP (10/100 vs. 0/46, p=0.031, Fisher's Exact Test), and rate of RASP (20/100 vs. 1/32, p=0.025) Conclusion: This is the only cohort study to our knowledge comparing surgery for CASP in trauma patients to those with degenerative disease. A higher rate of repeat surgery in degenerative disease patients was found. This suggests that CASP is more related to patient factors predisposing to progressive degenerative disease and not increased mechanical stress.

A Conceptual Overview of Axonopathy in Infants and Children with Allegedly Inflicted Head Trauma.

Fatal, allegedly inflicted pediatric head trauma remains a controversial topic in forensic pathology. Recommendations for systematic neuropathologic evaluation of the brains of supposedly injured infants and children usually include the assessment of long white matter tracts in search of axonopathy - specifically, diffuse axonal injury. The ability to recognize, document, and interpret injuries to axons has significant academic and medicolegal implications. For example, more than two decades of inconsistent nosology have resulted in confusion about the definition of diffuse axonal injury between various medical disciplines including radiology, neurosurgery, pediatrics, neuropathology, and forensic pathology. Furthermore, in the pediatric setting, acceptance that "pure" shaking can cause axonal shearing in infants and young children is not widespread. Additionally, controversy abounds whether or not axonal trauma can be identified within regions of white matter ischemia - a debate with very significant implications. Immunohistochemistry is often used not only to document axonal injury, but also to estimate the time since injury. As a result, the estimated post-injury interval may then be used by law enforcement officers and prosecutors to narrow "exclusive opportunity" and thus, identify potential suspects. Fundamental to these highly complicated and controversial topics is a philosophical understanding of the diffuse axonal injury spectrum disorders.

Difficulty in Diagnosing Secondary Peripheral Chondrosarcoma: Radiology versus Anatomical Pathology

Chondrosarcoma is a malignant tumor derived from bone cartilage. This tumor can be either primary or secondary. Secondary chondrosarcoma has some differences compared to the primary type i.e. the incidence is rarer, the younger age group, and many are low grade. The authors report a case of a 26-year-old man came to Hasan Sadikin Hospital with a chief complaint of a lump in the right thigh with mild pain since 5 months before consulation that is increasingly enlarging. After undergoing physical and radiological examinations, the patient was diagnosed with suspect chondrosarcoma in right thigh. Histopathologic examinations were performed 2 times, one of which used ultrasound guidance, giving a diagnosis of chondroma in right thigh. However the lesion was finally treated as chondrosarcoma. We suspected that the patient was more likely to suffer from secondary peripheral chondrosarcoma originating from malignant transformation of multiple osteochondromas. As widely known, it is almost impossible to differentiate between the low grade chondrosarcoma and chondroma with full certainty and this poses a classical problem in diagnostic medicine. Case described here was an example of the difficulty in distinguishing between these two diseases. Key words: secondary chondrosarcoma, peripheral chondrosarcoma, chondrosarcoma arising in osteochondroma

Diagnosis of Periprosthetic Infection - What's Obligation, What's Optional?

Periprothetic infection after primary or revision arthroplasty is of increasing importance. The incidence of infection in primary arthroplasty is approximately 1 %. Revision arthroplasty has higher infection rates, which increase with the number of revision surgeries. Aim of this Paper: An overview of the current diagnosis of periprosthetic infection. This selective analysis is based on a lecture by the author at the DKOU 2015. Periprosthetic infection is taken as having been demonstrated when either two periprosthetic cultures contain the same microorganism, or if there is a fistula communicating with a joint. If only minor criteria are met, the detection of an infection is more difficult. The medical history only provides supporting evidence, especially as regards the course of the pain. Physical examination is more helpful, especially if there is redness, swelling, heat or wound dehiscence. Radiological pathologies, such as osteolysis or bone resorption can only be found in advanced infections. Nuclear medicine scans only possess acceptable sensitivity and specificity in combination with leukocyte scintigraphy. ESR, CRP and leukocyte blood count of the blood are of poor specificity. Important and targeted diagnostic steps include joint aspiration under aseptic conditions, although this exhibits a relatively high rate of false negative results. The conditions for this must be stringently observed. This is usefully complemented by cytological examinations and biopsies for tissue culture. Sensitivity and specificity are then increased. Sonication can significantly enhance the detection of an infection. The leukocyte esterase test is inexpensive and easy to perform and is therefore very much in vogue at the moment; however it is useless if there is contamination with blood. Recent studies indicate that the alpha-defensin test possesses high sensitivity and specificity, but has the disadvantage of being expensive. In patients with suspected periprosthetic infection, the primary aim is either to exclude an infection, or to detect a pathogen. The essential components are careful evaluation of the medical history, accompanied by imaging and laboratory tests. A critical approach is essential. Joint aspiration has become the gold standard in detecting periprosthetic infections. This should be performed in conjunction with a cytological analysis of the synovial fluid. An improvement in sensitivity and specificity can be archived by taking tissue samples. Sonication significantly improves the results. The latter method, the leukocyte esterase test and the alpha-defensin test are optional. The essential components are a rigorous evaluation, a clear algorithm and interdisciplinary collaboration with microbiologists and possibly infectiologists.

Using complexity theory to develop a student-directed interprofessional learning activity for 1220 healthcare students.

BackgroundMore and better interprofessional practice is predicated to be necessary to deliver good care to the patients of the future. However, universities struggle to create authentic learning activities that enable students to experience the dynamic interprofessional interactions common in healthcare and that can accommodate large interprofessional student cohorts. We investigated a large-scale mandatory interprofessional learning (IPL) activity for health professional students designed to promote social learning.MethodsA mixed methods research approach determined feasibility, acceptability and the extent to which student IPL outcomes were met. We developed an IPL activity founded in complexity theory to prepare students for future practice by engaging them in a self-directed (self-organised) learning activity with a diverse team, whose assessable products would be emergent creations. Complicated but authentic clinical cases (n = 12) were developed to challenge student teams (n = 5 or 6). Assessment consisted of a written management plan (academically marked) and a five-minute video (peer marked) designed to assess creative collaboration as well as provide evidence of integrated collective knowledge; the cohesive patient-centred management plan.ResultsAll students (including the disciplines of diagnostic radiology, exercise physiology, medicine, nursing, occupational therapy, pharmacy, physiotherapy and speech pathology), completed all tasks successfully. Of the 26 % of students who completed the evaluation survey, 70 % agreed or strongly agreed that the IPL activity was worthwhile, and 87 % agreed or strongly agreed that their case study was relevant. Thematic analysis found overarching themes of engagement and collaboration-in-action suggesting that the IPL activity enabled students to achieve the intended learning objectives. Students recognised the contribution of others and described negotiation, collaboration and creation of new collective knowledge after working together on the complicated patient case studies. The novel video assessment was challenging to many students and contextual issues limited engagement for some disciplines.ConclusionsWe demonstrated the feasibility and acceptability of a large scale IPL activity where design of cases, format and assessment tasks was founded in complexity theory. This theoretically based design enabled students to achieve complex IPL outcomes relevant to future practice. Future research could establish the psychometric properties of assessments of student performance in large-scale IPL events.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0717-y) contains supplementary material, which is available to authorized users.

Twinkle artefact in the ultrasound diagnosis of superficial epidermoid cysts.

The aim of the study was to evaluate whether the twinkle artefact is a valuable feature in the sonographic diagnosis of superficial epidermoid cysts. A retrospective search was undertaken of our institution's Radiology Information System and pathology database to identify cases of superficial masses showing the twinkle artefact that proceeded to surgical excision. Eighteen superficial masses demonstrating the twinkle artefact were identified that were submitted for pathological analysis. Of these, 17 were confirmed to represent epidermoid cysts and only 1 case had an alternative diagnosis (proliferating trichilemmal cyst). The presence of the twinkle artefact appears to be a specific and valuable ancillary sonographic feature for the diagnosis of superficial epidermoid cysts.

Clinical and radiologic characteristics of craniomaxillofacial primary tumor induced osteomalacia: a retrospective analysis

To investigate the diagnosis strategy, radiology and clinical pathology feature of craniomaxillofacial primary tumor induced osteomalacia. Twelve cases of craniomaxillofacial primary tumor induced osteomalacia were reviewed, including 5 male and 7 female with a age range from 16 to 69 years. The clinical characteristics, radiology examinations and pathological features were analyzed. The craniomaxillofacial primary tumor induced osteomalacia occurred in different ages, with 2 to 30 years of medical history. Seven of the twelve cases were octreotide scintigraphy positive, nine of the twelve cases invaded bone, exhibiting destruction of the adjacent cortex, ten of the twelve showed gingival lesions of local thickening or epulis. The tumor arises from mesenchymal tissue, infiltrating local gingiva and bone trabecular with spindle like fibroblasts and dental epithelial rests. The concealed nature of the tumor induced osteomalacia requires multiple methods to locate the primary tumor and the tumors located in craniomaxillofacial region have unique clinical and pathological features.

Fine-Needle Aspiration Biopsy of Palpable Breast Masses: Patterns of Clinical Use and Patient Experience.

Timeliness is an important and recognized measure of health care quality. Multiple health organizations worldwide have published timeliness targets for breast cancer care. We performed the first comparison of patient wait times and utilization patterns for palpable breast mass diagnosis and treatment with regard to biopsy method. Palpable breast masses in women biopsied via a fine-needle aspiration (FNA) or core biopsy at 2 affiliated academic medical centers in 2009 were analyzed if subsequently treated with excision or neoadjuvant therapy. Patient demographics, mass size and radiologic features, pathology diagnoses, and wait times to diagnosis and treatment were recorded. Patients diagnosed by FNA biopsy received their biopsy diagnosis more than 8 days sooner than those diagnosed by core biopsy. Most FNA biopsies occurred the same day the patient clinically presented. Time to treatment did not differ significantly between groups. Both biopsy methods demonstrated comparable diagnostic accuracy. Breast masses diagnosed by FNA biopsy had Breast Imaging Reporting and Data System (BI-RADS) scores ranging from 1 through 5, whereas nearly all core biopsy cases had a BI-RADS score of 4 or greater. All patient groups were demographically comparable and presented with similar breast mass sizes. Wait times for breast biopsies were significantly shorter for patients diagnosed by FNA compared with core biopsy. FNA biopsy was often used to evaluate breast masses of low clinical suspicion. In light of health care goals for practice improvement and cost containment, breast FNA biopsy may be an underused resource.

Farmer's Lung Disease. A Review

Farmer's lung disease (FLD) is a form of hypersensitivity pneumonitis (HP) caused by inhaling microorganisms from hay or grain stored in conditions of high humidity in the agricultural workplace. It is probably underdiagnosed, especially in northern Spain, where climatic conditions favor the development of this disease.According to previous studies, the most common antigens are usually thermophilic actinomycetes and fungi. The epidemiology of the disease is not well known, and is based on studies conducted by Central European and Asian groups.The clinical presentation may vary, differentiating the chronic (exposure to lower concentrations of the antigen over a longer period time) and the acute forms (after exposure to high concentrations of the antigen). In patients with respiratory symptoms and agricultural occupational exposure, radiological, lung function and/or anatomical pathology findings must be compatible with FLD, bronchoalveolar lavage must show lymphocytosis, and tests must find sensitivity to the antigen.The main treatment is avoidance of the antigen, so it is essential to educate patients on preventive measures. To date, no controlled studies have assessed the role of immunosuppressive therapy in this disease. Corticosteroid treatment has only been shown to accelerate resolution of the acute forms, but there is no evidence that it is effective in preventing disease progression in the long-term or reducing mortality.

Is it Necessary to Fuse to S1 for the Tilted L5 in the Treatment of Adult Degenerative Scoliosis?

Introduction The extension of fusion to S1 compared with L5 and lower thoracic levels compared with L1 remains a highly controversial topic in the surgical treatment for adult degenerative scoliosis (ADS). As one of the criterion, if the tilted L5 were over 15°, the distal fusion level should extend to the sacrum. Could the tilted L5 be neutralized and the L5S1 be saved in the ADS correction? Material and Methods Posterior one stage of facetectomy and interbody release combined with key segment anterior structural column support were used to treat 32 ADS cases. The thoroughly interbody release and fusion were done with both side in all involved segment, a little bigger inserter were inserted into L3,4 and L4,5 cave side to neutralize the tilted L5 maximally. The operating time and the blood loss were recorded. Mean follow-up was at least two years. All the subjects were analyzed by visual analog scale, Oswestry Disability Index (ODI), and SF-36 scores, SRS 22 before and after surgery and at follow-up. The scoliotic curve, thoracic kyphosis, lumbar lordosis, pelvic incidence (PI), pelvic tilt (PT), sacral slope, and C7 plumb line were measured. For the statistical analysis, multivariate multiple regression models were formulated, considering as significant ( p &lt; 0.05). Results The average operating time were 150min and the mean blood loss were 520ml. A statistically significant clinical and radiological amelioration was noted after surgery and at final follow-up. The ODI, and SF-36 scores, SRS 22 improved. The Cobb angle of lumbar lordosis (7 plumb line) and spino-pelvic parameters (PI, PT, sacral slope) returned to the normal range after surgery. L5S1 radiological adjacent segment pathology (RASP) happened in two cases at the follow-up, one was extended to the S1,there is no symptom in another case. Conclusion The tilted L5 can be neutralized and the L5S1 can be saved in the ADS correction. Even with a little movement, the saved L5S1 is important for a whole body to balance.

Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 1. The 1st Decade: From the Radiologic Pathology Archives.

Wilms tumor is the second most common pediatric solid tumor and by far the most common renal tumor of infants and young children. As most tumors are large at presentation and are treated with nephrectomy, the role of imaging is primarily in preoperative planning and evaluation for metastatic disease. However, with treatment protocols increasingly involving use of preoperative (neoadjuvant) chemotherapy (the standard in Europe) and consideration of nephron-sparing surgery, the role of imaging is evolving to include providing initial disease staging information and a presumptive diagnosis to guide therapy. Differential diagnostic considerations include lesions that are clinically benign and others that require more intensive therapy than is used to treat Wilms tumor. In part 1 of this article, the unique histologic spectrum of renal neoplasms of infants and young children is reviewed with emphasis on radiologic-pathologic correlation. Part 2 will focus on renal tumors of older children and adolescents.

Revisión de la enfermedad del pulmón de granjero

Farmer's lung disease (FLD) is a form of hypersensitivity pneumonitis (HP) caused by inhaling microorganisms from hay or grain stored in conditions of high humidity in the agricultural workplace. It is probably underdiagnosed, especially in northern Spain, where climatic conditions favor the development of this disease.According to previous studies, the most common antigens are usually thermophilic actinomycetes and fungi. The epidemiology of the disease is not well known, and is based on studies conducted by Central European and Asian groups.The clinical presentation may vary, differentiating the chronic (exposure to lower concentrations of the antigen over a longer period time) and the acute forms (after exposure to high concentrations of the antigen). In patients with respiratory symptoms and agricultural occupational exposure, radiological, lung function and/or anatomical pathology findings must be compatible with FLD, bronchoalveolar lavage must show lymphocytosis, and tests must find sensitivity to the antigen.The main treatment is avoidance of the antigen, so it is essential to educate patients on preventive measures. To date, no controlled studies have assessed the role of immunosuppressive therapy in this disease. Corticosteroid treatment has only been shown to accelerate resolution of the acute forms, but there is no evidence that it is effective in preventing disease progression in the long-term or reducing mortality.

A new classification system of patellar instability and patellar maltracking.

To date there is no classification of patellar dislocations considering clinical and radiological pathologies. As a result many studies mingle the dislocation's underlying pathologies, so that there are no consistent therapy recommendations. It is this article's objective to introduce a patellar dislocation classification based on the current literature to allow for the application of a structured diagnosis and treatment algorithm. The classification is based on instability criteria as well as on clinical and radiological analyses of maltracking and on loss of patellar tracking. There are five types of patellar instability and maltracking. The rare type 1 is a simple (traumatic) patellar dislocation without maltracking and instability with a low risk of redislocation. Type 2 has a high risk of redislocation after primary dislocation; there is no maltracking. Here, a stabilising operation (in most cases MPFL reconstruction) is indicated and sufficient. Type 3 shows both instability and maltracking. Maltracking is mainly caused by: (a) soft tissue contracture, (b) patella alta, (c) pathological tibial tuberosity-trochlea groove distance, (d) valgus deviations and (e) torsional deformities. Stabilisation by means of isolated MPFL reconstruction is not sufficient in these types and additional osseous corrective surgeries are required to achieve physiological patellar tracking and to prevent redislocation. Type 4 features a highly unstable "floating patella" with complete loss of tracking caused by severe trochlear dysplasia. Therapy of choice is trochleoplasty, and if necessary combined with bony and soft-tissue procedures. Type 5 shows a patellar maltracking without instability. Maltracking can only be fixed by means of corrective osteotomy. The classification is referenced to current literature and each type is introduced by a case example. The resulting treatment consequence is also presented.

ATİPİK DİŞ AĞRISI

Atypical odontalgia is a chronic pain disorder without any obvious clinical and radiological pathology at the site of pain. The pain is usually dull and continuous. Pain initiates mostly after common dental treatments performed by dentists. Etiology, diagnosis criteria and management of atypical odontagia have not been clarified yet. Present review focused to emphasis that dentists should avoid further invasiv treatments when presence of ongoing tooth pain in spite of carrying out all known dental treatments

Singapore Cancer Network (SCAN) Guidelines for the Initial Evaluation, Diagnosis and Management of Retroperitoneal Soft Tissue Sarcoma

The SCAN sarcoma workgroup aimed to develop Singapore Cancer Network (SCAN) clinical practice guidelines for the initial evaluation, diagnosis and management of patients with retroperitoneal soft tissue sarcoma. The workgroup utilised a consensus approach to create high quality evidence-based clinical practice guidelines suited for our local setting. Various international guidelines from the fields of radiology, pathology, surgical, medical and radiation oncology were reviewed. Recommendations on the role of radiological imaging, pathology, surgery, radiotherapy and systemic therapy in the management of retroperitoneal soft tissue sarcoma were developed. These guidelines form the SCAN Guidelines 2015 for the diagnosis, staging and optimal management of patients with retroperitoneal soft tissue sarcoma.

Murphy's Law: What Can Go Wrong in the Gallbladder.

1From the Departments of Radiologic Sciences (N.W., R.M., B.M.K., M.K.P.) and Pathology (J.P.), UCLA Medical Center, 757 Westwood Plaza, Ste 1638, Los Angeles, CA 900957473; and Department of Radiology, Olive View–UCLA Medical Center, Sylmar, Calif (C.M.J., M.K.P.). Recipient of a Certificate of Merit award for an education exhibit at the 2013 RSNA Annual Meeting. Received April 10, 2014; revision requested October 6 and received February 1, 2015; accepted February 16. All authors have disclosed no relevant relationships. Address correspondence to N.W. (e-mail: nwoldenberg@mednet.ucla.edu). The full digital presentation is available online.