Faculty Bibliography

Low dose (<3 mSv) noncontrast CT (NCCT) is the imaging study of choice for accurate evaluation of patients with acute onset of flank pain and suspicion of stone disease (sensitivity 97%, specificity 95%). NCCT can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain such as appendicitis. By comparison, the sensitivity of radiographs (59%) and ultrasound (24-57%) for the detection of renal and ureteral calculi is relatively poor. Ultrasound can accurately diagnose pelvicaliectasis and ureterectasis, but it may take several hours for these findings to develop. In the pregnant patient, however, ultrasound is a first line test as it does not expose the fetus to ionizing radiation. MR is an accurate test for the diagnosis of pelvicaliectasis and ureterectasis, but is less sensitive than CT for the diagnosis of renal and ureteral calculi. For patients with known stone disease whose stones are visible on radiographs, radiographs are a good tool for post-treatment follow-up.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

BACKGROUND: Cervical lymph node metastases from differentiated thyroid cancer (DTC) are common. Thirty to eighty percent of patients with papillary thyroid cancer harbor lymph node metastases, with the central neck being the most common compartment involved. The goals of this study were to: (1) identify appropriate methods for determining metastatic DTC in the lateral neck and (2) address the extent of lymph node dissection for the lateral neck necessary to control nodal disease balanced against known risks of surgery. METHODS: A literature review followed by formulation of a consensus statement was performed. RESULTS: Four proposals regarding management of the lateral neck are made for consideration by organizations developing management guidelines for patients with thyroid nodules and DTC including the next iteration of management guidelines developed by the American Thyroid Association (ATA). Metastases to lateral neck nodes must be considered in the evaluation of the newly diagnosed thyroid cancer patient and for surveillance of the previously treated DTC patient. CONCLUSIONS: Lateral neck lymph nodes are a significant consideration in the surgical management of patients with DTC. When current guidelines formulated by the ATA and by other international medical societies are followed, initial evaluation of the DTC patient with ultrasound (or other modalities when indicated) will help to identify lateral neck lymph nodes of concern. These findings should be addressed using fine-needle aspiration biopsy. A comprehensive neck dissection of at least nodal levels IIa, III, IV, and Vb should be performed when indicated to optimize disease control.

Men or boys, who present with acute scrotal pain without prior trauma or a known mass, most commonly suffer from torsion of the spermatic cord; epididymitis or epididymoorchitis; or torsion of the testicular appendages. Less common causes of pain include a strangulated hernia, segmental testicular infarction, or a previously undiagnosed testicular tumor. Ultrasound is the study of choice to distinguish these disorders; it has supplanted Tc-99 m scrotal scintigraphy for the diagnosis of spermatic cord torsion. MRI should be used in a problem solving role if the ultrasound examination is inconclusive. The ACR Appropriateness Criteria (R) are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Although prostate cancer can be effectively treated, recurrent or residual disease after therapy is not uncommon and is usually detected by a rise in prostate-specific antigen. Patients with biochemical prostate-specific antigen relapse should undergo a prompt search for the presence of local recurrence or distant metastatic disease, each requiring different forms of therapy. Various imaging modalities and image-guided procedures may be used in the evaluation of these patients. Literature on the indications and usefulness of these radiologic studies and procedures in specific clinical settings is reviewed. The ACR Appropriateness Criteria((R)) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

INTRODUCTION: It is a common practice to soak Titan((R)) Coloplast penile implants in antibiotic solution prior to implantation. Experience with Inhibizone impregnation suggests that rifampin coating significantly reduces infection rates of penile implant surgery. In this article we describe the results of coating Titan Coloplast penile implants with rifampin/gentamicin solution. AIM: To compare infection rates of Titan((R)) Coloplast penile implants coated with vancomycin/gentamycin, rifampin/gentamicin, and Inhibizone-impregnated American Medical Systems (AMS) penile implants. METHODS: Chart review was done for all Mentor/Coloplast and AMS implant surgeries performed at our center between the dates January 1, 2002 and February 8, 2010. Infection rates for Titan((R)) Coloplast penile implants coated with vancomycin/gentamycin, rifampin/gentamicin, and Inhibizone-impregnated (AMS) penile implants were compared. MAIN OUTCOME MEASURES: Infection rates for penile implants coated with different antibiotics. RESULTS: Infection rates for Titan((R)) Coloplast penile implants coated with vancomycin/gentamycin and Inhibizone-impregnated (AMS) penile implants was 4.4% and 1.3%, respectively (P = 0.05). None of the rifampin/gentamicin-coated Titan((R)) Coloplast penile implants have developed infection. Rifampin is the common antibiotic both in rifampin/gentamicin-coated Coloplast implants and Inhibizone((R)) . The infection rate in this combined rifampin/gentamicin-coated Titan Coloplast implants and Inhibizone-coated AMS implants group was 0.63% (P = 0.03). CONCLUSION: Both rifampin/gentamicin-coated Titan((R)) Coloplast penile implants and Inhibizone-impregnated (AMS) penile implants appear to have lower infection rates compared with vancomycin/gentamycin-coated Titan((R)) Coloplast penile implants The present study does not suggest superiority of rifampin/gentamicin-coated Titan((R)) Coloplast penile implants or Inhibizone-impregnated (AMS) penile implants but we strongly suggest that all Titan((R)) Coloplast penile implants should be coated with rifampin/gentamicin solution.

BACKGROUND/AIMS/OBJECTIVE:Sestamibi scintigraphy and neck ultrasonography have both been proposed as screening modalities for the detection of abnormal parathyroid glands in patients with primary hyperparathyroidism. As a result, many surgeons use both techniques prior to surgery. The goal of this study was to independently evaluate both ultrasound and sestamibi as single-modality preoperative screening tools for primary hyperparathyroidism. METHODS:A retrospective review of consecutive patients who underwent surgery for primary hyperparathyroidism from January 1999 to December 2009. Imaging results were compared to surgical findings. RESULTS:440 patients were found to meet inclusion criteria. Sensitivities for correct localization of a single parathyroid adenoma for sestamibi versus ultrasound were: 83% (95% CI 78-86) versus 72% (95% CI 67-76). Ultrasound operator had no influence on sensitivity, and ultrasound identified nodular thyroid disease in 31% of patients. CONCLUSION/CONCLUSIONS:Ultrasonography alone can be used as the primary screening modality in patients with primary hyperparathyroidism. Ultrasound sensitivity is conserved despite operator variability, and identifies concomitant thyroid pathology.

OBJECTIVE: This article will review the current literature regarding the detection of thyroid nodules with an emphasis on CT diagnosis. We will also discuss management strategies. CONCLUSION: With advances in cross-sectional imaging, the detection of incidental thyroid nodules has increased significantly. Detection of thyroid nodules is common on chest CT that is being performed for unrelated reasons. The workup of these nodules can be timeconsuming and expensive.

Small cell osteosarcoma may present a challenging primary diagnosis on cytologic assessment owing to its rarity and its morphologic similarity to other small round blue cell tumors. Five cases of small cell osteosarcoma from our cytopathology archives were identified and reviewed and cytologic features elaborated. Three cases were fine-needle aspirations from bony lesions in the classic location for osteosarcoma (2 distal femur and 1 proximal tibia), and 2 aspirations were from metastases. Common cytomorphologic features included relatively small to intermediate cell size, high nuclear/cytoplasmic ratios, round nuclei, minimal anisonucleosis, finely granular nuclear chromatin, fine cytoplasmic vacuoles, and only rare osteoid. Small cell osteosarcoma shares many of the well-described cytomorphologic features of classic osteosarcoma, but the relatively small cells, round hyperchromatic nuclei, and scant osteoid constitute the common denominator. Correlation with radiographic findings and ancillary tests can aid in definitive diagnosis.

Ultrasonography (US) is the single-most valuable imaging modality in the evaluation of the thyroid gland. This review discusses the US appearances of thyroid nodules, emphasizing sonographic features associated with potentially malignant or, at the other end of the spectrum, likely benign nodules. Diffuse thyroid abnormalities have also been reviewed. The technique of ultrasound-guided fine-needle aspiration biopsy and the emerging role of elastography in characterizing thyroid nodules have also been addressed.

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