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Everything you need to know about Computed Tomography (CT) & CT Scanning

May 2021 Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ May 2021

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3D and Workflow

  • “Blinded reading is the process by which imaging studies in clin- ical trials are evaluated by independent radiologists. The method by which imaging studies are submitted to blinded independent reviewers for evaluation of clinical endpoints is referred to as independent central review. Although methods for blind- ed reading vary across trials, several key components of reading design are common. Before evaluating treatment response, trial design teams typically discretely outline methods of image ac- quisition and the specific methods by which imaging will be eval- uated (e.g., RECIST 1.1 criteria, specific scoring criteria). Adju- dication is the process by which disagreements between readers are resolved in a systemic manner. Because of the issue of vari- ability in interpretation between readers, studies often are con- ducted by consensus or double reading with various methods of adjudication disagreements among readers.”  
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Phase 0  
    ”Given the high rate of failure of anticancer drug development, the FDA released exploratory investigational new drug guidance in 2006 to start pilot clinical studies after limited preclinical toxicology studies. In these pilot studies, called phase 0 clinical trials, new drugs are administered in limited doses to a small number of patients with the aims of selecting the lead agent from multiple analogue entities, modulating the drug tar- get in human samples of a tumor in vivo, and assessing pharmacokinetic and pharmacodynamic characteristics. Phase 0 clinical trials have no treatment intent.  In phase 0 clinical trials, molecular imaging in the form of PET with a radiolabeled drug is frequently used to study pharmacokinetics, drug distribution in the body and tumor, and correlation with drug uptake and drug target expression. Given that microdose studies have no treatment intent, studies are commonly not evaluated for response, and TRC are not applied. Because of the low dose of radiopharmaceutical administered, less than 1% of the therapeutic dose, direct toxicity is typically not observed.”
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Phase 1  
    Phase 1 trials are commonly performed with a small sample of patients to evaluate the safety, tolerability, and maximal tol- erated dose of a novel drug, which is commonly tested across a range of doses. Pharmacokinetic and pharmacodynamic properties of the drug can be studied with various functional imaging techniques, including PET and SPECT and dynamic contrast-enhanced MRI and CT . When the efficacy of a drug is tested, CT, MRI, or FDG PET is performed, and response is evaluated with TRC according to the study designing (Table 1). RECIST are commonly used for evaluation of oncologic treatment re- sponse, and imaging-based RECIST classification has been found to correlate with overall survival in phase 1 trials. Adverse events are generally reported by means of the National Cancer Institute CTCAE.  
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111

  • Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Phase 2  
    Phase 2 clinical trials, also called therapeutic exploratory stud- ies, are designed to evaluate the safety and efficacy of the drug being studied within a targeted patient population. In most cases, phase 2 trials test the study drug on patients with one specific cancer type on the basis of data gathered from preclinical studies and phase 1 clinical trials. Phase 2 trials can be single- or double-arm randomized single-center or multicenter, and the therapy tested can be first-line or performed on patients who have undergone prior treatment. These trials are common- ly performed with hundreds of patients. The data on efficacy and safety gathered are used to decide whether further investments in larger, expensive trials should be pursued.  Response in phase 2 trials is commonly assessed with RECIST, although various trials have used alternative TRC, according to cancer type and study drug. In some cases, progression according to more than one set of TRC is used as a surrogate end- point for survival. Adverse events are reported, commonly according to CTCAE.  
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Phase 3  
    “Evidence from prior studies regarding drug safety and efficacy prompts the pursuit of phase 3 trials, referred to as a therapeu- tic confirmatory studies, which are randomized multicenter trials performed in a large population . The aim of these trials is to obtain robust evidence of efficacy and tolerability of the drug in the study population . These studies involve hundreds to thou- sands of patients and are frequently double-blind, double-arm studies comparing the study drug with either a placebo or, in oncologic trials, the current standard of care . Statistical analysis may be performed at the end of the trial or through interim analyses. Endpoints are commonly PFS or overall survival and safety. Most phase 3 RCTs are conducted to evaluate PFS with RECIST and CT; few studies are conducted with MRI or molecular imaging. Alternative criteria may be used as an adjunct. Regarding safety, phase 3 trials usually test a drug on hundreds to a few thousand patients and have the statistical power to establish an adverse event rate of no less than 1%, but in rare in- stances potentially severe adverse events might be missed. The FDA usually requires more than one phase 3 trial to establish drug safety and efficacy and to grant approval.”
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Phase 4  
    “Once a drug has been granted FDA approval, a phase 4, or post- marketing, study is initiated by the sponsor. The aim of this type of trial is to identify less common adverse reactions and evaluate the costs and efficacy of the approved drug in populations different from the original study population.”
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • "Given the known limitations and ongoing efforts to improve efficiency in the approval of novel anticancer therapeutics, cli ical trials will likely continue to evolve. There exist many limitations of standard imaging response criteria, which may not cor- relate with therapeutic effect for many classes of molecular targeted therapies and immune-checkpoint inhibitors. There are also ongoing efforts to promote the development and validation of quantitative imaging methods and tools for the measurement of tumor response to therapies in clinical trials, which could facilitate more accurate evaluation of response. Examples of such novel methods include those proposed by the Quantitative Imaging Network promoted by the National Cancer Institute, the Quantitative Imaging Biomarkers Alliance organized by the Radiological Society of North America, and the American College of Radiology Imaging Network. Various emerging quantitative imaging methods are being developed for use in clinical trials, such as perfusion measurements (dynamic contrast-enhanced MRI and dynamic contrast-enhanced CT), cellularity measurements (DWI, ADC), metabolic measurements (FDG PET, 18F-fluorothymidine (FLT)-PET), and radiomic measurements, such as texture analysis. “
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
  • “Knowledge of the concept of clinical trials is critical not only for oncologists but also for radiologists and other medical professionals. The widespread use of different imaging modalities for patients undergoing clinical trial treatments necessitates an understanding of the fundamental methods underlying oncology clinical trials. As the number of clinical trials continues to increase, radiologists will be tasked with interpreting an increasing number of imaging studies for patients in clinical trials. Methods of conducting and analyzing oncology clinical trials have continued to evolve in recent years. A thorough understanding of modern oncology clinical trial structures and future directions in clinical trials will continue to be beneficial in the realm of clinical imaging.”  
    Cancer Clinical Trials: What Every Radiologist Wants to Know but Is Afraid to Ask  
    Francesco Alessandrino et al.
    AJR Am J Roentgenol. 2021 Apr;216(4):1099-1111
Adrenal

  • “Adrenal collision tumor is a rare tumor defined as the coexistence of two or more adjacent but histologically distinct neoplasms in the adrenal gland without a histological admixture at the interface.”  
    A collision between vascular adrenal cyst and  adrenocortical adenoma
    Hiroko Tagawa et al.
    Radiology Case Reports 16 (2021) 1294–1299 
Colon

  • However, a colonoscopy is the most common cause of iatrogenic splenic injury (in comparison to other procedures or surgeries). The risk factors for splenic injury are both patient and operator dependent. Patient-dependent factors include pre-existing enlargement of the spleen, surgical adhesions, inflammatory bowel disease, and severe diverticular disease. Operator dependent factors include placing the patient on their back, excessive traction, over sedation, slide by advancement, and applying excessive external pressure. Despite these factors, it is still difficult to discern if the complication is unpredictable or directly related to technical factors given rarity of this complication.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy.  
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
Deep Learning

  • “The multivariable logistic regression model included sex, size, location, shape, cyst characteristic, and cystic wall thickening. The individualized prediction nomogram showed good discrimination in the training sample (AUC 0.89; 95% CI 0.83–0.95) and in the validation sample (AUC 0.81; 95% CI 0.70–0.94). If the threshold probability is between 0.03 and 0.9, and > 0.93 in the prediction model, using the nomogram to predict SCN and MCN is more beneficial than the treat-all- patients as SCN scheme or the treat-all-patients as MCN scheme. The prediction model showed better discrimination than the radiologists’ diagnosis (AUC = 0.68).”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • All tumors were evaluated for the following characteristics: (1) CT-reported tumor size (i.e., the maximum cross-sectional diameter of the tumor [13]); (2) tumor location: pancreatic head, body, or tail; (3) shape: round or lobulated (lobulation was defined as the presence of rounded contours that could not be described as the borders of the same circle [9]); (4) cyst characteristic: oligocystic or polycystic; (5) cystic wall: thin or thick (thin was defined as < 2 mm while thick was defined as ≥ 2 mm [9]); (6) calcification; (7) enhanced mural nodule; (8) parenchymal atrophy; (9) common bile duct cutoff and dila- tion (> 10 mm); (10) main pancreatic duct (MPD) cutoff and dilation (> 3 mm); (11) pancreatitis identified by stranding of the peripancreatic fat tissue, ill-defined parenchymal contours, and fluid collections in the peripancreatic region; (12) contour abnormality; and (13) number of lesions: 1 or ≥ 2.  
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • “There were several limitations to this study. First, the number of patients was relatively small. Second, this was a single-center, retrospective analysis. In the future, we will expand the number of cases and perform a multi-center validation of the model. Third, the predicted model in this study only focused on SCN and MCN, and did not include other cystic lesions of the pancreas such as IPMN, pseudocyst, and retention cyst. Lastly, we only used CT characteristics to develop the model. We did not combine radiomics features, although artificial intelligence is becoming a hot topic. In the future, we will combine the CT characteristics and radiomics features to develop a more accurate model.”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • “Lastly, we only used CT characteristics to develop the model. We did not combine radiomics features, although artificial intelligence is becoming a hot topic. In the future, we will combine the CT characteristics and radiomics features to develop a more accurate model.”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3  
  • “Pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) is associated with a dire prognosis and a 5-year survival rate of only 10%. This statistic is somewhat misleading given that 52% of the patients will develop metastatic disease, with a resulting 2.9%, 5-year relative survival rate. However, for those patients with localized cancer where the tumor is confined to the primary site, the 5-year relative survival rate is 39.4%. It is estimated that in 2020, there will be 57,600 new cases of PDAC  and an estimated 47,050 will die of this disease.”  
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Pancreatic ductal adenocarcinoma has the poorest overall survival of all the major cancer types, with a 5-year relative  survival rate that just reached 10%. This is due in part to the latestage at presentation, so that 49.6% of cases of newly diagnosed PDAC present with distant metastases, 29.1% present with re- gional lymph node involvement, and only 10.8% have tumors that are localized solely within the pancreas.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279

  • Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "In this context, the big data field provides a conceptual framework for analysis across the full spectrum of disease that may better capture patient subcategories, in particular when considering longitudinal disease development in a lifelong perspective. Here, variation in “healthy” diagnosis-free routes toward disease and later differences in disease comorbidities are currently of high interest. Using health care sector, socioeconomic, and consumer data, the precision medicine field works increasingly toward such a disease spectrum-wide approach. Ideally, this involves data describing healthy individuals, many of whom will later become sick—to have long-range correlations that relate to outcomes available for analysis. This notion extends the traditional disease trajectory concept into healthy life-course periods potentially enabling stratification of patient cohorts by systematically observed differences present before the onset and diagnosis of disease.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Ultimately, it is likely that AI will transform much of the practice of medicine. AI will be used to interpret radiographs, ultrasounds, CT, and MRI, either as an adjunct to the clinician's interpretation or as the standalone reading.88 Health care organizations will use AI systems to extract and analyze electronic health record (EHR) data to better allocate staff and other resources, identify patients at risk for acute decompensation, and prevent medication errors.148 Using sensors on commodity devices such as smartphones, wearables, smart speakers, laptops, and tablets, individuals will be able to share health data during their daily lives and help generate a longitudinal personal health record, with pertinent information incorporated into their EHR. By extracting information from the EHR and incorporating data during an encounter with a patient, clinicians can be provided with a differential diagnosis in real-time with probabilities included.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Because of the “black box” quality of many deep learning algorithms, clinicians and patients may be hesitant to depend on AI-based solutions. This fear is not unfounded. For example, it was discovered that an algorithm evaluating data from images of skin lesions was more likely to classify the lesion as malignant if a ruler was included in the photograph.149 The reticence by clinicians to embrace AI-based medical devices may also be explained by the paucity of peer-reviewed prospective studies assessing the efficacy of these systems.Finally, regulatory assessment of the effectiveness and safety of AI-based products is different from that of traditional medical devices.Regulatory agencies are working to find the best processes for determining whether an AI medical device should be cleared for clinical use.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "The ability to reliably detect very early-stage PDAC in asymptomatic patients should result in a major improvement in survival. This hypothesis is based on the observation that the prognosis for PDAC is clearly related to the pathological stage of the tumor at the time of diagnosis. Using the SEER database, Ansari et al reported that 5-year survival for patients with lymph node–negative primary PDAC less than 1-cm cancers is ~60%; with primary tumors of 2 cm or larger even without lymph node metastasis, survival was less than 20%. However, less than 1% of patients are found with primary PDAC less than 1 centimeter in size. Pancreatic ductal adenocarcinoma is diagnosed in the large majority of even stage IA patients because of symptoms, not as a result of an early detection program. The hypothesis that the earlier the stage of a PDAC, the better the outcome, is in concert with data from many other solid tumors, including breast, non–small cell lung, colorectal, prostate, and gastric cancers.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Project Felix is a Lustgarten Foundation initiative led by Elliott Fishman at Johns Hopkins University to develop deep learning tools that can detect pancreatic tumors when they are smaller and with greater reliability than human readers alone. This effort has involved meticulous manual segmentation of thousands of abdominal CT scans to serve as a training and testing cohort, which represents the largest effort in this domain in the world. In collaboration with the computer scientist Alan Yuille. Project Felix has produced at least 17 articles on techniques to automatically detect and characterize lesions within the pancreas (https://www.ctisus.com/responsive/deep-learning/felix.asp).”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Eugene Koay from The University of Texas MD Anderson Cancer Center (MDACC) has previously characterized subtypes of PDAC on CT scans, whereby conspicuous (high delta) PDAC tumors are more likely to have aggressive biology, a higher rate of common pathway mutations, and poorer clinical outcomes compared with inconspicuous (low delta) tumors.His group has recently completed an analysis, currently under review, that shows that high-delta tumors demonstrate higher growth rates and shorter initiation times than their low-delta counterparts in the prediagnostic period. Although not strictly an AI initiative, his work serves as a rich foundation for future AI initiatives in this space. Drs Koay and Anirban Maitra at the MDACC are leading the NCI-sponsored EDRN initiative to assemble a prediagnosis pancreatic cancer cohort that could facilitate AI research into screening and early detection.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
Kidney

  • “Thromboembolic complications in COVID-19 disease are likely multifactorial in etiology. However, it is believed to be in- duced by profound inflammation characterized by exaggerated re- lease of inflammatory cytokines (cytokine storm). This exaggerated inflammatory response is also known to promote thrombosis by 91%.in the assessment of patients with complications associated with COVID-19 disease, along with clinical assessment and pertinent laboratory tests, including RT-PCR. Radiologic imaging studies play an important role  altering fibrinolysis and natural anticoagulant pathways. The  hypercoagulable state in this disease has been aptly named  COVID-19–associated coagulopathy. Patients who have severe  disease have a higher prevalence of thrombotic complication;  however, patients who do not have severe disease may also be at risk”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 

  • Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “Cardiac involvement in COVID-19 disease may be a primary consequence of direct invasion of the myocardium. However, it can also be secondary to a hyperinflammatory state, which can predispose atherosclerotic plaques to rupture. Consequently, the endothelial dysfunction and increased procoagulant activity of the blood raise the risk for thromboembolism. It is also important to note that as many as 40% of hospitalized patients with COVID-19 disease have preexisting CVD, which could worsen during the course of critical illness.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “The spectrum of bowel cross-sectional imaging manifestations on COVID-19 patients during their hospital confinement ranges from inflammation to ischemia and necrosis. Specific findings include ileus, bowel wall thickening, altered bowel wall  enhancement, pneumatosis, and portal venous gas In critically ill patients, fluid-filled colon indicative of diarrhea, as well as cholestasis, was commonly noted.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “It is postulated that at least 10% of affected patients have abnormal renal function, in which the virus affects renal cells, specifically renal tubular cells. Renal cell damage could cause smalltubule atrophy, renal interstitial fibrosis, and acute kidney injury that are strongly associated with increased mortality and morbidity. Computed tomography imaging findings include inflammation and edema of the renal parenchyma, showing lower CT attenuation compared with normal. In addition multiple wedge shaped kidney defects compatible with infarctions may also be seen..”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • "Coronavirus disease 2019 disease caused by SARS-CoV-2 virus infection is a novel disease and knowledge about its pathophysiology and manifestations continue to evolve. Although the respiratory tract is the primary system involved, extrapulmonary organ systems including cardiovascular, GI, urinary, and central nervous systems also show COVID-19–associated manifestations. It is important for both clinicians and radiologists to be familiar with these associated extrapulmonary findings to aid in early recognition and appropriate management of this disease.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 

  • Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • “The most commonly used single bolus CT urography protocol includes precontrast scan, nephrographic phase (at 100 s after 100–125 ml intravenous (IV) contrast injection), and delayed excretory phase at 5–20 minutes.”  
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • “Ureteral duplication is the most common congenital ureteral abnormality, affecting up to 1% of the population. Duplication can be partial/incomplete or complete, and unilateral or bilateral, with partial duplication being more common. In partial duplication, separate ureters of the upper and lower poles fuse together after a variable distance from the kidney and insert as a single ureter into the urinary bladder. Uretero-ureteral reflux (also known as yo-yo, seesaw, or saddle reflux) is a common but transitory phenomenon. Uretero-ureteral reflux prevents the upper pole moiety from being completely empty and should be suspected when there is asymmetry of the ureters. It results in urine stasis and increased frequency of urinary tract infection . Partial duplication may be associated with pelviureterical junction obstruction of the lower pole resulting in urine stasis, infection, and decrease in the renal excretory func- tion. Uncommonly, it may simulate a renal mass.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "Ureterocele is defined as cystic dilatation of the intramural portion of the distal ureter which appears as a filling defect projecting into the urinary bladder lumen. The inci- dence of ureterocele is 1:5000–12,000 and is 4–7 times more common in females. Ureterocele is subdivided based on location. Intravesical or orthotopic ureterocele occurs when confined within the urinary bladder lumen accounting for 25% of cases and almost always occurring in adults. Ectopic ureterocele extends beyond trigone or outside the bladder and accounts for 75% of cases.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "CT urography is the modality of choice to diagnose ret- rocaval ureter. IVC is seen lateral to the right pedicle of L3 vertebra in 96% of patients with retrocaval ureter, in contrast to 6% of normal people. Therefore, it is the pathognomonic feature of retrocaval ureter. MR urogram is equally effective as CT urography in diagnosing retrocaval ureter. It has advantage of being radiation free modality and also can be performed in patients with poor renal function, during pregnancy, or in pediatric patients. Open surgical ureteroureterostomy is considered as a gold standard surgical intervention.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "Genitourinary tuberculosis is the second most common form of extrapulmonary tuberculosis and usually caused by hematogenous dissemination. It accounts for 15–20% of all extrapulmonary tuberculosis cases. Genitourinary tuberculosis involves the ureter in approximately 50% of the cases.  In early disease, IVU or retrograde urography shows ragged and dilated ureter and occasional filling defects of mucosal granulomas. CT urography demonstrates ureteral mural thickening with periureteral inflammatory changes. Tuberculosis tends to involve distal third of the ureter and causes multiple strictures and fibrotic changes with disease progression resulting in a characteristic “beaded or corkscrew” appearance. Chronic mural thickening of the ureter results in foreshortening and “pipestem” ureter. Tuberculosis may also present as pseudotumor due to inflammatory ureteral mural thickening and would be dif- ficult to distinguish from malignancy on imaging. In a small number of cases, ureteral calcifications can be seen.”
  • "Schistosomiasis is the most common cause of urinary bladder wall calcification in the endemic nations [80]. Calcification begins at the bladder base which later progresses to circumferential pattern with involvement of entire bladder wall. Circumferential urinary bladder wall calcification resembles “fetal head” on plain radiograph or “shell-like” rim of calcification with reduced capacity on CT. The closest differential of bladder wall calcification is tuberculosis. Linear or parallel linear calcifications of ureters are initially seen in distal ureters, which may progress cranially.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "TCC is the most common urothelial malignancy. The urinary bladder is the most common site, and the renal pelvis is the second most common site. TCC is uncommon in the ureter. TCC occurs in upper urinary tract approximately 5 to 10% of the time, and only 25% of upper urinary tract TCC involves the ureter with the distal one-third ureter being the most common site. TCC constitutes approximately 1% of upper urinary tract malignancies. Synchronous bilateral ureteral TCC occurs in 2–9% of cases. Approximately 11–13% cases develop metachronous upper urinary tract TCC with a mean disease-free interval of 28 months. Metachronous tumor develops in the urinary bladder in 50% of cases of ureteral TCC within 24 months of post-surgical treatment.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "Approximately 15% of ureteral TCC presents with radiological evidence of extramural tumor spread. The most important risk factors of the disease are age > 60 years, male gender, and smoking. Other risk factors include analgesic abuse, occupational exposure to chemical carcinogens such as industrial dyes and plastic, and prior treatment with cyclophosphamide. Chemical exposure predisposes for multifocal lesions . Patients usually present with microscopic or gross hematuria, flank pain, and weight loss. TCC has different growth patterns—“papillary” appears as a filling defect, while “infiltrating” appears as stenosis/stricture.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "It is extremely rare to have disease metastatic to the ureter from any type of primary malignancy. The most com- mon primary malignancies metastasizing to the ureter are breast, colorectal, stomach, prostate, cervical, and melanoma. Three patterns of ureteral metastasis have been described—(1) transmural involvement, (2) periureteral infiltration, and (3) submucosal nodules. The first two patterns are seen as stricture while the is usually multiple filling defects. The adventitia is the most common layer of the ureteral wall to be involved by metastatic disease, while the mucosa is the least common Clinically, most of the patients are asymptomatic and may present with non-specific flank pain and dysuria.”
  • "Retroperitoneal fibrosis represents fibro-inflammatory soft tissue plaque in the retroperitoneal space that often encases the aorta and one or both ureters resulting in obstruction. RPF is idiopathic in majority of the cases and has been associated with malignancy, autoimmune inflammatory disorders, GVHD, drugs, surgery, and multiple sclerosis in small number of cases. RPF usually affects males in their 4th–6th decades of life and often pre- sents with non-specific symptoms such as malaise, anorexia, and chronic backache. RPF is predominantly benign with a favorable prognosis. Small number cases, up to 8%, have been reported as malignant RPF with a poor prognosis and typical 3–6 months survival.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "The important distinguishing feature of benign RPF from malignant RPF, lymphoma, and metastatic lymph nodes is that the fibrotic plaque may extend behind the aorta and anterior to the spine but rarely displaces the aorta anteriorly, although it has poor sensitivity and specificity. Degree of enhancement of benign RPF on CT correlates with fibrotic activity, avid enhancement suggests active phase, and minimal to no enhancement seen in avascular chronic plaque. Variable enhancement pattern is also seen in malignant RPF. There is significant overlap between benign RPF and malignant RPF in imaging morphology and enhancement patterns.”  
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • "Malacoplakia is a rare granulomatous inflammatory disease of the genitourinary tract, but rarely may affect other organ systems. Most commonly, it occurs in the urinary bladder followed by the ureter and renal pelvis. Malacoplakia is caused by bacterial infection; Escherichia coli is the most common organism. Common presenting symptoms are flank pain, hematuria, and fever. On CT, common finding is segmental mural thickening of the ureter with or without proximal dilatation. Hydronephrosis is uncommon but can be seen and may result in renal dysfunction. Malacoplakia is usually diagnosed on biopsy and treated conservatively with antibiotics. It may require surgical plaque resection with possible ureteral stenting.”
    Imaging of ureter: a primer for the emergency radiologist  
    Mohd Zahid et al.
    Emergency Radiology (in press)
  • “Between January 2007 and December 2019, 11 out of 660 (1.6%) mRCC patients had metastases of the gastrointestinal tract. The median age was 62 years. Of the 11 patients, 81.8% experienced digestive bleeding or anemia. Only 2 patients were asymptomatic. The metastases were mainly duodenal (50%) and gastric (41.6%). The median time from cancer diagnosis and from metastatic disease to gastrointestinal metastasis was 4.3 years (3 months−19.2 years) and 2.25 years (0 days−10.2 years), respectively.”
    Gastrointestinal Metastases From Primary Renal Cell Cancer: A Single Center Review  
    Rony Maelle et al.
    Front. Oncol. 11:644301. doi: 10.3389/fonc.2021.644301 
  • “DM of kidney cancer, whether gastric, duodenal or jejunal, is rare. In autoptic studies, the stomach has been reported as a metastatic site in 0.2–0.7% of cases, regardless of the primary site. The prevalence of RCC gastric metastases in the Pollheimer study was 0.2% over 22 years. Our study is, to the best of our knowledge, the largest monocentric study providing the prevalence of RCC metastasis throughout the digestive tract.”
    Gastrointestinal Metastases From Primary Renal Cell Cancer: A Single Center Review  
    Rony Maelle et al.
    Front. Oncol. 11:644301. doi: 10.3389/fonc.2021.644301 
  • “The interval between diagnosis of the primary tumor and gastric metastasis depends on the primary tumor. For lung cancer and melanoma, metastasis is diagnosed an average of 2 years after the initial diagnosis. For RCC, the average interval is 7 years (0–24 years) . In the Pollheimer et al. study of 17 patients, the mean interval was 6.5 years with a median of 4.7 years (0.1–20 years) , and the same timelines were found in Kim et al.’s study of 36 patients.”
    Gastrointestinal Metastases From Primary Renal Cell Cancer: A Single Center Review  
    Rony Maelle et al.
    Front. Oncol. 11:644301. doi: 10.3389/fonc.2021.644301 
  • "DM in patients with RCC appears to be a late event in the course of the disease. In the majority of cases, they are discovered upon digestive bleeding, but sometimes only anemia is present. It is important to be aware that unexplained anemia or persistent digestive symptoms should be explored by endoscopy. However, due to the evolved molecular targeted and new immunotherapies, the survival period of the patients with mRCC was prolonged. Therefore, at the routine follow-up CT scan, we must be aware that formerly rare metastatic sites including digestive wall may increase.”
    Gastrointestinal Metastases From Primary Renal Cell Cancer: A Single Center Review  
    Rony Maelle et al.
    Front. Oncol. 11:644301. doi: 10.3389/fonc.2021.644301 
  • “RCC is the second most common renal malignancy of childhood after Wilms tumor; however, it is more common than Wilms tumor in individuals who are in their 2nd decade of life. Overall, the annual incidence of pediatric RCC is approximately four cases per one million children, 30 times lower than the annual incidence of Wilms tumor.There is an equal gender distribution. Pediatric RCC is different from adult RCC. In adults, the most common RCC tumor types are clear cell carcinoma (80%–85%), papillary carcinoma (10%–15%), and chromophobe carcinoma (5%). In contrast, the most frequent types of RCC in children are translocation carcinoma (20%– 47%), papillary carcinoma (17%–30%), and medullary carcinoma (11%), with chromophobe and clear cell RCCs occurring quite rarely .”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • TEACHING POINTS  
    * RCC is the second most common renal malignancy of child- hood after Wilms tumor; however, it is more common than Wilms tumor in individuals who are in their 2nd decade of life.  
    * At imaging, translocation RCCs generally have a heteroge- neous appearance owing to solid and cystic components with hemorrhage, necrosis, and calcifications.  
    * Renal medullary carcinoma is an aggressive tumor that affects almost exclusively older children and young adults with the  sickle cell trait or heterozygous sickle cell disease.  
    * Angiomyolipoma is a neoplasm of mixed cellular composition and is now considered part of the family of perivascular epi-  thelioid cell tumors.  
    * Metanephric tumors comprise a spectrum of rare differenti- ated epithelial and stromal tumors that are derived from metanephric blastema and are histogenetically related to Wilms tumor.  
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "First classified as a genetically distinct subtype of RCC by the World Health Organization, translocation RCC accounts for one-third to nearly one-half of all pediatric RCCs.There is a slight female predominance, with a male-to- female ratio of 1.0:1.4. Although patients may have symptoms such as flank pain, a mass, or gross hematuria, these tumors are often found incidentally.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "Xp11.2 translocation involves gene fusion and subsequent overexpression of transcription factor E3 (TFE3). Multiple variations of the Xp11.2 chromosome translocation have been reported, and all of them cause overexpression of the TFE3 gene.While the origin of these translo- cations is poorly understood, a known risk factor is a history of cytotoxic chemotherapy during childhood. In their review of 39 genetically confirmed cases, Argani et al found that 15% of the cases involved treatment with cytotoxic chemotherapy.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 

  • Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "Renal medullary carcinoma is an aggressive tumor that affects almost exclusively older children and young adults with the sickle cell trait or hetero- zygous sickle cell disease. The age range of affected individuals is 5–39 years (mean age, 14.8 years). Among persons younger than 25 years, males are affected three times more often than are females, but there is an equal distribution between the sexes after age 25 years.The most common features at presentation are gross hematuria and flank pain; however, hematuria is not uncommon in individuals who have the sickle trait without tumor. An abdominal mass, weight loss, and fever are less common.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • “These tumors arise from the terminal collecting ducts or papillary epithelium, where a chronic hypoxic sickle cell trait environment causes epithelial cell proliferation. There is a predilection for the right kidney. At gross specimen inspection, the tumor is centered in the renal medulla, with an infiltrative growth pattern and extension into the renal collecting system. In addition, satellite nodules are typically seen in the renal cortex and peripelvic soft tissues.Tumor necrosis and hemorrhage are usually identified, and calcifications are rare, weight loss, and fever are less common.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "The differential diagnosis for renal medullary carcinoma includes renal lymphoma, which also may grow in an infiltrative pattern. Lymphoma is usually distinguished by associated widespread lymphadenopathy and involvement of other organs. However, renal medullary carcinoma also can manifest with extensive disease, so patient age and history of the sickle cell trait are help-  ful clues to the diagnosis. Rhabdoid tumor and mesoblastic nephroma are additional medullary tumors with infiltrative growth patterns; however, both of these neoplasms occur in much younger patients. Infection may have an infiltrative appearance, with extension into the perinephric fat and enlargement of regional lymph nodes, mimicking the appearance of medullary carcinoma. Clinical and laboratory findings help to distinguish infection from tumor.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "Metanephric adenoma is the most com- mon of these tumors and occurs most often in adult women with a mean age of 41 years (age range, 14 months to 83 years). There is a female predominance, with a female-to-male ratio of 2.6:1.0. Metanephric stromal tumors occur most commonly in young children witha mean age of 2 years (age range, 5 months to 15 years). Metanephric adenofibroma most commonly affects children and young adults. The mean age of affected persons is 82.2 months (age range, 5 months to 36 years). Presenting signs include pain, hematuria, hyper- tension, and a palpable mass, but these tumors frequently are found incidentally. Davis et al found an association between metanephric adenoma and polycythemia in 12% of cases.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • "Lymphomas may affect the kidneys as solitary masses; however, they are more often multiple bilateral expansile renal masses or nodules. Less commonly, diffuse infiltration is observed, and rarely, the tumor involves only the perinephric tissues. At pathologic analysis, large masses demonstrate central hemorrhage and necrosis. At histologic examination, Burkitt lymphoma is composed of uniform medium basophilic cells interspersed with clear histiocytes that contain debris from apoptotic cells, conferring a “starry sky” appearance. Mitoses are frequent. Tumor cells express mature B-cell markers (ie, CD19, CD20, CD22, and CD79a) and a Ki-67 pro- liferation index of nearly 100%. The imaging appearances of lymphoma vary according to the type of tumor growth.The most common appearance is that of multiple round masses or nodules.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • “1At CT, the masses are hypoattenuating and enhance less intensely compared with the adjacent parenchyma. Lymphomatous lesions are more conspicuous on MR images than on CT images. Diffuse infiltration, usually of both kidneys, is the typical appearance of leukemic infiltration at imaging and may also be seen with lymphoma. The kidneys are enlarged but remain reniform, with decreased corticomedullary differentiation; these findings are often quite subtle.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
  • “At gross specimen inspection, the tumor appears solid, with areas of hemorrhage, necrosis, and cyst formation. Histologically, the tumor is composed of monomorphic spindle cells arranged in intersecting fascicles or solid sheets. Mitotic activity is typically seen. The tumor also contains cysts lined by eosinophilic cells with apically oriented nuclei.This lining is known as a hobnailed epithelium.The cysts probably represent entrapped tubules and may be quite dilated. Ninety percent of these tumors have the characteristic translocation t(X;18)(p11.2;q11).  Imaging studies reveal a well-circumscribed solid mass with prominent fluid-attenuating areas that represent necrosis, old hemorrhage, or cysts. The cysts may predominate. The septa, cyst walls, and solid components enhance. Subcapsular hemorrhage or renal vein invasion may be seen, but lymphadenopathy is absent.”
    Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade  
    Ellen M. Chung et al.
    RadioGraphics 2017; 37:1538–1558 
OB GYN

  • “Placenta percreta (PP) is a condition in which the placenta abnormally penetrates entirely through the myometrium and into the uterine serosa. This might be complicated by attachment of the placenta to surrounding structures or organs, such as the urinary  bladder or rectum. PP is a potentially fatal condition, and mortality rate is correlated to the extent of involvement of surrounding structures. When PP is complicated by bladder invasion, mortality  rates have been estimated as high as 9.5% and 24% for mother and child, respectively.”
    Placenta Percreta With Invasion into the Urinary Bladder  
    Zachary L. Smith et al.
    Urology Case Reports,Volume 2, Issue 1,2014,Pages 31-32
  • "The incidence of PP has increased 50-fold in the last half-century to a currently estimated 1 in 1000 pregnancies. This increased prevalence is attributed to the increased frequency of  Caesarean deliveries. The incidence of concomitant bladder invasion is much lower, occurring in approximately 1 in 10,000 births.  he diagnosis of PP might be made during prenatal screening ultrasound; however, bladder involvement is usually not identified  until the time of delivery.”
    Placenta Percreta With Invasion into the Urinary Bladder  
    Zachary L. Smith et al.
    Urology Case Reports,Volume 2, Issue 1,2014,Pages 31-32
  • "PP is a morbid condition of increasing incidence. It should be considered in any pregnant patient presenting with gross hematuria, although this is not a sensitive finding. A previous history of Caesarean section might be associated with PP; however, there has been no correlation between other pelvic procedures to this con- dition, making screening even more difficult. After review of our case and the current published data available, it is our opinion that early urologic consultation and a multidisciplinary approach to delivery and management are of utmost importance. If possible, preoperative ureteral catheter placement is recommended to aid in intraoperative identification of ureters.”
    Placenta Percreta With Invasion into the Urinary Bladder  
    Zachary L. Smith et al.
    Urology Case Reports,Volume 2, Issue 1,2014,Pages 31-32
Pancreas

  • “The multivariable logistic regression model included sex, size, location, shape, cyst characteristic, and cystic wall thickening. The individualized prediction nomogram showed good discrimination in the training sample (AUC 0.89; 95% CI 0.83–0.95) and in the validation sample (AUC 0.81; 95% CI 0.70–0.94). If the threshold probability is between 0.03 and 0.9, and > 0.93 in the prediction model, using the nomogram to predict SCN and MCN is more beneficial than the treat-all- patients as SCN scheme or the treat-all-patients as MCN scheme. The prediction model showed better discrimination than the radiologists’ diagnosis (AUC = 0.68).”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • All tumors were evaluated for the following characteristics: (1) CT-reported tumor size (i.e., the maximum cross-sectional diameter of the tumor [13]); (2) tumor location: pancreatic head, body, or tail; (3) shape: round or lobulated (lobulation was defined as the presence of rounded contours that could not be described as the borders of the same circle [9]); (4) cyst characteristic: oligocystic or polycystic; (5) cystic wall: thin or thick (thin was defined as < 2 mm while thick was defined as ≥ 2 mm [9]); (6) calcification; (7) enhanced mural nodule; (8) parenchymal atrophy; (9) common bile duct cutoff and dila- tion (> 10 mm); (10) main pancreatic duct (MPD) cutoff and dilation (> 3 mm); (11) pancreatitis identified by stranding of the peripancreatic fat tissue, ill-defined parenchymal contours, and fluid collections in the peripancreatic region; (12) contour abnormality; and (13) number of lesions: 1 or ≥ 2.  
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • “There were several limitations to this study. First, the number of patients was relatively small. Second, this was a single-center, retrospective analysis. In the future, we will expand the number of cases and perform a multi-center validation of the model. Third, the predicted model in this study only focused on SCN and MCN, and did not include other cystic lesions of the pancreas such as IPMN, pseudocyst, and retention cyst. Lastly, we only used CT characteristics to develop the model. We did not combine radiomics features, although artificial intelligence is becoming a hot topic. In the future, we will combine the CT characteristics and radiomics features to develop a more accurate model.”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3 
  • “Lastly, we only used CT characteristics to develop the model. We did not combine radiomics features, although artificial intelligence is becoming a hot topic. In the future, we will combine the CT characteristics and radiomics features to develop a more accurate model.”
    A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm  
    Chengwei Shao et al.
    Abdominal Radiology https://doi.org/10.1007/s00261-021-03038-3  
  • “Pancreatic cancer (pancreatic ductal adenocarcinoma [PDAC]) is associated with a dire prognosis and a 5-year survival rate of only 10%. This statistic is somewhat misleading given that 52% of the patients will develop metastatic disease, with a resulting 2.9%, 5-year relative survival rate. However, for those patients with localized cancer where the tumor is confined to the primary site, the 5-year relative survival rate is 39.4%. It is estimated that in 2020, there will be 57,600 new cases of PDAC  and an estimated 47,050 will die of this disease.”  
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Pancreatic ductal adenocarcinoma has the poorest overall survival of all the major cancer types, with a 5-year relative  survival rate that just reached 10%. This is due in part to the latestage at presentation, so that 49.6% of cases of newly diagnosed PDAC present with distant metastases, 29.1% present with re- gional lymph node involvement, and only 10.8% have tumors that are localized solely within the pancreas.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279

  • Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "In this context, the big data field provides a conceptual framework for analysis across the full spectrum of disease that may better capture patient subcategories, in particular when considering longitudinal disease development in a lifelong perspective. Here, variation in “healthy” diagnosis-free routes toward disease and later differences in disease comorbidities are currently of high interest. Using health care sector, socioeconomic, and consumer data, the precision medicine field works increasingly toward such a disease spectrum-wide approach. Ideally, this involves data describing healthy individuals, many of whom will later become sick—to have long-range correlations that relate to outcomes available for analysis. This notion extends the traditional disease trajectory concept into healthy life-course periods potentially enabling stratification of patient cohorts by systematically observed differences present before the onset and diagnosis of disease.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Ultimately, it is likely that AI will transform much of the practice of medicine. AI will be used to interpret radiographs, ultrasounds, CT, and MRI, either as an adjunct to the clinician's interpretation or as the standalone reading.88 Health care organizations will use AI systems to extract and analyze electronic health record (EHR) data to better allocate staff and other resources, identify patients at risk for acute decompensation, and prevent medication errors.148 Using sensors on commodity devices such as smartphones, wearables, smart speakers, laptops, and tablets, individuals will be able to share health data during their daily lives and help generate a longitudinal personal health record, with pertinent information incorporated into their EHR. By extracting information from the EHR and incorporating data during an encounter with a patient, clinicians can be provided with a differential diagnosis in real-time with probabilities included.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Because of the “black box” quality of many deep learning algorithms, clinicians and patients may be hesitant to depend on AI-based solutions. This fear is not unfounded. For example, it was discovered that an algorithm evaluating data from images of skin lesions was more likely to classify the lesion as malignant if a ruler was included in the photograph.149 The reticence by clinicians to embrace AI-based medical devices may also be explained by the paucity of peer-reviewed prospective studies assessing the efficacy of these systems.Finally, regulatory assessment of the effectiveness and safety of AI-based products is different from that of traditional medical devices.Regulatory agencies are working to find the best processes for determining whether an AI medical device should be cleared for clinical use.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "The ability to reliably detect very early-stage PDAC in asymptomatic patients should result in a major improvement in survival. This hypothesis is based on the observation that the prognosis for PDAC is clearly related to the pathological stage of the tumor at the time of diagnosis. Using the SEER database, Ansari et al reported that 5-year survival for patients with lymph node–negative primary PDAC less than 1-cm cancers is ~60%; with primary tumors of 2 cm or larger even without lymph node metastasis, survival was less than 20%. However, less than 1% of patients are found with primary PDAC less than 1 centimeter in size. Pancreatic ductal adenocarcinoma is diagnosed in the large majority of even stage IA patients because of symptoms, not as a result of an early detection program. The hypothesis that the earlier the stage of a PDAC, the better the outcome, is in concert with data from many other solid tumors, including breast, non–small cell lung, colorectal, prostate, and gastric cancers.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Project Felix is a Lustgarten Foundation initiative led by Elliott Fishman at Johns Hopkins University to develop deep learning tools that can detect pancreatic tumors when they are smaller and with greater reliability than human readers alone. This effort has involved meticulous manual segmentation of thousands of abdominal CT scans to serve as a training and testing cohort, which represents the largest effort in this domain in the world. In collaboration with the computer scientist Alan Yuille. Project Felix has produced at least 17 articles on techniques to automatically detect and characterize lesions within the pancreas (https://www.ctisus.com/responsive/deep-learning/felix.asp).”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
  • "Eugene Koay from The University of Texas MD Anderson Cancer Center (MDACC) has previously characterized subtypes of PDAC on CT scans, whereby conspicuous (high delta) PDAC tumors are more likely to have aggressive biology, a higher rate of common pathway mutations, and poorer clinical outcomes compared with inconspicuous (low delta) tumors.His group has recently completed an analysis, currently under review, that shows that high-delta tumors demonstrate higher growth rates and shorter initiation times than their low-delta counterparts in the prediagnostic period. Although not strictly an AI initiative, his work serves as a rich foundation for future AI initiatives in this space. Drs Koay and Anirban Maitra at the MDACC are leading the NCI-sponsored EDRN initiative to assemble a prediagnosis pancreatic cancer cohort that could facilitate AI research into screening and early detection.”
    Artificial Intelligence and Early Detection of Pancreatic Cancer: 2020 Summative Review  
    Barbara Kenner, PhD,* Suresh T. Chari, MD,† David Kelsen, MD, Fishman EK et al.
    Pancreas. 2021 Mar 1;50(3):251-279
Practice Management

  • “The concept of black swan events was popularized by finance professor Nassim Nicholas Taleb. Briefly, a black swan event is an exceptionally rare occurrence with catastrophic consequences that is impossible to predict but is described in hindsight as though it was inevitable and should have been predicted. It is hard to imagine an event that more clearly fits the definition of a black swan than the ongoing coronavirus pandemic.”
    Surviving and Thriving in a Black Swan Event.  
    Grossman KA, Fishman EK, Chu LC, Rowe SP.  
    J Am Coll Radiol. 2021 Apr 13:S1546-1440(21)00236-2.
  • “Lastly, we could see that many careers were going to be permanently changed by the pandemic and associated events. Whole industries have been disrupted. We wanted to provide tools for people to upgrade their skills for their current career or retrain for a new career. We partnered with Columbia Business School to offer certificates for $200. This allowed people, who may have been laid off or furloughed, to obtain Ivy League business school skills for a relatively affordable sum.”
    Surviving and Thriving in a Black Swan Event.  
    Grossman KA, Fishman EK, Chu LC, Rowe SP.  
    J Am Coll Radiol. 2021 Apr 13:S1546-1440(21)00236-2.
  • “The coronavirus pandemic and the associated societal changes “punched us in the mouth.” We had already diversified the ways in which we engaged with many of our consumers, but the pandemic accelerated that and made us re-examine many of our plans. The nature of a black swan event is that it cannot be predicted— but you can develop appropriate responses when it occurs and, with the right decision making, you can thrive despite the catastrophic circumstances..”
    Surviving and Thriving in a Black Swan Event.  
    Grossman KA, Fishman EK, Chu LC, Rowe SP.  
    J Am Coll Radiol. 2021 Apr 13:S1546-1440(21)00236-2.
  • “Black swan events may be rare and impossible to predict, but when they occur there are still opportunities for organizations to successfully navigate the downstream consequences. The coronavirus pandemic has obviously radically altered how medicine is practiced, but those hospitals and departments that quickly found robust ways to work around their previous models of doing business are primed for long-term success. Many health care systems, hospitals, and practices are trusted content producers that people go to for information; ensuring that health care consumers have access to trustworthy information across multiple possible platforms is more important now than ever.”
    Surviving and Thriving in a Black Swan Event.  
    Grossman KA, Fishman EK, Chu LC, Rowe SP.  
    J Am Coll Radiol. 2021 Apr 13:S1546-1440(21)00236-2.
  • “Our educational models for medical students, residents, fellows, and radiologists in practice (ie, continuing medical education) has been evolving in recent years. The pandemic forced more changes to be instituted rapidly to maintain our educational missions. Like Time, Inc, we had to be nimble and to rethink how we could provide training despite lectures and conferences no longer being in-person events. Some of the changes that have been made may evolve again if the pandemic finally passes, but many of the changes will remain longer term.”
    Surviving and Thriving in a Black Swan Event.  
    Grossman KA, Fishman EK, Chu LC, Rowe SP.  
    J Am Coll Radiol. 2021 Apr 13:S1546-1440(21)00236-2.
  • “Despite these obstacles, women of color are winning every day across a wide range of fields. By working with allies of all ages, genders, and races, we can spread “Black brilliance” widely and generate an economic revolution globally. Women of color are projected to represent the majority of the US population by 2060. The American Express “2019 State of Women-Owned Businesses Report” showed that, although the number of women-owned businesses grew 21% from 2014 to 2019, firms owned by women of color grew at double that rate, at 43%. The 6.4 million businesses owned by women of color generated $422.5 billion of revenue in 2019. More women of color on both sides of the political aisle are running for office, and many of them have won.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • “By 2027, people of color ages 18 to 29 (Generation Z and young Millennials) will be in the majority. This demographic tipping point will shape the future of the United States as well as the global economy. That is why we have embraced the term generational diversity to describe the need for innovation in the “race for talent”: new ways not only to find and hire these young people but to retain them. To that end, we will need both inclusive leaders and deeper “allyship” across the races, genders, generations, and industry sectors. Our focus is business, given our experiences and educational backgrounds, but the rules of the game, and the race for talent, exist in every arena, including academics and medicine.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • We endorse Deloitte’s six signature traits of an inclusive leader:  
    1. Commitment: Inclusive leaders are committed to diversity and inclusivity based on their intrinsic values and deep-seated sense of fairness, rather than some extrinsic reward.  
    2. Courage: These leaders have the courage to challenge entrenched organizational attitudes, display humility, and acknowledge personal limitations and to seek contributions from others to overcome them.  
    3. Cognizance of bias: They have checks and balances to prevent organizational bias.  
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • We endorse Deloitte’s six signature traits of an inclusive leader:  
    4. Curiosity: They ask respectful questions and engage with active listening. They make people feel valued, respected, and represented.  
    5. Cultural intelligence: They value modesty and different cultural backgrounds.  
    6. Collaboration: They ensure all individuals feel empowered to express their opinions. Diversity of thinking is critical to effective collaboration.  
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • “Our message is that we should team up, rather than pursue solo journeys. Once we team up, we are an unstoppable force. Teaming up is a scalable proposition to advancement and to increasing the camaraderie among women of color. We call it “SaaS”: sisters as a service. Career growth comes from referring others. We must also embrace the change that comes from moving beyond “an only” ourselves. By supporting referrals, we can assist organizations as they enhance their succession planning for every role leading to the C-suite and a pipeline for venture funding. As women of color, we can create a joyous sense of belonging through career sisterhood, and hiring more of us in multiples is a fundamental place to start. As the African proverb says, “If you want to go quickly, go alone. If you want to go far, go together!”.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • “Underrepresented minorities are traditionally defined as Black, Hispanic, Native American, Alaskan Native, Native Hawaiian, and Pacific Islander. They are underrepresented as practicing radiologists (6.5%) and diagnostic radiology residents (8.3%) compared with the US population (30%). Our departments need inclusive leaders who are committed to promoting racial diversity and will go beyond the tokenism of hiring a few underrepresented minorities for the department. We hope that our leadership landscape will one day become as diverse as the population we serve. Our leaders, most of whom are White men, need to commit to racial diversity and inclusion and open the glass door for our minority colleagues to welcome them in. They can act as effective sponsors of opportunities for career advancement and talent retention, which in turn will attract other minorities to join the department. Although it is important for faculty members from minority backgrounds to serve on diversity and inclusion committees, they should not be pigeonholed into that role to the exclusion of other leadership opportunities.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • “We need to attract more underrepresented minorities into our specialty at the residency training level. Often, we passively wait for applicants to apply to our residencies and then put on a superficial display of diversity and inclusion on the interview day. We need deeper and sustained investment to groom our future pipeline. Programs can partner with historically Black medical schools, the Student National Medical Association, and the Latino Medical Student Association to maximize their reach to underrepresented minorities [8]. They can develop longitudinal mentorship programs in the form of student interest groups, electives, and summer fellowships to engage minority medical students who may otherwise have limited exposure to our specialty.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
  • “Men and women of color should team up in this uphill climb toward racial diversity, equity, and inclusion. They can seek out partners from inside and outside the department, share their common struggles, and remember that they are not alone. This partnership may empower them to be bold and speak up against injustices and smooth the path for the next generation.”
    Empowering Women of Color to Lead and Succeed.  
    Stewart BC, Adams J, Fishman EK, Rowe SP, Chu LC.  
    J Am Coll Radiol. 2021 Mar 12:S1546-1440(21)00143-5.
Spleen

  • However, a colonoscopy is the most common cause of iatrogenic splenic injury (in comparison to other procedures or surgeries). The risk factors for splenic injury are both patient and operator dependent. Patient-dependent factors include pre-existing enlargement of the spleen, surgical adhesions, inflammatory bowel disease, and severe diverticular disease. Operator dependent factors include placing the patient on their back, excessive traction, over sedation, slide by advancement, and applying excessive external pressure. Despite these factors, it is still difficult to discern if the complication is unpredictable or directly related to technical factors given rarity of this complication.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy.  
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • “Acute splenic sequestration crisis, the sudden pooling of red blood cells in the spleen, is an emergent process typically seen in children with homozygous sickle cell disease. Splenic sequestration has rarely been reported in adults with heterozygous sickle cell conditions, including sickle cell beta(+)-thalassemia disease (HbS/β+-thalassemia).”
    Splenic sequestration in the adult: cross sectional imaging appearance of an uncommon diagnosis
    Yonah B. Esterson, Sheila Sheth, Satomi Kawamoto
    Clinical Imaging  VOLUME 69, P369-373, JANUARY 01, 2021
  • “Acute splenic sequestration crisis results from the trapping (or “sequestration”) of red blood cells in the spleen of a person with sickle cell disease. The pooling and destruction of blood cells within the spleen results in decreased circulating blood volume, potentially leading to hypovolemic shock, cardiovascular collapse, and even death. Clini- cally, splenic sequestration crisis is defined as a drop in hemoglobin level by 2 g/dL in the setting of an enlarging spleen.”
    Splenic sequestration in the adult: cross sectional imaging appearance of an uncommon diagnosis
    Yonah B. Esterson, Sheila Sheth, Satomi Kawamoto
    Clinical Imaging  VOLUME 69, P369-373, JANUARY 01, 2021
  • “CT will show an enlarged spleen with a thick irregular rim of peripheral low attenuation repre- senting infarcts and hemorrhage. Alternatively, CT may show larger, more diffuse areas of hypoattenuation within an enlarged spleen. Similar to CT, ultrasound will demonstrate an irregular peripheral hypoechoic rim within an enlarged spleen. Both modalities will demonstrate patency of the splenic artery and vein.”
    Splenic sequestration in the adult: cross sectional imaging appearance of an uncommon diagnosis
    Yonah B. Esterson, Sheila Sheth, Satomi Kawamoto
    Clinical Imaging  VOLUME 69, P369-373, JANUARY 01, 2021
  • "On cross sectional imaging, differential considerations for splenic sequestration include subcapsular splenic hematoma and splenic infarction. However, a subcapsular splenic hematoma classically appears as a lenticular or crescentic perisplenic collection which smoothly flattens the splenic contour as opposed to the irregular appearance at the periphery of the splenic tissue seen in sequestration. Splenic infarction typically appears as a single or multiple, peripheral, wedge-shaped area (s) of hypoattenuation as opposed to the more diffuse peripheral hypoattenuation associated with splenic sequestration.”
    Splenic sequestration in the adult: cross sectional imaging appearance of an uncommon diagnosis
    Yonah B. Esterson, Sheila Sheth, Satomi Kawamoto
    Clinical Imaging  VOLUME 69, P369-373, JANUARY 01, 2021
Trauma

  • However, a colonoscopy is the most common cause of iatrogenic splenic injury (in comparison to other procedures or surgeries). The risk factors for splenic injury are both patient and operator dependent. Patient-dependent factors include pre-existing enlargement of the spleen, surgical adhesions, inflammatory bowel disease, and severe diverticular disease. Operator dependent factors include placing the patient on their back, excessive traction, over sedation, slide by advancement, and applying excessive external pressure. Despite these factors, it is still difficult to discern if the complication is unpredictable or directly related to technical factors given rarity of this complication.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • Splenic injury is a rare but serious complication of colonoscopy. Since the mid-1970s, 68 splenic injuries during colonoscopy including our 2 cases have been described. With the increasing use of colonoscopy, endoscopists, surgeons, and radiologists are more likely to encounter this unusual complication. Any cause of increased splenocolic adhesions, splenomegaly, or underlying splenic disease might be a predisposing factor for splenic injury during colonoscopy. However, it can occur in patients without significant adhesions or underlying splenic pathology. The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy.  
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
  • The diagnosis is often described in the literature as delayed, because many physicians are not aware of this complication of colonoscopy. Although computerized tomography is highly sensitive, knowledge of this complication is the best tool to aid in early diagnosis. Patients with abdominal pain, hypotension, and a drop in hematocrit without rectal bleeding after colonoscopy should be suspected of having splenic injury.
    Splenic injury after elective colonoscopy.
    Sarhan M, Ramcharan A, Ponnapalli S.  
    JSLS. 2009;13(4):616-619.
Vascular

  • “Thromboembolic complications in COVID-19 disease are likely multifactorial in etiology. However, it is believed to be in- duced by profound inflammation characterized by exaggerated re- lease of inflammatory cytokines (cytokine storm). This exaggerated inflammatory response is also known to promote thrombosis by 91%.in the assessment of patients with complications associated with COVID-19 disease, along with clinical assessment and pertinent laboratory tests, including RT-PCR. Radiologic imaging studies play an important role  altering fibrinolysis and natural anticoagulant pathways. The  hypercoagulable state in this disease has been aptly named  COVID-19–associated coagulopathy. Patients who have severe  disease have a higher prevalence of thrombotic complication;  however, patients who do not have severe disease may also be at risk”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 

  • Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “Cardiac involvement in COVID-19 disease may be a primary consequence of direct invasion of the myocardium. However, it can also be secondary to a hyperinflammatory state, which can predispose atherosclerotic plaques to rupture. Consequently, the endothelial dysfunction and increased procoagulant activity of the blood raise the risk for thromboembolism. It is also important to note that as many as 40% of hospitalized patients with COVID-19 disease have preexisting CVD, which could worsen during the course of critical illness.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “The spectrum of bowel cross-sectional imaging manifestations on COVID-19 patients during their hospital confinement ranges from inflammation to ischemia and necrosis. Specific findings include ileus, bowel wall thickening, altered bowel wall  enhancement, pneumatosis, and portal venous gas In critically ill patients, fluid-filled colon indicative of diarrhea, as well as cholestasis, was commonly noted.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • “It is postulated that at least 10% of affected patients have abnormal renal function, in which the virus affects renal cells, specifically renal tubular cells. Renal cell damage could cause smalltubule atrophy, renal interstitial fibrosis, and acute kidney injury that are strongly associated with increased mortality and morbidity. Computed tomography imaging findings include inflammation and edema of the renal parenchyma, showing lower CT attenuation compared with normal. In addition multiple wedge shaped kidney defects compatible with infarctions may also be seen..”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
  • "Coronavirus disease 2019 disease caused by SARS-CoV-2 virus infection is a novel disease and knowledge about its pathophysiology and manifestations continue to evolve. Although the respiratory tract is the primary system involved, extrapulmonary organ systems including cardiovascular, GI, urinary, and central nervous systems also show COVID-19–associated manifestations. It is important for both clinicians and radiologists to be familiar with these associated extrapulmonary findings to aid in early recognition and appropriate management of this disease.”
    Cross-sectional Imaging Manifestations of Extrapulmonary Involvement in COVID-19 Disease  
    Bernard F. Laya et al.
    (J Comput Assist Tomogr 2021;45: 253–262) 
© 1999-2021 Elliot K. Fishman, MD, FACR. All rights reserved.