Interobserver variability for interpretation of DMSA scans in the RIVUR trial

The Intrarenal Reflux Diagnosed by Contrast-Enhanced Voiding Urosonography (ceVUS): A Reason for the Reclassification of Vesicoureteral Reflux and New Therapeutic Approach?

Vesicoureteral reflux (VUR) is defined as the urine backflow from the urinary bladder to the pyelo-caliceal system. In contrast, intrarenal reflux (IRR) is the backflow of urine from the renal calyces into the tubulointerstitial space. VURs, particularly those associated with IRR can result in reflux nephropathy when accompanied by urinary tract infection (UTI). The prevalence of IRR in patients with diagnosed VUR is 1-11% when using voiding cystourethrography (VCUG), while 11.9-61% when applying the contrast-enhanced voiding urosonography (ceVUS). The presence of IRR diagnosed by VCUG often correlates with parenchymal scars, when diagnosed by a 99mTc dimercaptosuccinic acid scan (DMSA scan), mostly in kidneys with high-grade VURs, and when diagnosed by ceVUS, it correlates with the wide spectrum of parenchymal changes on DMSA scan. The study performed by both ceVUS and DMSA scans showed IRRs associated with non-dilated VURs in 21% of all detected VURs. A significant difference regarding the existence of parenchymal damage was disclosed between the IRR-associated and IRR-non-associated VURs. A higher portion of parenchymal changes existed in the IRR-associated VURs, regardless of the VUR grade. That means that kidneys with IRR-associated VURs represent the high-risk group of VURs, which must be considered in the future classification of VURs. When using ceVUS, 62% of places where IRR was found were still unaffected by parenchymal changes. That was the basis for our recommendation of preventive use of long-term antibiotic prophylaxis until the IRR disappearance, regardless of the VUR grade. We propose a new classification of VURs using the ceVUS method, in which each VUR grade is subdivided based on the presence of an IRR.

Primary Vesicoureteral Reflux and Renal Scarring

Vesicoureteral reflux (VUR) is the commonest congenital anomaly of urinary tract in children. It is mostly diagnosed after a urinary tract infection or during evaluation for congenital anomalies of the kidney and urinary tract. High-grade VUR, recurrent pyelonephritis, and delayed initiation of antibiotic treatment are important risk factors for renal scarring. The management of VUR depends on multiple factors and may include surveillance only or antimicrobial prophylaxis; very few patients with VUR need surgical correction. Patients with renal scarring should be monitored for hypertension and those with significant scarring should also be monitored for proteinuria and chronic kidney disease.

Discordance Between Oncology Clinician-Perceived and Radiologist-Intended Meaning of the Postradiotherapy Positron Emission Tomography/Computed Tomography Freeform Report for Head and Neck Cancer

Importance

Assessment of response after radiotherapy (RT) using 18F-fluorodeoxyglucose positron emission tomography (PET) with computed tomography (CT) is routine in managing head and neck squamous cell carcinoma (HNSCC). Freeform reporting may contribute to a clinician's misunderstanding of the nuclear medicine (NM) physician's image interpretation, with important clinical implications.

Objective

To assess clinician-perceived freeform report meaning and discordance with NM interpretation using the modified Deauville score (MDS).

Design, Setting, and Participants

In this retrospective cohort study that was conducted at an academic referral center and National Cancer Institute-designated Comprehensive Cancer Center and included patients with HNSCC treated with RT between January 2014 and December 2019 with a posttreatment PET/CT and 1 year or longer of follow-up, 4 masked clinicians independently reviewed freeform PET/CT reports and assigned perceived MDS responses. Interrater reliability was determined. Clinician consensus-perceived MDS was then compared with the criterion standard NM MDS response derived from image review. Data analysis was conducted between December 2021 and February 2022.

Exposures

Patients were treated with RT in either the definitive or adjuvant setting, with or without concurrent chemotherapy. They then underwent posttreatment PET/CT response assessment.

Main Outcomes and Measures

Clinician-perceived (based on the freeform PET/CT report) and NM-defined response categories were assigned according to MDS. Clinical outcomes included locoregional control, progression-free survival, and overall survival.

Results

A total of 171 patients were included (45 women [26.3%]; median [IQR] age, 61 [54-65] years), with 149 (87%) with stage III to IV disease. Of these patients, 52 (30%) received postoperative RT and 153 (89%) received concurrent chemotherapy. Interrater reliability was moderate (κ = 0.68) among oncology clinicians and minimal (κ = 0.36) between clinician consensus and NM. Exact agreement between clinician consensus and the NM was 64%. The NM-rated MDS was significantly associated with locoregional control, progression-free survival, and overall survival.

Conclusions and Relevance

The results of this cohort study suggest that considerable variation in perceived meaning exists among oncology clinicians reading freeform HNSCC post-RT PET/CT reports, with only minimal agreement between MDS derived from clinician perception and NM image interpretation. The NM use of a standardized reporting system, such as MDS, may improve clinician-NM communication and increase the value of HNSCC post-RT PET/CT reports.

The role of renal contour change in the diagnosis of cortical scarring after urinary tract infection

Urinary tract infections in children can lead to permanent renal scarring in approximately 15% of cases. Technetium-99m (^99mTc)-dimercaptosuccinic acid (DMSA) scintigraphy is the gold standard for identifying renal scarring. Using data and scans from children enrolled at our center in a 2-year prospective clinical trial (RIVUR study), we included children with radiologically confirmed pyelonephritis who exhibited renal scarring on their 1 and/or 2-year follow-up scans and asked 3 blinded pediatric nuclear medicine physicians to reexamine the renal contours in these scans. Five girls met all eligibility criteria (each had two late ^99mTc-DMSA scans 1 and 2 years after index UTI). Of the 20 kidneys imaged, 10 exhibited renal scarring and of these, 7 exhibited renal contour abnormalities. These findings suggest that the presence of abnormalities of the renal contour is not necessary for diagnosis of renal scarring.

Initial Referring Physician and Radiologist Experience with Neck Imaging Reporting and Data System

OBJECTIVES/HYPOTHESIS

Neck Imaging Reporting and Data System (NI-RADS) is a radiology reporting system developed for head and neck cancer surveillance imaging, using standardized terminology, numeric levels of suspicion, and linked management recommendations. Through a multidisciplinary, interdepartmental quality improvement initiative, we implemented NI-RADS for the reporting of head and neck cancer surveillance CT. Our objective is to summarize our initial experience from the standpoints of head and neck cancer providers and radiologists.

STUDY DESIGN

Quality improvement study.

METHODS

Before and 3 months post-implementation, surveys were offered to referring physicians (n = 21 pre-adoption; 22 post-adoption) and radiologists (n = 17 pre- and post-adoption). NI-RADS utilization was assessed over time.

RESULTS

Survey response rates were 62% (13/21) and 73% (16/22) for referring physicians pre- and post-adoption, respectively, and 94% (16/17) for radiologists pre- and post-adoption. Among post-adoption provider respondents, 100% (16/16) strongly agreed or agreed with "I want our radiologists to continue using NI-RADS," "The NI-RADS numerical rating of radiologic suspicion is helpful," and "The language and style of NI-RADS neck CT reports are clear and understandable." Among radiologist respondents, 88% (14/16) strongly agreed or agreed with "NI-RADS improves consistency among our radiologists in the reporting of surveillance neck CTs." Radiologist NI-RADS utilization increased over time (46% month 1; 72% month 3).

CONCLUSIONS

Most referring physicians and radiologists preferred NI-RADS. Head and neck cancer providers indicated that NI-RADS reports are clear, understandable, direct, and helpful in guiding clinical management. Radiologists indicated that NI-RADS improves radiologist consistency in the reporting of surveillance neck CT, and radiologists increasingly used NI-RADS over time.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2021.

Types of Parenchymal Changes Diagnosed on DMSA Scans of Kidneys Affected by Different Grades of Vesicoureteral Reflux

Background

Renal parenchymal damage and scarring usually is associated with urinary tract infection (UTI), whereas the impact of vesicoureteral reflux (VUR) on the kidneys is unclear. We aimed to compare kidneys with all grades of VUR (grades Io-V) and those without VUR by using direct radionuclide cystography, voiding cystourethrography, and findings from ^99mTc-DMSA scintigraphy (DMSA scan).

Material/Methods

The present analysis included 253 renal ureteral units (RUU) from 129 children with VUR and recurrent UTI and children with a single febrile UTI associated with abnormal ultrasonographic findings. The 6 grades of VUR (Io, I, II, III, IV, and V) and 35 RUUs without VUR were divided into 4 groups: 1. Non-dilated VUR (grades Io-II); 2. Mildly dilated VUR (grade III); 3. Dilated VUR (grades IV–V); and 4. The control group.

Results

DMSA scanning showed significant differences between the groups with non-dilated VUR, grade III VUR, grades IV–V VUR, and the control group in kidney width (χ²=30.5; P<0.001); position and shape (χ²=30.6; P<0.001); intensity of activity (χ²=38.1; P<0.001); distribution of activity (χ²=34.5; P<0.001); and existence of scars (χ²=16; P<0.001). The probability of abnormalities on DMSA scans increased with the VUR grade. However, inside the groups of dilated and non-dilated VUR we found no significant statistical differences between those characteristics.

Conclusions

Our results indicate that kidneys without VUR or with non-dilated lateral VUR and dilated VUR on the contralateral side represent 2 different categories of parenchymal changes.

Targeted Indication of Imaging for Detection of Vesicoureteric Reflux after Pediatric Febrile Urinary Tract Infections Based on a Multiparametric Computational Tool

OBJECTIVES

Diagnostic workup after febrile urinary tract infections (fUTIs) in children remains a matter of debate. The authors aimed to evaluate multiple parameters in order to design a predictive tool enabling a targeted indication of voiding cystourethrography (VCUG).

METHODS

Records of 383 consecutive children who underwent a VCUG as well as a dimercaptosuccinic-acid (DMSA) scan after febrile urinary tract infections (fUTIs) at a single institution between 04/2009 and 06/2014 were reviewed. Twenty parameters were recorded. After regression analysis, 6 parameters were incorporated into a computational tool aiming at a targeted indication of an eventual VCUG. The performance of the tool was prospectively tested on 100 patients.

RESULTS

Postpyelonephritic alterations on DMSA, duplex systems, age 1-3 y, duration of fever >3 d, >2 fUTIs before VCUG and abnormal sonography findings were identified as significant predictors (p < 0.05 each); the presence of bladder and bowel dysfunction (BBD) was negatively associated with vesicoureteric reflux (VUR). The resulting computational tool achieved an Area under the curve (AUC) of 0.686 (CI 0.633-0.740). Prospective evaluation (100 new patients) revealed a sensitivity of 85.1%, a specificity of 49.1%, a positive predictive value of 59.7% and a negative predictive value of 78.7%.

CONCLUSIONS

The differentiated indication of a VCUG based on the use of a tool was efficient in optimizing the specificity of the diagnostic algorithm after fUTIs. The tool outperformed other common clinical approaches in terms of VUR detection and VCUG frequency. After validation and further refinement in a multicentric approach, this strategy could significantly enhance VUR detection whilst reducing the number of VCUGs.

[SMAR3T©-a new time-saving diagnostic emergency room management algorithm]

BACKGROUND

Primary computed tomography (CT) plays an increasingly important role in diagnosing life-threatening conditions in polytrauma patients; however, it is associated with two major problems: suboptimal interobserver reliability with unstructured reports especially when the reporting is undertaken by physicians in training during working hours and a delay in beginning urgent surgical interventions, which is mainly due to the time taken until the CT report is available and less to the technical time necessary for the CT. This is why the clinical benefits of a primary CT scan in hemodynamically unstable patients after polytrauma is currently under interdisciplinary discussion.

OBJECTIVE

The present study focused on the development and evaluation of a standardized imaging and reporting protocol for initial CT diagnostics of injuries that need immediate treatment after polytrauma.

METHODS

In this study 30 patients after polytrauma were subjected to a novel imaging and reporting protocol, SMAR³T, consisting of an imaging protocol with decreased thin-slice axial scan sequences and a standardized structured reporting protocol. These were compared to conventional emergency room CT protocol with respect to time efficiency and quality of the results.

RESULTS

The application of the SMAR³T algorithm significantly reduced the time from scan to reporting from an average of 59.6 ± 4.2 min to an average of 8.5 ± 0.6 min (p < 10^-23). With the conventional reporting protocol as well as the novel SMAR³T reporting protocol, all life-threatening conditions and injuries requiring immediate treatment were detected.

CONCLUSION

Based on the results of 30 CT scans in polytraumatized patients, the SMAR³T algorithm significantly reduced the time to surgical intervention without compromising diagnostic accuracy with respect to life-threatening conditions. Additionally, the reduction in imaging data volume could facilitate telemedical transmission of data to superordinate centers.