What is the added value of specialist radiology review of multidisciplinary team meeting cases in a tertiary care center?

PURPOSE

Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. This study investigated how often subspecialized radiologists change patient management in MDTMs at a tertiary care institution.

MATERIALS AND METHODS

Over 2 years, six subspecialty radiologists documented their contributions to MDTMs at a tertiary care center. Both in-house and external imaging examinations were discussed at the MDTMs. All imaging examinations (whether primary or second opinion) were interpreted and reported by subspecialty radiologist prior to the MDTMs. The management change ratio (MCratio) of the radiologist was defined as the number of cases in which the radiologist's input in the MDTM changed patient management beyond the information that was already provided by the in-house (primary or second opinion) radiology report, as a proportion of the total number of cases whose imaging examinations were prepared for demonstration in the MDTM.

RESULTS

Sixty-eight MDTMs were included. The time required for preparing and attending all MDTMs (excluding imaging examinations that had not been reported yet) was 11,000 min, with a median of 172 min (IQR 113-200 min) per MDTM, and a median of 9 min (IQR 8-13 min) per patient. The radiologists' input changed patient management in 113 out of 1138 cases, corresponding to an MCratio of 8.4%. The median MCratio per MDTM was 6% (IQR 0-17%).

CONCLUSION

Radiologists' time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM. The use of radiologists for MDTMs should therefore be improved.

CLINICAL RELEVANCE STATEMENT

The use of radiologists for MDTMs (multidisciplinary team meetings) should be improved, because their time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM.

KEY POINTS

• Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. • In a tertiary care center in which all imaging examinations have already been interpreted and reported by subspecialized radiologists before the MDTM takes place, the median time investment of a radiologist for preparing and demonstrating one MDTM patient is 9 min. • In this setting, the radiologist changes patient management in only a minority of cases in the MDTM.

Is work overload associated with diagnostic errors on 18F-FDG-PET/CT?

PURPOSE

To determine the association between workload and diagnostic errors on 18F-FDG-PET/CT.

MATERIALS AND METHODS

This study included 103 18F-FDG-PET/CT scans with a diagnostic error that was corrected with an addendum between March 2018 and July 2023. All scans were performed at a tertiary care center. The workload of each nuclear medicine physician or radiologist who authorized the 18F-FDG-PET/CT report was determined on the day the diagnostic error was made and normalized for his or her own average daily production (workloadnormalized). A workloadnormalized of more than 100% indicates that the nuclear medicine physician or radiologist had a relative work overload, while a value of less than 100% indicates a relative work underload on the day the diagnostic error was made. The time of the day the diagnostic error was made was also recorded. Workloadnormalized was compared to 100% using a signed rank sum test, with the hypothesis that it would significantly exceed 100%. A Mann-Kendall test was performed to test the hypothesis that diagnostic errors would increase over the course of the day.

RESULTS

Workloadnormalized (median of 121%, interquartile range: 71 to 146%) on the days the diagnostic errors were made was significantly higher than 100% (P = 0.014). There was no significant upward trend in the frequency of diagnostic errors over the course of the day (Mann-Kendall tau = 0.05, P = 0.7294).

CONCLUSION

Work overload seems to be associated with diagnostic errors on 18F-FDG-PET/CT. Diagnostic errors were encountered throughout the entire working day, without any upward trend towards the end of the day.

Radiologist-patient communication of musculoskeletal ultrasonography results: a choice between added value and costs

BACKGROUND

Literature on radiologist-patient communication of musculoskeletal ultrasonography (US) results is currently lacking.

PURPOSE

To investigate the patient's view on receiving the results from a radiologist after a musculoskeletal US examination, and the additional time required to provide such a service.

MATERIAL AND METHODS

This prospective study included 106 outpatients who underwent musculoskeletal US, and who were equally randomized to either receive or not receive the results from the radiologist directly after the examination.

RESULTS

In both randomization groups, all quality performance metrics (radiologist's friendliness, explanation, skill, concern for comfort, concern for patient questions/worries, overall rating of the examination, and likelihood of recommending the examination) received median scores of good/high to very good/very high. Patients who had received their US results from the radiologist rated the radiologist's explanation and concern for patient questions/worries as significantly higher (P = 0.009 and P = 0.002) than patients who had not. In both randomization groups, there were no significant differences between anxiety levels before and after the US examination (P = 0.222 and P = 1.000). Of the 48 responding patients, 46 (95.8%) rated a radiologist-patient discussion of US findings as important. US examinations with a radiologist-patient communication regarding US findings (median = 11.29 min) were significantly longer (P < 0.0001) than those without (median = 8.08 min).

CONCLUSION

Even without communicating musculoskeletal US results directly to patients, radiologists can still achieve high ratings from patients for their communication and empathy. Nevertheless, patient experience can be further enhanced if a radiologist adds this communication to the examination. However, this increases total examination time and therefore costs.

Work overload and diagnostic errors in radiology

PURPOSE

To determine the association between workload and diagnostic errors on clinical CT scans.

METHOD

This retrospective study was performed at a tertiary care center and covered the period from January 2020 to March 2023. All clinical CT scans that contained an addendum describing a perceptual error (i.e. failure to detect an important abnormality) in the original report that was issued on office days between 7.30 a.m. and 18.00 p.m., were included. The workload of the involved radiologist on the day of the diagnostic error was calculated in terms of relative value units, and normalized for the known average daily production of each individual radiologist (workloadnormalized). A workloadnormalized of less than 100% indicates relative work underload, while a workloadnormalized of > 100% indicates relative work overload in terms of reported examinations on an individual radiologist's basis.

RESULTS

A total of 49 diagnostic errors were included. Top-five locations of diagnostic errors were lung (n = 8), bone (n = 8), lymph nodes (n = 5), peritoneum (n = 5), and liver (n = 4). Workloadnormalized on the days the diagnostic errors were made was on average 121% (95% confidence interval: 106% to 136%), which was significantly higher than 100% (P = 0.008). There was no significant upward monotonic trend in diagnostic errors over the course of the day (Mann-Kendall tau of 0.005, P = 1.000), and there were no other notable temporal trends either.

CONCLUSIONS

Radiologists appear to have a relative work overload when they make a diagnostic error on CT. Diagnostic errors occurred throughout the entire day, without any increase towards the end of the day.

Why don't we inform patients about the risk of diagnostic errors?

The principles of autonomy and informed consent dictate that patients who undergo a radiological examination should actually be informed about the risk of diagnostic errors. Implementing such a policy could potentially increase the quality of care. However, due to the vast number of radiological examinations that are performed in each hospital each day, financial constraints, and the risk of losing trust, patients, and income if the requirement for informed consent is not imposed by law on a state or national level, it may be challenging to inform patients about the risk of diagnostic errors. Future research is necessary to determine if and how an informed consent procedure for diagnostic errors can be implemented in clinical practice.

A new medical imaging postprocessing and interpretation concept to investigate the clinical relevance of incidentalomas: can we keep Pandora's box closed?

BACKGROUND

Incidental imaging findings (incidentalomas) are common, but there is currently no effective means to investigate their clinical relevance.

PURPOSE

To introduce a new concept to postprocess a medical imaging examination in a way that incidentalomas are concealed while its diagnostic potential is maintained to answer the referring physician's clinical questions.

MATERIAL AND METHODS

A deep learning algorithm was developed to automatically eliminate liver, gallbladder, pancreas, spleen, adrenal glands, lungs, and bone from unenhanced computed tomography (CT). This deep learning algorithm was applied to a separately held set of unenhanced CT scans of 27 patients who underwent CT to evaluate for urolithiasis, and who had a total of 32 incidentalomas in one of the aforementioned organs.

RESULTS

Median visual scores for organ elimination on modified CT were 100% for the liver, gallbladder, spleen, and right adrenal gland, 90%-99% for the pancreas, lungs, and bones, and 80%-89% for the left adrenal gland. In 26 out of 27 cases (96.3%), the renal calyces and pelves, ureters, and urinary bladder were completely visible on modified CT. In one case, a short (<1 cm) trajectory of the left ureter was not clearly visible due to adjacent atherosclerosis that was mistaken for bone by the algorithm. Of 32 incidentalomas, 28 (87.5%) were completely concealed on modified CT.

CONCLUSION

This preliminary technical report demonstrated the feasibility of a new approach to postprocess and evaluate medical imaging examinations that can be used by future prospective research studies with long-term follow-up to investigate the clinical relevance of incidentalomas.

[18F]FDG-PET/CT in mechanically ventilated critically ill patients with COVID-19 ARDS and persistent inflammation

Purpose

We report the findings of four critically ill patients who underwent an [18F]FDG-PET/CT because of persistent inflammation during the late phase of their COVID-19.

Methods

Four mechanically ventilated patients with COVID-19 were retrospectively discussed in a research group to evaluate the added value of [18F]FDG-PET/CT.

Results

Although pulmonary PET/CT findings differed, bilateral lung anomalies could explain the increased CRP and leukocytes in all patients. This underscores the limited ability of the routine laboratory to discriminate inflammation from secondary infections. Based on PET/CT findings, a secondary infection/inflammatory focus was suspected in two patients (pancreatitis and gastritis). Lymphadenopathy was present in patients with a detectable SARS-CoV-2 viral load. Muscle uptake around the hips or shoulders was observed in all patients, possibly due to the process of heterotopic ossification.

Conclusion

This case series illustrates the diagnostic potential of [18F]FDG-PET/CT imaging in critically ill patients with persistent COVID-19 for the identification of other causes of inflammation and demonstrates that this technique can be performed safely in mechanically ventilated critically ill patients.

Value-based radiology cannot thrive without reforms and research

KEY POINTS

• A value-based system aims to achieve improved patient-relevant outcomes without increasing costs.• Value-based radiology cannot thrive as long as volume dominates as the most important metric to reward clinical performance.• Reforms and research are needed to enable radiologists to practice value-based healthcare.

Radiologist-patient consultation of imaging findings after neck ultrasonography: An opportunity to practice value-based radiology

OBJECTIVE

To investigate how patients experience a radiologist-patient consultation of imaging findings directly after neck ultrasonography (US), and how much time this consumes.

MATERIALS AND METHODS

This prospective randomized study included 109 consecutive patients who underwent neck US, of whom 44 had a radiologist-patient consultation of US results directly after the examination, and 65 who had not.

RESULTS

The median ratings of all healthcare quality metrics (friendliness of the radiologist, explanation of the radiologist, skill of the radiologist, radiologist's concern for comfort during the examination, radiologist's concern for patient questions/worries, overall rating of the examination, and likelihood of recommending the examination) were either good/high or very good/very high, without any significant differences between both patient groups. Patients who did not discuss the US results with the radiologist, were significantly more worried during the examination (P = 0.040) and had significantly higher anxiety levels after completion of the US examination (P = 0.027) than patients who discussed the US results with the radiologist. Fifty-one out of 55 responding patients (92.7%) indicated a radiologist-patient consultation of US results to be important. The median duration of US examinations that included a radiologist-patient consultation of US results was 7.57 min (range: 5.15-12.10 min), while the median duration of US examinations without a radiologist-patient consultation of US results was 7.34 min (range: 3.45-14.32 min), without any significant difference (P = 0.637).

CONCLUSION

A radiologist-patient consultation of imaging findings after neck US decreases patient anxiety, is desired by most patients, and does not significantly prolong total examination time.

Patient safety incidents in radiology: frequency and distribution of incident types

BACKGROUND

Patient safety incidents may be a valuable source of information to learn from and to prevent future errors.

PURPOSE

To determine the distribution of patient safety incident types in radiology according to the International Classification for Patient Safety (ICPS), and to comprehensively review those incidents that were either harmful or serious in terms of risk of patient harm and reoccurrence.

MATERIAL AND METHODS

The most recent five-year database (2014-2019) of a radiology incident reporting system was evaluated.

RESULTS

A total of 480 patient safety incidents were included. Top three ICPS incident types were clinical administration (119/480, 24.8%), resources/organizational management (112/480, 23.3%), and clinical process/procedure (91/480, 19.0%). Harm severities were none in 457 (95.2%) cases, mild in 14 (2.9%), moderate in 4 (0.8%), severe in 3 (0.6%), and unknown in one case. Subsequent Prevention Recovery Information System for Monitoring and Analysis (PRISMA) reviews were performed in 4 (0.8%) cases. The three patient safety incidents that caused severe harm (of which one underwent PRISMA review) involved resources/organizational management (n = 1), clinical process/procedure (n = 1), and medication/IV fluids (n = 1). Three other cases (with no harm in two cases and moderate harm in one case) that underwent PRISMA review involved resources/organizational management (n = 2) and medical device/equipment/property (n = 1).

CONCLUSION

Radiology-related patient safety incidents predominantly occur in three ICPS domains (clinical administration, resources/organizational management, and clinical process/procedure). Harmful/serious incidents are relatively rare. The standardly and transparently reported findings from this study may be used for healthcare quality improvement, benchmarking purposes, and as a primer for future studies.

Towards a benchmark of abdominal CT use during duty shifts: 15-year sample from the Netherlands

Purpose

To investigate temporal changes in the utilization and patient impact of abdominal CT during duty shifts in the past 15 years.

Methods

This study included a random sample of 1761 abdominal CT scans that were made during evening and night duty shifts in a tertiary care center between 2005 and 2019.

Results

The number of CT scans significantly increased (almost threefold) between 2005 and 2019 (Mann–Kendall tau of 0.829, P < 0.001). The proportion of negative CT scans (i.e., the absence of findings related to the reason that the CT scan was made and no disease deterioration or other new and clinically relevant findings compared to a previous imaging examination when available) was 40.0% (700/1749) in the entire 15-year study frame and did not significantly change over time (Mann–Kendall tau of − 0.219, P = 0.276). The overall frequency of same-day hospital discharge after negative CT was 20.6% (150/729) in the past 15 years and showed a significant increase over time (Mann–Kendall tau of 0.505, P = 0.010). The overall proportion of CT scans with incidental findings was 3.4% (60/1761) and remained statistically stable over the past 15 years (Mann–Kendall tau of − 0.057, P = 0.804).

Conclusion

Over the past 15 years, the number of CT scans and the frequency of same-day hospital discharge after negative CT have increased, while the proportions of negative CT scans and incidental findings have remained stable in our tertiary care center. The data from this study can be used for interinstitutional benchmarking to define, monitor, and improve the appropriateness of imaging utilization.

Requests for radiologic imaging: Prevalence and determinants of inadequate quality according to RI-RADS

PURPOSE

To determine the prevalence and determinants of radiologic imaging requests that are of inadequate quality according to the Reason for exam Imaging Reporting and Data System (RI-RADS).

METHODS

This study included a random sample of 673 radiologic examinations performed at a tertiary care center. The quality of each imaging request was graded according to RI-RADS. Ordinal regression analysis was performed to determine the association of RI-RADS grade with patient age, gender, and hospital status, indication for imaging, requesting specialty, imaging modality, body region, time of examination, and relationship with previous imaging within the past one year.

RESULTS

RI-RADS grades A (adequate request), B (barely adequate request), C (considerably limited request), and D (deficient request) were assigned to 159 (23.6 %), 166 (24.7 %), 214 (31.8 %), and 134 (19.9 %) of cases, respectively. Indication for imaging, requesting specialty, and body region were independently significantly associated with RI-RADS grades. Specifically, routine preoperative imaging (odds ratio [OR]: 3.422, P = 0.030) and transplantation imaging requests (OR: 8.710, P = 0.000) had a higher risk of poorer RI-RADS grades, whereas infection/inflammation as indication for imaging (OR: 0.411, P = 0.002), pediatrics as requesting specialty (OR: 0.400, P = 0.007), and head (OR: 0.384, P = 0.017), spine (OR: 0.346, P = 0.016), and upper extremity (OR: 0.208, P = 0.000) as body regions had a lower risk of poorer RI-RADS grades.

CONCLUSION

The quality of radiologic imaging requests is inadequate in >75 % of cases, and is affected by several factors. The data from this study can be used as a baseline and benchmark for further investigation and improvement.

Time to Reconsider Routine Percutaneous Biopsy in Spondylodiscitis?

Percutaneous image-guided biopsy currently has a central role in the diagnostic work-up of patients with suspected spondylodiscitis. However, on the basis of recent evidence, the value of routine image-guided biopsy in this disease can be challenged. In this article, we discuss this recent evidence and also share a new diagnostic algorithm for spondylodiscitis that was recently introduced at our institution. Thus, we may move from a rather dogmatic approach in which routine image-guided biopsy is performed in any case to a more individualized use of this procedure.

MRI after Whoops procedure: diagnostic value for residual sarcoma and predictive value for an incomplete second resection

OBJECTIVE

To determine the value of MRI for the detection and assessment of the anatomic extent of residual sarcoma after a Whoops procedure (unplanned sarcoma resection) and its utility for the prediction of an incomplete second resection.

MATERIALS AND METHODS

This study included consecutive patients who underwent a Whoops procedure, successively followed by gadolinium chelate-enhanced MRI and second surgery at a tertiary care sarcoma center.

RESULTS

Twenty-six patients were included, of whom 19 with residual tumor at the second surgery and 8 with an incomplete second resection (R1: n = 6 and R2: n = 2). Interobserver agreement for residual tumor at MRI after a Whoops procedure was perfect (κ value: 1.000). MRI achieved a sensitivity of 47.4% (9/19), a specificity of 100% (7/7), a positive predictive value of 100% (9/9), and a negative predictive value of 70.0% (7/17) for the detection of residual tumor. MRI correctly classified 2 of 19 residual sarcomas as deep-seated (i.e., extending beyond the superficial muscle fascia) but failed to correctly classify 3 of 19 residual sarcomas as deep-seated. There were no significant associations between MRI findings (presence of residual tumor, maximum tumor diameter, anatomic tumor extent, tumor margins, tumor spiculae, and tumor tail on the superficial fascia) with an incomplete (R1 or R2) second resection.

CONCLUSION

Gadolinium chelate-enhanced MRI is a reproducible method to rule in residual sarcoma, but it is insufficiently accurate to rule out and assess the anatomic extent or residual sarcoma after a Whoops procedure. Furthermore, MRI has no utility in predicting an incomplete second resection.

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

Objective

To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST.

Methods

This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST.

Results

FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038).

Conclusion

Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available.

Diagnostic value of MRI signs in differentiating Ewing sarcoma from osteomyelitis

Background

The value of magnetic resonance imaging (MRI) signs in differentiating Ewing sarcoma from osteomyelitis has not be thoroughly investigated.

Purpose

To investigate the value of various MRI signs in differentiating Ewing sarcoma from osteomyelitis.

Material and Methods

Forty-one patients who underwent MRI because of a bone lesion of unknown nature with a differential diagnosis that included both Ewing sarcoma and osteomyelitis were included. Two observers assessed several MRI signs, including the transition zone of the bone lesion, the presence of a soft-tissue mass, intramedullary and extramedullary fat globules, and the penumbra sign.

Results

Diagnostic accuracies for discriminating Ewing sarcoma from osteomyelitis were 82.4% and 79.4% for the presence of a soft-tissue mass, and 64.7% and 58.8% for a sharp transition zone of the bone lesion, for readers 1 and 2 respectively. Inter-observer agreement with regard to the presence of a soft-tissue mass and the transition zone of the bone lesion were moderate (κ = 0.470) and fair (κ = 0.307), respectively. Areas under the receiver operating characteristic curve of the diameter of the soft-tissue mass (if present) were 0.829 and 0.833, for readers 1 and 2 respectively. Mean inter-observer difference in soft-tissue mass diameter measurement ± limits of agreement was 35.0 ± 75.0 mm. Diagnostic accuracies of all other MRI signs were all < 50%.

Conclusion

Presence and size of a soft-tissue mass, and sharpness of the transition zone, are useful MRI signs to differentiate Ewing sarcoma from osteomyelitis, but inter-observer agreement is relatively low. Other MRI signs are of no value in this setting.

Surveillance MRI for the detection of locally recurrent Ewing sarcoma seems futile

PURPOSE

To determine the frequency of locally recurrent Ewing sarcoma on surveillance MRI and the outcome of these patients.

MATERIALS AND METHODS

This retrospective single-center study included all patients with newly diagnosed Ewing sarcoma who underwent surveillance MRI of the primary tumor location after primary treatment between 1997 and 2016.

RESULTS

Thirty-two patients underwent a total of 176 local surveillance MRI scans, yielding an average of 5.5 ± 4.4 MRI scans per patient. Follow-up time of surveillance MRI after completion of primary treatment ranged between 1 and 111 months. Surveillance MRI detected five (15.6%) locally recurrent Ewing sarcomas, at 2, 4, 6, 6, and 7 months after completion of primary treatment, of whom three also had simultaneous recurrent (metastatic) disease elsewhere. Two patients had recurrent metastatic disease without any signs of locally recurrent disease on surveillance MRI. All five patients with locally recurrent disease on surveillance MRI died, at 2, 4, 5, 8, and 9 months after local recurrence detection. Patients with locally recurrent disease had a significantly worse overall survival than patients without locally recurrent disease (log-rank test, P < 0.0001).

CONCLUSIONS

A limited number of patients have locally recurrent Ewing sarcoma on surveillance MRI. These patients often have simultaneous recurrent (metastatic) disease elsewhere, and their outcome is poor. Moreover, some patients present without locally recurrent disease on MRI but disease recurrence elsewhere. Therefore, surveillance MRI currently seems to have little value and should be reconsidered, also given the costs and the repeated exposure of surviving patients to gadolinium-based contrast agents.

Primary tumor volume measurements in Ewing sarcoma: MRI inter- and intraobserver variability and comparison with FDG-PET

BACKGROUND

Primary tumor volume is as an important and independent prognostic factor in Ewing sarcoma. However, the observer variability of magnetic resonance imaging (MRI)-based primary tumor volume measurements in newly diagnosed Ewing sarcoma has never been investigated. Furthermore, it is unclear how MRI-based volume measurements compare to ¹⁸F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)-based volume measurements. This study aimed to determine the observer variability of simplified MRI-based primary tumor volume measurements in newly diagnosed treatment-naive Ewing sarcoma and to compare them to the actual primary tumor volume at MRI and the FDG-PET-based metabolically active tumor volume (MATV).

MATERIAL AND METHODS

Twenty-nine newly diagnosed Ewing sarcoma patients with pretreatment MRI (of whom 11 also underwent FDG-PET) were included. Both exact and dichotomized (according to the proposed threshold of 200 mL) primary tumor volume measurements were analyzed.

RESULTS

Mean inter- and intraobserver differences of MRI-based simplified tumor volume ± limits of agreement varied between 15-42 ± 155-204 mL and between 9-16 ± 64-250 mL, respectively. Inter- and intraobserver agreements of dichotomized MRI-based simplified tumor volume measurements was very good (κ = 0.827-1.000). Mean difference between simplified and actual tumor volumes at MRI ± limits of agreement was 60 ± 381 mL. Agreement between dichotomized simplified and actual tumor volumes at MRI was very good (κ = 0.839). Mean difference between MRI-based simplified tumor volume and MATV ± limits of agreement was 181 ± 549 mL and almost significantly different (p = .0581). Agreement between dichotomized MRI-based simplified tumor volume and MATV was moderate (κ = 0.560).

CONCLUSIONS

Exact MRI-based simplified primary tumor volume measurements in Ewing sarcoma suffer from considerable observer variability, but observer agreement of dichotomized measurements (≤200 mL vs. >200 mL) is very good and generally matches MRI-based actual volume measurements. MRI-based primary tumor volume measurements poorly-moderately agree with and tend to be higher than the MATV.

CT-guided biopsy in suspected spondylodiscitis: microbiological yield, impact on antimicrobial treatment, and relationship with outcome

PURPOSE

To investigate the clinical impact of CT-guided biopsy, as performed in routine clinical practice, in patients with suspected spondylodiscitis on MRI in terms of culture yield, impact on antimicrobial treatment, and outcome.

METHODS

This study included 64 patients with MRI findings compatible with spondylodiscitis who underwent CT-guided biopsy.

RESULTS

Initial CT-guided biopsies were culture-positive in 20/64 (31.3%, 95% confidence interval [CI] 21.2-43.3%). Repeat CT-guided biopsies (after initial negative biopsy) were culture-positive in an additional 5/15 (33.3%, 95% CI 15.2-58.3%). Serum leukocytes, C-reactive protein, pre-biopsy use of antibiotics, neurological symptoms, MRI findings, vertebral height loss, and hyperkyphosis were not significantly different between culture-positive and culture-negative cases (P = 0.214-1.000); 75% (15/20) of initial CT-guided biopsies that were culture-positive provided additional information to clinicians for guiding antibiotic treatment. Sixty-two of 64 patients (96.9%, 95% CI 89.3-99.1%) would have been adequately treated if a strategy was followed that would subject all patients without clinical findings suspicious for "atypical" microorganisms and negative blood cultures to empirical antibiotics (i.e., clindamycin for coverage of Gram-positive bacteria) without using biopsy results to determine the optimal antibiotic regimen. Outcome within 6 months (development of neurologic or orthopedic complications, surgery, and death) was not significantly different (P = 0.751) between culture-positive and culture-negative patients.

CONCLUSIONS

Although CT-guided biopsies are culture-positive in a minority of cases, the majority of positive cultures are useful to tailor antibiotic treatment. Empirical treatment with clindamycin may cover almost all micro-organisms in positive biopsy specimens, provided patients are not immunocompromised. Outcome appears similar between culture-positive and culture-negative patients.

Culture yield of repeat percutaneous image-guided biopsy after a negative initial biopsy in suspected spondylodiscitis: a systematic review

OBJECTIVE

To systematically review the published data on the culture yield of a repeat (second) percutaneous image-guided biopsy after negative initial biopsy in suspected spondylodiscitis.

MATERIALS AND METHODS

A systematic search was performed of the PubMed/Medline and Embase databases. The methodological quality of the studies included was assessed. The proportions of positive cultures among all initial biopsies and second biopsies (after a negative initial biopsy) were calculated for each study and assessed for heterogeneity (defined as I² > 50%).

RESULTS

Eight studies, comprising a total of 107 patients who underwent a second percutaneous image-guided biopsy after a culture-negative initial biopsy in suspected spondylodiscitis, were included. All eight studies were at risk of bias and were concerning with regard to applicability, particularly patient selection, flow of patients through the study, and timing of the biopsy. The proportions of positive cultures among all initial biopsies ranged from 10.3 to 52.5%, and were subject to heterogeneity (I² = 73.7%). The proportions of positive cultures among all second biopsies after negative initial biopsy ranged from 0 to 60.0%, and were not subject to heterogeneity (I² = 38.7%).

CONCLUSION

Although a second percutaneous image-guided biopsy may have some value in patients with suspected spondylodiscitis, its exact value remains unclear, given the available poor-quality evidence. Future well-designed studies are needed to determine the role of a second percutaneous image-guided biopsy in this setting. Such studies should clearly describe the spectrum of patients that was selected for a second percutaneous image-guided biopsy, the method of biopsy, and differences compared with the first biopsy, if any.