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Ross J, Hammouche S, Chen Y, Rockall AG. Beyond regulatory compliance: evaluating radiology artificial intelligence applications in deployment. Clin Radiol 2024; 79:338-345. [PMID: 38360516 DOI: 10.1016/j.crad.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
The implementation of artificial intelligence (AI) applications in routine practice, following regulatory approval, is currently limited by practical concerns around reliability, accountability, trust, safety, and governance, in addition to factors such as cost-effectiveness and institutional information technology support. When a technology is new and relatively untested in a field, professional confidence is lacking and there is a sense of the need to go above the baseline level of validation and compliance. In this article, we propose an approach that goes beyond standard regulatory compliance for AI apps that are approved for marketing, including independent benchmarking in the lab as well as clinical audit in practice, with the aims of increasing trust and preventing harm.
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Affiliation(s)
- J Ross
- Department of Cancer and Surgery, Imperial College London, UK.
| | - S Hammouche
- Department of Cancer and Surgery, Imperial College London, UK
| | - Y Chen
- School of Medicine, University of Nottingham, UK
| | - A G Rockall
- Department of Cancer and Surgery, Imperial College London, UK
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Rockall AG, Shelmerdine SC, Chen M. AI and ML in radiology: Making progress. Clin Radiol 2023; 78:81-82. [PMID: 36639174 DOI: 10.1016/j.crad.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/26/2022] [Indexed: 01/12/2023]
Affiliation(s)
- A G Rockall
- Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Rd, W12 0NN, UK.
| | - S C Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - M Chen
- Department of Surgery and Cancer, Imperial College London, UK
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Thomassin-Naggara I, Belghitti M, Milon A, Abdel Wahab C, Sadowski E, Rockall AG. O-RADS MRI score: analysis of misclassified cases in a prospective multicentric European cohort. Eur Radiol 2021; 31:9588-9599. [PMID: 34041567 DOI: 10.1007/s00330-021-08054-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/18/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To retrospectively review the causes of categorization errors using O-RADS-MRI score and to determine the presumptive causes of these misclassifications. METHODS EURAD database was retrospectively queried to identify misclassified lesions. In this cohort, 1194 evaluable patients with 1502 pelvic masses (277 malignant / 1225 benign lesions) underwent standardized MRI to characterize adnexal masses with histology or 2 years' follow-up as a reference standard. An expert radiologist reviewed cases with two junior radiologists and lesions termed misclassified if malignant lesion was scored ≤ 3, a benign lesion was scored ≥ 4, the site of origin was incorrect, or a non-adnexal mass was incorrectly categorized as benign or malignant. RESULTS There were 139 / 1502 (9.2%) misclassified masses in 116 women including 109 adnexal and 30 non-adnexal masses. False-negative cases corresponded to 16 borderline or invasive malignant adnexal masses rated score ≤ 3 (16 / 139, 11.5%). False-positive cases corresponded to 88 benign masses were rated score 4 (67 / 139, 48.2%) or 5 (18 / 139,12.9%) or considered suspicious non-adnexal lesions (3 / 139, 2.2%). Misclassifications were only due to origin error in 12 adnexal masses (8 benign, 4 malignant) (8.6%, 12 / 139) and 23 non-adnexal masses (18 benign, 5 malignant,16.5%, 23 / 139) perceived respectively as non-adnexal and adnexal masses. Interpretive error (n = 104), failure to recognize technical insufficient exams (n = 9), and perceptual errors (n = 4) were found. Most interpretive was due to misinterpretation of solid tissue or incorrect assignment of mass origin. Eighty-four out of 139 cases were correctly reclassified by the readers with strict adherence to the score rules. CONCLUSION Most errors were due to misinterpretation of solid tissue or incorrect assignment of mass origin. KEY POINTS • Prospective assignment of O-RADS-MRI score resulted in misclassification of 9.25% of sonographically indeterminate pelvic masses. • Most errors were interpretive (74.8%) due to misinterpretation of solid tissue as defined by the lexicon or incorrect assignment of mass origin. • Pelvic inflammatory disease is a common source of misclassification (8.9%) (12 / 139).
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Affiliation(s)
- I Thomassin-Naggara
- APHP, Sorbonne Université, Hôpital Tenon, Service de radiologie, 58 avenue Gambetta, 75020, Paris, France. .,Institut Universitaire de Cancérologie, Sorbonne Université, Hôpital Tenon, Service de radiologie, 75020, Paris, France.
| | - M Belghitti
- APHP, Sorbonne Université, Hôpital Tenon, Service de radiologie, 58 avenue Gambetta, 75020, Paris, France.,Institut Universitaire de Cancérologie, Sorbonne Université, Hôpital Tenon, Service de radiologie, 75020, Paris, France
| | - A Milon
- APHP, Sorbonne Université, Hôpital Tenon, Service de radiologie, 58 avenue Gambetta, 75020, Paris, France.,Institut Universitaire de Cancérologie, Sorbonne Université, Hôpital Tenon, Service de radiologie, 75020, Paris, France
| | - C Abdel Wahab
- APHP, Sorbonne Université, Hôpital Tenon, Service de radiologie, 58 avenue Gambetta, 75020, Paris, France.,Institut Universitaire de Cancérologie, Sorbonne Université, Hôpital Tenon, Service de radiologie, 75020, Paris, France
| | - E Sadowski
- Departments of Radiology, Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E3/372, Madison, WI, 53792-3252, USA
| | - A G Rockall
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
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Bazot M, Bharwani N, Huchon C, Kinkel K, Cunha TM, Guerra A, Manganaro L, Buñesch L, Kido A, Togashi K, Thomassin-Naggara I, Rockall AG. European society of urogenital radiology (ESUR) guidelines: MR imaging of pelvic endometriosis. Eur Radiol 2016; 27:2765-2775. [PMID: 27921160 PMCID: PMC5486785 DOI: 10.1007/s00330-016-4673-z] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 10/05/2016] [Accepted: 11/23/2016] [Indexed: 12/21/2022]
Abstract
Abstract Endometriosis is a common gynaecological condition of unknown aetiology that primarily affects women of reproductive age. The accepted first-line imaging modality is pelvic ultrasound. However, magnetic resonance imaging (MRI) is increasingly performed as an additional investigation in complex cases and for surgical planning. There is currently no international consensus regarding patient preparation, MRI protocols or reporting criteria. Our aim was to develop clinical guidelines for MRI evaluation of pelvic endometriosis based on literature evidence and consensus expert opinion. This work was performed by a group of radiologists from the European Society of Urogenital Radiology (ESUR), experts in gynaecological imaging and a gynaecologist expert in methodology. The group discussed indications for MRI, technical requirements, patient preparation, MRI protocols and criteria for the diagnosis of pelvic endometriosis on MRI. The expert panel proposed a final recommendation for each criterion using Oxford Centre for Evidence Based Medicine (OCEBM) 2011 levels of evidence. Key Points • This report provides guidelines for MRI in endometriosis. • Minimal and optimal MRI acquisition protocols are provided. • Recommendations are proposed for patient preparation, best MRI sequences and reporting criteria. Electronic supplementary material The online version of this article (doi:10.1007/s00330-016-4673-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Bazot
- Department of Radiology, Tenon Hospital, 58 Avenue Gambetta, Paris, 75020, France.
| | - N Bharwani
- Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, 3rd Floor Queen Elizabeth the Queen Mother Building, Praed Street, London, W2 1NY, UK
| | - C Huchon
- Department of Obtetrics and Gynaecology, CHI Poissy Saint-Germain en Laye,Versailles University France, 10 rue du champ Gaillard, 78300, Poissy, France
| | - K Kinkel
- Institut de radiologie, Clinique des Grangettes, 7, chemin des Grangettes, CH 1224, Chêne-Bougeries, Switzerland
| | - T M Cunha
- Serviço de Radiologia, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal
| | - A Guerra
- Department of Radiology, Hospital da Luz, Lisbon, Portugal
| | - L Manganaro
- Department of Radiological Sciences, Sapienza University of Rome, Vle. Regina Elena 324, 00162, Rome, Italy
| | - L Buñesch
- Department of Radiology (Urogenital Section), Hospital Clínic Barcelona, Villarroel, 170, Barcelona, 08036, Spain
| | - A Kido
- Department of Diagnostic Radiology, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - K Togashi
- Department of Diagnostic Radiology, Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - I Thomassin-Naggara
- Department of Radiology, Tenon Hospital, 58 Avenue Gambetta, Paris, 75020, France
| | - A G Rockall
- Department of Radiology, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
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Tang YZ, Benardin L, Booth TC, Miquel ME, Dilks P, Sahdev A, Rockall AG. Use of an internal reference in semi-quantitative dynamic contrast-enhanced MRI (DCE MRI) of indeterminate adnexal masses. Br J Radiol 2014; 87:20130730. [PMID: 25237836 DOI: 10.1259/bjr.20130730] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Semi-quantitative dynamic contrast-enhanced MRI (DCE MRI) has proven useful in discriminating benign from borderline/malignant adnexal lesions. Our aim was to assess if the use of a lesion-to-internal-reference ratio improved the performance in characterizing adnexal masses and which internal reference was suitable. METHODS Semi-quantitative DCE MRI images of 71 indeterminate adnexal lesions were retrospectively reviewed. A region of interest was manually drawn onto the enhancing solid component, psoas muscle and normal outer myometrium. The DCE parameters were evaluated, and the lesion-to-internal-reference ratios were calculated. RESULTS When the wash in rate of the lesion was higher than that of the myometrium, 97% specificity and 12% sensitivity for borderline/malignancy was reached. When the maximum relative enhancement and maximum absolute enhancement (SImax) of the lesion was less than those of the psoas, 100% specificity for benignity was achieved. The highest area under the curve (AUC) (0.807) was achieved using a SImax lesion-myometrium ratio. A slightly lower AUC (0.799) was achieved using a SImax lesion-psoas ratio, but the psoas muscle was more frequently measurable in the same slice as the lesion ROI. Although the AUC was higher, when using ratios instead of individual DCE values, this was not significantly different. CONCLUSION DCE MRI has added diagnostic value in the assessment of adnexal lesions, and the use of internal references enables high specificity for malignancy and benignity. Lesion-internal-reference ratios have no added diagnostic value over DCE values alone. ADVANCES IN KNOWLEDGE Both psoas muscle and myometrium are suitable internal references in the DCE assessment of adnexal lesions enabling high specificity for malignancy and benignity.
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Affiliation(s)
- Y Z Tang
- 1 St Bartholomew's Hospital Imaging Department, Barts and the London NHS Trust, London, UK
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Bharwani N, Miquel ME, Powles T, Dilks P, Shawyer A, Sahdev A, Wilson PD, Chowdhury S, Berney DM, Rockall AG. Diffusion-weighted and multiphase contrast-enhanced MRI as surrogate markers of response to neoadjuvant sunitinib in metastatic renal cell carcinoma. Br J Cancer 2013; 110:616-24. [PMID: 24366299 PMCID: PMC3915138 DOI: 10.1038/bjc.2013.790] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 11/17/2013] [Accepted: 11/21/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Current imaging criteria for categorising disease response in metastatic renal cell carcinoma (mRCC) correlate poorly with overall survival (OS) in patients on anti-angiogenic therapies. We prospectively assess diffusion-weighted and multiphase contrast-enhanced (MCE) MR imaging (MRI) as markers of outcome. METHODS Treatment-naive mRCC patients on a phase II trial using sunitinib completed an MRI substudy. Whole-tumour apparent diffusion coefficient (ADC) maps and histograms were generated, and mean ADC and AUC(low) (proportion of the tumour with ADC values lying below the 25th percentile of the ADC histogram) recorded. On MCE-MRI, regions of interest were drawn around the most avidly enhancing components to analyse enhancement parameters. Baseline (n=26) and treatment-related changes in surviving patients (n=20) were correlated with OS. Imaged metastases were also analysed. RESULTS Forty-seven per cent of the patients showed significant changes in whole-tumour mean ADC following therapy, but there was no correlation with outcome. Patients with a high baseline AUC(low) and greater-than-median AUC(low) increase had reduced OS (HR=3.67 (95% confidence interval (CI)=1.23-10.9), P=0.012 and HR=3.72 (95% CI=0.98-14.21), P=0.038, respectively). There was no correlation between MCE-MRI parameters and OS. Twenty-eight metastases were analysed and showed positive correlation with primary tumour mean ADC for individual patients (r=0.607; P<0.001). CONCLUSION Primary RCC ADC histogram analysis shows dynamic changes with sunitinib. Patients in whom the tumour ADC histogram demonstrated high baseline AUC(low) or a greater-than-median increase in AUC(low) with treatment had reduced OS.
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Affiliation(s)
- N Bharwani
- Department of Radiology, Barts Health NHS Trust, St Bartholomew's Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - M E Miquel
- 1] Department of Clinical Physics, Barts Health NHS Trust, St Bartholomew's Hospital, 4th Floor Dominion House, 60 St Bartholomew's Close, London EC1A 7BE, UK [2] Barts and the London NIHR Cardiovascular Biomedical Research Unit, Centre for Advanced Cardiovascular Imaging, Queen Mary University of London, Bonner Road, London E2 9JX, UK
| | - T Powles
- Barts Cancer Institute, Experimental Cancer Medicine Centre, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - P Dilks
- Department of Radiology, Barts Health NHS Trust, St Bartholomew's Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - A Shawyer
- Department of Radiology, Barts Health NHS Trust, St Bartholomew's Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - A Sahdev
- Department of Radiology, Barts Health NHS Trust, St Bartholomew's Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - P D Wilson
- Department of Medical Oncology, St Bartholomew's Hospital, 7th Floor Gloucester House, London EC1A 7BE, UK
| | - S Chowdhury
- Department of Medical Oncology, Guys and St Thomas' NHS Foundation Trust, Great Maze Pond, London SE1 9RT, UK
| | - D M Berney
- Barts Cancer Institute, Molecular Oncology and Cellular Pathology, Queen Mary University of London, Charterhouse Square, London EC1M 6BQ, UK
| | - A G Rockall
- Department of Radiology, Barts Health NHS Trust, St Bartholomew's Hospital, King George V Building, West Smithfield, London EC1A 7BE, UK
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Miquel ME, Scott AD, Macdougall ND, Boubertakh R, Bharwani N, Rockall AG. In vitro and in vivo repeatability of abdominal diffusion-weighted MRI. Br J Radiol 2012; 85:1507-12. [PMID: 22674704 DOI: 10.1259/bjr/32269440] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To study the in vitro and in vivo (abdomen) variability of apparent diffusion coefficient (ADC) measurements at 1.5 T using a free-breathing multislice diffusion-weighted (DW) MRI sequence. METHODS DW MRI images were obtained using a multislice spin-echo echo-planar imaging sequence with b-values=0, 100, 200, 500, 750 and 1000 s mm(-2). A flood-field phantom was imaged at regular intervals over 100 days, and 10 times on the same day on 2 occasions. 10 healthy volunteers were imaged on two separate occasions. Mono-exponential ADC maps were fitted excluding b=0. Paired analysis was carried out on the liver, spleen, kidney and gallbladder using multiple regions of interest (ROIs) and volumes of interest (VOIs). RESULTS The in vitro coefficient of variation was 1.3% over 100 days, and 0.5% and 1.0% for both the daily experiments. In vivo, there was no statistical difference in the group mean ADC value between visits for any organ. Using ROIs, the coefficient of reproducibility was 20.0% for the kidney, 21.0% for the gallbladder, 24.7% for the liver and 28.0% for the spleen. For VOIs, values fall to 7.7%, 6.4%, 8.6% and 9.6%, respectively. CONCLUSION Good in vitro repeatability of ADC measurements provided a sound basis for in vivo measurement. In vivo variability is higher and when considering single measurements in the abdomen as a whole, only changes in ADC value greater than 23.1% would be statistically significant using a two-dimensional ROI. This value is substantially lower (7.9%) if large three-dimensional VOIs are considered.
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Affiliation(s)
- M E Miquel
- Clinical Physics, Barts Health NHS Trust, London, UK.
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Bharwani N, Miquel ME, Sahdev A, Narayanan P, Malietzis G, Reznek RH, Rockall AG. Diffusion-weighted imaging in the assessment of tumour grade in endometrial cancer. Br J Radiol 2011; 84:997-1004. [PMID: 21896664 DOI: 10.1259/bjr/14980811] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Endometrial cancer is the most common gynaecological malignancy in developed countries. Histological grade and subtype are important prognostic factors obtained by pipelle biopsy. However, pipelle biopsy "samples" tissue and a high-grade component that requires more aggressive treatment may be missed. The purpose of the study was to assess the use of diffusion-weighted MRI (DW-MRI) in the assessment of tumour grade in endometrial lesions. METHOD 42 endometrial lesions including 23 endometrial cancers and 19 benign lesions were evaluated with DW-MRI (1.5T with multiple b-values between 0 and 750 s mm(-2)). Visual evaluation and the calculation of mean and minimum apparent diffusion coefficient (ADC) value were performed and correlated with histology. RESULTS The mean and minimum ADC values for each histological grade were 1.02 ± 0.29×10(-3) mm(2) s(-1) and 0.74 ± 0.24×10(-3) mm(2) s(-1) (grade 1), 0.88 ± 0.39×10(-3) mm(2) s(-1) and 0.64 ± 0.36×10(-3) mm(2) s(-1) (grade 2), and 0.94 ± 0.32×10(-3) mm(2) s(-1) and 0.72 ± 0.36×10(-3) mm(2) s(-1) (grade 3), respectively. There was no statistically significant difference between tumour grades. However, the mean ADC value for endometrial carcinoma was 0.97 ± 0.31, which was significantly lower (p<0.0001) than that of benign endometrial pathology (1.50 ± 0.14). Applying a cut-off mean ADC value of less than 1.28 × 10(-3) mm(2) s(-1)we obtained a sensitivity, specificity, positive predictive value and negative predictive value for malignancy of 87%, 100%, 100% and 85.7%, respectively. CONCLUSION Tumour mean and minimum ADC values are not useful in differentiating histological tumour grade in endometrial carcinoma. However, mean ADC measurement can provide useful information in differentiating benign from malignant endometrial lesions. This information could be clinically relevant in those patients where pre-operative endometrial sampling is not possible.
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Affiliation(s)
- N Bharwani
- Department of Imaging, Barts and The London NHS Trust, London, UK.
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Rockall AG, Planche K, Power N, Nowosinska E, Monson JP, Grossman AB, Reznek RH. Detection of neuroendocrine liver metastases with MnDPDP-enhanced MRI. Neuroendocrinology 2009; 89:288-95. [PMID: 19023191 DOI: 10.1159/000176207] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 07/24/2008] [Indexed: 11/19/2022]
Abstract
PURPOSE The sensitivity of computerised tomography (CT) in detecting neuroendocrine liver metastases is variable and three-phase imaging is advocated. However, patients are often young and may require prolonged follow-up, thus a technique that avoids radiation exposure would be desirable. Our purpose was to assess the diagnostic performance of MRI, before and after administration of mangafodipir trisodium (MnDPDP), in the detection of neuroendocrine liver metastases. METHODS Patients who had undergone single-phase or multi-phase contrast-enhanced MD-CT for neuroendocrine liver metastases were invited to have MRI. Two independent observers made quantitative measurements (number and size of lesions). All measurements were made on each available CT phase and all MRI sequences independently, and repeated after an interval to assess reproducibility. The final number of lesions was agreed on by consensus of three observers. A qualitative assessment (contrast and spatial resolution) and preferred modality were agreed on by consensus. RESULTS 265 lesions were detected by consensus in 11 patients. Non-contrast CT was available in 4/11, arterial phase in 6/11 and portal phase in 10/11 patients. When compared with the consensus number of lesions, MD-CT identified 17% on non-contrast, 44% on arterial and 43% on portal venous imaging. Lesion detection on MRI was 48% on T(1)W, 52% on T(2)W and 92% on MnDPDP-MRI. The number of lesions detected on MnDPDP-MRI was closest to the final consensus reading (variance = 0.994, p = 0.0027). The reproducibility of lesion size measurements was best on MnDPDP-MRI (variance = 0.033, p = 0.0021). The preferred modality subjectively was MnDPDP-MRI in 9/11 cases and T(2)W MRI in 2/11. CONCLUSION MRI is a robust technique in the demonstration of neuroendocrine liver metastases. It is highly reproducible in both detecting the number and measuring the size of lesions. We recommend T(2)W MRI and MnDPDP-MRI in detection and follow-up of neuroendocrine liver metastases.
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Affiliation(s)
- A G Rockall
- Department of Radiology, St. Bartholomew's Hospital, London, UK.
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Bent CL, Sahdev A, Rockall AG, Singh N, Sohaib SA, Reznek RH. MRI appearances of borderline ovarian tumours. Clin Radiol 2008; 64:430-8. [PMID: 19264189 DOI: 10.1016/j.crad.2008.09.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Revised: 09/03/2008] [Accepted: 09/10/2008] [Indexed: 12/13/2022]
Abstract
This review was performed to describe the range of magnetic resonance imaging (MRI) appearances of borderline ovarian tumours. The MRI findings in 26 patients with 31 borderline ovarian tumours (mean age: 40.1 years, range: 14-85 years) were retrospectively reviewed. For each tumour, site, size, MRI characteristics, and enhancement following gadolinium administration were recorded. There were 20 serous and 11 mucinous borderline ovarian subtypes. Nine of 26 patients demonstrated bilateral disease on MRI; synchronous contralateral ovarian disease included three benign, five serous borderline, and one serous invasive tumour. A history of a metachronous mucinous borderline tumour was identified in one patient. MRI appearances were classified into four morphological categories: group 1 (6/31, 19%), unilocular cysts; group 2 (6/31, 19%), minimally septate cysts with papillary projections; group 3 (14/31, 45%), markedly septate lesions with plaque-like excrescences; and group 4 (5/31, 16%), predominantly solid with exophytic papillary projections, all of serous subtype. There was a significant difference in mean volume between serous (841.5 cm(3)) and mucinous (6358.2 cm(3)) subtypes (p=0.009). All tumours demonstrated at least one MRI feature suggestive of malignancy. The present review demonstrates the variable MRI appearances of borderline ovarian tumours along with imaging features suggestive of tumour subtype. In patients in whom the clinical features are suggestive of a borderline ovarian tumour (young age and normal or minimally elevated CA125), the ability to predict a borderline disease using morphological features observed on MRI would be extremely helpful in surgical planning, with the potential to offer fertility or ovary-preserving surgery. Future studies are required to further this aim.
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Affiliation(s)
- C L Bent
- Department of Diagnostic Imaging, St Bartholomew's Hospital, West Smithfield, London, UK.
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Whitley SA, Moyes VJ, Park KM, Brooke AM, Grossman AB, Chew SL, Rockall AG, Monson JP, Reznek RH. The appearance of the adrenal glands on computed tomography in multiple endocrine neoplasia type 1. Eur J Endocrinol 2008; 159:819-24. [PMID: 18827064 DOI: 10.1530/eje-08-0516] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To review the morphology of the adrenal glands in multiple endocrine neoplasia type 1 (MEN1) on computed tomography (CT) to compare the results with established normal values for adrenal size and nodularity and to correlate adrenal size with serum cortisol secretory dynamics. MATERIALS AND METHODS Two observers independently reviewed the adrenal CT in 28 patients with MEN1, measuring the maximum width of the body of the gland and the medial and lateral limbs. Incidence and location of nodules >5 mm within the gland were recorded. Following exclusion of known cases of Cushing's syndrome, adrenal gland size was compared with previously documented normative data. Adrenal gland size was compared between patients with normal and abnormal cortisol dynamics. RESULTS Comparison of mean adrenal size in MEN1 patients with normative data showed that the adrenal limbs were significantly larger in MEN1 than normal (P<0.0001 in all four limbs). Adrenal body was also significantly larger (P<0.05). Nodules were demonstrated in 17 (60%) of patients (versus 0.4-2% in the normal population). No statistically significant correlation was demonstrated between adrenal limb hyperplasia and abnormal cortisol dynamics. CONCLUSIONS In patients with MEN1, adrenal limb hyperplasia and adrenal nodules are significantly more common than in the normal population, a phenomenon not previously documented in a quantitative manner. There was no significant correlation between adrenal limb hyperplasia and abnormal cortisol dynamics.
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Affiliation(s)
- S A Whitley
- Department of Diagnostic Imaging, St Bartholomew's Hospital, Barts and the London NHS Trust and QMUL, London, UK
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Sohaib SA, Rockall AG. Oncological imaging. Imaging 2008. [DOI: 10.1259/imaging/24183533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Sahdev A, Hughes JH, Barwick T, Rockall AG, Gallagher CJ, Reznek RH. Computed tomography features of recurrent ovarian carcinoma according to time to relapse. Acta Radiol 2007; 48:1038-44. [PMID: 17957523 DOI: 10.1080/02841850701557255] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although the sites of recurrent ovarian cancer are individually described in the literature, patterns of recurrent disease are poorly understood. PURPOSE To describe CT patterns of disease in recurrent ovarian cancer. To emphasize common patterns, recognise subtle and unusual sites of recurrent disease. MATERIALS AND METHODS We identified patients between 1981-2004 presenting with clinical recurrence or elevated CA 125 after complete primary clinical and radiological response. CT imaging at primary diagnosis, during and after treatment and at recurrence was retrospectively reviewed. Site, distribution, stage of disease and time to relapse was recorded. RESULTS 400 patients were treated for ovarian cancer. 214(54%) achieved complete primary response. 161(75%) relapsed with complete imaging available in 67 patients. Of the 67 patients, 14 (21%) recurred within 1 year, 44 (66%) relapsed between 1-5 years. Therefore 87% of relapses occurred within 5 years following primary treatment. Five (8%) relapsed between 5-10 years and 4 (6%) relapsed after 10 years. Commonest pattern of relapse was pelvic mass in 35 (48%) patients, solitary in 15 (22%). 27 (45%) relapsed with peritoneal thickening, 27 (45%) had small or large bowel serosal disease, 22 (33%) had enlarged lymphadenopathy, 6 as sole manifestation of recurrence, 20 (30%) presented with unusual sites of recurrence: 6 splenic, 10 hepatic, 2 biliary, 3 brain and 2 muscle. CONCLUSION Our study is the first to describe common patterns of recurrence in ovarian cancer. Most frequent site is pelvis, followed by peritoneum, serosal surfaces and nodal disease. 30% presented with disease at 'unusual' sites.
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Affiliation(s)
- A. Sahdev
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - J. H. Hughes
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - T. Barwick
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - A. G. Rockall
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - C. J. Gallagher
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - R. H. Reznek
- Academic Department of Radiology and Department of Clinical Oncology, St. Bartholomew's Hospital, West Smithfield, London, UK
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Taylor A, Rockall AG, Powell MEB. An Atlas of the Pelvic Lymph Node Regions to Aid Radiotherapy Target Volume Definition. Clin Oncol (R Coll Radiol) 2007; 19:542-50. [PMID: 17624745 DOI: 10.1016/j.clon.2007.05.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2007] [Accepted: 05/02/2007] [Indexed: 11/17/2022]
Abstract
AIMS The implementation of advanced three-dimensional radiotherapy planning techniques requires accurate target volume localisation. We have previously developed guidelines to aid definition of the pelvic lymph node regions, and the aim of this study was to produce a CT atlas. MATERIALS AND METHODS The guidelines were applied to a CT scan of a patient to receive adjuvant radiotherapy. RESULTS Reference CT images of the pelvis were generated, illustrating the nodal regions and a typical target volume for adjuvant pelvic radiotherapy for gynaecological cancer. CONCLUSION These images can be used as an aid for target volume definition of the pelvic nodal regions.
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Affiliation(s)
- A Taylor
- Department of Radiotherapy, St Bartholomew's Hospital, London, UK.
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Rockall AG, Meroni R, Sohaib SA, Reynolds K, Alexander-Sefre F, Shepherd JH, Jacobs I, Reznek RH. Evaluation of endometrial carcinoma on magnetic resonance imaging. Int J Gynecol Cancer 2007; 17:188-96. [PMID: 17291252 DOI: 10.1111/j.1525-1438.2007.00805.x] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Our aims were to assess diagnostic performance of T2-weighted (T2W) and dynamic gadolinium-enhanced T1-weighted (T1W) magnetic resonance imaging (MRI) in the preoperative assessment of myometrial and cervical invasion by endometrial carcinoma and to identify imaging features that predict nodal metastases. Two radiologists retrospectively reviewed MR images of 96 patients with endometrial carcinoma. Tumor size, depth of myometrial and cervical invasion, and nodal enlargement were recorded and then correlated with histology. The sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the identification of any myometrial invasion (superficial or deep) were 0.94, 0.50, 0.93, 0.55 on T2W and 0.92, 0.50, 0.92, 0.50 on dynamic T1W, and for deep myometrial invasion were 0.84, 0.78, 0.65, 0.91 on T2W and 0.72, 0.88, 0.72, 0.88 on dynamic T1W. The sensitivity, specificity, PPV and NPV for any cervical invasion (endocervical or stromal) were 0.65, 0.87, 0.57, 0.90 on T2W and 0.50, 0.90, 0.46, 0.92 on dynamic T1W, and for cervical stromal involvement were 0.69, 0.95, 0.69, 0.95 on T2W and 0.50, 0.96, 0.57, 0.95 on dynamic T1W. Leiomyoma or adenomyosis were seen in 73% of misdiagnosed cases. Sensitivity and specificity for the detection of nodal metastases was 66% and 73%, respectively. Fifty percent of patients with cervical invasion on MRI had nodal metastases. In conclusion, MRI has a high sensitivity for detecting myometrial invasion and a high NPV for deep invasion. MRI has a high specificity and NPV for detecting cervical invasion. Dynamic enhancement did not improve diagnostic performance. MRI may allow accurate categorization of cases into low- or high-risk groups ensuring suitable extent of surgery and adjuvant therapy
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Affiliation(s)
- A G Rockall
- Department of Radiology, St Bartholomew's Hospital, West Smithfield, 59 Bartholomew Close, West Smithfield, London, United Kingdom.
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Sohaib SA, Houghton SL, Meroni R, Rockall AG, Blake P, Reznek RH. Recurrent endometrial cancer: patterns of recurrent disease and assessment of prognosis. Clin Radiol 2007; 62:28-34; discussion 35-6. [PMID: 17145260 DOI: 10.1016/j.crad.2006.06.015] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 06/09/2006] [Accepted: 06/18/2006] [Indexed: 11/16/2022]
Abstract
AIM To evaluate patterns of disease and identify factors predicting outcome in patients presenting with recurrent endometrial adenocarcinoma following primary surgery. MATERIALS AND METHODS A retrospective review was performed of the imaging and clinical data in 86 patients (median age 66 years, range 42-88 years) presenting with recurrent endometrial adenocarcinoma following primary surgery. RESULTS Following primary surgery recurrent disease occurred within 2 years in 64% and within 3 years in 87%. Relapse was seen within lymph nodes in 41 (46%), the vagina in 36 (42%) the peritoneum in 24 (28%) and the lung in 21 (24%). Unusual sites of disease included spleen, pancreas, rectum, muscle and brain. Univariate survival analysis showed the factors significant for poor outcome were: multiple sites of disease, liver and splenic disease, haematogenous, peritoneal and nodal spread, poorly differentiated tumour, and early relapse. The presence of disease within the vagina, bladder or lung was not associated with poor prognosis. Multivariate analysis identified multiple sites of disease, liver and splenic metastases to be independent predictors of poor outcome. CONCLUSION The most frequently observed sites of relapse are: lymph nodes, vagina, peritoneum and lung. Significant predictors of poor outcome in recurrent disease are multiple sites of disease and liver and splenic metastases.
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Affiliation(s)
- S A Sohaib
- Department of Radiology, Royal Marsden Hospital, London, UK
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17
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Barwick TD, Rockall AG, Barton DP, Sohaib SA. Imaging of endometrial adenocarcinoma. Clin Radiol 2006; 61:545-55. [PMID: 16784939 DOI: 10.1016/j.crad.2006.03.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2005] [Revised: 03/06/2006] [Accepted: 03/15/2006] [Indexed: 10/24/2022]
Abstract
Endometrial cancer is the most common gynaecological malignancy and the incidence rising. Prognosis depends on age of patient, histological grade, depth of myometrial invasion and cervical invasion and lymph node metastases. Myometrial invasion and accurate cervical involvement cannot be predicted clinically. Pre-treatment knowledge of these criteria is advantageous in order to plan treatment. The clinical challenge is to effectively select patients at risk of relapse for more radical treatment whilst avoiding over treating low risk cases. This is important as endometrial cancer predominately occurs in postmenopausal women with co-morbidities. Modern imaging provides important tools in the accurate pre-treatment assessment of endometrial cancer and may optimize treatment planning. However, there is little consensus to date on imaging in the routine preoperative assessment of endometrial carcinoma and practice varies amongst many gynaecologists. Transvaginal ultrasound is often the initial imaging examination for women with uterine bleeding. However, once the diagnosis of endometrial cancer has been made, contrast-enhanced magnetic resonance imaging (MRI) provides the best assessment of the disease. The results of contrast-enhanced MRI may identify patients who need more aggressive therapy and referral to a cancer centre. In this article we review the role of imaging in the diagnosis and staging/preoperative assessment of endometrial carcinoma.
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Affiliation(s)
- T D Barwick
- Department of Radiology, St Bartholomew's Hospital, West Smithfield, London, UK
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18
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Rockall AG, Ghosh S, Alexander-Sefre F, Babar S, Younis MTS, Naz S, Jacobs IJ, Reznek RH. Can MRI rule out bladder and rectal invasion in cervical cancer to help select patients for limited EUA? Gynecol Oncol 2006; 101:244-9. [PMID: 16310245 DOI: 10.1016/j.ygyno.2005.10.012] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Revised: 10/05/2005] [Accepted: 10/14/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Although invasion of the bladder or rectum is rare in cervical carcinoma, endoscopic assessment of both organs is part of the standard FIGO clinical staging system, with associated increase in cost and risk of complications. Our objective was to evaluate whether MRI could be used to select patients who did not require invasive staging of the bladder or rectum. METHODS Two observers, blinded to the results of cystoscopy and endoscopic examination of the rectum, retrospectively reviewed the MR images of 112 patients with cervical carcinoma. A 5-point invasion score was used to determine bladder and rectal invasion (1 = no invasion, 5 = definite invasion). A confidence score of 3 or above was used to identify patients with possible bladder or rectal involvement. The results of cystoscopy and endoscopic examination of the rectum were recorded and correlated with the MR findings. RESULTS MRI was negative for both bladder and rectal invasion in 94/112 patients. Cystoscopy and endoscopic examination of the rectum were confirmed to be normal in all 94 cases. MRI identified 12 patients with possible rectal invasion, 2 confirmed at endoscopy. MRI identified 14 patients with possible bladder invasion, one confirmed at cystoscopy. Using a low threshold cut-off score of >3 to predict invasion resulted in a 100% negative predictive value (NPV) in detection of bladder and rectal invasion. CONCLUSION The absence of bladder or rectal invasion can be diagnosed with sufficient confidence using an MRI scoring system to safely obviate the need for invasive cystoscopic or endoscopic staging in the majority of patients with cervical cancer. This could potentially lead to a reduction in staging costs and morbidity.
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Affiliation(s)
- A G Rockall
- Department of Radiology, Dominion House, St. Bartholomew's Hospital, West Smithfield, London EC1A 7ED, UK.
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Abstract
Technological developments in cross-sectional imaging have revolutionized the localization and characterization of functioning adrenal pathology. With effective use of modern imaging, the diagnosis of the cause and nature of functioning adrenal pathology can be reached speedily, accurately and efficiently in the majority of patients. We review the appearance of primary and secondary adrenal pathology, evaluate the diagnostic performance of imaging modalities, highlight newer technical developments, and propose a rational use of these tests in identifying functioning adrenal disease.
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Affiliation(s)
- S A Sohaib
- Department of Diagnostic Radiology, Royal Marsden Hospital, Fulham Road, London SW3 6JJ, UK.
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20
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Taylor A, Rockall AG, Powell MEB. Magnetic resonance lymphography to localise pelvic lymph nodes for intensity-modulated radiotherapy in gynaecological cancer. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.5070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- A. Taylor
- St Bartholomew's Hospital, London, United Kingdom
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21
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Lingam RK, Sohaib SA, Rockall AG, Isidori AM, Chew S, Monson JP, Grossman A, Besser GM, Reznek RH. Diagnostic performance of CT versus MR in detecting aldosterone-producing adenoma in primary hyperaldosteronism (Conn's syndrome). Eur Radiol 2004; 14:1787-92. [PMID: 15241622 DOI: 10.1007/s00330-004-2308-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2003] [Revised: 02/19/2004] [Accepted: 03/04/2004] [Indexed: 01/31/2023]
Abstract
The aim of the present study is to compare the diagnostic performance of CT and MR imaging in detecting aldosterone-producing adenoma and to compare the interobserver variability in the detection of an aldosterone-producing adenoma on CT and MR. A retrospective study of 34 patients with primary hyperaldosteronism was performed. A total of 17 cases of aldosterone-producing adenoma and 17 cases of bilateral adrenal hyperplasia were included. The final diagnosis of an adenoma was made by surgery with histological confirmation, whereas that of bilateral adrenal hyperplasia was made on adrenal venous sampling or a good biochemical and clinical response following medical treatment alone and in the absence of a unilateral radiological abnormality. The CT (n=30) and MR (n=24) scans were reviewed independently by two radiologists experienced in adrenal imaging, who were unaware of the cause of the primary hyperaldosteronism. The diagnostic performances of both observers in detecting an aldosterone-producing adenoma on CT and MR imaging were compared. The 16 adenomatous nodules that were detected on imaging ranged from 1 to 4.75 cm in diameter. The calculated sensitivity and specificity for detecting aldosterone-producing adenoma were 87 and 93% for one observer and 85 and 82% for the other observer on CT, and 83 and 83% for one observer and 92 and 92% for the other observer on MR, respectively. Receptor operating characteristics curve analysis showed similar performances of both observers in detecting an aldosterone-producing adenoma on CT and MR imaging. There was good interobserver agreement on CT (k=0.71) and on MR (k=0.67). We have demonstrated comparable diagnostic performance and good interobserver agreement on CT and MR imaging for the detection of aldosterone-producing adenoma.
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Affiliation(s)
- R K Lingam
- Department of Diagnostic Imaging, St Bartholomew's Hospital, West Smithfield, EC1A 7BE, London, UK
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22
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Rockall AG, Sohaib SA, Evans D, Kaltsas G, Isidori AM, Monson JP, Besser GM, Grossman AB, Reznek RH. Computed tomography assessment of fat distribution in male and female patients with Cushing's syndrome. Eur J Endocrinol 2003; 149:561-7. [PMID: 14640998 DOI: 10.1530/eje.0.1490561] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Our aims were to describe the abdominal fat distribution in male patients with Cushing's syndrome (CS) on computerised tomography (CT), to compare our findings with non-cushingoid patients, to validate previous reports of increased visceral fat in female patients with CS and to identify any correlations between fat distribution and biochemical findings. DESIGN Retrospective and observational. PATIENTS Appropriate CT scans were identified in 31 patients (seven male) with active CS. MEASUREMENTS Total, visceral and subcutaneous fat areas were obtained. The percentage of visceral fat and the visceral to subcutaneous fat ratio (V:S ratio) were calculated. Biochemical data were recorded. Control data of fat distribution were obtained from the literature. RESULTS There was a significant increase in the V:S ratio in male patients with CS when compared with non-cushingoid controls (1.175+/-0.59 vs 0.77+/-0.39, 95% confidence interval (CI) 0.0817-0.728). There was a significant increase in the V:S ratio in female patients with CS (0.845+/-0.53 vs 0.38+/-0.19, 95% CI 0.269-0.661). There was no difference in the V:S ratio between male and female patients with CS (1.175+/-0.59 vs 0.845+/-0.53, 95% CI -0.144-0.804). No significant correlations between fat distribution and glucose levels, circulating cortisol, ACTH or lipids were found. CONCLUSIONS Our data demonstrate an increase in visceral fat distribution in both male and female patients with CS, with the abolition of the normal male to female difference in visceral fat. Increased visceral fat may increase the risk of the metabolic syndrome in this group of patients.
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Affiliation(s)
- A G Rockall
- Department of Diagnostic Radiology, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
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Rockall AG, Sohaib SA, Evans D, Kaltsas G, Isidori AM, Monson JP, Besser GM, Grossman AB, Reznek RH. Hepatic steatosis in Cushing's syndrome: a radiological assessment using computed tomography. Eur J Endocrinol 2003; 149:543-8. [PMID: 14640995 DOI: 10.1530/eje.0.1490543] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Hepatic steatosis may occur in association with insulin resistance and obesity, two features commonly seen in Cushing's syndrome (CS). The aim of this report is to assess the prevalence of hepatic steatosis in patients with active CS using computed tomography (CT) and to identify any associations between hepatic steatosis, endocrine and biochemical variables and body fat distribution. PATIENTS AND MEASUREMENTS We identified 50 patients with active CS in whom appropriate CT was available to allow measurement of liver and spleen attenuation. In 26 patients, abdominal fat measurements were also available. Serum markers of CS and liver function tests were recorded. RESULTS Ten of 50 patients had a liver-to-spleen CT attenuation ratio (L/S) of less than 1, indicating hepatic steatosis. There was a significant negative correlation between both liver attenuation and L/S ratio with total abdominal fat area, visceral fat area, the percentage of visceral fat and the visceral to subcutaneous fat ratio; the strongest negative correlation was found between visceral fat area and L/S ratio (r=-0.638, P<0.001, n=26). L/S ratio positively correlated with alkaline phosphatase levels (r=+0.423, P=0.044, n=23) but with no other serum marker of CS activity or liver enzyme. CONCLUSIONS We have demonstrated hepatic steatosis on CT in 20% of patients with active CS. The presence of hepatic steatosis was significantly correlated with total abdominal fat area and visceral fat area.
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Affiliation(s)
- A G Rockall
- Department of Diagnostic Radiology, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.
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Lingam RK, Sohaib SA, Vlahos I, Rockall AG, Isidori AM, Monson JP, Grossman A, Reznek RH. CT of primary hyperaldosteronism (Conn's syndrome): the value of measuring the adrenal gland. AJR Am J Roentgenol 2003; 181:843-9. [PMID: 12933492 DOI: 10.2214/ajr.181.3.1810843] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objectives of our study of patients with primary hyperaldosteronism (Conn's syndrome) were to determine whether the adrenal glands are larger in patients with bilateral adrenal hyperplasia than in those with aldosterone-producing adenomas or in healthy control subjects; and whether a CT criterion based on adrenal gland size can be developed to positively diagnose bilateral adrenal hyperplasia. MATERIALS AND METHODS A retrospective study of CT scans of 28 patients with primary hyperaldosteronism was performed. The means of two observers' measurements of adrenal gland size were recorded and compared with published normal values. In addition, a radiologist experienced in adrenal imaging and unaware of the cause of the primary hyperaldosteronism diagnosed either bilateral adrenal hyperplasia or aldosterone-producing adenoma by visual inspection. RESULTS The adrenal glands in patients with bilateral adrenal hyperplasia were significantly (p < 0.05) larger than those in patients with aldosterone-producing adenoma or in healthy control subjects. A sensitivity of 100% was achieved when a mean limb width of greater than 3 mm was used to diagnose bilateral adrenal hyperplasia, and a specificity of 100% was achieved when the mean limb width was 5 mm or greater. Receiver operating characteristic curve analysis showed that the overall performance of the radiologist and the mean adrenal limb width in detecting bilateral adrenal hyperplasia were equivalent. CONCLUSION In patients with primary hyperaldosteronism, adrenal limb measurements on CT can aid in differentiating bilateral adrenal hyperplasia from aldosterone-producing adenoma because the adrenal glands in bilateral adrenal hyperplasia are larger.
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Affiliation(s)
- R K Lingam
- Department of Diagnostic Imaging, St. Bartholomew's Hospital, West Smithfield, London EC1A 7BE, United Kingdom
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Walker AE, Schelvan C, Rockall AG, Rickards D, Kellett MJ. Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate? BJU Int 2002; 90:883-6. [PMID: 12460350 DOI: 10.1046/j.1464-410x.2002.03025.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate whether injection with pericapsular lignocaine before transrectal ultrasonography (TRUS)-guided biopsy reduces the perceived pain of prostatic biopsy. PATIENTS AND METHODS The study included 121 patients referred for TRUS-guided biopsy of the prostate; 27 underwent biopsy with no previous injection and 94 were randomized to pericapsular injection with either 1% lignocaine or a placebo (saline). Both patient and operator were unaware of the content of the injection. The injection was delivered under TRUS guidance to the apex of the prostate. Routine sextant biopsies were taken using an 18 G needle in a spring-loaded biopsy gun. A validated pain scale, the NRS11 (0, no pain, to 10, unbearable pain), was used to record the pain of each biopsy. RESULTS No significant placebo effect was detected between the 'no injection' and the placebo-injection group, with mean (95% confidence interval) pain scores of 3.58 (2.77-4.39) and 4.01 (3.46-4.51), respectively, using the unpaired Student's t-test (P = 0.409). There was a statistically significant lower mean pain score in the lignocaine group, at 2.54 (2.00-3.10), than in the placebo-injection group (P < 0.001). CONCLUSION Pericapsular injection with 1% lignocaine significantly reduces the perceived pain of TRUS-guided prostatic biopsy.
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Affiliation(s)
- A E Walker
- Department of Uroradiology, UCL Hospitals, and Radiology, St. Bartholomew's Hospital, London, UK.
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26
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Rockall AG, Reznek RH. Mini-symposium: Endocrine imaging. Imaging 2002. [DOI: 10.1259/img.14.2.1400vi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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27
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Evanson EJ, Clarke SEM, Rankin SC, Power N, Reznek RH, Rockall AG, Sahdev A, Lyon SM, Lee MJ. Picture quiz. Imaging 2002. [DOI: 10.1259/img.14.2.140169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Affiliation(s)
- A G Rockall
- Department of Radiology, University College London Hospitals, London, UK
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30
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Abstract
The development of a fibrin sheath at the tip of a long-term haemodialysis catheter may lead to deteriorating blood flow rates, resulting in inadequate haemodialysis. Restoration of functional patency has been described using the technique of percutaneous fibrin sheath stripping (PFSS) using a wire snare device. Our purpose was to assess this technique within an established renal vascular access service. All catheters referred for the assessment of low blood flow rates on dialysis were considered for the procedure. Initial fluoroscopic assessment of the catheter was followed by stripping of the tip of the catheter using a gooseneck snare. Seventeen of 22 well-positioned catheters undergoing a single PFSS attempt were restored to function with a median prolongation of patency of 4.25 months. Two catheters underwent a second PFSS procedure providing additional patency. Nineteen of a total of 24 (79%) PFSS procedures successfully restored catheter function. Seven catheters with poorly positioned tips or a kink were not restored to functional patency using PFSS. Two patients developed a puncture site haematoma. No patient developed symptoms of pulmonary emoblism. In conclusion, PFSS restored function in 79% of attempts in well positioned catheters. The method is technically straightforward, with a low complication rate and has become a routine part of the renal vascular access service.
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Affiliation(s)
- A G Rockall
- Department of Radiology, St Mary's Hospital, London, UK
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31
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Affiliation(s)
- C J Harvey
- Department of Radiology, University College London Hospitals Trust, UK
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32
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Abstract
Many serious and potentially treatable diseases of the urinary tract may have haematuria as their only manifestation. However, asymptomatic microscopic haematuria detected by dipstick testing may be seen in up to 16% of screening populations. The great majority of such cases will have no sinister underlying cause, particularly in those under 40 years of age, and so the schedule of further investigations, some of which may be invasive, time-consuming and expensive, needs to be rationalised. In addition, the increasing popularity of 'fast track' clinics for the investigation of haematuria enhances the need for a clear strategy of investigation. Analysis of the epidemiology of asymptomatic haematuria and its causes combined with a consideration of the risk-benefit profile of the available investigations, makes it possible to set out an algorithm for the initial management of this common finding. Careful clinical assessment and basic laboratory tests for renal function, analysis of the urinary sediment and cytological examination of the urine are followed by ultrasound and plain radiography of the urinary tract. Flexible cystoscopy under local anaesthetic is central to the algorithm in patients of all ages. The importance of a nephrological opinion and consideration of renal biopsy, especially in younger patients with other evidence of glomerular disease, is stressed. The role of intravenous urography in excluding pathology of the upper urinary tract, especially in patients over the age of 40, is also considered.
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Affiliation(s)
- A G Rockall
- Department of Radiology, St Mary's Hospital, London, UK
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Abstract
There is considerable debate concerning the investigation of patients with asymptomatic microscopic haematuria. Urine dipstick testing is a sensitive screening test but may be positive in some normal individuals. The present consensus is that urine microscopy should be performed to confirm haematuria prior to further investigation. We have performed a retrospective study to establish whether urine microscopy was used in addition to dipstick testing before a request for intravenous urography (IVU) in three centres. IVU request forms from a District General, a Teaching Hospital and a Uroradiological Referral Centre were audited over a 9-month-period. Patients referred with asymptomatic microscopic haematuria were selected. The case notes and urine microscopy results were reviewed. The date of microscopy and its result and the interval between the result and the IVU request were established. One hundred and two cases have been examined, 17 (16.7%) of which were under the age of 40. Only 37 in total had significant haematuria on microscopy and of these, 32 results (31.4% of all cases) were available before the IVU request. In eight patients there was no evidence that urine microscopy had been performed. Fourteen patients had a urinary tract infection. Our findings show that IVUs are often requested on the basis of dipstick testing alone. Only one third of patients had confirmed significant haematuria at the time of IVU request and in some patients infection had not yet been excluded. Although prompt investigation of microscopic haematuria is important, it is essential that the diagnosis is established by microscopy before an IVU is requested.
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Affiliation(s)
- A G Rockall
- Department of Radiology, St. Mary's Hospital, London, UK
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