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ABSTRACT |
Monday, May 7, 1:30 PM–3:30 PM
Abstracts 079-090
Moderator(s): Dean Nakamoto and Benjamin Yeh
1:30 PM
079. Unsuspected Extracolonic Malignancies Detected at Screening CT Colonography
Meiners R.*; Pickhardt P. J.; Kim D. H.; Taylor A. J.; Winter T. C. University of Wisconsin Medical School, Madison, WI
Address correspondence to R. Meiners (rmeiners{at}uwhealth.org)
Objective: To assess the frequency and types of unsuspected extracolonic malignancies detected at screening CT colonography (CTC) in asymptomatic adults.
Materials and Methods: The study group consisted of 4159 adults (mean age, 57.2 years; 2127 women, 2032 men) undergoing primary CTC evaluation over a 40-month period. Prospective evaluation for extracolonic CT findings was performed using contiguous 5-mm reconstructions of the supine CTC dataset. Medical record review was performed to document clinical work-up of extracolonic findings, diagnosis of extracolonic malignancy, and patient outcome, including mortality.
Results: After complete clinical work-up, unsuspected extracolonic malignancy was documented in 14 (0.3%) of 4159 patients (mean age, 60.0 years; 8 women, 6 men). 13 of the 14 patients were diagnosed with unsuspected primary cancers, including bronchogenic carcinoma (n = 4), non-Hodgkin's lymphoma (n = 4), renal cell carcinoma (n = 3), ovarian carcinoma (n = 1), and gastric gastrointestinal stromal tumor (n = 1). One patient with a past history of known but presumably cured stage 1B endometrial carcinoma had unsuspected peritoneal carcinomatosis at CTC. At the time of most recent clinical follow-up (range, 3–25 months), all 14 patients were alive. In comparison, unsuspected invasive colorectal cancers were found in 9 patients from this same screening cohort.
Conclusion: Unsuspected extracolonic malignancies detected at CTC screening are uncommon but not rare, seen approximately once in every 300 asymptomatic adults. Patient outcome to date has been favorable in all cases, possibly related to early asymptomatic detection. Because colorectal screening is primarily targeted for the detection and removal of benign precursor lesions (advanced adenomas) and not cancer itself, extracolonic malignancy is paradoxically seen more commonly at CTC screening than colorectal cancer.
080. Asymptomatic Pneumatosis at CT Colonography: A Self-Limited Incidental Imaging Finding Distinct from Perforation
Pickhardt P. J.*; Kim D. H.; Taylor A. J. University of Wisconsin Medical School, Madison, WI
Address correspondence to P. Pickhardt (ppickhardt2{at}uwhealth.org)
Objective: CT colonography (CTC) is a minimally invasive colorectal screening tool that has a very favorable safety profile compared with optical colonoscopy. We report our experience with incidental discovery of asymptomatic pneumatosis in patients undergoing CTC evaluation.
Materials and Methods: A total of 2,766 patients (mean age, 59.4 years; 1,436 women, 1,176 men) underwent CTC evaluation at our institution over a 2-year period. The database was searched for all cases in which pneumatosis (gas within the bowel wall) was present. The CTC studies and pertinent medical history was reviewed for these cases.
Results: Colonic pneumatosis was identified in 5 (0.18%) of 2766 total CTC studies, including 5 (0.22%) of 2314 patients who underwent colonic distention via automated carbon dioxide delivery. Pneumatosis was not seen in any of the 452 patients undergoing room air insufflation. Pneumatosis involved the ascending colon in all 5 cases and the cecum in four cases. Right-sided pneumatosis had a thin curvilinear configuration in all 5 cases, composed of small intramural or subserosal gas bubbles or channels measuring up to 3 mm in width, with variable extension around the short-axis colonic circumference. In one case, more extensive macrocystic pneumatosis was present within the left colon, which may have been a pre-existing condition. No free intraperitoneal or portomesenteric venous gas was present in any case. During CTC examination, no abdominal symptoms developed beyond the expected mild discomfort associated with low-pressure colonic distention. All patients were asymptomatic following the procedure, with a minimum follow-up interval of 2 hours. None of the patients required observation or intervention.
Conclusion: Asymptomatic right-sided colonic pneumatosis is an uncommon self-limited condition associated with carbon dioxide delivery at CTC. This incidental benign imaging finding should not be confused with symptomatic perforation, which is exceedingly rare at screening CTC with low-pressure automated carbon dioxide delivery.
081. The Significance of Additional Polyps Detected at Optical Colonoscopy (OC) in Patients Referred From Positive CT Colonography (CTC)
Kim D. H.*; Pickhardt P. J.; Taylor A. J. University of Wisconsin Medical School, Madison, WI
Address correspondence to D. Kim (dkim{at}uwhealth.org)
Objective: Therapeutic OC examinations to remove CTC-detected
polyps can lead to removal of additional polyps, including diminutive lesions
(which are not reported at CTC) and CTC false negative polyps (
6 mm). The
purpose of this study was to evaluate the characteristics of these additional
polyps in order to assess the potential clinical significance.
Materials and Methods: Retrospective review of the CTC screening database at a single institution was performed (n = 2,695 patients). Of the positive CTC examinations (n = 329), 194 ultimately underwent OC with polypectomy. The removed polyps were tabulated. The index lesions seen at CTC generating the therapeutic OC were not included in the analysis. The characteristics of size, histology, presence of high-grade dysplasia, and invasive carcinoma for these additional polyps were recorded.
Results: Of the positive CTC examinations that underwent
subsequent OC, 61.3% (119/194) had no additional polyps seen while 38.6%
(75/194) had additional lesions removed. A total of 179 additional polyps were
identified. 76% (136/179) were diminutive; 19% (34/179) were small 6–9
mm and 5% (9/179) were large 10 mm in size. Of the diminutive lesions,
27.2% (37/136) were adenomas; 37.5% (51/136) were nonneoplastic (e.g.,
hyperplastic, mucosal, etc.); and the remainder were fulgurated. Of the CTC
false-negative lesions ( 6 mm), 30.2% (13/43) were adenomas; 65.1% (28/43)
were nonneoplastic; and 4.6% (2/43) were not retrieved. No cases of high-grade
dysplasia or invasive carcinoma were seen in either group. There were 3
advanced adenomas (characterized by a villous component) among subcentimeter
lesions and 4 among the large polyp group (characterized as advanced by size
criterion). All cases with additional advanced lesions had large CTC-detected
advanced adenomas as well.
Conclusion: The yield of additional polyps at OC not reported at CTC consisted mainly of diminutive lesions with a minority of CTC false negatives. These lesions tended to be nonneoplastic or non-advanced adenomas. No isolated cases of advanced adenomas, high grade dysplasia or carcinoma were seen in this additional group of removed polyps. These observations support current CTC screening practices and point to the effectiveness of polyp detection with this modality.
082. CT Colonography in Older Patients with Incomplete Conventional Colonoscopy or Contraindications to Colonoscopy
Lev-Toaff A. S.*; Yucel C.; Bergin D.; Durrani H. Thomas Jefferson University, Philadelphia, PA
Address correspondence to A. Lev-Toaff (anna.lev-toaff{at}jefferson.edu)
Objective: Contraindications to conventional colonoscopy or incomplete colonoscopy exams are more common in the elderly due to diverticular disease, colonic redundancy, anticoagulation, or increased sedation risk. Our purpose was to assess the success of CT colonography (CTC) in older patients who were referred because colonoscopy was contraindicated or incomplete.
Materials and Methods: Over a two-year period 42 patients (25 women, 17 men) who had CTC at our institution were older than 60 years (range: 60–87, mean age = 71). Following a 24–48 hour liquid diet and Fleet Prep Kit #1 prep with Tagitol for fecal tagging, patients were scanned using a 16-slice scanner (Brilliant, Philips) 16 x 0.75 mm. collimation, pitch 0.9; increment 0.5 mm; 1 mm reconstruction interval. Colonic distention was achieved by automated CO2 insufflation (EZ-M, NY); images were obtained in the supine and prone positions, right and left lateral decubitus positions were used as needed. Axial 2D images and volume-rendered filet and 3D endoluminal views were evaluated on a dedicated 3D workstation.
Results: 13/42 (31%) patients were referred to CTC because conventional colonoscopy was contraindicated for the following reasons; anticoagulation therapy (8), increased anesthesia risk (3), poor tolerance for colonoscopy preparation (1), unknown (1). 27/42 (64%) were referred to CTC because colonoscopy was incomplete due to diverticular disease (11), redundancy (8), adhesions (3), residual colonic content (3), sigmoid stricture (1), abdominal wall hernia (1). One patient was referred to CTC for screening purposes; in one other patient the findings at colonoscopy were unknown. No complications were observed due to CTC. Adequate distension of the entire colon was achieved in 38/42 (90%); 39/42 (93%) patients had positive findings on CTC: diverticular disease (25), one or more polyps (22), polypoid mass lesion (1), lipoma (1), sigmoid inflammatory stricture (1). Extracolonic findings judged to be clinically significant (further radiologic investigation, follow-up, or medical or surgical treatment indicated) were seen in 25/42 (60%).
Conclusion: CTC using CO2 insufflation is well tolerated by older patients and is successful in imaging the entire colon in the vast majority, despite the presence of advanced sigmoid diverticular disease and colonic redundancy. Clinically significant extracolonic findings are commonly found in this group of patients.
083. Can Multienergy MDCT Help to Differentiate Between Polyps and Fecal Matter in an Unprepped Colon? A Phantom Study
Sebastian S.1*; Kalra M.2; Fox T.1; Small W.1 1. Emory University School of Medicine, Atlanta, GA; 2. Massachusetts General Hospital, Boston, MA
Address correspondence to S. Sebastian (Sunit.Sebastian{at}emoryhealthcare.org)
Objective: To assess whether multi-energy MDCT can help differentiate between polyps and fecal matter in an unprepped colon using custom-made phantom.
Materials and Methods: We designed a custom-made anthropomorphic colon phantom (The Phantom Laboratory, NY) with a total of 23 lesions to simulate polyps (n = 17) and fecal matter (n = 6) of varying attenuation, size and morphology in the colon. The phantom was scanned with 64-slice MDCT (Lightspeed VCT, GE Healthcare Technologies) at kVp of 80 (267 mAs), 100 (208 mAs), 120 (156 mAs), and 140 (100 mAs) at constant contrast to noise ratio with remaining parameters constant. Two abdominal radiologists independently reviewed each dataset from 80 kVp to 140 kVp for size, site, and attenuation values of all lesions in the colon phantom. The readers differentiated between polyps and fecal matter on each dataset on the basis of subjective assessment and degree of confidence for this differentiation was determined on a five-point scale. The gold standard was original blueprint of polyps and fecal matter provided by the vendor. Image quality was graded on a five-point scale. Statistical analysis performed.
Results: Both readers detected all lesions at all kVps with no significant difference in the size of the measured polyps (p > 0.05).Versus 140 kVp, there was a mean drop of 5.4 HU in the attenuation value of fecal matter at 80 kVp. No change in HU value was noted for polyps. Reader 1 had 2 false positive (feces called polyp) and 1 false negative (polyp called feces) at 80 kVp. Reader 2 had 1 false positive and 2 false negative result at 80 kVp. False positives for reader 1 at 100,120, and 140 kVp were 4, 6, and 6, respectively. False positives for reader 2 were 3, 4, and 4 at 100, 120, and 140 kVp, respectively. 1, 2, and 2 false negatives were noted for reader 2 at 100, 120, and 140 kVp, respectively; no false negatives were noted for reader 1 at 100, 120, and 140 kVp. Accuracy for detection of polyps for both readers was 87% and 82% respectively at lower kVp (80) as compared to accuracy of 73% and 69% respectively for routinely used 120 and 140 kVp. Higher confidence noted for differentiating between polyps and fecal material at 80 kVp.
Conclusion: In an unprepped colon, CT performed with lower kVp (80) may allow enhanced differentiation of fecal matter from polyps as compared to 120 or 140 kVp.
Clinical Relevance/Application: Dual energy CTC could obviate colonic preparation
085. CT Colonography (CTC) Without Cathartic Preparation Using Primary Three-dimensional (3D) Reading: Translucency Rendering to Differentiate Polyps from Polypoid-like Fecal Residues
Guerrisi A.*; Catalano C.; Laghi A.; Marin D.; Sedati P.; Di Martino M.; Passariello R. Università degli Studi di Roma "La Sapienza", Rome, Italy
Address correspondence to A. Guerrisi (antonioguerrisi{at}msn.com)
Objective: To assess the specificity of translucency rendering in CTC without cathartic preparation using primary 3D reading.
Materials and Methods: 50 pathologically proven polyps and 50 polypoid-like fecal residues were retrospectively selected. All polyps and fecal residues were present in patients who underwent CTC without cathartic preparation. In all patients, fecal tagging was achieved using diatrizoate meglumine and diatri-zoate sodium. All CT examinations were acquired with a 64-slice scanner (Sensation 64, Siemens). CT imaging parameters were: collimation, 0.6 x 64 mm; section thickness, 3.0 mm; effective mAs, 10; and kVp, 140. Colonoscopy with segmental unblinding was performed 3–7 days after CT. Three independent radiologists analyzed translucency rendered CTC images using a dedicated software package (V3D-colon system, Viatronix) that provides translucency rendering analysis. On the basis of the color pattern generated by translucency rendering for each lesion, readers were asked to assign a diagnostic confidence level using a 4-point grade scale (1, definitely fecal residue; probably fecal residue; 3, probably polyp; 4, definitely polyp).
Results: With regard to polyps, 49, 48, and 48 of 50 lesions were correctly characterized by readers 1, 2, and 3, respectively (average specificity for polyp characterization, 96.6%). With regard to polypoid-like fecal residues, 48, 47, and 48 lesions were correctly characterized by readers 1, 2, and 3, respectively (average specificity for fecal residue characterization, 95.3%).
Conclusion: Translucency rendering is a highly accurate tool to differentiate polyps from fecal residues when interpreting CTC examinations without cathartic preparation and primary 3D reading
086. Appendiceal Wall Thickening at CT in Asymptomatic Patients with Extraintestinal Malignancy May Mimic Appendicitis
Webb E. M.*; Joe B. N.; Coakley F. V.; Qayyum A.; Westphalen A. C.; Yeh B. M. University of California, San Francisco, San Francisco, CA
Address correspondence to E. Webb (emma.webb{at}radiology.ucsf.edu)
Objective: To describe the appearance and prevalence of thick-walled appendices mimicking appendicitis in patients with an extra-intestinal primary malignancy.
Materials and Methods: We retrospectively identified CT scans of 200 consecutive patients (148 women and 52 men with mean age of 57) with cancer (115 breast, 52 lung, 33 melanoma) performed over a five-year period. One reader reviewed all scans and recorded the presence of an appendix with single-wall thickness > 3 mm. None of these total 200 patients had appendicitis found on subsequent follow-up of 3 months or greater. For all patients with appendiceal single-wall thickness >3 mm, we recorded the mean single-wall thickness, double-wall thickness, and the presence or absence of periappendiceal fat stranding and fascial thickening.
Results: On systematic review, 4 of the 200 retrospectively identified patients had a thick-walled appendix. The mean single-wall thickness in these 4 cases was 4.4 mm (range 3.5 to 5.5 mm) and the double-wall thickness was 8.8 mm (range 7 to 11 mm). None of these scans showed periappendiceal fat stranding nor associated fascial thickening.
Conclusion: In patients with an extra-intestinal primary malignancy, marked appendiceal wall thickening exceeding that of the normal range may occur in up to 2%. Awareness of this pitfall and the need for clinical correlation are important to avoid unnecessary laparotomy in the cancer population. This is the first report of the appearance and prevalence of pseudoappendicitis in patients with malignancy, an important CT diagnostic pitfall.
087. Duodenal Switch Gastric Bypass Surgery: Normal Anatomy and Imaging Findings in Complications
Mitchell M.*; Shah R.; Carabetta J.; Gasparaitis A. University of Chicago, Chicago, IL
Address correspondence to M. Mitchell (mmitchell{at}radiology.bsd.uchicago.edu)
Objective: To evaluate the radiology imaging findings in patients who have undergone pancreaticobiliary diversion duodenal switch (DS) gastric bypass surgery, with demonstration of normal postsurgical findings and of abnormal findings in complications of this surgery that can be diagnosed radiographically.
Materials and Methods: This study was performed with IRB approval and was HIPAA compliant. The need for patient informed consent was waived. We performed a 4-year retrospective review of all patients who underwent DS gastric bypass surgery. The database consisted of 218 patients. Radiographic files for all patients who underwent imaging of the GI tract were reviewed. The medical records were reviewed for clinical course, treatment, and surgical-pathological correlation when available. The imaging findings were compared with the clinical database to identify normal findings and to identify surgical GI tract complications diagnosed by contrast fluoroscopy and/or CT. Fluoroscopic exams and CT exams were analyzed by two attending GI radiologists to confirm accuracy of findings.
Results: Normal radiographic anatomic findings show a larger gastric pouch than with Roux-en-Y gastric bypass surgery, with an intact pylorus and an RUQ Roux anastomosis. The most common complication was bowel obstruction, seen in 38 patients. The majority were due to anastomotic stricture at the gastric outlet (n = 26), with other obstructions occurring at the distal anastomosis (n = 3) or elsewhere in the small bowel. About 30% of obstructions occurred within one week of surgery (n = 12), with the rest occurring anywhere from 3 weeks to 4 years postoperatively. Hernias occurred in 15 patients and were usually ventral hernias (n = 13). Anastomotic leaks occurred in 5% of patients (n = 10) and were seen more often within one month of surgery. Other less common complications of the GI tract were ulcers (n = 3), fistulas (n = 3), and hiatal hernias (n = 3).
Conclusion: Bowel obstruction due to anastomotic stenosis was the most common postsurgical GI complication of DS gastric bypass surgery, typically occurring at the gastric outlet. Ventral hernias and anastomotic leaks were also relatively common complications.
088. Noninvasive Evaluation of Active Lower Gastrointestinal Hemorrhage (ALGIB): Preliminary Results of a Prospective Comparison between Contrast Enhanced Multi-Detector Computed Tomography (CE-MDCT) and Tc-99m Labeled RBC Scan
Zink S. I.1*; Ohki S.1; Stein B.1; Zambuto D. A.1; Rosenberg R. J.1; Choi J. J.3 1. Hartford Hospital, Hartford, CT; 2. Jefferson Radiology, P.C., Hartford, CT; 3. University of Connecticut School of Medicine, Farmington, CT
Address correspondence to S. Zink (choizink{at}cox.net)
Objective: To demonstrate that CE-MDCT can be used to assess ALGIB and is equivalent to Tc-99m labeled RBC scan, currently the accepted modality for noninvasive evaluation of ALGIB.
Materials and Methods: IRB approval for this study was received prior to enrollment of any subjects. Written informed consent was obtained from each patient receiving CE-MDCT. Following Institutional adoption of CEMDCT as Standard of Care (SOC) for after-hour clinical presentation of ALGIB, a waiver of consent was obtained from IRB for the SOC cases. Evaluation by surgery or GI consult was required prior to imaging to clinically confirm active hemorrhage. Between February and October of 2006, 15 men and 9 women, ages 43–89 were evaluated prospectively. For each exam, scans of the abdomen and pelvis were obtained pre-contrast and followed by an intravenous contrast-enhanced phase utilizing 100 cc of Ultravist 300 mg I/ml. Active hemorrhage was defined as pooling of contrast-enhanced blood within the bowel lumen (HU unit range: 133–262). Tc-99m labeled RBC scans were obtained on 19/24 patients in close temporal proximity to the time of CE-MDCT and were reviewed in a blinded fashion. Following noninvasive evaluation, twelve patients went on to angiography for attempted embolization. Sensitivity for detection of active bleeding as well as the ALGIB location was recorded for each imaging modality. Results of any colonoscopy and/or surgeries were also recorded.
Results: Agreement of CE-MDCT and Tc-99m-RBC scan: positive on both = 3, negative on both = 9, positive CE-MDCT and negative Tc-99m-RBC scan = 2, negative CE-MDCT and positive Tc-99m-RBC scan = 5. Overall 8/24 CE-MDCT scans were positive and all accurately localized the site of bleeding. Also, in 3 cases the underlying lesion was detected. Overall 8/19 Tc-99m-RBC scans were positive. However, only 1 out of the 5 cases detected on Tc-99m-RBC scan, but not seen on CE-MDCT, was positive on angiography. 12/24 patients went on to angiography. In 5 patients the site of bleeding was confirmed, but in 7 the findings were negative.
Conclusion: For the limited number of patients currently evaluated, in this ongoing study, preliminary data indicates that CE-MDCT shows great promise in the detection and localization of ALGIB.
089. Long-term Follow-up CT after Radical Gastrectomy for Early Gastric Cancer: Cancer Recurrence and Incidental Findings
Park M.*; Choi D. Department of Radiology & Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
Address correspondence to M. Park (mindung97{at}hanmail.net)
Objective: To evaluate the cancer recurrence and incidental findings on longterm follow-up CT after radical gastrectomy for early gastric cancer.
Materials and Methods: We retrospectively analyzed 656 follow-up abdomino-pelvic CT of 154 patients who underwent radical gastrectomy for early gastric cancer. Three abdominal radiologists reviewed serial follow-up CT scans for detection of recurrence of early gastric cancer, and correlated with endoscopy and pathology. They analyzed the recurrent rate, time and type of recurrence. They simultaneously assessed new incidental findings on follow-up CT scans, and classified them as having high or low clinical importance.
Results: The recurrent rate was 3.9% (6 of 154) during 5–7 years after gastrectomy for early gastric cancer. All recurrences could be demonstrated on follow-up CT. The recurrence was detected on 2–5 years after operation. The types of recurrence were lymph node metastases (n = 5), liver metastases (n = 4), recurrences in the residual stomach or anastomotic site (n = 3), adrenal metastasis (n = 1), and lung metastasis (n = 1). On follow-up CT, we found four new diseases (2.6%, 4 of 154) with high clinical importance, which were primary malignancies in the other organs. Twenty-one new diseases (13.6%, 21 of 154) with low clinical importance were also observed.
Conclusion: Long-term follow-up CT after radical gastrectomy for early gastric cancer could show all gastric cancer recurrences with very low rate. However, many new incidental diseases were found on follow-up-CT, and some of them had high clinical importance.
090. Mesenteric Vascular Contact with Soft Tissue: A Novel Sign of Mesenteric Metastases at CT
Yeh B. M.2*; Joe B. N.2; Qayyum A.2; Westphalen A. C.2; Coakley F. V.2; Sirlin C. B.1 1. University of California San Diego, San Diego, CA; 2. University of California San Francisco, San Francisco, CA
Address correspondence to B. Yeh (ben.yeh{at}radiology.ucsf.edu)
Objective: To evaluate the diagnostic utility of mesenteric vascular contact as a novel CT sign to allow distinction of subtle mesenteric metastases from adjacent bowel.
Materials and Methods: We retrospectively identified 129 consecutive abdominopelvic CT scans of non-oncology patients. We recorded whether there was contact (fat plane obscuration) between a mesenteric vessel > 1 mm diameter and adjacent bowel, as well as the location of such contact. We also identified a second set of 16 abdominopelvic CT scans of 7 oncologic patients in whom mesenteric metastases were missed on the prospective CT reports. We recorded the maximal diameters of the masses, time interval to eventual detection, and whether there was contact with a mesenteric vessel >1 mm.
Results: In the 129 non-oncology patients, superior mesenteric vessels contacted the third and fourth duodenal portions in 36 (28%) and 12 patients (9.4%), respectively, and the proximal jejunum in 9 (7.0%). Inferior mesenteric vessels contacted the fourth duodenal portion in 58 patients (48%) and the proximal jejunum in 6 (4.7%). Contact between the mesenteric vessels and the distal jejunum, ileum, and colon was uncommon (6, 5, and 0 patients, respectively). In the 16 CT examinations where mesenteric metastases were missed in the CT report, the mean size of the missed mesenteric metastases was 2.4 cm (range, 1.0 to 4.5 cm) and the mean time between the initial CT scan and eventual diagnosis was 13 months (range, 1.5 to 44 months). The missed mesenteric mass was the only sign of tumor recurrence in 4 of 16 scans (25%). Mesenteric vessels contacted the metastases in 15 of 16 scans (94%).
Conclusion: At CT, mesenteric vessels >1 mm diameter rarely contact bowel segments other than the duodenum and proximal jejunum; however, they often contact mesenteric metastases and careful inspection for this vascular contact sign may facilitate identification of subtle mesenteric masses.
Clinical Signifi cance: Mesenteric metastases may be missed at CT and inspection of the mesenteric vessels for contact with adjacent soft tissue may allow more reliable detection of such tumors.
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