Radiology – Abdomen and Pelvis
AGA Clinical Practice Update on Managing Portal Vein Thrombosis in Cirrhotic Patients: Expert Review
3 Jan, 2025 | 10:00h | UTCIntroduction: This summary highlights key recommendations from an AGA expert review on portal vein thrombosis (PVT) in cirrhotic patients. PVT is common in cirrhosis, with an estimated five-year incidence of around 11%, and may worsen portal hypertension and elevate mortality. Management is challenging because of limited evidence, the potential complications of both PVT and anticoagulation, and significant heterogeneity regarding clot characteristics, host factors, and cirrhosis severity. This review presents the latest guidance on identifying clinically relevant PVT, selecting anticoagulation, and considering endovascular interventions, including TIPS (transjugular intrahepatic portosystemic shunt).
Key Recommendations:
- No Routine Screening: Asymptomatic patients with compensated cirrhosis do not require regular screening for PVT in the absence of suggestive clinical changes.
- Imaging Confirmation: When Doppler ultrasound reveals suspected PVT, contrast-enhanced CT or MRI is recommended to confirm the diagnosis, exclude malignancy, and characterize clot extent and occlusion.
- Hypercoagulability Testing: Extensive thrombophilia workup is not indicated unless there is family or personal history of thrombotic events, or associated laboratory abnormalities.
- Intestinal Ischemia Management: Patients who develop PVT with evidence of intestinal ischemia should receive prompt anticoagulation and, ideally, multidisciplinary team care involving gastroenterology, hepatology, interventional radiology, hematology, and surgery.
- Observation of Minor or Recent Thrombi: In cirrhotic patients without ischemia, with recent (<6 months) thrombi that are <50% occlusive, close imaging follow-up every three months is a reasonable option to track potential spontaneous clot regression.
- Anticoagulation for Significant PVT: Consider anticoagulation for more extensive or obstructive (>50%) recent PVT, especially if the main portal vein or mesenteric vessels are involved. Candidates for liver transplantation and those with inherited thrombophilia may derive additional benefit.
- Chronic Cavernous PVT: Anticoagulation is generally not advised in patients with long-standing (>6 months) complete occlusion and well-formed collateral channels.
- Variceal Screening: Perform endoscopic screening or ensure prophylaxis for varices. Avoid delays in initiating anticoagulation, as timeliness is essential for better recanalization outcomes.
- Choice of Anticoagulant: Vitamin K antagonists, low-molecular-weight heparin, and direct oral anticoagulants (DOACs) are all viable options in cirrhosis. DOACs may be appropriate in well-compensated (Child-Turcotte-Pugh class A or certain class B) cirrhosis but should be avoided in class C. Treatment selection should consider patient preferences, monitoring feasibility, and risk of bleeding.
- Duration of Therapy: Reassess clot status with cross-sectional imaging every three months. Continue anticoagulation for transplant-eligible individuals who show partial or complete recanalization, and consider discontinuation in nonresponders after six months if futility is evident.
- TIPS Revascularization: Portal vein revascularization using TIPS may be pursued in patients who have other TIPS indications (like refractory ascites or variceal bleeding) or to improve transplant feasibility by recanalizing portal flow.
Conclusion: PVT in cirrhosis remains a complex clinical issue requiring careful evaluation of clot extent, timing, and the potential need for transplantation. The recommendations presented here underscore prompt imaging, timely anticoagulation for high-risk thrombi, and individualized therapy based on Child-Turcotte-Pugh classification and bleeding risk. When necessary, multidisciplinary collaboration is key to achieving optimal patient outcomes. Prospective randomized trials and standardized classifications of PVT will be instrumental in refining future guidelines.
Reference:
Davis JPE, Lim JK, Francis FF, Ahn J. AGA Clinical Practice Update on Management of Portal Vein Thrombosis in Patients With Cirrhosis: Expert Review. Gastroenterology. 2024. DOI: http://doi.org/10.1053/j.gastro.2024.10.038
RCT: MRI-Guided Biopsy Reduces Overdiagnosis of Clinically Insignificant Prostate Cancer
26 Sep, 2024 | 12:22h | UTCBackground: Overdiagnosis of clinically insignificant prostate cancer is a significant issue in population-based screening programs, primarily when prostate-specific antigen (PSA) testing is followed by systematic biopsy. Magnetic resonance imaging (MRI)-guided biopsies, which avoid systematic biopsies in men with negative MRI results, have shown potential in reducing unnecessary cancer diagnoses. However, long-term data are needed to confirm the safety and efficacy of this approach.
Objective: To evaluate whether MRI-targeted biopsies, when combined with PSA screening, can reduce the detection of clinically insignificant prostate cancer without compromising the identification of clinically significant or advanced disease.
Methods: This population-based, randomized trial in Sweden (GÖTEBORG-2) enrolled 13,153 men aged 50-60 years who underwent PSA screening. Men with PSA levels ≥3 ng/mL were randomized into two groups: (1) MRI-targeted biopsy only in cases with suspicious lesions, or (2) systematic biopsy in all cases with PSA elevation. Screening occurred every 2, 4, or 8 years depending on PSA levels, with follow-up for up to four years. The primary outcome was the detection of clinically insignificant prostate cancer, and secondary outcomes included clinically significant and advanced or high-risk prostate cancer.
Results: After a median follow-up of 3.9 years, the detection of clinically insignificant prostate cancer was significantly lower in the MRI-targeted biopsy group (2.8%) compared to the systematic biopsy group (4.5%), with a relative risk (RR) of 0.43 (95% CI, 0.32-0.57; P < 0.001). The relative risk of detecting clinically significant cancer was 0.84 (95% CI, 0.66-1.07), indicating no significant difference between the two groups. Advanced or high-risk cancers were detected in 15 men in the MRI group and 23 men in the systematic group (RR, 0.65; 95% CI, 0.34-1.24). Severe adverse events occurred in five patients (three in the systematic biopsy group, two in the MRI-targeted biopsy group).
Conclusions: Omitting biopsies in men with negative MRI results substantially reduced the diagnosis of clinically insignificant prostate cancer without increasing the risk of missing clinically significant or advanced cancers. MRI-targeted biopsy strategies can effectively limit overdiagnosis while maintaining safety in screening programs.
Implications for Practice: MRI-targeted biopsies offer a promising strategy to reduce unnecessary cancer diagnoses and avoid overtreatment in prostate cancer screening. Clinicians should consider integrating MRI into prostate cancer screening algorithms, especially in cases with elevated PSA but no MRI-detected lesions. This approach may also decrease biopsy-related complications and patient anxiety.
Study Strengths and Limitations: Strengths of this trial include its population-based design, large sample size, and thorough follow-up. Limitations include its single-center setting in Sweden, which may limit generalizability to more diverse populations, and a modest participation rate of 50%.
Future Research: Further studies should assess the cost-effectiveness of widespread MRI use in prostate cancer screening and explore its utility in diverse populations. Investigations into novel biomarkers that could further refine patient selection for MRI-targeted biopsy are also warranted.
IDSA 2024 Guidelines for Managing Complicated Intra-abdominal Infections – Clin Infect Dis
10 Aug, 2024 | 22:10h | UTCIntroduction: The Infectious Diseases Society of America (IDSA) has updated its clinical practice guidelines for managing complicated intra-abdominal infections in adults, children, and pregnant individuals. The update focuses on risk assessment, diagnostic imaging, and microbiological evaluation, with recommendations grounded in systematic literature reviews and the GRADE approach for rating evidence.
Key Points:
1 – Risk Stratification:
– For adults with complicated intra-abdominal infections, the APACHE II score is recommended for risk stratification within 24 hours of hospital or ICU admission. The WSES Sepsis Severity Score is an acceptable alternative.
– No specific severity scoring system is recommended for pediatric patients.
2 – Diagnostic Imaging for Appendicitis:
– In non-pregnant adults, CT is suggested as the initial imaging modality for suspected acute appendicitis.
– For children, an abdominal ultrasound (US) is preferred initially, with MRI or CT recommended if the US is inconclusive.
– In pregnant individuals, US or MRI can be considered, with MRI suggested if initial US results are inconclusive.
3 – Imaging for Acute Cholecystitis and Cholangitis:
– For non-pregnant adults, US is recommended initially. If inconclusive, a CT scan is suggested.
– For pregnant individuals, US or MRI can be used, but the guidelines do not specify a preferred modality due to a knowledge gap.
4 – Blood Cultures:
– Blood cultures are recommended in adults and children with suspected intra-abdominal infections presenting with severe symptoms such as hypotension or tachypnea, especially when antibiotic-resistant organisms are a concern.
– Routine blood cultures are not recommended for patients without these risk factors.
5 – Intra-abdominal Fluid Cultures:
– In complicated intra-abdominal infections requiring source control procedures, obtaining intra-abdominal cultures is advised to guide antimicrobial therapy.
– In uncomplicated appendicitis cases, routine cultures are not recommended unless the patient is immunocompromised or complicated disease is suspected during surgery.
Conclusion: These guidelines provide evidence-based recommendations to improve the management of complicated intra-abdominal infections, emphasizing appropriate risk stratification, targeted diagnostic imaging, and the selective use of cultures to guide therapy.
Deep Learning Model Noninferior to Radiologists in Detecting Clinically Significant Prostate Cancer at MRI – Radiology
10 Aug, 2024 | 21:31h | UTCStudy Design and Population: This retrospective study evaluated the performance of a deep learning (DL) model for detecting clinically significant prostate cancer (csPCa) using multiparametric MRI (mpMRI) images from 5215 patients (5735 examinations) with a mean age of 66 years. The study included patients who underwent prostate MRI between January 2017 and December 2019 at a single academic institution. The DL model was trained on T2-weighted, diffusion-weighted, and contrast-enhanced MRI sequences, with pathologic diagnosis as the reference standard.
Main Findings: The DL model achieved an area under the receiver operating characteristic curve (AUC) of 0.89 on the internal test set and 0.86 on an external test set, demonstrating noninferiority to radiologists, who had AUCs of 0.89 and 0.84, respectively. Additionally, the combination of the DL model and radiologists improved diagnostic performance (AUC of 0.89). Gradient-weighted class activation maps (Grad-CAMs) effectively localized csPCa lesions, overlapping with true-positive cases in 92% of internal test set and 97% of external test set cases.
Implications for Practice: The DL model showed comparable performance to experienced radiologists in detecting csPCa at MRI, suggesting its potential to assist radiologists in improving diagnostic accuracy and reducing interobserver variability. Future research should focus on integrating the model into clinical workflows and assessing its impact on biopsy targeting.
Meta-Analysis: Efficacy of MRI in prostate cancer screening for reducing unnecessary biopsies
28 Apr, 2024 | 20:13h | UTCThis meta-analysis evaluated the effectiveness of incorporating magnetic resonance imaging (MRI) into prostate cancer screening pathways, compared to prostate-specific antigen (PSA)–only screening strategies. Analyzing data from 80,114 men across 12 studies, the findings demonstrate that MRI-based screening, particularly when using a sequential approach and a PI-RADS score ≥3 cutoff for biopsy, significantly increases the odds of detecting clinically significant prostate cancers (OR, 4.15) while reducing unnecessary biopsies (OR, 0.28) and detection of clinically insignificant cancers (OR, 0.34). Implementing a higher PI-RADS score of ≥4 further decreased the detection of insignificant cancers and biopsies performed, without impacting the detection rate of significant cancers. These results support the integration of MRI into screening programs to enhance diagnostic precision and reduce patient harm.
Reference (link to abstract – $ for full-text):
Determination of “borderline resectable” pancreatic cancer – A global assessment of 30 shades of grey
8 Aug, 2023 | 13:22h | UTC
Commentary on Twitter
What is BORDERLINE respectable?! 🤔
A global assessment of 30 shades of grey 🌗🌑🌓
🚀 Interobserver variability among radiologists and surgeons globally is high
👩⚖️ Central review of images required for quality control initiativeshttps://t.co/Z2G1cInZ5f pic.twitter.com/mlucwMT5f9
— Giovanni Marchegiani (@Gio_Marchegiani) July 30, 2023
Review | Radiomics-based fertility-sparing treatment in endometrial carcinoma
24 Jul, 2023 | 13:00h | UTC
Magnetic resonance imaging to evaluate kidney structure, function, and pathology: moving towards clinical application
7 Jun, 2023 | 13:57h | UTC
2023 Rectal cancer lexicon update | Revised consensus on terminology and staging
15 May, 2023 | 12:50h | UTC
Study shows unenhanced CT shows 30% lower diagnostic accuracy in abdominal pain evaluation
9 May, 2023 | 15:02h | UTCDiagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department – JAMA Surgery (free for a limited period)
Editorial: Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain – JAMA Surgery (free for a limited period)
Commentary: New data suggest clinicians should think twice before foregoing contrast-enhanced imaging – Health Imaging
Commentary on Twitter
In a general population of emergency department patients with abdominal pain, using unenhanced CT to avoid risks of intravenous contrast medium administration is associated with a large diagnostic penalty. https://t.co/CVg04763yd
— JAMA Surgery (@JAMASurgery) May 3, 2023
A review of modern imaging landscape for prostate cancer: a comprehensive clinical guide
9 May, 2023 | 14:34h | UTC
Consensus Statement | Best current practice and research priorities in active surveillance for prostate cancer
15 Mar, 2023 | 15:11h | UTC
Guideline | Diagnosis, management, and follow-up of the incidentally discovered adrenal mass
6 Mar, 2023 | 14:16h | UTC
RCT | Single CT colonography vs. three rounds of fecal immunochemical test for screening of colorectal cancer
1 Mar, 2023 | 13:43h | UTCSingle CT colonography versus three rounds of faecal immunochemical test for population-based screening of colorectal cancer (SAVE): a randomised controlled trial – The Lancet Gastroenterology & Hepatology (link to abstract – $ for full-text)
Commentary on Twitter
New research – Sali et al – Single CT colonography versus three rounds of faecal immunochemical test for population-based screening of #colorectalcancer (SAVE): a randomised controlled trialhttps://t.co/RBxgAm0xJA#gitwitter #crcsm #colorectalcancerscreening #colonography pic.twitter.com/XSeJHxuO7c
— The Lancet Gastroenterology & Hepatology (@LancetGastroHep) September 16, 2022
Study suggests there is little added value from follow-up pelvic CT after treatment of hepatocellular carcinoma
23 Feb, 2023 | 13:39h | UTCSummary: The study investigated the added value of pelvic coverage at follow-up liver CT in detecting pelvic metastasis or incidental tumors in patients treated for hepatocellular carcinoma (HCC). The study found that the incidence of isolated pelvic metastasis or incidental pelvic tumor was low in patients treated for HCC. The cumulative rates of isolated pelvic metastasis and incidental pelvic tumor were 1.4% and 0.5%, respectively, at 3 years. Only baseline T stage was associated with an increased risk of isolated pelvic metastasis. The study concludes that excluding the pelvic scan can reduce radiation dose and decrease the workload for radiologists. However, the study also had limitations, such as being retrospective and single-center. Therefore, more research is necessary to study the optimal scanning strategy for the pelvis and the effect of pelvic CT coverage on survival in patients with HCC.
Article: Added Value of Pelvic CT after Treatment of HCC – Radiology
Review | The role of MRI in the diagnosis and prognostic evaluation of fetuses with congenital diaphragmatic hernia
9 Feb, 2023 | 13:40h | UTC
Development and validation of a deep learning algorithm to differentiate colon carcinoma from diverticulitis in CT images
31 Jan, 2023 | 13:49h | UTCCommentaries:
Artificial Intelligence May Help Differentiate Colon Carcinoma From Acute Diverticulitis – AJMC
Deep Learning Model Aids Differentiation of Colon Cancer, Acute Diverticulitis – HealthDay
Commentary on Twitter
A #DeepLearning model shows non-inferior performance in distinguishing colon cancer from diverticulitis in CT images. It may help board-certified radiologists and residents as an #AI-support system. https://t.co/YpwtN4508n
— JAMA Network Open (@JAMANetworkOpen) January 27, 2023
Diagnostic Study | Usefulness of CT radiomics in differentiating histologic subtypes of epithelial ovarian carcinoma
27 Jan, 2023 | 12:01h | UTC
Commentary on Twitter
Radiomic features extracted from contrast-enhanced CT scans were useful in the classification of histologic subtypes in epithelial ovarian carcinoma, high-grade serous carcinoma (HGSC) and non-HGSC. https://t.co/DBAXnl9r0X #OAResearch
— JAMA Network Open (@JAMANetworkOpen) December 6, 2022
Meta-analysis reaffirms benefits of O-RADS MRI for diagnosing indeterminate adnexal lesions
24 Jan, 2023 | 14:05h | UTCOriginal Study: O-RADS MRI: A Systematic Review and Meta-Analysis of Diagnostic Performance and Category-wise Malignancy Rates – Radiology (link to abstract – $ for full-text)
Commentary on Twitter
A meta-analysis of 4520 adnexal lesions from 12 studies showed that MRI O-RADS has a 92% summary sensitivity and a 91% summary specificity in characterizing lesions that are indeterminate at US. https://t.co/WSJVQUiM4T pic.twitter.com/kssAK2s02N
— Radiology (@radiology_rsna) November 23, 2022
MRI anatomy of the rectum: key concepts important for rectal cancer staging and treatment planning
20 Jan, 2023 | 14:34h | UTC
Review | Interventional gastroenterology in oncology.
12 Dec, 2022 | 12:46h | UTCInterventional gastroenterology in oncology – CA: A Cancer Journal for Clinicians
A review of more than 2000 cases of site-specific pelvic endometriosis rates by MRI: a guide to minimizing under/overdiagnosis non-invasively.
26 Aug, 2022 | 13:08h | UTC
Review | Multimodality imaging of renal lymphoma and its mimics.
26 Aug, 2022 | 13:07h | UTCMultimodality imaging of renal lymphoma and its mimics – Insights into Imaging
Cohort Study | Excluding hollow viscus injury for abdominal seat belt sign using computed tomography.
26 Jul, 2022 | 12:27h | UTCExcluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography – JAMA Surgery (link to abstract – $ for full-text)
Commentary on Twitter
Prospective multicenter study found that for patients with abdominal seatbelt sign, the incidence of hollow viscus injury was exceedingly low, if not zero, with a high-quality negative CT scan. https://t.co/khZoQiQeXI
— JAMA Surgery (@JAMASurgery) July 14, 2022
Cystic liver lesions: a pictorial review.
18 Jul, 2022 | 10:48h | UTCCystic liver lesions: a pictorial review – Insights into Imaging