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Background The American Association for the Surgery of Trauma (AAST) developed a severity scale for surgical conditions, including diverticulitis. The Hinchey classification requires operative intervention yet remains the established scoring system for acute diverticulitis. This is a pilot study to compare the AAST grading scale for acute colonic diverticulitis with the traditional Hinchey classification. We hypothesize that the AAST classification scale is equivalent to the Hinchey in predicting outcomes. Methods This is a retrospective cohort study at an academic medical center. A consecutive sample of patients with acute diverticulitis and computed tomography imaging was reviewed. Chart review identified demographic and physiologic data with interventional and clinical outcomes. Each computed tomography scan was assigned AAST and modified Hinchey classification scores by a radiologist. Multivariate regression and receiver operating characteristic curve analysis compared six outcomes: need for procedure, complication, intensive care unit (ICU) admission, length of stay, 30-day readmission, and mortality. Results One hundred twenty-nine patients were included. Of the total patients, 42.6% required procedural intervention, 21.7% required ICU admission, 18.6% were readmitted, and 6.2% died. Both AAST and Hinchey predicted the need for operation (AAST odds ratios, 1.55, 12.7, 18.09, and 77.24 for stages 2-5; Hinchey odds ratios, 8.85, 11.49, and 22.9 for stages 1b-3, stage 4 predicted perfectly). The need for operation c-statistics (area under the curve) for AAST and Hinchey was 0.80 and 0.83 for Hinchey and AAST, respectively (p = 0.35). The complication c-statistics curve for AAST and Hinchey was 0.83 and 0.80, respectively (p = 0.33). The AAST and Hinchey scores were less predictive for ICU admission, readmission, and mortality with c-statistics of less than 0.80. Conclusion The AAST grading of acute diverticulitis is equivalent to the modified Hinchey classification in predicting procedural intervention and complications. The AAST system may be preferable to Hinchey because it can be applied preoperatively. Although this pilot study demonstrated that the AAST score predicts surgical need, a larger study is required to evaluate the AAST score for other outcomes. Level of evidence Prognostic and epidemiological study, level III.

Computerized tomography urography is used to evaluate patients with gross or microscopic hematuria. Computerized tomography urography is a high radiation dose scan and, thus, it confers a higher risk of secondary malignancy. A computerized tomography urography split bolus protocol reduces radiation exposure but it may reduce sensitivity. In this study we used a theoretical cohort of patients with hematuria in which to model the risk of missing malignancies against the benefit of averting secondary malignancies.We calculated the prevalence of renal cell carcinoma and upper tract urothelial carcinoma in patients with hematuria by pooled analysis of cohort studies, which in conjunction with split bolus sensitivity allows for the estimation of missed malignancies. The number of prevented secondary malignancies was calculated from lifetime attributable risk estimates. Sensitivity analyses were run to determine the minimum sensitivity required for a net population benefit.Estimates of split bolus computerized tomography urography sensitivity ranged from 80% to 100% (mean 95.2%). At the low estimate of 80% sensitivity split bolus computerized tomography urography was beneficial in men and women with microscopic hematuria at ages less than 50 and less than 60 years, respectively. An increase in sensitivity to 90% improved the benefit 1 decade in each gender, representing 68.8% of patients with microscopic hematuria. The overall population of patients with microscopic hematuria benefited from split bolus computerized tomography urography at 91.1% sensitivity. However, in patients with gross hematuria the threshold for an overall population benefit was high at 98.4% sensitivity.Exposure to ionizing radiation risks causing secondary malignancy. These data indicate that split bolus computerized tomography urography may be performed safely in 70% of the population of patients with microscopic hematuria. However, it is not currently advisable in patients with gross hematuria or in other patients at high risk.

The NCCN Guidelines for Kidney Cancer provide multidisciplinary recommendations for the clinical management of patients with clear cell and non–clear cell renal cell carcinoma, and are intended to assist with clinical decision-making. These NCCN Guidelines Insights summarize the NCCN Kidney Cancer Panel discussions for the 2020 update to the guidelines regarding initial management and first-line systemic therapy options for patients with advanced clear cell renal cell carcinoma.

These NCCN Guidelines Insights discuss the major recent updates to the NCCN Guidelines for Bladder Cancer based on the review of the evidence in conjunction with the expert opinion of the panel. Recent updates include (1) refining the recommendation of intravesical bacillus Calmette-Guérin, (2) strengthening the recommendations for perioperative systemic chemotherapy, and (3) incorporating immunotherapy into second-line therapy for locally advanced or metastatic disease. These NCCN Guidelines Insights further discuss factors that affect integration of these recommendations into clinical practice.

The NCCN Clinical Practice Guidelines in Oncology for Bladder Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up of patients with bladder cancer. These NCCN Guidelines Insights discuss important updates to the 2018 version of the guidelines, including implications of the 8th edition of the AJCC Cancer Staging Manual on treatment of muscle-invasive bladder cancer and incorporating newly approved immune checkpoint inhibitor therapies into treatment options for patients with locally advanced or metastatic disease.

Abdominal radiologists are often asked to perform difficult percutaneous chest, abdomen, and pelvis biopsies and drainages with imaging guidance. Many of these procedures involve small target lesions far from the skin surface, in close proximity to critical structures. Organ location is changeable due to respiration, peristalsis, and pulsation, further complicating the planning process. High-level three-dimensional spatial awareness is critical to mastery of complex image-guided procedures. A comprehensive grasp of anatomy and expected changes can be exploited in certain cases to target lesions within a solid organ or to avoid injury to sensitive structures during biopsy, drain placement, or thermal ablation. In this article, we will use illustrative cases to explore the use of anatomic knowledge and the ability to synthesize this three-dimensional data dynamically during planning and execution of difficult CT- and ultrasound-guided procedures. We will discuss unusual biopsy requests-such as bowel biopsies-and the benefits of using ultrasound guidance for certain procedures in the chest. Additionally, we will describe multiple special techniques, including out of standard plane angulation and endocavitary techniques, in order to maximize chances of success.

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Bladder Cancer focuses on systemic therapy for muscle-invasive urothelial bladder cancer, as substantial revisions were made in the 2017 updates, such as new recommendations for nivolumab, pembrolizumab, atezolizumab, durvalumab, and avelumab. The complete version of the NCCN Guidelines for Bladder Cancer addresses additional aspects of the management of bladder cancer, including non-muscle-invasive urothelial bladder cancer and nonurothelial histologies, as well as staging, evaluation, and follow-up.

There are many considerations in the evaluation of liver malignancy before planned surgical treatment. This article focuses on interpretation of MR imaging of the liver for surgical treatment planning of hepatocellular carcinoma, colorectal cancer metastases, and hilar cholangiocarcinoma. Clinical status, anatomic variants, future liver remnant, and underlying liver disease are all important factors in the decision to proceed with liver resection. The primary objective of preoperative imaging is to correctly identify patients who are candidates for curative intervention and to accurately stage their disease. Treatment planning for these complex patients is best done with a multidisciplinary team approach.

Squamous cell carcinoma of the penis represents approximately 0.5% of all cancers among men in the United States and other developed countries. Although rare, it is associated with significant disfigurement, and only half of the patients survive beyond 5 years. Proper evaluation of both the primary lesion and lymph nodes is critical, because nodal involvement is the most important factor of survival. The NCCN Clinical Practice Guidelines in Oncology for Penile Cancer provide recommendations on the diagnosis and management of this devastating disease based on evidence and expert consensus.

Urothelial tumors represent a spectrum of diseases with a range of prognosis. After a diagnosis is established at any point within the urothelial tract, the patient remains at risk for developing a new lesion at a different or the same location and at a similar or more advanced stage. Continued monitoring for recurrence is an essential part of management, because most recurrences are superficial and can be managed endoscopically. Within each category of disease, more refined methods to determine prognosis and guide management, based on molecular staging, are under development with the goal of optimizing the individual patient's likelihood of cure and chance for organ preservation. For patients with more extensive disease, newer treatments typically involve combined-modality approaches, using recently developed surgical procedures, or three-dimensional treatment planning for more precise delivery of radiation therapy. Although these are not appropriate in all cases, they do offer the promise of an improved quality of life and prolonged survival. Finally, within the category of metastatic disease, a number of new agents have been identified that appear to be superior to those currently considered to be standard therapies. Experts believe, therefore, that the treatment of urothelial tumors will evolve rapidly over the next few years, with improved outcomes for patients at all stages of disease.

Fine needle aspiration with and without concurrent core needle biopsy is a minimally invasive method to diagnose and assist in management of renal masses. We assessed the pathological accuracy of fine needle aspiration compared to and associated with core needle biopsy and the impact on management.We performed a single institution, retrospective study of 342 cases from 2001 to 2015 with small and large renal masses (4 or less and greater than 4 cm, respectively). Diagnostic and concordance rates, and the impact on management were analyzed.Adequacy rates for fine needle aspiration only, core needle biopsy only and fine needle aspiration plus core needle biopsy were 21%, 12% and 8% (aspiration vs aspiration plus biopsy p0.026). In the aspiration plus biopsy group adding aspiration to biopsy and biopsy to aspiration reduced the inadequacy rate from 23% to 8% and from 27% to 8% for a total reduction rate of 15% and 19%, respectively, corresponding to 32 cases (9.3%). Rapid on-site examination contributed to a 22.5% improvement in fine needle aspiration adequacy rates. In this cohort 30% of aspiration only, 5% of biopsy only and 12% of aspiration plus biopsy could not be subtyped (aspiration vs biopsy p0.0001, aspiration vs aspiration plus biopsy p0.0127 and biopsy vs aspiration plus biopsy p = 0.06). The diagnostic concordance rate with surgical resection was 99%. Conversion of an inadequate specimen to an adequate one by a concurrent procedure impacted treatment in at least 29 of 32 patients. Limitations include the retrospective design and accuracy measurement based on surgical intervention.Fine needle aspiration plus core needle biopsy vs at least fine needle aspiration alone may improve diagnostic yield when sampling renal masses but it has subtyping potential similar to that of core needle biopsy only.

Cotyledonoid dissecting leiomyoma is a rare benign uterine tumor whose gross and radiological appearance may raise the possibility of a malignancy. The authors summarize herein the clinical, radiological, and pathological features of the 41 previously reported cases. The patients typically presented with menorrhagia or symptoms that were ultimately relatable to the presence of a pelvic mass. The median patient age was 46 years (range 23-73). The average tumor size was 15.4 cm (range 4-41); most were exophytic, multinodular, occasionally cystic masses with a congested, spleen or placenta-like color, protruding over the uterine serosa and, variably, the broad ligaments and adjacent organs. In most cases, the exophytic component was contiguous with the intramural dissecting leiomyomatous components. Histological features suggestive of malignancy, such as cytological atypia, necrosis, or increased mitotic activity were absent. Intravascular growth, as assessed histologically, was present in 20% of reported cases, and this finding is apparently devoid of clinical significance based on limited data. Reported information on radiological features is limited. However, these lesions are typically isointense to myometrium on T1-weighted MRI and are in general less heterogeneous on T2 and postcontrast-imaging than sarcomatous lesions. The tumor may display extension to but not frank invasion of surrounding organs. Ultrasound features are nonspecific. Follow-up information was available in 25 (61%) of 41 reported patients: none experienced a tumor recurrence or metastases during the follow-up period, which ranged from 1 month to 41 years. This affirms the benign nature of this tumor, its alarming gross appearance and growth patterns notwithstanding.

Evaluation of mechanical stiffness imaging biomarkers, through magnetic resonance elastography (MRE), has shown considerable promise for non-invasive assessment of liver stiffness to monitor hepatic fibrosis. MRE typically requires specialized externally-applied vibratory excitation and scanner-specific motion-sensitive pulse sequences. In this work, we have developed an elasticity imaging approach that utilizes natural diaphragmatic respiratory motion to induce deformation and eliminates the need for external deformation excitation hardware and specialized pulse sequences. Our approach uses clinically-available standard of care volumetric imaging acquisitions, combined with offline model-based post-processing to generate volumetric estimates of stiffness within the liver and surrounding tissue structures. We have previously developed a novel methodology for non-invasive elasticity imaging which utilizes a model-based elasticity reconstruction algorithm and MR image volumes acquired under different states of deformation. In prior work, deformation was external applied through inflation of an air bladder placed within the MR radiofrequency coil. In this work, we extend the methodology with the goal of determining the feasibility of assessing liver mechanical stiffness using diaphragmatic respiratory motion between end-inspiration and end-expiration breath-holds as a source of deformation. We present initial investigations towards applying this methodology to assess liver stiffness in healthy volunteers and cirrhotic patients. Our preliminary results suggest that this method is capable of non-invasive image-based assessment of liver stiffness using natural diaphragmatic respiratory motion and provides considerable enthusiasm for extension of our approach towards monitoring liver stiffness in cirrhotic patients with limited impact to standard-of-care clinical imaging acquisition workflow.

Diagnosis of acute cholecystitis involves clinical, laboratory, and radiographic findings. The Tokyo Guidelines for the Management of Acute Cholangitis and Cholecystitis (TG13) provide a diagnostic algorithm that optimizes specificity and sensitivity in those patients with a history suggestive of possible acute cholecystitis. Physical exam and laboratory findings should suggest acute inflammatory processes. Imaging should start with RUQ ultrasound and include HIDA if inconclusive. For patients with atypical symptoms, CT may be a better initial imaging modality. The role of MRI is less clear, but may become more important as radiation exposure concerns grow. In select patient populations and certain clinical settings, diagnosis may be difficult or delayed. A high index of suspicion and an attentive approach in at-risk populations is required to limit delays in diagnosis and possible complications.

There are many considerations in the evaluation of liver malignancy before planned surgical treatment. This article focuses on interpretation of MR imaging of the liver for surgical treatment planning of hepatocellular carcinoma, colorectal cancer metastases, and hilar cholangiocarcinoma. Clinical status, anatomic variants, future liver remnant, and underlying liver disease are all important factors in the decision to proceed with liver resection. The primary objective of preoperative imaging is to correctly identify patients who are candidates for curative intervention and to accurately stage their disease. Treatment planning for these complex patients is best done with a multidisciplinary team approach.

Squamous cell carcinoma of the penis represents approximately 0.5% of all cancers among men in the United States and other developed countries. Although rare, it is associated with significant disfigurement, and only half of the patients survive beyond 5 years. Proper evaluation of both the primary lesion and lymph nodes is critical, because nodal involvement is the most important factor of survival. The NCCN Clinical Practice Guidelines in Oncology for Penile Cancer provide recommendations on the diagnosis and management of this devastating disease based on evidence and expert consensus.

The liver is one of the most challenging organs of the body to image with magnetic resonance because it is large and mobile, receives a dual blood supply, and is surrounded by organs and structures that contribute to artifacts from flow and susceptibility. Recent advances in imaging hardware, in addition to improvements in temporal resolution and development of hepatocyte-specific contrast agents, make imaging of the liver more approachable than in the past; however, it remains a complex process that requires compromise. In this article the authors discuss development and optimization of a liver imaging protocol at 1.5 T, with common variations in each element of the protocol, as well as the strengths and weaknesses associated with the relevant sequences.