Publications by authors named "Alan C Legasto"

19 Publications

  • Page 1 of 1

Imaging Utilization and Outcomes in Vulnerable Populations during COVID-19 in New York City.

Radiol Cardiothorac Imaging 2020 Dec 17;2(6):e200464. Epub 2020 Dec 17.

Department of Radiology, Weill Cornell Medicine, New York, NY (D.T., J.R., L.K.G., S.V.W., J.G.E., A.C.L., A.S.M., J.F.G., Q.A.T); Division of Cardiology, Department of Medicine, Weill Cornell Medicine, New York, NY (S.S.M., E.P.C., Q.A.T); Department of Medicine, Weill Cornell Medicine, New York, NY (T.B., L.B); Weill Cornell Medical College, New York, NY (Y.C., P.R., O.Z); Information Technologies & Services, Weill Cornell Medicine, New York, NY (S.A).

Background: Coronavirus disease 2019 (COVID-19) affects vulnerable populations (VP) adversely.

Purpose: To evaluate overall imaging utilization in vulnerable subgroups (elderly, racial/ethnic minorities, socioeconomic status [SES] disadvantage) and determine if a particular subgroup has worse outcomes from COVID-19.

Materials/methods: Of 4110 patients who underwent COVID-19 testing from March 3-April 4, 2020 at NewYork-Presbyterian Hospital (NYP) health system, we included 1121 COVID-19 positive adults (mean age 59±18 years, 59% male) from two academic hospitals and evaluated imaging utilization rates and outcomes, including mortality.

Results: Of 897 (80%) VP, there were 465 (41%) elderly, 380 (34%) racial/ethnic minorities, and 479 (43%) SES disadvantage patients. Imaging was performed in 88% of patients and mostly portable/bedside studies, with 87% of patients receiving chest radiographs. There were 83% hospital admissions, 25% ICU admissions, 23% intubations, and 13% deaths. Elderly patients had greater imaging utilization, hospitalizations, ICU/intubation requirement, longer hospital stays, and >4-fold increase in mortality compared to non-elderlies (adjusted hazard ratio[aHR] 4.79, p<0.001). Self-reported minorities had fewer ICU admissions (p=0.03) and reduced hazard for mortality (aHR 0.53, p=0.004; complete case analysis: aHR 0.39, p<0.001 excluding "not reported"; sensitivity analysis: aHR 0.61, p=0.005 "not reported" classified as minorities) with similar imaging utilization, compared to non-minorities. SES disadvantage patients had similar imaging utilization and outcomes as compared to their counterparts.

Conclusions: In a predominantly hospitalized New York City cohort, elderly patients are at highest mortality risk. Racial/ethnic minorities and SES disadvantage patients fare better or similarly to their counterparts, highlighting the critical role of access to inpatient medical care during the COVID-19 pandemic.
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http://dx.doi.org/10.1148/ryct.2020200464DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751279PMC
December 2020

The Design and Preliminary Experience with a Virtual Diversity Visiting Student Acting Internship in Radiology for Underrepresented Minority Medical Students.

Acad Radiol 2021 Mar 24. Epub 2021 Mar 24.

Department of Radiology, Weill Cornell Medicine, 525 E 68(th) Street, New York, NY 10065.

Objective: Benefits of a diverse physician workforce are numerous and the impact of a lack of diversity has been highlighted with the COVID-19 pandemic. Despite the commitment of professional societies such as the American College of Radiology to diversity in Radiology, the field and its residency training programs remain the least diverse. With COVID-19 related suspension of in-person medical student rotations, our Department of Radiology redesigned and implemented a virtual radiology internship for underrepresented minority (URM) medical students.

Methods: A four-week virtual radiology internship was designed to provide clinical exposure to radiology and to allow students to gain an understanding of what a career in radiology entails. Course design included videoconference patient care sessions, didactic lectures, online modules, mentoring, and extra-clinical curriculum. Feedback from students was collected using online surveys assessing pre- and postcourse attitudes and understanding of a career in radiology and the students' perceived aptitude for such a career, as well as course component evaluation.

Results: Three participants were enrolled in the inaugural clerkship. All noted exceptional educational course content and ample opportunities to build connections with faculty and residents-with mentoring seen as the highlight of the course. All indicated a significant shift in perception of the field and in declaring interest in pursuing a career in radiology.

Conclusion: Virtual radiology internship for URM students is a feasible paradigm to address potential impediments to diversification of the specialty by both engaging interested URM medical students in a career in radiology and arming them with the tools for a successful application to radiology residency.
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http://dx.doi.org/10.1016/j.acra.2021.02.021DOI Listing
March 2021

Central paradiaphragmatic middle lobe involvement in nonspecific interstitial pneumonia.

Eur Radiol 2021 Feb 23. Epub 2021 Feb 23.

Department of Radiology, Division of Cardiothoracic Imaging, New York-Presbyterian Hospital - Weill Cornell Medical Center, 525 East 68th Street, New York, NY, 10065, USA.

Objectives: Nonspecific interstitial pneumonia (NSIP) lacks specific diagnostic guidelines or criteria for imaging diagnosis, and the need for more reliable computed tomography (CT) characterization remains. We hypothesized that central paradiaphragmatic middle lobe (ML) involvement is present in most patients with NSIP. The purpose of this study was to evaluate the prevalence of ML involvement and thus to assess its potential as a unique feature of NSIP.

Methods: We conducted a retrospective CT-imaging review of 40 patients with biopsy-proven (7/40, 18%) or clinically established (33/40, 82%) NSIP. Three subspecialty-trained thoracic radiologists reviewed CTs for ML involvement both independently and in consensus, and additional CT findings previously described in NSIP independently.

Results: ML involvement was present in most cases (70%, 28/40, independent review, 78%, 31/40, consensus reading), with substantial agreement among all three readers (κ = 0.65). Fibrosis was present in almost all cases (93%, 37/40). Subpleural sparing occurred in one-third of patients (30%, 12/40). Homogeneity (48%, 19/40), central bronchiectasis (45%, 18/40), and peripheral bronchiectasis (53%, 21/40) were present in about half of patients. Apart from substantial inter-reader agreement on fibrosis (κ = 0.65), the above-mentioned imaging characteristics had fair to slight universal agreement (κ = 0.07-0.30).

Conclusions: Central paradiaphragmatic ML ground glass attenuation superimposed on reticulation and traction bronchiectasis occurs in most patients with NSIP, with high interobserver agreement.

Key Points: • Central paradiaphragmatic middle lobe ground glass attenuation superimposed on reticulation and traction bronchiectasis is common in nonspecific interstitial pneumonia (NSIP). • This finding occurs more frequently than subpleural sparing and has a better interobserver agreement.
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http://dx.doi.org/10.1007/s00330-021-07741-zDOI Listing
February 2021

Imaging of the rare cystic lung diseases.

Curr Probl Diagn Radiol 2021 Feb 7. Epub 2021 Feb 7.

Department of Radiology, University of Colorado, Aurora, CO.

When discussing cystic lung diseases, a certain group of diseases tends to receive the majority of attention. Other less frequently discussed cystic lung diseases are also important causes of morbidity in patients. Etiologies include genetic syndromes, lymphoproliferative diseases, infections, exogenous exposures, and a developmental abnormality. This review article focuses on the clinical and imaging features of these other cystic lung diseases.
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http://dx.doi.org/10.1067/j.cpradiol.2021.02.003DOI Listing
February 2021

Thoracic Manifestations of Rheumatoid Arthritis.

Radiographics 2021 Jan-Feb;41(1):32-55

From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065.

Rheumatoid arthritis (RA) is one of the most common chronic systemic inflammatory diseases and the most common chronic inflammatory arthritis. Classically a progressive symmetric polyarthritis, RA is characterized by inflammation, erosions, bone loss, and joint destruction. Up to half of patients with RA exhibit extra-articular manifestations (EAMs), which may precede articular disease and are more common in patients with seropositive RA (patients with detectable serum levels of rheumatoid factor and/or anticitrullinated peptide antibodies). Cardiovascular and pulmonary EAMs are the largest contributors to morbidity and mortality in RA and may be especially devastating. Imaging has a significant role in diagnosing these EAMs and assessing response to treatment. Although treatment with disease-modifying antirheumatic drugs has redefined the natural history of RA and helped many patients achieve low disease activity, patients are at risk for treatment-related complications, as well as infections. The clinical features of drug-induced lung disease and infection can overlap considerably with those of EAMs, presenting a diagnostic challenge. Radiologists, by recognizing the imaging characteristics and evolution of these various processes, are essential in diagnosing and distinguishing among EAMs, treatment-related complications, and unrelated processes and formulating an appropriate differential diagnosis. Moreover, recognizing these disease processes at imaging and contextualizing imaging findings with clinical information and laboratory and pathologic findings can facilitate definitive diagnosis and proper treatment. The authors review the articular and extra-articular thoracic imaging manifestations of RA, including cardiovascular, respiratory, and pleural diseases, as well as treatment-related complications and common infections. RSNA, 2021.
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http://dx.doi.org/10.1148/rg.2021200091DOI Listing
January 2021

A Case-Based Review of Vaping-Induced Injury-Pulmonary Toxicity and Beyond.

Curr Probl Diagn Radiol 2021 May-Jun;50(3):401-409. Epub 2020 Jun 26.

Department of Radiology, Division of Cardiothoracic Imaging, New York-Presbyterian Hospital - Weill Cornell Medical Center, New York, NY. Electronic address:

The last 10 years has seen a steady rise in the use of electronic cigarettes ("e-cigarettes" or ECIGs) or "vape pens." Though initially developed to assist with smoking cessation, use among adolescents has been particularly high. A concomitant rise in ECIG-related injuries disproportionately affecting young patients has been recognized. This unique case series highlights both pulmonary and extra-pulmonary ECIG-induced injuries including vape tip ingestion, maxillofacial fractures after vape pen explosion, myocarditis, and several different manifestations of vaping-associated lung injury. Becoming familiar with expected imaging findings in the wide array of ECIG-induced complications will help radiologists recognize these findings, recommend further imaging as needed, facilitate early diagnosis by help referring clinicians elicit the relevant history from patients, and expedite appropriate treatment.
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http://dx.doi.org/10.1067/j.cpradiol.2020.06.003DOI Listing
June 2020

Potential impact of dynamic automated CT aortic annular measurements on outcomes for transcatheter aortic valve replacement sizing.

Int J Cardiovasc Imaging 2020 Nov 3;36(11):2291-2297. Epub 2020 Jul 3.

Division of Cardiology, Department of Medicine, Weill Cornell Medicine and New York-Presbyterian Hospital, New York, NY, USA.

To determine the potential impact of automated computed tomography (CT) software used for aortic annular sizing for transcatheter aortic valve replacement (TAVR) on paravalvular leak (PVL) and major adverse cardiovascular events (MACE) as compared to standard CT manual measurement. In 60 TAVR patients (84 ± 7 years, 60% male), we evaluated the preprocedural CT scans. For the standard manual measurement, we measured the perimeter and area from a single cardiac phase deemed to be of maximum systolic opening. Valve type and size were determined by a multidisciplinary TAVR team per clinical routine. From the dynamic automated software, we determined the aortic annular perimeter and area as the maximum value from an entire cardiac cycle. Valve size was readjudicated by a blinded interventional cardiologist who was provided with valve type and automated values. Clinical endpoints were adjudicated for presence of at least mild PVL and MACE at 30 days. There were 16 (28%) patients with PVL and 4 (7%) with 30-day MACE. When reclassifying valve size using dynamic automated values, 12 (20%) patients were undersized and 3 (5%) patients were oversized. Undersized patients were more likely to have mild-to-moderate PVL at 30 days (27% vs 4%, p = 0.04) than those not undersized. Of the 5 (45%) undersized patients with at least mild PVL, all were balloon-expandable valves. Automated dynamic CT annular measurements have the potential to reclassify patients with PVL with larger TAVR valve size, particularly balloon-expandable valves.
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http://dx.doi.org/10.1007/s10554-020-01928-zDOI Listing
November 2020

Performance of Dynamic Automated CT Annular Measurements Compared to Standard Manual Measurements for Transcatheter Aortic Valve Replacement Sizing.

Radiol Cardiothorac Imaging 2019 Aug 29;1(3). Epub 2019 Aug 29.

Department of Biostatistics, New York University, New York, NY.

Purpose: We sought to determine the performance of an automated computed tomography (CT) software that provides dynamic annular measurements of all available cardiac phases for transcatheter aortic valve replacement (TAVR) sizing as compared to the standard single manual measurement.

Materials And Methods: In 60 TAVR patients (84±7 years, 60% male) who underwent pre-procedural CT scans, we measured the aortic annular diameters, perimeter, and area using (1) the dynamic automated CT measurements and (2) standard single manual measurement from the cardiac phase of maximum systolic opening by visual estimate.

Results: The automated software was successful in providing annular measurements in 43/60 (72%) of cases, with the remainder requiring semi-automated contours. The maximum dynamic automated values were predominantly in systole (46/60[77%] for diameter, 44/60[73%] for perimeter, 48/60[80%] for area), and was a different phase from the standard manual phase in 46/60 (77%) cases. The maximum dynamic automated annular values were larger than the standard manual values measured (Δdiameter 0.35 mm, p=0.04; Δperimeter 1.71 mm, p<0.001; Δarea 15.6 mm, p<0.001). When comparing standard manual to the same phase by automated measurements, while there was no difference in annular mean diameter (p=0.80), perimeter and area were larger with the automated measurements (Δperimeter 0.95 mm, p=0.002; Δarea 10.8 mm, p=0.03). However, the maximum automated measurements were consistently larger than the same phase automated measurements (Δdiameter 0.13 mm, p<0.001; Δperimeter 0.42 mm, p<0.001; Δarea 4.4 mm, p<0.001).

Conclusions: Automated maximum dynamic CT annular measurements provide larger values than standard manual and same phase automated measurements.
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http://dx.doi.org/10.1148/ryct.2019180025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727651PMC
August 2019

Multilobulated thymoma with an acute angle: a new predictor of lung invasion.

Eur Radiol 2019 Sep 26;29(9):4555-4562. Epub 2019 Feb 26.

Department of Radiology, Weill Cornell Medicine, New York-Presbyterian Hospital, 525 E. 68th St, Box 141, New York, NY, 10065, USA.

Objective: Imaging features of thymomas such as lobulation, infiltration into lung, and adjacent lung abnormality have been associated with lung invasion but are unreliable. The goal of this study was to develop a more objective and reproducible method for predicting lung invasion by thymomas.

Subjects And Methods: Fifty-four thymomas resected from 2007 to 2017 were included for analysis. Pre-operative CT scans for these thymomas were reviewed, and multiple features were evaluated, including the interface of each thymoma with the adjacent lung. A multilobulated thymoma with at least one acute angle between lobulations was considered suspicious for lung invasion. Two blinded radiologists then tested this hypothesis by reviewing all 54 CT scans and using this single criterion to predict lung invasion.

Results: Twelve thymomas invaded the lung. All lung-invasive thymomas were multilobulated. Twenty-nine thymomas had a multilobulated interface with the lung. Multilobulated thymomas were more likely to invade the lung than thymomas with a single lobulation or no lobulation (p = 0.0008). Using the criterion of multilobulation with at least one acute angle between lobulations to predict lung invasion, the two readers achieved a sensitivity of 67-83%, specificity of 93-98%, positive predictive value of 77-89%, and negative predicted value of 91-95%. Nine lung-invasive thymomas also invaded mediastinal structures or disseminated to the pleura.

Conclusions: A multilobulated thymoma with at least one acute angle between lobulations predicts lung invasion with a high degree of accuracy. When lung invasion is suspected, the findings are indicative of a locally aggressive tumor, and the pleura and mediastinal structures should also be closely inspected for invasion.

Key Points: • A multilobulated thymoma with at least one acute angle between lobulations is predictive of lung invasion. • Coronal and sagittal reformations and thin sections are helpful in challenging cases. • Lung invasion indicates a locally aggressive tumor, and the pleura and other mediastinal structures should also be closely inspected for invasion.
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http://dx.doi.org/10.1007/s00330-019-06059-1DOI Listing
September 2019

Screening for Lung Cancer: Communicating With Patients.

AJR Am J Roentgenol 2018 Mar 22;210(3):497-502. Epub 2017 Nov 22.

1 Department of Radiology, New York Presbyterian-Weill Cornell Medical Center, 525 E 68th St, Box 141, Rm L-017A, New York, NY 10065.

Objective: The purposes of this article are to detail the experience of a single-center academic institution in applying the patient-centered approach to a lung cancer screening program and to examine how this approach can expand to other aspects of follow-up imaging of lung nodules.

Conclusion: As the practice of patient-centered radiology gains attention, diagnostic radiologists are findings new ways to become more involved in patient care. A lung cancer screening program is one opportunity for radiologists to consult with and educate patients.
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http://dx.doi.org/10.2214/AJR.17.18836DOI Listing
March 2018

Dendriform Pulmonary Ossification in the Absence of Usual Interstitial Pneumonia: CT Features and Possible Association With Recurrent Acid Aspiration.

AJR Am J Roentgenol 2017 Dec 5;209(6):1209-1215. Epub 2017 Oct 5.

2 Department of Radiology, Mayo Clinic Hospital, Phoenix, AZ.

Objective: Dendriform pulmonary ossification (DPO) is a rare lung disease in which mature bone is present in the peripheral interstitium of the lung. It typically occurs in patients with usual interstitial pneumonia (UIP). We assessed patients with CT findings of DPO without UIP to determine possible causative factors and to assess the clinical and CT course. We hypothesized that DPO without UIP would be a unique entity.

Materials And Methods: We retrospectively reviewed CT reports for the word "ossification." Two observers reviewed each examination for micronodules 1-5 mm in diameter in the peripheral interstitium (subpleural and perifissural spaces and interlobular septa), some of which had high attenuation on mediastinal windows, presence of contiguous clusters of nodules resulting in a branching pattern, and lack of findings of UIP or focal lung disease. We reviewed the electronic medical records and follow-up CT and clinical information in all eligible patients.

Results: The study population consisted of 52 men with a median age of 79 years old. Seventy-five percent of the patients had gastroesophageal reflux disease, obstructive sleep apnea, or a chronic neurologic disorder. No progressive pulmonary symptoms were attributed directly to DPO, and no patient developed pulmonary fibrosis or suffered clinical decline from DPO. CT showed minimal progression or remained stable at follow-up (77% for at least 1 year, 25% for over 4 years).

Conclusion: DPO in the absence of UIP occurs in elderly men and appears to be associated with chronic aspiration of gastric acid. The course is indolent.
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http://dx.doi.org/10.2214/AJR.17.18063DOI Listing
December 2017

Pulmonary fibrosis on the lateral chest radiograph: Kerley D lines revisited.

Insights Imaging 2017 Oct 7;8(5):483-489. Epub 2017 Aug 7.

Department of Radiology, New York-Presbyterian Hospital/Weill Cornell Medical College, 525 E. 68th St, Box 141, New York, NY, 10065, USA.

The retrosternal clear space (RCS) is a lucent area on the lateral chest radiograph located directly behind the sternum. The two types of pathology classically addressed in the RCS are anterior mediastinal masses and emphysema. Diseases of the pulmonary interstitium are a third type of pathology that can be seen in the RCS. Retrosternal reticular opacities, known as Kerley D lines, were initially described in the setting of interstitial oedema. Pulmonary fibrosis is another aetiology of Kerley D lines, which may be more easily identified in the RCS than elsewhere on the chest radiograph.

Teaching Points: • The RCS is one of three lucent spaces on the lateral chest radiograph. • Reticular opacities in the RCS are known as Kerley D lines. • Pulmonary fibrosis can be seen in the RCS as Kerley D lines. • Kerley D lines should be further evaluated with chest CT.
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http://dx.doi.org/10.1007/s13244-017-0565-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5621990PMC
October 2017

The King laryngeal tube: a mimic of esophageal intubation in the emergency department.

Emerg Radiol 2017 Dec 20;24(6):701-704. Epub 2017 Jun 20.

Department of Emergency Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, USA.

The King Airway is a temporary airway device used primarily in the pre-hospital setting and typically exchanged for an endotracheal tube upon arrival to the emergency department. Since this usually occurs before imaging, many radiologists are unfamiliar with the King Airway. This lack of familiarity can have important consequences for the patient and treating team. The purpose of this article is to raise awareness of the King Airway among radiologists, emphasize appropriate positioning, and review the imaging complications of incorrect positioning.
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http://dx.doi.org/10.1007/s10140-017-1529-zDOI Listing
December 2017

A Woman with a Breast Mass, Multiple Pulmonary Nodules, and Wheezing.

Ann Am Thorac Soc 2017 01;14(1):134-139

1 Division of Pulmonary and Critical Care Medicine.

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http://dx.doi.org/10.1513/AnnalsATS.201606-446CCDOI Listing
January 2017

Chronic Cough and Bilateral Pneumothoraces in a Nonsmoker.

Chest 2016 Feb;149(2):e49-e55

Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY.

An 82-year-old Japanese nonsmoking man presented with persistent dry cough and small left apical pneumothorax. High resolution CT scan of the chest demonstrated bilateral upper lobe pleuroparenchymal thickening and architectural distortion. Serial imaging revealed mild progression and development of small bilateral pneumothoraces, and pneumomediastinum. A surgical lung biopsy was required to confirm the diagnosis.
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http://dx.doi.org/10.1016/j.chest.2015.10.070DOI Listing
February 2016

Tracheal web.

Pediatr Radiol 2004 Mar 28;34(3):256-8. Epub 2003 Oct 28.

Department of Radiology, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201, USA.

Congenital tracheal web is a rare entity often misdiagnosed as refractory asthma. Clinical suspicion based on patient history, examination, and pulmonary function tests should lead to its consideration. Bronchoscopy combined with CT imaging and multiplanar reconstruction is an accepted, highly sensitive means of diagnosis.
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http://dx.doi.org/10.1007/s00247-003-1030-6DOI Listing
March 2004

Imaging neuroblastoma in children.

Crit Rev Comput Tomogr 2003 ;44(1):47-61

Department of Radiology, Long Island College Hospital, 339 Hicks Street, Brooklyn, NY 11201, USA.

Neuroblastoma is a common solid tumor of childhood that can involve the abdomen, thorax, pelvis, or the head and neck. The clinical manifestations are dependent on the widespread distribution of neural crest tissue and the length of the sympathetic chain involvement. Abdominal pain and hypertension may occur as a result of renal vasculature compression; respiratory distress may be evident in thoracic tumors; and Homer's syndrome or heterochromia of the iris may manifest from neuroblastoma of the head and neck. In addition, symptoms of cord compression and back pain may result from spinal cord compromise due to epidural invasion. Metastatic involvement of the liver, skin, periorbital regions, or bone may cause hepatomegaly, skin nodules, proptosis, or bone marrow failure, respectively. Clinical findings along with tumor metastasis may be studied by various imaging modalities to assess the nature and extent of the tumor. Diagnostic tests include plain radiography, ultrasonography, CT scanning, and MR imaging. Bone marrow studies, bone scans, and scintigraphy with 131I-metaiodobenzylmandelic may be utilized for metastatic evaluation. By using these imaging studies to detect the nature and behavior of neuroblastoma, early intervention may indeed improve patient survival.
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June 2003