Publications by authors named "Randy Ernst"

32 Publications

Nodal drainage pathways in primary rectal cancer: anatomy of regional and distant nodal spread.

Abdom Radiol (NY) 2019 11;44(11):3527-3535

Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.

Nodal involvement is a significant prognostic factor in rectal cancer and difficult to assess preoperatively. An understanding of the patterns of nodal spread from different regions of the rectum can assist in this process and is essential for the purposes of surgical planning. In this article we define patterns of spread to mesenteric and pelvic sidewall nodal subgroups and discuss the importance of accurate anatomic localization of nodes for the purposes of staging and surgical planning.
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http://dx.doi.org/10.1007/s00261-019-02094-0DOI Listing
November 2019

MR staging of anal cancer: what the radiologist needs to know.

Abdom Radiol (NY) 2019 11;44(11):3726-3739

Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Anal canal cancer is a rare disease and squamous cell carcinoma is the most common histologic subtype. Traditionally, anal cancer is imaged with CT and PET/CT for purposes of TNM staging. With the increased popularity of MRI for rectal cancer evaluation, MRI has become increasingly utilized for local staging of anal cancer. In this review, we focus on the necessary information radiologists need to know to understand this rare and unique disease and to be familiar with staging of anal cancer on MRI.
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http://dx.doi.org/10.1007/s00261-019-02020-4DOI Listing
November 2019

Diagnosis and Diagnostic Imaging of Anal Canal Cancer.

Surg Oncol Clin N Am 2017 01;26(1):45-55

Department of Radiology, The Royal Marsden NHS Foundation Trust and Imperial College London, Downs Road, Sutton, Surrey SM2 5PT, UK.

Anal canal cancer is an uncommon malignancy but one that is often curable with optimal therapy. Owing to its unique location, histology, risk factors, and usual presentation, a careful diagnostic approach is warranted. This approach includes an excellent history and physical examination, including digital rectal examination, laboratory data, and comprehensive imaging. Anal cancer staging and formulation of a treatment plan depends on accurate imaging data. Modern radiographic techniques have improved staging quality and accuracy, and a thorough knowledge of anal anatomy is paramount to the optimal multidisciplinary treatment of this disease.
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http://dx.doi.org/10.1016/j.soc.2016.07.002DOI Listing
January 2017

Variation in positron emission tomography use after colon cancer resection.

J Oncol Pract 2015 May 7;11(3):e363-72. Epub 2015 Apr 7.

University of Texas MD Anderson Cancer Center, Houston, TX

Purpose: Colon cancer surveillance guidelines do not routinely include positron emission tomography (PET) imaging; however, its use after surgical resection has been increasing. We evaluated the secular patterns of PET use after surgical resection of colon cancer among elderly patients and identified factors associated with its increasing use.

Patients And Methods: We used the SEER-linked Medicare database (July 2001 through December 2009) to establish a retrospective cohort of patients age ≥ 66 years who had undergone surgical resection for colon cancer. Postoperative PET use was assessed with the test for trends. Patient, tumor, and treatment characteristics were analyzed using univariable and multivariable logistic regression analyses.

Results: Of the 39,221 patients with colon cancer, 6,326 (16.1%) had undergone a PET scan within 2 years after surgery. The use rate steadily increased over time. The majority of PET scans had been performed within 2 months after surgery. Among patients who had undergone a PET scan, 3,644 (57.6%) had also undergone preoperative imaging, and 1,977 (54.3%) of these patients had undergone reimaging with PET within 2 months after surgery. Marriage, year of diagnosis, tumor stage, preoperative imaging, postoperative visit to a medical oncologist, and adjuvant chemotherapy were significantly associated with increased PET use.

Conclusion: PET use after colon cancer resection is steadily increasing, and further study is needed to understand the clinical value and effectiveness of PET scans and the reasons for this departure from guideline-concordant care.
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http://dx.doi.org/10.1200/JOP.2014.001933DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438115PMC
May 2015

Local magnetic resonance imaging staging of rectal adenocarcinoma.

J Comput Assist Tomogr 2014 Nov-Dec;38(6):885-9

From the Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX.

Successful multidisciplinary evaluation of potentially resectable rectal adenocarcinoma depends on high-resolution preoperative magnetic resonance imaging (MRI). Magnetic resonance imaging accurately identifies important risk factors of local recurrence and distant metastasis, thus facilitating enhanced preoperative prognostic stratification and treatment. When combined with appropriate neoadjuvant chemotherapy and total mesorectal excision, the treatment of rectal cancer has dramatically improved. Accurate local staging by MRI requires a robust combination of imaging sequences. Herein, we review MRI imaging and rectal anatomy related to the staging of rectal adenocarcinoma.
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http://dx.doi.org/10.1097/RCT.0000000000000170DOI Listing
January 2015

Intraoperative sonography during open partial nephrectomy for renal cell cancer: does it alter surgical management?

AJR Am J Roentgenol 2014 Oct;203(4):822-7

1 Department of Diagnostic Radiology, University of Texas M. D. Anderson Cancer Center, Unit 1350, 1515 Holcombe Blvd, Houston, TX 77030.

Objective: The purpose of this study is to evaluate whether intraoperative ultrasound (IOUS) during open partial nephrectomy alters the surgical management for renal cell cancer (RCC).

Materials And Methods: One hundred ninety-eight consecutive patients undergoing IOUS during open partial nephrectomy for RCC were selected for retrospective review of clinical and imaging data. Patient age and sex, the local extent of the primary lesion, and the presence of additional lesions were recorded. Ultrasound findings were compared with preoperative CT or MRI to determine whether the IOUS findings changed surgical management. Summary statistics were performed to assess what percentage of patients with additional IOUS findings had a change in their surgical management. The Kaplan-Meier method was used to estimate 5-year overall survival (OS) and event-free survival (EFS) rates for all patients. Patients were followed for 9-12 years to assess survival and measure recurrence rates.

Results: Twenty-one of 198 patients (10.6%; 95% CI, 6.7-15.8%) had additional findings on IOUS not seen on preoperative imaging. As a result, surgery was modified in 15 of these 21 patients (71.4%; 95% CI, 47.8-88.7%). The 5-year OS rate was 81%, and the EFS rate was 76% for the whole group; most deaths were due to unrelated causes. There was no statistically significant difference in OS (p = 0.867) and EFS (p = 0.069) rates among patients who had a change of management because of additional lesions seen by IOUS.

Conclusion: IOUS performed during open partial nephrectomy for resection of RCC shows additional findings compared with preoperative cross-sectional imaging that may alter surgical management.
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http://dx.doi.org/10.2214/AJR.13.12254DOI Listing
October 2014

Optimization of MR imaging for pretreatment evaluation of patients with endometrial and cervical cancer.

Radiographics 2014 Jul-Aug;34(4):1082-98

From the Departments of Diagnostic Radiology (G.M.R., H.K., H.C., R.D.E., P.B., L.P.M.), Radiation Oncology (A.H.K.), and Gynecologic Oncology and Reproductive Medicine (S.N.W.), University of Texas MD Anderson Cancer Center, 1400 Pressler St, Mail Unit 1473, Houston, TX 77030-4009.

Endometrial and cervical cancer are the most common gynecologic malignancies in the world. Accurate staging of cervical and endometrial cancer is essential to determine the correct treatment approach. The current International Federation of Gynecology and Obstetrics (FIGO) staging system does not include modern imaging modalities. However, magnetic resonance (MR) imaging has proved to be the most accurate noninvasive modality for staging endometrial and cervical carcinomas and often helps with risk stratification and making treatment decisions. Multiparametric MR imaging is increasingly being used to evaluate the female pelvis, an approach that combines anatomic T2-weighted imaging with functional imaging (ie, dynamic contrast material-enhanced and diffusion-weighted imaging). MR imaging helps guide treatment decisions by depicting the depth of myometrial invasion and cervical stromal involvement in patients with endometrial cancer and tumor size and parametrial invasion in those with cervical cancer. However, its accuracy for local staging depends on technique and image quality, namely thin-section high-resolution multiplanar T2-weighted imaging with simple modifications, such as double oblique T2-weighting supplemented by diffusion weighting and contrast enhancement.
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http://dx.doi.org/10.1148/rg.344140001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307629PMC
November 2015

Superior mesenteric artery syndrome after ileal pouch anal anastomosis.

Am Surg 2013 Jan;79(1):E14-6

Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA.

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January 2013

MR imaging of ectopic pregnancy with an emphasis on unusual implantation sites.

Jpn J Radiol 2013 Feb 7;31(2):75-80. Epub 2012 Nov 7.

Department of Radiology, Antalya Education and Research Hospital, Antalya 07100, Turkey.

Ectopic pregnancy (EP) is a life-threatening condition and remains the leading cause of death in the first trimester of pregnancy, although the mortality rate has significantly decreased over the past few decades because of earlier diagnoses and great improvements in treatment. EP is most commonly located in the ampullary portion of the fallopian tube and rarely in unusual sites such as the interstitium, cervix, cesarean scar, anomalous rudimentary horn of the uterus and peritoneal abdominal cavity. MRI may confirm or give additional information to ultrasonography, which is the most user-dependent imaging modality. Magnetic resonance imaging can accurately localize the site of abnormal implantation. It could be helpful for EP patient treatment by distinguishing the ruptured and unruptured cases before methotrexate treatment. MRI is quite sensitive to blood and can identify the hemorrhage phase.
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http://dx.doi.org/10.1007/s11604-012-0151-yDOI Listing
February 2013

Pretreatment high-resolution rectal MRI and treatment response to neoadjuvant chemoradiation.

Dis Colon Rectum 2012 Apr;55(4):371-7

Department of Surgical Oncology and Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Use of rectal MRI evaluation of patients with rectal cancer for primary tumor staging and for identification for poor prognostic features is increasing. MR imaging permits precise delineation of tumor anatomy and assessment of mesorectal tumor penetration and radial margin risk.

Objective: The aim of this study was to evaluate the ability of pretreatment rectal MRI to classify tumor response to neoadjuvant chemoradiation.

Design: This study is a retrospective, consecutive cohort study and central review.

Setting: This study was conducted at a tertiary academic hospital.

Patients: Sixty-two consecutive patients with locally advanced (stage cII to cIII) rectal cancer who underwent rectal cancer protocol high-resolution MRI before surgery (December 2009 to March 2011) were included.

Main Outcome Measures: The primary outcomes measured were the probability of good (ypT0-2N0) vs poor (≥ypT3N0) response as a function of mesorectal tumor depth, lymph node status, extramural vascular invasion, and grade assessed by uni- and multivariate logistic regression.

Results: Tumor response was good in 25 (40.3%) and poor in 37 (59.7%). Median interval from MRI to surgery was 7.9 weeks (interquartile range, 7.0-9.0). MRI tumor depth was <1 mm in 10 (16.9%), 1 to 5 mm in 30 (50.8%), and >5 mm in 21 (33.9%). Lymph node status was positive in 40 (61.5%), and vascular invasion was present in 16 (25.8%). Tumor response was associated with MRI tumor depth (p = 0.001), MRI lymph node status (p < 0.001) and vascular invasion (p = 0.009). Multivariate regression indicated >5 mm MRI tumor depth (OR = 0.08; 95% CI = 0.01-0.93; p = 0.04) and MRI lymph node positivity (OR = 0.12; 95% CI = 0.03-0.53; p = 0.005) were less likely to achieve a good response to neoadjuvant chemoradiotherapy.

Limitations: Generalizability is uncertain in centers with limited experience with MRI staging for rectal cancer.

Conclusion: MRI assessment of tumor depth and lymph node status in rectal cancer is associated to tumor response to neoadjuvant chemoradiotherapy. These factors should therefore be considered for stratification of patients for novel treatment strategies reliant on pathologic response to treatment or for the selection of poor-risk patients for intensified treatment regimens.
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http://dx.doi.org/10.1097/DCR.0b013e31824678e3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3546551PMC
April 2012

MR imaging for preoperative evaluation of primary rectal cancer: practical considerations.

Radiographics 2012 Mar-Apr;32(2):389-409

Department of Diagnostic Radiology, University of Texas M.D. Anderson Cancer Center, 1400 Pressler St, Unit 1473, Houston, TX 77030, USA.

High-resolution magnetic resonance (MR) imaging plays a pivotal role in the pretreatment assessment of primary rectal cancer. The success of this technique depends on obtaining good-quality high-resolution T2-weighted images of the primary tumor; the mesorectal fascia, peritoneal reflection, and other pelvic viscera; and superior rectal and pelvic sidewall lymph nodes. Although orthogonal axial high-resolution T2-weighted MR images are the cornerstone for the staging of primary rectal cancer, high-resolution sagittal and coronal images provide additional value, particularly in tumors that arise in a redundant tortuous rectum. Coronal high-resolution T2-weighted MR images also improve the assessment of nodal morphology, particularly for superior rectal and pelvic sidewall nodes, and of the relationship between advanced-stage tumors and adjacent pelvic structures. Rectal gel should be used in MR imaging examinations conducted for the staging of polypoid tumors, previously treated lesions, and small rectal tumors. However, it should not be used in examinations performed to stage large or low rectal tumors. Diffusion-weighted imaging is useful for identifying nodes and, occasionally, the primary tumor when the tumor is difficult to visualize with other sequences. Three-dimensional T2-weighted imaging provides multiplanar capability with a superior signal-to-noise ratio compared with two-dimensional T2-weighted imaging.
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http://dx.doi.org/10.1148/rg.322115122DOI Listing
July 2012

Quality initiatives: CT radiation dose reduction: how to implement change without sacrificing diagnostic quality.

Radiographics 2011 Nov-Dec;31(7):1823-32. Epub 2011 Oct 3.

Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Unit 1473, P.O. Box 301402, Houston, TX 77230-1402, USA.

The risks and benefits of using computed tomography (CT) as opposed to another imaging modality to accomplish a particular clinical goal should be weighed carefully. To accurately assess radiation risks and keep radiation doses as low as reasonably achievable, radiologists must be knowledgeable about the doses delivered during various types of CT studies performed at their institutions. The authors of this article propose a process improvement approach that includes the estimation of effective radiation dose levels, formulation of dose reduction goals, modification of acquisition protocols, assessment of effects on image quality, and implementation of changes necessary to ensure quality. A first step toward developing informed radiation dose reduction goals is to become familiar with the radiation dose values and radiation-associated health risks reported in the literature. Next, to determine the baseline dose values for a CT study at a particular institution, dose data can be collected from the CT scanners, interpreted, tabulated, and graphed. CT protocols can be modified to reduce overall effective dose by using techniques such as automated exposure control and iterative reconstruction, as well as by decreasing the number of scanning phases, increasing the section thickness, and adjusting the peak voltage (kVp setting), tube current-time product (milliampere-seconds), and pitch. Last, PDSA (plan, do, study, act) cycles can be established to detect and minimize negative effects of dose reduction methods on image quality.
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http://dx.doi.org/10.1148/rg.317115027DOI Listing
April 2012

Magnetic resonance imaging of cystic adnexal lesions during pregnancy.

Curr Probl Diagn Radiol 2008 Jul-Aug;37(4):139-44

Department of Radiology, University of Texas Medical Branch at Galveston, Galveston, TX, USA.

Management of cystic adnexal lesions diagnosed during pregnancy is a challenging issue for obstetricians. The range of treatment options changes from immediate surgery to close follow-up. This pictorial essay illustrates the magnetic resonance imaging findings of various cystic adnexal lesions in pregnant patients. Magnetic resonance imaging may help in better characterization of some of the cystic adnexal lesions diagnosed during pregnancy without exposing the fetus to ionizing radiation.
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http://dx.doi.org/10.1067/j.cpradiol.2007.08.002DOI Listing
August 2008

Gadolinium-based contrast exposure, nephrogenic systemic fibrosis, and gadolinium detection in tissue.

AJR Am J Roentgenol 2008 Apr;190(4):1060-8

Department of Radiology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555, USA.

Objective: The objective of our study was to retrospectively review one institution's cases of nephrogenic systemic fibrosis (NSF), evaluate possible associated factors, determine the prevalence of NSF, and search for gadolinium in skin samples obtained from patients with NSF.

Materials And Methods: A retrospective review of our dermatopathology database from 1997 to 2007 was performed to search for patients with NSF. The records of patients with NSF were reviewed for factors suspected to be associated with NSF such as acidosis, low hemoglobin levels, low serum calcium levels, inflammatory conditions, serum antibodies, pharmaceutical erythropoietin, angiotensin-converting enzyme inhibitors, gadolinium-based contrast agents (GBCAs), renal failure, and dialysis. The biopsy samples from NSF patients and from control subjects were examined with energy-dispersive X-ray spectroscopy to detect gadolinium. Retrospective chart reviews of patients evaluated at our local dialysis center and our dermatology clinic were conducted to identify patients who underwent MRI, who had NSF managed exclusively by our tertiary referral centers, or both from 1997 to 2007.

Results: Seven cases of NSF were found in the dermatopathology database. Two of the seven patients were also followed up at our outpatient dialysis clinic. No other cases of NSF were discovered within the dialysis clinic's population exclusively followed within our institution. All seven dermatopathology database NSF patients developed symptoms of NSF after receiving GBCAs during renal failure and showed concomitant proinflammatory conditions. No other proposed risk factors were uniformly present in these NSF cases. All four NSF patients with chronic renal failure developed NSF after hemodialysis, with one patient dialyzed 12 hours after receiving a contrast dose. Gadodiamide was the only GBCA that all seven NSF patients received before symptom onset. Symptom onset was from 3 weeks to 18 months after GBCA exposure, with cumulative GBCA doses ranging from 0.16 to 0.43 mmol/kg. Gadolinium was detected in six of seven NSF patients' skin biopsies. Seven of eight random control specimens obtained from three healthy control subjects, three patients with renal insufficiency who had not been exposed to gadodiamide, and two patients without renal disease who had been exposed to gadodiamide were negative. Seventy-two dialysis clinic patients underwent 127 contrast-enhanced MR examinations from 1997 to 2007. Eighteen patients received gadopentetate, none of whom developed NSF. Sixty-three patients received gadodiamide, two of whom developed NSF (prevalence of NSF in patients exposed to GBCA, 2.8%; odds ratio, 0.82 [95% CI, 0.04-18.10]; likelihood ratio, 1.16 [95% CI, 1.06-1.26]). Nine patients received both contrast agents.

Conclusion: An association with GBCAs in the development of NSF is suggested in the setting of renal insufficiency, but other factors seem to play a role. Dialysis did not prevent the development of NSF. Gadolinium was detected in skin samples from NSF patients.
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http://dx.doi.org/10.2214/AJR.07.2822DOI Listing
April 2008

MR imaging in the triage of pregnant patients with acute abdominal and pelvic pain.

Abdom Imaging 2009 Mar-Apr;34(2):243-50

Department of Radiology, The University of Chicago, 5841 S Maryland Avenue, MC 2026, Chicago, IL 60637, USA.

Purpose: To retrospectively assess the performance of MR imaging in the evaluation and triage of pregnant patients presenting with acute abdominal or pelvic pain.

Method And Materials: MRI studies of pregnant patients who were referred for acute abdominal pain between 2001 and 2007 were included. MR images were retrospectively reviewed and compared with surgical and pathologic findings and clinical follow-up data. Analysis of imaging findings included evaluation of the visceral organs, bowel and mesentery, appendix (for presence of appendicitis), ovaries (detection and adnexal masses were evaluated), focal inflammation, presence of abscesses, and any other abnormal findings.

Results: A total of 118 pregnant patients were included. MR findings were inconclusive in 2 patients and were positive for acute appendicitis in 11 patients (n = 9 confirmed by surgery, n = 2 improved without surgery). One patient with inconclusive MR had surgically confirmed appendicitis; the other patient with inconclusive MR had surgically confirmed adnexal torsion. Other surgical/interventional diagnoses suggested by MR imaging were adnexal torsion (n = 4), abscess (n = 4), acute cholecystitis (n = 1), and gastric volvulus (n = 1). Two patients with MR diagnosis of torsion improved without surgery. One patient with MR diagnosis of abscess had biliary cystadenoma at surgery. The rest of the MR diagnoses above were confirmed surgically or interventionally. MR imaging was normal in 67 patients and demonstrated medically treatable etiology in 28 patients: adnexal lesions (n = 9), urinary pathology (n = 6), cholelithiasis (n = 4), degenerating fibroid (n = 3), DVT (n = 2), hernia (n = 1), colitis (n = 1), thick terminal ileum (n = 1), rectus hematoma (n = 1). Three of these patients had negative surgical exploration and one had adnexal mass excision during pregnancy. Other patients were discharged with medical treatment. The sensitivity, specificity, accuracy, positive predictive values (ppv), and negative predictive values (npv) of MR imaging for acute appendicitis, and surgical/ interventional diagnoses were 90.0% vs. 88.9%, 98.1% vs. 95.0%, 97.5% vs. 94.1%, 81.8% vs. 76.2%, 99.1% vs. 97.9%, respectively.

Conclusion: MR imaging is an excellent modality for diagnosis of acute appendicitis and exclusion of diseases requiring surgical/interventional treatment. Therefore MR imaging is useful for triage of pregnant patients with acute abdominal and pelvic pain.
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http://dx.doi.org/10.1007/s00261-008-9381-yDOI Listing
June 2009

Magnetic resonance imaging of the chest, abdomen, and pelvis in the evaluation of pregnant patients with neoplasms.

Am J Perinatol 2007 Apr;24(4):243-50

Department of Radiology, The University of Texas Medical Branch, Galveston, Texas 77555-0709, USA.

This article illustrates the magnetic resonance (MR) technique and MR imaging (MRI) findings of various neoplasms in chest, abdomen, and pelvis in pregnant patients. MRI can provide useful information about characterization and staging of maternal neoplasms without exposing the fetus to ionizing radiation and can be considered as a first-line cross sectional imaging method as an adjunct to ultrasonography.
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http://dx.doi.org/10.1055/s-2007-973444DOI Listing
April 2007

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia.

Ann Diagn Pathol 2007 Apr;11(2):122-6

Division of Surgical Pathology, Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555-0588, USA.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia is an extremely rare pulmonary lesion, with only 39 cases reported in the literature. We report an additional case and review the literature. The patient is a 41-year-old man with a 5-year history of progressive dyspnea, cough, and wheezing. He was initially diagnosed as having bronchial asthma but did not respond to treatment of bronchodilators and inhaled steroids. Pulmonary function tests showed airflow obstruction. Chest computed tomography revealed a mosaic pattern of air trapping and thickening of bronchial walls. Open lung biopsy showed diffuse proliferation of pulmonary neuroendocrine cells within the bronchiolar epithelium, often bulging into or obliterating the bronchiolar lumen. These cells also breached the basement membrane, forming tumorlets. There was prominent peribronchiolar fibrosis and obliterative bronchiolitis. The pathologic evaluation of lung tissue is currently the gold standard in making a definitive diagnosis of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia, and all the reported cases were diagnosed by either open lung biopsy or lobectomy.
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http://dx.doi.org/10.1016/j.anndiagpath.2005.12.008DOI Listing
April 2007

A subepithelial mass determined by EUS to be a splenic artery aneurysm.

Gastrointest Endosc 2007 Jan 20;65(1):153-4; discussion 154. Epub 2006 Sep 20.

University of Texas Medical Branch, Galveston, Texas, USA.

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http://dx.doi.org/10.1016/j.gie.2006.06.015DOI Listing
January 2007

Localization of appendix with MDCT and influence of findings on choice of appendectomy incision.

AJR Am J Roentgenol 2006 Oct;187(4):987-90

Department of Radiology, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0709, USA.

Objective: The purpose of this study was to show the relation between McBurney's point and the appendix in patients undergoing 3D MDCT and to investigate the effect of this information on a surgeon's choice of appendectomy incision.

Material And Methods: Among 142 adults undergoing consecutive MDCT studies, 100 patients (35 women, 65 men; mean age, 52.1 years) with an identifiable appendix on abdominopelvic MDCT examinations were selected for the study group. The presence of intraabdominal mass or a history of abdominal surgery were the exclusion criteria. Three-dimensional reconstruction of the CT data was performed with a surface shaded display algorithm. The locations of the base of the appendix and McBurney's point were marked on a single 3D image that allowed display of the skin surface markings for each patient. The superoinferior and mediolateral distances from the level of the appendix to the level of McBurney's point were measured, and the radial distance was calculated from these measurements. A surgeon experienced in emergency abdominal surgery reviewed 3D CT images and one axial image showing the appendix, and his choice of incision for each patient based on the CT information was recorded. The influence of the superoinferior and mediolateral distances of the appendix from McBurney's point on the surgeon's decision was analyzed with a multivariate logistic regression model.

Results: The appendix was exactly at McBurney's point in only 4% of the patients. In 36% of the cases, the appendix was within 3 cm, in 28% of cases it was 3-5 cm, and in 36% of the cases it was more than 5 cm away from McBurney's point. Mean +/- SD superoinferior, mediolateral, and radial distances between the appendix and McBurney's point were 33.0 +/- 24.1, 20.8 +/- 19.3, and 42.1 +/- 26.7 mm, respectively. After reviewing the images, the surgeon would have altered his incision site in 35% of the cases. The surgeon preferred a higher incision in 28% and a lower incision in 7% of the cases. Both positive and negative superoinferior displacement away from McBurney's point were significant factors regarding the surgeon's decision to alter the incision (p = 0.005), and the superoinferior distance was more than 3 cm in 94% of the cases in which the surgeon would have altered the incision.

Conclusion: The location of the appendix varies widely among individuals, and McBurney's point has limitations as an anatomic landmark. Three-dimensional MDCT findings can be useful to surgeons customizing appendectomy incisions. Additional information about the location of the appendix in the CT report (if possible, together with a 3D image showing the location of the appendix) may be beneficial for surgeons performing appendectomy.
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http://dx.doi.org/10.2214/AJR.05.1084DOI Listing
October 2006

Mimicks of pancreatic malignancy in patients with chronic pancreatitis: correlation of computed tomography imaging features with histopathologic findings.

Curr Probl Diagn Radiol 2006 Sep-Oct;35(5):199-205

Department of Radiology, The University of Texas Medical Branch (UTMB), Galveston, TX 77555-0709, USA.

Differentiation of chronic pancreatitis and pancreatic carcinoma can be a clinical and radiologic dilemma. Several patients with chronic pancreatitis can undergo unnecessary major abdominal surgery for benign lesions. This pictorial review illustrates the computed tomographic findings and histopathologic features of lesions mimicking pancreatic neoplasm in patients with chronic pancreatitis. Several benign lesions can simulate pancreatic malignancy in patients with chronic pancreatitis. Knowledge of the computed tomographic appearance of these benign entities is important to prevent unnecessary surgeries.
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http://dx.doi.org/10.1067/j.cpradiol.2006.06.001DOI Listing
January 2007

Medical qualification of a commercial spaceflight participant: not your average astronaut.

Aviat Space Environ Med 2006 May;77(5):475-84

Preventive Medicine and Community Health, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1150, USA.

Background: Candidates for commercial spaceflight may be older than the typical astronaut and more likely to have medical problems that place them at risk during flight. Since the effects of microgravity on many medical conditions are unknown, physicians have little guidance when evaluating and certifying commercial spaceflight participants. This dynamic new era in space exploration may provide important data for evaluating medical conditions, creating appropriate medical standards, and optimizing treatment alternatives for long-duration spaceflight.

Case: A 57-yr-old spaceflight participant for an ISS mission presented with medical conditions that included moderately severe bullous emphysema, previous spontaneous pneumothorax with talc pleurodesis, a lung parenchymal mass, and ventricular and atrial ectopy. The medical evaluation required for certification was extensive and included medical studies and monitoring conducted in analogue spaceflight environments including altitude chambers, high altitude mixed-gas simulation, zero-G aircraft, and high-G centrifuge. To prevent recurrence of pneumothorax, we performed video-assisted thoracoscopic pleurodesis, and to assess lung masses, several percutaneous or direct biopsies. The candidate's 10-d mission was without incident.

Conclusion: Non-career astronauts applying for commercial suborbital and orbital spaceflight will, at least in the near future, challenge aerospace physicians with unknowns regarding safety during training and flight, and highlight important ethical and risk-assessment problems. The information obtained from this new group of space travelers will provide important data for the evaluation and in-flight treatment of medical problems that space programs have not yet addressed systematically, and may improve the medical preparedness of exploration-class missions.
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May 2006

Revisiting MRI for appendix location during pregnancy.

AJR Am J Roentgenol 2006 Mar;186(3):883-7

Department of Radiology, The University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555-0709, USA.

Objective: The purpose of this study is to determine the location of the appendix in pregnant patients by MRI and to investigate the possibility of gradual upward displacement of the appendix during pregnancy.

Conclusion: The gradual upward displacement of the appendix during pregnancy was confirmed. MRI can be used for determination of the appendix localization in pregnant patients. Further studies with a larger number of patients will be helpful to answer this clinically relevant question.
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http://dx.doi.org/10.2214/AJR.05.0270DOI Listing
March 2006

Rapid CT diagnosis of acute appendicitis with IV contrast material.

Emerg Radiol 2006 Mar 17;12(3):99-102. Epub 2005 Dec 17.

University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, USA.

The purpose of this study was to determine the sensitivity and specificity of computed tomography (CT) without administration of oral contrast in confirming suspected acute appendicitis. One hundred seventy-three patient studies were retrieved by a computer-generated search for the word "appendicitis" in radiology reports. Patients presenting to the emergency department over an 8-month period were examined for acute abdominal pain or suspected acute appendicitis. IV-contrast-enhanced CT scans of the abdomen and pelvis were obtained without oral or rectal contrast. Criteria for diagnosis of acute appendicitis included a dilated appendix (>6 mm), periappendiceal inflammation, or abscess. Final diagnoses were established with surgical/clinical follow-up, histopathological analysis or both. The standard time (1 h) for the administration of oral contrast prior to the CT scan was eliminated. Fifty-nine CT diagnoses were made of acute appendicitis, 56 of which were histologically verified and three of which resulted in another diagnosis. One hundred fourteen CT diagnoses were negative for appendicitis. This corresponds to a sensitivity of 100% and specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 100%. CT with IV contrast is sensitive and specific for the confirmation or exclusion of acute appendicitis. By eliminating the time required to administer oral contrast, the diagnosis might be made more rapidly.
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http://dx.doi.org/10.1007/s10140-005-0456-6DOI Listing
March 2006

Magnetic resonance imaging of maternal diseases causing acute abdominal pain during pregnancy: a pictorial review.

J Comput Assist Tomogr 2005 May-Jun;29(3):408-14

Department of Radiology, University of Texas Medical Branch, Galveston, TX 77555-0709, USA.

Evaluation of acute abdominal pain in a pregnant patient is a clinical challenge. In these patients, magnetic resonance imaging (MRI) can allow a systematic cross-sectional evaluation of the entire abdomen and can provide clinically useful information in a short enough time for emergent diagnosis. This pictorial essay demonstrates MRI findings of various maternal diseases that can present as acute abdominal pain in pregnant patients. Familiarity with these findings is important for the radiologist to make an accurate and prompt diagnosis.
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http://dx.doi.org/10.1097/01.rct.0000162154.55253.1dDOI Listing
June 2005

Right-lower-quadrant pain and suspected appendicitis in pregnant women: evaluation with MR imaging--initial experience.

Radiology 2005 Feb 10;234(2):445-51. Epub 2004 Dec 10.

Department of Radiology, University of Texas Medical Branch at Galveston, 301 University Blvd, Galveston, TX 77555-0709, USA.

Purpose: To determine if there is a role for magnetic resonance (MR) imaging in evaluation of pregnant women with acute right-lower-quadrant pain in whom acute appendicitis is suspected.

Materials And Methods: Informed consent and institutional review board approval were obtained. Images obtained with a 1.5-T MR imager and medical records of 23 pregnant women (age range, 19-34 years; mean age, 24.7 years) who presented with acute right-lower-quadrant pain were retrospectively reviewed. MR protocol included use of transverse, coronal, and sagittal noncontiguous T2-weighted single-shot fast spin-echo (SE) sequences; transverse fat-suppressed T2-weighted fast SE sequences; transverse T1-weighted gradient-recalled-echo sequences; and transverse and coronal short inversion time inversion-recovery sequences performed through the lower abdomen and pelvis. MR findings were evaluated by two radiologists and compared with surgical and pathologic findings and clinical follow-up data.

Results: Appendix was detected in 20 (86.9%) of 23 patients. Seven patients underwent surgery; four had acute appendicitis, and three had ovarian torsion. Two patients with pelvic abscesses not related to appendicitis underwent percutaneous drainage. Fourteen patients were treated medically. Dilated thick-walled appendix and periappendiceal inflammation were detected in three (75%) of four patients with acute appendicitis. In one patient with appendicitis, the appendix could not be visualized, but inflammation was present in the right lower quadrant. In three patients with ovarian torsion, MR imaging demonstrated right adnexal mass or inflammation. MR imaging was used to correctly identify pelvic abscesses and healthy appendix in two patients. A healthy appendix was depicted in 17 (89.5%) of 19 patients without acute appendicitis.

Conclusion: MR imaging shows promise for evaluation of pregnant women in whom acute appendicitis is suspected by enabling diagnosis of other possible causes of right-lower-quadrant pain, including ovarian torsion or pelvic abscesses, and demonstrating a healthy or unhealthy appendix.
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http://dx.doi.org/10.1148/radiol.2341032002DOI Listing
February 2005

Emergent MRI utilizing a 5-inch surface coil to evaluate for acute penile fracture.

Emerg Radiol 2002 Mar 12;9(1):35-7. Epub 2002 Feb 12.

The University of Texas Medical Branch at Galveston, Department of Radiology, 301 University Blvd., Galveston, TX 77555-0709, USA.

MR imaging is useful in rapidly detecting penile fractures and in guiding surgical planning.
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http://dx.doi.org/10.1007/s10140-001-0191-6DOI Listing
March 2002

Adult intussuception as a cause of abdominal symptoms: a case report and review of literature.

Emerg Radiol 2003 Apr 12;10(1):53-6. Epub 2003 Mar 12.

The University of Texas Medical Branch at Galveston, Department of Radiology, 301 University Blvd., Galveston, TX 77555-0709, USA.

Intussusceptions are frequently encountered in children. In adults, they are uncommon and have a different etiology. Our case is one such example of a rare, pathologically proven, recto-rectal intussusception due to an adenocarcinoma with characteristic CT findings.
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http://dx.doi.org/10.1007/s10140-002-0266-zDOI Listing
April 2003

Traumatic diaphragmatic rupture: can oral contrast increase CT detectability?

Emerg Radiol 2004 Jul 23;10(6):334-6. Epub 2004 Mar 23.

Department of Radiology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA.

Traumatic diaphragmatic rupture is a frequently missed diagnosis. We present a patient with traumatic diaphragmatic hernia. Diagnosis was suggested by a emergent computed tomography (CT) examination without oral contrast. Diaphragmatic rupture and herniation of stomach were confirmed by repeating CT examination after the administration of oral contrast and using multiplanar reconstruction.
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http://dx.doi.org/10.1007/s10140-004-0335-6DOI Listing
July 2004

Alternative diagnoses to stone disease on unenhanced CT to investigate acute flank pain.

Emerg Radiol 2004 Jul 11;10(6):327-33. Epub 2004 May 11.

Department of Radiology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA.

Acute flank pain is a common problem in emergency medicine. The most frequent cause is urolithiasis, but many other entities can cause the same clinical presentation. In many institutions unenhanced computed tomography (CT) of the abdomen is used in this setting. One of the major advantages of unenhanced CT is its ability to detect other pathologies causing flank pain. In this pictorial review, we present the CT findings of pathologies other than stone disease in patients with acute flank pain.
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http://dx.doi.org/10.1007/s10140-004-0336-5DOI Listing
July 2004

Computerized tomographic colonography: performance evaluation in a retrospective multicenter setting.

Gastroenterology 2003 Sep;125(3):688-95

Department of Radiology, Mayo Clinic, Rochester, Minnesota 55905, USA.

Background & Aims: No multicenter study has been reported evaluating the performance and interobserver variability of computerized tomographic colonography. The aim of this study was to assess the accuracy of computerized tomographic colonography for detecting clinically important colorectal neoplasia (polyps >or=10 mm in diameter) in a multi-institutional study.

Methods: A retrospective study was developed from 341 patients who had computerized tomographic colonography and colonoscopy among 8 medical centers. Colonoscopy and pathology reports provided the standard. A random sample of 117 patients, stratified by criterion standard, was requested. Ninety-three patients were included (47% with polyps >or=10 mm; mean age, 62 years; 56% men; 84% white; 40% reported colorectal symptoms; 74% at increased risk for colorectal cancer). Eighteen radiologists blinded to the criterion standard interpreted computerized tomography colonography examinations, each using 2 of 3 different software display platforms.

Results: The average area under the receiver operating characteristic curve for identifying patients with at least 1 lesion >or=10 mm was 0.80 (95% lower confidence bound, 0.74). The average sensitivity and specificity were 75% (95% lower confidence bound, 68%) and 73% (95% lower confidence bound, 66%), respectively. Per-polyp sensitivity was 75%. A trend was observed for better performance with more observer experience. There was no difference in performance across software display platforms.

Conclusions: Computerized tomographic colonography performance compared favorably with reported performance of fecal occult blood testing, flexible sigmoidoscopy, and barium enema. A prospective study evaluating the performance of computerized tomography colonography in a screening population is indicated.
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http://dx.doi.org/10.1016/s0016-5085(03)01058-8DOI Listing
September 2003
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