Publications by authors named "Shannon P Sheedy"

38 Publications

Dual contrast liver MRI: a pictorial illustration.

Abdom Radiol (NY) 2021 Jun 2. Epub 2021 Jun 2.

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Liver magnetic resonance imaging (MRI) is a commonly performed imaging technique with multiple indications and applications. There are two general groups of contrast agents used when imaging the liver, extracellular contrast agents (ECA) and hepatobiliary agents (HBA), each of which has its own advantages and limitations. Liver MRI with ECA provides excellent information on abdominal vasculature and better quality multi-phasic studies for characterization of focal liver lesions. HBA improves lesion detection, provides information regarding liver function and can be helpful for evaluating biliary tree anatomy, excretion, anastomotic stenoses, or leaks. Most liver MRI studies are usually performed with one agent, however in some cases, a second study is performed with another agent to obtain additional information or confirm the findings in the first study. Administering both agents in a single exam can potentially eliminate the need for additional imaging in certain situations. In this pictorial review, the techniques and indications for dual contrast MRI will be detailed with multiple demonstrative examples.
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http://dx.doi.org/10.1007/s00261-021-03129-1DOI Listing
June 2021

The diagnosis and outcome of Krukenberg tumors.

J Gastrointest Oncol 2021 Apr;12(2):226-236

Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA.

Background: Accurate diagnostic tools are crucial to distinguish patients with Krukenberg tumors from those with ovarian cancers before decision on initial management. To address this unmet need, we aimed to evaluate the diagnostic utility of clinical, biochemical, and radiographic factors in this patient population.

Methods: Patients with Krukenberg tumors or primary ovarian cancers were retrospectively identified from institutional cancer registry. Kaplan-Meier method and Cox proportional hazards models were used for survival analysis. Logistic regression evaluated clinical, biochemical, and radiographic factors; residual deep neural network model evaluated features in computed tomography images as predictors to distinguish Krukenberg tumors from ovarian cancers. Model performance was summarized as accuracy and area under the receiver operating characteristic curve (AUC).

Results: This study included 214 patients with Krukenberg tumors with median age of 52 years. Among 104 (48.6%) patients with colorectal cancer, those who received palliative surgery had significantly higher median overall survival (48.1 versus 30.6 months, P=0.015) and progression-free survival (22.2 versus 6.7 months, P<0.001) than those with medical management only. The accuracy of radiology reports to make either diagnosis of Krukenberg tumors or primary ovarian cancers was 60.7%. In contrast, multivariable logistic regression model with age [odds ratio (OR) 2.98, P<0.001], carbohydrate antigen 125 (OR 1.57, P=0.004), and carcinoembryonic antigen (OR 0.03, P=0.031) had 87.5% [95% confidence interval (CI): 75.0-100.0%] accuracy with AUC 0.96 (95% CI: 0.87-1.00). The neural network model had 62.8% (95% CI: 51.8-74.5%) accuracy with AUC of 0.61 (95% CI: 0.53-0.72).

Conclusions: We developed a diagnostic model with clinical and biochemical features to distinguish Krukenberg tumors from primary ovarian cancers with promising accuracy.
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http://dx.doi.org/10.21037/jgo-20-364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107606PMC
April 2021

Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE): a 20-year single-center clinical and radiologic experience.

Abdom Radiol (NY) 2021 Mar 16. Epub 2021 Mar 16.

Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.

Objective: The purpose of this article is to describe clinical and imaging characteristics of confirmed cases of cryptogenic multifocal ulcerous stenosing enteritis (CMUSE).

Methods: Retrospective review of electronic medical records identified patients considered for a diagnosis CMUSE over 20-years in a single large tertiary center. Clinical data were abstracted and diagnosis was confirmed based on published criteria. Two GI radiologists reviewed CT and MR enterography (CTE/MRE) exams in consensus of confirmed patients to characterize the imaging features of CMUSE.

Results: Eight patients with confirmed CMUSE diagnosis were included for image review, and 9 CTEs and 1 MRE were analyzed. Most patients were males (75%) with a median age at diagnosis of 59.5 years (25-71) presenting with iron deficiency anemia (75%). Patients were commonly refractory (87.5%) to their first therapy, including steroids, with half being refractory to surgical intervention. Major imaging features included multiple (≥ 5; 88%; 7/8), short (< 2 cm; 100%; 8/8), circumferential (100%; 8/8) strictures with moderate wall thickening (6-9 cm), and stratified hyper enhancement (100%; 8/8) located in the ileum (100%; 8/8). Median proximal small bowel dilation was 2.95 cm (2.5-4.1 cm). No CMUSE cases demonstrated penetrating disease (e.g., abscess, fistula).

Conclusion: CT and MR enterography are invaluable tools in the multidisciplinary diagnostic evaluation of CMUSE, a rare cause of small bowel strictures with overlapping clinical and imaging features of Crohn's disease and NSAID enteropathy.
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http://dx.doi.org/10.1007/s00261-021-03005-yDOI Listing
March 2021

REPLY.

Hepatology 2021 Jan 11. Epub 2021 Jan 11.

Department of Radiology, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1002/hep.31711DOI Listing
January 2021

Hepatic Mucinous Cystic Neoplasm Versus Simple Biliary Cyst: Assessment of Distinguishing Imaging Features Using CT and MRI.

AJR Am J Roentgenol 2021 02 23;216(2):403-411. Epub 2020 Dec 23.

Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

The purpose of our study was to identify the imaging features that differentiate a hepatic mucinous cystic neoplasm (MCN) from a simple biliary cyst. Surgically resected hepatic MCNs and simple biliary cysts over a 20-year period (October 29, 1997-January 23, 2018) with preoperative CT, MRI, or both were retrospectively identified. Included cases underwent histopathologic confirmation of diagnosis based on the 2010 World Health Organization criteria and blinded imaging review. Various imaging features, including cyst shape and septal enhancement, were assessed for performance. For septate cysts, the relationship of the septation to the cyst wall-that is, arising from the wall without an indentation versus arising from an external macrolobulation-was recorded. Statistical analysis was performed for the imaging features with the chi-square test. The study group comprised 22 hepatic MCNs and 56 simple biliary cysts. A unilocular hepatic cystic lesion was highly predictive of a simple biliary cyst (positive predictive value = 95.2%). The imaging feature of septations arising only from macro-lobulations was 100% specific for a simple biliary cyst on CT ( = 0.001). The presence of septations arising from the cyst wall without indentation was 100% sensitive for hepatic MCN but was only 56.3% specific on CT. Septal enhancement reached 100% sensitivity for hepatic MCN on MRI ( = 0.018). The presence of septations, relationship of the septations to the cyst wall, and septal enhancement were sensitive imaging features in the detection of hepatic MCN. The imaging feature of septations arising only from macrolobulations in the cyst wall was specific for simple biliary cysts on CT and helped differentiate simple biliary cysts from hepatic MCNs.
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http://dx.doi.org/10.2214/AJR.20.22768DOI Listing
February 2021

Early Cholangiocarcinoma Detection With Magnetic Resonance Imaging Versus Ultrasound in Primary Sclerosing Cholangitis.

Hepatology 2021 May 19;73(5):1868-1881. Epub 2021 Apr 19.

Department of Radiology, Mayo Clinic, Rochester, MN.

Background And Aims: Early detection of perihilar cholangiocarcinoma (CCA) among patients with primary sclerosing cholangitis (PSC) is important to identify more people eligible for curative therapy. While many recommend CCA screening, there are divergent opinions and limited data regarding the use of ultrasound or magnetic resonance imaging (MRI) for early CCA detection, and it is unknown whether there is benefit in testing asymptomatic individuals. Our aims were to assess the diagnostic performances and prognostic implications of ultrasound and MRI-based CCA detection.

Approach And Results: This is a multicenter review of 266 adults with PSC (CCA, n = 120) who underwent both an ultrasound and MRI within 3 months. Images were re-examined by radiologists who were blinded to the clinical information. Respectively, MRI had a higher area under the curve compared with ultrasound for CCA detection: 0.87 versus 0.70 for the entire cohort; 0.81 versus 0.59 for asymptomatic individuals; and 0.88 versus 0.71 for those listed for CCA transplant protocol. The absence of symptoms at CCA diagnosis was associated with improved 5-year outcomes including overall survival (82% vs. 46%, log-rank P < 0.01) and recurrence-free survival following liver transplant (89% vs. 65%, log-rank P = 0.04). Among those with asymptomatic CCA, MRI detection (compared with ultrasound) was associated with reduction in both mortality (hazard ratio, 0.10; 95% confidence interval, 0.01-0.96) and CCA progression after transplant listing (hazard ratio, 0.10; 95% confidence interval, 0.01-0.90). These benefits continued among patients who had annual monitoring and PSC for more than 1 year before CCA was diagnosed.

Conclusions: MRI is superior to ultrasound for the detection of early-stage CCA in patients with PSC. Identification of CCA before the onset of symptoms with MRI is associated with improved outcomes.
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http://dx.doi.org/10.1002/hep.31575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8177077PMC
May 2021

Magnetic resonance imaging features of small-duct primary sclerosing cholangitis.

Abdom Radiol (NY) 2020 08;45(8):2388-2399

Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, 200, First Street SW, Rochester, MN, 55905, USA.

Purpose: To evaluate the biliary tree and hepatic parenchymal findings on magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) in small-duct primary sclerosing cholangitis (SD-PSC).

Methods: Thirty-nine patients with biopsy-proven primary sclerosing cholangitis (PSC) without any bile duct abnormality on MRCP (n = 15) or ERCP (n = 24) at the time of diagnosis were identified. Follow-up MRCP was available in 36/39 patients (12/15 Baseline MRCP group and 24 Baseline ERCP group). Two radiologists in consensus assessed the MRI/MRCP findings. The baseline MRI/MRCP of 15 SD-PSC patients was compared with MRI/MRCP of 15 normal healthy potential liver donors (Control group). Comparisons were made between SD-PSC patients and the Control group, and between baseline and follow-up MRI/MRCP findings in the SD-PSC patients.

Results: In the 15 Baseline MRCP SD-PSC subjects, the biliary tree was normal with a trend of larger bile ducts compared to the Control group. Periductal enhancement (arterial phase: 70%, 7/10; delayed phase: 90%, 9/10), heterogeneous parenchymal signal on T2-weighted (53%, 8/15) and post contrast-enhanced images (70%, 7/10), and enlarged periportal lymph nodes (73%, 11/15) were frequently present in patients with SD-PSC. Eight (33%) of 24 SD-PSC patients who had normal MRCP at baseline MRCP or initial follow-up MRCP after normal baseline ERCP showed large-duct PSC (LD-PSC) features on follow-up and the 10-year cumulative incidence for progression to LD-PSC rate was 8.5%.

Conclusion: SD-PSC patients have a normal biliary tree but frequently have peribiliary enhancement, abnormal parenchymal signal intensity, and periportal lymphadenopathy. One-third shows progression to LD-PSC on follow-up.
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http://dx.doi.org/10.1007/s00261-020-02572-wDOI Listing
August 2020

Patterns of inguinal lymph node metastases in anal canal cancer and recommendations for elective clinical target volume (CTV) delineation.

Radiother Oncol 2020 08 15;149:128-133. Epub 2020 May 15.

Department of Radiation Oncology, Mayo Clinic, Rochester, USA. Electronic address:

Purpose: Optimal clinical target volume (CTV) for inguinal lymph node irradiation in anal cancer remains uncertain. This study documents the location of radiographically involved inguinal lymph nodes and proposes guidelines for CTV delineation.

Materials And Methods: Patients with anal canal squamous cell carcinoma with inguinal lymph node metastases were identified. Criteria for lymph node involvement included: >15 mm short axis or suspicious morphology on CT or MRI, increased avidity on 18-FDG-PET, or positive biopsy. Distances from center of involved nodes to femoral vessels and inferior pubic symphysis were measured.

Results: Forty patients with 79 inguinal lymph nodes were included. Relative to right femoral vessels, nodes were located: 12:00 (n = 6); 1:00 (n = 28); 2:00 (n = 35), 3:00 (n = 5); 4:00 (n = 1); 10:00 (n = 1); 11:00 (n = 3). No nodes were identified lateral or posterior to vessels. Published AGITG guidelines covered 68% of nodes anteriorly and 85% medially. Margins from nearest femoral vessel to cover 95% of nodes were 30 mm anteriorly and 26 mm medially. Inferior margin to cover 95% of nodes was 14 mm below inferior pubic symphysis. Proposed borders include cranial, where external iliac vessels leave bony pelvis; caudal, 14 mm below inferior pubic symphysis; posterior, posterior border of femoral vessels; lateral, lateral border of femoral vessels; anterior, 30 mm margin on femoral vessels and medial, 26 mm margin on femoral vessels, including radiographically suspicious nodes.

Conclusions: Published guidelines for inguinal CTV in anal cancer may result in inadequate coverage of high risk areas. Updated guidelines based on this study ensure coverage of at-risk areas.
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http://dx.doi.org/10.1016/j.radonc.2020.05.018DOI Listing
August 2020

Quantitative Inflammation Assessment for Crohn Disease Using Ultrasensitive Ultrasound Microvessel Imaging: A Pilot Study.

J Ultrasound Med 2020 Sep 16;39(9):1819-1827. Epub 2020 Apr 16.

Departments of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Objectives: Crohn disease (CD) is a chronic inflammation in the digestive tract that affects millions of Americans. Bowel vascularity has important diagnostic information because inflammation is associated with blood flow changes. We recently developed an ultrasensitive ultrasound microvessel imaging (UMI) technique with high vessel sensitivity. This study aimed to evaluate the feasibility of UMI to assist CD detection and staging.

Methods: Ultrasound microvessel imaging was performed on 76 bowel wall segments from 48 symptomatic patients with CD. Clinically indicated computed tomographic/magnetic resonance enterography was used as the reference standard. The vessel-length ratio (VLR, the number of vessel pixels in the bowel wall segment normalized to the segment length) was derived in both conventional color flow imaging (CFI) and UMI to quantitatively stage disease activity. Receiver operating characteristic curves were then analyzed between different disease groups.

Results: The VLR-CFI and VLR-UMI detected similar correlations between vascularization and disease activity: severe inflammation had a higher VLR than normal/mildly inflamed bowels (P < .05). No significant difference was found between quiescent and mild CD due to the small sample size. The VLR-CFI had more difficulties in distinguishing quiescent versus mild CD compared to the VLR-UMI. After combining the VLR-UMI with thickness, in the receiver operating characteristic curve analysis, the areas under the curves (AUCs) improved to AUC = 0.996 for active versus quiescent CD, AUC = 0.978 for quiescent versus mild CD, and AUC = 0.931 for mild versus severe CD, respectively, compared to those using thickness alone (AUC = 0.968; P = .04; AUC = 0.919; P = .16; AUC = 0.857; P = .01).

Conclusions: Ultrasound microvessel imaging offers a safe and cost-effective tool for CD diagnosis and staging, which may potentially assist disease activity classification and therapy efficacy evaluation.
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http://dx.doi.org/10.1002/jum.15290DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442589PMC
September 2020

The evolving role of imaging for small bowel neuroendocrine neoplasms: estimated impact of imaging and disease-free survival in a retrospective observational study.

Abdom Radiol (NY) 2020 03;45(3):623-631

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Purpose: To determine how small bowel neuroendocrine neoplasms (SBNEN's) are diagnosed and examine the effect of CT enterography (CTE) on diagnosis and rates of disease-free survival.

Methods: Histopathologically-confirmed SBNEN's diagnosed at our institution between 1996 and 2016 were identified. Clinical presentation, radiology, endoscopy, surgery, and pathology reports were reviewed and compared between consecutive 5-year periods.

Results: Of the 178 SBNEN initially diagnosed at our institution, the incidence increased 12-fold from 9 (during 1996-2000) to 114 (during 2011-2016). Comparing the first 5 to the last 5 years, GI bleeding and abdominal pain increased significantly as indications (with both increasing from 0 to > 25%, p ≤ 0.023). Initial diagnosis by radiology increased 2-fold [from 33% (n = 3) to 66% (n = 75); p = 0.263]. Detection of a small bowel mass and the suggestion that SBNEN was present varied significantly between imaging modalities (p < 0.0001; CTE - 95% (52/55) and 91% (50/55) vs. abdominal CT 45% (37/85) and 35% (29/85), respectively). Recurrence rates increased with SBNEN size (p = 0.012; e.g., of SBNEN diagnosed by endoscopy, 18% of SBNEN measuring 0.6 ± 0.3 cm recurred vs. 75% measuring 3.7 ± 1.0 cm). Rates of disease-free survival, and the incidence of local and liver metastases were decreased when tumors were first identified by CTE rather than other CT/MR imaging modalities (p = 0.0034, 0.0475, and 0.0032, respectively).

Conclusion: There has been a dramatic increase in SBNENs detected by CTE and endoscopy over the last 20 years. SBNEN's detected by CTE and small tumors detected at endoscopy have longer disease-free survival after surgical resection.
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http://dx.doi.org/10.1007/s00261-020-02410-zDOI Listing
March 2020

Imaging Findings of Ileal Inflammation at Computed Tomography and Magnetic Resonance Enterography: What do They Mean When Ileoscopy and Biopsy are Negative?

J Crohns Colitis 2020 May;14(4):455-464

Division of Abdominal Imaging, Mayo Clinic, Rochester, MN, USA.

Background And Aims: Our goal was to determine the importance of ileal inflammation at computed tomography or magnetic resonance enterography in Crohn's disease patients with normal ileoscopy.

Methods: Patients with negative ileoscopy and biopsy within 30 days of CT or MR enterography showing ileal inflammation were included. The severity [0-3 scale] and length of inflammation within the distal 20 cm of the terminal ileum were assessed on enterography. Subsequent medical records were reviewed for ensuing surgery, ulceration at ileoscopy, histological inflammation, or new or worsening ileal inflammation or stricture on enterography. Imaging findings were classified as: Confirmed Progression [subsequent surgery or radiological worsening, new ulcers at ileoscopy or positive histology]; Radiologic Response [decreased inflammation with medical therapy]; or Unlikely/Unconfirmed Inflammation.

Results: Of 1471 patients undergoing enterography and ileoscopy, 112 [8%] had imaging findings of inflammation with negative ileoscopy, and 88 [6%] had negative ileoscopy and ileal biopsy. Half [50%; 44/88] with negative biopsy had moderate/severe inflammation at enterography, with 45%, 32% and 11% having proximal small bowel inflammation, stricture or fistulas, respectively. Two-thirds with negative biopsy [67%; 59/88] had Confirmed Progression, with 68%, 70% and 61% having subsequent surgical resection, radiological worsening or ulcers at subsequent ileoscopy, respectively. Mean length and severity of ileal inflammation in these patients was 10 cm and 1.6. Thirteen [15%] patients had Radiologic Response, and 16 [18%] had Unlikely/Unconfirmed Inflammation.

Conclusion: Crohn's disease patients with unequivocal imaging findings of ileal inflammation at enterography despite negative ileoscopy and biopsy are likely to have active inflammatory Crohn's disease. Disease detected by imaging may worsen over time or respond to medical therapy.
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http://dx.doi.org/10.1093/ecco-jcc/jjz122DOI Listing
May 2020

Cystic Lymph Node Metastases From HPV-Associated Squamous Cell Carcinoma of the Anal Canal.

Pract Radiat Oncol 2020 Mar - Apr;10(2):e111-e115. Epub 2019 Dec 19.

Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota. Electronic address:

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http://dx.doi.org/10.1016/j.prro.2019.12.008DOI Listing
November 2020

Malabsorption Syndromes, Vasculitis, and Other Uncommon Diseases.

Magn Reson Imaging Clin N Am 2020 Feb 1;28(1):55-73. Epub 2019 Nov 1.

Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA. Electronic address:

MR enterography is frequently ordered for patients with suspected small bowel disorders. In this article, disease-causing malabsorption, vasculitides, and some of the less common small bowel diseases are reviewed. The clinical presentations, diagnostic criteria, and imaging findings of these diseases are discussed. Because the imaging findings in several small bowel diseases are nonspecific and/or overlap, radiologists must correlate clinical data with imaging to develop a narrower differential diagnosis. The unique or characteristic findings in certain diseases are also emphasized.
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http://dx.doi.org/10.1016/j.mric.2019.09.001DOI Listing
February 2020

Endometriosis in the postmenopausal female: clinical presentation, imaging features, and management.

Abdom Radiol (NY) 2020 06;45(6):1790-1799

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Postmenopausal endometriosis is an important clinical entity which is likely under-recognized and in which the Radiologist can play a valuable role. In this review, we describe the clinical presentation and management of postmenopausal endometriosis, appraising the literature and providing case examples. Persons with postmenopausal endometriosis may present with symptoms including pelvic pain or dyschezia, but endometriosis may also be an asymptomatic, incidental finding. Women may or may not have a prior history of endometriosis or a history of symptoms consistent with it. Therapies and conditions which increase exogenous or endogenous estrogen, respectively, increase the risk. Endometriosis can be found in different locations throughout the body, and the possibility of malignancy should be assessed, especially in the postmenopausal population, where age increases cancer risk. Treatment may involve surgery or medical interventions. Guidelines describing appropriate imaging surveillance in these patients are lacking. In the postmenopausal population, Radiologists need to consider endometriosis as a diagnosis, recommend appropriate exams such as MRI and US, and suggest endometriosis-associated malignancies when appropriate, based on classic morphologic features.
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http://dx.doi.org/10.1007/s00261-019-02309-4DOI Listing
June 2020

Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel.

Abdom Radiol (NY) 2019 11;44(11):3508-3517

Department of Radiology, Hospital Sirio-Libanes, São Paulo, São Paulo, Brazil.

Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.
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http://dx.doi.org/10.1007/s00261-019-02170-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824987PMC
November 2019

Comparison of routine pelvic US and MR imaging in patients with pathologically confirmed endometriosis.

Abdom Radiol (NY) 2020 06;45(6):1670-1679

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Purpose: To estimate the benefit of pelvic magnetic resonance (MR) imaging after routine pelvic ultrasound (US) in patients with pathologically or surgically proven endometriosis.

Methods: Patients with surgically or pathologically proven endometriosis who had routine pelvic US followed by pelvic MR within 6 months prior to surgery were included. Patients were excluded if they had previously confirmed endometriosis, pregnancy, or surgery > 6 months after MR. The detection rate of endometriosis by pelvic US and MR was compared to the surgical/pathological reference standard.

Results: 83 female patients (mean age 40 ± 9) met inclusion criteria and had surgical/pathological confirmation of endometriosis. The mean time interval between pelvic US and MR was 33 ± 43 days, with 64 ± 69 days between MR examination and surgery. US detected endometriosis in 22% (18/83) of patients compared to 61% (51/83) for MR (p < 0.0001). 51% (33/65) of patients with a negative pelvic US exam had a positive MR. MR identified additional sites or sequela in the majority of patients with a positive US (14/18; 78%), including extraovarian locations [e.g., fallopian tubes 7/18 (39%), uterus 7/18 (39%), uterine ligaments 6/18 (33%), posterior cul de sac 5/18 (28%), pelvic side walls 5/18 (28%), abdominal wall 1/18 (6%)] and sequela [ovarian tethering 5/18 (28%), 6/18 (33%) bowel adhesive disease, posterior cul de sac obliteration 2/18 (11%), hydrosalpinx 2/18 (11%), and hydronephrosis 1/18 (6%)]. 3 T MR detected endometriosis in 33/46 (72%) patients compared to 18/37 (49%) for 1.5 T MR (p = 0.03).

Conclusion: Pelvic MR imaging had a higher detection rate of surgically/pathologically proven endometriosis and provides more information about disease location and sequela compared to routine pelvic US.
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http://dx.doi.org/10.1007/s00261-019-02124-xDOI Listing
June 2020

Procedure-Related Pain During Image-Guided Percutaneous Biopsies: A Retrospective Study of Prevalence and Predictive Factors.

AJR Am J Roentgenol 2019 10 9;213(4):755-761. Epub 2019 Jul 9.

Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

The purpose of this study was to evaluate the prevalence and severity of pain reported during image-guided percutaneous biopsies and to identify factors associated with increased reported pain. In this retrospective study, a database of adult patients who underwent CT- or ultrasound-guided percutaneous core needle biopsy between July 22, 2013, and February 1, 2018, was reviewed. Data collected included patient age and sex, biopsy site, biopsy type (lesion or parenchymal), needle gauge, number of passes, use of sedation, and whether it was the patient's first recorded biopsy. The maximum procedure-related pain reported on a 0-10 numeric rating scale was recorded. Multivariable logistic regression with generalized estimating equations was used to assess the association between covariates and patient-reported pain. A total of 13,344 biopsy procedures were performed in 10,474 patients. Patients reported no pain (0 of 10 scale) during 9765 (73.2%) procedures. Female sex, younger age at biopsy, undergoing IV sedation, and larger needle diameter were all associated with increases in patient-reported pain. Biopsies of renal allografts were the least likely to be painful, followed by hepatic allografts. Patients typically report mild or no pain from image-guided biopsy performed by radiologists. Younger patients and women report greater pain. This information can assist preprocedural counseling and reassurance of patients and may help them predict procedure-related patient needs.
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http://dx.doi.org/10.2214/AJR.19.21248DOI Listing
October 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

Mucinous appendiceal neoplasms: classification, imaging, and HIPEC.

Abdom Radiol (NY) 2019 05;44(5):1686-1702

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Recent advances, specifically cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), offer advantages compared to the traditional therapeutic approach of systemic chemotherapy in the treatment of peritoneal carcinomatosis from mucinous appendiceal neoplasms (MAN). This review provides an up-to-date, comprehensive summary of the histologic classification of MAN, reviews common imaging findings of mucoceles and pseudomyxoma peritonei, and describes the radiologist's role in the multidisciplinary care team in quantifying disease and in helping select patients for definitive surgery.
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http://dx.doi.org/10.1007/s00261-018-01888-yDOI Listing
May 2019

MRI review of female pelvic fistulizing disease.

J Magn Reson Imaging 2018 11;48(5):1172-1184

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

A wide variety of fistulae occur in the female pelvis, most of which cause significant morbidity. Diagnosis, characterization, and treatment planning may be difficult using traditional imaging modalities such as fluoroscopy and computed tomography. To date, there is no comprehensive literature review of the radiologic findings associated with various types of female pelvic fistulae, and furthermore, none dedicated to magnetic resonance imaging (MRI). In this article, we seek to provide a broad overview of the MRI characteristics of female pelvic fistulizing disease in combination with epidemiologic and clinical characteristics. MRI is often considered the imaging modality of choice for evaluation of fistulae owing to its superior soft-tissue contrast and ability to provide surgeons with the highest quality information derived from just one study, including anatomic location of fistulae and associated pelvic pathology. In other instances, MRI can be complementary to the more traditional imaging techniques. This review will describe the etiology, anatomy, MRI findings, and treatment pearls for several of the more common pelvic fistulae found in female patients, including anovaginal, rectovaginal, colovaginal, vesicovaginal, colovesical, and other complex fistulae. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1172-1184.
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http://dx.doi.org/10.1002/jmri.26248DOI Listing
November 2018

Judging the J pouch: a pictorial review.

Abdom Radiol (NY) 2019 03;44(3):845-866

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Restorative total proctocolectomy with ileal pouch-anal anastomosis is the surgery of choice for patients with medically refractory ulcerative colitis, ulcerative colitis with high-grade dysplasia or multi-focal low-grade dysplasia, and for patients with familial adenomatous polyposis. The natural history of the surgery is favorable, and patients generally experience improved quality of life and acceptable long-term functional outcome. However, some patients experience significant long-term morbidity from early and/or late pouch-related complications. When complications arise, radiologists must understand the advantages and disadvantages of the various imaging modalities that can be used to assess the pouch. Radiologist familiarity with the surgical technique, pouch anatomy, and imaging appearance of the various potential early and late complications will help facilitate appropriate clinical and surgical decision-making. This review provides an anatomic-based imaging review of the pouch and pouch-related complications, including numerous illustrative fluoroscopic and cross-sectional imaging examples.
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http://dx.doi.org/10.1007/s00261-018-1786-7DOI Listing
March 2019

Imaging and Surgical Management of Anorectal Vaginal Fistulas.

Radiographics 2018 Sep-Oct;38(5):1385-1401

From the Department of Radiology (W.M.V., S.P.S., M.C.W., J.G.F.), Department of Surgery (A.L.L.), and School of Medicine (S.T.K.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.).

Anorectal vaginal fistulas (ARVFs) can result in substantial morbidity and potentially embarrassing symptoms in adult women of all ages. Despite having what may be obvious clinical manifestations, the fistulas themselves can be difficult to identify with imaging. MRI is the modality of choice for the diagnosis and characterization of ARVFs. A dedicated protocol involving the use of vaginal gel and optimized imaging planes with respect to the vagina, as well as an understanding of the MRI pelvic floor anatomy, is crucial for reporting surgically relevant details. Ancillary findings such as postsurgical changes, inflammation, abscess, sphincter destruction, and neoplasm are well evaluated. Vaginography, contrast enema, endoscopic US, and CT can be highly useful complementary diagnostic examinations. The entities that result in ARVFs may be obstetric, inflammatory (eg, Crohn disease and diverticulitis), neoplastic, iatrogenic, and/or radiation induced. Surgical management is heavily dependent on the cause and complexity of the fistulizing disease, which are related to the location of the fistula in the vagina, the type and extent of fistula branching, the number of fistulas, sphincter tears, inflammation, and abscess. RSNA, 2018.
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http://dx.doi.org/10.1148/rg.2018170167DOI Listing
December 2018

Computed Tomography Enterography.

Radiol Clin North Am 2018 Sep 11;56(5):649-670. Epub 2018 Jul 11.

Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.

Computed tomography (CT) enterography is a noninvasive imaging modality with superb spatial and temporal resolution, specifically tailored to evaluate the small bowel. It has several advantages over other radiologic and optical imaging modalities, all of which serve as complementary investigations to one another. This article describes CTE technique, including dose reduction techniques, special considerations for the pediatric population, common technical and interpretive pitfalls, and reviews some of the more common small bowel entities seen with CTE.
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http://dx.doi.org/10.1016/j.rcl.2018.04.002DOI Listing
September 2018

Non-alcoholic fatty liver disease-associated hepatocellular carcinoma: effect of hepatic steatosis on major hepatocellular carcinoma features at MRI.

Br J Radiol 2018 Dec 29;91(1092):20180345. Epub 2018 Aug 29.

1 Department of Radiology, Mayo Clinic School of Medicine, Mayo Clinic , Rochester, MN , USA.

Objective:: To evaluate the effect of hepatic steatosis on LI-RADS® major features at MRI in patients with non-alcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC).

Methods:: HCC and liver parenchyma features at MRI from 48 consecutive patients with NAFLD and histology proven HCC (mean ± SD; 4.5 ± 3.4 cm) were independently reviewed by three radiologists. Inter-rater agreement was determined by prevalence/bias-adjusted kappa. Hepatic fat signal fraction (FS%) was independently calculated. HCC features were compared by FS% at MRI using logistic regression analysis and histologic steatosis grade using Cochran-Armitage test for trend, stratified by cirrhotic liver morphology or histologic fibrosis stage. Receiver operating characteristic curves were generated to determine the sensitivity and specificity for major HCC features by FS%.

Results:: Major HCC features included arterial phase hyperenhancement (APHE) in 45 (93%), portal venous phase washout (PVWO) in 30 (63%), delayed phase washout (DPWO) in 38 (79%) and enhancing "capsule" in 34 (71%). Cirrhotic morphology was present in 22 (46%). Inter-rater agreement was 0.75 for APHE, 0.42-0.58 for PVWO, 0.58-0.71 for DPWO and 0.38-0.67 for enhancing "capsule". There was an 18%, 14% and 22% increase in the odds of absent PVWO, DPWO and capsule appearance for every 1% increase in hepatic FS% in patients with non-cirrhotic liver morphology (p = 0.011, 0.040 and 0.029, respectively). Hepatic FS% ≥ 14.8% had a sensitivity and specificity of 64 and 100% for absent PVWO and 71 and 90% for absent DPWO in patients with non-cirrhotic liver morphology.

Conclusion:: Absent washout and capsule appearance are associated with increasing hepatic steatosis in patients with non-cirrhotic, NAFLD-associated HCC.

Advances In Knowledge:: In patients with non-cirrhotic, non-alcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC), absent HCC washout and capsule appearance are associated with increasing hepatic steatosis, thereby potentially impacting the noninvasive imaging diagnosis of HCC in these patients. Lack of washout or capsule appearance in steatotic livers at MRI may require alternative criteria for the diagnosis of HCC in patients with non-cirrhotic NAFLD.
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http://dx.doi.org/10.1259/bjr.20180345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6319849PMC
December 2018

J Pouch: Imaging Findings, Surgical Variations, Natural History, and Common Complications.

Radiographics 2018 Jul-Aug;38(4):1073-1088. Epub 2018 May 22.

From the Departments of Radiology (J.D.R., J.M.B., S.P.S., J.G.F.), Colorectal Surgery (A.L.L.), and Gastroenterology (D.H.B.), Mayo Clinic, 200 First St SW, Rochester, MN 55905; and Department of Radiology, Mayo Clinic, Scottsdale, Ariz (C.O.M.).

Ileal pouch-anal anastomosis, or J pouch, surgery has become the procedure of choice for treatment of medically refractory ulcerative colitis and familial adenomatous polyposis. Overall, this operation is associated with a low rate of postoperative morbidity and good long-term function. However, when complications develop, there is a heavy reliance on imaging to facilitate an accurate diagnosis. Reported postoperative complication rates range from 5% to 35%. Complications generally can be categorized as structural, inflammatory, or neoplastic conditions. Structural complications include leaks, strictures, afferent and efferent limb syndromes, and pouch prolapse. Inflammatory conditions include cuffitis, pouchitis, and Crohn disease of the pouch. In addition, a variety of neoplastic conditions can develop in the pouch. Overall, pouchitis and leaks are the most common complications, occurring in up to 50% and 20% of individuals, respectively. Many imaging modalities are used to evaluate the J pouch and associated postoperative complications. The indications and various surgical techniques for J pouch surgery, normal postoperative appearance of the pouch, and most common associated complications are reviewed. In addition, the various imaging findings associated with J pouch surgery are described and illustrated. The radiologist's familiarity with the potential complications of the pouch can facilitate appropriate imaging, hasten an accurate diagnosis, and aid in rendering proper management. RSNA, 2018.
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http://dx.doi.org/10.1148/rg.2018170113DOI Listing
October 2018

Predictors of Durability of Radiological Response in Patients With Small Bowel Crohn's Disease.

Inflamm Bowel Dis 2018 07;24(8):1815-1825

Division of Gastroenterology and Hepatology, Rochester, Minnesota.

Background: The long-term significance of radiological transmural response (TR) as a treatment goal at the first follow-up scan in small bowel Crohn's disease (CD) has been previously shown. We examined the durability of a long-term strategy of treating to a target of radiological TR and the influence of baseline predictors on the maintenance of TR.

Methods: Small bowel CD patients between January 1, 2002, and December 31, 2014, were identified with serial computed tomography enterography (CTE)/magnetic resonance enterography (MRE) before and after initiation of therapy or on maintenance therapy. Overall TR (inflammatory lesions with/without strictures) w1as characterized by abdominal radiologists in up to 5 small bowel lesions per patient at each serial scan until last follow-up or small bowel resection, as response, partial response, or nonresponse. The rate of conversion between TR states and transition to surgery, including the effect of baseline patient/disease characteristics, was examined using a multistate model (mstate R-package).

Results: CD patients (n = 150, 705 CTE/MRE) with a median of 4 CTE/MRE during 4.6 years of follow-up, 49% with ileal-only distribution, had 260 examined bowel segments. Conversion from response to partial response/nonresponse was 37.4% per year of follow-up with no transitions seen directly from response to surgery. Current smoking status (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.1-4.3) and internal penetrating disease at baseline scan (HR, 2.2; 95% CI, 1.2-4.1) were associated with a 2-fold increased risk of transition from partial response/nonresponse to surgery.

Conclusions: Achievement and maintenance of radiological response is associated with avoidance of small bowel surgery. Continued follow-up with CTE/MRE is recommended to identify loss of response, especially in current smokers and patients with internal penetrating disease at baseline CTE/MRE.
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http://dx.doi.org/10.1093/ibd/izy074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391864PMC
July 2018

Clinical significance of enlarged cardiophrenic lymph nodes in advanced ovarian cancer: Implications for survival.

Gynecol Oncol 2018 01 10;148(1):68-73. Epub 2017 Nov 10.

Department of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA. Electronic address:

Objective: Advanced ovarian cancer (OC) commonly spreads to cardiophrenic lymph nodes (CPLNs), and is often visible on preoperative imaging. We investigated the prognostic significance of abnormal CPLNs in OC detected by preoperative CT scans using three different definitions.

Methods: Patients undergoing primary debulking surgery for stage IIIC/IV with residual disease (RD) ≤1.0cm and a preoperative abdominopelvic CT scan available were included. Scans were reviewed by two blinded radiologists. We characterized abnormal CPLNs using three different definitions: i) qualitative assessment score (QAS); ii) nodes >7mm on the short axis; or, iii) nodes ≥10mm on the short axis. We compared overall survival (OS) using the log-rank test.

Results: Of the 253 patients (mean age 64.0years), 136 had no gross residual disease (NGR) and 117 had RD. By the QAS definition, CPLNs were abnormal in 28 (11.1%) patients and removed in one case. Among patients with NGR, presence of abnormal CPLNs was associated with worse OS (median OS, 38.4 vs. 69.6months, p=0.08). We observed no association between abnormal CPLNs and OS among patients with RD (median OS, 37.5 vs. 28.5months, p=0.49). OS was significantly better in NGR group without abnormal CPLNs (median OS for NGR vs. RD, 69.6 vs. 28.5months, p<0.001); however, there was no difference in OS between patients with NGR versus RD when abnormal CPLNs were present (median OS, 38.4 vs. 37.5months, p=0.99). Lack of benefit from NGR when abnormal CPLNs were present was observed for all three definitions tested.

Conclusion: Abnormal CPLNs are an important predictor of survival in advanced stage OC. Management of abnormal CPLNs should be considered in treatment planning when the goal is NGR.
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http://dx.doi.org/10.1016/j.ygyno.2017.10.024DOI Listing
January 2018

Reproducible imaging features of biologically aggressive gastrointestinal stromal tumors of the small bowel.

Abdom Radiol (NY) 2018 07;43(7):1567-1574

Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

Purpose: To identify reproducible CT imaging features of small bowel gastrointestinal stromal tumors (GIST) that are associated with biologic aggressiveness.

Methods: Patients with histologically proven small bowel GISTs and CT enterography or abdominopelvic CT were included. Biologic aggressiveness was established based on initial histologic grading (very low risk to malignant), with "malignant" assigned if recurrence or metastases developed subsequently. CT exams were independently evaluated by three gastrointestinal radiologists for tumor size, growth pattern, enhancement, tumor borders, necrosis, calcification, ulceration, multiplicity, internal air or enteric contrast, nodal metastasis, liver metastasis, peritoneal metastasis, ascites, and draining vein size. Inter-observer variability and imaging features associated with high-grade and malignant small bowel GISTs were determined.

Results: Of 78 patients with small bowel GISTs, 10/78 (13%) were high grade and 18/78 (23%) were malignant. There was moderate to substantial inter-observer agreement (Kappa > 0.4) for all findings except tumor border, ulceration, and nodal metastases. Tumor size, irregular or invasive tumor border, necrosis, liver metastasis, ascites, and iso-enhancement were associated with high-grade/malignant small bowel GISTs (p < 0.04). Internal air or enteric contrast and peritoneal metastases additionally predicted malignant behavior (p < 0.03). When imaging features predicting malignant small bowel GISTs were absent and size was ≤ 3 cm, 0% (0/16), 5% (1/19), and 5% (1/17) of patients had high grade, and 0% (0/16, 0/19, and 0/17) had malignant tumors for the three readers, respectively.

Conclusion: Multiple, reproducibly identified, small bowel GIST imaging features suggest biologic aggressiveness. The absence of these imaging features may identify small tumors that can be followed in asymptomatic or high-risk patients.
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http://dx.doi.org/10.1007/s00261-017-1370-6DOI Listing
July 2018

MR Imaging of Perianal Crohn Disease.

Radiology 2017 Mar;282(3):628-645

From the Departments of Radiology (S.P.S., J.G.F.), Internal Medicine (D.H.B., W.A.F.), and Surgery (E.J.D.), Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Pelvic magnetic resonance (MR) imaging is currently the standard for imaging perianal Crohn disease. Perianal fistulas are a leading cause of patient morbidity because closure often requires multimodality treatments over a prolonged period of time. This review summarizes clinically relevant anal sphincter anatomy, imaging methods, classification systems, and treatment objectives. In addition, the MR appearance of healing perianal fistulas and fistula complications is described. Difficult imaging tasks including the assessment of rectovaginal fistulas and ileoanal anastomoses are highlighted, along with illustrative cases. Emerging innovative treatments for perianal Crohn disease are now available and have the promise to better control sepsis and maintain fecal continence. Different treatment modalities are selected based on fistula anatomy, patient factors, and management goals (closure versus sepsis control). Radiologists can help maximize patient care by being familiar with MR imaging features of perianal Crohn disease and knowledgeable about what features may influence therapy decisions. RSNA, 2017 Online supplemental material is available for this article.
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http://dx.doi.org/10.1148/radiol.2016151491DOI Listing
March 2017

Beyond moulage sign and TTG levels: the role of cross-sectional imaging in celiac sprue.

Abdom Radiol (NY) 2017 02;42(2):361-388

Department of Radiology, Mayo Clinic, 200 First Street, S.W., Rochester, MN, 55905, USA.

Celiac disease is an autoimmune disorder that causes inflammation and destruction in the small intestine of genetically susceptible individuals following ingestion of gluten. Awareness of the disease has increased; however, it remains a challenge to diagnose. This review summarizes the intestinal and extraintestinal cross-sectional imaging findings of celiac disease. Small intestine fold abnormalities are the most specific imaging findings for celiac disease, whereas most other imaging findings reflect a more generalized pattern seen with malabsorptive processes. Familiarity with the imaging pattern may allow the radiologist to suggest the diagnosis in patients with atypical presentations in whom it is not clinically suspected. Earlier detection allows earlier treatment initiation and may prevent significant morbidity and mortality that can occur with delayed diagnosis. Refractory celiac disease carries the greatest risk of mortality due to associated complications, including cavitating mesenteric lymph node syndrome, ulcerative jejunoileitis, enteropathy-associated T cell lymphoma, and adenocarcinoma, all of which are described and illustrated. Radiologic and endoscopic investigations are complimentary modalities in the setting of complicated celiac disease.
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http://dx.doi.org/10.1007/s00261-016-1006-2DOI Listing
February 2017