Publications by authors named "Susan J Back"

50 Publications

Contrast-enhanced voiding urosonography part 2: urethral imaging.

Pediatr Radiol 2021 Aug 13. Epub 2021 Aug 13.

Department of Radiology, Medical University of Gdansk, Gdansk, Poland.

Ultrasound (US) has been increasingly used as an important imaging tool to assess the urethra in children. The earliest reports of pediatric urethral sonography involved imaging the urethra in a non-voiding state, during physiological voiding of urine, and after instillation of saline. The introduction of US contrast agents has continued to improve visualization of urethral anatomy. Contrast-enhanced US of the urethra can be performed during the voiding phase of a standard contrast-enhanced voiding urosonography (ceVUS) exam or with retrograde instillation of a contrast agent, depending on the exam indication. Both techniques are well tolerated by children and provide accurate information about urethral pathology and periurethral soft tissues. This article reviews the technical aspects and imaging findings of urethral pathologies in children using contrast-enhanced US, both by the voiding and retrograde instillation techniques.
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http://dx.doi.org/10.1007/s00247-021-05116-6DOI Listing
August 2021

Contrast-enhanced ultrasound in children: a first-of-its-kind comprehensive compendium!

Pediatr Radiol 2021 Jul 23. Epub 2021 Jul 23.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

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http://dx.doi.org/10.1007/s00247-021-05120-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300977PMC
July 2021

Pediatric contrast-enhanced ultrasound: shedding light on the pursuit of approval in the United States.

Pediatr Radiol 2021 Jun 11. Epub 2021 Jun 11.

Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA.

For two decades, pediatric contrast US has been well accepted throughout Europe and other parts of the world outside the United States because of its high diagnostic efficacy and extremely favorable safety profile. This includes intravenous (IV) administration, contrast-enhanced US (CEUS) and the intravesical application, contrast-enhanced voiding urosonography (ceVUS). However, the breakthrough for pediatric contrast US in the United States did not come until 2016, when the U.S. Food and Drug Administration (FDA) approved the first pediatric indication for a US contrast agent. This initial approval covered the use of Lumason (Bracco Diagnostics, Monroe Township, NJ) for the evaluation of focal liver lesions via IV administration in children. A second pediatric indication followed shortly thereafter, when the FDA extended the use of Lumason for assessing known or suspected vesicoureteral reflux via intravesical application in children. Both initial pediatric approvals were granted without prospective pediatric clinical trials, based instead on published literature describing favorable safety and efficacy in children. Three years later, in 2019, the FDA approved Lumason for pediatric echocardiography following a clinical trial involving a total of 12 subjects at 2 sites. The story of how we achieved these FDA approvals spans more than a decade and involves the extraordinary dedication of two professional societies, namely the International Contrast Ultrasound Society (ICUS) and the Society for Pediatric Radiology (SPR). Credit also must be given to the FDA staff for their commitment to the welfare of children and their openness to compelling evidence that contrast US is a safe, reliable, radiation-free imaging option for our pediatric patients. Understanding the history of this approval process will impact the practical application of US contrast agents, particularly when expanding off-label indications in the pediatric population. This article describes the background of the FDA's approval of pediatric contrast US applications to better illuminate the potential pathways to approvals of future indications.
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http://dx.doi.org/10.1007/s00247-021-05102-yDOI Listing
June 2021

Contrast-enhanced ultrasound of benign and malignant liver lesions in children.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, TN, USA.

Contrast-enhanced ultrasound (CEUS) is increasingly being used in children. One of the most common referrals for CEUS performance is characterization of indeterminate focal liver lesions and follow-up of known liver lesions. In this setting, CEUS is performed with intravenous administration of ultrasound contrast agents (UCAs). When injected into a vein, UCA microbubbles remain confined within the vascular network until they dissipate. Therefore, visualization of UCA within the tissues and lesions corresponds to true blood flow. CEUS enables continuous, real-time observation of the enhancement pattern of a focal liver lesion, allowing in most cases for a definite diagnosis and obviating the need for further cross-sectional imaging or other interventional procedures. The recent approval of Lumason (Bracco Diagnostics, Monroe Township, NJ) for pediatric liver CEUS applications has spurred the widespread use of CEUS. In this review article we describe the role of CEUS in pediatric liver applications, focusing on the examination technique and interpretation of main imaging findings of the most commonly encountered benign and malignant focal liver lesions. We also compare the diagnostic performance of CEUS with other imaging modalities for accurate characterization of focal liver lesions.
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http://dx.doi.org/10.1007/s00247-021-04976-2DOI Listing
May 2021

Starting a pediatric contrast ultrasound service: made simple!

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

The addition of contrast US to an existing pediatric US service requires several preparatory steps. This overview provides a guide to simplify the process. Initially, it is important to communicate to all stakeholders the justifications for pediatric contrast US, including (1) its comparable or better diagnostic results relative to other modalities; (2) its reduction in procedural sedation or anesthesia by avoiding MRI or CT; (3) its reduction or elimination of radiation exposure by not having to perform fluoroscopy or CT; (4) the higher safety profile of US contrast agents (UCA) compared to other contrast agents; (5) the improved exam comfort and ease inherent to US, leading to better patient and family experience, including bedside US exams for children who cannot be transported; (6) the need for another diagnostic option in light of increasing demand by parents and providers; and (7) its status as an approved and reimbursable exam. It is necessary to have an UCA incorporated into the pharmacy formulary noting that only SonoVue/Lumason is currently approved for pediatric use. In the United States this UCA is approved for intravenous administration for cardiac and liver imaging and for vesicoureteric reflux detection with intravesical application. In Europe and China it is only approved for the intravesical use in children. All other applications are off-label. The US scanner needs to be equipped with contrast-specific software. The UCA has to be prepared just before the exam and it is important to strictly follow the steps as outlined in the packaging inserts in order to prevent premature destruction of the microbubbles. The initial training in contrast US is best focused on the frontline staff actually performing the US studies; these might be sonographers, pediatric or interventional radiologists, or trainees. It is important from the outset to educate the referring physicians about contrast US. It is helpful to participate in existing contrast US courses, particularly those with hands-on components.
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http://dx.doi.org/10.1007/s00247-021-04998-wDOI Listing
May 2021

Contrast-enhanced ultrasound of the kidneys and adrenals in children.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Medical University of Gdansk, Gdansk, Poland.

Pediatric applications of contrast-enhanced ultrasound (CEUS) are growing. Evaluation of the kidneys and adrenal glands in children using intravenous administration of US contrast agents, however, is still an off-label indication. Pediatric CEUS applications for kidneys are similar to those in adults, including ischemic disorders, pseudo- versus real tumors, indeterminate lesions, complex cystic lesions, complicated pyelonephritis, and abscesses. CEUS applications for evaluation of adrenal glands in children are limited, mainly focusing on the assessment and follow-up of adrenal trauma and the differentiation between an adrenal hemorrhage and a mass. This review addresses the current experience in pediatric CEUS of the kidneys and adrenal glands. By extrapolating the established knowledge for US contrast evaluations in the adult kidney to the pediatric context we can note opportunities for CEUS clinical use in children.
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http://dx.doi.org/10.1007/s00247-020-04849-0DOI Listing
May 2021

Contrast-enhanced ultrasound of blunt abdominal trauma in children.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.
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http://dx.doi.org/10.1007/s00247-020-04869-wDOI Listing
May 2021

Contrast-enhanced genitosonography and colosonography: emerging alternatives to fluoroscopy.

Pediatr Radiol 2021 May 12. Epub 2021 May 12.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Imaging plays a crucial role in evaluating newborns and infants with cloacal and urogenital malformations. Contrast-enhanced genitosonography (ceGS) and contrast-enhanced colosonography (ceCS) are sensitive and radiation-free alternatives to fluoroscopic genitography and colography for diagnosis and surgical planning. These imaging techniques are performed by instilling a US contrast agent into specific body cavities to define the genitourinary and colorectal anatomy. This review article presents the experience with ceGS and ceCS applications in children, focusing on the background, examination technique, and interpretation of imaging findings, as well as strengths and weaknesses compared to conventional techniques.
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http://dx.doi.org/10.1007/s00247-020-04770-6DOI Listing
May 2021

Contrast-enhanced ultrasound of the small organs in children.

Pediatr Radiol 2021 Apr 8. Epub 2021 Apr 8.

Department of Radiology, King's College Hospital, Denmark Hill, London, UK.

In pediatric and adult populations, intravenous contrast-enhanced ultrasound (CEUS) remains off-label for imaging of organs other than the liver and heart. This limited scope inhibits potential benefits of the new modality from a more widespread utilization. Yet, CEUS is potentially useful for imaging small organs such as the thyroid gland, lymph nodes, testes, ovaries and uterus, with all having locations and vasculature favorable for this type of examination. In the adult population, the utility of CEUS has been demonstrated in a growing number of studies for the evaluation of these small organs. The aim of this article is to present a review of pediatric CEUS of the thyroid gland, lymph nodes, testes, ovaries and uterus as well as to draw from the adult literature indications for possible applications in children.
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http://dx.doi.org/10.1007/s00247-021-05006-xDOI Listing
April 2021

Contrast-enhanced voiding urosonography, part 1: vesicoureteral reflux evaluation.

Pediatr Radiol 2021 Mar 31. Epub 2021 Mar 31.

Pediatric Ultrasound Center, Thessaloniki, Greece.

Contrast-enhanced voiding urosonography (ceVUS) is a well-established, sensitive and safe ultrasound (US) modality for detecting and grading vesicoureteral reflux (VUR) and urethral imaging in children. Nearly three decades of remarkable advances in US technology and US contrast agents have refined ceVUS's diagnostic potential. The recent approval of Lumason/SonoVue in the United States, Europe and China for pediatric intravesical applications marked the beginning of a new era for this type of contrast US imaging. Consequently, the use of ceVUS in children has expanded to multiple places around the globe. In the first part of this review article, we describe the current experience in the use of ceVUS for VUR evaluation, with an emphasis on historical background, examination technique, image interpretation and diagnostic accuracy. In the second part, we will present the role of ceVUS for urethral imaging in children.
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http://dx.doi.org/10.1007/s00247-020-04906-8DOI Listing
March 2021

Contrast-enhanced ultrasound for musculoskeletal indications in children.

Pediatr Radiol 2021 Mar 30. Epub 2021 Mar 30.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

The increasing use of contrast-enhanced ultrasound (CEUS) has opened exciting new frontiers for musculoskeletal applications in adults and children. The most common musculoskeletal-related CEUS applications in adults are for detecting inflammatory joint diseases, imaging skeletal muscles and tendon perfusion, imaging postoperative viability of osseous and osseocutaneous tissue flaps, and evaluating the malignant potential of soft-tissue masses. Pediatric musculoskeletal-related CEUS has been applied for imaging juvenile idiopathic arthritis and Legg-Calvé-Perthes disease and for evaluating femoral head perfusion following surgical hip reduction in children with developmental hip dysplasia. CEUS can improve visualization of the capillary network in superficial and deep tissues and also in states of slow- or low-volume blood flow. In addition, measurements of blood flow imaging parameters performed by quantitative CEUS are valuable when monitoring the outcome of treatment interventions. In this review article we present current experience regarding a wide range of CEUS applications in musculoskeletal conditions in adults and children, with emphasis on the latter, and discuss imaging techniques and CEUS findings in musculoskeletal applications.
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http://dx.doi.org/10.1007/s00247-021-04964-6DOI Listing
March 2021

Pediatric magnetic resonance imaging training versus job-readiness: using education research tools to re-align.

Pediatr Radiol 2021 Aug 27;51(9):1732-1737. Epub 2021 Mar 27.

Department of Radiology, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY, 10305, USA.

Background: Fellows begin MRI training with variable experience and expertise. To better serve patients, pediatric radiology fellows should gain competence in MRI that enables seamless transition to independent practice.

Objective: We implemented a needs assessment survey and conducted a focus group discussion to identify knowledge gaps and inform creation of a curriculum for pediatric body MRI.

Materials And Methods: We electronically distributed a comprehensive anonymous needs assessment survey in October 2016 to current fellows and recent (<5 years) graduates from Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric radiology fellowships, with follow-up in January 2017. We conducted a focus group discussion among current fellows at our institution in October 2017 to inform a better understanding of the results.

Results: Eighty-one pediatric radiologists (8 fellows/73 attendings) completed the survey (24%); 5 current fellows participated in the focus group. The technical issues most commonly identified with limited or no instruction during training included setting up an MR service, accessory equipment (coil) selection and MRI field inhomogeneity correction. Areas needing increased attention and inclusion within the curriculum included coil choice/patient positioning (n=42, 52%), contrast agents (n=40, 49%), field strength (n=33, 41%) and strategies for motion correction (n=33, 41%). Most fellows were uncomfortable with setting up an MR service (n=57, 70%), correcting field inhomogeneity (n=56, 69%) and improving image quality (n=50, 62%). The focus group showed consensus that there was insufficient MR training in residency to prepare them for fellowship. The group also preferred shorter lectures and streaming via video education/tutorials.

Conclusion: While traditional instruction emphasizes image interpretation, trainees in pediatric radiology need a curriculum that also emphasizes technical and non-interpretive aspects of MRI.
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http://dx.doi.org/10.1007/s00247-021-05047-2DOI Listing
August 2021

Utility of contrast-enhanced ultrasound for solid mass surveillance and characterization in children with tuberous sclerosis complex: an initial experience.

Pediatr Nephrol 2021 Jul 13;36(7):1775-1784. Epub 2021 Feb 13.

Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Background: Patients with tuberous sclerosis complex (TSC) can develop solid kidney masses from childhood. Imaging surveillance is done to detect renal cell carcinoma (RCC) and angiomyolipomas (AML), including AMLs at risk for hemorrhage. Intravenous contrast-enhanced ultrasound (CEUS) may be useful for screening as ultrasound is well tolerated by children and ultrasound contrast agents (UCA) are not nephrotoxic.

Methods: Retrospective review of kidney CEUS exams of pediatric TSC patients. Qualitative CEUS analysis by consensus of 3 radiologists assessed rate, intensity, and pattern of lesion enhancement. Quantitative CEUS analysis was performed using Vuebox®. Where available, abdominal MRI was analyzed qualitatively for the same features and quantitatively by in-house-developed software. Time-intensity curves were generated from both CEUS and MRI where possible. Appearance of lesions were compared between CEUS and MRI and histology where available.

Results: Nine masses in 5 patients included one histologically proven RCC and 8 AMLs diagnosed by imaging. Quantitative CEUS of RCC showed malignant features including increased peak enhancement 162%, rapid wash-in rate 162%, and elevated washout rate 156% compared to normal kidney tissue; versus AML which was 68%, 105%, and 125%, respectively. All masses were hypoenhancing on MRI compared to normal kidney tissue; MR dynamic contrast study offered no distinction between RCC and AML. The only MRI feature differentiating RCC from AML was absence of fat.

Conclusion: Temporal resolution afforded by CEUS was useful to distinguish malignant from benign kidney masses. CEUS may prove useful for screening, characterizing, and follow-up of kidney lesions in pediatric TSC patients.
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http://dx.doi.org/10.1007/s00467-020-04835-6DOI Listing
July 2021

Recommendations for Preclinical Renal MRI: A Comprehensive Open-Access Protocol Collection to Improve Training, Reproducibility, and Comparability of Studies.

Methods Mol Biol 2021 ;2216:3-23

Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine (MDC) in the Helmholtz Association, Berlin, Germany.

Renal MRI holds incredible promise for making a quantum leap in improving diagnosis and care of patients with a multitude of diseases, by moving beyond the limitations and restrictions of current routine clinical practice. Clinical and preclinical renal MRI is advancing with ever increasing rapidity, and yet, aside from a few examples of renal MRI in routine use, it is still not good enough. Several roadblocks are still delaying the pace of progress, particularly inefficient education of renal MR researchers, and lack of harmonization of approaches that limits the sharing of results among multiple research groups.Here we aim to address these limitations for preclinical renal MRI (predominantly in small animals), by providing a comprehensive collection of more than 40 publications that will serve as a foundational resource for preclinical renal MRI studies. This includes chapters describing the fundamental principles underlying a variety of renal MRI methods, step-by-step protocols for executing renal MRI studies, and detailed guides for data analysis. This collection will serve as a crucial part of a roadmap toward conducting renal MRI studies in a robust and reproducible way, that will promote the standardization and sharing of data.This chapter is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers.
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http://dx.doi.org/10.1007/978-1-0716-0978-1_1DOI Listing
March 2021

Pediatric contrast-enhanced ultrasound: optimization of techniques and dosing.

Pediatr Radiol 2020 Sep 21. Epub 2020 Sep 21.

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

When performing contrast-enhanced ultrasound (CEUS), ultrasound (US) scanner settings, examination technique, and contrast agent dose and administration must be optimized to ensure that high-quality, diagnostic and reproducible images are acquired for qualitative and quantitative interpretations. When carrying out CEUS in children, examination settings should be tailored to their body size and specific indications, similar to B-mode US. This review article details the basic background knowledge that is needed to perform CEUS optimally in children, including considerations related to US scanner settings and US contrast agent dose selection and administration techniques.
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http://dx.doi.org/10.1007/s00247-020-04812-zDOI Listing
September 2020

Developmental dysplasia of the hip: can contrast-enhanced MRI predict the development of avascular necrosis following surgery?

Skeletal Radiol 2021 Feb 9;50(2):389-397. Epub 2020 Aug 9.

Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.

Objective: To investigate the performance of contrast-enhanced MRI for predicting avascular necrosis (AVN) of the treated femoral head after surgical reduction for developmental dysplasia of the hip (DDH) using qualitative and quantitative methods.

Methods And Materials: This IRB-approved, HIPAA compliant retrospective study included 47 children who underwent same-day contrast-enhanced MRI following unilateral surgical hip reduction between April 2009 and June 2018. Blinded to the clinical outcome, 3 reviewers (2 pediatric radiologists and 1 pediatric orthopedist) independently categorized the enhancement pattern of the treated femoral head. Signal intensities, measured using regions of interest (ROI), were compared between treated and untreated hips and percent enhancements were compared between hips that developed and did not develop AVN. Post-reduction radiographs were evaluated using Salter's criteria for AVN and Kalmachi and MacEwen's classification for growth disturbance. Non-parametric tests and Fisher exact test were used to compare enhancement values between AVN and non-AVN hips. Bonferroni correction was used for multiple comparisons.

Results: Ten (21%) out of the 47 children (7 boys and 40 girls; mean age 9.0 ± 4.7 months) developed AVN. Age at surgical reduction was significantly higher (p = 0.03) for hips that developed AVN. No significant differences were found in gender (p = 0.61), laterality (p = 0.46), surgical approach (p = 0.08), history of pre-operative bracing (p = 0.72), abduction angle (p = 0.18-0.44), enhancement pattern (p = 0.66-0.76), or percent enhancement (p = 0.41-0.88) between AVN and non-AVN groups.

Conclusion: Neither enhancement pattern nor percent enhancement predicted AVN, suggesting that post-reduction conventional MRI does not accurately distinguish between reversible and permanent vascular injury.
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http://dx.doi.org/10.1007/s00256-020-03572-zDOI Listing
February 2021

Does contrast-enhanced ultrasound have a role in evaluation and management of pediatric renal trauma? A preliminary experience.

J Pediatr Surg 2020 Dec 17;55(12):2740-2745. Epub 2020 Jun 17.

Division of Pediatric Urology, Department of Pediatric Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.

Background: To report our initial experience using intravenous contrast-enhanced ultrasound (CEUS) in pediatric renal trauma with the potential for substantial radiation reduction.

Methods: A retrospective review of all patients who underwent intravenous CEUS at our institution between May 2015 and January 2018 for the suspicion of blunt renal trauma. CEUS was obtained either as an immediate or short-term comparison to contrast-enhanced computed tomography (CECT), or in outpatient follow-up.

Results: CEUS was performed on 7 patients (9 kidneys) with age range 2 months to 16 years old. CEUS was utilized as a comparison to CECT in 4 of 7 patients for initial evaluation, clinical change, or short-term follow-up. CEUS alone was used in one patient with low suspicion for renal injury. In the remaining two patients, CEUS was obtained as a follow-up study weeks after the initial CECT, following conservative management. All patients with confirmed renal injury by CECT (n = 5) underwent a follow-up CEUS at 1-2 months.

Conclusions: In an era of conservative management for renal trauma in which operative intervention is dictated more often by the clinical course than radiographic findings, it is reasonable to consider alternative imaging methods such as CEUS in stable patients to decrease radiation exposure.

Level Of Evidence Rating: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.06.010DOI Listing
December 2020

Identification and characterization of calyceal diverticula with MR urography (MRU) in children.

Abdom Radiol (NY) 2021 01;46(1):303-310

Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Blvd, Philadelphia, PA, 19104, USA.

Purpose: To determine the MRU imaging findings of calyceal diverticula in a large cohort of children and to compare the frequency of calyceal diverticula in our cohort with what has been previously reported.

Methods: This was a HIPAA-compliant, IRB-approved retrospective study of all patients with suspected CD based on their medical records. All patients in this study underwent MRU at our institution between 2010 and 2017. Two pediatric radiologists reviewed each MRU blinded to clinical information and other urologic imaging regarding the presence, size, location, and morphology of the cyst and presence/absence of contrast within it. The time when contrast first appeared within the cystic mass was recorded, and a χ test was used to determine significance on differences between the different characteristics of renal cysts and diverticula.

Results: Fifty children (29 girls and 21 boys; median age of 11.5 years, IQR 7-16) with a total of 66 individual cystic masses were included. 21 (21/66, 31.8%) Cystic masses demonstrated contrast filling and were characterized as diverticula, resulting in a frequency of 26.6 cases per 1000 patients (21/787). The remaining 45 cystic masses (45/66, 68.1%) were cysts. The median diameter of CD was 2.5 cm (IQR 1.5-3.7). Contrast was observed within the cystic mass on average at 4.6 min (SD ± 2.4; range 1.5-13 min). The agreement between both radiologists was 91% (k = 0.78). 6 Cysts and 18 CD were confirmed surgically, MRU demonstrated accurate diagnosis in 100% of those cases.

Conclusion: Magnetic resonance urography is reliable in differentiating calyceal diverticula from renal cysts. On MRU, all diverticula were identified within 15 min of contrast administration; hence longer delays in imaging are unnecessary.
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http://dx.doi.org/10.1007/s00261-020-02623-2DOI Listing
January 2021

Intraoperative contrast enhanced sonourethrography to characterize urethral stricture in a pediatric patient.

Urol Case Rep 2020 Sep 22;32:101223. Epub 2020 Apr 22.

Division of Urology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Care, 3400 Civic Center Blvd, 3rd Floor West Pavilion, Philadelphia, PA, 19104, USA.

Fluoroscopic retrograde urethrogram (RUG) is the current gold standard to define urethral strictures, however, sonourethrography (SU) has been shown to be effective in this setting as well. Some advantages of SU include more accurate measurement of stricture length, lack of radiation, and ability to assess soft tissue surrounding strictures to help guide operative management. Contrast enhanced ultrasound (CEUS) is an evolving imaging modality with increasing clinical utility in both pediatric and adult patient populations. We present a unique case in which contrast enhanced sonourethrography (CESU) was used to further characterize a urethral stricture intraoperatively to aid in surgical decision making.
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http://dx.doi.org/10.1016/j.eucr.2020.101223DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191200PMC
September 2020

Reply.

J Ultrasound Med 2020 09 13;39(9):1883-1884. Epub 2020 Apr 13.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

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http://dx.doi.org/10.1002/jum.15287DOI Listing
September 2020

Supine versus prone positioning for ultrasound evaluation of postnatal urinary tract dilation in children.

Pediatr Radiol 2020 03 12;50(3):357-362. Epub 2019 Nov 12.

Department of Radiology,, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Background: Ultrasound (US) is used in the initial evaluation and surveillance of urinary tract dilation in children. Urinary tract dilation is diagnosed in 1-2% of all pregnancies during routine prenatal sonography with technological advances in US imaging. Urinary tract dilation classification systems, including the 2014 multidisciplinary consensus, assess anterior-posterior renal pelvic diameter and calyceal dilation. There is no consensus regarding optimal patient positioning - supine versus prone - during US assessment of urinary tract dilation.

Objective: We performed this study to determine whether there is a significant difference in the measurement of the anterior-posterior renal pelvic diameter, presence of calyceal dilation, or resulting urinary tract dilation consensus score obtained between supine and prone positions.

Materials And Methods: Two raters retrospectively reviewed renal bladder US exams of children with urinary tract dilation of one or both kidneys. We included technically adequate US examinations of orthotopic kidneys that were imaged in both supine and prone positions; we excluded children with renal anomalies or prior surgery. Anterior-posterior renal pelvic diameter measurements as well as central and peripheral calyceal dilation were documented in both supine and prone positions. A postnatal urinary tract dilation consensus score was assigned to each kidney based only on these features.

Results: Urinary tract dilation in either the supine or prone position was performed in 146 kidneys (69 right, 77 left) in 89 children. Median age was 0.26 years (interquartile ratio [IQR] 0.08-0.61 years). Female-to-male ratio was 1:3 (21/89). The interclass correlations of the anterior-posterior renal pelvic diameter were 0.88 and 0.87 in the supine and prone positions, respectively, without significant differences (P=0.1). When comparing all kidneys together, the mean anterior-posterior renal pelvic diameter was 7.1 mm (95% confidence interval [CI] 6.4-7.8) in supine and 7.9 (95% CI 7.1-8.7) in prone, with a mean difference between the measurements of 0.83 mm (95% CI 0.3-1.4; P=0.16). Central calyceal and peripheral calyceal dilation were more commonly found in the prone position versus the supine position in both kidneys. Central calyceal dilation was observed in 15 cases in the prone but not in the supine position. In one kidney, it was seen only in the supine but not in the prone position. Overall the urinary tract dilation score differed between positions in 10.3% (15/146) of cases, most of them (14/15) with a higher score in prone compared to the supine position.

Conclusion: Scanning in prone position tends to more frequently show calyceal dilation and a greater size of the anterior-posterior renal pelvic diameter, resulting in higher urinary tract dilation classification scores, with almost perfect interobserver agreement.
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http://dx.doi.org/10.1007/s00247-019-04546-7DOI Listing
March 2020

Liver, Spleen, and Kidney Size in Children as Measured by Ultrasound: A Systematic Review.

J Ultrasound Med 2020 Feb 16;39(2):223-230. Epub 2019 Aug 16.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Ultrasound is commonly the first-line imaging modality for assessing the pediatric abdomen. An abnormal size of the liver, spleen, or kidneys may indicate disease, but the evaluation is challenging because the normal size changes with age. In addition, published normal value charts for children may vary by population and methods. In this systematic review, we summarized published data on the normal size of the pediatric liver, spleen, and kidneys as measured by ultrasound in which we found similar values across different populations, ages, and sexes.
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http://dx.doi.org/10.1002/jum.15114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980276PMC
February 2020

Intraoperative Contrast-Enhanced Ultrasound Imaging of Femoral Head Perfusion in Developmental Dysplasia of the Hip: A Feasibility Study.

J Ultrasound Med 2020 Feb 23;39(2):247-257. Epub 2019 Jul 23.

Division of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Objectives: Developmental dysplasia of the hip (DDH) is one of the most common developmental deformities of the lower extremity. Although many children are successfully treated with a brace or harness, some require intraoperative closed or open reduction and spica casting. Surgical reduction is largely successful to relocate the hip; however, iatrogenic avascular necrosis is a major source of morbidity. Recent research showed that postoperative gadolinium-enhanced magnetic resonance imaging (MRI) can depict hip perfusion, which may predict a future incidence of avascular necrosis. As contrast-enhanced ultrasound (CEUS) assesses blood flow in real time, it may be an effective intraoperative alternative to evaluate femoral head perfusion. Here we describe our initial experience regarding the feasibility of intraoperative CEUS of the hip for the assessment of femoral head perfusion before and after DDH reduction.

Methods: This single-institution retrospective Institutional Review Board-approved study with a waiver of informed consent evaluated intraoperative hip CEUS in children with DDH compared to postoperative contrast-enhanced MRI. Pediatric radiologists, blinded to prior imaging findings and outcomes, reviewed both CEUS and MRI examinations separately and some time from the initial examination both independently and in consensus.

Results: Seventeen patients had 20 intraoperative CEUS examinations. Twelve of 17 (70.6%) had prereduction hip CEUS, postreduction hip CEUS, and postreduction gadolinium-enhanced MRI. Seven of 12 (58.3%) were evaluable retrospectively. All CEUS studies showed blood flow in the femoral epiphysis before and after reduction, and all MRI studies showed femoral head enhancement after reduction. The CEUS and MRI for all 7 patients also showed physeal blood flow.

Conclusions: Contrast-enhanced ultrasound is a feasible intraoperative tool for assessing adequate blood flow after hip reduction surgery in DDH.
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http://dx.doi.org/10.1002/jum.15097DOI Listing
February 2020

Morphologic and functional evaluation of duplicated renal collecting systems with MR urography: A descriptive analysis.

Clin Imaging 2019 Sep - Oct;57:69-76. Epub 2019 May 15.

Section of Genitourinary Imaging, Division of Body Imaging, Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Children's Hospital of Philadelphia, 3401 Civic Center blvd, Philadelphia, PA 19104, United States of America; Diagnostic and Intervention Radiology Department, Cairo University Hospitals, Kasr Al-Ainy, Cairo, Egypt. Electronic address:

Purpose: To describe the morphology and function of duplicated collecting systems in pediatric patients undergoing functional MR urography (fMRU).

Methods: This is a HIPAA compliant IRB approved retrospective study of all patients with duplicated renal collecting systems undergoing fMRU at our institution between 2010 and 2017. Two pediatric radiologists evaluated the studies to determine the presence, morphology and function of duplicated collecting systems using both T2-weighted and dynamic post-contrast fat saturated T1-weighted images. Assessed morphologic features included pelvic and calyceal dilation, partial or complete ureteral duplication, ureteral dilation, ectopic ureteral insertion and ureteroceles. Functional analysis was carried out per moiety.

Results: A total of 86 examinations (63 girls; 23 boys), median age 2.6 years (Standard Deviation 6.4 years, interquartile range: 0.4-10.3 years) and 107 kidneys (39 right; 30 left and 19 bilateral), which yielded 214 evaluable moieties, were included in the final sample. One hundred and sixty-three (76.1%) of the moieties had normal morphological features and normal functional results (average calyceal transit time and renal transit time of 2 min 28 s and 3 min 16 s, respectively). The remaining 51 moieties (23.8%) were hypoplastic or dysplastic. Seventy-seven (35.9%) had pelvic and calyceal dilation. Slightly more than half of the kidneys had complete ureteral duplication (60/107; 56%); 50 (50/107, 46.7%) had ectopic ureters (23 intra- and 27 extravesical) and 9 (9/107, 8.4%) had ureteroceles.

Conclusion: fMRU provides comprehensive information regarding the morphology and function of duplicated renal collecting systems in children. In particular, fMRU is useful for assessing barely or non-functioning renal poles and ectopic ureters.
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http://dx.doi.org/10.1016/j.clinimag.2019.05.004DOI Listing
January 2020

Pilot study on renal magnetic resonance diffusion tensor imaging: are quantitative diffusion tensor imaging values useful in the evaluation of children with ureteropelvic junction obstruction?

Pediatr Radiol 2019 02 8;49(2):175-186. Epub 2018 Oct 8.

Department of Radiology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Background: Ureteropelvic junction (UPJ) obstruction is a common cause of renal injury in children. Indications for surgery are still controversial. Currently, there is no threshold to differentiate patients with suspected UPJ obstruction requiring surgery from the ones that do not, or to predict renal outcome after surgery. Several studies have demonstrated that diffusion tensor imaging (DTI) results may correlate with microstructural changes in the kidneys.

Objective: To evaluate the feasibility of using DTI to identify UPJ obstruction kidneys.

Materials And Methods: We analyzed functional MR urography (fMRU) with renal DTI (b=0 and b=400, 20 directions, 1.5 Tesla, no respiratory triggering) in 26 kidneys of 19 children (mean age: 6.15 years) by comparing 13 kidneys with UPJ obstruction configuration that underwent pyeloplasty following the fMRU, and 13 anatomically normal age- and gender-matched kidneys. DTI tractography was reconstructed using a fractional anisotropy threshold of 0.10 and an angle threshold of 55°. User-defined regions of interest (ROIs) of the renal parenchyma (excluding collecting system) were drawn to quantify DTI parameters: fractional anisotropy, apparent diffusion coefficient (ADC), track length and track volume. The failure rate was evaluated.

Results: All DTI parameters changed with age; fractional anisotropy decreased (P<0.032). Track volume and track length increased (P<0.05). ADC increased with age in normal kidneys (P<0.001) but not in UPJ obstruction kidneys (P=0.11). After controlling for age, the fractional anisotropy (UPJ obstruction mean: 0.18, normal kidney mean: 0.21; P=0.001) and track length (UPJ obstruction mean: 11.9 mm, normal kidney mean: 15.4 mm; P<0.001) were lower in UPJ obstruction vs. normal kidneys. There was a trend toward a higher ADC in UPJ obstruction kidneys vs. normal kidneys (P=0.062). The failure rate in UPJ obstruction kidneys due to technical limitations of DTI was 13/26 (50%).

Conclusion: We demonstrated that fractional anisotropy is lower in UPJ obstruction than in normal kidneys. It is necessary to improve this technique to increase the success rate and to perform more studies to evaluate if a decrease in fractional anisotropy can differentiate UPJ obstruction kidneys from hydronephrotic kidneys without UPJ obstruction.
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http://dx.doi.org/10.1007/s00247-018-4268-8DOI Listing
February 2019

Contrast enhanced genitosonography (CEGS) of urogenital sinus: A case of improved conspicuity with image inversion.

Radiol Case Rep 2018 Jun 6;13(3):652-654. Epub 2018 Apr 6.

Department of Radiology, Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104, USA.

Imaging plays a pivotal role in evaluating the urogenital anatomy in children with ambiguous genitalia. Contrast enhanced genitosonography (CEGS) represents a low-cost and radiation-free alternative to the traditional techniques of fluoroscopic genitography and magnetic resonance imaging. We report a case of a child with ambiguous genitalia whose urogenital sinus anomaly is clearly demonstrated using CEGS and the postprocessing technique of image inversion. This case report shows the utility of CEGS in this patient population and the enhanced conspicuity with image inversion.
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http://dx.doi.org/10.1016/j.radcr.2018.03.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6046367PMC
June 2018

Rater reliability of postnatal urinary tract dilation consensus classification.

Pediatr Radiol 2018 10 20;48(11):1606-1611. Epub 2018 Jun 20.

Division of Body Imaging, Department of Radiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.

Background: A multidisciplinary urinary tract dilation (UTD) classification system was published in 2014 to standardize definitions and renal/bladder ultrasound image interpretation.

Objective: To evaluate intra- and inter-rater reliability of this system on postnatal RBUS.

Materials And Methods: Renal/bladder US of 60 infants (<12 months) with urinary tract dilation were anonymized, retrospectively reviewed and scored twice using the UTD classification system by a pediatric urologist and four pediatric radiologists. Exams included supine and prone images of each kidney. Raters recorded the anterior posterior renal pelvis diameter in each position; and when present calyceal dilation (central and peripheral), ureteral dilation, parenchymal and bladder abnormalities. A UTD score was given to each kidney based on these components.

Results: Intraclass correlation (ICC) of anterior posterior renal pelvis diameter measures was 0.99 (P<0.001). Intra-rater reliability for the anterior posterior renal pelvis diameter of each kidney was high, with ICC >0.95 (P<0.001). Inter-rater kappa values for UTD scores of both kidneys ranged from 0.60 to 0.77 (P <0.001). Intra-rater kappa values for UTD scores of both kidneys ranged from 0.74 to 0.92 (P <0.001). Of the six categories comprising the UTD score, discrepancy between raters was highest for interpretation of central and peripheral calyceal dilation.

Conclusion: Present inter- and intra-rater reliability findings were similar to those previously reported for grading systems for urinary tract dilation. Across these studies, kappa values are generally lower than the 0.8 cut-off advocated for medical measures. Here, calyceal dilation commonly determined the kidney UTD score and was also the source of greatest discrepancy between raters. Improving consistency of calyceal dilation interpretation may improve UTD consensus score reliability.
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http://dx.doi.org/10.1007/s00247-018-4173-1DOI Listing
October 2018

A Low-Cost, Durable and Re-Usable Bladder Phantom: Teaching Intravesical Ultrasound Contrast Administration.

Ultrasound Med Biol 2018 08 22;44(8):1918-1926. Epub 2018 May 22.

Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.

Contrast-enhanced voiding urosonography (ceVUS) is a radiation-free and highly sensitive examination for detecting vesicoureteral reflux and imaging the urethra in children. This examination is performed with ultrasound and intravesical administration of a gas-filled microbubble US contrast agent. The U.S. Food and Drug Administration recently approved the use of a US contrast agent for ceVUS in children. Because of the growing interest among physicians and US technologists in using ceVUS in children, a urinary bladder phantom was developed to teach intravesical ultrasound contrast administration to perform ceVUS procedures. Described here are the preparation and utility of a low-cost, durable and re-usable phantom that simulates the administration, distribution and effects of different US parameters on US contrast agent appearance in the bladder during ceVUS in children.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2018.04.008DOI Listing
August 2018

Pediatric contrast-enhanced ultrasound in the United States: a survey by the Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology.

Pediatr Radiol 2018 06 13;48(6):852-857. Epub 2018 Feb 13.

Division of Pediatric Radiology, Department of Radiology, Georgetown University, Washington, DC, USA.

Background: The United States Food and Drug Administration (FDA) recently approved an ultrasound (US) contrast agent for intravenous and intravesical administration in children.

Objective: Survey the usage, interest in and barriers for contrast-enhanced US among pediatric radiologists.

Materials And Methods: The Contrast-Enhanced Ultrasound Task Force of the Society for Pediatric Radiology (SPR) surveyed the membership of the SPR in January 2017 regarding their current use and opinions about contrast-enhanced US in pediatrics.

Results: The majority (51.1%, 166) of the 325 respondents (26.7% of 1,218) practice in either a university- or academic affiliated group. The most widely used US contrast agent was Lumason® 52.3% (23/44). While lack of expertise and training were reported barriers, all respondents who are not currently using US contrast agents are considering future use.

Conclusion: Interest in pediatric contrast US is very high. Education and training are needed to support members who plan to adopt contrast US into practice.
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http://dx.doi.org/10.1007/s00247-018-4088-xDOI Listing
June 2018

Practical advantages of contrast-enhanced ultrasound in abdominopelvic radiology.

Abdom Radiol (NY) 2018 04;43(4):998-1012

Division of Abdominal Imaging, Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9316, USA.

Computed tomography (CT) and magnetic resonance imaging (MRI) are two of the workhorse modalities of abdominopelvic radiology. However, these modalities are not without patient- and technique-specific limitations that may prevent a timely and accurate diagnosis. Contrast-enhanced ultrasound (CEUS) is an effective, rapid, and cost-effective imaging modality with expanding clinical utility in the United States. In this pictorial essay, we provide a case-based discussion demonstrating the practical advantages of CEUS in evaluating a variety of pathologies in which CT or MRI was precluded or insufficient. Through these advantages, CEUS can serve a complementary role with CT and MRI in comprehensive abdominopelvic radiology.
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http://dx.doi.org/10.1007/s00261-017-1442-7DOI Listing
April 2018
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