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Departments ■
This Month in Radiology
©RSNA, 2009
US Followed by CT Cost-Effective for Diagnosing Pediatric Appendicitis
For diagnosis of pediatric appendicitis, a cost-effective method is to start with US (especially
when prevalence is extremely low) and follow negative US findings with CT. In a Markov-
based model comprising lifetime radiation risk, societal willingness to pay, and other fac-
tors, Wan and colleagues found that US followed by CT was a cost-effective imaging strategy
in children as young as 5 years old. Acknowledging that clinicians should avoid radiation
exposure to children whenever possible, the researchers said they hoped the study would
encourage clinicians to recognize that the use of CT is justified when the diagnosis of
appendicitis is in question, especially in those cases when US is inconclusive. ❚ Page 378
CT Texture Analysis Predicts Colorectal Cancer Survival
Texture analysis shows promise as a potential biomarker for survival in patients with col-
orectal cancer. In an evaluation of 48 patients, Miles and colleagues found that a texture pa-
rameter comparing the uniformity of distribution of CT image features between 10 and 12
pixels, when applied to portal phase CT of the liver, can help identify patients who had poor
survival outcomes. The researchers concluded that the method is potentially a better pre-
dictor of survival in patients with colorectal cancer than CT perfusion imaging. ❚ Page 444
CT Excludes Appendicitis, Even When the Appendix Is Not Visualized
The accuracy of excluding the diagnosis of appendicitis on a normal pediatric abdomi-
nopelvic CT image with a nonvisualized appendix is similar to that obtained in cas-
es with a partially or even fully visualized appendix. In a study of 156 children sus-
pected of having appendicitis, Garcia and colleagues found that while the amount
of pericecal fat correlated positively with the detectability of the appendix, CT im-
ages with nonvisualized appendix yielded a high negative predictive value similar to
that of CT images with a partially or fully visualized appendix. The false-negative
rate was similar to those in two adult series, the researchers observed. ❚ Page 531
Consensus Panel Improves Breast Screening Diagnosis, Reduces Recall Rates
A consensus review of cases with discordant findings increases the number of malignant
cancers diagnosed, reduces unwarranted patient recall, and is associated with a low
false-negative rate. Shaw and colleagues found that the Irish National Breast Screen-
ing Program consensus panel—which reviewed 1% of the 128 569 screening cases—
identified 7.33% of the 968 cancers diagnosed in the screening population, with an
overall recall rate of 4.41%. The researchers concluded this method facilitates the
early diagnosis of cancers with subtle findings on mammograms while significant-
ly reducing the number of normal cases recalled for further assessment. ❚ Page 354
Combined CT Protocol Cuts Time to Differentiate Adrenal Adenomas from Nonadenomas
A combined diagnostic CT protocol for distinguishing adrenal adenomas from non-
adenomas with a short examination time yields results comparable to those with
longer protocols. In a retrospective study of CT diagnostic parameters in 61 pa-
tients, Kamiyama and colleagues found that combined use of unenhanced CT at-
tenuation, 5-minute enhanced CT attenuation, percentage enhancement washout
ratio, and relative percentage enhancement washout ratio yielded high specific-
ity in diagnosing total adrenal adenomas and lipid-poor adenomas. The researchers
concluded that the combined methods demonstrate high diagnostic accuracy with a
shorter examination time than does a standard 10-minute protocol. ❚ Page 474
Radiology: Volume 250: Number 2—February 2009 3A

2. THIS MONTH IN Radiology ■ ContinueD
Functional MR Demonstrates Early Transarterial Chemoembolization Response in
Hepatocellular Carcinoma
Functional MR imaging of hepatocellular carcinoma demonstrates vascular and cellu-
lar response to transarterial chemoembolization (TACE) well before changes in tumor
size occur. In 24 patients who underwent TACE, Kamel and colleagues found a signif-
icant persistent reduction in tumor enhancement within 24 hours after treatment, as
well as changes in apparent diffusion coefficient values during the following weeks. Tu-
mor size remained unchanged up to 4 weeks after therapy. The researchers conclud-
ed functional images depicting vascularization and cellularity may be an early indica-
tor of TACE response and should be incorporated into early assessment. ❚ Page 466
An editorial by Padhani accompanies this article (p 324).
Right Pulmonary Artery Distensibility Assists Pulmonary Hypertension Diagnosis
Measuring right pulmonary artery (RPA) distensibility on electrocardiographi-
cally gated multidetector CT can improve diagnosis of pulmonary hypertension. In
45 patients, Revel and colleagues evaluated RPA distensibility, as well as right ven-
tricular outflow tract myocardial thickness, diameter, and cross-sectional area, dur-
ing the systole and diastole. They found the largest area under the receiver oper-
ating characteristic curve for RPA distensibility, which also showed the closest corre-
lation with mean pulmonary arterial pressure. RPA distensibility could be useful for
pulmonary hypertension risk stratification, the researchers concluded. ❚ Page 558
Airflow Obstruction from Asthma Persists Despite Treatment, Disease Severity
MR imaging with hyperpolarized helium 3 (3He) reveals that focal airflow impediment
within the lungs of asthma patients can persist over time. de Lange and colleagues ob-
served in 26 patients imaged twice on the same day that 75% of focal airway narrow-
ing defects remained in the same location, with 71% remaining unchanged in size. The
researchers observed in another 17 patients imaged on multiple days that up to 67% of
defects persisted between the first and second examinations, with 46%–58% remaining
unchanged in size. More than a third of defects remained in the same location after ap-
proximately 3 months, the researchers noted, and more than 50% of those defects did not
change in size. The persistence of regional airflow impediment was independent of disease
severity or whether patients used asthma medications, the researchers found. They con-
cluded that 3He MR imaging improves understanding of the changes in regional airflow
obstruction occurring over time within the lungs of patients with asthma. ❚ Page 567
PET/CT Algorithm Refines Characterization of Adrenal Nodules in Lung Cancer
A proposed combined PET/CT algorithm for evaluating adrenal nodules provides more
definitive characterization in patients known to have or suspected of having lung can-
cer. In 147 patients with 187 adrenal nodules, Brady and colleagues found that com-
bined PET/CT criteria utilizing a standardized uptake value (SUV) of the most intense
pixel within the adrenal nodule (maximum SUV) of greater than 3.1 and hyperattenua-
tion (>10 HU) was highly sensitive for depicting metastatic nodules, and applying a fur-
ther cutoff—ratio of nodule maximum SUV to liver average SUV greater than 2.5—identi-
fied 22 of 37 metastatic lesions and excluded all fluorodeoxyglucose-avid benign nodules.
The proposed algorithm refines adrenal nodule characterization, the researchers con-
cluded, and can spare some patients from undergoing further interventions. ❚ Page 523
In Patients with Intermittent Claudication Supervised Exercise Offers Same Benefits as
Endovascular Revascularization
Patients with intermittent claudication who undergo a supervised exercise program may ex-
perience the same benefits within a year of intervention as those who undergo endovascular
revascularization. Spronk and colleagues observed 151 patients who either underwent en-
dovascular revascularization with an angioplasty-first approach or participated in hospital-
based supervised exercise. The researchers found that, while patients who underwent en-
dovascular revascularization saw more immediate improvement in functional capacity and
quality of life, there was no significant difference in these parameters between the two treat-
ment groups after 6 months and 12 months. The researchers noted that the findings may lead
to further investigation of supervised exercise in addition to revascularization. ❚ Page 586
4A Radiology: Volume 250: Number 2—February 2009

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