The investigation of vesicoureteral reflux (VUR) has been a long standing practice in pediatric radiology, traditionally accomplished using voiding cystourethrogram (VCUG). However, our institution demonstrates that the days of lead aprons and iodinated radiation may be behind us. Contrast-enhanced voiding urosonography (CeVUS) offers a safer, more sensitive alternative to VCUG in the diagnosis of VUR. Residents practicing at this children’s hospital are exposed to and assist with CeVUS at an early stage in their training, enabling their familiarity and understanding of the modality to facilitate medical society’s shift from fluoroscopic technique. Residents on their pediatric radiology rotation are expected to engage in the performance of CeVUS exams and in the dictation of associated reports. They quickly learn that the technical aspects of VCUG and CeVUS are very similar involving aseptic bladder catheterization, intravesicular instillation of contrast, and subsequent imaging of the urinary tract system. The sonographic contrast agent of choice is Lumason, a safe second generation microbubble formulation. Trainees also learn that the international grading system of VUR is maintained across the two modalities. Most importantly, however, is the lesson that CeVUS more frequently captures the clinically significant grades of VUR. This concept may be two fold. Firstly, the reflux of microbubbles into the kidney has greater visibility than that of its iodinated counterpart on fluoroscopy. Secondly, in order to reduce radiation-associated adverse effects of VCUG, radiologists will perform “pulse sequencing”, which potentiates missed episodes of VUR. The field of pediatrics is certainly amidst a cultural shift with increasing awareness of the benefits and utility of contrast-enhanced ultrasonography. CeVUS is simply one example. Radiology residents at this institution are actively involved with this newer modality early in their training. This report demonstrates radiology residents performing these exams with supervision by the attending radiologist. CeVUS has been added to the teaching curriculum in pediatric radiology at our institution. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Lee Samantha, Amodio John

Keywords: vesicoureteral reflux

Peritoneal disease in the pediatric population is exceedingly rare. When encountered, differential diagnoses typically include infection, inflammation, and metastatic disease. However, we report a case of malignant epithelial peritoneal mesothelioma to emphasize that this primary malignancy should also be considered. A 14 year old male with a history of growth hormone deficiency, gastroesophageal reflux disease, and asthma presented to his primary care physician with chronic abdominal pain, mild anemia, and over 20 pound weight loss in a 9 month period. Outpatient workup by gastroenterology showed elevated ESR and CRP and a single hyperplastic polyp on endoscopy. MRI enterography of the abdomen and pelvis with intravenous contrast was completed to evaluate for inflammatory bowel disease. This exam revealed a thickened omentum, hyperenhancement of the peritoneum and omentum, peritoneal nodularity, a moderate to large volume of ascites, and enhancing nodules along the superior surface of the diaphragm. The nodules were further evaluated with a dedicated CT chest, abdomen, and pelvis, which confirmed the above findings. Differential diagnosis of an abdominal mesothelial process as above includes familial mediterreanean fever, malignancy, and infection. Laparoscopic omental and peritoneal biopsies showed mesothelial hyperplasia. Genetic testing returned positive for a CDKN2A homozygous and heterozygous deletion, confirming the diagnosis of diffuse malignant peritoneal mesothelioma. The patient is currently under treatment with a cisplatin-based chemotherapy regimen and is being closely followed. Our case exemplifies the symptoms, imaging findings, diagnosis, and treatment associated with malignant epithelial peritoneal mesothelioma. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Lee Samantha, Bellew Elizabeth, Amodio John

Keywords: Mesothelioma, Peritoneal Mesothelioma