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

Pediatric primary liver tumors, including hepatoblastoma and hepatocellular carcinoma (HCC), are staged according to the PRETEXT system (PRE-Treatment EXTent of Tumor). Although primary hepatic tumors are rare in the pediatric population, hepatoblastoma is increasing in prevalence due to its association with prematurity and the prolonged survival of this patient population. Therefore, it is prudent for radiologists to refamiliarize themselves with these malignancies and how to accurately describe their imaging appearance using descriptors defined by PRETEXT. Various imaging modalities offer a role in the evaluation of primary hepatic tumors, including ultrasound (US), magnetic resonance (MR), and computed tomography (CT). Contrast enhanced ultrasound (CEUS) is not currently a primary modality but has potential to evaluate vascular involvement and satellite lesions. PRETEXT is the standard to describe a tumor’s imaging features on CT or MR; MR is preferred due to improved soft tissue detail, and emphasis is placed on use of a hepatobiliary contrast agent. For PRETEXT staging, the liver is divided into four sections: right posterior, right anterior, left medial, and left lateral. Depending on the number of continuous, uninvolved sections, patients are assigned a group ranging from I-IV. Tumors are often large at presentation, and determination of anatomic boundaries can be challenging for the radiologist. Other special circumstances discussed include variant hepatic venous anatomy and pedunculated tumors. PRETEXT also considers “annotation factors”, such as vascular involvement, tumor rupture, and metastases, among others. In combination with clinical factors, such as the patient's age and alpha-fetoprotein (AFP) level, PRETEXT is also used to stratify patient risk and ultimately influence patient management. If the tumor is not resectable upfront, percutaneous biopsy is recommended to confirm the diagnosis. First line therapy includes surgical resection and systemic chemotherapy. In cases not amenable to this treatment, palliative options offered by pediatric interventional radiology include transarterial chemoembolization (TACE) and percutaneous ablation. The goal of this educational exhibit is to provide a case-based illustration of PRETEXT staging and annotations factors for the pediatric radiologist. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Lee Samantha, Cajigas-loyola Stephanie, Acord Michael

Keywords: PRETEXT, Primary Hepatic Tumor, Staging