We analysed magnetic resonance imaging (MRI) findings after traumatic brain injury (TBI) aiming to improve the grading of traumatic axonal injury (TAI) to better reflect the outcome. Four-hundred sixty-three patients (8–70 years) with mild (n = 158), moderate (n = 129), or severe (n = 176) TBI and early MRI were prospectively included. TAI presence, numbers, and volumes at predefined locations were registered on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging, and presence and numbers on T2*GRE/SWI. Presence and volumes of contusions were registered on FLAIR. We assessed the outcome with the Glasgow Outcome Scale Extended. Multivariable logistic and elastic-net regression analyses were performed. The presence of TAI differed between mild (6

Background and aimsTumour rupture (TR) signifies stage III disease and requires treatment intensification, which includes radiotherapy. We studied the associations between radiological, surgical and pathology TR in children with Wilms tumour (WT) in a United Kingdom multicentre clinical study.Patients and methodsThe IMPORT (Improving Population Outcomes for Renal Tumours of Childhood) study registered 712 patients between 2012 and 2021. Children with TR on central radiology review (CRR) at diagnosis and/or indication of preoperative TR on surgical forms were included. Correlation between radiology/surgery/pathology findings was made.ResultsTotal 141 patients had TR identified (69 on CRR, 43 on surgical form and 29 on both), and 124/141 had images available for CRR, and 98/124 had features suggestive of TR on diagnostic CRR (63 magnetic resonance imaging/35 computed tomography). TR was limited to the renal fossa in 47/98 (48%) and intraperitoneal in 51/98 (52%). Three of 98(3%) had upfront surgery, and 87/95 (92%) had TR confirmed on post-chemotherapy preoperative scans. Among 80/98 (82%) cases with TR on CRR and available surgical forms, TR was not confirmed on surgery or pathology in 38/80, giving a false-positive rate of 48%. Preoperative TR was indicated on 72 surgical forms, with images available for CRR in 55. Twenty-six of 55 (47%) were false-negative for TR on CRR and of those 10/26 (38%) had TR confirmed on pathology.ConclusionsRadiology alone should not be used to define TR, as it does not accurately correlate with surgical or pathology findings, and therefore cannot be relied upon for definitive staging and treatment. A multidisciplinary team should take the decision regarding the final abdominal stage and treatment using a multimodality approach considering clinical, radiological, surgical and pathological findings.

PURPOSE International comparisons of patient demographics, tumor characteristics, and survival can shed light on areas for health care system improvement. The International Society of Pediatric Oncology Wilms Tumor 2001 trial/study registered patients through national clinical study groups in Western Europe and Brazil. This retrospective post hoc analysis of the International Society of Pediatric Oncology Wilms Tumor 2001 database aims to make visible and suggest reasons for any variations in outcomes. METHODS All patients with unilateral Wilms tumor (WT), age > 6 months, treated with preoperative chemotherapy as per protocol, and registered between 2001 and 2011 were eligible. Countries were grouped to give comparable case numbers and geographical representation. Cox univariable and multivariable (MVA) statistics were applied, with the German collaborative group (Gesellschaft für Pädiatrische Onkologie und Hämatologie—Austria, Germany, and Switzerland) as reference for hazard ratios for event-free survival (EFS) and overall survival (OS). RESULTS A total of 3,176 eligible patients were registered from 24 countries assigned into six groups. Age and histologic risk group distribution were similar across all groupings. The distribution of WT stage varied by country grouping, with 14.9% (range, 11.1%-18.2%) metastatic at diagnosis. Median follow-up was 78.9 months. For localized WT, 5-year EFS varied from 80% (Brazilian group) to 91% (French group; P < .0001), retaining significance only for Brazil in MVA ( P = .001). Five-year OS varied from 89% (Brazilian group) to 98% (French group; P < .0001). In MVA, only superior OS in France was significant ( P = .001). Five-year EFS/OS for stage IV did not vary significantly. High-risk histology and tumor volume at surgery were significantly associated with increased risk of death in MVA for metastatic disease. CONCLUSION International benchmarking of survival rates from WT within a large trial/study database has demonstrated statistically significant differences. Clinical interpretation should take account of variation in tumor stage but also treatment factors.

Objectives To investigate the reliability and agreement of hand-held ultrasound devices (HUDs) compared with conventional duplex ultrasound (HIGH) in examination for carotid stenosis in patients with suspected transitory ischaemic attack (TIA) or ischaemic stroke. Methods Cardiologists, experienced in carotid ultrasound, examined patients admitted to a community hospital with suspected stroke or TIA. Patients were first examined by an HUD and second by HIGH as per usual care. Different operators performed HUD and HIGH blinded to each other. On clinical discretion, CT angiography (CTA) was performed, and analysed by a radiologist blinded to the results from the ultrasound. Results Of 80 patients included, 9 (11%) were found to have >50% internal carotid artery (ICA) stenosis on reference examination. Agreement for classification of the degree of ICA stenosis was good for HUD versus HIGH (weighted Kappa 0.76) and HUD versus CTA (weighted Kappa 0.66). Agreement between HUD and HIGH examinations was excellent when ICA was classified as <50% diameter stenosis by HUD (99% agreement), but significantly lower when ICA diameter stenosis was classified as >50% by HUD (OR 0.15, 95% CI 0.06 to 0.42). Overall, HUD tended to overestimate the degree of carotid stenoses rather than underestimate (p=0.048). Conclusion Hand-held carotid ultrasound performed by experts demonstrated good agreement with conventional duplex ultrasound. The use of HUDs was reliable for ruling out significant carotid artery disease, but less reliable for ruling in significant disease.

Background and purpose: To evaluate the feasibility and clinical influence of carotid artery examinations in patients admitted with stroke or TIA with hand-held ultrasound by experts, to identify individuals not in need of further carotid artery diagnostics. Materials and methods: Cardiologists experienced in carotid ultrasound examined 80 patients admitted to a stroke unit with suspected stroke or TIA with hand-held ultrasound devices (HUD). Grey scale and color Doppler images were stored using a GE Vscan with dual probe (phased array and linear transducer). High-end triplex ultrasound performed by a cardiologist, blinded to the details of the HUD study, was performed in all patients and used as reference. Computer tomography angiography was performed when clinically indicated. Results: Stroke or TIA was diagnosed in 62 (78%) patients. Age was median (range) 72 (23-93) years. A significant stenosis (> 50% diameter reduction) was ruled out in 61 (76%) of patients by the HUD examinations. Sensitivity and specificity for diagnosing a significant stenosis was 92% and 93%, respectively. One of 12 significant stenoses was missed by HUD. All four patients in need of surgery were identified by the HUD examination. Sensitivity and specificity to identify a significant stenosis by HUD was 87% and 83%, respectively, compared to CT angiography. Conclusion: HUD examinations of the carotid arteries by experts, using hand-held ultrasound devices, were feasible and may reduce the need for high-end diagnostic imaging of the carotid vessels in patients with stroke and TIA. Thus, HUD may improve diagnostic workflow in stroke units in the future.

BackgroundThe SIOP‐Renal Tumor Study Group (RTSG) does not advocate invasive procedures to determine histology before the start of therapy. This may induce misdiagnosis‐based treatment initiation, but only for a relatively small percentage of approximately 10% of non‐Wilms tumors (non‐WTs). MRI could be useful for reducing misdiagnosis, but there is no global consensus on differentiating characteristics.PurposeTo identify MRI characteristics that may be used for discrimination of newly diagnosed pediatric renal tumors.Study TypeConsensus process using a Delphi method.PopulationNot applicable.Field Strength/SequenceAbdominal MRI including T1‐ and T2‐weighted imaging, contrast‐enhanced MRI, and diffusion‐weighted imaging at 1.5 or 3 T.AssessmentTwenty‐three radiologists from the SIOP‐RTSG radiology panel with ≥5 years of experience in MRI of pediatric renal tumors and/or who had assessed ≥50 MRI scans of pediatric renal tumors in the past 5 years identified potentially discriminatory characteristics in the first questionnaire. These characteristics were scored in the subsequent second round, consisting of 5‐point Likert scales, ranking‐ and multiple choice questions.Statistical TestsThe cut‐off value for consensus and agreement among the majority was ≥75% and ≥60%, respectively, with a median of ≥4 on the Likert scale.ResultsConsensus on specific characteristics mainly concerned the discrimination between WTs and non‐WTs, and WTs and nephrogenic rest(s) (NR)/nephroblastomatosis. The presence of bilateral lesions (75.0%) and NR/nephroblastomatosis (65.0%) were MRI characteristics indicated as specific for the diagnosis of a WT, and 91.3% of the participants agreed that MRI is useful to distinguish NR/nephroblastomatosis from WT. Furthermore, all participants agreed that age influenced their prediction in the discrimination of pediatric renal tumors.Data ConclusionAlthough the discrimination of pediatric renal tumors based on MRI remains challenging, this study identified some specific characteristics for tumor subtypes, based on the shared opinion of experts. These results may guide future validation studies and innovative efforts.Level of Evidence: 3Technical Efficacy Stage: 3

Chapter 3 discusses cancer diagnosis, risk stratification, and therapeutic choices in children and young people. Radiological investigations support the diagnosis and provide staging information for accurate risk stratification. Interventional radiology is useful for obtaining tissue for pathological examination. Histopathology and molecular studies define the precise tumour type and subtype and are used to confirm or rule out the presence of metastatic disease. Post-operative histopathology defines the extent of spread and is important for the staging of some tumours. Together, these findings inform multidisciplinary team discussion and help to identify the best treatment schedule. A significant proportion of cancers have a genetic basis, and it is important to identify these from the family history, predisposing syndromes, or tumour type. Modern molecular genomic techniques have made definitive diagnosis easier. Some genetic conditions lead to increased radiosensitivity and may predispose the patient to excessive radiation-related morbidity and a high risk of second primary tumours.

Chapter 7 discusses paediatric extracranial solid tumours. Paediatric extracranial solid tumours are very diverse. They include soft tissue and bone sarcomas, embryonal tumours such as neuroblastoma and Wilms tumour, and carcinomas. The prognosis of each type varies considerably depending on stage, tumour biology, and other factors. Careful risk stratification is necessary to determine the best approach to treatment. This is often multimodal, usually including chemotherapy and surgery, and sometimes radiotherapy. It is often possible to avoid radiotherapy in the better-prognosis risk groups, reserving this treatment, and the associated late effects, for those with the worst outlook. A strong evidence base has developed for the most common tumour types, but further clinical trials are required to optimize the role of radiotherapy.

OBJECTIVEThe aim in this study was to investigate if MRI findings of traumatic axonal injury (TAI) after traumatic brain injury (TBI) are related to the admission Glasgow Coma Scale (GCS) score and prolonged duration of posttraumatic amnesia (PTA).METHODSA total of 490 patients with mild to severe TBI underwent brain MRI within 6 weeks of injury (mild TBI: median 2 days; moderate to severe TBI: median 8 days). The location of TAI lesions and measures of total TAI lesion burden (number and volume of lesions on FLAIR and diffusion-weighted imaging and number of lesions on T2*-weighted gradient echo or susceptibility-weighted imaging) were quantified in a blinded manner for clinical information. The volume of contusions on FLAIR was likewise recorded. Associations between GCS score and the location and burden of TAI lesions were examined with multiple linear regression, adjusted for age, Marshall CT score (which includes compression of basal cisterns, midline shift, and mass lesions), and alcohol intoxication. The predictive value of TAI lesion location and burden for duration of PTA > 28 days was analyzed with multiple logistic regression, adjusted for age and Marshall CT score. Complete-case analyses of patients with TAI were used for the regression analyses of GCS scores (n = 268) and PTA (n = 252).RESULTSTAI lesions were observed in 58% of patients: in 7% of mild, 69% of moderate, and 93% of severe TBI cases. The TAI lesion location associated with the lowest GCS scores were bilateral lesions in the brainstem (mean difference in GCS score -2.5), followed by lesions bilaterally in the thalamus, unilaterally in the brainstem, and lesions in the splenium. The volume of TAI on FLAIR was the measure of total lesion burden most strongly associated with the GCS score. Bilateral TAI lesions in the thalamus had the largest predictive value for PTA > 28 days (OR 16.2, 95% CI 3.9-87.4). Of the measures of total TAI lesion burden, the FLAIR volume of TAI predicted PTA > 28 days the best.CONCLUSIONSBilateral TAI lesions in the brainstem and thalamus, as well as the total volume of TAI lesions on FLAIR, had the strongest association with the GCS score and prolonged PTA. The current study proposes a first step toward a modified classification of TAI, with grades ranked according to their relation to these two measures of clinical TBI severity.

Imaging has a key role in the assessment of paediatric renal tumours, especially when the initial treatment approach is to proceed to standard chemotherapy without histological confirmation. In Europe, according to the International Society of Paediatric Oncology guidelines, core needle biopsy is not routinely done unless the child is older than 10 years. Between age 6 months and 9 years, the child is treated with a standard regimen of preoperative chemotherapy unless there are concerns about non-Wilms' tumour pathology. Atypical imaging findings could therefore stratify a child into a different treatment protocol, and can prompt the need for pretreatment histology. This review details the latest protocols and techniques used in the assessment of paediatric renal tumours. Important imaging findings are discussed, especially the features that might prompt the need for a pretreatment biopsy. Local radiology practices vary, but both MRI and CT are widely used as routine imaging tests for the assessment of paediatric renal tumours in Europe. Advances in imaging technology and MRI sequences are facilitating the development of new techniques, which might increase the utility of imaging in terms of predicting tumour histology and clinical behaviour. Several of these new imaging techniques are outlined here.

Objectives To investigate the extent to which observer variability of CT lung nodule assessment may affect clinical treatment stratification in Wilms Tumor (WT) patients, according to the recent SIOP-RTSG UMBRELLA protocol. Methods I: CT thoraces of children with WT submitted for central review, were used to estimate size distribution of lung metastases. II: Scans were selected for blinded review by five radiologists to determine intra and inter-observer variability. They assessed identical scans on two occasions six months apart. III: Monte Carlo simulation (MCMC) was used to predict the clinical impact of observer variation when applying the UMBRELLA protocol size criteria. Results Lung nodules were found in 84 out of 360 (23%) children with WT. For 21 identified lung nodules, inter-observer limits of agreement (LOA) for the five readers were ±2.4mm and ±1.4mm (AP diameter), ±1.9mm and ±1.8mm (TS diameter) and ±2.0mm and ±2.4mm (LS diameter) at assessments 1 and 2. Intra-observer LOA across the three dimensions were ±1.5mm, ±2.2mm, ±3.5mm, ±3.1mm and ± 2.6mm (readers 1-5). MCMC demonstrated that 17% of the patients with a ‘true’ nodule size of 3mm will be scored as <3 mm, and 21% of the patients with a ‘true’ nodule size of <3mm will be scored as being 3 mm. Conclusion A significant intra-inter observer-variation was found when measuring lung nodules on CT for patients with WT. This may have significant implications on treatment stratification, and thereby outcome, when applying a threshold of 3 mm for a lung nodule to dictate metastatic status.

Chapter 8 discusses lymphoid and haematological malignancy and related conditions in children and young people. Radiotherapy is less frequently used in haematological malignancy and allied disorders than it once was. In Hodgkin lymphoma, better risk stratification, more effective systemic therapy and the use of 18F-fluoro-deoxyglucose positron emission tomography (18F-FDG-PET) imaging to assess response to chemotherapy have facilitated a safe reduction in the indications for radiotherapy. Nonetheless, radiotherapy remains an important component of multimodality therapy in patients with advanced or poorly responding disease. In acute leukaemia, radiotherapy is no longer used as part of first-line treatment schedules. Instead, it is reserved for refractory and relapsed disease. Total body irradiation remains valuable as part of conditioning prior to haemopoietic stem cell transplantation. Cranial and testicular radiotherapy is helpful for selected patients who relapse in these sanctuary sites. Radiotherapy is also indicated infrequently in some unusual and benign haematological conditions.

Diagnostic medical imaging is central to almost all areas of modern medical practice and advances at an astonishing pace. Since the prior edition, there have been numerous significant advances in thoracic imaging, particularly in CT, with better image quality despite lower radiation exposures, and in MRI, with many new structural and, more excitingly, functional and quantitative techniques reported in the literature. As before, the authors review the technical details of imaging modalities and describe imaging findings, in their clinical context, starting with plain radiography and progressing to CT, MRI, and ultrasound, extensively illustrated throughout. There have been many additions to the previous edition including computed radiology measures from CT in suppurative lung disease and new representative radiation dose exposures from the current top of the line CT scanners; new respiratory applications of MRI with both structural and quantitative ventilation and perfusion techniques and a critical review of thoracic applications of ultrasound. A further resource has been provided, with the addition of online videos explaining CT reconstruction techniques, dynamic examples of fluoroscopic and ultrasound examination of respiratory disorders, and several imaging cases.

Background Wilms' tumour is the most common renal cancer in childhood and about 15% of patients will relapse. There is scarce evidence about optimal surveillance schedules and methods for detection of tumour relapse after therapy. Methods The Renal Tumour Study Group-International Society of Paediatric Oncology (RTSG-SIOP) Wilms' tumour 2001 trial and study is an international, multicentre, prospective registration, biological study with an embedded randomised clinical trial for children with renal tumours aged between 6 months and 18 years. The study covers 243 different centres in 27 countries grouped into five consortia. The current protocol of SIOP surveillance for Wilms' tumour recommends that abdominal ultrasound and chest x-ray should be done every 3 months for the first 2 years after treatment and be repeated every 4-6 months in the third and fourth year and annually in the fifth year. In this retrospective cohort study of the protocol database, we analysed data from participating institutions on timing, anatomical site, and mode of detection of all first relapses of Wilms' tumour. The primary outcomes were how relapse of Wilms' tumour was detected (ie, at or between scheduled surveillance and with or without clinical symptoms, scan modality, and physical examination) and to estimate the number of scans needed to capture one subclinical relapse. The RTSG-SIOP study is registered with Eudra-CT, number 2007-004591-39. Findings Between June 26, 2001, and May 8, 2015, of 4271 eligible patients in the 2001 RTSG-SIOP Wilms' tumour database, 538 (13%) relapsed. Median follow-up from surgery was 62 months (IQR 32-93). The method used to detect relapse was registered for 410 (76%) of 538 relapses. Planned surveillance imaging captured 289 (70%) of these 410 relapses. The primary imaging modality used to detect relapse was reported for 251 patients, among which relapse was identified by abdominal ultrasound (80 [32%] patients), chest x-ray (78 [31%]), CT scan of the chest (64 [25%]) or abdomen (20 [8%]), and abdominal MRI (nine [4%]). 279 (68%) of 410 relapses were not detectable by physical examination and 261 (64%) patients did not have clinical symptoms at relapse. The estimated number of scans needed to detect one subclinical relapse during the first 2 years after nephrectomy was 112 (95% CI 106-119) and, for 2-5 years after nephrectomy, 500 (416-588). Interpretation Planned surveillance imaging captured more than two-thirds of predominantly asymptomatic relapses of Wilms' tumours, with most detected by abdominal ultrasound, chest x-ray, or chest CT scan. Beyond 2 years post-nephrectomy, a substantial number of surveillance scans are needed to capture one relapse, which places a burden on families and health-care systems. Copyright (c) 2018 Elsevier Ltd. All rights reserved.