- Diagnostic Radiology
- Genitourinary Imaging
- Urology Imaging
- Gynecology Imaging
Clinical Assistant Professor, Radiology
Co-Medical Director, Point of Care Ultrasound (2021 - Present)
Honors & Awards
Distinguished Honors Scholar, University of Cincinnati Honors Program (2008)
Summa Cum Laude, Unversity of Cincinnati (2008)
Phi Beta Kappa Society, University of Cincinnati (2008)
Alpha Omega Alpha Honor Medical Society, University of Cincinnati College of Medicine (2011)
Boards, Advisory Committees, Professional Organizations
Member, Society of Point of Care Ultrasound (2022 - Present)
Member, SRU Research Committee (2022 - 2022)
Editorial board member, European Journal of Radiology Open (EJRO) (2021 - Present)
Member, SAR International Task Force Committee (2021 - Present)
Member, SAR Disease Focused Panel (DFP) Pelvic Floor Dysfunction (2021 - Present)
Member, Society of Radiologists in Ultrasound (SRU) (2021 - Present)
Member, Society of Advanced Body Imaging (SABI) (2021 - 2021)
Member, American College of Radiology (ACR) (2019 - Present)
Member, Society of Abdominal Radiology (SAR) (2019 - Present)
Peer reviewer, European Journal of Radiology (2019 - 2020)
Peer reviewer, Journal of Abdominal Radiology (2018 - Present)
Member, European Society of Radiology (ESR) (2016 - 2020)
Member, Radiological Society of North America (RSNA) (2013 - Present)
Fellowship: UCLA Radiology Fellowships (2018) CA
Residency: UCLA Radiology Residency (2017) CA
Internship: University of California Irvine Dept of Internal Medicine (2013) CA
Medical Education: University of Cincinnati College of Medicine Registrar (2012) OH
Board Certification: American Board of Radiology, Diagnostic Radiology (2018)
Community and International Work
RAD-AID Radiology Serving the World, China
Underserved areas in China
Opportunities for Student Involvement
Current Research and Scholarly Interests
GU and Gyn clinical imaging
Safety of percutaneous, image-guided biopsy of hepatocellular carcinoma with and without concurrent ablation.
Abdominal radiology (New York)
PURPOSE: To determine the prevalence of adverse events after image-guided biopsy of histologically proven hepatocellular carcinomas (HCC) using a standardized, indirect access, coaxial biopsy technique.METHODS: In this IRB-approved, HIPAA compliant, and retrospective study, we evaluated all consecutive adult patients from 2011 to 2016 who underwent image-guided biopsy of HCC with and without concurrent ablation. Tumor seeding was defined as any new lesion along the needle tract on subsequent imaging. Adverse events were graded using both the Clavien-Dindo Complication Classification system and the most recently proposed Society of Interventional Radiology (SIR) Adverse Event Classification System.RESULTS: A total of 383 patients underwent 398 biopsies (64±11years; 112 women, 271 men). Most patients (282; 71%) underwent concurrent ablation. Adverse events occurred after 18 biopsies (4.5%): 13 were Grade I (Clavien-Dindo) or minor (SIR) and included hematoma (7), hepatic vein thrombus (2), portal vein thrombus (2), moderate pleural effusion (1), and small pneumothorax (1). The remaining 5 (1.3%) adverse events were classified as Grade II-IIIa (Clavien-Dindo) or moderate (SIR) and included hematoma requiring blood products (n=1), arrhythmia (n=1), and symptomatic pleural effusions requiring treatment (n=3). Baseline age, sex, cause of liver disease, HCC diameter, and HCC grade were not associated with adverse events. There were no tumor seeding events after a median follow-up of 611days (interquartile range of 211-1104).CONCLUSION: Percutaneous image-guided tissue sampling using a standardized, indirect access, coaxial technique can be performed safely with and without concurrent ablation by trained cross-sectional interventional radiologists at a tertiary liver transplant center.
View details for DOI 10.1007/s00261-022-03494-5
View details for PubMedID 35396970
- Growth kinetics and progression rates of cystic renal masses on active surveillance. LIPPINCOTT WILLIAMS & WILKINS. 2022
Evaluation of early sonographic predictors of gangrenous cholecystitis: mucosal discontinuity and echogenic pericholecystic fat.
Abdominal radiology (New York)
PURPOSE: To identify early sonographic features of gangrenous cholecystitis.MATERIALS AND METHODS: 101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p<0.05 to determine statistical significance.RESULTS: Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67±17 vs 48±18years; p=0.0001), male (ratio of male:female 2:1 vs 0.6:1; p=0.005), tachycardic (60% vs 28%; p=0.001), and diabetic (25% vs 8%; p=0.001). Median time between pre-operative sonogram and surgery was 1day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p=0.001), mucosal discontinuity (p=0.010), and frank perforation (p=0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p=0.104), pericholecystic fluid (p=0.523) or wall striations (p=0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9-11.3) and 14.4 (2.0-106), respectively.CONCLUSION: Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation.
View details for DOI 10.1007/s00261-021-03320-4
View details for PubMedID 34985635
Growth Kinetics and Progression Rate of Bosniak Classification, Version 2019 III and IV Cystic Renal Masses on Imaging Surveillance.
AJR. American journal of roentgenology
Background: Active surveillance is increasingly used as first-line management for localized renal masses. Triggers for intervention primarily reflect growth kinetics, which are poorly investigated for cystic masses defined by Bosniak classification version 2019 (v2019). Objective: To determine growth kinetics and incidence rates of progression of class III and IV cystic renal masses, as defined by Bosniak classification v2019. Methods: This retrospective study included 105 patients (68 men, 37 women; median age, 67 years) with 112 Bosniak v2019 class III or IV cystic renal masses on baseline renal-mass protocol CT or MRI examinations from January 2005 to September 2021. Mass dimensions were measured. Progression was defined as any of: linear growth rate (LGR) ≥5 mm per year (representing clinical guideline threshold for intervention), volume doubling time <1 year, T category increase, or N1 or M1 disease. Class III and IV masses were compared. Time-to-progression was estimated using Kaplan-Meier curve analysis. Results: At baseline, 58 masses were class III and 54 were class IV. Median follow-up was 406 days. Median LGR was for class III masses 0.0 mm per year [interquartile range (IQR) -1.3 to 1.8] and for class IV masses 2.3 mm per year (IQR 0.0¬¬-5.7) (p<.001). LGR exceeded 5 mm per year in 4 (7%) class 3 masses and 15 (28%) class IV masses (p=.005). Two patients, both with class IV masses, developed distant metastases. Incidence rate of progression was for class III masses 11.0 (95% CI 4.5-22.8) and for class IV masses 73.6 (95% CI 47.8-108.7) per 100,000 person-days of follow-up. Median time-to-progression was undefined for class III mases given small number of progression events and 710 days for class IV masses. Hazard ratio of progression for class IV relative to class III masses was 5.1 (95% CI 2.5-10.8) (p<.001). Conclusion: During active surveillance of cystic masses evaluated using Bosniak classification v2019, class IV masses grew faster and were more likely to progress than class III masses. Clinical Impact: In comparison with current active surveillance guidelines that treat class III and IV masses similarly, future iterations may incorporate relatively more intensive surveillance for class IV masses.
View details for DOI 10.2214/AJR.22.27400
View details for PubMedID 35293234
Inflammatory pseudotumor-like follicular dendritic cell tumor of the spleen: a case report and approach to differential diagnosis.
Radiology case reports
2021; 16 (11): 3213-3216
We present a case of an inflammatory pseudotumor-like follicular dendritic cell tumor of the spleen. The patient is a 44-year-old woman, without significant underlying history, who presented with nonspecific abdominal pain for a few months. Both a contrast enhanced computed tomography and magnetic resonance imaging revealed a new 2.5 cm enhancing splenic lesion, which demonstrated hypermetabolic activity on subsequent positron emission tomography and computed tomography scan. Since the lesion was new compared to more remote imaging and hypermetabolic, a splenectomy was performed. Pathology confirmed the diagnosis and demonstrated positivity for Epstein-Barr Virus .
View details for DOI 10.1016/j.radcr.2021.07.078
View details for PubMedID 34484521
Prevalence of Malignancy and Histopathologic Association of Bosniak Classification, Version 2019 Class III and IV Cystic Renal Masses.
The Journal of urology
PURPOSE: Bosniak Classification, version 2019 (v2019) describes two types of class III and IV masses each: 1) thick, wall/septa ≥4 mm (III-WS), 2) obtuse protrusion ≤3 mm (III-OP), 3) obtuse protrusion ≥4 mm (IV-OP), and 4) acute protrusion of any size (IV-AP). The purposes were to determine the prevalence of malignancy and histopathologic features of class III and IV masses and subclasses.MATERIALS AND METHODS: In this IRB-approved and HIPAA-compliant study, three fellowship-trained abdominal radiologists (R1-3) reviewed cystic renal masses that had tissue pathology and pre-operative renal mass protocol CT or MRI. Classes based on v2019 and prior classification systems were retrospectively re-assigned and associated with malignancy, aggressive histologic features (necrosis or high Fuhrman grade), and radiologic progression following resection.RESULTS: The final sample included 79 masses (59 malignant, 20 benign) from 74 patients. Based on v2019, prevalence of malignancy ranged from 56-61% (mean 60%) for class III and 83-83% (mean 83%) for class IV (p=0.036, 0.013, 0.036 for R1-3). Prevalence of malignancy within subclasses were: III-WS (47-53%); III-OP (71-85%); IV-OP (75-87%); IV-AP (87-95%; p=0.029, 0.001, 0.005). All readers were more likely to classify malignancies with aggressive histologic features as class IV (88-100%) rather than class III (0-12%; p=0.012, <0.001, 0.002), corresponding to a negative predictive value of 96-100%. Following treatment (mean follow-up length 1210 days), one patient developed metastases.CONCLUSIONS: Bosniak Classification, version 2019 can help risk stratification of class III-IV masses by identifying those likely to be malignant and have aggressive histologic features.
View details for DOI 10.1097/JU.0000000000001438
View details for PubMedID 33085925
Bosniak Classification of Cystic Renal Masses Version 2019: Comparison of Categorization using CT and MRI.
AJR. American journal of roentgenology
Please see the Author Video associated with this article. Background: Bosniak Classification, version 2019 recently proposed refinements for cystic renal mass characterization and now formally incorporates MRI, which may improve concordance with CT. Purpose: To compare concordance of CT and MRI in evaluation of cystic renal masses using Bosniak Classification, version 2019. Materials and Methods: In this IRB-approved and HIPAA compliant study, three abdominal radiologists (R1-R3) retrospectively reviewed 68 consecutive cystic renal masses from 45 patients assessed with both CT and MR renal mass protocols within a year between 2005-2019. CT and MRI were reviewed independently and in separate sessions, using both the original and version 2019 Bosniak Classification systems. Results: Using Bosniak Classification, version 2019, cystic renal masses were classified into 12 category I, 19 category II, 13 category IIF, 4 category III, and 20 category IV by CT and 8 category I, 15 category II, 23 category IIF, 9 category III, and 13 category IV by MRI. Among individual features, MRI depicted more septa (p<0.001, p=0.046, p=0.005 for R1-R3; McNemar's test) for all radiologists, though both CT and MRI showed a similar number of protrusions (p=0.823, 1.0, 0.302) and maximal septa/wall thickness (p=1.0, 1.0, 0.145). Of discordant cases with version 2019, MRI led to the higher category in 12 masses. Reason for upgrade was most commonly due to protrusions identified only on MRI (n=4), increased number of septa (n=3), and a new category of heterogeneously T1-hyperintense (n=3). Neither modality was more likely to lead to a category change for both version 2019 (p=0.502; McNemar's test) and the original Bosniak classification system (p=0.823). Overall inter-rater agreement was substantial for both CT (κ=0.745) and MRI (κ=0.655) using version 2019 and was slightly higher than that of the original system (CT κ=0.707; MRI κ=0.623). Conclusion: CT and MRI were concordant in the majority of cases using Bosniak Classification, version 2019 and category changes by modality were not statistically significant. Inter-rater agreements were substantial for both CT and MRI. Clinical Impact: Bosniak Classification, version 2019 applied to cystic renal masses has substantial inter-rater agreement and does not lead to systematic category upgrades with either CT or MRI.
View details for DOI 10.2214/AJR.20.23656
View details for PubMedID 32755181
Human-machine partnership with artificial intelligence for chest radiograph diagnosis.
NPJ digital medicine
2019; 2: 111
Human-in-the-loop (HITL) AI may enable an ideal symbiosis of human experts and AI models, harnessing the advantages of both while at the same time overcoming their respective limitations. The purpose of this study was to investigate a novel collective intelligence technology designed to amplify the diagnostic accuracy of networked human groups by forming real-time systems modeled on biological swarms. Using small groups of radiologists, the swarm-based technology was applied to the diagnosis of pneumonia on chest radiographs and compared against human experts alone, as well as two state-of-the-art deep learning AI models. Our work demonstrates that both the swarm-based technology and deep-learning technology achieved superior diagnostic accuracy than the human experts alone. Our work further demonstrates that when used in combination, the swarm-based technology and deep-learning technology outperformed either method alone. The superior diagnostic accuracy of the combined HITL AI solution compared to radiologists and AI alone has broad implications for the surging clinical AI deployment and implementation strategies in future practice.
View details for DOI 10.1038/s41746-019-0189-7
View details for PubMedID 31754637
View details for PubMedCentralID PMC6861262
- Author Correction: Human-machine partnership with artificial intelligence for chest radiograph diagnosis. NPJ digital medicine 2019; 2 (1): 129
- Erratum: Author Correction: Human-machine partnership with artificial intelligence for chest radiograph diagnosis. NPJ digital medicine 2019; 2: 129
Translabial US: Preoperative Detection of Midurethral Sling Erosion in Stress Urinary Incontinence.
2018; 289 (3): 721-727
Purpose To evaluate the performance of translabial (TL) US in preoperative detection of sling erosion into pelvic organs with cystourethroscopic and surgical correlation. Materials and Methods The study cohort included women who underwent surgery at a subspecialty center (from 2008 to 2016) for suspected mesh complications in the setting of previous midurethral sling placement for stress urinary incontinence (from 1999 to 2012) with available preoperative TL US imaging. Clinical information, the finding of sling erosion identified intraoperatively and at cystourethroscopy, and blinded dual-reader radiologic analysis of the TL US studies for mesh location (intraluminal, mural, or extramural) relative to pelvic organs (bladder, urethra, vagina, or rectum) were evaluated. The diagnostic performance of TL US was correlated with the reference standard of surgical findings. The consensus of two radiologists was recorded, and interobserver agreement was evaluated with the κ statistic. Results Of the 124 women who were suspected of having sling erosion (mean age, 57.5 years ± 11.1 [standard deviation]), 15 women (12.1%) had sling erosion into the urethra or bladder at surgery. Sensitivity and specificity for erosion at TL US were 53% (95% confidence interval: 45%, 62%) and 100% (95% confidence interval: 97%, 100%), respectively, when erosion was defined as only intraluminal mesh products. Sensitivity and specificity for erosion at TL US were 93% (95% confidence interval: 89%, 98%) and 72% (95% confidence interval: 65%, 80%), respectively, when erosion was defined as visualizing either intraluminal or intramural mesh products. Interobserver agreement (κ value) was 0.95. Cystourethroscopy had 67% sensitivity and 100% specificity for sling erosion. Conclusion Preoperative translabial US can be used to detect sling erosion into the lower urinary tract, with sensitivity up to 93% and specificity up to 100%. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Benson and Phillips in this issue.
View details for DOI 10.1148/radiol.2018180786
View details for PubMedID 30106346
Pathological and 3 Tesla Volumetric Magnetic Resonance Imaging Predictors of Biochemical Recurrence after Robotic Assisted Radical Prostatectomy: Correlation with Whole Mount Histopathology.
The Journal of urology
2018; 199 (5): 1218-1223
We sought to identify the clinical and magnetic resonance imaging variables predictive of biochemical recurrence after robotic assisted radical prostatectomy in patients who underwent multiparametric 3 Tesla prostate magnetic resonance imaging.We performed an institutional review board approved, HIPAA (Health Insurance Portability and Accountability Act) compliant, single arm observational study of 3 Tesla multiparametric magnetic resonance imaging prior to robotic assisted radical prostatectomy from December 2009 to March 2016. Clinical, magnetic resonance imaging and pathological information, and clinical outcomes were compiled. Biochemical recurrence was defined as prostate specific antigen 0.2 ng/cc or greater. Univariate and multivariate regression analysis was performed.Biochemical recurrence had developed in 62 of the 255 men (24.3%) included in the study at a median followup of 23.5 months. Compared to the subcohort without biochemical recurrence the subcohort with biochemical recurrence had a greater proportion of patients with a high grade biopsy Gleason score, higher preoperative prostate specific antigen (7.4 vs 5.6 ng/ml), intermediate and high D'Amico classifications, larger tumor volume on magnetic resonance imaging (0.66 vs 0.30 ml), higher PI-RADS® (Prostate Imaging-Reporting and Data System) version 2 category lesions, a greater proportion of intermediate and high grade radical prostatectomy Gleason score lesions, higher pathological T3 stage (all p <0.01) and a higher positive surgical margin rate (19.3% vs 7.8%, p = 0.016). On multivariable analysis only tumor volume on magnetic resonance imaging (adjusted OR 1.57, p = 0.016), pathological T stage (adjusted OR 2.26, p = 0.02), positive surgical margin (adjusted OR 5.0, p = 0.004) and radical prostatectomy Gleason score (adjusted OR 2.29, p = 0.004) predicted biochemical recurrence.In this cohort tumor volume on magnetic resonance imaging and pathological variables, including Gleason score, staging and positive surgical margins, significantly predicted biochemical recurrence. This suggests an important new imaging biomarker.
View details for DOI 10.1016/j.juro.2017.10.042
View details for PubMedID 29128577
View details for PubMedCentralID PMC6946378
Automatic Classification of Ultrasound Screening Examinations of the Abdominal Aorta.
Journal of digital imaging
2016; 29 (6): 742-748
Our work facilitates the identification of veterans who may be at risk for abdominal aortic aneurysms (AAA) based on the 2007 mandate to screen all veteran patients that meet the screening criteria. The main research objective is to automatically index three clinical conditions: pertinent negative AAA, pertinent positive AAA, and visually unacceptable image exams. We developed and evaluated a ConText-based algorithm with the GATE (General Architecture for Text Engineering) development system to automatically classify 1402 ultrasound radiology reports for AAA screening. Using the results from JAPE (Java Annotation Pattern Engine) transducer rules, we developed a feature vector to classify the radiology reports with a decision table classifier. We found that ConText performed optimally on precision and recall for pertinent negative (0.99 (0.98-0.99), 0.99 (0.99-1.00)) and pertinent positive AAA detection (0.98 (0.95-1.00), 0.97 (0.92-1.00)), and respectably for determination of non-diagnostic image studies (0.85 (0.77-0.91), 0.96 (0.91-0.99)). In addition, our algorithm can determine the AAA size measurements for further characterization of abnormality. We developed and evaluated a regular expression based algorithm using GATE for determining the three contextual conditions: pertinent negative, pertinent positive, and non-diagnostic from radiology reports obtained for evaluating the presence or absence of abdominal aortic aneurysm. ConText performed very well at identifying the contextual features. Our study also discovered contextual trigger terms to detect sub-standard ultrasound image quality. Limitations of performance included unknown dictionary terms, complex sentences, and vague findings that were difficult to classify and properly code.
View details for DOI 10.1007/s10278-016-9889-6
View details for PubMedID 27400914
View details for PubMedCentralID PMC5114229
MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and Guyon's canal.
2015; 40 (2): 263-74
Ulnar neuropathy is a common and frequent reason for referral to hand surgeons. Ulnar neuropathy mostly occurs in the cubital tunnel of the elbow or Guyon's canal of the wrist, and it is important for radiologists to understand the imaging anatomy at these common sites of impingement. We will review the imaging and anatomy of the ulnar nerve at the elbow and wrist, and we will present magnetic resonance imaging examples of different causes of ulnar neuropathy, including trauma, overuse, arthritis, masses and mass-like lesions, and systemic diseases. Treatment options will also be briefly discussed.
View details for DOI 10.1016/j.clinimag.2015.11.008
View details for PubMedID 26995584