5th Nordic Course, Oslo Imaging of body-packing: the Geneva experience
Pierre-Alexandre Poletti Emergency Radiology Unit University Hospital, Geneva
Courtesy of Dr Laurent Getaz, Geneva Univ. Hosp. © Hôpitaux Universitaires de Genève
2
Geneva = Amsterdam: 1.5 g cocaine /1000 inhabitants/day Oslo: 0.15 g / 1000 / day
© Hôpitaux Universitaires de Genève
3
© Hôpitaux Universitaires de Genève
4
Bogusz et al
Journal of Forensic Sciences 1995
Frankfurt airport, 1993 (n=33) « Only 30% urine samples […] showed cocain despite large quantities of body-packets (BP) … On the contrary, in all cases, abdominal radiograph gave unequivocally positive results » © Hôpitaux Universitaires de Genève
5
Imaging of swallowed intracorporeal containers (BP) Abdominal radiograph most frequently used imaging procedure
© Hôpitaux Universitaires de Genève
6
Abdominal radiograph
© Hôpitaux Universitaires de Genève
7
Geneva, 2005 Antinarcotic police officers’ complaints
Impression that more and more radiographs are falsely reported as negative What is their value for depiction of BP ? How can we improve the detection of BP ?
© Hôpitaux Universitaires de Genève
8
Abdominal CT Very accurate for detection of BP
Schmidt et al. Eur J Radiol, 2007 © Hôpitaux Universitaires de Genève
9
Abdominal CT
2 main limitations for the screening of BP: 1) High cost 2) Large dose of radiation => carcinogenic risk Ethical concern !
* Commission Fédérale de la Protection contre les Radiations, 16 juin 1998 Biological Effects of Ionizing Radiations (BEIR VII) National Academies, Washington DC © Hôpitaux Universitaires de Genève
10
Brenner DJ et al. , N Engl J Med , 2007 Risk of cancer related to CT with regard to age and technique
Center for Radiological Research College of P hysicians & Surgeons of Colum bia University 630 W est 168th Street, 11 th floor, New York, N.Y. 10032
From Brenner DJ
© Hôpitaux Universitaires de Genève
11
« Low-dose CT » = LDCT Low-dose CT
collaboration with Institute for Applied Radiophysics, Lausanne
4 x 5 mm 120 kV 30 mAs pitch 1.25
1.2 to 1.5 mSv
~ 1 abdominal radiograph
Phantom tests © Hôpitaux Universitaires de Genève
12
Collaboration between Geneva University Hospital State Police & Border Guards Corps VI, Geneva
Aim •
to assess the value and the limitations of abdominal radiograph for the screening of BP (cocain only in Geneva)
Methods •
abdominal radiograph + LDCT (reference standard) in every suspect
Ethical review board approval 06-023
© Hôpitaux Universitaires de Genève
13
Conditions of the collaboration Every suspect is brought to our hospital
© Hôpitaux Universitaires de Genève
14
June 2007: beginning of the study
1) Abdominal radiograph (supine)
2) Immediate interpretation by the radiologist on call: electronic report
© Hôpitaux Universitaires de Genève
15
Electronic report form Protocole ASP + CT low-dose pour identifier la présence de boulette(s) intraabdominale(s) de substances illicites. CER 06-023 Nom du radiologue : Coordonnées Patient Veuillez inscrire une croix dans chaque rubrique : Provenance : □ police (brigade des stupéfiants) □ aéroport □ gardes frontières □ autre (préciser) Morphotype : □ Maigre (BMI30) Présence de body-packs sur l’abdomen sans préparation couché- ASP-: □ Oui □ Non Degré de certitude (1 = faible, 2 = moyen, 3 = élevé, 4 = très élevé) □1 □2 □3 □4
© Hôpitaux Universitaires de Genève
16
3) Low-dose CT in every suspect (reference standard)
Intracorporeal container □Yes □ No
© Hôpitaux Universitaires de Genève
17
True positive radiograph
© Hôpitaux Universitaires de Genève
18
False negative radiograph
© Hôpitaux Universitaires de Genève
19
False positive radiograph
© Hôpitaux Universitaires de Genève
20
False negative radiograph Positive LDCT
© Hôpitaux Universitaires de Genève
21
Concealed banknotes
© Hôpitaux Universitaires de Genève
22
Detection of residual BP after evacuation
Negative radiograph 6 days after evacuation of 80 BP © Hôpitaux Universitaires de Genève
LDCT: 1 remaining BP stuck within the stomach => surgery required 23
31 y-o man Admitted for acute abdominal pain
© Hôpitaux Universitaires de Genève
24
Non BP related incidental findings 17 major pathologies detected by CT since 2007 (1.2% of all screening CT )
Enlarged spleen (TBC) © Hôpitaux Universitaires de Genève
Pulmonary disease (Sarcoïdosis) 25
© Hôpitaux Universitaires de Genève
26
Abdominal radiographs compared to CT: July 2007-July 2010
Sensitivity 77% (41 / 53) = 23% of suspects with BP were falsely considered negative
Specificity 96% (267 / 277) = 4% of suspects without BP were falsely considered positive
© Hôpitaux Universitaires de Genève
27
Value of the abdominal radiograph with regard to the confidence of the radiologist Confidence 1 or 2 (n=103, 31% of cases) Sensitivity 36% => 64% of BP falsely considered as negative Specificity 91%
Confidence 3 or 4 (n= 227, 69% of cases) Sensitivity 95% => 5% des BP of BP falsely considered as negative Specificity 99% © Hôpitaux Universitaires de Genève
28
Detection of BP at abdominal radiograph with regard to their density at LDCT
Poletti PA et al. Radiology 2012
© Hôpitaux Universitaires de Genève
29
Geneva University Hospital
Since October 1st 2010 Abdominal Radiograph LDCT only
© Hôpitaux Universitaires de Genève
30
Reasons for false negative abdominal radiographs Observation Visible BP are hyperdense (« white ») on LDCT
© Hôpitaux Universitaires de Genève
31
Reasons for false negative abdominal radiographs Observation: « Invisible » BP on radiographs are isodense (grey) on LDCT
© Hôpitaux Universitaires de Genève
32
Ongoing study chemical analysis of the BP content Collaboration with the Faculty of Law and Criminal Justice, Lausanne
School of Criminal Sciences University of Lausanne
© Hôpitaux Universitaires de Genève
33
© Hôpitaux Universitaires de Genève
34
Dual Energy CT
© Hôpitaux Universitaires de Genève
35
« New trend » Liquid cocain: almost undetectable on radiographs French customs seizure
Courtesy of: French customs and M. Robert MOURACHKO, DCPJ
© Hôpitaux Universitaires de Genève
36
« New trend » Liquid cocain: almost undetectable on radiographs
Low density No air crescent between wrapping and content (no « double condom-sign »)
Courtesy of: French customs and M. Robert MOURACHKO, DCPJ
© Hôpitaux Universitaires de Genève
37
« New trend » « mushy » cocain content (French customs seizure)
Reported as undetectable on the abdominal radiograph by the French colleagues
Courtesy of: French customs and M. Robert MOURACHKO, DCPJ
© Hôpitaux Universitaires de Genève
38
© Hôpitaux Universitaires de Genève
39
Thank you
© Hôpitaux Universitaires de Genève
40
