Utility of Nipple Markers in the Era of Digital Imaging.

PURPOSE: Nipple markers maybe used to decrease the recall of patients undergoing chest radiography by aiding in distinguishing between a nipple shadow and lung nodule. We evaluated the use of digital chest radiographs in clinical practice including accuracy of placement and markers that do not contribute to interpretation (ie, projected outside the lung fields). We also evaluated the recall rate for additional imaging in patients who received nipple markers compared to those who did not. MATERIAL AND METHODS: In this Institutional Review Board approved retrospective study, 1000 consecutive outpatient frontal and lateral chest radiographs performed in 2018 for which nipple markers were provided to patients formed the study group. Three cardiothoracic radiologists evaluated the images for the presence of markers and accuracy of placement. The recall rate was calculated over a 3-year period from March 21, 2016 and March 21, 2019. RESULTS: One or both markers were missing without an explanation (such as mastectomy), misplaced or outside the lung fields in 57.8% (578/1000) of studies. The 3-year recall rate for all chest radiographs was very low (0.03%; 42/135,792) and was lower for patients provided nipple markers (0.007%; 5/62,587) than those who were not (0.05%; 37/73,205) ( P <0.001). CONCLUSIONS: The low overall recall rate and high prevalence of inaccurate marker placement or markers that do not contribute to interpretation (ie, outside the lung fields) does not justify the routine use of nipple markers for chest radiography.

Lessons Learned from Peer Learning Conference in Cardiothoracic Radiology.

Medical errors may lead to patient harm and may also have a devastating effect on medical providers, who may suffer from guilt and the personal impact of a given error (second victim experience). While it is important to recognize and remedy errors, it should be done in a way that leads to long-standing practice improvement and focuses on systems-level opportunities rather than in a punitive fashion. Traditional peer review systems are score based and have some undesirable attributes. The authors discuss the differences between traditional peer review systems and peer learning approaches and offer practical suggestions for transitioning to peer learning conferences. Peer learning conferences focus on learning opportunities and embrace errors as an opportunity to learn. The authors also discuss various types and sources of errors relevant to the practice of radiology and how discussions in peer learning conferences can lead to widespread system improvement. In the authors' experience, these strategies have resulted in practice improvement not only at a division level in radiology but in a broader multidisciplinary setting as well. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2022.

Epicardial adipose tissue volume is greater in men with severe psoriasis, implying an increased cardiovascular disease risk: A cross-sectional study.

BACKGROUND: Patients with psoriasis have elevated risk of coronary artery disease. OBJECTIVE: Do patients with severe psoriasis have larger epicardial adipose tissue volumes (EAT-V) that are associated with cardiovascular risk? METHODS: For this cross-sectional study, we recruited dermatology patients with severe psoriasis and control patients without psoriasis or rheumatologic disease themselves or in a first-degree relative. Participants aged 34 to 55 years without known coronary artery disease or diabetes mellitus underwent computed tomography (CT); EAT-V was obtained from noncontrast CT heart images. RESULTS: Twenty-five patients with psoriasis (14 men, 11 women) and 16 controls (5 men, 11 women) participated. Groups had no statistical difference in age, body mass index, various cardiovascular risk factors (except high-sensitivity C-reactive protein in men), CT-determined coronary artery calcium scores or plaque, or family history of premature cardiovascular disease. Mean EAT-V was greater in the psoriasis group compared to controls (P = .04). There was no statistically significant difference among women; however, male patients with psoriasis had significantly higher EAT-V than controls (P = .03), even when corrected for elevated high-sensitivity C-reactive protein (P = .05). LIMITATIONS: A single-center convenience sample may not be representative. CONCLUSION: Males with psoriasis without known coronary disease or diabetes had greater EAT-V than controls. EAT-V may be an early identifier of those at increased risk for cardiovascular events.

Cardiac MRI for Patients With Cardiac Implantable Electronic Devices.

OBJECTIVE. Patients with cardiac implantable electronic devices (CIEDs) require cardiac MRI (CMRI) for a variety of reasons. The purpose of this study is to review and evaluate the value and safety of CMRI for patients with in situ CIEDs. CONCLUSION. Late gadolinium enhancement CMRI is the reference standard for assessing myocardial viability in patients with ventricular tachycardia before ablation of arrhythmogenic substrates. The use of late gadolinium enhancement CMRI for patients with CIEDs is safe as long as an imaging protocol is in place and precaution measures are taken.

Left Ventricular Hypertrophy: Evaluation With Cardiac MRI.

OBJECTIVE: Left ventricular hypertrophy (LVH) is a frequent problem in clinical practice and can be caused by diverse conditions including hypertension, aortic stenosis, hypertrophic cardiomyopathy, athletic training, infiltrative heart muscle disease, storage and metabolic disorders. Identification of the precise etiology can be challenging and is a common cause of referral for cardiac MRI (CMR). In this article, CMR findings in various causes of LVH will be reviewed with an emphasis on determination of etiology and emerging role of CMR in risk stratification. CONCLUSIONS: In patients with LVH, CMR allows precise determination of the severity and distribution of hypertrophy, evaluation of ventricular function, and tissue characterization. The information obtained from CMR enables identification of the etiology of LVH and may aid in determining prognosis and therapy.

Role of Radiologists in the Diagnosis of Unsuspected Birt-Hogg-Dubé Syndrome in a Tertiary Clinical Practice.

OBJECTIVE. Birt-Hogg-Dubé (BHD) syndrome is considered rare. Growing evidence indicates that it is underdiagnosed. The purpose of this study is to ascertain the impact of radiology reports that suggest the possibility of BHD syndrome on downstream management and a final diagnosis of BHD syndrome. MATERIALS AND METHODS. In this retrospective study, electronic medical records were searched to identify radiology reports suggesting the possibility of BHD syndrome in patients without a known or suspected diagnosis. Clinical and demographic information, the specialty of the ordering clinician, and imaging findings and confidence conveyed in the radiology report (with BHD syndrome listed as the most likely diagnosis versus one among several possibilities but not as the leading diagnosis) were recorded. The resultant downstream evaluations that were captured included referral for genetic evaluation and subsequent diagnosis of BHD. RESULTS. Between 2004 and 2016, radiologists suggested a diagnosis of BHD syndrome in 87 patients. Of these patients, 15% (13/87) underwent genetic evaluation, and 54% of those patients (7/13) had positive findings. Genetic evaluation was more likely for patients with a history of pneumothorax (p = 0.004) or involvement of the lungs and kidneys (p = 0.003). The urology department referred the highest percentage of patients (31% [4/13]) for genetic evaluation. CONCLUSION. Radiologists have a unique opportunity to suggest BHD syndrome, allowing appropriate genetic testing, screening, and counseling of patients and their families. Clinical presentation, including a history of pneumothorax and involvement of both the lungs and kidneys on imaging, may determine which patients are ultimately referred for genetic evaluation. We hope that increasing awareness that BHD syndrome is not so rare may lead to early diagnosis.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know.

OBJECTIVE: Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT. CONCLUSION: This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

Hypersensitivity Pneumonitis: Radiologic Phenotypes Are Associated With Distinct Survival Time and Pulmonary Function Trajectory.

BACKGROUND: Hypersensitivity pneumonitis (HP) is an interstitial lung disease with a better prognosis, on average, than idiopathic pulmonary fibrosis (IPF). We compare survival time and pulmonary function trajectory in patients with HP and IPF by radiologic phenotype. METHODS: HP (n = 117) was diagnosed if surgical/transbronchial lung biopsy, BAL, and exposure history results suggested this diagnosis. IPF (n = 152) was clinically and histopathologically diagnosed. All participants had a baseline high-resolution CT (HRCT) scan and FVC % predicted. Three thoracic radiologists documented radiologic features. Survival time is from HRCT scan to death or lung transplant. Cox proportional hazards models identify variables associated with survival time. Linear mixed models compare post-HRCT scan FVC % predicted trajectories. RESULTS: Subjects were grouped by clinical diagnosis and three mutually exclusive radiologic phenotypes: honeycomb present, non-honeycomb fibrosis (traction bronchiectasis and reticulation) present, and nonfibrotic. Nonfibrotic HP had the longest event-free median survival (> 14.73 years) and improving FVC % predicted (1.92%; 95% CI, 0.49-3.35; P = .009). HP with non-honeycomb fibrosis had longer survival than IPF (> 7.95 vs 5.20 years), and both groups experienced a significant decline in FVC % predicted. Subjects with HP and IPF with honeycombing had poor survival (2.76 and 2.81 years, respectively) and significant decline in FVC % predicted. CONCLUSIONS: Three prognostically distinct, radiologically defined phenotypes are identified among patients with HP. The importance of pursuing a specific diagnosis (eg, HP vs IPF) among patients with non-honeycomb fibrosis is highlighted. When radiologic honeycombing is present, invasive diagnostic testing directed at determining the diagnosis may be of limited value given a uniformly poor prognosis.

Development and validation of a radiological diagnosis model for hypersensitivity pneumonitis.

High-resolution computed tomography (HRCT) may be useful for diagnosing hypersensitivity pneumonitis. Here, we develop and validate a radiological diagnosis model and model-based points score.Patients with interstitial lung disease seen at the University of Michigan Health System (derivation cohort) or enrolling in the Lung Tissue Research Consortium (validation cohort) were included. A thin-section, inspiratory HRCT scan was required. Thoracic radiologists documented radiological features.The derivation cohort comprised 356 subjects (33.9% hypersensitivity pneumonitis) and the validation cohort comprised 424 subjects (15.5% hypersensitivity pneumonitis). An age-, sex- and smoking status-adjusted logistic regression model identified extent of mosaic attenuation or air trapping greater than that of reticulation ("MA-AT>Reticulation"; OR 6.20, 95% CI 3.53-10.90; p<0.0001) and diffuse axial disease distribution (OR 2.33, 95% CI 1.31-4.16; p=0.004) as hypersensitivity pneumonitis predictors (area under the receiver operating characteristic curve 0.814). A model-based score >2 (1 point for axial distribution, 2 points for "MA-AT>Reticulation") has specificity 90% and positive predictive value (PPV) 74% in the derivation cohort and specificity 96% and PPV 44% in the validation cohort. Similar model performance is seen with population restriction to those reporting no exposure (score >2: specificity 91%).When radiological mosaic attenuation or air trapping are more extensive than reticulation and disease has diffuse axial distribution, hypersensitivity pneumonitis specificity is high and false diagnosis risk low (<10%), but PPV is diminished in a low-prevalence setting.

Interpretation and Reporting of Coronary Arteries in Transposition of the Great Arteries: Cross-sectional Imaging Perspective.

Knowledge of coronary artery nomenclature in transposition of the great arteries is essential, given the increasing population of adults with congenital heart disease and greater utilization of imaging in these patients. This article reviews appropriate terminology for describing coronary artery anatomy, commonly encountered coronary artery patterns, and postoperative coronary complications in the setting of transposition of the great arteries.

Skeletal Muscle Metastasis from Renal Cell Carcinoma: 21 cases and review of the literature.

OBJECTIVES: This study aimed to raise radiologists' awareness of skeletal muscle metastases (SMM) in renal cell carcinoma (RCC) cases and to clarify their imaging appearance. METHODS: A retrospective analysis was undertaken of 21 patients between 44-75 years old with 72 SMM treated from January 1990 to May 2009 at the MD Anderson Cancer Center in Houston, Texas, USA. Additionally, 37 patients with 44 SMM from a literature review were analysed. RESULTS: Among the 21 patients, the majority of SMM were asymptomatic and detected via computed tomography (CT). Mean metastasis size was 18.3 mm and the most common site was the trunk muscles (83.3%). The interval between discovery of the primary tumour and metastasis detection ranged up to 234 months. Peripheral enhancement (47.1%) was the most common post-contrast CT pattern and non-contrasted CT lesions were often isodense. Magnetic resonance imaging (MRI) characteristics were varied. Five lesions with available T1-weighted pre-contrast images were hyperintense to the surrounding muscle. Other organ metastases were present in 20 patients. Of the 44 SMM reported in the literature, the majority were symptomatic. Average metastasis size was 53.4 mm and only 20.5% of SMM were in trunk muscles. The average interval between tumour discovery and metastasis detection was 101 months. Other organ metastases were recorded in 17 out of 29 patients. CONCLUSION: SMM should always be considered in patients with RCC, even well after primary treatment. SMM from RCC may be invisible on CT without intravenous contrast; contrast-enhanced studies are therefore recommended. SMM are often hyperintense to the surrounding muscle on T1-weighted MRI scans.

Evaluation and management of pulmonary nodules: state-of-the-art and future perspectives.

INTRODUCTION: The imaging evaluation of pulmonary nodules, often incidentally detected on imaging examinations performed for other clinical reasons, is a frequently encountered clinical circumstance. With advances in imaging modalities, both the detection and characterization of pulmonary nodules continue to evolve and improve. AREAS COVERED: This article will review the imaging modalities used to detect and diagnose benign and malignant pulmonary nodules, with a focus on computed tomography (CT), which continues to be the mainstay for evaluation. The authors discuss recent advances in the lung nodule management, and an algorithm for the management of indeterminate pulmonary nodules. EXPERT OPINION: There are set of criteria that define a benign nodule, the most important of which are the lack of temporal change for 2 years or more, and certain benign imaging criteria, including specific patterns of calcification or the presence of fat. Although some indeterminate pulmonary nodules are immediately actionable, generally those approaching 1 cm or larger in diameter, at which size the diagnostic accuracy of tools such as positron emission tomography (PET)/CT, single photon emission CT (SPECT) and biopsy techniques are sufficient to warrant their use. The majority of indeterminate pulmonary nodules are under 1 cm, for which serial CT examinations through at least 2 years for solid nodules and 3 years for ground-glass nodules, are used to demonstrate either benign biologic behavior or otherwise. The management of incidental pulmonary nodules involves a multidisciplinary approach in which radiology plays a pivotal role. Newer imaging and postprocessing techniques have made this a more accurate technique eliminating ambiguity and unnecessary follow-up.