Why Thyroid Surgeons Are Frustrated with Radiologists: Lessons Learned from Pre- and Postoperative US.

Optimal treatment of thyroid cancer is highly dependent on accurate staging of the extent of disease at presentation. Preoperative ultrasonography (US) is the most sensitive method for detecting metastatic lymph nodes and is recommended as part of the standard preoperative workup. Missed findings on preoperative scans may lead to understaging and inadequate surgical management, which subsequently predispose these patients to residual disease postoperatively and a higher risk for recurrence, possibly requiring repeat surgery. Traditionally, thyroid US for pre- and postoperative staging has been performed by radiologists. However, there is a growing trend away from radiologist-performed US in favor of surgeon-performed US. Recent surgical and endocrinology literature has shown that, when compared with surgeon-performed US, radiologist-performed preoperative staging US is less accurate and is inadequate for presurgical planning, with higher local recurrence rates. This review highlights the importance of accurate preoperative US for patients with differentiated thyroid cancer, with specific attention to deficiencies that exist in general radiology department thyroid US reports. We present a standardized approach to neck US reporting that incorporates the newly updated 2015 recommendations from the American Thyroid Association and also addresses the pertinent questions for thyroid surgeons. By ensuring comprehensive preoperative assessment and improving thyroid US reporting, we seek to improve patient access to optimized care. ©RSNA, 2016.

Uncommon pancreatic tumors and pseudotumors.

A heterogeneous group of uncommon neoplastic and non-neoplastic pancreatic pathologies exists that can mimic pancreatic adenocarcinoma. These "imitators" are unique and may demonstrate characteristic clinical and imaging features. Imaging characteristics of some of these diverse lesions are not well described in the literature, and erroneous diagnoses of these entities as pancreatic carcinoma may be responsible for unnecessary surgeries. Knowledge of these selected pancreatic pathologies is essential to facilitate optimal patient management.

The Reliability of a Standardized Reporting System for the Diagnosis of Appendicitis.

PURPOSE: Computed tomography (CT) is a fast and ubiquitous tool to evaluate intra-abdominal organs and diagnose appendicitis. However, traditional CT reporting does not necessarily capture the degree of uncertainty and indeterminate findings are still common. The purpose of this study was to evaluate the reproducibility of a standardized CT reporting system for appendicitis across a large population and the system's impact on radiologists' certainty in diagnosing appendicitis. METHODS: Using a previously described standardized reporting system, eight radiologists retrospectively evaluated CT scans, blinded to all clinical information, in a stratified random sample of 237 patients from a larger cohort of patients imaged for possible appendicitis (2010-2014). Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) were used to evaluate the diagnostic performance of readers for identifying appendicitis. Two-thirds of these scans were randomly selected to be independently read by a second reader, using the original CT reports to balance the number of positive, negative and indeterminate exams across all readers. Inter-reader agreement was evaluated. RESULTS: There were 113 patients with appendicitis (mean age 38, 67% male). Using the standardized report, radiologists were highly accurate at identifying appendicitis (AUC=0.968, 95%CI confidence interval: 0.95, 0.99. Inter-reader agreement was >80% for most objective findings, and certainty in diagnosing appendicitis was high and reproducible (AUC=0.955 and AUC=0.936 for the first and second readers, respectively). CONCLUSIONS: Using a standardized reporting system resulted in high reproducibility of objective CT findings for appendicitis and achieved high diagnostic accuracy in an at-risk population. Predictive tools based on this reporting system may further improve communication about certainty in diagnosis and guide patient management, especially when CT findings are indeterminate.

Corporatized Radiology: From Down Under to Over Here?

In this article, we reflect on the current state of corporatized radiology, forces driving consolidation, and alternatives to corporatization that allow radiologists to maintain their autonomy while providing the highest level of care to their medical communities.

Thyroid Nodule Doubling Time is Not a Reliable Indicator of Benign or Malignant Nature.

Thyroid nodules are often followed up with serial ultrasound imaging. Doubling time is well established in the evaluation of lung nodules. We examined whether benign and malignant thyroid nodules exhibit differences in doubling time.This retrospective, IRB-approved study included patients with nodules aspirated between January and June 2012 (benign), and January 2012 to December 2014 (suspicious or malignant), no interval thyroidectomy, and two ultrasound examinations longer than 180 days apart. Diameters and morphology were assessed by a single observer, demographics recorded, and doubling time calculated. Area under the receiver operating characteristic curve was derived. Society of Radiologists in Ultrasound criteria were used to determine aspiration appropriateness initially and after follow-up.59 patients with 61 nodules were included. Statistically significant between-group differences exist for sex, solidity, echogenicity, and microcalcifications, with no significant differences in doubling time, age, days between studies, vascularity, or mean diameter. Benign nodules' doubling time was 340 to 7134 days (mean, 2196; median, 1593), with 9 nodules that decreased in size. Malignant nodules' doubling time was 451 to 17182 days (mean, 3940; median, 2137), with 7 nodules that decreased in size. Using a threshold of 1100 days, sensitivity and specificity of doubling time to predict malignancy are 19.0% and 86.7%, respectively. Area under the receiver operating characteristic curve is 0.39. Follow-up imaging resulted in 6 additional benign and 0 additional malignant nodules meeting criteria.There is no significant difference in benign or malignant nodules' doubling times, and a decrease in nodule size is nonspecific. These findings challenge the underlying rationale for routine imaging follow-up of thyroid nodules.

Multimodality imaging of pancreatic arteriovenous malformation.

Arteriovenous malformation of the pancreas (PAVM) is a very rare entity, although it may be increasingly diagnosed with the expanding use of cross-sectional imaging of the abdomen. PAVM is characterized by a network of tangled vasculature within and surrounding all or part of the pancreas, resulting in the shunting of the arteries of the pancreas directly into the portal venous system. Here, we present a patient with chronic abdominal pain and pancreatitis found to have PAVM, based on the findings of computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography, and angiography. Differential considerations are discussed. Although PAVM is uncommon, it should be considered in the differential of patients with recurrent abdominal pain or gastrointestinal bleeding.

Hepatocellular Carcinoma: Review of Epidemiology, Screening, Imaging Diagnosis, Response Assessment, and Treatment.

Hepatocellular carcinoma is a common malignancy for which prevention, screening, diagnosis, treatment, and surveillance demand a multidisciplinary approach. Knowledge of the underlying pathophysiology as well as advances in clinical management should be employed by radiologists to effectively communicate with hepatologists, surgeons, and oncologists. In this review article, we present recent developments in the clinical management of hepatocellular carcinoma.

Lung CT Screening Reporting and Data System Speed and Accuracy Are Increased With the Use of a Semiautomated Computer Application.

PURPOSE: The Lung CT Screening Reporting and Data System (Lung-RADS™) is an algorithm that can be used to classify lung nodules in patients with significant smoking histories. It is published in table format but can be implemented as a computer program. The aim of this study was to assess the efficiency and accuracy of the use of a computer program versus the table in categorizing lung nodules. METHODS: The Lung-RADS algorithm was implemented as a computer program. Through the use of a survey tool, respondents were asked to categorize 13 simulated lung nodules using the computer program and the Lung-RADS table as published. Data were gathered regarding time to completion, accuracy of each nodule's categorization, users' subjective categorization confidence, and users' perceived efficiency using each method. RESULTS: The use of a computer program to categorize lung nodules resulted in significantly increased interpretation speed (80.8 ± 37.7 vs 156 ± 105 seconds, P < .0001), lung nodule classification accuracy (99.6% vs 76.5%, P < .0001), and perceived confidence and efficiency compared with the use of the table. There were no significant differences in accuracy when comparing thoracic radiologists with the remainder of the group. CONCLUSIONS: Radiologists were both more efficient and more accurate in lung nodule categorization when using computerized decision support tools. The authors propose that other institutions use computerized implementations of Lung-RADS in the interests of both efficiency and patient outcomes through proper management. Furthermore, they suggest the ACR design future iterations of the Lung-RADS algorithm with computerized decision support in mind.

Perceived Barriers to the Use of High-Fidelity Hands-On Simulation Training for Contrast Reaction Management: Why Programs are Not Using It.

Although subjective and objective benefits of high-fidelity simulation have been reported in medicine, there has been slow adoption in radiology. The purpose of our study was to identify the perceived barriers in the use of high-fidelity hands-on simulation for contrast reaction management training. An IRB exempt 32 questions online web survey was sent to 179 non-military radiology residency program directors listed in the Fellowship and Residency Electronic Interactive Database Access system (FREIDA). Survey questions included the type of contrast reaction management training, cost, time commitment of residents and faculty, and the reasons for not using simulation training. Responses from the survey were summarized as count (percentage), mean ± standard deviation (SD), or median (range). 84 (47%) of 179 programs responded, of which 88% offered CRM training. Most (72%) conducted the CRM training annually while only 4% conducted it more frequently. Didactic lecture was the most frequently used training modality (97%), followed by HFS (30%) and computer-based simulation (CBS) (19%); 5.5% used both HFS and CBS. Of the 51 programs that offer CRM training but do not use HFS, the most common reason reported was insufficient availability (41%). Other reported reasons included cost (33%), no access to simulation centers (33%), lack of trained faculty (27%) and time constraints (27%). Although high-fidelity hands-on simulation training is the best way to reproduce real-life contrast reaction scenarios, many institutions do not provide this training due to constraints such as cost, lack of access or insufficient availability of simulation labs, and lack of trained faculty. As a specialty, radiology needs to better address these barriers at both an institutional and national level.

Imaging of complications from hematopoietic stem cell transplant.

Stem cell transplant has been the focus of clinical research for a long time given its potential to treat several incurable diseases like hematological malignancies, diabetes mellitus, and neuro-degenerative disorders like Parkinson disease. Hematopoietic stem cell transplantation (HSCT) is the oldest and most widely used technique of stem cell transplant. HSCT has not only been used to treat hematological disorders including hematological malignancies, but has also been found useful in treamtent of genetic, immunological, and solid tumors like neuroblastoma, lymphoma, and germ cell tumors. In spite of the rapid advances in stem cell technology, success rate with this technique has not been universal and many complications have also been seen with this form of therapy. The key to a successful HSCT therapy lies in early diagnosis and effective management of complications associated with this treatment. Our article aims to review the role of imaging in diagnosis and management of stem cell transplant complications associated with HSCT.

Tumoral pulmonary emboli from angioinvasive hepatocellular carcinoma.

Tumoral pulmonary emboli from hepatocellular carcinoma (HCC) have rarely been described, although invasion of the portal and hepatic venous systems is a well-known complication. HCC originating in a noncirrhotic liver in the absence of chronic hepatitis B infection is also uncommon. We present a case of a patient with chronic hepatitis C infection without hepatic cirrhosis who developed angioinvasive HCC with intracardiac extension and tumoral pulmonary emboli. Differential considerations, including combined HCC-cholangiocarcinoma, other hepatic mesenchymal tumors, and metastasis, are discussed. Owing to poor prognosis, no resection was attempted. Autopsy was performed because of the unusual clinical presentation, and immunohistochemistry of the hepatic tumor, the intracardiac extension, and the pulmonary emboli were concordant with hepatocellular origin. Even though definitive diagnosis may not affect patient outcome, it is important for radiologists and clinicians to be aware that angioinvasive HCC may arise in the absence of cirrhosis.

Imaging evaluation of maternal complications associated with repeat cesarean deliveries.

The rate of cesarean deliveries continues to rise, while the rate of vaginal delivery after cesarean birth continues to decline. Many women now tend to undergo multiple cesarean deliveries, and therefore the associated chronic maternal morbidities are of growing concern. Accurate diagnosis of these conditions is crucial in maternal and fetal well-being. Many of these complications are diagnosed by imaging, and radiologists should be aware of the type and imaging appearances of these conditions.