O-RADS US Risk Stratification and Management System: A Consensus Guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.

Simple Adnexal Cysts: SRU Consensus Conference Update on Follow-up and Reporting.

This multidisciplinary consensus update aligns prior Society of Radiologists in Ultrasound (SRU) guidelines on simple adnexal cysts with recent large studies showing exceptionally low risk of cancer associated with simple adnexal cysts. Most small simple cysts do not require follow-up. For larger simple cysts or less well-characterized cysts, follow-up or second opinion US help to ensure that solid elements are not missed and are also useful for assessing growth of benign tumors. In postmenopausal women, reporting of simple cysts greater than 1 cm should be done to document their presence in the medical record, but such findings are common and follow-up is recommended only for simple cysts greater than 3-5 cm, with the higher 5-cm threshold reserved for simple cysts with excellent imaging characterization and documentation. For simple cysts in premenopausal women, these thresholds are 3 cm for reporting and greater than 5-7 cm for follow-up imaging. If a cyst is at least 10%-15% smaller at any time, then further follow-up is unnecessary. Stable simple cysts at initial follow-up may benefit from a follow-up at 2 years due to measurement variability that could mask growth. Simple cysts that grow are likely cystadenomas. If a previously suspected simple cyst demonstrates papillary projections or solid areas at follow-up, then the cyst should be described by using standardized terminology. These updated SRU consensus recommendations apply to asymptomatic patients and to those whose symptoms are not clearly attributable to the cyst. These recommendations can reassure physicians and patients regarding the benign nature of simple adnexal cysts after a diagnostic-quality US examination that allows for confident diagnosis of a simple cyst. Patients will benefit from less costly follow-up, less anxiety related to these simple cysts, and less surgery for benign lesions.

Visualization of the Oropharynx With Transcervical Ultrasound.

OBJECTIVE: The purposes of this article are to illustrate the sonographic appearance of the oropharynx and to discuss the potential role of ultrasound in evaluation of the oropharynx. CONCLUSION: Ultrasound is not currently used in the standard clinical evaluation of the oropharynx, but it is a promising imaging modality for evaluating the base of the tongue and the palatine tonsils. Ultrasound is comparable and complementary to CT and MRI, which have recognized limitations.

Oral choline supplementation in children with intestinal failure.

Choline deficiency leads to steatohepatitis, elevated transaminases, susceptibility to septic shock, and an increased risk of central catheter thrombosis. Children with intestinal failure (IF) are at risk for choline deficiency. In an unblinded, open-label study, we studied 7 children with IF on parenteral nutrition, measured their plasma free choline level, and, if low, supplemented enterally with adequate intake (AI) doses of choline. Four to 6 weeks later we remeasured their plasma free choline. Unlike adults, infants did not respond to oral choline supplementation at AI doses. Additionally, we have calculated plasma free choline percentiles versus age for normal children.

Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound Consensus Conference Statement.

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.

Intra-operative ultrasound elasticity imaging for monitoring of hepatic tumour thermal ablation.

BACKGROUND: Thermal ablation is an accepted therapy for selected hepatic malignancies. However, the reliability of thermal ablation is limited by the inability to accurately monitor and confirm completeness of tumour destruction in real time. We investigated the ability of ultrasound elasticity imaging (USEI) to monitor thermal ablation. OBJECTIVES: Capitalizing on the known increased stiffness that occurs with protein denaturation and dehydration during thermal therapy, we sought to investigate the feasibility and accuracy of USEI for monitoring of liver tumour ablation. METHODS: A model for hepatic tumours was developed and elasticity images of liver ablation were acquired in in vivo animal studies, comparing the elasticity images to gross specimens. A clinical pilot study was conducted using USEI in nine patients undergoing open radiofrequency ablation for hepatic malignancies. The size and shape of thermal lesions on USEI were compared to B-mode ultrasound and post-ablation computed tomography (CT). RESULTS: In both in vivo animal studies and in the clinical trial, the boundary of thermal lesions was significantly more conspicuous on USEI when compared with B-mode imaging. Animal studies demonstrated good correlation between the diameter of ablated lesions on USEI and the gross specimen (r = 0.81). Moreover, high-quality strain images were generated in real time during therapy. In patients undergoing tumour ablation, a good size correlation was observed between USEI and post-operative CT (r = 0.80). CONCLUSION: USEI can be a valuable tool for the accurate monitoring and real-time verification of successful thermal ablation of liver tumours.

Evaluating oropharyngeal carcinoma with transcervical ultrasound, CT, and MRI.

OBJECTIVE: To compare transcervical ultrasonography (US) to standard cross-sectional imaging for the visualization of human papillomavirus-related oropharyngeal cancer (HPV-OPC). MATERIALS AND METHODS: Patients with HPV-OPC and available standard imaging (CT and/or MRI) were identified in clinic and prospectively enrolled. US was performed to visualize the oropharynx and lymph nodes. Tumor characteristics across imaging modalities were evaluated (CT versus MRI, and US versus standard imaging (SI)). RESULTS: Forty-three patients were included. The overall blinded detection rates for CT and MRI were 83% and 71%, respectively. The unblinded detection rate for US was 98%. Agreement of tumor anatomic subsite was moderate for both CT vs MRI (κ = 0.59) and US vs SI (κ = 0.47). Comparison of tumor size by CT and MRI showed statistically significant correlations in craniocaudal (CC), anteroposterior (AP), and mediolateral (ML) dimensions (RhoCC = 0.51, pCC = 0.038; RhoAP = 0.81, pAP < 0.0001; RhoML = 0.57, pML = 0.012). Tumor size estimates by US and SI showed statistically significant correlations in CC and AP, but not ML (RhoCC = 0.60, pCC = 0.003; RhoAP = 0.71, pAP < 0.0001; RhoML = 0.30, pML = 0.08). Tumor volume estimates improved correlations between US and SI (Rho = 0.66, p < 0.0001). Stratification of US patients into early and late imaging studies demonstrated an increase in correlation strength from early (Rho = 0.32, p = 0.32) to late groups (Rho = 0.77, p < 0.0001) demonstrating that ultrasound accuracy improved with experience. CONCLUSIONS: Our findings suggest that transcervical ultrasonography is a sensitive and relatively accurate adjunct to standard imaging for the evaluation of oropharyngeal tumors. Its cost, portability, and potential for in-clinic and serial imaging render US an attractive modality to further develop for imaging oropharyngeal tumors.

Reader performance in the ultrasonographic evaluation of oropharyngeal carcinoma.

OBJECTIVE: To examine reader performance in evaluating oropharyngeal anatomy on ultrasonography. MATERIALS AND METHODS: Ultrasound images of the oropharynx comprising normal and malignant anatomic variants were organized into slideshows. Slideshows were administered to 6 readers blinded to participant tumor status and with varying experience reading oropharyngeal sonograms. A training slideshow oriented readers to images of the oropharynx with and without malignant lesions. Readers then evaluated images in a test slideshow for tumor presence and marked orthogonal long and short dimensions of the tumor. Results were analyzed for accuracy, sensitivity, specificity, inter-reader agreement, and measurement error relative to prospectively-identified reference measurements. RESULTS: Eighty-seven percent of base of tongue (BOT) sonograms were identified correctly by a majority of readers. In identifying BOT tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 79%, 73%, 85%, and 0.51, respectively. Median measurement error in the long and short axes for BOT tumors was -2.6% (range: -40% to 29%) and -2.6% (range: -56% to 156%), respectively. Eighty-four percent of palatine tonsil sonograms were identified correctly by a majority of readers. In identifying tonsil tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 77%, 74%, 78%, and 0.41, respectively. Median measurement error in the long and short axes for tonsil tumors was 3.8% (range: -45% to 32%) and -6.5% (range: -83% to 42%), respectively. CONCLUSIONS: Overall, US has clinically useful sensitivity for identification of oropharyngeal carcinoma among readers of diverse clinical backgrounds and experience. US may be useful for the evaluation of features such as tumor dimensions.

Ovarian-Adnexal Reporting Lexicon for Ultrasound: A White Paper of the ACR Ovarian-Adnexal Reporting and Data System Committee.

Ultrasound is the most commonly used imaging technique for the evaluation of ovarian and other adnexal lesions. The interpretation of sonographic findings is variable because of inconsistency in descriptor terminology used among reporting clinicians. The use of vague terms that are inconsistently applied can lead to significant differences in interpretation and subsequent management strategies. A committee was formed under the direction of the ACR initially to create a standardized lexicon for ovarian lesions with the goal of improving the quality and communication of imaging reports between ultrasound examiners and referring clinicians. The ultimate objective will be to apply the lexicon to a risk stratification classification for consistent follow-up and management in clinical practice. This white paper describes the consensus process in the creation of a standardized lexicon for ovarian and adnexal lesions and the resultant lexicon.

Ultrasound evaluation of the lower extremity veins.

Over the past 2 decades venous ultrasonography has become the standard primary imaging technique for the initial evaluation of patients for whom there is clinical suspicion of deep venous thrombosis (DVT) of the lower extremity veins. This article addresses the role of duplex ultrasonography and color Doppler ultrasonography in today's clinical practice for the evaluation of patients suspected of harboring a thrombus in their lower extremity veins. It reviews the clinical presentation and differential diagnoses, technique, and diagnostic criteria for acute and chronic DVT. In addition, it addresses the sonographic evaluation of venous insufficiency.

ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee.

Thyroid nodules are a frequent finding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identify the small number that are malignant or require surgery for a definitive diagnosis. Since 2009, many professional societies and investigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic follow-up. Because some of these systems were founded on the BI-RADS® classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committee's recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committee's future directions.

Association of Ultrasound Characteristics With Extranodal Extension in Metastatic Papillary Thyroid Carcinoma.

IMPORTANCE: The presence of extranodal extension (ENE) in metastatic papillary thyroid carcinoma (PTC) has emerged as an important prognostic factor, independently associated with tumor persistence after initial resection, decreased likelihood of complete biochemical response, and worse cause-specific survival. Therefore, the ability to determine ENE before surgery is desirable and advantageous but to date has not yet been evaluated. OBJECTIVE: To evaluate the use of preoperative ultrasound characteristics in predicting pathologic ENE in patients with metastatic PTC. DESIGN, SETTING, AND PARTICIPANTS: Single-institutional, retrospective analysis of patients with metastatic PTC between December 1, 2007, and May 31, 2012. The dates of the analysis were September 1, 2014, to July 31, 2015. Clinicodemographic and histopathologic data were extracted. Preoperative ultrasound images were scored for characteristics of interest by 2 independent radiologists masked to radiology and pathology reports. The setting was an academic tertiary care center. Patients were excluded if they were younger than 18 years, did not have clinical or imaging follow-up after surgery, were found to have histologic diagnoses other than PTC, or were being treated for recurrent disease. EXPOSURES: Preoperative ultrasound and neck dissection. MAIN OUTCOMES AND MEASURES: Association of ultrasound characteristics with ENE. RESULTS: Data from 29 patients with metastatic PTC and available preoperative ultrasound images and pathologic data from neck dissection were included. The patients had a median age at diagnosis of 47 years (age range, 19-85 years); and 76% (22 of 29) were female. Among 29 patients, 11 (38%) had ENE. There were no significant differences in distributions of clinicodemographic or histopathologic characteristics between patients with vs without ENE. The following ultrasound characteristics were significantly associated with ENE positivity: node matting (odds ratio [OR], 6.67; 95% CI, 1.01-44.10; P = .049), presence of node matting or cystic areas (OR, 11.70; 95% CI, 1.85-74.19; P = .009), composite score of 3 or more ultrasound characteristics (OR, 14.00; 95% CI, 2.06-95.09; P = .007), and presence of node matting, perinodal edema, unclear margins, or cystic areas (OR, 10.00; 95% CI, 1.05-95.24; P = .045), as well as presence of node matting, perinodal edema, or unclear margins (OR, 7.07; 95% CI, 1.17-42.85; P = .03). A composite score of 3 or more ultrasound characteristics had the highest accuracy (79.3%) for predicting ENE positivity. CONCLUSIONS AND RELEVANCE: This study identifies preoperative ultrasound characteristics of metastatic PTC that are significantly associated with pathologically determined ENE and supports prospective analyses to further evaluate this use of preoperative ultrasound.

Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee.

Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.

Inflammatory pseudotumor: a diagnostic dilemma in cytopathology.

Inflammatory pseudotumor (IPT) is a rare space-occupying lesion of unknown etiology that can mimic malignancy on clinicoradiological and pathological examination. A review of the cytopathology archives at The Johns Hopkins Hospital identified 12 cases from eight patients with histologically proven IPT (lung, seven patients; liver, five patients). There were six men and two women with an age range of 28-84 yr (mean age, 59 yr). Presenting complaints of IPT of the lung included shortness of breath and hemoptysis, and in cases of IPT of the liver complaints included abdominal pain and elevated liver function tests (LFTs). All cases were found to have mass lesions suspicious for a neoplasm on radiographic examination. Cytological specimens consisted of fine-needle aspiration (FNA; seven specimens) and bronchial brush/wash (five specimens). Diagnostic accuracy of cytology for IPT was low (5/12, 42%). IPT showed hypercellular smears (on FNA) with an admixture of various cell types including inflammatory cells with predominance of plasma cells, fibroblastic proliferation, granulation tissue formation, and atypical-appearing histiocytes with enlarged nuclei and intranuclear inclusions. Fibroblastic proliferation with mitoses may mimic mesenchymal neoplasms. Cytomorphology is nonspecific and IPT usually is a diagnosis of exclusion.

Vascular and nonvascular complications of liver transplants: sonographic evaluation and correlation with other imaging modalities and findings at surgery and pathology.

Liver transplantation is performed in adults and children to treat patients with irreversible liver damage when medical or other surgical treatment has failed. The most common indications for transplantation are cirrhosis secondary to fulminant acute hepatitis or chronic active hepatitis, sclerosing cholangitis, primary biliary cirrhosis, Budd-Chiari syndrome, inborn errors of metabolism, and unresectable but local hepatocellular carcinoma. This article reviews the sonographic findings in the preoperative evaluation of liver transplant recipients, briefly describes the surgical technique, and demonstrates normal postoperative findings in liver transplant recipients as well as complications associated with liver transplantation.

Ultrasonography evaluation of pelvic masses.

Ultrasonography is the primary imaging modality for evaluation of pelvic masses. Ultrasonography has the advantage of being inexpensive, widely available, and offering superior tissue characterization compared with computed tomography. The real-time imaging ability of ultrasonography and three-dimensional ultrasonography also has the advantage of being able to identify the organ of origin of the pelvic mass. Many pelvic masses have characteristic sonographic appearances that allow confident diagnosis and management. This article reviews the sonographic appearances and management of common pelvic masses encountered in nonpregnant women, and is organized based on anatomic location: uterus, cervix, ovaries, and fallopian tubes.

The role of sonography in thyroid cancer.

Sonography plays several important roles in the diagnosis and management of thyroid cancer. Ultrasound (US) is used for the detection and characterization of thyroid nodules as well as a guidance modality for fine-needle aspiration biopsy of indeterminate or suspicious nodules. US is also used to help stage thyroid cancer by identifying cervical lymph nodes suspicious for metastasis so they can be biopsied prior to subsequent neck dissection. Post-thyroidectomy, routine surveillance of the neck is performed with US to identify local recurrence and/or nodal metastatic disease so that focused and limited repeat neck dissection or alcohol ablation can be accomplished.

Teaching ultrasound professionalism.

Professionalism is part of the milestone program instituted by the Accreditation Council for Graduate Medical Education and the American Board of Radiology. A unique feature of ultrasound professionalism is the relationship between the radiologist and the sonographer. Because this relationship is important for sonographic quality and ultimately patient outcome, residents should be trained to achieve an optimal professional relationship with sonographers. This article describes milestones for ultrasound professionalism and suggests methods of implementation.

National ultrasound curriculum for medical students.

Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: "What should a student graduating from medical school know about US?" To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.