Adrenal Mass Biopsy in Patients Without Extraadrenal Primary Malignancy: A Multicenter Study.

BACKGROUND. Adrenal washout CT is not useful for evaluating incidental adrenal masses in patients without known or suspected primary extraadrenal malignancy. OBJECTIVE. The purpose of our study was to evaluate the diagnostic utility of adrenal mass biopsy in patients without known or suspected extraadrenal primary malignancy. METHODS. This retrospective six-center study included 69 patients (mean age, 56 years; 32 men, 37 women) without known or suspected extraadrenal primary malignancy who underwent image-guided core needle biopsy between January 2004 and June 2021 of a mass suspected to be arising from the adrenal gland. Biopsy results were classified as diagnostic or nondiagnostic. For masses resected after biopsy, histopathologic concordance was assessed between diagnoses from biopsy and resection. Masses were classified as benign or malignant by resection or imaging follow-up, and all nondi-agnostic biopsies were classified as false results. RESULTS. The median mass size was 7.4 cm (range, 1.9-19.2 cm). Adrenal mass biopsy had a diagnostic yield of 64% (44/69; 95% CI, 51-75%). After biopsy, 25 masses were resected, and 44 had imaging follow-up. Of the masses that were resected after diagnostic biopsy, diagnosis was concordant between biopsy and resection in 100% (12/12). Of the 13 masses that were resected after nondiagnostic biopsy, the diagnosis from re-section was benign in eight masses and malignant in five masses. The 44 masses with imaging follow-up included one mass with diagnostic biopsy yielding benign adenoma and two masses with nondiagnostic biopsy results that were classified as malignant by imaging follow-up. Biopsy had overall sensitivity and specificity for malignancy of 73% (22/30) and 54% (21/39), respectively; diagnostic biopsies had sensitivity and specificity for malignancy of 96% (22/23) and 100% (21/21), respectively. Among nine nondi-agnostic biopsies reported as adrenocortical neoplasm, six were classified as malignant by the reference standard (resection showing adrenocortical carcinoma in four, resection showing adrenocortical neoplasm of uncertain malignant potential in one, imaging follow-up consistent with malignancy in one). CONCLUSION. Adrenal mass biopsy had low diagnostic yield, with low sensitivity and low specificity for malignancy. A biopsy result of adrenocortical neoplasm did not reliably differentiate benign and malignant adrenal masses. CLINICAL IMPACT. Biopsy appears to have limited utility for the evaluation of incidental adrenal masses in patients without primary extraadrenal malignancy.

Validating the diagnostic accuracy of an MRI-based scoring system for differentiating benign uterine leiomyomas from leiomyosarcomas.

OBJECTIVE: Uterine leiomyomas are the most common benign uterine tumors. They are difficult to distinguish from their malignant counterparts-smooth muscle tumors of unknown malignant potential (STUMP) and leiomyosarcoma. The purpose of this study is to propose and validate the diagnostic accuracy of the MRI-based Oman-Canada Scoring System of Myometrial Masses (OCSSMM) to differentiate uterine leiomyomas from STUMP/leiomyosarcomas. METHODS: This is a retrospective study performed at two tertiary care centers. All patients with a pathology-proven uterine mass who underwent pre-operative pelvic MRI between January 2010 and January 2020 were included. Using a 1.5T MRI machine, sequences included were axial/coronal/sagittal T2 and T1 weighted imaging, axial diffusion weighted and apparent diffusion coefficient map, and axial or sagittal dynamic contrast-enhanced sequences. A scoring system was designed based on previously published worrisome MRI features for uterine leiomyosarcoma. Each feature was allocated a score from 0 to 2 according to the strength of association with malignancy. Subsequently, the MR images were blindly and independently reviewed by a fellowship-trained radiologist and a clinical fellow/senior resident. Each uterine mass was scored according to their imaging features. The scores were divided into five categories according to the sum of scores. Category III and above was considered positive for leiomyosarcoma/STUMP. Sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: A total of 244 women were included (age range 20-74 years, mean 40). Of these, 218 patients had benign leiomyoma, 13 had STUMP, and 13 had leiomyosarcoma. The sensitivity and specificity of the scoring system were 92.3% and 64.7%, respectively. The negative predictive value was 98.6%. No leiomyosarcoma was missed using this scoring system. The presence of non-cystic T2 hyperintensity or diffusion restriction in a uterine mass were the most sensitive signs of a leiomyosarcoma/STUMP. CONCLUSION: The proposed multi-parametric MRI scoring system may be useful in differentiating benign uterine leiomyomas from leiomyosarcomas/STUMP.

Incidental findings on staging rectal MRI: clinical significance and outcomes.

BACKGROUND: Incidental findings (IFs) are commonly seen in staging rectal magnetic resonance imaging (MRI) scans. Their prevalence and clinical significance have not been previously documented. PURPOSE: To assess the prevalence, clinical significance, and outcomes of incidental findings in MRI scans performed for the staging of rectal cancer. MATERIAL AND METHODS: A retrospective study was performed at a tertiary colorectal imaging institution. Consecutive MRI rectal staging scans with correlative pathology confirmed primary rectal cancer between March 2014 and March 2021 were identified. The respective imaging reports were reviewed for IFs, which were classified as high, moderate, and low, according to their clinical significance. Medical records were reviewed to assess the outcomes of the highly significant IFs. RESULTS: There were 266 eligible patients (97 women; mean age = 64.2 years) during the study period. A total of 120 (45%) patients did not have any IFs. A total of 238 IFs in 146 (55%) patients were found. There were 21 (9%) IFs of high clinical significance, 122 (51%) of moderate clinical significance, and 95 (40%) of low clinical significance. The prostate and uterus had the most IFs of high clinical significance, two of which were subsequently pathology confirmed as prostate adenocarcinomas. CONCLUSION: IFs were seen in more than half of the staging MRI scans in rectal cancer but less than 10% of these were of high clinical significance. The results of this study highlight the range of potential IFs and can guide future research assessing the potential impact of these IFs on patients and the healthcare system.

Evaluation of a BERT Natural Language Processing Model for Automating CT and MRI Triage and Protocol Selection.

Purpose: To evaluate the accuracy of a Bidirectional Encoder Representations for Transformers (BERT) Natural Language Processing (NLP) model for automating triage and protocol selection of cross-sectional image requisitions. Methods: A retrospective study was completed using 222 392 CT and MRI studies from a single Canadian university hospital database (January 2018-September 2022). Three hundred unique protocols (116 CT and 184 MRI) were included. A BERT model was trained, validated, and tested using an 80%-10%-10% stratified split. Naive Bayes (NB) and Support Vector Machine (SVM) machine learning models were used as comparators. Models were assessed using F1 score, precision, recall, and area under the receiver operating characteristic curve (AUROC). The BERT model was also assessed for multi-class protocol suggestion and subgroups based on referral location, modality, and imaging section. Results: BERT was superior to SVM for protocol selection (F1 score: BERT-0.901 vs SVM-0.881). However, was not significantly different from SVM for triage prediction (F1 score: BERT-0.844 vs SVM-0.845). Both models outperformed NB for protocol and triage. BERT had superior performance on minority classes compared to SVM and NB. For multiclass prediction, BERT accuracy was up to 0.991 for top-5 protocol suggestion, and 0.981 for top-2 triage suggestion. Emergency department patients had the highest F1 scores for both protocol (0.957) and triage (0.986), compared to inpatients and outpatients. Conclusion: The BERT NLP model demonstrated strong performance in automating the triage and protocol selection of radiology studies, showing potential to enhance radiologist workflows. These findings suggest the feasibility of using advanced NLP models to streamline radiology operations.

Investigating Canadian Radiology Residents' Personal Financial Literacy: A Nation-Wide Assessment.

Purpose: Canadian resident physicians carry large debt to finance their education, which impacts their wellness and their future decision making. The objective of this observational study is to assess the financial literacy of Canadian radiology residents through testing their financial knowledge and examining their current financial status. Methods: A survey was designed to assess the financial literacy and current financial status of radiology residents, which was distributed to Canadian radiology residents via Google Forms. Descriptive analyses on preliminary data and the association between level of training and financial quiz scores were obtained. Results: 104 valid responses from 16 universities were received. The majority (53%) of residents indicated that their debt was greater than $150 000. Residents on average scored 71% on the financial quiz and the scores were not associated with training level (P = .71). The majority (89%) of residents indicated a strong interest in a formal financial literacy curriculum, with 80% preferring a physician-led curriculum. Conclusion: Overall, residents face a high debt burden. Current resident physicians value a formal financial literacy curriculum as a part of their residency program despite existing financial knowledge. Most importantly, residents feel that a curriculum created with involvement of other physicians would be optimal.

Supplemental Breast Cancer Screening in Women with Dense Breasts and Negative Mammography: A Systematic Review and Meta-Analysis.

Background The best supplemental breast cancer screening modality in women at average risk or intermediate risk for breast cancer with dense breast and negative mammogram remains to be determined. Purpose To conduct systematic review and meta-analysis comparing clinical outcomes of the most common available supplemental screening modalities in women at average risk or intermediate risk for breast cancer in patients with dense breasts and mammography with negative findings. Materials and Methods A comprehensive search was conducted until March 12, 2020, in Medline, Epub Ahead of Print and In-Process and Other Non-Indexed Citations; Embase Classic and Embase; Cochrane Central Register of Controlled Trials; and Cochrane Database of Systematic Reviews, for Randomized Controlled Trials and Prospective Observational Studies. Incremental cancer detection rate (CDR); positive predictive value of recall (PPV1); positive predictive value of biopsies performed (PPV3); and interval CDRs of supplemental imaging modalities, digital breast tomosynthesis, handheld US, automated breast US, and MRI in non-high-risk patients with dense breasts and mammography negative for cancer were reviewed. Data metrics and risk of bias were assessed. Random-effects meta-analysis and two-sided metaregression analyses comparing each imaging modality metrics were performed (PROSPERO; CRD42018080402). Results Twenty-two studies reporting 261 233 screened patients were included. Of 132 166 screened patients with dense breast and mammography negative for cancer who met inclusion criteria, a total of 541 cancers missed at mammography were detected with these supplemental modalities. Metaregression models showed that MRI was superior to other supplemental modalities in CDR (incremental CDR, 1.52 per 1000 screenings; 95% CI: 0.74, 2.33; P < .001), including invasive CDR (invasive CDR, 1.31 per 1000 screenings; 95% CI: 0.57, 2.06; P < .001), and in situ disease (rate of ductal carcinoma in situ, 1.91 per 1000 screenings; 95% CI: 0.10, 3.72; P < .04). No differences in PPV1 and PPV3 were identified. The limited number of studies prevented assessment of interval cancer metrics. Excluding MRI, no statistically significant difference in any metrics were identified among the remaining imaging modalities. Conclusion The pooled data showed that MRI was the best supplemental imaging modality in women at average risk or intermediate risk for breast cancer with dense breasts and mammography negative for cancer. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Hooley and Butler in this issue.

Pancreatic Cystic Lesions on MRI: What Is The Likelihood of a Present or Future Diagnosis of Pancreatic Carcinoma?

BACKGROUND: Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship. PURPOSE: To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma. STUDY TYPE: Single-center retrospective cohort. POPULATION: A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016. FIELD STRENGTH/SEQUENCES: 1.5 T and 3 T, including T2 WI, T1 WI, diffusion weighted imaging and contrast-enhanced T1 WI. ASSESSMENT: Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67 months (interquartile range: 43-88 months). STATISTICAL TESTS: Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance. RESULTS: The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively. DATA CONCLUSION: A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow-up. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: 5.

Classification of Musculoskeletal Radiograph Requisition Appropriateness Using Machine Learning.

Objective: Poor quality imaging requisitions lower report quality and impede good patient care. Manual control of such requisitions is time consuming and can be a source of friction with referring physicians. The purpose of this study was to determine if poor quality requisitions could be identified automatically using machine learning and natural language processing techniques in order to allow for more efficient workflow. Methods: Exam indications from 50 000 musculoskeletal radiograph requisitions were manually classified, reviewed and deemed 'appropriate' or 'inappropriate' by two staff radiologists based on ACR appropriateness criteria. The requisitions were divided into training and test groups (80/20 split). The training set was pre-processed, converted to a bag-of-words model and used to train a Multinomial Naïve Bayes classifier which was then applied to the test set. Results: Out of 50 000 requisitions, 12 253 (24.5%) were deemed to contain an inappropriate indication. A Naive Bayes model correctly classified requisitions with an accuracy of 98%. In the test set, 107 of 7561 (1.4%) appropriate requisitions were incorrectly flagged and 92 of 2439 (3.8%) inappropriate requisitions were not flagged. Conclusions: Accurate automated identification of inappropriate indications on musculoskeletal requisitions is feasible using machine learning and natural language processing.

A Single-Center Audit of BI-RADS 3 Assessment Category Utilization in Mammography and Breast Ultrasound.

Purpose: To evaluate outcomes of breast lesions assessed at our institution as probably benign (Breast Imaging Reporting and Data System [BI-RADS] category 3) with an expected malignancy rate of less than or equal to 2 %. Methods: Average-risk women with a BI-RADS 3 assessment following mammographic and/or ultrasound evaluation at our institution between January 1 and December 31, 2017 were included. Cancer yield was calculated within 90 days and at 6-month intervals up to 36 months. Results: Among 517 women (median age, 52 years; range, 13-89 years) with a BI-RADS 3 assessment, 349 (67.5 %) underwent biopsy or completed follow-up imaging up to 36 months. One hundred and 68 (32.5 %) were lost to follow-up. Thirty of 349 (8.6 %) had their imaging upgraded and underwent biopsy, yielding six cancers (cancer yield, 6 of 349 women [1.7 %]). Among 569 lesions assessed as BI-RADS 3, 92 (16.2 %) were characterized by morphologic features other than those validated as probably benign in prospective clinical studies. Fifty three of 517 women (10.3 %) had follow-up beyond 24 months, and 24 (4.6 %) had follow-up beyond 36 months. Conclusion: Overall utilization of the BI-RADS 3 assessment category at our institution is appropriate with a 1.7 % cancer yield. However, the rate of loss to follow-up, percentage of non-validated findings assessed as probably benign, and redundancy in follow-up protocols are too high, and warrant intervention. A patient handout explaining the BI-RADS 3 assessment category and automatic scheduling of follow-up studies have been implemented at our center to address loss to follow-up.

Radiologist Productivity Analytics: Factors Impacting Abdominal Pelvic CT Exam Reporting Times.

The purpose is to determine factors impacting radiologist abdominal pelvic CT exam reporting time. This study was Research Ethics Board approved. Between January 2019 and March 2020, consecutive abdominal pelvic CT exams were documented as structured or unstructured based on application of templates with separate sections for different organs or organ systems. Radiologist reporting location, patient class (inpatient, Emergency Department (ED) patient, outpatient), radiologist fellowship-training, report word count, and radiologist years of experience were documented. Median reporting times were compared using the Wilcoxon Rank-sum test, Kruskal-Wallis test, and regression analysis. Spearman's rank correlation was used to determine correlation between word count and radiologist experience with reporting time. P < 0.05 is defined statistical significance. A total of 3602 abdominal pelvic CT exam reports completed by 33 radiologists were reviewed, including 1150 outpatient and 2452 inpatient and Emergency Department (ED) cases. 1398 of all reports were structured. Median reporting time for structured and unstructured reports did not differ (P = 0.870). Reports dictated in-house were completed faster than reports dictated remotely (P < 0.001), and reports for inpatients/ED patients were completed faster than for outpatients (P < 0.001). Reporting time differences existed between radiologists (P < 0.001) that were not explained by fellowship training (P = 0.762). Median reporting time had a weak correlation with word count (ρ = 0.355) and almost no correlation with radiologist years of experience (ρ = 0.167), P < 0.001. Abdominal pelvic CT reporting is most efficient when dictations are completed in-house and for high-priority cases; the use of structured templates, radiologist fellowship training, and years of experience have no impact on reporting times.

The Impact of Slice Thickness on Diagnostic Accuracy in Digital Breast Tomosynthesis.

Purpose: To evaluate the effect of slice thickness on diagnostic accuracy in Digital Breast Tomosynthesis (DBT). Method: Two readers retrospectively interpreted 150 DBT (125 normal and 25 pathology-proven cancer) cases scanned between October 2017-November 2020. The DBT studies were randomised and reviewed independently by the two readers. DBT studies were reviewed using a standard protocol (1 mm slices, no overlap and synthetic 2D-mammography (SM)) and an experimental protocol (10 mm slabs, 5 mm overlap and SM). Any abnormality and BIRADS scores were recorded by each reader. Sensitivity, specificity, interobserver and intraobserver agreement were calculated (Cohen's Kappa κ). For diagnostic accuracy, the reference standard was histopathology or a normal mammogram at 2 years. Results: The sensitivity and specificity for reader 1 and 2 for cancer detection was reader 1 (97% and 79% for the standard protocol, 97% and 76% for the experimental protocol) and reader 2 (97% and 74% for both protocols). Reader 1 had 97.6% intraobserver agreement (κ .95) and reader 2 had 96.4% intraobserver agreement (κ .92) when assessing the standard and experimental protocols. There was 90.5% agreement between the readers for the standard protocol (κ .80). There was 90.9% agreement between the readers for the experimental protocol (κ .81). Of the 25 DBT studies with pathology-proven cancer, one cancer was missed by both readers using both protocols. Conclusion: The diagnostic accuracy was similar between the standard and experimental DBT protocols, demonstrating excellent interobserver and intraobserver agreement. This suggests 10-mm thick slabs can potentially replace 1-mm thin slices in the interpretation of DBT.

The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience.

PURPOSE: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.

Canadian Association of Radiologists Prostate MRI White Paper.

Prostate cancer is the most common malignancy and the third most common cause of death in Canadian men. In light of evolving diagnostic pathways for prostate cancer and the increased use of MRI, which now includes its use in men prior to biopsy, the Canadian Association of Radiologists established a Prostate MRI Working Group to produce a white paper to provide recommendations on establishing and maintaining a Prostate MRI Programme in the context of the Canadian healthcare system. The recommendations, which are based on available scientific evidence and/or expert consensus, are intended to maintain quality in image acquisition, interpretation, reporting and targeted biopsy to ensure optimal patient care. The paper covers technique, reporting, quality assurance and targeted biopsy considerations and includes appendices detailing suggested reporting templates, quality assessment tools and sample image acquisition protocols relevant to the Canadian healthcare context.

Synthetic 2D Mammography Versus Standard 2D Digital Mammography: A Diagnostic Test Accuracy Systematic Review and Meta-Analysis.

BACKGROUND. The use of synthetic 2D mammography (SM) with digital breast tomosynthesis (DBT) in place of standard 2D digital mammography (DM) may reduce radiation dose without sacrificing accuracy. OBJECTIVE. The purpose of our study was to compare the diagnostic accuracy of SM, DM, SM with DBT, and DM with DBT for breast cancer detection. EVIDENCE ACQUISITION. A search of MEDLINE, Embase, and Cochrane databases was performed for relevant articles published up to September 11, 2019. Studies included compared the diagnostic accuracy of SM versus DM and SM plus DBT versus DM plus DBT for breast cancer detection. Relevant study data metrics and risk of bias were assessed. A bivariate random-effects meta-analysis and meta-regression were performed to assess diagnostic accuracy (PROSPERO CRD42020150737). EVIDENCE SYNTHESIS. Thirteen studies reporting on 201,304 patients (7252 patients with breast cancer) were included. The SM group (six studies: 20,728 patients, 724 with breast cancer) had 75% sensitivity (95% CI, 67-82%) and 92% specificity (95% CI, 85-96%). The DM group (nine studies: 52,082 patients, 2249 patients with breast cancer) had 73% sensitivity (95% CI, 65-80%) and 88% specificity (95% CI, 77-94%). The SM plus DBT group (10 studies, 64,224 patients, 2149 with breast cancer) had 85% sensitivity (95% CI, 80-89%) and 93% specificity (95% CI, 86-96%). The DM plus DBT group (nine studies, 64,270 patients, 2130 with breast cancer) had 84% sensitivity (95% CI, 80-88%) and 91% specificity (95% CI, 83-95%). Meta-regression models did not reveal significant differences in accuracy between the SM and DM groups (p = .25-.77). CONCLUSION. SM and SM plus DBT showed comparable diagnostic accuracy to DM and DM plus DBT, respectively. CLINICAL IMPACT. The findings support the implementation of SM in place of standard DM for mammographic imaging of the breasts. This may lead to an overall reduction in radiation exposure.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

OBJECTIVE: To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. METHODS: We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. RESULTS: Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. CONCLUSION: In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Ultrasound- Versus CT-Guided Subpleural Lung and Pleural Biopsy: An Analysis of Wait Times, Procedure Time, Safety, and Diagnostic Adequacy.

PURPOSE: To compare the wait times, safety, and diagnostic adequacy of computed tomography (CT)-guided percutaneous lung biopsies with ultrasound (US) guidance for subpleural lung and pleural lesions. METHODS: Consecutive CT- and US-guided biopsies performed at our institution between January 2018 and January 2019 were retrospectively reviewed. Biopsy wait times, lesion size, degree of pleural contact, procedure duration, number of needle passes, complications, and pathologic diagnosis were recorded and compared. RESULTS: A total of 158 biopsies of subpleural or pleural-based lesions were reviewed. Forty-three cases utilized US guidance, while 115 cases used CT, 41 with conventional CT (CCT), and 74 with cone-beam CT guidance (CBCT). Overall, the mean lesion maximum axial diameter and length of pleural contact for US-guided biopsies was greater than for CT (4.8 ± 2.6 cm vs 3.2 ± 1.9 cm and 4.0 ± 2.5 cm vs 2.6 ± 1.7 cm, respectively, P < .001). Wait times for US-guided biopsies were significantly shorter than CCT by 10.9 days on average while being equivalent to CBCT. Procedure time was shorter for lesions localized with US than CT (29.5 ± 16.4 minutes vs 37.6 ± 19.5 minutes, P = .007) despite CT using less needle passes per lesion (3.5 ± 1.1 vs 3.1 ± 0.8, P = .034). Sample adequacy was equivalent for both modalities (88% for US and 92% for CT). The frequency of pneumothoraces was similar between US (12%) and CT (15%). CONCLUSION: Ultrasound and CT guidance have similar safety and diagnostic adequacy for subpleural lung and pleural biopsies. Ultrasound guidance has shorter wait and procedure times.

The Diagnostic Yield of CT Urography in the Workup of Hematuria With Negative Cystoscopy [Formula: see text].

PURPOSE: To determine the diagnostic yield of computed tomography urography (CTU) in patients evaluated for hematuria with negative cystoscopy and to assess the added value of CTU when compared with ultrasound (US) in this patient population. METHODS: A retrospective study was conducted of patients who underwent CTU within 12 months of negative cystoscopy for workup of hematuria at our institution from January 2016 to December 2017. Computed tomography urography findings were recorded and compared to clinical diagnoses to determine diagnostic yield. Computed tomography urography and US findings were compared in patients who underwent both examinations. Patient characteristics (age, sex, smoking history, and hematuria subtype) were reported. RESULTS: A total of 657 patients met the inclusion criteria, including 108 patients aged 50 years and younger. No cause for hematuria was identified in 41% of patients overall and 58% of patients aged 50 years and younger. The most common diagnoses were benign prostatic hyperplasia and urolithiasis, accounting for 25% and 21% of patients, respectively; 0.6% of patients were diagnosed with an upper urinary tract malignancy, all older than 50 years. Although US was superior or equal to CTU for diagnosis in 83% of patients who underwent both examinations, US had a 0% sensitivity for detection of upper urinary tract malignancy. CONCLUSION: The low diagnostic yield of CTU and low prevalence of upper urinary tract malignancy in patients evaluated for hematuria with negative cystoscopy, particularly those aged 50 years and younger, call into question the appropriateness of multiphasic CTU as a first-line imaging modality in this population.

Digital breast tomosynthesis for breast cancer detection: a diagnostic test accuracy systematic review and meta-analysis.

OBJECTIVES: No consensus exists on digital breast tomosynthesis (DBT) utilization for breast cancer detection. We performed a diagnostic test accuracy systematic review and meta-analysis comparing DBT, combined DBT and digital mammography (DM), and DM alone for breast cancer detection in average-risk women. METHODS: MEDLINE and EMBASE were searched until September 2018. Comparative design studies reporting on the diagnostic accuracy of DBT and/or DM for breast cancer detection were included. Demographic, methodologic, and diagnostic accuracy data were extracted. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. Accuracy metrics were pooled using bivariate random-effects meta-analysis. The impact of multiple covariates was assessed using meta-regression. PROSPERO ID: CRD 42018111287. RESULTS: Thirty-eight studies reporting on 488,099 patients (13,923 with breast cancer) were included. Eleven studies were at low risk of bias. DBT alone, combined DBT and DM, and DM alone demonstrated sensitivities of 88% (95% confidence interval [CI] 83-92), 88% (CI 83-92), and 79% (CI 75-82), as well as specificities of 84% (CI 76-89), 81% (CI 73-88), and 79% (CI 71-85), respectively. The greater sensitivities of DBT alone and combined DBT and DM compared to DM alone were preserved in the combined meta-regression models accounting for other covariates (p = 0.003-0.006). No significant difference in diagnostic accuracy between DBT alone and combined DBT and DM was identified (p = 0.175-0.581). CONCLUSIONS: DBT is more sensitive than DM, while the addition of DM to DBT provides no additional diagnostic benefit. Consideration of these findings in breast cancer imaging guidelines is recommended. KEY POINTS: • Digital breast tomosynthesis with or without additional digital mammography is more sensitive in detecting breast cancer than digital mammography alone in women at average risk for breast cancer. • The addition of digital mammography to digital breast tomosynthesis provides no additional diagnostic benefit in detecting breast cancer compared to digital breast tomosynthesis alone. • The specificity of digital breast tomosynthesis with or without additional digital mammography is no different than digital mammography alone in the detection of breast cancer.

Prospective evaluation of the value of dynamic contrast enhanced (DCE) imaging for prostate cancer detection, with pathology correlation.

INTRODUCTION: The aim of this study was to evaluate the value of dynamic contrast enhanced (DCE) imaging in multi-parametric prostate MRI (mpMRI) for the detection and staging of prostate cancer in comparison with T2W and DWI images alone in biparametric MRI (bpMRI) in treatment naïve patients. MATERIALS AND METHODS: One hundred consecutive patients who underwent a prostate MRI at our institution from June-August 2017, as well as a systematic ultrasound-guided prostate biopsy or prostatectomy, were included. Strictly following PIRADSv2, the MRI studies were independently interpreted by a body radiologist and a body-imaging fellow on two different occasions 8-10 weeks apart. Initially, with all mpMRI sequences and then without the DCE sequence (bpMRI). The readers were blinded to the clinical information. Ethics approval was obtained. RESULTS: One hundred treatment-naïve patients were included (median age 64, age range 48-81, mean PSA 10.3). There was almost perfect intra-observer agreement for mpMRI versus bpMRI for both readers [Cohen's Kappa (k) 0.88-0.86] and substantial inter-observer agreement (k = 0.74 for mpMRI and 0.76 for bpMRI). The sensitivity and specificity did not significantly change between multi-parametric and bi-parametric MRI (Sensitivity 91.7% and 90%, Specificity of 85.5% and 85% for mpMRI and bpMRI, respectively). CONCLUSION: Based on our findings, prostate MRI without DCE (bpMRI) is of comparable diagnostic accuracy to mpMRI in treatment-naïve patients. Performing prostate MRI without DCE (bpMRI) will reduce acquisition time, decrease cost and potentially improve patient safety.

Impact of the COVID-19 pandemic on emergency CT head utilization in Ontario-an observational study of tertiary academic hospitals.

PURPOSE: To determine the impact of the Coronavirus disease-2019 (COVID-19) pandemic on the volume, indications, and results of CT heads performed in the emergency department (ED) at Canadian tertiary academic centers in Ontario. METHODS: A retrospective review of consecutive CT head examinations ordered through the ED during the early stages of the COVID-19 pandemic in Canada (March 12-April 8, 2020) was performed and compared with that during the pre-COVID-19 period (February 12-March 10, 2020). CT reports were reviewed for the exam indication and the presence of predefined acute findings. A two-sample t test was utilized to compare the cohorts. Daily averages were calculated for all measures to control for the sample size difference between each period. A p value < 0.05 was considered significant. RESULTS: Of the total 751 CT head reports, 290 (38.6%) were ordered during the pandemic and 461 (61.4%) were ordered pre-pandemic. The average daily volume of CT head orders decreased significantly during COVID-19 compared with that during pre-COVID-19 (10.4 scans/day vs 16.5 scans/day; p = 0.001). In terms of indications, the frequency of "non-traumatic ICH" was significantly lower during COVID-19 compared with that during pre-COVID-19 (p = 0.01). Also, there was a significant increase in acute findings on CT during COVID-19 compared with that during pre-COVID-19 (p = 0.001). CONCLUSION: The decreased volume of emergency CT heads performed during the COVID-19 pandemic was associated with a significant increase in the proportion of cases with acute findings. This could be a result of the pandemic's influence on the health-seeking behavior of patients as well as the decision-making process of ordering clinicians.