Diagnostic performance of artificial intelligence for pediatric pulmonary nodule detection on chest computed tomography: comparison of simulated lower radiation doses.

The combination of low dose CT and AI performance in the pediatric population has not been explored. Understanding this relationship is relevant for pediatric patients given the potential radiation risks. Here, the objective was to determine the diagnostic performance of commercially available Computer Aided Detection (CAD) for pulmonary nodules in pediatric patients at simulated lower radiation doses. Retrospective chart review of 30 sequential patients between 12-18 years old who underwent a chest CT on the Siemens SOMATOM Force from December 20, 2021, to April 12, 2022. Simulated lower doses at 75%, 50%, and 25% were reconstructed in lung kernel at 3 mm slice thickness using ReconCT and imported to Syngo CT Lung CAD software for analysis. Two pediatric radiologists reviewed the full dose CTs to determine the reference read. Two other pediatric radiologists compared the Lung CAD results at 100% dose and each simulated lower dose level to the reference on a nodule by nodule basis. The sensitivity (Sn), positive predictive value (PPV), and McNemar test were used for comparison of Lung CAD performance based on dose. As reference standard, 109 nodules were identified by the two radiologists. At 100%, and simulated 75%, 50%, and 25% doses, lung CAD detected 60, 62, 58, and 62 nodules, respectively; 28, 28, 29, and 26 were true positive (Sn = 26%, 26%, 27%, 24%), 30, 32, 27, and 34 were false positive (PPV = 48%, 47%, 52%, 43%). No statistically significance difference of Lung CAD performance at different doses was found, with p-values of 1.0, 1.0, and 0.7 at simulated 75%, 50%, and 25% doses compared to standard dose. CONCLUSION: The Lung CAD shows low sensitivity at all simulated lower doses for the detection of pulmonary nodules in this pediatric population. However, radiation dose may be reduced from standard without further compromise to the Lung CAD performance. WHAT IS KNOWN: • High diagnostic performance of Lung CAD for detection of pulmonary nodules in adults. • Several imaging techniques are applied to reduce pediatric radiation dose. WHAT IS NEW: • Low sensitivity at all simulated lower doses for the detection of pulmonary nodules in our pediatric population. • Radiation dose may be reduced from standard without further compromise to the Lung CAD performance.

Joint EANM/SIOPE/RAPNO practice guidelines/SNMMI procedure standards for imaging of paediatric gliomas using PET with radiolabelled amino acids and [18F]FDG: version 1.0.

Positron emission tomography (PET) has been widely used in paediatric oncology. 2-Deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) is the most commonly used radiopharmaceutical for PET imaging. For oncological brain imaging, different amino acid PET radiopharmaceuticals have been introduced in the last years. The purpose of this document is to provide imaging specialists and clinicians guidelines for indication, acquisition, and interpretation of [18F]FDG and radiolabelled amino acid PET in paediatric patients affected by brain gliomas. There is no high level of evidence for all recommendations suggested in this paper. These recommendations represent instead the consensus opinion of experienced leaders in the field. Further studies are needed to reach evidence-based recommendations for the applications of [18F]FDG and radiolabelled amino acid PET in paediatric neuro-oncology. These recommendations are not intended to be a substitute for national and international legal or regulatory provisions and should be considered in the context of good practice in nuclear medicine. The present guidelines/standards were developed collaboratively by the EANM and SNMMI with the European Society for Paediatric Oncology (SIOPE) Brain Tumour Group and the Response Assessment in Paediatric Neuro-Oncology (RAPNO) working group. They summarize also the views of the Neuroimaging and Oncology and Theranostics Committees of the EANM and reflect recommendations for which the EANM and other societies cannot be held responsible.

Working from home during the COVID-19 pandemic: surveys of the Society for Pediatric Radiology and the Society of Chiefs of Radiology at Children's Hospitals.

BACKGROUND: Due to the COVID-19 pandemic, some pediatric radiologists have shifted to working from home; the long-term ramifications for pediatric radiologists and departments have not yet been defined. OBJECTIVE: To characterize experiences of working from home associated with the COVID-19 pandemic and guide expectations after the pandemic is controlled, via separate surveys of Society for Pediatric Radiology (SPR) and Society of Chiefs of Radiology at Children's Hospitals (SCORCH) members. MATERIALS AND METHODS: Two separate surveys were conducted. In the first, SPR members were surveyed Jan. 11 through Feb. 8, 2021. The response rate was 17.0% (255 of 1,501). Survey questions included demographics, information on the ability to work from home and subjective experiences ranked on a scale of 0 to 10. The survey enabled segregation and comparison of responses between those with and without home PACS. In the second survey, SCORCH members were surveyed Dec. 8, 2020, through Jan. 8, 2021. The response rate was 51.5% (51/99). Survey questions included the logistics of working from home, technical specifications and the expectations on clinical duties performed from home. The Wilcoxon rank test was used to determine statistical significance of compared variables between respondents with and without home PACS in SPR members, and expectations between SPR and SCORCH members. Descriptive statistics summarized demographic questions and free text responses. RESULTS: The majority of member respondents (81.2%, 207/255) had a home PACS and most departments provided home PACS to faculty (94.1%, 48/51). Overall, radiologists who could work from home were satisfied with their ability to work from home (mean rating: 8.3/10) and were significantly more satisfied than predicted by those without home PACS (5.9/10, P<0.0001). Respondents overwhelmingly indicated they were less able to teach trainees (mean rating: 2.7/10) and had decreased emotional engagement (mean rating: 4.4/10), but had improved research productivity and cognitive ability for research when working from home (mean rating for both: 5.3/10). Regarding the expectations of the ability to work from home after no longer needing to address the pandemic, department chairs generally favored fewer rotations from home, with 97.9% (47/48) indicating working from home should be 60% or fewer assignments, compared with 84.1% (164/195) of individual radiologists (P=0.071). CONCLUSIONS: Due to the COVID-19 pandemic, there has been a shift to working from home using PACS. Results of these SPR and SCORCH member surveys can help inform future decisions regarding pediatric radiologists working from home once the pandemic has been controlled.

Acute appendicitis and SARS-CoV-2 in children: imaging findings at a tertiary children's hospital during the COVID-19 pandemic.

BACKGROUND: Evidence suggests severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be associated with appendicitis or clinical symptoms that mimic appendicitis, but it is not clear if the findings or utility of imaging in pediatric patients with suspected appendicitis have changed since the onset of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: To evaluate for potential differences in SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients imaged for suspected appendicitis to determine the reliability of the existing medical imaging approach for appendicitis in a population that contains both SARS-CoV-2 positive and SARS-CoV-2 negative pediatric patients. MATERIALS AND METHODS: Patients imaged for suspected appendicitis Apr. 1, 2020, to Dec. 31, 2020, were identified via an electronic medical records search. Differences in ultrasound (US) diagnostic performance, use of computed tomography (CT) following US, rates of appendicitis, imaging findings of appendicitis and perforation were compared between SARS-CoV-2 positive and SARS-CoV-2 negative tested patients, using pathology and surgery as reference standards for appendicitis and perforation, respectively. Fisher exact test and Student's t-test were used for statistical analysis. RESULTS: One thousand, six hundred and ninety-three patients < 18 years old met inclusion criteria, with 46% (772/1,693) female, 11 imaged with only CT and 1,682 with US. Comparing SARS-CoV-2 positive and SARS-CoV-2 negative patients, no statistically significant differences in sensitivity or specificity of US (P = 1 and P = 1, respectively), or in the US (P-values ranging from 0.1 to 1.0) or CT imaging findings (P-values ranging from 0.2 to 1.0) in appendicitis were found. Perforation rates were similar between SARS-CoV-2 positive (20/57, 35.1% perforated) and SARS-CoV-2 negative (359/785, 45.7% perforated) patients with appendicitis (P = 0.13). Use of CT following first-line US was similar, with 7/125 (5.6%) of SARS-CoV-2 positive imaged with CT after US and 127/1,557 (8.2%) of SARS-CoV-2 negative imaged with CT after US (P = 0.39). CONCLUSION: In pediatric patients with suspected appendicitis, no significant difference was found in the diagnostic performance of US, CT usage or perforation rates between SARS-CoV-2 positive and SARS-CoV-2 negative patients.

Ileocolic intussusception in pediatric SARS-CoV-2 patients: experience at a tertiary pediatric center.

PURPOSE: COVID-19 disease can manifest with intussusception in pediatric patients, but prevalence of abnormalities on ultrasounds performed for intussusception is uncertain. We aim to report our experience in children with COVID-19 presenting with suspected intussusception imaged with ultrasound. METHODS: Children under 18 years who had an ultrasound for possible intussusception underwent retrospective analysis and were tested for COVID-19 between April 1 and December 14, 2020. Patients' demographic, clinical, radiological and surgical characteristics were reviewed. RESULTS: Twenty-four COVID-19-positive patients were identified; 19 boys with mean age 3 years (range: 3 months-18 years). Ultrasound was abnormal in 11 patients (11/24, 46%). Sonographic features of enterocolitis were documented in seven children (7/24, 29%). Three boys (3/24, 13%) were found to have ileocolic intussusception on ultrasound and underwent air enema with failed reduction (3/3, 100%), precipitating surgical reductions, all with favorable outcomes. One patient (1/24, 4%) was found to have a long segment of persistent small bowel-small bowel intussusception which was surgically repaired. CONCLUSION: Given the known association between failed reduction at air enema and delayed presentation, heightened awareness for intussusception in the setting of COVID-19 should be maintained, though more often, the etiology was attributed to other GI manifestations of COVID-19.

Peptide receptor radionuclide therapy for treatment of metastatic neuroendocrine tumors in children.

Neuroendocrine tumors (NETs) of the pancreas and midgut are extremely rare in children, and patients presenting with metastatic disease have poor survival. Given this rarity, treatments are extrapolated from guidelines for adults with NET. Recent clinical trials in adults with NETs have shown that the addition of peptide receptor radionuclide therapy (PRRT) with 177 Lu-DOTATATE resulted in a disease control rate of nearly 80%, with minimal side effects. We report our experience using 177 Lu-DOTATATE to treat two pediatric patients with metastatic NET.

Prospective cost implications with a clinical decision support system for pediatric emergency head computed tomography.

BACKGROUND: Unnecessary imaging is a potential cost driver in the United States health care system. OBJECTIVE: Using a clinical decision support tool, we determined the percentage of low-utility non-contrast head computed tomography (CT) examinations on emergency patients and calculated the prospective cost implications of providing low-value imaging using time-driven activity-based costing at an academic quaternary pediatric hospital. MATERIALS AND METHODS: A clinical decision support tool for imaging, CareSelect (National Decision Support Co., Madison, WI), was integrated in silent mode into the electronic health record from September 2018 through August 2019. Each non-contrast head CT order received a score from the clinical decision support tool based on the American College of Radiology Appropriateness Criteria. Descriptive statistics for all levels of appropriateness scores were compiled with an emphasis on low-utility exams. A micro-costing assessment was conducted using time-driven activity-based costing on head CT without contrast examinations. RESULTS: Within the 11-month time period, 3,186 head CT examinations without contrast were ordered for emergency center patients. Among these orders, 28% (896/3,186) were classified as low-utility studies. The base case CT pathway time was 43 min and base case total cost was $193.35. The base case opportunity cost of these low-utility exams extrapolated annually amounts to $188,902 for our institution. CONCLUSION: Silent mode implementation of a clinical decision support tool resulted in 28% of head CT non-contrast exams on emergency patients being graded as low-utility studies. Prospective cost implications resulted in an annual base case cost of $188,902 to Texas Children's Hospital.

Response to the COVID-19 Pandemic: Practical Guide to Rapidly Deploying Home Workstations to Guarantee Radiology Services During Quarantine, Social Distancing, and Stay Home Orders.

OBJECTIVE. The purpose of this article is to share an experience in the rapid deployment of home workstations that illustrates a creative solution that transcended typical administrative barriers. CONCLUSION. In response to the global coronavirus disease (COVID-19) pandemic, radiology departments need to rapidly deploy home PACS workstations to facilitate physical distancing and to guarantee radiologic expertise despite possible home quarantining or stay home, work safe orders.

Current trends in pediatric nuclear medicine: a Society for Pediatric Radiology membership survey.

BACKGROUND: Pediatric nuclear medicine is evolving, and its practice patterns are uncertain. Knowledge of the current trends in pediatric nuclear medicine might be helpful to direct local decisions, including expectations for patient care, needs for capital acquisitions, and staffing recruitment strategies. OBJECTIVE: To provide data regarding the current practice of pediatric nuclear medicine via a Society for Pediatric Radiology (SPR) membership survey. MATERIALS AND METHODS: The SPR emailed our 25-question survey to all 1,847 SPR members in August 2018 and we accepted responses until April 2019. Questions focused on nuclear medicine staffing, positron emission tomography (PET) utilization, and radiotherapy availability. Respondents could indicate their affiliated hospital, which we used for data cataloguing only. Analysis of survey responses was blinded to reported institution. We analyzed response data using contingency tables. Independence testing between categorical variables based on proportions of physicians with additional nuclear medicine board certification was performed on a subset of questions regarding PET and therapy practices. RESULTS: Sixty-seven people from at least 29 hospitals responded to the survey, including all 10 of the 2018-2019 U.S. News & World Report best children's hospitals. The majority (48/67, 71.6%) of respondents indicated that pediatric nuclear medicine examinations were interpreted in the pediatric radiology department by pediatric radiologists and that most physicians interpreting the exams (43/67, 64.2%) did not have subspecialty certification in nuclear medicine or nuclear radiology. Most facilities offered PET/CT (57/67, 85.1%); few offered PET/MRI (12/67, 17.9%). Most facilities offered radiotherapies (57/67, 85.1%) but at most of these facilities (30/57, 52.6%), fewer than half the physicians who cover nuclear medicine were approved to administer therapies. In the subset analyses based on proportion of physicians with additional nuclear medicine board certification, there were statistically significant differences between the groups in availability of PET/MRI, lutetium-177 dotatate therapy programs, and percentages of physicians approved to administer therapies. CONCLUSION: Pediatric nuclear medicine is largely practiced by pediatric radiologists without subspecialty certification. Staffing, PET practices and therapies vary among practices, in part associated with the number of radiologists with nuclear medicine board certification.

Pediatric applications of Dotatate: early diagnostic and therapeutic experience.

In recent years, new somatostatin receptor agents (SSTRs) have become available for diagnostic imaging and therapy in neuroendocrine tumors. The novel SSTR ligand DOTA-DPhel-Tyr3-octreotate (Dotatate) in particular can be linked with 68Gallium for diagnostic imaging purposes, and with the ß-emitter 177Lutetium for radiotherapy in the setting of neuroendocrine tumors. Dotatate imaging offers distinct advantages in the evaluation of neuroendocrine tumors compared to standard techniques, including greater target-to-background ratio and lesion conspicuity, high sensitivity/specificity, improved spatial resolution with positron emission tomography (PET)/CT or PET/MR, and decreased radiation exposure. Although currently off-label in pediatrics, Dotatate theranostics in children are being explored, most notably in the setting of neuroblastoma and hereditary neuroendocrine syndromes. This article provides a multicenter case series of Dotatate imaging and therapy in pediatric patients in order to highlight the spectrum of potential clinical applications.

Neuroblastoma of the Bone and Bone Marrow Without an Apparent Primary Site: Report of 4 Cases With Long-term Follow-up.

Children with neuroblastoma rarely present with metastatic disease without identifiable primary tumors. We describe the clinical and histopathologic characteristics of 4 patients aged 1, 7, 7, and 11 years with neuroblastoma involving bone or bone marrow without an apparent primary site. One patient presented with a periorbital bone lesion, 1 presented with a distal femoral lesion, and 2 presented with diffuse bone marrow involvement. All tumors were negative for MYCN amplification. All patients were alive without evidence of disease 5 years after completion of multimodality therapy. Patients with neuroblastoma of the bone and bone marrow without an apparent primary site may constitute a unique group characterized by older age at diagnosis, nonamplified MYCN tumors, and good response to treatment.

Comparison of the diagnostic accuracy of PET/MRI to PET/CT-acquired FDG brain exams for seizure focus detection: a prospective study.

BACKGROUND: There is great interest in positron emission tomography (PET)/magnetic resonance (MR) as a clinical tool due to its capacity to provide diverse diagnostic information in a single exam. OBJECTIVE: The goal of this exam is to compare the diagnostic accuracy of PET/MR-acquired [F-18]2-fluoro-2-deoxyglucose (FDG) brain exams to that of PET/CT with respect to identifying seizure foci in children with localization-related epilepsy. MATERIALS AND METHODS: Institutional Review Board approval and informed consent were obtained for this Health Insurance Portability and Accountability Act-compliant, prospective study. All patients referred for clinical FDG-PET/CT exams of the brain at our institution for a diagnosis of localization-related epilepsy were prospectively recruited to undergo an additional FDG-PET acquisition on a tandem PET/MR system. Attenuation-corrected FDG images acquired at PET/MR and PET/CT were interpreted independently by five expert readers. Readers were blinded to the scanner used for acquisition and attenuation correction as well as all other clinical and imaging data. A Likert scale scoring system (1-5) was used to assess image quality. The locale of seizure origin determined at multidisciplinary epilepsy surgery work rounds was considered the reference standard. Non-inferiority testing for paired data was used to compare the diagnostic accuracy of PET/MR to that of PET/CT. RESULTS: The final study population comprised 35 patients referred for a diagnosis of localization-related epilepsy (age range: 2-19 years; median: 11 years; 21 males, 14 females). Image quality did not differ significantly between the two modalities. The accuracy of PET/MR was not inferior to that of PET/CT for localization of a seizure focus (P=0.017). CONCLUSION: The diagnostic accuracy of FDG-PET images acquired on a PET/MR scanner and generated using MR-based attenuation correction was not inferior to that of PET images processed by traditional CT-based correction.

Assessment of Sequential PET/MRI in Comparison With PET/CT of Pediatric Lymphoma: A Prospective Study.

OBJECTIVE: The objective of our study was to compare the diagnostic performance of sequential (18)F-FDG PET/MRI (PET/MRI) and (18)F-FDG PET/CT (PET/CT) in a pediatric cohort with lymphoma for lesion detection, lesion classification, and disease staging; quantification of FDG uptake; and radiation dose. SUBJECTS AND METHODS: For this prospective study of 25 pediatric patients with lymphoma, 40 PET/CT and PET/MRI examinations were performed after a single-injection dual-time-point imaging protocol. Lesions detected, lesion classification, Ann Arbor stage, and radiation dose were tabulated for each examination, and statistical evaluations were performed to compare the modalities. Quantification of standardized uptake values (SUVs) was performed for all lesions. All available examinations and clinical history were used as the reference standard. RESULTS: No statistically significant differences between PET/MRI and PET/CT were observed in lesion detection rates, lesion classification, or Ann Arbor staging. Fifty-four regions of focal uptake were observed on PET/MRI compared with 55 on PET/CT. Both modalities accurately classified 82% of the lesions relative to the reference standard. Disease staging based on PET/MRI was correct for 35 of the 40 studies, and disease staging based on PET/CT was correct for 35 of the 40 studies; there was substantial agreement between the modalities for disease staging (κ = 0.684; p < 0.001). PET SUVs were strongly correlated between PET/CT and PET/MRI (ρ > 0.72), although PET/MRI showed systematically lower SUV measurements. PET/MRI offered an average 45% reduction in radiation dose relative to PET/CT. CONCLUSION: In a pediatric cohort with lymphoma, sequential PET/MRI showed lesion detection, lesion classification, and Ann Arbor staging comparable to PET/CT. PET/MRI quantification of FDG uptake strongly correlated with PET/CT, but the SUVs were not interchangeable. PET/MRI significantly reduced radiation exposure and is a promising new alternative in the care of pediatric lymphoma patients.

Comparison of Standardized Uptake Values in Normal Structures Between PET/CT and PET/MRI in a Tertiary Pediatric Hospital: A Prospective Study.

OBJECTIVE: The purpose of this study was to compare standardized uptake values (SUVs) of normal tissues using MR attenuation-corrected versus CT attenuation-corrected (18)F-FDG PET in a pediatric population. SUBJECTS AND METHODS: Thirty-five patients (21 boys; mean age, 13.3 years) referred for 47 PET/CT scans were recruited to undergo PET/MRI. MR attenuation correction was performed using an automated three-segment model. ROIs were drawn over nine normal structures to estimate SUV(min), SUV(mean), and SUV(max). Pearson rank correlation coefficients were calculated to compare SUVs obtained from MR and CT attenuation correction. In nine patients who underwent multiple PET/MRI studies, coefficients of variance and intraclass correlation coefficients were calculated to evaluate intrapatient SUV(max) variation. RESULTS: Mean (± SD) time to imaging after FDG injection was 108 ± 17 minutes for PET/CT and 61 ± 6 minutes for PET/MRI. PET/MRI SUVs in all tissues were lower than those for PET/CT (mean difference, -28.9% ± 31.1%; p < 0.05). Very high or high correlation between PET/MRI and PET/CT SUV(max) was found in brain (r = 0.72), myocardium (r = 0.95), and bone marrow (r = 0.85) (p < 0.001). Moderate correlation was found in liver (r = 0.54), fat (r = 0.41), mean blood pool (r = 0.40), and psoas muscle (r = 0.38) (p < 0.01). Weak correlation was found in lung (r = 0.12) and iliacus muscle (r = 0.12). Compared with PET/CT, PET/MRI systematically undermeasured SUV. In nine patients who underwent multiple PET/MRI examinations, moderate or strong agreement was found in the SUV(max) of six of nine tissues, similar to the corresponding PET/CT examinations. CONCLUSION: Our study showed overall high correlation for SUV measurements obtained from MR attenuation correction compared with CT attenuation correction, although PET/MRI underestimated SUV compared with PET/CT. SUVs measured from PET/MRI indicated good intrapatient reliability.

Qualitative FDG PET Image Assessment Using Automated Three-Segment MR Attenuation Correction Versus CT Attenuation Correction in a Tertiary Pediatric Hospital: A Prospective Study.

OBJECTIVE: The purpose of this study was to systematically evaluate the diagnostic quality of (18)F-FDG PET images generated using MR attenuation correction (MRAC) compared with those images generated using CT attenuation correction (CTAC) in a pediatric population. SUBJECTS AND METHODS: Forty-two patients (mean age, 12.8 years; percentage who were male, 57%) who were referred for 62 indicated whole-body PET/CT studies were prospectively recruited to undergo PET/MRI examinations during the same clinic visit in which PET/CT was performed. MRAC was performed using an automatic three-segment model. Three nuclear radiologists scored the diagnostic quality of the PET images generated by MRAC and CTAC using a Likert scale (range of scores, 1-5). Images graded with a score of 1-3 were considered clinically unacceptable, whereas images with a score of 4-5 were considered clinically acceptable. A Wilcoxon signed-rank test was used to compare differences in the grading of PET/MRI and PET/CT images. The Fisher exact test was used to evaluate potential differences in clinically acceptable image quality and the presence of artifact. Fleiss kappa statistics were used to examine interobserver agreement. RESULTS: There was no statistically significant difference in the proportion of PET images generated with MRAC and CTAC for which image quality was considered clinically acceptable. A total of 3.9% of PET assessments generated with MRAC were of unacceptable image quality, compared with 2.2% of PET images generated with CTAC. Two of the three radiologists who reviewed the PET images reported the presence of artifacts more often on MRAC-derived images, and they graded the mean quality of these images 0.48 and 0.29 points lower on the 5-point Likert scale than they graded the mean quality of CTAC-derived images (p < 0.0001). Interobserver agreement was fair (κ = 0.39). CONCLUSION: The diagnostic quality of PET images obtained from a pediatric population with the use of an automatic three-segmentation MRAC method was comparable to that of PET images obtained with the use of CTAC.