Gastrointestinal neuroendocrine tumor with discordant metastatic disease on 111In-pentetreotide SPECT/CT, 18F-DOPA PET/CT and 68Ga-HA-DOTATATE PET/CT.

A 62-year-old man with resected, pathology-proven small bowel neuroendocrine tumor underwent 111In-pentetreotide SPECT/CT, 18F-DOPA PET/CT and 68Ga-HA-DOTATATE PET/CT to assess metastatic disease. The 111In-pentetreotide SPECT/CT scan showed no metastatic disease. Both 18F-DOPA and 68Ga-HA-DOTATATE PET/CT showed hepatic and peritoneal metastatic disease. However, the burden of 18F-DOPA-avid metastatic disease was far greater compared to the burden of 68Ga-HA-DOTATATE-avid metastatic disease.

Tips for improving consistency of thyroid nodule interpretation with ACR TI-RADS.

Thyroid nodules are very common in the general population. Most are benign and even those that are malignant are typically slow-growing and do not require treatment. Overdiagnosis and overtreatment of thyroid nodules has resulted in significant healthcare costs. ACR TI-RADS was developed to address these concerns, and reduce the number of unnecessary biopsies and follow-up intervals. ACR TI-RADS offers a point-based risk stratification system centered on five sonographic features: consistency, echogenicity, shape, margins and echogenic foci. While the system has noticeable benefits and comparable accuracy with other available risk stratification systems (ATA, EU-TIRADS and K-TIRADS), there are inherent challenges relating to suboptimal inter-reader agreement. In this article, we include 10 educational tips that may be helpful to the ultrasound practitioner for improving the consistency of nodule interpretation with ACR TI-RADS.

Effect of training on resident inter-reader agreement with American College of Radiology Thyroid Imaging Reporting and Data System.

BACKGROUND: The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) was introduced to standardize the ultrasound characterization of thyroid nodules. Studies have shown that ACR-TIRADS reduces unnecessary biopsies and improves consistency of imaging recommendations. Despite its widespread adoption, there are few studies to date assessing the inter-reader agreement amongst radiology trainees with limited ultrasound experience. We hypothesize that in PGY-4 radiology residents with no prior exposure to ACR TI-RADS, a statistically significant improvement in inter-reader reliability can be achieved with a one hour training session. AIM: To evaluate the inter-reader agreement of radiology residents in using ACR TI-RADS before and after training. METHODS: A single center retrospective cohort study evaluating 50 thyroid nodules in 40 patients of varying TI-RADS levels was performed. Reference standard TI-RADS scores were established through a consensus panel of three fellowship-trained staff radiologists with between 1 and 14 years of clinical experience each. Three PGY-4 radiology residents (trainees) were selected as blinded readers for this study. Each trainee had between 4 to 5 mo of designated ultrasound training. No trainee had received specialized TI-RADS training prior to this study. Each of the readers independently reviewed the 50 testing cases and assigned a TI-RADS score to each case before and after TI-RADS training performed 6 wk apart. Fleiss kappa was used to measure the pooled inter-reader agreement. The relative diagnostic performance of readers, pre- and post-training, when compared against the reference standard. RESULTS: There were 33 females and 7 males with a mean age of 56.6 ± 13.6 years. The mean nodule size was 19 ± 14 mm (range from 5 to 63 mm). A statistically significant superior inter-reader agreement was found on the post-training assessment compared to the pre-training assessment for the following variables: 1. "Shape" (k of 0.09 [slight] pre-training vs 0.67 [substantial] post-training, P < 0.001), 2. "Echogenic foci" (k of 0.28 [fair] pre-training vs 0.45 [moderate] post-training, P = 0.004), 3. 'TI-RADS level' (k of 0.14 [slight] pre-training vs 0.36 [fair] post-training, P < 0.001) and 4. 'Recommendations' (k of 0.36 [fair] pre-training vs 0.50 [moderate] post-training, P = 0.02). No significant differences between the pre- and post-training assessments were found for the variables 'composition', 'echogenicity' and 'margins'. There was a general trend towards improved pooled sensitivity with TI-RADS levels 1 to 4 for the post-training assessment while the pooled specificity was relatively high (76.6%-96.8%) for all TI-RADS level. CONCLUSION: Statistically significant improvement in inter-reader agreement in the assigning TI-RADS level and recommendations after training is observed. Our study supports the use of dedicated ACR TI-RADS training in radiology residents.