Imaging of the hepatic arterial infusion pump: Primer for radiologists.

Hepatic arterial infusion (HAI) pumps are used to deliver liver-directed therapy by allowing the administration of selective chemotherapy to the liver via a catheter implanted most commonly into the gastroduodenal artery connected to a subcutaneous pump. This selective administration helps maximize the chemotherapeutic effect within the hepatic tumors while minimizing systemic toxicity. While HAI therapy has primarily been used to treat liver-only metastatic colorectal cancer, the indications have expanded to other malignancies, including intrahepatic cholangiocarcinoma. Radiologists play an important role in pre-operative planning, assessment of treatment response, and evaluation for potential complications using various imaging studies, including computed tomography angiography, magnetic resonance imaging, and perfusion scintigraphy. This article describes the radiologist's role as part of a multi-disciplinary oncology team to help maximize the success of HAI therapy and also helps radiologists familiarize themselves with various aspects of HAI pumps.

ACR Appropriateness Criteria® Abnormal Liver Function Tests.

Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Understanding the role of radiologists in complex treatment decisions for patients with hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver and represents a significant global health burden. Management of HCC can be challenging due to multiple factors, including variable expectations for treatment outcomes. Several treatment options are available, each with specific eligibility and ineligibility criteria, and are provided by a multidisciplinary team of specialists. Radiologists should be aware of the types of treatment options available, as well as the criteria guiding the development of individualized treatment plans. This awareness enables radiologists to contribute effectively to patient-centered multidisciplinary tumor boards for HCC and play a central role in reassessing care plans when the treatment response is deemed inadequate. This comprehensive review aims to equip radiologists with an overview of HCC staging systems, treatment options, and eligibility criteria. The review also discusses the significance of imaging in HCC diagnosis, treatment planning, and monitoring treatment response. Furthermore, we highlight the crucial branch points in the treatment decision-making process that depend on radiological interpretation.

A Multicenter Assessment of Interreader Reliability of LI-RADS Version 2018 for MRI and CT.

Background Various limitations have impacted research evaluating reader agreement for Liver Imaging Reporting and Data System (LI-RADS). Purpose To assess reader agreement of LI-RADS in an international multicenter multireader setting using scrollable images. Materials and Methods This retrospective study used deidentified clinical multiphase CT and MRI and reports with at least one untreated observation from six institutions and three countries; only qualifying examinations were submitted. Examination dates were October 2017 to August 2018 at the coordinating center. One untreated observation per examination was randomly selected using observation identifiers, and its clinically assigned features were extracted from the report. The corresponding LI-RADS version 2018 category was computed as a rescored clinical read. Each examination was randomly assigned to two of 43 research readers who independently scored the observation. Agreement for an ordinal modified four-category LI-RADS scale (LR-1, definitely benign; LR-2, probably benign; LR-3, intermediate probability of malignancy; LR-4, probably hepatocellular carcinoma [HCC]; LR-5, definitely HCC; LR-M, probably malignant but not HCC specific; and LR-TIV, tumor in vein) was computed using intraclass correlation coefficients (ICCs). Agreement was also computed for dichotomized malignancy (LR-4, LR-5, LR-M, and LR-TIV), LR-5, and LR-M. Agreement was compared between research-versus-research reads and research-versus-clinical reads. Results The study population consisted of 484 patients (mean age, 62 years ± 10 [SD]; 156 women; 93 CT examinations, 391 MRI examinations). ICCs for ordinal LI-RADS, dichotomized malignancy, LR-5, and LR-M were 0.68 (95% CI: 0.61, 0.73), 0.63 (95% CI: 0.55, 0.70), 0.58 (95% CI: 0.50, 0.66), and 0.46 (95% CI: 0.31, 0.61) respectively. Research-versus-research reader agreement was higher than research-versus-clinical agreement for modified four-category LI-RADS (ICC, 0.68 vs 0.62, respectively; P = .03) and for dichotomized malignancy (ICC, 0.63 vs 0.53, respectively; P = .005), but not for LR-5 (P = .14) or LR-M (P = .94). Conclusion There was moderate agreement for LI-RADS version 2018 overall. For some comparisons, research-versus-research reader agreement was higher than research-versus-clinical reader agreement, indicating differences between the clinical and research environments that warrant further study. © RSNA, 2023 Supplemental material is available for this article. See also the editorials by Johnson and Galgano and Smith in this issue.

The adoption of LI-RADS: a survey of non-academic radiologists.

PURPOSE: To understand the practice and determinants of non-academic radiologists regarding LI-RADS and the four current LI-RADS algorithms: CT/MRI, contrast-enhanced ultrasound (CEUS), ultrasound (US), and CT/MRI Treatment Response. MATERIALS AND METHODS: Seven themes were covered in this international survey, as follows: (1) demographics of participants and sub-specialty, (2) HCC practice and interpretation, (3) reporting practice, (4) screening and surveillance, (5) HCC imaging diagnosis, (6) treatment response, and (7) CT and MRI technique. RESULTS: Of the 232 participants, 69.4% were from the United States, 25.0% from Canada, and 5.6% from other countries and 45.9% were abdominal/body imagers. During their radiology training or fellowship, no formal HCC diagnostic system was used by 48.7% and LI-RADS was used by 44.4% of participants. In their current practice, 73.6% used LI-RADS, 24.7% no formal system, 6.5% UNOS-OPTN, and 1.3% AASLD. Barriers to LI-RADS adoption included lack of familiarity (25.1%), not used by referring clinicians (21.6%), perceived complexity (14.5%), and personal preference (5.3%). The US LI-RADS algorithm was used routinely by 9.9% of respondents and CEUS LI-RADS was used by 3.9% of the respondents. The LI-RADS treatment response algorithm was used by 43.5% of the respondents. 60.9% of respondents thought that webinars/workshops on LI-RADS Technical Recommendations would help them implement these recommendations in their practice. CONCLUSION: A majority of the non-academic radiologists surveyed use the LI-RADS CT/MR algorithm for HCC diagnosis, while nearly half use the LI-RADS TR algorithm for assessment of treatment response. Less than 10% of the participants routinely use the LI-RADS US and CEUS algorithms.

ACR Appropriateness Criteria® Right Upper Quadrant Pain: 2022 Update.

Acute right upper quadrant pain is one of the most common presenting symptoms in hospital emergency departments, as well as outpatient settings. Although gallstone-related acute cholecystitis is a leading consideration in diagnosis, a myriad of extrabiliary sources including hepatic, pancreatic, gastroduodenal, and musculoskeletal should also be considered. This document focuses on the diagnostic accuracy of imaging studies performed specifically to evaluate acute right upper quadrant pain, with biliary etiologies including acute cholecystitis and its complications being the most common. An additional consideration of extrabiliary sources such as acute pancreatitis, peptic ulcer disease, ascending cholangitis, liver abscess, hepatitis, and painful liver neoplasms remain a diagnostic consideration in the right clinical setting. The use of radiographs, ultrasound, nuclear medicine, CT, and MRI for these indications are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Building Effective Teams in the Real World From Traps to Triumph.

Quality patient care and advancements in medical education, investigation, and innovation require effective teamwork. High-functioning teams navigate stressful environments, learning openly from failures and leveraging successes to fuel future initiatives. The authors review foundational concepts for implementing and sustaining successful teams, including emotional intelligence, trust, inclusivity, clear communication, and accountability. Focus is given to real-world examples and actionable, practical solutions.

MRI assessment of rectal cancer response to neoadjuvant therapy: a multireader study.

OBJECTIVES: A watch and wait strategy with the goal of organ preservation is an emerging treatment paradigm for rectal cancer following neoadjuvant treatment. However, the selection of appropriate patients remains a challenge. Most previous efforts to measure the accuracy of MRI in assessing rectal cancer response used a small number of radiologists and did not report variability among them. METHODS: Twelve radiologists from 8 institutions assessed baseline and restaging MRI scans of 39 patients. The participating radiologists were asked to assess MRI features and to categorize the overall response as complete or incomplete. The reference standard was pathological complete response or a sustained clinical response for > 2 years. RESULTS: We measured the accuracy and described the interobserver variability of interpretation of rectal cancer response between radiologists at different medical centers. Overall accuracy was 64%, with a sensitivity of 65% for detecting complete response and specificity of 63% for detecting residual tumor. Interpretation of the overall response was more accurate than the interpretation of any individual feature. Variability of interpretation was dependent on the patient and imaging feature investigated. In general, variability and accuracy were inversely correlated. CONCLUSIONS: MRI-based evaluation of response at restaging is insufficiently accurate and has substantial variability of interpretation. Although some patients' response to neoadjuvant treatment on MRI may be easily recognizable, as seen by high accuracy and low variability, that is not the case for most patients. KEY POINTS: • The overall accuracy of MRI-based response assessment is low and radiologists differed in their interpretation of key imaging features. • Some patients' scans were interpreted with high accuracy and low variability, suggesting that these patients' pattern of response is easier to interpret. • The most accurate assessments were those of the overall response, which took into consideration both T2W and DWI sequences and the assessment of both the primary tumor and the lymph nodes.

The multidisciplinary management of cholangiocarcinoma.

Cholangiocarcinoma is a lethal malignancy of the biliary epithelium that can arise anywhere along the biliary tract. Surgical resection confers the greatest likelihood of long-term survivability. However, its insidious onset, difficult diagnostics, and resultant advanced presentation render the majority of patients unresectable, highlighting the importance of early detection with novel biomarkers. Developing liver-directed therapies and emerging targeted therapeutics may offer improved survivability for patients with unresectable or advanced disease. In this article, the authors review the current multidisciplinary standards of care in resectable and unresectable cholangiocarcinoma, with an emphasis on novel biomarkers for early detection and nonsurgical locoregional therapy options.

Optional MRI sequences for LI-RADS: why, what, and how?

Hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the liver worldwide. Noninvasive diagnosis of HCC is possible based on imaging features, without the need for tissue diagnosis. Liver Imaging Reporting and Data System (LI-RADS) CT/MRI diagnostic algorithm allows for standardized radiological interpretation and reporting of imaging studies for patients at high risk for HCC. Diagnostic categories of LR-1 to LR-5 designate each liver observation to reflect the probability of overall malignancy, HCC, or benignity based on imaging features, where LR-5 category has > 95% probability of HCC. Optimal imaging protocol and scanning technique as described by the technical recommendations for LI-RADS are essential for the depiction of features to accurately characterize liver observations. The LI-RADS MRI technical guidelines recommend the minimum required sequences of T1-weighted out-of-phase and in-phase Imaging, T2-weighted Imaging, and multiphase T1-weighted Imaging. Additional sequences, including diffusion-weighted imaging, subtraction imaging, and the hepatobiliary phase when using gadobenate dimeglumine as contrast, improve diagnostic confidence, but are not required by the guidelines. These optional sequences can help differentiate true lesions from pseudolesions, detect additional observations, identify parenchymal observations when other sequences are suboptimal, and improve observations conspicuity. This manuscript reviews the optional sequences, the advantages they offer, and discusses technical optimization of these sequences to obtain the highest image quality and to avoid common artifacts.

Gallbladder Imaging Interpretation Pearls and Pitfalls: Ultrasound, Computed Tomography, and Magnetic Resonance Imaging.

The gallbladder is a source of common disease processes with a wide variety of presentations. Common pathologies include acute or chronic cholecystitis, adenomyomatosis, cancer, polyps, and postoperative complications. Accurate imaging assessment of the gallbladder can be very challenging and fraught with potential pitfalls. Ultrasound is the imaging modality of choice for the initial evaluation of patients who present with right upper quadrant pain. CT is often used as part of a broader evaluation of patient's abdominal pain if nongallbladder pathologies are also suspected. MRI/MRCP is typically reserved for problem-solving and evaluating patients who present with cholestatic presentation. We discuss common pitfalls, diagnostic challenges, and problem-solving approaches to the imaging evaluation of common gallbladder patho logies.

Emerging Frontline Leaders' Voices in Response to COVID-19 Crisis.

BACKGROUND: The COVID-19 pandemic has significantly affected healthcare institutions, introducing new challenges for nurse leaders and their colleagues. However, little is known about how the pandemic has specifically affected the lives of these leaders and what methods and strategies they are using to overcome pandemic-related challenges. OBJECTIVES: The aim of this study was to examine the effect of the 2019 pandemic on emerging healthcare leaders and highlight methods and strategies they used to overcome pandemic-related challenges. METHODS: The participants in this study represent a diverse group of interprofessional healthcare faculty enrolled in a transformational leadership course (Paths to Leadership) when the pandemic first appeared. Three months into the pandemic, the leadership cohort was invited to participate in this qualitative study, exploring four questions: Q1: How have you transformed your working styles in response to the pandemic? Q2: How have you adjusted your personal life in response to the pandemic? Q3: How have you used leadership skills learned from Paths to Leadership during the pandemic? Q4: What lessons have you learned from the pandemic? Participant narratives were analyzed by a team of nurse researchers using conventional qualitative content analysis. RESULTS: Themes for Q1 (working styles) included shifted from face-to-face to telework, faced novel disease and decisions, worked more from home, and challenged to maintain contact with professional peers and team. Themes for Q2 (personal life) included accommodate adults working and children learning from home, looked for and found the positive, and continue to struggle. Themes for Q3 (leadership skills) included reflective practice, listening, holding, and reframing. Finally, themes for Q4 (pandemic lessons) included leadership, human connection, be prepared, taking care of ourselves, and connecting with nature. DISCUSSION: The 2019 pandemic brought hardships and opportunities to faculty members enrolled in an interprofessional transformational leadership course. In conjunction with this course, the pandemic provided a unique opportunity for participants to apply newly acquired relationship building, positive organizational psychology, and reframing skills during a time of crisis. Nursing leaders, whose educational offerings may be immediately "put to the test," may find our lessons learned helpful as they develop strategies to cope with unanticipated future challenges.

ACR Appropriateness Criteria® Epigastric Pain.

Epigastric pain can have multiple etiologies including myocardial infarction, pancreatitis, acute aortic syndromes, gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, and hiatal hernia. This document focuses on the scenarios in which epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis, which raise suspicion for gastroesophageal reflux disease, esophagitis, peptic ulcer disease, gastritis, duodenal ulcer disease, gastric cancer, or hiatal hernia. Although endoscopy may be the test of choice for diagnosing these entities, patients may present with nonspecific or overlapping symptoms, necessitating the use of imaging prior to or instead of endoscopy. The utility of fluoroscopic imaging, CT, MRI, and FDG-PET for these indications are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Computed Tomography Techniques, Protocols, Advancements, and Future Directions in Liver Diseases.

Computed tomography (CT) is often performed as the initial imaging study for the workup of patients with known or suspected liver disease. Our article reviews liver CT techniques and protocols in clinical practice along with updates on relevant CT advances, including wide-detector CT, radiation dose optimization, and multienergy scanning, that have already shown clinical impact. Particular emphasis is placed on optimizing the late arterial phase of enhancement, which is critical to evaluation of hepatocellular carcinoma. We also discuss emerging techniques that may soon influence clinical care.

Hepatocarcinogenesis: Radiology-Pathology Correlation.

In the background of chronic liver disease, hepatocellular carcinoma develops via a complex, multistep process called hepatocarcinogenesis. This article reviews the causes contributing to the process. Emphasis is made on the imaging manifestations of the pathologic changes seen at many stages of hepatocarcinogenesis, from regenerative nodules to dysplastic nodules and then to hepatocellular carcinoma.

How to Use LI-RADS to Report Liver CT and MRI Observations.

Primary liver cancer is the fourth leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) comprising the vast majority of primary liver malignancies. Imaging plays a central role in HCC diagnosis and management. As a result, the content and structure of radiology reports are of utmost importance in guiding clinical management. The Liver Imaging Reporting and Data System (LI-RADS) provides guidance for standardized reporting of liver observations in patients who are at risk for HCC. LI-RADS standardized reporting intends to inform patient treatment and facilitate multidisciplinary communication and decisions, taking into consideration individual clinical factors. Depending on the context, observations may be reported individually, in aggregate, or as a combination of both. LI-RADS provides two templates for reporting liver observations: in a single continuous paragraph or in a structured format with keywords and imaging findings. The authors clarify terminology that is pertinent to reporting, highlight the benefits of structured reports, discuss the applicability of LI-RADS for liver CT and MRI, review the elements of a standardized LI-RADS report, provide guidance on the description of LI-RADS observations exemplified with two case-based reporting templates, illustrate relevant imaging findings and components to be included when reporting specific clinical scenarios, and discuss future directions. An invited commentary by Yano is available online. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.