Evaluation and application of American College of Radiology Thyroid Imaging Reporting and Data System for improved malignancy detection in paediatric thyroid nodules.

OBJECTIVE: The American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) is a widely used method for the management of adult thyroid nodules. However, its use in paediatric patients is controversial because adult fine needle aspiration biopsy (FNAB) recommendations may lead to delayed diagnoses of cancer in children. The objectives of this study were to evaluate the performance of TI-RADS in paediatric thyroid nodules and to tailor FNAB recommendations for children. METHODS: Consecutive surgically resected paediatric thyroid nodules from two tertiary care centres between 2003 and 2021 were reviewed. Ultrasounds were blindly scored by radiologists according to TI-RADS. Management recommendations based on TI-RADS were evaluated. Various modelling methodologies were used to determine the optimal cutoff for FNAB in children. RESULTS: Of the 96 patients, 79 (82%) were female and the median age at surgery was 16.1 years. Fifty (52%) nodules were malignant on surgical pathology. The area under the receiver operating characteristic curve of TI-RADS for predicting malignancy was 0.78. Adult TI-RADS recommendations would have resulted in 4% of cancerous nodules being lost to follow-up. Modifications to TI-RADS (FNAB of all TR3 nodules ≥1.5 cm, FNAB of TR4 and TR5 nodules ≥0.5 cm, surveillance of nodules ≥1 cm, consider surgery for nodules >4 cm) reduced this missed malignancy rate to 0%. CONCLUSIONS: TI-RADS can risk-stratify paediatric thyroid nodules. However, the system requires modifications to reduce the missed malignancy rate in paediatric thyroid nodules. Our data suggest that lower size thresholds for FNAB are warranted in children.

Imaging of pediatric thyroid tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper.

Pediatric thyroid cancer is rare in children; however, incidence is increasing. Papillary thyroid cancer and follicular thyroid cancer are the most common subtypes, comprising about 90% and 10% of cases, respectively. This paper provides consensus imaging recommendations for evaluation of pediatric patients with thyroid cancer at diagnosis and during follow-up.

Assessment of the American College of Radiology Thyroid Imaging Reporting and Data System for Thyroid Nodule Malignancy Risk Stratification in a Pediatric Population.

OBJECTIVE: The purpose of this study is to assess the diagnostic performance of the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TIRADS) for malignancy risk in pediatric thyroid nodules. MATERIALS AND METHODS: Two radiologists reviewed ultrasound images of 74 tissue-proven thyroid nodules in 62 children. Points were given for individual features and then added to determine the ACR TI-RADS category, ranging from 1 (benign) to 5 (high suspicion). Kappa coefficients were generated to assess intra- and interobserver agreement. Generalized linear mixed-effects models were used to estimate the odds of malignancy with construction of a supplementary ROC curve. RESULTS: Fifty-four nodules were benign and 20 were malignant, with a median ACR TI-RADS category of 4 (interquartile range, 4-5). Nineteen of 20 (95.0%) malignant nodules were rated as TI-RADS category 4 or 5. There was substantial intraobserver agreement (κ = 0.69-0.77; p < 0.001) and moderate interobserver agreement (κ = 0.37; p = 0.002) for TIRADS category. Univariable analysis showed that, with every 1-unit increase of TI-RADS category, the likelihood of malignancy increased 2.63 times (95% CI, 1.08-6.41; p = 0.03). After adjusting for nodule size, TI-RADS category remained marginally associated with malignancy (adjusted odds ratio, 2.27; 95% CI, 0.93-5.54; p = 0.07). The AUC was 0.75 (95% CI, 0.64-0.86). An optimal cut point of TI-RADS category 5 was selected, with TI-RADS category 5 nodules 10.44 times (95% CI, 2.71-40.21; p < 0.0001) more likely than categories 1-4 nodules to be malignant. CONCLUSION: ACR TI-RADS discriminates well between malignant and benign nodules in a pediatric population, particularly at TI-RADS category 5.

A Practical Approach to Quantitative Grayscale Ultrasound Analysis of Hepatic Steatosis in Pediatric Patients Using a Picture Archiving and Communication System-Based Tool.

OBJECTIVES: To evaluate the efficacy of a picture archiving and communication system (PACS)-based ultrasound (US) quantification technique for diagnosis of hepatic steatosis in a pediatric population. METHODS: Abdominal US images of 49 pediatric patients (≤18 years) with histopathologically proven diagnoses of hepatic steatosis (n = 17), nonsteatotic liver disease (n = 19), and a normal liver (n = 13) were retrospectively reviewed. Patient demographics, the fibrosis stage, and the steatosis grade were obtained from the database. Quantitative grayscale measurements of the echo intensity level of the liver and kidneys were performed on the US images using the PACS measuring tool. The hepatorenal ratio was obtained by dividing mean liver by mean kidney values. The heterogeneity index for the liver was calculated by dividing the liver standard deviation by mean liver values. Hepatorenal ratio and heterogeneity index values of the 3 groups were correlated with pathologic results and compared by a 1-way analysis of variance. A receiver operating characteristic curve analysis was performed, and cutoff values were determined. RESULTS: The hepatorenal ratio of the hepatic steatosis group was significantly greater than those of the control and nonsteatotic liver disease groups (P < .001). The heterogeneity index of the hepatic steatosis group was significantly greater than that of the control group (P = .046). For a hepatorenal ratio cutoff value of 1.5, 88.2% sensitivity, 91.4% specificity, 88.3% positive predictive value, and 94.1% negative predictive value were obtained for predicting hepatic steatosis. CONCLUSIONS: PACS-based quantitative grayscale US quantification is a safe, accurate, and easily applicable objective method for the diagnosis of hepatic steatosis in children. A hepatorenal ratio of greater than 1.5 can be used as a conservative parameter, permitting increased confidence in discriminating hepatic steatosis from other conditions.

Ultrasound risk stratification for malignancy using the 2015 American Thyroid Association Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer.

BACKGROUND: The 2015 American Thyroid Association (ATA) Management Guidelines for Children with Thyroid Nodules and Differentiated Thyroid Cancer provides selection criteria for nodules prior to ultrasound-guided fine-needle aspiration biopsy. OBJECTIVE: To evaluate the diagnostic performance of pediatric thyroid nodule risk stratification for predicting malignancy when applying the ultrasound (US) criteria recommended. MATERIALS AND METHODS: US characteristics of 39 thyroid nodules in 33 pediatric patients who underwent US fine-needle aspiration biopsy were reviewed by two radiologists. Based on the aggregated US criteria from the ATA Guidelines, each nodule was assigned a level of malignancy risk. Kappa coefficients were estimated to assess intra- and interobserver reliability. Using each patient's largest nodule observation (n = 33), univariable exact logistic regression analyses of US parameters were then conducted to estimate the odds of a malignant pathology diagnosis. A penalized Firth correction was employed in the univariable models analyzing composition, shape and level of suspicion due to quasi-complete data separation. RESULTS: Twenty-seven nodules in 21 patients (median age: 16 years; 17 female) were benign and 12 nodules in 12 patients (median age: 16.5 years; 11 female) were malignant. Intraobserver agreement was substantial to almost perfect for composition, echogenicity, shape and margins. Interobserver agreement was almost perfect for composite level of suspicion. High level of suspicion was assigned to all 12 malignant nodules versus 9/21 (43%) of the benign nodules. Level of suspicion, solid/predominantly solid composition, irregular margins and echogenic foci emerged as significant predictors of malignancy with odds ratios (OR) of 8.5 (95% confidence interval [CI]: 1.7-1,130, P = 0.001), 10.5 (95% CI: 1.1-1,417, P = 0.04), 53.2 (95% CI: 5.1-2,988, P < 0.0001) and 3.5 (95% CI: 1.1-23.2, P = 0.03), respectively. CONCLUSION: The composite, US-based risk stratification criteria from the 2015 ATA Guidelines may provide an appropriate and reproducible method for estimating risk of malignancy for pediatric thyroid nodules.

"Yes, and " Exploring the Future of Learning Analytics in Medical Education.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Northeastern Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. Commentators brainstormed "what's next" with learning analytics in medical education, including advancements in interaction metrics and the use of interactivity analysis to deepen understanding of perceptual, cognitive, and social learning and transfer processes.

Evaluation of lymphocytic thyroiditis in children with quantitative gray-scale ultrasound echo intensity using a PACS-based tool.

PURPOSE: To evaluate diagnostic performance of PACS-based quantitative gray-scale ultrasound as an objective method in evaluation of pediatric thyroiditis. METHODS: Quantitative measurements of the echo-intensity level of the thyroid were obtained from ultrasound images, retrospectively using a PACS-based tool in 37 children with the tissue-proven diagnosis. Thyroid/muscle ratio was calculated by dividing the mean echo intensity of thyroid by that of adjacent strap muscle. Heterogeneity index (HI) was calculated by dividing thyroid standard deviation (SD) by thyroid mean values. For qualitative evaluation, two radiologists independently reviewed ultrasounds twice for the presence of thyroiditis. A consensus session was performed for patients for whom there was disagreement. Intra- and inter-observer reliability were assessed. Thyroid/muscle ratio and HI were correlated with final pathology. RESULTS: Lymphocytic thyroiditis was found by histopathology in 19/37 (51%). No significant difference between thyroiditis and normal thyroid groups was found for either thyroid/muscle ratio (1.51 and 1.62, respectively, p = .82) or HI (0.23 and.23, respectively, p = .37). A larger proportion of patients for whom the consensus review indicated thyroiditis were confirmed by histopathology than would be expected by chance alone (12/19 (63%), p = .03). There was fair inter-observer agreement (κ with 95% confidence intervals of 0.36 (0.14-0.57), p = .004) and slight intra-observer agreement for each radiologist (κ with 95% confidence intervals of 0.13 (0.17-0.43), p = .39 and 0.17 (0.15-0.49), p = .31). CONCLUSION: Quantitative gray-scale echo intensity analysis of US was not sufficient to diagnose thyroiditis in a pediatric population. Consensus qualitative analysis of ultrasound was more consistent with pathological diagnosis.

Role of breast sonography in imaging of adolescents with palpable solid breast masses.

OBJECTIVE: The purpose of this study was to assess the role of sonography in the diagnosis and management of palpable solid breast masses in adolescents and to correlate the sonographic findings with the histopathologic findings and clinical outcome. MATERIALS AND METHODS: A retrospective study was conducted with the breast sonograms of 20 adolescent girls 13-19 years old who presented with palpable breast masses found to be solid at breast sonography. The Stavros sonographic criteria were used to assess the benignity or malignancy of solid breast masses. All sonographic findings were correlated with histopathologic or clinical follow-up findings. RESULTS: Sonography showed 21 solid masses in 20 patients (one patient had bilateral solid breast masses). All but six solid masses were presumed benign according to the Stavros sonographic criteria. All solid masses were proved benign at histopathologic or clinical follow-up examination. CONCLUSION: Sonography was not useful for predicting the histologic diagnosis of all solid benign breast masses in adolescent patients. The Stavros sonographic criteria, however, were useful for predicting benignity in 65% of the breast masses on which histopathologic examination was performed. Tissue biopsy may be performed on solid breast masses that do not meet the criteria for benign masses according to the Stavros sonographic criteria.

Atypically presenting kaposiform hemangioendothelioma of the knee: ultrasound findings.

Kaposiform hemangioendothelioma (KHE) is a rare vascular tumor of early childhood and infancy. Kasabach-Merritt phenomenon, a common complication of KHE, is characterized by life-threatening thrombocytopenia, hemolytic anemia, and consumption coagulopathy. There may be atypical cases that do not present with Kasabach-Merritt phenomenon and do have atypical imaging findings. Knowledge of atypical imaging features may assist radiologists in identifying KHE. In this report, we present a 4-year-old case of KHE with atypical ultrasound findings.

CT findings of a unicameral calcaneal bone cyst containing a fluid-fluid level.

Calcaneal unicameral bone cysts often contain fluid, but rarely contain fluid-fluid levels. We present a case focusing on the CT findings of a large calcaneal bone cyst with a fluid-fluid level and a review of the literature.

Is the unaffected eye really unaffected? Color Doppler ultrasound findings in unilaterally active central serous chorioretinopathy.

PURPOSE: To evaluate ocular hemodynamic changes using color Doppler ultrasonography imaging (CDI) with an emphasis on unaffected eyes of patients with central serous chorioretinopathy (CSC). METHODS: Twenty-seven patients with active CSC and 25 controls were analyzed using spectral domain-optical coherence tomography (SD-OCT) and CDI for choroidal imaging and evaluation of retrobulbar vessels, respectively. RESULTS: Resistive index (RI), pulsatility index (PI), and peak systolic velocity (PSV) of the ophthalmic artery (OA) and PSV, end-diastolic velocity (EDV), and mean velocity (Vmean) of the central retinal artery (CRA) in the patient group were less than those in the control group. RI and PI of the CRA were greater in the patient group compared to the control group. RI, PI, PSV, and Vmean of the OA and PSV, EDV, and Vmean of the CRA in the patients' unaffected eyes were less than those in the control group. OCT measurements of central choroidal thickness (CCT) of the affected eyes in the patient group were significantly greater than those of the unaffected eyes in the patient and control groups; that of the unaffected eyes was greater than that in the control group. CONCLUSIONS: Hemodynamic changes in OA reflect choroidal hyperperfusion. Hemodynamic and OCT changes in the unaffected eyes of the patient group suggest CSC as a bilateral disorder and the systemic nature of the disease. Further investigations may aid in the evaluation of treatment response and the follow-up of disease, providing a new insight into management strategies.

Esophageal perforation: An uncommon initial manifestation of eosinophilic esophagitis.

EoE-Perforation: Eosinophilic esophagitis (EoE) is commonly observed in children and young adults. Common manifestations of EoE include dysphagia and food impaction in adolescents and adults, whereas children present with failure to thrive, regurgitation, or heartburn and abdominal pain. We describe two patients presenting with esophageal perforation and EoE. Diagnosing perforation promptly is critical to minimize and/or to avoid the multitude of complications resulting from esophageal perforation and to treat EoE because if left untreated, this condition may result in the recurrence of perforation, major morbidity, or rarely death.

A Vertically Integrated Online Radiology Curriculum Developed as a Cognitive Apprenticeship: Impact on Student Performance and Learning.

RATIONALE AND OBJECTIVES: The principles of Collins' cognitive apprenticeship model were used to design a radiology curriculum in which medical students practice radiological skills using online case-based modules. The modules are embedded within clinical third-year clerkships, and students are provided with personalized feedback from the instructors. We describe the development of the vertical online radiology curriculum and evaluate its impact on student achievement and learning process using a mixed method approach. MATERIALS AND METHODS: The curriculum was developed over a 2-year period. Student participation was voluntary in the first year and mandatory in the second year. For quantitative curriculum evaluation, student metrics for voluntary versus mandatory groups were assessed using independent sample t tests and variable entry method regression analysis. For qualitative analysis, responses from a survey of students about the value of the curriculum were organized into defined themes using consensus coding. RESULTS: Mandatory participation significantly improved (p = .001) the mean radiology examination score (82 %) compared to the voluntary group (73%), suggesting that mandatory participation had a beneficial effect on student performance. Potential preexisting differences in underlying general academic performance were accounted for by including mean basic science grades as the first variable in the regression model. The significant increase in R(2) from .16 to .28 when number of radiology cases completed was added to the original model, and the greater value of the standardized beta for this variable, suggest that the curriculum made a significant contribution to students' radiology examination scores beyond their baseline academic performance. Five dominant themes about curricular characteristics that enhanced student learning and beneficial outcomes emerged from consensus coding. These themes were (1) self-paced design, (2) receiving feedback from faculty, (3) clinical relevance of cases, (4) gaining confidence in interpreting radiological images, and (5) transfer of conceptual knowledge to actual practice. CONCLUSIONS: The vertically integrated online radiology curriculum can positively impact student performance and learning process in the context of the cognitive apprenticeship model.

Imaging of the pediatric athlete: use and overuse.

This article highlights the unique patterns of sports-related injury of the upper extremity that radiologists are likely to encounter in children and adolescents. The injuries are classified as acute "use" injuries or chronic "overuse" injuries, and reviewed separately for the shoulder, elbow, and wrist. Recommendations for imaging strategies are provided and characteristic imaging findings are discussed and illustrated.

Sonographic appearance of ruptured ovarian cyst in the neonatal period.

Rupture is a rare complication of ovarian cysts diagnosed during the prenatal period. We present a case that focuses on the postnatal sonographic appearance of rupture of an ovarian cyst after vaginal delivery. Histopathologic correlation is provided. The main sonographic features include complicated ascites and a collapsed cystic structure in the abdomen. Ruptured ovarian cyst should be included in the differential diagnosis of unexplained ascites in a newborn girl.

Characteristic sonographic findings of hepatic erosion by umbilical vein catheters.

OBJECTIVE: The purpose of this series is to describe findings seen on abdominal sonography in neonates with erosion into the liver by umbilical vein catheters (UVCs). METHODS: Four neonates with erosion of the UVC into hepatic parenchyma within a 2-year period were identified. A retrospective case analysis was performed to determine the symptoms and clinical scenario of presentation. Plain radiographs were examined to establish the location of the UVC placement, and abdominal sonograms were reviewed. RESULTS: All 4 neonates had abdominal distension within 9 days of UVC placement, and in all of them, the UVC tip was located below the hemidiaphragm and superimposed over the liver. Sonographic examination of all patients showed intraparenchymal liver lesions with an echogenic rim and hypoechoic center. Two neonates also had subcapsular fluid collections. Complex ascites was seen in all 4 patients. The fluid was proven to be total parenteral nutrition by paracentesis in 2 patients. Treatment consisted of removal of the UVC. All patients were followed for a period of 2 to 18 months and showed clinical resolution of symptoms or sonographic improvement of the liver lesions. CONCLUSIONS: A characteristic liver lesion can be seen on sonography with hepatic erosion by UVCs. Our study shows the importance of a high index of suspicion of UVC erosion into the liver in neonates with catheters positioned in the liver. When such neonates have abdominal distension, prompt abdominal sonograms should be obtained.