Hand, foot, and mouth disease presenting with a testicular mass in an adult.

The majority of solid testicular tumors are treated with orchiectomy given the high risk of malignancy. We present a case of a testicular mass in an adult patient in the setting of recent hand, foot, and mouth disease that was managed conservatively with serial ultrasounds. Even though cases of viral-associated testicular masses are rare, this differential diagnosis should be considered in patients with a new testicular mass in the setting of recent viral infection and negative tumor markers. For these patients, observation may be an option instead of immediate orchiectomy.

Serial ultrasonographic measurements of fetal parameters over three successive pregnancies in a captive Eastern black-and-white colobus monkey (Colobus guereza).

This study provides ultrasonographic fetal growth charts for the Eastern black-and-white colobus monkey (Colobus guereza). Throughout three consecutive gestations (-162 to -2 days to parturition) in a single dam, we opportunistically obtained ultrasonographic measurements for the following parameters: biparietal diameter, head circumference, humerus length, femur length, tibia length, radius length, thoracic width, kidney length, and crown-rump length. Biparietal diameter was the most consistently measured parameter. First detection of fetuses occurred between 96 and 162 days before parturition. This report demonstrates that voluntary transabdominal ultrasound can be well-tolerated in the colobus monkey using operant conditioning. These findings may be useful to assess fetal development and predict parturition dates in the absence of a known conception date in this species.

Reproductive one health in primates.

One Health is a collaborative trans-disciplinary approach to health; integrating human, animal, and environmental health. The focus is often on infection disease transmission and disease risk mitigation. However, One Health also includes the multidisciplinary and comparative approach to disease investigation and health of humans, animals, and the environment. One key aspect of environmental/ecosystem health is conservation, the maintenance of healthy, actively reproducing wildlife populations. Reproduction and reproductive health are an integral part of the One Health approach: the comparative aspects of reproduction can inform conservation policies or breeding strategies (in situ and ex situ) in addition to physiology and disease. Differences in reproductive strategies affect the impact poaching and habitat disruption might have on a given population, as well as ex situ breeding programs and the management of zoo and sanctuary populations. Much is known about chimpanzees, macaques, and marmosets as these are common animal models, but there is much that remains unknown regarding reproduction in many other primates. Examining the similarities and differences between and within taxonomic groups allows reasonable extrapolation for decision-making when there are knowledge gaps. For example: (1) knowing that a species has very low reproductive rates adds urgency to conservation policy for that region or species; (2) identifying species with short or absent lactation anestrus allows ex situ institutions to better plan contraception options for specific individuals or prepare for the immediate next pregnancy; (3) recognizing that progestin contraceptives are effective contraceptives, but may be associated with endometrial hyperplasia in some species (in Lemuridae but not great apes) better guides empirical contraceptive choice; (4) recognizing the variable endometriosis prevalence across taxa improves preventive medicine programs. A summary of anatomical variation, endocrinology, contraception, pathology, and diagnostics is provided to illustrate these features and aid in routine physical and postmortem examinations as well as primate management.

Chromophobe Renal Cell Carcinoma with Radiologic-Pathologic Correlation.

Renal cell carcinoma (RCC) is a heterogeneous group of neoplasms derived from the renal tubular epithelial cells. Chromophobe RCC (chRCC) is the third most common subtype of RCC, accounting for 5% of cases. chRCC may be detected as an incidental finding or less commonly may manifest with clinical symptoms. The mainstay of therapy for chRCC is surgical resection. chRCC has a better prognosis compared with the more common clear cell RCC. At gross pathologic analysis, chRCC is a solid well-defined mass with lobulated borders. Histologic findings vary by subtype but include large pale polygonal cells with abundant transparent cytoplasm, crinkled "raisinoid" nuclei with perinuclear halos, and prominent cell membranes. Pathologic analysis reveals only moderate vascularity. The most common imaging pattern is a predominantly solid renal mass with circumscribed margins and enhancement less than that of the renal cortex. The authors discuss chRCC with emphasis on correlative pathologic findings and illustrate the multimodality imaging appearances of chRCC by using cases from the Radiologic Pathology Archives of the American Institute for Radiologic Pathology. ©RSNA, 2021.

Mucinous Neoplasms of the Ovary: Radiologic-Pathologic Correlation.

Mucinous neoplasms of the ovary account for 10%-15% of ovarian neoplasms. They may be benign, borderline, or malignant. The large majority are benign or borderline, accounting for 80% and 16%-17%, respectively. Mucinous neoplasms of the ovary most commonly affect women in their 20s to 40s. The clinical manifestation is nonspecific, but most mucinous ovarian neoplasms manifest as large unilateral pelvic masses. At gross pathologic analysis, mucinous ovarian neoplasms appear as large multiloculated cystic masses. The contents of the cyst loculi vary on the basis of differences in internal mucin content. At histologic analysis, mucinous ovarian neoplasms are composed of multiple cysts lined by mucinous epithelium, often resembling gastrointestinal-type epithelium. Imaging evaluation most commonly includes US and/or MRI. The imaging findings parallel the gross pathologic features and include a large, unilateral, multiloculated cystic mass. The cyst loculi vary in echogenicity, attenuation, and signal intensity depending on the mucin content. Mucinous neoplasms of the ovary are staged surgically using the FIGO (International Federation of Gynecology and Obstetrics) staging system. Primary treatment is surgical, with adjuvant chemotherapy considered in the uncommon case of mucinous carcinoma with extraovarian disease. Since most mucinous ovarian neoplasms are benign or borderline, the overall prognosis is excellent.

Comparison of Utilization of the Family and Medical Leave Act in Radiology Practices Between 2015 and 2016.

OBJECTIVE: The objective of our study was to assess utilization of the Family and Medical Leave Act (FMLA) in radiology practices in 2016 and compare with 2015 utilization. MATERIALS AND METHODS: The Practice of Radiology Environment Database was used to identify practice leaders, and these leaders were asked to complete the annual American College of Radiology Commission on Human Resources workforce survey. The 2017 survey, which asked about 2016 experiences, again included questions about the number of radiologists in each practice who took FMLA, reasons why, and how absences were covered. RESULTS: Twenty-six percent (477/1811) of practice leaders responded to the survey. Of these respondents, 73% (346/477) answered FMLA questions, and 23% (80/346) of those answered affirmatively that a radiologist in their practice had taken FMLA leave in 2016 (previously 15% in 2015; p = 0.15). The reasons for FMLA leave included taking care of a newborn or adopted child (57%, previously 49%; p = 0.26), personal serious health condition (35%, previously 42%; p = 0.31), caring for an immediate family member (8%, unchanged), and engaging in active military duty (< 1%, unchanged). Although more women (72%) than men (32%) took FMLA leave for the first reason (p < 0.01), more men (63%) than women (18%) took FMLA leave for the second (p < 0.01), and there was no significant difference between women (10%) and men (5%) taking leave to care for an immediate family member (p = 0.18). Most practices (80%) again made no workforce changes to cover absences due to FMLA leave (previously 82%). CONCLUSION: Utilization of FMLA leave in radiology practices in 2016 was similar to that in 2015 and represents the beginning of longitudinal accrual of data on this important topic for both male and female radiologists.

Retroperitoneal Leiomyosarcoma From the Radiologic Pathology Archives.

Leiomyosarcoma is a malignant neoplasm that shows smooth muscle differentiation. It is the second most common sarcoma to affect the retroperitoneum. Retroperitoneal leiomyosarcomas may grow to large sizes before detection and may be an incidental finding at imaging. When symptomatic, retroperitoneal leiomyosarcoma may cause compressive symptoms, including pain. Retroperitoneal leiomyosarcoma most commonly manifests as a large soft-tissue mass, with areas of necrosis. The most frequent pattern of growth is an entirely extravascular mass. Less commonly, leiomyosarcoma may demonstrate both extravascular and intravascular components. Rarely, retroperitoneal leiomyosarcomas are completely intravascular, typically arising from the inferior vena cava. Given its variable imaging features, a large variety of neoplastic and nonneoplastic conditions are included in the differential diagnosis of retroperitoneal leiomyosarcoma. In this review, the authors discuss retroperitoneal leiomyosarcoma, with emphasis on the pathologic basis of disease, and illustrate the multimodality imaging appearances of retroperitoneal leiomyosarcoma using cases from the Radiologic Pathology Archives of the American Institute for Radiologic Pathology. The authors review important differential considerations of retroperitoneal leiomyosarcoma, focusing on the extravascular pattern of growth, and emphasize clinical and imaging features that help radiologists differentiate leiomyosarcoma from the most frequent mimics. The information presented in this review will aid radiologists in fulfilling their key roles in the diagnosis, operative planning, and follow-up of patients with retroperitoneal leiomyosarcoma.

Leiomyoma Infarction after Uterine Artery Embolization: Influence of Embolic Agent and Leiomyoma Size and Location on Outcome.

PURPOSE: To study the factors that might impact infarction of individual uterine leiomyomas and total tumor burden after uterine artery embolization (UAE). MATERIALS AND METHODS: This retrospective study included 91 patients (mean age, 44 y [range, 34-54 y]) who underwent UAE with tris-acryl gelatin microspheres (TAGMs) or nonspherical polyvinyl alcohol (PVA) particles. Twenty-one patients were treated with PVA (23%) and 70 were treated with TAGMs (77%). A total of 356 uterine leiomyomas were assessed, with a median uterine volume of 533 cm3 (range, 321-848 cm3). A reader masked to demographic and technical details reviewed contrast-enhanced magnetic resonance images before and 3 months after UAE to estimate the extent of tumor infarction. RESULTS: There was no significant difference in global or individual tumor infarction rate between embolizations with TAGMs and PVA particles (P = .73 and P = .3, respectively). Global infarction was not affected by age (P = .53), race (P = .12), number of leiomyomas (P = .72), or uterine volume (P = .74). Leiomyoma size did not influence individual tumor infarction (P = .41). Leiomyoma location was the sole factor that influenced individual tumor infarction rates, with pedunculated serosal tumors significantly less likely to show complete infarction than transmural tumors (odds ratio, 0.24; P = .01). CONCLUSIONS: Nonspherical PVA particles and TAGMs produce similar rates of uterine leiomyoma infarction. Complete infarction of individual tumors is less likely in serosal and pedunculated serosal tumors.

Testicular Seminoma and Its Mimics: From the Radiologic Pathology Archives.

Testicular seminoma is the most common malignant tumor of the testis. It classically manifests as a painless mass. Radiologic evaluation with high-frequency ultrasonography (US) is critical for diagnosis. Seminomas are usually homogeneously hypoechoic masses at US. In challenging cases, magnetic resonance (MR) imaging may help confirm that a mass is intratesticular and provide data for local staging. Computed tomography (CT) provides valuable information for staging, including the presence and size of retroperitoneal lymph nodes. Testicular seminoma is treated with radical inguinal orchiectomy and is highly curable even at advanced stages of disease. Several neoplastic and nonneoplastic conditions may mimic testicular seminoma at imaging. Benign mimics include segmental infarction, hematoma, infection, epidermoid cyst, adrenal rests, sarcoidosis, splenogonadal fusion, and sex cord-stromal tumors. Malignant mimics include nonseminomatous germ cell tumors, lymphoma, and metastases. These conditions are individually reviewed with emphasis on features that allow differentiation from seminoma. Spermatocytic tumor, formerly known as spermatocytic seminoma, accounts for only 1% of testicular tumors. It is distinct from classic seminoma, with unique histologic, molecular, and genetic features. It affects an older patient population than classic seminoma and demonstrates indolent clinical behavior. Radiologists serve a key role in diagnosis, staging, and surveillance of patients with seminoma. A thorough knowledge of related clinical, radiologic, and pathologic findings will help the radiologist contribute to high-quality interdisciplinary care of affected patients.

Mesenchymal Extratesticular Tumors and Tumorlike Conditions: From the Radiologic Pathology Archives.

Both benign and malignant tumors and tumorlike conditions can arise from the nonepididymal extratesticular tissues. Benign tumors are far more common than malignant tumors, with lipoma being the most common lesion found at this site. Several imaging features can help narrow the differential diagnosis of these lesions, including the presence of fat and imaging features suggestive of fibrous tissue. Lesions that contain fat represent lipoma, liposarcoma, or angiomyofibroblastoma (AMF)-like tumor. If enhancing soft tissue is present in conjunction with fat, the differential diagnosis narrows further to just liposarcoma and AMF-like tumor. Lesions that display magnetic resonance imaging characteristics compatible with fibrous tissue are likely to be fibrous pseudotumor. However, many of the lesions in this location have overlapping imaging findings, and surgical excision is most often necessary for accurate diagnosis. The ability to narrow the differential diagnosis with imaging, however, is helpful for the clinician for both treatment planning and patient counseling.

Appendiceal adenocarcinoma presenting as a bladder tumor.

We present a case of an appendiceal adenocarcinoma that invaded the urinary bladder, which was preoperatively mistaken for urachal adenocarcinoma. The patient underwent open removal of the umbilicus, urachus, partial cystectomy and bilateral pelvic lymph node dissection. Intraoperatively the tumor was noted to involve the appendix, and so an appendectomy was also performed. The pathology showed an appendiceal adenocarcinoma invading the bladder wall. Urologists must have a high degree of suspicion for spread from a gastrointestinal primary when adenocarcinoma is found within the urinary bladder.

Unsustainable: COVID-19 Demands Increased Support for Radiologists.

Life is sometimes described as a complex tapestry and progress is not linear, but twisted like stitches, contributing to the final fabric. When tension arises, the most recent stitches unravel first. The COVID-19 pandemic is pulling back the thread of humanity's progress. Those disproportionately affected by the pandemic's tension are those whose progress is most recent and, therefore most tenuous, including women in medicine. The profession of radiology, recently acknowledged by practice leaders as experiencing burnout as a very significant problem (Parikh et al., 2020 [1]), is rapidly facing an untenable situation.

ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update.

The appropriate evaluation of adrenal masses is strongly dependent on the clinical circumstances in which it is discovered. Adrenal incidentalomas are masses that are discovered on imaging studies that have been obtained for purposes other than adrenal disease. Although the vast majority of adrenal incidentalomas are benign, further radiological and biochemical evaluation of these lesions is important to arrive at a specific diagnosis. Patients with a history of malignancy or symptoms of excess hormone require different imaging evaluations than patients with incidentalomas. This document reviews imaging approaches to adrenal masses and the various modalities utilized in evaluation of adrenal lesions. 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.

Mapping the Ultrasound Landscape to Define Point-of-Care Ultrasound and Diagnostic Ultrasound: A Proposal From the Society of Radiologists in Ultrasound and ACR Commission on Ultrasound.

Current descriptions of ultrasound evaluations, including use of the term "point-of-care ultrasound" (POCUS), are imprecise because they are predicated on distinctions based on the device used to obtain images, the location where the images were obtained, the provider who obtained the images, or the focus of the examination. This is confusing because it does not account for more meaningful distinctions based on the setting, comprehensiveness, and completeness of the evaluation. In this article, the Society of Radiologists in Ultrasound and the members of the American College of Radiology Ultrasound Commission articulate a map of the ultrasound landscape that divides sonographic evaluations into four distinct categories on the basis of setting, comprehensiveness, and completeness. Details of this classification scheme are elaborated, including important clarifications regarding what ensures comprehensiveness and completeness. Practical implications of this framework for future research and reimbursement paradigms are highlighted.

ACR Appropriateness Criteria® Renal Failure.

Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio. 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.

Radiologist Burnout According to Surveyed Radiology Practice Leaders.

Overall, 55% of surveyed radiology practice leaders reported that burnout was a very significant problem, and 22% reported that burnout was a significant problem. Burnout did not vary by geographical region but did vary by practice size. Overall, 71% of respondents reported stress from workplace factors, and 36% reported stress from personal or social factors very significantly affected radiologist employee wellness; both sets of factors varied by geographical region, practice size, and practice type. Only 19% of practice leader respondents reported mechanisms to assess burnout, which varied by region and practice type.

ACR Appropriateness Criteria® Hematuria.

Hematuria is a common reason for patients to be referred for imaging of the urinary tract. All patients diagnosed with hematuria should undergo a thorough history and physical examination, urinalysis, and serologic testing prior to any initial imaging. Ultrasound, CT, and MRI are the most common imaging modalities used to evaluate hematuria. This document discusses the following clinical scenarios for hematuria: initial imaging of microhematuria without risk factors or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation; initial imaging of microhematuria in patients with known risk factors and no history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation or renal parenchymal disease; initial imaging of microhematuria in the pregnant patient and initial imaging of gross hematuria. Follow-up of normal or abnormal findings is beyond the scope of this review. 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.

ACR Appropriateness Criteria® Indeterminate Renal Mass.

Renal masses are increasingly detected in asymptomatic individuals as incidental findings. CT and MRI with intravenous contrast and a dedicated multiphase protocol are the mainstays of evaluation for indeterminate renal masses. A single-phase postcontrast dual-energy CT can be useful when a dedicated multiphase renal protocol CT is not available. Contrast-enhanced ultrasound with microbubble agents is a useful alternative for characterizing renal masses, especially for patients in whom iodinated CT contrast or gadolinium-based MRI contrast is contraindicated. 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.

Resident bullying in diagnostic radiology.

PURPOSE: Workplace bullying has been reported in multiple medical specialties outside of diagnostic radiology within the United States. The purpose of this study was to survey diagnostic radiology residents in the United States to determine if: (1) residents had experienced bullying, (2) residents had witnessed bullying of other residents, (3) residents were aware of zero-tolerance policy for workplace bullying at their institution, (4) residents were aware of no retaliation policies for reporting bullying at their institution. MATERIALS AND METHODS: In December 2017, a weekly E-mail for 4 weeks was sent to diagnostic radiology residents in the United States (residents) who had attended the July 2017, September 2017 and October 2017 4-week American Institute for Radiologic Pathology (AIRP) resident course to participate in an online, anonymous, voluntary survey. RESULTS: 28% of radiology resident respondents reported workplace bullying during their residency. One third of radiology residents have witnessed workplace bullying of another radiology resident at their facility. Approximately one half (48%) of respondents did not know if their institution had a zero-tolerance policy for workplace bullying, and approximately one half (55%) of respondents did not know if their institution had a no retaliation policy for reporting workplace bullying. CONCLUSION: Our survey of diagnostic radiology residents across the United States confirms workplace bullying during residency, and the opportunity for implementation of zero-tolerance and zero retaliation policies for reporting workplace bullying in residency training institutions.

2018 ACR Commission on Human Resources Workforce Survey.

PURPOSE: The ACR Commission on Human Resources conducts an annual workforce survey to determine the makeup of the radiology workforce and to identify potential plans for hiring new staff in an attempt to better understand our profession. METHODS: The Practice of Radiology Environment Database group leaders were asked to complete an electronic survey regarding the makeup of their present workforce by subspecialty as well as the numbers and types of subspecialists hired in 2017 and the numbers and types of subspecialists expected to be hired in 2018 and 2019. They were also asked about midlevel practitioner employment. RESULTS: Twenty-three percent of practice leaders (367) represente 10,179 radiologists, 30% of all practicing radiologists in the United States, responded to the survey. The number of radiology groups represented in this survey decreased from 1,811 in the 2017 survey to 1,588 groups in the 2018 survey. The current makeup of radiology workforce remains similar to 2016 and 2017. The workforce distribution by practice type and radiologists' ages has been relatively stable since 2012. Practice leaders report they plan to hire between 1,393 to 1,808 radiologists in 2018 (similar to 2017 reported hires between 1,434 to 1,861) with the greatest number of hires to be in breast imaging, neuroradiology, and interventional radiology. The study represented 549 midlevel practitioners and 693 medical physicists. CONCLUSION: The 2018 ACR workforce survey continues to show a positive picture and outlook for those seeking jobs as practicing radiologists in 2018.