ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease.

Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. 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.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

The Role of Imaging for Gastrointestinal Bleeding: Consensus Recommendations From the American College of Gastroenterology and Society of Abdominal Radiology.

Gastrointestinal (GI) bleeding is the most common GI diagnosis leading to hospitalization within the United States. Prompt diagnosis and treatment of GI bleeding is critical to improving patient outcomes and reducing high healthcare utilization and costs. Radiologic techniques including computed tomography angiography, catheter angiography, computed tomography enterography, magnetic resonance enterography, nuclear medicine red blood cell scan, and technetium-99m pertechnetate scintigraphy (Meckel scan) are frequently used to evaluate patients with GI bleeding and are complementary to GI endoscopy. However, multiple management guidelines exist which differ in the recommended utilization of these radiologic examinations. This variability can lead to confusion as to how these tests should be used in the evaluation of GI bleeding. In this document, a panel of experts from the American College of Gastroenterology and Society of Abdominal Radiology provide a review of the radiologic examinations used to evaluate for GI bleeding including nomenclature, technique, performance, advantages, and limitations. A comparison of advantages and limitations relative to endoscopic examinations is also included. Finally, consensus statements and recommendations on technical parameters and utilization of radiologic techniques for GI bleeding are provided.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement.

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Radiomics Beyond the Hype: A Critical Evaluation Toward Oncologic Clinical Use.

Radiomics is a promising and fast-developing field within oncology that involves the mining of quantitative high-dimensional data from medical images. Radiomics has the potential to transform cancer management, whereby radiomics data can be used to aid early tumor characterization, prognosis, risk stratification, treatment planning, treatment response assessment, and surveillance. Nevertheless, certain challenges have delayed the clinical adoption and acceptability of radiomics in routine clinical practice. The objectives of this report are to (a) provide a perspective on the translational potential and potential impact of radiomics in oncology; (b) explore frequent challenges and mistakes in its derivation, encompassing study design, technical requirements, standardization, model reproducibility, transparency, data sharing, privacy concerns, quality control, as well as the complexity of multistep processes resulting in less radiologist-friendly interfaces; (c) discuss strategies to overcome these challenges and mistakes; and (d) propose measures to increase the clinical use and acceptability of radiomics, taking into account the different perspectives of patients, health care workers, and health care systems. Keywords: Radiomics, Oncology, Cancer Management, Artificial Intelligence © RSNA, 2024.

High Dynamic Range Dual-Modal White Light Imaging Improves the Accuracy of Tumor Bed Sampling After Neoadjuvant Therapy for Breast Cancer.

OBJECTIVES: Accurate evaluation of residual cancer burden remains challenging because of the lack of appropriate techniques for tumor bed sampling. This study evaluated the application of a white light imaging system to help pathologists differentiate the components and location of tumor bed in specimens. METHODS: The high dynamic range dual-mode white light imaging (HDR-DWI) system was developed to capture antiglare reflection and multiexposure HDR transmission images. It was tested in 60 specimens of modified radical mastectomy after neoadjuvant therapy. We observed the differential transmittance among tumor tissue, fibrosis tissue, and adipose tissue. RESULTS: The sensitivity and specificity of HDR-DWI were compared with x-ray or visual examination to determine whether HDR-DWI was superior in identifying tumor beds. We found that tumor tissue had lower transmittance (0.12 ± 0.03) than fibers (0.15 ± 0.04) and fats (0.27 ± 0.07) (P < .01). CONCLUSIONS: HDR-DWI was more sensitive in identifying fiber and tumor tissues than cabinet x-ray and visual observation (P < .01). In addition, HDR-DWI could identify more fibrosis areas than the currently used whole slide imaging did in 12 samples (12/60). We have determined that HDR-DWI can provide more in-depth tumor bed information than x-ray and visual examination do, which will help prevent diagnostic errors in tumor bed sampling.

Radiologic Technologists' Perceived Reasons for Inappropriate Imaging.

PURPOSE: To examine whether radiologic technologists' perceptions of imaging appropriateness differed based on their primary imaging modality, work shift, shift length, and primary practice type. METHODS: A national, cross-sectional study was conducted in the fourth quarter of 2019 using a simple, randomized sample of American Society of Radiologic Technologists (ASRT) members. Study participants were employed in health care settings in radiography, computed tomography (CT), mammography, or radiology leadership. Seven potential reasons for inappropriate imaging procedures (ie, patient expectations, provide patient with a feeling of being taken seriously, lack of time, expectations from relatives, compensation for insufficient clinical examination, normal findings would reassure the patient, and fear of lawsuits) were evaluated for relationships with their primary imaging modality, work shift, shift length, and primary practice type. RESULTS: Disparities in perceived reasons affecting imaging appropriateness were found. Providing the patient with a feeling of being taken seriously was related to primary practice type (P = .022). Lack of time was related to primary imaging modality (P = .005) and primary practice type (P = .006). Expectations from relatives was related to primary imaging modality (P = .016) and primary practice type (P = .027). Compensation for insufficient clinical examination was related to primary imaging modality (P < .001), shift length (P = .011), work shift (P = .002), and primary practice type (P < .001). Fear of lawsuits was related to primary imaging modality (P = .001)) and work shift (P = .002). DISCUSSION: The study reveals that radiologic technologists' perceptions of patient-centered factors and defensive medicine-related factors differ among imaging modalities, shift types, and practice settings. However, more research is required to determine why radiologic technologists perceive these reasons to be present, investigate whether providers feel similarly, and determine perceptual alignment with evidence-based guidelines. CONCLUSION: The findings suggest that attention should focus on the appropriateness of CT imaging procedures performed in hospitals during night shifts.

An estimate of rate of deviation from NCCN guideline recommendations for central nervous system imaging in trials forming basis for drug approval in first line advanced non-small cell lung cancer (NSCLC).

IMPORTANCE: It is unknown whether and to what degree trials submitted to the US FDA to support drug approval adhere to NCCN guideline-recommended care in their baseline and surveillance CNS imaging protocols. OBJECTIVE: We sought to characterize the frequency with which the trials cited in US FDA drug approvals for first line advanced NSCLC between 2015 and 2020 deviated from NCCN guideline-recommended care for baseline and surveillance CNS imaging. DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational analysis using publicly available data of (1) list of trials cited by the FDA in drug approvals for first line advanced NSCLC from 2015 to 2020 (2) individual trial protocols (3) published trial data and supplementary appendices (4) archived versions of the NCCN guidelines for NSCLC from 2009 to 2018 (the years during which the trials were enrolling). MAIN OUTCOMES AND MEASURES: Estimated percentage of trials for first line advanced NSCLC leading to FDA approval which deviated from NCCN guideline-recommended care with regards to CNS baseline and surveillance imaging. RESULTS: A total of 14 studies that had been cited in FDA drug approvals for first line advanced NSCLC met our inclusion criteria between January 1, 2015 and September 30, 2020. Of these trials, 8 (57.1%) deviated from NCCN guidelines in their baseline CNS imaging requirement. The frequency of re-assessment of CNS disease was variable amongst trials as well, with 9 (64.3%) deviating from NCCN recommendations. CONCLUSIONS AND RELEVANCE: The trials supporting US FDA drug approvals in first line advanced NSCLC often have CNS imaging requirements that do not adhere to NCCN guidelines. Many trials permit alternative, substandard methods and the proportion of patients undergoing each modality is uniformly not reported. Nonstandard CNS surveillance protocols are common. To best serve patients with advanced NSCLC in the US, drug approvals by the FDA must be based on trials that mirror clinical practice and have imaging requirements consistent with current US standard of care.

Biomedical Applications of Translational Optical Imaging: From Molecules to Humans.

Light is a powerful investigational tool in biomedicine, at all levels of structural organization. Its multitude of features (intensity, wavelength, polarization, interference, coherence, timing, non-linear absorption, and even interactions with itself) able to create contrast, and thus images that detail the makeup and functioning of the living state can and should be combined for maximum effect, especially if one seeks simultaneously high spatiotemporal resolution and discrimination ability within a living organism. The resulting high relevance should be directed towards a better understanding, detection of abnormalities, and ultimately cogent, precise, and effective intervention. The new optical methods and their combinations needed to address modern surgery in the operating room of the future, and major diseases such as cancer and neurodegeneration are reviewed here, with emphasis on our own work and highlighting selected applications focusing on quantitation, early detection, treatment assessment, and clinical relevance, and more generally matching the quality of the optical detection approach to the complexity of the disease. This should provide guidance for future advanced theranostics, emphasizing a tighter coupling-spatially and temporally-between detection, diagnosis, and treatment, in the hope that technologic sophistication such as that of a Mars rover can be translationally deployed in the clinic, for saving and improving lives.

AGA Clinical Practice Update on Surveillance After Pathologically Curative Endoscopic Submucosal Dissection of Early Gastrointestinal Neoplasia in the United States: Commentary.

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update was to review the available evidence and provide expert advice regarding surveillance using endoscopy and other relevant modalities after removal of dysplastic lesions and early gastrointestinal cancers with endoscopic submucosal dissection deemed to be pathologically curative. This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors, who are advanced endoscopists with high-level expertise in performing endoscopic submucosal dissection to treat dysplasia and early cancers in the luminal gastrointestinal tract.

Contribution of imaging to the diagnosis and follow up of X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is the most common form of inheritable rickets. The disease is caused principally by PHEX mutations leading to increased concentrations of circulating intact FGF23, hence renal phosphate wasting, hypophosphatemia, and decreased circulating levels of 1,25(OH)2 vitamin D. The chronic hypophosphatemia leads to rickets and osteomalacia through a combination of mechanisms, including a lack of endochondral ossification and impaired mineralization. Imaging has a major role in determining the diagnosis of rickets and its cause, detecting complications as early as possible, and helping in treatment monitoring.

Oropharyngeal cancer patient stratification using random forest based-learning over high-dimensional radiomic features.

To improve risk prediction for oropharyngeal cancer (OPC) patients using cluster analysis on the radiomic features extracted from pre-treatment Computed Tomography (CT) scans. 553 OPC Patients randomly split into training (80%) and validation (20%), were classified into 2 or 3 risk groups by applying hierarchical clustering over the co-occurrence matrix obtained from a random survival forest (RSF) trained over 301 radiomic features. The cluster label was included together with other clinical data to train an ensemble model using five predictive models (Cox, random forest, RSF, logistic regression, and logistic-elastic net). Ensemble performance was evaluated over the independent test set for both recurrence free survival (RFS) and overall survival (OS). The Kaplan-Meier curves for OS stratified by cluster label show significant differences for both training and testing (p val < 0.0001). When compared to the models trained using clinical data only, the inclusion of the cluster label improves AUC test performance from .62 to .79 and from .66 to .80 for OS and RFS, respectively. The extraction of a single feature, namely a cluster label, to represent the high-dimensional radiomic feature space reduces the dimensionality and sparsity of the data. Moreover, inclusion of the cluster label improves model performance compared to clinical data only and offers comparable performance to the models including raw radiomic features.

Radiation Reduction Strategies in Pediatric Orthopaedics.

INTRODUCTION: Pediatric orthopaedic patients have the potential for significant radiation exposure from the use of imaging studies, such as computed tomography and bone scintigraphy. With the potential for long-term treatment, such as is required for scoliosis or osteogenesis imperfecta, patients are at even greater risk of radiation-induced carcinogenesis. DISCUSSION: Although an association between radiation and cancer risk is evident, causation is difficult to prove because comorbidities or genetic predispositions may play a role in the higher baseline rates of malignancy later in life. Efforts have been made over the years to reduce exposure using more modern imaging techniques and simple radiation reduction strategies. Educational efforts and clinical practice guidelines are decreasing the rate of computed tomography scan use in pediatrics. Although considerable work is being done on the development of radiation-free imaging modalities, imaging that uses ionizing radiation will, in the near term, be necessary in specific circumstances to provide optimal care to pediatric orthopaedic patients. CONCLUSION: Knowledge of the ionizing radiation exposure associated with commonly used tests as well as radiation-reduction strategies is essential for the optimal and safe care of pediatric orthopaedic patients.

NCI Imaging Data Commons.

The National Cancer Institute (NCI) Cancer Research Data Commons (CRDC) aims to establish a national cloud-based data science infrastructure. Imaging Data Commons (IDC) is a new component of CRDC supported by the Cancer Moonshot. The goal of IDC is to enable a broad spectrum of cancer researchers, with and without imaging expertise, to easily access and explore the value of deidentified imaging data and to support integrated analyses with nonimaging data. We achieve this goal by colocating versatile imaging collections with cloud-based computing resources and data exploration, visualization, and analysis tools. The IDC pilot was released in October 2020 and is being continuously populated with radiology and histopathology collections. IDC provides access to curated imaging collections, accompanied by documentation, a user forum, and a growing number of analysis use cases that aim to demonstrate the value of a data commons framework applied to cancer imaging research. SIGNIFICANCE: This study introduces NCI Imaging Data Commons, a new repository of the NCI Cancer Research Data Commons, which will support cancer imaging research on the cloud.

The U.S. Food and Drug Administration's role in improving radiation dose management for medical X-ray imaging devices.

The U.S. Food and Drug Administration (FDA) has been concerned with minimizing the unnecessary radiation exposure of people for half a century. Manufacturers of medical X-ray imaging devices are important partners in this effort. Medical X-ray imaging devices are regulated by FDA under both its electronic product regulations andits medical device regulations. FDA also publishes guidance documents that represent FDA's current thinking on a topic and provide a suggested or recommended approach to meet the requirements of a regulation or statute. FDA encourages manufacturers to develop medical devices that conform to voluntary consensus standards. Use of these standards is a central element of FDA's system to ensure that all medical devices marketed in the U.S. meet safety and effectiveness requirements. FDA staff participate actively in the development and maintenance of these standards, often advancing or introducing new safety and dose management requirements. Use of voluntary consensus standards reduces the amount of time necessary to evaluate a premarket submission and reduces the burden on manufacturers. FDA interacts with industry and other stakeholders through meetings with industry groups, public meetings, public communications, and through the development of voluntary consensus standards. In these interactions, FDA staff introduce new concepts for improving the safety of these devices and provide support for similar initiatives from professional organizations. FDA works with all stakeholders to achieve its mission of protecting and promoting the public health.

Physiological Imaging Methods for Evaluating Response to Immunotherapies in Glioblastomas.

Glioblastoma (GBM) is the most malignant brain tumor in adults, with a dismal prognosis despite aggressive multi-modal therapy. Immunotherapy is currently being evaluated as an alternate treatment modality for recurrent GBMs in clinical trials. These immunotherapeutic approaches harness the patient's immune response to fight and eliminate tumor cells. Standard MR imaging is not adequate for response assessment to immunotherapy in GBM patients even after using refined response assessment criteria secondary to amplified immune response. Thus, there is an urgent need for the development of effective and alternative neuroimaging techniques for accurate response assessment. To this end, some groups have reported the potential of diffusion and perfusion MR imaging and amino acid-based positron emission tomography techniques in evaluating treatment response to different immunotherapeutic regimens in GBMs. The main goal of these techniques is to provide definitive metrics of treatment response at earlier time points for making informed decisions on future therapeutic interventions. This review provides an overview of available immunotherapeutic approaches used to treat GBMs. It discusses the limitations of conventional imaging and potential utilities of physiologic imaging techniques in the response assessment to immunotherapies. It also describes challenges associated with these imaging methods and potential solutions to avoid them.