Accelerated Fellowships Applicable Across all Subspecialty Areas of Diagnostic Radiology as a Catalyst for Academic Recruitment.

RATIONALE AND OBJECTIVES: To build a sustainable faculty development program based on potential acceleration of all subspecialty fellowships types into the PGY 5 year. MATERIALS AND METHODS: Single center experience in programmatic change to enhance faculty recruitment. Diagnostic Radiology (DR) residents apply to subspecialty fellowships per SCARD Fellowship Embargo Guidelines. Based on projected faculty hiring needs, internal candidates are vetted and agree to enter an accelerated fellowship. The commitment is two years: the PGY5 senior year schedule prioritizes rotations in the subspecialty area while fulfilling requirements of all DR graduates, including call. Accelerated fellows (AF) participate in junior faculty development and concentrated mentoring. A subsequent instructor faculty year within our department is required to ensure professional maturity and provides financial remuneration greater than PGY 6 fellowships. RESULTS: From July 1, 2018, to June 30, 2022, 34 trainees have graduated from our DR program, and 32 have gone through the process of securing fellowships. Over this interval, our DR program has matched 7-9 residents per year. Up to four early specialization positions consisting of 2 Early Specialization in Interventional Radiology (ESIR), and 2 Early Specialization in Nuclear Medicine (ESNM), per year, are available. Over four years of the program, 8 residents participated in standard early specialization opportunities: 5 ESIR, and 3 ESNM. These 8 residents were excluded from consideration for AFs. Two additional residents declined fellowships, leaving 22 seeking standard fellowships for PGY 6 year. 6 (27%) of those were approached as potential AFs; 3 (50%) agreed to and completed the 24-month process. 2 of 3 (67%) continue to serve on faculty after the required instructor year. CONCLUSION: The novel concept of early specialization outside of ESIR and ESNM presents an opportunity to tailor the PGY 5 DR year to increase recruitment to academic faculty positions.

Imaging for Response Assessment in Cancer Clinical Trials.

The use of biomarkers is integral to the routine management of cancer patients, including diagnosis of disease, clinical staging and response to therapeutic intervention. Advanced imaging metrics with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) are used to assess response during new drug development and in cancer research for predictive metrics of response. Key components and challenges to identifying an appropriate imaging biomarker are selection of integral vs integrated biomarkers, choosing an appropriate endpoint and modality, and standardization of the imaging biomarkers for cooperative and multicenter trials. Imaging biomarkers lean on the original proposed quantified metrics derived from imaging such as tumor size or longest dimension, with the most commonly implemented metrics in clinical trials coming from the Response Evaluation Criteria in Solid Tumors (RECIST) criteria, and then adapted versions such as immune-RECIST (iRECIST) and Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST) for immunotherapy response and PET imaging, respectively. There have been many widely adopted biomarkers in clinical trials derived from MRI including metrics that describe cellularity and vascularity from diffusion-weighted (DW)-MRI apparent diffusion coefficient (ADC) and Dynamic Susceptibility Contrast (DSC) or dynamic contrast enhanced (DCE)-MRI (Ktrans, relative cerebral blood volume (rCBV)), respectively. Furthermore, Fluorodexoyglucose (FDG), fluorothymidine (FLT), and fluoromisonidazole (FMISO)-PET imaging, which describe molecular markers of glucose metabolism, proliferation and hypoxia have been implemented into various cancer types to assess therapeutic response to a wide variety of targeted- and chemotherapies. Recently, there have been many functional and molecular novel imaging biomarkers that are being developed that are rapidly being integrated into clinical trials (with anticipation of being implemented into clinical workflow in the future), such as artificial intelligence (AI) and machine learning computational strategies, antibody and peptide specific molecular imaging, and advanced diffusion MRI. These include prostate-specific membrane antigen (PSMA) and trastuzumab-PET, vascular tumor burden extracted from contrast-enhanced CT, diffusion kurtosis imaging, and CD8 or Granzyme B PET imaging. Further excitement surrounds theranostic procedures such as the combination of 68Ga/111In- and 177Lu-DOTATATE to use integral biomarkers to direct care and personalize therapy. However, there are many challenges in the implementation of imaging biomarkers that remains, including understand the accuracy, repeatability and reproducibility of both acquisition and analysis of these imaging biomarkers. Despite the challenges associated with the biological and technical validation of novel imaging biomarkers, a distinct roadmap has been created that is being implemented into many clinical trials to advance the development and implementation to create specific and sensitive novel imaging biomarkers of therapeutic response to continue to transform medical oncology.

Financial implications of biparametric prostate MRI.

BACKGROUND: Multiparametric magnetic resonance imaging (MP-MRI) targeted biopsy has been shown to identify more clinically-significant cancers and reduce the detection of clinically-insignificant disease when compared to systematic biopsy; however, the wide-spread accessibility of MP-MRI is limited. A potential strategy for reducing the cost, study time, and contrast-associated risks associated with MP-MRI is elimination of the dynamic contrast-enhanced (DCE) sequence, relying instead on biparametric MRI (BP-MRI). BP-MRI has been shown to have a diagnostic accuracy and cancer detection rate that are equivalent to those of MP-MRI. METHODS: We modeled the potential cost of BP-MRI compared to MP-MRI to determine what cost savings would occur if DCE was eliminated from these studies. RESULTS: When controlled for a 45 min time window that allows for one full MP-MRI or three full BP-MRI studies, the BP-MRI 45 min gross profit is $1531.32. This is an increase in gross profit of $892.58 for the 45 min time window or $10,710.98 in a 9-h business day when performing BP-MRI compared to MP-MRI for prostate cancer detection. CONCLUSIONS: BP-MRI has the potential to result in substantial cost benefit and increased access to MRI in the diagnostic workflow and risk-stratification of men being evaluated for prostate cancer when compared to conventional MP-MRI.