Shape-Sensing Robotic-Assisted Bronchoscopy versus Computed Tomography-Guided Transthoracic Biopsy for the Evaluation of Subsolid Pulmonary Nodules.

INTRODUCTION: Lung cancer remains the leading cause of cancer death worldwide. Subsolid nodules (SSN), including ground-glass nodules (GGNs) and part-solid nodules (PSNs), are slow-growing but have a higher risk for malignancy. Therefore, timely diagnosis is imperative. Shape-sensing robotic-assisted bronchoscopy (ssRAB) has emerged as reliable diagnostic procedure, but data on SSN and how ssRAB compares to other diagnostic interventions such as CT-guided transthoracic biopsy (CTTB) are scarce. In this study, we compared diagnostic yield of ssRAB versus CTTB for evaluating SSN. METHODS: A retrospective study of consecutive patients who underwent either ssRAB or CTTB for evaluating GGN and PSN with a solid component less than 6 mm from February 2020 to April 2023 at Mayo Clinic Florida and Rochester. Clinicodemographic information, nodule characteristics, diagnostic yield, and complications were compared between ssRAB and CTTB. RESULTS: A total of 66 nodules from 65 patients were evaluated: 37 PSN and 29 GGN. Median size of PSN solid component was 5 mm (IQR: 4.5, 6). Patients were divided into two groups: 27 in the ssRAB group and 38 in the CTTB group. Diagnostic yield was 85.7% for ssRAB and 89.5% for CTTB (p = 0.646). Sensitivity for malignancy was similar between ssRAB and CTTB (86.4% vs. 88.5%; p = 0.828), with no statistical difference. Complications were more frequent in CTTB with no significant difference (8 vs. 2; p = 0.135). CONCLUSION: Diagnostic yield for SSN was similarly high for ssRAB and CTTB, with ssRAB presenting less complications and allowing mediastinal staging within the same procedure.

Robotic-assisted bronchoscopy versus CT-guided transthoracic biopsy for diagnosis of pulmonary nodules.

BACKGROUND AND OBJECTIVE: Currently, computed tomography-guided transthoracic biopsy (CTTB) is the most accurate diagnostic approach for pulmonary nodules suspected of malignancy. Traditional bronchoscopy has shown suboptimal diagnostic sensitivity, but the emergence of robotic-assisted bronchoscopy (RAB) has the potential to improve diagnostic accuracy, maximize diagnostic yield and complete mediastinal and hilar staging in a single procedure. We aim to assess the efficacy and diagnostic performance of RAB compared to CTTB for diagnosing pulmonary nodules suspected of lung cancer. METHODS: A multicenter retrospective review of consecutive patients who underwent RAB and CTTB for evaluating pulmonary nodules from January 2019 to March 2021 at Mayo Clinic Florida and Mayo Clinic Rochester, United States. Clinical and demographic information, nodule characteristics, outcomes and complications were compared between RAB and CTTB. RESULTS: A total of 225 patients were included: 113 in the RAB group and 112 in the CTTB group. Overall diagnostic yield was 87.6% for RAB and 88.4% for CTTB. For malignant disease, RAB had a sensitivity of 82.1% and a specificity of 100%, CTTB had a sensitivity of 88.5% and a specificity of 100%. Complication rate was significantly higher for CTTB compared to RAB (17% vs. 4.4%; p = 0.002). CONCLUSION: RAB, when available, can be as accurate as CTTB for sampling pulmonary nodules with similar or reduced complications and should be considered as a means for nodule biopsy, particularly when mediastinal staging is also clinically warranted.

Ultrasound Simulation Training for Radiology Residents-Curriculum Design and Implementation.

Medical simulation training can be used to improve clinician performance, teach communication and professionalism skills, and enhance team training. Radiology residents can benefit from simulation training in diagnostic ultrasound, procedural ultrasound, and communication skills prior to direct patient care experiences. This paper details a weeklong ultrasound simulation training curriculum for radiology residents during the PGY-1 clinical internship. The organization of established teaching methods into a dedicated course early in radiology residency training with the benefit of a multi-disciplinary approach makes this method unique. This framework can be adapted to fit learners at different skill levels or with specific procedural needs.

Incidentalomas are associated with an increase in liver transplantation in patients with cirrhosis: a single-center retrospective study.

BACKGROUND: Incidentalomas, defined as incidental findings on imaging, are a growing concern. Our aim was to determine the impact and outcomes of extrahepatic incidentalomas on liver transplantation. METHODS: Patients at a large liver transplant center, who had an initial MRI for hepatocellular carcinoma screening between January 2004 and March 2020 were identified. Clinical data were collected retrospectively. Survival analysis, utilizing Kaplan Meier estimates and Cox proportional hazards regression analysis, was utilized to determine factors associated with liver transplantation. RESULTS: 720 patients were included. NASH (24.9%), HCV (22.1%) and alcohol (20.6%) were the most common causes of cirrhosis. 79.7% of patients had an extrahepatic incidentaloma. Older age and having received a liver transplant by the end of the study were associated with an incidentaloma. MELD was not associated with the presence of an incidentaloma. On univariate Cox proportional hazards regression, male sex, history of moderate alcohol use, smoking history, MELD, and incidentalomas were predictors of liver transplantation. On multivariate analysis, only MELD and the presence of an incidentaloma were found to be significant. Discovery of an incidentaloma was associated with a 30% increase in the risk of liver transplantation. Median time to transplantation did not differ based on the presence on an incidentaloma. Patients with cirrhosis from alcohol or HCV had a significantly shorter median time to transplantation than those with NASH. Renal and pancreatic lesions comprised 91% of all incidentalomas. CONCLUSIONS: In this single-center retrospective study, extrahepatic incidentalomas were common in patients with cirrhosis. The finding of an incidentaloma was associated with a higher risk of liver transplantation despite a similar median time to transplantation if no incidentaloma was discovered.

Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions.

Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.

Kaizen Process Improvement in Radiology: Primer for Creating a Culture of Continuous Quality Improvement.

Kaizen process improvement is an element of lean production that is an approach to creating continuous improvement. Kaizen is based on the idea that small ongoing positive changes in workflow and elimination of waste can yield major improvements over time. A focused Kaizen event, or rapid process improvement event, can lead to sustainable process improvement in health care settings that are resistant to change. This approach has been proven to be successful in health care. These events are led by a trained facilitator and coach who provides appropriate team education and engagement. To ensure success, the team must embrace the Kaizen culture, which emphasizes the development of a "learning organization" that is focused on relentless pursuit of perfection. The culture empowers all staff to improve the work they perform, with an emphasis on the process and not the individual. Respect for individual people is key in Kaizen. In radiology, this method has been successful in empowering frontline staff to improve their individual workflows. A 5-day Kaizen event has been successful in increasing on-time starts, decreasing lead time, increasing patient and staff satisfaction, and ensuring sustainability. Sustainable success can occur when the team stays true to lean principles, engages leaders, and empowers team members with the use of timely data to drive decision making. Online supplemental material is available for this article. ©RSNA, 2022.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion.

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ©RSNA, 2020.

Gastrointestinal Manifestations of Rheumatological Diseases.

Rheumatological diseases (RDs) represent a diverse group of diseases that are inherited or related to environmental factors. RDs frequently affect the gastrointestinal (GI) tract, and gastroenterologists are often asked to evaluate patients with symptoms thought to represent an underlying or coexisting RD. GI manifestations of RDs vary based on the organ involved as well as the extent and duration of involvement. Although most manifestations of RD are nonspecific and not life-threatening, the chronicity and severity of symptoms can be debilitating and may lead to serious injury. This narrative review discusses the most common RD encountered by gastroenterologists: systemic lupus erythematosus, systemic sclerosis (scleroderma), dermatomyositis/polymyositis, rheumatoid arthritis, Sjögren syndrome, overlap syndromes, mixed connective tissue disease, Ehlers-Danlos syndromes, and other vasculitides. Each section begins with a brief overview of the condition, followed by a discussion of the etiopathophysiology, physical examination findings, GI manifestations, diagnostic tools (i.e., serologic, imaging, endoscopic, and functional), and treatment options.

Diagnosis and Management of Genetic Iron Overload Disorders.

Iron overload disorders lead to excess iron deposition in the body, which can occur as a result of genetic or secondary causes. Genetic iron overload, referred to as hereditary hemochromatosis, may present as a common autosomal recessive mutation or as one of several uncommon mutations. Secondary iron overload may result from frequent blood transfusions, exogenous iron intake, or certain hematological diseases such as dyserythropoietic syndrome or chronic hemolytic anemia. Iron overload may be asymptomatic, or may present with significant diseases of the liver, heart, endocrine glands, joints, or other organs. If treated appropriately prior to end-organ damage, life expectancy has been shown to be similar compared to matched populations. Alongside clinical assessment, diagnostic studies involve blood tests, imaging, and in some cases liver biopsy. The mainstay of therapy is periodic phlebotomy, although oral chelation is an option for selected patients.

A narrative review of imaging for pancreas adenocarcinoma: staging, surgical considerations, and surveillance.

Background and Objective: Pancreas adenocarcinoma is a disease with dire prognosis. Imaging is pivotal to the diagnosis, staging, reassessment, surgical planning, and surveillance of pancreas cancer. The purpose of this paper is to provide the reader an overview of current imaging practices for pancreas adenocarcinoma. Methods: A literature search of original papers and reviews through 2022 was performed using the PubMed database. The most current American College of Radiology Appropriateness Criteria and National Comprehensive Cancer Network guidelines on pancreas cancer imaging were also included. Key Content and Findings: Multidisciplinary team care at a high-volume institution is instrumental to optimal patient management and outcomes. It is therefore important for all team members to be aware of imaging modality options, strengths, and challenges. Additionally, a high-level understanding of imaging findings is useful clinically. This manuscript provides a current overview of imaging modalities used in the identification and assessment of pancreas adenocarcinoma, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. Imaging findings, including the expected and unexpected, are reviewed to give the novice imager a better understanding. Conclusions: This review provides a current overview of imaging for pancreas adenocarcinoma, including strengths and weakness of various imaging modalities; therefore, providing the reader with a robust resource when considering imaging in the management of this disease.

Preference Signaling for the Diagnostic Radiology Match: A Single Institution Experience.

The Association of American Medical Colleges announced the addition of preference signaling to the 2022-2023 residency match cycle for Diagnostic and Interventional Radiology. This new offering provided applicants the option to indicate their specific interest in up to 6 residency programs during initial application submission. Our institutional diagnostic radiology residency program received a total of 1294 applications. One hundred and eight applicants signaled the program. Interview invitations were sent to 104 applicants, 23 of which signaled the program. Out of the top 10 ranked applicants, 6 applicants signaled the program. Out of the 5 matched applicants, 80% used the program signal, and 100% did the geographic preference. Opting to signal programs during the initial application submission may be beneficial for both the applicants and the programs in finding the optimal match.

Needle types used in abdominal cross-sectional interventional radiology: a survey of the Society of Abdominal Radiology emerging technology commission.

PURPOSE: To identify commonly used needle types in cross-sectional interventional radiology (CSIR) and to review features and safety profiles of those needles. METHODS: Members of the Society of Abdominal Radiology (SAR) emerging technologies commission (ETC) on CSIR were sent a 13-question survey about what needles they use for common CSIR procedures: random and targeted solid organ biopsy, ultrasound-guided paracentesis, and ultrasound-guided thyroid fine needle aspiration (FNA). Results were compiled with descriptive statistics, and features of the most commonly used needles were reviewed. RESULTS: 19 surveys were completed (response rate 57.6%, 19/33) from 16 institutions. For solid organ biopsies, the majority of respondents reported using an 18-gauge needle with an automatic firing mechanism and a variable throw length option. The most commonly used needle for both random and targeted biopsies was the Argon BioPince (26.3%, 5/19) The three most commonly used needles for solid organ biopsies all featured automatic firing, variable throw length options, and 18-gauge size. A 5 French Cook Yueh needle was most the most commonly used paracentesis needle (36.8%, 7/19). For thyroid FNA, all respondents used spinal needles, and 25-gauge was the most common size (72.2%, 13/18). CONCLUSION: Abdominal radiologists use a variety of needles when performing common interventional procedures. Members of the SAR CSIR ETC commonly use automatic, 18-gauge, variable throw length needles for solid organ biopsies, 5 French catheter style needles for paracentesis, and 25-gauge spinal needles for thyroid FNA.

Resident Scholarly Activity for Diagnostic Radiology Residency - A Point System Approach.

Scholarly activity is an important aspect of diagnostic radiology residency training, however, there is no clear standard for what is expected and deemed appropriate for scholarly activity. This article discusses the rationale and development of a point system approach for resident scholarly activity at our diagnostic radiology residency program.

Prophylactic Intravenous Access: Is It Necessary for Renal Transplant Biopsies?

INTRODUCTION: Percutaneous renal transplant biopsies have long been a safe and effective procedure with bleeding being the most common significant complication. Only a few studies, however, have addressed the need for intravenous access prior to the procedure. OBJECTIVES: We postulate that the number of patients requiring intravenous resuscitation after a routine renal transplant biopsy is sufficiently low enough to prove that eliminating pre-procedural peripheral IV placement will have no negative impact on patient safety and could improve departmental efficiency. METHODS: This is a retrospective analysis of complications that occurred in patients who underwent routine percutaneous renal transplant biopsies at an academic center. Patients were divided into two groups: the IV cohort that had peripheral IV access placed before the procedure (n=1318) and the no-IV cohort that did not (n=492). RESULTS: This is a retrospective analysis of complications that occurred in patients who underwent routine percutaneous renal transplant biopsies at an academic center. Patients were divided into two groups: the IV cohort that had peripheral IV access placed before the procedure (n=1318) and the no-IV cohort that did not (n=492). CONCLUSIONS: Placement of prophylactic peripheral IV access in patients undergoing routine renal transplant biopsies does not significantly impact the rate of biopsy complications.

Vascular applications of ferumoxytol-enhanced magnetic resonance imaging of the abdomen and pelvis.

Ferumoxytol is an injectable ultrasmall superparamagnetic iron oxide that has been gaining interest regarding its off-label use as an intravenous contrast agent in magnetic resonance imaging (MRI). Due to its large particle size, its use with MRI produces exquisite images of blood vessels with little background contamination or parenchymal enhancement of the abdominopelvic organs, except for the liver and spleen. Because ferumoxytol is neither an iodinated nor a gadolinium-based contrast agent, there are no restrictions for its use in patients with poor renal function. This article will highlight normal features in ferumoxytol-enhanced MRI in the abdomen and pelvis as well as its applications in evaluating vascular pathology, presurgical planning, and other problem solving.

Implementation of peer learning conferences throughout a multi-site abdominal radiology practice.

PURPOSE: To initiate a peer learning conference for our abdominal radiology division across multiple geographically separated sites and different time zones, and to determine radiologist preference for peer learning versus traditional score-based peer review. METHODS: We implemented a monthly peer learning videoconference for our abdominal radiology division. Surveys regarding radiologist opinion regarding traditional peer review and the new peer learning conferences were conducted before and after 6 months of conferences. RESULTS: Peer learning conferences were well attended across our multiple sites, with an average of 43 participants per conference. Radiologist opinion regarding peer review was poor, with survey radiologists responding positively to only 1 out of 12 process questions. Opinion regarding peer learning was extremely favorable, with radiologists responding positively to 12 out of the same 12 process questions. After 6 months of peer learning conferences, 87.9% of surveyed radiologists wished to continue them in some fashion, and no one preferred to return to score-based peer review alone. CONCLUSION: We successfully implemented a peer learning conference for our abdominal radiology division spread out over multiple geographic sites. Our radiologists strongly preferred peer learning conferences over our traditional peer review system for quality control.

Esophagopericardial Fistula Causing Pyopneumopericardium.

An esophagopericardial fistula is a rare complication of esophageal malignancy, trauma, or surgery. Imaging is a cornerstone of diagnosis, with detection of pneumopericardium or hydropneumopericardium at imaging raising suspicion for pyopneumopericardium and prompting immediate search for the causative pathologic process. Given the high associated mortality rate of over 50% for patients with esophagopericardial fistulas, early diagnosis and intervention are vital. Supplemental material is available for this article. © RSNA, 2020.