The Virtual Radiology Reading Room: Initial Perceptions of Referring Providers and Radiologists.

The objective of this study is to assess the initial perception of referring providers and radiologists to a virtual consultation solution (the Virtual Radiology Reading Room, VR3). VR3 is specifically designed to replace the radiology reading room phone and enable the radiologist to continue to work as part of the clinical care team fielding radiology consults without being confined to the same physical space. Surveys of providers' and radiologists' initial experience were conducted approximately 6 months after initial deployment. Users were asked about their overall impression, and how well the solution integrates with their workflow as well as how it compares to traditional phone calls to the reading room. Forty of 71 referring providers and 27 of 44 radiologists responded to our survey. VR3 was rated 4.7 out of 5 stars by referrers and 4.1 by radiologists. Seventy percent of referrers and radiologists preferred VR3 to the phone while 4.5% of referrers and 11% of radiologists preferred the phone. Referring providers and radiologists expressed a positive initial perception of the Virtual Radiology Reading Room and prefer it to traditional phone calls to the reading room.

Approach to Cystic Lesions in the Abdomen and Pelvis, with Radiologic-Pathologic Correlation.

Cystic lesions found in and around the peritoneal cavity can often be challenging to diagnose owing to significant overlap in imaging appearance between the different entities. When the cystic lesion can be recognized to arise from one of the solid abdominal organs, the differential considerations can be more straightforward; however, many cystic lesions, particularly when large, cannot be clearly associated with one of the solid organs. Cystic lesions arising from the mesentery and peritoneum are less commonly encountered and can be caused by relatively rare entities or by a variant appearance of less-rare entities. The authors provide an overview of the classification of cystic and cystic-appearing lesions and the basic imaging principles in evaluating them, followed by a summary of the clinical, radiologic, and pathologic features of various cystic and cystic-appearing lesions found in and around the peritoneal cavity, organized by site of origin. Emphasis is given to lesions arising from the mesentery, peritoneum, or gastrointestinal tract. Cystic lesions arising from the liver, spleen, gallbladder, pancreas, urachus, adnexa, or soft tissue are briefly discussed and illustrated with cases to demonstrate the overlap in imaging appearance with mesenteric and peritoneal cystic lesions. When approaching a cystic lesion, the key imaging features to assess include cyst content, locularity, wall thickness, and presence of internal septa, solid components, calcifications, or any associated enhancement. While definitive diagnosis is not always possible with imaging, careful assessment of the imaging appearance, location, and relationship to adjacent structures can help narrow the differential diagnosis. Online supplemental material is available for this article. ©RSNA, 2021.

The Radiology Virtual Reading Room: During and Beyond the COVID-19 Pandemic.

The COVID-19 pandemic has disrupted the radiology reading room with a potentially lasting impact. This disruption could introduce the risk of obviating the need for the reading room, which would be detrimental to many of the roles of radiology that occur in and around the reading room. This disruption could also create the opportunity for accelerated evolution of the reading room to meet the strategic needs of radiology and health care through thoughtful re-design of the virtual reading room. In this article, we overview the impact of the COVID-19 pandemic on radiology in our institution and across the country, specifically on the dynamics of the radiology reading room. We introduce the concept of the virtual reading room, which is a redesigned alternative to the physical reading room that can serve the diverse needs of radiology and healthcare during and beyond the pandemic.

Radiology Reporting in the Era of Patient-Centered Care: How Can We Improve Readability?

Radiology reports are consumed not only by referring physicians and healthcare providers, but also by patients. We assessed report readability in our enterprise and implemented a two-part quality improvement intervention with the goal of improving report accessibility. A total of 491,813 radiology reports from ten hospitals within the enterprise from May to October, 2018 were collected. We excluded echocardiograms, rehabilitation reports, administrator reports, and reports with negative scores leaving 461,219 reports and report impressions for analysis. A grade level (GL) was calculated for each report and impression by averaging four readability metrics. Next, we conducted a readability workshop and distributed weekly emails with readability GLs over a period of 6 months to each attending radiologist at our primary institution. Following this intervention, we utilized the same exclusion criteria and analyzed 473,612 reports from May to October, 2019. The mean GL for all reports and report impressions was above 13 at every hospital in the enterprise. Following our intervention, a statistically significant drop in GL for reports and impressions was demonstrated at all locations, but a larger and significant improvement was observed in impressions at our primary site. Radiology reports across the enterprise are written at an advanced reading level making them difficult for patients and their families to understand. We observed a significantly larger drop in GL for impressions at our primary site than at all other sites following our intervention. Radiologists at our home institution improved their report readability after becoming more aware of their writing practices.

Integration of Peer Review in PACS Results in a Marked Increase in the Discrepancies Reported.

OBJECTIVE. The objective of this article is to assess the impact of integrating peer review in PACS on the reporting of discrepancies. Our hypothesis is that a PACS-integrated machine-randomized and semiblinded peer review tool leads to an increase in discrepancies reported. MATERIALS AND METHODS. A PACS tool was implemented to prompt radiologists to perform peer review of prior comparison studies in a randomized fashion. The reviewed radiologist's name was omitted from the prior report in PACS. Before this implementation, radiologists entered peer reviews directly on the RADPEER website. Three academic subspecialty sections comprising 24 radiologists adopted the tool (adopters group). Three sections comprising 14 radiologists did not adopt the tool (nonadopters group). Peer review submissions were analyzed for 4 months before and 4 months after the implementation. The mean rate of significant discrepancies (RADPEER score 2b or higher) reported per radiologist was calculated and the discrepancy rates of the periods before and after the implementation were compared. RESULTS. The mean significant discrepancy rate reported per radiologist in the adopters group increased from 0.19% ± 0.46% (SD) before the implementation to 0.93% ± 1.45% after implementation (p = 0.01). No significant discrepancies were reported by the nonadopters group in either period. CONCLUSION. In this single institutional retrospective analysis, integrating peer review in PACS resulted in a fivefold increase in reported significant discrepancies. These results suggest that peer review data are influenced by the design of the tool used including PACS integration, randomization, and blinding.

Pitfalls in liver MRI: Technical approach to avoiding misdiagnosis and improving image quality.

The following is an illustrative review of common pitfalls in liver MRI that may challenge interpretation. This article reviews common technical and diagnostic challenges encountered when interpreting dynamic multiphasic T1 -weighted imaging, hepatobiliary phase imaging, and diffusion-weighted imaging of the liver. Additionally, each section includes suggestions for avoiding diagnostic and technical errors. Level of Evidence: 5 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:41-58.

Providing MR Imaging for Cervical Cancer Brachytherapy: Lessons for Radiologists.

Brachytherapy (BT), the use of a locally placed or implanted radioactive source for treatment of an adjacent tumor, is an important component in the treatment of patients with both early- and advanced-stage cervical cancer and is increasingly part of the standard treatment protocol. When it is feasible, many radiation oncologists choose to include a magnetic resonance (MR) imaging examination for planning BT treatment (ie, an MR imaging examination after placement of the applicator but before radiation dosing). MR imaging provides excellent soft-tissue contrast and allows radiation oncologists to individualize the radiation dose to the target volume and minimize the dose to adjacent organs that are at risk for radiation damage. However, traditionally, the radiology department has not performed imaging studies for planning, and the requirements are different compared with those of standard diagnostic imaging. In addition, many applicators are available for use in BT treatment of cervical cancer, and each must considered separately to determine MR safety and to define the best imaging parameters. Starting and supporting a robust gynecologic BT program includes implementing imaging protocols that are helpful to both radiation oncologists and diagnostic radiologists. By becoming more familiar with this treatment modality and the logistics of imaging patients undergoing BT, radiologists can provide imaging support for colleagues in the radiation oncology department and better care for patients. ©RSNA, 2018.

Evaluation of the gallbladder and cystic duct patency with gadoxetate disodium enhanced MR cholangiography: prospective comparison of patients with normal gallbladder function and acute cholecystitis.

BACKGROUND: Using hepatocyte-specific magnetic resonance imaging (MRI) contrast agents such as gadoxetate disodium, MRI can provide functional information regarding the patency of the cystic duct similar to hepatobiliary scintigraphy in addition to anatomic images. PURPOSE: To describe the gadoxetate disodium enhanced MR cholangiography (GDE-MRC) findings in patients with acute cholecystitis and to compare them with findings in patients without acute cholecystitis and with normal hepatobiliary scintigraphy. MATERIAL AND METHODS: This study was HIPAA compliant and institutional review board approved. Twenty-three patients (n = 14 diagnosed with acute calculous cholecystitis based on ultrasound [US] or computed tomography [CT]; n = 9 controls with normal hepatobiliary scintigraphy) were prospectively enrolled. All patients underwent GDE-MRC within 2 days of the US, CT, or hepatobiliary scintigraphy. GDE-MRC included axial gradient echo T1-weighted images before and 3, 10, 20, 30, and 60 min after injection of 10 mL of gadoxetate disodium. If excretion of contrast into the gallbladder was not noted at 60 min, intravenous morphine was administered (0.04 mg/kg) and images were acquired 30 min later. RESULTS: In all nine controls, gadoxetate disodium was excreted into the gallbladder within 60 min (7/9 in <30 min). Twelve out of 14 patients with acute cholecystitis completed the study. Six out of 12 (50%) patients demonstrated contrast in their gallbladder within 1 h of administration similar to the control group (2/6 in <30 min). In the remaining 6/12 patients, contrast was not present in the gallbladder within 1 h from injection. Following morphine augmentation, contrast was subsequently noted in the gallbladder in 2/6 patients. CONCLUSION: GDE-MRC can assess the patency of the cystic duct. Delayed (>60 min) or lack of filling of the gallbladder during GDE-MRC supports the diagnosis of acute cholecystitis. However, filling of the gallbladder with contrast in <60 min does not exclude the diagnosis of acute calculous cholecystitis.

Reading Room Interruptions are Less Disruptive When Using Asynchronous Communication Methods.

Radiologist interruptions, though often necessary, can be disruptive. Prior literature has shown interruptions to be frequent, occurring during cases, and predominantly through synchronous communication methods such as phone or in person causing significant disengagement from the study being read. Asynchronous communication methods are now more widely available in hospital systems such as ours. Considering the increasing use of asynchronous communication methods, we conducted an observational study to understand the evolving nature of radiology interruptions. We hypothesize that compared to interruptions occurring through synchronous methods, interruptions via asynchronous methods reduce the disruptive nature of interruptions by occurring between cases, being shorter, and less severe. During standard weekday hours, 30 radiologists (14 attendings, 12 residents, and 4 fellows) were directly observed for approximately 90-min sessions across three different reading rooms (body, neuroradiology, general). The frequency of interruptions was documented including characteristics such as timing, severity, method, and length. Two hundred twenty-five interruptions (43 Teams, 47 phone, 89 in-person, 46 other) occurred, averaging 2 min and 5 s with 5.2 interruptions per hour. Microsoft Teams interruptions averaged 1 min 12 s with only 60.5% during cases. In-person interruptions averaged 2 min 12 s with 82% during cases. Phone interruptions averaged 2 min and 48 s with 97.9% during cases. A substantial portion of reading room interruptions occur via predominantly asynchronous communication tools, a new development compared to prior literature. Interruptions via predominantly asynchronous communications tools are shorter and less likely to occur during cases. In our practice, we are developing tools and mechanisms to promote asynchronous communication to harness these benefits.

Checklist for Reproducibility of Deep Learning in Medical Imaging.

The application of deep learning (DL) in medicine introduces transformative tools with the potential to enhance prognosis, diagnosis, and treatment planning. However, ensuring transparent documentation is essential for researchers to enhance reproducibility and refine techniques. Our study addresses the unique challenges presented by DL in medical imaging by developing a comprehensive checklist using the Delphi method to enhance reproducibility and reliability in this dynamic field. We compiled a preliminary checklist based on a comprehensive review of existing checklists and relevant literature. A panel of 11 experts in medical imaging and DL assessed these items using Likert scales, with two survey rounds to refine responses and gauge consensus. We also employed the content validity ratio with a cutoff of 0.59 to determine item face and content validity. Round 1 included a 27-item questionnaire, with 12 items demonstrating high consensus for face and content validity that were then left out of round 2. Round 2 involved refining the checklist, resulting in an additional 17 items. In the last round, 3 items were deemed non-essential or infeasible, while 2 newly suggested items received unanimous agreement for inclusion, resulting in a final 26-item DL model reporting checklist derived from the Delphi process. The 26-item checklist facilitates the reproducible reporting of DL tools and enables scientists to replicate the study's results.

Evolving role of MRI in Crohn's disease.

MR enterography is playing an evolving role in the evaluation of small bowel Crohn's disease (CD). Standard MR enterography includes a combination of rapidly acquired T2 sequence, balanced steady-state acquisition, and contrast enhanced T1-weighted gradient echo sequence. The diagnostic performance of these sequences has been shown to be comparable, and in some respects superior, to other small bowel imaging modalities. The findings of CD on MR enterography have been well described in the literature. New and emerging techniques such as diffusion-weighted imaging (DWI), dynamic contrast enhanced MRI (DCE-MRI), cinematography, and magnetization transfer, may lead to improved accuracy in characterizing the disease. These advanced techniques can provide quantitative parameters that may prove to be useful in assessing disease activity, severity, and response to treatment. In the future, MR enterography may play an increasing role in management decisions for patients with small bowel CD; however, larger studies are needed to validate these emerging MRI parameters as imaging biomarkers.

Imaging-guided prostate biopsy: conventional and emerging techniques.

Transrectal ultrasonography (US)-guided biopsy is the standard approach for histopathologic diagnosis of prostate cancer. However, this technique has multiple limitations owing to the operator's inability in most cases to directly visualize and target prostate lesions. Magnetic resonance (MR) imaging of the prostate overcomes many of these limitations by directly depicting areas of abnormality and allowing targeted biopsies. Accuracy in the detection of prostate cancer is improved by the combined use of standard T2-weighted MR imaging and advanced MR imaging techniques such as diffusion-weighted imaging, dynamic contrast-enhanced imaging, and MR spectroscopy. Suspicious-appearing regions of the prostate seen on MR images can be targeted at real-time transrectal US-guided biopsy to improve the diagnostic yield. MR imaging also can be performed for real-time guidance of transrectal prostate biopsy. Studies among patients who underwent at least one transrectal US-guided biopsy with a negative result before undergoing an MR imaging-guided biopsy showed improved detection rates with MR imaging-guided biopsy in comparison with the detection rates achieved with a repeat transrectal US-guided biopsy; however, MR imaging-guided biopsy is a more time-consuming procedure. A technique known as fused MR imaging- and transrectal US-guided biopsy, which relies on the coregistration of previously acquired MR images with real-time transrectal US images acquired during the procedure, shows promise but is limited by deformation of the prostate; this limitation is the subject of ongoing investigation. Another technique that is currently under investigation, MR imaging-guided prostate biopsy with robotic assistance, may one day help improve the accuracy of biopsy needle placement.

Errors and Misinterpretations in Imaging of Chronic Liver Diseases.

MRI is an important problem-solving tool for accurate characterization of liver lesions. Chronic liver disease alters the typical imaging characteristics and complicates liver imaging. Awareness of imaging pitfalls and technical artifacts and ways to mitigate them allows for more accurate and timely diagnosis.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation. Part two: noncurative intention.

Locoregional therapies can be offered to hepatocellular carcinoma patients as a bridge to transplant, to downstage disease burden for transplant eligibility, or for disease control to prolong survival. Systemic therapies also play a large role in HCC treatment, occasionally in conjunction with other methods. This manuscript reviews the various treatment options for HCC with a historically noncurative intent.

Therapies for hepatocellular carcinoma: overview, clinical indications, and comparative outcome evaluation-part one: curative intention.

Hepatocellular carcinoma (HCC) offers unique management challenges as it commonly occurs in the setting of underlying chronic liver disease. The management of HCC is directed primarily by the clinical stage. The most commonly used staging system is the Barcelona-Clinic Liver Cancer system, which considers tumor burden based on imaging, liver function and the patient's performance status. Early-stage HCC can be managed with therapies of curative intent including surgical resection, liver transplantation, and ablative therapies. This manuscript reviews the various treatment options for HCC with a curative intent, such as locablative therapy types, surgical resection, and transplant. Indications, contraindications and outcomes of the various treatment options are reviewed. Multiple concepts relating to liver transplant are discussed including Milan criteria, OPTN policy, MELD exception points, downstaging to transplant and bridging to transplant.

NRG Oncology/RTOG Consensus Guidelines for Delineation of Clinical Target Volume for Intensity Modulated Pelvic Radiation Therapy in Postoperative Treatment of Endometrial and Cervical Cancer: An Update.

PURPOSE: Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions. METHODS AND MATERIALS: An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers. RESULTS: Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus. CONCLUSIONS: Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes.

Suitability of the woodchuck HCC as a preclinical model for evaluation of intra-arterial therapies.

The most commonly used preclinical models of hepatocellular carcinoma (HCC) are limited for use in testing of intra-arterial therapies such as transarterial chemoembolization and radioembolization. Issues encountered with the more commonly used animal models include dissimilarity in their disease development compared with humans and the size of the vasculature which can make intra-arterial therapy testing difficult or impossible. Here we describe the suitability of the woodchuck HCC model for testing of intra-arterial therapies. We describe the techniques for pre-embolization imaging assessment using CT and MRI, technical tips on performing angiography and embolization, and pathological assessment of treated liver.

Clinicians and surgeon survey regarding current and future versions of CT/MRI LI-RADS.

PURPOSE: To determine preferences of clinicians and surgeons regarding radiology reporting of liver observations in patients at risk for hepatocellular carcinoma (HCC). METHODS: Members of the American College of Radiology Liver Imaging and Data Reporting System (LI-RADS) Outreach & Education Group (30 members) as well as Society of Abdominal Radiology Disease-Focused Panel on HCC diagnosis (27 members) created and distributed an 18-question survey to clinicians and surgeons, with focus on preferences regarding radiology reporting of liver observations in patients. The survey questions were directed to physician demographics, current use of LI-RADS by their local radiologists, their opinions about current LI-RADS and potential improvements. RESULTS: A total of 152 physicians responded, 66.4% (101/152) from North America, including 42 surgeons, 81 physicians and 29 interventional radiologists. Participants were predominantly from academic centers 83% (126/152), while 13.8% (21/152) worked in private/community centers and 3.2% (5/152) worked in a hybrid practice. Almost 90% (136/152) of participants preferred the use of LI-RADS (compared to nothing or other standardized reporting systems; OPTN and AASLD) to communicate liver-related observations. However, only 28.5% (43/152) of participants input was sought at the time of implementing LI-RADS in their institutions. Fifty-eight percent (88/152) of all participants found standardized LI-RADS management recommendations in radiology reports to be clinically helpful. However, a subgroup analysis of surgeons in academic centers showed that 61.8% (21/34) prefer not to receive standardized LI-RADS recommendations. CONCLUSIONS: Most participants preferred the use LI-RADS in reporting CT and MRI examination. When considering inclusion of management recommendations, radiologists should consult with their referring physicians, as preference may differ.

MR Imaging of Prostate Zonal Anatomy.

McNeal first described the zonal anatomy of the prostate about 40 years ago, outlining 4 zones of the prostate and defining their relation to the urethra and the ejaculatory ducts. The zonal anatomy remains the accepted model for describing the prostate and the zones are well-depicted on MR imaging, including the central zone, which until recently was grouped with the transition zone in the radiology literature. An accurate understanding of the zonal anatomy and periprostatic anatomy is key for accurate interpretation of the prostate MR imaging.

Reduction of MRI signal distortion from titanium intracavitary brachytherapy applicator by optimizing pulse sequence parameters.

PURPOSE: To demonstrate that optimized pulse sequence parameters for a T2-weighted (T2w) fast spin echo acquisition reduced artifacts from a titanium brachytherapy applicator compared to conventional sequence parameters. METHODS AND MATERIALS: Following Institutional Review Board approval and informed consent, seven patients were successfully imaged with both standard sagittal T2w fast spin echo parameters (voxel size of 0.98 × 0.78 × 4.0 mm3; readout bandwidth of 200 Hz/px; repetition time of 2800 ms; echo time of 91 ms; echo train length of 15; 36 slices; and imaging time of 3:16 min) and an additional optimized T2w sequence (voxel size of 0.98 × 0.98 × 4.0 mm3; readout bandwidth of 500 Hz/px; repetition time of 3610 ms; echo time of 91 ms; echo train length of 25; 18-36 slices; and imaging time of 1:15-2:30 min), which had demonstrated artifact reduction in prior phantom work. Visualized intracavitary tandem was hand-segmented by two of the authors. Three body imaging radiologists assessed image quality and intraobserver agreement scores were analyzed. RESULTS: The average segmented volume of the intracavitary applicator significantly (p < 0.05) decreased with the experimental pulse sequence parameters as compared to the standard pulse sequence. Comparison of experimental and standard T2w sequence qualitative scores for each reviewer showed no significant differences between the two techniques. CONCLUSIONS: This study demonstrated that pulse sequence parameter optimization can significantly reduce distortion artifact from titanium applicators while maintaining image quality and reasonable imaging times.