Radiology State-of-the-art Review: Endometriosis Imaging Interpretation and Reporting.

Endometriosis is a common condition impacting approximately 190 million individuals and up to 50% of women with infertility globally. The disease is characterized by endometrial-like tissue located outside of the uterine corpus, which causes cyclical hemorrhage, inflammation, and fibrosis. Based on clinical suspicion or findings at routine transvaginal pelvic US or other prior imaging, dedicated imaging for endometriosis may be warranted with MRI or advanced transvaginal US. Deep endometriosis (DE) in the pelvis includes evaluation for stromal and fibrotic components and architectural distortion resulting from fibrosis and tethering. It is a disease requiring a compartment-based, pattern-recognition approach. MRI has the benefit of global assessment of the pelvis and is effective in assessing for features of malignancy and for evaluating extrapelvic locations. Transvaginal US has the advantage of dynamic maneuvers to assess for adhesions and may achieve higher spatial resolution for assessing the depth of bowel wall invasion. T1-weighted MRI evaluation increases the specificity of diagnosis by identifying hemorrhagic components, but the presence of T1 signal hyperintensity is not essential for diagnosing DE. Endometriosis is a disease with a broad spectrum; understanding the mild through advanced manifestations, including malignancy evaluation, is within the scope and breadth of radiologists' interpretation.

Prevalence of Malignancy in Adrenal Nodules With Heterogeneous Microscopic Fat on Chemical-Shift MRI: A Multiinstitutional Study.

BACKGROUND. Homogeneous microscopic fat within adrenal nodules on chemical-shift MRI (CS-MRI) is diagnostic of benign adrenal adenoma, but the clinical relevance of heterogeneous microscopic fat is not well established. OBJECTIVE. This study sought to determine the prevalence of malignancy in adrenal nodules with heterogeneous microscopic fat on dual-echo T1-weighted CS-MRI. METHODS. We performed a retrospective study of adult patients with adrenal nodules detected on MRI performed between August 2007 and November 2020 at seven institutions. Eligible nodules had a short-axis diameter of 10 mm or larger with heterogeneous microscopic fat (defined by an area of signal loss of < 80% on opposed-phase CS-MRI). Two radiologists from each center, blinded to reference standard results, determined the signal loss pattern (diffuse, two distinct parts, speckling pattern, central loss, or peripheral loss) within the nodules. The reference standard used was available for 283 nodules (pathology for 21 nodules, ≥ 1 year of imaging follow-up for 245, and ≥ 5 years of clinical follow-up for 17) in 282 patients (171 women and 111 men; mean age, 60 ± 12 [SD] years); 30% (86/282) patients had prior malignancy. RESULTS. The mean long-axis diameter was 18.7 ± 7.9 mm (range, 10-80 mm). No malignant nodules were found in patients without prior cancer (0/197; 95% CI, 0-1.5%). Four of the 86 patients with prior malignancy (hepatocellular carcinoma [HCC], renal cell carcinoma [RCC], lung cancer, or both colon cancer and RCC) (4.7%; 95% CI, 1.3-11.5%) had metastatic nodules. Detected patterns were diffuse heterogeneous signal loss (40% [114/283]), speckling (28% [80/283]), two distinct parts (18% [51/283]), central loss (9% [26/283]), and peripheral loss (4% [12/283]). Two metastases from HCC and RCC showed diffuse heterogeneous signal loss. Lung cancer metastasis manifested as two distinct parts, and the metastasis in the patient with both colon cancer and RCC showed peripheral signal loss. CONCLUSION. Presence of heterogeneous microscopic fat in adrenal nodules on CS-MRI indicates a high likelihood of benignancy, particularly in patients without prior cancer. This finding is also commonly benign in patients with cancer; however, caution is warranted when primary malignancies may contain fat or if the morphologic pattern of signal loss may indicate a collision tumor. CLINICAL IMPACT. In the absence of prior cancer, adrenal nodules with heterogeneous microscopic fat do not require additional imaging evaluation.

Adrenal Neoplasms: Lessons from Adrenal Multidisciplinary Tumor Boards.

The radiologic diagnosis of adrenal disease can be challenging in settings of atypical presentations, mimics of benign and malignant adrenal masses, and rare adrenal anomalies. Misdiagnosis may lead to suboptimal management and adverse outcomes. Adrenal adenoma is the most common benign adrenal tumor that arises from the cortex, whereas adrenocortical carcinoma (ACC) is a rare malignant tumor of the cortex. Adrenal cyst and myelolipoma are other benign adrenal lesions and are characterized by their fluid and fat content, respectively. Pheochromocytoma is a rare neuroendocrine tumor of the adrenal medulla. Metastases to the adrenal glands are the most common malignant adrenal tumors. While many of these masses have classic imaging appearances, considerable overlap exists between benign and malignant lesions and can pose a diagnostic challenge. Atypical adrenal adenomas include those that are lipid poor; contain macroscopic fat, hemorrhage, and/or iron; are heterogeneous and/or large; and demonstrate growth. Heterogeneous adrenal adenomas may mimic ACC, metastasis, or pheochromocytoma, particularly when they are 4 cm or larger, whereas smaller versions of ACC, metastasis, and pheochromocytoma and those with washout greater than 60% may mimic adenoma. Because of its nonenhanced CT attenuation of less than or equal to 10 HU, a lipid-rich adrenal adenoma may be mimicked by a benign adrenal cyst, or it may be mimicked by a tumor with central cystic and/or necrotic change such as ACC, pheochromocytoma, or metastasis. Rare adrenal tumors such as hemangioma, ganglioneuroma, and oncocytoma also may mimic adrenal adenoma, ACC, metastasis, and pheochromocytoma. The authors describe cases of adrenal neoplasms that they have encountered in clinical practice and presented to adrenal multidisciplinary tumor boards. Key lessons to aid in diagnosis and further guide appropriate management are provided. © RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Exploratory Study of Apparent Diffusion Coefficient Histogram Metrics in Assessing Pancreatic Malignancy.

PURPOSE: To evaluate whole-lesion 3D-histogram apparent diffusion coefficient (ADC) metrics for assessment of pancreatic malignancy. METHODS: Forty-two pancreatic malignancies (36 pancreatic adenocarcinoma [PDAC], 6 pancreatic neuroendocrine [PanNET]) underwent abdominal magnetic resonance imaging (MRI) with diffusion-weighted imaging before endoscopic ultrasound biopsy or surgical resection. Two radiologists independently placed 3D volumes of interest to derive whole-lesion histogram ADC metrics. Mann-Whitney tests and receiver operating characteristic analyses were used to assess metrics' diagnostic performance for lesion histology, T-stage, N-stage, and grade. RESULTS: Whole-lesion ADC histogram metrics lower in PDACs than PanNETs for both readers (P ≤ .026) were mean ADC (area under the curve [AUC] = 0.787-0.792), mean of the bottom 10th percentile (mean0-10) (AUC = 0.787-0.880), mean of the 10th-25th percentile (mean10-25) (AUC = 0.884-0.917) and mean of the 25th-50th percentile (mean25-50) (AUC = 0.829-0.829). For mean10-25 (metric with highest AUC for identifying PDAC), for reader 1 a threshold > 0.94 × 10-3 mm2/s achieved sensitivity 94% and specificity 83%, and for reader 2 a threshold > 0.82 achieved sensitivity 97% and specificity 67%. Metrics lower in nodal status ≥ N1 than N0 for both readers (P ≤ .043) were mean0-10 (AUC = 0.789-0.822) and mean10-25 (AUC = 0.800-0.822). For mean10-25 (metric with highest AUC for identifying N0), for reader 1 a threshold <1.17 achieved sensitivity 87% and specificity 67%, and for reader 2 a threshold <1.04 achieved sensitivity 87% and specificity 83%. No metric was associated with T-stage (P > .195) or grade (P > .215). CONCLUSION: Volumetric ADC histogram metrics may serve as non-invasive biomarkers of pancreatic malignancy. Mean10-25 outperformed standard mean for lesion histology and nodal status, supporting the role of histogram analysis.

Imaging features of benign and malignant ampullary and periampullary lesions.

The ampulla of Vater is an important anatomic landmark where the common bile duct and main pancreatic duct converge in the major duodenal papilla. Imaging evaluation of the ampulla and periampullary region poses a unique diagnostic challenge to radiologists because of the region's complex and variable anatomy and the variety of lesions that can occur. Lesions intrinsic to the ampulla and involved segment of the biliary tree can be neoplastic, inflammatory, or congenital. Neoplastic lesions include ampullary adenocarcinomas and adenomas, which often are difficult to differentiate, as well as pancreatic or duodenal adenocarcinomas, pancreatic neuroendocrine tumors, and cholangiocarcinomas. Ultrasonography (US), computed tomography, magnetic resonance (MR) imaging, and MR cholangiopancreatography are commonly used to evaluate this region. Endoscopic retrograde cholangiopancreatography or endoscopic US examination may be necessary for more definitive evaluation. Periampullary conditions in the duodenum that may secondarily involve the ampulla include neoplasms, duodenitis, duodenal diverticula, and Brunner's gland hyperplasia or hamartomas. Because these lesions can exhibit a wide overlap of imaging features and subtle or nonspecific imaging findings, diagnosis is made on the basis of patient age, clinical history, and imaging and laboratory findings. Given the complexity of imaging evaluation of the ampulla and periampullary region, it is essential for radiologists to understand the variety of lesions that can occur and recognize their imaging characteristics.

De-misty-fying the mesentery: an algorithmic approach to neoplastic and non-neoplastic mesenteric abnormalities.

Mesenteric abnormalities are often incidentally discovered on cross-sectional imaging performed during daily clinical practice. Findings can range from the vague "misty mesentery" to solid masses, and the possible etiologic causes encompass a wide spectrum of underlying pathologies including infectious, inflammatory, and neoplastic processes. Unfortunately, the clinical and imaging findings are often non-specific and may overlap. This article discusses the various diseases that result in mesenteric abnormalities. It provides a framework to non-invasively differentiate these entities, when possible.

MR Imaging of Endometriosis of the Adnexa.

Endometriosis is the presence of ectopic endometrial glands outside of the uterus. MR imaging is particularly useful for characterizing deep infiltrating endometriosis but can also be useful in characterizing endometriomas and hematosalpinges, characterizing broad ligament deposits, assessing for endometriosis-associated malignancy, and differentiating malignancy from decidualized endometriomas. Masses and cysts with hemorrhagic or proteinaceous contents can sometimes be difficult to distinguish from endometriomas. Imaging protocols should include pre-contrast T1-weighted imaging with fat saturation, T2-weighted imaging without fat saturation, opposed- and in-phase or Dixon imaging, administration of contrast media, and subtraction imaging.

Lexicon for adrenal terms at CT and MRI: a consensus of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel.

PURPOSE: Substantial variation in imaging terms used to describe the adrenal gland and adrenal findings leads to ambiguity and uncertainty in radiology reports and subsequently their understanding by referring clinicians. The purpose of this study was to develop a standardized lexicon to describe adrenal imaging findings at CT and MRI. METHODS: Fourteen members of the Society of Abdominal Radiology adrenal neoplasm disease-focused panel (SAR-DFP) including one endocrine surgeon participated to develop an adrenal lexicon using a modified Delphi process to reach consensus. Five radiologists prepared a preliminary list of 35 imaging terms that was sent to the full group as an online survey (19 general imaging terms, 9 specific to CT, and 7 specific to MRI). In the first round, members voted on terms to be included and proposed definitions; subsequent two rounds were used to achieve consensus on definitions (defined as ≥ 80% agreement). RESULTS: Consensus for inclusion was reached on 33/35 terms with two terms excluded (anterior limb and normal adrenal size measurements). Greater than 80% consensus was reached on the definitions for 15 terms following the first round, with subsequent consensus achieved for the definitions of the remaining 18 terms following two additional rounds. No included term had remaining disagreement. CONCLUSION: Expert consensus produced a standardized lexicon for reporting adrenal findings at CT and MRI. The use of this consensus lexicon should improve radiology report clarity, standardize clinical and research terminology, and reduce uncertainty for referring providers when adrenal findings are present.

ACR Appropriateness Criteria® Staging of Renal Cell Carcinoma: 2022 Update.

Renal cell carcinoma is a complex group of highly heterogenous renal tumors demonstrating variable biological behavior. Pretreatment imaging of renal cell carcinoma involves accurate assessment of the primary tumor, presence of nodal, and distant metastases. CT and MRI are the key imaging modalities used in the staging of renal cell carcinoma. Important imaging features that impact treatment include tumor extension into renal sinus and perinephric fat, involvement of pelvicalyceal system, infiltration into adrenal gland, involvement of renal vein and inferior vena cava, as well as the presence of metastatic adenopathy and distant metastases. 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.

ACR Appropriateness Criteria® Acute Onset Flank Pain-Suspicion of Stone Disease (Urolithiasis).

Noncontrast CT (NCCT) is the imaging study of choice for initial evaluation of patients with acute onset of flank pain and suspicion of stone disease without known prior stone disease. NCCT can reliably characterize the location and size of an offending ureteral calculus, identify complications, and diagnose alternative etiologies of abdominal pain. Although less sensitive in the detection of stones, ultrasound may have a role in evaluating for signs of obstruction. Radiography potentially has a role, although has been shown to be less sensitive than NCCT. For patients with known disease and recurrent symptoms of urolithiasis, NCCT remains the test of choice for evaluation. In pregnancy, given radiation concerns, ultrasound is recommended as the initial modality of choice with potential role for noncontrast MRI. In scenarios where stone disease suspected and initial NCCT is inconclusive, contrast-enhanced imaging, either with MRI or CT/CT urogram may be appropriate. 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.

ACR Appropriateness Criteria® Acute Pyelonephritis: 2022 Update.

Acute pyelonephritis (APN) is a severe urinary tract infection (UTI) that has the potential to cause sepsis, shock, and death. In the majority of patients, uncomplicated APN is diagnosed clinically and is responsive to treatment with appropriate antibiotics. In patients who are high risk or when treatment is delayed, microabscesses may coalesce to form an acute renal abscess. High-risk patients include those with a prior history of pyelonephritis, lack of response to therapy for lower UTI or for APN, diabetes, anatomic or congenital abnormalities of the urinary system, infections by treatment-resistant organisms, nosocomial infection, urolithiasis, renal obstruction, prior renal surgery, advanced age, pregnancy, renal transplant recipients, and immunosuppressed or immunocompromised patients. Pregnant patients and patients with renal transplants on immunosuppression are at an elevated risk of severe complications. Imaging studies are often requested to aid with the diagnosis, identify precipitating factors, and differentiate lower UTI from renal parenchymal involvement, particularly in high-risk individuals. Imaging is usually not appropriate for the first-time presentation of suspected APN in an uncomplicated patient. The primary imaging modalities used in high-risk patients with suspected APN are CT, MRI, and ultrasound, although CT was usually not appropriate for initial imaging in a pregnant patient with no other complications. The ACR 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 in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Post-Treatment Follow-up and Active Surveillance of Clinically Localized Renal Cell Carcinoma: 2021 Update.

Renal cell carcinoma (RCC) accounts for most malignant renal tumors and is considered the most lethal of all urologic cancers. For follow-up of patients with treated or untreated RCC and those with neoplasms suspected to represent RCC, radiologic imaging is the most valuable component of surveillance, as most relapses and cases of disease progression are identified when patients are asymptomatic. Understanding the strengths and limitations of the various imaging modalities for the detection of disease, recurrence, or progression is essential when planning follow-up regimens. This document addresses the appropriate imaging examinations for asymptomatic patients who have been treated for RCC with radical or partial nephrectomy or ablative therapies. It also discusses the appropriate imaging examinations for asymptomatic patients with localized biopsy-proven or suspected RCC undergoing active surveillance. 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.

The humbling hemangioma: uncommon CT and MRI imaging features and mimickers of hepatic hemangiomas.

Cavernous hemangiomas are among the most common liver lesions encountered in abdominal imaging. While classical imaging characteristics usually aid the radiologist in confidently arriving at its diagnosis, atypical hemangiomas can prove to be difficult to distinguish from other more worrisome hepatic lesions such as metastases and hepatocellular carcinoma. Furthermore, some malignant lesions can display features that simulate hemangiomas. The radiologist must be aware of these pitfalls to make an accurate diagnosis, when possible.

Hepatocarcinogenesis: Radiology-Pathology Correlation.

In the background of chronic liver disease, hepatocellular carcinoma develops via a complex, multistep process called hepatocarcinogenesis. This article reviews the causes contributing to the process. Emphasis is made on the imaging manifestations of the pathologic changes seen at many stages of hepatocarcinogenesis, from regenerative nodules to dysplastic nodules and then to hepatocellular carcinoma.

Visceral adipose tissue in patients with COVID-19: risk stratification for severity.

PURPOSE: To assess visceral (VAT), subcutaneous (SAT), and total adipose tissue (TAT) estimates at abdominopelvic CT in COVID-19 patients with different severity, and analyze Body Mass Index (BMI) and CT estimates of fat content in patients requiring hospitalization. METHODS: In this retrospective IRB approved HIPPA compliant study, 51 patients with SARS-CoV-2 infection with abdominopelvic CT were included. Patients were stratified based on disease severity as outpatient (no hospital admission) and patients who were hospitalized. Subset of hospitalized patient required mechanical ventilation (MV). A radiologist blinded to the clinical outcome evaluated single axial slice on CT at L3 vertebral body for VATL3, SATL3, TATL3, and VAT/TATL3. These measures along with age, gender, and BMI were compared. A clinical model that included age, sex, and BMI was compared to clinical + CT model that also included VATL3 to discriminate hospitalized patients from outpatients. RESULTS: There were ten outpatients and 41 hospitalized patients. 11 hospitalized patients required MV. There were no significant differences in age and BMI between the hospitalized and outpatients (all p > 0.05). There was significantly higher VATL3 and VAT/TATL3 in hospitalized patients compared to the outpatients (all p < 0.05). Area under the curve (AUC) of the clinical + CT model was higher compared to the clinical model (AUC 0.847 versus 0.750) for identifying patients requiring hospitalization. CONCLUSION: Higher VATL3 was observed in COVID-19 patients that required hospitalization compared to the outpatients, and addition of VATL3 to the clinical model improved AUC in discriminating hospitalized from outpatients in this preliminary study.

Retrospective Assessment of the Impact of Primary Language Video Instructions on Image Quality of Abdominal MRI.

PURPOSE: To assess the impact of instructional videos in patients' primary language on abdominal MR image quality for whom English is a second language (ESL). METHODS: Twenty-nine ESL patients viewed Spanish or Mandarin Chinese instructional videos (approximately 2.5 min in duration) in the preparation room before abdominal MRI (ESL-video group). Comparison groups included 50 ESL patients who underwent MRI before video implementation (ESL-no video group) and 81 English-speaking patients who were matched for age, sex, magnet strength, and history of prior MRI with patients in the first two groups. Three radiologists independently assessed respiratory motion and image quality on turbo spin-echo T2-weighted images (T2WI) and postcontrast T1-weighted images (T1WI) using 1 to 5 Likert scales. Groups were compared using Kruskal-Wallis tests as well as generalized estimating equations (GEEs) to adjust for possible confounders. RESULTS: For T2WI respiratory motion and T2WI overall image quality, Likert scores of the ESL-no video group (mean score across readers of 2.6 ± 0.1 and 2.6 ± 0.1) were lower (all P < .001) compared with English-speaking (3.3 ± 0.2 and 3.3 ± 0.1) and ESL-video (3.2 ± 0.1 and 3.0 ± 0.2) groups. In the GEE model, mean T2WI respiratory motion (both adjusted P < .001) and T2WI overall quality (adjusted P = .03 and .11) were higher in English and ESL-video groups compared with ESL-no video group. For T1WI respiratory motion and T1WI overall image quality, Likert scores were not different between groups (P > .05), including in the GEE model (adjusted P > .05). CONCLUSION: Providing ESL patients with an instructional video in their primary language before abdominal MRI is an effective intervention to improve imaging quality.

Impact on Participants of Family Connect, a Novel Program Linking COVID-19 Inpatients' Families With the Frontline Providers.

PURPOSE: With clinical volumes decreased, radiologists volunteered to participate virtually in daily clinical rounds and provide communication between frontline physicians and patients with coronavirus disease 2019 (COVID-19) and their families affected by restrictive hospital visitation policies. The purpose of this survey-based assessment was to demonstrate the beneficial effects of radiologist engagement during this pandemic and potentially in future crises if needed. METHODS: After the program's completion, a survey consisting of 13 multiple-choice and open-ended questions was distributed to the 69 radiologists who volunteered for a minimum of 7 days. The survey focused on how the experience would change future practice, the nature of interaction with medical students, and the motivation for volunteering. The electronic medical record system identified the patients who tested positive for or were suspected of having COVID-19 and the number of notes documenting family communication. RESULTS: In all, 69 radiologists signed or cosigned 7,027 notes. Of the 69 radiologists, 60 (87.0%) responded to the survey. All found the experience increased their understanding of COVID-19 and its effect on the health care system. Overall, 59.6% agreed that participation would result in future change in communication with patients and their families. Nearly all (98.1%) who worked with medical students agreed that their experience with medical students was rewarding. A majority (82.7%) chose to participate as a way to provide service to the patient population. CONCLUSION: This program provided support to frontline inpatient teams while also positively affecting the radiologist participants. If a similar situation arises in the future, this communication tool could be redeployed, especially with the collaboration of medical students.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings.

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.