Thymic Imaging Pitfalls and Strategies for Optimized Diagnosis.

Thymic imaging is challenging because the imaging appearance of a variety of benign and malignant thymic conditions are similar. CT is the most commonly used modality for mediastinal imaging, while MRI and fluorine 18 fluorodeoxyglucose (FDG) PET/CT are helpful when they are tailored to the correct indication. Each of these imaging modalities has limitations and technical pitfalls that may lead to an incorrect diagnosis and mismanagement. CT may not be sufficient for the characterization of cystic thymic processes and differentiation between thymic hyperplasia and thymic tumors. MRI can be used to overcome these limitations but is subject to other potential pitfalls such as an equivocal decrease in signal intensity at chemical shift imaging, size limitations, unusual signal intensity for cysts, subtraction artifacts, pseudonodularity on T2-weighted MR images, early imaging misinterpretation, flow and spatial resolution issues hampering assessment of local invasion, and the overlap of apparent diffusion coefficients between malignant and benign thymic entities. FDG PET/CT is not routinely indicated due to some overlap in FDG uptake between thymomas and benign thymic processes. However, it is useful for staging and follow-up of aggressive tumors (eg, thymic carcinoma), particularly for detection of occult metastatic disease. Pitfalls in imaging after treatment of thymic malignancies relate to technical challenges such as postthymectomy sternotomy streak metal artifacts, differentiation of postsurgical thymic bed changes from tumor recurrence, or human error with typical "blind spots" for identification of metastatic disease. Understanding these pitfalls enables appropriate selection of imaging modalities, improves diagnostic accuracy, and guides patient treatment. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Imaging of Malignant Pleural, Pericardial, and Peritoneal Mesothelioma.

Malignant mesothelioma is a rare tumor arising from the mesothelial cells that line the pleura, pericardium, peritoneum, and tunica vaginalis. Imaging plays a primary role in the diagnosis, staging, and management of malignant mesothelioma. Multimodality imaging, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT), is used in a variety of scenarios, including diagnosis, guidance for tissue sampling, staging, and reassessment of disease after therapy. CT is the primary imaging modality used in staging. MRI has superior contrast resolution compared with CT and can add value in terms of determining surgical resectability in equivocal cases. MRI can further assess the degree of local invasion, particularly into the mediastinum, chest wall, and diaphragm, for malignant pleural and pericardial mesotheliomas. FDG PET/CT plays a role in the diagnosis and staging of malignant pleural mesothelioma (MPM) and has been shown to be more accurate than CT, MRI, and PET alone in the staging of malignant pleural mesothelioma. PET/CT can also be used to target lesions for biopsy and to assess prognosis, treatment response, and tumor recurrence.

Imaging Follow-Up of Nonsurgical Therapies for Lung Cancer: AJR Expert Panel Narrative Review.

Lung cancer continues to be the most common cause of cancer-related death worldwide. In the past decade, with the implementation of lung cancer screening programs and advances in surgical and nonsurgical therapies, the survival of patients with lung cancer has increased, as has the number of imaging studies that these patients undergo. However, most patients with lung cancer do not undergo surgical re-section, because they have comorbid disease or lung cancer in an advanced stage at diagnosis. Nonsurgical therapies have continued to evolve with a growing range of systemic and targeted therapies, and there has been an associated evolution in the imaging findings encountered at follow-up examinations after such therapies (e.g., with respect to posttreatment changes, treatment complications, and recurrent tumor). This AJR Expert Panel Narrative Review describes the current status of nonsurgical therapies for lung cancer and their expected and unexpected imaging manifestations. The goal is to provide guidance to radiologists regarding imaging assessment after such therapies, focusing mainly on non-small cell lung cancer. Covered therapies include systemic therapy (conventional chemotherapy, targeted therapy, and immunotherapy), radiotherapy, and thermal ablation.

Imaging of Immune Checkpoint Inhibitor Immunotherapy for Non-Small Cell Lung Cancer.

The normal immune system identifies and eliminates precancerous and cancerous cells. However, tumors can develop immune resistance mechanisms, one of which involves the exploitation of pathways, termed immune checkpoints, that normally suppress T-cell function. The goal of immune checkpoint inhibitor (ICI) immunotherapy is to boost T-cell-mediated immunity to mount a more effective attack on cancer cells. ICIs have changed the treatment landscape of advanced non-small cell lung cancer (NSCLC), and numerous ICIs have now been approved as first-line treatments for NSCLC by the U.S. Food and Drug Administration. ICIs can cause atypical response patterns such as pseudoprogression, whereby the tumor burden initially increases but then decreases. Therefore, response criteria have been developed specifically for patients receiving immunotherapy. Because ICIs activate the immune system, they can lead to inflammatory side effects, termed immune-related adverse events (irAEs). Usually occurring within weeks to months after the start of therapy, irAEs range from asymptomatic abnormal laboratory results to life-threatening conditions such as encephalitis, pneumonitis, myocarditis, hepatitis, and colitis. It is important to be aware of the imaging appearances of the various irAEs to avoid misinterpreting them as metastatic disease, progressive disease, or infection. The basic principles of ICI therapy; indications for ICI therapy in the setting of NSCLC; response assessment and atypical response patterns of ICI therapy, as compared with conventional chemotherapy; and the spectrum of irAEs seen at imaging are reviewed. An invited commentary by Nishino is available online. ©RSNA, 2022.

Imaging Primer on Chimeric Antigen Receptor T-Cell Therapy for Radiologists.

Chimeric antigen receptor (CAR) T-cell therapy is a recently approved breakthrough treatment that has become a new paradigm in treatment of recurrent or refractory B-cell lymphomas and pediatric or adult acute lymphoid leukemia. CAR T cells are a type of cellular immunotherapy that artificially enhances T cells to boost eradication of malignancy through activation of the native immune system. The CAR construct is a synthetically created functional cell receptor grafted onto previously harvested patient T cells, which bind to preselected tumor-associated antigens and thereby activate host immune signaling cascades to attack tumor cells. Advantages include a single treatment episode of 2-3 weeks and durable disease elimination, with remission rates of over 80%. Responses to therapy are more rapid than with conventional chemotherapy or immunotherapy, with intervening short-interval edema. CAR T-cell administration is associated with therapy-related toxic effects in a large percentage of patients, notably cytokine release syndrome, immune effect cell-associated neurotoxicity syndrome, and infections related to immunosuppression. Knowledge of the expected evolution of therapy response and potential adverse events in CAR T-cell therapy and correlation with the timeline of treatment are important to optimize patient care. Some toxic effects are radiologically evident, and familiarity with their imaging spectrum is key to avoiding misinterpretation. Other clinical toxic effects may be occult at imaging and are diagnosed on the basis of clinical assessment. Future directions for CAR T-cell therapy include new indications and expanded tumor targets, along with novel ways to capture T-cell activation with imaging. An invited commentary by Ramaiya and Smith is available online. Online supplemental material is available for this article. ©RSNA, 2022.

Imaging of Lung Cancer Staging.

Lung cancer is a leading cause of cancer-related mortality worldwide. Imaging is integral in accurate clinical staging to stratify patients into groups to predict survival and determine treatment. The eighth edition of the tumor, node, and metastasis (TNM-8) staging system proposed by the International Association for the Study of Lung Cancer in 2016, accepted by both the Union for International Cancer Control and the American Joint Committee on Cancer, is the current standard method of staging lung cancer. This single TNM staging is used for all histologic subtypes of lung cancer, including nonsmall cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoid tumor, and it addresses both clinical and pathologic staging. Familiarity with the strengths and limitations of imaging modalities used in staging, the nuances of TNM-8, its correct nomenclature, and potential pitfalls are important to optimize patient care. In this article, we discuss the role of computed tomography (CT) and positron emission tomography/CT in lung cancer staging, as well as current imaging recommendations pertaining to TNM-8.

Imaging of the mediastinum: Mimics of malignancy.

In the imaging of the mediastinum, benign lesions mimicking malignancy constitute potential pitfalls in interpretation. Localization and characteristic imaging features are key to narrow the differential diagnosis and avoid potential pitfalls in interpretation. Based on certain anatomic landmarks, the mediastinal compartment model enables accurate localization. Depending on the anatomic origin, mediastinal lesions can have various etiologies. The anatomic location and structures contained within each mediastinal compartment are helpful in generating the differential diagnoses. These structures include thyroid, thymus, parathyroid, lymph nodes, pericardium, embryogenic remnants, and parts of the enteric tracts, vessels, and nerves. Imaging characteristics on computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography-computed tomography (PET/CT), including attenuation (fluid, fat, calcification), contrast enhancement, and metabolic activity, aid in narrowing the differential diagnoses. Understanding the roles and limitations of various imaging modalities is helpful in the evaluation of mediastinal masses. In this review, we present potential pitfalls in the imaging of mediastinal lesions with emphasis on the mimics of malignancy.

In Situ Pulmonary Artery Thrombosis: Unrecognized Complication of Radiation Therapy.

OBJECTIVE. The purpose of this study is to evaluate the CT and clinical characteristics of in situ pulmonary artery thrombosis (PAT) associated with radiation therapy (RT). MATERIALS AND METHODS. A database search was performed to identify patients who had PAT develop after receiving RT. The CT characteristics of PAT, including the number, location, and appearance of filling defects as well as the presence of associated lung fibrosis, were recorded. The terminology (in situ thrombosis vs acute or chronic pulmonary embolism) used by the interpreting radiologists to describe PAT, the time between the completion of RT and development of PAT, the change in the size of the PAT, and observation of any new thrombi and emboli on follow-up imaging, were also recorded. RESULTS. Of the 27 patients in the study cohort, 22 (81%) had lung cancer and five (19%) had mesothelioma. Most PATs were solitary (93%) and nonocclusive (96%) and formed an obtuse angle to the vessel wall (89%). All PATs were eccentric within the involved PA and were located within the RT volume. The time from completion of RT to initial diagnosis of PAT on CT ranged from 53 to 2522 days (mean, 675 days). Radiation-induced lung fibrosis was present in the ipsilateral lung in all patients. No evidence of additional PA filling defects that suggested embolization were seen on follow-up images of any of the patients, even those who did not receive anticoagulant therapy. CONCLUSION. In situ PAT associated with RT, which to our knowledge has not previously been described in the English literature, has imaging features different from those of acute pulmonary emboli and does not appear to embolize. Radiologist awareness of PAT can facilitate accurate diagnosis and impact management.

Leukemic Involvement in the Thorax.

Leukemias are malignancies in which abnormal white blood cells are produced in the bone marrow, resulting in compromise of normal bone marrow hematopoiesis and subsequent cytopenias. Leukemias are classified as myeloid or lymphoid depending on the type of abnormal cells produced and as acute or chronic according to cellular maturity. The four major types of leukemia are acute myeloid leukemia, chronic myeloid leukemia, acute lymphoblastic leukemia, and chronic lymphocytic leukemia. Clinical manifestations are due to either bone marrow suppression (anemia, thrombocytopenia, or neutropenia) or leukemic organ infiltration. Imaging manifestations of leukemia in the thorax are myriad. While lymphadenopathy is the most common manifestation of intrathoracic leukemia, leukemia may also involve the lungs, pleura, heart, and bones and soft tissues. Myeloid sarcomas occur in 5%-7% of patients with acute myeloid leukemia and represent masses of myeloid blast cells in an extramedullary location. ©RSNA, 2019.

Revisions to the TNM Staging of Lung Cancer: Rationale, Significance, and Clinical Application.

Lung cancer remains the leading cause of cancer-related mortality worldwide. To formulate effective treatment strategies and optimize patient outcomes, accurate staging is essential. Lung cancer staging has traditionally relied on a TNM staging system, for which the International Association for the Study of Lung Cancer (IASLC) has recently proposed changes. The revised classification for this eighth edition of the TNM staging system (TNM-8) is based on detailed analysis of a new large international database of lung cancer cases assembled by the IASLC for the purposes of this project. Fundamental changes incorporated into TNM-8 include (a) modifications to the T classification on the basis of 1-cm increments in tumor size; (b) grouping of lung cancers that result in partial or complete lung atelectasis or pneumonitis; (c) grouping of tumors with involvement of a main bronchus irrespective of distance from the carina; (d) reassignment of diaphragmatic invasion in terms of T classification; (e) elimination of mediastinal pleural invasion from the T classification; and (f) subdivision of the M classification into different descriptors on the basis of the number and site of extrathoracic metastases. In response to these revisions, established stage groups have been modified, and others have been created. In addition, recommendations for classifying patterns of disease that result in multiple sites of pulmonary involvement, including multiple primary lung cancers, lung cancers with separate tumor nodules, multiple ground-glass/lepidic lesions, and consolidation, as well as recommendations for lesion measurement, are addressed. Understanding the key revisions introduced in TNM-8 allows radiologists to accurately stage patients with lung cancer and optimize therapy. ©RSNA, 2018.

IASLC/ITMIG Staging System and Lymph Node Map for Thymic Epithelial Neoplasms.

Thymic epithelial neoplasms are rare malignancies that arise from the thymus and include thymoma, thymic carcinoma, and thymic neuroendocrine tumors. At least 15 different stage classifications have been proposed for thymic epithelial neoplasms and used to varying degrees in clinical practice, many of which have been constructed from small groups of patients. Traditionally, the Masaoka and Masaoka-Koga staging systems have been the schemes most commonly employed, and the latter has been recommended for use by the International Thymic Malignancy Interest Group (ITMIG). An official, consistent stage classification system has recently been recognized by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC), which are responsible for defining stage classifications for neoplasms. To establish this stage classification system, the International Association for the Study of Lung Cancer (IASLC) and ITMIG amassed a large retrospective database and evaluated this group of cases to develop proposals for the eighth edition of the stage classification manuals. For this endeavor, IASLC provided funding and statistical analysis and ITMIG provided the involvement of the clinicians and researchers actively participating in the study of thymic epithelial neoplasms. To accomplish this, a Thymic Domain of the Staging and Prognostic Factors Committee (TD-SPFC) was established to formulate the rationale, methodology, and definitions of this tumor-node-metastasis (TNM) staging system, which is presented in this article. © RSNA, 2017.

ITMIG Classification of Mediastinal Compartments and Multidisciplinary Approach to Mediastinal Masses.

Division of the mediastinum into specific compartments is beneficial for a number of reasons, including generation of a focused differential diagnosis for mediastinal masses identified on imaging examinations, assistance in planning for biopsies and surgical procedures, and facilitation of communication between clinicians in a multidisciplinary setting. Several classification schemes for the mediastinum have been created and used to varying degrees in clinical practice. Most radiology classifications have been based on arbitrary landmarks outlined on the lateral chest radiograph. A new scheme based on cross-sectional imaging, principally multidetector computed tomography (CT), has been developed by the International Thymic Malignancy Interest Group (ITMIG) and accepted as a new standard. This clinical division scheme defines unique prevascular, visceral, and paravertebral compartments based on boundaries delineated by specific anatomic structures at multidetector CT. This new definition plays an important role in identification and characterization of mediastinal abnormalities, which, although uncommon and encompassing a wide variety of entities, can often be diagnosed with confidence based on location and imaging features alone. In other scenarios, a diagnosis may be suggested when radiologic features are combined with specific clinical information. In this article, the authors present the new multidetector CT-based classification of mediastinal compartments introduced by ITMIG and a structured approach to imaging evaluation of mediastinal abnormalities. ©RSNA, 2017.

Correlation between FDG/PET, histology, characteristics, and survival in 332 patients with chronic lymphoid leukemia.

Richter syndrome (RS) is associated with poor outcome. The prognosis of patients with histologically aggressive chronic lymphocytic leukemia (CLL), or HAC, has not been studied. We aimed to correlate 2-deoxy-2-[(18)F]fluoroglucose/positron emission tomography (FDG/PET) data, histological diagnosis, clinical characteristics, and survival in patients with CLL. A total of 332 patients with CLL were histologically classified as: 95 RS, 117 HAC, and 120 histologically indolent CLL (HIC). HAC and RS patients had higher maximum standardized uptake value (SUVmax), more frequent constitutional symptoms, poorer performance status (PS), lower hemoglobin and platelets, and higher lactate dehydrogenase and ß-2-microglobulin. An SUVmax ≥10 strongly correlated with mortality (overall survival [OS], 56.7 vs 6.9 months in patients with SUVmax <10 vs ≥10). Survival of patients with RS and HAC was similar among patients with SUVmax <10 or ≥10. SUVmax ≥10, PS ≥2, bulky disease, and age ≥65 were independently associated with shorter OS. In patients undergoing both fine-needle aspiration and biopsy, the former proved diagnostically inadequate in 23%, 29%, and 53% of HIC, HAC, and RS, respectively. FDG/PET is a useful diagnostic tool in patients with CLL and suspected transformation. Patients with HAC show different characteristics and worse prognosis compared with those with HIC. Patients with different CLL phases, but similar SUVmax have similar outcome. Tissue biopsy should be preferred for diagnosing RS.

Pulmonary Legionellosis in Oncologic Patients: Findings on Chest CT.

OBJECTIVE: The purpose of this study was to report the computed tomography (CT) findings of non-pneumophila Legionella pneumonia and to compare these CT findings to those caused by Legionella pneumophila in oncologic patients. METHODS: Chest CT scans of 34 oncologic patients with culture-proven Legionella infection (16 L. pneumophila and 18 non-pneumophila Legionella) were retrospectively reviewed. Radiologic checkpoints included consolidation, ground-glass opacities, cavitation, nodules, tree-in-bud opacities, septal thickening, pleural effusions, and adenopathy, as well as the halo, reversed halo, and bulging fissure signs. RESULTS: The most common imaging feature of Legionella pneumonia was consolidation, seen in 94% of patients. Ground-glass opacities were the next most common abnormality. The halo sign was present in 26% of patients, in both immunocompetent and immunosuppressed hosts. Most features occurred with similar frequency between L. pneumophila and non-pneumophila Legionella. CONCLUSIONS: Findings in L. pneumophila pneumonia and non-pneumophila Legionella pneumonia are similar but nonspecific. Airspace consolidation is almost always present; the halo sign is not uncommon.

Overdiagnosis of Pulmonary Embolism by Pulmonary CT Angiography.

OBJECTIVE: The purpose of this study is to evaluate the rate of overdiagnosis of pulmonary embolism (PE) by pulmonary CT angiography (CTA) in a tertiary-care university hospital. MATERIALS AND METHODS: This study is a retrospective review of all pulmonary CTA examinations performed in a tertiary-care university hospital over a 12-month period. Studies originally reported as positive for PE were retrospectively reinterpreted by three subspecialty chest radiologists with more than 10 years' experience. A pulmonary CTA was considered negative for PE when all three chest radiologists were in agreement that the pulmonary CTA study was negative for PE. The location and potential causes for PE overdiagnosis were recorded. RESULTS: A total of 937 pulmonary CTA studies were performed over the study period. PE was diagnosed in the initial report in 174 of these cases (18.6%). There was discordance between the chest radiologists and the original radiologist in 45 of 174 (25.9%) cases. Discordance occurred more often where the original reported PE was solitary (46.2% of reported solitary PEs were considered negative on retrospective review) and located in a segmental or subsegmental pulmonary artery (26.8% of segmental and 59.4% of subsegmental PE diagnoses were considered negative on retrospective review). The most common cause of diagnostic difficulty was breathing motion artifact, followed by beam-hardening artifact. CONCLUSION: In routine clinical practice, PEs diagnosed by pulmonary CTA are frequently overdiagnosed, when compared with the consensus opinion of a panel of expert chest radiologists. Improvements in the quality of pulmonary CTA examination and increased familiarity with potential diagnostic pitfalls in pulmonary CTA are recommended to minimize misdiagnosis of PE.

Small cell lung carcinoma: staging, imaging, and treatment considerations.

Small cell lung carcinoma (SCLC) is the most common primary pulmonary neuroendocrine malignancy and is characterized by a rapid doubling time and high growth fraction. Approximately 60%-70% of patients present with metastatic disease at the time of diagnosis, and their prognosis is poor. However, improved survival has been demonstrated when SCLC is diagnosed early and specific treatment strategies are used. A modified version of the Veterans Administration Lung Cancer Study Group (VALSG) staging system has traditionally been used to categorize SCLC as limited-stage or extensive-stage disease to guide therapy. However, the International Association for the Study of Lung Cancer has recommended that the current seventh edition of the American Joint Committee on Cancer tumor-node-metastasis staging system for lung cancer replace the VALSG system for staging of SCLC. Appropriate staging and patient management require knowledge of imaging manifestations of SCLC across multiple imaging modalities, the strengths and weaknesses of specific examinations, the correlation of these findings with the staging criteria used in clinical practice, and the impact of appropriate staging on patient treatment and survival. Computed tomography (CT) is primarily used to evaluate the primary tumor and the extent of intrathoracic disease. In recent years, however, 2-[fluorine-18]fluoro-2-deoxy-d-glucose positron emission tomography/CT has proved to be more accurate than conventional imaging in the staging of SCLC and can be used to guide therapy and assess treatment response.

Update in the evaluation of the solitary pulmonary nodule.

A solitary pulmonary nodule (SPN) is defined as a round opacity that is smaller than 3 cm. It may be solid or subsolid in attenuation. Semisolid nodules may have purely ground-glass attenuation or be partly solid (mixed solid and ground-glass attenuation). The widespread use of multidetector computed tomography (CT) has increased the detection of SPNs. Although clinical assessment of patients' risk factors for malignancy--such as age, smoking history, and history of malignancy--is important to determine appropriate treatment, in the recently published Fleischner guidelines for subsolid nodules, smoking history does not factor into their recommendations for management because there is an increasing incidence of lung adenocarcinoma in younger and nonsmoking patients. At imaging evaluation, obtaining prior chest radiographs or CT images is useful to assess nodule growth. Further imaging evaluation, including CT enhancement studies and positron emission tomography (PET), helps determine the malignant potential of solid SPNs. For subsolid nodules, initial follow-up CT is performed at 3 months to determine persistence, because lesions with an infectious or inflammatory cause can resolve in the interval. CT enhancement studies are not applicable for subsolid nodules, and PET is of limited utility because of the low metabolic activity of these lesions. Because of the likelihood that persistent subsolid nodules represent adenocarcinoma with indolent growth, serial imaging reassessment for a minimum of 3 years and/or obtaining tissue samples for histologic analysis are recommended. In the follow-up of subsolid SPNs, imaging features that indicate an increased risk for malignancy include an increase in size, an increase in attenuation, and development of a solid component.

Abdominal and pelvic complications of nonoperative oncologic therapy.

Oncologic patients are treated with a combination of chemotherapy, radiation therapy, and surgery. Advances in therapeutic options have greatly improved the survival of patients with cancer. Examples of these advances are newer chemotherapeutic agents that target the cell receptors and advanced radiation therapy delivery systems. It is imperative that radiologists be aware of the variety of imaging findings seen after therapy in patients with cancer. Complications may occur with classic cytotoxic therapies (eg, 5-fluorouracil), usually at higher or prolonged doses or when administered to radiosensitive areas. Newer targeted systemic agents, such as bevacizumab and imatinib, have associated characteristic toxicities because their effects on cells do not depend on dose. Radiation may induce early and late effects in local normal tissues that may be seen at imaging. Imaging findings after chemotherapy include fatty liver, pseudocirrhosis, hepatic veno-occlusive disease, and splenic rupture. Complications of radiation therapy include large and small bowel strictures and radiation-induced hepatitis and tumors. Awareness of the various therapeutic options and knowledge of the spectrum of posttherapeutic complications allows radiologists to provide a comprehensive report that may impact patient management.

Differentiating pericardial recesses from mediastinal adenopathy: potential pitfalls in oncological imaging.

In oncological imaging, staging with computed tomography (CT) is widely used to determine treatment. Misinterpretation of fluid in pericardial recesses as mediastinal adenopathy can lead to inaccurate clinical staging and inappropriate management. In this review, we describe normal pericardial anatomy and illustrate imaging features to differentiate fluid in pericardial sinuses and recesses from mediastinal adenopathy.

Drug-induced Lung Disease in the Oncology Patient: From Cytotoxic Agents to Immunotherapy.

Drug-induced lung disease is commonly encountered, especially in the oncology setting. Diagnosis is challenging because clinical and radiologic findings are nonspecific, often overlapping with other lung pathologies in these patients due to underlying neoplasia, infection, or other treatment effects such as radiotherapy. Furthermore, oncology patients often receive multiple antineoplastic agents concurrently, and virtually every agent has an association with lung injury. In this article, we will review a variety of antineoplastic agents that are associated with drug-induced injury and discuss incidence, their typical timing of onset, and imaging features.