Social Determinants of Health in Imaging-based Cancer Screening: A Case-based Primer with Strategies for Care Improvement.

Health disparities, preventable differences in the burden of disease and disease outcomes often experienced by socially disadvantaged populations, can be found in nearly all areas of radiology, including emergency radiology, neuroradiology, nuclear medicine, image-guided interventions, and imaging-based cancer screening. Disparities in imaging-based cancer screening are especially noteworthy given the far-reaching population health impact. The social determinants of health (SDoH) play an important role in disparities in cancer screening and outcomes. Through improved understanding of how SDoH can drive differences in health outcomes in radiology, radiologists can effectively provide patient-centered, high-quality, and equitable care. Radiologists and radiology practices can become active partners in efforts to assist patients along their imaging journey and overcome existing barriers to equitable cancer screening care for traditionally marginalized populations. As radiology exists at the intersection of diagnostic imaging, image-guided diagnostic intervention, and image-guided treatment, radiologists are uniquely positioned to design these strategies. Cost-effective and socially conscious strategies that address barriers to equitable care can improve both public health and equitable health outcomes. Potential strategies include championing supportive health policy, reducing out-of-pocket costs, increasing price transparency, improving education and outreach efforts, ensuring that appropriate language translation services are available, providing individualized assistance with appointment scheduling, and offering transportation assistance and childcare. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

The "Speckle Sign" in the Diagnosis of Posterior Compartment Endometriosis.

OBJECTIVE: To determine usefulness of the "speckle sign" in the diagnosis of deep invasive endometriosis. MATERIALS AND METHODS: This HIPAA-compliant, institutional review board-approved retrospective study with informed consent waived included 25 women (mean age 20-69 years) with histopathologically confirmed posterior cul-de-sac endometriosis between 2013 and 2018. Transvaginal ultrasound exams of these patients were reviewed by 2 expert radiologists searching for the "speckle sign," defined as irregular obliteration of the posterior cul-de-sac and bright (hyperechoic) internal echoes. The frequency of additional findings such as "kissing ovaries," endometriomas in the adnexa, bowel tethering in the posterior pelvic compartment, retroflexed uterus, adenomyosis, and pelvic free fluid were also analyzed. Data regarding clinical features, histopathologic findings and management were collected through a review of the medical record. RESULTS: Reader one identified posterior compartment endometriosis in 20/25 patients, and reader two in 22/25 patients, with 96% agreement. Adnexal endometriomas were found in 21/25 patients for both readers (k = 0.70) and were bilateral in 23% of patients. The ovaries were adherent to each other in the midline ("kissing ovaries") in 50% of patients; the bowel was tethered anteriorly in 20%; the presence of adenomyosis was seen in about 27%, and a retroflexed uterus was seen in 24% of patients. CONCLUSIONS: The speckle sign could be helpful in making the diagnosis of posterior compartment endometriosis, and the sign is often found in conjunction with other imaging features of endometriosis.

Use of ring-enhancement and focal necrosis to differentiate pancreatic adenosquamous carcinoma from pancreatic ductal adenocarcinoma on CT and MRI.

PURPOSE: To assess the ability of the ring-enhancing sign and focal necrosis to diagnose adenosquamous carcinoma (ASqC), a variant of pancreatic ductal adenocarcinoma (PDAC), on MRI and CT. METHODS: The following features of ASqC and conventional PDAC were evaluated on CT and MRI: tumor size, location, margins, borders (non-exophytic, exophytic), and T1 signal intensity. Two readers, blinded to histopathology results, rated their confidence in detecting ring-enhancement and focal necrosis (FN) on a 5-point Likert scale on both MRI and CT. Inter-reader agreement was assessed with Cohen's kappa (k). RESULTS: A total of 24 patients were included: eight patients with treatment naïve and histologically proven ASqC (six women, mean age: 63, range: 40-75) and 16 patients with PDAC (eight women, mean age: 67, range: 47-83). Statistically significant differences between ASqC and PDAC were seen in tumor size, location, presence of FN, and ring enhancement (p = 0.01-0.037). The readers were more confident in depicting the key differentiating feature ring-enhancement in ASqC on MRI compared to CT (confidence 1.71 ± 0.49 vs. 0.88 ± 0.35, p = 0.017) with moderate inter-reader agreement (k = 0.46 and 0.5, respectively). FN showed substantial inter-reader agreement on MR and moderate agreement on CT (k = 0.67 and 0.5, respectively). CONCLUSIONS: Compared to CT, MRI depicts ring-enhancement in ASqC with greater reader confidence and FN in ASqC with higher inter-reader agreement. The concurrent presence of these two imaging features should raise high suspicion for ASqC.

Imaging of gastrointestinal endometriosis: what the radiologist should know.

Deep invasive gastrointestinal endometriosis (DIGIE) is a frequent and severe presentation of endometriosis. Although most cases invade the rectosigmoid colon, DIGIE can involve any portion of the gastrointestinal tract from the stomach to the rectum, and is commonly multifocal and multicentric. Although histopathologic confirmation with surgery remains the gold standard for diagnosis, ultrasound (US) and magnetic resonance imaging (MRI) are the key non-invasive imaging modalities for initial assessment. US may be preferred as a screening study because of its easy availability and low-cost. Pelvic MRI and magnetic resonance enterography (MRE) provide substantial advantages for disease mapping in the pre-operative period, particularly in extensive bowel endometriosis. Although medical management of DIGIE with hormonal therapy can help control symptoms, disease course can be relentless and require surgical intervention. Surgical options depend on, the location; length; depth; circumference; multicentric or multifocal disease. With procedures including simple excision, fulguration of superficial lesions, shaving, disc excision, and segmental resection. A successful treatment outcome is largely dependent on good communication between the treating surgeon and the radiologist, who can provide vital information for effective surgical planning by reporting the key elements that we elaborate upon in this paper.

Multimodality imaging and clinicopathologic assessment of abdominal wall endometriosis: knocking down the enigma.

PURPOSE: To review the clinical, multimodality imaging, and pathologic characteristics of abdominal wall endometriosis (AWE), the most common type of extra-pelvic endometriosis. METHODS: 116 women with histopathologically confirmed extragenital endometriosis diagnosed between 2/2014 and 6/2017 were evaluated retrospectively. Of these, 26 (22.4%) were found to have AWE and 18/26 met inclusion criteria for imaging. Available imaging studies were re-reviewed by two expert radiologists. Data regarding clinical features, histopathologic findings, and management were collected through medical record review. RESULTS: 21 pathology-proven AWE deposits were identified by imaging in 18 women [mean age at diagnosis of 38.5 years (range 31-48)]. Prior C-section was present in 15/18 (83.3%) and pelvic endometriosis in 3/18 (16.7%) patients. Patients presented with abdominal pain in 14/18 (77.8%) cases, which was cyclical in 8/14; palpable mass in 12/18 (66.7%); fluid discharge in 2/18 (11.1%); and local skin discoloration in 2/18 (11.1%). Of the 21 lesions, 15 were evaluated with US, 10 with CT, and 5 with MRI. Mean lesion dimensions were 2.5 × 2.2 × 2.6 cm, and deposits were predominantly located at midline or left hemiabdomen [22/30 (73.3%)], were either stellate [15/30 (50%)] or round [15/30 (50%)] in shape, had ill-defined margins [21/30 (70%)], were heterogenous in appearance [27/30 (90%)], and involved both deep and superficial abdominal wall layers [17/30 (56.7%)]. On US, lesions were mainly isoechoic/hyperechoic [7/15 (46.7%)], and scarcely vascular [8/15 (53.3%)] with a peripheral vascular pattern [8/13 (61.5%)]. On CT, AWEs were hypervascular and homogeneous [8/10 (80%)], superiorly located to scar tissue, and on MRI lesions appeared hyperintense [4/5 (80%)] to muscle with T2 cystic and T1 hemorrhagic foci [4/5 (80%)]. In 23/27 (85.1%) original reports, there was at least one known mass prior to imaging; AWE was correctly diagnosed in only 7/23 (30.4%) cases. In those with no prior knowledge of a mass, the lesion was detected in 3/4 (75%), but AWE was only diagnosed in a single case. Median time between onset of symptoms and histopathology was 24.41 moths (IQR 15.18-47.33). CONCLUSIONS: AWE is a challenging clinical entity frequently diagnosed with a significant delay and easily misinterpreted despite multimodality imaging. Familiarity with its radiologic features holds the potential for positively impacting diagnosis.

Pelvic MRI in the diagnosis and staging of pelvic endometriosis: added value of structured reporting and expertise.

PURPOSE: To compare the diagnostic characteristics of routine-read (RR), structured-reported read (SR), and structured expert-read pelvic (SER) MRI for staging of pelvic endometriosis in a tertiary care academic center. METHODS: Of 530 patients with endometriosis (2013-2018), 59/530 (11.1%) were staged surgically and underwent pelvic MRI. Radiology reports were considered RR; MRI studies were independently reassessed by SR and SER. Involvement was recorded by compartment [anterior (AC), middle (MC), posterior (PC), adnexal (AX), and other (OC)]. Diagnostic discrepancy between review methods was assessed with McNemar's test. Interobserver agreement was assessed using Cohen's unweighted kappa. RESULTS: Of 295 compartments in 59 women (mean age = 38.8 years; range 20-69), 147/295 (49.8%) had confirmed endometriosis. Overall sensitivity: RR = 42.9%; SR = 86.4%; SER = 74.2%. SR's increased sensitivity was significant for PC (p < 0.001), MC (p < 0.001), AC (p = 0.001), AX (p = 0.038). Higher sensitivity by SER was significant for PC (p < 0.001), MC (p = 0.004) and AC (p < 0.001), but not AX (p > 0.05). Overall specificity: RR = 95.3%; SR = 45.9%; SER = 81.8%. SER specificity was no different than RR for PC or AX (p > 0.5). RR sensitivity relied heavily on detection of AX involvement, whereas SR and SER showed additional sites of disease while maintaining comparable specificity for SER. Overall agreement between SR and SER was fair [k = 0.342 (95% CI 0.25, 0.44)]. CONCLUSIONS: Even at a tertiary care academic center, SER outperforms both SR and RR in the assessment of pelvic endometriosis. Although lack of expertise may negatively impact specificity, use of structured reporting is significantly more sensitive than RR. Therefore, its use can be of assistance in surgical planning and patient counseling.

DWI of Pancreatic Ductal Adenocarcinoma: A Pilot Study to Estimate the Correlation With Metastatic Disease Potential and Overall Survival.

OBJECTIVE: The purpose of this study is to analyze the relationship between the apparent diffusion coefficient (ADC) of pancreatic ductal adenocarcinoma (PDAC) and the presence or development of metastasis and overall survival (OS). MATERIALS AND METHODS: Of 290 consecutive patients with histopathologically proven PDAC from January 2013 to December 2014, staging DWI was performed for 124 patients. Image quality was adequate in 112 studies. Sixty-five patients were treatment naïve, but 17 of the 65 were excluded because of the presence of other associated pancreatic pathologic abnormalities. Data for the remaining 48 patients (24 men and 24 women; median age, 65.5 years; interquartile range, 56-77 years) were obtained during a 4-year follow-up period (mean [± SD], 397 ± 415.1 days). The correlation between ADC and the presence or development of metastasis was assessed using descriptive statistics. OS was determined and mortality analysis was performed using Pearson correlation and Kaplan-Meier curves. RESULTS: Of 48 patients, 10 had metastases at staging MRI, and 12 later developed metastatic disease. Among the latter, the mean time from staging MRI to metastasis was 258 ± 274.1 days. Most (86%) metastases were hepatic (n = 19). During the follow-up period, the remaining 26 patients (54%) never developed metastases. Patients with metastatic disease (n = 22) had significantly lower mean ADCs than did those without metastases (1.27 × 10-3 vs 1.43 × 10-3 mm2/s; p = 0.047). The ADC of PDAC had a positive correlation with survival: patients with PDAC with lower ADCs (< 1.36 × 10-3 mm2/s) had significantly worse 4-year OS rates than did patients with higher ADC values (p = 0.036). CONCLUSION: Pretreatment ADC values of PDAC may be significantly lower in patients who have or will develop metastatic disease and may correlate with worse OS.

Structured versus narrative reporting of pelvic MRI in perianal fistulizing disease: impact on clarity, completeness, and surgical planning.

OBJECTIVE: To evaluate clarity, completeness, and impact on surgical planning of MRI reporting of perianal fistulizing disease using a structured disease-specific template versus narrative reporting for planning of disease treatment by colorectal surgeons. MATERIALS AND METHODS: In this HIPAA-compliant, IRB-approved study with waiver of informed consent, a structured reporting template for perianal fistulizing disease MRIs was developed based on collaboration between colorectal surgeons and abdominal radiologists. The study population included 45 consecutive patients who underwent pelvic MRI for perianal fistulizing disease prior to implementation of structured reporting, and 60 consecutive patients who underwent pelvic MRI for perianal fistulizing disease after implementation of structured reporting. Objective evaluation of the reports for the presence of 12 key features was performed, as also subjective evaluation regarding the clarity and completeness of reports, and impact on surgical planning. RESULTS: Significantly more key features were absent in narrative reports [mean: 6.3 ± 1.8 (range 3-11)] than in structured reports [mean: 0.3 ± 0.9 (range 1-5)] (p ≤ 0.001). The use of structured reporting also increased the percentage of completeness (72.5-88.3% for surgeon 1, and 61.2-81.3% for surgeon 2; p = 0.05 and 0.03, respectively), helpfulness in surgical planning (7.1 ± 1.5-7.6 ± 1.5 for surgeon 1, and 5.8 ± 1.4-7.1 ± 1.1 for surgeon 2; p = 0.05 and p < 0.001, respectively), and clarity (7.6 ± 1.3-8.3 ± 1.1 for surgeon 1, and 5.2 ± 1.4-7.1 ± 1.3 for surgeon 2; p = 0.006 and p < 0.001, respectively) of the reports. CONCLUSION: Structured MRI reports in patients with perianal fistulizing disease miss fewer key features than narrative reports. Moreover, structured reports were described as more complete and clear, and more helpful for treatment planning.

Applicability of current NCCN Guidelines for pancreatic adenocarcinoma resectability: analysis and pitfalls.

PURPOSE: To test the applicability of National Comprehensive Cancer Network (NCCN v 3.2017) resectability criteria for pancreatic ductal adenocarcinoma (PDAC) in clinical practice, at a high-volume tertiary referral center. MATERIALS AND METHODS: 102 consecutive patients (53 female; mean age 66.2 years, range 34-90 years) with biopsy proven, non-metastatic PDAC were evaluated by our multidisciplinary pancreatic cancer program between July 2013 and February 2016. Retrospective review of staging pancreatic CT angiography was performed, and radiographic features were categorized as conforming to or non-conforming to existing v 3.2017 definitions. RESULTS: Among 102 patients, 10 (10%) had CTA evidence of vascular involvement that did not conform to existing NCCN Guidelines. Six new scenarios of vascular involvement were identified. The remaining 92 patients presented with resectable (n = 20 [22%]), borderline resectable (n = 42 [45.6%]), or unresectable (n = 30 [33%]) PDAC. Approximately half (n = 21 [51%]) of borderline resectable patients' tumors demonstrated isolated venous involvement, whereas 39% had both arterial and venous involvement. A minority (11%) demonstrated only major arterial involvement. Assignment to unresectable status reflected both arterial and venous involvement (11, 37%), arterial involvement only (10, 33%) patients, and unreconstructible venous involvement in 9 (30%). CONCLUSION: In our experience, current NCCN resectability guidelines for PDAC do not accurately classify vascular involvement identified in approximately 10% of patients. Revision of the current guidelines could be helpful to clinical practice.