Development, Implementation, and Assessment of a Quality, Research, Education, and Wellness (QREW) Professional Development Lecture Series for Radiology Faculty.

RATIONALE AND OBJECTIVES: Professional development is important to academic radiologists. We developed, implemented, and assessed an internal professional development lecture series focusing on the non-interpretative themes of Quality, Research, Education, and Wellness (QREW). MATERIALS AND METHODS: The faculty of a 29-member abdominal radiology division at an academic hospital were invited to deliver 1-hour virtual lectures on noninterpretative topics to division colleagues. Topics were curated by division leadership based on the perceived needs of faculty. Anonymous feedback was collected from attendees for quality improvement purposes and analyzed using descriptive statistics and Fisher's exact test. RESULTS: Over 17 months, 13 QREW lectures were delivered. In total, 91 feedback forms were completed by faculty (mean 7 forms, range 2-12 per session). Of these, 57 responses (63%) were by those <7 years post training ("junior faculty"), 34 responses (37%) by those ≥ 7 years from training ("senior faculty"). Most respondents reported low levels of prior instruction (80/90, 89%) and personal knowledge (49/91, 54%) on topics. Compared to senior faculty, a greater proportion of junior faculty reported less prior instruction (73% vs 98%, P < 0.001) and less personal knowledge (32% vs 65%, P < 0.01). Most respondents agreed or strongly agreed that the topics were important to their clinical practice (87/90, 97%), professional development (86/90, 96%), and personal well-being (82/91, 90%). Faculty identified the QREW program as a major contributor to their professional development. CONCLUSION: A noninterpretative professional development lecture series delivered by radiology faculty in a virtual, interactive format is feasible and effective, particularly for junior faculty.

MRI-Targeted, Systematic, or Combined Biopsy for Detecting Clinically Significant Prostate Cancer.

PURPOSE: The aim of this study was to assess MRI-targeted, systematic, or combined prostate biopsy for diagnosing prostate cancer to identify opportunities for diagnostic accuracy improvement. METHODS: This institutional review board-approved, retrospective study, performed at a large, quaternary hospital, included all men undergoing prostate multiparametric MRI (mpMRI) from January 1, 2015, to December 31, 2019, with prostate-specific antigen ≥ 4 ng/mL, biopsy target on mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] 3-5 lesion), and combined targeted and systematic biopsy ≤6 months after MRI. Analysis included the highest grade lesion per patient. The primary outcome was prostate cancer diagnosis by grade group (GG; 1, 2, and ≥3). Secondary outcomes were rates of cancer upgrading by biopsy type and cancer proximity to the targeted biopsy site in patients upgraded by systematic biopsy. RESULTS: Two hundred sixty-seven biopsies (267 patients) were included; 94.4% (252 of 267) were biopsy naive. The most suspicious mpMRI lesion was PI-RADS 3 in 18.7% (50 of 267), PI-RADS 4 in 52.4% (140 of 267), and PI-RADS 5 in 28.8% (77 of 267). Prostate cancer was diagnosed in 68.5% (183 of 267): 22.1% (59 of 267) GG 1, 16.1% (43 of 267) GG 2, and 30.3% (81 of 267) GG ≥ 3. Combined biopsy (124 of 267) yielded more GG ≥ 2 prostate cancer diagnoses than systematic (87 of 267) or targeted (110 of 267) biopsy alone. More GG ≥ 2 cancers were upgraded by targeted biopsy than by systematic biopsy (P = .0062). Systematic biopsy upgrades were in close proximity to the targeted biopsy site in 42.1% (24 of 57); GG ≥ 3 cancers 62.5% (15 of 24) constituted most proximal misses. CONCLUSIONS: In men with prostate-specific antigen ≥ 4 ng/mL and PI-RADS 3, 4, or 5 lesion on mpMRI, combined biopsy led to more prostate cancer diagnoses than targeted or systematic biopsy alone. Cancers upgraded by systematic biopsy proximal and distant from the targeted biopsy site may indicate opportunities for biopsy and mpMRI improvement, respectively.

Radiologists' Contribution to Variation in Detecting Clinically Significant Prostate Cancer in Men With Prostate MRI.

OBJECTIVE: Assess radiologists' contribution to variation in clinically significant prostate cancer (csPCa) detection in patients with elevated prostate-specific antigen (PSA) and multiparametric MRI (mpMRI). METHODS: This institutional review board-approved, retrospective cohort study was performed at a tertiary, academic, National Cancer Institute-designated Comprehensive Cancer Center with a multidisciplinary prostate cancer program. Men undergoing mpMRI examinations from January 1, 2015, to December 31, 2019, with elevated PSA (≥4 ng/mL) and biopsy within 6 months pre- or post-MRI or prostatectomy within 6 months post-mpMRI were included. Univariate and multivariable hierarchical logistic regression assessed impact of patient, provider, mpMRI examination, mpMRI report, and pathology factors on the diagnosis of Grade Group ≥ 2 csPCa. RESULTS: Study cohort included 960 MRIs in 928 men, mean age 64.0 years (SD ± 7.4), and 59.8% (555 of 928) had csPCa. Interpreting radiologist was not significant individually (P > .999) or combined with mpMRI ordering physician and physician performing biopsy or prostatectomy (P = .41). Prostate Imaging Reporting and Data System (PI-RADS) category 2 (odds ratio [OR] 0.18, P = .04), PI-RADS category 4 (OR 2.52, P < .001), and PI-RADS category 5 (OR 4.99, P < .001) assessment compared with no focal lesion; PSA density of 0.1 to 0.15 ng/mL/cc (OR 2.46, P < .001), 0.15 to 0.2 ng/mL/cc (OR 2.77, P < .001), or ≥0.2 ng/mL/cc (OR 4.52, P < .001); private insurance (reference = Medicare, OR 0.52, P = .001), and unambiguous extraprostatic extension on mpMRI (OR 2.94, P = .01) were independently associated with csPCa. PI-RADS 3 assessment (OR 1.18, P = .56), age (OR 0.99, P = .39), and African American race (OR 0.90, P = .75) were not. DISCUSSION: Although there is known in-practice variation in radiologists' interpretation of mpMRI, in our multidisciplinary prostate cancer program we found no significant radiologist-attributable variation in csPCa detection.

Learning From Experience- Confronting Challenges and Adapting to Change in a Large Academic Abdominal Radiology Practice: Insights From a Faculty Retreat.

RATIONALE: Substantial organizational changes, increasing clinical volumes, and the COVID-19 pandemic presented compound stressors to faculty radiologists in our large academic abdominal radiology division and necessitated multiple changes in our practice. METHODS: To address the challenges and establish group consensus, we conducted a virtual divisional faculty retreat centered on themes of team building, clinical work, trainee education, and faculty mentorship. A pre-retreat survey evaluated satisfaction with aspects of professional life and clinical work practices and invited personal reflections. Survey data were presented in the retreat segments focused on each theme, and subsequent discussion was facilitated in small group breakouts. RESULTS: Responses to the team-building survey revealed common values and sources of gratitude, including health, family and meaningful work and relationships. Faculty reported a strong sense of personal accomplishment, but with varied emotional exhaustion scores. Faculty were satisfied with remote work assignments but identified opportunities to improve the clinical work schedule including reversion of some remote assignments to in-person and increased interventional radiology shift staggering. Compared to pre-COVID practice, faculty respondents perceived giving lower quality and less frequent feedback to trainees; evolving educational resource needs were identified. A more formal approach to faculty mentoring was sought. A post-retreat survey revealed high participant satisfaction. OUTCOMES: In the future, we plan to continue divisional retreat activities to respond to evolving challenges and further improve team building, clinical workflow, trainee education, and faculty mentorship.

Rectal MRI after neoadjuvant chemoradiation therapy: a pictorial guide to interpretation.

Magnetic resonance imaging (MRI) is the current reference standard imaging modality for restaging rectal cancer after neoadjuvant chemoradiation and is used to guide clinical management decisions. This pictorial essay provides an illustrative atlas of the key MRI features used to assess rectal cancer after treatment. MRI findings of residual tumor including non-mucinous, mucinous, and signet-ring cell adenocarcinoma subtypes are correlated with histopathology. Imaging appearances of treatment changes that mimic residual tumor in the setting of confirmed pathological complete response at resection are illustrated. Treatment complications are also shown. Knowledge of these imaging findings and their importance may help radiologists comply with all elements of the structured reporting templates proposed by the Rectal Cancer Disease Focused Panel of the Society of Abdominal Radiology and by the European Society of Gastrointestinal and Abdominal Radiology.

Assessing ablation margins of FDG-avid liver tumors during PET/CT-guided thermal ablation procedures: a retrospective study.

BACKGROUND: To retrospectively assess liver tumor ablation margins using intraprocedural PET/CT images from FDG PET/CT-guided microwave or cryoablation procedures and to correlate minimum margin measurements with local progression outcomes. METHODS: Fifty-six patients (ages 36 to 85, median 62; 32 females) with 77 FDG-avid liver tumors underwent 60 FDG PET/CT guided, percutaneous microwave, or cryoablation procedures. Single breath-hold PET/CT images were used for intraprocedural assessment of the tumor ablation margin: liver tumors remained visible on PET immediately following ablation; microwave ablation zones were visible using contrast-enhanced CT; cryoablation zones (ice balls) were visible using unenhanced CT. Two readers retrospectively determined ablation margin assessability and measured the minimum ablation margin on intraprocedural PET/CT (n = 77) and postprocedural MRI (n = 56). Local tumor progression was assessed on all available follow-up imaging (1-49 months, mean 15). Local tumor progression was correlated with PET/CT minimum margin measurements using clustered survival models for 61 tumors. RESULTS: Minimum ablation margins were more often assessable using intraprocedural PET/CT (≥ 73/77 tumors, 95%) than postprocedural MRI (≤ 35/56 tumors, 63%). In 61 tumors with PET/CT-assessable margins (excluding tumors with overlapping ablations after PET/CT), there was a 6-fold increased risk of local tumor progression [hazard ratio (HR) 6.05; P = 0.004] for minimum ablation margins < 5 mm. CONCLUSION: Breath-hold PET/CT scans, during PET/CT-guided microwave or cryoablation procedures for FDG-avid liver tumors, enable reliable intraprocedural assessment of the entire tumor ablation margin; a minimum PET/CT ablation margin threshold of 5 mm correlates well with local tumor progression outcomes.

F-18 FDG perfusion PET: intraprocedural assessment of the liver tumor ablation margin.

PURPOSE: To evaluate 18F-fluorodeoxyglucose (FDG) perfusion PET during FDG PET/CT-guided liver tumor microwave ablation procedures for assessing the ablation margin and correlating minimum margin measurements with local progression. METHODS: This IRB-approved, HIPAA-compliant study included 20 adult patients (11 M, 9 F; mean age 65) undergoing FDG PET/CT-guided liver microwave ablation to treat 31 FDG-avid tumors. Intraprocedural FDG perfusion PET was performed to assess the ablation margin. Intraprocedural decisions regarding overlapping ablations were recorded. Two readers retrospectively interpreted intraprocedural perfusion PET and postprocedural contrast-enhanced MRI. Assessability of the ablation margin and minimum margin measurements were recorded. Imaging follow-up for local progression ranged from 30 to 574 days (mean 310). Regression modeling of minimum margin measurements was performed. Hazard ratios were calculated to correlate an ablation margin threshold of 5 mm with outcomes. RESULTS: Intraprocedural perfusion PET prompted additional overlapping ablations of two tumors, neither of which progressed. Incomplete ablation or local progression occurred in 8/31 (26%) tumors. With repeat ablation, secondary efficacy was 26 (84%) of 31. Both study readers deemed ablation margins fully assessable more often using perfusion PET than MRI (OR 69.7; CI 6.0, 806.6; p = 0.001). Minimum ablation margins ≥ 5 mm on perfusion PET correlated with a low risk of incomplete ablation/local progression by both study readers (HR 0.08 and 0.02, p < 0.001). CONCLUSION: Intraprocedural FDG perfusion PET consistently enabled complete liver tumor microwave ablation margin assessments, and the perfusion PET minimum ablation margin measurements correlated well with local outcomes. Clinical trial registration clinicaltrials.gov (NCT02018107).

Improving the completeness of structured MRI reports for rectal cancer staging.

PURPOSE: Assess the impact of a multifaceted intervention to improve the completeness of structured MRI reports for patients undergoing initial staging for rectal cancer. METHODS: This Institutional Review Board-approved retrospective study was performed at a large academic hospital. MRI reports for initial staging of rectal cancer in 2017 and 2019 were analyzed pre- and post-implementation of multiple quality improvement interventions in 2018, including harmonizing MRI protocols across the institution, educational conferences and modules, and requiring second opinion consultation for all MRI rectal cancer examinations. The primary outcome measure was the completeness of rectal cancer staging MRI reports, classified as optimal, satisfactory, or unsatisfactory based on the inclusion of 15 quality measures pre-defined by a consensus of abdominal and cancer imaging subspecialists, colorectal surgeons, and radiation oncologists at our institution, based on published recommendations. Fisher's exact test was used to evaluate changes in report quality and documentation of each quality measure. RESULTS: The study included 138 MRI reports, of which 72 (52%) were completed in 2017 pre-intervention. Post intervention, the proportion of optimal reports increased significantly from 52.8% (38/72) to 71.2% (47/66) (p = 0.035). Documentation of 1 quality measure (N stage) increased post intervention from 91.7% (66/72) to 100% (66/66) (p = 0.029). Documentation of 7 quality measures was 100% post intervention, with a documentation rate of > 95% for all quality measures except radial location of tumor. CONCLUSION: A combination of educational and system-wide interventions was associated with an improvement in the completeness of structured MRI reports for rectal cancer staging.

Trainee and Attending Perspectives on Remote Radiology Readouts in the Era of the COVID-19 Pandemic.

RATIONALE AND OBJECTIVES: Social distancing mandates due to COVID-19 have necessitated adaptations to radiology trainee workflow and educational practices, including the radiology "readout." We describe how a large academic radiology department achieved socially distant "remote readouts," provide trainee and attending perspectives on this early experience, and propose ways by which "remote readouts" can be used effectively by training programs beyond COVID-19. MATERIALS AND METHODS: Beginning March 2020, radiologists were relocated to workspaces outside of conventional reading rooms. Information technologies were employed to allow for "remote readouts" between trainees and attendings. An optional anonymous open-ended survey regarding remote readouts was administered to radiology trainees and attendings as a quality improvement initiative. From the responses, response themes were abstracted using thematic analysis. Descriptive statistics of the qualitative data were calculated. RESULTS: Radiologist workstations from 14 traditional reading rooms were relocated to 36 workspaces across the hospital system. Two models of remote readouts, synchronous and asynchronous, were developed, facilitated by commercially available information technologies. Thirty-nine of 105 (37%) trainees and 42 of 90 (47%) attendings responded to the survey. Main response themes included: social distancing, technology, autonomy/competency, efficiency, education/feedback and atmosphere/professional relationship. One hundred and forty-eight positive versus 97 negative comments were reported. Social distancing, technology, and autonomy/competency were most positively rated. Trainees and attending perspectives differed regarding the efficiency of remote readouts. CONCLUSION: "Remote readouts," compliant with social distancing measures, are feasible in academic radiology practice settings. Perspectives from our initial experience provide insight into how this can be accomplished, opportunities for improvement and future application, beyond the COVID-19 pandemic.

Comparing Breast and Abdominal Subspecialists' Follow-Up Recommendations for Incidental Liver Lesions on Breast MRI.

PURPOSE: The aim of this study was to compare breast imaging subspecialists' follow-up recommendations for incidental liver lesions (ILLs) on breast MRI with abdominal subspecialty radiologists' opinions informed by best-practice recommendations. METHODS: In this retrospective study at an academic medical center, natural language processing identified reports with ILLs among 2,181 breast MRI studies completed in 2015. Electronic health record and radiology report reviews abstracted malignancy presence or absence, prior imaging, and breast subspecialists' recommendations regarding ILLs for random sets of 30 patients: ILLs with follow-up recommendations, ILLs without recommendations, and without ILLs. Two abdominal radiologists evaluated MRI liver findings and offered follow-up recommendations in consensus. The primary outcome was agreement between breast and abdominal subspecialists in patients with ILL follow-up recommendations compared with those without (χ2 analysis). Secondary outcomes were agreement between subspecialists when ILLs were reported and referring clinicians' adherence to follow-up recommendations. RESULTS: ILLs were identified in 11.3% of breast MRI reports (247 of 2,181); breast subspecialists made follow-up recommendations in 12% of them (30 of 247). Abdominal subspecialists agreed with breast subspecialists when ILLs required no follow-up (29 of 30 cases) but disagreed with 28 of 30 breast subspecialists' follow-up recommendations (agreement proportion 29 of 30 versus 2 of 30, P < .0001). Subspecialists agreed in 93% of cases (28 of 30) when breast imagers reported no ILLs. Overall, 16 of 30 breast subspecialists' follow-up recommendations were performed; ILLs were benign in 15. CONCLUSIONS: Abdominal subspecialists disagreed frequently with breast subspecialists regarding follow-up recommendations for ILLs on breast MRI. Abdominal subspecialty consultation or embedding liver imaging decision support in breast imaging reporting workflow may reduce unnecessary imaging and improve care. Improvement opportunities may exist in other cross-subspecialty interpretation workflows.

Technologist Productivity and Accuracy in Assigning Protocols for Abdominal CT and MRI Examinations at an Academic Medical Center: Implications for Physician Workload.

OBJECTIVE. The purpose of this study was to evaluate the technologist productivity and accuracy in assigning protocols for abdominal CT and MRI examinations compared with a standard work flow whereby protocols are assigned by physicians. MATERIALS AND METHODS. In this quality improvement project at a large academic medical center, two CT technologists and two MRI technologists assigned protocols for examinations during a 15-week study period. The primary outcome measure was mean number of protocols assigned by technologists per hour. Secondary outcome measures were proportion of examinations with protocols assigned by technologists and rate of filing of quality assurance reports for protocols completed by technologists. A two-tailed t test was used to compare mean number of protocols; a chi-square test was used to compare proportions between CT and MRI. RESULTS. The mean number of protocols assigned by technologists per hour was not different between CT and MRI (CT, 22/h; MRI, 19/h; p = 0.28). CT and MRI technologist protocols accounted for 1650 of 4867 (33.9%) CT examinations (range, 23-275 per week) and 569 of 2388 (23.8%) MRI examinations (range, 0-95 per week) (p < 0.001). Radiologist quality assurance reports on inaccurate protocols were rare: three for CT (3/1650 [0.18%]), five for MRI (5/569 [0.88%]) (p = 0.017). A retrospective review of randomly selected CT and MRI protocols revealed no errors (80/80 correct). No patients were called back for repeat imaging due to protocol error. CONCLUSION. Technologists can efficiently and accurately assign protocols for abdominal CT and MRI examinations at an academic medical center, leading to increased radiologist time spent on other value-added activities.

Repeat CT Performed Within One Month of CT Conducted in the Emergency Department for Abdominal Pain: A Secondary Analysis of Data From a Prospective Multicenter Study.

OBJECTIVE: The purpose of this study is to determine both the frequency of repeat CT performed within 1 month after a patient visits the emergency department (ED) and undergoes CT evaluation for abdominal pain and the frequency of worsened or new CT-based diagnoses. SUBJECTS AND METHODS: Secondary analysis was performed on data collected during a prospective multicenter study. The parent study included patients who underwent CT in the ED for abdominal pain between 2012 and 2014, and these patients constituted the study group of the present analysis. The proportion of patients who underwent (in any setting) repeat abdominal CT within 1 month of the index CT examination was calculated. For each of these patients, results of the index and repeat CT scans were compared by an independent panel and categorized as follows: no change (group 1); same process, improved (group 2); same process, worse (group 3); or different process (group 4). The proportion of patients in groups 1 and 2 versus groups 3 and 4 was calculated, and patient and ED physician characteristics were compared. RESULTS: The parent study included 544 patients (246 of whom were men [45%]; mean patient age, 49.4 years). Of those 544 patients, 53 (10%; 95% CI, 7.5-13%) underwent repeat abdominal CT. Patients' CT comparisons were categorized as follows: group 1 for 43% of patients (23/53), group 2 for 26% (14/53), group 3 for 15% (8/53), and group 4 for 15% (8/53). New or worse findings were present in 30% of patients (16/53) (95% CI, 19-44%). When patients with findings in groups 1 and 2 were compared to patients with findings in groups 3 and 4, no significant difference was noted in patient age (p = 0.25) or sex (p = 0.76), the number of days between scans (p = 0.98), and the diagnostic confidence of the ED physician after the index CT scan was obtained (p = 0.33). CONCLUSION: Short-term, repeat abdominal CT was performed for 10% of patients who underwent CT in the ED for abdominal pain, and it yielded new or worse findings for 30% of those patients.

Irradiation of FDG-PET-Defined Active Bone Marrow Subregions and Acute Hematologic Toxicity in Anal Cancer Patients Undergoing Chemoradiation.

PURPOSE: Irradiation of pelvic bone marrow (BM) has been correlated with hematologic toxicity (HT) in patients undergoing chemoradiation for anal cancer. We hypothesized that irradiation of hematologically active bone marrow (ABM) subregions defined by fluorodeoxyglucose (FDG) positron emission tomography (PET) is a principal cause of radiation-associated HT. METHODS AND MATERIALS: The cohort included 45 patients with nonmetastatic anal cancer who underwent FDG-PET imaging prior to definitive chemoradiation with mitomycin-C and 5-fluorouracil. Total bone marrow (TBM) was defined as the external contour of the pelvic bones from the top of lumbar 5 (L5) to the bottom of the ischial tuberosity. Standardized uptake values (SUV) for all voxels within the TBM were quantified and normalized by comparison to normal liver SUV. Subvolumes of the TBM that exhibited the highest and lowest 50% of the SUVs were designated ABM50 and IBM50, respectively. The primary endpoint was the absolute neutrophil count (ANC) nadir during or within 2 weeks of completion of treatment. Multivariate linear modeling was used to analyze the correlation between the equivalent uniform doses (EUD) with an a value of 0.5, 1 (equivalent to mean dose), 3, 7, and 12 to the BM structures and the ANC. RESULTS: Mean ± SD ANC nadir was 0.77 × 10(9)/L (±0.66 × 10(9)/L). Grades 3 and 4 ANC toxicity occurred in 26.7% and 44.4% of patients, respectively. The EUD a parameter of 0.5 was optimal for all BM models indicating high radiation sensitivity. EUD of TBM and ABM50 and IBM50 were all significantly associated with ANC nadir. However, model performance for ABM50 was not superior to that of the TBM and IBM50 models. CONCLUSIONS: Irradiation of pelvic BM was associated with HT. However, FDG-PET-defined ABM models failed to improve model performance compared to the TBM model.

Acute gastrointestinal toxicity and bowel bag dose-volume parameters for preoperative radiation therapy for retroperitoneal sarcoma.

PURPOSE: Acute gastrointestinal (GI) toxicity has been studied in GI and gynecological (GYN) cancers, with volume receiving 15 Gy (V15) <830 mL, V25 <650 mL, and V45 <195 mL identified as dose constraints for the peritoneal space (bowel bag [BB]). There are no reported constraints derived from retroperitoneal sarcoma (RPS), and prospective trials for RPS have adopted some of the GI and GYN constraints. This study quantified GI toxicity during preoperative radiation therapy (RT) for RPS, assessed toxicity using published constraints, and evaluated predictors for toxicity. METHODS AND MATERIALS: From 2003 to 2013, 56 patients with RPS underwent preoperative RT at 2 institutions. Toxicity was scored using Radiation Therapy Oncology Group criteria for upper and lower acute GI toxicity. BB was contoured on planning computed tomography scans per Radiation Therapy Oncology Group atlas guidelines with review by a radiologist. Relationships among toxicity, clinical factors, and BB dose were analyzed. RESULTS: Three patients (5%) developed grade ≥3 acute GI toxicity: 2 grade 3 toxicities (anorexia and nausea) and 1 grade 5 toxicity (tumor-bowel fistula). Thirty-six patients (64%) had grade 2 toxicity (nausea, 55%; diarrhea, 23%; pain, 20%). Tumor size was the only significant clinical predictor of grade ≥2 acute GI toxicity. Larger mean BB volumes predicted for grade ≥2 toxicity (P = .001). On receiver operating characteristics analysis, V30 was the best discriminator for toxicity (P = .0001). Median BB V15 was 1375 mL; 75% of patients had V15 ≥830 mL. Median V25 was 1083 mL; 68% had V25 ≥650 mL. Median V45 was 575 mL; 82% had V45 ≥195 mL. V25 ≥650 mL was significantly associated with grade ≥2 toxicity (P = .01). CONCLUSIONS: Among patients treated with preoperative RT for RPS, significant acute GI toxicity was very low despite BB dose exceeding established constraints for most cases. Acceptable dose constraints for RPS may be higher than those for GI or GYN cancers. Further assessment of dose-volume constraints for RPS is needed.

Autoimmune pancreatitis in the context of IgG4-related disease: review of imaging findings.

Current understanding of autoimmune pancreatitis (AIP) recognizes a histopathological subtype of the disease to fall within the spectrum of IgG4-related disease. Along with clinical, laboratory, and histopathological data, imaging plays an important role in the diagnosis and management of AIP, and more broadly, within the spectrum of IgG4-related disease. In addition to the defined role of imaging in consensus diagnostic protocols, an array of imaging modalities can provide complementary data to address specific clinical concerns. These include contrast-enhanced computed tomography (CT) and magnetic resonance (MR) imaging for pancreatic parenchymal lesion localization and characterization, endoscopic retrograde and magnetic resonance cholangiopancreatography (ERCP and MRCP) to assess for duct involvement, and more recently, positron emission tomography (PET) imaging to assess for extra-pancreatic sites of involvement. While the imaging appearance of AIP varies widely, certain imaging features are more likely to represent AIP than alternate diagnoses, such as pancreatic cancer. While nonspecific, imaging findings which favor a diagnosis of AIP rather than pancreatic cancer include: delayed enhancement of affected pancreas, mild dilatation of the main pancreatic duct over a long segment, the "capsule" and "penetrating duct" signs, and responsiveness to corticosteroid therapy. Systemic, extra-pancreatic sites of involvement are also often seen in AIP and IgG4-related disease, and typically respond to corticosteroid therapy. Imaging by CT, MR, and PET also play a role in the diagnosis and monitoring after treatment of involved sites.

Trends in the hospitalization of ischemic stroke in the United States, 1998-2007.

BACKGROUND: The late 1990s/early 2000s was a time of change in both the prevention and acute care of ischemic stroke, with primary prevention driven by increased utilization of antihypertensive, antiplatelet, anticoagulation, and lipid-lowering agents. AIM: To examine whether ischemic stroke hospitalization rates and outcomes in the United States have changed. METHOD: We retrospectively identified 894 169 hospitalizations with a primary diagnosis of ischemic stroke from 1 January 1998 through to 31 December 2007 in the Nationwide Inpatient Sample, the largest all-payer healthcare database in the United States. Annual, national case estimates were combined with US Census data to derive age-adjusted and age-specific population hospitalization rates. Temporal trends were tested using linear regression. RESULTS: From 1998 through 2007, there were an estimated 4 382 336 ischemic stroke hospitalizations in the United States. Overall, the age-adjusted rate of ischemic stroke hospitalization decreased from 184 to 128 per 100 000 (P < 0·0001). Age-specific rates decreased among those 55+ years old (P < 0·0001), but increased among those 25-34 and 35-44 years old (P < 0·001 and P < 0·0001, respectively). Rates among those <25 and 45-54 years old were unchanged. In-hospital mortality decreased from 7·0% (standard error 0·1) to 5·4% (standard error 0·1) (P < 0·0001). Case proportion at the highest quintile of hospitals by annual caseload increased from 54·0% (standard error 2·1) to 61·8% (standard error 2·0) (P < 0·0001). Mean adjusted hospitalization costs increased from $9273 (standard deviation 199) to $10 524 (standard deviation 77) (P < 0·0001). CONCLUSION: In 1998 through to 2007, the overall rate of ischemic stroke hospitalization in the United States decreased. However, rates among young adults increased. In-hospital mortality rates decreased over the study period.

Incidence and treatment patterns in hospitalizations for malignant spinal cord compression in the United States, 1998-2006.

PURPOSE: To characterize patterns in incidence, management, and costs of malignant spinal cord compression (MSCC) hospitalizations in the United States, using population-based data. METHODS AND MATERIALS: Using the Nationwide Inpatient Sample, an all-payer healthcare database representative of all U.S. hospitalizations, MSCC-related hospitalizations were identified for the period 1998-2006. Cases were combined with age-adjusted Surveillance, Epidemiology and End Results cancer death data to estimate annual incidence. Linear regression characterized trends in patient, treatment, and hospital characteristics, costs, and outcomes. Logistic regression was used to examine inpatient treatment (radiotherapy [RT], surgery, or neither) by hospital characteristics and year, adjusting for confounding. RESULTS: We identified 15,367 MSCC-related cases, representing 75,876 hospitalizations. Lung cancer (24.9%), prostate cancer (16.2%), and multiple myeloma (11.1%) were the most prevalent underlying cancer diagnoses. The annual incidence of MSCC hospitalization among patients dying of cancer was 3.4%; multiple myeloma (15.0%), Hodgkin and non-Hodgkin lymphomas (13.9%), and prostate cancer (5.5%) exhibited the highest cancer-specific incidence. Over the study period, inpatient RT for MSCC decreased (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.61-0.81), whereas surgery increased (OR 1.48, 95% CI 1.17-1.84). Hospitalization costs for MSCC increased (5.3% per year, p < 0.001). Odds of inpatient RT were greater at teaching hospitals (OR 1.41, 95% CI 1.19-1.67), whereas odds of surgery were greater at urban institutions (OR 1.82, 95% CI 1.29-2.58). CONCLUSIONS: In the United States, patients dying of cancer have an estimated 3.4% annual incidence of MSCC requiring hospitalization. Inpatient management of MSCC varied over time and by hospital characteristics, with hospitalization costs increasing. Future studies are required to determine the impact of treatment patterns on MSCC outcomes and strategies for reducing MSCC-related costs.