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The treatment planning for patients with hepatocellular carcinoma (HCC) relies predominantly on tumor burden, clinical performance, and liver function test results. Curative treatments such as resection, liver transplantation, and ablative therapies of small lesions should be considered for all patients with HCC. However, many patients are ineligible for these treatments owing to advanced disease stage and comorbidities. Despite efforts to increase screening, early-stage HCC remains difficult to diagnose, which decreases the possibility of curative therapies. In this context, local-regional treatment of HCC is accepted as a form of curative therapy in selected patients with early-stage disease, as a therapeutic option in patients who are not eligible to undergo curative therapies, as a downstaging approach to decrease tumor size toward meeting the criteria for liver transplantation, and as a bridging therapy to avoid tumor growth while the patient is on the waiting list for liver transplantation. The authors review the indications, types, mechanism of action, and possible complications of local-regional treatment, as well as the expected postprocedural imaging features of HCC. Furthermore, they discuss the role of imaging in pre- and postprocedural settings, provide guidance on how to assess treatment response, and review the current limitations of imaging assessment. Finally, the authors summarize the potential future directions with imaging tools that may add value to contemporary practice at response assessment and imaging biomarkers for patient selection, treatment response, and prognosis.

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented.

Sickle cell disorder (SCD) refers to a spectrum of hematologic disorders that cause a characteristic clinical syndrome affecting the entire body. It is the most prevalent monogenetic hemoglobinopathy worldwide, with a wide range of focal and systemic expressions. Hemoglobin gene mutation leads to the formation of abnormal sickle-shaped red blood cells, which cause vascular occlusion and result in tissue and organ ischemia and infarction. Recurrent episodes of acute illness lead to progressive multisystem organ damage and dysfunction. Vaso-occlusion, hemolysis, and infection as a result of functional asplenia are at the core of the disease manifestations. Imaging plays an essential role in the diagnosis and management of SCD-related complications in the abdomen and pelvis. A thorough understanding of the key imaging findings of SCD complications involving hepatobiliary, gastrointestinal, genitourinary, and musculoskeletal systems is crucial to timely recognition and accurate diagnosis. The authors aim to familiarize the radiologist with the SCD spectrum, focusing on the detection and evaluation of manifestations that may appear at imaging of the abdomen and pelvis. The topics the authors address include

The use of standardized terms in assessing and reporting disease processes has well-established benefits, such as clear communication between radiologists and other health care providers, improved diagnostic accuracy and reproducibility, and the enhancement and facilitation of research. Recently, the Liver Imaging Reporting and Data System (LI-RADS) Steering Committee released a universal liver imaging lexicon. The current version of the lexicon includes 81 vetted and precisely defined terms that are relevant to acquisition of images using all major liver imaging modalities and contrast agents, as well as lesion- and organ-level features. Most terms in the lexicon are applicable to all patients undergoing imaging of the liver, and only a minority of the terms are strictly intended to be used for patients with high risk factors for hepatocellular carcinoma. This pictorial atlas familiarizes readers with the liver imaging lexicon and includes discussion of general concepts, providing sample definitions, schematics, and clinical examples for a subset of the terms in the liver imaging lexicon. The authors discuss general, technical, and imaging feature terms used commonly in liver imaging, with the goal of illustrating their use for clinical and research applications.

Artificial intelligence (AI) is the most revolutionizing development in the health care industry in the current decade, with diagnostic imaging having the greatest share in such development. Machine learning and deep learning (DL) are subclasses of AI that show breakthrough performance in image analysis. They have become the state of the art in the field of image classification and recognition. Machine learning deals with the extraction of the important characteristic features from images, whereas DL uses neural networks to solve such problems with better performance. In this review, we discuss the current applications of machine learning and DL in the field of diagnostic radiology.Deep learning applications can be divided into medical imaging analysis and applications beyond analysis. In the field of medical imaging analysis, deep convolutional neural networks are used for image classification, lesion detection, and segmentation. Also used are recurrent neural networks when extracting information from electronic medical records and to augment the use of convolutional neural networks in the field of image classification. Generative adversarial networks have been explicitly used in generating high-resolution computed tomography and magnetic resonance images and to map computed tomography images from the corresponding magnetic resonance imaging. Beyond image analysis, DL can be used for quality control, workflow organization, and reporting.In this article, we review the most current AI models used in medical imaging research, providing a brief explanation of the various models described in the literature within the past 5 years. Emphasis is placed on the various DL models, as they are the most state-of-art in imaging analysis.

BACKGROUND: Radiology education is essential for non-radiologist specialists and practitioners as well as for radiologists. We conducted a survey to gather the opinions of Turkish medical students regarding their radiology curricula, radiology education content, and perceptions of various imaging modalities and to assess the amount, adequacy, and homogeneity of radiology education in various schools. METHODS: Turkish medical students were reached by student ambassadors from 10 different schools of medicine via social media and email. They were provided with a 20-question survey -- via the SurveyMonkey platform -- related to their radiology curriculum and their perceptions of the radiology education at their schools and of different imaging modalities. Subjective parameters were scaled by a 4-point Likert scale and the results are reported by percentages of students. RESULTS: A total of 988 medical students (F/M: 61%/39%) from 41 different medical schools participated in this survey. Of those, 57% were preclinical students (≤3rd year of medical school), while 43% were clinical students (>3rd year). More than half of the students (51%) stated that the amount of radiology education included in their curriculum was too little, while 44% of them stated it was just right and only 5% stated it was too much. Only 31% of the participants stated that they were able to review radiology images on their own. When asked about their level of confidence for identifying the position of lines and tubes, pneumonia, pneumothorax, and pleural effusion on chest radiographs, 41%, 39%, 41%, and 41% of the participants, respectively, stated that they were not confident. Thirty-five percent of the participants had not received any training in comparing normal to abnormal imaging of bone fractures, pneumonia, pleural effusion, subdural hemorrhage, or pneumothorax. The majority of the Turkish medical students in this survey had never heard (57%) nor used (64%) the American College of Radiology Appropriateness Criteria. CONCLUSIONS: The radiology curriculum in Turkey differs among various schools and most students stated that preclinical radiology course content was inadequate. Further studies and improvements must be conducted to provide high-quality, equitable radiology education that begins during preclinical training with respect to the students’ opinions.

Hepatocellular carcinoma (HCC) has limited systemic therapy options when discovered at an advanced stage. Thus, there is a need for accessible and minimally invasive biomarkers of response to guide the selection of patients for treatment. This study investigated the biomarker value of plasma growth hormone (GH) level as a potential biomarker to predict outcome in unresectable HCC patients treated with current standard therapy, atezolizumab plus bevacizumab (Atezo/Bev).Study included unresectable HCC patients scheduled to receive Atezo/Bev. Patients were followed to determine progression-free survival (PFS) and overall survival (OS). Plasma GH levels were measured by ELISA and used to stratify the HCC patients into GH-high and GH-low groups (the cutoff normal GH levels in women and men are ≤3.7 μg/L and ≤0.9 μg/L, respectively). Kaplan-Meier method was used to calculate median OS and PFS and Log rank test was used to compare survival outcomes between GH-high and -low groups.Thirty-seven patients were included in this analysis, of whom 31 were males and 6 females, with a median age of 67 years (range: 37-80). At the time of the analysis, the one-year survival rate was 70% (95% CI: 0.51, 0.96) among GH low patients and 33% (95% CI: 0.16, 0.67) among GH high patients. OS was significantly superior in GH-low compared to GH-high patients (median OS: 18.9 vs. 9.3 months;Plasma GH is a biomarker candidate for predicting treatment outcomes in advanced HCC patients treated with Atezo/Bev. This finding should be further validated in larger randomized clinical trials in advanced HCC patients.

Purpose: To construct, apply, and evaluate a multidisciplinary approach in teaching radiology to Canadian medical students. Methods: A multidisciplinary team of radiology and other disciplines experts designed an online 5-session course that was delivered to medical students. The topics of each session were clinical cases involving different systems. The target audience was medical students of Canadian schools. Pretests and post-tests were administered before and after each session respectively. An evaluation survey was distributed at the end of the course to gauge students’ perceptions of this experience. Results: An average of 425 medical students attended the live sessions. For each session, 405 students completed both the pre-tests and post-tests. In general, students scored an average of 56% higher on the post-test than on the pre-test. The final course survey was completed by 469 students. The survey results show that more than 98% of students found the course to meet or exceed their expectations. Over 80% of students agreed that the course increased their interest in radiology and about 81% agree that the topics presented were excellent and clinically important. The ratings in the final survey results also indicate that students increased their confidence in basic radiology skills after completing the course. Conclusions: The implementation of an integrative clinical approach to teaching radiology in a virtual setting is achievable. It provides efficient use of educational resources while being accessible by a large number of students across different medical schools.

Ahmed Omar Kaseb,1 S Cheenu Kappadath,2 Sunyoung S Lee,1 Kanwal Pratap Raghav,1 Yehia I Mohamed,1 Lianchun Xiao,3 Jeffrey S Morris,4 Chimela Ohaji,1 Rony Avritscher,5 Bruno C Odisio,5 Joshua Kuban,5 Mohamed E Abdelsalam,5 Beth Chasen,6 Khaled M Elsayes,7 Mohamed Elbanan,7 Robert A Wolff,1 James C Yao,1 Armeen Mahvash2 1Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 4Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 5Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 6Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 7Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USACorrespondence: Ahmed Omar Kaseb Email akaseb@mdanderson.orgPurpose: The most common cause of death in advanced/metastatic hepatocellular carcinoma (HCC) is liver failure due to tumor progression. While retrospective studies and meta-analyses of systemic therapy combined with liver-directed therapy have been performed, prospective studies of safety/efficacy of antiangiogenesis followed by intra-arterial therapies are lacking. We tested our hypothesis that sorafenib followed by yttrium 90 glass microspheres (90Y GMs) is safe and that survival outcomes may improve by controlling hepatic tumors.Methods: We enrolled 38 Child–Pugh A patients with advanced/metastatic HCC. In sum, 34 received sorafenib, followed after 4 weeks by 90Y GMs. Analysis of safety and survival outcomes was performed to assess adverse events, median progression-free survival, and overall survival.Results: A total of 34 patients were evaluable: 14 (41.2%) with chronic hepatitis, nine (26.5%) with vascular invasion, and eleven (32.4%) with extrahepatic diseases. Safety analysis revealed that the combination therapy was well tolerated. Grade III–IV adverse events comprised fatigue (n=3), diarrhea (n=2), nausea (n=1), vomiting (n=2), hypertension (n=4), thrombocytopenia (n=1), hyperbilirubinemia (n=1), proteinuria (n=1), hyponatremia (n=1), and elevated alanine or aspartate aminotransferase (n=5). Median progression-free and overall survival were 10.4 months (95% CI 5.8– 14.4) and 13.2 months (95% CI 7.9– 18.9), respectively. Twelve patients (35.3%) achieved partial responses and 16 (47.0%) stable disease. Median duration of sorafenib was 20 (3– 90) weeks, and average dose was 622 (466– 800) mg daily. Dosimetry showed similar mean doses between planned and delivered calculations to normal liver and tumor:normal liver uptake ratio, with no significant correlation with adverse events at 3 and 6 months post-90Y treatment.Conclusion: This is the first prospective study to evaluate sorafenib followed by 90Y in patients with advanced HCC. The study validated our hypothesis of safety with encouraging efficacy signals of the sequencing treatment, and provides proof of concept for future combination modalities for patients with advanced or metastatic HCC.Clinical Trial Registration Number: NCT01900002.Keywords: HCC, sorafenib, yttrium 90, BCLC, hepatocellular carcinoma

Vascular anomalies encompass a spectrum of tumors and malformations that can cause significant morbidity and mortality in children and adults. Use of the International Society for the Study of Vascular Anomalies (ISSVA) classification system is strongly recommended for consistency. Vascular anomalies can occur in isolation or in association with clinical syndromes that involve complex multifocal lesions affecting different organ systems. Thus, it is critical to be familiar with the differences and similarities among vascular anomalies to guide selection of the appropriate imaging studies and possible interventions. Syndromes associated with simple vascular malformations include hereditary hemorrhagic telangiectasia, blue rubber bleb nevus syndrome, Gorham-Stout disease, and primary lymphedema. Syndromes categorized as vascular malformations associated with other anomalies include Klippel-Trenaunay-Weber syndrome, Parkes Weber syndrome, Servelle-Martorell syndrome, Maffucci syndrome, macrocephaly-capillary malformation, CLOVES (

Muhammad O Awiwi,1 Khaled M Elsayes,1 Yehia I Mohamed,2 Lina Altameemi,2 Migena Gjoni,3 Omayr Muhammad Irshad,4 Ahmed Sayed Ahmed,5 Ahmad O Kaseb,2 Usama Salem1 1Department of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 2Department of Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; 3Department of Internal Medicine, The of Istanbul-Cerrahpasa Hospital, Istanbul, Turkey; 4John Sealy School of Medicine, Galveston, TX, USA; 5Department of Gastroenterology, The University of Texas MD Anderson Cancer Center, Houston, TX, USACorrespondence: Khaled M Elsayes, 1515 Holcombe Blvd, Houston, TX, 77030, USA, Tel +1 877 632-6789, Fax +1 713 794-4535, Email KMElsayes@mdanderson.orgPurpose: To identify prognostic clinical and radiologic features in patients with unresectable hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab.Patients and Methods: Clinical and imaging records of patients with unresectable HCC were retrospectively reviewed, and baseline features were recorded. Patients’ records and imaging studies were used to determine the patients’ overall survival (OS) and progression-free survival (PFS). Univariate and multivariate analyses were performed to determine prognostic features. Subanalyses of treatment-naïve patients (who never received local or systemic therapy) and previously treated patients were also performed.Results: Fifty-five patients were included in the final analysis, 23 (41.8%) of whom were treatment naïve. The median PFS and OS for the entire cohort were 3.0 months and 7.9 months. The 3-, 6- and 12-month OS rates were 85.5%, 79.8% and 45.7%, respectively. The 3-, 6- and 12-month PFS rates were 50.1%, 41.2% and 20.1%, respectively. On multivariate analysis, independent prognostic features for poor PFS of the entire cohort were pleural effusions (p = 0.047, HR: 6.3; CI: 1.03– 38.90) and hepatic vein tumor thrombus (p = 0.005; HR: 23.37; CI: 2.63– 207.67); independent prognostic features for poor OS were ascites (p = 0.008; HR: 37.37; CI: 2.53– 467.64), pleural effusion (p = 0.003; HR: 110.17; CI: 5.00– 2426.54), and low (< 40HU) pre-contrast attenuation on CT images (p = 0.007; HR: 0.09; CI: 0.02– 0.53). On subanalysis of treatment-naïve patients, the median OS and PFS were 7.4 months and 2.8 months, respectively. The 3-, 6- and 12-month PFS rates were 43.5%, 38.6% and 24.8%, respectively. Pleural effusion was the only independent poor prognostic feature (p = 0.036; HR: 206.34; CI: 1.41– 30,167.58).Conclusion: Independent prognostic features for survival outcomes include the presence of ascites, pleural effusions, hepatic vein tumor thrombus, and HCC with low attenuation (< 40 HU) on unenhanced CT images. Although several biochemical variables were significant on univariate analysis, none were independent predictors of OS or PFS.Keywords: radiographic, radiology, RECIST, survival, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio

Extraskeletal Ewing sarcoma (EES) is a rare subtype in the Ewing sarcoma family of tumors (ESFT), which also includes Ewing sarcoma of bone (ESB) and, more recently, primitive neuroectodermal tumors. Although these tumors often have different manifestations, they are grouped on the basis of common genetic translocation and diagnosis from specific molecular and immunohistochemical features. While the large majority of ESFT cases occur in children and in bones, approximately 25% originate outside the skeleton as EES. Importantly, in the adult population these extraskeletal tumors are more common than ESB. Imaging findings of EES tumors are generally nonspecific, with some variation based on location and the tissues involved. A large tumor with central necrosis that does not cross the midline is typical. Despite often nonspecific findings, imaging plays an important role in the evaluation and management of ESFT, with MRI frequently the preferred imaging modality for primary tumor assessment and local staging. Chest CT and fluorine 18 fluorodeoxyglucose PET/CT are most sensitive for detecting lung and other distant or nodal metastases. Management often involves chemotherapy with local surgical excision, when possible. A multidisciplinary treatment approach should be used given the propensity for large tumor size and local invasion, which can make resection difficult. Despite limited data, outcomes are similar to those of other ESFT cases, with 5-year survival exceeding 80%. However, with metastatic disease, the long-term prognosis is poor.

Infections are the most commonly encountered complications in patients with cancer. The classical signs and symptoms of infections are often not present in this patient population, which makes the diagnosis more challenging. Host factors play a major role in the development and prognosis of infections in cancer patients; these can be related to the underlying type of malignancy (solid organ versus hematological), tumor burden, anatomic obstruction, altered integrity of barriers (skin or mucosa), treatment-related factors (from chemotherapy, radiation treatment, surgery, interventional procedures, and/or medical device placement) and the degree of immunosuppression. This article reviews common, as well as less common, imaging manifestations of infections and their potential mimics in the abdomen and pelvis in cancer patients and discusses their differentiating features, with the role of imaging in various organs in the abdomen and pelvis taking into consideration relevant clinical background information and the main risk factors.

Purpose To evaluate the value of follow-up chest CT in the surveillance of HCC patients. Background Imaging guidelines for the surveillance of hepatocellular carcinoma (HCC) patients recommend multiple follow-up computed tomography (CT) examinations of the chest, abdomen, and pelvis. Imaging studies are a major driver of rising healthcare costs. The appropriate use of imaging studies must be evaluated to provide valued health care. Methods We reviewed the radiology reports of baseline and follow-up chest, abdominal, and pelvic CT examinations of HCC patients. We categorized the incidence of malignancy in the chest and abdomen for the baseline and follow-up examinations. We also categorized the follow-up examinations as showing improved disease, stable disease, or disease progression. We correlated any progression of disease in the chest with progression of disease in the abdomen. We determined the extent to which disease progression in the chest occurred alongside that in the abdomen. Descriptive statistical analysis was carried out using R (version 3.5.2, R Development Core Team). Results Of the 226 patients included in our study, only 7 (3%) had disease progression in the chest without corresponding disease progression in the abdomen and pelvis on follow-up CT. Only 1.8% of patients with disease progression in the chest had a negative CT chest at baseline. Conclusion Follow-up chest CT has limited benefit in the surveillance of HCC patients, especially those with negative baseline chest CT findings.

Objectives: Radiology and medical imaging are important yet often an underrepresented facet of medical education. Notably, there is concern among radiologists that students do not receive enough radiology exposure and that they struggle to interpret image findings on entering residency. Therefore, this survey aims to identify how medical students perceive the radiology curriculum and to determine gaps in delivery. Material and Methods: Students were recruited from United States (US) medical schools and given a 21-question survey assessing their perception of the radiology curriculum as well as asking about their confidence levels regarding medical imaging. The inclusion criteria were age >18 and enrolled in US medical school. The surveys were completed in April–July 2020 by students across the US. Objective parameters were measured as percentage correct, while subjective parameters used a 4-point Likert scale. Results: A total of 472 medical students across 31 medical schools completed the surveys with a response rate of 69%. Responses represented all class years within medical schools and showed equal distribution among the future career plans. Students responded that didactic lectures were the most common teaching method and that radiologists were their primary teachers during preclinical education. Students were unfamiliar with the American College of Radiology appropriateness criteria with 65% responding they had never heard of it and 33% reporting that they have heard of it but never used it. In assessing students’ perceptions of radiology education, 72% of students responded that they received too little, and 28% of students responded, “Just right.” Conclusion: Radiologists are increasing their educational representation in medical school curricula. Despite this, radiology continues to be under-represented with students desiring more exposure to medical imaging. Integrating the student’s perceptions with existing curricula suggests that efforts should focus on increasing awareness of which studies are appropriate and teaching students how to systematically interpret an image.

Venous thromboembolism (VTE), which includes deep venous thrombosis and pulmonary embolism, is a significant cause of morbidity and mortality. In recent decades, US, CT, and MRI have surpassed catheter-based angiography as the imaging examinations of choice for evaluation of vascular structures and identification of thrombus owing to their ready availability, noninvasive nature, and, in the cases of US and MRI, lack of exposure to ionizing radiation. As a result, VTE and associated complications are commonly identified in day-to-day radiologic practice across a variety of clinical settings. A wide range of hereditary and acquired conditions can increase the risk for development of venous thrombosis, and many patients with these conditions may undergo imaging for unrelated reasons, leading to the incidental detection of VTE or one of the associated complications. Although the development of VTE may be an isolated occurrence, the imaging findings, in conjunction with the clinical history and vascular risk factors, may indicate a predisposing condition or underlying diagnosis. Furthermore, awareness of the many clinical conditions that result in an increased risk of venous thrombosis may aid in detection of thrombus and any concomitant complications. For these reasons, it is important that practicing radiologists be familiar with the multimodality imaging findings of thrombosis, understand the spectrum of diseases that contribute to the development of thrombosis, and recognize the potential complications of hypercoagulable states and venous thrombosis.

Awareness of the myriad of hereditary, acquired, infectious, and anatomic conditions that result in increased risk of venous thrombosis can aid radiologists in detection of thrombus and concomitant...

Hepatocellular carcinoma (HCC) is one of the most common tumors worldwide, usually occurring on a background of liver cirrhosis. HCC is a highly vascular tumor in which angiogenesis plays a major role in tumor growth and spread. Tumor-induced angiogenesis is usually related to a complex interplay between multiple factors and pathways, with vascular endothelial growth factor being a major player in angiogenesis. In the past decade, understanding of tumor-induced angiogenesis has led to the emergence of novel anti-angiogenic therapies, which act by reducing neo-angiogenesis, and improving patient survival. Currently, Sorafenib and Lenvatinib are being used as the first-line treatment for advanced unresectable HCC. However, a disadvantage of these agents is the presence of numerous side effects. A major challenge in the management of HCC patients being treated with anti-angiogenic therapy is effective monitoring of treatment response, which decides whether to continue treatment or to seek second-line treatment. Several criteria can be used to assess response to treatment, such as quantitative perfusion on cross-sectional imaging and novel/emerging MRI techniques, including a host of known and emerging biomarkers and radiogenomics. This review addresses the pathophysiology of angiogenesis in HCC, accurate imaging assessment of angiogenesis, monitoring effects of anti-angiogenic therapy to guide future treatment and assessing prognosis.

Objectives Adrenal adenoma with myelolipomatous degeneration (AMD) is a rarely reported and often overlooked entity. The aim of this study is to improve understanding of these lesions by characterizing the imaging findings with pathologic and clinical correlation. Methods In the largest series to date, we report 11 nodules in 11 patients confirmed with a pathologic diagnosis of AMD. The available cross-sectional imaging and histopathologic features were reviewed by two radiologists and two pathologists, respectively. Clinical and laboratory data for each patient were obtained from the electronic medical records, when available. Results All 11 patients had a CT prior to resection or biopsy of the adrenal nodule, with five having received an adrenal mass protocol study. An MRI was available in three patients. The median size of the nodules on imaging was 4.5 cm (range 2.8–8.7) and all but one had macroscopic fat. The largest focus of macroscopic fat had a median size of 0.7 cm (range 0.2–1.6) and on average was 14.4% the size of the tumor, using greatest dimensions. Four (36.4%) patients had a diagnosis of Cushing syndrome prior to nodule resection. Conclusions Not all adrenal nodules with macroscopic fat on imaging are pure myelolipomas. An AMD should be considered, especially if the foci of fat are small and other features of an adenoma are present. Some may also be associated with Cushing syndrome. Advances in knowledge: Myelolipomatous degeneration within an adrenal adenoma has only rarely been previously reported with very few reports emphasizing the imaging features. There may be an association with cortisol hypersecretion and improved recognition of this entity could lead to changes in clinical management.

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.

Simple Summary In this review will discuss the clinical presentation, pathophysiology, and role of imaging in detection and extent estimation of the systemic involvement of the disease, in addition to demonstration of appearance on varying imaging modalities. Familiarity with the potential imaging findings associated with mastocytosis can aid in early disease diagnosis and classification and accordingly can lead directing further work up and better management. Abstract Mastocytosis is a rare disorder due to the abnormal proliferation of clonal mast cells. Mast cells exist in most tissues, mature in situ from hematopoietic stem cells and develop unique characteristics of local effector cells. Mastocytosis develops by activation mutation of the KIT surface receptor which is involved in the proliferation of a number of cell lines such as mast cells, germ cells, melanocytes, and hematopoietic cells. It manifests as two main categories: cutaneous mastocytosis and systemic mastocytosis. Imaging can play an important role in detection and characterization of the disease manifestation, not only by radiography and bone scans, but also magnetic resonance imaging and computed tomography, which can be more sensitive in the assessment of distinctive disease patterns. Radiologists should be aware of various appearances of this disease to better facilitate diagnosis and patient management. Accordingly, this review will discuss the clinical presentation, pathophysiology, and role of imaging in detection and extent estimation of the systemic involvement of the disease, in addition to demonstration of appearance on varying imaging modalities. Familiarity with the potential imaging findings associated with mastocytosis can aid in early disease diagnosis and classification and accordingly can lead directing further work up and better management.

Simple Summary Familiarity with the updated fourth edition WHO classification of lymphoid malignancies released in 2016, and the new terminology introduced, is crucial for oncologists, pathologists and radiologists. It is mandatory to be aware of rare variants of T-cell lymphomas, specifically mature T-cell lymphomas, including clinicopathologic keys and the most common imaging features and sites of involvement for each subtype. Even though some of these disorders may have perceptible clinical and imaging features, they may overlap with more common disorders, causing delay in diagnosis and treatment. Understanding the appropriate clinical setting and imaging findings will help radiologists to include these disorders in their differential diagnosis. Imaging plays a pivotal role in subclassifying these subtypes of MTCLs, affecting prognosis and treatment implications. Many of these disorders if diagnosed early can be potentially treatable, and early, aggressive intervention may be lifesaving. Abstract Understanding the pathogenesis and molecular biology of malignant lymphomas is challenging, given the complex nature and incongruity of these disorders. The classification of lymphoma is continually evolving to account for advances in clinical, pathological, molecular biology and cytogenetic aspects, which impact our understanding of these disorders. The latest fourth edition of the WHO classification of lymphoid malignancies was released in 2016 to account for these changes. Additionally, unlike B-cell lymphomas (BCL), T-cell lymphomas (TCL) are uncommon, and may be sporadically experienced in clinical practice. These disorders are rare, thus early diagnosis is challenging for both physicians and radiologists, owing to the overlap in clinical and imaging features with other, more common disorders. We aim to discuss some rare variants of T-cell lymphomas, including clinicopathologic and imaging features, as well as to give a glimpse of the updates contained within the new 2016 WHO classification.

The need for liver transplants is increasing because the prevalence of liver diseases and the indications for transplants are growing. In response to the shortage of grafts from deceased donors, more transplants are being performed worldwide with grafts from living donors. Radiologic evaluation is an integral component in the assessment of donor candidates to ensure their eligibility and to choose the most appropriate surgical approach. MRI is the preferred modality for evaluation of the liver parenchyma and biliary tree. In most centers, a combination of MRI and CT is used to take advantage of the higher spatial resolution of CT for evaluation of arteries. However, MRI-only assessment is feasible. In addition to assessment of the liver parenchyma for abnormalities such as steatosis, a detailed evaluation of the hepatic vascular and biliary system for pertinent anatomic variants is crucial, because these variants can affect surgical techniques and outcomes in both recipients and donors. In this pictorial article, after a brief review of the most common surgical techniques and postsurgical liver anatomy, the biliary and vascular anatomy are discussed, with specific attention paid to the variants that are pertinent to this surgical procedure. The roles of liver segmentation and volumetric assessment and current imaging techniques and protocols are also discussed.

Simple Summary The Peutz-Jeghers Syndrome is a rare autosomal dominant syndrome characterized by mucocutaneous pigmentations, multiple gastrointestinal hamartomatous polyps, and an elevated risk of malignancy. Awareness of various Peutz-Jeghers Syndrome imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide an overview of this condition, associated malignancies, and imaging surveillance protocols. Abstract The Peutz-Jeghers Syndrome (PJS) is an autosomal dominant neoplastic syndrome defined by hamartomatous polyps through the gastrointestinal tract, development of characteristic mucocutaneous pigmentations, and an elevated lifetime cancer risk. The majority of cases are due to a mutation in the STK11 gene located at 19p13.3. The estimated incidence of PJS ranges from 1:50,000 to 1:200,000. PJS carries an elevated risk of malignancies including gastrointestinal, breast, lung, and genitourinary (GU) neoplasms. Patients with PJS are at a 15- to 18-fold increased malignancy risk relative to the general population. Radiologists have an integral role in the diagnosis of these patients. Various imaging modalities are used to screen for malignancies and complications associated with PJS. Awareness of various PJS imaging patterns, associated malignancies, and their complications is crucial for accurate imaging interpretation and patient management. In this manuscript, we provide a comprehensive overview of PJS, associated malignancies, and surveillance protocols.

Liver lesions have different enhancement patterns at dynamic contrast-enhanced imaging. The Liver Imaging Reporting and Data System (LI-RADS) applies the enhancement kinetic of liver observations in its algorithms for imaging-based diagnosis of hepatocellular carcinoma (HCC) in at-risk populations. Therefore, careful analysis of the spatial and temporal features of these enhancement patterns is necessary to increase the accuracy of liver mass characterization. The authors focus on enhancement patterns that are found at or around the margins of liver observations-many of which are recognized and defined by LI-RADS, such as targetoid appearance, rim arterial phase hyperenhancement, peripheral washout, peripheral discontinuous nodular enhancement, enhancing capsule appearance, nonenhancing capsule appearance, corona enhancement, and periobservational arterioportal shunts-as well as peripheral and periobservational enhancement in the setting of posttreatment changes. Many of these are considered major or ancillary features of HCC, ancillary features of malignancy in general, features of non-HCC malignancy, features associated with benign entities, or features related to treatment response. Distinction between these different patterns of enhancement can help with achieving a more specific diagnosis of HCC and better assessment of response to local-regional therapy.

Primary liver cancer is the fourth leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) comprising the vast majority of primary liver malignancies. Imaging plays a central role in HCC diagnosis and management. As a result, the content and structure of radiology reports are of utmost importance in guiding clinical management. The Liver Imaging Reporting and Data System (LI-RADS) provides guidance for standardized reporting of liver observations in patients who are at risk for HCC. LI-RADS standardized reporting intends to inform patient treatment and facilitate multidisciplinary communication and decisions, taking into consideration individual clinical factors. Depending on the context, observations may be reported individually, in aggregate, or as a combination of both. LI-RADS provides two templates for reporting liver observations: in a single continuous paragraph or in a structured format with keywords and imaging findings. The authors clarify terminology that is pertinent to reporting, highlight the benefits of structured reports, discuss the applicability of LI-RADS for liver CT and MRI, review the elements of a standardized LI-RADS report, provide guidance on the description of LI-RADS observations exemplified with two case-based reporting templates, illustrate relevant imaging findings and components to be included when reporting specific clinical scenarios, and discuss future directions. An invited commentary by Yano is available online. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

Simple Summary The lymphatic system is an essential component of the human circulatory system that plays a critical role in antigen presentation, mounting immune reactions, gastrointestinal tract lipid absorption, and maintenance of interstitial homeostasis. This complex network of specially adapted vessels and lymphoid organs also represents major pathway for cancer spread. Knowledge of lymphatic anatomy, physiology, and expected imaging appearances is crucial in understanding the pattern of cancer spread, with great implications for treatment and management. In this review article, we discuss lymphatic anatomy, physiology, imaging techniques, and radiographic appearances of cancer spread with relevant illustrative cases. Abstract The lymphatic system is an anatomically complex vascular network that is responsible for interstitial fluid homeostasis, transport of large interstitial particles and cells, immunity, and lipid absorption in the gastrointestinal tract. This network of specially adapted vessels and lymphoid tissue provides a major pathway for metastatic spread. Many malignancies produce vascular endothelial factors that induce tumoral and peritumoral lymphangiogenesis, increasing the likelihood for lymphatic spread. Radiologic evaluation for disease staging is the cornerstone of oncologic patient treatment and management. Multiple imaging modalities are available to access both local and distant metastasis. In this manuscript, we review the anatomy, physiology, and imaging of the lymphatic system.

We aimed to provide insights into the adaptive strategies, benefits, and challenges faced by the radiology programs during the 2021 residency virtual Match. Furthermore, we explored the potential impacts of related topics, such as diversity and social media use on the Match process and outcomes.A cross-sectional survey of 31 questions was designed and distributed via e-mails to individuals involved radiology programs match process during the 2021 Match. Descriptive statistics were used to analyze the results of most questions. Two questions comparing the changes in factors influencing the selection of applicants on a Likert scale of 1-5 were analyzed using paired t-test and Wilcoxon signed-rank test where p-value0.05 was considered statistically significant.Responses from 125 participants were analyzed. The following factors carried less weight in evaluating applicants during 2021 Match: away rotations (p0.01), no failed attempts in USMLE Step 1/CK (p0.01), grades in radiology clerkship (p0.04), and class rank/quartile (p0.04), while personal statements were more important (p0.03). Out of the 125 respondents, 80 (64%) and 58 (47%) strongly or somewhat agree on the effectiveness of virtual interviews in gauging applicants' candidacy and showing their programs' advantages, respectively. Advantages of virtual interviews included decreased cost, time flexibility, less faculty burden, and an increased number of offered interviews according to 81% (101/125), 46% (58/125), 40%, (50/125), and 34% (43/125), respectively. The most helpful platforms that showcased program advantages were program websites followed by Twitter and Instagram.Most radiology programs were able to adjust to the virtual interview process, and the majority agree on their effectiveness citing many benefits. However, there were mixed opinions if it could be sustained in future cycles.

Simple Summary In this manuscript, we present the associated imaging findings and imaging screening recommendations. Knowledge of the types of cancers commonly seen in Cowden syndrome and their imaging findings can aid in early tumor recognition during cancer screening to help ensure near-normal life spans in Cowden syndrome patients. Abstract PTEN hamartoma tumor syndrome/Cowden syndrome (CS) is a rare autosomal dominant syndrome containing a germline PTEN mutation that leads to the development of multisystem hamartomas and oncogenesis. Benign tumors such as Lhermitte–Duclos disease and malignant tumors involving the breast, thyroid, kidneys, and uterus are seen in CS. Radiologists have an integral role in the comanagement of CS patients. We present the associated imaging findings and imaging screening recommendations. Knowledge of the types of cancers commonly seen in CS and their imaging findings can aid in early tumor recognition during cancer screening to help ensure near-normal life spans in CS patients.

Purpose The most common cause of death in advanced/metastatic hepatocellular carcinoma (HCC) is liver failure due to tumor progression. While retrospective studies and meta-analyses of systemic therapy combined with liver-directed therapy have been performed, prospective studies of safety/efficacy of antiangiogenesis followed by intra-arterial therapies are lacking. We tested our hypothesis that sorafenib followed by yttrium 90 glass microspheres (90Y GMs) is safe and that survival outcomes may improve by controlling hepatic tumors. Methods We enrolled 38 Child–Pugh A patients with advanced/metastatic HCC. In sum, 34 received sorafenib, followed after 4 weeks by 90Y GMs. Analysis of safety and survival outcomes was performed to assess adverse events, median progression-free survival, and overall survival. Results A total of 34 patients were evaluable: 14 (41.2%) with chronic hepatitis, nine (26.5%) with vascular invasion, and eleven (32.4%) with extrahepatic diseases. Safety analysis revealed that the combination therapy was well tolerated. Grade III–IV adverse events comprised fatigue (n=3), diarrhea (n=2), nausea (n=1), vomiting (n=2), hypertension (n=4), thrombocytopenia (n=1), hyperbilirubinemia (n=1), proteinuria (n=1), hyponatremia (n=1), and elevated alanine or aspartate aminotransferase (n=5). Median progression-free and overall survival were 10.4 months (95% CI 5.8–14.4) and 13.2 months (95% CI 7.9–18.9), respectively. Twelve patients (35.3%) achieved partial responses and 16 (47.0%) stable disease. Median duration of sorafenib was 20 (3–90) weeks, and average dose was 622 (466–800) mg daily. Dosimetry showed similar mean doses between planned and delivered calculations to normal liver and tumor:normal liver uptake ratio, with no significant correlation with adverse events at 3 and 6 months post-90Y treatment. Conclusion This is the first prospective study to evaluate sorafenib followed by 90Y in patients with advanced HCC. The study validated our hypothesis of safety with encouraging efficacy signals of the sequencing treatment, and provides proof of concept for future combination modalities for patients with advanced or metastatic HCC. Clinical Trial Registration Number NCT01900002.

According to the World Health Organization (WHO), as of today, there are 2.165.500 confirmed cases of the novel coronavirus disease (COVID-19) and 145.705 deaths in over 185 countries. Unfortunately, despite the tremendous efforts to develop a vaccine initiated by various leading health institutions all over the world, it may be 18 months before a vaccine against the coronavirus is publicly available. We are proposing a theory about testing the use of the Bordetella pertussis vaccine to protect against COVID-19. We deliver this theory to the scientific community, aiming to raise the concern about it, and to provide us with support by realistic and experimental evidence.

The Liver Imaging Reporting and Data System (LI-RADS) is composed of four individual algorithms intended to standardize the lexicon, as well as reporting and care, in patients with or at risk for hepatocellular carcinoma in the context of surveillance with US; diagnosis with CT, MRI, or contrast material–enhanced US; and assessment of treatment response with CT or MRI. This report provides a broad overview of LI-RADS, including its historic development, relationship to other imaging guidelines, composition, aims, and future directions. In addition, readers will understand the motivation for and key components of the 2018 update. © RSNA, 2018

The risk of developing malignancy is higher in patients with human immunodeficiency virus (HIV) infection than in non-HIV-infected patients. Several factors including immunosuppression, viral coinfection, and high-risk lifestyle choices lead to higher rates of cancer in the HIV-infected population. A subset of HIV-related malignancies are considered to be acquired immunodeficiency syndrome (AIDS)-defining malignancies, as their presence confirms the diagnosis of AIDS in an HIV-infected patient. The introduction of highly active antiretroviral therapy (HAART) has led to a significant drop in the rate of AIDS-defining malignancies, including Kaposi sarcoma, non-Hodgkin lymphoma, and invasive cervical carcinoma. However, non-AIDS-defining malignancies (eg, Hodgkin lymphoma, lung cancer, hepatocellular carcinoma, and head and neck cancers) now account for an increasing number of cancer cases diagnosed in HIV-infected patients. Although the number has decreased, AIDS-defining malignancies account for 15%-19% of all deaths in HIV-infected patients in the post-HAART era. Most HIV-related malignancies in HIV-infected patients manifest at an earlier age with a more aggressive course than that of non-HIV-related malignancies. Understanding common HIV-related malignancies and their specific imaging features is crucial for making an accurate and early diagnosis, which impacts management. Owing to the weakened immune system of HIV-infected patients, other entities such as various infections, particularly opportunistic infections, are prevalent in these patients. These processes can have confounding clinical and imaging manifestations that mimic malignancy. This article reviews the most common AIDS-defining and non-AIDS-defining malignancies, the role of imaging in their diagnosis, and the imaging mimics of malignancies in HIV-infected patients. ©RSNA, 2018.

Simple Summary The recent increase in the use of targeted molecular therapy including anti-angiogenetic agents in cancer treatment necessitate the use of robust tools to assess and guide treatment. Angiogenesis, the formation of new disorganized blood vessels, is used by tumor cells to grow and spread using different mechanisms that could be targeted by anti-angiogenetic agents. In this review, we discuss the biological principles of tumor angiogenesis and the imaging modalities that could provide information beyond gross tumor size and morphology to capture the efficacy of anti-angiogenetic therapeutic response. Abstract There have been rapid advancements in cancer treatment in recent years, including targeted molecular therapy and the emergence of anti-angiogenic agents, which necessitate the need to quickly and accurately assess treatment response. The ideal tool is robust and non-invasive so that the treatment can be rapidly adjusted or discontinued based on efficacy. Since targeted therapies primarily affect tumor angiogenesis, morphological assessment based on tumor size alone may be insufficient, and other imaging modalities and features may be more helpful in assessing response. This review aims to discuss the biological principles of tumor angiogenesis and the multi-modality imaging evaluation of anti-angiogenic therapeutic responses.