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A common opportunity to collect research samples is during image-guided percutaneous core needle biopsies (CNBs) performed when clinically indicated or for assessing clinical trial eligibility. The relative safety of extra CNBs collected for research is undefined.Patients who underwent CNB for research purposes only [RO], as clinically indicated [CI], or as part of a clinical trial [CT] were identified. 30-day post-procedure adverse events (AEs) among the cohorts were examined and compared to the 2020 Society of Interventional Radiology QI guidelines.236 patients with thoracic cancers (90 % NSCLC, 5 % SCLC, 4 % mesothelioma, and 1 % thymic) had 292 CNBs (63 RO, 229 CI + CT). AEs occurred in 13 % of both the RO and CI + CT groups. Compared to the CI + CT group, the RO group did not have a higher pneumothorax incidence (RO: 5/29 [17 %], CI + CT: 18/114 [16 %], p = 0.79); both were below the suggested QI threshold of 45 % for pneumothorax. There was a negative association between number of cores obtained and risk of AE (AE vs no AE mean cores = 3.5 vs 4.8). After adjusting for the number of cores and smoking history, RO vs CI + CT lung biopsies had a higher risk of AEs (adjusted relative risk [aRR] = 2.44, 1.08-5.55, p = 0.03 vs non-lung aRR = 0.86, 0.10-7.09, p = 0.89).CNBs performed for research purposes do not have a significantly increased risk of AEs when compared to those performed for clinical trials and/or when clinically indicated. However, AEs were most frequent in lung biopsies. When performing research biopsies, a target other than lung may be preferred when clinically appropriate.

This study aimed to determine effect of modality, care setting, and radiology subspecialty on frequency of diagnostic image quality issues identified by radiologists during image interpretation.This Institutional Review Board-exempt retrospective study was performed 10/1/18-6/30/20 at an academic radiology practice performing 700,000+ examinations annually. A closed-loop communication tool integrated in PACS workflow enabled radiologists to alert technologists to image quality issues. Radiologists categorized communications as requiring patient callback, or as technologist learning opportunities if image quality was adequate to generate a diagnostic report. Fisher's exact test assessed impact of imaging modality, radiology subspecialty, and care setting on radiologist-identified image quality issues.976,915 imaging examinations were performed during the study period. Radiologists generated 1,935 technologist learning opportunities (0.20%) and 208 callbacks (0.02%). Learning opportunity rates were highest for MRI (0.60%) when compared to CT (0.26%) and radiography (0.08%) (p0.0001). The same was true for patient callbacks (MRI 0.13%, CT 0.02%, radiography 0.0006%; p0.0001). Outpatient examinations generated more learning opportunities (1479/637,092; 0.23%) vs. inpatient (305/200,206; 0.15%) and Emergency Department (151/139,617; 0.11%) (p0.0001). Abdominal subspecialists were most likely to generate learning opportunities when compared to other subspecialists and cardiovascular imagers were most likely to call a patient back.Image quality issues identified by radiologists during the interpretation process were rare and 10 times more commonly categorized as learning opportunities not interfering with a clinically adequate report than as requiring patient callback. Further work is necessary to determine if creating learning opportunities leads to fewer patients requiring repeat examinations.

Background Adrenal masses are common, but radiology reporting and recommendations for management can be variable. Purpose To create a machine learning algorithm to segment adrenal glands on contrast-enhanced CT images and classify glands as normal or mass-containing and to assess algorithm performance. Materials and Methods This retrospective study included two groups of contrast-enhanced abdominal CT examinations (development data set and secondary test set). Adrenal glands in the development data set were manually segmented by radiologists. Images in both the development data set and the secondary test set were manually classified as normal or mass-containing. Deep learning segmentation and classification models were trained on the development data set and evaluated on both data sets. Segmentation performance was evaluated with use of the Dice similarity coefficient (DSC), and classification performance with use of sensitivity and specificity. Results The development data set contained 274 CT examinations (251 patients; median age, 61 years; 133 women), and the secondary test set contained 991 CT examinations (991 patients; median age, 62 years; 578 women). The median model DSC on the development test set was 0.80 (IQR, 0.78-0.89) for normal glands and 0.84 (IQR, 0.79-0.90) for adrenal masses. On the development reader set, the median interreader DSC was 0.89 (IQR, 0.78-0.93) for normal glands and 0.89 (IQR, 0.85-0.97) for adrenal masses. Interreader DSC for radiologist manual segmentation did not differ from automated machine segmentation (

To assess the association of imaging features of acute pancreatitis (AP) with the magnitude of lipase elevation in Emergency Department (ED) patients.This Institutional Review Board-approved retrospective study included 509 consecutive patients presenting from 9/1/13-8/31/15 to a large academic ED with serum lipase levels ≥3× the upper limit of normal (ULN) (≥180 U/L). Patients were excluded if they did not have imaging (n = 131) or had a history of trauma, abdominal metastases, altered mental status, or transfer from an outside hospital (n = 190); the final study population was 188 patients. Imaging exams were retrospectively evaluated, and a consensus opinion of two subspecialty-trained abdominal radiologists was used to diagnose AP. Primary outcome was presence of imaging features of AP stratified by lipase level (≥3×-10× ULN and10× ULN). Secondary outcome was rate of discordant consensus evaluation compared to original radiologist's report.25.0% of patients (47/188) had imaging features of AP. When lipase was10× ULN (n = 94), patients were more likely to have imaging features of AP (34%) vs. those with mild elevation (16%) (p = 0.0042). There was moderately strong correlation between lipase level and presence of imaging features of AP (r = 0.48, p0.0001). Consensus review of CT and MRI images was discordant with the original report in 14.9% (28/188) of cases.Prevalence of imaging signs of AP in an ED population with lipase ≥3× ULN undergoing imaging is low. However, the probability of imaging features of AP increases as lipase value increases.

This study aimed to determine the incidence, identify imaging and patient factors, and measure individual radiologist variation associated with follow-up recommendations for small focal cystic pancreatic lesions (FCPLs), a common incidental imaging finding.This institutional review board-approved retrospective study analyzed 146,709 reports from abdominal CTs and MRIs performed in a large academic hospital from July 1, 2016, to June 30, 2018. A trained natural language processing tool identified 4,345 reports with FCPLs, which were manually reviewed to identify those containing one or more1.5-cm pancreatic cysts. For these patients, patient, lesion, and radiologist features and follow-up recommendations for FCPL were extracted. A nonlinear random-effects model estimated degree of variation in follow-up recommendations across radiologists at department and division levels.Of 2,872 reports with FCPLs1.5 cm, 708 (24.7%) had FCPL-related follow-up recommendations. Average patient age was 67 years (SD ± 11). In all, 1,721 (60.0%) reports were for female patients; 59.3% of patients had only one cyst. In multivariable analysis, older patients had slightly lower follow-up recommendation rates (odds ratio [OR]: 0.98 [0.98-1.00] per additional year), and lesions associated with main duct dilatation and septation were more likely to have a follow-up recommendation (ORs: 1.93 [1.11-3.36] and 2.88 [1.89-4.38], respectively). Radiologist years in practice (P = .51), trainee presence (P = .21), and radiologist gender (P = .52) were not associated with increased follow-up recommendations. There was significant interradiologist variation in the Abdominal Imaging Division (P = .04), but not in Emergency Radiology (P = .31) or Cancer Imaging Divisions (P = .29).Interradiologist variation significantly contributes to variability in follow-up imaging recommendations for FCPLs.

Interventions designed to limit the spread of coronavirus disease 2019 (COVID-19) are having profound effects on the delivery of health care, but data showing the impact on oncology clinical trial enrollment, treatment, and monitoring are limited. We prospectively tracked relevant data from oncology clinical trials at Dana-Farber Cancer Institute from January 1, 2018, to June 30, 2020, including the number of open trials, new patient enrollments, in-person and virtual patient visits, dispensed investigational infusions, dispensed or shipped oral investigational agents, research biopsies, and blood samples. We ascertained why patients came off trials and determined on-site clinical research staffing levels. We used 2-sided Wilcoxon rank sum tests to assess the statistical significance of the reported changes. Nearly all patients on interventional treatment trials were maintained, and new enrollments continued at just under one-half the prepandemic rate. The median number of investigational prescriptions shipped to patients increased from 0 to 74 (range = 22-107) per week from March to June 2020. The median number of telemedicine appointments increased from 0 to 107 (range = 33-267) per week from March to June 2020. Research biopsies and blood collections decreased dramatically after Dana-Farber Cancer Institute implemented COVID-19–related policies in March 2020. The number of research nurses and clinical research coordinators on site also decreased after March 2020. Substantial changes were required to safely continue clinical research during the pandemic, yet we observed no increases in serious adverse events or major violations related to drug dosing. Lessons learned from adapting research practices during COVID-19 can inform industry sponsors and governmental agencies to consider altering practices to increase operational efficiency and convenience for patients.

OBJECTIVE. The objective of this study was to assess impact of a report template quality improvement (QI) initiative on use of preferred phrases for communicating normal findings in structured abdominal CT and MRI reports. SUBJECTS AND METHODS. This prospective QI initiative, designed to decrease use of equivocal phrases and increase use of preferred and acceptable phrases (defined by multidisciplinary experts including patient advocates) in radiology reports, was performed in an academic medical center with over 800,000 annual radiologic examinations and was exempt from institutional review board approval. The intervention populated the preferred term "normal" (default) and acceptable specified pertinent negative phrases (pick-list option) when describing abdominal organ subheadings (liver, pancreas, spleen, adrenal glands, kidneys) within the "Findings" heading of abdominal CT and MRI report templates. We tabulated frequencies of the term "normal", specified pertinent negatives, and equivocal phrases in 21,629 reports before (June 1, 2017, to February 28, 2018) and 23,051 reports after (April 1, 2018, to December 31, 2018) the intervention using natural language processing and recorded trainee participation in report generation. We assessed intervention impact using statistical process control (SPC) charts and the Fisher exact test. RESULTS. Equivocal phrases were used less frequently in abdominal CT and MRI reports for both attending radiologists and trainees after the intervention (p < 0.05, SPC). Use of the term "normal" increased for reports generated by attending radiologists alone but decreased for reports created with trainee participation (p < 0.05, SPC). Frequency of pertinent negatives increased for reports with trainee participation (p < 0.05, SPC). CONCLUSION. A QI intervention decreased use of equivocal terms and increased use of preferred and acceptable phrases when communicating normal findings in abdominal CT and MRI reports.

Prior studies used submission numbers or report addendum rates to measure peer learning programs' (PLP) impact. We assessed the educational value of a PLP by manually reviewing cases submitted to identify factors correlating with meaningful learning opportunities (MLOs).This institutional review board-exempted, retrospective study was performed in a large academic radiology department generating800,000 reports annually. A PLP facilitating radiologist-to-radiologist feedback was implemented May 1, 2017, with subsequent pay-for-performance initiatives encouraging increasing submissions,18,000 by 2019. Two radiologists blinded to submitter and receiver identity categorized 336 randomly selected submissions as a MLO, not meaningful, or equivocal, resolving disagreements in consensus review. Primary outcome was proportion of MLOs. Secondary outcomes included percent engagement by subspecialty clinical division and comparing MLO and report addendum rates via Fisher's exact tests. We assessed association between peer learning category, pay-for-performance interventions, and subspecialty division with MLOs using logistic regression.Of 336 PLP submissions, 65.2% (219 of 336) were categorized as meaningful, 27.4% (92 of 336) not meaningful, and 7.4% (25 of 336) equivocal, with substantial reviewer agreement (86.0% [289 of 336], κ = 0.71, 95% confidence interval 0.64-0.78). MLO rate (65.2% [219 of 336]) was five times higher than addendum rate (12.9% [43 of 333]) for the cohort. MLO proportion (adjusted odds ratios 0.05-1.09) and percent engagement (0.5%-3.6%) varied between subspecialty divisions, some submitting significantly fewer MLOs (P.01). MLO proportion did not vary between peer learning categories.Educational value of a large-scale PLP, estimated through manual review of case submissions, is likely a more accurate measure of program impact. Incentives to enhance PLP use did not diminish the program's educational value.

Purpose To assess the impact of periprocedural factors, including adverse events, on overall patient survival following image-guided liver tumor cryoablation procedures. Methods In this retrospective single-institution study, 143 patients (73 male, 70 female, ages 29–88) underwent 169 image-guided liver tumor cryoablation procedures between October 1998 and August 2014. Patient, tumor and procedural variables were recorded. The primary outcome was overall survival post-procedure (Kaplan–Meier analysis). Secondary outcomes were the impact of 15 variables on patient survival, which were assessed with multivariate cox regression and log-rank tests. Results Mean tumor diameter was 2.5 ± 1.2 cm. 26 of 143 (18.2%) patients had primary hepatic malignancies; 117 of 143 (81.8%) had liver metastases. Survival analysis revealed survivor functions at 3, 5, 7, 10 and 12 years post-ablation of 0.54, 0.37, 0.30, 0.17 and 0.06, with mean survival time of 40.8 ± 4.9 months. Tumor size ≥4 cm (p = .018), pre-procedural platelet count

Assess use of a diagnostic certainty scale (CS) for abdominal imaging reports and identify factors associated with greater adoption.This retrospective, Institutional Review Board-exempt study was conducted at an academic health system. Abdominal radiology reports containing diagnostic certainty phrases (DCPs) generated 4/1/2019-3/31/2021 were identified by a natural language processing tool. Reports containing DCPs were subdivided into those with/without a CS inserted at the end. Primary outcome was monthly CS use rate in reports containing DCPs. Secondary outcomes were assessment of factors associated with CS use, and usage of recommended DCPs over time. Chi-square test was used to compare proportions; univariable and multivariable regression assessed impact of other variables.DCPs were used in 81,281/124,501 reports (65.3%). One-month post-implementation, 82/2310 (3.6%) of reports with DCPs contained the CS, increasing to 1862/4644 (40.1%) by study completion (p 0.001). Multivariable analysis demonstrated reports containing recommended DCPs were more likely to have the CS (Odds Ratio [OR] 4.5; p 0.001). Using CT as a reference, CS use was lower for ultrasound (OR 0.73; p 0.001) and X-ray (OR 0.38; p 0.001). There was substantial inter-radiologist variation in CS use (OR 0.01-26.3, multiple p values).DCPs are very common in abdominal imaging reports and can be further clarified with CS use. Although voluntary CS adoption increased 13-fold over 2 years, 50% of reports with DCPs lacked the CS at study's end. More stringent interventions, including embedding the scale in report templates, are likely needed to reduce inter-radiologist variation and decrease ambiguity in conveying diagnostic certainty to referring providers and patients.

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.

To review the current evidence and guidelines for diagnosis and management of incidental adrenal masses with a focus on the recent changes made by the American College of Radiology (ACR) Incidental Findings Committee. Incidentally detected adrenal nodules are a commonly encountered finding estimated to occur in 5–7% of the adult population. By following current recommendations, radiologists can improve patient care by efficiently determining which masses require further diagnostic testing and which masses can be considered benign and not require further follow-up.

Purpose The aim of this study was to improve the geometric fidelity and spatial resolution of multi-b diffusion-weighted magnetic resonance imaging of the prostate. Materials and Methods An accelerated segmented diffusion imaging sequence was developed and evaluated in 25 patients undergoing multiparametric magnetic resonance imaging examinations of the prostate. A reduced field of view was acquired using an endorectal coil. The number of sampled diffusion weightings, or b-factors, was increased to allow estimation of tissue perfusion based on the intravoxel incoherent motion (IVIM) model. Apparent diffusion coefficients measured with the proposed segmented method were compared with those obtained with conventional single-shot echo-planar imaging (EPI). Results Compared with single-shot EPI, the segmented method resulted in faster acquisition with 2-fold improvement in spatial resolution and a greater than 3-fold improvement in geometric fidelity. Apparent diffusion coefficient values measured with the novel sequence demonstrated excellent agreement with those obtained from the conventional scan (R-2 = 0.91 for b(max) = 500 s/mm(2) and R-2 = 0.89 for b(max) = 1400 s/mm(2)). The IVIM perfusion fraction was 4.0% +/- 2.7% for normal peripheral zone, 6.6% +/- 3.6% for normal transition zone, and 4.4% +/- 2.9% for suspected tumor lesions. Conclusions The proposed accelerated segmented prostate diffusion imaging sequence achieved improvements in both spatial resolution and geometric fidelity, along with concurrent quantification of IVIM perfusion.

Background and Purpose. Chronic rectal toxicity significantly decreases the quality of life for men who receive radiotherapy for prostate cancer. The most significant predictor of rectal toxicity is rectal dose-volume exceeding tolerance. To minimize the volume of rectum in the high dose field, it is essential to accurately define the prostate-rectum interface. This can be challenging to do by computed tomography (CT) imaging alone. The current study was undertaken to formally demonstrate in a clinical trial setting that image-guided intensity-modulated radiation therapy (IG-IMRT) planning using magnetic resonance imaging (MRI) can reduce the volume of rectum exceeding 70 Gy, a validated metric that predicts the risk of late rectal toxicity. Materials and Methods. This prospective single-arm study enrolled 15 men treated with IG-IMRT for localized prostate cancer. All participants received a dedicated 3 Tesla MRI examination of the prostate in addition to a pelvic CT examination for treatment planning. Two volumetric modulated arc therapy (VMAT) plans with a prescription dose of 79.2 Gy were designed using identical constraints based on CT- and MRI-defined consensus volumes. The volume of rectum exposed to 70 Gy or more was compared using the Wilcoxon paired signed rank test. Results. For CT-based treatment plans, the median volume of rectum receiving 70 Gy or more was 9.3 cubic centimeters (cc) (IQR 7.0 to 10.2) compared with 4.9 cc (IQR 4.1 to 7.8) for MRI-based plans. This resulted in a median volume reduction of 2.1 cc (IQR 0.5 to 5.3, P

Incidentally detected adrenal nodules are common, and prevalence increases with patient age. Although most are benign, it is important for the radiologist to be able to accurately determine which nodules require further testing and which are safely left alone. The American College of Radiology incidental adrenal White Paper provides a structured algorithm based on expert consensus for management of incidental adrenal nodules. If further diagnostic testing is indicated, adrenal computed tomography is the most appropriate test in patients for nodules less than 4 cm. In addition to imaging, biochemical testing and endocrinology referral is warranted to exclude a functioning mass.

PURPOSE To reduce CT and MRI protocol variation across a multisite radiology practice at an academic medical center so that patients with similar clinical presentations are examined the same way. MATERIALS AND METHODS This study was performed at a large academic radiology practice performing ∼800,000 radiology examinations annually. To diminish variability across the enterprise (2 general radiology divisions; 10 subspecialty imaging divisions), a Harmonization Oversight Committee was created and tasked with ensuring patients with similar clinical presentations undergo the same CT or MRI protocol, regardless of where they are imaged. A process for decision making and conflict resolution was established, supported by the department chair. Primary outcome measure was standardization of CT and MRI protocols across all sites. Secondary outcome was percent reduction of CT and MRI protocols postharmonization. RESULTS Over the 5-month harmonization process, most conflicts arose for abdominal imaging protocols because they are performed in four distinct subspecialty divisions, but all were addressed effectively through the conflict resolution process. Overall, there was a 31% reduction in the total number of CT and MRI protocols (before harmonization 481, after harmonization 331). There was significant variation in reduction of protocols per workgroup (multiple P values; range

The purpose of this article is to report our intermediate to long-term outcomes with image-guided percutaneous hepatic tumor cryoablation and to evaluate its technical success, technique efficacy, local tumor progression, and adverse event rate.Between 1998 and 2014, 299 hepatic tumors (243 metastases and 56 primary tumors; mean diameter, 2.5 cm; median diameter, 2.2 cm; range, 0.3-7.8 cm) in 186 patients (95 women; mean age, 60.9 years; range, 29-88 years) underwent cryoablation during 236 procedures using CT (n = 126), MRI (n = 100), or PET/CT (n = 10) guidance. Technical success, technique efficacy at 3 months, local tumor progression (mean follow-up, 2.5 years; range, 2 months to 14.6 years), and adverse event rates were calculated.The technical success rate was 94.6% (279/295). The technique efficacy rate was 89.5% (231/258) and was greater for tumors smaller than 4 cm (93.4%; 213/228) than for larger tumors (60.0%; 18/30) (p0.0001). Local tumor progression occurred in 23.3% (60/258) of tumors and was significantly more common after the treatment of tumors 4 cm or larger (63.3%; 19/30) compared with smaller tumors (18.0%; 41/228) (p0.0001). Adverse events followed 33.8% (80/236) of procedures and were grade 3-5 in 10.6% (25/236) of cases. Grade 3 or greater adverse events more commonly followed the treatment of larger tumors (19.5%; 8/41) compared with smaller tumors (8.7%; 17/195) (p = 0.04).Image-guided percutaneous cryoablation of hepatic tumors is efficacious; however, tumors smaller than 4 cm are more likely to be treated successfully and without an adverse event.

The purpose of this study is to determine the interobserver agreement of the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) for diagnosing prostate cancer using in-bore MRI-guided prostate biopsy as the reference standard.Fifty-nine patients underwent in-bore MRI-guided prostate biopsy between January 21, 2010, and August 21, 2013, and underwent diagnostic multiparametric MRI 6 months or less before biopsy. A single index lesion per patient was selected after retrospective review of MR images. Three fellowship-trained abdominal radiologists (with 1-11 years' experience) blinded to clinical information interpreted all studies according to PI-RADSv2. Interobserver agreement was assessed using Cohen kappa statistics.Thirty-eight lesions were in the peripheral zone and 21 were in the transition zone. Cancer was diagnosed in 26 patients (44%). Overall PI-RADS scores were higher for all biopsy-positive lesions (mean ± SD, 3.9 ± 1.1) than for biopsy-negative lesions (3.1 ± 1.0; p0.0001) and for clinically significant lesions (4.2 ± 1.0) than for clinically insignificant lesions (3.1 ± 1.0; p0.0001). Overall suspicion score interobserver agreement was moderate (κ = 0.45). There was moderate interobserver agreement among overall PI-RADS scores in the peripheral zone (κ = 0.46) and fair agreement in the transition zone (κ = 0.36).PI-RADSv2 scores were higher in the biopsy-positive group. PI-RADSv2 showed moderate interobserver agreement among abdominal radiologists with no prior experience using the scoring system.

OBJECTIVE. Variability in reports of the same imaging study performed at the same institution may be confusing to referrers and patients, hindering results communication. The purpose of this study was to introduce a quality improvement initiative aimed at reducing variation in radiology report templates at a large academic center. MATERIALS AND METHODS. The quality improvement initiative was undertaken at a large multisite, multidivision academic radiology practice performing more than 820,000 radiologic examinations annually. A project charter defined the goals, scope, and personnel of the initiative and an escalation pathway for conflict resolution. Standard requirements for templates were initially developed. From September 2017 to May 2018, an oversight committee (24 organ system and modality-based work groups with representatives from nine subspecialty divisions) reviewed and harmonized all institutional radiology report templates across the enterprise irrespective of the imaging site or division that interpreted the study. The primary outcome measure was percentage reduction in report templates after harmonization. The secondary outcome measure was monthly adherence to harmonized templates for 9 months after implementation assessed by manual review of 40 randomly selected reports per month. The paired t test was used to assess template reduction, and the chi-square trend test was used to study trend in adherence to harmonized templates. RESULTS. Among 19,687 total templates at baseline, 597 harmonized templates remained after harmonization (p < 0.001). There was variation in template reduction by work group (multiple p < 0.05; reduction range, 79.2-99.3%). Radiologist adherence to harmonized templates ranged from 88.0% to 100%, unchanged in the 9 months after implementation (p = 0.23, chi-square trend). CONCLUSION. A radiology report harmonization initiative reduced 97.0% of report templates with a sustained high degree of adherence to harmonized templates after implementation at a large multisite multidivision academic radiology practice.

The most recent edition of the prostate imaging reporting and data system (PI-RADS version 2) was developed based on expert consensus of the international working group on prostate cancer. It provides the minimum acceptable technical standards for MR image acquisition and suggests a structured method for multiparametric prostate MRI (mpMRI) reporting. T1-weighted, T2-weighted (T2W), diffusion-weighted (DWI), and dynamic contrast-enhanced (DCE) imaging are the suggested sequences to include in mpMRI. The PI-RADS version 2 scoring system enables the reader to assess and rate all focal lesions detected at mpMRI to determine the likelihood of a clinically significant cancer. According to PI-RADS v2, a lesion with a Gleason score ≥7, volume >0.5 cc, or extraprostatic extension is considered clinically significant. PI-RADS v2 uses the concept of a dominant MR sequence based on zonal location of the lesion rather than summing each component score, as was the case in version 1. The dominant sequence in the peripheral zone is DWI and the corresponding apparent diffusion coefficient (ADC) map, with a secondary role for DCE in equivocal cases (PI-RADS score 3). For lesions in the transition zone, T2W images are the dominant sequence with DWI/ADC images playing a supporting role in the case of an equivocal lesion.

Objective Assess information integrity (concordance and completeness of documented exam indications from the electronic health record [EHR] imaging order requisition, compared to EHR provider notes), and assess potential impact of indication inaccuracies on exam planning and interpretation. Methods This retrospective study, approved by the Institutional Review Board, was conducted at a tertiary academic medical center. There were 139 MRI lumbar spine (LS-MRI) and 176 CT abdomen/pelvis orders performed 4/1/2016-5/31/2016 randomly selected and reviewed by 4 radiologists for concordance and completeness of relevant exam indications in order requisitions compared to provider notes, and potential impact of indication inaccuracies on exam planning and interpretation. Forty each LS-MRI and CT abdomen/pelvis were re-reviewed to assess kappa agreement. Results Requisition indications were more likely to be incomplete (256/315, 81%) than discordant (133/315, 42%) compared to provider notes (p Conclusions Improved availability of relevant documented clinical information within EHR imaging requisition is necessary for optimal exam planning and interpretation.

Rationale and Objectives To implement a preprocedural checklist in gastrointestinal (GI)/genitourinary (GU) fluoroscopy suites to assist radiology residents in performing studies with optimal fluoroscopic technique with a goal to lower radiation dose delivered to patients and operators. Materials and Methods We introduced a preprocedural checklist in the form of a mnemonic to first-year resident fluoroscopy operators. The checklist was augmented by teaching sessions at the fluoroscopy tower. Fluoroscopy time (FT) was collected for GI/GU fluoroscopy studies performed by first-year residents who did not use the checklist (year 1) and compared with FT from first-year residents who used the checklist for one full academic year (year 2). Residents in both groups were surveyed to assess their knowledge of radiation safety at the end of their respective radiology 1 (R1) academic years. Results A total of 778 examinations were analyzed from year 1, and 941 total examinations from year 2. After implementation of the checklist, mean FT for all studies decreased by 41.1 seconds ( P P = .144). Conclusions A visual preprocedural radiation safety checklist in GI/GU fluoroscopy was associated with a reduction in mean FT and may contribute to a culture of radiation safety awareness.

To compare diagnostic performance of PI-RADSv2 with ADC parameters to identify clinically significant prostate cancer (csPC) and to determine the impact of csPC definitions on diagnostic performance of ADC and PI-RADSv2. We retrospectively identified treatment-naive pathology-proven peripheral zone PC patients who underwent 3T prostate MRI, using high b-value diffusion-weighted imaging from 2011 to 2015. Using 3D slicer, areas of suspected tumor (T) and normal tissue (N) on ADC (b = 0, 1400) were outlined volumetrically. Mean ADCT, mean ADCN, ADCratio (ADCT/ADCN) were calculated. PI-RADSv2 was assigned. Three csPC definitions were used: (A) Gleason score (GS) ≥ 4 + 3; (B) GS ≥ 3 + 4; (C) MRI-based tumor volume >0.5 cc. Performances of ADC parameters and PI-RADSv2 in identifying csPC were measured using nonparametric comparison of receiver operating characteristic curves using the area under the curve (AUC). Eighty five cases met eligibility requirements. Diagnostic performances (AUC) in identifying csPC using three definitions were: (A) ADCT (0.83) was higher than PI-RADSv2 (0.65, p = 0.006); (B) ADCT (0.86) was higher than ADCratio (0.68, p

To determine test characteristics of CT urography for detecting bladder cancer in patients with hematuria and those undergoing surveillance, and to analyze reasons for false-positive and false-negative results. A HIPAA-compliant, IRB-approved retrospective review of reports from 1623 CT urograms between 10/2010 and 12/31/2013 was performed. 710 examinations for hematuria or bladder cancer history were compared to cystoscopy performed within 6 months. Reference standard was surgical pathology or 1-year minimum clinical follow-up. False-positive and false-negative examinations were reviewed to determine reasons for errors. Ninety-five bladder cancers were detected. CT urography accuracy: was 91.5% (650/710), sensitivity 86.3% (82/95), specificity 92.4% (568/615), positive predictive value 63.6% (82/129), and negative predictive value was 97.8% (568/581). Of 43 false positives, the majority of interpretation errors were due to benign prostatic hyperplasia (n = 12), trabeculated bladder (n = 9), and treatment changes (n = 8). Other causes include blood clots, mistaken normal anatomy, infectious/inflammatory changes, or had no cystoscopic correlate. Of 13 false negatives, 11 were due to technique, one to a large urinary residual, one to artifact. There were no errors in perception. CT urography is an accurate test for diagnosing bladder cancer; however, in protocols relying predominantly on excretory phase images, overall sensitivity remains insufficient to obviate cystoscopy. Awareness of bladder cancer mimics may reduce false-positive results. Improvements in CTU technique may reduce false-negative results.

312 Background: Chronic rectal toxicity significantly decreases the quality of life for men who receive radiotherapy for prostate cancer. The volume of rectum exposed to 70 Gy or more is a validated metric that predicts the risk of late rectal toxicity. We hypothesized that MRI as compared to CT-based prostate radiotherapy treatment planning can reduce the volume of rectum exceeding 70 Gy. Methods: This prospective study single arm study enrolled 15 men treated with external beam radiation therapy for localized prostate cancer. At the time of treatment planning a 3 Tesla T2-weighted magnetic resonance imaging examination of the prostate was obtained. A radiotherapy plan was designed by a medical physicist using identical constraints for both CT and MRI-based consensus volumes defined by a radiologist and radiation oncologist. The volume of rectum exposed to 70 Gy or more was calculated and compared using the paired Signed Rank Test. Results: The median age was 70 years (range 56-84), median PSA 7.3 ng/mL (range 3.2 – 22.1), and median prostate volume 40 mL (range 25 - 65) by transrectal ultrasound. Sixty percent (n=9) were intermediate risk and 40 percent (n=6) high risk by NCCN guidelines. The majority were either clinical stage T1c (n=7) or T2 (n=6). Two men had extracapsular extension (T3a). None of the participants had seminal vesicle invasion (T3b), rectal or bladder involvement (T4), or lymph node metastasis (N1). All 15 men enrolled on the study completed both a standard radiation planning CT and research MRI examination. For CT-based treatment plans the median volume of rectum receiving 70 Gy or more was 9.3 cubic centimeters (cc) [IQR 7.0 to 10.2] compared with 4.9 cc [IQR 4.1 to 8.7] for MRI-based plans. This resulted in a median volume reduction of 2.1 cc [IQR 0.5 to 5.3, P < .001]. Conclusions: MRI-planned prostate radiotherapy can reduce the volume of rectum receiving radiation doses in excess of tolerance (70 Gy or more) and should be considered in men who are at high risk for late rectal toxicity. Clinical trial information: NCT02470910.

OBJECTIVE. The purpose of this article is to evaluate single-source dual-energy CT (DECT) for distinguishing benign and indeterminate adrenal nodules, with attention to the effects of phase of IV contrast enhancement. MATERIALS AND METHODS. A retrospective review revealed 273 contrast-enhanced abdominal DECT examinations from November 2009 through March 2012. Fifty adrenal nodules 0.8 cm or larger were identified in 41 patients (22 women and 19 men; average age, 66 years; age range, 36–88 years). CT postprocessing and measurements were independently performed by two radiologists (readers 1 and 2) for each nodule, as follows: attenuation (in Hounsfield units) on true unenhanced images; contrast-enhanced attenuation (in Hounsfield units) on monochromatic spectral images at 40, 75, and 140 keV; and contrast-enhanced material density (in milligrams per milliliter) on virtual unenhanced images. Nodules were classified as benign (< 10 HU) and indeterminate (≥ 10 HU) according to true unenhanced images. RESULTS....

To determine for expert and novice radiologists repeatability of major diagnostic features and scoring systems (ie, Liver Imaging Reporting and Data System [LI-RADS], Organ Procurement and Transplantation Network [OPTN], and American Association for the Study of Liver Diseases [AASLD]) for hepatocellular carcinoma (HCC) by using magnetic resonance (MR) imaging.Institutional review board approval was obtained and patient consent was waived for this HIPAA-compliant, retrospective study. The LI-RADS discussed in this article refers to version 2013.1. Ten blinded readers reviewed 100 liver MR imaging studies that demonstrated observations preliminarily assigned LI-RADS scores of LR1-LR5. Diameter and major HCC features (arterial hyperenhancement, washout appearance, pseudocapsule) were recorded for each observation. LI-RADS, OPTN, and AASLD scores were assigned. Interreader agreement was assessed by using intraclass correlation coefficients and κ statistics. Scoring rates were compared by using McNemar test.Overall interreader agreement was substantial for arterial hyperenhancement (0.67 [95% confidence interval {CI}: 0.65, 0.69]), moderate for washout appearance (0.48 [95%CI: 0.46, 0.50]), moderate for pseudocapsule (0.52 [95% CI: 050, 0.54]), fair for LI-RADS (0.35 [95% CI: 0.34, 0.37]), fair for AASLD (0.39 [95% CI: 0.37, 0.42]), and moderate for OPTN (0.53 [95% CI: 0.51, 0.56]). Agreement for measured diameter was almost perfect (range, 0.95-0.97). There was substantial agreement for most scores consistent with HCC. Experts agreed significantly more than did novices and were significantly more likely than were novices to assign a diagnosis of HCC (P.001).Two of three major features for HCC (washout appearance and pseudocapsule) have only moderate interreader agreement. Experts and novices who assigned scores consistent with HCC had substantial but not perfect agreement. Expert agreement is substantial for OPTN, but moderate for LI-RADS and AASLD. Novices were less consistent and less likely to diagnose HCC than were experts.

To determine if tumor cell density and percentage of Gleason pattern within an outlined volumetric tumor region of interest (TROI) on whole-mount pathology (WMP) correlate with apparent diffusion coefficient (ADC) values on corresponding TROIs outlined on pre-operative MRI. Men with biopsy-proven prostate adenocarcinoma undergoing multiparametric MRI (mpMRI) prior to prostatectomy were consented to this prospective study. WMP and mpMRI images were viewed using 3D Slicer and each TROI from WMP was contoured on the high b-value ADC maps (b0, 1400). For each TROI outlined on WMP, TCD (tumor cell density) and the percentage of Gleason pattern 3, 4, and 5 were recorded. The ADCmean, ADC10th percentile, ADC90th percentile, and ADCratio were also calculated in each case from the ADC maps using 3D Slicer. Nineteen patients with 21 tumors were included in this study. ADCmean values for TROIs were 944.8 ± 327.4 vs. 1329.9 ± 201.6 mm2/s for adjacent non-neoplastic prostate tissue (p

Radioiodine imaging has a well-established role in depicting metastatic disease after thyroidectomy in patients with well-differentiated thyroid cancer. Uptake of radioiodine in thyroid metastases depends on expression of sodium-iodide symporter (NIS) by tumor tissues. However, because radioiodine may also accumulate in normal structures and tissues, it is important to distinguish physiologic radioiodine activity from metastatic disease. Furthermore, secretions that contain radioiodine may also simulate pathologic uptake. A spectrum of physiologic distributions, normal variants, and benign mimics of disease have been described in the literature; yet, even when armed with a comprehensive knowledge of these patterns, interpreting radiologists and nuclear physicians may still encounter diagnostic uncertainty. Single-photon emission computed tomography (SPECT) with integrated computed tomography (CT) is a novel technology that, when applied to diagnostic iodine 123 or iodine 131 ((131)I) radioiodine scintigraphy, may accurately localize and help distinguish benign mimics of disease, with the potential to alter the management plan. SPECT/CT is increasingly being used with radioiodine scintigraphy to evaluate patients with thyroid cancer and shows promise for improving imaging specificity and reducing false-positive results.

The purpose of this study was to evaluate stone detection, assessment of secondary signs of stone disease, and diagnostic confidence utilizing submillisievert CT with model-based iterative reconstruction (MBIR) in a North American population with diverse body habitus.Fifty-two adults underwent stone CT using a split-dose protocol; weight-based projected volume CT dose index (CTDIvol) and dose-length product (DLP) were divided into two separate acquisitions at 80% and 20% dose levels. Images were reconstructed with MBIR. Five blinded readers counted stones in three size categories and rated "overall diagnostic confidence" and "detectability of secondary signs of stone disease" on a 0-4 scale at both dose levels. Effective dose (ED) in mSv was calculated as DLP multiplied by conversion coefficient, k, equal to 0.017.Mean ED (80%, 3.90±1.44 mSv; vs 20%, 0.97±0.34 mSv [p0.001]) and number of stones detected (80%, 193.6±25.0; vs 20%, 154.4±15.4 [p=0.03]) were higher in scans at 80% dose level. Intrareader correlation between scans at 80% and 20% dose levels was excellent (0.83-0.97). With 80% scans as reference standard, mean sensitivity and specificity at 20% varied with stone size (3 mm, 74% and 77%; ≥3 mm, 92% and 82%). The 20% scans scored lower than 80% scans in diagnostic confidence (2.46±0.50; vs 3.21±0.36 [p0.005]) and detectability of secondary signs (2.41±0.39; vs 3.19±0.29 [p0.005]).Aggressively dose-reduced (~1 mSv) MBIR scans detected most urinary tract stones of 3 mm or larger but underperformed the low-dose reference standard (3-4 mSv) scans in small (3 mm) stone detection and diagnostic confidence.

To determine whether focal peripheral zone enhancement on routine venous-phase CT is predictive of higher-grade (Gleason 4 + 3 and higher) prostate cancer.IRB approval was obtained and informed consent waived for this HIPAA-compliant retrospective study. Forty-three patients with higher-grade prostate cancer (≥Gleason 4 + 3) and 96 with histology-confirmed lower-grade (≤Gleason 3 + 4 [n = 47]) or absent (n = 49) prostate cancer imaged with venous-phase CT comprised the study population. CT images were reviewed by ten blinded radiologists (5 attendings, 5 residents) who scored peripheral zone enhancement on a scale of 1 (benign) to 5 (malignant). Mass-like peripheral zone enhancement was considered malignant. Likelihood ratios (LR) and specificities were calculated. Multivariate conditional logistic regression analyses were conducted.Scores of "5" were strongly predictive of higher-grade prostate cancer (pooled LR+ 9.6 [95% CI 5.8-15.8]) with rare false positives (pooled specificity: 0.98 [942/960, 95% CI 0.98-0.99]; all 10 readers had specificity ≥95%). Attending scores of "5" were more predictive than resident scores of "5" (LR+: 14.7 [95% CI 5.8-37.2] vs. 7.6 [95% CI 4.2-13.7]) with similar specificity (0.99 [475/480, 95% CI 0.98-1.00] vs. 0.97 [467/480, 95% CI 0.96-0.99]). Significant predictors of an assigned score of "5" included presence of a peripheral zone mass (p0.0001), larger size (p0.0001), and less reader experience (p = 0.0008). Significant predictors of higher-grade prostate cancer included presence of a peripheral zone mass (p = 0.0002) and larger size (p0.0001).Focal mass-like peripheral zone enhancement on routine venous-phase CT is specific and predictive of higher-grade (Gleason 4 + 3 and higher) prostate cancer.

Ultrasound (US) is an extremely useful diagnostic imaging modality because of its real-time capability, noninvasiveness, portability, and relatively low cost. It carries none of the potential risks of ionizing radiation exposure or intravenous contrast administration. For these reasons, numerous medical specialties now rely on US not only for diagnosis and guidance for procedures, but also as an extension of the physical examination. In addition, many medical school educators recognize the usefulness of this technique as an aid to teaching anatomy, physiology, pathology, and physical diagnosis. Radiologists are especially interested in teaching medical students the appropriate use of US in clinical practice. Educators who recognize the power of this tool have sought to incorporate it into the medical school curriculum. The basic question that educators should ask themselves is: "What should a student graduating from medical school know about US?" To aid them in answering this question, US specialists from the Society of Radiologists in Ultrasound and the Alliance of Medical School Educators in Radiology have collaborated in the design of a US curriculum for medical students. The implementation of such a curriculum will vary from institution to institution, depending on the resources of the medical school and space in the overall curriculum. Two different examples of how US can be incorporated vertically or horizontally into a curriculum are described, along with an explanation as to how this curriculum satisfies the Accreditation Council for Graduate Medical Education competencies, modified for the education of our future physicians.

This is an interactive module aimed at senior medical students and radiology residents during a nuclear medicine rotation that discusses the common imaging findings of conditions that cause hyperthyroidism. Typical cases of Graves disease, Plummer disease, toxic multinodular goiter, and thyroiditis are presented in an interactive fashion using illustrative case examples accompanied by multiple-choice questions. Issues that arise following radioiodine therapy with regard to Nuclear Regulatory Commission rules, and causes and mechanisms of iodine-induced hyperthyroidism and hypothyroidism are also discussed. It is anticipated that an individual will go through the presentation in a self-guided manner. It will likely take approximately 1 hour to complete the entire presentation. While this basic presentation should suffice for medical students and junior residents, it is not meant to be a definitive source of facts for more senior radiologists. Those that require more in-depth information can utilize some of the selected resources listed at the end of the presentation or consult a nuclear medicine textbook. Because of the question and answer format, it is hoped that this presentation will be useful for medical students, radiology residents, and even practicing radiologists as a review tool.

Timbre is a major structuring force in music and one of the most important and ecologically relevant fea- tures of auditory events. We used sound stimuli se- lected on the basis of previous psychophysiological studies to investigate the neural correlates of timbre perception. Our results indicate that both the left and right hemispheres are involved in timbre processing, challenging the conventional notion that the elemen- tary attributes of musical perception are predomi- nantly lateralized to the right hemisphere. Significant timbre-related brain activation was found in well-de- fined regions of posterior Heschl's gyrus and superior temporal sulcus, extending into the circular insular sulcus. Although the extent of activation was not sig- nificantly different between left and right hemi- spheres, temporal lobe activations were significantly posterior in the left, compared to the right, hemi- sphere, suggesting a functional asymmetry in their respective contributions to timbre processing. The im- plications of our findings for music processing in par- ticular and auditory processing in general are dis- cussed. © 2002 Elsevier Science (USA)

An abdominal computed tomographic scan was modified by inserting 10 simulated colonic polyps with use of methods that closely mimic the attenuation, noise, and polyp-colon wall interface of naturally occurring polyps. A shape-based polyp detector successfully located six of the 10 polyps. When settings that enhanced the edge profile of polyps were chosen, eight of 10 polyps were detected. There were no false-positive detections. Shape analysis is technically feasible and is a promising approach to automated polyp detection.