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Twisting of the abdominal organs usually leads to acute abdomen, and a timely diagnosis is critical to salvage organ viability. Early diagnosis and prompt intervention are essential to avoid complications of ischemia and gangrene. Volvulus/torsion of the abdominal and pelvic organs present with non-specific clinical symptoms such as acute severe abdominal or pelvic pain generally necessitating imaging diagnosis. Since the timely critical diagnosis is necessary, emergency radiologists need to be well versed with the pertinent imaging findings of this acute surgical condition.

Background In 2019, the total National Healthcare Expenditure (NHE) reached $3.8 trillion, or nearly 20% of the total Gross Domestic Product. This represents a 4-fold increase in its Gross Domestic Product share since 1960. Given the magnitude and growth of such expenditures, healthcare cost containment is central to the country's financial sustainability. Moreover, as Medicare represents nearly 20% of the total NHE, it is a primary target for piloting, implementing and scaling initiatives that reduce expenditures. Objective To assess trends in Medicare Physician Fee Schedule for Service (Part B) payments and utilization for Imaging relative to other services from 2009 through 2019. Materials and methods We conducted a retrospective observational study of annual expenditures and utilization of imaging services using data from Centers for Medicare and Medicaid Services Medicare Part B. Data was grouped according to the Berenson-Eggers Type of Service Classification. The values were adjusted for inflation and we calculated the annual changes and the compound annual growth rates and the price elasticity of supply. Results For the 10-year period, Imaging represented on average 8% of the total Medicare Part B expenditures, an equivalent of 1.4% of total Medicare expenditures or 0.05% of the NHE. While NHE, overall Medicare and overall Part B had positive growth rates of total expenditures, Imaging did not. Moreover, Imaging had the most negative CAGR compared to all other categories, including Drugs, Procedures, Evaluation and Management and Durable Medical Equipment. Conclusion Imaging did not contribute to the increase in Medicare Part B expenditures, and it might have been disproportionately affected by cost containment policies.

Background: The frequency of clinically significant prostate cancer (csPCa) following negative biparametric MRI (bpMRI) and multiparametric MRI (mpMRI) has not been well investigated in direct comparative studies. Objective: To compare the frequency of csPCa after negative prebiopsy bpMRI and mpMRI, and to evaluate factors that predict csPca in the two cohorts. Methods: This retrospective study included 232 men (mean age, 64.5 years) with negative bpMRI from August 2017 to March 2020 and193 men (mean age, 69.0 years) with negative mpMRI from January 2018 to December 2018, defining PI-RADS category of 1 or 2 as negative. Our institution offers bpMRI as a low-cost self-pay option for patients without insurer coverage of prebiospy mpMRI. Patient characteristics and subsequent biopsy results were recorded. csPCa was defined as Gleason score ≥3+4. Multivariable regression analyses were performed to identify independent predictors of csPCa. AUC of prostate specific antigen density (PSAD) for csPCA was computed, and diagnostic performance of PSAD was assessed at a clinically established threshold of 0.15 ng/mL2. Results: Systematic biopsy was performed after negative bpMRI in 41.4% (96/232), versus after negative mpMRI in 30.5% (59/193) (p=.02). Among those undergoing biopsy, csPCa was present in 15.6% (15/96) in the mpMRI cohort versus 13.6% (8/59) in the bpMRI cohort (p=.69). NPV for csPCa was 84% (81/96) for bpMRI and 86% (51/59) for mpMRI. In multivariable analyses, independent predictors of csPCa included smaller prostate volume (OR=0.27, p .05). PSAD had AUC for csPCa of 0.77 (95% CI: 0.64, 0.89) in the bpMRI cohort versus 0.68 (95% CI: 0.42, 0.93) in the mpMRI cohort. For detecting csPCa, PSAD threshold of 0.15 ng/mL2 had NPV of 90% and PPV of 28%, in the bpMRI cohort, versus NPV of 92% and PPV of 44%in the mpMRI cohort. Conclusion: The frequency of csPCa was not significantly different on systematic biopsy performed after negative bpMRI and mpMRI examinations. PSAD had similar diagnostic utility for csPca in both cohorts. Clinical Impact: Either bpMRI or mpMRI, in combination with PSAD, can help avoid negative prostate biopsies.

Dysphagia, or a disorder of swallowing, is very common and is reported in 1 out of 25 adults with approximately 1 million new cases per year in the United States alone. This also disproportionately impacts elderly patients, with a prevalence of 17%. Patients with dysphagia may have severe clinical complications such as starvation, dehydration, and airway obstruction- which may further increase mortality. Hence, timely and accurate diagnosis of dysphagia is hence crucial in management considerations. The gold standard for evaluating and diagnosing dysphagia is a modified barium swallow study (MBSS). The study is typically performed as a collaborative effort between a speech language pathologist (SLP) and a radiologist, who bring their individual skill sets to the table. Current MBSS reporting involves separately dictated and interpreted reports from the SLP and radiologist. In this paper, we elucidate our experience in a multi-institutional healthcare system wherein we have devised a single, integrated report for MBSS, which involves collaborative effort between SLP and the radiologist. We weight the advantages and disadvantages of unified reporting, the challenges of implementing it in a large healthcare system, and note how it can help improve efficiency and deliver unified patient care. We hope that this would be a template for other institutions as well as improve standardization of reporting techniques.

Purpose To analyze emergency department (ED) computerized tomography (CT) utilization in cancer patients with coronavirus disease 2019 (COVID-19). Methods A retrospective chart review was performed to identify cancer patients who received COVID-19 diagnosis within the single healthcare system and presented to the ED within 30 days of COVID-19 positive date between May 1 and December 31, 2020. Results In our 61 patients, the mean age was 72.5 years old, with 34% of patients (n = 21) on active cancer therapy and 66% (n = 40) on surveillance only. Most patients (n = 53) received their COVID-19 diagnosis within the ED, with 8 patients diagnosed prior to initial ED visit. The most common CT studies ordered within the ED were CT chest (n = 25), CT abdomen/pelvis (A/P) (n = 20), CT head (n = 8), and CT chest/abdomen/pelvis (C/A/P) (n = 7). COVID-19 findings were present on 33 scans, findings of worsening malignancy on 12 scans, and non-COVID non-cancer findings on 9 scans. Significant differences in CT severity score (p = 0.0001), indication for hospitalization (p = 0.026), length of hospitalization (p = 0.004), interventions (remdesivir, mechanical ventilation, and vasopressor support) while hospitalized (p

Serum and tissue tumor markers provide crucial information in the diagnosis, treatment, and follow-up of colorectal cancers. Tissue tumor markers are increasingly used for determination of targeted chemotherapy planning based on genotyping of tumor cells. Recently, plasma-based technique of liquid biopsy is being evaluated for providing tumor biomarkers in the management of colorectal cancer. Tumor markers are commonly used in conjunction with imaging during initial staging, treatment determination, response assessment, and determination of recurrence or metastatic disease. Knowledge of tumor markers and their association with radiological findings is thus crucial for radiologists. Additionally, various novel imaging techniques are being evaluated as potential noninvasive imaging biomarkers to predict tumor genotypes, features, and tumor response. We review and discuss the potential role of these newer imaging techniques.

OBJECTIVE The objective of this study was to evaluate the clinical, laboratory, imaging, and pathology findings associated with emergency department presentations of posttransplant lymphoproliferative disorder (PTLD) after solid organ transplant (SOT). METHODS Fifteen patients presenting to a single tertiary care center between 2004 and 2019 with PTLD after SOT were identified from a pathology database. Twelve patients presenting through the emergency department were included in the study. Demographic, clinical, imaging, pathology, treatment, and outcome data were reviewed. RESULTS Among this 12 patient cohort (7 men; mean age, 44.2 years), transplant history included 4 combined kidney/pancreas, 4 kidney, 2 liver, 1 cardiac, and 1 lung. Mean time from transplant to diagnosis was 7.6 years. Posttransplant lymphoproliferative disorder was identified on initial computed tomography scans in 10 of 12 patients. The most common sites for PTLD development were the gastrointestinal tract (4/12) and liver (3/12). Outcomes included resolution of PTLD in 9 of 12 patients, with 3 patients dying within 6 months of diagnosis. CONCLUSIONS Posttransplant lymphoproliferative disorder is a serious consequence of solid organ transplantation that can present in various locations and with varied symptomatology in the emergency setting. Other posttransplant complications may present similarly including chronic rejection and infection. Posttransplant lymphoproliferative disorder should be considered in SOT patients presenting with worsening abdominal pain or constitutional symptoms, even with normal laboratory workup.

Summary: Background: Biparametric MRI (comprising T2-weighted MRI and apparent diffusion coefficient maps) is increasingly being used to characterise prostate cancer. Although previous studies have combined Prostate Imaging–Reporting & Data System (PI-RADS)-based MRI findings with routinely available clinical variables and with deep learning-based imaging predictors, respectively, for prostate cancer risk stratification, none have combined all three. We aimed to construct an integrated nomogram (referred to as ClaD) combining deep learning-based imaging predictions, PI-RADS scoring, and clinical variables to identify clinically significant prostate cancer on biparametric MRI. Methods: In this retrospective multicentre study, we included patients with prostate cancer, with histopathology or biopsy reports and a screening or diagnostic MRI scan in the axial view, from four cohorts in the USA (from University Hospitals Cleveland Medical Center, Icahn School of Medicine at Mount Sinai, Cleveland Clinic, and Long Island Jewish Medical Center) and from the PROSTATEx Challenge dataset in the Netherlands. We constructed an integrated nomogram combining deep learning, PI-RADS score, and clinical variables (prostate-specific antigen, prostate volume, and lesion volume) using multivariable logistic regression to identify clinically significant prostate cancer on biparametric MRI. We used data from the first three cohorts to train the nomogram and data from the remaining two cohorts for independent validation. We compared the performance of our ClaD integrated nomogram with that of integrated nomograms combining clinical variables with either the deep learning-based imaging predictor (referred to as DIN) or PI-RADS score (referred to as PIN) using area under the receiver operating characteristic curves (AUCs). We also compared the ability of the nomograms to predict biochemical recurrence on a subset of patients who had undergone radical prostatectomy. We report cross-validation AUCs as means for the training set and used AUCs with 95% CIs to assess the performance on the test set. The difference in AUCs between the models were tested for statistical significance using DeLong's test. We used log-rank tests and Kaplan-Meier curves to analyse survival. Findings: We investigated 592 patients (823 lesions) with prostate cancer who underwent 3T multiparametric MRI at five hospitals in the USA between Jan 8, 2009, and June 3, 2017. The training data set consisted of 368 patients from three sites (the PROSTATEx Challenge cohort [n=204], University Hospitals Cleveland Medical Center [n=126], and Icahn School of Medicine at Mount Sinai [n=38]), and the independent validation data set consisted of 224 patients from two sites (Cleveland Clinic [n=151] and Long Island Jewish Medical Center [n=73]). The ClaD clinical nomogram yielded an AUC of 0·81 (95% CI 0·76–0·85) for identification of clinically significant prostate cancer in the validation data set, significantly improving performance over the DIN (0·74 [95% CI 0·69–0·80], p=0·0005) and PIN (0·76 [0·71–0·81], p

To investigate the differences in small cell lung cancer (SCLC) diagnostic imaging utilization relative to National Comprehensive Cancer Network (NCCN) guidelines.We retrospectively reviewed SCLC records at our institution between January 1, 2003 and August 1, 2019 (n = 529). Patients were grouped by extensive-stage versus limited-stage and diagnosis date. Clinical, CT, MRI, and nuclear imaging data was collected. Imaging utilization was compared using Student's t-test or Kruskal-Wallis-test/Wilcoxon-Rank-Sums test. Survival was compared using Log-rank-test and Kaplan-Meier-curves.SCLC patients had a median survival of 290 days. Extensive-stage patients with SCLC demonstrated an increase in emergency imaging utilization when diagnosed in 2011-2019 compared to 2003-2010 (CT abdomen/pelvis p 0.001, CTA chest for pulmonary embolism p 0.01, CT head p 0.003). Limited-stage patients with SCLC demonstrated an increase in inpatient imaging utilization (CT abdomen/pelvis p 0.04) and decreased total/outpatient imaging utilization (CT chest-abdomen-pelvis p 0.05, CT head p 0.003) when diagnosed in 2011-2019 compared to 2003-2010. All patients with SCLC had decreased average number of bone-scan studies when diagnosed in 2011-2019 compared to 2003-2010 (Extensive-stage p 0.006, Limited-stage p 0.0006).Imaging utilization trends in the management of patients with SCLC at our institution differed between 2003 and 2010 and 2011-2019 reflecting the changes in the NCCN guidelines.

OBJECTIVE. The purpose of this article is to provide radiologists with a guide to the fundamental principles of oncology clinical trials. The review summarizes the evolution and structure of modern...

Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness.

OBJECTIVE. The purpose of this article is to review the spectrum, etiopathogenesis, clinical presentation, imaging features, differential diagnoses, and management of emphysematous infections of the abdomen and pelvis. CONCLUSION. Emphysematous infections are associated with high morbidity and mortality and thus need urgent medical and surgical interventions. CT is the most sensitive modality to detect gas; CT provides definitive diagnosis in most cases and can depict the extent of involvement.

Objective The study aims to demonstrate risk factors for colitis in intensive care unit patients with and without coronavirus disease 2019 (COVID-19). Methods Retrospective review was performed to identify intensive care unit (ICU) patients with the diagnosis of COVID-19 with computed tomography (CT) between March 20 and December 31, 2020. ICU patients without COVID-19 diagnosis with CT between March 20 and May 10, 2020 were also identified. CT image findings of colitis or terminal ileitis as well as supportive treatment including ventilator, vasopressors, or extracorporeal membrane oxygenation (ECMO) were recorded. Statistical analysis was performed to determine if clinical factors differed in patients with and without positive CT finding. Results Total 61 ICU patients were selected, including 32 (52%) COVID-19-positive patients and 29 (48%) non-COVID-19 patients. CT findings of colitis or terminal ileitis were identified in 27 patients (44%). Seventy-four percent of the patients with positive CT findings (20/27) received supportive therapies prior to CT, while 56% of the patients without abnormal CT findings (19/34) received supportive therapies. Vasopressor treatment was significantly associated with development of colitis and/or terminal ileitis (p = 0.04) and COVID-19 status was not significantly different between these groups (p = 0.07). Conclusions In our study, there was significant correlation between prior vasopressor therapy and imaging findings of colitis or terminal ileitis in ICU patients, independent of COVID-19 status. Our observation raises a possibility that the reported COVID-19-related severe gastrointestinal complications and potential poor outcome could have been confounded by underlying severe critically ill status, and warrants a caution in diagnosis of gastrointestinal complication.

Unintended weight loss (UWL) is a common presenting symptom in the emergency department (ED) with several etiologies. Our study looks to evaluate the diagnostic utility of computed tomography (CT) in the evaluation of UWL in the ED. We identified all patients who underwent CT of the chest, abdomen, or pelvis in the ED at our institution for the diagnosis of UWL from 2004 to 2020 and retrospectively reviewed their clinical history and imaging. CT findings were organized into 4 types: (1) definite cause for UWL identified, (2) possible findings for UWL, (3) incidental findings unrelated to UWL, and (4) normal scan. Associations between clinical and laboratory findings with positive CT scans were also examined. One hundred seventy-three eligible patients were identified; 40 patients were excluded due to history of malignancy or inadequate follow-up. One hundred thirty-three patients were included in the final cohort. Overall, the most common causes of UWL were non-malignant gastrointestinal (GI) conditions (n = 41, 30%) and cancer (n = 30, 23%). True-positive CT findings were identified in 48.8% of patients (65/133). Elevated white blood cell counts (p =

Unintentional weight loss (UWL) is a common presenting symptom with a wide differential diagnosis. Causes may be organic (e.g., malignancy or gastrointestinal disease) or inorganic (e.g., psychosocial). The purpose of this review is to provide a guide for radiologists and other clinicians to understand the imaging modalities and laboratory studies involved in the diagnosis and treatment of UWL and the evidence supporting their routine use. Cases illustrating both common and uncommon causes of UWL are presented to emphasize both the breadth of pathology that may cause UWL as well as the importance of a multi-modality diagnostic approach. Imaging studies are crucial in the diagnosis of unintentional weight loss, particularly with regard to evaluating for the presence of malignancy. It is important for both the radiologist and other clinicians to understand the relative prevalence of the various causes of UWL and the utility of different imaging modalities in diagnosis and management.

Treatment strategies for malignant melanoma have rapidly evolved over the past decade. Because of its propensity to develop advanced stage and metastatic disease, melanoma has contributed to the majority of mortalities among patients with skin cancer. The development of novel therapeutics such as immunotherapy and targeted molecular therapies has revolutionized the treatment of patients with advanced stage and metastatic malignant melanoma. Immune checkpoint inhibitors, BRAF/MEK inhibitors, and other revolutionary therapies have demonstrated remarkable success in the treatment of this common malignancy. Along with these advancements in systemic therapies, imaging has continued to play a critical role in the diagnosis and follow-up of patients with malignant melanoma. As the use of these novel therapies continues to expand, knowledge of the evolving therapeutic landscape of melanoma is becoming critical for radiologists. In this review, we provide a primer for radiologists outlining the evolution of immunotherapy and targeted therapy in the treatment of melanoma. We discuss the critical role of imaging in evaluation of treatment response, including a summary of current imaging response guidelines. Last, we summarize the essential role of imaging in the evaluation of potential adverse events seen in patients with malignant melanoma undergoing treatment with immune checkpoint inhibitors.

To quantify downstream healthcare utilization and revenue associated with a self-pay bi-parametric prostate MRI (bpMRI) program.Medical records of 592 patients who underwent bpMRI between August 2017 and March 2020 were examined for follow-up clinical activities. These include prostate biopsy, radical prostatectomy, external beam radiation therapy, brachytherapy, androgen deprivation therapy, CT Chest, Abdomen and Pelvis, PET/CT, MRI Pelvis, and Nuclear Medicine Bone Scans. The charges for each clinical activity were derived from the Medicare Physician Fee Schedule to conservatively estimate revenues. This patient population was further divided into four groups: Group A, patients who demonstrated an MRI lesion and underwent prostatectomy; Group B, patients who did not demonstrate lesion but underwent prostatectomy; Group C, patients who demonstrated lesion but did not undergo prostatectomy; and Group D, patients who neither demonstrated lesion nor underwent prostatectomy. Revenues for each group were categorized by Urology, Radiation Oncology and Radiology subspecialties.Conservative estimates yielded $520 of downstream revenue per patient who underwent bpMRI. Group A patients yielded 47% of total revenue ($1974 per patient). Group B patients, the smallest group, yielded $1828 per patient. Group C patients made up the largest group and grossed $398 per patient. Group D demonstrated the lowest per patient revenue of $179. Groups A and B yielded most relative revenue for Urology. Group C yielded most relative revenue for Radiation Oncology, and Group D yielded most relative revenue for Radiology.A self-pay bpMRI program has the potential to improve patient access to prostate cancer screening while remaining financial sustainable.

The purpose of this article is to review the spectrum of rare non-epithelial tumors of the prostate. This focused article will help the readers to understand the imaging findings of such rare entities attributed to their clinicopathological features. Radiologists must be familiar with the spectrum of non-epithelial tumors of the prostate, which helps to suggest alternate diagnosis other than adenocarcinoma, when imaging features are atypical. This is important because these tumors have different management approaches and prognoses when compared to adenocarcinoma of the prostate.

To create a CT texture-based machine learning algorithm that distinguishes benign from potentially malignant cystic renal masses as defined by the Bosniak Classification version 2019. In this IRB-approved, HIPAA-compliant study, 4,454 adult patients underwent renal mass protocol CT or CT urography from January 2011 to June 2018. Of these, 257 cystic renal masses were included in the final study cohort. Each mass was independently classified using Bosniak version 2019 by three radiologists, resulting in 185 benign (Bosniak I or II) and 72 potentially malignant (Bosniak IIF, III or IV) masses. Six texture features: mean, standard deviation, mean of positive pixels, entropy, skewness, kurtosis were extracted using commercial software TexRAD (Feedback PLC, Cambridge, UK). Random forest (RF), logistic regression (LR), and support vector machine (SVM) machine learning algorithms were implemented to classify cystic renal masses into the two groups and tested with tenfold cross validations. Higher mean, standard deviation, mean of positive pixels, entropy, skewness were statistically associated with the potentially malignant group (P ≤ 0.0015 each). Sensitivity, specificity, positive predictive value, negative predictive value, and area under curve of RF model was 0.67, 0.91, 0.75, 0.88, 0.88; of LR model was 0.63, 0.93, 0.78, 0.86, 0.90, and of SVM model was 0.56, 0.91, 0.71, 0.84, 0.89, respectively. Three CT texture-based machine learning algorithms demonstrated high discriminatory capability in distinguishing benign from potentially malignant cystic renal masses as defined by the Bosniak Classification version 2019. If validated, CT texture-based machine learning algorithms may help reduce interreader variability when applying the Bosniak classification.

Objective The aim of the study was to study clinical, imaging findings, response patterns, and immune-related adverse events in classical Hodgkin lymphoma (cHL) and non-Hodgkin lymphoma (NHL) patients treated with immune checkpoint inhibitors (ICIs). Methods A retrospective search was performed to identify patients with relapsed/refractory cHL and NHL treated with ICIs from 2015 to 2019. Clinical and laboratory data were collected. Imaging studies were reviewed for treatment response and immune-related adverse events. Results Ten patients with relapsed/refractory cHL (median age, 41 years) and 14 patients with relapsed/refractory NHL (median age, 61 years) were identified. Overall response rate was 70% for cHL patients. None of the NHL patients demonstrated complete or partial response. One case of hyperprogression and one case with atypical response were radiologically detected in cHL patients. Hypothyroidism requiring treatment occurred in 2 (20%) of 10 cHL patients, one of which had imaging correlate. Of 14 NHL patients, 1 (7%) had radiologic evidence of pneumonitis and 1 (7%) had colitis. Conclusions This single-institution observational study demonstrated that overall response rate was higher in patients with cHL undergoing ICI. Immune checkpoint inhibitor therapy has unique response patterns and toxicities in both cHL and NHL patients that radiologists should keep in mind.

The presence of extraprostatic extension (EPE) on multiparametric MRI (mpMRI) is an important factor in determining the management of prostate cancer. EPE is an established risk factor for biochemical recurrence of prostate cancer after radical prostatectomy (RP) and patients with EPE may be considered for wider resection margins, non-nerve-sparing surgery, adjuvant radiation therapy (RT), or androgen deprivation therapy (ADT). Several statistical nomograms and scoring systems have been developed to predict pathological stage at time of RP but with varying accuracies. Using the current PI-RADS v2 mpMRI staging guidelines results in high specificity but lacks in sensitivity. These findings reveal the need for more standardization and further refinement of existing MRI protocols and prostate cancer prediction tools. Current studies have looked into indirect additional imaging criteria such as index tumor volume, length of capsular contact, and apparent diffusion coefficient. Measuring for these features can improve the robustness of mpMRI in staging prostate cancer, as they have been shown to be independent predictors of EPE. MRI/ultrasound fusion-guided targeted biopsy can detect EPE not found on standard biopsy. Collectively, these measurements and imaging techniques can augment the detection of EPE and subsequent risk stratification.

Background Evaluation of small cystic lesions of the pancreas remains a challenging task, as due to their size appearance can be rather hypodense than clearly fluid-filled. Purpose To evaluate whether additional information provided by novel dual-layer spectral-detector computed tomography (SDCT) imaging can improve assessment of these lesions. Material and Methods For this retrospective study, we reviewed reports of 1192 contrast-enhanced portal-venous phase SDCT scans of the abdomen conducted between May 2017 and January 2019. On basis of the radiological report 25 small (≤1.5 cm) cystic pancreatic lesions in 22 patients were identified, in which additional short-term follow-up imaging was recommended to confirm/clarify cystic nature. Conventional images (CI) and spectral images (SI) including virtual-monoenergetic images at 40 keV (VMI), iodine-density and iodine-overlay images were reconstructed. Two readers indicated lesion conspicuity and confidence for presence of cystic nature on three-point scales. First, solely CI were evaluated, while in a second reading after a four-week interval, the combination of CI and corresponding SI were reviewed. Quantitatively, ROI-based mean attenuation was measured in CI and VMI. Results In the subjective reading, SI significantly improved lesion conspicuity (CI 2 [1–2], SI 3 [2–3], P Conclusion Compared to CI alone, combination with SI significantly improves visualization and confidence in evaluation of small equivocal cystic pancreatic lesions.

Non-traumatic adrenal crisis is a rare but critical diagnosis to make in emergency settings due to grave consequences. Various pathologies can present as acute crisis, such as spectrum of endocrine imbalance, ranging from catecholamine excess in pheochromocytomas to acute adrenal insufficiency related to glandular dysfunction. Critical manifestations may be due to structural causes related to adrenal hemorrhage, especially when they are bilateral. Oncological complications such as vascular invasion, tumoral bleed, rupture, and hormonal dysfunction can occur. Due to non-specific clinical presentation, these conditions may come as a surprise on imaging performed for other reasons. Recognition of these imaging findings is critical for appropriate patient management. Although there are few articles discussing non-traumatic emergencies in literature, this review is inclusive of all possible etiologies, thus provides a holistic approach and insight into each situation. Specific imaging approach is needed to tailor the diagnosis. This article will also discuss about the advanced imaging techniques that will complement diagnosis.

Immune checkpoint inhibitor (ICI)-associated myocarditis is a rare but potentially fatal complication associated with development of other immune-related adverse events (irAEs). Troponin levels, ECG, echocardiography, and cardiac MR can assist with the diagnosis of this rare albeit serious adverse effect related to immunotherapy. In this case report, we present the clinical and radiological features of myocarditis in three patients presenting with acute symptoms while receiving therapy with ICIs. Blood troponin and ECG were abnormal in all three myocarditis cases. Initial echocardiography was abnormal in two patients with reduced left ventricular ejection fraction (LVEF). The third patient demonstrated an initially normal LVEF with subsequent transient decrease in LVEF on follow-up echocardiogram. Cardiac MR was abnormal in three cases with areas of mid-myocardial/epicardial delayed enhancement. All patients experienced additional irAEs. One patient died shortly after myocarditis diagnosis, one was made comfort care due to poor clinical status, and one improved with steroid treatment.

We performed a systematic review and meta-analysis of the treatment efficacy of immune checkpoint inhibitors (ICIs) in advanced/metastatic neuroendocrine neoplasms (NENs). MEDLINE and EMBASE were searched to identify studies that provide data on treatment response and/or survival outcomes of advanced/metastatic NEN patients treated with ICIs. The overall response rate (ORR) was pooled using a random-effects model. Meta-regression was performed to explore factors influencing the ORR. Individual patient data (IPD) meta-analysis of survival was performed using stratified Cox regression. Ten studies (464 patients) were included. The overall pooled ORR was 15.5% (95% confidence interval (CI), 9.5–24.3%), and it varied according to the primary site (thoracic, 24.7%; gastro–entero–pancreatic, 9.5%), tumor differentiation (poorly differentiated, 22.7%; well-differentiated, 10.4%), and drug regimen (combination, 25.3%; monotherapy, 10.1%). All these variables significantly influenced the ORR. Tumor differentiation was associated with both overall survival and progression-free survival (hazard ratio of poorly differentiated tumors, 4.2 (95% CI, 2.0–8.7) and 2.6 (95% CI, 1.6–4.4), respectively). Thus, the treatment efficacy of ICIs for advanced/metastatic NENs varied according to primary site, tumor differentiation, and drug regimen. Poorly differentiated NENs showed a better ORR than well-differentiated NENs but had a negative impact on survival.

ObjectiveTo derive and evaluate the association of prostate shape distension descriptors from T2-weighted MRI (T2WI) with prostate cancer (PCa) biochemical recurrence (BCR) post-radical prostatectomy (RP) independently and in conjunction with texture radiomics of PCa.MethodsThis retrospective study comprised 133 PCa patients from two institutions who underwent 3T-MRI prior to RP and were followed up with PSA measurements for ≥3 years. A 3D shape atlas-based approach was adopted to derive prostate shape distension descriptors from T2WI, and these descriptors were used to train a random forest classifier (CS) to predict BCR. Texture radiomics was derived within PCa regions of interest from T2WI and ADC maps, and another machine learning classifier (CR) was trained for BCR. An integrated classifier CS+R was then trained using predictions from CS and CR. These models were trained on D1 (N = 71, 27 BCR+) and evaluated on independent hold-out set D2 (N = 62, 12 BCR+). CS+R was compared against pre-RP, post-RP clinical variables, and extant nomograms for BCR-free survival (bFS) at 3 years.ResultsCS+R resulted in a higher AUC (0.75) compared to CR (0.70, p = 0.04) and CS (0.69, p = 0.01) on D2 in predicting BCR. On univariable analysis, CS+R achieved a higher hazard ratio (2.89, 95% CI 0.35–12.81, p < 0.01) compared to other pre-RP clinical variables for bFS. CS+R, pathologic Gleason grade, extraprostatic extension, and positive surgical margins were associated with bFS (p < 0.05). CS+R resulted in a higher C-index (0.76 ± 0.06) compared to CAPRA (0.69 ± 0.09, p < 0.01) and Decipher risk (0.59 ± 0.06, p < 0.01); however, it was comparable to post-RP CAPRA-S (0.75 ± 0.02, p = 0.07).ConclusionsRadiomic shape descriptors quantifying prostate surface distension complement texture radiomics of prostate cancer on MRI and result in an improved association with biochemical recurrence post-radical prostatectomy.

Background: Traditional approaches for evaluating multiple myeloma (MM) treatment response have low sensitivity for residual disease. Recent studies highlight utility of whole-body MRI or FDG PET/CT in evaluating treatment response, with increasing emphasis on DWI. Objective: This systematic review was conducted to assess the diagnostic accuracy of whole-body MRI and FDG PET/CT for treatment response assessment in MM. Evidence Acquisition: Studies using whole-body MRI or FDG PET/CT to evaluate MM treatment response were identified through search of PubMed and EMBASE databases through June 30, 2021. Pooled sensitivity and specificity for detecting response were calculated by bivariate modeling. Diagnostic performance of whole-body MRI and FDG PET/CT were compared. Subgroup analyses assessed studies comparing both modalities and studies in which whole-body MRI included DWI. Evidence Synthesis: Twelve studies comprising 373 patients were included: six evaluated both modalities, four evaluated whole-body MRI only, and two evaluated FDG PET/CT only; of studies with MRI, five used DWI. Pooled sensitivity and specificity were 87% (95% CI, 75%-93%) and 57% (95% CI, 37%-76%) for whole-body MRI, versus 64% (95% CI, 45%-79%) and 82% (95% CI, 75%-88%) for FDG PET/CT (sensitivity: p = .29; specificity: p = .01). For studies directly comparing the modalities, pooled sensitivity and specificity were 90% (95% CI, 80%-100%) and 56% (95% CI, 44%-68%) for whole-body MRI, versus 66% (95% CI, 47%-85%) and 81% (95% CI, 72%-90%) for FDG PET/CT (sensitivity: p = .18; specificity: p < .001). Sensitivity and specificity were 93% (95% CI, 75%-98%) and 57% (95% CI, 21%-87%) for DWI, versus 74% (95% CI, 60%-85%) and 56% (95% CI, 38%-73%) for whole-body MRI without DWI (sensitivity: p = .27; specificity: p = .99). AUC was 0.84 for whole-body MRI, 0.83 for FDG PET/CT, and 0.92 for DWI. Conclusion: FDG PET/CT had significantly higher specificity, whereas whole-body MRI had higher sensitivity (though non-significant). DWI may contribute to the high sensitivity of whole-body MRI. Clinical Impact: This meta-analysis suggests potential complementary roles of whole-body MRI and FDG PET/CT in MM treatment response assessment. Future studies should explore their combination through PET/MRI.

Prostate cancer represents one of the leading causes of cancer-related mortality in the United States and the most common cancer among men. Treatment paradigms for the management of advanced stages of prostate cancer have continued to evolve in recent years. These advancements in the therapeutic landscape of metastatic prostate cancer and diagnostic imaging modalities have fundamentally changed the treatment of patients with prostate cancer. In this review article we provide a primer for radiologists highlighting the most recent developments in treatment options and imaging techniques utilized in the modern oncologic management of metastatic prostate cancer. We will examine current therapy options and associated toxicities with an emphasis on relevant imaging findings commonly encountered by radiologists. We also summarize the role of modalities including CT, MRI, PET, bone scintigraphy, and PET in the diagnosis and follow-up of patients with metastatic prostate cancer.

Lung cancer continues to be a major cause of death throughout the world. The ability to both accurately diagnose lung cancer in its early stages and monitor response to treatment is essential to reducing the morbidity and mortality associated with the disease. Serum tumor markers have been identified as potential biomarkers that may aid in lung cancer diagnosis and surveillance. These markers, when combined with cross-sectional imaging, may result in more robust screening and surveillance protocols. The future role of serum tumor markers in lung cancer includes the advancement of "liquid biopsies," in which peripheral blood samples are analyzed for tumor components without the need for a tissue biopsy.