Publications

Background: Adrenal incidentalomas are common findings at contrast-enhanced CT, yet their management remains controversial. Objective: The purpose of this study was to determine the prevalence of malignancy among incidental indeterminate adrenal nodules detected on contrast-enhanced CT in patients without known cancer. Methods: We performed a 12-institution retrospective cohort study of adult patients without known cancer who underwent contrast-enhanced CT of the abdomen from January 1, 2010, to April 2, 2016. Consecutive reports from 10,646 cases were reviewed. CT images were reviewed for 2603 cases with reports describing an adrenal nodule measuring 1 cm or larger. Malignancy or benignity was determined using the following reference standards: pathology, diagnostic imaging (attenuation on unenhanced CT < 10 HU or signal-intensity loss at chemical shift MRI), imaging stability for at least 1 year, or clinical follow-up of at least 5 years. Descriptive statistics were performed using the binomial exact method and chi-square test. Results: The final cohort included 1320 patients (813 women, 507 men; mean age, 63.1 ± 15.2 years) with 1506 adrenal nodules. Mean nodule size was 2.1 cm ± 0.7 cm (range, 1.0-10.7 cm; IQR, 1.6-2.5 cm). The prevalence of malignancy among all nodules, nodules measuring 1-2 cm, nodules measuring 2-4 cm, and nodules measuring more than 4 cm was 0.07% (1/1506; 95% CI, 0.0-0.37%), 0.0% (0/773; 95% CI, 0.0-0.39%), 0.14% (1/694; 95% CI, 0.0-0.80%), and 0.0% (0/39; 95% CI, 0.0-7.4%). respectively. The one malignant nodule was an adrenocortical carcinoma diagnosed 9 years after initial detection. A total of 940 nodules underwent unenhanced CT after the index CT; all were benign. Of these, 654 were less than 10 HU, 157 were 10-20 HU, and 129 were more than 20 HU. Conclusion: The prevalence of malignancy among incidental indeterminate adrenal nodules on contrast-enhanced CT in patients without known cancer was exceedingly low. Clinical Impact: Follow-up imaging is not warranted for small (1-2 cm) incidental indeterminate adrenal nodules detected on contrast-enhanced CT in patients without known cancer.

OBJECTIVE: Metabolomic risk factors for dementia are under studied, especially in Latinos. We examined the relationship between plasma metabolomic profiles and a Magnetic-Resonance Imaging (MRI)-based markers of brain aging in a cohort of older adult Puerto Ricans residing in the greater Boston area.

METHODS: We used multiple linear regression, adjusted for covariates, to examine the association between metabolite concentration and MRI-derived brain age deviation. Metabolites were measured at baseline with untargeted metabolomic profiling (Metabolon, Inc). Brain age deviation was calculated at wave 4 (  9 years from Boston Puerto Rican Health Study (BPRHS) baseline) as chronologic age, minus MRI-estimated brain age, representing the rate of biological brain aging relative to chronologic age. We also examined if metabolites associated with brain age deviation were similarly associated with hippocampal volume and global cognitive function.

RESULTS: Several metabolites, including isobutyrylcarnitine, propionylcarnitine, phenylacetylglutamine, phenylacetylcarnitine (acetylated peptides), p-cresol-glucuronide, phenylacetylglutamate, and trimethylamine N-oxide (TMAO) were associated with worse brain aging. Taurocholate sulfate, a bile salt, was marginally associated with better brain aging. Most metabolites with negative associations with brain age deviation also were inversely, although not significantly, associated with hippocampal volume and cognitive function.

CONCLUSION: The metabolites associated with brain aging in this study are generally consistent with prior literature and highlight the potential role of TMAO, BCAA and other microbially derived metabolites in dementia.

PURPOSE: To evaluate the histopathologic effects of resin Yttrium-90 Transarterial Radioembolization (90Y-TARE) on intrahepatic cholangiocarcinoma (iCCA), and correlate dose with outcomes.

MATERIALS AND METHODS: This retrospective, single-center study included adult patients with iCCA treated with 90Y-TARE using resin microspheres. Histopathologic and dosimetry results were evaluated. Imaging response was assessed. Complete pathologic necrosis (CPN) was defined as 100% tumor necrosis, and extensive necrosis as > 90% necrosis. Treatment factors affecting the pathologic necrosis rate were evaluated.

RESULTS: For 18 patients, the median age was 69 years [IQR, 67-71 years], with 56% male, and median tumor size of 6.4 cm [IQR,5.1-8.2 cm]. Surgical resection was performed 127 [IQR, 100-182] days after 90Y-TARE. CPN was achieved in 4/18 (22%) patients, with extensive necrosis in 13/18 (72%) patients. Extensive necrosis rate was higher in patients with a prescribed dose ≥ 180 Gy (10/11 [91%]), compared to patients with a prescribed dose < 180 Gy (3/7 [43%], p = 0.03). Patients treated with 90Y-TARE as a first line treatment had higher odds of achieving extensive necrosis compared to patients who received 90Y-TARE after chemotherapy (OR = 11, p = 0.047). All lesions classified as complete response by mRECIST at the 3-month evaluation exhibited extensive necrosis, corresponding to a sensitivity of 58% and a positive predictive value (PPV) of 100%.

CONCLUSION: 90Y-TARE with resin microspheres is associated with a CPN rate of 22% and extensive necrosis rate of 72% in iCCA, with a prescribed dose of ≥ 180 Gy predicting extensive necrosis.

We summarize a new process for developing algorithm-based recommendations for the ACR. This process is currently applied to the ACR's incidental findings recommendations, and other committees providing evidence-based recommendations may elect to adopt these processes in the future. The prior process relied upon informal consensus and was versatile but more limited in scalability and generalizability. Most importantly, the absence of a formal, evidence-driven process prevented incidental findings and other algorithms from receiving designation as clinical guidelines per the National Academy of Medicine's Trustworthy Guidelines criteria and limited both referrer and policymaker adoption. In response, a committee of key stakeholders was formed with approval of the ACR to develop a new process that would overcome these drawbacks, including members from the ACR's Incidental Findings and Reporting and Data Systems committees, the ACR's Commissions on Quality and Safety and Informatics, academic and private practice settings, as well as ACR staff. Here we present the formal, evidence-driven process for algorithm-based imaging recommendations developed by this committee. This process is generalizable to committees across the ACR.

Medical errors are a significant cause of morbidity and mortality. Literature on common mechanisms to reduce radiological error are reviewed including shifting from general to subspecialized care, improving expertise, instituting shift volume and shift length limits, minimizing non-interpretive tasks, participating in focused educational and multidisciplinary conferences, and increasing practice size. Implementation of shift volume limits and full sub-specialization has the potential to significantly reduce radiologist error rates.