Publications

PURPOSE: After a slow and challenging transition period, peer learning and improvement (PLI) is now being more widely adopted by practices as an option for continuous personal and practice performance improvement. In addition to gaps that exist in the understanding of what PLI is and how it should be practiced, wide variation exists in how the process is implemented, administered, how outcomes are measured, and what strategies are employed to engage radiologists. This report aims to describe lessons learned from our 20-year experience with the design, implementation, and continuous improvements of a PLI program in a large academic program.

METHODS: Since initial implementation in 2004, an oversight team prospectively documented iterative process improvements and data submission trends in our PLI process. Process data included strategies for engaging radiologists in the PLI process (fostering case submission, PLI meeting participation), steps for achieving regulatory compliance, and template content for facilitating the value and impact of PLI meetings (case analysis, review of contributing factors, identification of improvement opportunities).

RESULTS: Submission trends, submitted case content, and improvement opportunities varied by clinical section. Process improvements that fostered engagement included closing the loop with participants, expanding criteria for case submission beyond interpretive disagreements (e.g., great pickups, near misses), minimizing impacts to workflow, and using evidence-based templates for case and contributor categorization, bias analysis, and identification of improvement opportunities.

CONCLUSION: Implementing an effective PLI program requires sustained communication, education, and continuous process improvement. While PLI can certainly lead to process and individual performance improvement, the program requires trained champions, designated time, effort, resources, education, and patience to be effectively implemented.

Approach to imaging ischemia in women Coronary artery disease in women tends to have a worse short- and long-term prognosis relative to men and remains the leading cause of mortality worldwide. Both clinical symptoms and diagnostic approach remain challenging in women due to lesser likelihood of women presenting with classic anginal symptoms on one hand and underperformance of conventional exercise treadmill testing in women on the other. Moreover, a higher proportion of women with signs and symptoms suggestive of ischemia are more likely to have nonobstructive coronary artery disease (CAD) that requires additional imaging and therapeutic considerations. New imaging techniques such as coronary computed tomography (CT) angiography, CT myocardial perfusion imaging, CT functional flow reserve assessment, and cardiac magnetic resonance imaging carry substantially better sensitivity and specificity for the detection of ischemia and coronary artery disease in women. Familiarity with various clinical subtypes of ischemic heart disease in women and with the major advantages and disadvantages of advanced imaging tests to ensure the decision to select one modality over another is one of the keys to successful diagnosis of CAD in women. This review compares the 2 major types of ischemic heart disease in women - obstructive and nonobstructive, while focusing on sex-specific elements of its pathophysiology.

PURPOSE: To characterize intratumoral immune cell trafficking in ablated and synchronous tumors following combined radiofrequency ablation (RFA) and systemic liposomal granulocyte-macrophage colony stimulation factor (lip-GM-CSF).

METHODS: Phase I, 72 rats with single subcutaneous R3230 adenocarcinoma were randomized to 6 groups: a) sham; b&c) free or liposomal GM-CSF alone; d) RFA alone; or e&f) combined with blank liposomes or lip-GM-CSF. Animals were sacrificed 3 and 7 days post-RFA. Outcomes included immunohistochemistry of dendritic cells (DCs), M1 and M2 macrophages, T-helper cells (Th1) (CD4+), cytotoxic T- lymphocytes (CTL) (CD8+), T-regulator cells (T-reg) (FoxP3+) and Fas Ligand activated CTLs (Fas-L+) in the periablational rim and untreated index tumor. M1/M2, CD4+/CD8+ and CD8+/FoxP3+ ratios were calculated. Phase II, 40 rats with double tumors were randomized to 4 groups: a) sham, b) RFA, c) RFA-BL and d) RFA-lip-GM-CSF. Synchronous untreated tumors collected at 7d were analyzed similarly.

RESULTS: RFA-lip-GMCSF increased periablational M1, CTL and CD8+/FoxP3+ ratio at 3 and 7d, and activated CTLs 7d post-RFA (p<0.05). RFA-lip-GMSCF also increased M2, T-reg, and reduced CD4+/CD8+ 3 and 7d post-RFA respectively (p<0.05). In untreated index tumor, RFA-lip-GMCSF improved DCs, M1, CTLs and activated CTL 7d post-RFA (p<0.05). Furthermore, RFA-lip-GMSCF increased M2 at 3 and 7d, and T-reg 7d post-RFA (p<0.05). In synchronous tumors, RFA-BL and RFA-lip-GM-CSF improved DC, Th1 and CTL infiltration 7d post-RFA.

CONCLUSION: Systemic liposomal GM-CSF combined with RFA improves intratumoral immune cell trafficking, specifically populations initiating (DC, M1) and executing (CTL, FasL+) anti-tumor immunity. Moreover, liposomes influence synchronous untreated metastases increasing Th1, CTL and DCs infiltration.

OBJECTIVES: To determine the factors that affect successful ultrasound-guided biopsy of liver lesions and build a model predicting feasibility of US-guided liver biopsy.

METHODS: This is IRB-approved HIPAA-compliant retrospective review of consecutive ultrasound-guided targeted liver biopsies performed or attempted between 1/2018 and 9/2020 at a single tertiary academic institution with a total of 501 patients included. Mann-Whitney and chi-square tests were used to compare continuous and categorical variables, respectively. Logistic regression model was built to predict feasibility of successful ultrasound-guided biopsy.

RESULTS: Liver lesion biopsy was successfully performed with US guidance in 429/501 (86%) patients. Lesions not amenable for US biopsy were smaller (median size 1.6 cm vs 3.3 cm, p < 0.0001) and deeper within the liver (median depth 9.0 cm vs 5.8 cm, p < 0.0001). The technical success rate was lowest for lesions in segment II (40/53, 75%), while lesions in segment IVb (87/91, 96%) had highest success rate (p < 0.003). US targeting in patients with 1 or 2 lesions was less feasible than in patients with 3 or more lesions, 126/180 (70%) vs. 303/321 (94%), (p < 0.0001). Model including lesion size, depth, location, and number of lesions predicts feasibility of US-guided biopsy with Area under the ROC curve (AUC) = 0.92.

CONCLUSIONS: Linear logistic regression model that includes lesion size, depth and location, and number of lesions is highly successful in predicting feasibility of ultrasound-guided biopsy for liver lesions. Smaller lesions, deeper lesions, and lesions in segment II and VIII in patients with less than 3 lesions were less feasible for ultrasound-guided biopsy of liver lesions.

Cervical cancer is the second most encountered cancer in pregnant patients. The 2018 International Federation of Gynecology and Obstetrics (FIGO) staging system for cervical cancer updated the staging of primary cervical carcinoma and disease process, with formal incorporation of imaging as a vital source of information in the management process to improve accuracy. Diagnosis and treatment of the pregnant population is a complex interplay of achieving adequate diagnostic information and optimal treatment while minimizing toxicity and risks to the mother and fetus. While novel imaging techniques and anticancer therapies are rapidly developed, much information on the safety and feasibility of different therapies is not yet available in the pregnant population. Therefore, managing pregnant patients with cervical cancer is complex and requires a multidisciplinary approach.

Imaging plays an important role in characterizing and risk-stratifying commonly encountered adnexal lesions. Recently, the American College of Radiology (ACR) released the Ovarian-Adnexal Reporting and Data System (O-RADS) for ultrasound and subsequently for magnetic resonance imaging (MRI). The goal of the recently developed ACR O-RADS MRI risk stratification system is to improve the quality of imaging reports as well as the reproducibility of evaluating adnexal lesions on MRI. This review focuses on exploring this new system and its future refinements.

Adnexal masses during pregnancy are a relatively uncommon entity. Their clinical management is challenging given the overlapping features of certain entities on imaging and histopathology, which can mimic malignancy, and the potential side effects to the mother and fetus, whether expectant management versus surgery is pursued. Ultrasonography with Doppler evaluation is the modality of choice for evaluating adnexal masses during pregnancy. Magnetic resonance imaging is the second-line modality useful when US findings are inconclusive/indeterminate. Most adnexal masses in pregnant patients are benign in origin (e.g., functional cysts, mature cystic teratoma, decidualization of endometrioma), but a few are malignant in origin (e.g., dysgerminoma, granulosa cell tumor). Most cases of adnexal masses are asymptomatic, but complications such as ovarian torsion can occur. This review aims to familiarize the radiologist with the imaging of adnexal lesions during pregnancy so that the radiologist can identify ovarian cancer. Specifically, the review will detail the most common benign and malignant adnexal masses in pregnancy, mimickers, and their corresponding imaging findings on US and MRI.

BACKGROUND AND OBJECTIVE: In recent years, there has been a large-scale dissemination of guidelines in radiology in the form of Reporting & Data Systems (RADS). The use of iodinated contrast media (ICM) has a fundamental role in enhancing the diagnostic capabilities of computed tomography (CT) but poses certain risks. The scope of the present review is to summarize the current role of ICM only in clinical reporting guidelines for CT that have adopted the "RADS" approach, focusing on three specific questions per each RADS: (I) what is the scope of the scoring system; (II) how is ICM used in the scoring system; (III) what is the impact of ICM enhancement on the scoring.

METHODS: We analyzed the original articles for each of the latest versions of RADS that can be used in CT [PubMed articles between January, 2005 and March, 2023 in English and American College of Radiology (ACR) official website].

KEY CONTENT AND FINDINGS: We found 14 RADS suitable for use in CT out of 28 RADS described in the literature. Four RADS were validated by the ACR: Colonography-RADS (C-RADS), Liver Imaging-RADS (LI-RADS), Lung CT Screening-RADS (Lung-RADS), and Neck Imaging-RADS (NI-RADS). One RADS was validated by the ACR in collaboration with other cardiovascular scientific societies: Coronary Artery Disease-RADS 2.0 (CAD-RADS). Nine RADS were proposed by other scientific groups: Bone Tumor Imaging-RADS (BTI-RADS), Bone‑RADS, Coronary Artery Calcium Data & Reporting System (CAC-DRS), Coronavirus Disease 2019 Imaging-RADS (COVID-RADS), COVID-19-RADS (CO-RADS), Interstitial Lung Fibrosis Imaging-RADS (ILF-RADS), Lung-RADS (LU-RADS), Node-RADS, and Viral Pneumonia Imaging-RADS (VP-RADS).

CONCLUSIONS: This overview suggests that ICM is not strictly necessary for the study of bones and calcifications (CAC-DRS, BTI-RADS, Bone-RADS), lung parenchyma (Lung-RADS, LU-RADS, COVID-RADS, CO-RADS, VP-RADS and ILF-RADS), and in CT colonography (C-RADS). On the other hand, ICM plays a key role in CT angiography (CAD-RADS), in the study of liver parenchyma (LI-RADS), and in the evaluation of soft tissues and lymph nodes (NI-RADS, Node-RADS). Future studies are needed in order to evaluate the impact of the new iodinated and non-iodinate contrast media, artificial intelligence tools and dual energy CT in the assignment of RADS scores.

Total neoadjuvant therapy (TNT), which includes chemotherapy and radiation prior to surgical resection, has been recently accepted as the new standard of care for patients with locally advanced low and mid rectal cancers. Multiple clinical trials have evaluated this approach in the last several decades and demonstrated improvement in, local control and reduced risk of recurrence. In addition, in the course of these investigations, it has been shown that between a third and a half of patients experience a clinical complete response (cCR) after being treated with the TNT approach, leading to the development of new organ preservation protocol, now known as watch-and-wait (W&W). On this protocol, cCR patients are not referred for surgery after total neoadjuvant treatment. Instead, they remain on close surveillance and, thus, avoid potential complications associated with surgical resection. Multiple clinical trials are ongoing, investigating the long-term outcomes of these new approaches and the development of less toxic and more effective TNT regimens for LARC. Improvements in technology and rectal MRI protocols position radiologists as vital members of multidisciplinary rectal cancer management teams. Rectal MRI has become a critical tool for rectal cancer initial staging, treatment response assessment, and surveillance on W&W protocols. In this review, we summarize the findings of the pivotal clinical trials that contributed to establishing the current treatment paradigms in locally advanced rectal cancer (LARC) management, with the intention of helping radiologists play more effective roles in their multidisciplinary teams.

PURPOSE: The purpose of this consensus article was to develop guidelines by a focused panel of experts to elaborate a lexicon of image interpretation, and a standardized region-based reporting of deep infiltrating endometriosis (DIE) with magnetic resonance imaging (MRI).

MATERIALS AND METHODS: Evidence-based data and expert opinion were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts scoring of pelvic compartment delineation and reporting template were collected; responses were analyzed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (when ≥ 80% consensus among experts) or uncertain (when < 80% consensus among experts).

RESULTS: Consensus regarding pelvic compartment delineation and DIE reporting was attained using the RAND-UCLA Appropriateness Method. The pelvis was divided in nine compartments and extrapelvic lesions were assigned to an additional (tenth) compartment. A consensus was also reached for each structure attributed to a compartment and each reporting template item among the experts. No consensus was reached for a normal aspect of uterosacral ligament, but a consensus was reached for an unequivocal involvement leading to a positive diagnosis and an equivocal involvement leading to uncertain diagnosis. Tailored MRI lexicon and standardized region-based report were proposed.

CONCLUSION: These consensus recommendations should be used as a guide for DIE reporting and staging with MRI. Standardized MRI compartment-based structured reporting is recommended to enable consistent accuracy and help select the best therapeutic approach.