Publications

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.

PURPOSE: To develop guidelines by international experts to standardize data acquisition, image interpretation, and reporting in rectal cancer restaging with magnetic resonance imaging (MRI).

MATERIALS AND METHODS: Evidence-based data and experts' opinions were combined using the RAND-UCLA Appropriateness Method to attain consensus guidelines. Experts provided recommendations for reporting template and protocol for data acquisition were collected; responses were analysed and classified as "RECOMMENDED" versus "NOT RECOMMENDED" (if ≥ 80% consensus among experts) or uncertain (if < 80% consensus among experts).

RESULTS: Consensus regarding patient preparation, MRI sequences, staging and reporting was attained using the RAND-UCLA Appropriateness Method. A consensus was reached for each reporting template item among the experts. Tailored MRI protocol and standardized report were proposed.

CONCLUSION: These consensus recommendations should be used as a guide for rectal cancer restaging with MRI.

Expert representatives from 11 professional societies, as part of an autonomous work group, researched and developed appropriate use criteria (AUC) for lymphoscintigraphy in sentinel lymph node mapping and lymphedema. The complete findings and discussions of the work group, including example clinical scenarios, were published on October 8, 2022, and are available at https://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=42021 The complete AUC document includes clinical scenarios for scintigraphy in patients with breast, cutaneous, and other cancers, as well as for mapping lymphatic flow in lymphedema. Pediatric considerations are addressed. These AUC are intended to assist health care practitioners considering lymphoscintigraphy. Presented here is a brief overview of the AUC, including the rationale and methodology behind development of the document. For detailed findings of the work group, the reader should refer to the complete AUC document online.

PURPOSE: To identify factors associated with adherence to radiology follow-up recommendations by the referring physicians.

MATERIALS AND METHODS: In this retrospective study, CT, ultrasound, and MRI reports with the keyword "recommend" and synonyms between March 11, 2019, and March 29, 2019, were included. Emergency department and inpatient examinations and routine surveillance recommendations, such as lung nodules, were excluded. Performance of follow-up examinations was correlated with the strength of recommendation, conditionality of recommendation, direct communication of results to ordering provider, and history of cancer. Outcomes included adherence to recommendations and time to follow-up. Statistical comparison between groups was performed using χ2, Kruskal-Wallis, and Spearman correlation.

RESULTS: Qualifying recommendations were provided in 255 reports (age 60.1 ± 16.5 years, female: 151 of 255, 59.22%). Imaging follow-up was performed in 166 of 255 (65%) reports: 148 of 166 (89.15%) nonconditional versus 18 of 166 (10.48%) conditional recommendations (P = .008), and more frequently in the patients with a strong follow-up recommendation (138 of 166 [83.13%], versus 28 of 166 [16.86%]) (P = .009). The median time to follow-up was 28 days versus 82 days in patients without versus with a history of cancer (P = .00057), 28 days versus 70 days with direct communication with the provider versus without (P = .0069), 82.5 versus 21 days for reports in which a specific follow-up interval was provided (86 of 255, 33.72%) versus those without (169 of 255, 66.27%) (P < .001).

CONCLUSION: The adherence rate for radiological nonroutine recommendations was 65%. Reports with strongly worded and nonconditional follow-up recommendations were followed more frequently. Direct communication with providers, patients without a known cancer history, and recommendations with no specified time interval identified were followed up earlier.

CLINICAL RELEVANCE: Strongly worded and nonconditional follow-up recommendations increase the likelihood of follow-up being performed. Direct communication of imaging follow-up recommendations to the provider and lack of specific time intervals decreases the median time to follow-up, which in turn may decrease the delay in medical care.

BACKGROUND: Multidisciplinary orthopaedic oncology conferences are important in developing the treatment plan for patients with suspected orthopaedic bone and soft tissue tumors, involving physicians from several services. Past studies have shown the clinical value of these conferences; however, the impact of radiology input on the management plan and time cost for radiology to staff these conferences has not been fully studied.

QUESTIONS/PURPOSES: (1) Does radiology input at multidisciplinary conference help guide clinical management and improve clinician confidence? (2) What is the time cost of radiology input for a multidisciplinary conference?

METHODS: This prospective study was conducted from October 2020 to March 2022 at a tertiary academic center with a sarcoma center. A single data questionnaire for each patient was sent to one of three treating orthopaedic oncologists with 41, 19, and 5 years of experience after radiology discussion at a weekly multidisciplinary conference. A data questionnaire was completed by the treating orthopaedic oncologist for 48% (322 of 672) of patients, which refers to the proportion of those three oncologists' patients for which survey data were captured. A musculoskeletal radiology fellow and musculoskeletal fellowship-trained radiology attending physician provided radiology input at each multidisciplinary conference. The clinical plan (leave alone, follow-up imaging, follow-up clinically, recommend different imaging test, core needle biopsy, surgical excision or biopsy or fixation, or other) and change in clinical confidence before and after radiology input were documented. A second weekly data questionnaire was sent to the radiology fellow to estimate the time cost of radiology input for the multidisciplinary conference.

RESULTS: In 29% (93 of 322) of patients, there was a change in the clinical plan after radiology input. Biopsy was canceled in 30% (24 of 80) of patients for whom biopsy was initially planned, and surgical excision was canceled in 24% (17 of 72) of patients in whom surgical excision was initially planned. In 21% (68 of 322) of patients, there were unreported imaging findings that affected clinical management; 13% (43 of 322) of patients had a missed finding, and 8% (25 of 322) of patients had imaging findings that were interpreted incorrectly. For confidence in the final treatment plan, 78% (251 of 322) of patients had an increase in clinical confidence by their treating orthopaedic oncologist after the multidisciplinary conference. Radiology fellows and attendings spent a mean of 4.2 and 1.5 hours, respectively, reviewing and presenting at a multidisciplinary conference each week. The annual combined prorated time cost for the radiology attending and fellow was estimated at USD 24,310 based on national median salary data for attendings and internal salary data for fellows.

CONCLUSION: In a study taken at one tertiary-care oncology program, input from radiology attendings and fellows in the setting of a multidisciplinary conference helped to guide the final treatment plan, reduce procedures, and improve clinician confidence in the final treatment plan, at an annual time cost of USD 24,310.

CLINICAL RELEVANCE: Multidisciplinary orthopaedic oncology conferences can lead to changes in management plans, and the time cost to the radiologists should be budgeted for by the radiology department or parent institution.

BACKGROUND. Complete pathologic necrosis (CPN) is associated with improved survival in patients who undergo liver transplant (LT) after locoregional therapy (LRT) for hepatocellular carcinoma (HCC). OBJECTIVE. The purpose of this article was to identify patient, HCC, and transplant center characteristics associated with rates of CPN on explant evaluation using a large national sample of patients undergoing LT after LRT for HCC measuring 3 cm or smaller. METHODS. This retrospective study used data from the United Network for Organ Sharing database. The study included 6265 adults (median age, 62 years; 1505 women, 4760 men) who underwent LT after a single type of LRT (either transarterial chemoembolization [TACE], thermal ablation, or transarterial radioembolization [TARE]) for HCCs measuring 3 cm or smaller at one of 118 U.S. transplant centers from April 12, 2012, to March 31, 2020. Patients were classified as having CPN if explant evaluation showed 100% necrosis of all HCCs. Associations with CPN were explored. Centers were categorized into tertiles on the basis of center-level CPN rates, and tertiles were compared. RESULTS. LRT was performed by TACE in 69.5% (4352/6265), thermal ablation in 19.4% (1217/6265), and TARE in 11.1% (696/6265) of patients. CPN rate was 18.5% (805/4352) after TACE, 35.8% (436/1217) after thermal ablation, 33.6% (234/696) after TARE, and 23.5% (1475/6265) overall. In multivariable analysis incorporating age, sex, model for end-stage liver disease score, α-fetoprotein level before LRT, wait list time, number of HCCs, HCC size, and the transplant center (as a random factor), use of thermal ablation (OR, 2.19; 95% CI, 1.86-2.57; p < .001) or TARE (OR, 1.92; 95% CI, 1.57-2.36; p < .001), with TACE as reference, independently predicted greater likelihood of CPN. Center-level CPN rates ranged from 0.0% to 50.0%. With centers stratified by CPN rates, ablation was performed more frequently than TACE in 5.0% of centers in the first, 15.4% in the second, and 23.1% in the third tertiles (p = .07). CONCLUSION. CPN rate on explant evaluation was low. Thermal ablation or TARE, rather than TACE, was associated with higher likelihood of CPN in patient-level and center-level analyses. CLINICAL IMPACT. Findings from this large national sample support a potential role of thermal ablation or TARE for achieving CPN of HCC measuring 3 cm or smaller.

BACKGROUND. Distal pancreatitis is an atypical imaging subtype of acute pancreatitis involving only the pancreatic body and tail, the head being spared. If no cause is identified, suspicion of a small imaging-occult cancer may be warranted. OBJECTIVE. The purpose of this study was to determine the frequency of subsequently diagnosed pancreatic cancer in patients with unexplained acute distal pancreatitis and to compare this frequency to that found in patients with unexplained nondistal pancreatitis. METHODS. This retrospective study included patients who underwent contrast-enhanced CT between January 1, 2019, and December 31, 2020, that showed acute pancreatitis without identifiable explanation. Studies were classified as showing distal or nondistal acute pancreatitis on the basis of consensus. The Fisher exact test was used to compare the frequency of subsequent histologic diagnosis of pancreatic cancer between groups. Negative classification required 6 or more months of imaging follow-up and/or 12 or more months of clinical follow-up. Interreader agreement among seven readers of varying experience was assessed by Fleiss kappa. RESULTS. Among 215 patients with acute pancreatitis, 116 (54%) had no identifiable explanation and formed the study sample. A total of 100 of 116 (86%) patients (59 men, 41 women; mean age, 57 ± 18 [SD] years) had nondistal acute pancreatitis; 16 of 116 (14%) patients (10 men, six women; mean age, 66 ± 14 years) had distal acute pancreatitis. Among patients with nondistal pancreatitis, none were subsequently diagnosed with pancreatic cancer; 62 had sufficient follow-up (median, 2.5 years) to be classified as having negative follow-up for pancreatic cancer. Among patients with distal pancreatitis, nine were subsequently diagnosed with pancreatic cancer (median interval to suspected cancer on subsequent CT, 174 days); five had sufficient follow-up (median, 3.1 years) to be classified as having negative follow-up for pancreatic cancer. The frequency of pancreatic cancer was higher (p < .001) in patients with distal pancreatitis (9/14 [64%; 95% CI, 35-87%]) than in with those with nondistal pancreatitis (0/62 [0%; 95% CI, 0-6%]). Interreader agreement on classification of distal versus nondistal pancreatitis was almost perfect (κ = 0.81). CONCLUSION. Distal pancreatitis without identifiable cause on CT is an uncommon but unique imaging subtype of acute pancreatitis that is associated with a high frequency of pancreatic cancer. CLINICAL IMPACT. In patients with acute distal pancreatitis without identifiable cause, endoscopic ultrasound-guided biopsy should be considered to evaluate for an underlying small cancer.

BACKGROUND. A major cause of burnout is moral distress: when one knows the right course of action but institutional constraints make the right course impossible to pursue. OBJECTIVE. The purpose of this study was to assess the frequency and severity with which radiologists experience moral distress and to explore moral distress's root causes and countermeasures. METHODS. This study entailed a national survey that evaluated moral distress in radiology. The survey incorporated the validated Moral Distress Scale for Health Care Professionals, along with additional questions. After the scale was modified for applicability to radiology, respondents were asked to assess 16 clinical scenarios in terms of frequency and severity of moral distress. On May 10, 2022, the survey was sent by e-mail to 425 members of radiology practices included on a national radiology society's quality-and-safety LISTSERV. The Measure of Moral Distress for Health Care Professionals (MMD-HP) score was calculated for each respondent as a summary measure of distress across scenarios (maximum possible score, 256). RESULTS. After 12 surveys with incomplete data were excluded, the final analysis included 93 of 425 respondents (22%). A total of 91 of 93 respondents (98%) experienced at least some moral distress for at least one scenario. A total of 17 of 93 respondents (18%) had left a clinical position due to moral distress; 26 of 93 (28%) had considered leaving a clinical position due to moral distress but did not leave. The mean MMD-HP score was 73 ± 51 (SD) for those who had left, 89 ± 47 for those who had considered leaving but did not leave, and 39 ± 35 for those who had never considered leaving (p < .001). A total of 41 of 85 respondents (48%) thought that the COVID-19 pandemic had influenced their moral distress level. Across respondents, the three scenarios with highest moral distress were related to systemic causes (higher case volume than could be read safely, high case volume preventing teaching residents, and lack of administrative action or support). The countermeasure most commonly selected to alleviate moral distress was educating leadership about sources of moral distress (71%). CONCLUSION. Moral distress is prevalent in radiology, typically relates to systemic causes, and is a reported contributor to radiologists changing jobs. CLINICAL IMPACT. Urgent action by radiology practice leadership is required to address moral distress, as radiologists commonly practice in environments contradictory to their core values as physicians.