Publications

The diaphragm, the principle muscle of inspiration, is an under-recognized contributor to respiratory disease. Dysfunction of the diaphragm can occur secondary to lung disease, prolonged ventilation, phrenic nerve injury, neuromuscular disease, and central nervous system pathology. In light of the global pandemic of coronavirus disease 2019 (COVID-19), there has been growing interest in the utility of ultrasound for evaluation of respiratory symptoms including lung and diaphragm sonography. Diaphragm ultrasound can be utilized to diagnose diaphragm dysfunction, assess severity of dysfunction, and monitor disease progression. This article reviews diaphragm and phrenic nerve ultrasound and describes clinical applications in the context of COVID-19.

PURPOSE: To assess the impact of radiology review for discordance between pathology results from computed tomography (CT)-guided biopsies versus imaging findings performed before a biopsy.

MATERIALS AND METHODS: In this retrospective review, which is compliant with the Health Insurance Portability and Accountability Act and approved by the institutional review board, 926 consecutive CT-guided biopsies performed between January 2015 and December 2017 were included. In total, 453 patients were presented in radiology review meetings (prospective group), and the results were classified as concordant or discordant. Results from the remaining 473 patients not presented at the radiology review meetings were retrospectively classified. Times to reintervention and to definitive diagnosis were obtained for discordant cases; of these, 49 (11%) of the 453 patients were in the prospective group and 55 (12%) of the 473 patients in the retrospective group.

RESULTS: Pathology results from CT-guided biopsies were discordant with imaging in 11% (104/926) of the cases, with 57% (59/104) of these cases proving to be malignant. In discordant cases, reintervention with biopsy and surgery yielded a shorter time to definitive diagnosis (28 and 14 days, respectively) than an imaging follow-up (78 days) (P < .001). The median time to diagnosis was 41 days in the prospective group and 56 days in the retrospective group (P = .46). When radiologists evaluated the concordance between pathology and imaging findings and recommended a repeat biopsy for the discordant cases, more biopsies were performed (50% [11/22] vs 13% [4/31]; P = .005).

CONCLUSIONS: Eleven percent of CT-guided biopsies yielded pathology results that were discordant with imaging findings, with 57% of these proving to be malignant on further workup.

PURPOSE: To compare detection rates of NET liver metastases of MRI and Ga-68-DOTATATE PET/CT to provide more clarity when selecting diagnostic imaging tests for NET staging.

METHODS: In this IRB-approved single-institution retrospective study, all patients with pathology-proven NET who underwent Ga-68-DOTATATE and MRI scans within 8 weeks of each other (3/2017-2/2020) were reviewed. Number of metastases for each patient on diffusion-weighted imaging (DWI), dynamic contrast-enhanced (DCE) MRI, and Ga-68 DOTATATE were recorded by two blinded radiologists, followed by consensus review with two separate blinded readers for MRI and nuclear medicine. Per-lesion and -modality scoring at each lesion location were then performed in consensus. Per-patient linear regression was performed comparing MRI and Ga-68 DOTATATE detection rates for each reader and in consensus, and per-lesion-matched pair difference means were used to compare detection frequency between modalities.

RESULTS: 32 patients (mean age 59 years, 59.4% male) and 90 liver metastases were analyzed. Intraclass coefficients (ICC) [95% CI] between the two readers were 0.97 [0.95, 0.99], 0.89 [0.82, 0.94], and 0.98 [0.97, 0.99] for Ga-68 DOTATATE, DWI, and DCE, respectively. Matched per-lesion mean differences were + 0.17 ± 0.07 (p = 0.01) and + 0.22 ± 0.06 (p =  < 0.001) for DWI versus Ga-68 DOTATATE and DCE vs Ga-68 DOTATATE, respectively, favoring MRI. Case-based linear regressions estimate that DWI and DCE detect 1.28 [1.07, 1.49] and 1.33 [1.12, 1.54] lesions, respectively, for each one detected on Ga-68 DOTATATE.

CONCLUSION: MRI detects more hepatic NET metastasis in comparison to Ga-68 DOTATATE. Liver MRI should be performed in concert with Ga-68 DOTATATE in NET staging.

Background The Liver Imaging Reporting and Data System (LI-RADS) assigns a risk category for hepatocellular carcinoma (HCC) to imaging observations. Establishing the contributions of major features can inform the diagnostic algorithm. Purpose To perform a systematic review and individual patient data meta-analysis to establish the probability of HCC for each LI-RADS major feature using CT/MRI and contrast-enhanced US (CEUS) LI-RADS in patients at high risk for HCC. Materials and Methods Multiple databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus) were searched for studies from January 2014 to September 2019 that evaluated the accuracy of CT, MRI, and CEUS for HCC detection using LI-RADS (CT/MRI LI-RADS, versions 2014, 2017, and 2018; CEUS LI-RADS, versions 2016 and 2017). Data were centralized. Clustering was addressed at the study and patient levels using mixed models. Adjusted odds ratios (ORs) with 95% CIs were determined for each major feature using multivariable stepwise logistic regression. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) (PROSPERO protocol: CRD42020164486). Results A total of 32 studies were included, with 1170 CT observations, 3341 MRI observations, and 853 CEUS observations. At multivariable analysis of CT/MRI LI-RADS, all major features were associated with HCC, except threshold growth (OR, 1.6; 95% CI: 0.7, 3.6; P = .07). Nonperipheral washout (OR, 13.2; 95% CI: 9.0, 19.2; P = .01) and nonrim arterial phase hyperenhancement (APHE) (OR, 10.3; 95% CI: 6.7, 15.6; P = .01) had stronger associations with HCC than enhancing capsule (OR, 2.4; 95% CI: 1.7, 3.5; P = .03). On CEUS images, APHE (OR, 7.3; 95% CI: 4.6, 11.5; P = .01), late and mild washout (OR, 4.1; 95% CI: 2.6, 6.6; P = .01), and size of at least 20 mm (OR, 1.6; 95% CI: 1.04, 2.5; P = .04) were associated with HCC. Twenty-five studies (78%) had high risk of bias due to reporting ambiguity or study design flaws. Conclusion Most Liver Imaging Reporting and Data System major features had different independent associations with hepatocellular carcinoma; for CT/MRI, arterial phase hyperenhancement and washout had the strongest associations, whereas threshold growth had no association. © RSNA, 2021 Online supplemental material is available for this article.

PURPOSE: Pancreatic ductal adenocarcinoma (PDAC) remains a significant health issue. For most patients, there are no options for targeted therapy, and existing treatments are limited by toxicity. The HOPE trial (Harnessing Organoids for PErsonalized Therapy) was a pilot feasibility trial aiming to prospectively generate patient-derived organoids (PDO) from patients with PDAC and test their drug sensitivity and correlation with clinical outcomes.

EXPERIMENTAL DESIGN: PDOs were established from a heterogeneous population of patients with PDAC including both basal and classical PDAC subtypes.

RESULTS: A method for classifying PDOs as sensitive or resistant to chemotherapy regimens was developed to predict the clinical outcome of patients. Drug sensitivity testing on PDOs correlated with clinical responses to treatment in individual patients.

CONCLUSIONS: These data support the investigation of PDOs to guide treatment in prospective interventional trials in PDAC.

PURPOSE: Imposter phenomenon refers to feelings of inadequacy due to inability to internalize evident success. While high achievers such as physicians have been known to exhibit imposter phenomenon, there is limited literature specific to radiologists. Our purpose was to (1) investigate imposter phenomenon in radiologists and assess correlation with burnout, and (2) pilot an intervention aimed at addressing imposter phenomenon through improvisational theater techniques.

METHODS: Part 1 - Clinical radiology faculty at a single large academic medical center completed an anonymous survey with questions related to demographics, burnout (derived from the validated Mini-Z assessment tool), and imposter phenomenon. Part 2 - A one-hour interactive workshop on imposter phenomenon was organized for the radiology department at the same institution. The workshop included the Clance Imposter Phenomenon Scale (CIPS). A post-workshop survey rating was also performed.

RESULTS: Part 1 - Of 30 clinical radiology faculty who participated in the survey, 83% reported feelings of imposter phenomenon during their career. There was significant (p = 0.024) correlation between imposter phenomenon and burnout. Part 2 - Of 21 members of the Department of Radiology who completed the CIPS in the interactive workshop, 71% exhibited frequent or intense symptoms of imposter phenomenon. On the post-workshop survey asking participants to rate the workshop, the mean score was 4.4 and the mode score was 5 on a scale of 1 (poor) to 5 (excellent).

CONCLUSION: Imposter phenomenon affects radiologists and is correlated with burnout. Innovative interventions to address imposter phenomenon such as workshops utilizing medical improvisational techniques are well-received.