Role of Radiologists in Contract Research Organizations (CROs)

Clinical trials play a vital role in advancing technology and novel therapies in the healthcare world. However, the increasing scale of trials and the complexity of the regulatory approval process is often a barrier for those interested in conducting research. Contract research organizations (CROs) aim to address this problem by offering their infrastructure and expertise to bring a therapy from conception to approval without the need for in-house staff. Clinical trial imaging often plays an essential role in this process, creating a need for radiologists and a unique opportunity to provide irreplaceable value in their ability to interpret and analyze the imaging outcomes of therapies in question. This paper explores the concept of CROs, the crucial role played by radiologists in their operation, and the nature of the CRO - radiologist relationship.

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

PURPOSE

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED).

MATERIALS AND METHODS

A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status.

RESULTS

A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival.

CONCLUSION

Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

A Decade of Success in Melanoma Immunotherapy and Targeted Therapy: What Every Radiologist Should Know

ABSTRACT

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.

Efficacy of Immune Checkpoint Inhibitors against Advanced or Metastatic Neuroendocrine Neoplasms: A Systematic Review and Meta-Analysis

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.

The modern therapeutic & imaging landscape of metastatic prostate cancer: a primer for radiologists

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.

Primary peritoneal serous carcinoma: a primer for radiologists

Primary peritoneal serous carcinoma (PPSC) is a rare primary peritoneal tumor characterized by a unique range of clinical features and imaging findings. Though it shares many clinical, histologic, and imaging features with serous ovarian carcinoma, it remains a distinct clinical entity. Although less common than its primary ovarian counterpart, PPSC is characterized by a prognosis that is often equally poor with presentations common in late stages of disease. Key imaging modalities used in the evaluation of PPSC include ultrasound, CT, MRI, and PET/CT. For radiologists, an understanding of the pertinent imaging findings, pathologic correlations, and clinical features of PPSC is essential for arriving at the correct diagnosis and guiding the subsequent appropriate management of this complex malignancy.

Overview of serum and tissue markers in colorectal cancer: a primer for radiologists

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.

Imaging-based Toxicity and Response Pattern Assessment Following CAR T-Cell Therapy

Background Chimeric antigen receptor (CAR) T-cell immunotherapy is increasingly used for refractory lymphoma but may lead to cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Imaging may assist in clinical management. Associations between CRS or ICANS grade and imaging findings remain not fully established. Purpose To determine associations between imaging findings and clinical grade of CRS or ICANS, evaluate response patterns, and assess imaging use following CAR T-cell treatment. Materials and Methods Patients with refractory B-cell lymphoma who received CAR T-cell infusion between 2018 and 2020 at a single center were analyzed retrospectively. Clinical CRS or ICANS toxicity grade was assessed using American Society for Transplantation and Cellular Therapy, or ASTCT, consensus grading. Thoracic and head images (radiographs, CT scans, MRI scans) were evaluated. Associations between imaging findings and clinical CRS or ICANS grade were analyzed. Wilcoxon signed-rank and χ² tests were used to assess associations between thoracic imaging findings, clinical CRS toxicity grade, and imaging-based response. Response to therapy was evaluated according to Deauville five-point scale criteria. Results A total of 38 patients (mean age ± standard deviation, 59 years ± 10; 23 men) who received CAR T-cell infusion were included. Of these, 24 (63% [95% CI: 48, 79]) and 11 (29% [95% CI: 14, 44]) experienced clinical grade 1 or higher CRS and ICANS, respectively. Patients with grade 2 or higher CRS were more likely to have thoracic images with abnormal findings (10 of 14 patients [71%; 95% CI: 47, 96] vs five of 24 patients [21%; 95% CI: 4, 37]; P = .002) and more likely to have imaging evidence of pleural effusions (five of 14 [36%; 95% CI: 10, 62] vs two of 24 [8.3%; 95% CI: 0, 20]; P = .04) and atelectasis (eight of 14 [57%; 95% CI: 30, 84] vs six of 24 [25%; 95% CI: 7, 43]; P = .048). Positive imaging findings were identified in three of seven patients (43%) with grade 2 or higher ICANS who underwent neuroimaging. The best treatment response included 20 of 36 patients (56% [95% CI: 39, 72]) with complete response, seven of 36 (19% [95% CI: 6, 33]) with partial response, one of 36 (2.8% [95% CI: 0, 8]) with stable disease, and eight of 36 (22% [95% CI: 8, 36]) with progressive disease. Conclusion Thoracic imaging findings, including pleural effusions and atelectasis, correlated with cytokine release syndrome grade following chimeric antigen receptor (CAR) T-cell infusion. CAR T-cell therapy yielded high response rates. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Langer in this issue.

Past, Present, and Future of Serum Tumor Markers in Management of Ovarian Cancer: A Guide for the Radiologist

The ability to accurately detect early ovarian cancer and subsequently monitor treatment response is essential to improving survival for patients with ovarian malignancies. Several serum tumor markers (STMs)-including cancer antigen 125 (CA-125), human epididymis protein 4 (HE4), cancer antigen 19-9 (CA 19-9), and carcinoembryonic antigen (CEA)-have been used as a noninvasive method of identifying ovarian cancer in conjunction with imaging. Although current guidelines do not recommend use of STMs as screening tools for ovarian cancer, these markers have clinical utility in both diagnosis and surveillance for women with ovarian cancer. CA-125 is the most commonly used STM; its level may be elevated in several types of ovarian cancer, including epithelial cell tumors, carcinosarcoma, teratomas, and secondary ovarian malignancies. An elevated level of CA 19-9 is associated with clear cell tumors, teratomas, and secondary malignancies. CEA is most commonly associated with mucinous ovarian cancers. Finally, HE4 is being increasingly used to identify certain subtypes of epithelial ovarian cancers, particularly serous and endometrioid tumors. Diagnosis of ovarian cancers relies on a combination of CA-125 levels and US findings, which include a large adnexal mass or high-risk features, including septa and increased vascularity. CT is preferred for staging and is used along with PET and STM monitoring for surveillance. Increasingly, MRI is being used to characterize ovarian lesions that are indeterminate at US or CT. The future of STM testing involves development of "liquid biopsies," in which plasma samples are analyzed for evidence of tumors, including circulating tumor DNA or tumor cells and tumor micro-RNA. When combined with traditional imaging techniques, liquid biopsies may lead to earlier diagnosis and improved survival. An invited commentary by Shinagare is available online. ^©RSNA, 2021.

COVID-19 infection in the cancer population: a study of emergency department imaging utilization and findings

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 < 0.05), and mortality (p = 0.042) were found between the prior diagnosis and ED diagnosis groups. No such differences were found between the active treatment and surveillance groups.

Conclusion

ED CT imaging findings in patients with cancer and COVID-19 are predominantly related to COVID-19 infection, rather than cancer history or anti-cancer therapy status.

High-dose interleukin-2 therapy related adverse events and implications on imaging

High-dose interleukin-2 (HDIL-2) therapy was initially approved by the U.S. Food and Drug Administration for metastatic renal cell carcinoma (mRCC) and metastatic melanoma. IL-2 is able to promote CD8+ T cell and natural killer (NK) cell cytotoxicity to increase tumoricidal activity of the innate immune system. HDIL-2 therapy is associated with a wide spectrum of immune-related adverse events (irAEs) that can be radiologically identified. HDIL-2 toxicity can manifest in multiple organ systems, most significantly leading to cardiovascular, abdominal, endocrine, and neurological adverse events. The collective impact of the irAEs and the rise of immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors led to the demise of HDIL-2 as a primary therapy for mRCC and metastatic melanoma. However, with innovation in ICIs and the creation of mutant IL-2 conjugates, there has been a drive for combination therapy. Knowledge of the HDIL-2 therapy and HDIL-2 related adverse events with radiology relevance is critical in diagnostic image interpretation.

Trends in Medicare Part B Payments and Utilization for Imaging Services Between 2009 and 2019

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.

Imaging features of hypercalcemia: A primer for emergency radiologists

Hypercalcemia is a marker for a wide variety of underlying etiologies, and its presentation in the emergency setting may be asymptomatic, incidental, or a primary complaint with associated symptoms and physical exam findings. While the workup is initially driven through serum laboratory testing, imaging plays an important role in diagnosis and post-treatment follow up. This review covers multiple common and uncommon etiologies of hypercalcemia, details their underlying mechanisms, and identifies the most important associated imaging findings. It is important for radiologists to be familiar with these etiologies and imaging findings, particularly in the emergency setting since hypercalcemia may represent the only significant laboratory abnormality associated with the presenting condition. Furthermore, the radiologist's interpretation of a study may be directly influenced by knowing about a patient's hypercalcemia.

Impact of BRAF mutations on outcomes in metastatic melanoma with central nervous system metastases treated with immune checkpoint inhibitors

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Background: Half of patients (pts) with melanoma (mel) develop central nervous system (CNS) metastases (mets), leading to death in over 90% in the pre-immune checkpoint inhibitor (ICI) era. Overall survival (OS) has improved in the ICI era for those with CNS mets, yet the association of survival with ICI treatment for those with tumors harboring genomic variants (var) remains unclear. Methods: We retrospectively reviewed our electronic medical records to identify pts with mel and CNS mets who received ICI from 2010 to 2018. Treatment history, systemic and CNS responses, and genomic data were recorded. Genomic var were categorized as BRAFV600E (BRAF), NRAS, cKIT, other var, and no var. Concurrent RT (CRT) was defined as RT to CNS mets within 30 days of ICI. OS was calculated from date of first ICI or RT to date of death or last follow up, and comparison analyses made using Kaplan-Meier estimate. Fisher's exact or Chi-squared tests were used to compare categorical variables and Wilcoxon or Kruskal-Wallis tests to compare continuous variables. A two-sided p-value of < 0.05 was considered statistically significant. Results: A total of 49 pts were identified; 37 had var results available. BRAFV600E was the most common var identified (32%), followed by NRAS (19%), cKIT (5%), and other (5%); 38% had no var. BRAFV600K was not identified. Pts with BRAF had lower rates of CNS progression on ICI at 3 and 6 months than all other pts (17% vs 50%, p< 0.01 and 12.5% vs 40%, p< 0.01, respectively). Of 38 pts (10 BRAF) who had CNS mets at the start of ICI, 6-month OS was 50% in pts with BRAF, compared to 0% in pts with non-BRAF var ( p= 0.01) and 36% in pts with no var ( p= 0.7). 4 of the 10 pts with BRAF who had CNS mets at start of ICI received BRAF-targeted therapy after ICI. On ICI, only 30% of pts with BRAF developed new CNS mets, compared to 57% of all other pts ( p= 0.08). Pts who developed new CNS mets on ICI had worse OS than pts who did not (median OS (mOS) 314 days vs 662 days, p= 0.04). A majority of pts (55%) received anti-CTLA4 monotherapy as first ICI, and 39% received anti-CTLA4 plus anti-PD1. Pts with BRAF were just as likely to receive dual anti-CTLA4/PD-1 as pts without BRAF (33% vs 40%, p= 0.74). 40 pts underwent RT for CNS mets, of whom 22 received CRT. There was no difference in mOS between pts who received CRT and non-concurrent RT/no RT (468 days vs 314 days, p= 0.8). Rates of CRT between pts with BRAF and pts without BRAF were similar ( p> 0.9), and there was no difference in mOS between these groups (400 days vs 536 days, p= 0.9). Conclusions: Pts with BRAF-mutated mel with CNS mets receiving ICI had lower rates of progression in CNS and improved OS compared to other var. CRT was not associated with improved survival over non-concurrent RT. There has been significant improvement in OS of pts with mel CNS mets in the era of ICI and additional studies are warranted to understand the biology of BRAF var and the host immune system response in the CNS.

Correlation of liver-to-spleen ratio, lung CT scores, clinical, and laboratory findings of COVID-19 patients with two consecutive CT scans

PURPOSE

Given the lack of information about abdominal imaging findings and correlation with clinical features of COVID-19, we aimed to evaluate the changes in hepatic attenuation during the course of disease. Our aim was to correlate the liver-to-spleen ratio (L/S), clinical, laboratory findings, and lung CT scores of patients with COVID-19 who had two consecutive chest CTs.

METHODS

A retrospective search was performed between March 1, 2020 and April 26, 2020 to identify patients who had positive RT-PCR tests and two unenhanced chest CTs. Scans that were obtained at hospital admission and follow-up were reviewed to assess L/S and lung CT scores. Patients were divided into two groups based on lung CT scores (non-progressive vs progressive). Patient demographics, laboratory findings, length of hospital stay, and survival were noted from electronic medical records.

RESULTS

Twenty patients in the progressive group and 7 patients in the non-progressive group were identified. The mean L/S of the progressive group (1.13 ± 0.3) was lower than that of the non-progressive group (1.21 ± 0.29) at hospital admission but there was no significant difference between the two groups (p = 0.547). L/S at follow-up was significantly different between the groups as the mean L/S values of the progressive and non-progressive groups were 1.02 ± 0.23 and 1.25 ± 0.29, respectively (p = 0.009). L/S was negatively correlated with AST and ALT (r =  - 0.46, p = 0.016 and r =  - 0.534, p = 0.004, respectively). There were significant differences between the two groups in terms of WBC, neutrophil, lymphocyte, monocyte, and platelet counts that were obtained at hospital admission. Length of hospital stay was significantly longer in patients in the progressive group (p = 0.035).

CONCLUSIONS

Decrease in L/S may be observed in patients with elevated lung CT scores at follow-up. WBC, neutrophil, lymphocyte, monocyte, and platelet counts at hospital admission may predict the progression of COVID-19.

Definition, Incidence, and Challenges for Assessment of Hyperprogressive Disease During Cancer Treatment With Immune Checkpoint Inhibitors: A Systematic Review and Meta-analysis

IMPORTANCE

Hyperprogressive disease (HPD) is a recognized pattern of rapid tumor progression during immune checkpoint inhibitor (ICI) treatment. Definitions of HPD have not been standardized, posing the risk of capturing different tumoral behaviors.

OBJECTIVES

To provide a systematic summary of definitions and the incidence of HPD in patients undergoing ICI treatment and discuss the challenges of current assessment of HPD.

DATA SOURCES

Articles that evaluated HPD published before March 3, 2020, were identified from MEDLINE and EMBASE.

STUDY SELECTION

Clinical trials and observational studies providing the incidence and definition of HPD from patients with cancer treated with ICIs.

DATA EXTRACTION AND SYNTHESIS

Factors included in the analysis comprised authors, year of publication, cancer type, ICI type, number of previous treatment lines, definition of HPD, time frame used to assess HPD, number of patients with HPD, onset of HPD, and prognosis of patients with HPD. Quantitative and qualitative syntheses for the incidence of HPD were performed.

MAIN OUTCOMES AND MEASURES

Definitions of HPD were categorized and the range of incidence of HPD was evaluated. Subgroup analysis on the incidence of HPD according to the category was performed and the challenges associated with current HPD assessment were evaluated.

RESULTS

Twenty-four studies with 3109 patients were analyzed. The incidence of HPD varied from 5.9% to 43.1%. The definitions were divided into 4 categories based on the calculation of tumor growth acceleration: tumor growth rate ratio (pooled incidence of HPD, 9.4%; 95% CI, 6.9%-12.0%), tumor growth kinetics ratio (pooled incidence, 15.8%; 95% CI, 8.0%-23.7%), early tumor burden increase (pooled incidence, 20.6%; 95% CI, 9.3%-31.8%), and combinations of the above (pooled incidence, 12.4%; 95% CI, 7.3%-17.5%). Hyperprogressive disease could be overestimated or underestimated if the assessment was limited to tumor growth rate or tumor growth kinetics ratio, target lesions, or response evaluation criteria in solid tumors (RECIST)-defined progressors, or if the assessment time frame conformed to RECIST. Study results on clinical outcome were heterogeneous on discriminating patients with HPD from those with natural progressive disease.

CONCLUSIONS AND RELEVANCE

Definitions of HPD appear to be diverse, with the incidence of HPD varying from 5.9% to 43.1% across studies examined in this meta-analysis. Varying incidence and definitions of HPD indicate the need for establishing its uniform and clinically relevant criteria based on currently available evidence.

Trends in imaging utilization for small cell lung cancer: a decision tree analysis of the NCCN guidelines

PURPOSE

To investigate the differences in small cell lung cancer (SCLC) diagnostic imaging utilization relative to National Comprehensive Cancer Network (NCCN) guidelines.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

A Foundational Guide to Understanding Radiology Department Business Operations for Trainees

The financial success of a radiology department is crucial to the well-being of both the hospital and the community it serves. Radiology trainees should therefore be conscious of how the department maintains its value within the health system. The purpose of this review is to provide a concise foundational resource for contemporary radiology residents and fellows to understand the basic financial operations of a hospital-based radiology department and to demonstrate its importance in supporting clinical activities. The radiology report is at the heart of reimbursement. Coders use this tool to assign International Classification of Diseases and Current Procedural Terminology codes to file reimbursement claims. Medicare, commanding the highest market share for third-party payers, sets algorithmic standards for compensation practices. Private insurers contract with hospitals, and providers use these systems or create their own contractual framework. Radiology leaders strategically balance these revenue streams with various departmental costs utilizing tools such as budgets and forecasts to ensure long-term organizational viability. Notably, payment practices in the United States are transforming from fee-for-service to value-based care. The roles of the radiologist and the radiology report are evolving with it. Examples of value-based payment models are accountable care organizations and bundled payments. Radiologists participating in these models are increasingly expected to be stewards of imaging utilization and effectively manage health care resources. Within this context of a globally changing incentive structure, trainees must reconceptualize their educational experience to equip themselves for both current and future types of clinical practice.

Extraprostatic extension in prostate cancer: primer for radiologists

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.

Imaging and clinical manifestations of immune checkpoint inhibitor-related colitis in cancer patients treated with monotherapy or combination therapy

PURPOSE

To determine the frequency, imaging, and clinical manifestations of immune checkpoint inhibitor (ICI)-related colitis in cancer patients on monotherapy or combination therapy.

METHODS

The electronic medical records of 1044 cancer patients who received ICIs were retrospectively reviewed to identify 48 patients who had a clinical diagnosis of immune-related colitis. Imaging studies were reviewed to identify patients with imaging manifestations of colitis. Demographic data, type of ICIs, symptoms, presence of other immune-related adverse events (irAEs), and management were recorded.

RESULTS

There was imaging evidence of immune-related colitis in 34 patients (24 men; median age: 63.5 years). The median time to onset of colitis was 75 days (IQR 25-75, 49.5-216 days) in patients receiving monotherapy (group 1) and 78 days (IQR 25-75, 44.3-99.5 days) in patients undergoing combination therapy (group 2) following start of ICI. Symptoms included diarrhea (91.1% [31 of 34]), nausea/vomiting (52.9% [18 of 34]), and abdominal pain (52.9% [18 of 34]). The most common imaging findings were bowel wall thickening (97% [33 of 34]) and fluid-filled colon (82.3% [28 of 34]). Colitis was diffuse in 21 of 34 (61.8%) patients. Imaging manifestations did not differ between the two groups (p > 0.05). Steroids and antibiotics were used to treat colitis in 29 of 34 (85.2%) and 13 of 34 (38.2%) patients, respectively. No patients in group 1 experienced concurrent irAEs, but 5 of 18 (27.8%) of patients in group 2 had other irAEs (p = 0.046).

CONCLUSION

Immune-related colitis occurred in 3.3% of patients receiving ICIs with bowel wall thickening, fluid-filled colon and pancolitis being the most common imaging manifestations. Imaging manifestations did not differ between patients receiving monotherapy or combination therapy. However, concurrent irAEs were significantly observed in patients undergoing combination therapy.

Imaging features of gastrointestinal toxicity in non-small cell lung cancer patients treated with erlotinib: A single institute 13-year experience

OBJECTIVES

To investigate the imaging features of erlotinib-associated gastrointestinal toxicity (GT) in patients with non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

The electronic medical records of 157 patients with NSCLC who received erlotinib between 2005 and 2018 were retrospectively reviewed to identify patients with GT. Clinical and radiologic evidence of erlotinib-associated GT was evaluated. Imaging findings were cross-referenced with clinical presentation, management, and outcomes.

RESULTS

24 (15%) patients (16 women; median age, 68 years) with radiologic evidence of GT were identified. The median time to detection of GT on imaging was 4.5 months (range: 0-58 months). 3/24 (12.5%) patients had no clinical symptoms, but GT was radiologically identified. Erlotinib-associated GT manifested in the large bowel in either a diffuse (42%) or segmental (58%) pattern. The most common imaging finding was fluid-filled bowel (23/24, 96%).

CONCLUSION

Erlotinib-associated GT was identified in 15% patients with NSCLC. Fluid-filled colon and segmental involvement were the most common imaging manifestations.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio

Purpose

To illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic.

Methods

A retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change.

Results

Our multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633).

Conclusion

ED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.