ACR Appropriateness Criteria® Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Adding Value in Radiology Reporting

The major goal of the radiology report is to deliver timely, accurate, and actionable information to the patient care team and the patient. Structured reporting offers multiple advantages over traditional free-text reporting, including reduction in diagnostic error, comprehensiveness, adherence to national consensus guidelines, revenue capture, data collection, and research. Various technological innovations enhance integration of structured reporting into everyday clinical practice. This review discusses the benefits of innovations in radiology reporting to the clinical decision process, the patient experience, the cost of imaging, and the overall contributions to the health of the population. Future directions, including the use of artificial intelligence, are reviewed.

Radiological approach to COVID-19 pneumonia with an emphasis on chest CT

Coronavirus disease 2019 (COVID-19) has recently become a worldwide outbreak with several millions of people infected and more than 160.000 deaths. A fast and accurate diagnosis in this outbreak is critical to isolate and treat patients. Radiology plays an important role in the diagnosis and management of the patients. Among various imaging modalities, chest CT has received attention with its higher sensitivity and specificity rates. Shortcomings of the real-time reverse transcriptase-polymerase chain reaction test, including inappropriate sample collection and analysis methods, initial false negative results, and limited availability has led to widespread use of chest CT in the diagnostic algorithm. This review summarizes the role of radiology in COVID-19 pneumonia, diagnostic accuracy of imaging, and chest CT findings of the disease.

Computer-aided diagnosis system of thyroid nodules ultrasonography: Diagnostic performance difference between computer-aided diagnosis and 111 radiologists

To evaluate the diagnostic efficiency of computer-aided diagnosis (CAD) system and 111 radiologists with different experience in identifying benign and malignant thyroid nodules, and to summarize the ultrasound features that may affect the diagnostic of CAD and radiologists.Fifty thyroid nodules and 111 radiologists were enrolled in this study. All the 50 nodules were diagnosed by the 111 radiologists and the CAD system simultaneously. The diagnostic performance of the CAD system, senior and junior radiologists with the maximum accuracy were calculated and compared. Interobserver agreement for different ultrasound characteristics between the CAD and senior radiologist were analyzed.CAD system showed a higher specificity than junior radiologist (87.5% vs 70.4%, P = .03), and a lower sensitivity than the senior radiologist and junior radiologist but the statistics were not significant (76.9% vs 86.9%, P > .5; 76.9% vs 82.6%, P > .5). The CAD system and senior radiologist got larger AUC than junior radiologist but the differences were not statistically significant (0.82 vs 0.76, respectively; P = .5). The interobserver agreement for the US characteristics between the CAD system and senior radiologist were: substantial agreement for hypoechoic and taller than wide (kappa value = 0.66, 0.78), and moderate agreement for irregular margin and micro-calcifications (kappa value = 0.52, 0.42).The CAD system achieved equal diagnostic accuracy to the senior radiologists and higher accuracy than the junior radiologists. The interobserver agreements in the US features between the CAD system and senior radiologist were substantial agreement for hypoechoic and taller than wide; moderate agreement for irregular margin and micro-calcifications. The location of a thyroid nodule and the feature of macrocalcification with wide acoustic shadow may influence the analysis of the CAD system.

Immune-related (IR)-pneumonitis during the COVID-19 pandemic: multidisciplinary recommendations for diagnosis and management

Immune-related (IR)-pneumonitis is a rare and potentially fatal toxicity of anti-PD(L)1 immunotherapy. Expert guidelines for the diagnosis and management of IR-pneumonitis include multidisciplinary input from medical oncology, pulmonary medicine, infectious disease, and radiology specialists. Severe acute respiratory syndrome coronavirus 2 is a recently recognized respiratory virus that is responsible for causing the COVID-19 global pandemic. Symptoms and imaging findings from IR-pneumonitis and COVID-19 pneumonia can be similar, and early COVID-19 viral testing may yield false negative results, complicating the diagnosis and management of both entities. Herein, we present a set of multidisciplinary consensus recommendations for the diagnosis and management of IR-pneumonitis in the setting of COVID-19 including: (1) isolation procedures, (2) recommended imaging and interpretation, (3) adaptations to invasive testing, (4) adaptations to the management of IR-pneumonitis, (5) immunosuppression for steroid-refractory IR-pneumonitis, and (6) management of suspected concurrent IR-pneumonitis and COVID-19 infection. There is an emerging need for the adaptation of expert guidelines for IR-pneumonitis in the setting of the global COVID-19 pandemic. We propose a multidisciplinary consensus on this topic, in this position paper.

European guidelines on chronic mesenteric ischaemia - joint United European Gastroenterology, European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Gastrointestinal and Abdominal Radiology, Netherlands Association of Hepatogastroenterologists, Hellenic Society of Gastroenterology, Cardiovascular and Interventional Radiological Society of Europe, and Dutch Mesenteric Ischemia Study group clinical guidelines on the diagnosis and treatment of patients with chronic mesenteric ischaemia

Chronic mesenteric ischaemia is a severe and incapacitating disease, causing complaints of post-prandial pain, fear of eating and weight loss. Even though chronic mesenteric ischaemia may progress to acute mesenteric ischaemia, chronic mesenteric ischaemia remains an underappreciated and undertreated disease entity. Probable explanations are the lack of knowledge and awareness among physicians and the lack of a gold standard diagnostic test. The underappreciation of this disease results in diagnostic delays, underdiagnosis and undertreating of patients with chronic mesenteric ischaemia, potentially resulting in fatal acute mesenteric ischaemia. This guideline provides a comprehensive overview and repository of the current evidence and multidisciplinary expert agreement on pertinent issues regarding diagnosis and treatment, and provides guidance in the multidisciplinary field of chronic mesenteric ischaemia.

Optimisation in daily practice - it's more than just radiation dose

On this editorial, the importance of optimisation of diagnostic imaging and radiation therapy in terms of diagnostic and therapeutic tests and treatments, education and service provision are discussed.

Multiparametric radiomics methods for breast cancer tissue characterization using radiological imaging

BACKGROUND AND PURPOSE

Multiparametric radiological imaging is vital for detection, characterization, and diagnosis of many different diseases. Radiomics provide quantitative metrics from radiological imaging that may infer potential biological meaning of the underlying tissue. However, current methods are limited to regions of interest extracted from a single imaging parameter or modality, which limits the amount of information available within the data. This limitation can directly affect the integration and applicable scope of radiomics into different clinical settings, since single image radiomics are not capable of capturing the true underlying tissue characteristics in the multiparametric radiological imaging space. To that end, we developed a multiparametric imaging radiomic (mpRad) framework for extraction of first and second order radiomic features from multiparametric radiological datasets.

METHODS

We developed five different radiomic techniques that extract different aspects of the inter-voxel and inter-parametric relationships within the high-dimensional multiparametric magnetic resonance imaging breast datasets. Our patient cohort consisted of 138 breast patients, where, 97 patients had malignant lesions and 41 patients had benign lesions. Sensitivity, specificity, receiver operating characteristic (ROC) and areas under the curve (AUC) analysis were performed to assess diagnostic performance of the mpRad parameters. Statistical significance was set at p < 0.05.

RESULTS

The mpRad features successfully classified malignant from benign breast lesions with excellent sensitivity and specificity of 82.5% and 80.5%, respectively, with Area Under the receiver operating characteristic Curve (AUC) of 0.87 (0.81-0.93). mpRad provided a 9-28% increase in AUC metrics over single radiomic parameters.

CONCLUSIONS

We have introduced the mpRad framework that extends radiomic analysis from single images to multiparametric datasets for better characterization of the underlying tissue biology.

PET/CT radiomics in breast cancer: Mind the step

The aim of the present review was to assess the current status of positron emission tomography/computed tomography (PET/CT) radiomics research in breast cancer, and in particular to analyze the strengths and weaknesses of the published papers in order to identify challenges and suggest possible solutions and future research directions. Various combinations of the terms "breast", "radiomic", "PET", "radiomics", "texture", and "textural" were used for the literature search, extended until 8 July 2019, within the PubMed/MEDLINE database. Twenty-six articles fulfilling the inclusion/exclusion criteria were retrieved in full text and analyzed. The studies had technical and clinical objectives, including diagnosis, biological characterization (correlation with histology, molecular subtypes and IHC marker expression), prediction of response to neoadjuvant chemotherapy, staging, and outcome prediction. We reviewed and discussed the selected investigations following the radiomics workflow steps related to the clinical, technical, analysis, and reporting issues. Most of the current evidence on the clinical role of PET/CT radiomics in breast cancer is at the feasibility level. Harmonized methods in image acquisition, post-processing and features calculation, predictive models and classifiers trained and validated on sufficiently representative datasets, adherence to consensus guidelines, and transparent reporting will give validity and generalizability to the results.

PRELIMINARY STAFF DOSE ASSESSMENT FOR COMMON FLUOROSCOPY GUIDED PROCEDURES AT KORLE-BU TEACHING HOSPITAL, ACCRA, GHANA

Preliminary studies on effective and eye lens doses of six Radiologists, four Cardiologists have been conducted for a period of 3 months. Electronic dosemeters positioned under and over lead apron of staff were used for the dosimetry. The estimated effective dose per month to Cardiologist and Radiologist were 0.01-0.07 mSv and 0.03-0.14 mSv, respectively. The estimated eye lens doses per month to Cardiologists and Radiologists were also 0.15-0.30 mSv and 0.53-3.39 mSv, respectively. The effective doses per month to staff were below the ICRP acceptable limit of 1.67 mSv/month but the upper limit of the range of estimated eye lens dose exceeded the ICRP acceptable limit by a factor of 2. Regular use of protective goggles and consistent eye lens dose monitoring is encouraged at the hospital for dose optimization.

Reason for exam Imaging Reporting and Data System (RI-RADS): A grading system to standardize radiology requisitions

Radiologists often encounter imaging requisitions that lack important information needed for accurate diagnostic studies. Reason for exam Imaging Reporting and Data System (RI-RADS) is proposed as a grading system for evaluation of the quality of clinically pertinent information provided in imaging requisitions. Three categories of information are suggested as key indicators of quality: impression, clinical findings, and the diagnostic question. This scheme is intended to improve the quality of imaging requisitions and overall patient care.

Systematic Layout Planning of a Radiology Reporting Area to Optimize Radiologists' Performance

Optimizing radiologists' performance is a major priority for managers of health services/systems, since the radiologists' reporting activity imposes a severe constraint on radiology productivity. Despite that, methods to optimize radiologists' reporting workplace layout are scarce in the literature. This study was performed in the Radiology Division (RD) of an 850-bed University-based general hospital. The analysis of the reporting workplace layout was carried out using the systematic layout planning (SLP) method, in association with cluster analysis as a complementary tool in early stages of SLP. Radiologists, architects, and hospital managers were the stakeholders consulted for the completion of different stages of the layout planning process. A step-by-step description of the proposed methodology to plan an RD reporting layout is presented. Clusters of radiologists were defined using types of exams reported and their frequency of occurrence as clustering variables. Sectors with high degree of interaction were placed in proximity in the new RD layout, with separation of noisy and quiet areas. Four reporting cells were positioned in the quiet area, grouping radiologists by subspecialty, as follows: cluster 1-abdomen; cluster 2-musculoskeletal; cluster 3-neurological, vascular and head & neck; cluster 4-thoracic and cardiac. The creation of reporting cells has the potential to limit unplanned interruptions and enhance the exchange of knowledge and information within cells, joining radiologists with the same expertise. That should lead to improvements in productivity, allowing managers to more easily monitor radiologists' performance.

Overview and comparison of guidelines for management of pancreatic cystic neoplasms

Pancreatic cysts are identified at an increasing frequency. Although mucinous cystic neoplasms represent a pre-malignant condition, the majority of these lesions do not progress to cancer. Over the last 10 years several societies have established guidelines for the diagnosis, initial evaluation and surveillance of these lesions. Here we provide an overview of five commonly used guidelines: 2015 American Gastroenterological Association, 2017 International Association of Pancreatology, American College of Gastroenterology 2018, European Study Group and American College of Radiology. We describe the similarities and differences between the methods used to formulate these guidelines, the population they target and their approaches towards initial evaluation and surveillance of cystic lesions.

Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions

Interpretation of increasingly complex imaging studies involves multiple intricate tasks requiring visual evaluation, cognitive processing, and decision-making. At each stage of this process, there are opportunities for error due to human factors including perceptual and ergonomic conditions. Investigation into the root causes of interpretive error in radiology first began over a century ago. In more recent work, there has been increasing recognition of the limits of human image perception and other human factors and greater acknowledgement of the role of the radiologist's environment in increasing the risk of error. This article reviews the state of research on perceptual and interpretive error in radiology. This article focuses on avenues for further error examination, and strategies for mitigating these errors are discussed. The relationship between artificial intelligence and interpretive error is also considered.

dp-BREATH: Heat maps and probabilistic classification assisting the analysis of abnormal lung regions

BACKGROUND AND OBJECTIVE

Identifying abnormalities in chest CT scans is an important and challenging task, demanding time and effort from specialists. Different parts of a single lung image may present both normal and abnormal characteristics. Thus, detecting a single lung as healthy (normal) or not is inaccurate.

METHODS

In this work we propose dp-BREATH, a method capable of detecting abnormalities in pulmonary tissue regions and directing the specialist's attention to the lung region containing them. It starts by highlighting regions that may indicate pulmonary abnormalities based on the healthy pulmonary tissue behavior using a superpixel-based approach and a heat map visualization. This is achieved by modeling regions of healthy tissue using a statistical model. All regions considered abnormal are modeled and classified according to their probability of containing each of the studied abnormalities. Further, dp-BREATH provides a better recognition of radiological patterns, with the likelihood of a selected lung region to contain abnormalities.

RESULTS

We validate the statistical model of healthy and abnormal detection using a representative dataset of chest CT scans. The model has shown almost no overlap between healthy and abnormal regions, and the detection of abnormalities presented precision higher than 86%, for all recall values. Additionally, the fitted models describing pulmonary radiological patterns present precision of up to 87%, with a high separation for three of five radiological patterns.

CONCLUSIONS

dp-BREATH's heat map representation and its list of radiological patterns probabilities provided are intuitive methods to assist physicians during diagnosis.

The need for standardization of nuclear cardiology reporting and data system (NCAD-RADS): Learning from coronary artery disease (CAD), breast imaging (BI), liver imaging (LI), and prostate imaging (PI) RADS

Newer structured reporting manners, the reporting and data system (RADS), have made vast steps in improving standardized and structured reporting, allowing better communication between radiologists and referring providers. This has been implemented in several fields: breast (BI-RADS), lung (Lung-RADS), liver (LI-RADS), thyroid (TI-RADS), prostate (PI-RADS), and in cardiovascular radiology (CAD-RADS). The field of nuclear cardiology began its efforts of standardization years ago; however, a widespread standardized reporting structure has not yet been adopted. Such an approach in nuclear cardiology, the nuclear cardiology reporting and data system (NCAD-RADS), will assist radiologists and treating clinicians in conveying and understanding reports and determining the appropriate next steps in management. By linking explicit findings to defined recommendations, patients will receive more consistent and appropriate care.

Clinical decision support: practical implementation at two pediatric hospitals

Clinical decision support has been identified by the United States government as a method to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of this method will be incentivized by requiring appropriate use criteria to qualify for Medicare reimbursement starting in January 2020. While Medicare reimbursement is unlikely to directly impact pediatric imaging because of largely disparate patient populations, insurance providers typically use Medicare to benchmark their reimbursement guidelines. Therefore soon after their adoption these guidelines could become relevant to pediatric imaging. In this article we discuss how pediatric imaging was initially underrepresented in the clinical decision support realm, and how this was addressed by a subcommittee involving both American College of Radiology and Society for Pediatric Radiology members. We also present the experience of implementing clinical decision support software at two standalone pediatric hospitals and summarize the lessons learned from these deployments.

A Call to Improve the Visibility and Access of the American College of Radiology Practice Parameters in Neuroradiology: A Powerful Value Stream Enhancer for Both Neuroradiologists and Patients

Clinical practice guidelines and clinical practice parameters are among the tools that clinicians and radiologists use to inform decision making in the diagnosis and treatment of patients. Radiologists have been urged to objectively establish their value and measurable contributions to patient care. Radiology's contribution to the health care value stream can be established in the development of sound clinical practice guidelines. Neuroradiologists have been quite active in developing clinical guidelines, particularly in collaboration with the American College of Radiology, but there is a need to increase the visibility and accessibility of such documents. Increasing access and visibility can contribute to improved patient outcomes and an improved overall quality of care.

[Ultrasound training in the professional development of radiological specialists : Concepts and challenges]

ISSUE

Ultrasound is an integral part of imaging diagnostics but, unlike CT or MRI, requires the physician to have advanced technical skills for the implementation and documentation of studies.

CURRENT SITUATION

Owing to poor remuneration and the large effort required, ultrasound is not a priority at many institutions, and compared to CT, MRI or interventions, little reward is given to those committed to ultrasound. Intense practical teaching is rarely given. As a result, residents have to teach themselves or gain experience during rotations outside radiology. In some cases, they are not educated at all. Only rarely do residents in radiology participate in certified ultrasound courses, compared to other clinical disciplines. ONGOING DEVELOPMENTS: (1) Standardized ultrasound curricula accompanying resident training, training focused on contrast-enhanced ultrasound, ultrasound-guided interventions, vascular ultrasound, and typical radiological applications of ultrasound like image fusion for biopsies or therapeutic interventions; (2) interdisciplinary ultrasound centers; (3) fostering of ultrasound education by the German Radiological Society (DRG) through intensive courses during the annual meeting.

ACHIEVEMENTS

The above measures will help to increase skill and dexterity of radiologists in ultrasound, to introduce typical radiological applications of ultrasound into a broader field of applications and increase the awareness of these methods, and to strengthen the role of ultrasound in resident training. FUTURE REQUIREMENTS: (1) One senior radiologist in charge of ultrasound in each department; (2) communication of and adherence to examination and documentation standards; (3) demonstration of ultrasound studies during rounds and boards; (4) interdisciplinary centers for ultrasound education.

IMPLEMENTATION OF QUALITY ASSURANCE PROGRAM IN RADIOGRAPHY-2-YEAR EXPERIENCE OF COLLABORATION WITH PUBLIC HEALTH INSTITUTIONS IN WEST REGION OF CROATIA

Quality Assurance program on using ionizing radiation is mandatory in all EU member states but this is still not implemented in most facilities in Croatia mostly because of a lack of medical physicists in diagnostic radiology. Since public health institutions in Croatia do not employ medical physicists in diagnostic radiology, collaboration between these institutions in west region of Croatia with Clinical Hospital Center Rijeka (CHC) was initiated during the year 2015. Physicists from CHC Rijeka performed periodical Quality Control (QC) tests and were included in optimization process. Results of QC tests during the period of 2 years showed a lot of improvements-equipment is maintained more frequently, some old units were replaced with new ones and all institutions acquired QC equipment so radiographers could perform daily and monthly QC tests. All these activities showed that medical physics support in radiology departments is necessary and can improve clinical practice.

[Radiological evaluation of advanced gastric cancer: from image to big data radiomics]

Following the increased demand of personalized medicine to precise radiology in advanced gastric cancer, there is particular need for objective and powerful surrogate to help the gastro-radiology to break through the bottleneck of imaging resolution and the defect of subjective diagnosis, which can further improve the efficacy of staging and response evaluation. On the basis of the existing imaging resolution, the radiomics can perform massive data mining through texture analysis and big data, using artificial intelligence deep learning and other algorithms to screen and integrate images and clinical features for modeling and diagnosis, which may further improve the efficacy of staging and response evaluation theoretically. In this paper, we focused on gastro-radiology and radiomics, and reviewed five dimensions progressively: (1) As the first choice for staging and response evaluation, CT application is limited by radiologists' ability to excavate image features and information integration, which needs more powerful image processing method. (2) Radiomics texture analysis can provide massive objective image information that can not be identified by the radiologists' naked eye. It is more detailed and provides quantitative evaluation of the characteristics of tumors better than the radiologists' subjective vision analysis, which can dig potential microscopic information. In the recent two years, the research on the application has been progressing rapidly, covering almost all the solid tumors, and solving the various clinical focuses using entropy, skewness, heterogeneity and other texture analysis indicators. (3) The research progress of radiomics in gastric cancer from the following three directions was summarized: differential diagnosis and biological behavior analysis, staging, and response prediction and evaluation. The current research confirmed the high efficiency of radiomics and texture analysis in differentiating different types, stages and responders of gastric cancer, which can act at least as an important supplement for the subjective evaluation of the radiologists.(4) The congenital defects of radiomics and the current problems on research were summarized, in order to avoid misuse and pitfalls. (5) The radiologists need not to worry about being replaced in the expectation of the future AI radiomics; on the contrary, AI radiomics will be a good assistant. The radiologist should actively take part in the MDT and cooperate with multi-center colleagues to promote the development of large data radiomics in gastric cancer.