Comparison of breast density assessments according to BI-RADS 4th and 5th editions and experience level

Background

Breast density is an important variable that can change the sensitivity of mammography. It can be analyzed with using the 4th and 5th editions of the Breast Imaging and Reporting Data System (BI-RADS) recommendations from the American College of Radiology (ACR).

Purpose

To define the intra- and inter-reader agreement levels of breast density assignments performed by readers with different experience levels using two versions of BI-RADS.

Material and Methods

The breast density assessments of 330 women were conducted by two readers with different levels of experience (one breast radiologist and one resident). Each reader independently defined the breast density four times-twice using the 4th edition and twice using the 5th edition. Assessments were analyzed on four- and two-category scales.

Results

The intra-reader agreement of the breast radiologist for the 4th and 5th editions of BI-RADS was almost perfect (k = 0.90 and k = 0.87, respectively.) The resident had similar results (k = 0.88 and k = 0.87, respectively). The agreement between the breast radiologist and resident for the 4th and 5th edition of BI-RADS was substantial (k = 0.70 and k = 0.63, respectively). There was a statistically significant difference with the two-category scale analysis between the dense and non-dense for both readers and versions of BI-RADS (McNemar's test, P < 0.001).

Conclusion

Although there were high intra- and inter-reader agreement levels when using both versions, the percentage of women having dense breasts increased when using the 5th edition, and the difference was statistically significant. There were no differences found with regard to the readers' level of experience in all analyses.

Increased trend of unnecessary use of radiological diagnostic modalities in Pakistan: radiologists perspective

BACKGROUND

Over the past few years, a significant overuse of radiological investigations influenced the quality and cost of healthcare of the country as it may lead to non-compliance of the patient due to non-affordability and also may harm the patient in terms of radiation hazards. Pakistan, being a low-income, resource-constraint country, is facing financial impact on families as well as health system due to multiple reasons.

OBJECTIVES

The purpose of study is to identify reasons of unnecessary use of radiological diagnostic modalities in Pakistani hospitals as perceived by radiologists.

METHODS

A cross-sectional study was conducted on a total of all 105 radiologists, having at least 1 year experience of working in radiology, working in five tertiary care hospitals in Lahore. A self-constructed, self-administered, pretested 5-point Likert scale opinion-based questionnaire was administered after taking informed consent. It includes questions about excessive radiological use that may be attributed to the physicians, investigations, patients and other non-categorized causes. Results were analyzed using SPSS version 23.

RESULTS

Since the assessment forms were handed over and collected from the radiologists in person, the response rate was 100%. Of a total of 105 respondents, 78 (74.28%) respondentsagreed that there is an actual increase, 25 (23.80%) respondents disagreed and 2 (1.90%) respondents were unsure. Most important reasons for increased usage of radiological investigations are 'need of accuracy of diagnosis' (P = 0.009), 'trend of physicians to repeat tests in order to confirm preset diagnoses' (P-value = 0.03), 'lack of knowledge about proper usage of radiological advances' (P-value = 0.005) and 'lack of proper clinical examination' (P-value = 0.04).

CONCLUSION

Unnecessary use of radiological investigations is actually there as perceived by radiologists, which is attributed to inadequate knowledge, attitude and training of physicians to refer patients to radiological resources. This research can be a stepping stone for future researchers as it can be used for elaborating these causes individually and finding ways as to how each of these causes can be controlled and minimized to bring about a decline in excessive usage of these modalities for the betterment of the patients.

Determining whether surgeons perform thyroid fine-needle aspiration as well as radiologists: an analysis of the adequacy and efficiency of ultrasound-guided fine-needle aspiration performed by newly trained head and neck surgeons and radiologists

Background

Ultrasound-guided fine-needle aspiration (FNA) cytology is a crucial diagnostic technique used to assess thyroid nodules. In the past, ultrasound-guided FNA was performed mainly by radiologists. However, many surgeons are increasingly being trained for this procedure now. In this study, we aimed to compare the adequacy and efficiency of ultrasound-guided FNA performed by newly trained head and neck surgeons with experienced radiologists in a single institution. We also assessed the malignancy rates in nondiagnostic nodules and the differences between benign and malignant nodules.

Methods

This is a retrospective study. The data from patients who underwent ultrasound-guided FNA performed by surgeons or radiologists in two consecutive years were collected. Medical records, cytology results, and surgical pathology results were analyzed.

Results

During the study period, a total of 2,405 ultrasound-guided FNAs were performed on 2,163 patients. The head and neck surgeons and radiologists performed 1,132 and 1,273 ultrasound-guided FNA procedures, respectively. The nondiagnostic rate was 14.49% for surgeons and 15.40% for radiologists (P=0.533). There were no differences in patient age, gender, nodule size, and other sonographic characteristics between the groups of patients who were treated by radiologists versus surgeons. The median waiting time from biopsy appointment to performing ultrasound-guided FNA was 0 days for head and neck surgeons, and 6 days for radiologists (P<0.001). Of the 40 patients who had a repeat FNA or surgery, 19 (47.50%) had a malignancy. Preoperative information about age, gender, operator, and characteristics of nodules did not predict the outcome of nodules with Bethesda category I.

Conclusions

The adequacy of ultrasound-guided FNAs performed by head and neck surgeons is similar to that of skilled radiologists, while surgeons are more efficient than radiologists. Nondiagnostic FNA reports should not be considered benign, and repeat FNA or selective surgical treatment is recommended.

How Safety Can Undermine Creativity

OBJECTIVE. Safety and creativity are important but are not entirely convergent medical goals: Physicians are responsible to avoid harm, but progress in medicine requires creativity and risk taking. To strike the appropriate balance between the two, radiologists need to understand potential points of tension between them, ensuring that neither completely overrides the other. CONCLUSION. For medical discovery and innovation to thrive in the future, we need to foster a culture that prizes habits of thinking outside the box, posing novel questions, and taking risks. Caution and safety are important but so too are courage and imagination. If our understanding is ever to reach a higher level, we must be willing to let go of the rung to which we are clinging.

Evaluation of self-reported confidence amongst radiology staff in initiating basic life support across hospitals in the Cape Town Metropole West region

Background

The immediate response to cardiac arrest is regarded as the most time-critical intervention. First responders for cardiac arrests in imaging departments are often radiology staff. The study aim was to determine radiology staff members' confidence in initiating basic life support.

Objectives

The objectives of this study included determining the general confidence levels regarding identifying cardiac arrest and initiation of basic life support (BLS) amongst Radiology staff within the studied sites, as well as to identify potential areas of uncertainty. Another objective included identifying what would contribute to increasing levels of confidence and competence in identifying cardiac arrest and initiating BLS.

Method

A multi-centre cross-sectional survey was conducted using peer-validated, anonymous questionnaires. Questionnaires were distributed to radiology staff working in public sector hospitals within the Cape Town Metropole West. Due to the limited subject pool, a convenience sample was collected. Data were therefore statistically analysed using only summary statistics (mean, standard deviation, proportions, and so on), and detailed comparisons were not made.

Results

We disseminated 200 questionnaires, and 74 were completed (37%). There were no incomplete questionnaires or exclusions from the final sample. Using a 10-point Likert scale, the mean ability to recognise cardiac arrest was 6.45 (SD ± 2.7), securing an airway 4.86 (SD ± 2.9), and providing rescue breaths and initiating cardiac compressions 6.14 (SD ± 2.9). Only two (2.7%) of the participants had completed a basic life support course in the past year; 11 (14.8%) had never completed any basic life support course and 28 (37.8%) had never completed any life support or critical care course. Radiologists, radiology trainees and nurses had the greatest confidence in providing rescue breaths and initiating cardiac compressions from all the groups.

Conclusion

The study demonstrated a substantial lack of confidence in providing basic life support in the participating hospital imaging departments' staff. The participants indicated that regular training and improved support systems would increase confidence levels and improve skills.

Dementia Care in Radiology

OBJECTIVE. Much of the radiology literature on dementia naturally focuses on the use of imaging for diagnosis. However, dementia presents other important challenges for radiology. One of the most important stems from the projected large increase in the number of patients with dementia who will be presenting for care in radiology departments. CONCLUSION. It is important, and increasingly so, that patient-facing radiology personnel understand dementia and the special needs of patients with dementia and their caregivers.

Interdisciplinary Comparison of PADUA and R.E.N.A.L. Scoring Systems for Prediction of Conversion to Nephrectomy in Patients with Renal Mass Scheduled for Nephron Sparing Surgery

PURPOSE

We examined interdisciplinary variability using 2 established preoperative nephrometry scores to predict conversion to nephrectomy in patients with a renal mass who were scheduled for partial nephrectomy.

MATERIALS AND METHODS

A total of 229 consecutive candidates for partial nephrectomy were included in this study at a single institution between January 2013 and May 2017. Patient, tumor and treatment characteristics were assessed. The PADUA (preoperative aspects and dimensions used for an anatomical) score and the R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines) score were independently calculated by board certified radiologists and urological residents using computerized tomography or magnetic resonance imaging. Statistical analyses were done with the κ statistic, ROC curves, and univariable and multivariable binary logistic regression analyses.

RESULTS

Partial nephrectomy was performed in 198 of the 229 cases (86.5%) while 31 (13.5%) were converted to nephrectomy. The prevalent tumor stage was pT1a, noted in 94 of the 229 cases (41.1%), and the predominant histological entity was clear cell carcinoma, found in 128 (55.9%). Radiologist and urologist interdisciplinary comparison of the PADUA and R.E.N.A.L. scores revealed a κ of 0.40 and 0.56, respectively. ROC curve analyses demonstrated a higher AUC predicting conversion to nephrectomy using the PADUA score by the urologist and the radiologist (0.79 and 0.782) compared to that of the R.E.N.A.L. score (0.731 and 0.766, respectively). Using a cutoff of 10 or greater the PADUA score determined by the urologist had 81% sensitivity and 71% specificity, and it was independently associated with conversion to nephrectomy (OR 10.98, p<0.001).

CONCLUSIONS

Our results indicate higher prediction of conversion to nephrectomy when using the PADUA score compared to the R.E.N.A.L. score. Calculation of the PADUA and the R.E.N.A.L. score by physicians without specialized radiological training is feasible and might achieve comparable results to predict conversion to nephrectomy compared to the gold standard provided by board certified radiologists. This information is helpful if nephrometry scores are not regularly included in the radiology report.

An automated mammogram classification system using modified support vector machine

Purpose

Breast cancer remains a serious public health problem that results in the loss of lives among women. However, early detection of its signs increases treatment options and the likelihood of cure. Although mammography has been established to be a proven technique of examining symptoms of cancer in mammograms, the manual observation by radiologists is demanding and often prone to diagnostic errors. Therefore, computer aided diagnosis (CADx) systems could be a viable alternative that could facilitate and ease cancer diagnosis process; hence this study.

Methodology

The inputs to the proposed model are raw mammograms downloaded from the Mammographic Image Analysis Society database. Prior to the classification, the raw mammograms were preprocessed. Then, gray level co-occurrence matrix was used to extract fifteen textural features from the mammograms at four different angular directions: θ={0°, 45°, 90°, 135°}, and two distances: D={1,2}. Afterwards, a two-stage support vector machine was used to classify the mammograms as normal, benign and malignant.

Results

All of the 37 normal images used as test data were classified as normal (no false positive) and all 41 abnormal images were correctly classified to be abnormal (no false negative), meaning that the sensitivity and specificity of the model in detecting abnormality is 100%. After the detection of abnormality, the system further classified the abnormality on the mammograms to be either "benign" or "malignant". Out of 23 benign images, 21 were truly classified as benign. Also, out of 18 malignant images, 17 were truly classified to be malignant. From these findings, the sensitivity, specificity, positive predictive value, and negative predictive value of the system are 94.4%, 91.3%, 89.5%, and 95.5%, respectively.

Conclusion

This article has further affirmed the prowess of automated CADx systems as a viable tool that could facilitate breast cancer diagnosis by radiologists.

Radiological Clinical Practice Guidelines Published in the Last Decade: A Bibliometric Analysis

Objectives:

To provide a comprehensive review of radiological clinical practice guidelines (CPGs) and to establish their characteristics and impact in the field of radiology.

Material and Methods:

A MEDLINE search was performed for CPGs in which at least half of the authors were from the radiology or imaging department. The following information was extracted from each CPG: year of publication, journal, provider, number of authors, number of pages, number of references, collaboration, country of origin, radiological subspecialty, imaging modality used, topic, source of funding, and number and pattern of citations.

Results:

In total, 120 radiological CPGs published between July 2006 and June 2016 were identified. One hundred nine (90.8%) radiological CPGs were published in radiology journals, 96 (80.0%) were provided by the scientific community, 108 (90.0%) were collaborative studies, 64 (53.3%) originated from the United States, 36 (30.0%) were concerned with the field of vascular/interventional radiology, 38 (31.7%) used combined imaging techniques, 52 (43.3%) were focused on interpretation and management, and 118 (98.4%) were not funded. Radiological CPGs included a median of 8 authors, 9 pages, and 49 references. The median number of citations and annual citations were 18 (range, 0–540) and 3.5 (range, 0–75.6), respectively.

Conclusion:

Our study presents several interesting insights into the characteristics and impact of radiological CPGs.

Breast Cancer Diagnostic Efficacy in a Developing South-East Asian Country

Background: Breast cancer, is increasing in prevalence amongst South East (SE) Asian women, highlighting the need for high quality, early diagnoses. This study investigated radiologists’ detection efficacy in a developing (DC) and developed (DDC) SE Asian country, as compared to Australian radiologists. Methods: Using a test-set of 60 mammographic cases, 20 containing cancer, JAFROC figures of merit (FOM) and ROC area under the curves (AUC) were calculated as well as location sensitivity, sensitivity and specificity. The test set was examined by 35, 15, and 53 radiologists from DC, a DDC and Australia, respectively. Results: DC radiologists, compared to both groups of counterparts, demonstrated significantly lower JAFROC FOM, ROC AUC and specificity scores. DC radiologists had a significantly lower location sensitivity than Australian radiologists. DC radiologists also demonstrated significantly lower values for age, hours of reading per week, and years of mammography experience when compared with other radiologists. Conclusion: Significant differences in breast cancer detection parameters can be attributed to the experience of DC radiologists. The development of inexpensive, innovative, interactive training programs are discussed. This nonuniform level of breast cancer detection between countries must be addressed to achieve the World Health Organisation goal of health equity.

Artificial intelligence in radiology: friend or foe? Where are we now and where are we heading?

The use of artificial intelligence (AI) has been rapidly progressing in medicine, particularly in radiology. AI has also been the source of great innovation and a prominent topic of discussion within radiology societies and ground-breaking research in recent years. Despite the risks and quality assurance issues involved in AI, it offers tremendous opportunities for changing how radiological services are delivered. Moreover, it is conceivable that AI could become a reliable, hard-working friend to the radiologist rather than a foe, in addition to being a useful training tool for radiologist trainees.

Basic Concepts of Contrast Injection Protocols for Coronary Computed Tomography Angiography

BACKGROUND

Coronary Computed Tomography Angiography (CTA) has become one of the most important diagnostic imaging modalities for the evaluation of coronary artery diseases. During coronary computed CTA, sufficient vascular enhancement is essential for the accurate detection and evaluation of lesions in the coronary arteries. To obtain optimal contrast enhancement and perform appropriate clinical coronary CTA, physicians, radiologists, and radiology technologists should acquire a basic knowledge of contrast injection protocols.

CONCLUSION

This review article summarizes the basic concepts of contrast injection protocols for coronary CTA.

A review of factors influencing radiologists' visual search behaviour

This narrative literature review aims to identify the various factors that have significant impact on radiologists' visual search patterns. Identifying the factors that influences readers' visual search behaviour helps to understand their perception and interpretation of medical images, which in turn could lead to the development and implementation of effective strategies that could aid in improving the ability to detect abnormalities. Databases including PubMed, MedLine, Web of Science and ScienceDirect were searched using terms 'visual search', 'eye-tracking', 'radiology OR radiography', 'mammogram OR mammography' published since the early 1960s until June 30, 2016. Some of the factors that have been identified to significantly influence radiologists' visual search patterns were (i) readers' expertise, (ii) Satisfaction of Search, (iii) readers' visual fatigue, (iv) readers' confidence in reporting abnormalities, (v) training received and (vi) readers' prior knowledge. Readers' level of expertise was the factor that has been identified to have the most significant impact on their visual search pattern. Eye-tracking studies have shown the differences in visual search patterns of readers with different levels of experience and not so surprisingly, more experienced readers have shown effective visual search strategies. Readers' expertise has also been found to have significant impact in their confidence in reporting abnormalities and their ability to discriminate lesions from background structures in medical images.

Multidisciplinary quality improvement initiative to standardize reporting of lung cancer screening

Structured reporting of lung cancer screening (LCS) results with low-dose computed tomography (LDCT) is necessary for appropriate follow-up and management of lung nodules. We describe processes for standardizing the reporting and tracking of screen-detected lung nodules by increasing documentation of Lung-RADS categorization of lung nodules. Our multidisciplinary team developed a project charter and key driver diagram, revised the radiology reporting template, and provided monthly audit reports to thoracic radiologists. Quarterly from Q1-2015 to Q2-2016, we measured the proportion of screening LDCT reports that included a documented Lung-RADS category. In Q1- and Q2-2015, no LDCT scans contained a Lung-RADS assessment. By the end of Q1-2016, 94% of screening LDCTs contained a Lung-RADS assessment with a recommended follow-up action. We developed systematic processes for lung nodule categorization, documentation, and tracking using Lung-RADS that improved structured reporting at one academic medical center.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound

OBJECTIVE

Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty.

METHODS

This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups.

RESULTS

A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist.

CONCLUSION

There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

InforMD: a new initiative to raise public awareness about breast density

On a mammogram, breast density (also known as mammographic density) is shown as white and bright regions and is associated with reduced sensitivity in cancer detection and increased breast cancer risk. However, many Australian women are unaware of the significance of breast density as it is not routinely reported or discussed. In order to address this lack of knowledge, Australian breast cancer researchers with expertise in mammographic density formed the InforMD alliance (INformation FORum on Mammographic Density) in 2016. The alliance is working to raise awareness of breast density with the goal of improving breast cancer diagnosis and health outcomes for women. The InforMD website (www.InforMD.org.au) was launched in October 2016, coinciding with a major nationwide public awareness campaign by the alliance during breast cancer awareness month. The website contains unbiased, accurate, updated information on breast density. The website also provides summaries of major research articles in layperson language, recent news items related to breast density, links to relevant information for health professionals, events, and feature articles. Members of the public and health professionals can also subscribe for news updates. The interactive online Forum section facilitates discussion between health professionals, scientists and members of the public. To increase online traffic to the website, Facebook (www.facebook.com/BeInforMD) and Twitter (https://twitter.com/BeInforMD_) pages were launched in December 2016. Since its launch, InforMD has generated considerable interest. The public awareness campaign reached over 7 million Australians through a combination of newspaper, TV, radio, and online news. The website has attracted 13,058 unique visitors and 30,353 page views (data as of 19/12/2017). Breast cancer researchers have a significant role to play in disseminating information to the public on breast density. A combination of mainstream and social media, together with a well-informed and updated website, has laid the groundwork for the InforMD alliance to reach a wide audience.

Decoding diagnosis and lifetime consumption in alcohol dependence from grey-matter pattern information

OBJECTIVE

We investigated the potential of computer-based models to decode diagnosis and lifetime consumption in alcohol dependence (AD) from grey-matter pattern information. As machine-learning approaches to psychiatric neuroimaging have recently come under scrutiny due to unclear generalization and the opacity of algorithms, our investigation aimed to address a number of methodological criticisms.

METHOD

Participants were adult individuals diagnosed with AD (N = 119) and substance-naïve controls (N = 97) ages 20-65 who underwent structural MRI. Machine-learning models were applied to predict diagnosis and lifetime alcohol consumption.

RESULTS

A classification scheme based on regional grey matter attained 74% diagnostic accuracy and predicted lifetime consumption with high accuracy (r = 0.56, P < 10^-10 ). A key advantage of the classification scheme was its algorithmic transparency, revealing cingulate, insular and inferior frontal cortices as important brain areas underlying classification. Validation of the classification scheme on data of an independent trial was successful with nearly identical accuracy, addressing the concern of generalization. Finally, compared to a blinded radiologist, computer-based classification showed higher accuracy and sensitivity, reduced age and gender biases, but lower specificity.

CONCLUSION

Computer-based models applied to whole-brain grey-matter predicted diagnosis and lifetime consumption in AD with good accuracy. Computer-based classification may be particularly suited as a screening tool with high sensitivity.