ACR Appropriateness Criteria® Staging of Renal Cell Carcinoma: 2022 Update

Renal cell carcinoma is a complex group of highly heterogenous renal tumors demonstrating variable biological behavior. Pretreatment imaging of renal cell carcinoma involves accurate assessment of the primary tumor, presence of nodal, and distant metastases. CT and MRI are the key imaging modalities used in the staging of renal cell carcinoma. Important imaging features that impact treatment include tumor extension into renal sinus and perinephric fat, involvement of pelvicalyceal system, infiltration into adrenal gland, involvement of renal vein and inferior vena cava, as well as the presence of metastatic adenopathy and distant metastases. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Hepatobiliary mucinous cystic neoplasms and mimics

This review will provide an overview of hepatobiliary mucinous cystic neoplasms and their mimics such as complex appearing benign cysts, intraductal papillary neoplasm of bile ducts, choledochal cysts, infectious cysts, and other cystic neoplasms. Preoperative imaging, particularly abdominal MRI with MRCP, plays a key role in differentiating these entities which differ widely in management. Familiarity with the differentiating imaging features of mucinous cystic neoplasms and their mimics allows radiologists to provide management-guiding reports.

Oncology-specific radiation dose and image noise reference levels in adult abdominal-pelvic CT

OBJECTIVES

To provide our oncology-specific adult abdominal-pelvic CT reference levels for image noise and radiation dose from a high-volume, oncologic, tertiary referral center.

METHODS

The portal venous phase abdomen-pelvis acquisition was assessed for image noise and radiation dose in 13,320 contrast-enhanced CT examinations. Patient size (effective diameter) and radiation dose (CTDIvol) were recorded using a commercial software system, and image noise (Global Noise metric) was quantified using a custom processing system. The reference level and range for dose and noise were calculated for the full dataset, and for examinations grouped by CT scanner model. Dose and noise reference levels were also calculated for exams grouped by five different patient size categories.

RESULTS

The noise reference level was 11.25 HU with a reference range of 10.25-12.25 HU. The dose reference level at a median effective diameter of 30.7 cm was 26.7 mGy with a reference range of 19.6-37.0 mGy. Dose increased with patient size; however, image noise remained approximately constant within the noise reference range. The doses were 2.1-2.5 times than the doses in the ACR DIR registry for corresponding patient sizes. The image noise was 0.63-0.75 times the previously published reference level in abdominal-pelvic CT examinations.

CONCLUSIONS

Our oncology-specific abdominal-pelvic CT dose reference levels are higher than in the ACR dose index registry and our oncology-specific image noise reference levels are lower than previously proposed image noise reference levels.

ADVANCES IN KNOWLEDGE

This study reports reference image noise and radiation dose levels appropriate for the indication of abdomen-pelvis CT examination for cancer diagnosis and staging. The difference in these reference levels from non-oncology-specific CT examinations highlight a need for indication-specific, dose index and image quality reference registries.

ACR Appropriateness Criteria® Acute Pyelonephritis: 2022 Update

Acute pyelonephritis (APN) is a severe urinary tract infection (UTI) that has the potential to cause sepsis, shock, and death. In the majority of patients, uncomplicated APN is diagnosed clinically and is responsive to treatment with appropriate antibiotics. In patients who are high risk or when treatment is delayed, microabscesses may coalesce to form an acute renal abscess. High-risk patients include those with a prior history of pyelonephritis, lack of response to therapy for lower UTI or for APN, diabetes, anatomic or congenital abnormalities of the urinary system, infections by treatment-resistant organisms, nosocomial infection, urolithiasis, renal obstruction, prior renal surgery, advanced age, pregnancy, renal transplant recipients, and immunosuppressed or immunocompromised patients. Pregnant patients and patients with renal transplants on immunosuppression are at an elevated risk of severe complications. Imaging studies are often requested to aid with the diagnosis, identify precipitating factors, and differentiate lower UTI from renal parenchymal involvement, particularly in high-risk individuals. Imaging is usually not appropriate for the first-time presentation of suspected APN in an uncomplicated patient. The primary imaging modalities used in high-risk patients with suspected APN are CT, MRI, and ultrasound, although CT was usually not appropriate for initial imaging in a pregnant patient with no other complications. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Post-Treatment Follow-up and Active Surveillance of Clinically Localized Renal Cell Carcinoma: 2021 Update

Renal cell carcinoma (RCC) accounts for most malignant renal tumors and is considered the most lethal of all urologic cancers. For follow-up of patients with treated or untreated RCC and those with neoplasms suspected to represent RCC, radiologic imaging is the most valuable component of surveillance, as most relapses and cases of disease progression are identified when patients are asymptomatic. Understanding the strengths and limitations of the various imaging modalities for the detection of disease, recurrence, or progression is essential when planning follow-up regimens. This document addresses the appropriate imaging examinations for asymptomatic patients who have been treated for RCC with radical or partial nephrectomy or ablative therapies. It also discusses the appropriate imaging examinations for asymptomatic patients with localized biopsy-proven or suspected RCC undergoing active surveillance. 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.

Mimics and Pitfalls of Primary Ovarian Malignancy Imaging

The complex anatomy and similarity of imaging features of various pathologies in the pelvis can make accurate radiology interpretation difficult. While prompt recognition of ovarian cancer remains essential, awareness of processes that mimic ovarian tumors can avoid potential misdiagnosis and unnecessary surgery. This article details the female pelvic anatomy and highlights relevant imaging features that mimic extra-ovarian tumors, to help the radiologists accurately build a differential diagnosis of a lesion occupying the adnexa.

ACR Appropriateness Criteria® Adrenal Mass Evaluation: 2021 Update

The appropriate evaluation of adrenal masses is strongly dependent on the clinical circumstances in which it is discovered. Adrenal incidentalomas are masses that are discovered on imaging studies that have been obtained for purposes other than adrenal disease. Although the vast majority of adrenal incidentalomas are benign, further radiological and biochemical evaluation of these lesions is important to arrive at a specific diagnosis. Patients with a history of malignancy or symptoms of excess hormone require different imaging evaluations than patients with incidentalomas. This document reviews imaging approaches to adrenal masses and the various modalities utilized in evaluation of adrenal lesions. 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.

Current update on molecular cytogenetics, diagnosis and management of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract and are thought to arise from precursors of the interstitial cells of Cajal. GISTs can arise anywhere in the GI tract, but most commonly originate from the stomach and small intestine. The majority of GISTs occur as a result of activating mutations in two receptor protein tyrosine kinases: KIT and/or platelet-derived growth factor receptor-α. Mutational analyses allow for predicting patient prognosis and treatment response. Clinical presentations can vary from no symptoms, typical in the case of small incidentally found tumors, to GI bleeding, abdominal discomfort, and ulcer-related symptoms when the tumor is enlarged. Imaging plays a critical role in the diagnosis and management of these tumors with multiphasic computed tomography serving as the imaging modality of choice. Magnetic resonance imaging and positron emission tomography-computed tomography can serve as imaging adjuncts in lesion characterization, especially with liver metastases, and subsequent staging and assessment for treatment response or recurrence. Surgical resection is the preferred management for small GISTs, while tyrosine kinase inhibitors − imatinib mesylate and sunitinib malate − serve as crucial molecular-targeted therapies for locally advanced and metastatic GISTs. This review article highlights the clinical presentation, pathology and molecular cytogenetics, imaging features, and current management of GISTs.

Side Effects of Oncologic Treatment in the Chest: Manifestations at FDG PET/CT

Fluorodeoxyglucose (FDG) PET/CT is a vital imaging technique used for staging, assessing treatment response, and restaging following completion of therapy in patients who are undergoing or have completed oncologic treatment. A variety of adverse effects from chemotherapy, targeted therapy, immunotherapy, and radiation therapy are commonly encountered in oncologic patients. It is important to be aware of the manifestations of these adverse effects seen on FDG PET/CT images to avoid misinterpreting these findings as disease progression. Furthermore, early identification of these complications is important, as it may significantly affect patient management and even lead to a change in treatment strategy. The authors focus on the FDG PET/CT manifestations of a broad spectrum of oncologic therapy-related adverse effects in the thorax, as well as some treatment-related changes that may potentially mimic malignancy. Online supplemental material is available for this article. ^©RSNA, 2021.

Current update on vaginal malignancies

Primary vaginal cancers are rare and account for 1-3% of all gynecologic malignancies. There are several histological subtypes that affect a wide range of the population. Imaging plays an important role in the diagnosis, staging, and treatment planning of vaginal cancers. This article reviews the relevant anatomy, clinical findings, imaging characteristics, and recent advances in the management of vaginal malignancies.

Current update on IVC leiomyosarcoma

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma associated with poor prognosis. Patients are often asymptomatic or present with nonspecific abdominal symptoms, which delays initial diagnosis and contributes to poor oncologic outcome. Key imaging modalities include ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). Characteristic imaging features include imperceptible caval lumen, dilation of the IVC, heterogeneous enhancement of the tumor, and development of extensive collateral circulation. Surgical resection is the mainstay of treatment, while chemotherapy and/or radiation may serve as therapy adjuncts. This article reviews the pathology, clinical findings, imaging features and management of IVC leiomyosarcoma.

Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings

Adrenal hemorrhage (AH) is a rare condition. It can be traumatic or non-traumatic. Most common causes are septicemia, coagulopathy or bleeding diathesis, and underlying neoplasms. Other reported less common causes of AH are COVID-19 and neonatal stress. Clinical diagnosis of AH is challenging due to its non-specific presentation and occurrence in the setting of acute medical illness. Therefore, most cases are diagnosed incidentally on imaging. Having high clinical suspicion in the proper clinical setting for AH is crucial to avoid life-threatening adrenal insufficiency that occurs in 16-50% of patients with bilateral AH. We discuss the clinical situations that predispose to AH, review the imaging features on different imaging modalities, highlight a variety of clinical cases, imaging features that should be concerning for an underlying neoplasm, and outline the potential role of interventional radiology in management of AH.

Current update on imaging for pancreatic neuroendocrine neoplasms

Pancreatic neuroendocrine neoplasms (panNEN) are a heterogeneous group of tumors with differing pathological, genetic, and clinical features. Based on clinical findings, they may be categorized into functioning and nonfunctioning tumors. Adoption of the 2017 World Health Organization classification system, particularly its differentiation between grade 3, well-differentiated pancreatic neuroendocrine tumors (panNET) and grade 3, poorly-differentiated pancreatic neuroendocrine carcinomas (panNEC) has emphasized the role imaging plays in characterizing these lesions. Endoscopic ultrasound can help obtain biopsy specimen and assess tumor margins and local spread. Enhancement patterns on computed tomography (CT) and magnetic resonance imaging (MRI) may be used to classify panNEN. Contrast enhanced MRI and diffusion-weighted imaging have been reported to be useful for characterization of panNEN and quantifying metastatic burden. Current and emerging radiotracers have broadened the utility of functional imaging in evaluating panNEN. Fluorine-18 fluorodeoxyglucose positron emission tomography (PET)/CT and somatostatin receptor imaging such as Gallium-68 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid–octreotate PET/CT may be useful for improved identification of panNEN in comparison to anatomic modalities. These new techniques can also play a direct role in optimizing the selection of treatment for individuals and predicting tumor response based on somatostatin receptor expression. In addition, emerging methods of radiomics such as texture analysis may be a potential tool for staging and outcome prediction in panNEN, however further investigation is required before clinical implementation.

Features of primary pancreatic lymphoma: A bi-institutional review with an emphasis on typical and atypical imaging features

BACKGROUND

Primary pancreatic lymphoma (PPL) is a rare neoplasm. Being able to distinguish it from other pancreatic malignancies such as pancreatic ductal adenocarcinoma (PDAC) is important for appropriate management. Unlike PDAC, PPL is highly sensitive to chemotherapy and usually does not require surgery. Therefore, being able to identify PPL preoperatively will not only direct physicians towards the correct avenue of treatment, it will also avoid unnecessary surgical intervention.

AIM

To evaluate the typical and atypical multi-phasic computed tomography (CT) imaging features of PPL.

METHODS

A retrospective review was conducted of the clinical, radiological, and pathological records of all subjects with pathologically proven PPL who presented to our institutions between January 2000 and December 2020. Institutional review board approval was obtained for this investigation. The collected data were analyzed for subject demographics, clinical presentation, laboratory values, CT imaging features, and the treatment received. Presence of all CT imaging findings including size, site, morphology and imaging characteristics of PPL such as the presence or absence of nodal, vascular and ductal involvement in these subjects were recorded. Only those subjects who had a pre-treatment multiphasic CT of the abdomen were included in the study.

RESULTS

Twenty-nine cases of PPL were diagnosed between January 2000 and December 2020 (mean age 66 years; 13 males/16 females). All twenty-nine subjects were symptomatic but only 4 of the 29 subjects (14%) had B symptoms. Obstructive jaundice occurred in 24% of subjects. Elevated lactate dehydrogenase was seen in 81% of cases, whereas elevated cancer antigen 19-9 levels were present in only 10% of cases for which levels were recorded. The vast majority (90%) of tumors involved the pancreatic head and uncinate process. Mean tumor size was 7.8 cm (range, 4.0-13.8 cm). PPL presented homogenous hypoenhancement on CT in 72% of cases. Small volume peripancreatic lymphadenopathy was seen in 28% of subjects. Tumors demonstrated encasement of superior mesenteric vessels in 69% of cases but vascular stenosis or occlusion only manifested in 5 out of the twenty-nine individuals (17%). Mild pancreatic duct dilatation was also infrequent and seen in only 17% of cases, whereas common bile duct (CBD) dilation was seen in 41% of subjects. Necrosis occurred in 10% of cases. Size did not impact the prevalence of pancreatic and CBD dilation, necrosis, or mesenteric root infiltration (P = 0.525, P = 0.294, P = 0.543, and P = 0.097, respectively). Pancreatic atrophy was not present in any of the subjects.

CONCLUSION

PPL is an uncommon diagnosis best made preoperatively to avoid unnecessary surgery and ensure adequate treatment. In addition to the typical CT findings of PPL, such as homogeneous hypoenhancement, absence of vascular stenosis and occlusion despite encasement, and peripancreatic lymphadenopathy, this study highlighted many less typical findings, including small volume necrosis and pancreatic and bile duct dilation.

Tuberous Sclerosis: Current Update

Tuberous sclerosis complex (TSC) is a relatively rare autosomal dominant neurocutaneous disorder secondary to mutations in the TSC1 or TSC2 tumor suppressor genes. Although manifestation of the classic triad of seizures, intellectual disability, and facial angiofibromas may facilitate timely diagnosis of TSC, the multisystem features that may indicate TSC in the absence of these manifestations remain highly variable. In addition, patients with TSC are at risk of developing multiple benign and malignant tumors in various organ systems, resulting in increased morbidity and mortality. Thus, imaging plays a critical role in diagnosis, surveillance, and management of patients with TSC. It is crucial that radiologists be familiar with TSC and the various associated imaging features to avoid a delayed or incorrect diagnosis. Key manifestations include cortical dysplasias, subependymal nodules, subependymal giant cell astrocytomas, cardiac rhabdomyomas, lymphangioleiomyomatosis, and angiomyolipomas. Renal angiomyolipomas in particular can manifest with imaging features that mimic renal malignancy and pose a diagnostic dilemma. Other manifestations include dermatologic and ophthalmic manifestations, renal cysts, renal cell carcinomas, multifocal micronodular pneumocyte hyperplasia, splenic hamartomas, and other rare tumors such as perivascular epithelioid tumors. In addition to using imaging and clinical features to confirm the diagnosis, genetic testing can be performed. In this article, the molecular pathogenesis, clinical manifestations, and imaging features of TSC are reviewed. Current recommendations for management and surveillance of TSC are discussed as well. ^©RSNA, 2021.

ACR Appropriateness Criteria® Hematuria

Hematuria is a common reason for patients to be referred for imaging of the urinary tract. All patients diagnosed with hematuria should undergo a thorough history and physical examination, urinalysis, and serologic testing prior to any initial imaging. Ultrasound, CT, and MRI are the most common imaging modalities used to evaluate hematuria. This document discusses the following clinical scenarios for hematuria: initial imaging of microhematuria without risk factors or history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation; initial imaging of microhematuria in patients with known risk factors and no history of recent vigorous exercise, or presence of infection, or viral illness, or present or recent menstruation or renal parenchymal disease; initial imaging of microhematuria in the pregnant patient and initial imaging of gross hematuria. Follow-up of normal or abnormal findings is beyond the scope of this review. 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.

Ovarian teratomas: clinical features, imaging findings and management

Ovarian teratomas are the most common type of germ cell tumors. There are three major subtypes of ovarian teratomas including mature, immature, and monodermal teratomas. Ultrasound, computed tomography and magnetic resonance imaging can demonstrate specific imaging findings for mature teratoma. Imaging features of immature and monodermal teratomas are less specific, but a combination of clinical features and imaging findings can help in the diagnosis. Imaging is also very helpful in guiding management. In this article, we review the epidemiology, histopathology, clinical presentation, imaging features and management of ovarian teratomas.

ACR Appropriateness Criteria® Renal Failure

Renal failure can be divided into acute kidney injury and chronic kidney disease. Both are common and result in increased patient morbidity and mortality. The etiology is multifactorial and differentiation of acute kidney injury from chronic kidney disease includes clinical evaluation, laboratory tests, and imaging. The main role of imaging is to detect treatable causes of renal failure such as ureteral obstruction or renovascular disease and to evaluate renal size and morphology. Ultrasound is the modality of choice for initial imaging, with duplex Doppler reserved for suspected renal artery stenosis or thrombosis. CT and MRI may be appropriate, particularly for urinary tract obstruction. However, the use of iodinated and gadolinium-based contrast should be evaluated critically depending on specific patient factors and cost-benefit ratio. 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.

Imaging and Management of Bladder Cancer

Simple Summary

Bladder cancer is a complex disease, the sixth most common cancer, and one of the most expensive cancers to treat. In the last few decades, there has been a significant decrease in the bladder cancer-related mortality rate, potentially related to decreased smoking prevalence, improvements in diagnosing bladder cancer, and advances in treatment. Those advances in diagnostic tools and therapies and greater understanding of the disease are helping to evolve how bladder cancer is managed. The purpose of this article is to provide a review of bladder cancer pathology, diagnosis, staging, radiologic imaging, and management, and highlight recent developments and research.

Abstract

Methods: Keyword searches of Medline, PubMed, and the Cochrane Library for manuscripts published in English, and searches of references cited in selected articles to identify additional relevant papers. Abstracts sponsored by various societies including the American Urological Association (AUA), European Association of Urology (EAU), and European Society for Medical Oncology (ESMO) were also searched. Background: Bladder cancer is the sixth most common cancer in the United States, and one of the most expensive in terms of cancer care. The overwhelming majority are urothelial carcinomas, more often non-muscle invasive rather than muscle-invasive. Bladder cancer is usually diagnosed after work up for hematuria. While the workup for gross hematuria remains CT urography and cystoscopy, the workup for microscopic hematuria was recently updated in 2020 by the American Urologic Association with a more risk-based approach. Bladder cancer is confirmed and staged by transurethral resection of bladder tumor. One of the main goals in staging is determining the presence or absence of muscle invasion by tumor which has wide implications in regards to management and prognosis. CT urography is the main imaging technique in the workup of bladder cancer. There is growing interest in advanced imaging techniques such as multiparametric MRI for local staging, as well as standardized imaging and reporting system with the recently created Vesicle Imaging Reporting and Data System (VI-RADS). Therapies for bladder cancer are rapidly evolving with immune checkpoint inhibitors, particularly programmed death ligand 1 (PD-L1) and programmed cell death protein 1 (PD-1) inhibitors, as well as another class of immunotherapy called an antibody-drug conjugate which consists of a cytotoxic drug conjugated to monoclonal antibodies against a specific target. Conclusion: Bladder cancer is a complex disease, and its management is evolving. Advances in therapy, understanding of the disease, and advanced imaging have ushered in a period of rapid change in the care of bladder cancer patients.

ACR Appropriateness Criteria® Indeterminate Renal Mass

Renal masses are increasingly detected in asymptomatic individuals as incidental findings. CT and MRI with intravenous contrast and a dedicated multiphase protocol are the mainstays of evaluation for indeterminate renal masses. A single-phase postcontrast dual-energy CT can be useful when a dedicated multiphase renal protocol CT is not available. Contrast-enhanced ultrasound with microbubble agents is a useful alternative for characterizing renal masses, especially for patients in whom iodinated CT contrast or gadolinium-based MRI contrast is contraindicated. 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.

Burnout in Academic Radiologists in the United States

RATIONALE AND OBJECTIVES

To assess the prevalence and associated factors of burnout among U.S. academic radiologists.

MATERIALS AND METHODS

An online survey was sent to the radiologists who were full members of the Association of University Radiologists in December 2018. Burnout was measured using the abbreviated Maslach Burnout Inventory Human Services Survey. Survey respondents were also requested to complete questions on demographics, potential professional stressors, sense of calling, and career satisfaction. Associations between survey participants' characteristics and burnout were tested using logistic regression model.

RESULTS

The survey response rate was 27% (228/831). Twenty-nine percent met all three criteria for high burnout, including high emotional exhaustion, high depersonalization, and low personal accomplishment. Seventy-nine percent had one or more symptoms of burnout. Numerous factors including work overload, inability to balance personal and professional life, lack of autonomy, lack of appreciation from patients and other medical staff were significantly associated (p < 0.05) with high burnout. Older age (OR, 0.95; 95%CI 0.92-0.98; p < 0.05), higher number of years of experience practicing as radiologists (OR, 0.95; 95%CI 0.92-0.98; p < 0.05), and holding academic rank of professor (OR, 0.25; 95%CI 0.11-0.56; p < 0.05) were factors associated with lower odds of experiencing burnout. Radiologists with high burnout were more likely to be dissatisfied with their career (OR, 2.28; 95%CI 1.70-3.07; p < 0.0001) and less likely to identify medicine as a calling.

CONCLUSION

Multiple factors contribute to high burnout in academic radiologists. Familiarity with these factors may help academic radiology departments to develop strategies to promote health and wellness of their faculty.

Aligning the Implicit Curriculum with the Explicit Curriculum in Radiology

Physician education occurs through two mechanisms that operate in tandem: the explicit and the implicit curriculum. The explicit, or formal, curriculum is the official version that is usually taken as the one-and-only curriculum and which is detailed in official documentation; however, an implicit curriculum exists, comprised of subtle messaging about professional norms, values, and beliefs that are tacitly communicated through both positive and negative role modeling. Both contribute to the overall education of the medical student and physician-in-training. Despite its well-documented influence in medical education, much of the teachings of the implicit curriculum occurs in the shadows, unspoken and unarticulated, and outside the awareness of both teacher and student. As panel members of the The Implicit Curriculum in Radiology Task Force of the Association of University Radiologists-Radiology Research Alliance (AUR-RRA), we present a review of the implicit curriculum, exploring its origin and impact on medical education, and on the overall professional development of medical students, post-graduate medical trainees and practicing physicians. Strategies for recognizing and contending with the implicit curriculum in radiology training are discussed, with a special emphasis on opportunities to leverage its potential through positive role modeling.

Does dual-energy CT differentiate benign and malignant ovarian tumours?

AIM

To assess the ability of dual-energy computed tomography (DECT) to distinguish benign from malignant ovarian tumours (OTs).

MATERIALS AND METHODS

Following approval of the institutional review board, the institutional database was mined for treatment-naive patients who underwent primary cytoreduction for OT. Thirty-seven patients were included and divided into those with benign OTs (n = 11) and malignant OTs (n = 26), including high-grade (n = 20) and low-grade (n = 6) malignant OTs. Advanced processing and region of interest delineation on the ovarian mass were performed using the preoperative staging DECT examination using the Advantage Workstation. The pixel-level data of the CT attenuation values at 50, 70, and 120 keV and the effective atomic number (Z_eff), water content (WC), and iodine content (IC) in the ovarian mass were recorded. The Wilcoxon rank-sum test was used to compare CT attenuation data at different voltages, Z_eff, and WC and IC levels between benign and malignant OTs and between high- and low-grade malignant OTs. Simple logistic regression was used to correlate the imaging characteristics with malignant status and grade.

RESULTS

Malignant OTs had significantly higher Z_eff and IC compared with benign OTs. The threshold values for the diagnosis of malignant OT were IC≥9.74 (100 μg/cm³) with 81% sensitivity and 73% specificity and Z_eff ≥8.16 with 85% sensitivity and 73% specificity. High-grade OTs had significantly higher WC compared with low-grade OTs, and a threshold of ≥1,013.92 mg/cm³ differentiated them with 80% sensitivity and 83% specificity.

CONCLUSION

DECT may be a tool to help distinguish malignant and benign OTs and predict tumour grade.

Adrenal cortical adenoma: current update, imaging features, atypical findings, and mimics

Adrenal adenoma is the most common adrenal lesion. Due to its wide prevalence, adrenal adenomas may demonstrate various imaging features. Thus, it is important to identify typical and atypical imaging features of adrenal adenomas and to be able to differentiate atypical adrenal adenomas from potentially malignant lesions. In this article, we will discuss the diagnostic approach, typical and atypical imaging features of adrenal adenomas, as well as other lesions that mimic adrenal adenomas.

Hepatic hemangioendothelioma: CT, MR, and FDG-PET-CT in 67 patients-a bi-institutional comprehensive cancer center review

OBJECTIVE

To evaluate the imaging features of hepatic epithelioid hemangioendothelioma (HEH) on multiphasic CT, MR, and FDG-PET-CT.

METHODS

Bi-institutional review identified 67 adults (mean age, 47 years; 23 M/44 F) with pathologically proven HEH and pretreatment multiphasic CT (n = 67) and/or MR (n = 30) and/or FDG-PET-CT (n = 13).

RESULTS

HEHs were multifocal in 88% (59/67). Mean size of the dominant mass was 4.1 cm (range, 1.4-19 cm). The tumors were located in the peripheral, subcapsular regions of the liver in 96% (64/67). Capsular retraction was present in 81% (54/67 cases) and tumors were coalescent in 61% (41/67). HEH demonstrated peripheral ring enhancement on arterial phase imaging in 33% (21/64) and target appearance on the portal venous phase in 69% (46/67). Persistent peripheral enhancement on the delayed phase was seen in 49% (31/63). On MR, multilayered target appearance was seen on the T2-weighted sequences in 67% (20/30) and on the diffusion-weighted sequences in 61% (11/18). Target appearance on hepatobiliary phase of MRI was seen in 57% (4/7). On pre-therapy FDG-PET-CT, increased FDG uptake above the background liver parenchyma was seen in 62% (8/13).

CONCLUSION

HEHs typically manifest as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. Peripheral arterial ring enhancement and target appearance on portal venous phase are commonly seen on CT. Similarly, multilayered target appearance correlating with its histopathological composition is typically seen on multiple sequences of MR including T2-weighted, diffusion-weighted, and dynamic contrast-enhanced multiphasic MR.

KEY POINTS

• Hepatic epithelioid hemangioendotheliomas manifest on CT and MR as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. • Enhancement pattern on contrast-enhanced CT and MR can vary but peripheral ring enhancement on arterial phase and target appearance on portal venous phase are commonly seen. • Retrospective two-center study showed that cross-sectional imaging may help in the diagnosis.

Beyond adenocarcinoma: MRI of uncommon rectal neoplasms and mimickers

OBJECTIVE

To provide a review of rare rectal tumors beyond adenocarcinoma.

RESULTS

Rectal cancer is a common malignancy, both in the United States and abroad. In addition to adenocarcinoma, abdominal radiologists will encounter a variety of other less common rectal masses, both benign and malignant neoplasms as well as non-neoplastic mimickers. Familiarity with these conditions and their characteristic features on MRI is useful in clinical practice. In this article, a number of such conditions are discussed, with an emphasis on distinguishing features on MRI of the rectum.

CONCLUSION

Familiarity with the MRI features of rare rectal tumors beyond adenocarcinoma, as well as a small number of non-neoplastic mimics, is important for abdominal imagers to make diagnostic differentials and to assist in treatment planning.

Rectal cancer lexicon: consensus statement from the society of abdominal radiology rectal & anal cancer disease-focused panel

Standardized terminology is critical to providing consistent reports to referring clinicians. This lexicon aims to provide a reference for terminology frequently used in rectal cancer and reflects the consensus of the Society of Abdominal Radiology Disease Focused Panel in Rectal cancer. This lexicon divided the terms into the following categories: primary tumor staging, nodal staging, treatment response, anal canal anatomy, general anatomy, and treatments.

Locally recurrent rectal cancer: what the radiologist should know

Despite advances in surgical techniques and chemoradiation therapy, recurrent rectal cancer remains a cause of morbidity and mortality. After successful treatment of rectal cancer, patients are typically enrolled in a surveillance strategy that includes imaging as studies have shown improved prognosis when recurrent rectal cancer is detected during imaging surveillance versus based on development of symptoms. Additionally, patients who experience a complete clinical response with chemoradiation therapy may elect to enroll in a "watch-and-wait" strategy that includes imaging surveillance rather than surgical resection. Factors that increase the likelihood of recurrence, patterns of recurrence, and the imaging appearances of recurrent rectal cancer are reviewed with a focus on CT, PET CT, and MR imaging.

Burnout in Chairs of Academic Radiology Departments in the United States

OBJECTIVE

We aimed to estimate the self-reported prevalence of burnout in chairs of academic radiology departments in the United States and identify factors associated with high burnout in chairs.

MATERIALS AND METHODS

An anonymous cross-sectional online survey was conducted of members of the Society of Chairs of Academic Radiology Departments. Burnout was measured using the abbreviated Maslach Burnout Inventory Human Services Survey. Associations between survey participants' characteristics and burnout were tested using Fisher's exact test and Wilcoxon rank sum test.

RESULTS

Of the 123 chairs invited to complete the survey, 87 responded (response rate, 71%). The mean age of the participants was 58 years. The survey respondents had an average of 9 years of experience as department chair. The average number of work hours per week was 62 hours. Four participants (5%) of the academic chairs met all three criteria for high burnout including high emotional exhaustion, high depersonalization, and low personal accomplishment. Thirty-three participants (38%) had high emotional exhaustion and/or high depersonalization score. Low professional satisfaction score, low work-life balance satisfaction score, and low chair effectiveness score were significantly associated with high burnout. High emotional exhaustion and/or high depersonalization were significantly associated with numerous professional stressors. Lack of an institutional support group for chairs and lower number of faculty members in the department were significantly associated with burnout.

CONCLUSION

A significant proportion of chairs of academic radiology departments are experiencing 1 or more symptoms of burnout. Efforts to address burnout in radiology chairs should be initiated promptly at the national, institutional, and departmental levels.

Addressing Burnout in Radiologists

Burnout is a global health problem affecting physicians across all medical specialties. Radiologists, in particular, experience high rates of burn out, and this trend has only continued to worsen. The "Promoting Health and Wellness for Radiologists Task Force of the Association of University Radiologists-Radiology Research Alliance" presents a review of the prevalence, causes, and impact of burnout among radiology faculty and trainees, and a discussion on strategies for overcoming burnout and promoting overall health and well-being among radiologists.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ^©RSNA, 2018.

Role of Imaging in the Era of Precision Medicine

Precision medicine is an emerging approach for treating medical disorders, which takes into account individual variability in genetic and environmental factors. Preventive or therapeutic interventions can then be directed to those who will benefit most from targeted interventions, thereby maximizing benefits and minimizing costs and complications. Precision medicine is gaining increasing recognition by clinicians, healthcare systems, pharmaceutical companies, patients, and the government. Imaging plays a critical role in precision medicine including screening, early diagnosis, guiding treatment, evaluating response to therapy, and assessing likelihood of disease recurrence. The Association of University Radiologists Radiology Research Alliance Precision Imaging Task Force convened to explore the current and future role of imaging in the era of precision medicine and summarized its finding in this article. We review the increasingly important role of imaging in various oncological and non-oncological disorders. We also highlight the challenges for radiology in the era of precision medicine.

Cancer therapy-related complications in the bowel and mesentery: an imaging perspective

Cancer therapy-induced complications in the bowel and mesentery are fairly common. It is important for clinicians to be aware of these complications and the agents most frequently implicated. Cancer therapy is rapidly evolving and often encompasses both classic cytotoxic drugs and newer molecular targeted agents. Drugs from both broad classes can have numerous adverse effects on the bowel and mesentery that can be detected on imaging. These adverse effects include ileus, various forms of enterocolitis, gastrointestinal perforation, pneumatosis intestinalis, secretory diarrhea, and sclerosing mesenteritis. These complications are diverse and range from relatively benign to life threatening. The management is also variable, but many of these conditions are easily controlled and reversed with supportive care and cessation of the particular cancer therapy. The objective of this pictorial essay is to demonstrate some of the more common cancer therapy-induced complications of the bowel and mesentery, with a focus on the radiographic findings.

Increase in post-therapy tumor calcification on CT scan is not an indicator of response to therapy in low-grade serous ovarian cancer

PURPOSE

The aim of the study was to determine if increasing post-therapy calcification in peritoneal metastases in recurrent low-grade serous ovarian carcinomas indicated response to therapy.

MATERIALS AND METHODS

Retrospective analysis of patients with histologically confirmed, recurrent low-grade serous ovarian carcinoma who received treatment at our institution between 2000 and 2014 was performed. Only patients who had calcified tumor implants and showed either interval increase or decrease in tumor calcification following therapy were included in the study. Pre- and post-therapy CT scans of these patients were reviewed by 2 radiologists independently. Changes in the tumor calcification status and tumor deposits size were correlated with serum CA-125 levels. Fisher's exact test was used to assess the association between peritoneal deposit and calcification status with serum CA-125 status.

RESULTS

35 Patients were included in the study. Based on serial serum CA 125 levels, 22 patients (63%) had progressive disease, 12 (34%) had partial response and 1 (3%) had stable disease. Using RECIST 1.1, 16 had progressive disease, 3 had partial response and 16 had stable disease. In the patients with progressive disease, post-therapy tumor calcification increased in 77% and decreased in 23%. Fischer's exact test showed that serum CA 125 change was significantly associated with change in size of peritoneal deposits and calcification change.

CONCLUSIONS

This preliminary study shows that post-therapy increase in peritoneal implant calcification in low-grade serous ovarian carcinomas is not an indicator of response to therapy.

Staging, surveillance, and evaluation of response to therapy in renal cell carcinoma: role of MDCT

Renal cell carcinoma is the most common malignant renal tumor in the adults. Significant advances have been made in the management of localized and advanced renal cell carcinoma. Surgery is the standard of care and accurate pre-operative staging based on imaging is critical in guiding appropriate patient management. Besides staging, imaging plays a key role in the post-operative surveillance and evaluation of response to systemic therapies. Both CT and MR are useful in the staging and follow up of renal cell carcinoma, but CT is more commonly used due to its lower costs and wider availability. In this article, we discuss and illustrate the role of multi-detector CT in pre-operative staging, post-operative surveillance, and evaluation of response to systemic therapy in renal cell carcinoma.

Staging, surveillance, and evaluation of response to therapy in renal cell carcinoma: role of MDCT

Renal cell carcinoma is the most common malignant renal tumor in the adults. Significant advances have been made in the management of localized and advanced renal cell carcinoma. Surgery is the standard of care and accurate pre-operative staging based on imaging is critical in guiding appropriate patient management. Besides staging, imaging plays a key role in the post-operative surveillance and evaluation of response to systemic therapies. Both CT and MR are useful in the staging and follow up of renal cell carcinoma, but CT is more commonly used due to its lower costs and wider availability. In this article, we discuss and illustrate the role of multi-detector CT in pre-operative staging, post-operative surveillance, and evaluation of response to systemic therapy in renal cell carcinoma.

Clinical utility of quantitative imaging

Quantitative imaging (QI) is increasingly applied in modern radiology practice, assisting in the clinical assessment of many patients and providing a source of biomarkers for a spectrum of diseases. QI is commonly used to inform patient diagnosis or prognosis, determine the choice of therapy, or monitor therapy response. Because most radiologists will likely implement some QI tools to meet the patient care needs of their referring clinicians, it is important for all radiologists to become familiar with the strengths and limitations of QI. The Association of University Radiologists Radiology Research Alliance Quantitative Imaging Task Force has explored the clinical application of QI and summarizes its work in this review. We provide an overview of the clinical use of QI by discussing QI tools that are currently used in clinical practice, clinical applications of these tools, approaches to reporting of QI, and challenges to implementing QI. It is hoped that these insights will help radiologists recognize the tangible benefits of QI to their patients, their referring clinicians, and their own radiology practice.

Methods and challenges in quantitative imaging biomarker development

Academic radiology is poised to play an important role in the development and implementation of quantitative imaging (QI) tools. This article, drafted by the Association of University Radiologists Radiology Research Alliance Quantitative Imaging Task Force, reviews current issues in QI biomarker research. We discuss motivations for advancing QI, define key terms, present a framework for QI biomarker research, and outline challenges in QI biomarker development. We conclude by describing where QI research and development is currently taking place and discussing the paramount role of academic radiology in this rapidly evolving field.

Extrahepatic biliary cancer: New staging classification

Tumor staging defines the point in the natural history of the malignancy when the diagnosis is made. The most common staging system for cancer is the tumor, node, metastases classification. Staging of cancers provides useful parameters in the determination of the extent of disease and prognosis. Cholangiocarcinoma are rare and refers to cancers that arise from the biliary epithelium. These tumors can occur anywhere along the biliary tree. These tumors have been previously divided into extrahepatic and intrahepatic lesions. Until recently the extrahepatic bile duct tumors have been considered as a single entity per American Joint Commission on Cancer (AJCC) staging classification. The most recent changes to the AJCC classification of bile duct cancers divide the tumors into two major categories: proximal and distal tumors. This practical classification is based on anatomy and surgical management. High quality cross-sectional computed tomography (CT) and/or magnetic resonance (MR) imaging of the abdomen are essential information to accurately stage this tumors. Imaging plays an important role in diagnosis, localization, staging and optimal management of cholangiocarcinoma. For example, it helps to localize the tumor to either perihilar or distal bile duct, both of which have different management. Further, it helps to accurately stage the disease and identify the presence of significant nodal and distant metastasis, which may preclude surgery. Also, it helps to identify the extent of local invasion, which has a major impact on the management. For example, extensive involvement of hepatic duct reaching up to second-order biliary radicals or major vascular encasement of portal vein or hepatic arteries precludes curative surgery and patient may be managed by palliative therapy. Further, imaging helps to identify any anatomical variations in the hepatic arterial or venous circulation and biliary ductal system, which is vital information for surgical planning. This review presents relevant clinical presentation and imaging acquisition and presentation for the accurate staging classification of bile duct tumors based on the new AJCC criteria. This will be performed with the assistance of anatomical diagrams and representative CT and MR images. The image interpretation must include all relevant imaging information for optimum staging. Detailed recommendations on the items required on the radiology report will be presented.