Joint EANM-SNMMI guideline on the role of 2-[18F]FDG PET/CT in no special type breast cancer : (endorsed by the ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA)

INTRODUCTION

There is much literature about the role of 2-[18F]FDG PET/CT in patients with breast cancer (BC). However, there exists no international guideline with involvement of the nuclear medicine societies about this subject.

PURPOSE

To provide an organized, international, state-of-the-art, and multidisciplinary guideline, led by experts of two nuclear medicine societies (EANM and SNMMI) and representation of important societies in the field of BC (ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA).

METHODS

Literature review and expert discussion were performed with the aim of collecting updated information regarding the role of 2-[18F]FDG PET/CT in patients with no special type (NST) BC and summarizing its indications according to scientific evidence. Recommendations were scored according to the National Institute for Health and Care Excellence (NICE) criteria.

RESULTS

Quantitative PET features (SUV, MTV, TLG) are valuable prognostic parameters. In baseline staging, 2-[18F]FDG PET/CT plays a role from stage IIB through stage IV. When assessing response to therapy, 2-[18F]FDG PET/CT should be performed on certified scanners, and reported either according to PERCIST, EORTC PET, or EANM immunotherapy response criteria, as appropriate. 2-[18F]FDG PET/CT may be useful to assess early metabolic response, particularly in non-metastatic triple-negative and HER2+ tumours. 2-[18F]FDG PET/CT is useful to detect the site and extent of recurrence when conventional imaging methods are equivocal and when there is clinical and/or laboratorial suspicion of relapse. Recent developments are promising.

CONCLUSION

2-[18F]FDG PET/CT is extremely useful in BC management, as supported by extensive evidence of its utility compared to other imaging modalities in several clinical scenarios.

The 2021 ACR/RBMA Workforce Survey: Practice Types, Employment Trends, and Hiring Needs

PURPOSE

The aim of this study was to analyze current radiology practice types, specific subspecialty needs, employment trends, and retirement trends.

METHODS

ACR members, nonmembers, and Radiology Business Management Association members were surveyed using predominantly structured closed-ended questions about a variety of current and recent radiology practice characteristics. Responses were group practice deduplicated and weighted.

RESULTS

Of 1,702 survey respondents, 64% were men, with a median age of 51 years. In 2021, 62% of responding practices hired radiologists, with the average practice hiring 2 radiologists and academic practices on average hiring the most (3.5). Most radiologists (87%) were hired for full-time positions, with independent practices hiring the largest proportion of part-time positions. Body and breast imagers represented the largest numbers of hired radiologists (17% each). Practices anticipated similar hiring patterns in 2022, prioritizing breast (37%) and body (35%) imaging. Of all practice types, academic groups were least likely to prioritize general radiologist hiring. A large majority (82%) of radiology practices permit remote work (teleradiology), more common at academic than other practices. Of currently employed radiologists, 16% plan to seek new employment in the next year; early-career radiologists indicated the highest likelihood (92%) and academic radiologists the lowest (66%) of remaining in the same practice for at least 5 years. A large majority of practices (80%) reported no radiologist retirements in 2021. Of those retiring, the average age was 75 years, and 66% worked full-time until retirement.

CONCLUSIONS

Radiologist recruiting remains robust. Current information on practice characteristics may help inform radiology practice leaders seeking to right-size their groups.

The 2021 ACR/Radiology Business Management Association Workforce Survey: Diversity in Radiology

The landscape of the radiology workforce is changing, especially in the diversity of the demographics of practicing radiologists across subspecialties, practice types, and leadership positions in both academic and nonacademic settings. The 2021 ACR/Radiology Business Management Association Workforce Survey examines these facets in detail and contributes to our understanding of the current state of diversity in the radiology workforce and potential barriers to change. The results suggest opportunities and future directions for improving diversity, equity, and inclusion.

Diversity in interventional radiology: Survey of medical student interest with focus on women and members of underrepresented in medicine racial and ethnic groups

PURPOSE

To assess: 1) the percentage of female and underrepresented in medicine (URiM) medical students interested in interventional radiology (IR), and 2) the motivations for and deterrents from IR for female and URiM students.

METHODS

The study was IRB exempt. Data from a 19-item survey sent to 5 US medical schools were collected from 10/2018-01/2019 using REDCap and analyzed with SAS GLIMMIX.

RESULTS

16% (56/346) of women and 27% (69/258) of men strongly considered IR. 21% (19/89) of URiM versus 21% (105/508) of non-URiM students, p = .88, seriously considered IR. On a 0-to-4 scale (0 = not a motivator, 4 = strong motivator), women rated "Female mentorship" "2.5" versus males' "0.4", p < .0001, independent of IR interest URiM students uninterested in IR rated "Lack of ethnic diversity in training""2.3" versus "1.2" for IR-interested URiM, p < .01. 18% (9/50) of IR-interested women reported adequate gender-specific mentorship in IR in medical school. Of IR-interested URiM students 5% (1/19) reported adequate ethnicity/race-specific mentorship.

CONCLUSION

Fewer female medical students considered IR compared to males. Female mentorship was a significant motivator for women. Similar numbers of URiM and non-URiM students consider IR. Few women and URiM students report adequate gender/ethnicity/race-specific mentorship. For students not interested in IR, lack of ethnic diversity in training was a significant deterrent. Increasing numbers and visibility of female and URiM interventional radiologists in mentoring and clinical practice may improve recruitment of medical students from these underrepresented groups.

Can incorrect artificial intelligence (AI) results impact radiologists, and if so, what can we do about it? A multi-reader pilot study of lung cancer detection with chest radiography

OBJECTIVE

To examine whether incorrect AI results impact radiologist performance, and if so, whether human factors can be optimized to reduce error.

METHODS

Multi-reader design, 6 radiologists interpreted 90 identical chest radiographs (follow-up CT needed: yes/no) on four occasions (09/20-01/22). No AI result was provided for session 1. Sham AI results were provided for sessions 2-4, and AI for 12 cases were manipulated to be incorrect (8 false positives (FP), 4 false negatives (FN)) (0.87 ROC-AUC). In the Delete AI (No Box) condition, radiologists were told AI results would not be saved for the evaluation. In Keep AI (No Box) and Keep AI (Box), radiologists were told results would be saved. In Keep AI (Box), the ostensible AI program visually outlined the region of suspicion. AI results were constant between conditions.

RESULTS

Relative to the No AI condition (FN = 2.7%, FP = 51.4%), FN and FPs were higher in the Keep AI (No Box) (FN = 33.0%, FP = 86.0%), Delete AI (No Box) (FN = 26.7%, FP = 80.5%), and Keep AI (Box) (FN = to 20.7%, FP = 80.5%) conditions (all ps < 0.05). FNs were higher in the Keep AI (No Box) condition (33.0%) than in the Keep AI (Box) condition (20.7%) (p = 0.04). FPs were higher in the Keep AI (No Box) (86.0%) condition than in the Delete AI (No Box) condition (80.5%) (p = 0.03).

CONCLUSION

Incorrect AI causes radiologists to make incorrect follow-up decisions when they were correct without AI. This effect is mitigated when radiologists believe AI will be deleted from the patient's file or a box is provided around the region of interest.

CLINICAL RELEVANCE STATEMENT

When AI is wrong, radiologists make more errors than they would have without AI. Based on human factors psychology, our manuscript provides evidence for two AI implementation strategies that reduce the deleterious effects of incorrect AI.

KEY POINTS

• When AI provided incorrect results, false negative and false positive rates among the radiologists increased. • False positives decreased when AI results were deleted, versus kept, in the patient's record. • False negatives and false positives decreased when AI visually outlined the region of suspicion.

Metabolic Positron Emission Tomography in Breast Cancer

Metabolic PET, most commonly 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT), has had a major impact on the imaging of breast cancer and can have important clinical applications in appropriate patients. While limited for screening, FDG PET/CT outperforms conventional imaging in locally advanced breast cancer. FDG PET/CT is more sensitive than conventional imaging in assessing treatment response, accurately predicting complete response or nonresponse in early-stage cases. It also aids in determining disease extent and treatment response in the metastatic setting. Further research, including randomized controlled trials with FDG and other metabolic agents such as fluciclovine, is needed for optimal breast cancer imaging.

Imaging and Management of Radial Scars and Complex Sclerosing Lesions

Radial scars and complex sclerosing lesions, often collectively referred to as radial sclerosing lesions (RSLs), are breast lesions characterized by sclerotic stroma with entrapped epithelial elements. RSLs have imaging features that overlap with those of breast malignancy and often become the target of imaging-guided biopsy given their suspicious imaging appearance. These can be identified in isolation or can also be associated with atypia or other high-risk lesions that have intrinsic malignant potential, increasing the risk of carcinoma and affecting prognosis and management of RSLs. Because of this, management of these lesions remains controversial. Traditional management has been surgical excisional biopsy. However, as more RSLs are identified (because digital breast tomosynthesis allows identification of more architectural distortions), optimal management is evolving. Physicians in some practices are using a multidisciplinary approach to the management of RSLs when deciding on surgical excision of these lesions versus imaging follow-up. These discussions also incorporate individual patient risk factors and greater patient informed medical decision making. Reported upgrade rates of RSLs at core needle biopsy vary and can depend on the sampling method, number of samples, gauge of the needle, target being sampled, and radiologic-pathologic concordance or discordance. A precise sampling technique also allows greater accuracy of diagnosis and lower upgrade rates for these lesions, with radiologic-pathologic correlation as an integral component for further management decisions. The authors review the overall histopathologic, clinical, and imaging features of RSLs and discuss appropriate management based on currently available data regarding upgrade rates. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.

FDG PET in Evaluation of Patients With Fever of Unknown Origin: AJR Expert Panel Narrative Review

Fever of unknown origin (FUO) is a diagnostic challenge, with its cause remaining undiagnosed in approximately half of patients. Nuclear medicine tests typically are performed after a negative or inconclusive initial workup. Gallium-67 citrate and labeled leukocytes were previous mainstays of radionuclide imaging for FUO, although they had limited diagnostic performance. FDG PET/CT has subsequently emerged as the nuclear medicine imaging test of choice, supported by a growing volume of evidence. A positive FDG PET/CT result contributes useful information by identifying potential causes of fever, localizing sites for further evaluation, and guiding further management; a negative result contributes useful information by excluding focal disease as the cause of fever and predicts a favorable prognosis. In 2021, CMS rescinded a prior national noncoverage determination for FDG PET for infection and inflammation, leading to increasing national utilization of FDG PET/CT for FUO workup. This article reviews the current status of the role of FDG PET/CT in the evaluation of patients with FUO. The literature reporting the diagnostic performance and yield of FDG PET/CT in FUO workup is summarized, with comparison with historically used nuclear medicine tests included. Attention is also given to the test's clinical impact; protocol, cost, and radiation considerations; and application in children.

Summary: Appropriate Use Criteria for Lymphoscintigraphy in Sentinel Node Mapping and Lymphedema/Lipedema

Expert representatives from 11 professional societies, as part of an autonomous work group, researched and developed appropriate use criteria (AUC) for lymphoscintigraphy in sentinel lymph node mapping and lymphedema. The complete findings and discussions of the work group, including example clinical scenarios, were published on October 8, 2022, and are available at https://www.snmmi.org/ClinicalPractice/ content.aspx?ItemNumber=42021. The complete AUC document includes clinical scenarios for scintigraphy in patients with breast, cutaneous, and other cancers, as well as for mapping lymphatic flow in lymphedema. Pediatric considerations are addressed. These AUC are intended to assist health care practitioners considering lymphoscintigraphy. Presented here is a brief overview of the AUC, including the rationale and methodology behind development of the document. For detailed findings of the work group, the reader should refer to the complete AUC document online.

Fertility Treatments and Breast Cancer: A Significant Risk for Our Patients?

Fertility medications have been postulated to increase the risk of breast cancer because of the transient but substantial elevation in hormones occurring with their use. Multiple studies exploring the relationship between fertility medications and risk of breast cancer are limited by the wide variety of fertility treatment regimens and confounded by infertility as an independent risk factor for breast cancer. The Practice Committee Guidelines of the American Society of Reproductive Medicine acknowledge that although this relationship is complex, no additional risk of breast cancer has been consistently linked to infertility medications. This article reviews the major studies both supporting and refuting this statement and makes recommendations regarding risk counseling and breast cancer screening in patients with a history of fertility treatments and infertility.

ACR Appropriateness Criteria® Imaging of the Axilla

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. 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.

Advances and Future Directions in Molecular Breast Imaging

Molecular breast imaging (MBI) using ^99mTc-sestamibi has advanced rapidly over the past decade. Technical advances allow lower-dose, higher-resolution imaging and biopsy capability. MBI can be used for supplemental breast cancer screening with mammography for women with dense breasts, as well as to assess neoadjuvant therapy response, evaluate disease extent, and predict breast cancer risk. This article highlights the current state of the art and future directions in MBI.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. 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.

ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density

Mammography remains the only validated screening tool for breast cancer, however, there are limitations to mammography. One of the limitations of mammography is the variable sensitivity based on breast density. Supplemental screening may be considered based on the patient's risk level and breast density. For average-risk women with nondense breasts, the sensitivity of digital breast tomosynthesis (DBT) screening is high; additional supplemental screening is not warranted in this population. For average-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhanced mammography, screening ultrasound (US), breast MRI, or abbreviated breast MRI. In intermediate-risk women, there is emerging evidence suggesting that women in this population may benefit from breast MRI or abbreviated breast MRI. In intermediate-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhancedmammography or screening US. There is strong evidence supporting screening high-risk women with breast MRI regardless of breast density. Contrast-enhanced mammography, whole breast screening US, or abbreviated breast MRI may be also considered. 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.

BI-RADS 3 on dense breast screening ultrasound after digital mammography versus digital breast tomosynthesis

OBJECTIVE

Compare the BI-RADS 3 rate and follow-up of dense breast ultrasound (US) screening following digital mammography (DM) versus digital breast tomosynthesis (DBT).

METHODS

IRB-approved, HIPAA compliant retrospective search was performed of databases at two tertiary breast centers and an office practice for BI-RADS 3 screening US examinations performed 10/1/14-9/30/16. Prior DM versus DBT, downgrade and upgrade rate, and timing and pathology results were recorded. Differences were compared using the two-sample proportions test.

RESULTS

3183 screening US examinations were performed, 1434/3183 (45.1%) after DM and 1668/3183 (52%) after DBT (2.5% (81/3183) no prior mammogram available). 13.9% (199/1434) had BI-RADS 3 results after DM and 10.6% (177/1668) after DBT (p < 0.01). Median imaging follow-up after DM was 12 months (IQR 6, 24) versus 18 after DBT (IQR 11, 25), p = 0.02. 19.5% (73/375) of patients were lost to follow-up (19.2% (38/198) after DM (68.4% (26/38) no follow-up after initial exam) versus 19.8% (35/177) after DBT (54.3% (19/35) no follow-up after initial exam). 1.3% (5/375) of patients elected biopsy (1.5% (3/198) after DM and 1.1% (2/177) after DBT). 75.2% (282/375) of patients were downgraded (75.3% (149/198) after DM and 75.1% (133/177) after DBT). 2.5% (5/198) were upgraded after DM and 0.6% (1/177) after DBT. Median time to upgrade was 6 months after both DM and DBT. 0.3% (1/375) of patients with BI-RADS 3 results had cancer on follow-up.

CONCLUSION

Patients with prior DBT had a lower risk of encountering BI-RADS 3 findings on screening ultrasound. BI-RADS 3 findings on screening ultrasound had an extremely low rate of being cancer.

PET/computed tomography in inpatients: part 1, international survey

PURPOSE

The purposes of this study are to (1) identify patterns of inpatient PET/computed tomography (CT) use in and outside of the USA and (2) characterize inpatient PET/CT use by location and indication.

MATERIALS AND METHODS

The study was deemed exempt by the Institutional Review Board. A survey link through REDCap was emailed to the Society of Nuclear Medicine and Molecular Imaging (SNMMI) members and PET Centers of Excellence members and posted on the SNMMI website. Data were collected from May 2018 to August 2018. Analyses were conducted using SAS Software 9.4 with the NPAR1WAY procedure. Differences were evaluated using the Kruskal-Wallis test with statistical significance defined as P ≤ 0.05.

RESULTS

A total of 124 people responded to the survey, 71.8% (89/124) in the USA, and 26.6% (33/124) outside the USA [1.6% (2/124) no response]. 81.5% (101/124) read inpatient PET/CTs. Median percent of inpatient PET/CTs was 8.0% (range 0-100). Use of inpatient PET/CT was different (P < 0.0001) in the USA (5%, range 0-80%) versus outside USA (17.7%, range 0-100%). Use of inpatient PET/CT was different by institution type: median percent of inpatient PET/CTs in community teaching hospitals was 4.5% (range 0-50) versus 1.1% (range 0-20) in community nonteaching, 10% (range 0-80) in academic medical centers, and 20.0% (range 6.3-40) in government-affiliated institutions (P = 0.0001).

CONCLUSIONS

Most US and non-US respondents read inpatients PET/CTs. Non-US respondents read a higher percentage of inpatient PET/CTs than US respondents. Respondents in government-affiliated institutions read the highest percent of inpatient PET/CTs and community nonteaching institutions the least. Results of this survey may help physicians evaluate whether their practice of providing inpatient PET/CT fits with current practice patterns.

ACR Appropriateness Criteria® Syncope

Syncope and presyncope lead to well over one million emergency room visits in the United States each year. Elucidating the cause of syncope or presyncope, which are grouped together given similar etiologies and outcomes, can be exceedingly difficult given the diverse etiologies. This becomes more challenging as some causes, such as vasovagal syncope, are relatively innocuous while others, such as cardiac-related syncope, carry a significant increased risk of death. While the mainstay of syncope and presyncope assessment is a detailed history and physical examination, imaging can play a role in certain situations. In patients where a cardiovascular etiology is suspected based on the appropriate history, physical examination, and ECG findings, resting transthoracic echocardiography is usually considered appropriate for the initial imaging. While no imaging studies are considered usually appropriate when there is a low probability of cardiac or neurologic pathology, chest radiography may be appropriate in certain clinical situations. 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 a Fever-Redefining the Role of 2-deoxy-2-[18F]Fluoro-D-Glucose-Positron Emission Tomography/Computed Tomography in Fever of Unknown Origin Investigations

Growing evidence suggests that 2-deoxy-2-[18F]fluoro-D-glucose (18FDG)-positron emission tomography/computed tomography (PET/CT) is a useful imaging technique for the evaluation of fever of unknown origin (FUO). This imaging technique allows for accurate localization of foci of hypermetabolism based on 18FDG uptake in glycolytically active cells that may represent inflammation, infection, or neoplasia. The presence of abnormal uptake can help direct further investigation that may yield a final diagnosis. A lack of abnormal uptake can be reasonably reassuring that these conditions are not present, thereby avoiding unnecessary additional testing. Insurers have not routinely covered outpatient 18FDG-PET/CT for the indication of FUO in the United States. However, data published since 2007 suggest early use in FUO diagnostic evaluations improves diagnostic efficiency and reduces costs. Clinicians and insurers should consider 18FDG-PET/CT as a useful tool when preliminary studies are unrevealing.

Diversity, Equity, and Inclusion in Academic Nuclear Medicine: National Survey of Nuclear Medicine Residency Program Directors

A diverse health-care workforce is a necessary component of equitable care delivery to an increasingly diverse U.S. population. In nuclear medicine (NM), there is a paucity of data on the numbers of women and members of racial and ethnic groups that are underrepresented in medicine in the United States (URiMs). This study sought to characterize the current state of women and URiMs in academic NM, describe the demographics of Accreditation Council for Graduate Medical Education (ACGME)-accredited NM residency program faculty and trainees, and assess the extent of NM exposure during medical school. Methods: This study was reviewed by the Institutional Review Board and deemed exempt. In this cross-sectional study, a link to an online 15-item survey was emailed to 41 ACGME-accredited NM residency program directors (PDs) in the United States. Data were collected between September 2018 and December 2018 using a secure web application that serves as an electronic data capture tool for research studies. Results: 23 of 41 (56.1%) PDs responded to the survey, 18 of 23 (78.3%) of whom were men and 5 of 23 (21.7%) women. Three of 23 (13.0%) PDs reported being URiMs. Of the 60 residents in the 23 NM residency programs whose PDs responded, 37 of 60 (61.7%) were men (7/37 [18.9%] URiMs) and 23 of 60 (38.3%) women (5/23 [21.7%] URiMs). Fourteen of 60 (23.3%) residents were U.S. medical school graduates (U.S. grads). PDs described demographics of 121 current NM faculty members: 86 of 121 (71.1%) were men (8/121 [6.6% URIMs] and 35 of 121 (28.9%) women (7/121 (5.8% URiMs). Sixty-five of 121 (53.7%) were U.S. grads. Sixteen of 23 (69.6%) divisional chiefs were men, and 7 of 23 (30.4%) were women. Four of 23 (17.4%) divisional chiefs were URiMs, and 7 of 20 (35.0%) NM PDs reported that NM was part of the medical school curriculum. Conclusion: Women and URiMs are underrepresented in NM training programs. This diversity gap is more pronounced among NM faculty and to an even greater extent in leadership positions. A greater proportion of NM trainees are international medical graduates compared with NM faculty members, suggesting declining NM recruitment among U.S. grads. NM is included in the medical school curriculum at fewer than one third of academic centers with NM residency programs, typically toward the end of medical school. Increased and earlier exposure to NM, especially for women and URiMs, may improve recruitment and mitigate diversity gaps.

Considerations in Specialty Selections: What Medical Students Think, Know, and Think They Know about Interventional Radiology

PURPOSE

To compare the motivation, deterrents, knowledge, exposure, and other specialty considerations of first- to fourth-year medical students interested in interventional radiology (IR) with those who are not.

MATERIALS AND METHODS

Matriculants of 5 medical schools varying by region, public/private, class size, and National Institutes of Health research ranking received a 19-question survey with questions about demographics, specialty interests, motivations/deterrents, knowledge, and exposure to IR.

RESULTS

A total of 25.8% (611/2370) of students completed the survey, of which 20.5% (125/611) expressed interest in IR, and 25% (47/186), 26% (40/153), 24% (34/143), and 3% (3/117) of first-year, second-year, third-year, and fourth-year medical students, respectively, were seriously considering IR. Those interested in IR were less motivated by direct patient care (mean, 2.8/5; 95% confidence interval [CI], 2.6-3.0) and longitudinal patient care (mean, 1.6/5; 95% CI, 1.4-1.7) (both, P < .01) and more motivated by salary (2.6/5; 95% CI, 2.3-2.9), job market (2.8/5; 95% CI, 2.6-2.9), and procedures (3.1/5; 95% CI, 2.8-3.4) compared with their peers (all P < .05). Those interested in IR were more certain about their IR knowledge (mean range, 1.6-2.0/3.0; 95% CI, 1.3-2.3) than their peers (mean range, 1.9-2.4/3.0; 95% CI, 1.6-2.1, in which 0 = certain, P ≤ .01); however, both groups scored low in actual knowledge (those considering IR: 35.0-73.2% correct; 95% CI, 23.5-81.4; those who were not: 26.6-66.7% correct; 95% CI, 24.3-75.9, P > .05).

CONCLUSIONS

Although medical students showed interest in IR, they had a limited understanding of IR. IR educators may increase IR interest and understanding among medical students by clarifying the procedural aspects and longitudinal care present in a comprehensive IR practice.

Will the Effect of New Federal Breast Density Legislation Be Diminished by Currently Available Online Patient Educational Materials?

RATIONALE AND OBJECTIVES

To evaluate readability of commonly accessed online patient educational materials (OPEM) on breast density in setting of recently passed federal breast density legislation.

MATERIALS AND METHODS

The term "breast density" was queried using an online search engine to identify the top 50 commonly accessed websites based on order of search results on December 15, 2018. Location, cookies, and user account information were disabled prior to our query. Only websites with OPEM, defined as any educational material on breast density targeted towards the general public, were evaluated in our study. Sponsored hits and research journal articles were excluded. Available patient-directed information from websites meeting inclusion criteria was then downloaded. Grade-level readability was then determined from formatted content using generalized estimating equations, with observations nested within readability metrics from each website. Results were compared to American Medical Association recommended readability parameters (sixth-grade reading level). All interval estimates were calculated for 95% confidence.

RESULTS

Fouty-one websites met inclusion criteria representing patient-directed OPEM on breast density. Average grade-level readability of health information on breast density in our study ranged from 8.5-16.5 years with an average grade reading level of 11.1 years across all websites. Of websites fitting into a specific category, academic websites had the highest average grade reading level (12.0), while nonprofit websites had the lowest average grade reading level (10.4). Nearly half (19/41) of all websites in our study had diagrams to aid in patient comprehension, while few websites (2/41; 4.8%) displayed videos in addition to written content. The website with the lowest average grade reading level was WebMD, which had an average reading level of 8.5. No individual website in our study met American Medical Association recommended parameters of a sixth-grade reading level CONCLUSION: Readability of currently available OPEM on breast density may be written at a level too difficult for the general public to comprehend, which may represent a barrier to educational goals of newly passed federal breast density legislation.

Survey of radiologists and emergency department providers after implementation of a global radiology report categorization system

PURPOSE

Breakdown in communication of important imaging results threatens patient safety and risks malpractice claims. To facilitate closed-loop communication, our institution developed a unique radiology report categorization (RADCAT) system employing automated alert notification systems. This study aimed to understand users' initial experiences with the RADCAT system and obtain feedback.

METHODS

Web-based surveys were distributed to radiologists and emergency department (ED) providers at our hospital system within 1 year of institution-wide RADCAT implementation. Survey designs differed based on clinical setting. Most prompts utilized declarative statements with 5-point agreement Likert scales. Closed-response data was analyzed with descriptive statistics.

RESULTS

Response rates among radiologists and ED providers were 59.4% (63/106) and 38.4% (69/211), respectively. 78.0% (46/59) of radiologists and 60.9% (42/69) of ED providers agreed that RADCAT improves patient care. Of radiologists, 84.1% (53/63) agreed that RADCAT design is intuitive, and 57.6% (34/59) agreed that RADCAT improves efficiency. Of ED providers, 69.6% (48/69) agreed that RADCAT appropriately differentiates urgent and non-urgent findings, and 65.2% (45/69) agreed that auto-population of discharge documents with imaging results containing follow-up recommendations protects them from liability. Only 35.6% (21/59) of radiologists and 21.7% (15/69) of ED providers agreed that RADCAT implementation decreased reading room visits by ordering providers. Open-response feedback showed that some ED providers find RADCAT too complex while some radiologists desire improved transparency regarding imaging study communication status.

CONCLUSION

Since its implementation, RADCAT has been well received among radiologists and ED providers with agreement that it improves patient care and effectively distinguishes and communicates important imaging findings.

Dense Breast Notification Letters: What Do Breast Radiologists Think?

OBJECTIVE

The Food and Drug Administration is currently creating national standards for language used in letters sent to women after mammography concerning dense breasts. The purpose of the current study is to survey breast radiologists on their opinions about language to be included in dense breast notification (DBN) letters.

METHODS

An anonymous survey (17 questions and 10 open-ended response fields) was sent to Society of Breast Imaging members between May 2019 and June 2019. Analyses were conducted using a chi-square test and the generalized linear model.

RESULTS

A total of 262 surveys were completed (25% response rate). The majority of breast radiologists believe letters should be sent to patients (91%), with most (66%) believing that patients should receive DBN letters regardless of having dense breasts or not. The majority of breast radiologists believe DBNs should be sent to referring physicians (69%), include statements that define masking (89%), inform patients that dense breasts are associated with cancer risk (77%), inform patients about the possible benefits of supplemental screening (86%), be written at the sixth- or eighth-grade reading level (92%), and should be provided in other languages in addition to English (89%); half of the respondents (51%) believe the letters should contain BI-RADS density descriptors.

CONCLUSION

There is consensus that patients and referring physicians should receive DBN letters and that those letters should address masking, increased cancer risk, and supplemental screening. Respondents believe the letters should be written at a sixth- or eighth-grade reading level.

F18-FDG PET/CT Diagnoses Vasculitis after a Negative Indium-111 Leukocyte Scan

We present a case of a 38-year-old man with a prior episode of fever of unknown origin (FUO) four years ago who presented with acute severe dull nonradiating abdominal pain centered in the epigastric region associated with nausea and vomiting. Bloodwork showed a normal leukocyte count but elevated erythrocyte sedimentation rate of 26 and elevated C-reactive protein of 40; syphilis titers and anti-neutrophil cytoplasmic antibodies (pANCA and cANCA) were negative. CT angiogram (CTA) of the abdomen and pelvis showed diffuse medium vessel vascular inflammation. Indium-111 labeled leukocyte scan did not show evidence of infection and, specifically, no evidence of infectious vasculitis. Subsequent F18-FDG PET/CT scan showed diffuse uptake in the mesenteric vasculature in the area of abnormality seen on prior contrast-enhanced CT and confirmed the diagnosis of vasculitis, subsequently deemed by rheumatology to be most consistent with segmental arterial mediolysis.

Readability of Online Patient Educational Materials Related to Breast Lesions Requiring Surgery

Purpose To evaluate readability of websites that are commonly accessed for information on breast lesions requiring surgery. Materials and Methods An internet search using three malignant and eight nonmalignant breast lesions that traditionally require lumpectomy or excisional biopsy as search terms was conducted to identify websites commonly accessed for patient information on breast lesions requiring surgery. Nine websites with information on breast diagnoses were identified based on search engine results for each breast lesion queried. Available patient-directed information was downloaded for each lesion from each website on May 15, 2018. Grade-level readability of downloaded content for each lesion was then determined by using generalized estimating equations, with observations nested within readability metrics from each website. Readability of associated terms breast biopsy, breast cancer, and breast surgery was also evaluated with the same method. Results were compared with American Medical Association (AMA) recommended readability parameters (sixth-grade reading level). All interval estimates were calculated for 95% confidence. Results Average grade level readability score of health information on breast lesions requiring surgery was 11.7, which exceeded the AMA parameters. Information on Wikipedia was written at the highest reading level (grade level readability score, 14.2), while information on the National Institutes of Health website ( http://cancer.gov ) was written at the lowest reading level (grade level readability score, 9.7). Educational materials on malignant breast lesions (grade level readability score, 12.3) were written at a higher reading level than were those on nonmalignant breast lesions (grade level readability score,11.4). Information on the terms breast biopsy (grade level readability score, 10.9), breast cancer (grade level readability score, 10.6), and breast surgery (grade level readability score, 11.1) were all written above a sixth-grade reading level. Conclusion Readability of current online resources on breast biopsy lesions traditionally requiring surgery may be too complex for the general public to comprehend, leading to misinformation and confusion. © RSNA, 2019 See also the editorial by Haygood in this issue.

Effectiveness of a Staged US and Unenhanced MR Imaging Algorithm in the Diagnosis of Pediatric Appendicitis

Purpose To establish, in a large cohort, the diagnostic performance of a staged algorithm involving ultrasonography (US) followed by conditional unenhanced magnetic resonance (MR) imaging for the imaging work-up of pediatric appendicitis. Materials and Methods A staged imaging algorithm in which US and unenhanced MR imaging were performed in pediatric patients suspected of having appendicitis was implemented at the authors' institution on January 1, 2011, with US as the initial modality followed by unenhanced MR imaging when US findings were equivocal. A search of the radiology database revealed 2180 pediatric patients who had undergone imaging for suspected appendicitis from January 1, 2011, through December 31, 2012. Of the 2180 patients, 1982 (90.9%) were evaluated according to the algorithm. The authors reviewed the electronic medical records and imaging reports for all patients. Imaging reports were reviewed and classified as positive, negative, or equivocal for appendicitis and correlated with surgical and pathology reports. Results The frequency of appendicitis was 20.5% (407 of 1982 patients). US alone was performed in 1905 of the 1982 patients (96.1%), yielding a sensitivity of 98.7% (386 of 391 patients) and specificity of 97.1% (1470 of 1514 patients) for appendicitis. Seventy-seven patients underwent unenhanced MR imaging after equivocal US findings, yielding an overall algorithm sensitivity of 98.2% (400 of 407 patients) and specificity of 97.1% (1530 of 1575 patients). Seven of the 1982 patients (0.4%) had false-negative results with the staged algorithm. The negative predictive value of the staged algorithm was 99.5% (1530 of 1537 patients). Conclusion A staged algorithm of US and unenhanced MR imaging for pediatric appendicitis appears to be effective. The results of this study demonstrate that this staged algorithm is 98.2% sensitive and 97.1% specific for the diagnosis of appendicitis in pediatric patients. ^© RSNA, 2017.

Precision Medicine and PET/Computed Tomography in Cardiovascular Disorders

PET/computed tomography (CT) can evaluate the metabolic and anatomic involvement of a variety of inflammatory, infectious, and malignant cardiovascular disorders. PET/CT is useful in evaluating coronary vasculature, hibernating myocardium, cardiac sarcoidosis, cardiac amyloidosis, cerebrovascular disease, acute aortic syndromes, cardiac and vascular neoplasms, cardiac and vascular infections, and vasculitis. Novel targeted radiopharmaceutical agents and novel use of established techniques show promise in diagnosing and monitoring cardiovascular diseases.

Role of PET/CT in Workup of Fever without a Source

Fever without source is a febrile illness without localizing signs or initial obvious cause. Early workup will often include chest radiography and computed tomography (CT) of the abdomen and pelvis, with or without CT of the chest. To evaluate localizing signs or symptoms or to further evaluate findings from initial studies, targeted imaging according to body part can be performed by using radiography, ultrasonography, CT, or magnetic resonance (MR) imaging. Nuclear medicine studies can provide imaging of the whole body and may be helpful when the clinical and conventional imaging workup findings are negative or equivocal in identifying a source of fever. Nuclear medicine studies can be used to detect pathologic changes early in a disease course, even in the absence of an anatomic abnormality. Gallium 67 scintigraphy, indium 111- and technetium 99m-labeled leukocyte scintigraphy, and fluorine 18 fluorodeoxyglucose positron emission tomography (PET)/CT studies are all useful in the evaluation of fever, but the radiopharmaceutical cost for PET/CT is much lower than that for radiolabeled leukocyte studies. The increased use of bundled payments for inpatient admissions requires updated cost evaluations for the preferred nuclear medicine study. For inpatients in whom the findings from the initial clinical workup and imaging studies are nondiagnostic, PET/CT examination may be preferable to radiolabeled leukocyte studies because of its high sensitivity and lower cost. Negative findings at PET/CT can be helpful in excluding a suspected site of infection, and positive findings at PET/CT can be helpful in confirming a suspected site of infection or in identifying an unexpected cause of fever. (©)RSNA, 2016.

Toxoplasmosis versus lymphoma: Cerebral lesion characterization using DSC-MRI revisited

OBJECTIVE

CNS toxoplasmosis and lymphoma are often indistinguishable by conventional contrast-enhanced MRI. There is limited literature on the diagnostic efficacy of dynamic susceptibility contrast (DSC) MRI for differentiating these entities. This study assesses the clinical utility of relative cerebral blood volume (rCBV) for making a diagnosis and determines rCBV thresholds for differentiation using contemporary DSC-MRI.

PATIENTS AND METHODS

Thirteen patients with 25 lesions (13 toxoplasmosis and 12 lymphoma) and pre-treatment DSC-MRI were identified retrospectively. Volumetric regions of interest of segmented enhancement were used to extract mean rCBV normalized to normal-appearing white matter for each lesion. We compared average mean rCBV between all toxoplasmosis and lymphoma lesions using a general mixed model. Three models were also compared for evaluating rCBV-based disease status in each patient: 1) mean rCBV of each lesion using a generalized estimating equation, 2) volume-weighted mean rCBV, and 3) maximum mean rCBV of all lesions using logistic regression.

RESULTS

The average mean rCBV for all toxoplasmosis lesions was 0.98 (95% CI 0.55-1.41) compared to 2.07 (95% CI 1.71-2.43) for all lymphoma lesions, a significant difference (1.09, 95% CI 0.53-1.65, p=0.0013). For the three models used to evaluate rCBV-based disease status in each patient, a significant relationship was observed, with an optimal rCBV threshold of approximately 1.5 for distinguishing lymphoma from toxoplasmosis in each model.

CONCLUSION

RCBV derived from contemporary DSC-MRI is helpful for distinguishing between cerebral toxoplasmosis and cerebral lymphoma on an individual patient basis and may facilitate more timely initiation of appropriate directed therapy.

Review of outside studies by radiology residents: national survey of chief residents

The purpose of this study was to establish practice patterns of radiology residents in regards to interpretation and reporting of outside studies for transferred patients. We performed a national survey of radiology residency chief residents, administered by email through the Association of Program Directors in Radiology (APDR). There were 81 chief resident respondents, representing 42.8 % of 187 total Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency training programs in the USA. In 97.5 % of programs, residents perform interpretations of outside studies. Up to 76.7 % of respondents state that when outside studies are reviewed by residents, an original report is available in less than one quarter of cases. While 55.1 % of respondents state that there is a mechanism for recording their findings and impressions for outside studies, only 32.1 % are aware of a policy requiring documentation. Of the respondents, 42.3 % report they have no means for documenting their findings and impressions on outside studies. Further, 65.4 % state that there is no policy requiring an attending to review and document agreement with their interpretation of outside studies. There is wide institutional variation in both policy and practice regarding reinterpretation of outside studies for patients transferred to academic hospitals. While the majority of radiology residents are providing the service of reinterpreting outside studies, only a minority of residency programs have a policy requiring (1) documentation of their impressions or (2) attending oversight and documentation of discrepant opinions.

18F-FDG metabolic tumor volume and total glycolytic activity of oral cavity and oropharyngeal squamous cell cancer: adding value to clinical staging

(18)F-FDG metabolic tumor volume (MTV) and total glycolytic activity (TGA) have been proposed as potential prognostic imaging markers for patient outcome in human solid tumors. The purpose of this study was to establish whether MTV and TGA add prognostic information to clinical staging in patients with oral and oropharyngeal squamous cell carcinomas (SCCs).

METHODS

The Institutional Review Board approved this Health Insurance Portability and Accountability Act-compliant single-institution retrospective study. Forty-five patients with histologically proven oral or oropharyngeal SCC underwent PET/CT for initial cancer staging and were included in the study. MTV was measured using a gradient-based method (PET Edge) and fixed-threshold methods at 38%, 50%, and 60% of maximum standardized uptake value (SUV). The TGA is defined as MTV × mean SUV. Bland-Altman analysis was used to establish the reliability of the methods of segmentation. Outcome endpoints were overall survival (OS) and progression-free survival. Cox proportional hazards univariate and multivariate regression analyses were performed.

RESULTS

In Cox regression models, MTV and TGA were the only factors significantly associated with survival outcome after adjusting for all other covariates including American Joint Committee on Cancer (AJCC) stage, with hazards ratio of 1.06 (95% confidence interval, 1.01-1.10; P = 0.006) and 1.00 (95% confidence interval, 1.00-1.01; P = 0.02). The model fit was significantly better when MTV was added to AJCC stage in model I (χ(2) value change, 1.16-6.71; P = 0.01) and when TGA was added to AJCC stage in model II (χ(2) value change, 1.16-4.37; P = 0.04). The median cutoff point of 7.7 mL for primary tumor MTV was predictive of time to OS (log rank P = 0.04). The median cutoff point of 55 g for PET Edge primary tumor TGA was predictive of time to OS (log rank P = 0.08), though the result was not statistically significant.

CONCLUSION

Gradient-based segmentations of primary tumor MTV and TGA are potential (18)F-FDG markers for time to survival in patients with oral and oropharyngeal SCC and may provide prognostic information in addition to AJCC stage. These exploratory imaging markers need validation in larger cohort studies.

The John A. Andrew Memorial Hospital

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