Features associated with clinically actionable hyperechoic hepatic lesions to determine the need for follow-up.

PURPOSE: To evaluate the rate of hyperechoic liver lesions that are clinically actionable and evaluate imaging and clinical factors associated with these to determine the need for follow-up. MATERIALS AND METHODS: This retrospective study included 228 hyperechoic hepatic lesions on ultrasound in 228 patients. Reference standards included either dynamic contrast enhanced MRI (n = 130) or CT (n = 46), follow-up ultrasound performed at least 2 years from baseline (n = 50), or histopathology (n = 2). Three radiologists independently assessed imaging features including lesion orientation, degree of hyper-echogenicity, lesion heterogeneity, and background liver echotexture. Univariable and multivariable logistic regression was used to determine features associated with an actionable hyperechoic lesion. RESULTS: Of the 228 hyperechoic lesions, 14 (6.1%) lesions were clinically actionable (or requiring follow-up), and 214 (93.9%) were clinically insignificant. Features that differed between patients with clinically insignificant vs. actionable lesions included: age (52.9 ± 15.1 vs. 63.9 ± 15.8 years, p = 0.004), male sex (43.9% vs 71.4%, p = 0.045), history of cirrhosis (6.5% vs 50%, p < 0.001), lesion size (1.9 ± 1.4 cm vs. 3.5 ± 2.8 cm, p = 0.003), heterogeneous lesion echogenicity (16.4% vs. 50%, p = 0.006), and cirrhotic/coarsened background liver (7.5% vs. 35.7%, p = 0.005). Stepwise logistic regression and multivariable analysis identified age, presence of cirrhosis, and lesion size as features most predictive of an actionable lesion (OR 1.04, 24.3, 1.77 respectively). Reader agreement for imaging features was fair to moderate (k = 0.29-0.53). 100%(168/168) of hyperechoic liver lesions measuring ≤ 3 cm in patients without a history of malignancy or underlying liver disease were clinically insignificant. CONCLUSION: Our study findings support the overall favorable diagnoses of hyperechoic liver lesions ≤ 3 cm in patients without underlying risk factors.

Thriving In and Out of the Reading Room: A Faculty Development Workshop.

RATIONALE AND OBJECTIVES: Given the immense time and energy radiologists dedicate to their profession, the experience at work should be a major contributor to a meaningful and fulfilling life. In pursuit of this vision, our department launched a novel faculty development workshop entitled "Thriving In and Out of the Reading Room: What They Didn't Teach Us in Training." We report on the design, implementation and initial outcomes of this faculty development workshop. MATERIALS AND METHODS: The workshop drew upon positive psychology research and the PERMA model of well-being, which encompasses five key elements: Positive emotion, Engagement, Relationships, Meaning, and Achievement. These elements have been shown to enhance work satisfaction and foster resilience. Using interactive, small group exercises, the workshop provided strategies for incorporating PERMA elements into daily life. At the conclusion of each workshop, an anonymous voluntary electronic survey was distributed to participants. RESULTS: The final version of the workshop was offered to 58 faculty over eight sessions between September 2022 and May 2023. Survey results indicate that participants found the workshop to be highly valuable and practical. They also found the workshop to promote camaraderie and peer learning. Developing the workshop internally allowed us to customize it to our faculty's unique experiences and engage a large number of participants. CONCLUSION: The workshop shows promise in improving job satisfaction and addressing burnout among academic radiologists.

Pancreatic Cystic Lesions: Imaging Techniques and Diagnostic Features.

The detection of incidental pancreatic cystic lesions has increased over time. It is crucial to separate benign from potentially malignant or malignant lesions to guide management and reduce morbidity and mortality. The key imaging features used to fully characterize cystic lesions are optimally assessed by contrast-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography, with pancreas protocol computed tomography offering a complementary role. While some imaging features have high specificity for a particular diagnosis, overlapping imaging features between diagnoses may require further investigation with follow-up diagnostic imaging or tissue sampling.

Pancreatic Cystic Lesions: Next Generation of Radiologic Assessment.

Pancreatic cystic lesions are frequently identified on cross-sectional imaging. As many of these are presumed branch-duct intraductal papillary mucinous neoplasms, these lesions generate much anxiety for the patients and clinicians, often necessitating long-term follow-up imaging and even unnecessary surgical resections. However, the incidence of pancreatic cancer is overall low for patients with incidental pancreatic cystic lesions. Radiomics and deep learning are advanced tools of imaging analysis that have attracted much attention in addressing this unmet need, however, current publications on this topic show limited success and large-scale research is needed.

Prostate MRI with PI-RADS v2.1: initial detection and active surveillance.

The role of prostate MRI in clinical practice has continued to broaden over time. Multiple iterations of PI-RADS reporting have aided in improving detection and reporting of prostate cancer. In addition, recent recommendations from the PI-RADS Steering Committee promote an MRI-first approach with an MRI-directed prostate cancer diagnostic pathway. It is imperative for radiologists to be knowledgeable and familiar with prostate MRI and PI-RADS recommendations, as there is an increasing demand for prostate imaging by clinicians and patients alike.

Virtual Monochromatic Dual-Energy Aortoiliac CT Angiography With Reduced Iodine Dose: A Prospective Randomized Study.

OBJECTIVE: The purpose of this study was to assess the feasibility of performing abdominopelvic aortoiliac CT angiography (CTA) with 16.0 g of iodine contrast medium acquired with low-energy (40 and 50 keV) virtual monochromatic (VMC) images with rapid-kilovoltage-switching dual-energy CT. SUBJECTS AND METHODS: A total of 52 adults with abdominal aortoiliac aneurysm and prior 120-kVp single-energy CTA (SECTA) with 33 g iodine (standard dose) underwent follow-up dual-energy CTA (DECTA) with a 52% reduced iodine dose. Subjects were randomly assigned to a contrast medium protocol for DECTA examinations: one group (n = 26) received 16.2 g (270 mg I/mL) and the other (n = 26) received 16.0 g (320 mg I/mL). Two readers independently assessed SECTA and VMC DECTA datasets for image quality using a 5-point scale. Aortoiliac intravascular attenuation was measured, and ANOVA was used to compare measurements between VMC DECTA and SECTA images. In a subset of patients with DECTA after endovascular aortic repair, endoleak detection was evaluated on VMC images. Volume CT dose index, dose-length product, and size-specific dose estimate were compared between DECTA and SECTA. RESULTS: All DECTA examinations (n = 52) were rated diagnostic with image quality scores comparable to those of 120-kVp single-energy CTA (40 keV, 4.2-4.4; 50 keV, 4.6-4.8; SECTA, 4.4-4.5). Intravascular attenuation was uniform in all reduced-iodine DECTA examinations and was significantly higher on 40- and 50-keV images than on standard-iodine-dose SECTA images (720 ± 125 HU and 482 ± 82 HU vs 303 ± 65 HU) (p < 0.01). There was no difference in intravascular attenuation between the 16.2-g and the 16.0-g doses (p = 0.82). Sensitivity and specificity for endoleak detection were 78.9-94.7% and 100%. Total dose-length product was lower for DECTA (788 ± 166 mGy · cm) than for SECTA (1114 ± 468 mGy · cm). CONCLUSION: Low-energy VMC DECTA images (40 and 50 keV) acquired with two contrast protocols at approximately 50% reduced iodine dose (16.0 and 16.2 g) provide adequate intravascular attenuation and diagnostic quality for aortoiliac evaluation.

MR Imaging of Pancreatic Neuroendocrine Tumors.

Imaging plays a crucial role in identifying, diagnosing, treatment, and surveillance of pancreatic neuroendocrine tumors (PNETs). Although computed tomography has been traditionally used for evaluation of PNETs, evolving techniques with MR imaging have broadened and strengthened its role as an important tool in diagnosis, staging, and assessment of response to therapy.

Advances in Pancreatic CT Imaging.

OBJECTIVE: The purpose of this article is to discuss the advances in CT acquisition and image postprocessing as they apply to imaging the pancreas and to conceptualize the role of radiogenomics and machine learning in pancreatic imaging. CONCLUSION: CT is the preferred imaging modality for assessment of pancreatic diseases. Recent advances in CT (dual-energy CT, CT perfusion, CT volumetry, and radiogenomics) and emerging computational algorithms (machine learning) have the potential to further increase the value of CT in pancreatic imaging.

Imaging and Screening of Pancreatic Cancer.

Given the low disease prevalence of both exocrine and endocrine cancers in the general population, screening is not recommended. However, in as many as 25% of cases there is a precursor lesion or an identifiable genetic predisposition. For these patients at increased risk, screening with imaging is recommended. Multidetector computed tomography, MR imaging or magnetic resonance cholangiopancreatography, and endoscopic ultrasound examination can be used as screening modalities. Recent advances in dual energy CT and total body MR imaging have increased the suitability of these noninvasive modalities as first-line imaging screening options.

Material density iodine images in dual-energy CT: Detection and characterization of hypervascular liver lesions compared to magnetic resonance imaging.

PURPOSE: To determine the diagnostic potential of Material Density (MD) iodine images in dual-energy CT (DECT) for the detection and characterization of hypervascular liver lesions compared to monenergetic 65keV images, using MRI as the standard. MATERIALS AND METHODS: The study complied with HIPAA guidelines and was approved by the institutional review board. Fifty-two patients (36 men, 16 women; age range, 29-87 years) with 236 hypervascular liver lesions (benign, n=31; malignant, n=205; mean diameter, 29.4mm; range: 6-90.6mm) were included. All of them underwent both contrast-enhanced single-source DECT and contrast-enhanced abdominal MRI within three months. Late arterial phase CT imaging was performed with dual energies of 140 and 80kVp. Protocol A showed monoenergetic 65keV images, and protocol B presented MD-iodine images. Three radiologists qualitatively evaluated randomized images, and lesion detection, characterization, and reader confidence were recorded. Liver-to-lesion ratio (LLR) and contrast-to-noise ratio (CNR) were assessed on protocol A, protocol B, and MRI. Paired t-tests were used to compare LLR, CNR, and the number of detected lesions. RESULTS: LLR was significantly increased in protocol B (2.8±2.33) compared to protocol A (0.77±0.55) and MRI (0.61±0.66). CNR was significantly higher in protocol B (0.08±0.04) compared to protocol A (0.01±0.01) and MRI (0.01±0.01). All three observers correctly identified more liver lesions using protocol B vs protocol A: 83.13% vs 63.64%, 84.57% vs 68.09%, and 79.37% vs 65.52%. There was no significant difference between the three observers in classification of a lesion as benign or malignant. However, higher diagnostic confidence was reported more frequently by the experienced radiologist when using protocol B vs protocol A (84.6% vs 75%). CONCLUSION: MD-iodine images in DECT help to increase the conspicuity and detection of hypervascular liver lesions.

Feasibility and reproducibility of liver surface nodularity quantification for the assessment of liver cirrhosis using CT and MRI.

PURPOSE: To assess intra-observer, inter-observer and inter-modality (CT vs. MRI) reproducibility of liver surface nodularity (LSN) scores measured with software used for detection of liver fibrosis. METHODS: This IRB-approved retrospective study included patients with both abdominal CT and MRI within 6 months of histopathologic sampling. Two independent observers used post-processing software to quantify LSN scores on axial non-contrast CT (NCT), axial contrast-enhanced CT (CECT), axial T2-weighted (T2W) HASTE, and axial and coronal post-gadoxetic acid T1-weighted (T1W) images obtained during the hepatobiliary phase (HBP). Ten slices were used to acquire the LSN scores. Intra-observer, inter-observer, and inter-modality (CT vs. MRI) reproducibility were assessed with intraclass correlation coefficient (ICC) and coefficients of variability (CV). Accuracy for detection of cirrhosis was evaluated for each technique. RESULTS: 26 patients (M/F 19/7, mean age 57 years), including 7 with cirrhosis (26.9%), were assessed. Technical failure occurred with NCT (1/23, 4.3%) and T2 HASTE (8/28, 28.6%). Intra-observer reproducibility was excellent for NCT, CECT, axial and coronal T1W HBP [ICC ≥ 0.92, CV ≤ 8%]. Inter-observer reproducibility was also excellent for NCT and CECT (ICC ≥ 0.95, CV ≤ 7.3%) and for coronal T1W HBP (ICC = 0.84, CV = 5.6%). There was fair to moderate agreement between CT and MRI (ICC 0.20-0.44). There were significant differences in mean LSN scores between non-cirrhotic and cirrhotic patients with NCT (2.6 vs. 4.2, p = 0.04) and T1W HBP (3.7 vs. 4.6; p = 0.01) images, with AUCs of 0.81 and 0.82, respectively. CONCLUSIONS: LSN measurement is highly reproducible with NCT and post-contrast T1W HBP on MRI, with different results obtained between CT and MRI.

Isolated fallopian tube torsion: two case reports of a rare entity.

Isolated fallopian tube torsion is a rare entity that is difficult to diagnose, as its clinical presentation is often highly nonspecific. Early diagnosis is important to avoid damage or loss of the fallopian tube or even the ovary, as this diagnosis occurs predominantly in women of child-bearing age. Imaging may be helpful in suggesting this difficult diagnosis, with confirmation of this entity made in the operating room. Treatment can range from detorsing the tube to salpingectomy or even salpingo-oopherectomy. Here, we present two cases of isolated fallopian tube torsion, followed by a discussion of its imaging findings.

Transjugular Intrahepatic Portosystemic Shunt Flow Reduction with Adjustable Polytetrafluoroethylene-Covered Balloon-Expandable Stents Using the "Sheath Control" Technique.

PURPOSE: A complication of transjugular intrahepatic portosystemic shunts (TIPS) placement is refractory portosystemic encephalopathy (PSE) often requiring TIPS reduction. We report the results of a "sheath control technique" utilizing constraining sheaths during deployment of polytetrafluoroethylene (PTFE)-covered balloon-expandable stents, minimizing stent migration, and providing additional procedural control. METHODS: TIPS reduction was performed in 10 consecutive patients for PSE using Atrium iCast covered stents (Atrium Maquet Getinge Group, Germany). Within the indwelling TIPS stent, a 9 mm × 59 mm iCast stent was deployed with 2 cm exposed from the sheath's distal end and the majority of the stent within the sheath to create the distal hourglass shape. During balloon retraction, the stent was buttressed by the sheath. The proximal portion of the stent was angioplastied to complete the hourglass configuration, and the central portion of the stent was dilated to 5 mm. Demographics, pre- and post-procedure laboratory values, and outcomes were recorded. RESULTS: Ten patients underwent TIPS reduction with 100 % technical success. There was no stent migration during stent deployment. All patients experienced initial improvement of encephalopathy. One patient ultimately required complete TIPS occlusion for refractory PSE, and another developed TIPS occlusion 36 days post-procedure. There was no significant trend toward change in patients' MELD scores immediately post-procedure or at 30 days (p = 0.46, p = 0.47, respectively). CONCLUSION: TIPS reduction using Atrium iCast PTFE balloon-expandable stents using the "sheath control technique" is safe and effective, and minimizes the risk of stent migration.