What is the added value of specialist radiology review of multidisciplinary team meeting cases in a tertiary care center?

PURPOSE: Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. This study investigated how often subspecialized radiologists change patient management in MDTMs at a tertiary care institution. MATERIALS AND METHODS: Over 2 years, six subspecialty radiologists documented their contributions to MDTMs at a tertiary care center. Both in-house and external imaging examinations were discussed at the MDTMs. All imaging examinations (whether primary or second opinion) were interpreted and reported by subspecialty radiologist prior to the MDTMs. The management change ratio (MCratio) of the radiologist was defined as the number of cases in which the radiologist's input in the MDTM changed patient management beyond the information that was already provided by the in-house (primary or second opinion) radiology report, as a proportion of the total number of cases whose imaging examinations were prepared for demonstration in the MDTM. RESULTS: Sixty-eight MDTMs were included. The time required for preparing and attending all MDTMs (excluding imaging examinations that had not been reported yet) was 11,000 min, with a median of 172 min (IQR 113-200 min) per MDTM, and a median of 9 min (IQR 8-13 min) per patient. The radiologists' input changed patient management in 113 out of 1138 cases, corresponding to an MCratio of 8.4%. The median MCratio per MDTM was 6% (IQR 0-17%). CONCLUSION: Radiologists' time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM. The use of radiologists for MDTMs should therefore be improved. CLINICAL RELEVANCE STATEMENT: The use of radiologists for MDTMs (multidisciplinary team meetings) should be improved, because their time investment in MDTMs is considerable relative to the small proportion of cases in which they influence patient management in the MDTM. KEY POINTS: • Multidisciplinary team meetings (MDTMs) are an important component of the workload of radiologists. • In a tertiary care center in which all imaging examinations have already been interpreted and reported by subspecialized radiologists before the MDTM takes place, the median time investment of a radiologist for preparing and demonstrating one MDTM patient is 9 min. • In this setting, the radiologist changes patient management in only a minority of cases in the MDTM.

Can we revolutionize diagnostic imaging by keeping Pandora's box closed?

Incidental imaging findings are a considerable health problem, because they generally result in low-value and potentially harmful care. Healthcare professionals struggle how to deal with them, because once detected they can usually not be ignored. In this opinion article, we first reflect on current practice, and then propose and discuss a new potential strategy to pre-emptively tackle incidental findings. The core principle of this concept is to keep the proverbial Pandora's box closed, i.e. to not visualize incidental findings, which can be achieved using deep learning algorithms. This concept may have profound implications for diagnostic imaging.

Work overload and diagnostic errors in radiology.

PURPOSE: To determine the association between workload and diagnostic errors on clinical CT scans. METHOD: This retrospective study was performed at a tertiary care center and covered the period from January 2020 to March 2023. All clinical CT scans that contained an addendum describing a perceptual error (i.e. failure to detect an important abnormality) in the original report that was issued on office days between 7.30 a.m. and 18.00 p.m., were included. The workload of the involved radiologist on the day of the diagnostic error was calculated in terms of relative value units, and normalized for the known average daily production of each individual radiologist (workloadnormalized). A workloadnormalized of less than 100% indicates relative work underload, while a workloadnormalized of > 100% indicates relative work overload in terms of reported examinations on an individual radiologist's basis. RESULTS: A total of 49 diagnostic errors were included. Top-five locations of diagnostic errors were lung (n = 8), bone (n = 8), lymph nodes (n = 5), peritoneum (n = 5), and liver (n = 4). Workloadnormalized on the days the diagnostic errors were made was on average 121% (95% confidence interval: 106% to 136%), which was significantly higher than 100% (P = 0.008). There was no significant upward monotonic trend in diagnostic errors over the course of the day (Mann-Kendall tau of 0.005, P = 1.000), and there were no other notable temporal trends either. CONCLUSIONS: Radiologists appear to have a relative work overload when they make a diagnostic error on CT. Diagnostic errors occurred throughout the entire day, without any increase towards the end of the day.

Why don't we inform patients about the risk of diagnostic errors?

The principles of autonomy and informed consent dictate that patients who undergo a radiological examination should actually be informed about the risk of diagnostic errors. Implementing such a policy could potentially increase the quality of care. However, due to the vast number of radiological examinations that are performed in each hospital each day, financial constraints, and the risk of losing trust, patients, and income if the requirement for informed consent is not imposed by law on a state or national level, it may be challenging to inform patients about the risk of diagnostic errors. Future research is necessary to determine if and how an informed consent procedure for diagnostic errors can be implemented in clinical practice.

A new medical imaging postprocessing and interpretation concept to investigate the clinical relevance of incidentalomas: can we keep Pandora's box closed?

BACKGROUND: Incidental imaging findings (incidentalomas) are common, but there is currently no effective means to investigate their clinical relevance. PURPOSE: To introduce a new concept to postprocess a medical imaging examination in a way that incidentalomas are concealed while its diagnostic potential is maintained to answer the referring physician's clinical questions. MATERIAL AND METHODS: A deep learning algorithm was developed to automatically eliminate liver, gallbladder, pancreas, spleen, adrenal glands, lungs, and bone from unenhanced computed tomography (CT). This deep learning algorithm was applied to a separately held set of unenhanced CT scans of 27 patients who underwent CT to evaluate for urolithiasis, and who had a total of 32 incidentalomas in one of the aforementioned organs. RESULTS: Median visual scores for organ elimination on modified CT were 100% for the liver, gallbladder, spleen, and right adrenal gland, 90%-99% for the pancreas, lungs, and bones, and 80%-89% for the left adrenal gland. In 26 out of 27 cases (96.3%), the renal calyces and pelves, ureters, and urinary bladder were completely visible on modified CT. In one case, a short (<1 cm) trajectory of the left ureter was not clearly visible due to adjacent atherosclerosis that was mistaken for bone by the algorithm. Of 32 incidentalomas, 28 (87.5%) were completely concealed on modified CT. CONCLUSION: This preliminary technical report demonstrated the feasibility of a new approach to postprocess and evaluate medical imaging examinations that can be used by future prospective research studies with long-term follow-up to investigate the clinical relevance of incidentalomas.

[A female patient with liver failure and pseudocirrhosis]. / Een patiënte met leverfalen en pseudocirrose.

BACKGROUND: Acute-on-chronic liver failure encompasses an acute deterioration of liver function in patients with pre-existent cirrhosis. Sometimes the clinical picture of acute-on-chronic liver failure is misleading and may not be secondary to primary liver disease, as described in our case. CASE DESCRIPTION: A 65-year-old woman with cirrhosis was transferred to our transplantation centre because of suspected acute-on-chronic liver failure. Given her medical history of breastcancer and suspicious laboratory results, we performed a liver biopsy. This showed diffuse metastases of mammary carcinoma. Earlier CT-scans showed features of cirrhosis without signs of malignancy: a misleading phenomenon called pseudocirrhosis. CONCLUSION: Diffuse malignant hepatic infiltration can resemble cirrhosis and acute-on-chronic liver failure, both in clinical presentation as in imaging. Liver transplantation is contraindicated in malignant liver failure. To assure a solid indication for transplantation, a liver biopsy has to be considered, even in emergency situations.

Value-based radiology cannot thrive without reforms and research.

KEY POINTS: • A value-based system aims to achieve improved patient-relevant outcomes without increasing costs.• Value-based radiology cannot thrive as long as volume dominates as the most important metric to reward clinical performance.• Reforms and research are needed to enable radiologists to practice value-based healthcare.

Beware of False-Positive FDG PET/CT Interpretations for Presacral Recurrent Rectal Cancer.

FDG PET/CT is considered an accurate method for the detection of recurrent rectal cancer in the pelvis. Excess presacral soft tissue is found in up to half of patients after (chemo)radiation and surgery for rectal cancer, and usually represents fibrosis that is metabolically inactive. However, presacral soft tissue that is FDG avid is generally considered suspicious for recurrent cancer. Nevertheless, FDG avidity in the presacral space not uncommonly proves to be due to benign inflammatory changes, and additional MRI may be diagnostically useful, as demonstrated in the presented 2 cases.

FDG-avid presacral soft tissue mass in previously treated rectal cancer: Diagnostic outcome and additional value of MRI, including diffusion-weighted imaging.

INTRODUCTION: This study aimed to determine the positive predictive value (PPV) of positron emission tomography/computed tomography (PET/CT) with an 18F-fluoro-2-deoxy-D-glucose (FDG)-avid presacral lesion for locally recurrent rectal cancer, and the additional value of magnetic resonance imaging (MRI), including diffusion-weighted imaging (DWI). MATERIALS AND METHODS: This retrospective study included 38 patients who completed primary rectal cancer treatment and who presented with a suspicious FDG-avid presacral lesion on PET/CT. Twenty-seven patients also underwent MRI, of whom 24 with DWI. PPV of FDG-PET/CT and additional value of MRI, including DWI, for the diagnosis of recurrent presacral cancer were determined. RESULTS: The PPV of PET/CT with an FDG-avid presacral lesion for the diagnosis of locally recurrent rectal cancer was 58% (22/38). Air in the FDG-avid presacral lesion, as visible on the CT component of the PET/CT examination, favoured the diagnosis of benign presacral tissue with a sensitivity of 56.3% (9/16) and a specificity 81.8% (18/22). Areas under the receiver operating characteristic curve (AUCs) of MRI without DWI for the diagnosis of locally recurrent rectal cancer in FDG-avid presacral tissue were 0.765 and 0.840, for observers 1 and 2. AUCs of MRI with DWI were 0.803 and 0.811, for observers 1 and 2. There were no significant differences among any of these AUCs (P = 0.169 to 0.906). CONCLUSIONS: FDG-PET/CT has a poor PPV for locally recurrent rectal cancer in the presacral space. The observation of air in the FDG-avid presacral lesion and additional MRI assessment are diagnostically helpful, without a significant additional value of DWI.

Liver Cancer in Tyrosinemia Type 1.

Hereditary Tyrosinemia type I (HT1) is clinically mainly characterised by severe liver disease. Most patients present in their first months of life with liver failure, but others can present later with issues of compensated cirrhosis, renal tubulopathy or acute intermittent porphyria. If patients survive the acute phase with liver failure or if they present later with compensated cirrhosis, they often develop hepatocellular carcinoma early but also later in life. The course of the disease changed after the introduction of 2-(2 nitro-4-3 trifluoro-methylbenzoyl)-1, 3-cyclohexanedione (NTBC), which blocks the tyrosine degradation pathway at an earlier step. Therefore, the toxic products did not accumulate anymore and all clinical problems resolved. However, the risk (although clearly decreased) for developing liver cancer remained, especially if NTBC treatment is initiated late, a slow decrease of the tumor marker α-fetoprotein is seen or if the α-fetoprotein concentrations remain just above the normal range. A rise of α-fetoprotein in these HT1 patients is more or less pathognomonic for liver cancer. Although hepatoblastoma development occurs in HT1 patients, most HT1 patients develop hepatocellular carcinoma (HCC) or a mixed type of carcinoma consisting of HCC and hepatoblastoma. Due to the small risk of liver cancer development, screening for liver cancer (especially HCC) is still recommended in HT1 patients using regular measures of α-fetoprotein and imaging. Ultrasound is mostly the modality of choice for surveillance, because it is widely available, it does not use radiation and is noninvasive. When a suspicious lesion is present, the higher sensitivity of MRI could be used for characterization and staging of lesions. At this moment, no HCC development in pre-symptomatically treated patients is reported. These different situations could possibly indicate that NTBC can prevent the start of the development of HCC when initiated early, but can't stop the development of HCC if it is prescribed at a later stage, stressing the importance of early diagnosis.