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, Victor J. Pizzitola, Roxanne Lorans, , , Catherine M. Appleton,
American Journal of Roentgenology, Volume 210, pp 292-300; https://doi.org/10.2214/ajr.17.18749

Abstract:
OBJECTIVE. The purpose of this article is to discuss facilitators of and barriers to future implementation of contrast-enhanced mammography (CEM) in the United States. CONCLUSION. CEM provides low-energy 2D mammographic images analogous to digital mammography and contrast-enhanced recombined images that allow assessment of neovascularity similar to that offered by MRI. The utilization of CEM in the United States is currently low but could increase rapidly given the many potential indications for its clinical use.
, , , , Victor J. Pizzitola, Carl J. D'Orsi
American Journal of Roentgenology, Volume 210, pp 222-227; https://doi.org/10.2214/ajr.17.17923

Abstract:
OBJECTIVE. Because of observed clinical variance and the discretion of referring physicians and radiologists in patient follow-up, the purpose of this study was to conduct a survey to explore whether broad discrepancy exists in imaging protocols used for postsurgical surveillance. SUBJECTS AND METHODS. An online survey was created to assess radiologists' use of diagnostic versus screening mammography for women with a personal history of breast cancer and determine whether the choice of protocol was associated with practice characteristics (setting, region, and reader type). RESULTS. Of 8170 surveys sent, 849 (10%) completed responses were returned. Seventy-nine percent of respondents recommended initial diagnostic mammography after lumpectomy (65% at 6 months, 14% at 12 months); 49% recommended diagnostic surveillance for up to 2 years before a return to screening mammography; and 33% continued diagnostic surveillance for 2–5 years before returning to screening. For imaging after mastectomy, 57% of respondents recommended diagnostic mammography of the unaffected breast. Among the 57%, however, 37% recommended diagnostic screening for only the first postmastectomy follow-up evaluation, and the other 20% permanently designated patients for diagnostic mammography after mastectomy. CONCLUSION. The optimal surveillance mammography regimen must be better defined. This preliminary study showed variability in diagnostic versus screening surveillance mammography for women with a history of breast cancer. Future studies should evaluate why these variations occur and how to standardize recommendations to tailor personalized imaging.
, Nikita Lakomkin, Allison Hainline, , M. Shane Hutson, Carlos L. Arteaga
American Journal of Roentgenology, Volume 210; https://doi.org/10.2214/ajr.17.18249

Abstract:
OBJECTIVE. The objective of our study was to compare attenuation distribution across the long-axis (ADLA) measurements, Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, and Choi criteria for predicting overall survival (OS) in patients with metastatic breast cancer treated with bevacizumab. MATERIALS AND METHODS. We obtained HIPAA-compliant data from a prospective, multisite, phase 3 trial of bevacizumab for the treatment of metastatic breast cancer. For patients with one or more liver metastases measuring 15 mm or larger at baseline, we evaluated up to two target liver lesions using RECIST, Choi criteria, and ADLA measurements, with the latter defined as the SD of the CT attenuation values of each pixel along the tumor long-axis diameter. The optimal percentage change threshold for defining an ADLA response was computed by cross-validation analysis in a Cox model. The log-rank test was applied to evaluate RECIST, Choi criteria, and ADLA for discriminating patients with superior OS. The predictive accuracies of all three techniques were compared using Brier scores and areas under the ROC curve (AUC). All analyses were performed separately using best overall response (BOR) and response at the first follow-up time point (FU1). RESULTS. One hundred sixty-four patients met the inclusion criteria. A 25% decrease in the ADLA measurement from baseline was the optimal ADLA response threshold for BOR and FU1. RECIST, Choi criteria, and ADLA successfully identified patients with superior OS when using BOR (RECIST, p = 0.02; Choi and ADLA, p < 0.001), but only Choi criteria and ADLA measurements were successful when using FU1 (RECIST, p = 0.43; Choi and ADLA, p < 0.001). In a direct comparison, ADLA measurements outperformed both RECIST and Choi criteria using BOR (95% CI for Brier score differences, ADLA-RECIST [–0.58 to –0.08] and ADLA-Choi [–0.55 to –0.06]; 95% CI for AUC differences, ADLA-RECIST [0.16–0.33] and ADLA-Choi [0.17–0.36]) as well as using FU1 (95% CI for Brier score differences, ADLA-RECIST [–0.77 to –0.08] and ADLA-Choi [–0.58 to –0.03]; 95% CI for AUC differences, ADLA-RECIST [0.22–0.39] and ADLA-Choi [0.01–0.22]). CONCLUSION. ADLA measurements may be a useful noninvasive indicator of cancer treatment response. Because ADLA measurements may be extracted relatively easily using existing radiologist workflows, further investigation of the ADLA technique is warranted.
, Shiva Gupta, Wei Wei, Lina Lu, Marc R. Matrana, Nizar M. Tannir, Haesun Choi
American Journal of Roentgenology, Volume 209, pp 1278-1284; https://doi.org/10.2214/ajr.17.18018

Abstract:
OBJECTIVE. The purpose of this study is to compare the prognostic value of various solid tumor response criteria as well as the additive value of clinical risk factors in patients with advanced renal cell carcinoma (RCC). MATERIALS AND METHODS. Two sets of CT scans (pretreatment scans and scans obtained 1–3.5 months after treatment) were reviewed for 57 patients with metastatic RCC treated with pazopanib in the salvage setting. Tumor response on the posttherapy scan was evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) and Choi, modified Choi (mChoi), MASS (Morphology, Attenuation, Size, and Structure), and 10% threshold criteria. In addition, combined Memorial Sloan-Kettering Cancer Center (MSKCC) risk factors plus imaging criteria were used to define response groups. Response evaluations using these criteria were correlated with overall survival (OS) and progression-free survival (PFS), with use of the log-rank test. RESULTS. Patients classified as having progressive disease (PD) on the basis of RECIST, mChoi, and MASS criteria had a significantly worse OS than patients with stable disease (SD) and partial response (PR). With the addition of MSKCC risk factors, all groups with PD defined by combined criteria had significantly worse OS. For 37 patients with no or one MSKCC risk factor, response groups defined by Choi, mChoi, MASS, and 10% threshold criteria did not differ in PFS or OS. However, among 20 patients with two to three MSKCC risk factors, those classified as having PR had longer PFS than did those with SD and had longer OS than did those with PD. CONCLUSION. For patients with advanced RCC for which prior therapies have failed, the prognostic value of various imaging-based tumor response criteria differs on the basis of the MSKCC clinical risk status.
Dillon Barron, Thomas Spiegel, Gregory L. Katzman, Kateland Haas,
American Journal of Roentgenology, Volume 210; https://doi.org/10.2214/ajr.17.18558

Abstract:
OBJECTIVE. The accuracy of radiologic interpretations is higher when appropriate clinical information is provided, as is the likelihood of reimbursement for the studies. The purpose of this project was to evaluate and improve the quality of clinical information provided on head CT requisitions from an urban emergency department (ED). SUBJECTS AND METHODS. In a prospective study conducted from July 2015 to May 2016, attending neuroradiologists evaluated 1100 randomly selected ED requisitions for unenhanced head CT, grading them for clinical and billing adequacy on a scale of 0–2. After acquisition of baseline data (400 studies), an intervention was performed that consisted of education of ED staff on the importance of clinical information in requisitions. A reminder slide was placed on a large screen in the ED staff working area with examples of appropriate history. Postintervention data (700 studies) were subsequently obtained. Mean scores and payment lag time before versus after the intervention were compared by Wilcoxon rank sum test. RESULTS. Statistically significant improvement was found in mean scores after the intervention for both clinical (1.32 to 1.43, p = 0.003) and billing (1.64 to 1.74, p = 0.02) adequacy categories. The percentage of studies with a score of 2 increased in both categories, and the percentages of 0 and 1 scores declined. There was a 21.1-day decrease in payment lag time (from 75.8 to 54.7 days, p < 0.0001). CONCLUSION. The quality of clinical information provided on imaging requisitions by ED faculty and residents improved after a fairly simple intervention. Billing efficiency improved, and payment lag time decreased substantially.
American Journal of Roentgenology, Volume 210; https://doi.org/10.2214/ajr.17.18223

Abstract:
OBJECTIVE. The purpose of this study is to review the ultrasound (US) features of developing asymmetries and correlate them with histopathologic findings. MATERIALS AND METHODS. We searched the mammography database of an academic medical center, affiliated cancer center, and two ambulatory imaging facilities from 2009 to 2012 and identified 201 patients with developing asymmetries, 187 of whom had US at the time of, or within 1 month of, diagnostic mammography evaluation. Seventy-five (40.1%) of these 187 patients had a US correlate, and three additional patients had a positive second-look US after MRI (US results were initially negative), and one patient had a US correlate for a newly palpable developing asymmetry 1 month after receiving a BI-RADS category 3 mammography-only assessment. These 78 developing asymmetries with US correlates comprised the study cases. US features were obtained by consensus image review; patient demographic characteristics and outcomes were obtained from the electronic medical record. RESULTS. Thirty-six of 78 US correlates (46.2%) were masses, the echotexture of which was as follows: 26 (72.2%) were hypoechoic, four (11.1%) were hyperechoic, three (8.3%) were mixed hyperechoic and hypoechoic, and three (8.3%) were anechoic. Forty-two of 78 US correlates (53.8%) were nonmass findings, the echotexture of which was as follows: 24 (57.1%) were mixed hyperechoic and hypoechoic, 13 (31.0%) were hypoechoic, and five (11.9%) were hyperechoic. Twenty-one of 78 lesions (26.9%) were malignant; of these, eight were invasive ductal carcinoma, seven were invasive lobular carcinoma, three were mixed invasive ductal and lobular carcinoma, and three were ductal carcinoma in situ. Malignant findings on US included 17 masses (81.0%) (13 hypoechoic and four mixed hyperechoic and hypoechoic), and four nonmass findings (19.0%) (three mixed hyperechoic and hypoechoic and one hypoechoic). CONCLUSION. When present, US correlates for developing asymmetries are often nonmass findings with mixed echotexture. Most malignant developing asymmetries with US correlates present as a hypoechoic mass, but 19% present as a nonmass finding with either mixed hyperechoic and hypoechoic echotexture or hypoechoic echotexture.
, Amanda Santacroce
American Journal of Roentgenology, Volume 210, pp 279-284; https://doi.org/10.2214/ajr.17.18730

Abstract:
OBJECTIVE. Screening mammography has been widely used for breast cancer detection and has been found to decrease mortality, but debate continues. The purpose of this article is to review screening recommendations and the benefits and perceived harms of earlier and more frequent screening. CONCLUSION. Annual mammography beginning at age 40 decreases mortality. Clinicians should educate women and preserve recommendations for early and annual screening.
, Seng Thipphavong, , Ashleigh E. Stueck, Sharon E. Clarke
American Journal of Roentgenology, Volume 210, pp 68-77; https://doi.org/10.2214/ajr.17.18136

Abstract:
OBJECTIVE. The purpose of this article is to review how fat is detected on imaging and to discuss the differential diagnosis of fat-containing liver lesions. CONCLUSION. Fat is a highly useful feature in characterizing liver lesions on imaging. Although a variety of liver lesions can show fat on cross-sectional imaging, the presence of fat usually indicates that the lesion is of hepatocellular origin. Less commonly, nonhepatocellular fatty lesions may be distinguished by ancillary clinical and imaging features.
, Justin E. Boatsman, Cynthia A. Swann, Aaron D. Kirkpatrick, Alicia Y. Toledano
American Journal of Roentgenology, Volume 210, pp 685-694; https://doi.org/10.2214/ajr.17.18185

Abstract:
OBJECTIVE. Digital breast tomosynthesis (DBT) is more accurate than full-field digital mammography alone but requires a longer reading time. A radiologist reader study evaluated the use of concurrent computer-aided detection (CAD) to shorten the reading time while maintaining interpretation performance. MATERIALS AND METHODS. A CAD system was developed to detect suspicious soft-tissue densities in DBT planes. Abnormalities are extracted from the plane in which they are detected and blended into the corresponding synthetic image. The study used an enriched sample of 240 DBT cases with 68 malignancies in 61 patients. Twenty radiologists retrospectively reviewed all 240 cases in a multireader multicase crossover design to compare reading time and performance with and without CAD. The performance of CAD alone was also evaluated. RESULTS. Reading time improved by 29.2% with CAD (95% CI, 21.1–36.5%; p< 0.01). Reader performance, measured by ROC AUC, was noninferior with CAD (p< 0.01). The mean AUC increased from 0.841 without to 0.850 with CAD (95% CI, −0.012 to 0.030). Mean sensitivity increased from 0.847 without to 0.871 with CAD (difference 95% CI, −0.005 to 0.055), showing a 0.033 increase in sensitivity for cases with soft-tissue densities (95% CI, −0.002 to 0.068). Mean specificity decreased from 0.527 without to 0.509 with CAD (difference 95% CI, −0.041 to 0.005), and mean recall rate for noncancers slightly increased from 0.474 without to 0.492 with CAD (difference 95% CI, −0.006 to 0.041). CONCLUSION. Concurrent use of CAD with DBT resulted in 29.2% faster reading time, while maintaining reader interpretation performance.
Kyongmin Sarah Beck, Eun Kyung Cho, Mi Hyung Moon, Yeon Kim, Hyun Song,
American Journal of Roentgenology, Volume 210, pp 52-57; https://doi.org/10.2214/AJR.17.18186

Abstract:
OBJECTIVE. The purpose of this study was to investigate the incidence and natural history of incidentally found and untreated pulmonary embolism (PE) at coronary CT angiography after coronary artery bypass grafting. MATERIALS AND METHODS. We retrospectively reviewed the records of 353 patients consecutively registered between January 1, 2010, and November 11, 2015, who underwent coronary artery bypass grafting followed within 2 weeks by coronary CT angiography. All patients received 100 mg of aspirin and 75 mg of clopidogrel after surgery. We collected relevant clinical and CT data, including total follow-up duration after coronary artery bypass grafting, follow-up CT findings, mortality, and incidence of any recurrent PE. RESULTS. PE was diagnosed in 22 of the 353 patients (6.2%) who remained in the study after the exclusion criteria were applied. Most of the PEs occurred at the segmental or subsegmental level. All patients were in hemodynamically stable condition, had no symptoms, and underwent follow-up for a median of 53 months (range 19–74 months). Twenty of the 22 patients did not receive anticoagulation, and all but one of these patients had complete resolution of PE at second follow-up coronary CT angiography (median, 149 days after surgery). There was no associated mortality or recurrent PE. CONCLUSION. Incidental PE after coronary artery bypass grafting is found in approximately 6% of patients undergoing postoperative coronary CT angiography, and most PEs resolve spontaneously without anticoagulation. No patient in this study died or had recurrent PE during a median follow-up period of 53 months.
, , Nayana U. Patel, , Daniel J. Margolis,
American Journal of Roentgenology, Volume 210, pp 101-107; https://doi.org/10.2214/ajr.17.18241

Abstract:
OBJECTIVE. The purpose of this study is to compare radiologists' and urologists' opinions regarding prostate MRI reporting. SUBJECTS AND METHODS. Radiologist members of the Society of Abdominal Radiology and urologist members of the Society of Urologic Oncology received an electronic survey regarding prostate MRI reporting. RESULTS. The response rate was 12% (135/1155) for Society of Abdominal Radiology and 8% (54/663) for Society of Urologic Oncology members. Most respondents in both specialties prefer Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) (radiologists, 84%; urologists, 84%), indicate that it is used at their institution (radiologists, 84%; urologists, 78%), understand its implications for patient care (radiologists, 89%; urologists, 71%), and agree that radiologists apply PI-RADSv2 categories correctly (radiologists, 57%; urologists, 61%). Both specialties agreed regarding major barriers to PI-RADSv2 adoption: radiologist inexperience using PI-RADSv2 (radiologists, 51%; urologists, 51%), urologist inexperience using PI-RADSv2 (radiologists, 46%; urologists, 51%), and lack of standardized templates (radiologists, 47%; urologists, 52%). The specialties disagreed (p ≤ 0.039) regarding whether reports should include the following management recommendations: targeted biopsy (radiologists, 58%; urologists, 34%), follow-up imaging (radiologists, 46%; urologists, 28%), and time interval for follow-up imaging (radiologists, 35%; urologists, 16%). There was also disagreement (p = 0.037) regarding report style: 54% of urologists preferred fully structured reports, whereas 53% of radiologists preferred hybrid structured and free-text reports. CONCLUSION. Radiologists and urologists both strongly prefer PI-RADSv2 for prostate MRI reporting, despite recognizing barriers to its adoption. Urologists more strongly preferred a fully structured report and disagreed with radiologists' preference to include management recommendations. Collaborative radiologist-urologist educational efforts are warranted to help optimize the effect of prostate MRI reporting in patient care.
, Shoaib Shariff, Nizar Bhulani, , Tarek Noel Hanna
American Journal of Roentgenology, Volume 209, pp 1191-1196; https://doi.org/10.2214/ajr.17.18077

Abstract:
OBJECTIVE. The objective of our study was to investigate radiology manuscript characteristics that influence citation rate, capturing features of manuscript construction that are discrete from study design. MATERIALS AND METHODS. Consecutive articles published from January 2004 to June 2004 were collected from the six major radiology journals with the highest impact factors: Radiology (impact factor, 5.076), Investigative Radiology (2.320), American Journal of Neuroradiology (AJNR) (2.384), RadioGraphics (2.494), European Radiology (2.364), and American Journal of Roentgenology (2.406). The citation count for these articles was retrieved from the Web of Science, and 29 article characteristics were tabulated manually. A point-biserial correlation, Spearman rank-order correlation, and multiple regression model were performed to predict citation number from the collected variables. RESULTS. A total of 703 articles—211 published in Radiology, 48 in Investigative Radiology, 106 in AJNR, 52 in RadioGraphics, 129 in European Radiology, and 157 in AJR—were evaluated. Punctuation was included in the title in 55% of the articles and had the highest statistically significant positive correlation to citation rate (point-biserial correlation coefficient [rpb] = 0.85, p< 0.05). Open access status provided a low-magnitude, but significant, correlation to citation rate (rpb = 0.140, p< 0.001). The following variables created a significant multiple regression model to predict citation count (p< 0.005, R2 = 0.186): study findings in the title, abstract word count, abstract character count, total number of words, country of origin, and all authors in the field of radiology. CONCLUSION. Using bibliometric knowledge, authors can craft a title, abstract, and text that may enhance visibility and citation count over what they would otherwise experience.
, Rita I. Freimanis, Edward A. Sickles, , R. Edward Hendrick
American Journal of Roentgenology, Volume 210, pp 264-270; https://doi.org/10.2214/ajr.17.18707

Abstract:
OBJECTIVE. Breast cancer is an important health problem for women 40–49 years old, yet screening mammography for this age group remains controversial. This article reviews recent guidelines and supporting evidence on screening mammography in women of this age group. CONCLUSION. Evidence supports the benefit of annual screening mammography in women 40–49 years old. Models of different breast cancer screening strategies consistently show the greatest breast cancer mortality reduction and life-years gained with annual screening starting when women reach 40 years old.
Correction
American Journal of Roentgenology, Volume 209, pp 949-949; https://doi.org/10.2214/AJR.17.18875

, Vivek Narayan, Ritu R. Gill, Jyothi P. Jagannathan, Maria F. Barile, Feng Gao, Raphael Bueno,
American Journal of Roentgenology, Volume 209, pp 1216-1227; https://doi.org/10.2214/ajr.17.17857

Abstract:
OBJECTIVE. The purposes of this study are to develop quantitative imaging biomarkers obtained from high-resolution CTs for classifying ground-glass nodules (GGNs) into atypical adenomatous hyperplasia (AAH), adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (IAC); to evaluate the utility of contrast enhancement for differential diagnosis; and to develop and validate a support vector machine (SVM) to predict the GGN type. MATERIALS AND METHODS. The heterogeneity of 248 GGNs was quantified using custom software. Statistical analysis with a univariate Kruskal-Wallis test was performed to evaluate metrics for significant differences among the four GGN groups. The heterogeneity metrics were used to train a SVM to learn and predict the lesion type. RESULTS. Fifty of 57 and 51 of 57 heterogeneity metrics showed statistically significant differences among the four GGN groups on unenhanced and contrast-enhanced CT scans, respectively. The SVM predicted lesion type with greater accuracy than did three expert radiologists. The accuracy of classifying the GGNs into the four groups on the basis of the SVM algorithm was 70.9%, whereas the accuracy of the radiologists was 39.6%. The accuracy of SVM in classifying the AIS and MIA nodules was 73.1%, and the accuracy of the radiologists was 35.7%. For indolent versus invasive lesions, the accuracy of the SVM was 88.1%, and the accuracy of the radiologists was 60.8%. We found that contrast enhancement does not significantly improve the differential diagnosis of GGNs. CONCLUSION. Compared with the GGN classification done by the three radiologists, the SVM trained regarding all the heterogeneity metrics showed significantly higher accuracy in classifying the lesions into the four groups, differentiating between AIS and MIA and between indolent and invasive lesions. Contrast enhancement did not improve the differential diagnosis of GGNs.
, Lindsey Bergren, , Prashant Shrestha, , Nicholas Frank, Raja Kandaswamy,
American Journal of Roentgenology, Volume 210, pp 201-206; https://doi.org/10.2214/ajr.17.18171

Abstract:
OBJECTIVE. The aim of this retrospective study is to evaluate the endovascular treatment of hemorrhage in the nonperioperative setting in pancreas transplant recipients. MATERIALS AND METHODS. All angiograms performed between January 1, 1999, and June 1, 2016, to treat hemorrhage after pancreatic transplant at a single large-volume transplant center were reviewed. Fourteen patients who underwent 21 angiograms were identified. The patients' charts were reviewed for clinical indications, technical aspects of the endovascular interventions, outcomes, and complications. RESULTS. The mean number of angiograms was 1.5 per patient. The primary and primary assisted clinical success rates were 64.3% (9/14 patients) and 71.4% (10/14 patients), respectively. Five patients (35.7%) experienced complications. At presentation, eight patients had functioning grafts and seven of these eight patients (87.5%) maintained graft function. CONCLUSION. It is critical to recognize transplant-related hemorrhage after pancreas transplant. Endovascular management is associated with high clinical success and rarely results in loss of graft function, suggesting that it should be a consideration for first-line therapy in this patient population.
American Journal of Roentgenology, Volume 210, pp 241-245; https://doi.org/10.2214/ajr.17.18704

Abstract:
OBJECTIVE. The purposes of this article are to summarize breast cancer screening recommendations and discuss their differences and similarities and to explain the differences between two national databases to aid in interpretation of their benchmarks. CONCLUSION. The American College of Radiology, American Cancer Society, and U.S. Preventive Services Task Force all agree that annual mammography beginning at age 40 saves the most lives, and all acknowledge a woman's right to choose when to begin and stop screening. The National Mammography Database (NMD) differs from the Breast Cancer Surveillance Consortium database in that it acquires data using the same approach used by almost all mammography facilities in the United States. Therefore, NMD benchmarks, which include standard metrics, provide more meaningful comparisons to help mammography facilities and radiologists improve performance.
Wassef Khaled, , Lucie Corno, Isabelle Bouley-Coletta, Mohamed Amine Benadjaoud, , Marc Zins
American Journal of Roentgenology, Volume 210, pp 78-84; https://doi.org/10.2214/AJR.17.18126

Abstract:
OBJECTIVE. The objective of our study was to evaluate if the feces sign can be used to predict successful nonoperative treatment or progression to ischemia in patients with small-bowel obstruction (SBO) due to adhesions. MATERIALS AND METHODS. For this single-center retrospective observational study involving a blinded independent review by two radiologists of 237 consecutive CT examinations of 216 patients with SBO due to adhesions (age: mean, 70.9 years; median, 74 years; interquartile range, 62–84 years), the location of the transition zone (TZ), number of TZs, and presence and location of the feces sign relative to the TZ were recorded. The reference standard for diagnosing ischemia was surgical and pathologic findings (n = 108 CT examinations) or, when treatment was nonoperative (n = 129 CT examinations), clinical outcome. Factors associated with successful nonoperative treatment and ischemia were identified by univariate and multivariate analyses. RESULTS. A feces sign was seen in 88 of 237 CT examinations (37.1%). The feces sign was at the TZ, which we refer to as the “TZ feces” sign, in 82 of 88 (93.2%) patients; between two TZs, which we refer to as the “trapped feces” sign, in 14 (15.9%) patients; and in both locations in eight (9.1%) patients. By univariate analysis, an isolated TZ feces sign was associated positively with successful nonoperative treatment (odds ratio [OR], 3.37; 95% CI, 1.71–6.66; p< 0.001) and negatively with ischemia (OR, 0.33; 95% CI, 0.13–0.85; p = 0.02). Combined TZ and trapped feces signs were associated with ischemia (OR, 24.16; 95% CI, 2.86–203.89; p = 0.003). By multivariate analysis, regardless of the location of the feces sign, the feces sign was not significantly associated with successful nonoperative treatment or progression to ischemia. CONCLUSION. The feces sign is common and helps to identify the TZ. Among the CT signs of SBO, the feces sign does not independently help to predict successful nonoperative treatment or progression to ischemia.
, Andrew T. Trout, Emma N. Costello, Suraj D. Serai, Kristin S. Bramlage, Rohit Kohli, Stavra A. Xanthakos
American Journal of Roentgenology, Volume 210, pp 166-174; https://doi.org/10.2214/ajr.17.18446

Abstract:
OBJECTIVE. The purpose of this study is to determine the relationships between quantitative liver MRI measurements and liver biopsy findings in pediatric and young adult patients with nonalcoholic fatty liver disease (NAFLD). MATERIALS AND METHODS. Data were obtained from a registry that prospectively enrolls pediatric and young adult patients with biopsy-confirmed NAFLD at our tertiary medical center with parent or guardian and subject informed consent, as appropriate. Patients enrolled between November 2007 and June 2016 with a quantitative liver MRI examination within 6 months of biopsy were included (n = 69). Liver stiffness (kilopascals), volume (milliliters), and fat fraction (percentage) were extracted from MRI records. Multiple linear regression was used to determine the relationships between NAFLD activity score and quantitative MRI measures, and between MRI liver stiffness and histopathologic scores (steatosis, lobular inflammation, portal inflammation, hepatocyte ballooning, and fibrosis). Histopathologic data were extracted from medical records, with severity graded by hepatopathologists using Non-alcoholic Steatohepatitis (NASH) Clinical Research Network criteria. Ordinal logistic regression was used to assess the relationship between categoric NAFLD severity (simple steatosis vs NASH vs NASH with significant fibrosis) and MRI measures. RESULTS. The mean (± SD) patient age at the time of MRI was 14.3 ± 2.8 years (range, 8–21 years); 25 (36.2%) patients were female. Liver biopsy was performed within a mean of 64.4 days of the MRI examination. There was a positive correlation between histopathologic steatosis and MRI liver fat fraction (ρ = 0.57; p< 0.0001). MRI fat fraction was the only significant imaging predictor of NAFLD activity score (p = 0.017). Fibrosis score was the only significant histopathologic predictor of MRI liver stiffness (p = 0.001). MRI liver volume was the only imaging predictor of categoric NAFLD severity (odds ratio = 1.001; 95% CI, 1.000–1.002; p = 0.007). CONCLUSION. There was significant positive correlation between histopathologic and MRI liver fat measurements in our cohort. MRI liver stiffness did not predict the severity of fatty liver disease in children and young adults.
American Journal of Roentgenology, Volume 210, pp 246-255; https://doi.org/10.2214/ajr.17.18778

Abstract:
OBJECTIVE. Ductal carcinoma in situ (DCIS) is a noninvasive malignant breast disease traditionally described as a precursor lesion to invasive breast cancer. With screening mammography, DCIS now accounts for approximately 20% of newly diagnosed cancer cases. DCIS is not well understood because of its heterogeneous nature. CONCLUSION. Studies have aimed to assess prognostic factors to characterize its risk of invasive potential; however, there still remains a lack of uniformity in workup and treatment. We summarize current knowledge of DCIS and the ongoing controversies.
, YoungSik Lim, , Yong Sung Park, Sun Hwa Lee,
American Journal of Roentgenology, Volume 209, pp 1321-1330; https://doi.org/10.2214/ajr.16.17718

Abstract:
OBJECTIVE. The purpose of this study was to determine the validity of infrapatellar fat pad (IPFP) opacity grading based on lateral knee radiography for assessing knee synovitis using correlation with contrast-enhanced (CE) MRI. MATERIALS AND METHODS. Retrospective reviews of radiographs and CE knee MR images from 79 patients were independently performed by two radiologists. They evaluated IPFP opacity alteration (IPFPCR) and joint effusion grades on lateral knee conventional radiographs, IPFP signal intensity alteration (IPFPMR) and joint effusion grades on CE MR images, and synovitis (SYNMR) grade in nine divided regions, three compartments (parapatellar, periligamentous, perimeniscal), and the whole knee on CE MR images. Correlations between radiographic grades and MRI assessments were evaluated using Spearman correlation tests, and the correlation coefficients (ρ) were compared. Interobserver agreement was evaluated using weighted kappa values. RESULTS. The IPFPCR grade was very highly correlated with the IPFPMR grade (ρ = 0.906, p < 0.001) and highly correlated with SYNMR grades from four regions (suprapatellar, infrapatellar, intercondylar, lateral parapatellar recess), the parapatellar compartment, and the whole knee (ρ = 0.614–0.740, all p < 0.001). The IPFPCR grade was moderately correlated with the SYNMR grades of the remaining five regions and two compartments (ρ = 0.457–0.547, all p < 0.001). The differences between correlation coefficients for SYNMR grades and the IPFPCR and IPFPMR grades were not statistically significant (p = 0.290–1.0). Interobserver reliabilities were excellent or good for IPFPCR, IPFPMR, and SYNMR grades (κ = 0.661–1.000). CONCLUSION. IPFPCR grade assessment enables valid evaluation and reporting of knee synovitis, especially in the parapatellar compartment and the whole knee.
, Kelly Fountain, Onalisa Winblad, , Jacqueline Hill, Jo A. Wick,
American Journal of Roentgenology, Volume 210; https://doi.org/10.2214/ajr.17.18158

Abstract:
OBJECTIVE. Supplemental screening with ultrasound has been shown to detect additional breast malignancies in women with dense breast tissue and normal mammogram findings. The frequency of supplemental screening with automated breast ultrasound and the effect and type of breast tissue density notification on automated screening breast ultrasound utilization rates are unknown. MATERIALS AND METHODS. We examined normal mammogram results letters for patients with heterogeneously or extremely dense breast tissue between July 1, 2013, and June 30, 2014, by type of results letter, notification method, and sociodemographic characteristics. Logistic regression was used to examine the association between type of results letter and subsequent automated screening breast ultrasound. RESULTS. Among 3012 women with dense breast tissue and normal mammogram findings, 15% returned for supplemental automated screening breast ultrasound within 18 months of results letter notification. Compared with a similarly sized control group of women who did not undergo automated ultrasound, a significantly greater proportion of patients (86.9%) returned for breast ultrasound if they received a results letter indicating breast density in combination with a courtesy phone call (p< 0.001). Patients who received results letters with breast density notification including a statement that they may benefit from additional screening with automated breast ultrasound examination were 9.91 times (95% CI, 6.08–16.16) more likely to return for the examination than patients who did not receive breast density notification or mention of supplemental screening. CONCLUSION. Patient breast density notification and radiologists' recommendations for supplemental screening with breast ultrasound increase patient utilization of automated screening breast ultrasound examinations.
Yun Kyung Shin, , Ji Seon Park, Wook Jin, So Young Park,
American Journal of Roentgenology, Volume 210, pp 134-141; https://doi.org/10.2214/ajr.17.17915

Abstract:
OBJECTIVE. This study aimed to find independent prognostic factors related to retear of the rotator cuff tendon in patients with repaired full-thickness supraspinatus tendon tear by evaluation of pre- and postoperative MR images. MATERIALS AND METHODS. Shoulder MR images were retrospectively analyzed for 83 patients who had undergone arthroscopic or open rotator cuff repair with acromioplasty for full-thickness supraspinatus tendon tear from April 2014 to March 2015. On preoperative MR images, the type of rotator cuff tear, extent of retraction of torn tendon, anteroposterior (AP) dimension of torn tendon, signal intensity of tear edge, degree of fat infiltration in supraspinatus and infraspinatus muscles, and acromiohumeral interval (AHI) were assessed. Postoperative cuff integrity seen on MR images was classified into five categories according to the Sugaya classification system, and patients were categorized into retear or intact groups. Factors assessed on preoperative MR images were compared between the two groups. RESULTS. The overall retear rate was 57.8%. Significant differences were observed between the retear and intact groups in terms of the mean values of the extent of tendon retraction (20.4 vs 11.7 mm), AP dimension of the tear (16.1 vs 11.4 mm), AHI (6.8 vs 8.7 mm), and degree of fat infiltration of the supraspinatus and infraspinatus muscles (for the supraspinatus muscle, 3, 30, and 15 patients in the retear group vs 5, 27, and three patients in the intact group had Goutallier grade 1, grade 2, and grades 3 and 4 infiltration, respectively; for the infraspinatus muscle, 27, 12, and 9 patients in the retear group vs 29, 5, and one patient in the intact group had Goutallier grade 1, grade 2, and grades 3 and 4 infiltration, respectively). Multivariable analysis revealed that AHI and degree of tendon retraction were independent predictive factors affecting retear of rotator cuff after repair. CONCLUSION. The retear rate of repaired rotator cuff tendon was about 57.8%. Independent prognostic factors of retear were degree of tendon retraction and AHI on preoperative MR images.
American Journal of Roentgenology, Volume 210, pp 113-117; https://doi.org/10.2214/ajr.17.18495

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OBJECTIVE. The purpose of this study was to compare the reproducibility and diagnostic performance of 2D and 3D ROIs for prostate apparent diffusion coefficient (ADC) measurements. MATERIALS AND METHODS. The study included 56 patients with prostate cancer undergoing 3-T MRI including DWI (b = 50 and 1000 s/mm2) before radical prostatectomy. Histologic findings from prostatectomy specimens were reviewed to denote each patient's dominant tumor and a benign region with visually decreased ADC. Three readers independently measured the ADCs of both areas using an ROI placed on a single slice through the lesion (2D) and an ROI encompassing all slices through the lesion (3D). Readers repeated measurements after 3 weeks. Assessment included Bland-Altman analysis (coefficient of repeatability [CR] in which lower values indicated higher reliability) and ROC analysis. RESULTS. For intrareader variability, the CRs across readers for all ROIs were 9.9% for 2D and 9.3% for 3D. For tumor ROIs the CRs were 10.6% for 2D and 9.6% for 3D. For interreader variability, the CRs across readers for all ROIs were 17.1% for 2D and 20.5% for 3D and for tumor ROIs were 17.9% for 2D and 22.2% for 3D. For combined reader data, the AUCs for benign and malignant findings were 0.77 for 2D and 0.78 for 3D (p = 0.146). For differentiating Gleason score (GS) 3 + 3 from GS > 3 + 3 tumors, the AUCs were 0.92 for 2D and 0.92 for 3D ROIs (p = 0.649). For differentiating GS ≤ 3 + 4 from GS ≥ 4 + 3 tumors, the AUCs were 0.70 for 2D and 0.67 for 3D ROIs (p = 0.004). CONCLUSION. Use of a 3D ROI did not improve intrareader or interreader reproducibility or diagnostic performance compared with use of a 2D ROI for prostate ADC measurements. Interreader reproducibility of 2D ROIs was suboptimal nonetheless.
, Andrew Y. Lee, , Thomas W. Loehfelm, , Claude B. Sirlin
American Journal of Roentgenology, Volume 210, pp 1-6; https://doi.org/10.2214/AJR.17.18416

Abstract:
OBJECTIVE. The purpose of this study is to determine the correlation between malignancy risk of focal liver observations in patients at risk for hepatocellular carcinoma (HCC) implied by phrases used in nonstructured radiology reports with the risk inferred by hepatologists. MATERIALS AND METHODS. We performed a retrospective review of nonstructured radiology reports issued before Liver Imaging and Reporting Data System (LI-RADS) adoption from four-phase liver CT examinations of patients at risk for HCC. The phrase used by the radiologist in the report impression to describe each focal liver observation was recorded. Five hepatologists independently inferred the LI-RADS category from each phrase. Two abdominal radiologists independently reviewed the images and, blinded to all other information, assigned a LI-RADS category to each observation. Discrepancies were resolved by consensus. RESULTS. One hundred five observations in 77 patients were reported by 23 radiologists using 29 phrases. The most common phrase, “consistent with HCC” (n = 20), was applied to radiologist-assigned LR-3 (n = 1), LR-4 (n = 5), LR-5 (n = 11), and LR-5V (n = 3) observations. Eleven phrases were used more than once. Sixteen phrases were associated with LR-4 or higher observations; among these, hepatologists misinterpreted 37% of LR-4 or lower observations as definitely HCC and 46% of LR-5 and LR-5V observations as not definitely HCC. Overall, there was modest correlation (r = 0.69) between radiologist-assigned and hepatolo-gist-inferred categories. CONCLUSION. Nonstandardized terminology results in inaccurate communication of HCC risk. Structured reporting systems such as LI-RADS may improve communication by conveying unambiguous estimates of malignancy risk.
Stephen S. Currin, Cameron D. A. Simmers, , Gregory J. Harkness,
American Journal of Roentgenology, Volume 209, pp 1256-1262; https://doi.org/10.2214/ajr.17.17851

Abstract:
OBJECTIVE. The objective of our study was to retrospectively determine the anatomic distribution of chest wall ectopic gas resembling pneumoperitoneum (i.e., pseudopneumoperitoneum) and its relationship with trauma mechanisms and clinical outcomes using CT. MATERIALS AND METHODS. Investigators from two separate trauma referral centers screened 492 chest, abdomen, and pelvis CT examinations of patients who had sustained any form of trauma between 2010 and 2015. After excluding 186 patients with recognized causes of ectopic gas, 306 patients (211 men and 95 women; mean age, 44.5 years; range, 6–95 years) remained for analysis by two radiology residents in center 1 and a radiology resident in center 2. Positive cases were reviewed by all investigators, including an experienced fellowship-trained abdominal radiologist. The anatomic location of the pseudopneumoperitoneum, injury severity score, trauma velocity (high speed vs low or unknown speed), trauma mechanism, clinical findings on follow-up, and exploratory laparotomy data were collected for patients with pseudopneumoperitoneum. Two hundred consecutive nontrauma CT examinations from 2015 were selected as control cases by a resident in center 1. The t test and chi-square test were used for determining associations. RESULTS. Pseudopneumoperitoneum was identified in 5.2% of patients, occurring bilaterally adjacent to the lower six costochondral junctions, and was significantly more common with high-velocity trauma than with low-velocity trauma (p = 0.010). None of the patients with pseudopneumoperitoneum had evidence of perforated hollow viscus at surgery (n = 2) or on clinical follow-up (n = 14). No patients had unnecessary surgery due to pseudopneumoperitoneum. CONCLUSION. Pseudopneumoperitoneum is a posttraumatic phenomenon centered near the lower six costochondral junctions. Recognizing these findings may help prevent unnecessary laparotomy in the trauma setting.
, Mahmoud Al-Hawary, John D. Millet, Richard Burney, Jonathan Finks, Katherine Maturen
American Journal of Roentgenology, Volume 209, pp 1239-1246; https://doi.org/10.2214/ajr.17.18137

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OBJECTIVE. Incisional hernias are becoming more prevalent with increases in the obesity of the population and the complexity of abdominal surgeries. Radiologists' understanding of these hernias is limited. This article examines abdominal wall anatomy, surgical techniques, the role of imaging (current and emerging), and complications from the surgical perspective, to enhance to the role of the radiologist. CONCLUSION. Knowledge of the relevant anatomy, surgical techniques, and postoperative complications in patients with incisional hernial repair can help the radiologist improve care.
Marina I. Mityul, Brian Gilcrease-Garcia, , Jennifer L. Demertzis,
American Journal of Roentgenology, Volume 210, pp 123-126; https://doi.org/10.2214/ajr.17.18448

Abstract:
OBJECTIVE. Despite patients' increasing interest in reading their own imaging results, little is known about how patients interpret the reporting terminology of radiologists. The purpose of this study was to survey patients and radiologists to improve understanding of how each group views commonly used phrases within the radiology report. SUBJECTS AND METHODS. Patients and radiologists were asked to assign a numerical likelihood of the presence of metastatic disease based on their understanding of radiology report phrasing. Commonly used qualifying phrases, such as “likely represents,” “concerning for,” and “cannot exclude” were evaluated to compare differences in interpretation between patients and radiologists. Potential responses for statistical likelihoods included 0–25%, 26–50%, 51–75%, 76–99%, and 100%. RESULTS. There was a significant difference between the two groups with respect to assigned statistical likelihoods for most phrases. Patients identified the phrase “probably meta-static disease” as conferring the highest likelihood of true malignancy, even though radiologists rated this phrase as conferring the sixth highest likelihood (p = 0.002). Radiologists consistently identified the phrase “diagnostic for metastatic disease” as conveying the highest likelihood of metastatic disease, whereas patients ranked this phrase as having the third highest numerical likelihood (p< 0.001). The phrase “cannot exclude cancer” was assigned the lowest numerical likelihood by both groups. CONCLUSION. Patients and radiologists have differing perceptions of the specific semantic meaning of the language in radiology reports. A variable interpretation of the radiologist's diagnostic confidence may lead to confusion and dissatisfaction with the report. Radiologists should consider that patients read their reports and should endeavor to use strategies to convey imaging results clearly and effectively.
Hailey Hye-In Choi, Maria A. Manning, Anupamjit K. Mehrotra, Sean Wagner, Reena C. Jha
American Journal of Roentgenology, Volume 209; https://doi.org/10.2214/ajr.17.18100

Abstract:
OBJECTIVE. This article describes, illustrates, and correlates imaging and pathologic features of primary vascular mesenchymal neoplasms of the liver, which arise from the vascular endothelium and perivascular epithelioid cells. CONCLUSION. Familiarity with the spectrum of benign, malignant-potential and malignant vascular neoplasms, and nonneoplastic mimickers allows consideration in the differential diagnosis of enhancing hepatic masses. Understanding relevant pathologic features facilitates recognition of key imaging features, specifically dynamic contrast enhancement patterns on CT and MRI, which provide a useful classification system.
American Journal of Roentgenology, Volume 210, pp 158-165; https://doi.org/10.2214/ajr.17.18411

Abstract:
OBJECTIVE. Posthepatectomy liver failure (PHLF) is one of the most serious complications after hepatectomy. The objective of the present study is to assess the potential diagnostic ability of 99mTc-galactosyl human serum albumin (GSA) scintigraphy to predict PHLF as defined by the International Study Group of Liver Surgery (ISGLS). MATERIALS AND METHODS. Data from 100 patients who underwent 99mTc-GSA scintigraphy and subsequent hepatectomy were retrospectively analyzed. The blood clearance ratio (HH15), hepatic uptake ratio (LHL15), and maximal removal rate (Rmax) of 99mTc-GSA (GSA-Rmax) were calculated as scintigraphic parameters for the total liver. In addition to the ratio of preoperatively estimated remnant liver (ERL) counts to total liver counts (rERL-GSA), the ratio of actual remnant liver (ARL) counts to total liver counts (rARL-GSA), determined by applying a more accurate resection line with reference to both pre- and postoperative CT, was obtained from SPECT images. Functional remnant liver parameters of ERL-LHL15 (LHL15 of the estimated remnant liver), ERL-Rmax (maximal removal rate of estimated remnant liver counts), ARL-LHL15 (LHL15 of the actual remnant liver), and ARL-Rmax (maximal removal rate of actual remnant liver counts) were calculated using these values. ROC analysis was performed to evaluate the ability of these parameters to predict PHLF. Multivariate analysis was performed to identify independent predictors of PHLF. RESULTS. PHLF occurred in 33 patients. Each of the ARL parameters had a significantly higher diagnostic performance compared with the corresponding ERL parameter (AUC values: for rARL-GSA vs rERL-GSA, 0.77 vs 0.62 [p = 0.0004]; for ARL-LHL15 vs ERL-LHL15, 0.79 vs 0.64 [p = 0.0005]; and for ARL-Rmax vs ERL-Rmax, 0.78 vs 0.66 [p = 0.0003]). According to multivariate analysis, each of three ARL parameters was identified as an independent predictor of PHLF (p < 0.0001 for all). CONCLUSION. Technetium-99m–labeled GSA scintigraphy is useful for predicting PHLF, particularly for applying an accurate resection line on GSA-SPECT images.
American Journal of Roentgenology, Volume 209; https://doi.org/10.2214/ajr.17.18283

Abstract:
OBJECTIVE. The purpose of our study was to review the diagnostic performance of DWI for differentiating high- from low-grade clear cell renal cell carcinoma (RCC). MATERIALS AND METHODS. MEDLINE, EMBASE, and Cochrane library databases were searched up to March 15, 2017. We included diagnostic accuracy studies that used DWI for differentiating high- from low-grade clear cell RCC compared with histopathologic results of Fuhrman grade based on nephrectomy or biopsy specimens in original research articles. Two independent reviewers assessed methodologic quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Sensitivity and specificity of the included studies were pooled and graphically presented using a hierarchic summary ROC plot. For heterogeneity exploration, we assessed the presence of a threshold effect and performed meta-regression analyses. RESULTS. Eight retrospective studies (394 patients with 397 clear cell RCCs) were included. Pooled sensitivity was 0.78 (95% CI, 0.68–0.85) with a specificity of 0.86 (95% CI, 0.70–0.94). A considerable threshold effect was observed with a correlation coefficient of 0.811 (95% CI, 0.248–0.964) between the sensitivity and false-positive rate. At meta-regression analysis, apparent diffusion coefficient (× 10 mm2/s) cutoff value (< 1.57 vs ≥ 1.57; p = 0.03) and location of ROI (solid portion vs whole tumor; p = 0.04) were significant factors affecting heterogeneity. Other factors with regard to patients and tumors, study, and MRI characteristics were not significant (p = 0.17–0.91). CONCLUSION. DWI shows moderate diagnostic performance for differentiating high-from low-grade clear cell RCC. Substantial heterogeneity was observed because of a threshold effect. Further prospective studies may be needed; all included studies were retrospective.
American Journal of Roentgenology, Volume 209, pp 1360-1366; https://doi.org/10.2214/ajr.17.18351

Abstract:
OBJECTIVE. The objective of this study is to describe the anatomic and imaging features of CSF venous fistulas, which are a recently reported cause of spontaneous intracranial hypotension (SIH). MATERIALS AND METHODS. We retrospectively reviewed the records of patients with SIH caused by CSF venous fistulas who received treatment at our institution. The anatomic details of each fistula were recorded. Attenuation of the veins involved by the fistula was compared with that of adjacent control veins on CT myelography (CTM). Visibility of the CSF venous fistula on CTM and a modified conventional myelography technique we refer to as dynamic myelography was also compared. RESULTS. Twenty-two cases of CSF venous fistula were identified. The fistulas were located between T4 and L1. Ninety percent occurred without a concurrent epidural CSF leak. In most cases (82%), the CSF venous fistula originated from a nerve root sleeve diverticulum. On CTM, the abnormal veins associated with the CSF venous fistula were seen in a paravertebral location in 45% of cases, centrally within the epidural venous plexus in 32%, and lateral to the spine in 23%. Differences in attenuation between the fistula veins and the control veins was highly statistically significant (p< 0.0001), with a threshold of 70 HU perfectly discriminating fistulas from normal veins in our series. When both CTM and dynamic myelography were performed, the fistula was identified on both modalities in 88% of cases. CONCLUSION. CSF venous fistulas are an important cause of SIH that can be detected on both CTM and dynamic myelograph y and may occur without an epidural CSF leak. Familiarity with the imaging characteristics of these lesions is critical to providing appropriate treatment to patients with SIH.
Sebastian Manneck, , Lynne M. Hurwitz, Danielle M. Seaman,
American Journal of Roentgenology, Volume 209, pp 1396-1403; https://doi.org/10.2214/AJR.16.17695

Abstract:
OBJECTIVE. The purpose of this study was to assess the noninferiority of dual-source high-pitch CT angiography (CTA) performed with high-concentration (iopamidol 370) low-volume (60 mL) iodinated contrast material at low voltage (100 kVp) in comparison with dual-source high-pitch CTA with standard-of-care low-concentration (iopamidol 300) standard-volume (75 mL) iodinated contrast material at high voltage (120 kVp) to determine whether use of the high-concentration low-volume method would afford a reduction in radiation dose and contrast volume without negatively affecting vascular opacification. SUBJECTS AND METHODS. This study had three arms. A phantom was used to assess vascular contrast enhancement at different iodine and saline solution dilutions with iopamidol 300 or 370 to compare lower-iodination (iopamidol 300) high-voltage (120 kVp) high-pitch (120 kVp, 250 mAs) imaging with higher-iodination (iopamidol 370) low-voltage (100 kVp) high-pitch (100 kVp, 100–240 mAs) acquisition. Metal-oxide-semiconductor field-effect transistors were placed in an anthropomorphic phantom to extract organ-based radiation profiles, and ANOVA was performed. The study prospectively enrolled 150 patients: 50 patients received 75 mL iopamidol 300, and image acquisition was performed at 120 kVp and 250 mAs; 50 patients received 75 mL iopamidol 370, and acquisition was performed at 100 kVp and 240 mAs; and 50 patients received 60 mL iopamidol, and acquisition was performed at 370 at 100 kVp and 240 mAs. Vascular signal-to-noise ratio was evaluated at 18 anatomic locations. Longitudinal signal-to-noise ratio was used to assess homogeneity of contrast enhancement. Size-specific dose estimates were calculated. Statistical analyses were performed by ANOVA. RESULTS. Noninferiority of high-concentration (iopamidol 370) low-voltage (100 kVp) high-pitch acquisitions compared with low-concentration (iopamidol 300) high-voltage (120 kVp) high-pitch acquisition was achieved at 170 mAs in vitro. Radiation assessment showed significant decreases in radiation dose for the 100-kVp 240-mAs protocol (p< 0.0001). Noninferior vascular contrast (p > 0.280) and luminal homogeneity (p > 0.191) were found for all high-pitch protocols. Significantly decreased radiation dose was observed for the two groups that received 60 and 75 mL of iopamidol 370 at 100 kVp and 240 mAs (p< 0.0001). CONCLUSION. Dual-source high-pitch CTA with high-concentration (iopamidol 370) low-volume (60 mL) iodinated contrast medium and low-voltage acquisition (100 kVp) is noninferior to dual-source high-pitch CTA with low-concentration (iopamidol 300) standard-volume (75 mL) iodinated contrast material at high voltage (120 kVp) and affords simultaneous reduction in radiation dose and contrast volume without negatively affecting vascular contrast enhancement.
Dong Hwan Kim, Hyuk Jung Kim, , ,
American Journal of Roentgenology, Volume 209, pp 1263-1271; https://doi.org/10.2214/ajr.17.17869

Abstract:
OBJECTIVE. The purpose of this study was to retrospectively assess CT predictors of unfavorable outcomes of medical treatment in patients with right colonic diverticulitis. MATERIALS AND METHODS. Of 394 patients with right colonic diverticulitis diagnosed on the basis of CT findings from January 2010 through August 2013, we included 328 (190 men, 138 women; mean age, 41.3 ± 12.6 years) who had undergone medical treatment as inpatients. Two radiologists retrospectively reviewed the following CT findings associated with diverticulitis: number of diverticula per 10 cm of colon; length and thickness of affected colonic wall; diameter of inflamed diverticulum and abscess; presence of pericolic fluid collection, spilled feces, and contained air; and extent of fatty infiltration. Logistic regression analysis and the Cox proportional hazards regression model were used to determine significant variables predictive of unfavorable outcomes, including surgery after failed medical treatment, recurrence, and prolonged hospital stay. RESULTS. Of the 328 patients, nine underwent surgery after failed medical treatment. Of the other 319 patients, 35 had recurrence and 49 had a prolonged hospital stay. The spilled feces sign (adjusted odds ratio [OR], 111; p< 0.001) and serum WBC count (adjusted OR, 1.3; p = 0.047) were independent predictors of the need for surgery. More than five multiple diverticula per 10 cm of colon was significantly associated with recurrence (adjusted hazard ratio, 4.1; p< 0.001). Abscess larger than 4 cm (adjusted OR, 18.2; p = 0.01) and inflamed diverticulum larger than 2 cm (adjusted OR, 3.7; p = 0.001) were independent predictors of prolonged hospital stay. CONCLUSION. Some specific CT findings can be useful predictors of unfavorable clinical outcomes of right colonic diverticulitis.
, Peter Chang, Brent D. Weinberg, Daniela A. Bota, , Christopher G. Filippi
American Journal of Roentgenology, Volume 210, pp 30-38; https://doi.org/10.2214/ajr.17.18754

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OBJECTIVE. The purpose of this review is to summarize advances in the molecular analysis of gliomas, the role genetics plays in MRI features, and how machine-learning approaches can be used to survey the tumoral environment. CONCLUSION. The genetic profile of gliomas influences the course of treatment and clinical outcomes. Though biopsy is the reference standard for determining tumor genetics, it can suffer diagnostic delays due to surgical planning and pathologic assessment. Radiogenomics may allow rapid, low-risk characterization of genetic heterogeneity.
Min A Lee, , An Na Seo, , Kyung-Min Shin, See Hyung Kim,
American Journal of Roentgenology, Volume 209, pp 1247-1255; https://doi.org/10.2214/ajr.16.17242

Abstract:
OBJECTIVE. The purpose of this study was to evaluate the prognostic relevance of a modified 3-point MRI-based tumor regression grading system incorporating DWI for patients with locally advanced rectal cancer after preoperative chemoradiotherapy (CRT). MATERIALS AND METHODS. Between March 2012 and September 2013, 118 consecutively registered patients with middle or lower locally advanced rectal cancer who underwent CRT followed by surgery were enrolled in this retrospective study. Two radiologists in consensus assessed MRI tumor regression grade (mrTRG) based on T2-weighted images and high b value DW images (0 and 1000 s/mm2) using the following grades: 0, complete regression (no obvious tumor); 1, intermediate regression (dominant fibrosis, regression > 50%); 2, poor regression (dominant tumor, regression ≤ 50%). Multivariate analysis with a Cox regression model was performed to evaluate the association between modified mrTRG and 3-year disease-free survival (DFS) rate. A Kaplan-Meier method with a log-rank test was used to compare the DFS rate between responder (grades 0 and 1) and nonresponder (grade 2) groups. RESULTS. Both the accuracy (72.9% vs 38.1%; p< 0.001) and the interreader agreement (κ = 0.580 vs 0.338; p< 0.001) of modified 3-point mrTRG were improved over the established 5-point mrTRG. Modified mrTRG (adjusted hazard ratio, 2.505; 95% CI, 1.231–5.100) was independently associated with 3-year DFS rate (p = 0.011). There was also a significant difference in the 3-year DFS rate between responders (73.8%; 95% CI, 64.2–81.3%) and nonresponders (41.7%; 95% CI, 10.9–70.8%) (p = 0.028). CONCLUSION. In patients with middle or lower locally advanced rectal cancer, the modified 3-point mrTRG incorporating DWI was independently associated with the 3-year DFS rate after CRT followed by surgery. The grading scale may be used as a surrogate for expected prognosis of preoperative CRT. Further prospective trials are warranted.
American Journal of Roentgenology, Volume 209; https://doi.org/10.2214/AJR.17.17984

Abstract:
The purpose of this article is to review current image acquisition and interpretation for whole-body MRI, clinical applications, and the emerging roles in oncologic imaging, especially in the assessment of bone marrow diseases.
, Alison Harris, Emily Pang, Paramanand Maharaj, Silvia Chang
American Journal of Roentgenology, Volume 209, pp 1197-1208; https://doi.org/10.2214/ajr.17.18404

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OBJECTIVE. Neurocutaneous syndromes are a heterogeneous group of multisystemic disorders. We review the multimodality imaging findings in the disorders with a propensity for intraabdominal disease. We highlight more recently recognized disease patterns and discuss imaging surveillance optimization. CONCLUSION. Knowledge of varied intraabdominal phenotypic expressions can increase diagnostic rates. Limitation of radiation dose must be considered in screening this tumor-prone population. Early detection of neoplastic findings is critical for morbidity and mortality reduction.
American Journal of Roentgenology, Volume 209; https://doi.org/10.2214/ajr.17.17964

Abstract:
OBJECTIVE. The objective of our study was to compare Prostate Imaging Reporting and Data System Version 1 (PI-RADSv1) and Prostate Imaging Reporting and Data System Version 2 (PI-RADSv2) for the detection of peripheral zone (PZ) Gleason score 3 + 4 = 7 cancers. MATERIALS AND METHODS. Forty-seven consecutive patients with 52 PZ Gleason score 3 + 4 = 7 cancers that were 0.5 cm3 or larger underwent radical prostatectomy (RP) and 3-T MRI between 2012 and 2015. Two blinded radiologists (readers 1 and 2) retrospectively assigned PI-RADSv1 sequence (T2-weighted imaging, DWI, dynamic contrast-enhanced MRI [DCE-MRI]) and sum scores and PI-RADSv2 assessment categories. A third blinded radiologist (reader 3) measured apparent diffusion coefficient (ADC) ratio (ADC of tumor / ADC of normal PZ) using RP-MRI maps. Sensitivity, false-positive rate, and overall accuracy were compared using McNemar test. Pearson correlation was performed. RESULTS. Using PI-RADSv1, reader 1 detected 86.5% (45/52) of the cancers and reader 2, 76.9% (40/52) of the cancers. Using PI-RADSv2, reader 1 detected 78.9% (41/52) and reader 2, 67.3% (35/52). Reader 1 detected 7.7% (4/52) and reader 2 detected 9.6% (5/52) more tumors using PI-RADSv1 due to T2-weighted imaging score ≥ 4 or DCE-MRI score ≥ 3. Sensitivity was higher for PI-RADSv1 (p = 0.01 and 0.03, readers 1 and 2). False-positive rates were higher with PI-RADSv1 than with PI-RADSv2 (1.8% vs 0.9% for reader 1; 3.6% vs 1.8% for reader 2) without significant differences in false-positive rate (p = 0.41 and 0.25) or overall accuracy (p = 0.06 and 0.23). PI-RADSv1 sum scores correlated strongly with PI-RADSv2 categories (B = 0.78–0.93, p< 0.0001). The mean ADC ratio was 0.61 ± 0.14 mm2/s with no difference between visible and nonvisible tumors (p = 0.06–0.5). Interobserver agreement was moderate for PI-RADSv2 (κ = 0.41) and ranged from slight to substantial for PI-RADSv1 (T2-weighted imaging, κ = 0.32; DWI, κ = 0.52; DCE-MRI, κ = 0.13). CONCLUSION. There was no difference in overall detection of cancers comparing PI-RADSv1 and PI-RADSv2; however, PI-RADSv1 sequence scores on T2-weighted imaging and DCE-MRI detected approximately 10% more tumors that were otherwise underestimated on DWI and using PI-RADSv2 decision-tree rules.
Stefan C. Schatzki
American Journal of Roentgenology, Volume 209, pp 1430-1430; https://doi.org/10.2214/ajr.17.18541

Alexandra Grosse, Claudia Grosse, Irene M. Lang
American Journal of Roentgenology, Volume 209, pp 1228-1238; https://doi.org/10.2214/AJR.17.17871

Abstract:
The purpose of this study was to discern imaging findings that separate chronic thromboembolic pulmonary hypertension (CTEPH) from other causes of pulmonary hypertension (PH).
, Daniel B. Green, Alan C. Legasto, Eric A. Jensen, Prasad M. Panse
American Journal of Roentgenology, Volume 209, pp 1209-1215; https://doi.org/10.2214/ajr.17.18063

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OBJECTIVE. Dendriform pulmonary ossification (DPO) is a rare lung disease in which mature bone is present in the peripheral interstitium of the lung. It typically occurs in patients with usual interstitial pneumonia (UIP). We assessed patients with CT findings of DPO without UIP to determine possible causative factors and to assess the clinical and CT course. We hypothesized that DPO without UIP would be a unique entity. MATERIALS AND METHODS. We retrospectively reviewed CT reports for the word “ossification.” Two observers reviewed each examination for micronodules 1–5 mm in diameter in the peripheral interstitium (subpleural and perifissural spaces and interlobular septa), some of which had high attenuation on mediastinal windows, presence of contiguous clusters of nodules resulting in a branching pattern, and lack of findings of UIP or focal lung disease. We reviewed the electronic medical records and follow-up CT and clinical information in all eligible patients. RESULTS. The study population consisted of 52 men with a median age of 79 years old. Seventy-five percent of the patients had gastroesophageal reflux disease, obstructive sleep apnea, or a chronic neurologic disorder. No progressive pulmonary symptoms were attributed directly to DPO, and no patient developed pulmonary fibrosis or suffered clinical decline from DPO. CT showed minimal progression or remained stable at follow-up (77% for at least 1 year, 25% for over 4 years). CONCLUSION. DPO in the absence of UIP occurs in elderly men and appears to be associated with chronic aspiration of gastric acid. The course is indolent.
Pedro N. Mousessian, , , Ronaldo H. Baroni
American Journal of Roentgenology, Volume 209, pp 1285-1290; https://doi.org/10.2214/ajr.17.18142

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OBJECTIVE. The primary purpose of this study is to determine the malignancy rate, histologic grade, and initial stage of surgically treated complex renal cysts classified as Bosniak category III or IV. For nonsurgical lesions, a secondary objective was to evaluate lesion progression on follow-up examinations. MATERIALS AND METHODS. We searched our database for cystic lesions classified as Bosniak III or IV category on CT or MRI from January 2008 to April 2016. Surgically resected lesions, per category, were correlated with information on pathologic reports to obtain malignancy rates. For malignant lesions, histologic grade and initial stage were evaluated. Imaging follow-up of at least 2 years was used to evaluate progression of clinically followed lesions. RESULTS. We included 86 lesions in 85 patients in the final analysis. Of the 60 surgically resected lesions (70%), 46 (77%) were malignant and 14 (23%) were benign. Malignancy rates were 72% for Bosniak category III lesions and 86% for Bosniak category IV lesions. Most malignant cysts were early-stage (pT1) cysts with low histologic grades (89% of Bosniak III lesions and 91% of Bosniak IV lesions). Follow-up studies of the surgically resected lesions did not show local recurrence, metastasis, or lymph node enlargement. Among patients with lesions managed by watchful waiting (n = 26), all lesions remained unchanged in terms of size and complexity after at least 2-years of follow-up. CONCLUSION. Although high malignancy rates were observed for both Bosniak category III and IV lesions, our results suggest that such malignant cysts are usually early-stage tumors with a low histologic grade. Lesions that underwent follow-up remained unchanged on control examinations. These findings may indicate low aggressiveness of these lesions, supporting the idea that more conservative approaches may be used.
, Zeynep Ozbalkan, Murat Erdugan, , Sevinc Can Sandıkcı, Tunca Kaya, Suzan Şaylısoy
American Journal of Roentgenology, Volume 209; https://doi.org/10.2214/ajr.17.18143

Abstract:
OBJECTIVE. The purpose of this study was to investigate the role of flow parameters obtained with dynamic Doppler ultrasound in the objective follow-up of treatment response in patients with Raynaud phenomenon (RP). SUBJECTS AND METHODS. The study included 33 patients with newly diagnosed primary RP, 31 with secondary RP, and 26 healthy participants (control subjects). Both groups of patients with RP underwent sonography before and after treatment. The control group underwent sonography once. Baseline digital arterial diameter and flow volume were measured at room temperature. After cold provocation, diameter and flow volume were measured again, and flow starting time and flow normalizing time were recorded. Data were measured as mean (± SD) values. RESULTS. Baseline diameter did not significantly increase in either group after treatment (p > 0.05) (primary RP pretreatment, 0.79 ± 0.17 mm; posttreatment, 0.82 ± 0.19 mm; secondary RP pretreatment, 0.66 ± 0.13 mm; posttreatment, 0.68 ± 0.14 mm). Baseline flow volume increased significantly in both groups (p< 0.01) (primary RP pretreatment, 3.08 ± 2.96 mL/min; posttreatment, 3.91 ± 3.39 mL/min; secondary RP pretreatment, 2.14 ± 1.94 mL/min; posttreatment, 2.80 ± 2.15 mL/min). Cold provocation diameter increased significantly in both groups after treatment (p< 0.01) (primary RP pretreatment, 0.63 ± 0.15 mm; posttreatment, 0.70 ± 0.16 mm; secondary RP pretreatment, 0.56 ± 0.15 mm; posttreatment, 0.63 ± 0.13 mm). Cold provocation flow volume increased significantly in both groups after treatment (p< 0.01) (primary RP pretreatment, 1.18 ± 1.26 mL/min; posttreatment, 2.17 ± 2.16 mL/min; secondary RP pretreatment, 1.07 ± 1.40 mL/min; posttreatment, 1.46 ± 1.67 mL/min). After treatment, there was no statistically significant increase in flow starting time in patients with primary RP (p > 0.05), but there was a significant increase in patients with secondary RP (p< 0.05) (primary RP pretreatment, 1.15 ± 2.27 minutes; posttreatment, 0.61 ± 1.41 minutes; secondary RP pretreatment, 3.13 ± 4.81 minutes; posttreatment, 1.58 ± 2.36 minutes). After treatment, flow volume normalizing time improved significantly in both groups (p< 0.01) (primary RP pretreatment, 7.24 ± 7.60 minutes; posttreatment, 3.84 ± 3.39 minutes; secondary RP pretreatment, 9.58 ± 8.49 minutes; posttreatment, 4.32 ± 3.56 minutes). Among patients with primary RP, the posttreatment flow starting time was similar to that in the control group. Despite improvements, all remaining parameters differed in the treatment group compared with the control group. CONCLUSION. Doppler ultrasound can be used effectively to monitor RP treatment. Blood flow volume can be measured without cold provocation to facilitate follow-up care of patients with RP.
, , Ajaykumar Morani, Rabindra Gautam, , Peter L. Choyke, Vikas Kundra
American Journal of Roentgenology, Volume 209, pp 1291-1296; https://doi.org/10.2214/AJR.17.18071

Abstract:
Birt-Hogg-Dubé (BHD) syndrome is an autosomal dominant inherited syndrome involving multiple organs. In young patients, renal neoplasms that are multiple, bilateral, or both, such as oncocytomas, chromophobe renal cell carcinoma (RCC), hybrid chromophobe RCC-oncocytomas, clear cell RCC, and papillary RCC, can suggest BHD syndrome. Extrarenal findings, including dermal lesions, pulmonary cysts, and spontaneous pneumothoraces, also aid in diagnosis.
Samira Rathnayake, Felix Nautsch, Thomas Robin Goodman, ,
American Journal of Roentgenology, Volume 209, pp 1308-1311; https://doi.org/10.2214/AJR.17.18282

Abstract:
OBJECTIVE. The purpose of this study was to assess the importance of relative value unit (RVU) flow and other factors in report turnaround time (TAT) in emergency radiologic operations. MATERIALS AND METHODS. RVU flow was defined as the normalized (to 60 minutes) total work RVUs for studies performed in a given time interval of 30 minutes (RVU flow 30) or 60 minutes (RVU flow 60). Twenty-five weekday emergency radiology shifts each for four radiologists were randomly selected. The institutional radiology search engine was queried to obtain the following data for each study: study completion time, work RVU, attending radiologist, and report TAT. RVU flow 30, RVU flow 60, presence of resident, and number of hours since start of shift were computed. Two separate multiple linear regression analyses were performed with RVU flow 30 or RVU flow 60 and other factors as independent variables and TAT as the dependent variable. RESULTS. The study included 7378 radiology studies from 100 weekday shifts, from which 1537 RVU flow 30 and 792 RVU flow 60 data points were generated. RVU flow 60 (p = 0.0026) and RVU flow 30 (< 0.0001) were significantly associated with radiology report TAT. One attending radiologist had statistically significant lower TAT 30 and TAT 60, whereas another had a lower TAT 30 but not TAT 60. The presence of a resident was significantly associated with reduced TAT 30 (p = 0.0005) and TAT 60 (p = 0.0028). CONCLUSION. RVU flow 60, RVU flow 30, specific attending radiologist, and presence of a resident are significantly correlated with radiology report TAT. RVU flow should be considered when evaluating radiologist and overall system performance with respect to report TAT.
, Caoimhe A. Byrne, Abdullah Alkhayat, Stephen J. Eustace, Eoin C. Kavanagh
American Journal of Roentgenology, Volume 209, pp 883-888; https://doi.org/10.2214/ajr.17.17847

Abstract:
OBJECTIVE. Hyaluronic acid (HA) is increasingly used by musculoskeletal radiologists in the treatment of osteoarthritis (OA). Although the evidence base for its efficacy is controversial, it remains in common use. With initial evidence suggesting its efficacy in the knee, it is now offered for treating OA of the hip, ankle, and elsewhere. CONCLUSION. HA is available in a wide variety of preparations, which may vary in concentration and chemical composition. Clinicians offering intraarticular HA injection should be familiar with the common preparations available and the principal differences between them, its mechanism of action, and the profile of adverse effects associated with its use.
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