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Σάββατο 23 Μαρτίου 2019

Roentgenology

Editorial

AJR Reviewers: Heartfelt Thanks From the Editors and Staff

Thomas H. Berquist1
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Citation: American Journal of Roentgenology. 2019;212: 715-716. 10.2214/AJR.19.21180

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1. Berquist TH. AJR reviewers: thank you from the editors and staff. AJR 2018; 210:237–238 [Google Scholar]
2. Berquist TH. New AJR initiatives in 2017. AJR 2017; 208:231–232 [Google Scholar]
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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 717-726
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.20517) 
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Special Articles

Original Research

Detection of Hyperacute Reactions of Desacetylvinblastine Monohydrazide in a Xenograft Model Using Intravoxel Incoherent Motion DWI and R2* Mapping

Jianye Liang1, Rong Ma2, Heru Chen3 ... Show all
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Citation: American Journal of Roentgenology. 2019;212: 717-726. 10.2214/AJR.18.20517

ABSTRACT :

OBJECTIVE. This study aimed to investigate the feasibility of intravoxel incoherent motion (IVIM) DWI and R2* (transverse relaxation rate) mapping to monitor the hyperacute therapeutic efficacy of desacetylvinblastine monohydrazide (DAVLBH) on an experimental hepatocellular carcinoma mouse model within 24 hours.

MATERIALS AND METHODS. Forty-four mice were implanted with hepatocellular carcinoma and divided into three random groups. A treatment group and a control group underwent IVIM-DWI and R2* mapping examinations before and after a single injection of DAVLBH or saline at 1, 2, 4, and 24 hours. The pathology group was set for pathologic analysis, including H and E staining and CD31 and hypoxia-inducible factor (HIF)–1α immunohistochemical staining.

RESULTS. DAVLBH caused hyperacute disruptions on the tumor capillaries in the treatment group. Water molecule diffusion (D), microcirculation perfusion (D*), and perfusion fraction (f) decreased initially but then gradually recovered to the baseline level by 24 hours after the first injection of DAVLBH. In contrast, R2* increased dramatically at 1 hour and then gradually decreased from 1 hour to 24 hours after treatment. D*, f, and D showed similar trends and were positively correlated with CD31 expression (r = 0.868, 0.721, and 0.730, respectively), but were negatively correlated with HIF-1α expression (r = −0.784, −0.737, and −0.673, respectively). R2* showed a negative correlation with CD31 expression (r = −0.823) and a positive correlation with HIF-1α expression (r = 0.791).

CONCLUSION. Both IVIM-DWI and R2* mapping can adequately detect the vascular-disrupting effect of DAVLBH as early as 1 hour after injection in a mouse xenograft model. Moreover, D* and R2* are the two most sensitive hemodynamic parameters and can monitor the hyperacute changes associated with DAVLBH treatment in vivo.

Keywords: desacetylvinblastine monohydrazide, intravoxel incoherent motion DWI, perfusion, R2* mapping, vascular-disrupting agent

Supported by grant 2017A020215065 from the Science and Technology Planning Project of Guangdong Province and grant 21317241 from the National Natural Science Foundation of China.

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J. Liang and R. Ma contributed equally to this work.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 727-733
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20195) 
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FOCUS ON: Medical Physics and Informatics

Original Research

Evaluation of a Ferromagnetic Marker Technology for Intraoperative Localization of Nonpalpable Breast Lesions

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Citation: American Journal of Roentgenology. 2019;212: 727-733. 10.2214/AJR.18.20195

ABSTRACT :

OBJECTIVE. The purpose of this study was to evaluate the magnetic occult lesion localization instrument (MOLLI) system that involves implantation of a small, ferromagnetic marker to guide surgical excision of nonpalpable breast lesions. Characterization of the system was undertaken as part of what is, to our knowledge, the first study to assess the MOLLI system.

MATERIALS AND METHODS. The MOLLI system consists of a handheld probe that can detect the position and distance of an implanted magnetic marker. The system presents the surgeon with an accurate assessment of lesion location and depth measurement for precise 3D localization. The marker is implanted under ultrasound or mammographic guidance at any time before the surgical procedure and requires no special precautions. Experimental analysis focused on characterization of the following aspects of the MOLLI system: visualization of the marker under imaging, 3D detection of the magnetic marker, spatial resolution of the probe to detect markers placed in close proximity, and the effect of signal interference on system performance.

RESULTS. The MOLLI system can reliably detect mean (± SD) marker depths up to 53 ± 8.56 mm from the probe. Bracketing large lesions or localizing multiple lesions can be accomplished by placing markers as close as 10 mm apart, at depths of up to 42 mm. The biologically inert MOLLI marker is readily visible under ultrasound and mammographic guidance, and it is differentiable from radiologic clips. The effect of surgical instruments on MOLLI functioning is minimal and does not impact system accuracy or reliability.

CONCLUSION. The MOLLI system offers an accurate and efficient alternative lesion localization method for nonpalpable breast lesions.

Keywords: breast-conserving surgery, breast cancer, localization, lumpectomy, nonpalpable lesion

Supported by an internal Association of Fundraising Professionals grant from Sunnybrook Health Sciences Centre and an Innovation Grant from the Canadian Cancer Society Research Institute.

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A. Ravi and J. Dillon are listed as inventors on a provisional patent for several components of the magnetic occult lesion localization instrument (MOLLI) system.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 734-740
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.19869) 
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FOCUS ON: Medical Physics and Informatics

Original Research

Automatic Disease Annotation From Radiology Reports Using Artificial Intelligence Implemented by a Recurrent Neural Network

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Citation: American Journal of Roentgenology. 2019;212: 734-740. 10.2214/AJR.18.19869

ABSTRACT :

OBJECTIVE. Radiology reports are rich resources for biomedical researchers. Before utilization of radiology reports, experts must manually review these reports to identify the categories. In fact, automatically categorizing electronic medical record (EMR) text with key annotation is difficult because it has a free-text format. To address these problems, we developed an automated system for disease annotation.

MATERIALS AND METHODS. Reports of musculoskeletal radiography examinations performed from January 1, 2016, through December 31, 2016, were exported from the database of Hanyang University Medical Center. After sentences not written in English and sentences containing typos were excluded, 3032 sentences were included. We built a system that uses a recurrent neural network (RNN) to automatically identify fracture and nonfracture cases as a preliminary study. We trained and tested the system using orthopedic surgeon–classified reports. We evaluated the system for the number of layers in the following two ways: the word error rate of the output sentences and performance as a binary classifier using standard evaluation metrics including accuracy, precision, recall, and F1 score.

RESULTS. The word error rate using Levenshtein distance showed the best performance in the three-layer model at 1.03%. The three-layer model also showed the highest overall performance with the highest precision (0.967), recall (0.967), accuracy (0.982), and F1 score (0.967).

CONCLUSION. Our results indicate that the RNN-based system has the ability to classify important findings in radiology reports with a high F1 score. We expect that our system can be used in cohort construction such as for retrospective studies because it is efficient for analyzing a large amount of data.

Keywords: automatic annotation, deep learning, natural language processing, radiology reports, recurrent neural network

This study was supported by a grant from the National Research Foundation (NRF) of Korea that was funded by the Ministry of Science and ICT (grant no. 2011-0030075) and a grant through the NRF's Basic Science Research Program that was funded by the Ministry of Education (grant no. 2018R1D1A1B07048957).

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 741-747
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.20065) 
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FOCUS ON: Medical Physics and Informatics

Original Research

Comparison of Radiation Dose and Image Quality of Contrast-Enhanced Dual-Source CT of the Chest: Single-Versus Dual-Energy and Second-Versus Third-Generation Technology

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Citation: American Journal of Roentgenology. 2019;212: 741-747. 10.2214/AJR.18.20065

ABSTRACT :

OBJECTIVE. The purpose of this study was to compare radiation dose and image quality of single- and dual-energy CT (SECT, DECT) examinations of the chest in matched cohorts for second and third-generation dual-source CT (DSCT) systems.

MATERIALS AND METHODS. We analyzed 200 patients (100 men; mean age, 61.7 ± 14.8 years old; 100 women, mean age, 59.4 ± 15.1 years old), matched by sex and body mass index, who had undergone clinically indicated contrast-enhanced chest CT. Four study groups, each consisting of 50 patients, were evaluated. Contrast-enhanced chest CT was performed using vendor-preset second-generation DSCT (group A, 120-kV SECT; group C, 80/Sn140-kV DECT) or third-generation DSCT (group B, 90-kV SECT; group D, 90/Sn150-kV DECT) protocols. Radiation dose assessment was normalized to a scan range of 27.5 cm. Image quality was objectively analyzed using dose-independent figure-of-merit (FOM) contrast-to-noise ratio (CNR) calculations and subjectively evaluated by three independent radiologists.

RESULTS. Direct comparison of effective radiation dose for second-generation DSCT groups A and C showed statistically significant lower radiation dose values for DECT compared with SECT acquisition (3.2 ± 1.2 mSv vs 2.3 ± 0.6 mSv, p ≤ 0.004), but differences between third-generation SECT and DECT were not significant (1.2 ± 0.9 mSv vs 1.3 ± 0.6 mSv, p = 0.412). FOM CNR analysis revealed highest values for third-generation DECT (p ≤ 0.043). Differences in subjective image quality between the four groups were not statistically significant (p ≥ 0.179).

CONCLUSION. Contrast-enhanced DECT examinations of the chest can be performed routinely with second- and third-generation DSCT systems without either increased radiation exposure or decreased image quality compared with SECT acquisition.

Keywords: diagnostic imaging, lung, MDCT, radiation dose, thorax

M.H. Albrecht has received speakers' fees from Siemens Healthcare and Bracco. J. L. Wichmann has received speakers' fees from GE Healthcare and Siemens Healthcare. Data were controlled by authors with no potential conflict of interest.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 748-754
Posted online on December 17, 2018.
(https://doi.org/10.2214/AJR.18.20334) 
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FOCUS ON: Medical Physics and Informatics

Original Research

Ultra-Low-Dose Neck CT With Low-Dose Contrast Material for Preoperative Staging of Thyroid Cancer: Image Quality and Diagnostic Performance

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Citation: American Journal of Roentgenology. 2019;212: 748-754. 10.2214/AJR.18.20334

ABSTRACT :

OBJECTIVE. Although CT has been used as a complementary diagnostic method for the preoperative diagnosis of thyroid cancer, it has the shortcomings of substantial radiation exposure and the use of contrast material (CM). The purpose of this article is to evaluate the image quality and diagnostic performance of 70-kVp thyroid CT with low volumes of CM versus conventional 120-kVp thyroid CT protocol.

MATERIALS AND METHODS. Eighty patients referred for preoperative thyroid CT were randomly divided into two groups (group A: 40 patients, 70 kVp, 60 mL of CM; group B: 40 patients, 120 kVp, 100 mL of CM). Quantitative and qualitative image quality and radiation doses for the two groups were compared using the Mann-Whitney U and chi-square tests. Degrees of agreement between preoperative CT staging and pathologic results were evaluated and compared using the Wald statistic.

RESULTS. Calculated signal-to-noise ratios of different anatomic structures, calculated contrast-to-noise ratios, overall image quality, subjective noise, and streak artifacts were not significantly different between the two groups (all p > 0.05), and neither were the accuracies of preoperative CT staging (all p > 0.05). The estimated effective doses were significantly lower in group A (mean [± SD], 0.52 ± 0.14 mSv in group A and 2.28 ± 0.29 mSv in group B; p < 0.001).

CONCLUSION. Ultra-low-dose 70-kVp CT with a low volume of CM provides sufficient image quality for preoperative staging of thyroid cancer and substantially reduces the radiation dose compared with standard 120-kVp CT.

Keywords: neck, thyroid cancer, ultra-low-dose CT

Based on a presentation at the European Congress of Radiology 2018 annual meeting, Vienna, Austria.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 755-757
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20508) 
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FOCUS ON: Medical Physics and Informatics

Clinical Perspective

Patient Shielding in Diagnostic Imaging: Discontinuing a Legacy Practice

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Citation: American Journal of Roentgenology. 2019;212: 755-757. 10.2214/AJR.18.20508

ABSTRACT :

OBJECTIVE. Patient shielding is standard practice in diagnostic imaging, despite growing evidence that it provides negligible or no benefit and carries a substantial risk of increasing patient dose and compromising the diagnostic efficacy of an image. The historical rationale for patient shielding is described, and the folly of its continued use is discussed.

CONCLUSION. Although change is difficult, it is incumbent on radiologic technologists, medical physicists, and radiologists to abandon the practice of patient shielding in radiology.

Keywords: gonadal shielding, patient safety, patient shielding, radiation, shielding

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 758-765
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20036) 
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Cardiopulmonary Imaging

Original Research

Multireader Determination of Clinically Significant Obstruction Using Hyperpolarized 129Xe–Ventilation MRI

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Citation: American Journal of Roentgenology. 2019;212: 758-765. 10.2214/AJR.18.20036

ABSTRACT :

OBJECTIVE. The objective of our study was to identify the magnitude and distribution of ventilation defect scores (VDSs) derived from hyperpolarized (HP) 129Xe-MRI associated with clinically relevant airway obstruction.

MATERIALS AND METHODS. From 2012 to 2015, 76 subjects underwent HP 129Xe-MRI (48 healthy volunteers [mean age ± SD, 54 ± 17 years]; 20 patients with asthma [mean age, 44 ± 20 years]; eight patients with chronic obstructive pulmonary disease [mean age, 67 ± 5 years]). All subjects underwent spirometry 1 day before MRI to establish the presence of airway obstruction (forced expiratory volume in 1 second–to–forced vital capacity ratio [FEV1/FVC] < 70%). Five blinded readers assessed the degree of ventilation impairment and assigned a VDS (range, 0–100%). Interreader agreement was assessed using the Fleiss kappa statistic. Using FEV1/FVC as the reference standard, the optimum VDS threshold for the detection of airway obstruction was estimated using ROC curve analysis with 10-fold cross-validation.

RESULTS. Compared with the VDSs in healthy subjects, VDSs in patients with airway obstruction were significantly higher (p < 0.0001) and significantly correlated with disease severity (r = 0.66, p < 0.0001). Ventilation defects in subjects with airway obstruction did not show a location-specific pattern (p = 0.158); however, defects in healthy control subjects were more prevalent in the upper lungs (p = 0.014). ROC curve analysis yielded an optimal threshold of 12.4% ± 6.1% (mean ± SD) for clinically significant VDS. Interreader agreement for 129Xe-MRI was substantial (κ = 0.71).

CONCLUSION. This multireader study of a diverse cohort of patients and control subjects suggests a 129Xe–ventilation MRI VDS of 12.4% or greater represents clinically significant obstruction.

Keywords: airway obstruction, asthma, chronic obstructive pulmonary disease (COPD), MRI, xenon

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Funding for data acquisition was provided by the National Heart, Lung, and Blood Institute (grants NHLBI R01HL105643 and R01HL126771). L. Ebner received financial funding from the Swiss National Science Foundation (grant SNSF P2SKP3_158645/1). B. Driehuys is founder of and shareholder in Polarean Imaging.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 766-772
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20232) 
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Cardiopulmonary Imaging

Original Research

Differentiation Between Lymphangioleiomyomatosis and Birt-Hogg-Dubé Syndrome: Analysis of Pulmonary Cysts on CT Images

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Citation: American Journal of Roentgenology. 2019;212: 766-772. 10.2214/AJR.18.20232

ABSTRACT :

OBJECTIVE. The purposes of this study were to identify diagnostic imaging markers for differentiating pulmonary cysts in lymphangioleiomyomatosis and Birt-Hogg-Dubé syndrome and to identify potential risk factors for spontaneous pneumothorax in the two diseases.

MATERIALS AND METHODS. This retrospective study included 44 patients with lymphangioleiomyomatosis (44 women; mean age, 35 ± 10.9 years) and 13 patients with Birt-Hogg-Dubé syndrome (nine men, four women; mean age, 45.1 ± 10.9 years). CT findings were analyzed to determine the shape; presence of septation, wall visibility, and subpleural cysts; size; number; distribution; location of the largest cyst; and presence of cysts encircling the bronchovascular bundle ("air-cuff" sign) and of mediastinal fat indentation. Multiple logistic regression was performed to identify risk factors for spontaneous pneumothorax.

RESULTS. Compared with patients with lymphangioleiomyomatosis, patients with Birt-Hogg-Dubé syndrome were significantly older, and more of them were men. The cysts in these patients had a more irregular shape, more septation, lower and more peripheral distribution, larger maximum size, and more attachment to the pleura, air-cuff sign, indentation on mediastinal fat, and subpleural cysts larger than 2 cm. The maximum diameter of cysts was the sole independent risk factor for spontaneous pneumothorax (p = 0.027; 95% CI, 1.043–1.992) in both diseases. ROC analysis showed an AUC of 0.745 (95% CI, 0.612–0.851), and the optimal cutoff value was 22 mm (sensitivity, 72.5%; specificity, 76.5%).

CONCLUSION. Several CT imaging markers may help in differentiating pulmonary cysts in patients with lymphangioleiomyomatosis and those with Birt-Hogg-Dubé syndrome and in predicting spontaneous pneumothorax.

Keywords: Birt-Hogg-Dubé syndrome, CT, lymphangioleiomyomatosis, pulmonary cyst

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 773-781
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20519) 
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Cardiopulmonary Imaging

Original Research

Resected Pure Small Cell Lung Carcinomas and Combined Small Cell Lung Carcinomas: Histopathology Features, Imaging Features, and Prognoses

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Citation: American Journal of Roentgenology. 2019;212: 773-781. 10.2214/AJR.18.20519

ABSTRACT :

OBJECTIVE. The objective of our study was to investigate histopathology features, imaging features, and prognoses of surgically resected pure small cell lung carcinomas (SCLCs) and combined SCLCs.

MATERIALS AND METHODS. Forty-one patients with a pure SCLC or a combined SCLC underwent preoperative chest CT and 18F-FDG PET/CT and subsequent surgical resection. The clinicopathologic findings were noted by reviewing the electronic medical records. The imaging features of individual tumors were analyzed on chest CT and PET/CT scans. Each tumor was classified as being located centrally (at or in the segmental bronchus or proximal to the segmental bronchus) or peripherally (distal to the segmental bronchus). The maximum standardized uptake value (SUVmax) of each tumor was measured at PET. The 7th edition of the TNM staging system was adopted for staging.

RESULTS. The study group was composed of 34 men and seven women with a mean age of 62.0 ± 10.2 (SD) years. Sixteen of 41 (39%) patients had pure SCLC, and the remaining patients had combined SCLC. The most common combined SCLC histologic subgroup was combined SCLC and large cell neuroendocrine carcinoma in 17 (41%) patients. The mean SUVmax of pure SCLCs was 5.6 ± 2.2 and was significantly lower than that of combined SCLCs (p < 0.01). Thirty-one patients (76%) had a peripheral tumor, and 10 (24%) had a central tumor. The overall survival (OS) of the 10 patients with a central tumor was 44.6 months, significantly shorter than the OS of the 31 patients with a peripheral tumor (179.2 months) (p = 0.017). The OS of 21 patients with stage I disease was significantly longer than the OS of patients with higher-stage cancer (p = 0.004).

CONCLUSION. In our study group of patients with surgically resected SCLC, patients with a peripheral tumor (including a purely endobronchial tumor) or stage I disease showed a better prognosis than those with a central tumor or higher-stage disease.

Keywords: CT, PET/CT, prognosis, small cell lung cancer, small cell lung carcinoma (SCLC), surgery

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 782-787
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20526) 
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Gastrointestinal Imaging

Original Research

Imaging Characteristics of Liver Metastases Overlooked at Contrast-Enhanced CT

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Citation: American Journal of Roentgenology. 2019;212: 782-787. 10.2214/AJR.18.20526

ABSTRACT :

OBJECTIVE. The purpose of this study was to evaluate the imaging characteristics of liver metastases overlooked at contrast-enhanced CT.

MATERIALS AND METHODS. The records of 746 patients with a diagnosis of liver metastases from colorectal, breast, gastric, or lung cancer between November 2010 and September 2017 were reviewed. Images were reviewed when liver metastases were first diagnosed, and images from prior contrast-enhanced CT examinations were checked if available. These lesions were classified into two groups: missed lesions (those missed on the prior images) and detected lesions (those correctly identified and invisible on the prior images or there were no prior images). Tumor size, contrast-to-noise ratio, location, presence of coexisting liver cysts and hepatic steatosis, and indications for examination were compared between the groups. The t test and Fisher exact test were used to analyze the imaging characteristics of previously overlooked lesions.

RESULTS. The final analysis included 137 lesions, of which 68 were classified as missed. In univariate analysis, contrast-to-noise ratio was significantly lower in missed lesions (95% CI, 2.65 ± 0.24 vs 3.90 ± 0.23; p < 0.001). The proportion of subcapsular lesions (odds ratio, 3.44; p < 0.001), hepatic steatosis (odds ratio, 6.35; p = 0.007), and examination indication other than survey of malignant tumors (odds ratio, 9.07; p = 0.02) were significantly higher for missed lesions.

CONCLUSION. Liver metastases without sufficient contrast enhancement, those in patients with hepatic steatosis, those in subcapsular locations, and those found at examinations for indications other than to assess for tumors were significantly more likely to be overlooked.

Keywords: contrast-enhanced CT, liver metastases, overlooked, perceptual error

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 788-795
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20204) 
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Gastrointestinal Imaging

Original Research

Accuracy of 3-T MRI for Preoperative T Staging of Esophageal Cancer After Neoadjuvant Chemotherapy, With Histopathologic Correlation

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Citation: American Journal of Roentgenology. 2019;212: 788-795. 10.2214/AJR.18.20204

ABSTRACT :

OBJECTIVE. The purpose of this study was to explore the value of 3-T MRI for evaluating the preoperative T staging of esophageal cancer (EC) treated with neoadjuvant chemotherapy (NAC), with histopathologic confirmation.

SUBJECTS AND METHODS. This prospective study enrolled patients for whom endoscopic biopsy showed EC and pretreatment CT showed stage cT1N+M0 or cT2–T4aN0–N3M0. All patients received two cycles of NAC (paclitaxel and nedaplatin protocol) followed by 3-T MRI and surgical resection. Readers assigned a T category on MRI, and postoperative pathologic confirmation was considered the reference standard. Interreader agreement, the diagnostic accuracy of T staging on T2-weighted turbo spin-echo (TSE) BLADE (Siemens Healthcare), contrast-enhanced StarVIBE (Siemens Healthcare), high-resolution delayed phase StarVIBE, and the combination of the three sequences were analyzed and compared with postoperative pathologic T staging.

RESULTS. The study included 79 patients. Mean time between NAC and MRI was 23 days. Interreader agreements of T category assignment were excellent for T2-weighted TSE BLADE (κ = 0.810, p < 0.0001), contrast-enhanced StarVIBE (κ = 0.845, p < 0.0001), high-resolution delayed phase StarVIBE (κ = 0.897, p < 0.0001), and the combination of the three sequences (κ = 0.880, p < 0.0001). The highest accuracy for T0, T1, T2, and T4a lesions was on high-resolution delayed phase StarVIBE (96.2%, 92.4%, 91.1%, and 91.1% for reader 1; 94.9%, 89.9%, 91.1%, and 94.9% for reader 2), and the highest accuracy for T3 lesions was on T2-weighted TSE BLADE (92.4% and 94.9% for reader 1 and reader 2, respectively). Diagnostic accuracy of the combination of the three sequences was not improved compared with individual sequences.

CONCLUSION. High-resolution delayed phase StarVIBE had the highest diagnostic accuracy in staging EC after NAC for all T categories except T3, for which T2-weighted TSE BLADE had the highest accuracy. Combining all three sequences did not improve diagnostic accuracy.

Keywords: esophageal cancer, MRI, neoadjuvant therapy, neoplasm staging

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Z. Wang, J. Guo, and J. Qin contributed equally to this study.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 796-801
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20293) 
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Genitourinary Imaging

Original Research

Dual-Source Dual-Energy CT in Detection and Characterization of Urinary Stones in Patients With Large Body Habitus: Observations in a Large Cohort

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Citation: American Journal of Roentgenology. 2019;212: 796-801. 10.2214/AJR.18.20293

ABSTRACT :

OBJECTIVE. The objective of our study was to investigate the impact of large body habitus on dual-energy CT (DECT) image quality and stone characterization.

MATERIALS AND METHODS. We retrospectively included 105 consecutive patients with large body habitus (> 90 kg) who underwent stone protocol DECT between 2015 and 2017. The evaluation of DECT datasets was performed for image quality assessment based on European Guidelines on Quality Criteria for Computed Tomography and for determination of stone composition (i.e., uric acid vs non–uric acid). Correlation between DECT characterization and crystallography results was performed when available. The cohort was divided into two groups on the basis of body weight (≤ 104 kg and > 104 kg), and comparisons were made for image quality and stone characterization.

RESULTS. One hundred ninety-seven urinary tract calculi (size: mean ± SD, 5.7 ± 5.3 mm; range, 1.4–56 mm) were detected in 73% (79/108) of examinations in 105 patients (weight: mean ± SD, 104.0 ± 12.7 kg; range, 91–163 kg). The overall mean image quality score of blended images and color maps was 3.7 and 3.9, respectively, and the effective dual-energy FOV limitation did not hamper stone characterization. The diagnostic acceptability scores of blended images and color maps were slightly lower in patients weighing > 104 kg than in patients ≤ 104 kg (mean scores [highest score, 4 points]: blended images, 3.62 vs 3.82 [p = 0.0314]; color maps, 3.75 vs 3.98 [p = 0.0034]), but the scores were within acceptable range. Stone characterization as uric acid versus non–uric acid was achieved in 80% (158/197) of calculi (size: mean ± SD, 6.4 ± 5.7 mm; range, 1.6–56 mm), and DECT stone characterization was (95.6%) accurate with reference to crystallography. Twenty percent (39/197) of calculi could not be characterized on DECT, and these calculi were significantly smaller in size (size: mean ± SD, 2.8 ± 1.4 mm; range, 1.4–8.2 mm; p < 0.001) than those that could be characterized. The mean size of uncharacterized calculi was slightly larger in patients weighing > 104 kg (3.3 ± 1.6 mm) than in those weighing ≤ 104 kg (2.2 ± 0.6 mm).

CONCLUSION. In patients with large body habitus, dual-source DECT provides acceptable image quality and allows characterization of almost all clinically significant calculi.

Keywords: dual-source dual-energy CT, large body habitus, urolithiasis

Based on a presentation at the Radiological Society of North America 2016 annual meeting, Chicago, IL.

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H. Kordbacheh and V. Baliyan contributed equally to this study.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 802-807
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20077) 
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Genitourinary Imaging

Original Research

Isolated Right-Sided Varicocele: Is Further Workup Necessary?

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Citation: American Journal of Roentgenology. 2019;212: 802-807. 10.2214/AJR.18.20077

ABSTRACT :

OBJECTIVE. Unilateral left varicoceles are common and considered benign. Unilateral right varicoceles are reportedly associated with a pathologic process, namely malignancy affecting the retroperitoneum, for which further imaging is often recommended. The purpose of this study was to test the hypothesis that this correlation between unilateral right varicocele and malignancy may be weaker than once suggested, particularly in the absence of other clinical signs of malignancy.

MATERIALS AND METHODS. Medical charts and imaging at one institution were reviewed for all patients reported to have right varicocele. Follow-up cross-sectional imaging and clinical records and surgical and medical history were reviewed for possible nonmalignant or malignant causes of varicocele.

RESULTS. Ninety-six patients with unilateral right varicocele diagnosed by means of ultrasound were identified. Twenty-nine (30.2%) patients were excluded because of confounding factors (infection, testicular mass, intrascrotal surgery). Among the other 67, 55 had available follow-up information, 39 with cross-sectional imaging. Right-sided varicocele was attributable to nonmalignant causes in 16 of the 55 subjects (29.1%) and to malignancy in two subjects: one with metastatic disease of undetermined primary and one with confluent liver masses. Both patients presented with other signs of malignancy and represented only 3.6% of the cohort who underwent follow-up.

CONCLUSION. In this cohort, patients with right-sided varicocele attributable to malignancy presented with additional signs of metastatic disease. Nonmalignant causes were more common. Therefore, confounding conditions should be considered when incidental isolated right varicocele is identified. Health care costs, patient anxiety, and unnecessary harm can be substantially reduced through modulation of follow-up recommendations based on additional findings at presentation.

Keywords: health care economics, malignancy, ultrasound, varicocele

K. Bishop has a consultation agreement with Hewlett Packard Enterprise Company. D. T. Fetzer has research and consultation agreements with Philips Ultrasound and Siemens Healthcare and is a member of the speakers' bureaus of Philips Healthcare and Siemens Healthcare.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 808-814
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20154) 
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Genitourinary Imaging

Original Research

Comparison of Tin Filter–Based Spectral Shaping CT and Low-Dose Protocol for Detection of Urinary Calculi

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Citation: American Journal of Roentgenology. 2019;212: 808-814. 10.2214/AJR.18.20154

ABSTRACT :

OBJECTIVE. The purpose of this study was to assess the performance of tin filter–based spectral shaping CT compared with routine low-dose CT for detection of urolithiasis.

MATERIALS AND METHODS. Unenhanced third-generation dual-source CT scans of 129 consecutively registered patients were retrospectively reviewed: 43 patients underwent CT for detection of renal stones with tin filtration (Sn150 kV); 43 patients underwent a routine low-dose CT protocol at 100 kV; and 43 patients underwent a routine CT protocol with automated tube potential selection (110–120 kV). Image quality was evaluated subjectively and objectively. Volume CT dose index (CTDIvol) and size-specific dose estimate (SSDE) were recorded. To prospectively compare the performances of the spectral shaping protocol (Sn150 kV) with the standard (120 kV) and routine low-dose (100 kV) protocols, a phantom (sheep kidneys) containing stones were also scanned with each protocol and evaluated by two radiologists.

RESULTS. CT with tin filtration resulted in 28% and 66% reduction in CTDIvol compared with CT performed with routine low-dose and standard-dose protocols (p < 0.05). Accordingly, it also led to 24% and 55% reduction in SSDE compared with the low-dose and standard protocols (p < 0.05). Subjective image quality and signal-to-noise ratio were similar between the tin filtration and the routine low-dose groups (p > 0.05). The objective image noise was similar in the three groups (p > 0.05). The phantom study showed no difference in detection of renal stones between the three tube potential settings.

CONCLUSION. Using spectral shaping with tin filtration can substantially reduce radiation dose compared with routine standard- and low-dose abdominal CT for urinary stone disease.

Keywords: CT, dose reduction, image quality, kidney stone, spectral shielding, tin filtration

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A. Mozaffary and T. Agirlar Trabzonlu have received educational grants from Siemens Healthineers.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 815-822
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.20266) 
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Genitourinary Imaging

Original Research

Safety and Image Quality of 1.5-T Endorectal Coil Multiparametric MRI of the Prostate or Prostatectomy Fossa for Patients With Pacemaker or Implantable Cardioverter-Defibrillator

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Citation: American Journal of Roentgenology. 2019;212: 815-822. 10.2214/AJR.18.20266

ABSTRACT :

OBJECTIVE. The purpose of this study is to report the patient safety and image quality of 1.5-T multiparametric MRI of the prostate in patients with cardiac implantable electronic devices (CIEDs).

MATERIALS AND METHODS. In this retrospective study, a database was searched to identify prostate multiparametric 1.5-T MRI examinations performed with endorectal coils for patients with CIEDs from 2012 to 2016 (study group) and matched patients without CIEDs (control group). Clinical safety in the study group was reviewed. The specific absorption rate (SAR) and signal-to-noise ratio (SNR) were measured in both groups. Imaging quality and artifact on T2-weighted images, DW images, and dynamic contrast-enhanced images were rated on a 5-point scale by two independent readers.

RESULTS. The study group consisted of total 28 multiparametric MRI examinations in 25 patients. There were no serious device-related adverse effects observed (0/28; 0%), and the estimated whole-body SAR in the study group was never greater than 1.5 W/kg. The SNR values tended to be lower in the study group than in the control group. However, overall perceived image preferences and influences of artifacts on image quality for the study group were not significantly different from those for the control group (p > 0.05), which were rated above average (rating 3) by both readers 1 and 2.

CONCLUSION. Multiparametric 1.5-T MRI examination of the prostate can be safely performed in selected patients with CIEDs under controlled conditions with applicable image quality while maintaining a SAR less than 1.5 W/kg.

Keywords: image quality, implantable cardioverterdefibrillator, MRI, pacemaker, prostate

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 823-829
Posted online on February 4, 2019.
(https://doi.org/10.2214/AJR.18.20295) 
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Genitourinary Imaging

Original Research

The Influence of Background Signal Intensity Changes on Cancer Detection in Prostate MRI

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Citation: American Journal of Roentgenology. 2019;212: 823-829. 10.2214/AJR.18.20295

ABSTRACT :

OBJECTIVE. The objective of this study was to develop a scoring system for background signal intensity changes or prostate homogeneity on prostate MRI and to assess these changes' influence on cancer detection.

MATERIALS AND METHODS. This institutional review board–approved, HIPAA-compliant, retrospective study included 418 prostate MRI examinations in 385 men who subsequently underwent MRI-guided biopsy. The Likert score for suspicion of cancer assigned by the primary radiologist was extracted from the original report, and histopathologic work-up of the biopsy cores served as the reference standard. Two readers assessed the amount of changes on T2-weighted sequences and assigned a predefined prostate signal-intensity homogeneity score of 1–5 (1 = poor, extensive changes; 5 = excellent, no changes). The sensitivity and specificity of Likert scores for detection of prostate cancer and clinically significant cancer (Gleason score ≥ 3+4) were estimated in and compared between subgroups of patients with different signal-intensity homogeneity scores (≤ 2, 3, and ≥ 4).

RESULTS. Interreader agreement on signal-intensity homogeneity scores was substantial (κ = 0.783). Sensitivity for prostate cancer detection increased when scores were better (i.e., higher) (reader 1, from 0.41 to 0.71; reader 2, from 0.53 to 0.73; p ≤ 0.007, both readers). In the detection of significant cancer (Gleason score ≥ 3+4), sensitivity also increased with higher signal-intensity scores (reader 1, from 0.50 to 0.82; reader 2, from 0.63 to 0.86; p ≤ 0.028), though specificity decreased significantly for one reader (from 0.67 to 0.38; p = 0.009).

CONCLUSION. Background signal-intensity changes on T2-weighted images significantly limit prostate cancer detection. The proposed scoring system could improve the standardization of prostate MRI reporting and provide guidance for applying prostate MRI results appropriately in clinical decision-making.

Keywords: MRI, prostate cancer

Supported in part by National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.

Acknowledgment
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We thank Ada Muellner for editing the manuscript.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 830-838
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20415) 
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Genitourinary Imaging

Original Research

Active Surveillance Versus Nephron-Sparing Surgery for a Bosniak IIF or III Renal Cyst: A Cost-Effectiveness Analysis

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Citation: American Journal of Roentgenology. 2019;212: 830-838. 10.2214/AJR.18.20415

ABSTRACT :

OBJECTIVE. The objective of our study was to evaluate the cost-effectiveness of active surveillance (AS) versus nephron-sparing surgery (NSS) in patients with a Bosniak IIF or III renal cyst.

MATERIALS AND METHODS. Markov models were developed to estimate life expectancy and lifetime costs for 60-year-old patients with a Bosniak IIF or III renal cyst (the reference cases) managed by AS versus NSS. The models incorporated the malignancy rates, reclassification rates during follow-up, treatment effectiveness, complications and costs, and short- and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify management preference under an assumed $75,000 per quality-adjusted life-year (QALY) societal willingness-to-pay threshold, using data from studies in the literature and the 2015 Medicare Physician Fee Schedule. The effects of key parameters were addressed in a multiway sensitivity analysis.

RESULTS. The prevalence of malignancy for Bosniak IIF and III renal cysts was 26% (25/96) and 52% (542/1046). Under base case assumptions for Bosniak IIF cysts, the incremental cost-effectiveness ratio of NSS relative to AS was $731,309 per QALY for women, exceeding the assumed societal willingness-to-pay threshold, and AS outperformed NSS for both life expectancy and cost for men. For Bosniak III cysts, AS yielded greater life expectancy (24.8 and 19.4 more days) and lower lifetime costs (cost difference of $12,128 and $11,901) than NSS for men and women, indicating dominance of AS over NSS. Superiority of AS held true in sensitivity analyses for men 46 years old or older and women 57 years old or older even when all parameters were set to favor NSS.

CONCLUSION. AS is more cost-effective than NSS for patients with a Bosniak IIF or III renal cyst.

Keywords: active surveillance, Bosniak, cost-effectiveness analysis, renal cysts

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A. D. Smith is president of Radiostics LLC and is president of and has patents issued and pending for eMASS LLC, Liver Nodularity LLC, and Color Enhanced Detection LLC.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 839-846
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20498) 
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Genitourinary Imaging

Original Research

Prebiopsy Biparametric MRI for Clinically Significant Prostate Cancer Detection With PI-RADS Version 2: A Multicenter Study

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Citation: American Journal of Roentgenology. 2019;212: 839-846. 10.2214/AJR.18.20498

ABSTRACT :

OBJECTIVE. The purpose of this study was to evaluate the diagnostic performance of the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) with respect to prebiopsy MRI with and without dynamic contrast enhancement in the detection of clinically significant cancer (CSC).

MATERIALS AND METHODS. A total of 113 patients with prostate cancer who underwent radical prostatectomy and prebiopsy multiparametric 3-T MRI (mpMRI) that included T2-weighted imaging, DWI, and dynamic contrast-enhanced MRI (DCE-MRI) were enrolled in a retrospective study conducted at two institutions. For detecting CSC at prebiopsy mpMRI with DCE-MRI and biparametric MRI (bpMRI) without DCE-MRI, two independent radiologists using PI-RADSv2 scored suspicious lesions in all patients.

RESULTS. CSC was identified in 74.3% (84/113) of patients. For CSC detection rate, no statistical differences between bpMRI and mpMRI were found for any PI-RADS score (p > 0.05). For cancer in the peripheral zone, reader 1 upgraded 22 lesions and reader 2 upgraded 13 lesions from PI-RADS score 3 at bpMRI to PI-RADS 4 (3 + 1) at mpMRI. The CSC detection rate of PI-RADS 3 + 1 lesions at mpMRI (reader 1, 63.6%; reader 2, 69.2%) was slightly greater than that of PI-RADS 3 lesions at bpMRI (reader 1, 53.8%; reader 2, 60.0%), which was not statistically different (p > 0.05). Interreader agreement on PI-RADS scoring was moderate for both bpMRI (κ = 0.540) and mpMRI (κ = 0.478).

CONCLUSION. For detecting CSC, the diagnostic performance of prebiopsy bpMRI without DCE-MRI is similar to that of mpMRI with DCE-MRI.

Keywords: diagnosis, MRI, multicenter study, PI-RADS, prostate cancer

Supported by Samsung Biomedical Research Institute grant OTX0001931 and Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2017R1A2B4006020).

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 847-854
Posted online on February 26, 2019.
(https://doi.org/10.2214/AJR.18.20571) 
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Genitourinary Imaging

Original Research

A Systematic Review of the Existing Prostate Imaging Reporting and Data System Version 2 (PI-RADSv2) Literature and Subset Meta-Analysis of PI-RADSv2 Categories Stratified by Gleason Scores

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Citation: American Journal of Roentgenology. 2019;212: 847-854. 10.2214/AJR.18.20571

ABSTRACT :

OBJECTIVE. The objective of this study was to quantitatively and qualitatively assess the methodologic heterogeneity of the current Prostate Imaging Reporting and Data System version 2 (PI-RADSv2) literature and estimate the proportions of Gleason scores (GSs) diagnosed across PI-RADSv2 categories.

MATERIALS AND METHODS. This study was a systematic review and meta-analysis and was performed in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Only English-language studies and studies published before April 1, 2018, were assessed. The primary outcome of the meta-analysis was the estimated percentage of patients with GS ≥ 3 + 4 within each individual PI-RADSv2 score. We calculated the pooled estimates and 95% CIs on the basis of a random-effects model using the meta-analysis routine of Stata (version 13.1).

RESULTS. Our search revealed 434 titles, and 59 of these studies were selected. These studies were remarkable for their technical and terminological diverseness. Thirteen studies had sufficient data to be included in the meta-analysis. The prevalence of ≥ GS 3 + 4 in lesions assigned a PI-RADSv2 score of 3 or higher was approximately 45%. Lesions assigned PI-RADSv2 scores 1 or 2, 3, 4, and 5 represented high-grade disease in approximately 6%, 12%, 48%, and 72% of patients.

CONCLUSION. The data available in the literature are highly heterogeneous and challenging to analyze because of variations in terminology, patient cohort selection, criteria, imaging parameters, and reference standards. In spite of this heterogeneity, our meta-analysis shows that PI-RADSv2 has good sensitivity when a score of ≥ 3 is considered as a positive test.

Keywords: multiparametric MRI (mpMRI), prostate imaging, Prostate Imaging Reporting and Data System (PI-RADS), Prostate Imaging Reporting and Data System version 2 (PI-RADSv2)

A. C. Westphalen is a member of the scientific advisory board for 3D Biopsy, LLC.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W100-W105
Posted online on February 4, 2019.
(https://doi.org/10.2214/AJR.18.20527) 
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Genitourinary Imaging

Original Research

Diagnostic Accuracy of Dual-Energy CT for Evaluation of Renal Masses: Systematic Review and Meta-Analysis

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Citation: American Journal of Roentgenology. 2019;212: W100-W105. 10.2214/AJR.18.20527

ABSTRACT :

OBJECTIVE. The purpose of this study is to determine the diagnostic accuracy of dual-energy CT (DECT) using quantitative iodine concentration in patients with renal masses using histopathologic analysis or follow-up imaging as the reference standard. The secondary objective is to compare the accuracy of DECT (using iodine concentration) to that of conventional CT (using Hounsfield unit measurements).

MATERIALS AND METHODS. We searched the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases for studies evaluating the accuracy of DECT for renal mass characterization (1947–2018). To be included, studies had to evaluate quantitative iodine concentrations in human patients with indeterminate renal masses. Risk of bias and applicability were assessed using quality assessment of diagnostic accuracy studies–2. A bivariate random-effects model was used to determine pooled sensitivity and specificity. Variability was assessed by subgroup analyses (DECT technique and risk of bias) and metaregression using test type and threshold applied as covariates.

RESULTS. Of 201 studies identified, five were included (367 patients). Pooled sensitivity and specificity for DECT were 96.6% (95% CI, 85.9–99.3%) and 95.1% (95% CI, 90.7–97.5%), respectively. Metaregression evaluating the influence of the test type (DECT vs conventional CT) did not identify differences in accuracy (p = 0.06). No differences in accuracy based on risk of bias or DECT technique were identified. Limitations include the small number of studies, most of which were at risk of bias.

CONCLUSION. DECT with iodine quantification shows sensitivity and specificity greater than 95% for evaluation of renal masses and may be an alternative to conventional CT for assessment of renal masses. Larger scale trials are needed to corroborate our findings.

Keywords: kidney neoplasms, meta-analysis, routine diagnostic tests, x-ray CT

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 855-858
Posted online on February 26, 2019.
(https://doi.org/10.2214/AJR.18.20459) 
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Health Care Policy and Quality

Original Research

Optimization of MRI Turnaround Times Through the Use of Dockable Tables and Innovative Architectural Design Strategies

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Citation: American Journal of Roentgenology. 2019;212: 855-858. 10.2214/AJR.18.20459

ABSTRACT :

OBJECTIVE. The purpose of this study is to increase the value of MRI by reengineering the MRI workflow at a new imaging center to shorten the interval (i.e., turnaround time) between each patient examination by at least 5 minutes.

MATERIALS AND METHODS. The elements of the MRI workflow that were optimized included the use of dockable tables, the location of patient preparation rooms, the number of doors per scanning room, and the storage location and duplication of coils. Turnaround times at the new center and at two existing centers were measured both for all patients and for situations when the next patient was ready to be brought into the scanner room after the previous patient's examination was completed.

RESULTS. Workflow optimizations included the use of dockable tables, dedicated patient preparation rooms, two doors in each MRI room, positioning the scanner to provide the most direct path to the scanner, and coil storage in the preparation rooms, with duplication of the most frequently used coils. At the new imaging center, the median and mean (± SD) turnaround times for situations in which patients were ready for scanning were 115 seconds (95% CI, 113–117 seconds) and 132 ± 72 seconds (95% CI, 129–135 seconds), respectively, and the median and mean turnaround times for all situations were 141 seconds (95% CI, 137–146 seconds) and 272 ± 270 seconds (95% CI, 263–282 seconds), respectively. For existing imaging centers, the median and mean turnaround times for situations in which patients were ready for scanning were 430 seconds (95% CI, 424–434 seconds) and 460 ± 156 seconds (95% CI, 455–465 seconds), respectively, and the median and mean turnaround times for all situations were 481 seconds (95% CI, 474–486 seconds) and 537 ± 219 seconds (95% CI, 532–543 seconds), respectively.

CONCLUSION. The optimized MRI workflow resulted in a mean time savings of 5 minutes 28 seconds per patient.

Keywords: dockable table, MRI, turnaround time, value

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 859-866
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.19931) 
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Health Care Policy and Quality

Original Research

Effect of Clinical Decision Support on Appropriateness of Advanced Imaging Use Among Physicians-in-Training

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Citation: American Journal of Roentgenology. 2019;212: 859-866. 10.2214/AJR.18.19931

ABSTRACT :

OBJECTIVE. Clinical decision support (CDS) tools have been shown to reduce inappropriate imaging orders. We hypothesized that CDS may be especially effective for house staff physicians who are prone to overuse of resources.

MATERIALS AND METHODS. Our hospital implemented CDS for CT and MRI orders in the emergency department with scores based on the American College of Radiology's Appropriateness Criteria (range, 1–9; higher scores represent more-appropriate orders). Data on CT and MRI orders from April 2013 through June 2016 were categorized as pre-CDS or baseline, post-CDS period 1 (i.e., intervention with active feedback for scores of ≤ 4), and post-CDS period 2 (i.e., intervention with active feedback for scores of ≤ 6). Segmented regression analysis with interrupted time series data estimated changes in scores stratified by house staff and non–house staff. Generalized linear models further estimated the modifying effect of the house staff variable.

RESULTS. Mean scores were 6.2, 6.2, and 6.7 in the pre-CDS, post-CDS 1, and post-CDS 2 periods, respectively (p < 0.05). In the segmented regression analysis, mean scores significantly (p < 0.05) increased when comparing pre-CDS versus post-CDS 2 periods for both house staff (baseline increase, 0.41; 95% CI, 0.17–0.64) and non–house staff (baseline increase, 0.58; 95% CI, 0.34–0.81), showing no differences in effect between the cohorts. The generalized linear model showed significantly higher scores, particularly in the post-CDS 2 period compared with the pre-CDS period (0.44 increase in scores; p < 0.05). The house staff variable did not significantly change estimates in the post-CDS 2 period.

CONCLUSION. Implementation of active CDS increased overall scores of CT and MRI orders. However, there was no significant difference in effect on scores between house staff and non–house staff.

Keywords: appropriateness, clinical decision support, house staff, overutilization, radiology

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 867-873
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.20474) 
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Musculoskeletal Imaging

Original Research

Ulnar Collateral Ligament Insertional Injuries in Pediatric Overhead Athletes: Are MRI Findings Predictive of Symptoms or Need for Surgery?

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Citation: American Journal of Roentgenology. 2019;212: 867-873. 10.2214/AJR.18.20474

ABSTRACT :

OBJECTIVE. The purpose of this study was to determine whether ulnar collateral ligament (UCL) insertion below the articular margin (so-called T sign) exists in the pediatric population and whether MRI features can be used to identify insertional UCL injuries in overhead athletes that are symptomatic or require surgery.

MATERIALS AND METHODS. Retrospective review of elbow MR images of patients younger than 21 years from 2011 to 2017 yielded 26 control subjects who were not overhead athletes and 97 overhead athletes. According to the clinical diagnosis, 50 of the overhead athletes had symptoms. Two radiologists evaluated the UCL for thickness, abnormal insertional signal intensity, insertion distance, and adjacent marrow or soft-tissue edema. Insertion distance was defined as the coronal length of any T sign measured from the articular margin.

RESULTS. Mean insertion distance was greater in overhead athletes than in control subjects (1.42 vs 0.23 mm, p = 0.001) but not significantly different in athletes with symptoms compared with those without symptoms or in those who underwent operative treatment compared with those who did not. Mean UCL thickness was greater in overhead athletes than in control subjects (2.64 vs 1.74 mm, p < 0.0001), athletes with than those without symptoms (2.84 vs 2.41 mm, p = 0.005), and athletes who did versus those who did not undergo operative treatment (3.40 vs 2.73 mm, p = 0.011). Marrow (p = 0.002) and soft-tissue (p = 0.016) edema were found more frequently in athletes with symptoms. ROC analysis of UCL thickness and insertion distance as predictors of symptoms showed AUCs of 0.69 and 0.49, respectively.

CONCLUSION. The T sign is likely not an anatomic variation but is a poor predictor of symptoms and need for surgery. Soft-tissue and marrow edema are more frequently seen in overhead athletes with symptomatic injuries and can aid in the diagnosis of clinically relevant injury.

Keywords: insertional injuries, MRI, overhead athletes, pediatric, ulnar collateral ligament

Based on presentations at the Society of Skeletal Radiology, Santa Barbara, CA, and Radiological Society of North America, Chicago, IL, 2017 annual meetings.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 874-882
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20347) 
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Musculoskeletal Imaging

Original Research

Naviculocuneiform and Second and Third Tarsometatarsal Articulations: Underappreciated Normal Anatomy and How It May Affect Fluoroscopy-Guided Injections

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Citation: American Journal of Roentgenology. 2019;212: 874-882. 10.2214/AJR.18.20347

ABSTRACT :

OBJECTIVE. Because the second and third tarsometatarsal (TMT) and naviculocuneiform joints normally communicate, the least arthritic or technically most straightforward joint was injected when a fluoroscopically guided therapeutic injection was ordered for one or both joints. We hypothesized that pain relief would be equivalent regardless of the joint injected and would result in less radiation and a lower steroid dose compared with patients who had both articulations injected.

MATERIALS AND METHODS. Seventy-eight patients were divided into four joint groups: naviculocuneiform requested and injected (n = 15), nonrequested naviculocuneiform or second and third TMT injected (n = 25), both injected (n = 23), and TMT requested and injected (n = 15). Variables recorded included patient age and sex, fluoroscopy time, steroid dose, pre- and postprocedural pain, osteoarthrosis (OA) grade, and confidence of intraarticular injection. Statistical analysis compared mean pain level change before and after injection, mean fluoroscopy time, and mean steroid dose between groups. The mean OA grade of the nonrequested joint was compared with that of the requested joint in patients whose injected and requested joints did not match (group 2).

RESULTS. Pre- and postinjection pain reduction (p = 0.630) and postinjection pain (p = 0.935) were not significantly different. Mean steroid dose (p< 0.001) and fluoroscopy time (p = 0.0001) were significantly increased for the both joint injection group. Within the nonrequested naviculocuneiform or second and third TMT injection group, there was a significant difference in OA grade between injected (least arthritic) and requested joints (p = 0.001).

CONCLUSION. When faced with challenging naviculocuneiform or second and third TMT joint injections, choosing the technically most straightforward joint may result in less radiation and steroid dose without compromising quality of care or pain reduction.

Keywords: anatomy, fluoroscopy, injection, naviculocuneiform, osteoarthrosis, second and third tarsometatarsal joints

Acknowledgments
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We thank Nan Hu, Xuechen (Kathryn) Wang, and Ryan S. Hirschi for their help.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 883-891
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20531) 
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Neuroradiology/Head and Neck Imaging

Original Research

Integrated PET-MRI for Glioma Surveillance: Perfusion-Metabolism Discordance Rate and Association With Molecular Profiling

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Citation: American Journal of Roentgenology. 2019;212: 883-891. 10.2214/AJR.18.20531

ABSTRACT :

OBJECTIVE. Both 18F-FDG PET and perfusion MRI are commonly used techniques for posttreatment glioma surveillance. Using integrated PET-MRI, we assessed the rate of discordance between simultaneously acquired FDG PET images and dynamic contrast-enhanced (DCE) perfusion MR images and determined whether tumor genetics predicts discordance.

MATERIALS AND METHODS. Forty-one consecutive patients with high-grade gliomas (20 with grade IV gliomas and 21 with grade III gliomas) underwent a standardized tumor protocol performed using an integrated 3-T PET-MRI scanner. Quantitative measures of standardized uptake value, plasma volume, and permeability were obtained from segmented whole-tumor volumes of interest and targeted ROIs. ROC curve analysis and the Youden index were used to identify optimal cutoffs for FDG PET and DCE-MRI. Two-by-two contingency tables and percent agreement were used to assess accuracy and concordance. Twenty-six patients (63%) from the cohort underwent next-generation sequencing for tumor genetics.

RESULTS. The best-performing FDG PET and DCE-MRI cutoffs achieved sensitivities of 94% and 91%, respectively; specificities of 56% and 89%, respectively; and accuracies of 80% and 83%, respectively. FDG PET and DCE-MRI findings were discordant for 11 patients (27%), with DCE-MRI findings correct for six of these patients (55%). Tumor grade, tumor volume, bevacizumab exposure, and time since radiation predicted discordance between FDG PET and DCE-MRI findings, with an ROC AUC value of 0.78. Isocitrate dehydrogenase gene and receptor tyrosine kinase gene pathway mutations increased the ROC AUC value to 0.83.

CONCLUSION. FDG PET and DCE-MRI show comparable accuracy and sensitivity in identifying tumor progression. These modalities were shown to have discordant findings for more than a quarter of the patients assessed. Tumor genetics may contribute to perfusion-metabolism discordance, warranting further investigation.

Keywords: glioma, perfusion, permeability, PET-MRI, tumor

Based on a presentation at the American Society of Neuroradiology 2018 annual meeting, Vancouver, BC, Canada.

Supported in part by award UL1TR000457 from the National Center for Advancing Translational Sciences of the National Institutes of Health.

Acknowledgment
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We thank Gulce Askin, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, for her statistical guidance.

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The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 892-898
Posted online on February 11, 2019.
(https://doi.org/10.2214/AJR.18.20044) 
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Neuroradiology/Head and Neck Imaging

Original Research

Neurofibromatosis Type 1: Description of a Novel Diagnostic Scoring System in Pediatric Optic Nerve Glioma

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Citation: American Journal of Roentgenology. 2019;212: 892-898. 10.2214/AJR.18.20044

ABSTRACT :

OBJECTIVE. Neurofibromatosis type 1 (NF1) is a multisystemic genetic disease in which patients develop benign tumors including optic nerve gliomas (ONG). Optic nerve thickening and tortuosity are radiologic markers of tumors but can also be present in children with NF1 who do not have gliomas, thus complicating screening and diagnosis. We undertook this study to retrospectively determine quantitative and qualitative diagnostic criteria using MRI of the orbits for ONG in children with NF1.

MATERIALS AND METHODS. MR images of the orbits obtained from 2003 to 2016 for children with and without NF1 were reviewed. Optic nerves were divided into three groups: NF1 with glioma (n = 71 nerves), NF1 without glioma (n = 151 nerves), and healthy control subjects (n = 66 nerves). The diameter of each nerve was measured at multiple locations. Two radiologists assessed tortuosity using validated criteria, and subarachnoid dilatation was quantified. Last, a composite score using both optic nerve diameter and tortuosity was proposed.

RESULTS. The mean diameter of the optic nerve was significantly larger in patients with NF1 with glioma compared with those with NF1 without glioma and with control subjects at all locations. Maximal nerve diameter greater than 2 SD above the mean maximal diameter for control nerves was considered abnormally enlarged. The tortuosity parameters were all significantly associated with ONG compared with absence of ONG in NF1. A scoring system derived from these data were highly reliable in differentiating ONG from absence of ONG in NF1.

CONCLUSION. The radiologic diagnosis of ONG in patients with NF1 is challenging. The scoring systems we describe provide a framework for simple radiologic criteria for ONG in these patients.

Keywords: glioma, neurofibromatosis type 1, optic, pediatric, tortuosity

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 899-904
Posted online on January 30, 2019.
(https://doi.org/10.2214/AJR.18.20336) 
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Neuroradiology/Head and Neck Imaging

Original Research

Neurointerventional Radiology for the Aspiring Radiology Resident: Current State of the Field and Future Directions

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Citation: American Journal of Roentgenology. 2019;212: 899-904. 10.2214/AJR.18.20336

ABSTRACT :

OBJECTIVE. The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR).

MATERIALS AND METHODS. Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed.

RESULTS. From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists.

CONCLUSION. Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

Keywords: fellowship, interventional neuroradiology, neurointerventional radiology, radiology residents, training

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 905-913
Posted online on December 27, 2018.
(https://doi.org/10.2214/AJR.18.19811) 
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Pediatric Imaging

Original Research

Imaging Patterns of Pediatric Pulmonary Blastomycosis

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Citation: American Journal of Roentgenology. 2019;212: 905-913. 10.2214/AJR.18.19811

ABSTRACT :

OBJECTIVE. The objective of our study was to characterize and update the radiologic patterns of pediatric pulmonary blastomycosis, and correlate the radiologic patterns with patient age.

MATERIALS AND METHODS. Patients 0–18 years old with pulmonary blastomycosis who underwent chest imaging from 2005 to 2016 were included in this study. The following data were collected: age, sex, clinical information, and imaging findings including presence of extrapulmonary involvement and scarring on follow-up examinations. Concordance between radiography and CT was analyzed.

RESULTS. Thirty-six patients (28 boys and eight girls) ranging in age from 3 months to 17 years (mean, 10.5 years) were identified. Consolidation was found in 94.4% of patients and was unilateral in 76.5% of cases and bilateral in 23.5%. Upper (70.6%) and middle (47.1%) lobes were more frequently involved. Air bronchograms were identified in 76.5% of patients with consolidations, masslike consolidation was found in 55.9%, cavitation in 38.2%, and bubbly pattern (i.e., multiple small cavities) in 32.4%. In all patients younger than 5 years, consolidations involved multiple lobes. In 67.6% of patients, consolidations were associated with the following additional pulmonary or pleural abnormalities: pulmonary nodules (50% of patients), diffuse patchy opacification (26.5%), reticulonodular pattern (41.2%), atelectasis (5.9%), pleural effusion (20.6%), and hilar lymphadenopathy (23.5%). Pulmonary scarring was found in 70.4% of patients. Five patients had extrapulmonary involvement. The concordance between radiography and CT was excellent for location and extension of consolidation and diagnosis of cavitation, bubbly pattern, and nodules.

CONCLUSION. The most common pattern of lung involvement from pulmonary blastomycosis in our series was a combination of consolidations with bilateral lung nodules and reticulonodular opacification.

Keywords: chest CT, chest radiography, different age groups, imaging patterns, pediatric pulmonary blastomycosis

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 914-918
Posted online on February 4, 2019.
(https://doi.org/10.2214/AJR.18.20000) 
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Vascular and Interventional Radiology

Technical Innovation

Feasibility of Image Fusion for Concurrent MRI Evaluation of Vessel Lumen and Vascular Calcifications in Peripheral Arterial Disease

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Citation: American Journal of Roentgenology. 2019;212: 914-918. 10.2214/AJR.18.20000

ABSTRACT :

OBJECTIVE. With MR angiography of peripheral arterial disease, calcifications are unapparent, so a separate calcification-sensitive pulse sequence (proton density–weighted in-phase 3D stack-of-stars [PDIP-SOS]) is needed for complete assessment. We hypothesized that, despite being acquired separately, MR angiography and PDIP-SOS images could be coregistered and fused without loss of significant diagnostic information.

CONCLUSION. In a prospective study of 15 patients, MR image fusion enabled the simultaneous display of vessel lumen and vascular calcifications similarly to CT angiography.

Keywords: CT angiography, image fusion, MR angiography, unenhanced, vascular calcifications

Supported by grants R01 HL130093 and R21 HL126015 from the National Institutes of Health.

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The authors have received research support and royalties from Siemens Healthcare.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 919-924
Posted online on February 4, 2019.
(https://doi.org/10.2214/AJR.18.20306) 
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Women's Imaging

Original Research

Qualitative Radiogenomics: Association Between BI-RADS Calcification Descriptors and Recurrence Risk as Assessed by the Oncotype DX Ductal Carcinoma In Situ Score

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Citation: American Journal of Roentgenology. 2019;212: 919-924. 10.2214/AJR.18.20306

ABSTRACT :

OBJECTIVE. Treatment of ductal carcinoma in situ (DCIS) is controversial given the variable recurrence and progression to invasive carcinoma. Identifying women who would benefit from adjuvant radiation therapy on the basis of their recurrence risk may allow more individualized management strategies. The Oncotype DX Breast DCIS Score—which we refer to here as the "DCIS score"—is a validated surrogate marker of local recurrence. This study evaluated the association between BI-RADS mammographic calcification descriptors and the DCIS score.

MATERIALS AND METHODS. Fifty-eight women diagnosed with DCIS presenting with calcifications who had Oncotype DX Breast DCIS assay results were identified. Pretreatment BI-RADS mammographic calcification features were collected including morphology, distribution, and maximum span. The association between calcification descriptors and DCIS score was assessed with logistic regression modeling. Mean DCIS scores were calculated for calcification features significantly associated with DCIS score. All analyses were adjusted for patient age, DCIS grade, and progesterone receptor status.

RESULTS. Of the suspicious calcifications that proved to represent DCIS, 19.0% were amorphous; 25.9%, coarse heterogeneous; 39.7%, fine pleomorphic; and 15.5%, fine linear or fine linear branching in morphology. The mean DCIS scores by calcification morphology were 22.3, 35.5, 36.7, and 44.1, respectively. Amorphous calcification morphology had a significantly lower adjusted mean DCIS score compared with fine pleomorphic morphology (p = 0.01) and fine linear or fine linear branching morphology (p = 0.02). The adjusted odds ratio (OR) of intermediate or high risk of recurrence (defined as a DCIS score ≥ 39) was significantly higher for women with fine pleomorphic calcifications (OR = 53.1, p = 0.01) and for those with fine linear or fine linear branching calcifications (OR = 24.0, p = 0.04) than for women with amorphous calcifications.

CONCLUSION. Women with amorphous calcification morphology had the lowest DCIS scores compared with women with fine pleomorphic and fine linear or fine linear branching morphologies. Both fine pleomorphic and fine linear or fine linear branching morphologies were associated with higher odds of intermediate or high risk of recurrence. These findings suggest mammographic features are potential biomarkers of DCIS recurrence and could help individualize treatment decisions.

Keywords: biomarkers, calcifications, ductal carcinoma in situ (DCIS), Oncotype DX

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 925-932
Posted online on February 11, 2019.
(https://doi.org/10.2214/AJR.18.20421) 
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Women's Imaging

Original Research

Overstated Harms of Breast Cancer Screening? A Large Outcomes Analysis of Complications Associated With 9-Gauge Stereotactic Vacuum-Assisted Breast Biopsy

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Citation: American Journal of Roentgenology. 2019;212: 925-932. 10.2214/AJR.18.20421

ABSTRACT :

OBJECTIVE. The purpose of this study was to assess the rate, type, and severity of complications related to 9-gauge stereotactic vacuum-assisted breast biopsy (SVAB) and to delineate associated factors that may contribute to a higher rate of complications.

MATERIALS AND METHODS. This retrospective study included 4776 patients who underwent SVAB between 2003 and 2016. A total of 319 patients with documented postbiopsy complications were identified. Complications were subcategorized as bleeding, pain, lightheadedness, bruising, and other complications, and their severity was classified as minor, moderate, or severe. Hematoma volumes were correlated with biopsy location and complication severity. A group of control subjects who underwent SVAB but had no complications was compared with the group of study patients with regard to age, biopsy location, lesion type, and pathologic findings. Postbiopsy screening adherence was assessed. Statistical analyses were performed using the Fisher exact, Mann-Whitney, Kruskal-Wallis, and Spearman rank correlation tests.

RESULTS. Of the 319 patients with complications who were identified (representing 6.7% of the 4776 patients who underwent SVAB), 307 (96.2%) had mild complications, 12 (3.8%) had moderate complications, and no patients had severe complications. The most common complication was bleeding or hematoma (89.3% of patients [285/319]), followed by pain (6.9% [22/319]), lightheadedness (0.9% [3/319]), bruising (0.9% [3/319]), and other complications (1.9% [6/319]). No significant differences were noted between the study group and the control group in terms of age (p = 0.474), biopsy location (p = 0.065), histologic findings (p = 0.056), or lesion type (p = 0.568). Hematoma volume (median, 7.5 cm3) did not correspond to the severity of complications. Larger hematoma volumes were associated with a posterior biopsy location (p = 0.008). The rate of return to annual screening after biopsy was not adversely affected by the presence of biopsy complications.

CONCLUSION. Clinically significant complications associated with SVAB were exceedingly rare (0.3%) in this large study spanning 13 years.

Keywords: breast, complications, mammography, screening mammography, stereotactic breast biopsy

Based on a presentation at the Radiological Society of North America 2017 annual meeting, Chicago, IL.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 933-942
Posted online on February 19, 2019.
(https://doi.org/10.2214/AJR.18.20138) 
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Women's Imaging

Original Research

Ability of Dual-Energy CT to Detect Silicone Gel Breast Implant Rupture and Nodal Silicone Spread

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Citation: American Journal of Roentgenology. 2019;212: 933-942. 10.2214/AJR.18.20138

ABSTRACT :

OBJECTIVE. The purpose of this study is to compare the performance of dual-energy CT (DECT) with that of breast MRI for detection of silicone gel breast implant rupture and nodal spread of silicone.

SUBJECTS AND METHODS. This prospective study enrolled consecutive patients with current or prior silicone gel implants and clinical suspicion of implant rupture or extra-capsular silicone. All patients underwent MRI followed by unenhanced DECT. A breast radiologist not participating in image evaluation established reference standards for implant rupture (intra- or extracapsular) and regional nodal silicone spread (to axillary nodes and internal mammary [IM] and mediastinal nodes) using MRI, surgical findings, and medical records. After undergoing reader training, two radiologists who were blinded to all medical records interpreted randomized images in two sessions, indicating confidence in diagnosis using a 100-point visual scale.

RESULTS. A total of 46 patients who had a subpectoral silicone gel implant (n = 31), a subglandular silicone gel implant (n = 14), or a silicone gel implant that was removed (n = 1) underwent MRI and DECT (mean [± SD] volume CT dose index, 8.2 ± 2.0 mGy). Nineteen patients had implant rupture, and 13 of these patients had silicone within the IM or axillary nodes. Pooled data showed no significant difference between MRI and DECT interpretation of intra- or extracapsular rupture of implants (AUC value for intracapsular rupture, 0.958 [for MRI] vs 0.989 [for DECT]; p = 0.28; AUC value for extracapsular rupture, 0.864 [for MRI] vs 0.878 [for DECT]; p = 0.78). No difference was noted in the AUC value for silicone spread to regional lymph nodes: 0.823–0.866 [for MRI] vs 0.892–0.906 [for DECT]; p = 0.34–0.54).

CONCLUSION. DECT performs similar to MRI for the detection of silicone gel implant rupture and the presence of silicone in regional lymph nodes, and it may be an alternative for patients who are unable or unwilling to undergo MRI.

Keywords: breast implant, dual-energy CT, implant rupture, MRI, silicone

Mayo Clinic receives a grant from Siemens Healthineers and provided the CT system used in this research.

Based on a presentation at the Radiological Society of North America 2017 annual meeting, Chicago, IL.

Supported in part by a research grant from Siemens Healthcare.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. 943-946
Posted online on January 23, 2019.
(https://doi.org/10.2214/AJR.18.20363) 
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Women's Imaging

Technical Innovation

Tomosynthesis-Guided Needle Localization of Breast and Axillary Lesions: Our Initial Experience

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Citation: American Journal of Roentgenology. 2019;212: 943-946. 10.2214/AJR.18.20363

ABSTRACT :

OBJECTIVE. The purpose of this study is to review tomosynthesis-guided wire and seed needle localizations of the breast and axilla performed at our institution.

CONCLUSION. Tomosynthesis-guided needle localizations were performed for 38 lesions, including 14 architectural distortions, five groups of calcifications, two focal asymmetries, three masses, four breast clips, and 10 axillary clips. All lesions were successfully removed at surgery, indicating that breast and axillary lesions can be precisely localized under tomosynthesis.

Keywords: axilla, breast, localization, surgery, tomosynthesis

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W106-W106
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20803) 
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Letters

Medicolegal—Malpractice and Ethical Issues in Radiology
Referring Physician's Receipt of Radiology Report With Abnormal Findings May Be Guaranteed, but Is the Report Read and Action Taken?

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Citation: American Journal of Roentgenology. 2019;212: W106-W106. 10.2214/AJR.18.20803

WEB—This is a web exclusive article.

All opinions expressed herein are those of the author and do not necessarily reflect those of the AJR or the ARRS.

This monthly column answers common professional liability questions. The legal advice provided herein is intended to be general in nature and in specific circumstances is not a substitute for formal legal opinions obtained from the reader's personal legal counsel.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W107-W108
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20379) 
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Hallway Conversations in Physics
What Is Peak Skin Dose?

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Citation: American Journal of Roentgenology. 2019;212: W107-W108. 10.2214/AJR.18.20379

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W109-W109
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20645) 
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Letters

Methodologic Issues in Prediction of Posthepatectomy Liver Failure

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Citation: American Journal of Roentgenology. 2019;212: W109-W109. 10.2214/AJR.18.20645

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W110-W110
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20772) 
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Letters

Reply to "Methodologic Issues in Prediction of Posthepatectomy Liver Failure"

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Citation: American Journal of Roentgenology. 2019;212: W110-W110. 10.2214/AJR.18.20772

WEB—This is a web exclusive article.

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W111-W111
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20671) 
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Letters

CT Dose Management: Our Experience in Implementing a Program With an Education-Focused Approach

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Citation: American Journal of Roentgenology. 2019;212: W111-W111. 10.2214/AJR.18.20671

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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W112-W112
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20777) 
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Letters

Reply to "CT Dose Management: Our Experience in Implementing a Program With an Education-Focused Approach"

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Citation: American Journal of Roentgenology. 2019;212: W112-W112. 10.2214/AJR.18.20777

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Reference

1. Velasco S, Torres-Cortes D, Aguirre D. CT dose management: our experience in implementing a program with an education-focused approach. (letter) AJR 2019; 212:[web]W111 [Google Scholar]
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American Journal of Roentgenology
April, Vol. 212, No. 4, pp. W113-W113
Posted online on March 22, 2019.
(https://doi.org/10.2214/AJR.18.20724) 
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Letters

Use of Bioelectrical Phase Angle in the Estimation of Accurate Body Composition

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Citation: American Journal of Roentgenology. 2019;212: W113-W113. 10.2214/AJR.18.20724

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