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Objectives Reporting of United States Medical Licensing Examination Step 1 results will transition from a numerical score to a pass or fail result. We sought an objective analysis to determine changes in the relative importance of resident application attributes when numerical Step 1 results are replaced. Methods A discrete choice experiment was designed to model radiology resident selection and determine the relative weights of various application factors when paired with a numerical or pass or fail Step 1 result. Faculty involved in resident selection at 14 US radiology programs chose between hypothetical pairs of applicant profiles between August and November 2020. A conditional logistic regression model assessed the relative weights of the attributes, and odds ratios (ORs) were calculated. Results There were 212 participants. When a numerical Step 1 score was provided, the most influential attributes were medical school (OR: 2.35, 95% confidence interval [CI]: 2.07-2.67), Black or Hispanic race or ethnicity (OR: 2.04, 95% CI: 1.79-2.38), and Step 1 score (OR: 1.8, 95% CI: 1.69-1.95). When Step 1 was reported as pass, the applicant’s medical school grew in influence (OR: 2.78, 95% CI: 2.42-3.18), and there was a significant increase in influence of Step 2 scores (OR: 1.31, 95% CI: 1.23-1.40 versus OR 1.57, 95% CI: 1.46-1.69). There was little change in the relative influence of race or ethnicity, gender, class rank, or clerkship honors. Discussion When Step 1 reporting transitions to pass or fail, medical school prestige gains outsized influence and Step 2 scores partly fill the gap left by Step 1 examination as a single metric of decisive importance in application decisions.

PURPOSE: To develop a deep learning–based risk stratification system for thyroid nodules using US cine images. MATERIALS AND METHODS: In this retrospective study, 192 biopsy-confirmed thyroid nodules (175 benign, 17 malignant) in 167 unique patients (mean age, 56 years ± 16 [SD], 137 women) undergoing cine US between April 2017 and May 2018 with American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS)–structured radiology reports were evaluated. A deep learning–based system that exploits the cine images obtained during three-dimensional volumetric thyroid scans and outputs malignancy risk was developed and compared, using fivefold cross-validation, against a two-dimensional (2D) deep learning–based model (Static-2DCNN), a radiomics-based model using cine images (Cine-Radiomics), and the ACR TI-RADS level, with histopathologic diagnosis as ground truth. The system was used to revise the ACR TI-RADS recommendation, and its diagnostic performance was compared against the original ACR TI-RADS. RESULTS: The system achieved higher average area under the receiver operating characteristic curve (AUC, 0.88) than Static-2DCNN (0.72, P = .03) and tended toward higher average AUC than Cine-Radiomics (0.78, P = .16) and ACR TI-RADS level (0.80, P = .21). The system downgraded recommendations for 92 benign and two malignant nodules and upgraded none. The revised recommendation achieved higher specificity (139 of 175, 79.4%) than the original ACR TI-RADS (47 of 175, 26.9%; P < .001), with no difference in sensitivity (12 of 17, 71% and 14 of 17, 82%, respectively; P = .63). CONCLUSION: The risk stratification system using US cine images had higher diagnostic performance than prior models and improved specificity of ACR TI-RADS when used to revise ACR TI-RADS recommendation. Keywords: Neural Networks, US, Abdomen/GI, Head/Neck, Thyroid, Computer Applications–3D, Oncology, Diagnosis, Supervised Learning, Transfer Learning, Convolutional Neural Network (CNN) Supplemental material is available for this article. © RSNA, 2022

OBJECTIVE. Using the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS), this study sought to determine whether decreasing the point assignment for punctate echogenic foci in mixed solid and cystic nodules would reduce the number of benign mixed solid and cystic nodules that were biopsied and would not substantially increase the number of missed mixed carcinomas MATERIALS AND METHODS. A multiinstitutional database of 3422 pathologically proven thyroid nodules was evaluated to identify all mixed solid and cystic nodules with punctate echogenic foci. We determined the numbers of mixed benign and malignant nodules that would receive ACR TI-RADS recommendations of fine-needle aspiration, follow-up, and no further evaluation if the points assigned to punctate echogenic foci were changed from 3 points to 1 or 2 points. RESULTS. A total of 287 mixed nodules were adequately characterized for evaluation. When the number of points assigned to punctate echogenic foci was changed from 3 points to 1 point, the point categories changed for 198 mixed nodules. Seven carcinomas would not undergo biopsy, but six of those seven would receive follow-up, and 44 benign nodules would not undergo biopsy. When 2 points were assigned to punctate echogenic foci, the point categories changed for 66 mixed nodules. Three carcinomas would not undergo biopsy, but all three of these would receive follow-up, and eight benign nodules would not undergo biopsy. CONCLUSION. Consideration should be given to decreasing the number of points assigned to punctate echogenic foci in mixed solid and cystic thyroid nodules, given the substantial decrease in the number of benign nodules requiring biopsy and the recommendation of follow-up for any carcinoma 1 cm or larger that did not undergo biopsy.

PURPOSE: To automatically identify a cohort of patients with pancreatic cystic lesions (PCLs) and extract PCL measurements from historical CT and MRI reports using natural language processing (NLP) and a question answering system. MATERIALS AND METHODS: Institutional review board approval was obtained for this retrospective Health Insurance Portability and Accountability Act–compliant study, and the requirement to obtain informed consent was waived. A cohort of free-text CT and MRI reports generated between January 1991 and July 2019 that covered the pancreatic region were identified. A PCL identification model was developed by modifying a rule-based information extraction model; measurement extraction was performed using a state-of-the-art question answering system. The system's performance was evaluated against radiologists’ annotations. RESULTS: For this study, 430 426 free-text radiology reports from 199 783 unique patients were identified. The NLP model for identifying PCL was applied to 1000 test samples. The interobserver agreement between the model and two radiologists was almost perfect (Fleiss κ = 0.951), and the false-positive rate and true-positive rate were 3.0% and 98.2%, respectively, against consensus of radiologists’ annotations as ground truths. The overall accuracy and Lin concordance correlation coefficient for measurement extraction were 0.958 and 0.874, respectively, against radiologists’ annotations as ground truths. CONCLUSION: An NLP-based system was developed that identifies patients with PCLs and extracts measurements from a large single-institution archive of free-text radiology reports. This approach may prove valuable to study the natural history and potential risks of PCLs and can be applied to many other use cases. Keywords: Informatics, Abdomen/GI, Pancreas, Cysts, Computer Applications-General (Informatics), Named Entity Recognition Supplemental material is available for this article. © RSNA, 2022 See also commentary by Horii in this issue.

OBJECTIVE. The purpose of this study was to explore whether a quantitative framework can be used to sonographically differentiate benign and malignant thyroid nodules at a level comparable to that of experts. MATERIALS AND METHODS. A dataset of ultrasound images of 92 biopsy-confirmed nodules was collected retrospectively. The nodules were delineated and annotated by two expert radiologists using the standardized Thyroid Imaging Reporting and Data System lexicon of the American College of Radiology. In the framework studied, quantitative features of echogenicity, texture, edge sharpness, and margin curvature properties of thyroid nodules were analyzed in a regularized logistic regression model to predict malignancy of a nodule. The framework was validated by leave-one-out cross-validation technique, and ROC AUC, sensitivity, and specificity were used to compare with those obtained with six expert annotation-based classifiers. RESULTS. The AUC of the proposed method was 0.828 (95% CI, 0.715-0.942), which was greater than or comparable to that of the expert classifiers, for which the AUC values ranged from 0.299 to 0.829 (p = 0.99). Use of the proposed framework could have avoided biopsy of 20 of 46 benign nodules in a curative strategy (at sensitivity of 1, statistically significantly higher than three expert classifiers) or helped identify 10 of 46 malignancies in a conservative strategy (at specificity of 1, statistically significantly higher than five expert classifiers). CONCLUSION. When the proposed quantitative framework was used, thyroid nodule malignancy was predicted at the level of expert classifiers. Such a framework may ultimately prove useful as the basis for a fully automated system of thyroid nodule triage.

Bladder cancer is the most common cancer of the urinary system and often presents with hematuria. Despite its relatively high incidence, bladder cancer is often under-recognized sonographically. Moreover, even when bladder abnormalities are identified, numerous other entities may mimic the appearance of bladder cancer. Given the incidence and prevalence of bladder cancer, it is important to recognize its variable appearance sonographically and distinguish it from its common mimics. We review the sonographic appearance of bladder cancer and its mimics, providing correlative CT/MR imaging as well as pathology. We stress the importance and advantage of ultrasound as a dynamic imaging modality, with the ability to optimize distinguishing bladder cancer from similar-appearing entities.

Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.

Deception is a common feature of behavioral research design, although not commonly employed in the medical literature. It can promote scientific validity but is ethically controversial because it compromises subject autonomy and incurs additional costs. In this Point/Counterpoint monograph, we review the nature of deception in research and present arguments for and against its ethical use as a research methodology in behavioral studies. We describe the necessary guidelines, safeguards, and oversight, when deceptive methodology is considered, and report our experiences and lessons learned from conducting a multi-institutional audit study that relied upon deception of academic radiology faculty.

The American College of Radiology Ultrasound Liver Imaging Reporting and Data System (ACR US LI-RADS) Visualization Score conveys the expected level of sensitivity of screening and surveillance ultrasound exams in patients at risk for hepatocellular carcinoma (HCC). We sought to determine inter-reader agreement of the Visualization Score which is currently unknown. Consecutive 6998 ultrasound HCC screening and surveillance studies in 3115 patients from 2017 to 2020 were retrospectively retrieved. Of these, 6154 (87.9%) studies were Visualization A (No or minimal limitations), 709 (10.1%) were Visualization B (Moderate limitations), and 135 (1.9%) were Visualization C (Severe limitations). Randomly sampled 90 studies, with 30 studies in each Visualization category, were included for analysis. Nine radiologists (3 senior attendings, 3 junior attendings and 3 body imaging fellows) blinded to the original categorization independently reviewed each study and assigned a Visualization Score. Intraclass correlation coefficient (ICC) was used to quantify inter-reader agreement. ICC among all 9 radiologists was 0.70 (95% CI 0.63–0.77). ICCs among senior attendings, junior attendings and body imaging fellows were 0.68 (CI 0.58–0.76), 0.72 (CI 0.62–0.80) and 0.76 (CI 0.68–0.83), respectively. Subgroup analysis by liver parenchyma was further performed. ICC was highest in the patient group with normal liver parenchyma (0.69, CI 0.56–0.81), followed by steatosis (0.66, CI 0.54–0.79) and cirrhosis (0.58, CI 0.43–0.73), respectively. US LI-RADS Visualization Score is a reliable tool with good inter-reader agreement that can be used to indicate the expected level of sensitivity of a screening and surveillance ultrasound examination for detecting focal liver observations.

Emerging data suggest that the location of thyroid nodules influences malignancy risk. The purpose of this study was to explore the impact of including location in American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) scoring. Four of five revised scoring algorithms that added 1 or 2 points to higher-risk locations were associated with lowered accuracy due to lower specificity. However, an algorithm that added 1 point to isthmic nodules did not differ significantly from ACR TI-RADS in accuracy; one additional isthmic cancer was diagnosed for each 10.3 additional benign nodules recommended for biopsy.

OBJECTIVE. Compared with other guidelines, the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) has decreased the number of nodules for which fine-needle aspiration is recommended. The purpose of this study was to evaluate the characteristics of malignant nodules that would not be biopsied when the ACR TI-RADS recommendations are followed. MATERIALS AND METHODS. We retrospectively reviewed a total of 3422 thyroid nodules for which a definitive cytologic diagnosis, a definitive histologic diagnosis, or both diagnoses as well as diagnostic ultrasound (US) examinations were available. All nodules were categorized using the ACR TI-RADS, and they were divided into three groups according to the recommendation received: fine-needle aspiration (group 1), follow-up US examination (group 2), or no further evaluation (group 3). RESULTS. Of the 3422 nodules, 352 were malignant. Of these, 240 nodules were assigned to group 1, whereas 72 were assigned to group 2 and 40 were included in group 3. Sixteen of the 40 malignant nodules in group 3 were 1 cm or larger, and, on the basis of analysis of the sonographic features described in the ACR TI-RADS, these nodules were classified as having one of five ACR TI-RADS risk levels (TR1-TR5), with one nodule classified as a TR1 nodule, eight as TR2 nodules, and seven as TR3 nodules. If the current recommendation of no follow-up for TR2 nodules was changed to follow-up for nodules 2.5 cm or larger, seven additional malignant nodules and 316 additional benign nodules would receive a recommendation for follow-up. If the current size threshold (1.5 cm) used to recommend US follow-up for TR3 nodules was decreased to 1.0 cm, seven additional malignant nodules and 118 additional benign nodules would receive a recommendation for follow-up. CONCLUSION. With use of the ACR TI-RADS, most malignant nodules that would not be biopsied would undergo US follow-up, would be smaller than 1 cm, or would both undergo US follow-up and be smaller than 1 cm. Adjusting size thresholds to decrease the number of missed malignant nodules that are 1 cm or larger would result in a substantial increase in the number of benign nodules undergoing follow-up.

Implicit bias is common and is thought to drive discriminatory behaviour. Having previously demonstrated discrimination against specific applicant demographics by academic radiology departments in a simulated resident selection process, the authors sought to better understand the relationship between implicit bias and discrimination, as well as the potential and mechanisms for their mitigation.A total of 51 faculty reviewers at three academic radiology departments, who had participated in a 2017 audit study in which they were shown to treat applicants differently based on race or ethnicity and physical appearance, were invited to complete testing for implicit racial and weight bias using the Implicit Association Test in 2019. Respondents were also surveyed regarding awareness of their own personal racial and weight biases, as well as any prior participation in formal diversity training. Comparisons were made between implicit bias scores and applicant ratings, as well as between diversity training and self-awareness of bias.A total of 31 out of 51 faculty reviewers (61%) completed and submitted results of race and weight Implicit Association Tests. A total of 74% (23/31) reported implicit anti-obese bias, concordant with discrimination demonstrated in the resident selection simulation, in which obese applicants were rated 0.40 standard deviations (SDs) lower than non-obese applicants (P .001). A total of 71% (22/31) reported implicit anti-Black bias, discordant with application ratings, which were 0.47 SDs higher for Black than for White applicants (P .001). A total of 84% (26/31) of participants reported feeling self-aware of potential racial bias at the time of application review, significantly higher than the 23% (7/31) reporting self-awareness of potential anti-obese bias (P .001). Participation in formal diversity training was not associated with implicit anti-Black or anti-fat bias, nor with self-reported awareness of potential racial or weight-based bias (all P .2).These findings suggest that implicit bias, as measured by the Implicit Association Test, does not inevitably lead to discrimination, and that personal awareness of implicit biases may allow their mitigation.

OBJECTIVE. The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) provides guidelines to practitioners who interpret sonographic examinations of thyroid nodules...

Thyroid nodules are a frequent finding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identify the small number that are malignant or require surgery for a definitive diagnosis. Since 2009, many professional societies and investigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic follow-up. Because some of these systems were founded on the BI-RADS® classification that is widely used in breast imaging, their authors chose to apply the acronym TI-RADS, for Thyroid Imaging, Reporting and Data System. In 2012, the ACR convened committees to (1) provide recommendations for reporting incidental thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound reporting, and (3) propose a TI-RADS on the basis of the lexicon. The committees published the results of the first two efforts in 2015. In this article, the authors present the ACR TI-RADS Committee's recommendations, which provide guidance regarding management of thyroid nodules on the basis of their ultrasound appearance. The authors also describe the committee's future directions.

Objectives To determine whether hepatic arterial and portal venous Doppler ultrasound measurements of the liver in cirrhotic patients correlate with patients' Model for End-Stage Liver Disease (MELD) scores, splenomegaly, or ascites. Materials and Methods Sonographic images and reports were reviewed of 264 patients with hepatic cirrhosis who underwent abdominal ultrasound with Doppler in this internal review board–approved retrospective study. MELD scores were recorded at the time of ultrasound. On gray-scale ultrasound, spleen length was measured and the presence of ascites was noted. Hepatic arterial velocity (HAv) with angle correction, hepatic arterial resistive index, and portal vein velocity with angle correction were measured on Doppler ultrasound. Correlation of hepatic arterial and portal venous Doppler values with MELD score, presence of splenomegaly, and presence of ascites was tested using linear or binary logistic regression analysis. Diagnostic performance of Doppler parameters for high-risk MELD was assessed. Results The HAv statistically significantly correlated with the MELD score (P = .0001), spleen size (P =.027), and presence of ascites (P =.0001), whereas the hepatic arterial resistive index and portal vein velocity did not correlate with these factors. For MELD scores greater than 19, an HAv greater than 120 cm/s showed accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 74, 42, 90, 67, and 76%, respectively. With an HAv greater than 160 cm/s, the odds ratio for MELD scores greater than 19 was 42.1. Conclusions We found a statistically significant correlation with elevated HAv and increasing MELD scores, splenomegaly, and presence of ascites in patients with cirrhotic liver disease; this may be a useful imaging biomarker in the evaluation of patients with cirrhosis.

To evaluate for appearance-based discrimination in the selection of radiology residents.A deception study simulating the resident selection process examined the impact of attractiveness and obesity on resident selection. Seventy-four core faculty from 5 academic radiology departments reviewed mock residency applications in September and October 2017. Each application included demographic information and a photograph, representing a prespecified distribution of facial attractiveness and obesity, combined with randomized academic and supporting variables. Reviewers independently scored applications for interview desirability. Reviewer scores and application variables were compared using linear mixed fixed- and random-effects models.Reviewers evaluated 5,447 applications (mean: 74 applications per reviewer). United States Medical Licensing Examination Step 1 scores were the strongest predictor of reviewer rating (B = 0.35 [standard error (SE) = 0.029]). Applicant facial attractiveness strongly predicted rating (attractive vs unattractive, B = 0.30 [SE = 0.056]; neutral vs unattractive, B = 0.13 [SE = 0.028]). Less influential but still significant predictors included race/ethnicity (B = 0.25 [SE = 0.059]), preclinical class rank (B = 0.25 [SE = 0.040]), clinical clerkship grades (B = 0.23 [SE = 0.034]), Alpha Omega Alpha membership (B = 0.21 [SE = 0.032]), and obesity (vs not obese) (B = -0.14 [SE = 0.024]).Findings provide preliminary evidence of discrimination against facially unattractive and obese applicants in radiology resident selection. Obesity and attractiveness were as influential in applicant selection for interview as traditional medical school performance metrics. Selection committees should invoke strategies to detect and manage appearance-based bias.

Objectives To evaluate the interrupted mucosa sign for identification of endometrial polyps, using pathologic confirmation as the reference standard, compared to other accepted sonographic findings. Methods We reviewed 195 patients referred for pelvic sonographic evaluations for suspected endometrial polyps in this retrospective Institutional Review Board-approved study. Of these, 82 had tissue sampling of the endometrium and constituted the final study group. Patient data, including age, menopausal status, last menstrual period, and final pathologic diagnosis, were recorded. Sonograms were reviewed by 2 blinded board-certified radiologists for endometrial features, including thickness, echogenicity, vascularity, presence of a mass, and the interrupted mucosa sign. Descriptive statistics and multivariate logistic regression analysis were performed. Results The mean age of the patients was 44.99 (SD, 9.88) years, 79.1% of whom were premenopausal. Pathologic diagnosis confirmed polyps in 58 (70.73%). A single feeding vessel was visualized in 36 patients with polyps (62.07%), whereas the interrupted mucosa sign was visualized in 34 (58.62%). The presence of a feeding vessel, the interrupted mucosa sign, or both detected 48 (82.76%) of the polyps. In the multivariate analysis, only the interrupted mucosa sign was a statistically significant predictor of pathologic diagnosis of a polyp (P= .035), with an odds ratio of 3.83 (95% confidence interval, 1.10-13.29). Other sonographic findings were not independent predictors of a polyp: mass (P = .35), single feeding vessel (P = .31), endometrial thickness (P = .88), and endometrial echogenicity (P = .45). The sensitivity, specificity, and positive predictive value of the interrupted mucosa sign were 59%, 75%, and 85%, respectively. Conclusions The interrupted mucosa sign is a promising sonographic sign for identification of endometrial polyps, with greater predictive power than previously described signs. It has the potential to improve the diagnostic performance of sonography, especially when used in combination with other described signs.

Critically ill patients are commonly imaged for liver dysfunction. An often fatal condition, secondary sclerosing cholangitis, is an important and likely under-recognized hepatic condition in these patients. In presenting this case report, we hope to raise awareness of this condition amongst radiologists as well as other physicians caring for the critically ill.

Ultrasound assessment of the kidneys in patients with renal impairment has been described in various ways in the critical care, nephrology, and radiology literature, resulting in a somewhat heterogeneous picture of the gray-scale and Doppler ultrasound manifestation of acute kidney injury (AKI). Given that ultrasound assessment can potentially identify reversible causes of AKI or identify underlying chronic kidney disease, it is important for radiologists to be aware of the common etiologies of AKI and the spectrum of ultrasound findings. We review the definition and etiologies of renal injury and introduce the ultrasound SERVeillance framework-assessment of renal size, echogenicity, renal hilum, and vascularity-for the imaging assessment of AKI.

The purpose of this study was to evaluate thyroid nodule margins for specific morphologic features and determine the diagnostic performance of these features in differentiating papillary carcinoma from benign thyroid nodules.Nodules measuring 1-3 cm in largest diameter that had been evaluated with high-resolution ultrasound (12-18 MHz) and ultrasound-guided biopsy with definitive pathologic diagnosis were analyzed. Three blinded board-certified readers evaluated high-resolution images of each nodule for jagged edges, lobulated borders, and curved borders along their margins. Reader interpretations were correlated with the pathologic diagnosis to determine the diagnostic performance of each feature. A board-certified pathologist analyzed 10 randomly selected nodules with jagged edges by slide review to evaluate for structural correlation with the imaging finding.The diagnostic performance of jagged edges in papillary carcinoma of the thyroid was 67.4% sensitive and 78.3% specific (odds ratio, 7.44; p0.001) for malignancy. Jagged edges correlated with infiltrative variant expansion at slide review. Lobulated borders had sensitivity of 76.1% and specificity of 60.9% for papillary carcinoma (odds ratio, 4.95; p = 0.001) for malignancy. Curved borders were not a significant predictor of papillary carcinoma.Jagged edges and lobulated borders of thyroid nodule margins are statistically significant predictors of papillary carcinoma of the thyroid. Jagged edges correlate with infiltrative-type expansion and may be useful predictors of more aggressive papillary carcinomas.

Targeted cancer therapies encompass an exponentially growing number of agents that involve a myriad of molecular pathways. To excel within this rapidly changing field of clinical oncology, radiologists must eschew traditional organ system-based approaches of cataloging adverse effects in favor of a conceptual framework that incorporates molecular mechanisms and associated clinical outcomes. Understanding molecular mechanisms that underlie imaging manifestations of adverse effects and known associations with treatment response allows radiologists to more effectively recognize adverse effects and differentiate them from tumor progression. Radiologists can therefore more effectively guide oncologists in the management of adverse effects and treatment decisions regarding continuation or cessation of drug therapy. Adverse effects from targeted cancer therapies can be classified into four categories: (a) category 1, on-target adverse effects associated with treatment response; (b) category 2, on-target adverse effects without associated treatment response; (c) category 3, off-target adverse effects; and (d) category 4, tumor necrosis-related adverse effects. This review focuses on adverse effects primarily within the abdomen and pelvis classified according to established or hypothesized molecular mechanisms and illustrated with images of classic examples and several potential emerging toxic effects. ©RSNA, 2017.

Guidelines for managing thyroid nodules are highly dependent on risk stratification based on sonographic findings. The purpose of this study is to evaluate the risk stratification system used by the American College of Radiology Thyroid Imaging Reporting and Data System (TIRADS).Patients with thyroid nodules who underwent sonography and fine-needle aspiration were enrolled in a multiinstitutional study. The sonographic nodule features evaluated in the study were composition, echogenicity, margins, and echogenic foci. Images were reviewed by two radiologists who were blinded to the results of cytologic analysis. Nodules were assigned points for each feature, and the points were totaled to determine the final TIRADS level (TR1-TR5). The risk of cancer associated with each point total and final TIRADS level was determined.A total of 3422 nodules, 352 of which were malignant, were studied. The risk of malignancy was closely associated with the composition, echogenicity, margins, and echogenic foci of the nodules (p0.0001, in all cases). An increased aggregate risk of nodule malignancy was noted as the TIRADS point level increased from 0 to 10 (p0.0001) and as the final TIRADS level increased from TR1 to TR5 (p0.0001). Of the 3422 nodules, 2948 (86.1%) had risk levels that were within 1% of the TIRADS risk thresholds. Of the 474 nodules that were more than 1% outside these thresholds, 88.0% (417/474) had a risk level that was below the TIRADS threshold.The aggregate risk of malignancy for nodules associated with each individual TIRADS point level (0-10) and each final TIRADS level (TR1-TR5) falls within the TIRADS risk stratification thresholds. A total of 85% of all nodules were within 1% of the specified TIRADS risk thresholds.

Metastatic melanoma causes an unpredictable variety of manifestations in the chest and abdomen that may be indistinguishable from other diseases by imaging alone. Melanoma metastases commonly involve the lymph nodes, lungs, liver, and small bowel, but virtually any organ can be affected. Newer modalities, such as contrast-enhanced ultrasound and whole-body magnetic resonance imaging, may provide more sensitive detection of metastatic melanoma for diagnosis, staging, and surveillance. An understanding of the predominantly hematogenous nature of metastatic spread by melanoma as well as a high index of suspicion in any patient with a history of melanoma may allow for more precise and confident diagnosis.

To evaluate radiology residency applications to determine if any variables are predictive of a future academic radiology career.Application materials from 336 radiology residency graduates between 1993 and 2010 from the Department of Radiology, Duke University and between 1990 and 2010 from the Department of Radiology, Stanford University were retrospectively reviewed. The institutional review boards approved this Health Insurance Portability and Accountability Act-compliant study with a waiver of informed consent. Biographical (gender, age at application, advanced degrees, prior career), undergraduate school (school, degree, research experience, publications), and medical school (school, research experience, manuscript publications, Alpha Omega Alpha membership, clerkship grades, United States Medical Licensing Examination Step 1 and 2 scores, personal statement and letter of recommendation reference to academics, couples match status) data were recorded. Listing in the Association of American Medical Colleges Faculty Online Directory and postgraduation publications were used to determine academic status.There were 72 (21%) radiologists in an academic career and 264 (79%) in a nonacademic career. Variables associated with an academic career were elite undergraduate school (P = .003), undergraduate school publications (P = .018), additional advanced degrees (P = .027), elite medical school (P = .006), a research year in medical school (P.001), and medical school publications (P.001). A multivariate cross-validation analysis showed that these variables are jointly predictive of an academic career (P.001).Undergraduate and medical school rankings and publications, as well as a medical school research year and an additional advanced degree, are associated with an academic career. Radiology residency selection committees should consider these factors in the context of the residency application if they wish to recruit future academic radiologists.

Ultrasound of the thyroid has become increasingly common, with evaluation of thyroid nodules representing the main indication for its use. While detection of thyroid nodules with modern high-resolution sonographic equipment is generally not a challenge, pitfalls may occur by which normal structures or pathology in neighboring organs are mistaken for thyroid nodules. Numerous reports in the literature describe various sonographic features of nodules in an attempt to stratify lesions into benign or malignant categories. While neither nodule size nor number is reliable, echogenicity, microcalcifcation, shape, and composition have been reported to be helpful in classifying thyroid nodules. No single feature should be used in isolation, and consensus guidelines have been established as to when fine-needle aspiration is indicated. Pitfalls remain in the evaluation of thyroid nodules demonstrating atypical features, such as cystic papillary carcinomas. Focal presentation of typically diffuse processes, such as Graves' disease and Hashimoto thyroiditis, may mimic malignant nodules, but carcinomas occur in these settings as well as in a background of normal thyroid parenchyma. Finally, because ultrasound is commonly used for surveillance of patients with thyroid carcinoma after thyroidectomy, sonographers should be familiar with the ultrasound appearance of disease recurrence and its mimics.

Retained products of conception (RPOC) are a common and treatable complication after delivery or termination of pregnancy. The pathologic diagnosis of RPOC is made based on the presence of chorionic villi, which indicates persistent placental or trophoblastic tissue. In the setting of postpartum hemorrhage, however, distinguishing RPOC from bleeding related to normal postpartum lochia or uterine atony can be clinically challenging. Ultrasonographic (US) evaluation can be particularly helpful in these patients, and a thickened endometrial echo complex (EEC) or a discrete mass in the uterine cavity is a helpful gray-scale US finding that suggests RPOC. However, gray-scale US findings alone are inadequate for accurate diagnosis. Detection of vascularity in a thickened EEC or an endometrial mass at color or power Doppler US increases the positive predictive value for the diagnosis of RPOC. Computed tomography or magnetic resonance imaging may be helpful when US findings are equivocal and typically demonstrates an enhancing intracavitary mass in patients with RPOC. Diagnostic pitfalls are rare but may include highly vascular RPOC, which can be mistaken for a uterine arteriovenous malformation; true arteriovenous malformations of the uterus; invasive moles; blood clot; and subinvolution of the placental implantation site.

Sonography is the modality of choice for imaging cervical lymph nodes in patients with papillary thyroid cancer, both before surgery and for postoperative surveillance. Sonography is also an invaluable tool to guide fine-needle aspiration of abnormal nodes. Microcalcifications, cystic changes, abnormal morphology, and disordered vascularity are features of metastatic nodal involvement with papillary thyroid carcinoma and should be sought during surveillance scans as well as in targeting for fine-needle aspiration.

To determine whether hepatic arterial and portal venous Doppler ultrasound measurements of the liver in cirrhotic patients correlate with patients' Model for End-Stage Liver Disease (MELD) scores, splenomegaly, or ascites.Sonographic images and reports were reviewed of 264 patients with hepatic cirrhosis who underwent abdominal ultrasound with Doppler in this internal review board-approved retrospective study. MELD scores were recorded at the time of ultrasound. On gray-scale ultrasound, spleen length was measured and the presence of ascites was noted. Hepatic arterial velocity (HAv) with angle correction, hepatic arterial resistive index, and portal vein velocity with angle correction were measured on Doppler ultrasound. Correlation of hepatic arterial and portal venous Doppler values with MELD score, presence of splenomegaly, and presence of ascites was tested using linear or binary logistic regression analysis. Diagnostic performance of Doppler parameters for high-risk MELD was assessed.The HAv statistically significantly correlated with the MELD score (P = .0001), spleen size (P =.027), and presence of ascites (P =.0001), whereas the hepatic arterial resistive index and portal vein velocity did not correlate with these factors. For MELD scores greater than 19, an HAv greater than 120 cm/s showed accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 74, 42, 90, 67, and 76%, respectively. With an HAv greater than 160 cm/s, the odds ratio for MELD scores greater than 19 was 42.1.We found a statistically significant correlation with elevated HAv and increasing MELD scores, splenomegaly, and presence of ascites in patients with cirrhotic liver disease; this may be a useful imaging biomarker in the evaluation of patients with cirrhosis.

The use of Doppler sonography for evaluation of the liver is well established, and evaluation of the portal and hepatic veins in native livers, as well as the hepatic artery in transplant livers, is a standard part of the examination. Less well known, however, is that assessment hepatic of artery blood flow velocities and waveforms can permit inferences to be made about liver and system pathophysiology even in native livers. This review will illustrate that hepatic parenchymal abnormalities, as well as primary vascular abnormalities both upstream and downstream of the proper hepatic artery, can be inferred from careful interrogation of its Doppler signature during routine abdominal sonography.

Segmental testicular infarction is a relatively rare acute or subacute condition which is infrequently thought of in the differential diagnosis for testicular pain. However, missing or misdiagnosing this entity on clinical evaluation and/or imaging has significant implications for patients as they may undergo unnecessary surgery for suspected testicular torsion or tumor. Knowledge and recognition of the features of segmental testicular infarction on ultrasound and MRI will aid in the diagnosis of this disease early in the patient's course. The common imaging features of segmental testicular infarction and the clinical literature are reviewed, with an emphasis on ultrasound, utilizing seven recent cases from three institutions.

The purpose of this article is to analyze the sonographic appearance of nodular Hashimoto thyroiditis.As part of an ongoing multiinstitutional study, patients who underwent ultrasound examination and fine-needle aspiration of one or more thyroid nodules were analyzed for multiple predetermined sonographic features. Patients completed a questionnaire, including information about thyroid function and thyroid medication. Patients (n = 61) with fine-needle aspiration cytologic results consistent with nodular Hashimoto thyroiditis (n = 64) were included in the study.The mean (+/- SD) diameter of nodular Hashimoto thyroiditis was 15 +/- 7.33 mm. Nodular Hashimoto thyroiditis occurred as a solitary nodule in 36% (23/64) of cases and in the setting of five or more nodules in 23% (15/64) of cases. Fifty-five percent (35/64) of the cases of nodular Hashimoto thyroiditis occurred within a sonographic background of diffuse Hashimoto thyroiditis, and 45% (29/64) of cases occurred within normal thyroid parenchyma. The sonographic appearance was extremely variable. It was most commonly solid (69% [42/61] of cases) and hypoechoic (47% [27/58] of cases). Twenty percent (13/64) of nodules had calcifications (seven with nonspecific bright reflectors, four with macrocalcifications, and three eggshell), and 5% (3/64) of nodules had colloid. Twenty-seven percent (17/64) of nodules had a hypoechoic halo. The margins were well defined in 60% (36/60) and ill defined in 40% (24/60) of nodules. On Doppler analysis, 35% (22/62) of nodules were hypervascular, 42% (26/62) were isovascular or hypovascular, and 23% (14/62) were avascular.The sonographic features and vascularity of nodular Hashimoto thyroiditis were extremely variable.

The purpose of this article is to compare sonographic features of benign and malignant nodules in patients with diffuse Hashimoto thyroiditis.As part of an ongoing multiinstitutional study, patients who underwent ultrasound and fine-needle aspiration of one or more thyroid nodules were analyzed for a variety of predetermined sonographic features. Patients with a sonographic appearance consistent with diffuse Hashimoto thyroiditis and with coexisting nodules that could be confirmed to be benign or malignant by fine-needle aspiration or surgical pathologic analysis were included in the study.Among nodules within diffuse Hashimoto thyroiditis, 84% (69/82) were benign (35 nodular Hashimoto thyroiditis, 32 nodular hyperplasia, and two follicular adenoma), and 16% (13/82) were malignant (12 papillary carcinoma and one lymphoma). Malignant nodules were more likely to be solid and hypoechoic (62% vs 19%). All types of calcifications were more prevalent among malignant nodules, including microcalcifications (39% vs 0%), nonspecific tiny bright reflectors (39% vs 6%), macrocalcifications (15% vs 3%), and eggshell (15% vs 2%). Benign nodules were more likely to be hyperechoic (46% vs 9%), to have a halo (39% vs 15%), and to lack calcifications (88% vs 23%). Benign nodules more often had ill-defined margins (36% vs 8%).Sonographic features of benign and malignant nodules within diffuse Hashimoto thyroiditis are generally similar to the features typical of benign and malignant nodules in the general population. If calcifications of any type are added to the list of malignant sonographic features, the decision to biopsy a nodule in patients with diffuse Hashimoto thyroiditis can be based on recommendations that have been published previously.

Ultrasonography is often the initial imaging study in patients who present with right upper quadrant abdominal complaints. However, due to its intrinsic technical limitations, ultrasonography generally has a lower sensitivity than contrast-enhanced computed tomography or magnetic resonance imaging in detecting hepatic lesions. In this review, we describe several subtle sonographic signs that suggest the presence of an otherwise inconspicuous focal liver lesion, including disease in the pleural space or the lung parenchyma, refractive edge shadows, distorted or absent venous landmarks, abnormal Doppler patterns, and venous thrombosis. When encountered, these features should trigger careful evaluation of the adjacent areas for abnormalities and may warrant further studies with computed tomography, magnetic resonance imaging, or positron emission tomography. We also summarize common sonographic findings of diffuse liver diseases, including fatty infiltration and cirrhosis.

Postpartum complications can be broadly divided into 4 categories: postpartum hemorrhage, obstetrical trauma, thromboembolic complications, and puerperal infections. Postpartum hemorrhage is most commonly caused by uterine atony, abnormal placentation, or genital tract trauma. Secondary causes of hemorrhage include retained products of conception and, rarely, subinvolution of the placental implantation site. Uterine dehiscence or rupture may be occult on ultrasound examination and may be better visualized on sagittal computed tomography or magnetic resonance imaging. Obstetric trauma during prolonged vaginal or cesarean delivery may lead to fistula formation, ureteral injury, or bowel injury. Later potential complications of cesarean delivery include cesarean delivery scar ectopic, endometrial implants in the cesarean scar, and placenta accreta. Thromboembolic complications can include pulmonary embolism and deep vein thrombosis as well as ovarian vein thrombosis, the latter of which can be difficult to clinically differentiate from appendicitis in the postpartum female.

BACKGROUND: The authors report on the local control and toxicity of stereotactic body radiotherapy (SBRT) for patients with unresectable pancreatic adenocarcinoma. METHODS: Seventy-seven patients with unresectable adenocarcinoma of the pancreas received 25 gray (Gy) in 1 fraction. Forty-five patients (58%) had locally advanced disease, 11 patients (14%) had medically inoperable disease, 15 patients (19%) had metastatic disease, and 6 patients (8%) had locally recurrent disease. Nine patients (12%) had received prior chemoradiotherapy. Sixteen patients (21%) received between 45 to 54 Gy of fractionated radiotherapy and SBRT. Various gemcitabine-based chemotherapy regimens were received by 74 patients (96%), but 3 patients (4%) did not receive chemotherapy until they had distant failure. RESULTS: The median follow-up was 6 months (range, 3-31 months) and, among surviving patients, it was 12 months (range, 3-31 months). The overall rates of freedom from local progression (FFLP) at 6 months and 12 months were 91% and 84%, respectively. The 6- and 12-month isolated local recurrence rates were 5% and 5%, respectively. There was no difference in the 12-month FFLP rate based on tumor location (head/uncinate, 91% vs body/tail, 86%; P = .52). The progression-free survival (PFS) rates at 6 months and 12 months were 26% and 9%, respectively. The PFS rate at 6 months was superior for patients who had nonmetastatic disease versus patients who had metastatic disease (28% vs 15%; P = .05). The overall survival (OS) rates at 6 months and 12 months from SBRT were 56% and 21%, respectively. Four patients (5%) experienced grade ≥2 acute toxicity. Three patients (4%) experienced grade 2 late toxicity, and 7 patients (9%) experienced grade ≥3 late toxicity. At 6 months and 12 months, the rates of grade ≥2 late toxicity were 11% and 25%, respectively. CONCLUSIONS: SBRT for pancreatic adenocarcinoma was effective for local control with associated risk of toxicity and should be used with rigorous attention to quality assurance. Efforts to reduce complications are warranted. Distant metastases account for the vast majority of disease-related mortality. Cancer 2009. © 2008 American Cancer Society.

Acute pelvic pain in the female patient can have myriad presentations and, depending on the diagnosis, profound consequences. In the pregnant patient with pelvic pain or bleeding, an ectopic pregnancy must be first excluded. Ultrasound is important in determining the size and location of the ectopic pregnancy, and presence of bleeding, which in turn helps guide treatment decisions. Subchorionic or subplacental bleeds in an intrauterine pregnancy may also present with vaginal bleeding with consequences dependent on gestational age and size of bleed. In the postpartum female suspected to have retained products of conception, sonographic findings may vary from a thickened endometrial stripe to an echogenic mass with associated marked vascularity, often mimicking an arterial-venous malformation. In the nonpregnant patient, early diagnosis and treatment of ovarian torsion can preserve ovarian function. Other causes of peritoneal irritation may also cause acute pelvic pain including a ruptured hemorrhagic cyst or ruptured endometrioma. When pelvic inflammatory disease is suspected, imaging is used to evaluate for serious associated complications including the presence of a tuboovarian abscess or peritonitis. While leiomyomas of the uterus are largely asymptomatic, a leiomyoma that undergoes necrosis, torsion or prolapse through the cervix may be associated with acute severe pain or bleeding. The imaging features of these and other important clinical entities in the female pelvis will be presented.

Objectives It is commonly held that punctate nonshadowing echogenic foci on sonography, often termed microcalcifications, represent psammoma bodies. We aimed to determine the validity of this supposition by correlating the presence of punctate echogenic foci on sonography with their presence at histopathologic examination. Methods We examined 51 nodules (surgically proven papillary thyroid carcinoma) by sonography and histopathologic examination. On the latter, nodules were examined for evidence of psammomatous calcifications, dystrophic calcifications, and colloid. Two subspecialty-trained radiologists with 2 and 25 years of experience in sonography, respectively, reviewed the sonograms for the presence and distribution of punctate echogenic foci. Results All nodules contained colloid at histologic examination. Twenty of the papillary carcinomas lacked any calcification at pathologic examination. In the remaining 31 nodules with calcifications, 13 had psammomatous calcifications only; 6 had both coarse and psammomatous calcifications; and 12 had only coarse calcifications. The presence of punctate echogenic foci on sonography was 74% sensitive, was 46% to 53% specific, and had a positive predictive value of only 45% to 48% for the presence of psammomatous calcifications. The computed 2-tailed P value indicated that the punctate echogenic foci-to-psammoma body correlation was not statistically significant. Conclusions The sonographic signature commonly referred to as “microcalcifications” may represent a variety of entities, including psammomatous calcifications, dystrophic calcifications, and eosinophilic colloid; for this reason, “punctate echogenic foci” would be a more accurate term.

Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.

Objectives To determine whether radiologic assessment of thyroid nodules can potentially help guide clinical management after a cytologic diagnosis of atypia of undetermined significance or a follicular lesion of undetermined significance. Methods We identified 41 patients with 41 thyroid nodules initially diagnosed as atypia or follicular lesions of undetermined significance on fine-needle aspiration that were subsequently definitively diagnosed by either surgical resection or repeated fine-needle aspiration. All sonograms of nodules were reviewed by 2 blinded board-certifiedradiologists. Lesions were assessed in 3 ways: (1) Mayo pattern classification as benign, indeterminate, or worrisome for malignancy (Ultrasound Q 2005; 21:157-165); (2) thyroid imaging reporting and data system scores (scale of 1-5) based on 2 different previously published scoring criteria (Park et al [Thyroid 2009; 19:1257-1264] and Kwak et al [Radiology 2011; 260:892-899]); and (3) binary classification as benign or malignant. Results Of the 41 nodules, 25 had benign histologic findings, and 16 were malignant. Mayo pattern classification was 100% accurate for the benign score. Lesions with a Mayo score of indeterminate were malignant in 21% of cases (6 of 28) and benign in 79% (22 of 28). Lesions with a Mayo score of malignant were malignant in 91% of cases (10 of 11) and benign in 9% (1 of 11). Thyroid imaging reporting and data system scores had area under the receiver operating characteristic curve values of 0.827 for Park scores and 0.822 for Kwak scores. Radiologist binary classification of thyroid nodules showed 88% overall accuracy. Conclusions Radiologist assessment of thyroid nodules in cases of atypia of undetermined significance or follicular lesions of undetermined significance is highly predictive of the final diagnosis and can help guide management of thyroid nodules of these pathologic types.

Object of study Retained products of conception (RPOC) displays variable vascularity, ranging from avascular to markedly vascular on color Doppler sonography. We hypothesize that variability in sonographic vascularity may be due to histopathologic variation in the placental tissue. Materials, methods, and procedures After institutional review board approval, sonographic images and pathologic specimens were retrospectively reviewed in 26 patients with pathologically proven RPOC. Ultrasound (US) images were scored 0-3 for the degree of vascularity by two radiologists blinded to the diagnosis. Corresponding pathologic specimens were evaluated for vascularization of chorionic villi, degree of inflammation, morphology of maternal arteries, chorionic villous preservation, and percentage of clot, membranes, chorionic villi, and decidua/myometrium. Statistical analysis, including multiple linear regression, was performed. Results RPOC with histologically avascular chorionic villi or those with markedly reduced vascularization had significantly lower US vascularity scores (p = 0.030) than those with chorionic villi showing normal or decreased vascularization. Sonographically avascular RPOC had a significantly lower percentage villi (p = 0.028) and higher percentage of decidua (p = 0.004) than specimens where US showed any Doppler vascularity. Histologic vascularity of villi (p = 0.049) and non-observation of maternal arteries (p = 0.001) were significant predictors of US vascularity scores in multivariate linear regression analysis, while inflammation of villi (p = 0.053) was a marginally significant predictor. Significance of the conclusions Histologic vascularity of villi appears to contribute to the observed variation in sonographic vascularity. This finding may underlie known differences in clinical outcomes between sonographic vascularity groups.