Dr. Laurence Klotz discusses micro-ultrasound as a faster, less invasive, more cost-effective screening strategy compared to mpMRI in this podcast. 

Reading Room Podcast: Micro-Ultrasound for Easier Prostate Cancer Screening

Welcome to Diagnostic Imaging’s Weekly Scan. I’m senior editor, Whitney Palmer.

Before we get to our featured interview this week with Dr. Anupam Basu about the disparities in lung cancer screening guidelines and how they are overlooking African American smokers at risk for developing the disease, here are the top stories of the week.

When it comes to detecting lesions, researchers from University Hospital Essen in Germany published a study this week that shows PET/MRI outperforms PET/CT even though the latter has long been considered the gold standard in oncology imaging and staging. According to their article, published in the 

 the PET/MRI combination not only supports faster, more efficient use of local and whole-body staging in a single step, but it does so without exposing the patient to ionizing radiation. That makes it an ideal option for pediatric and adolescent patients. The team based their findings on 1,003 exams from 918 patients with a variety of cancers, including lung, gynecologic, breast, prostate, lymphoma, and several others. All patients underwent both PET/MRI and PET/CT, and based on the results, the team discovered PET/MRI found more lesions, finding additional information on 26.3 percent of scans not detected with PET/CT and changing treatment courses in 2.9 percent of cases. In addition, PET/MRI provided definite lesion classification in 11.1 percent more cases, promptings treatment changes in 0.5 percent of cases. But, perhaps, most importantly, the team said, PET/MRI reduced radiation exposure from 17.6 +/- 8.7 mSv with PET/CT down to 3.6 +/- 1.4 mSv – a 79.6-percent drop in dose.

More research surfaced this week that encourages radiologists to keep their eyes open for signs of COVID-19 outside the lungs. In a study published in the 

 investigators from New York University Langone Medical Center added to the body of knowledge about how the virus manifests in abdominal scans. Based on their review of abdominal and pelvic scans, they discovered thromboembolic findings appear more frequently in COVID-19-positive patients than in those who do not have the virus. The team compared CT scans of a cohort of 82 COVID-19-positive patients and a group of 82 healthy adults, looking for thromboembolism and solid-organ infarction. They found 11 percent of patients who were positive for the virus had thromboembolic findings – four had thromboembolism, three had arterial thromboembolism in the aorta and major branches, and two had splenic infarctions of patent vasculature. In addition, they discovered that COVID-19-positive patients had elevated levels of inflammatory markets. Ultimately, they said, if you see these types of findings in abdominopelvic scans, ring the alarm bell.

And, even though chest MRI hasn’t been discussed as a first-line imaging modality during the pandemic, evidence is emerging that it can be an effective non-ionizing alternative for COVID-19- positive patients who need follow-up imaging, picking up both specific and indeterminate signs of viral infection just as well as CT. In the journal 

 a team from Iran examined chest CT and chest MRI scans conducted on the same day on eight COVID-19-positive patients who all had mild symptoms. The reviewing radiologist was able to identify ground-glass, consolidative, nodular or reticular opacities on both CT and MRI studies. Still, the team cautioned, using MRI presents challenges, such as accessibility and equipment disinfection concerns during the pandemic.

Outside COVID-19 investigations, an investigative team from Switzerland took a deeper look into who should be reading and interpreting MRI scans of suspected endometriosis. It’s a condition that affects between 6 percent and 10 percent of women, and these researchers found that radiologists who have expertise in women’s health imaging are really the ones who should been looking at these studies. As the use of MRI continues to grow because it provides a wider field-of-view for the provider, the team outlined in 

 that even radiologists with up to two years’ experience have a lower diagnostic performance when identifying this condition. For their study, they had four radiologists – a junior resident, senior resident, fellow, and expert – interpret pelvic MRI scans of 59 women with suspected endometriosis. They found differences in sensitivity, specificity, and area under the curve for all providers with experts performing significantly better. These findings have both clinical and educational implications, the team said – not only should referring providers send their endometriosis patients to radiologists with expertise in women’s imaging, but radiology training programs should also beef up the instruction their provide in this area.

Unfortunately, this week, there was more concerning news about African American women and breast cancer. In a study out of the University of North Carolina at Chapel Hill published in 

 women in this patient population are more likely to face treatment delays and longer treatment courses than their white counterparts, especially when they opt for radiation therapy. In a study of 2,841 women with Stage 1 to Stage 3 cancer, the researchers found that 13.4 percent of African American women experience delayed treatment compared to 7.9 percent of white women and they also had longer treatment times – 29.9 percent and 21.2 percent, respectively. Even among the higher socioeconomic group, African American women faced these problems more often – 11.7 percent versus 6.7 percent of white women. Most significantly, when these women added radiation therapy to surgery, they were 22 percent more likely to have delayed care compared to 1.6 percent who opted for chemotherapy and surgery.

 spoke with Dr. Anupam Basu, a diagnostic radiologist with Cook County Health in Chicago, about his latest research published in the 

Journal of the American College of Radiology

 Based on his investigations with colleagues at Northwestern University, the team determined that the current 30-pack-year threshold that primary care providers use to determine which patients should be referred for lung cancer screening is too high for African American smokers. Consequently, many are being overlooked when it comes to efforts that exist to find the disease earlier. He spoke with us about the details of his findings, what they mean for African American smokers, and how radiologists can use this information. Here’s what he had to say.

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Videos

PET/MRI vs. PET/CT; Abdominal CT and COVID-19; Chest MRI vs Chest CT; Expert Interpretations of Endometriosis; and Delayed Breast Cancer Treatments for African American Women

Diagnostic Imaging Weekly Scan: Sept. 25, 2020

Using artificial intelligence (AI) to detect lung cancer on X-rays in the healthy general population can be just as effective as relying on a radiologist’s interpretation, potentially freeing providers up to focus on other studies, according to a new study.

Investigators from Seoul National University College of Medicine in Korea tested a deep learning algorithm that is already commercially available from Lunit with patients who participated in a screening program at Seoul National University Hospital Health System Gangnam Center between January 2008 and December 2012. Performance, they found, was equivalent to a radiologist alone.

“A deep learning algorithm detected lung cancer nodules on chest radiographs with a performance comparable to that of radiologists, which will be helpful for radiologists in healthy populations with a low prevalence of lung cancer,” said the team led by Chang Min Park, M.D., Ph.D., associate professor of radiology at Seoul University Hospital.

The team published their findings in the Sept. 22 

 Philips Launches 3D CT/X-Ray System for Faster Lung Cancer Diagnosis

Recently, AI has been gaining a foothold in lung cancer detection with X-ray in at-risk patient populations, Park’s team said. But, they set out to determine whether those same tools can be used effectively in healthy groups.

To make that assessment, they used a validation set comprised of 10,285 chest X-rays with 10 visible lung cancers. With this set, the algorithm had an area under the curve of 0.99 and comparable sensitivity to the individual radiologist – 90 percent and 60 percent, respectively. Their screening cohort included 100,525 chest X-rays with 47 visible lung cancers. The algorithm performed similarly, they said, with an area under the curve of 0.97 and sensitivity of 83 percent. For both sets, the false positive rate was roughly 3 percent.

Not only did these findings show equivalency between AI and radiologist performance, the team said, but the indicated the algorithm could be applied to wide patient populations.

“We performed our study in a real-world setting, using a real-world health screening population,” they said. “Therefore, we believe that the algorithm analyzed in our study could be reasonably applied for the detection of lung cancers on chest radiographs in a health screening population with an average risk of lung cancer.”

Implementing the algorithm, the team said, could reduce the number of simple mistakes or perceptual errors that can sometimes pop up with radiologists who have less experience. 

In an accompanying editorial, Samuel G. Armato, III, Ph.D., associate professor of radiology at the University of Chicago, did note that Park’s team used a pre-determined output threshold for their study, but any subsequent work most likely require system re-training. In addition, he said, the team did not include the quantified results extracted from lesion localization maps returned by the algorithm.

"Knowledge gained from such an assessment would benefit the medical imaging research community,” he said.

Ultimately, the team acknowledged that, even with these findings, additional work is necessary.

“To generalize the clinical use of the deep learning algorithm in a screening program of the general population,” they said, “further studies covering a variety of races and medical environments will be needed.”

Articles

A commercially available deep learning algorithm performed comparably to the individual radiologist when assessing patients at low risk for the disease.

AI Can ID Lung Cancer on X-rays in Healthy Patients As Well As Radiologists

Radiologists should alert referring clinicians to possible COVID-19 infection when they pick up evidence of thrombosis on abdominal and pelvic CT scans, new research reports.

Growing research around how COVID-19 manifests indicates that the virus can cause medium-to-large arterial and venous abdominal and extremity macrothrombi. And, in a new study published Sept. 24 in the 

 a team of researchers from New York University (NYU) Langone Medical Center shared their results that these findings do occur more frequently in patients positive for viral infection.

“Thromboembolic findings occurred more frequently in patients with than without COVID-19,” said the team led by Bari Dane, M.D., an NYU radiologist and clinical assistant professor of radiology at NYU Grossman School of Medicine.

By retrospectively reviewing details from the electronic medical records and the abdominal CT scans from 82 patients – 58 men and 24 women with an average age of 58 – who were confirmed COVID-19-positive. They compared these scans to those from 82 patients – 43 men and 39 women with an average age of 53.5 – who did not have COVID-19. They examined the scans for thromboembolism and solid-organ infarction.

Abdominal Radiologists Stay Alert: Some COVID-19 Patients Present with GI Symptoms Only

Based on their analysis, nine patients (11 percent) with COVID-19 had thromboembolic findings in their CT scans– four had thromboembolism, three had arterial thromboembolism in the aorta or major branches, and two had splenic infarctions with patent vasculature.

In addition, IV contrast-enhanced chest CT angiograms that were performed concurrently revealed lobar and segmental pulmonary emboli; probable left lower lobe pulmonary infarction instead of pneumonia; and bilateral, multi-lobar, patchy, but confluent, ground-glass opacities that are characteristic of COVID-19 infection.

The team also noted that in many COVID-19-positive cases, patients had elevated coagulation and inflammatory markers. Of that group, 64 were admitted to the hospital. Among those patients, 28 were intubated, and 13 died. Overall, their inflammatory markers were elevated: 3,588+/-3,588 ng/mL D-dimer levels, 86.4 +/- 42.2 mm/h erythrocyte sedimentation rate, 143.6 +/-250.8 mg/L C-reactive protein level, and 2,652+/-4,385 ng/mL ferritin level.

The study did have limitations, though. Not only did it include a small sample size from a single institution, but the team also acknowledged that not all patients with thromboembolism undergo confirmative findings. Some may not even experience symptoms, meaning that the prevalence could be much larger than reported.

Consequently, Dane’s team reiterated, radiologists must pay attention when they identify these findings.

“Radiologists should raise concern for COVID-19 when identifying thromboembolic abdominopelvic findings during this pandemic,” they said.

Thromboembolic findings in the abdomen and pelvis appear more often in patients with viral infection.


CT Reveals Higher Abdominal and Pelvic Hypercoagulability in COVID-19 Patients

Contrast-enhanced ultrasound (CEUS) is a safer, less costly option than CT and MRI when it comes to the accurate diagnosis of some types of liver cancer, according to recent research.

 a team of investigators from the University of Calgary outlined some the unique advantages that CEUS offers when characterizing focal liver disease.

“CEUS provides for the determination of malignancy and allows excellent differential diagnosis of a focal liver mass,” said lead study author Stephanie Wilson, M.D., chair of the University of Calgary radiology department. “CEUS regularly resolves an indeterminate result on CT/MRI and is exceptional as a problem-solving tool in liver imaging.”

Routinely, she said, CEUS demonstrates comparable performance to CT and MRI with the characterization and prediction of malignancy.

To determine the details of CEUS’ capabilities, Wilson’s team analyzed the results of a multi-center trial that included 1,349 patients. The study, they said, revealed no statistically significant difference between CEUS and spiral CT in differentiating between benign and malignant liver tumors, as well as tumor specification. The team also examined a meta-analysis of 21 studies that showed CEUS has 88-percent sensitivity, 81-percent specificity, and a diagnostic odds ratio of 38.62. Those studies also showed no statistical differences between contrast-enhanced MRI and contrast-enhanced CT.

In particular, the team noted, CEUS offers several advantages:

 CEUS is performed in dynamic real-time, providing superior temporal resolution and detection of enhancement.

 The intravascular contrast agent used accurately depicts the presence of microbubbles, comparing comparably to CT and MRI.

 CEUS accurately shows washout in malignant tumors.

 CEUS contrast specific software’s subtraction technique produces a contrast-only image with high sensitivity to enhancement in thin septations and small nodules.

Ultimately, the team concluded, CEUS can play a beneficial and effective role in liver cancer diagnostic imaging.

“CEUS has many similarities to contrast-enhanced CT/MRI, but also unique and valuable differences,” they said, “most showing the additional benefit of inclusion of CEUS with CT and MR for liver imaging.”

CEUS is a safer, less expensive option for diagnosing focal liver disease.


Contrast-Enhanced Ultrasound Outperforms CT and MRI with Some Liver Cancers

 revealed current breast cancer screening guidelines do not work well for African American women, leaving many to be diagnosed at a younger age with more aggressive cancers at later stages.

Currently, the accepted recommendation is to begin breast cancer screening between ages 45 and 50, but existing research shows African American women are more likely to develop aggressive cancers earlier than that. This reality has many radiologists in women’s imaging worried that they are missing significant numbers of treatable cancers.

 spoke with lead study author Murray Rebner, M.D., professor of diagnostic radiology and molecular imaging at Oakland University William Beaumont School of Medicine and director of the division of breast imaging at Beaumont Health System, about the complex reasons why these screening guidelines are not optimal for this patient population and what that means for radiologists.

 When we consider the intent and implementation of breast cancer screening guidelines, what do we need to keep in mind about how the disease impacts African American women differently from white women?

There are several things we need to keep in mind. First of all, even though white women are slightly more likely to get breast cancer over their lifetime than African American women, African American women have a 40-percent higher mortality rate than white women, which is quite significant. When you look back to 1990, the breast cancer mortality rates have dropped significantly. They’ve come down 40 percent for white women, but they’ve only come down 26 percent for African American women. So, the benefit is there, but it’s certainly not as good as we’d like to see in African American women.

The other thing we need to realize is that certain types of breast cancer – most notably the very aggressive, what we call, triple-negative cancers – occur twice as often in African American women than white women. And, they’re also more likely to be diagnosed at a young point in their lives. Therefore, those cancers tend to be more aggressive, and the effect on someone who has more life years ahead of them is more significant than a woman who is older. Also, from a genetic standpoint, African American women are twice as likely to have the BRAC gene than white women.

Because of all of these things, we recommend that all organizations recommend African American women start screening with mammography at age 40 and that they do it annually because we don’t want to miss some of these aggressive cancers by waiting too long.

African American Women Receiving Radiation Face Breast Cancer Treatment Delays

Given that background, what is the likelihood that they are following the existing guidelines?

 Unfortunately, the compliance rate is much lower in the African American population. Depending upon what study you read, they’re 70 percent to 80 percent less likely to get screened than white women. And, there are a lot of reasons for that. The primary one, according to our study, is that they’re not hooked up with a primary care doctor. Not just for breast cancer, but for other illnesses that are more common in their population, such as diabetes, hypertension, cardiovascular disease, they need to be plugged into the appropriate screening guidelines and therapies in order to benefit from these programs.

Another thing is that there might be some pain or embarrassment in getting a mammogram. And, there are socioeconomic factors. Even though there are laws that mandate that women have free screening mammograms, what happens if you have a positive one? Those laws don’t cover diagnostic mammograms. Surgery or treatment becomes very, very expensive – far more than the mammogram itself. So, a lot of women don’t want to go that route because they just can’t afford to do it. All of these things factor into why we think African American women are not partaking as much in screening as we would like them to.

What recommendations or suggestions can be made to potentially make screening more available to this patient population or, at least, alert them that they should have more access to the providers and imaging services they need?

The most important thing is education. Women, themselves, need to understand, No. 1, that they may be at increased risk overall. It’s difficult to pinpoint risk for a particular woman, but as a group, they are at increased risk. They have the 40-percent higher mortality rate. They’re at risk for being diagnosed later, and the risk is higher that they’re going to have the BRAC gene.

Studies have shown that African American women tend to perceive their own risk as much lower than white women. That’s one of the reasons why they don’t often ask for supplemental screenings like MRI if they’re BRAC-positive. It’s not so much denial – it’s probably more a function of education. They just don’t know or aren’t thinking they could be affected by breast cancer. Consequently, we recommend they have a risk assessment done by no later than age 30 to benefit from supplemental screening if they’re candidates for it. If they have the BRAC gene, they may need to speak to a genetic counselor to understand how this all affects not just them, but potentially their sisters, their daughters, and other members of their family.

We also think it’s important that other organizations strongly consider changing some of their guidelines to recommend annual screening starting at age 40. There are organizations like the National Comprehensive Cancer Network, the American College of Radiology, and the American College of Obstetricians & Gynecologists – they do that, and we think it’s terrific. But, some groups, like the family practitioners, the internists, the U.S. Preventive Service Task Force – they just say to start at age 50 and leave it up to the individual to consider age 40.

When you look at the data, if you were to consider an African American woman under age 50, with all we know about highly aggressive cancers occurring twice as likely in that population, we’re going to be missing a lot of breast cancer and, perhaps, having a lot of women die unnecessarily because these guidelines weren’t more tied in. All of these organizations admit that starting screening annually at age 40 saves the most lives, it’s in their own written reports. But, because they think the so-called harms of screening outweigh the benefits, they don’t start age 40.

To me, that’s mind-boggling. What’s the harm? Anxiety? Women can tolerate the anxiety of getting a bad diagnosis. They give birth, they can certainly tolerate that. The other issue is the callback. The callback rate is only about 10 percent, and most often, it involves a couple extra pictures, either being told you’re normal or to come back and see the radiologist in six weeks because there’s something of very low suspicion he or she wants to follow. The third thing is over-diagnosis. I can categorically say that that number is exceedingly low – way under 10 percent.

The benefits of doing all the things we talked about – finding cancer early; being able to treat patients morbidity, not just impact their mortality; paving the way for less extensive therapies – all these things far outweigh the theoretical risk of a few cases of cancer being diagnosed that wouldn’t affect the woman.

Getting organizations to sign on to these things that will recommend annual screening starting at age 40 is also very important. Cancer screening for breast cancer saves lives. We know that it doesn’t work in a lot of other areas – pancreatic cancer has dismal results, and it’s starting to work with lung cancer. But, breast cancer is the poster child that if you find the tumor early, you can help benefit mortality.

How can providers use these findings? What do they need to keep in mind about getting these breast cancer screening services to African American women?

 Radiologists need to be aware of the data that supports screening younger African American women annually. Many, I’m sure, don’t realize that these higher aggressive tumors occur in the young African American population twice as often as in the Caucasian population.

They need to know that, in our reports, we do recommend getting a risk assessment by age 30. Not to tie their hands, but we suggest the possibility that these women, if they are potentially going to benefit from supplemental screening, consider it. We need to educate them about what the ramifications of not doing it are – higher mortality, higher morbidity, more women likely to be diagnosed at late stages who will not benefit from less extensive therapies. All of these things have a negative impact on their patient population.

If they were to take heed and plug themselves into some of these recommendations for their African American patients, they would be doing them a great service. It’s about communication and education. Radiologists, people used to think, hid in the dark – that we never saw the light of day. But, nowadays, the focus is on being out there to talk to patients. In breast imaging, we see patients who have abnormal screening studies come in with lumps. We’re interfacing with them all the time, and I take that opportunity to try to, in the small amount of time I have with the patient, to educate them. Educating the patient, the referring physician, the clinical, the nurse practitioner – it’s all going to make a difference.

The patient needs to take ownership of her own healthcare and to be an advocate for herself. If she’s not raising these issues with her primary care doctor, she needs to start raising them, pointing out her increased risk and asking what the office can do. And, if her primary care doctor isn’t going to do anything, she needs to find someone who will.

In a one-on-one conversation, Murray Rebner, M.D., past president of the Society of Breast Imaging, discusses how current screening guidelines overlook these women and what that means for radiologists.

Q&A: Breast Cancer Screening Shortfalls for African American Women

While the COVID-19 pandemic is bringing profound change to healthcare, practices that planned for growth in teleradiology before the pandemic are seeing the upside of their forethought.

Teleradiology has many benefits but can result in detachment and isolation if culture is ignored and physicians are not involved in business decisions. Unfortunately, this scenario played out in too many teleradiology groups as competition in remote reading increased, even before the pandemic.

Under this pressure, many teleradiology groups transformed from a quality service provider into a production business with the primary objective of extracting maximum productivity from radiologists, partially by assigning key radiologist contributions to administrators to manage. In some groups, the isolation of radiologists was used as a tool for business owners to assert control over the radiologists. These financially driven business decisions resulted in a negative working environment with a lack of physician engagement and, ultimately, generated a negative stigma around teleradiology among physician colleagues.

Enter Matrix, an internal remote reading division of Radiology Partners (RP). At RP Matrix, we are committed to creating a new vision of teleradiology, one which provides a seamless transition from the high-quality care provided by the local practice. We are accomplishing this mission by utilizing the expertise of our radiologists by actively seeking their input to create a democratic, transparent, and fair practice.

We encourage camaraderie and group discussions resulting in a culture of belonging and safety that promotes a positive working and learning environment. We treat each other like family. Our radiologists are referred to as remote readers for our local practices, instead of generic teleradiologists, emphasizing our position as an accountable partner. We are integral members of the local practices we serve, involved and equally responsible for the wellbeing of the group and the care of its patients.

We are fortunate to have a model that allows us to enjoy the benefits and opportunities of a large practice with the feel and function as a small practice. This is more important than ever as practices work to recover from lower volumes caused by the pandemic. Structuring our team in regional subgroups has fostered a closer relationship between our remote radiologists, the local radiologists, and referring clinicians with whom we are servicing. This model facilitates a partner-to-partner collaboration and joint accountability between the local practice and Matrix.

As part of a large practice, we also benefit from the scale and expertise afforded by a nationwide structure. This larger structure affords scaled investments in multiple areas that allow our practice to drive value, including our clinical innovation programs, artificial intelligence, and data management systems, to name a few. Our practice values and seeks physician expertise and in turn, physician input drives all clinical decisions and provides oversight for our support teams. Unlike most teleradiology groups, our Matrix radiologists also have the opportunity to become a partner and owner in our practice.

I am proud to be part of my Matrix and RP family. A place where I am eager to read cases, happy to share my work and personal life with my peers, and excited to contribute to an environment in which our practice can continue to excel by providing the best clinical value and service, enhancing our radiologist’s experience, and fulfilling our mission to transform Radiology. Simply said, I feel lucky.

With the right structure, teleradiology can offer radiologists an inclusive environment, especially during stressful times.

Putting the Rad Back in Tele-radiology

Ultrasound developer Clarius Mobile Health announced this week the launch of its new Clarius L20HD, a system designed for medical practitioners in a variety of fields.

According to company representatives, the handheld system provides ultra-high definition medical imaging for superficial applications. It can be applied in musculoskeletal services, rheumatology, podiatry, plastic and microsurgery, pediatric anesthesia, and line placement. It is designed, they said, to replace cart-based systems that are currently used to visualize shallow anatomy.

“Every medical practitioner should have access to high definition imaging to improve confidence in diagnoses and accuracy in guided procedures,” said Laurent Pelissier, Clarius chief executive officer. “We’ve miniaturized ultrasound, without compromising image quality."

The system, which has 510(k) clearance from the U.S. Food & Drug Administration, as well as the CE Mark from the European Union, offers a frequency range of 8-to-20 MHz, enabling images down to 4 cm, and it features eight octal beams and 192 elements that provide for faster frame rates.

In addition, company officials said, it is compatible with both iOS and Android systems and can deliver images that are equivalent in quality to those captured by cart-based system, according to company details. Artificial intelligence can also adjust imaging parameters based on scanning application in real time.

The system retails for $6,900 in the United States compared to the $35,000 price tag for a cart-based system.

Wireless system offers highest definition to date, according to company.

Clarius Introduces Ultra-High Frequency Handheld Ultrasound for Superficial Applications

MRI scans of suspected endometriosis cases should be reviewed by experts in women’s health imaging, new research has revealed. Diagnostic accuracy is lower among all other radiologists interpreting those exams, even those providers with up to two years’ experience.

Endometriosis affects between 6 percent and 10 percent of women who are of reproductive age. Currently, ultrasound is considered to be the first-line modality for assessing the condition, but it does present challenges. It is both operator dependent, and it only provides a limited field-of-view. MRI is frequently a supplemental scan, but little is known about how much experience a radiologist needs to accurately interpret those studies.

A team of investigators from Geneve University Hospital in Switzerland examined provider performance to answer this question, and they published what they found in the Sept. 22 

“MRI is increasingly performed as an additional investigation in complex cases and for surgical planning, its importance lying also in overcoming the limitations of ultrasound,” said the team led by Clemence Bruyere, M.D., from the Geneve University Hospital division of radiology. “However, interpretation of pelvic MRI with the clinical question of endometriosis requires specific skill and experience.”

MRI scans are typically used to confirm an endometriosis diagnosis, and they also factor into surgical planning – study results can determine whether a colorectal surgeon or urologist should be present during surgery. But, correctly interpreting the images requires a certain level of expertise, the team said. This raises a concern, they added, because most radiology specialization programs include only 3-to-6 months of instruction in female pelvis imaging, and patients are largely referred as outpatients to small peripheral radiology centers where providers do not have sufficient experience.

To determine the differences in provider performance, Bruyere’s team conducted a prospective study to analyze the diagnostic performance of radiologists with varying levels of experience in their interpretations of MRI scans for endometriosis on 59 women. The women were imaged between December 2016 and August 2017, and their scans were interpreted by junior residents (0-to-6 weeks), senior residents (7-to-24 weeks), fellows (6-to-24 months), and an expert (10 years).

The team looked at provider performance around endometriomas, posterior compartment pooled lesions, vaginal invasion, and rectal invasion. According to their analysis, the overall diagnostic performance for all localizations was:

 Expert: 0.893 sensitivity; 0.964 specificity; 0.914 area under the curve

 Fellow: 0.807 sensitivity; 0.927 specificity; 0.849 area under the curve

 Senior resident: 0.731 sensitivity; 0.900 specificity; 0.787 area under the curve

 Junior resident: 0.491 sensitivity; 0.909 specificity; 0.721 area under the curve

While there was no statistically significant difference between the performance from fellows and the expert, senior and junior residents did not perform as well. They misclassified 14 and 18 lesions, respectively.

These results highlight the clear differences in diagnostic accuracy between radiologists at all levels, and they have both clinical and educational implications, the team said. Knowing that veteran radiologists are best equipped to interpret these exams can improve patient care.

“The aim [of our study] was to identify what degree of experience is considered ‘adequate,’” they explained, “so that clinicians could ideally address their patients to the appropriate radiologists.”

In addition, from an educational perspective, the results show that even radiologists who have two years of training are not sufficiently prepared and offer lower diagnostic performance. Consequently, training programs should consider curriculum changes, insisting on augmented instruction around female pelvic imaging, they suggested.

Even radiologists with two years’ experience have statistically inferior diagnostic performance.

Expert-Level Experience Needed to Diagnose Endometriosis with MRI

Chest MRI can be an effective, non-ionizing radiation alternative to chest CT when conducting follow-up imaging on patients with COVID-19 infection, according to a small study.

MRI scans can pick up both specific and indeterminate features of viral infection equivalently to CT scans, said a team of investigators from Iran. They published their findings in the Sept. 17 

“Our preliminary data…showed that common CT manifestations of COVID-19 pneumonia, such as bilateral multi-focal ground-glass, consolidative, nodular or reticular opacities can be identified and distinguished on MIR, although the imaging features are not specific,” said the team led by Shahram Akhlaghpoor, M.D., from the Pardis Noor Medical Imaging Center in Tehran, Iran. “Although MRI is not the modality of choice for evaluation of pulmonary opacities, it has similar capabilities in detection of COVID-19 pneumonia when compared to chest CT.”

According to the authors, this is the first case series to evaluate COVID-19 pneumonia on MRI.

To make this determination, the team conducted both chest CT and chest MRI scans on the same day on eight patients with an average age of nearly 41 who were positive for COVID-19 and were treated in their center from March 20, 2020 to April 8, 2020. Every patient presented with mild symptoms, and none needed supplemental oxygen support.

Patients first underwent chest CT scans of 1-mm thickness on a 16-slice scanner that revealed typical, indeterminate, or atypical features of COVID-19 pneumonia. Investigators, then, conducted an eight-sequence chest MRI protocol using a 1.5T scanner. All scans were reviewed by a 10-year veteran radiologist.

Based on the scan analysis, five patients had typical CT features, including ground-glass opacities and consolidations. These findings could also be easily seen on chest MRI. The other three patients had indeterminate or atypical findings that also showed up on chest MRI.

These results highlight the equivalency of both modalities, the team said.

“Our study drives home the fact that chest MRI can act as a potential alternative to chest CT in follow-up of COVID-19 pneumonia although further studies are warranted,” they said.

But, using MRI is not without its challenges, Akhlaghpoor’s team explained. As with every other modality in the current healthcare environment, there are concerns about COVID-19 infection and transmission risks.

Further research is needed, the team said, and subsequent investigations should include a larger patient population that is more diverse in age. Such studies can provide more details about these lung findings, as well as examine how diagnostic accuracy, sensitivity, specificity, false negative rates, and cost effectiveness compare between MRI and CT.

Ultimately, they said, radiologists must improve their understanding of COVID-19 in the context of MRI.

“Becoming familiar with typical findings of COVID-19 pneumonia in MRI is crucial for every radiologist,” they said.

Chest MRI picks up the same characteristics of COVID-19 pneumonia that are seen on chest CT, making it a good alternative without the radiation.


Chest MRI Matches Chest CT for COVID-19 Follow-up Imaging

The U.S. Food & Drug Administration (FDA) awarded 510(k) clearance to Ka Imaging, Inc., Monday for Reveal, its portable, dual-energy X-ray detector that, company officials, said can be used to slow the spread of COVID-19.

The detector differentiates itself by providing regular digital X-rays of bone and tissue in a single exposure, differentiating between the two without disruptions of other body parts that move during imaging, such as the heart. It is also designed for early detection of pneumonia, including COVID-19.

“What our dual energy X-ray imaging allows you to do is to produce in a single exposure of the lungs and ribs and look at them individually,” said Amol Karnick, Ka Imaging president and chief executive officer. “A good example is lung cancer where you may have a lesion or tumor hiding behind the rib cage. You remove the ribcage image and now you can see the lesion.”

In addition, Karnick said, Reveal also reduces radiation exposure and eliminates the quarter-to-half-second delay between separate exposures captured with existing dual energy X-ray imaging, eliminating potential image distortion.

Ka Imaging is testing the efficacy of its system in a 600-participant clinical trial at Toronto’s University of Health Network. The team is looking to determine how well it images lung disease, including pneumonia, as well as how effective it is in triaging COVID-19 infection prior to patients experiencing a drop in blood oxygen saturation. The trial will also compare thoracic tomograms to CT scans for early COVID-19 detection, and that data will be used to build an artificial intelligence model for automated and nearly instantaneous image interpretation, company officials said.

Portable, dual-energy X-ray detector delivers bone and tissue images in a single exposure.

Ka Imaging Secures FDA Clearance for COVID-19 Detecting Dual-Energy X-ray 

Close to three-quarters of transgender and non-binary (TGNB) patients report having at least one negative encounter associated with imaging services, according to the results of a newly released survey.

 reveal that there are many aspects to imaging encounters that can create uncomfortable and negative situations for patients. But, these incidents can help facilties improve their performance.

“Our data suggest that TGNB patients have endured negative experiences during imaging encounters,” said a team of investigators led by Frances Grimstad, M.D., an obstetrician-gynecologist with Boston Children’s Hospital. “These data highlight opportunities for radiology professionals and professional organizations to improve care delivery for TGNB patients.”

Particularly, she said, these experiences can be a launching point for improvements in cultural competency and sensitivity, such as re-designing facilities to be more accommodating of TGNB patients’ needs and incorporating their feedback into departmental policy developments.

To assess the impact of imaging encounters on TGNB patients, Grimstad and her colleagues surveyed 363 individuals through social media and listservs between January 2018 and December 2018. Of the group, 84 percent had received gender-affirming hormones, 63 percent had undergone at least one surgery, and 75 percent were imaged in outpatient centers. Within 22 questions, respondents were asked about the type of imaging completed, facility locations, and any emotional, psychological, or physical discomfort they felt during the encounter. 

According to the survey results, more than 70 percent of TGNB patients reported having at least one negative experience with imaging, and of those individuals, roughly 25 percent revealed they had had at least six negative encounters. Transgender women were 4.15 times more likely than transgender men to experience emotion discomfort, the team said, and 5.01 times more likely than gender non-binary individuals and all other genders combined.

Percentage of Patients Reporting Unexpected Physical Discomfort

Negative experiences included not being asked about personal pronouns or a chosen name, and many respondents said they felt imaging staff showed little regard for their comfort. In nearly one-third of instances, the team said, respondents had to instruct staff about TGNB patients in order to receive appropriate care, and nearly 25 percent said their gender was listed incorrectly 

Percentage of Patients Reporting Unexpected Emotional Discomfort

In a balance to the negative experiences, though, approximately 70 percent of respondents also said they had positive encounters when undergoing imaging services, the team explained. Many reported feeling safe, welcomed, and respected by imaging staff who showed concern for their comfort and privacy.

In addition, respondents reported that the type of imaging service they received affected them in different ways. Image-guided procedures, ultrasounds, and mammograms created the most unexpected physical and emotional discomfort, they said. In addition, X-ray, CT, and MRI also caused unexpected emotional distress with 40 percent saying they did not receive adequate explanations prior to procedures.

Grimstad’s team encouraged imaging facilities to use these results to improve their performance with and accommodations for TGNB patients and the LGBTQ community overall. To make beneficial changes, they offered these suggestions:

Train and educate radiology personnel in cultural sensitivity and gender-affirming care standards.

Consider no longer routinely including gender in the radiology report because misgendering occurs frequently.

Develop approaches and examination techniques that accommodate the needs and comfort of transgender men undergoing pelvic ultrasounds.

Create policies and appropriate management protocols for staff who fail to comply with the appropriate treatment of these patients.

Provide gender-neutral restrooms, and provide LGBTQ-affirming reading material in the facility.

Given the impact such steps can have on patient experience, outcomes, and retention, the team also suggested leadership organizations, such as the American College of Radiology, consider such factors when issuing standards for facility accreditation.

“Our results may be practice-changing for referring clinicians who wish to refer TGNB patients for imaging services,” the team said. “These data can assist clinicians in providing anticipatory guidance to their patients about uncomfortable experiences they may have during imaging encounters, selectively referring patients to imaging facilities that have shown sensitivity toward TGNB patients, or electing to limit referrals altogether for fear of subjecting their patients to untoward discomfort or even trauma.”

The majority of these patients have had at least one emotionally or physically uncomfortable experience, according to a survey, but imaging facilities can use this feedback to improve their performance. 

Imaging Services a Negative Experience for Most Transgender, Non-Binary Patients

It’s been a long-standing question in neuroscience: is Parkinson’s more than one disease? Now, thanks to MRI and PET scans, clinicians have an answer – yes. And, having this knowledge could pave the way for personalized medicine for these patients.

Based on the analysis of advanced imaging scans, researchers have determined that Parkinson’s in, in fact, two distinct conditions – one that begins in the intestines and moves to the brain, and one that starts in the brain and migrates to the intestines and other organs.

“Until now, many people have viewed the disease as relatively homogeneous and defined it based on the classical movement disorders. But, at the same time, we’ve been puzzled about why there was such a big difference between patient symptoms,” said Per Borghammer, Ph.D., professor of nuclear medicine and neuroscience at Aarhus University in Denmark. “With this new knowledge, the different symptoms make more sense, and this is also the perspective in which future research should be viewed.”

In addition to the showing the differences between the brain-first and body-first types of Parkinson’s, the team also hypothesized that isolated REM sleep behavior disorder (iRBD) – a known risk factor for developing Parkinson’s – could be specifically associated with body-first disease.

The team of Aarhus University researchers published their findings recently in the journal 

To reach this determination, Borghammer and his colleague Jacob Horsager, M.D., medical director in the department of clinical medicine, enrolled 37 consecutive de novo Parkinson’s patients in a longitudinal PET study. Of the groups, 24 did not have iRBD, but 13 did. The team also included a comparator group of 22 patients who had iRBD. They repeated the scans after three years and six years.

C-donepezil PET/CT to assess cholinergic (parasympathetic) innervation, 

I-metaiodobenzylguanidine (MIBG) scintigraphy to measure cardiac sympathetic innervation, neuromelanin-sensitive MRI to measure the integrity of locus coeruleus pigmented neurons, and 

F-dihydroxyphenylalanine (FDOPA) PET to assess putaminal dopamine storage capacity.

CT scans and radiopaque markers were used to evaluate colon volume and transit times, the team said.

Based on their results, the team found some patients experience damage to the brain’s dopamine system prior to developing intestinal damage, but others manifest damage to the nervous system of the intestines and heart before the disease reaches the brain. In those cases, it might be beneficial, they said, to study the composition of intestinal bacteria.

“It has long since been demonstrated that Parkinson’s patients have a different microbiome in the intestines than healthy people, without us truly understanding the significant of this,” Borghammer said. “The next step is to examine whether, for example, body-first Parkinson’s disease can be treated by treating the intestines with feces transplantation or in other ways that affect the microbiome.”

Detecting brain-first Parkinson’s is harder, they said, because it is largely symptom-free until movement disorders appear. At that point, patients have already lost more than half of their dopamine system.

Ultimately, the team said, their findings open doors for more targeted therapy plans.

“Previous studies have indicated that there could be more than one type of Parkinson’s, but this has not been demonstrated clearly until this study,” Borghammer said. “We now have knowledge that offers hope for better and more targeted treatment of people who are affected by Parkinson’s disease in the future.”

Advanced imaging shows Parkinson’s can begin as brain-first or body-first.


MRI and PET Reveal Parkinson’s Is Two Diseases

In less than 20 years, radiology has seen a 70-percent drop in happiness among its providers throughout all subspecialties, and breast imagers could rank among the most burned out, according to a new study.

To date, much has been written about how the increased workload and other pressures have consistently chipped away at radiologist happiness, said a multi-institutional team. Little research has focused on breast imaging, but the emotional and intellectual demands associated with this specialization indicate breast imagers could face higher levels of professional fatigue than their colleagues.

“Breast imaging shares common risk factors with other radiology subspecialties. In addition, compared to other radiology subspecialties, breast imaging has one of the highest litigation risks, as most errors lead to misdiagnosis of breast cancer,” said the team led by Sofya Kalantarova, M.D., a radiology resident at New York University Winthrop Hospital. “This medicolegal risk can place immense emotional burden on breast imaging radiologists who often need to have difficult conversations with patients to recommend invasive breast procedures of suspicious findings and to ultimately inform them of breast cancer diagnosis.”

4 Micro-Strategies to Avoid Post-COVID Burnout

 Kalantarova’s team explored not only the reasons why breast imagers experience such high levels of burnout, but they also laid out six tactics providers can use to mitigate that stress and exhaustion.

In an effort to avoid or recuperate from burnout, the team recommended providers try these steps:

Employ a patient coordinator or navigator to counsel patients prior to a procedure and deliver results. This can keep the level of patient interactions manageable for the provider.

Delegate procedure performance to a nurse practitioner or physicians assistant, freeing up more time for image interpretation.

Use artificial intelligence tools, such as computer-aided detection, to pinpoint significant findings.

Work to forge a collegial environment with colleagues from other specialties in order to lower stress, encourage collaboration, and foster open discussion about difficult cases.

Encourage flexible work schedules, providing resources, such as home workstations, to support these efforts.

Clearly communicate all productivity expectations and consider adopting the concept of an academic RVU alongside the traditional RVU to account for the writing, research, and teaching activities many breast imagers frequently do.

Ultimately, it is critical for the industry to address these high levels of burnout to help safeguard providers, the team said.

“Burnout is a major threat to healthcare providers, including breast radiologists. It is important for breast radiologists to understand key concepts relating to burnout, including how to evaluate for burnout and ways to address it,” the team said. “While both individual and organizational approaches to addressing burnout exist, it is essential for institutions to take an active role in embracing these concepts and encouraging their staff to have honest discussions about wellness, work-life balance, and burnout.”

Breast imagers could be among the most highly burned out sub-specialists, but there are ways to reduce the work fatigue.

Imaging Services a Negative Experience for Most Transgender, Non-Binary Patients

MRI and PET Reveal Parkinson’s Is Two Diseases

Breast Imaging Burnout: 6 Ways to Alleviate the Stress

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