Diagnostic Imaging brings you daily coverage of SIIM 2021 virtual annual meeting.

SIIM 2021 Virtual Annual Meeting: May 24 - 27, 2021

The Radiological Society of North American (RSNA) is looking for proposals from researchers who can help collect and submit COVID-19-related images and clinical data to the open-source Medical Imaging and Data Resource Center (MIDRC).

RSNA is looking for proposal from sites with substantial COVID-19 imaging and clinical data that can commit to contributing their information to the database. Funding preference will be given to sites that have data that includes diverse and vulnerable patient groups, as well as other types of information that is currently under-represented in the MIDRC database.

“We recognize that some health care organizations don’t have access to the resources needed to contribute data,” said Curtis Langlotz, M.D., Ph.D., RSNA board liaison for information technology and annual meeting. “Support for those sites helps assure that the MIDRC datasets reflect the full diversity of the patient population.”

Recipients will be able to use the funding to select, process, and submit data for use by the MIDRC research community to better understand, diagnose, monitor, and treat the virus. Awards will be up to $38,000 for a one- or two-year project and will be distributed in four payments over the project duration: 25 percent after project kick-off, 25 percent post Institutional Review Board and privacy approval, and 50 percent after data delivery. Funds can be applied to any institutional process or individual who can spearhead the data transfer.

Any U.S.-based investigators at any level is invited to apply. The application for the first round of funding is July 15, 2021, and RSNA will consider applications until all available funding has been awarded.

Articles

Funding will be given to sites that can contribute to the Medical Imaging and Data Resource Center (MIDRC).

Calling All Proposals: RSNA Seeking COVID-19 Images for Database

Breast imaging specialists, general radiologists, providers who read ultrasounds – when it comes to screening mammograms everyone is looking for the same thing. But, the level of accuracy in interpretation depends on many factors.

investigators from the Harvey L. Neiman Health Policy Institute and the American College of Radiology’s National Mammography Database Committee showed that interpretive performance with mammography is largely based on geography and breast sub-specialization, as well as diagnostic mammography and diagnostic ultrasound performance.

It was surprising, said the team led by Cindy Lee, M.D., FACMQ, FSBI, assistant professor of radiology at NYU Grossman School of Medicine, because these factors even outweighed length of practice. Still, the team stressed, these factors that predict performance aren’t well understood.

“It was interesting that in many cases certain characteristics predicted higher performance in some areas and, at the same time, lower performance in others,” Lee said, noting that academic-practice breast imaging radiologists with many years of practice may have higher recall rates alongside higher cancer detection rates. “This example highlights the importance of assessing performance across measures holistically versus individual metrics in isolation, supporting guidance in the ACR BI-RADS atlas.”

Rather than focusing on a provider’s clinical experience level, Lee’s team pivoted and concentrated on other factors that play into interpretive and diagnostic accuracy. Theirs is the largest study to date based on Medicare claims and screening performance data, including 1,223 radiologists from the National Mammography Database between 2018 and 2019.

The team examined provider demographics, clinical practice patterns, and any sub-specialization, and they used seven metrics to evaluate their mammography interpretation performance:

Cancer detection rate: at least 2.5 per 1,000 screening studies

Positive predictive value of recall (PPV 1): 3 percent-to-8 percent

Positive predictive value of biopsy (PPV 2): 20 percent-to-40 percent

Positive predictive value of biopsy (PPV 3) 25th percentile-to-75th percentile of study sample

Invasive cancer detection rate: at least 25th percentile of study sample

Percentage of ductal carcinoma in situ (DCIS): at least 25th percentile of study sample

Overall, the team found that 31.7 percent of participating radiologists reached an acceptable performance level on all metrics. For individual metrics, though, 52 percent-to-77 percent had acceptable performance ranges. 

When the team dug a little deeper, they determined that geography played a significant role in mammography interpretive performance, though, with radiologists in the Midwest achieving acceptable recall rates, PPV1, PPV2, and cancer detection rates (odd ratio of 1.4-2.5). Radiologists in the West were also more likely to achieve acceptable recall rates, PPV2, and PPV 3 (odd ratio of 1.7-2.1), however, they more often fell below acceptable rates of invasive cancer detection (odd ratio of 0.6).

As anticipated, providers with a specialization in breast imaging also performed better than general radiologists, the team said. According to their results, breast imagers were more likely to have acceptable levels for PPV1, invasive cancer detection rates, percentage of DCIS, and overall cancer detection rate (odd ratio of 1.4-4.4). In addition, providers who performed diagnostic mammography had higher levels of PPV1, PPV2, PPV3, invasive, cancer detection rate, and overall cancer detection rate (odds ratio of 1.9-2.9).

In contrast, though, performance was lower for those conducting breast ultrasound. These providers were less likely to have acceptable levels of PPV1, PPV2, percentage DCIS, and cancer detection rate (odds ratio of 0.5-0.7).

Although breast imaging specialists have higher interpretive performance, the accuracy of general radiologists – and efforts to improve their performance – will become more important in the coming years, said Andrew Rosenkrantz, M.D., MPA, professor and director of health policy in the NYU Grossman School of Medicine radiology department.

“Most mammograms performed in the United States are interpreted by general radiologists and not by breast subspecialty radiologists, who account for less than 10 percent of all radiologists,” said Rosenkrantz, who was also the lead study author and Neiman Institute senior affiliate research fellow. “As the U.S. population ages and greater numbers of women comply with screening guidelines, the demand for all radiologists to interpret screening mammograms is anticipated to increase. Hence, attention to the interpretive screening performance of all radiologists is critical and strategies to improve interpretive accuracy among generalists would be beneficial.”

Ultimately, the team said, their findings highlight the existing performance variations among all provider who interpret breast images, pointing to the need for more extensive training.

“The findings indicate not only variation in radiologist performance in screening mammography nationally, but also the association of such variation with specific radiologist characteristics in a predictable manner that can be applied to predict those radiologists with better or worse performance,” the team concluded. “Furthermore, the findings support the value of breast sub-specialization in achieving better patient outcomes among radiologists who interpret screening mammography.”

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Several factors – other than length of clinical experience – weigh into a provider’s interpretive accuracy.

What’s Behind Screening Mammography Interpretation?

Using an artificial intelligence algorithm to identify patients whose brain and chronological ages are out of sync could open the door to earlier detection and diagnosis of cognitive decline.

Before patients begin exhibiting the signs and symptoms of Alzheimer’s disease, they enter a phase known as amnestic mild cognitive impairment (aMCI) where they experience some episodes of memory loss that are more significant than would be expected for their age and education. However, their daily functioning is still normal.

Being able to better understand how these individuals’ brains differ from those who aren’t experiencing any cognitive changes could make earlier identification and intervention with these patients easier, said a team of investigators from Beijing Normal University in China. They found that individuals with older brain ages were more likely to progress with neurological degeneration.

“The predictive model we generated was highly accurate at estimating chronological age in healthy participants based on only the appearance of MRI scans,” said the team led by Ni Shu, Ph.D., associate professor from State Key Laboratory of Cognitive Neuroscience and Learning at Beijing Normal. “In contrast, for aMCI, the model estimated brain age to be greater than 2.7 years older on average than the patient’s chronological age.”

They published their findings with their predictive model on June 22 in 

Based on these findings, Shu’s team determined that predictive age difference (PAD) – predicted versus actual age – has significant potential to be a sensitive imaging marker that is specifically related to individual cognitive differences in patients who have aMCI.

Flowchart showing the framework of the brain age prediction model. A, The imaging data were split into training and test datasets. The training dataset consisted of structural magnetic resonance imaging data from 974 healthy individuals, whereas the test dataset included data from 2 groups, 231 healthy controls and 224 aMCI subjects. B, A Conventional Statistical Parametric Mapping structural preprocessing pipeline was used to generate GMV maps in the MNI space. C, The intensity values from the GMV maps were extracted and concatenated to create a feature matrix that was then cleaned and normalized. D, The best elastic net model was obtained by performing supervised learning on the training dataset. To optimize the hyperparameters, a grid search was performed. E, The test dataset was input into the trained model. An age was predicted for every participant included in the test dataset. The PAD scores were calculated by subtracting the participant's chronological age from his or her predicted age. aMCI = amnestic mild cognitive impairment, GMV = gray matter volume, MNI = Montreal Neurologic Institute, Dartel = Diffeomorphic Anatomic Registrations Through Exponentiated Lie Algebra, PAD = predicted age difference.

For their study, the team used T1-weighted MRI images captured from 974 healthy adults between ages 49.3 and 95.4 to train their machine learning model to predict brain age. They, then, implemented their model with two groups – 616 healthy controls and 80 aMCI patients from the Beijing Aging Brain Rejuvenation Initiative (BABRI) and 589 health controls and 144 aMCI patients from the Alzheimer’s Disease Neuroimaging Initiative (ADNI).

In addition to assessing the MRI images, they also evaluated the relationship between PAD and cognitive impairment, genetic risk factors, Alzheimer’s pathological biomarkers, and clinical progression in these patients.

According to their analysis, the team determined that aMCI patients had higher PADs than their healthy counterparts, and that PAD was significantly associated with individual cognitive impairment, particularly with memory, attention, and executive function. In fact, the predictive model could quantify individual deviations from the typical normal aging trajectory.

Predicted Age Differences of BABRI and ANDI Cohorts

The team also discovered that individuals who were carriers of the apolipoprotein E (APOE) ε4 exhibited a much bigger PAD difference than did non-carriers. The same was true for patients who were amyloid-positive rather than amyloid-negative.

Predictive Age Differences Between APOE Carriers and Amyloid-Positive aMCI Individuals

“We found that patients with progressive aMCI exhibited more deviations from typical normal aging than patients with stable aMCI,” they said, “and, the use of the PAD score along with other [Alzheimer’s disease]-specific markers had higher performance for predicting the progression of aMCI.”

Overall, the team said, when PAD scores and the other Alzheimer’s biomarkers were combined at baseline, they achieved an area under the curve of 0.87 for distinguishing between stable and progressive disease. Consequently, Shu said, it is highly possible their model could beneficially impact patient care.

“This work indicates that predicted age difference has the potential to be a robust, reliable and computerized biomarker for early diagnosis of cognitive impairment and monitoring response to treatment,” he and his colleagues concluded.

A deep learning algorithm used with brain MRI could help providers identify patients in the early stages of cognitive decline and Alzheimer’s.

AI-Predicted Age Differences Point to Early Cognitive Decline

When it comes to brain imaging, functional MRI – commonly called fMRI – is considered the gold standard. However, it can be costly, time consuming, and come with several restrictions that can prohibit use with certain patients. 

In recent years, investigators have been searching for a different brain imaging method that can side-step these problems and potentially provide better quality scans at the same time. Researchers from the University of Southern California Keck School of Medicine and California Institute of Technology recently succeeded. They’ve developed functional photoacoustic computed tomography (fPACT) – a technique that works by emitting a laser beam of light into the area being imaged. 

Drs. Charles Liu and Jonathan Russin join me to discuss the differences and benefits with fPACT.

Podcasts

Drs. Charles Liu and Jonathan Russin discuss the benefits and potential of fPACT, the alternative to functional MRI.

The Reading Room: Potential fMRI Alternative -- fPACT

X-rays should not be used to drive decisions about treating common forearm fractures, according to new research. Instead, providers should give more consideration to the patient’s needs and his or her environment.

researchers from Michigan Medicine reported results from a decade-long study that examined treatment outcomes for distal radius fractures. Based on their analysis, they determined that no one therapy works best for everyone.

At the core, though, they found that X-rays should not be the basis for these treatment decisions that impact more than 85,000 Medicare beneficiaries each year.

“Traditionally, surgeons look at these broken bones on X-rays, and they have to assess various ways of fixing it based off fracture anatomy and patient age,” said Kevin Chung, M.D., lead study author and Charles B.G. De Nancrede Professor of Surgery. “However, in older patients, we determined that the patient-centered care in tailoring particular treatments to their needs, social environment, and risk tolerance for surgery are all considerations in prescribing treatment.”

AI System Detects Frequently Overlooked Fractures on X-ray

In this study, Chung’s team examined data collected over a decade from 187 individuals from 20 medical centers worldwide who underwent surgery for their fractures. The team divided participants into the groups based on their treatment: volar locking plates, external fixation, and pinning. An additional 117 patients refused surgery and opted for casting.

Initially, they said, patients who chose volar plating were better able to perform daily tasks, but after six months, their advantages over other treatment methods had faded. Additionally, after 24 months, all patients reporting similar pain scores with everyone reporting satisfaction with their outcomes.

“For hand surgery, this is the most intense, collaborative effort to try and answer a 200-year puzzle about distal radius fractures in older adults,” Chung said. “It is one of the most common fractures in the world for this population – you have parents and grandparents that will get this fracture. For the good of public health, we needed to answer this question.”

Ultimately, he said, the outcome of the study highlighted the importance of communication and interaction between the patient, his or her family, and the surgeon. By working together, they can identify the best personalized approach to fixing the patient’s broken bone and maximizing their future capabilities and quality of life.

A more personalized approach rooted in the patient’s needs is a better course of action. 



Don’t Rely on X-rays to Determine Forearm Fracture Treatment

I arrived at the interventional radiology suite and was greeted by a man with a thick red beard. 

. This patient had metastatic bone lesions to the spine causing him great pain. Radiofrequency ablation was being used as a palliative measure.

I heard a lot about interventional radiology and was very excited. I heard it was a very procedure-oriented field and very innovation-driven. I knew everything about the patient. His history with cancer was humbling. I wrote the various patient details on a piece of paper. I took one last look at my paper, confidently donned gloves, and stepped up to the table. I was excited to get a close-up view and engage for the next 5 hours.

However, the procedure involved a few sticks and a few pokes. It was done in 30 minutes, and the patient was rolled out to the post-procedure bay. In the post-procedure bay, I spent time with the patient. The patient smiled, talked about his puppies, and talked about his wife. He was looking forward to his upcoming Alaskan cruise with his grandchildren.

after having cancer cells melted out of his spine.

My thick red beard is something I am really proud of. I have taken pride in my ability to grow it and groom it. It is the first thing that is on my mind in the morning. 

Do I need to trim it? Do I need to shave it? Do I need to oil it?

 Ever since my cancer was removed, I have been able to cover up the scar with my beard. It is 

Nine years ago, I noticed the mole on my chin begin to change. I scheduled a visit with the dermatologist. The administrative assistant was able to get me in the next day. At the dermatology clinic, the physician looked worried the minute he saw me. He measured my mole, looked at it with a magnifying glass, and performed a biopsy. A week later, I learned I had melanoma. I didn’t know what melanoma was, but I quickly learned that it was a “bad” type of skin cancer. This moment was the beginning of my saga with doctors, medicine, and pain.

I was assigned three doctors in the beginning. I had a blood doctor, a skin doctor, and a surgeon. I was placed on chemotherapy, had monthly full-body skin checks, and had metastases cut out of my liver. I was recently referred to an interventional radiologist by my surgeon because of pain in my back. This was weird to me because I thought radiologists looked at fancy screens all day to “diagnose” rather than “treat.”

I first met the interventional radiologist in the clinic. It wasn’t a busy clinic. And it wasn’t a part of the oncology suite. These differences did not bother me at all. I was in extreme pain. My melanoma had metastasized to my spine. I couldn’t sleep at night, and my medication for pain was not helping. The pain was piercing. It felt like a knife was being stabbed and twisted into my back.

The interventional radiologist told me about the kyphoplasty procedure. Once I heard that this had the chance to help my pain – and did not involve surgery – I did not need to hear anymore. I only cared about a reasonable chance of success and a reasonable risk of complications. The doctor spoke with such confidence and enthusiasm. I was convinced after the first minute.

A week later, I had my kyphoplasty. I remember being wheeled into the procedure bay. When the procedure was finished, I chatted with a nice medical student. He was great.

I have come to understand that perspectives extend deeper than simply calling a beard a 

Interventional radiologists, ultimately, bring their unique 

to medicine. The ability to combine imaging with intervention has resulted in fresh ideas to treat pathology. It is shocking to students and patients alike. Combating diseases through tiny holes in the body is the way of the future, but this future isn’t quite yet realized. Interventional radiology clinics aren’t yet as busy as they can be. Patients still may think that radiologists only deal with the diagnosis perspective of disease. And a medical student may have a rudimentary grasp on a procedure before seeing it because the concept feels like science-fiction.

The formal definition of perspective is, “a particular attitude toward or way of regarding something; a point of view.” (google.com). From my perspective, interventional radiology is a particular attitude or way of regarding illness – a point of approach to treatment.

Apparently, students are beginning to realize that interventional radiology accomplishes amazing tasks in a short amount of time. Patients are beginning to realize that the treatments have high efficacy. And people, such as me, are realizing that perspective is the core beauty of interventional radiology.

A provider’s first-person encounter with the specialty as a patient.

Perspectives on Interventional Radiology

Victor Shin, M.D. is a Board Certified, Fellowship Trained Radiologist. Dr. Shin completed medical school at Columbia University College of Physicians and Surgeons and his radiology residency at St. Luke’s Roosevelt Hospital, University Hospital of Columbia. Dr. Shin also completed his fellowship in Neuroradiology at Yale University, New Haven Hospital.

James K. Tatum, M.D. is a Board Certified, Fellowship Trained Radiologist. Dr. Tatum completed medical school at The University of Texas Medical Branch in Galveston and his radiology residency at Baylor College of Medicine in Houston. Dr. Tatum also completed his fellowship in Neurointerventional Radiology at The University of California in San Francisco.

A 30-year-old female presents with papilledema.


- Bilateral transverse sinuses stenoses are typically caused by compression from increased intracranial pressure
- The venous compartment and CSF compartment are intimately related with respect to pressure
- Lumbar puncture revealed an opening pressure of over 35 cm CSF.


 Stent placement, VP shunting, and weight loss
- Placement of self expanding stents in the transverse sinus is becoming a preferred treatment as it allows for improved egress of venous flow
- Many patients experience reversal of papilledema and regression of headache following stent placement


Slideshows

A 30-year-old female presents with papilledema. What is the imaging finding?

Image IQ Quiz: 30-Year-Old Woman Presents with Papilledema

It’s widely accepted – and research continues to show – that digital breast tomosynthesis (DBT) catches more cancers and brings fewer women back in for recall. But, are the gains that come with this imaging technique enough to change breast screening strategies overall?

Paola Clauser, M.D., and Pascal A.T. Baltzer, M.D., both from the Medical University of Vienna, Vienna General Hospital, took a quick look at existing investigations to determine the real-world impact and whether it is enough to re-shape breast cancer screening.

For their analysis, they looked at the results from a study published in the 

 (JNCI) that retrospectively analyzed 7,602,869 screening mammography exams from 4,580,698 women between the ages of 40 and 64 between 2015 and 2017. Mammography accounted for 72.5 percent of the studies, and DBT made up the additional 27.5 percent.

While that study showed DBT produces a lower recall rate, particularly among women between ages 40 and 44, and a significantly higher cancer detection rate across all groups, the JNCI researchers determined that women screened with DBT were more likely to undergo biopsy than women screened with mammography.

However, Clauser and Baltzer noted, the study did not examine nor report on women’s breast density. Getting insight into how DBT performs with women who have dense breasts would have been helpful, they said, because previous studies have not shown it reduces recall rate in this patient population.

Alongside the JNCI data, other findings point to a reduced interval cancer rate with DBT which could either be an over-diagnosis or early diagnosis of indolent cancers that require less aggressive treatments. More data is needed on tumor characteristics to pinpoint the real DBT screening benefits, they said.

Consequently, Clauser and Baltzer said, while DBT has exhibited several benefits to date, more work needs to be done before making widespread changes to breast cancer screening.

“Screening with DBT increases [cancer detection rate] and can improve [recall rates], particularly in younger women,” they said. “Further research should aim to identify those women who may benefit most from DBT screening by addressing the effects of breast density, as well as cancer stage, type, and molecular sub-type on long-term outcome, to provide point estimates of the actual effect of the introduction of screening with DBT.”

Digital breast tomosynthesis offers benefits over mammography, but it is enough to change screening?

Is It Time to Re-Shape Breast Cancer Screening?

More frequent screening with ultrasound for patients who are at high risk for hepatocellular carcinoma (HCC) results not only in lives saved, but also improved quality of life.

Liver cancer is the sixth most common cancer worldwide, and it is the third leading cause of cancer-related deaths. HCC accounts for most of the liver cancer cases. Despite recent improvements in medical technology and with treatments, the HCC 5-year survival rate remains low, underscoring the need for improved efforts for earlier detection.

investigators from Taiwan evaluated the impact on more frequent ultrasound screening in patients who are at high risk for developing HCC to see whether more observations could lead to better patient outcomes.

According to their analysis, it can. Specifically, regular ultrasound screening between less than 6 months and one year may be associated with earlier HCC detection, less loss of life, and improved quality of life, the team said.

“In this study, ultrasonography screening using shorter intervals for high-risk patients detected HCC earlier, suggesting that such a screening approach may save more lives and improve quality of life,” said the team led by Jung-Der Wang, M.D., ScD, from the public health department at National Cheng Kung University Hospital, College of Medicine.

Currently, three organizations – the American Association for the Study of Liver Disease, the Asian Pacific Association for the Study of the Liver, and the European Association for the Study of the Liver – all recommend abdominal ultrasound screening at 6-month intervals for high-risk patients. However, many studies don’t support this recommendation, and adherence to the guideline has been inadequate, the team said.

To determine what impact – if any – more frequent ultrasound screening has, Wang’s team assessed data from 59,194 patients (42,081 men and 17,113 women) from three national databases in Taiwan who had newly diagnosed HCC between 2002 and 2015. The team followed the patients for 14 years. In addition, they assessed quality of life measures on 1,059 patients. 

For the study, they divided participants into five screening interval groups: 6 months (0-to-6 months), 12 months (7-to-12 months), 24 months (13-to-24 months), 36 months (25-to-36 months), and more than 36 months.

Among both men and women, less than 50 percent complied with abdominal ultrasound screening within 6 or 12 months. Both sexes had a decreasing trend in the total number of ultrasound screenings in the three years before their HCC diagnosis.

Alongside HCC, study participants also had other conditions. Men had a higher proportion of underlying hepatitis B infection and alcoholic liver disease, and women had higher levels of underlying hepatitis C infection and liver cirrhosis.

When they examined the loss of quality-adjusted life expectancy, the team saw greater losses accompanied longer screening intervals. Based on their results, they also found that both men and women who had underlying hepatitis B infection or cirrhosis had the greatest improvement in life expectancy with shorter screening intervals.

Loss of quality-adjusted life expectancy based on ultrasound screening interval.

Additionally, in their results, the team discovered that patients who are screening more regularly were more likely to benefit from surgical intervention or loco-regional therapies, including radio-frequency ablation and percutaneous ethanol injection. Additionally, their HCC cancers were caught at earlier stages, the team said.

“The results of this study suggest that regular ultrasonography screening with an interval of 6-to-12 months or less may lead to early detection of HCC and may save lives and improve utility for patients with HCC from a lifetime perspective,” the team said. “Because people with underlying risk factors (including hepatitis B virus or hepatitis C virus infection, cirrhosis, and alcoholic liver disease) showed only slightly more frequent ultrasonography screening than those without underlying risk factors, we recommend improving this clinical practice.”

Undergoing more frequent abdominal screening can improve life expectancy and quality of life for patients with hepatocellular carcinoma.

6-to-12 Month Ultrasound Screening Intervals Improve HCC Outcomes

Pranav Chitkara, M.D. is a Board Certified, Fellowship Trained Radiologist. Dr. Chitkara completed medical school at The University of Texas Southwestern and his radiology residency at State University of New York in Brooklyn. Dr. Chitkara also completed his fellowship in Musculoskeletal Imaging at Cleveland Clinic.

A 70-year-old female with wrist pain


- Osteonecrosis of the lunate
- Sclerosis and flattening of the lunate, which can lead to collapse, then lunate rotation, and ultimately fragmentation of the lunate along with secondary degenerative disease
- Association with negative ulnar variance​


70 year old female with wrist pain. What is the imaging finding?

Is It Time to Re-Shape Breast Cancer Screening?

6-to-12 Month Ultrasound Screening Intervals Improve HCC Outcomes

Image IQ Quiz: 70-Year-Old Patient Presents with Wrist Pain