Diagnostic Imaging brings you coverage of ARRS 2022 annual meeting.

Coverage of ARRS 2022 Annual Meeting

Perhaps the biggest challenge in radiology right now is the current global shortage of iodinated contrast media (ICM), which is most commonly utilized for computed tomography (CT) exams. With the temporary shortage expected to last until the end of June, radiology departments and larger medical facilities are scrambling to address this issue, which can have a significant impact on patient care.

With this in mind, we recently spoke with two professors from the Yale School of Medicine: Dr. Joseph Cavallo, an Assistant Professor of Radiology and Biomedical Imaging, and Dr. Jay Pahade, an Associate Professor and Vice-Chair of Quality and Safety for Radiology and Biomedical Imaging.

co-authored an article on strategies that imaging facilities may take to address this acute shortage of iodinated contrast media.

 They outline three central strategies including ICM dose reduction, utilization of alternative imaging modalities and possible deferment of imaging deemed to be non-urgent in nature.

Dr. Pahade called ICM a mission critical agent.

“Most institutions rely heavily on contrast-enhanced CT for the management of their patients both inside and outside of the emergency department (ED). Almost every critical diagnosis in medicine has some arm tied to CT imaging in one fashion or another,” emphasized Dr. Pahade.

For additional insights on the shortage of iodinated contrast media, watch the video below.

Videos

In a recent video interview, two radiology professors from the Yale School of Medicine discussed the impact of the iodinated contrast media (ICM) shortage and potential strategies, ranging from ICM dose reduction to possible deferment of non-urgent imaging, that may provide a viable path moving forward. 

Emerging Strategies for Managing the Acute Shortage of Iodinated Contrast Media

A new study of over 3.9 million Korean women found that the combination of benign breast disease and dense breasts led to elevated 10-year risks for the development of breast cancer.

In a retrospective review drawing from the National Health Insurance Service-National Health Information Database (NHIS-NHID) in Korea, researchers assessed 3,911,348 Korean women who had mammography screening between January 2009 to December 2010. Study participants who had normal breasts (Breast Imaging Reporting and Data System (BI-RADS) category 1) or benign breast disease (BI-RADS category 2) at the time of this screening were included in the study, 

which was recently published in Radiology

Among the 58,321 women who developed breast cancer during a median follow-up of 10.6 years, researchers found a higher proportion of benign breast disease (18.4 percent) and dense breasts (55.4 percent) at the baseline screening in comparison to those who did not develop breast cancer (13.3 percent and 38.4 percent respectively).

Women who had no breast disease and BI-RADS category A breast density (almost entirely fatty tissue) at the baseline screening had a .73 percent risk of breast cancer at 10 years, according to the study. In contrast, the study authors noted a 2.18 percent risk for women who had baseline benign breast disease and BI-RADS category C breast density (heterogeneously dense) and a 2.64 percent risk for the combination of benign breast disease and BI-RADS category D breast density (extremely dense) at 10 years.

In other words, patients who had a combination of benign breast disease and BI-RADS category C or BI-RADS category D (extremely dense) breast density had a nearly threefold or greater 10-year risk for breast cancer in comparison to women who had no breast disease and BI-RADS category A breast density.

“Our findings strengthen the evidence suggesting that benign breast disease and breast density are important factors that should be carefully considered when stratifying breast cancer risk and should be incorporated in future breast cancer risk models,” wrote senior author Boyoung Park, M.D., Ph.D, who is affiliated with the Hanyang University College of Medicine in Seoul, Korea, and colleagues.

In a subsequent subgroup analysis, Park and colleagues found the combination of breast density and benign breast disease was associated with higher risks for developing invasive breast cancer and ductal carcinoma in situ (DCIS).

Given the overall findings of the study, the authors suggested that supplemental screening could be beneficial for this patient population and noted recent studies on the topic, including 

one study that found supplemental magnetic resonance imaging (MRI) in comparison to mammography alone reduced interval cancers in women with BI-RADS category D breast density in a two-year screening period

In regard to study limitations, Park and colleagues noted no biopsy results were available from the NHIS-NHID database utilized for the study. As per the Korean national cancer screening guidelines, the study authors pointed out that further workup and periodic mammography screenings are not recommended for those diagnosed via mammography with benign breast disease. Although the application of BI-RADS categories can vary with ability and experience level, the study authors acknowledged that at several screening centers, one radiologist interpreted the BI-RADS breast density and classification categories.

Articles

Researchers found that Korean women with a combination of benign breast disease and BI-RADS category C or BI-RADS category D breast density had a nearly threefold or greater 10-year risk for breast cancer.

Large Study Finds Elevated 10-Year Breast Cancer Risks in Women with Dense Breasts and Benign Breast Disease

Emphasizing that magnetic resonance imaging (MRI) is the most sensitive imaging test for the detection of breast cancer, Linda Moy, MD, FSBI, FACR, FISMRM, discussed a variety of tips for maximizing lesion conspicuity, minimizing false positives, and improving consistency in interpreting exam findings during her recent lecture at the Society of Breast Imaging (SBI)/American College of Radiology (ACR) conference.

Here are a few pertinent points from Dr. Moy’s lecture:

1. In order to facilitate optimal breast imaging with MRI, ensure the system:

• allows good fat saturation over both breasts;

• has a bilateral breast coil with prone positioning;

• has sufficient magnetic field gradients to facilitate fast gradient-echo imaging; and

• has sufficient magnetic field strength with good magnetic field homogeneity.1

2. While one study found that 1.5 T and 3 T MRI scanners are both suitable for breast MRI, Dr. Moy said 3T scanners are preferred for ultrafast MRI imaging as minimum spatial resolution is difficult to achieve with other scanners.2

3. In regard to coils, Dr. Moy emphasizes that radiologists should ensure the current hardware and software of the MRI system can accommodate the number of channels in the breast coil.

4. When it comes to axial versus sagittal imaging, sagittal imaging offers a small field of view with high spatial resolution and field uniformity, according to Dr. Moy, a professor of radiology at the New York University Grossman School of Medicine. She adds that you can get twice the number of slices in less than two minutes of acquisition time.

5. Dr. Moy said axial imaging is preferred with multiplanar reformation in the sagittal plane. She noted this approach makes it easier for radiologists to appreciate bilateral focal background parenchymal enhancement (BPE).

6. When it comes to slice thickness, Dr. Moy noted that thin slices are beneficial in evaluating foci and minimizing partial volume effects on diffuse non-mass enhancement (NME) (e.g. ductal carcinoma in situ (DCIS)).

7. In regard to breast MRI enhancement patterns, the ideal time to maximize cancer detection and normal BPE is at 90 seconds.

8. Obtain the first scan 60 to 90 seconds after contrast injection to maximize conspicuity of the cancer.

9. For high-quality breast MRI, Dr. Moy recommends multiphase T1-weighted contrast-enhanced scanning. Key aspects would include high in-plane spatial resolution (1 mm pixel sizes), thin slices (

2.5 mm thickness) and adequate temporal resolution (one to two minutes).

10. For patients with higher BPE, there are no significant decreases in sensitivity and cancer detection rates.

2. Dietzel M, Wenkel E, Hammon M, et al. Does higher field strength translate into better diagnostic accuracy? A prospective comparison of breast MRI at 3 and 1.5 Tesla. 

In a recent lecture at the Society of Breast Imaging (SBI)/American College of Radiology (ACR) conference, Linda Moy, MD, reviewed key tips for optimizing magnetic resonance imaging (MRI) of the breast.

Ten Key Considerations with Breast MRI

510(k) clearances from the Food and Drug Administration (FDA)

 for the artificial intelligence (AI)-enabled algorithms Saige-Dx™, which aids in detecting suspicious findings on mammograms, and Quantib® Prostate 2.0, which may bolster reporting of prostate magnetic resonance imaging (MRI) exams.

Saige-Dx reportedly enhances the detection of suspicious lesions on mammograms and reduces recalls, according to RadNet. Built on advanced deep learning algorithms, Saige-Dx decreased false positive rates and improved the ability of 18 radiologists to detect cancer in a study that preceded the FDA 510(k) clearance, noted DeepHealth, a subsidiary of RadNet.

Quantib Prostate 2.0 provides automated segmentation of prostate zones and glands as well as lesion localization on the PI-RADS sector map, according to RadNet.

The company noted that the software program enhances the quality and speed of reporting with prostate MRI exams. RadNet said other benefits of Quantib Prostate 2.0 include PSA density calculation, PI-RADS scoring support and one-click segmentation of possible lesions.

“Artificial intelligence will have a transforming impact on radiology and cancer care, and we are committed to delivering those advances to patients and health-care providers,” noted Howard Berger, the president and chief executive officer of RadNet. “ … We believe that these AI tools will play an important role in the early detection and diagnosis of cancer, resulting in improved survival rates and better patient outcomes.”

Could the emerging artificial intelligence platforms Saige-Dx and Quantib Prostate 2.0 improve cancer detection with mammography and prostate MRI?

RadNet Gets FDA Nods for AI-Powered Mammography and Prostate MRI Software Algorithms

Eric Postal, MD, is a diagnostic radiologist with the University of Pittsburgh Medical Center. 

A decent chunk of my daily radiological workload comes with “prelim” interpretations. Sometimes they come from residents. Some of them come from other health-care personnel. I don’t know that I would be able to identify the source for any particular case. It is not readily apparent. Maybe this is by design but there is a lot to be said for double-blinding in quality assurance (QA). Without knowing, I tend to assume it is coming from a resident rad but that is pure instinct.

After the most important aspect of prelim reads (identifying when there is a difference of opinion and communicating it to the clinicians), it seems to me the second priority is for the prelim reader to get feedback about when he or she has done well, or when the prelim reader has something to learn.

I don’t expect the prelim folks to always be enthusiastic about it. Given the usual structure of QA systems, I wouldn’t be surprised if the majority of participants preferred to opt out of it. One can’t be thrilled with the constant lurking threat of peers or superiors reaching out to say “Hey, you screwed up.”

Still, I perceive the whole prelim/final interplay to be mutually beneficial, a kind of professional handshake. The prelim reader gets to do a cursory read, learn stuff, and potentially have errors caught/corrected by someone else, and the final reader gets an extra set of eyes reviewing things while not having to work 24/7/365.

As a final reader guy, I therefore consider it my part of the bargain to provide whatever value I can, sometimes communicating stuff to the prelim readers beyond the mere (in)accuracy of their reads. This may be in the form of pointers or interesting tidbits. I do concede though that sometimes my days are so hectic that I don’t communicate as much as I would like to.

A recent case in point has prompted me to share my advice with my readers since I never caught up with the prelim reader who inspired it. There was a random emergency room (ER) or urgent care X-ray of an extremity. The prelim reader noted “No obvious fracture.”

I didn’t see one either and moved on. However, something about that prelim stuck in my mind. After a little while, I put my finger on it: Hey, prelim person, is that the limit of your value? You’re only willing to say there is nothing obvious on the images?

The study was good quality. There wasn’t any diagnostic limitation. Indeed, it was a simple three-view X-ray, not advanced imaging of any kind. I know folks can say stuff like “No gross pathology” if they want to underscore that they’re not getting the best view of things.

Could it be that the prelim reader wanted to emphasize that the final read guy has greater skills/experience to the point where there is subsequent appreciation of subtle pathology the prelim reader isn’t equipped to identify? Recognizing one’s own limitations is a good thing, and people like a reasonable dose of humility.

Let’s go with that notion for a moment: I 

 have issues with throwing in that “obvious.” What do you suppose it says to everyone else involved? As the final read guy, it puts the notion in my mind that maybe the prelim readers didn’t look too carefully. Maybe the referring clinician gets the same impression or, if the referrer wrote the prelim him- or herself, everyone else involved in the patient’s care gets that impression about the care that was rendered.

What if the patient got a look at the prelim? If you went to an ER because you thought your leg might be broken and the person responsible for treating you, someone you trusted to be an experienced professional, shrugged, and said you had no “obvious” injury, would that reassure you or would you feel like your case was casually dismissed?

I hear “obvious” applied to a fracture, and I think of something that doesn’t take a radiologist, physician, or other health-care individual to identify it. Google images for “fracture” and most of the pix you see will be things that a grade-schooler could look at and say, “That’s broken.”

I think we can hold ourselves to a higher standard than that—and this includes residents, physician assistants (PAs), and even medical students. If you are in a position to be rendering even preliminary interpretations, you’ve accomplished enough in life that you don’t need to be hedging by saying you’re only liable to find “obvious” stuff. Your opinion is worth more than that.

Alternatively, if you believe you can or should only be on the hook for seeing “obvious” abnormalities, you probably shouldn’t be rendering even preliminary interpretations.

Besides, when you do inevitably miss something, nobody’s going to consider your error any more forgivable because you used hedging terms like “obvious” or “gross.”

One other thought struck me with the “obvious” prelim comment. Some folks get so accustomed to throwing around words like that, it becomes a thoughtless reflex. It stops meaning anything to them, but others still hear it.

Possibly my best preceptor from medical school, a guy I have referenced in this column before, regularly corrected or otherwise commented on the verbiage of his house staff and students. H would tell interesting stories of word origins, and even address grammar and pronunciation. One of his enduring lessons was words matter, if not to you, then at least to your audience.

One of the interns on my rotation with that preceptor routinely used “basically.” Any time he was presenting a patient or giving an update on developments since previous rounds, he would launch with that word. He made it surprisingly far into the first week of that month before the preceptor called him on it. “You use that word a lot,” he observed. “Does it add anything to what you’re saying? It seems more like a nervous habit. You’re not simplifying anything for our benefit, are you?”

Of course, he wasn’t and knocked it off almost immediately. Darned if he did not immediately sound more professional and confident in his presentations.

Is it a thoughtless verbal reflex or a failure to go beyond a surface read of imaging?

Questioning 'Obvious' Notations from Prelim Readers

Recognizing the shift from age-based breast cancer screening to screening programs that are more focused on risk stratification, Volpara will be 

spotlighting its Volpara Risk Pathways™ software

 at the annual Society of Breast Imaging (SBI)/American College of Radiology (ACR) conference in Savannah, Ga. this week.

Drawing upon patient data from mammography reporting systems or electronic health records, Volpara Risk Pathways reportedly facilitates the identification and management of patients who are at high risk for breast cancer, according to Volpara. The company said the software’s assessment of an individual’s risk for breast cancer enables enhanced triage decisions for supplemental imaging and/or genetic testing.

Volpara will also spotlight the Analytics in Action program, which offers on-site training from Mammography Educators.

“The Analytics in Action program is designed to help deliver high-quality, personalized breast cancer screening by improving image quality, reducing errors, and increasing proficiency and efficiency. We are excited for our partnership with Volpara to deliver hands-on, personalized training sessions designed not only to help address common positioning performance issues but also to create a culture of quality and continuous improvement that ultimately will result in better screening and better patient care,” noted Louise Miller, R.T. (R)(M)(ARRT), CRT, FSBI, FNCBC, the director of education and co-founder of Mammography Educators.

The company will spotlight the breast cancer risk stratification software Volpara Risk Pathways and a new mammography training collaboration with Mammography Educators.

Volpara to Highlight Recent Additions to Breast Cancer Assessment Software at SBI/ACR Conference

's Weekly Scan is your chance to catch up on the latest radiology content, from new research and device news to the latest case quizzes and conference reports. Review the slideshow below to see this week's top content:

Diagnostic Imaging's Weekly Scan: May 8-May 14

Slideshows

Catch up on the top radiology content of the past week.

Despite a number of practical benefits for patients and having comparable detection rates to conventional colonoscopy for colorectal cancer, computed tomography colonography (CTC) remains significantly underutilized. In fact, a recently published survey of over 13,700 people between the ages of 50 to 75 found that 

only 1.4 percent of respondents had CTC for colorectal cancer screening

Various authors have pointed to the lack of Medicare coverage as a key factor in the limited access and use of CTC. Noting the potential impact CTC could have in improving colorectal cancer screening rates in at-risk populations, the 

American College of Radiology recently wrote a formal request to the Centers for Medicare and Medicaid Services (CMS)

, urging the organization to reconsider non-coverage of CTC for Medicare and Medicaid beneficiaries.

With this in mind, Syam Reddy, MD, Judy Yee, MD and Anand Narayan, MD, recently spoke with 

 to discuss the benefits of CTC, limitations of access to the procedure and suggested steps for potentially resolving this issue.

In recent video interviews, Syam Reddy, MD, Judy Yee, MD and Anand Narayan, MD, discussed various benefits of computed tomography colonography (CTC) for colorectal cancer screening, the underutilization of the CTC procedure and steps moving forward to improve access to this procedure.

Emerging Perspectives on Computed Tomography Colonography

Radiologist advocate. This term describes my approach to the profession. I have been a pediatric radiologist for eight years. During this time, I have learned a lot about myself, specifically outside of my clinical capabilities. I have been candid about my personal struggles with burnout, and how those experiences have made me grow as a person, clinician, colleague, and advocate for others in similar situations.

There are many drivers of burnout that need to be addressed in order to successfully mitigate it. In my ongoing research on this topic, I have become passionate about a few aspects that I want to delve into more in the future.

The first is the role of leadership in preventing burnout. The leaders in a company or department create the culture of the workplace, which is crucial in contributing to or mitigating burnout. Individual factors certainly play a role in burnout but addressing workplace stressors has the most significant impact. Effective leaders play a critical role in addressing these stressors and creating a healthier workplace.

Lack of inclusion is another driver of workplace burnout. This awareness has been significantly heightened in the past few years with diversity, equity and inclusion (DEI) efforts coming to the forefront in medicine. Creating a psychologically safe workplace that is inclusive of everyone is an important factor in mitigating burnout among physicians. This is true for all marginalized groups, regardless of age, race, ethnicity, sexual orientation, gender identification, etc., with evidence showing that inclusivity in the workplace creates a better work environment for everyone and increases productivity. As a minority woman in academic medicine, I have personally experienced being the “other” and have learned from this. I hope to share this experience with others to facilitate increased awareness and spark discussions of how to improve inclusivity moving forward.

Lastly, in the past two years with the COVID-19 pandemic, physical and mental vulnerability have also been heightened for many, including me. I had to face challenges associated with my underlying autoimmune disease, rheumatoid arthritis, which I have had for over 12 years. Being immunosuppressed during the uncertain times of the pandemic (which still continues) has added significant daily anxiety and stress for me both mentally and physically. The pandemic’s sudden, unexpected and sustained challenges has put a strain on my mental energy. I realized this may be the case for many in medicine with the pandemic potentially exacerbating burnout. As conditions like mine may exist unseen and unknown to colleagues, I have been sharing my story to bring awareness to this poorly appreciated driver of burnout in the hope that others dealing with medical conditions or illnesses can relate to this and be seen.

I have been lucky to have fantastic colleagues, mentors, friends and family to help me through my challenging times. Through this blog, I hope to share some of my experiences and lessons to help others as well as hear from others about their experiences and potential solutions. It is my hope that continued discussion of these issues can lead to meaningful change.

In addition to addressing workplace stressors, leaders in radiology should have an increased awareness of other key drivers of burnout, including inclusivity issues and challenges for radiologists who are managing their own health conditions. 

How Fostering a Culture of Inclusion Can Help Mitigate Burnout

The ongoing global shortage of iodinated contrast media has prompted state and national organizations to issue guidance advisories as well as suggested risk mitigation strategies to help ensure optimal medical imaging while managing limited supplies of iodinated contrast media typically used in computed tomography (CT). 

Here are the top 15 recommendations to help preserve supply during the shortage:

1. Reassess scanning protocols to scan without contrast when appropriate and adjust injection protocols to reduce contrast dosing amounts.

2. Evaluate the amount of on-hand inventory of Omnipaque (GE Healthcare) and reassess plans for obtaining additional product.

3. When it comes to orders for intravenous (IV) contrast imaging, consider alternative imaging options whenever possible.

 to match up recommended alternative imaging options with different clinical scenarios.

5. Reserve IV contrast for essential urgent and emergent imaging/procedures.

6. Reserve higher concentration (mg iodine/ml) agents for angiographic and multi-phase studies that require optimal vascular visualization.

7. Collaborate with emergency department physicians, cardiologists and other physicians who order imaging to reassess and adjust imaging protocols to ensure appropriate use of contrast media.

8. Raise awareness of wasted contrast media with computed tomography (CT), X-ray, interventional and catheterization lab technologists, and identify opportunities for conservation.

9. When feasible, use non-contrast CT for ambulatory patients in order to conserve contrast for trauma and stroke patients presenting to emergency rooms.

10. Consider alternative contrast agents that may be marketed with different brand names or intended clinical use.

11. For oral opacification in CT and positron emission tomography (PET)/CT, consider barium-based products or alternative iodine-based agents.

12. For radiologists who have access to a higher volume of single-use vials of contrast agents, check with your facility’s pharmacy to see if there are options for repackaging vials in smaller aliquot amounts to help reduce waste.

13. Reduce waste by minimizing the use of individual doses of contrast agents. Alternative options include: the use of weight-based dosing for CT exams in available aliquots and vial sizes; combining reduced dosing with low kVp protocols that bolster contrast conspicuity; combining reduce dosing with dual-energy protocol studies (where available) to improve contrast conspicuity.

14. When it comes to genitourinary, rectal, and oral administration, employ alternative agents to nonionic contrast, such as iothalamate meglumine or diatrizoate.

15. Consider other vendors/suppliers for contrast agents.

Greater New York Hospital Association (GNYHA). GE contrast media shortage and conservation strategies. Available at: 

https://www.gnyha.org/news/ge-contrast-media-shortage-and-conservation-strategies/

 . Published May 4, 2022. Accessed May 11, 2022.

Alabama Board of Medical Examiners and Medical Licensure Commission. Temporary shortage of contrast media. Available at: 

https://www.albme.gov/press-release/temporary-shortage-of-contrast-media

American College of Radiology. Statement from the ACR Committee on drugs and contrast media. Available at: 

https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Contrast-Media-Shortage

 . Published May 6, 2022. Accessed May 11, 2022.

Given the challenges with the shortage of the iodinated contrast agent Omnipaque, national and state organizations have issued suggested risk mitigation and conservation strategies to reprioritize imaging needs during this temporary shortage.