Diagnostic Imaging brings you daily coverage of the RSNA 2020 virtual annual meeting.

RSNA 2020: Nov. 30-Dec. 5

 radiologists first reported swollen lymph nodes linked to the COVID-19 vaccine that mimic breast malignancies. In that time, there has been much discussion about how breast imagers should proceed when they encounter these findings.

three radiologists from Harvard Medical School threw their hats into the ring, offering specifics about how they are approaching this issue. They have based their protocol on the American College of Radiology BI-RADS Atlas.

Their goal, they said, is to reassure women about the vaccine while limiting any unnecessary testing and continuing to provide the best care available.

COVID-19 Vaccine-Linked Adenopathies Could Mimic Breast Malignancies

“In this setting,” said the team led by Constance D. Lehman, M.D., Ph.D., director of breast imaging at Harvard Medical School, “we believe our model can avoid reducing or delaying vaccinations and avoid further reduced or delayed breast cancer diagnoses based on confusion amongst patients and/or their providers.”

For patients who present at Harvard with these unilateral axillary adenopathies, the team said they based their approach on the patient’s unique circumstances. Is the patient asymptomatic at screening? Does she have a symptomatic breast or axilla for diagnosis or has she recently received a cancer diagnosis in the pre- or peri-phase of treatment? In addition, the technologist confirms and documents vaccination status, first or second dose with administration dates, as well as vaccination side and location.

For specific instances, Lehman’s team offered this advice:

For swollen lymph nodes visualized on the side of vaccination via screening mammography or MRI within six weeks of administration, the team reports the finding as benign with no need for follow-up if the adenopathy dissipates within six weeks of the second dose. Patients receive a lay-language letter alerting them that the finding is a common post-vaccine reaction.

For lymph nodes a provider can feel, they recommend clinical follow-up using BI-RADS 2 (benign). However, if the swollen node persists after six weeks post-second dose, they suggest an axillary ultrasound.

For patients who recently received breast cancer diagnoses in the pre- or peri-treatment setting, Lehman’s team recommended timely imaging regardless of vaccination status.

The team did note, however, that for all patients who have swollen lymph nodes that linger after the post-vaccine six-week mark, axillary ultrasound should be performed. And, as other institutions have recommended, they also advised providers to include all vaccine information on patient intake forms.

While this guidance is intended to help institutions schedule screening mammograms and MRIs at optimal times for women who have received the COVID-19 vaccine, the team said they anticipate their approach could changes as the vaccination process continues to unfold.

“As we navigate through this phase of the pandemic with vaccination programs expanding, and as more data become available, we will continue to refine our patient management paradigm to guide best practices for our patients,” they said.

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Articles

The approach, based on ACR guidance, is intended to promote vaccine use while reducing patient anxiety and unnecessary imaging. 



A Pragmatic Approach: Harvard Breast Imagers Share Approach to COVID-19-Vaccine Adenopathies

Radiology pioneer and leader Ezequiel Silva III, M.D., is taking on a key leadership role in the American Medical Association (AMA) – and the American College of Radiology (ACR) is “greatly pleased.”

Silva, the immediate past chair of the ACR Commission of Economics, was announced Feb. 23 as the new chair of the American Medical Association Multi-Specialty Relative Value Scale Update Committee (RUC). In this role, he will be integral to evaluating and informing Medicare payment policy.

“Dr. Silva’s outstanding collaborative work and contributions in the fields of medicine and healthcare economics have earned the respect and trust of physicians and allied professionals across the house of medicine,” said William T. Thorwarth, M.D., FACR, ACR chief executive officer. “I can’t think of a better choice to lead the AMA Multi-Specialty Relative Value Scale Update Committee into the future.”

Silva’s two-year term with the 32-member committee begins March 1, and he will assess how science and technology medical advances have touched patient care. The San Antonio-based radiologist will also lead the charge in progressing Medicare reimbursement rules.

Alongside this new role, Silva, who has served on the 

Journal of the American College of Radiology 

editorial board, has a long history of radiology leadership. Not only is he a Harvey L. Neiman Health Policy® founding board member, but he has also served on the RUC since 2016, most recently as the committee’s Research Subcommittee chair. Within the AMA, he has served as past co-chair of the Digital Medicine Payment Advisory Group, a panel created to identify the stumbling blocks that exist to adopting digital medicine. That chairmanship uniquely prepared Silva for his new leadership position, AMA leaders said.

“The rise of the digital-native physician will have a profound impact on healthcare and patient outcomes, and the RUC will be increasingly called upon to assess the impact of digital health technologies on patient care,” said Russ Kridel, M.D., AMA board chair. “Dr. Silva’s respected insights into emerging digital technologies and his leadership qualities will help guide the RUC’s vital work as a source of physician input on policies that govern Medicare.”

In addition, Silva, who has co-authored roughly 70 peer-reviewed and 50 non-peer reviewed publications. has been a vocal advocate for safe and effective care during the COVID-19 pandemic, presenting to the Center for Medicare & Medicaid Services and White House COVID-19 Task Force “Lessons from the Front Lines: COVID-19” series and serving as faculty on the AMA webinar “Coding for Telemedicine and COVID-19.”



Ezequiel Silva III, M.D., will assume leadership of the AMA’s committee on Medicare policy payment on March 1.



ACR Leader Assumes AMA Role

Combining intraprocedural MRI with X-ray angiography can help neuroradiologists determine the best course of treatment for patients who have suffered acute ischemic stroke.

Although CT is typically used in the angiography suite, MRI can play a valuable role in helping providers determine if further attempts to recanalize steno-occlusive lesions are valuable or in guiding neuroprotective agent use. In an article published recently in 

investigators from the University of California at San Francisco (UCSF) laid out how integrating MRI with X-ray angiography can lead to better treatment options.

“Our study showed that combined use of angiography and MRI during endovascular acute ischemic stroke intervention is feasible and enabled tissue-based decision making regarding whether or not to proceed with mechanical thrombectomy, place intracranial stents, or administer antithrombotic or blood pressure medications,” said the team led by Steven W. Hetts, M.D., chief of interventional neuroradiology at UCSF Mission Bay Hospitals.

In a retrospective observational study, the team examined patients who received endovascular intervention for acute ischemic stroke between July 2019 and May 2020 who either had angiography with MRI or angiography alone. Of the 47 patients who underwent the stroke intervention, 12 had X-ray angiography with MRI.

According to their findings, MRI directly impacted treatment decision-making in all 12 patients:

Proceeding with mechanical thrombectomy: 

In two patients, further mechanical thrombectomy was aborted when MRI depicted acute infarct after the initial thrombectomy attempt resulted in incomplete reperfusion. For two additional patients, mechanical thrombectomy was pursued after MRI confirmed salvageable tissues without infarct distal to the persistent arterial occlusion.

For three patients, MRI contributed to determining whether to place an intracranial stent to treat acutely symptomatic intracranial atherosclerotic disease. One patient had a right M1 MCA for which mechanical thrombectomy showed severe underlying stenosis. Diffusion-weighted imaging showed infarct of the entire penumbra, so no stent was placed because reperfusion would have increased hemorrhage risk. In another patient with small posterior cerebral artery-MCA border zone infarcts visualized on diffusion-weighted imaging, MR angiography identified critical stenosis, and the patient was administered anti-platelet medications and was given a stent in the internal carotid artery stenosis. With the third patient, diffusion-weighted imaging helped differentiate several small new acute infarctions from an older infarction. Mechanical thrombectomy showed underlying high-grade right M1 MCA stenosis. The patient was administered a loading dose of anti-platelet therapy, the MCA underwent angioplasty, and a stent was administered.

Antithrombotic Medication Administration: 

For the five remaining patients, MRI helped inform the use of antithrombotics in the neurocritical care unit based on the extent of cerebral infarct or hemorrhage. It also helped determine infarct size.

“Our study showed that combined use of angiography and MRI during endovascular stroke intervention enabled tissue-based decision making to determine whether or not to proceed with mechanical thrombectomy, place intracranial stents, or administer antithrombotic or blood pressure medications,” the team said. “MRI influenced the surgical or medical treatment plan for all patients, which demonstrated the use of the combined use of angiography and MRI.”

Not only can MRI accurately depict core infarct with better contrast-to-noise ratio, but when it is incorporated into the neuroangiography suite, it can also reveal the extent of rapidly evolving tissue infarct.

Recent advancements with portable low-strength MRI machines that can be wheeled into the angiography suite could facilitate this combination with less time and cost investment, they said.

Although including MRI in the angiography suite can provide benefits, integrating it can present challenges, said Massachusetts General Hospital experts Michael H. Lev, M.D. director of emergency radiology and emergency neuroradiology, and Thabele M. Leslie-Mazwi, M.D., director of endovascular stroke services, in an 

While the average acquisition time with the MRI scanner is, on average, 12 minutes, the transfer time between the angiography unit and the MRI can be substantially longer at 45 minutes. This can present a significant problem with stroke patients where “time is brain.” Mitigating this challenge will require workflow optimization, they said.

But, the prospect of further integrating MRI into the angiography suite is attractive for treating this patient population and others, they said.

“MRI-derived information regarding brain parenchymal tissue status is feasible and may be valuable in making intraprocedural therapeutic decisions for patients with acute stroke in the angiography suite,” they said. “It is not hard to imagine the role of this approach in other neurovascular disease states.”

Using MRI in the angiography suite can help providers decide whether to continue with thrombectomy, to place stents, or to administer anti-thrombotic medications.

MRI in the Angiography Suite – Can It Guide Treatment Decisions?

African American women are more likely to experience better breast cancer detection and lower recall rates with digital breast tomosynthesis (DBT) – that is, if they can get the exam.

Journal of the American College of Radiology,

showed that while DBT benefits women of all ages and races, it is not used equally across all racial groups, leading to disparities in patient outcomes. In particular, when compared to white women, African American women were not only less likely to receive DBT, but they were also less likely to be screened multiple times during a five-year timeframe.

“Racial differences in screening frequency and DBT utilizations are likely rooted in social, economic, cultural, and educational disparities,” said the team led by Emily Conant, M.D., division chief of breast imaging at PennMedicine. “Black women are more likely to be diagnosed with breast cancer at a younger age and more advanced stage and to die from breast cancer.”

The results of this study, Conant’s team said, should prompt institutions to assess DBT utilization across women of all races included in their patient populations, as well as invest in educating providers about the benefits of more frequent DBT screening.

Race, Lower Income, Less Education Reduce DBT Access

To get a clear picture of how DBT is used across racial groups, Conant’s team conducted a retrospective study of 63 breast imaging facilities nationwide from 2015 to 2019. From 385,503 women, they gathered 804,304 mammograms – 542,945 DBT scans and 261,359 digital mammography (DM) screenings. They included only women with no history of cancer or breast implants.

Based on their analysis, they picked up on several DBT benefits that held true across racial and age groups. Overall, the aggregate recall rate was 8.74 percent for DBT compared to 10.06 percent for DM. The cancer detection rate was also better for women who received DBT – 4.73 for DBT compared with 4.60 for DM. In addition, the positive predictive value for recall was also greater with DBT overall (5.29 compared with 4.45, respectively).

But, when the team dug deeper, they found that, of the DBT screenings included in the study, African American women received the least. Only 44 percent of African American women underwent DBT compared to 63 percent of Asian women and 61 percent of white women. They were also less likely to receive more than one screening exam – 57 percent of the African American women in the study were screened two or more times compared with 63.7 percent of white women. When the team adjusted for age and institution, the difference was significant with an odds ratio of 0.895. However, the team did note that African American women who underwent DBT did have lower recall rates than white women.

Overall, the team said, their results reiterate that DBT improves patient screening metrics, including recall rate, cancer detection, and positive predictive value for women of all ages and races.

With this knowledge, providers can make decisions for better DBT utilization, the team said.

“If providers are educated about the benefits of more frequent screening applicability of risk scores for across racial groups, and the improved screening outcomes achieved with DBT, they may promote DBT uptake by their patients, potentially resulting in increased DBT access,” they said. “Interventions that increase awareness and enable primary care and breast imaging providers to decrease barriers to screening, particularly DBT, could have a positive impact.”

Such changes could open the door for earlier diagnosis and better patient outcomes for African American women. But, they could also have other, non-clinical positive impacts for patients.

“Benefits of improvements in these screening metrics likely include decreases in patient stress, time away from work, cost for diagnostic imaging, and the number of biopsies with benign results,” they said, adding that the cost associated with false-positive screenings can be a significant financial burden on women in lower socioeconomic groups.

Ultimately, the team said that their findings point to the need for overcoming these existing disparities in an effort to drive up DBT use for better breast cancer screening.

“This study suggests that the addition of DBT screening to DM is associated with improved screening performance, including improved [recall rate,] [cancer detection rate,] and [positive predictive value] across all racial groups,” they concluded. “Therefore, these data suggest that overcoming the existing disparities in DBT utilization may be key to improvement in the effectiveness and equity of breast cancer screening.”

While digital breast tomosynthesis improves cancer detection and recall rates among women of all ages and races, significantly fewer African American women have access to the exam.

Fewer African American Women Screened with Digital Breast Tomosynthesis

Applying a machine-based learning algorithm to images captured with CT colonography makes it possible for radiologists to differentiate between benign and pre-malignant colorectal polyps.

In industrialized countries across the globe, colorectal cancer ranks among the top three most common causes of cancer-related deaths among both men and women. In a study published Feb. 23 in 

a team of investigators from Germany showed how using radiomics can expand CT colonography beyond simply detecting polyps to pinpointing which ones are likely to progress to being cancerous.

“CT colonography does not enable a definite differentiation between benign and premalignant polyps, crucial for individuals risk stratification and therapy guidance,” said the team led by lead study author Sergio Grosu, M.D., a radiologist from University Hospital at Ludwig Maximilian University in Munich. “In this proof-of-concept study, machine learning-assisted CT colonography analysis allowed for differentiation of benign and premalignant colorectal polyps at high diagnostic performance associated with the histopathologic reference standard.”

A, Optical colonoscopy and, B–D, CT colonography of a 9-mm polyp (arrow) in the descending colon of a 78-year-old woman. B, Virtual fly-through three-dimensional reconstructions were used for exact polyp localization. C, Manual polyp segmentation was performed in multiplanar two-dimensional CT colonography images. D, CT colonography images were preprocessed for image feature extraction by application of a dedicated filter.

For nearly 20 years, CT colonography has gained popularity as a non-invasive screening method for colorectal cancer. It performs equally as well as optical colonoscopy (OC) in visualizing polyps that are at least 6 mm large in asymptomatic patients, and it is also provides better images of complex anatomical cases for which colonoscopy is frequently ineffective.

But, Grosu’s team investigated whether it was possible to push the screening method’s diagnostic value even further to potentially allow for pre-cancerous polyp identification.

To reach this goal, the researchers created a machine learning algorithm that uses radiomics to extract quantitative image features to predict whether the polyps would further develop into cancer. They applied this algorithm to CT colonography images taken in a group of asymptomatic patients who were at average colorectal cancer risk. They, then, trained the algorithm on 169 CT segmentations from 107 colorectal polyps from 63 patients and tested it on 118 segmentations from 77 polyps from 59 patients.

Top: Axial CT colonography images show representative colorectal polyps (arrow) in the training set. Bottom: Corresponding histopathologic work-up. (Hematoxylin-eosin staining; original magnification 320.) A, An 8-mm hyperplastic polyp in the ascending colon of a 54-year-old woman with hyperplastic epithelia. B, An 8-mm tubular adenoma in the sigmoid colon of a 68-year-old man with tubular growth pattern and elongated nuclei. C, An 11-mm tubulovillous adenoma in the rectum of a 73-year-old man with tubulovillous growth pattern and elongated nuclei.

Using random forest analysis, the team determined that their radiomics-based machine learning method allowed for non-invasive differentiation of benign and pre-malignant colorectal polyps with 82-percent sensitivity and 85-percent specificity. The area under the curve (AUC) was excellent, they said, at 0.91.

When the team examined the method’s performance based on the size of the polyps detected, they found that for polyps between 6 mm and 9 mm, the AUC was 0.87 – it was 0.90 for polyps that were at least 10 mm in size. The team also found that the most important image feature for decision making was quantifying first-order gray level histogram statistics.

These results fall in line with existing studies, the team said, but their findings add to the knowledge base around the use of CT colonography for polyp identification because they examined polyps that were smaller than 8 mm. In addition, their algorithm was trained on a balanced training set, and it was validated with an external multi-center test set.

Overall, Grosu said, incorporating a machine learning-derived algorithm can make CT colonography an even better colorectal cancer screening tool.

“Adding machine learning-assisted image analysis to conventional, radiological image reading could further improve the clinical significant of CT colonography-based colorectal cancer screening by allowing for a more precise selection of patients eligible for subsequent polypectomy,” he said. “Furthermore, machine learning-assisted CT colonography image analysis potentially provides the gastroenterologist with a road map of pre-malignant polyps eligible for OC-guided resection, particularly in patients with a high burden of colorectal polyps, such as in familial adenomatous polyposis.”

Still, he said, additional larger studies are needed to further validate the findings and refine the algorithm, making it better suited for the clinical environment.

Implementing a radiomics-based machine learning algorithm allows CT colonography to differentiate between benign and pre-cancerous polyps with high sensitivity and specificity.

CT Colonography Identifies Pre-Malignant Polyps with Machine-Based Learning Algorithm

Case submitted by Mohammad Osama Yonso, M.D., radiologist, to

 Asymptomatic 35-year-old male presents with respiratory symptoms to rule out pneumonia. No focal airspace opacities are seen to suggest pneumonia, but there is a congenital variant of right-sided aortic arch and knob visualized. No aneurysm or other vascular variant are identified. No situs inversus is seen.

 Right-sided aortic arch is a variant characterized by the aortic arch with course to right of the airway. Various patterns can be seen with patterns of right-sided aortic arch associated with mirror image branching or right-sided aortic arch associated with with aberrant left subclavian artery (ALSA). 

On chest X-ray, look for the absence of left-sided aortic contour. The trachea tends to bow towards the left slightly. Right-sided descending aorta is also visualized adjacent or overlying the spine. Finding can be mistaken as a mass in the right paratracheal region.

What is your diagnosis on this patient who got a CXR to rule out pneumonia?






Image IQ Quiz: Asymptomatic Patient Presents with Respiratory Symptoms

Even though it is rare, COVID-19-positive patients can develop leukoencephalopathy – white brain matter diseases – according to findings captured with brain MRI.

a team of investigators from the University of Pennsylvania (UPenn) stressed that radiologists must keep their eyes open for this possibility to appear on images.

“Increasingly, effects of COVID-19 on the brain are being reported,” said the team led by Colbey Freeman, M.D., a fourth-year radiology resident with the UPenn, “including acute necrotizing encephalopathy, infarcts, micro-hemorrhage, acute disseminated encephalomyelitis, and leukoencephalopathy.”

Currently, the industry does not have any criteria for defining COVID-19 disseminated leukoencephalopathy (CRDL). To help with potential diagnosis, Freeman’s team investigated whether findings existed that could facilitate identification.

63-year-old woman with history of hypertension and type 2 diabetes mellitus who presented with coronavirus disease (COVID-19) pneumonia complicated by acute respiratory distress syndrome.

A, Axial FLAIR MR image shows areas of T2 prolongation in posterior inferior cerebellar hemispheres (arrows).
B, Contrast-enhanced T1-weighted image shows enhancement of areas with T2 prolongation (arrows).

Courtesy: American Journal of Roentgenology

For their study, they examined 2,820 COVID-19-positive patients who were admitted to the hospital between March 2020 and June 2020. Brain MRI was performed on 59 patients (2.1 percent). Any scans that revealed white matter abnormalities that were not typically associated with other causes, such as hypoxic injury or chronic small vessel ischemic disease, that were picked up in the bilateral middle cerebellar peduncles or corpus callosum were considered suspicious for COVID-19, the team said.

Based on their findings from T1-weighed and T2-weighted FLAIR images, the team identified six patients (10.2 percent) who were suggestive of CRDL.

“[These images were] characterized by extensive confluent or multifocal white matter lesions (with characteristics and locations atypical for other causes), microhemorrhages, diffusion restriction, and enhancement,” the team said.

In addition, hypertension and type 2 diabetes were common in these six patients, affecting four (66.7 percent) and three (50 percent), respectively.

Alongside the CRDL-suggestive findings, the team also identified other neurological conditions:

Three (5.1 percent) with known multiple sclerosis white matter lesions.

23 (39 percent) had small vessel ischemic disease white matter lesions.

Four (6.8 percent) had subacute infarcts.

One (1.7 percent) had abnormal basal ganglia signal from hypoxemia.

Two (3.4 percent) had micro-hemorrhage associated with chronic infarcts.

Two (3.4 percent) had acute or subacute infarct-associated micro-hemorrhages.

The team did note that their study was limited because current CRDL criteria do not exist. Additionally, these findings could overlap with findings from other conditions, potentially over- or under-indicating CRDL cases. Still, they maintained that radiologists must stay alert to the potential presentation of this condition.

“CRDL is rare, limiting our ability to assess the full array of possible findings,” the team concluded. “Nevertheless, leukoencephalopathy represent an uncommon, but important, differential consideration in patients with COVID-19 with neurological manifestations.”

Images can show indications of rare condition that can affect white brain matter in patients who test positive for the virus.



Brain MRI Reveals Leukoencephalopathy Vulnerability in COVID-19 Patients

In this week’s preview, here are some highlights of what you can expect to see coming soon:

CT conolography has been growing in popularity for several years, largely due to the benefits for patient comfort. New research is now showing advancements and benefits of using machine learning with this method of screening for colon cancer. Look for coverage in the coming days of a study being published later this week.

Pinpointing the correct treatment strategy for patients with acute ischemic stroke can be difficult. But, incorporating MRI with X-ray angiography can make the process easier, leading to improved patient outcomes. Findings published in 

 recently shows that this combination works well to guide providers in deciding on the best therapy. Keep your eyes open for this story later in the week.

For more coverage acute ischemic stroke, 

February is American Heart Month, and state-of-the art, cutting edge cardiovascular imaging is critical to helping providers offer the best heart care possible. This week, 

 spoke with industry experts about what is on the horizon with cardiovascular imaging. What does the future look like, and what does this mean for both patient and provider? Look for the story later in the week.

For additional coverage on cardiovascular imaging

Here's what to expect this week on Diagnostic Imaging.

Diagnostic Imaging's A Look Ahead: Feb. 22, 2021, to Feb. 26, 2021

Over the almost-decade (yikes!) I’ve been writing this column, I’ve made reference to some of my nerdly sources of entertainment: Comic books, sci-fi/fantasy TV shows, and movies, etc. I suspect a decent chunk of my reading-audience shares such interests. Indeed, enough of that stuff has gone mainstream that knowing/liking it doesn’t carry much of a nerdish stigma anymore.

So much so, I’d be surprised if anybody hadn’t encountered the concept of alternate realities. Marvel had an entire comic-book series, and I think a forthcoming streaming show dedicated to it (“What If…?”). DC’s version was called “Elseworlds.”

It’s a handy enough plot device, especially back when there was more of a perceived need for fiction to serve as a vehicle for moral/societal commentary. Good ol’ 

 had its “Mirror Universe,” not only to entertain viewers with evil versions of Captain Kirk and Mr. Spock, but also to highlight the goodness of the regular characters by comparison.

It even works in reverse: A comic from Marvel just had one of their best villains visit an alternate universe in which his counterpart was a good guy, instrumental in making the world utopian. (The bad guy had intended to reform and do the same back home, but ultimately took exception to something his alternate self said and murdered the guy…then destroyed the alternate universe for good measure.)

So I found myself thinking about what it would be like to encounter a radiologist from a world in which diagnostic imaging, from our perspective, got everything right that we have wrong.

The our-world rad would be wowed, and more than a little envious, to hear about how good the other-world rads had it: They always got relevant, accurate clinical histories for the studies they read. Referrers knew and utilized appropriate modalities and protocols for their clinical questions—or, when they didn’t know what to order, they deferred to their rads for best practices. Support-staff were routinely competent and eager to help (in other words, supportive).

Other-world software worked reliably (“Why wouldn’t it? That’s what it’s there for,” the other-world rad would ask us with genuine puzzlement). When rads or other “stakeholders” identified potential improvements, they were implemented, even invented. Workflow protocols were structured to optimize the performance (and satisfaction) of those doing the work.

Part of the whole alternate-reality gimmick is to see how the otherworldly characters react to how we do things. In this case, with pitying disgust and/or horror. How little control the rads of our world have over their field! They’re held accountable for things they can’t do anything about, and they’re on a perpetual slide towards even less authority. Also less compensation and ever-increasing demands on them. Meanwhile, in the other world, they’re respected professionals, exercising responsible control over their own destinies.

I half-baked a fictional scenario to showcase this. A this-world radiologist cobbled together the prototype of a new-fangled quantum-imaging scanner, but during a glitchy test-run, the gantry opened a portal to the paradisical alternate reality. On the other side, a similarly-inventive rad quizzically peered through from his prototype machine. Their my-world/your-world discussion ensued.

Before I determined there was no way I was going to fit such a story into the space I use here—I have a hard enough time confining myself as it is—it occurred to me that the story would need a “twist” to be really interesting. Thus, the quantum-gateway would initially showcase the paradisical other world, but later on would hiccup and add a third reality—one far worse off than our own. On the other side of that window, there’d be a beaten-down shred of a rad for whom even our imperfect reality would be the answer to a prayer. Because, let us not forget, no matter how bad one may think things are, they could 

The plot could have gone any number of ways from there, but a major theme would be the imperfect and hellish-world rads wishing and wondering if there were any realistic ways their societies could take steps to more resemble the paradisical one. And the paradise and imperfect-world rads would consider their less-fortunate counterparts as cautionary tales; what might they do to avoid heading down similar dystopian paths in the future?

My favored notion for an ending had the hellish-world rad concluding that his society was too far gone; no matter what he brought back from this conversation, it would improve nothing. Instead, having seen how things could be so much better, his subsequent life would be that much more torturous. Thus, before the unstable quantum-portal collapsed, the worst-off of the rads climbed through it to live out the rest of his life in the radiology-paradise world.

The imperfect-world rad was invited to join them, but declined: Having seen how good (and bad) things could get, he chose to stay put. He had faith that he could make a difference in his native reality, making things better…or at least preventing them from getting worse.

Follow Editorial Board member Eric Postal, M.D., on Twitter: 

Radiology, in an imperfect world, can always be improved.

Alternate Radiologists

3D mammography is not equally accessible to all women. Women who come from racial or ethnic minority groups, women who are less educated, and women who have lower incomes are less likely to undergo the exam that is most likely to detect an existing breast cancer without raising a false red flag.

In a five-state study, including nearly 100 facilities, a multi-institutional team showed that less than half of women in these groups have access to this type of breast cancer screening.

“This study was about whether adoption of this technology is equitable. We’re showing that it has not been, even though it has been FDA-approved for a decade now,” said lead study author Christoph Lee, M.D., MS, MBA, professor of radiology from the University of Washington School of Medicine. “Black and Hispanic women, and less-educated and lower-income women have not been able to obtain 3D mammography as easily as white, well-educated, and higher-income women.”

Lee’s team published their findings on Feb. 19 in 

Digital breast tomosynthesis (DBT) has been a viable alternative to digital mammography since it received approval from the U.S. Food & Drug Administration in February 2011. In the intervening years, a plethora of studies have shown that DBT is actually more accurate than digital mammography and does a better job at detecting breast cancer with fewer false positives.

Digital Breast Tomosynthesis on Track to Replace Digital Mammography

For this study, the team examined 2.3 billion breast screening exams that were pulled from the Breast Cancer Surveillance Consortium. Patients, who were screened between January 2011 and December 2017, came from 92 imaging facilities across five states. With this volume, the team said, it is the largest study, to date, to analyze the access women have to DBT throughout the United States. In addition to looking at whether access was equitable among all women, the team also assessed whether facilities offered DBT at the time a patient was screened and compared DBT and mammography use at each facility across patient populations.

Their findings showed that DBT use and access did change over time. At the start of the study in 2011, only 3 percent of women included had access to DBT. By 2017, more facilities were using the technology, and 82 percent of women had access – but, it was not equal across all groups.

“Given the large research sample and our longitudinal data collection, we were able to evaluate use by minority and traditionally underserved populations,” said senior author Diana Miglioretti, Ph.D., professor and division chief of biostatistics from the University of California Davis. “Unfortunately, we were not surprised to find that these traditionally underserved populations were less likely to attend facilities that offered 3D mammography, and even when they did, they less likely to receive a 3D mammogram.”

According to their analysis – when both 2D and 3D mammograms were available – DBT was utilized by fewer than 50 percent of women who were in racial and ethnic minority groups, as well as those who were less educated and those who were of lower income.

Specifically, a DBT scan was provided to:

37 percent of African American women, 43 percent of Asian-American women, and 44 of Hispanic women versus 53 percent of white women

41 percent of women with less than a high school education compared to 50 percent of women who had earned a college degree

44 percent of women living in zip codes that had the lowest 25 percent of median household incomes versus 51 percent of women who lived in zip codes with the highest 25 percent of median household incomes

These results are critical, Lee said, because women with less access to 3D screening are already traditionally underserved, putting them at a greater risk of breast cancer morbidity and mortality.

Although addressing whether the institutional barriers to care, such as structural racism or cost, contributed to decreased access to newer technologies was outside the scope of the study, the team acknowledged that these obstacles are real and likely played into the inequity.

For example, Lee said, because DBT generates digital slices of breast tissue, acquisition and interpretation time are longer, and the cost is higher. While some states, including Washington, have laws in place that prevent charging patients more for DBT, most states do not. Consequently, depending on the type of insurance a patient has, she may have to pay high out-of-pocket costs for a 3D mammogram.

Additionally, a woman’s education could impact how much she knows about DBT mammography and the benefits it can provide. Women who have higher education levels could be more likely to explore healthcare options, to research the possible benefits of 3D mammography, or to search for a facility that offers the technology. They could also be more likely to directly ask for the service.

The physical availability of the technology also played a role. While approximately 40 percent of all certified mammography units actually have DBT capability, more than two-thirds of breast imaging facilities offer DBT in at least one of their units, according to FDA data. In addition, urban or rural location was less important than anticipated, Lee said.

In such situations, he said, a rural site could have one digital mammography machine that would provide access to all patients once switched to DBT. However, urban facilities might have more money to purchase machines, but if it can only afford one 3D-capable unit – at a cost of approximately $750,000 a pop – they will still have to direct some patients to 2D machines. Consequently, some sub-groups of women are not being screened with 3D mammography even when the option technically exists at their imaging facility.

“We’re going in the wrong direction. You have a lot more women in certain subpopulations benefitting from new technologies and other subpopulations not,” he said. “Existing disparities in breast cancer screening outcomes could widen unless these factors are addressed.”

Women with less education, with lower income, or from racial and ethnic minority groups have less access to 3D mammography and the potential benefits it provides. 

Case submitted by Kay Ogenda, M.D., radiologist, to

A 45-year-old female presents with an increasing growth on the right neck. A CT scan revealed an extremely large heterogeneous mass in the right supraclavicular region. Findings are consistent with a high grade sarcoma of the sternocleidomastoid muscle. Specifically, this lesion is consistent with rhabdomyosarcoma of muscular origin.

 Soft-tissue sarcomas are malignant lesions that originate from soft tissues. Rhabdomyosarcomas arise from muscle cells and are most commonly found in children. They account for up to 10 percent of childhood malignancies and 20 percent of all pediatric soft tissue sarcomas. 

There is a slight male predominance of incidence of sarcomas. Clinical presentation will vary on the location of a tumor. In this case, rhabdomyosarcomas are rapidly growing masses with mass effect on neurovascular structures, as well as with extensive infiltration often seen of adjacent structures, including bones and adjacent organs. Rhabdomyosarcomas can occur anywhere, but they particularly develop where skeletal muscle is located. The most common locations include the head, neck, and pelvis.

What is your diagnosis for a patient who presents with increasing size of neck and shoulder region?

Image IQ Quiz (Video): Patient Presents with Enlarging Neck and Shoulder Region

Clinical breast examination can lead to breast cancer diagnosis at a younger age and nearly one-third fewer disease-associated deaths in women over age 50 who live in low- or middle-income countries.

Mammography is the long-standing breast cancer screening tool in developed countries, but it is not always easily available in areas with fewer resources. Not only can cost and complexity be obstacles, but most women in these countries are also younger than 50 – the age group for which mammography is known to be less effective.

But, breast cancer rates are rising worldwide, particularly in low-to-middle income countries, and the women living there need access to effective breast cancer screening. Consequently, a team of researchers from India, led by Rajendra A. Badwe, MBBS, director and head of the surgical oncology division at Tata Memorial Center, tested whether clinical breast examination could be an acceptable fill-in for mammography.

The team’s results, published Feb. 24 in 

Better Understanding of Screening Mammography Cuts Imaging Rates Among Older Women

“Our study suggests that implementation of population screening by clinical breast examination in low-to-middle income countries is feasible,” the researchers said, “provided that adequate training of screening providers, careful monitoring, and quality of performance are assured.”

For this study, the investigators analyzed 20 years of data (May 1998 to March 2019) from 151,538 women between the ages of 35 and 64. These women, who had no history of breast cancer, lived in 20 geographically distinct clusters in Mumbai, and they were randomly divided into 10 screening and 10 control groups.

A trained female primary healthcare provider conducted four rounds of clinical breast examinations on the 75,360 women in the screening group. Providers followed these women through five rounds of active surveillance every two years, as well as provided cancer awareness along the same schedule. In the control group, however, 76,178 women underwent one round of cancer awareness followed by eight rounds of active surveillance every two years.

Based on the team’s data analysis, they identified some significant advantages for using clinical breast examination with women over age 50. Women in the screening group were diagnosed at an earlier age than those in the control groups – age 55 versus age 57, respectively. In addition, a lower percentage of women developed stage III or stage IV breast cancer – 37 percent and 47 percent, respectively.

When it came to changes in breast cancer mortality between the screening and control groups, the team identified a non-significant reduction across women of all ages – 21 versus 25 deaths per 100,000 person years. However, the drop in deaths in the screening group became much more apparent when they analyzed women by age. For women over age 50, implementing clinical breast examination reduced these deaths by 30 percent (25 versus 35 deaths per 100,000 person years). They saw no mortality reduction in women under age 50.

For all causes of mortality, the team said they pinpointed a non-statistically significant 5-percent drop when comparing the screening and control groups.

Overall, the team said their longitudinal study showed that clinical breast exam can be an effective replacement for mammography with women above age 50 who do not have access the traditional screening test.

“These results indicate that clinical breast examination conducted every two years by primary health workers significantly down-staged breast cancer at diagnosis,” the team said. “Clinical breast examination should be considered for breast cancer screening in low- and middle-income countries.”

For women who do not have easy access to mammography, clinical breast examination has been shown to increase breast cancer detection and save lives.



Mammography Alternative Saves Lives in Low-to-Middle Income Countries

Patients with schizophrenia have unique neuron structures that are not only different from healthy patients, but also from other patients with the condition.

By using X-rays and high-resolution optics that can capture 3D images of tissues, a team of researchers from Japan compared brain tissue from patients with schizophrenia to individuals with good mental health. The differences indicate that neuron structure is directly related to the disorder, said Ryuta Mizutani, Ph.D., professor of applied biochemistry at Tokai University. These findings could potentially lead to improved care in the future.

“The current treatment for schizophrenia is based on many hypotheses we don’t know how to confirm,” he said. “The first step is to analyze the brain and see how it is constituted differently.”

Mizutani’s team published its findings in 

Schizophrenia affects millions of people worldwide, but there is no cure. The key to treating the delusions, hallucinations, and thought-processing difficulties that accompany the condition lies in gaining a better understanding of how it arises to begin with.

These 3D images of neurons in the brain of a schizophrenia patient show wavy, distorted neurites, which indicate that the condition may be linked to the shape of the neurons. X-ray images were taken at the Advanced Photon Source.

To get that understanding Mizutani’s team brought eight small samples of brain tissue to the U.S. Department of Energy’s Argonne National Laboratory for analysis with its Advanced Photon Source (APS). All the samples – four from healthy individuals and four from the brains of people with schizophrenia -- were collected post-mortem.

APS offers powerful X-rays and extremely high-resolution optics – as high as 10 nanometers, roughly 700 times smaller than the width of the average red blood cell, Mizutani said. With this technology, the team was able to capture 3D images of the tissue.

“There are only a few places in the world where you can do this research,” he said. “Without 3D analysis of brain tissues this work would not be possible.”

Still the work is challenging, he noted, because the neurons being imaged can be centimeters long and can come in various sizes and shapes.

Upon examining the neurons, Mizutani’s team noticed a distinct difference between those from healthy brains and those from the brains of patients with schizophrenia. Healthy neurites were smooth and thick – those from brains with schizophrenia were twisted and thin. In addition, all images of the healthy neurons were relatively similar, but those from patients with schizophrenia deviated significantly even from each other.

“The schizophrenia cases shared a thin and tortuous neuronal network compared with the controls, suggesting that the neuronal structure is associated with the disorder,” he said. “The large heterogeneity of neurons in the schizophrenia cases can cause functional imbalances between brain areas that may result in disorders of total brain function.”

More research is needed, he said, to determine exactly how these neuron structures relate to the onset of disease, as well as to design treatment options that alleviate the symptoms. It will take time to image the full human brain, but as the X-ray technology at APS continues to improve, it will render greater sensitivity and image resolution, potentially accelerating the process.

Ultimately, Mizutani said, the goal is for fewer people to suffer the effects of schizophrenia.

“The differences in brain structure between healthy and schizophrenic people must be linked to mental disorders,” he said. “We must find some way to make people healthy.”

High resolution, 3D images reveal differences in the structure of neurons from healthy brains and those from patients with schizophrenia.

Image IQ Quiz (Video): Patient Presents with Enlarging Neck and Shoulder Region

Mammography Alternative Saves Lives in Low-to-Middle Income Countries

X-ray Reveals Neuron Differences in Patients with Schizophrenia