Adding MR-guided high intensity focused ultrasound (MR-HIFU) to existing cancer-induced bone pain (CIBP) control methods can result in better, faster pain management, according to the outcome of a recently published study.

Currently, external beam radiotherapy (EBRT), the CIBP standard-of-care, is effective for roughly 60 percent of patients. While it works, it can take up to three-to-four weeks to provide adequate pain relief, and as many as 50 percent of patients suffer a pain recurrence. These shortcomings leave the door open for improvements.

Clinical and Translational Radiation Oncology

investigators from the University Medical Center Utrecht in The Netherlands, tested whether adding MR-HIFU to EBRT would provide patients with a better result. According to the findings of their single-arm intervention study, it does.

“Our results show that combining these two treatment modalities is safe and feasible and may induce rapid pain relief in the first-line treatment of CIBP,” said the team led by Marcia M.T.J. Bartels, M.D., from the Utrecht radiology and radiation oncology departments.

MRI-Guided Focused Ultrasound Effective Option for Bone Metastasis Pain Relief

In fact, most patients experienced pain alleviation within a few days. At roughly a week after treatment, 83 percent of patients reported a pain reduction, and 60 percent indicated they benefitted from the combined treatment after 4 weeks.

This is the first study to combine both pain reduction methods, testing both safety and feasibility. The team enrolled six patients – five men – who had either prostate carcinoma, renal cell carcinoma, cholangiocarcinoma, or bladder cancer. All lesions were located in the pelvis or the extremities, and lesions averaged 56.5 mm in size. All patients reported a pain score of at least 4 on an 11-point scale.

After initially undergoing a single 8Gy dose or a five-session multi-fraction 20Gy dose regimen of EBRT, each patient also received MR-HIFU treatment via a 1.5T scanner. While patients were under sedation, they underwent a 1-second, 55-degree Celsius thermal dose. The team, then, collected their self-assessed pain levels after three days, as well as weekly for four weeks. A two-point drop in pain scores or a 25-percent reduction in use of analgesics indicated a positive pain response.

According to the team’s analysis, no study participant experienced any major adverse effects, and all patients said they were satisfied with the combined treatment, rating the dual therapy an 8.4 out of 10. Some patients achieved pain alleviation within three days, and, on average, pain relief scores fell by 3.5 points during the four weeks post-treatment.

Although larger studies are needed, the team said, this work is the first step toward broader research into using MR-HIFU as a first-line CIBP treatment.

“The biggest advantage of combining EBRT and MR-HIFU treatment could be that it achieves pain response as soon as three days after treatment, while also achieving the locoregional tumor control that EBRT sometimes strives for,” the team explained. “Moreover, the combined treatment could give better results as compared to either treatment modality separately due to complimentary and possible synergistic effects in the mechanisms of action.”

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Articles

Pairing MR-guided high intensity focused ultrasound with the standard-of-care, external beam radiotherapy, can offer faster pain relief to patients. 

Looking to Reduce Bone Pain from Cancer? Consider MR-Guided HIFU

Children have long been frightened by hospital stays. Daunting needles, sterile rooms, and scary machines can make hospitalization a frightening experience for young patients. Now, we can add one more major fear factor to the list: separation anxiety.

 of COVID-19 are increasing across the nation. Due to the contagious nature of the disease, a COVID-19 hospitalization stay can be a very lonely journey.

, 2 million children tested positive for COVID-19 since the onset of the pandemic, according to the American Academy of Pediatrics. Today, children represent 12.4 percent of all cases in states reporting cases by age as compared to just 2 percent of all COVID-19 cases in April.

Scientists believe that a new strain of COVID-19 recently detected in the United Kingdom may spread 

 than previous forms of the virus.Data collected over a six-week period found that the proportion of cases of the variant in those under 15 was “statistically significantly higher” than the non-variant virus.

Fortunately, most children with COVID-19 do not require hospitalization.While many will recover at home, kids who come down with more serious symptoms and/or complications and do end up hospitalized also end up isolated from their parents. Separation anxiety compounds an already frightening situation, which can impede both treatment and healing.

COVID-19 should be a powerful motivating factor for hospitals to “up the comfort quotient” for 

pediatric patients. The lessons learned from this tragic pandemic should be applied in the time of COVID and beyond. Simply put, children suffering from any malady are likely to have better experiences and outcomes when they are at ease—as free of fear as possible. This article will explore the many steps hospitals can take to improve pediatric patient comfort.

Diminished comfort-giving role for parents during pandemic

COVID-19 is turning back the clock on hospital visitation practices. According to an article in 

, unlimited parental visiting hours are relatively new in American hospitals.From the early 1900s to the late 1950s, most U.S. hospitals had strict rules separating children from their parents and limiting parental visits to just a few hours each week.

It wasn’t until the 1960s that advances in hospital architecture dramatically altered accommodations for family members. During this time, parents began to play a significant supporting role. They provided their children with the non-medical, but very necessary, comfort they needed to undergo tests and treatment and, ultimately, recover.

, all 135 U.S. and Canadian hospitals that completed the survey reported that their general pediatric unit “allowed parents to sleep at the bedside overnight.”Moreover, 99 percent of those hospitals (133) reported parental involvement in their child’s care at night, with 39 percent stating that this was an expectation.

However, with COVID-19 the pendulum has swung back to days of old.Now is the first time in many decades that so many pediatric patients must deal with being alone in the hospital.

Isolated children suffering from COVID-19 or other contagious diseases are likely more frightened than ever—and that, in turn, can impede treatment and healing. Moreover, even children with other ailments may find themselves cut off from parents due to COVID-19 precautions especially if it continues to surge and hospital visitation rules become as restricted as they were in the spring of 2020.

Now, more than ever, healthcare providers need every edge they can get when it comes to easing anxiety, pain, and trauma for the nation’s littlest patients.

Why comfort matters: A little psychology goes a long way

Children are easily frightened by the unfamiliar and are taught not to trust strangers. So, it is easy to understand how a stay in a hospital—and possible separation from parent(s)—can ignite terror in many young patients.

The problem for providers is not simply an unhappy child, but rather that anxiety and fear are a clinician’s worst enemy because these emotions hinder examinations, diagnosis and treatment. By reducing apprehensive emotions in young patients, clinicians can save time, obtain more accurate assessments, and are less likely to require a retake or “miss” something.

Adolescents, toddlers, and infants already have a hard time keeping still without the added dynamic of pain and fear.With relaxed pediatric patients—versus terrified, nervous ones—physicians can get to the root of the problem sooner. That translates into better more efficient exams, faster treatment, and improved patient experiences.

A little bit of psychology can go a long way. Comforting details and practices can make a world of difference in quelling anxieties. This includes everything from your facility setting and your staff, to your technology.

High tech form meets function for safer, more comfortable care

Technology saves lives, but for children it can be seen as scary stuff. Children in pain undergoing even routine tests can be filled with increased worry and fear, making them anxious and impeding care.To put children at ease, an X-ray can be introduced as something fascinating and a pain-free exam to undergo. Digital radiography (DR) is a painless and powerful tool in diagnosing a wide array of symptoms.

It’s imperative to utilize DR detectors that deliver high-quality images, with as low radiation dose as possible—to keep the smallest, most sensitive patients safe. Young patients are more susceptible to the negative effects of radiation dose and low dose and low penetration typically impede image quality. To this end, Fujifilm’s detectors all incorporate innovative and proprietary core technologies, designed to maximize sensitivity which in turn improves dose efficiency at ultra low doses and the resulting image quality compared to conventional designs. What’s more, these detectors take safety a step further incorporating an anti-bacterial coating to provide an added measure of infection controls against hospital-acquired infections. This was always important, but even more so during this era of COVID-19.

While safety always comes first, comfort is key. For instance, it's not news that children have a hard time holding still.

One example of technology that helps speed exams, minimize discomfort and image gently is Fujifilm’s FDR D-EVO GL. Long length views are commonly utilized for trauma and on adolescents for scoliosis treatment that spans over the course of several years. Naturally minimizing dose and preventing retakes are extremely critical to these exams.The GL is the world’s first single-exposure, long-length DR detector. It reduces discomfort for a better patient experience by speeding image acquisition with just one exposure. One-exposure minimizes the need for kids’ to hold still compared to traditional multi-exposure DR methods. So kids in pain and kids that are

 don’t have to hold still as long to get a great X-ray instantly. Instantaneous acquisition of a full length view minimizes dose and prevents repeat exams caused by patient movement and, of course, the additional associated radiation dose.

Portable and mobile equipment are also important to pediatric care departments for several reasons. It’s speedy, efficient, and mobile equipment helps keep kids comfortable. With mobile DR units, images are captured and displayed in seconds at the patient’s bedside—so children don't need to be transported to the radiology department. Kids can be easily frightened when they are moved from their beds and don't know where that gurney is going!

Children and adults are also commonly fearful of cold-looking X-ray exam rooms and machines – but there are ways to make mobile X-ray technology less intimidating and even fun.

 feature choices of kid-friendly graphic decals that ease young patients’ (and their parents) fears prior to the exam by making the equipment look more animated and less intimidating and clinical. This makes the tech’s job easier and improves the chances of getting a speedy, accurate exam the first time.

Moving away from bigger, bulkier units has put children at ease according to radiology staff at the Children’s Hospital at OU Medical Center in Oklahoma City. They say previous portables could put panic on kids’ faces as soon as they were wheeled into the room. But that has changed, thanks to kid-friendly designs and bright illustration vinyl wraps that are wrapped around the FDR Go units they presently utilize.

Portability can also help keep infants comfortable and safe in the NICU. These helpless tiny infants are wired up with countless wires and tubes—the slightest movement can cause them to stay awake and cry for hours. To help keep them safe and secure in their isolette, Fujifilm’s special small 24x30cm DR detector is designed to fit perfectly in the cassette tray under the the bed, so the infant doesn’t have to be picked up, placed and held directly on a cold detector, as is the case with larger detectors. Exams are faster, safer and the baby stays peacefully secure in its germ-free environment.

While comfortable testing is the secret sauce to effective pediatric care, there are several other steps hospitals can take to enhance the comfort quotient.

For starters, a cheerful setting establishes a positive mood and helps set the tone for a successful pediatric hospital stay. Calming colors, bright murals, playful images and plush toys put children at ease. Experts that create hospital spaces, say research shows kids prefer warm, inviting colors for corridors and rooms.

Music—the universal soother—can make a world of difference, too. Studies show that music can ease children’s anxiety during difficult procedures. A recent study published in 

 found that kids get through endoscopy procedures with less strife when music is played.

Communication helps alleviate fears, as well. Too often clinicians talk to parents and leave children in the dark. But fear is largely about the unknown.It’s important for physicians and X-ray techs to include kids in friendly conversations, and make the exams and equipment interesting to help put patients at ease. Conquering fears begins with young patients understanding what procedures they will undergo.

Finally, your staff can be your greatest asset in keeping our young patients happy and comfortable. A caring smile and a gentle touch can go a long way with little ones.

COVID-19 is just our latest reminder of how challenging hospitalization can be on the young. Every year more than 

 children are hospitalized in the United States. Whether it’s for a surgical procedure or a sudden illness, an accident or a traumatic event, a hospital stay can mean emotional upheaval for a young patient.

Upping the comfort quotient with everything from a cheerful space to well thought out technology can help ease patient anxiety and make clinicians’ jobs easier. A calm, secure child is easier to evaluate, diagnose and treat. Pave the way for better exams, treatment and outcomes by making comfort a top priority. The road to recovery will be far smoother.

Taking steps to improve pediatric imaging, comforting patients and securing high-quality scans, is critical now and for the post-pandemic era.

Pediatric Care: Upping the X-ray Comfort Quotient During COVID-19 and Beyond

Once upon a time in this column, I shared a bit of wisdom gained from a very successful individual: Standing on a soapbox and proclaiming your sociopolitical views to the world is asking for trouble.

Is it your right to do so? Absolutely. But is it smart? Maybe if your livelihood is based on it, such as being a talking-head political pundit on some not-really-news show. For most of us, however, that doesn’t apply. Instead, all you’re doing is risking backlash from people who don’t agree with you. That can range from getting your car keyed on account of your bumper-sticker to having your company blacklisted and boycotted.

As the great Michael Jordan said, “Republicans buy sneakers, too.” God bless you if you’re so confident in your success that you’re willing to alienate 50 percent of your customer base by saying things that will make the other 50 percent like you a little better, but I don’t know too many non-monopoly enterprises that operate with that kind of a margin.

I’ll preface the discussion below by saying this particular column isn't just about the matter of playing around on social media, by the way. This all comes home to roost for us in radiology – and healthcare at large – so tune in next week, as well, for part two.

So, last weekend, I decided to open a Parler account. I had resisted for a couple of reasons—first, I’m not crazy about social media to begin with, so using more sites/apps goes against my grain. Second, it’s not like my Twitter account is a hotbed of activity; if I got just as many followers on P as I had on T, I still wouldn’t quite have three dozen.

(Third, on a petty note, the academician in me aggravates about Parler’s name…is it supposed to be the French verb “to speak?” If so, why are we not pronouncing it “par-lay?” Or, if it’s supposed to be a parlor, like a place where guests would meet and converse, why spell it differently? End of digression.)

In any case, I was convinced a few months ago that, as a regular columnist, I should have some kind of social media presence. Even if I only have a handful of followers, I can see that my posts get hundreds of views, so somebody’s paying attention. And there’s no predicting when lightning might strike and I suddenly find myself with a much larger following. 

 getting on Parler, the way things were shaping up, would diminish my visibility.

As luck had it, I established my account and downloaded the app mere hours before Parler got shut down (at least temporarily) by the combined forces of Google, Apple, Amazon, and an armada of other players. All I lost was the bit of time it had taken me to sign up and create my profile. It hardly felt like a severed virtual limb or a stifling of my ability to speak in the public square.

Others who had been using that forum (8 million as of November, with a subsequent voluminous influx—a cursory look fails to give me numbers), however, are feeling decidedly more suppressed. Many originally flocked to Parler to get away from other social media that were exercising an increasingly-free hand at suspending or banning users. Rightly or wrongly, lots of those users felt that they, and others with similar opinions to their own, were being unfairly targeted.

Their newly-adopted platform, itself, now being targeted, there’s a certain sense that an electronic Iron Curtain came crashing down. More than a little talk about what constitutes free speech and prevention thereof. Also what corporate behavior constitutes collusion, and should be reined in by antitrust laws. Not going into that here.

Being a diagnostician (radiological and otherwise), I’m more inclined to focus on root causes, how damage is being done, and, when possible, niduses of trouble that might be removed or circumvented to result in an improved state of affairs. As big as the issues referenced above, I think there’s something even larger and more fundamental that’s led to this juncture. An underlying pathology that might have made this inevitable. And may lead to worse, if not addressed/corrected. Like a patient with obesity or diabetes who hasn’t yet had a heart attack, stroke, or renal failure…but just had a scary TIA.

The fundamental issue is one you’ve heard about before: People not listening to one another. In the age of social media, with varying degrees of lockdown and physical isolation, there’s an ever-increasing ability not only to render oneself selectively deaf to unwanted voices…but now, also, to force mutism on those voices by banning, de-platforming, or otherwise “canceling” them.

Sometimes there’s a good reason for it. Someone threatening/planning violence or other criminal behavior, for instance. But I think we’ve gotten a little too comfortable with the notion of silencing others just because we don’t like what they have to say. It seems increasingly common to decide to silence them first, and conjure an excuse afterwards.

I’m sure that some folks see nothing wrong with the notion of stamping out all voices and even ideas that run contrary to their own. And I suppose it can be a heady thing if one is in ideological synchrony with the folks doing the muting—look how all the wrong-thinking villains are being squelched! That’ll show ‘em.

However, unless you’re embracing the idea of rounding up all of the people with objectionable ideas and putting them in re-education camps or otherwise “de-programming” them (I leave it to the reader to look up which talking heads floated those ideas this past week), the people you’re silencing are still going to be in this society with you. And it might not be in your long-term interest to prevent yourself from hearing what they have to say.

So, as I said earlier, this isn’t just a discussion about social media. This impacts us directly in radiology, as well, and I’ll address that next week in this space. Stay tuned.

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

Selective Deafness and Forced Mutism

For patients with breast cancer receiving neoadjuvant therapy, MRI-guided breast biopsy could be a good way to assess how well they are responding to the treatment, according to the findings from a new study.

investigators from Memorial Sloan Kettering Cancer Center detailed how they used MRI-guided breast biopsy to correctly assess almost all patients post-chemotherapy. This outcome, they said, indicates that this strategy could give patients and providers an option other than surgical resection.

“This study’s results suggest that the accuracy of MRI-guided biopsy to diagnose a post-[neoadjuvant chemotherapy] [pathologic complete response] approaches that of reference-standard surgical resection,” said the team led by Elizabeth Sutton, M.D., breast MR expert and assistant professor of radiology at Weill Cornell Medical College. “MRI-guided biopsy may be a viable alternative to surgical resection for this population after [neoadjuvant chemotherapy].”

 Image-Guided Biopsy Picks Up Lingering Breast Cancer

Currently, the only available methods for evaluating a patient’s response to neoadjuvant therapy – treatments administered to side-step more invasive options – is surgical resection. Consequently, the push is on to find non-invasive ways to determine pathologic complete response in this patient group.

Sutton’s group decided to test MRI-guided biopsy because of the modality’s high level of sensitivity. To do this, they enrolled 20 patients between September 2017 to July 2019 into a non-randomized controlled trial. With this sample size, the team said, they had enough participants to accurately evaluate whether the strategy could reach a negative predictive value of at least 85 percent. The biopsy technique surpassed that benchmark, reaching a negative predictive value of nearly 95 percent, they found.

During the study, all participants received standard-of-care neoadjuvant chemotherapy, as well as definitive surgery for the treatment of stage IA to IIIC biopsy-proven operable invasive breast cancer. In addition, they also underwent non-contrast enhanced MRI both prior to and post-neoadjuvant chemotherapy.

Using a 1.5T or 3T whole body MRI scanner, as well as a vacuum-assisted biopsy system, the team removed between seven to 12 tissues samples from each patient via a single incision site which they marked before beginning chemotherapy.

According to their pathological analysis, 11 patients showed no residual cancer evidence, and eight were diagnosed with residual invasive cancer. Only one receive a ductal carcinoma in situ diagnosis. Of this group, the MRI-guided biopsy correctly pinpointed all the patients who did not have residual invasive cancer, but it did return a false-negative to a woman who had a residual cancer that measured less than 0.2 cm. In addition, they said, the MRI-guided biopsy also missed the ductal carcinoma in situ, returning a false negative to that patient, as well.

Overall, the team determined, MRI-guided biopsy offers a negative predictive value of 93 percent for invasive cancer and 86 percent for both in situ and invasive cancers.

“These preliminary results suggest that MRI-guided biopsy was an accurate approach for evaluating the extent of residual disease after [neoadjuvant chemotherapy],” the team concluded. “With an increasing focus on mitigating overtreatment and limiting potential toxic effects and cost, MRI-guided biopsy may be a viable alternative to surgical resection for appropriately selected patients after [neoadjuvant chemotherapy.]”

Still, they stressed, their results are not applicable to other patient populations, and further study around MRI-guided biopsy is needed.

Using MRI-guided biopsy could help women avoid surgical resection to determine how well chemotherapy is working.

MRI-Guided Breast Biopsy Could Provide Non-Invasive Evaluation of Response to Neoadjuvant Treatment

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

Last week, you saw news that dense breast notification laws are working – just not as well as anyone had originally hoped. More women are learning about their particular circumstances and their individual characteristics that can place them at greater risk for an undetected breast cancer, but there is still work to do. But, do not get too discouraged. According to breast imaging expert Stamatia Destounis, M.D., FACR, with Elizabeth Wende Breast Care, there is more to be hopeful and excited about when it comes to the impact of these laws. Look for her input later this week.

For more coverage about breast density and dense breast notification laws, click 

Traumatic brain injury (TBI) can be devastating for any patient, and it can affect individuals differently. In a recent study from the National Institute of Neurological Disorders and Stroke, investigators have looked into how TBI can specifically affect women. Published in the 

researchers examine the growing opportunities and strategies, including imaging studies, to better understand how women experience these injuries. Keep an eye out for the study in the coming days.

For additional articles on traumatic brain injury, click 

Bone pain from cancer can be debilitating, so effective strategies to minimize what patients experience are important. In a new study from 

Clinical and Translational Radiation Oncology, 

investigators from The Netherlands look at the efficacy of MR-Guided High Intensity Focused Ultrasound as a potential tool to relief pain in patients. Read more about their findings later this week.

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

Diagnostic Imaging's A Look Ahead: Jan. 18, 2021, to Jan. 22, 2021

An artificial intelligence (AI) tool, developed using MRI data, could soon top the list of strategies used to determine which men are most likely to experience a prostate cancer recurrence.

Together with a small group of institutions, Case Western Reserve University has developed RadClip, an AI tool that is designed to make it easier for providers target patients with better treatment options. The team, led by Case Western doctoral Lin Li, published the details of their development recently in 

“This tool can help urologists, oncologists, and surgeons create better treatment plans so that their patients can have the most precise treatment,” said Li, who is working on her doctorate from Case Western’s Center for Computational Imaging and Personalized Diagnostics (CCIPD).

Being able to pinpoint which men might have a recurrence or who might die from prostate cancer is vital because it helps providers deliver additional therapy to those men earlier. RadClip can help with these predictions, she said, and it can also identify, on pre-operative MRI, the small heterogeneity and texture pattern differences both inside and outside the tumor area. This way, she added, estimating and predicting post-surgical outcomes is easier.

To accomplish this, RadClip uses AI algorithms to examine MRI scan and molecular data culled from Cleveland Clinic, University Hospitals, and Louis Stokes Cleveland Veterans Administration Medical Center. For this multi-institutional study, Li’s team applied RadClip to pre-operative MRI scans from nearly 200 patients who had undergone radical prostatectomy.

“We’re bringing together and connecting a variety of information, from radiologic scans like MRI to digitized pathology specimen slides and genomic data, for providing a more comprehensive characterization of the disease,” said senior study author Anat Madabhushi, CCIPD director and Donnell Institute biomedical engineering professor at Case Western.

The team, then, compared its results to other predictive strategies, including Cancer of the Prostate Risk Assessment (CAPRA) score and the genomic-based Decipher ® Prostate Cancer Test. Their analysis showed that RadClip gleans superior prognostic information to these tools.

“Genomic-based tests cost several thousand dollars and involve destructive testing of the tissue,” Madabhushi said. “Prognostic predictions from an MRI scan provide a non-invasive method for making both short-term and long-term decisions on treatment.”

The information gathered with RadClip offers several benefits to both prostate surgery and post-operative management, Li said. Surgeons can use the predictive data about cancer existence and extent collected from pre-operative MRI to determine how much tissue to remove, and oncologists can use the estimates of recurrence to target patients who need post-surgical adjuvant treatment, including radiation therapy or chemotherapy.

“Having this information before surgery,” she said, “provides surgeons and oncologists the time and space to adjust treatment plans and come up with a plan that’s best suited to the patient.”

Using pre-operative MRI data, an AI algorithm can help predict recurrence better than existing models.

MRI AI Tool Could Lead to More Targeted Prostate Cancer Treatment

Hyperfine Research, Inc., secure 510(k) clearance from the U.S. Food & Drug Administration for its Advanced AI image assessment software that can automatically measure and return annotated and segmented brain images.

This software works with Hyperfine’s Swoop™ Portable MR Imaging System, the first MRI system develop to capture brain MRI images at the patient’s bedside. In particular, this tool offers ventricular volume, image extraction, alignment, and midline shift. This data gives providers of all expertise levels the quantitate markers that are necessary for decision support, as well as the immediate feedback that can be critical for diagnostic feedback.

“With this powerful tool now built into the Swoop™ system, we are making MR imaging not only accessible at the bedside, but making it easier for providers to move quickly from scan to a recommended course of treatment,” said Khan Siddiqui, M.D., Hyperfine’s chief medical officer. “The data provided by Hyperfine’s deep learning software will liberate users of our MR technology by providing simple, accessible information in just minutes.”

Software provides annotated and segmented brain images captured by Hyperfine’s portable MRI system.

Hyperfine’s Image Assessment Software Captures FDA Clearance

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

Before we get to our featured interview this week with Dr. Donald Frush, instructor of radiology in the Duke University School of Medicine and Health System, about the announced recommendation against across-the-board gonad shielding with X-ray imaging from the National Council on Radiation Protection and Measurements (NCRP), here are the top stories of the week.

In contrast to what you might have anticipated, the severity of a patient’s case of COVID-19 is not necessarily linked to how well his or her lungs will recover from the virus. Fortunately, post-recovery imaging at least shows that most people’s lungs will not experience any long-term scarring. In a study from Trinity College in Dublin, published in the 

, investigators followed 153 patients for an average of 75 days in an outpatient clinic, evaluating their condition with chest X-rays and CT, as well as a six-minute walk test. They also examined blood samples for disease indicators, such as C-reactive protein. The results surprised them. Only 4 percent of patients who had previous abnormal X-rays had any evidence of lung scarring on chest CT, and shorter six-minute walk test distances were associated with frailty and longer hospitalizations – not disease severity. These outcomes point to a need for greater cardiovascular and fitness assessment, as well as rehabilitation for patients who have fatigue and breathlessness after COVID-19 recovery.

Looking to reduce your emergency department medical imaging recall rates? It might be as easy as adding an attending radiologist to the overnight hours, according to University of Toronto researchers. This group of investigators tested an intervention at Sunnybrook Health Sciences Center from 2016 to 2018, and they found having an attending radiologist in-house after-hours sliced imaging exam recalls by approximately 90 percent. In fact, they said in their article in 

, the average number of recalls plummeted from 61 annually to 7. This drop was impressive they said since the number of images ordered in the emergency department actually rose annually during this time, climbing from 13,883 in 2016 to 15,112 in 2018. While radiology residents still provided preliminary reports and remained the main points-of-contact for referring physicians, the attending radiologists were responsible for final reports for both emergency department patients and inpatients. Not only did their intervention improve work flow, but it also improved patient comfort and safety because patient were not called back for a re-scan. In addition, emergency physicians also reported a higher level of satisfaction.

New findings this week from Vanderbilt University contradicted some alarming results published in the fall about the effects of COVID-19 on the cardiovascular health of athletes. Initially, it was reported that approximately 15 percent of athletes suffered from myocarditis, captured on cardiac MRI, after recovering from the virus. Vanderbilt’s investigators determined the real amount is 3 percent, and their findings were published by the American Heart Association in 

Vanderbilt researchers compared COVID-19-positive athletes to 60 healthy controls to make this determination. Unfortunately, they realized, no screening tests that they evaluated were effective in pinpointing which athletes had myocarditis – this was a let-down because the team had hoped those screenings would have been definitive, limiting the need for cardiac MRI to the most necessary instances. Still, in one beneficial result, they found both COVID-19-positive and health athletes experience similar levels of benign scarring in healthy heart muscle in the same location, indicating it is not a consequence of the virus and should not restrict an athlete from competition.

And, finally this week, Diagnostic Imaging spoke with Dr. Donald Frush, an instructor of radiology at Duke University School of Medicine and Duke University Health System about the recommendations against the universal use of gonad shielding during X-ray imaging that were released this week. Frush, who served as the chair of the NCRP subcommittee on gonadal shielding discussed the reasoning behind the recommendation, the challenges that exist to implementing the protocol change, what facilities can do to successfully shift their shielding practice, and the drawbacks that exist to still using shielding routinely.

Videos

COVID-19 and Long-Term Lung Effects; Reduce Emergency Department Imaging Recalls; COVID-19, Myocarditis, and Athletes; Plus, New Recommendation for X-ray Gonad Shielding

Diagnostic Imaging's Weekly Scan: Jan. 11 to Jan. 15, 2021

New lesions picked up by breast MRI scans conducted to assess neoadjuvant treatment for breast cancer are uncommon, and according to new research, they are not likely to be malignant.

Breast MRI is routinely used to evaluate a patient’s response to neoadjuvant therapy, but there is little-to-no guidance available on how to manage the new suspicious lesions that rarely occur. In a Jan. 14 article published in the 

investigators from the University of California at San Francisco (UCSF) show that new findings appear in only 5.5 percent of cases and none were malignant, potentially reducing the number of biopsies ordered.

“Our findings suggest that new lesions that arise in the setting of neoadjuvant therapy are highly unlikely to represent a new site of malignancy, particularly if the index malignancy shows treatment response,” wrote a team led by Donna A. Eckstein, M.D., from the radiology and biomedical imaging department at UCSF.

This is the first study, they said, to look at and evaluate the malignancy potential for lesions that appear on MRI during breast cancer treatment.

By examining results from 419 breast MRI scans conducted on 297 women from Jan. 1, 2010, to June 30, 2018, Eckstein’s team set out to determine the frequency and outcomes from these new suspicious lesions. Based on the exams conducted on 1.5T and 3T scanners, a group of 13 fellowship-trained breast radiologists identified 23 MRI exams – 5.5 percent – that included new suspicious findings that were distinct from those initially identified prior to neoadjuvant treatment.

These patients were treated with a variety of therapeutic combinations, including chemotherapy, anti-HER2 therapy, immunotherapy, hormonal therapy, and cyclin-dependent kinase inhibitors. And, on average, the time between baseline pretreatment breast MRI and follow-up MRI was 2.9 months.

According to the team’s analysis, all new suspicious MRI findings were assessed to be BI-RADS 4. Thirteen of the 23 lesions (56.5 percent) were contralateral to the known malignancy, nine (39.1 percent) were ipsilateral, and one (4.3 percent) involved the bilateral breasts. The lesions types included masses (69.6 percent), non-mass enhancements (21.7 percent), and focus (8.7 percent).

Overall, the team determined, these new lesions should not immediately raise a red flag if they appear on breast MRI during neoadjuvant therapy as the likelihood of malignancy is small. Still, as these results raise the possibility of averting biopsy, additional investigations are necessary. To validate that conclusion, larger studies in a variety of institutions should be conducted.

Suspicious lesions that develop during neoadjuvant therapy are uncommon, and they are highly unlikely to be malignant. 

Breast MRI-Identified Lesions During Neoadjuvant Therapy Are Largely Benign

Offering mammograms to inpatients could be a good way to screen women who might otherwise face challenges in getting imaged.

For many women, mammograms fall by the wayside either because they do not have transportation to the clinic or they cannot get time off work. To address this problem, investigators from Massachusetts General Hospital (MGH) tested an inpatient-mammogram intervention to see if it could be an easier way to tackle preventive care needs.

“We designed the study to reach the patients who face significant barriers to completing their mammograms in the outpatient setting,” said first author Andrew S. Hwang, M.D., MPH, and MGH internist.

Hwang’s team published their results in the January issue of 

Breast cancer screening rates are particularly low among Medicaid and dual-eligible patients, according to existing national and local data. If this intervention is successful, he said, it could help reduce disparities by simultaneously addressing patients’ acute and preventive care needs.

To test their intervention, Hwang’s team pinpointed women who were Medicaid and dual-eligible, had been admitted to MGH’s general medicine service between March 2019 and March 2020, and who were overdue for a mammogram. These inpatients also had a primary care provider associated with MGH with whom they could follow up for any abnormal results.

Overall, the team identified 21 women who met these criteria, and 17 went through with the inpatient mammogram – four were discharged before the screenings could be scheduled. For 35 percent of the screened group, this was their first mammogram – the remaining patients were overdue for a scan by an average of four years. All but one mammogram was negative, and providers recommended that patient pursue additional imaging to rule out cancer.

It is important to note, Hwang said, that scheduling a mammogram during the inpatient stay did not extend the patient’s hospitalization. Consequently, he and his team would like to extend the intervention to patients who are admitted into other areas of the hospital, as well as expand it to include other preventive services for low-income men and women, such as fecal immunochemical tests for colorectal cancer screening. Such innovative measures will be vital to addressing patients’ psychosocial needs and breaking down the barriers to care that many of them experience.

“[As] our healthcare system transitions from fee-for-service to value-based payment models, improving health outcomes among underserved patient populations will become increasingly important,” he said. “Completing preventive screening tests, such as mammograms, during hospitalizations can be one way to help patients who might otherwise miss preventive care.”

A pilot study intervention successfully provides mammograms for patients who face screening challenges. 

Innovative Inpatient Mammograms Can Diminish Breast Cancer Screening Disparities

Getting an abdominal CT scan for suspected acute appendicitis can increase the risk of developing a blood cancer, particularly in children under age 16, a new study has found.

The debate about whether exposure to CT radiation can actually augment the likelihood of cancer has been long-standing. In a study published on Jan. 20 in 

, investigators from South Korea examined a large study population, determined the risk exists, and pushed for radiologists to continue to be judicious in their use of radiation with children.

“The incidence of hematologic malignant neoplasms tended to increase with the number of abdominopelvic CT examinations,” said the team led by Ji Hoon Park, M.D., Ph.D., from the radiology department at Seoul National University Bundang Hospital. “The carcinogenic risk from abdominopelvic CT radiation was most pronounced in patients aged 0 to 15 years.”

: Getting an Abdominal CT in the ED Could Depend on Age

Appendicitis is a common problem among younger patients, and figuring out whether CT exposure actually raises their cancer risk is critical, the team explained. Not only are children more vulnerable to the effects of radiation, but CT is being used more and more often with this particular condition. This could be problematic, they pointed out, because roughly 10 percent of the body’s highly radiosensitive red bone marrow is contained in areas imaged by abdominopelvic CT.

To determine the impact of these diagnostic scans, the team examined records from the National Health Insurance Service for 825,820 individuals with no underlying cancer risks who also underwent an appendectomy between Jan. 1, 2005, and Dec. 31, 2015. They looked for both the incidence ratio rate (IRR) of hematologic malignant neoplasms within two years of the procedure, as well as organ cancers and overall cancers within five years.

They divided their study population into two groups: 306,727 patients who underwent a CT scan, averaging 14.7 mGy, either 7 days prior or 7 days after their appendectomy and 519,093 who did not have a CT scan. Based on their analysis, they identified cancer in 323 individuals in the CT-exposed group and 500 patients who did not undergo a CT scan, resulting in a hematologic malignant neoplasm IRR of 1.26.

Ultrasound Surpasses CT in Imaging Kids for Appendicitis

According to their evaluations, the uptick in neoplasms began at roughly three years post-CT exposure. While the absolute excess IRR for all neoplasms reached 4.44, the CT group, specifically, experienced a 1.40 IRR for leukemia. The risk of developing a hematologic neoplasm was highest among patients younger than age 16, they said. The rise in risk also corresponded to the number of CT scans – 1.21 IRR with one CT; 1.60 IRR for patients who had two or more.

In an accompanying invited commentary, a group of experts, led by Paulina Salminen, M.D., Ph.D., from the division of digestive surgery and urology at Turku University Hospital in Finland, stressed the need to optimize the use of CT for appendicitis in children. The modality is the gold standard with adults, they said, consequently, providers just be as gentle as possible and implement low-dose CT with children.

Park’s team agreed, noting that the results of their study point to a need for adjusting the use of CT for the younger population.

“From our results, we are not claiming that use of periappendectomy CT should be discouraged in all patients. Historically, the increase in the use of CT coincided with the reduction of negative appendectomy rates,” they said. “At least in children, the importance of judicious use of CT cannot be overstated, as suggested by the high IRR for hematologic malignant neoplasms in children younger than 16 years.”

The number of CT scans corresponds to an increase in risk of hematologic malignant neoplasms, especially in children under age 16.



Abdominal CT Raises Blood Cancer Risk in Appendicitis Patients, Particularly Kids

It could soon be easier for radiologists to make an in-the-moment decision about whether a breast lesion is malignant or benign.

On Jan. 19, the U.S. Food & Drug Administration (FDA) granted pre-market approval (PMA) to the Imagio® Breast Imaging System from Seno Medical Instruments, Inc. This system uses non-invasive opto-acoustic ultrasound (OA/US) to help providers determine in real-time if an identified mass will require more invasive diagnostic evaluation.

Currently, breast biopsies due to false positives account for more than $2 billion in healthcare costs each year. Imagio®, which comes paired with an artificial intelligence decision support tool (SenoGram®) that helps providers transition from ultrasound to OA/US, could help this number drop, company officials said, by giving radiologists the information they need to be more confident in their assessments of lesions.

“Optimizing the diagnosis of breast masses requires a combination of very high sensitivity (more than 98 percent) while simultaneously maximizing specificity and minimizing false positives and biopsies of benign masses,” said Seno’s chief medical officer A. Thomas Starvos, M.D., FACR, FSBI. “Other modalities have reported improvements in specificity, but these have often come at the expense of the desired high more than 98 percent sensitivity.”

Results from the PMA study, he said, reveal that OA/US does reach improved specificity at fixed 98-percent sensitivity -- the area of the ROC curve where radiologists decide whether to biopsy.

To attain this level of performance, OA/US brings together laser optics and grayscale ultrasound for fused functional and anatomical breast imaging. Alongside anatomical images, according to company details, the technology provides a blood map of the breast masses and the surrounding area that can reveal the presence or absence of angiogenesis and deoxygenation – two cancer hallmarks. With this data, a radiologist can better make decisions about whether to expose a patient to more diagnostic imaging.

This system is intended for use by trained radiologists to identify palpable and non-palpable breast abnormalities in adults who have been referred for diagnostic imaging breast follow-up after a screening mammogram.

Seno’s Imagio® breast imaging system can help providers distinguish, in real-time, between benign and malignant breast lesions.

FDA Gives Seno Medical Approval for Opto-Acoustic Breast Imaging System

The patient was diagnosed as having a partial tear of the Achilles tendon.

Key Take-aways: Based on these sagittal plane MR images, discontinuity and focal hyperintensity can be seen at the distal Achilles tendon. This is consistent with partial tears of the tendon. In addition, the images also visualize parts of the Achilles tendon that remains intact.

Case submitted by: Araceli Cabanillas, M.D., musculoskeletal radiologist, to the radRounds Radiology Network.

Patient presents with an Achilles tendon tear.

Abdominal CT Raises Blood Cancer Risk in Appendicitis Patients, Particularly Kids

FDA Gives Seno Medical Approval for Opto-Acoustic Breast Imaging System

Image IQ: Achilles Tendon Tear