Whitney J. Palmer has been with Diagnostic Imaging since 2011, serving as the Senior Editor since November 2019. She has 20 years experience in healthcare and academic medicine reporting.

Going through an MRI can be tough for some patients. Being in a small space and having to remain as still as possible can create fear and panic. And these problems can have a snowball effect – movement leads to blurry images that require repeated scans, prompting more discomfort.

“MRIs are frightening for everyone,” said Matthew David Hall, M.D., lead pediatric radiation oncologist at Miami Cancer Institute. “Even when my patients overcome the fear, they have no way to practice being still, so that the scans, or radiation treatments, can be as short and accurate as possible.”

Hall knew there had to be a way to alleviate those fears and help patients stay relatively motionless. To achieve that goal, his clinical team paired up with Reimagine Well, a company dedicated to improving the patient experience during the treatment process.

What they developed is a pre-MRI virtual reality (VR) game, call the MRI Stillness Game, that uses patient compliance as a way to override the uncomfortable stimuli that an MRI exam presents. Using a VR headset that detects movement, the team developed a three-level game that escalates from black-and-white to color. The game is timed to last as long as the MRI exam. Patients are tasked to hold the crosshairs at the center of a circle, increasing their score the longer they stay still.

Throughout the game, patients focus the crosshairs to colorize a rainforest, a hot air balloon scene, and a coral reef. Each level is longer and harder, and, as they play, the simulated MRI noises morph into part of the natural, surrounding environment, such as bird chirps or dolphin clicks. After each round, patients receive a score card on their performance.

The goal, the team said, is to help familiarize patients with the stillness requirement for an MRI exam with the hope that their scores will predict with how well they will successfully complete a scan without moving.

“Often virtual reality headsets are used in hospitals for distraction or entertainment purposes only. With this application, the patient is first acclimated to the sights and sounds of the MRI,” said Leonard Sender, M.D., co-founder of Reimagine Well. “We believe clinicians will be able to correlate the scores in the game to the accuracy of the imaging and the duration of the patient MRI sessions. Our hope is that it will become an important predictive tool, shortening the duration of procedures and getting more utilization out of their MRI suites.”

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Articles

Three-level game helps patients overcome fears of the scan and learn how to remain as motionless as possible during imaging.

Virtual Reality Game Improves Patient Stillness for MRI

COVID-19 vaccine-related adenopathies are a known entity, but in many instances, they can still give providers pause about what they’re seeing on a screening breast exam.

a team of investigators from the Diagnostic Center for Women in Miami shared a pattern on screening that, when visualized, can bolster a radiologist's confidence in rendering a benign assessment.

“Knowing that the COVID-19 vaccine is administered intramuscularly in the deltoid muscle of the upper arm and understanding the lymphatic drainage pattern of the breast and upper extremity,” said the team led by Michael J. Plaza, M.D., a radiologist at the Center, “we suggest that a pattern of unilateral axillary lymphadenopathy involving the lateral, central, and/or apical groups with relative sparing of the anterior group is typical for vaccine-related lymphadenopathy.”

For their study, they used findings from a screening breast MRI conducted on a 63-year-old asymptomatic female patient. She received her second vaccine dose in her left arm six days prior to the scan.

No suspicious enhancement present in the left breast.

Morphologically abnormal high level II/III axillary lymph nodes (central and apical group) in the presence of normal low level I axillary lymph nodes (anterior group)

“Identifying this pattern of unilateral axillary adenopathy in the setting of ipsilateral COVID-19 vaccine administration and a negative screening breast MRI allows one to confidently give a benign assessment in keeping with a pragmatic approach,” the team said.

Consequently, they added, radiologists may be able to reduce the number of unneeded follow-ups and/or biopsies. This knowledge also pushes back against the practice of delaying breast MRI screening due to recent vaccinations.

Still, the team cautioned, providers should treat every instance with patients who have a history of cancer as an individual experience. Determine the course of action and treatment with a multi-disciplinary team based on cancer type, lymph node drainage pathway, and metastasis risk.

Looking for these features could reduce biopsies and facilitate more timely screening.

Vaccine Adenopathy Pattern on Breast MRI Supports Benign Assessment

 Filling defect diffusely seen broadly within the small bowel consistent with a parasitic infection consistent with ascariasis.

 GI ascariasis appears as potentially single to multiple worms (nematodes) seen as a longitudinal linear filling defect on barium study. Often times, the intestinal tract of the worm itself can be visualized or if its GI tract is empty, a pure filling defect is seen.

What is the diagnosis in this patient with weight loss?


Image IQ Quiz: Patient Presents with Weight Loss

A new radiotracer can measure a tumor’s iron concentration, paving the way for iron-targeted treatments for cancer patients.

In a study published in the July issue of the 

a team of investigators revealed that the radiotracer 

F-TRX can accurately measure the iron concentration in a tumor with a dose similar to other 

F-based radiotracers, helping providers predict whether the cancer will respond to therapy.

Cancer cells rely on iron to have enough energy to grow. This gives them higher iron levels than healthy cells and has made the cytosolic ‘labile’ iron pool (LIP) of cancer cells an attractive target for treatment. But, there has been a need for a clear strategy for LIP measurement.

LIP expansion is detectable in an orthotopic glioma model with 18F-TRX. A. 18FTRX PET/CT data showing radiotracer uptake in a U87 MG tumor (arrow) implanted within the right hemisphere of a mouse brain. The image was acquired at 90 min post injection. B. Quantification of 18F-TRX uptake using region of interest analysis of the PET data from mice bearing U87 MG tumors (n = 3). The tumor uptake was compared to uninvolved normal white matter on the contralateral region of the brain. C. Digital autoradiography showing the distribution of the radiotracer within a coronal section of the mouse brain. The tissue was stained with H&E and merged with the pseudocolor image of the autoradiography.

Evans, Renslo et al. University of California San Francisco.

“LIP levels in patient tumors have never been quantified,” said Adam R. Renslo, Ph.D., professor in the pharmaceutical chemistry department at the University of California at San Francisco. “Iron rapidly oxidizes once its cellular environment is disrupted, so it can’t be quantified reliably from tumor biopsies. A biomarker for LIP could help determine which tumors have the highest LIP levels and might be especially vulnerable to LIP-targeted therapies.”

F-TRX PET to image 10 tissue graft models of glioma and renal cell carcinoma in order to measure LIP, assessing tumor avidity and sensitivity to the radiotracer. They also used an animal model to determine effective human dosimetry.

F-TRX pinpointed tumor accumulation, accurately indicating LIP levels in tumors and identifying those that were most likely to responds to targeted treatments. In addition, they determined that pre-treatment 

F-TRX uptake also predicted treatment sensitivity.

“Iron dysregulation occurs in many human disorders, including neurodegenerative and cardiovascular disease, and inflammation,” said Michael J. Evans, associate professor in residence in UCSF’s radiology and biomedical imaging departments. “Applying 

F-TRX in the respective patient populations to define the extent of LIP expansion in affected tissues will be an important milestone toward understanding the therapeutic potential of LIP-targeted therapies beyond oncology.”

Measurements can help predict which tumors will respond to targeted therapies.

New Radiotracer Identifies Iron Levels in Tumors

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

COVID-19 vaccine-related adenopathies picked up on breast imaging have garnered a great deal of attention over the past few months. In a new study published in 

investigators discuss patterns identified on scans that can give providers confidence in rendering a benign assessment. Look for the article later this week.

For more COVID-19 vaccine-related adenopathies and breast imaging coverage,

The use of contrast-enhanced mammography is growing, but does it work the same across all pieces of equipment? In a new study published this week, researchers point out that artifacts picked up via this type of scan show up differently on equipment produced by different vendors. Watch for the article this week.

For more contrast-enhanced mammography coverage

Have you ever wondered if there is a way to choose the best radiology resident for your program? It turns out there are factors you should consider that will help you select the best candidates who will likely to on to have the most success. Look for an article this week that outlines what those characteristics might be.

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

Diagnostic Imaging's A Look Ahead: July 26 to July 31, 2021

It might seem strange that I’d feel the need to advise fellow professionals to watch their language like this. We’re all respectable adults, yes? But you’d be amazed to hear the way some people talk…and words matter. Rightly or wrongly, people judge you by the ones you use.

I’m, therefore, here to advise you: Try to remove that nasty little 4-letter F-bomb from your repertoire. Under most circumstances, the word “fair” won’t help you. Even if it’s modified with things like “un-.”

I recall an episode from early-ish residency. We had a two-tier system for covering call, where junior and senior residents split responsibilities, and it was time for me to take over XR. I was unpleasantly surprised to enter the reading room and find that the now-departed senior had left a massive stack of films (yes, we were still using those) on the counter. They’d accumulated over a course of hours on her watch, but she’d left without looking at any of them.

I felt the need to tell the attending who’d just arrived for reading-out that this was not my mess…mostly because I didn’t want him to think I was slacking. Part of me also wanted him to know that she’d shirked her responsibilities. (It wasn’t the first time she’d demonstrated a crummy attitude in such regard, and had more than once left other residents in the lurch…evidently thus far without repercussions.)

The attending didn’t much seem to care, dismissively saying, “She’s old, and she’s tired.” I was disappointed by this…but I don’t consider it evidence that I’m an evil, vindictive individual. I’ve previously referenced in this column that humans are hard-wired to seek justice; some articles covering the matter refer to the “revenge center” of the brain. Functional MRI actually found circuits involving the amygdala and the dorsolateral prefrontal cortex, activated when subjects experience or just witness acts of unfairness.

So we’re physically set up to recognize and react to unfairness. Why not point it out when we see it? Especially if we feel we’re the ones being treated unfairly?

Because it wouldn’t change anything. At least, not in ways we’d want.

“Fair” is an entirely subjective concept. In an awful lot of circumstances, my “fair” isn’t going to be the same as yours, because we’ve had different lifetimes to form the concepts for ourselves. If I say that something you’ve done, or are passively benefitting from, is not “fair,” it’s almost certain that you’ll disagree.

Suppose you recognize that my accusation has merit. It might make you feel guilty or otherwise uncomfortable. You might have a cornered feeling: I’ve expressed a valid point that you unjustly have X or did Y, and you don’t have a reasonable retort to defend what you’ve got. Either you relinquish it (but you don’t want to), or you keep it, exposed as willfully benefitting from unfairness. You’re probably going to resent my putting you in this position…and might decide to make me pay for it later on.

Or you truly believe that I’m wrong about the unfairness. Maybe you try explaining to me why that is, maybe not. Either way, there are two people bashing their contrasting senses of what’s fair against each other. Nobody’s going to change their mind. One or both parties might be so unable to imagine the other’s perspective that they’ll believe the argument of “fairness” to be disingenuous, a manipulative path to ulterior motives.

Then, of course, either or both might simply resent the conflicting opinion: Who are 

 what’s fair here? How are your values any better than mine?

Griping about fairness can also do the complainer other disfavors. Even if they manage to do it without sounding whiny, it makes them look weak. They are essentially saying that they want something, but can’t get it for themselves. Even appealing to a higher authority to get it for them, they aren’t supporting their case with evidence or other logical points—they are depending on the magic word “fair” to get their way.

Such authorities, and indeed others interacting with a frequent “fair”-er, quickly develop fairness-fatigue. “Life’s not fair” isn’t just a parental parry against squabbling siblings, it’s actually helpful advice (which, at that age, tends to fall on deaf ears). But, later on, some folks might just learn the lesson: Avoid the F-word whenever possible.

Getting back to that situation with the stack of neglected X-rays, I know I didn’t say anything to the attending about fairness. Even if I‘d bothered to track down and confront the senior resident, I wouldn’t have used the word with her, either. It was a couple of decades ago, but even then I’d lived long enough to know that it wouldn’t have helped my case. Indeed, it probably would have taken me down a notch in their eyes.

Better, instead, to support your side of things by showing your audience what they need to conclude 

 what is fair. Persuasion has been nicknamed the art of “letting others have it your way,” and that’s a more effective route. Babbling about what you think is fair won’t help and might actually hurt your case. But if you can present your facts in a way so the other side assembles them to arrive at their own sense of “fairness” that meshes with yours…you can win without even fighting.

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

Rely on facts rather than persuasion when dealing with fairness.

The F-word: Think It, Just Don’t Say It

Diagnostic accuracy with appendicitis is virtually equivalent between general radiologists and providers who completed abdominal fellowships.

a team of investigators from the University of Wisconsin-Madison showed that general radiologists are just as proficient with these scans as are providers who complete an abdominal fellowship. This equivalency exists even though they encounter these MRI and CT scans less frequently in the community hospital setting.

These findings disproved the authors’ initial belief that general radiologists would have lower diagnostic accuracy.

“We found that community-based generalist radiologists demonstrated excellent accuracy when using MR to diagnose appendicitis,” said the team led by Michael D. Repplinger, M.D., Ph.D., clinical assistant professor in the department of emergency medicine. “Specifically, when comparing CT and MR images performed in tandem on patients seen in the ED for possible appendicitis, we found no statistically significant differences in accuracy among 198 paired image sets.”

For their study, the team assessed MRI and CT scan interpretations from six radiologists (three in community and academic settings each) over an 18-month period. Overall, the study included 198 patients, and the prevalence of appendicitis was 32.3 percent.

Based on their evaluation, the team determined that general radiologists had a sensitivity and specificity performance of 93.8 percent and 88.8 percent, respectively, for MR and 96.9 percent and 91.8 percent, respectively, for CT. In contrast, the fellowship-trained providers demonstrated sensitivity and specificity of 96.9 percent and 89.6 percent for MR, respectively, and 98.4 percent and 93.3 percent for CT, respectively.

Additionally, the team discovered that as the experience level grew for general radiologists, so did their accuracy. Specifically, they identified a significant increase in MR sensitivity (p=0.002) and a decrease in reading time – a reduction from 5 minutes to 3.9 minutes.

Despite being general radiologists, the team did note that these providers had significant familiarity with neuroradiology, as well as musculoskeletal radiology.

Ultimately, the team said, these findings could impact the imaging evaluation of suspected cases of appendicitis.

“This suggests MR may be a reliable, radiation-free imaging alternative to CT for the evaluation of appendicitis, including at community-based generalist radiology practices,” the team concluded.

Study shows general radiologists in community settings have nearly the same level of diagnostic accuracy as abdominal fellowship-trained providers.



MRI/CT Diagnostic Accuracy for Appendicitis Equivalent for Generalists and Specialists 

Incorporating artificial intelligence (AI) as a second reader with chest X-ray can improve both radiology resident and board-certified radiologist performance in recommending chest CT exams for patients suspected of having lung cancer.

 a team of investigators from Massachusetts General Hospital revealed that AI could have a roughly 30-percent impact on both residents and providers, catching more findings to drive the most appropriate treatment.

“The use of AI could help to detect pulmonary nodules accurately with chest X-rays, as well as reduce the need for unnecessary chest CT exams in some patients,” said study co-investigator Mannudeep K. Kalra, M.D., a radiologist at Massachusetts General. "This finding can benefit patients by enabling them to avoid unneeded radiation exposure, and it can benefit the healthcare system by preventing certain medical costs.”

Even though chest X-ray is more affordable and more easily accessible, it is limited in its utility for detecting pulmonary nodules, the team said. Its projectional nature means anatomical structures can hide the nodules, effectively creating blind spots for radiologists. In fact, data from the National Lung Screening Trial (NLST) shows that chest X-ray does not lower mortality when compared to low-dose CT.

Consequently, the team set out to determine if it were possible to improve chest X-ray performance.

For their study, they examined 519 chest X-rays – 173 cancer-positive and 346 cancer-negative – collected from the NLST. Eight radiologists – three residents and five board-certified providers – interpreted the exams, and an AI algorithm provided image-level probability of a nodule or mass on chest X-ray, as well as a heatmap of detected lesions. The team assessed reader performance for area under the curve, sensitivity, specificity, false positives, and rate of chest CT recommendation.

According to their analysis, by using AI, residents were able to recommend chest CT in 28 percent more cases of people with suspected lung cancer than without the algorithm (70.2 percent versus 54.7 percent). The tool also reduced unnecessary chest CT recommendations by radiologists by 30 percent (11.7 percent versus 16.4 percent) in cancer-negative patients.

“Our results suggest that AI algorithm benefits less-experience readers in terms of sensitivity, and more-experienced readers in terms of specificity,” the team said. “In this study, the AI algorithm likely reduced such errors by locating such subtle lesions for the residents…AI helped improve the performance of the residents up to the level that was on par with radiologists, which led to a significant increase in the chest CT recommendation rate for patients with visible lung cancer.”

Ultimately, the team said, incorporating AI into computer-aided detection (CAD) can alleviate reliance on hand-crafted features and limit the impact of both high false-positive and high false-negative findings.

“We believe our results support the use of AI CAD systems for the detection of lung cancer in chest X-rays,” the team concluded. “Our AI CAD system can help avoid such issues while assisting readers in identifying subtle lesions that may otherwise be missed.”



Both board-certified radiologists and radiology residents more appropriately suggested chest CT follow-up when using artificial intelligence with chest X-ray.

AI as a Second Chest X-ray Reader Better Informs Chest CT Recommendations for Lung Cancer

Filling defect disrupting the gastric contour and folds with suggestion of outpouching of the ulcer crater with a relatively smooth border consistent with an ulcer. No significant irregularity of the border.

Features that suggest a benign ulcer is an outpouching of the ulcer crater beyond the gastric border, smooth borders, smooth ulcer mound, smooth folds reaching the margin of the ulcer, “Hampton’s line”, and location along the lesser gastric curvature. Features that suggest malignant gastric ulcer includes irregularity of the borders, nodularity of the ulcer mound, and more commonly seen along the greater curvature of the gastric border.

What is the diagnosis in this patient with melena?

Image IQ Quiz: Patient Presents with Melena

Chest CT scans show thickening of lung tissue after six months in more than 70 percent of patients who are COVID-19-positive.

a team of investigators from Italy shared that it is possible to predict which patients are at higher risk for long-term effects by combining a baseline chest CT scan with clinical data.

Although chest CT findings have been used extensively during the pandemic, providers have mainly relied on them to reveal short- and mid-term progression of disease. As the pandemic enters this new phase, there is a need for a more long-term assessment.

“At six-month follow-up 72 percent of patients showed late sequelae, in particular fibrotic-like changes,” said the team led by Damiano Caruso, M.D., Ph.D., medical director with Sapienza University in Rome. “Baseline [lung severity score] and [quantitative chest CT] of well-aerated lung showed an excellent performance in predicting fibrotic-like changes at six-month chest CT.”

In order to learn more about any long-term impacts of the virus, Caruso’s team examined baseline CT scans captured between March 2020 and May 2020 from 118 patients who had moderate-to-severe COVID-19 infection. They followed up with additional CT scans after six months, looking at lung severity scores, quantitative chest CT measures, and qualitative findings.

In addition, the team evaluated three strategies that could predict long-term effects – radiological data alone, clinical data alone, or a combination of the two.

Based on their evaluation, the team determined that 72 percent of patients had fibrotic-like changes in their lungs, and 42 percent exhibited ground glass opacities. Their results indicated that quantitative chest CT measures and lung severity scores could effectively predict these fibrotic-like changes at follow-up.

However, there is a lack of consensus on whether Caruso’s team is taking the best approach in evaluating these lung changes in patients who have had COVID-19. In an accompanying 

, Athol Wells, consultant chest physician at Royal Brompton Hospital, and Anand Devaraj, professor of practice in thoracic radiologist at the National Lung and Heart Institute and consultant thoracic radiologist at the Royal Brompton Hospital, pointed out that all patients with residual disease at six months had a positive fibrotic-like score.

“The apparent increase in the prevalence of ‘fibrotic-like’ change at six months is highly deceptive as baseline scans were performed at admission, now when the disease was most severe, and before periods of prolonged ventilation in some of the study participants,” they said. “A more progressive lung fibrosis hypothesis post-COVID would instead require evaluating change from baseline CT performed at discharge from intensive care or at hospital discharge.”

Overall, they said, there is an urgent need to assess the clinical significance of residual disease on CT, as well as to create predictive models against this end point in future work.

More than 70 percent of patients exhibit lingering sequelae.

