David Seidenwurm

Metastases to the adrenal glands and the development of Addison's disease

Metastases to the adrenal glands are common in patients with cancer but symptomatic Addisons disease is rarely noted in this population. The development of body computerized tomography (CT) allows the diagnosis of adrenal metastases to be made more readily antemortem. From 1980 to 1981, 19% (4/21) of patients at the Massachusetts General Hospital who had metastatic cancer and who were noted to have enlarged adrenal glands on CT also had or developed symptomatic adrenal insufficiency. The case histories of 8 patients with Addisons disease and one patient with adrenal hemorrhage on the basis of metastatic infiltration are reviewed. Since adrenal insufficiency may develop abruptly in this group of patients, it is suggested that prophylactic maintenance glucocorticoid therapy be initiated as soon as the diagnosis of adrenal metastases is made.

ACR Appropriateness Criteria® on Cerebrovascular Disease

Stroke is the sudden onset of focal neurologic symptoms due to ischemia or hemorrhage in the brain. Current FDA-approved clinical treatment of acute ischemic stroke involves the use of the intravenous thrombolytic agent recombinant tissue plasminogen activator given <3 hours after symptom onset, following the exclusion of intracerebral hemorrhage by a noncontrast CT scan. Advanced MRI, CT, and other techniques may confirm the stroke diagnosis and subtype, demonstrate lesion location, identify vascular occlusion, and guide other management decisions but, within the first 3 hours after ictus, should not delay or be used to withhold recombinant tissue plasminogen activator therapy after the exclusion of acute hemorrhage on noncontrast CT scans. MR diffusion-weighted imaging is highly sensitive and specific for acute cerebral ischemia and, when combined with perfusion-weighted imaging, may be used to identify potentially salvageable ischemic tissue, especially in the period >3 hours after symptom onset. Advanced CT perfusion methods improve sensitivity to acute ischemia and are increasingly used with CT angiography to evaluate acute stroke as a supplement to noncontrast CT. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Performance Measures in Radiology

Performance measures in radiology play an increasingly significant role in health care quality assessment and now form the basis for a variety of pay-for-performance programs, including those administered by CMS. This article introduces the measure development process, beginning with topic selection, followed by measure development and testing, National Quality Forum endorsement, and implementation. Once implemented, measures may undergo further testing and be re-endorsed, modified, or retired. Radiologists should familiarize themselves with the measures relevant to their practice, develop ways to collect and report data efficiently, and implement the necessary practice changes to meet measure criteria and improve the quality of their practice.

Breast cancer screening with tomosynthesis and digital mammography.

The likelihood of this magnitude of imbalance is not known; from a clinical perspective it seems low, but it is possible that clusters of unmeasured confounders could create large imbalances. Even though the methods used in their study were sophisticated, observational studies are vulnerable to residual confounding. For example, a large body of observational data on the relationship between cardiovascular disease and postmenopausal hormone therapy overwhelmingly suggested benefit prior to the Women’s Health Initiative Clinical Trial, which proved that hormone therapy did not reduce the risk of heart disease and actually increased the risk of stroke.2,3 I agree with Roumie and colleagues that well-performed observational studies such as theirs provide invaluable information for both patients and their physicians, but I also urge caution in drawing causal inferences based on observational data, even with highly sophisticated analytic methods.

De-Adoption and Un-Diffusion

In medicine, as in life, we celebrate innovators and early adopters. Each year, Nobel Prizes are announced, rewarding significant discovery or innovation. Many radiology pioneers have been recognized, including Roentgen, Curie, Hounsfield, and Lauterbur, among others. Such pioneers are the giants on whose shoulders contemporary radiologists perch, and it is perfectly appropriate that we celebrate them.

Counterpoint: The New England Journal of Medicine article suggesting overdiagnosis from mammography screening is scientifically correct and should not be withdrawn.

After 30 years of mass mammographic screening for breast cancer, public health organizations unanimously endorse screening, and health plans and doctors are judged publicly on screening rates. Yet the procedure remains controversial. Last year, the US Preventive Services Task Force reduced its recommended screening duration and frequency, and now another study from respected medical scientists in a top-ranked journal calls mammography into question again. Using national ecologic data on breast cancer incidence and mammography prevalence, Bleyer and Welch [1] estimated that mass mammographic screening over 3 decades has resulted in overtreatment of 1 million women who might never have gotten sick, about 30% of all breast cancer cases. By extension, many millions more underwent mammography and biopsy while overestimating the benefits and underestimating their potential harms. This new study compares the yearly rates of early-stage breast cancer diagnosis with late-stage diagnosis from the period before mammography through the current period of high acceptance. The data show that early-stage breast cancer has increased markedly, while late-stage diagnosis has decreased only slightly, and that decrease is in highly treatable regional nodal disease, not metastases. In the absence of overdiagnosis, expected increases in early-stage cancer would eventually be followed by a commensurate reduction in latestage disease because detection and treatment of early cases should prevent their later presentation at more advanced stages. In the face of large increases in early-stage breast cancer, the small reduction in latestage breast cancer in the United States implies that screening yields smaller benefits and correspondingly greater harms of overdiagnosis and overtreatment than previously presumed. To draw these conclusions, the authors used the Surveillance, Epidemiology and End Results (SEER) comprehensive cancer epidemiology registry. For purposes of interpretation, they adjusted the data in ways that probably favor mammography. The principal adjustments concern the ramp-up period, the effects of hormone replacement, and the underlying rate of breast cancer in unscreened populations. The ramp-up adjustments correct for the early years of the SEER database, when reporting was incomplete, and a spike in early cancer detection in the 1970s, and they account for the gradual introduction of screening in the population as a whole. The adjustments for hormone replacement are more speculative, but they favor mammography by capping the rate of cancer after screening was introduced, to eliminate the effect of hormone replacement on cancer rate and diminished screening efficacy. Bleyer and Welch’s [1] assumptions regarding underlying cancer

Economic and Societal Aspects of Stroke Management

Stroke is a major health burden worldwide with attendant mortality, morbidity, and cost. In 2010, there were approximately 16.9 million strokes and an estimated 33 million stroke survivors worldwide. Also, in the United States, stroke is the third leading cause of death, with ischemic stroke resulting in 8% 30-day mortality (20% for hemorrhagic stroke). The staggering economic cost of the disease is driven largely by disability and long term care. Efforts in stroke healthcare delivery are focusing on performance, efficiency and value to better serve the consumer.

Management of Incidental Pituitary Findings on CT, MRI, and 18F-Fluorodeoxyglucose PET: A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing pituitary findings that are incidentally detected on CT, MRI and 18F-fluorodeoxyglucose PET. The Pituitary Subcommittee, which included radiologists practicing neuroradiology and an endocrinologist, developed this algorithm. The recommendations draw from published evidence and expert opinion and were finalized by informal iterative consensus. Algorithm branches successively categorize pituitary findings on the basis of imaging features. They terminate with an ascertainment of an indolent lesion (with sufficient confidence to discontinue follow-up) or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. The goal is to improve the quality of care by providing guidance on how to manage incidentally detected pituitary findings.

Assessing the Recall Rate for Screening Mammography: Comparing the Medicare Hospital Compare Dataset With the National Mammography Database

OBJECTIVE High-quality screening mammography has been shown to substantially reduce mortality from breast cancer. Recall rate is a principal performance metric for screening mammography because it directly relates to the rate of false-positive examinations. This study aims to compare the recall rate derived using two sources-the claims-based Hospital Compare (HC) dataset from the Centers for Medicare & Medicaid Services versus the National Mammography Database (NMD) from the American College of Radiology-to understand the implications in pay-for-performance and quality improvement activities. MATERIALS AND METHODS This study retrospectively compared the recall rate reported by NMD facilities with that reported in the HC dataset. Site matching was performed by facility name and zip code, followed by manual verification. Scatterplots, correlations, a paired t test, and Bland-Altman analysis were performed to assess association between the two measures. RESULTS During the period from October 1 to December 1, 2016, 92 facilities were unambiguously matched using 2014-2015 records in both datasets. The recall rates were positively correlated (r = 0.428, p < 0.001), but the mean HC recall rate (8.5% ± 2.86% [SD]) was significantly (p < 0.001) lower than the mean NMD recall rate (10.6% ± 3.90%). CONCLUSION The NMD and HC are two commonly used datasets for measuring screening mammography recall rate. Although recall rates are correlated at the individual facility level, there are important differences that have implications for quality improvement and pay-for-performance.