Mishal Mendiratta-Lala

Translating New Imaging Technologies to Clinical Practice

Radiology continues to benefit from constant innovation and technological advances. However, for promising new imaging technologies to reach widespread clinical practice, several milestones must be met. These include regulatory approval, early clinical evaluation, payer reimbursement, and broader marketplace adoption. Successful implementation of new imaging tests into clinical practice requires active stakeholder engagement and a focus on demonstrating clinical value during each phase of translation.

Small intrahepatic peripheral cholangiocarcinomas as mimics of hepatocellular carcinoma in multiphasic CT.

PurposeLiver transplant guidelines for diagnosing hepatocellular carcinoma (HCC) do not mandate pathologic confirmation; instead, ‘classic’ imaging features alone are deemed satisfactory. Intrahepatic peripheral mass forming cholangiocarcinoma (IHPMCC) is a relative contraindication for transplantation due to high rate of recurrence and poor prognosis. This study examines the imaging findings of IHPMCC, to aid in the identification and differentiation from potentially confounding cases of HCC.MethodsAfter IRB approval, 43 tissue-proven cases of IHPMCC on multiphase CT were retrospectively reviewed by 2 fellowship-trained radiologists. Tumor size, presence of cirrhosis, tumor capsule, vascular invasion, tumor markers, and enhancement pattern were assessed. A grading system was assigned as determined by enhancement pattern to background liver on arterial, portal venous, and equilibrium phases, ranging from typical HCC to typical IHPMCC enhancement pattern.ResultsAnalysis based on our grading system shows 5 (11.6%) tumors demonstrating grade 1–2 enhancement, 9 (21%) grade 3–4 enhancement, and 29 (67.4%) grade 5 enhancement. Kruskal–Wallis test comparing CA19-9 between the five groups, Wilcoxin rank-sum test comparing tumor markers with presence or absence of tumor capsule, vascular invasion and cirrhosis, and nonparametric Pearson’s correlation coefficient comparing tumor markers to tumor size were not statistically significant (p > 0.05).ConclusionTypical enhancement pattern of IHPMCC consisting of arterial phase hypoenhancement with progressive, centripetal-delayed enhancement is present in the majority of cases (68%). Five cases (11.7%) showed enhancement features potentially mimicking HCC, all of which are under 3.5 cm in size. Thus, small hyperenhancing lesions in a cirrhotic liver should be carefully scrutinized in light of differing therapy options from HCC, particularly in transplant situations.

Percutaneous image-guided pelvic procedures in women with gynecologic cancers: utilization, complications, and impact on patient management.

PurposeImage-guided percutaneous pelvic procedures often play an important role in the management of women with gynecologic cancers. The purpose of this study is to evaluate the utilization of and indications for these procedures, and quantify their impact on patient management.MethodsIRB-approved retrospective record review of percutaneous pelvic procedures requested by gynecologic oncology, 2005 to 2015. Descriptive statistics and logistic regression were performed.Results392 pelvic procedures, including fluid aspiration, core biopsy, and fine needle aspiration, were performed in 225 women. Procedures were performed under sonographic guidance (303/392, 77.30%), CT guidance (87/392, 22.19%), or both (2/392, 0.51%). Pathology results included: no specimen sent (157/392, 40.05%), new cancer diagnosis (55/392, 14.03%), recurrence or metastasis of known primary cancer (107/392, 27.30%), benign tissue (67/392, 17.09%), and nondiagnostic (6/392, 1.53%). In terms of management, some procedures led to oncologic surgery, radiation, or chemotherapy (158/392, 40.31%), cessation of oncologic treatment (36/392, 9.18%), or treatment of infection (10/392, 2.55%). Many procedures were therapeutic (178/392, 45.41%), while a minority were performed for genomics (1/392, 0.26%) or did not impact clinical management (9/392, 2.30%). The number of procedures per year increased over time during the period of data collection. Date of service was a significant positive predictor of a purely therapeutic procedure (OR 1.69 [95xa0% CI 1.44–1.98], pxa0<xa00.0001) and a significant negative predictor of a malignant diagnosis (OR 0.72 [95xa0% CI 0.64–0.81], pxa0<xa00.0001), for each year later in the 10-year cycle.ConclusionIn this single institution study, we identified a trend toward increased utilization of image-guided percutaneous pelvic interventions in women with gynecologic cancers. The case mix has shifted over the past 10 years, with procedures for symptom management constituting a larger proportion and diagnostic procedures constituting a smaller proportion of procedures over time.

Comparison of Stereotactic Body Radiation Therapy and Radiofrequency Ablation in the Treatment of Intrahepatic Metastases

PURPOSEnStereotactic body radiation therapy (SBRT) and radiofrequency ablation (RFA) are widely used therapies for the treatment of intrahepatic metastases; however, direct comparisons are lacking. We sought to compare outcomes for these 2 modalities.nnnMETHODS AND MATERIALSnFrom 2000 to 2015, 161 patients with 282 pathologically diagnosed unresectable liver metastases were treated with RFA (n = 112) or SBRT (nxa0= 170) at a single institution. The primary outcome was freedom from local progression (FFLP). The effect of treatment and covariates on FFLP was modeled using a mixed-effects Cox model with application of inverse probability treatment weighting to adjust for potential imbalances in treatment modality.nnnRESULTSnThe median follow-up period was 24.6xa0months. Patients receiving SBRT had larger tumors than those treated with RFA (median, 2.7xa0cm vs 1.8xa0cm; P < .01). On univariate analysis, tumor size was associated with worse FFLP for RFA (hazard ratio [HR]; 1.57; 95% confidence interval [CI], 1.15-2.14; P < .01) but not for SBRT (HR, 1.38; 95% CI, 0.76-2.51; P = .3).xa0The 2-year FFLP rate was 88.2% compared with 73.9%, favoring SBRT (P = .06). For tumors ≥2xa0cm in diameter, SBRT was associated with improved FFLP (HR, 0.28; 95% CI, 0.09-0.93; P < .01). On multivariate analysis, treatment with SBRT (HR, 0.21; 95% CI, 0.07-0.62; P = .005) and smaller tumor size (HR, 0.65; 95% CI, 0.47-0.91; P = .01) were associated with improved FFLP. The 2-year overall survival rate was 51.1%, with no difference between groups (P = .8). Grade ≥3 treatment-related toxicity was rare, with no difference between SBRT (n = 4) and RFA (n = 3).nnnCONCLUSIONSnTreatment with SBRT or RFA is well tolerated and provides excellent and similar local control for intrahepatic metastases <2xa0cm in size. For tumors ≥2xa0cm in size, treatment with SBRT is associated with improved FFLP and may be the preferable treatment.

Understanding Patient Preference in Female Pelvic Imaging: Transvaginal Ultrasound and MRI

RATIONALE AND OBJECTIVESnWomen with pelvic pain or abnormal uterine bleeding may undergo diagnostic imaging. This study evaluates patient experience in transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) and explores correlations between preference and symptom severity.nnnMATERIALS AND METHODSnInstitutional review board approval was obtained for this Health Insurance Portability and Accountability Act-compliant prospective study. Fifty premenopausal women with pelvic symptoms evaluated by recent TVUS and MRI and without history of gynecologic cancer or hysterectomy were included. A phone questionnaire used validated survey instruments including Uterine Fibroid Symptoms Quality of Life index, Testing Morbidities Index, and Wait Trade Off for TVUS and MRI examinations.nnnRESULTSnUsing Wait Trade Off, patients preferred TVUS over MRI (3.58 vs 2.80 weeks, 95% confidence interval [CI] -1.63, 0.12; Pu2009=u2009.08). Summary test utility of Testing Morbidities Index for MRI was worse than for TVUS (81.64 vs 87.42, 95%CI 0.41, 11.15; Pu2009=u2009.03). Patients reported greater embarrassment during TVUS than during MRI (Pu2009<.0001), but greater fear and anxiety both before (Pu2009<.0001) and during (Pu2009<.001) MRI, and greater mental (Pu2009=u2009.02) and physical (Pu2009=u2009.02) problems after MRI versus TVUS. Subscale correlations showed physically inactive women rated TVUS more negatively (Ru2009=u2009-0.32, Pu2009=u2009.03), whereas women with more severe symptoms of loss of control of health (Ru2009=u2009-0.28, Pu2009=u2009.04) and sexual dysfunction (Ru2009=u2009-0.30, Pu2009=u2009.03) rated MRI more negatively.nnnCONCLUSIONnWomen with pelvic symptoms had a slight but significant preference for TVUS over MRI. Identifying specific distressing aspects of each test and patient factors contributing to negative perceptions can direct improvement in both test environment and patient preparation. Improved patient experience may increase imaging value.

Radiology Research in Quality and Safety: Current Trends and Future Needs

Promoting quality and safety research is now essential for radiology as reimbursement is increasingly tied to measures of quality, patient safety, efficiency, and appropriateness of imaging. This article provides an overview of key features necessary to promote successful quality improvement efforts in radiology. Emphasis is given to current trends and future opportunities for directing research. Establishing and maintaining a culture of safety is paramount to organizations wishing to improve patient care. The correct culture must be in place to support quality initiatives and create accountability for patient care. Focused educational curricula are necessary to teach quality and safety-related skills and behaviors to trainees, staff members, and physicians. The increasingly complex healthcare landscape requires that organizations build effective data infrastructures to support quality and safety research. Incident reporting systems designed specifically for medical imaging will benefit quality improvement initiatives by identifying and learning from system errors, enhancing knowledge about safety, and creating safer systems through the implementation of standardized practices and standards. Finally, validated performance measures must be developed to accurately reflect the value of the care we provide for our patients and referring providers. Common metrics used in radiology are reviewed with focus on current and future opportunities for investigation.

Quantitative Assessment of Liver Stiffness Using Ultrasound Shear Wave Elastography in Patients With Chronic Graft‐Versus‐Host Disease After Allogeneic Hematopoietic Stem Cell Transplantation: A Pilot Study

The purpose of this study was to compare hepatic stiffness on ultrasound (US) shear wave elastography (SWE) in patients with chronic graft‐versus‐host disease (GVHD) after allogeneic hematopoietic stem cell transplantation versus patients with no underlying liver disease.

Radiologist Quality Assurance by Nonradiologists at Tumor Board

PURPOSEnTo explore the use of nonradiologists as a method to efficiently reduce bias in the assessment of radiologist performance using a hepatobiliary tumor board as a case study.nnnMATERIALS AND METHODSnInstitutional review board approval was obtained for this HIPAA-compliant prospective quality assurance (QA) effort. Consecutive patients with CT or MR imaging reviewed at one hepatobiliary tumor board between February 2016 and October 2016 (nxa0= 265) were included. All presentations were assigned prospective anonymous QA scores by an experienced nonradiologist hepatobiliary provider based on contemporaneous comparison of the imaging interpretation at a tumor board and the original interpretation(s): concordant, minor discordance, major discordance. Major discordance was defined as a discrepancy that may affect clinical management. Minor discordance was defined as a discrepancy unlikely to affect clinical management. All discordances and predicted management changes were retrospectively confirmed by the liver tumor program medical director. Logistic regression analyses were performed to determine what factors best predict discordant reporting.nnnRESULTSnApproximately one-third (30% [79 of 265]) of reports were assigned a discordance, including 51 (19%) minor and 28 (11%) major discordances. The most common related to mass size (41% [32 of 79]), tumor stage and extent (24% [19 of 79]), and assigned LI-RADS v2014 score (22% [17 of 79]). One radiologist had 11.8-fold greater odds of discordance (Pxa0= .002). Nine other radiologists were similar (Pxa0= .10-.99). Radiologists presenting their own studies had 4.5-fold less odds of discordance (Pxa0= .006).nnnCONCLUSIONSnQA conducted in line with tumor board workflow can enable efficient assessment of radiologist performance. Discordant interpretations are commonly (30%) reported by nonradiologist providers.

MR Imaging Evaluation of Hepatocellular Carcinoma Treated with Stereotactic Body Radiation Therapy (SBRT): Long Term Imaging Follow-Up

PURPOSEnTo determine the natural history of imaging findings seen on magnetic resonance imaging (MRI) of hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT). Although arterial hyperenhancement is a key feature of untreated HCC, our clinical experience suggested that tumors that never progressed could still show hyperenhancement. Therefore, we undertook a systematic study to test the hypothesis that persistent arterial phase hyperenhancement (APHE) after SBRT is an expected finding that does not suggest failure of treatment.nnnMETHODS AND MATERIALSnOne hundred forty-six patients undergoing SBRT for HCC between January 1, 2007, and December 31, 2015, were screened retrospectively using an institutional review board-approved prospectively maintained registry. Inclusion criteria were (1) HCC treated with SBRT, (2) multiphasic MRI ≤3xa0months before SBRT, (3) up to 1xa0year of follow-up MRI post-SBRT, and (4) cirrhosis. The exclusion criterion was ≤3xa0months of locoregional therapy to the liver segment containing the SBRT-treated HCC. Pre- and post-SBRT MRI from up to 3 years were analyzed in consensus by independent pairs of subspecialty-trained radiologists to determine the temporal evolution of major features for HCC and imaging findings in off-target parenchyma.nnnRESULTSnSixty-two patients with 67 HCCs (Organ Procurement and Transplantation Network imaging criteria [OPTN] 5a [nxa0=xa026], OPTN 5b [nxa0=xa028], OPTN 5x [nxa0=xa07]; Liver Imaging Reporting Data System [LI-RAD]-M [nxa0=xa04] and LiRADs-4 [nxa0=xa02]) were studied. Tumor size either decreased (66% [44 of 67]) or remained unchanged (34% [23 of 67]) within the first 12xa0months. Post-SBRT APHE was common (58% [39 of 67]). When graded using modified Response Evaluation Criteria in Solid Tumors at 3 to 6xa0months, 25% (17 of 67) met criteria for complete response and 75% (50 of 67) met criteria for stable disease.nnnCONCLUSIONSnSBRT is an effective locoregional treatment option for HCC. Persistent APHE is common and does not necessarily indicate viable neoplasm; thus, standard response assessment such as modified Response Evaluation Criteria should be used with caution, particularly in the early phases after SBRT therapy.

Imaging Findings Within the First 12 Months of Hepatocellular Carcinoma Treated With Stereotactic Body Radiation Therapy

PURPOSEnTo correlate the imaging findings of treated hepatocellular carcinoma (HCC) after stereotactic body radiation therapy (SBRT) with explant pathology and alpha-fetoprotein (AFP) response.nnnMETHODS AND MATERIALSnFrom 2007 to 2015, of 146 patients treated with liver SBRT for Barcelona Clinic Liver Cancer stage A hepatocellular carcinoma, 10 were identified with inclusion criteria and had regular interval follow-up magnetic resonance imaging/triple phase computed tomography and explant pathology or declining AFP values for radiology-pathology response correlation. Reference standards for successful response were >90% necrosis on explant pathology or pretreatment AFP >75xa0ng/mL normalizing to <10xa0ng/mL within 1xa0year after SBRT without other treatment. Subjects were treated with 24 to 50xa0Gy in 3 to 5 fractions. Multiphasic magnetic resonance imaging or computed tomography performed at 3, 6, 9, and 12xa0months after SBRT was compared with pretreatment imaging by 2 expert radiologists. Descriptive statistics were calculated.nnnRESULTSnThere were 10 subjects with 10 treated HCCs, classified as 3 Organ Procurement and Transplantation Network (OPTN) 5a, 4 OPTN 5b, and 3 OPTN 5x. All had successfully treated HCCs, according to explant pathology or declining AFP. Four of 10 HCCs had persistent central arterial hyperenhancement 3 to 12xa0months after SBRT; persistent wash-out was common up to 12xa0months (9 of 10). Of 10 treated HCCs, 9 exhibited decreased size at 12xa0months. Liver parenchyma adjacent to the lesion showed early (3-6xa0months) hyperemia followed by late (6-12xa0months) capsular retraction and delayed enhancement. No patient had a significant decline in liver function.nnnCONCLUSIONSnIn the absence of increasing size, persistent central arterial hyperenhancement and wash-out can occur within the first 12xa0months after SBRT in successfully treated HCCs and may not represent residual viable tumor. Liver parenchyma adjacent to the treated lesion showed inflammation followed by fibrosis, without significant change in hepatic function. Until a radiologic signature of tumor control is determined, freedom from local progression seems to be the best measure of HCC control after SBRT.