Faculty Bibliography

BACKGROUND:A high proportion of cytologically indeterminate, Afirma-suspicious thyroid nodules are benign. The Thyroid Imaging Reporting and Data System was proposed by the American College of Radiology in 2015 to determine appropriate management of thyroid nodules in a standardized fashion. Our aim was to determine the diagnostic value of the Thyroid Imaging Reporting and Data System in cytologically indeterminate and Afirma-suspicious nodules. METHODS:We retrospectively queried cytopathology archives for retrospectively for thyroid fine-needle aspiration specimens obtained between February 2012 and September 2016 that were associated with the following: (1) indeterminate diagnosis, (2) ultrasonographic imaging at our institution, (3) an Afirma Gene Expression Classifier-suspicious result, and (4) surgery at our institution. We then calculated the diagnostic value of the Thyroid Imaging Reporting and Data System in predicting surgical pathology. RESULTS:Our cohort consisted of 133 nodules among 131 patients who underwent thyroid surgery for cytologically indeterminate, Afirma-suspicious nodules. A total of 9 nodules (6.8%) were assigned TR2 "not suspicious," 25 (18.8%) TR3 "mildly suspicious," 81 (60.9%) TR4 "moderately suspicious," and 18 (13.5%) TR5 "highly suspicious." Among our cohort, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the Thyroid Imaging Reporting and Data System was 71.4%, 38.1%, 40.2%, 69.6%, and 50.4%, respectively. CONCLUSION:Among cytologically indeterminate and Afirma-suspicious nodules, the Thyroid Imaging and Reporting and Data System was a poor predictor of final surgical pathology. Additional prospective studies are needed to validate these findings.

OBJECTIVE:To examine reader performance in evaluating oropharyngeal anatomy on ultrasonography. MATERIALS AND METHODS/METHODS:Ultrasound images of the oropharynx comprising normal and malignant anatomic variants were organized into slideshows. Slideshows were administered to 6 readers blinded to participant tumor status and with varying experience reading oropharyngeal sonograms. A training slideshow oriented readers to images of the oropharynx with and without malignant lesions. Readers then evaluated images in a test slideshow for tumor presence and marked orthogonal long and short dimensions of the tumor. Results were analyzed for accuracy, sensitivity, specificity, inter-reader agreement, and measurement error relative to prospectively-identified reference measurements. RESULTS:Eighty-seven percent of base of tongue (BOT) sonograms were identified correctly by a majority of readers. In identifying BOT tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 79%, 73%, 85%, and 0.51, respectively. Median measurement error in the long and short axes for BOT tumors was -2.6% (range: -40% to 29%) and -2.6% (range: -56% to 156%), respectively. Eighty-four percent of palatine tonsil sonograms were identified correctly by a majority of readers. In identifying tonsil tumors, median accuracy, sensitivity, specificity, and Fleiss's kappa were 77%, 74%, 78%, and 0.41, respectively. Median measurement error in the long and short axes for tonsil tumors was 3.8% (range: -45% to 32%) and -6.5% (range: -83% to 42%), respectively. CONCLUSIONS:Overall, US has clinically useful sensitivity for identification of oropharyngeal carcinoma among readers of diverse clinical backgrounds and experience. US may be useful for the evaluation of features such as tumor dimensions.

BACKGROUND: Base of tongue (BOT) is a difficult subsite to examine clinically and radiographically. Yet, anatomic delineation of the primary tumor site, its extension to adjacent sites or across midline, and endophytic vs. exophytic extent are important characteristics for staging and treatment planning. We hypothesized that ultrasound could be used to visualize and describe BOT tumors. METHODS: Transcervical ultrasound was performed using a standardized protocol in cases and controls. Cases had suspected or confirmed BOT malignancy. Controls were healthy individuals without known malignancy. RESULTS: 100% of BOT tumors were visualized. On ultrasound BOT tumors were hypoechoic (90.9%) with irregular margins (95.5%). Ultrasound could be used to characterize adjacent site involvement, midline extent, and endophytic extent, and visualize the lingual artery. No tumors were suspected for controls. CONCLUSIONS: Ultrasonography can be used to transcervically visualize BOT tumors and provides clinically relevant characteristics that may not otherwise be appreciable.

Although localized renal cell carcinoma can be effectively treated by surgery or ablative therapies, local or distant metastatic recurrence after treatment is not uncommon. Because recurrent disease can be effectively treated, patient surveillance after treatment of renal cell carcinoma is very important. Surveillance protocols are generally based on the primary tumor's size, stage, and nuclear grade at the time of resection, as well as patterns of tumor recurrence, including where and when metastases occur. Various imaging modalities may be used in the evaluation of these patients. Literature on the indications and usefulness of these radiologic studies is reviewed. 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.

Imaging plays a role in the management of patients with acute kidney injury or chronic kidney disease. However, clinical circumstances strongly impact the appropriateness of imaging use. In patients with newly detected renal dysfunction, ultrasonography can assess for reversible causes, assess renal size and echogenicity, and thus, establish the chronicity of disease. Urinary obstruction can be detected, but imaging is most useful in high-risk groups or in patients in whom there is a strong clinical suspicion for obstruction. Computed tomography, computed tomography or magnetic resonance arteriography, and percutaneous ultrasound-guided renal biopsy are valuable in other clinical situations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 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 where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.