Faculty Bibliography

PURPOSE/OBJECTIVE:To determine whether the presence of an ultrasound hypoechoic region at the site of a MRI region of interest (ROI) results in improved prostate cancer (PCa) detection and predicts clinically significant PCa on MRI - ultrasound fusion targeted prostate biopsy (MRF-TB). MATERIALS AND METHODS/METHODS:Between July 2011 and June 2017, 1058 men who underwent MRF-TB and systematic biopsy by a single surgeon were prospectively entered into an IRB-approved database. MRI ROI were identified and scored for suspicion by a single radiologist. Each MRI ROI was prospectively evaluated for presence of a hypoechoic region at the site (ROI-HyR) by the surgeon and graded as 0,1,2 representing none, poorly demarcated, or well demarcated, respectively. Interaction of MRI suspicion score (mSS) and US grade (USG), and prediction of cancer detection rate (CDR) by USG, was evaluated by univariate and multivariate analysis. RESULTS:For 672 men, overall and Gleason Score (GS)≥7 CDR were 61.2% and 39.6%, respectively. CDR for USG 0,1,2 were 46.2%, 58.6%, 76.0% (p<0.001) for any cancer and 18.7%, 35.2%, 61.1% (p<0.001) for GS≥7, respectively. For MRF-TB only, GS≥7 CDR for USG 0,1,2 was 12.8%, 25.7%, 52.0% (p<0.001), respectively. On univariate analysis, among mSS 2-4, USG was predictive of GS≥7 CDR. Multivariable regression analysis revealed USG, PSAD, and mSS were predictive of GS≥7 PCa on MRF-TB. CONCLUSIONS:Ultrasound findings at the site of MRI ROI independently predict the likelihood of GS≥7 PCa, as men with a well demarcated ROI-HyR at the time of MRF-TB have a higher risk than men without.

Purpose: To assess changing utilization in extremity angiography from 2001 to 2016, focusing on relative shifts between modalities and provider specialties. Materials: Medicare PSPS Master Files from 2001-2016 were used to determine national utilization of traditional invasive catheter angiography, CTA, and MRA, normalized to extremities imaged per 100,000 beneficiaries. Result(s): From 2001 to 2016, extremity angiography increased from 769 to 1,352 total extremities imaged per 100,000 beneficiaries, largely attributable to massive early growth in CTA (22 in 2001 to 614 in 2009; plateau of 645 in 2016), with small changes in catheter angiography (702 to 676) and MRA (45 to 30). Extremity angiography shifted from 91% catheter, 6% MRA, 3% CTA in 2001 to 50% catheter, 48% CTA, and 2% MRA in 2016. For radiologists, overall angiography increased (488 to 733) due to a large increase in CTA (20 to 595) despite a large decrease in catheter (428 to 122), while MRA remained low (40 to 27); extremity angiography by radiologists shifted from 88% catheter, 8% MRA, and 4% CTA in 2001 to 81% CTA, 15% catheter, and 4% MRA in 2016. For cardiologists, there were increases in angiography overall (155 to 240) and catheter (153 to 205), and to a lesser extent in CTA (1 to 33); extremity angiography by cardiologists shifted from 99% catheter, <1% CTA, <1% MRA in 2001 to 85% catheter, 14% CTA, <1% MRA in 2016. For surgeons, overall angiography increased from 65 to 261 and was 99% catheter in both 2001 and 2016. Radiologists' market share of extremity angiography varied from 63% (2001) to 54% (2016). Despite a marked decrease in radiologists' share for catheter (61% to 17%), radiologists were the dominant provider throughout for CTA (89% to 92%) and MRA (89% to 90%). Conclusion(s): Utilization of extremity angiography in Medicare beneficiaries nearly tripled from 2001 to 2016, almost entirely due to the advent of CTA by radiologists. Cardiologists and surgeons acquired the large volume of catheter angiography given up by radiologists. Further work is necessary to assess if the growth of CTA represents additive (i.e., expanded patient populations being evaluated) vs. duplicative (i.e., same patients undergoing both tests) imaging.

Purpose: To evaluate trends in transcatheter hemodialysis conduit procedures in the Medicare population over a recent 15-year interval. Materials: Aggregate national claims data were extracted from CMS PSPS Master Files from 2001-2015 for hemodialysis conduit angiography and thrombectomy procedures. Utilization was stratified by billing specialty and site of service. Additionally, individual claims data from 2004-2015 CMS 5% Research Identifiable Files were used to assess state-level utilization. Utilization was normalized per 100,000 Medicare fee-for-service beneficiaries. Result(s): From 2001-2015, hemodialysis conduit angiography utilization rates increased from 385 to 1,045 per 100,000 beneficiaries [compound annual growth rate (CAGR) +7.4%)], and thrombectomy rates increased from 114 to 168 (CAGR +2.8%). The CAGR for angiography was, by specialty, +1.5% for radiologists, +18.4% for surgeons, and +24.0% for nephrologists, and by site, +29.1% for office and +0.8% for hospital settings. Radiologists' overall market share of angiography decreased from 81.5% in 37.0%. By combination of specialty and site of service, angiography utilization growth was greatest for nephrologists in the office (from 5 to 265) and surgeons in the office (0 to 128). The greatest decline was for radiologists in the hospital (299 to 205). At the state level, there was marked heterogeneity in dialysis angiography utilization in 2015 [0 (Wyoming) to 1,1,73 (Georgia)], temporal change in angiography utilization from 2004-2015 [CAGR -100.0% (Wyoming) to +19.9% (Nevada)], and radiologists' 2015 market share [4.8% (Washington DC) to 100.0% (North Dakota)]. Nonetheless, radiologists' market share decreased in 49 states, and in some states dramatically (e.g., in Nevada, from 100.0% in 2004 to 6.7% in 2015). Conclusion(s): Transcatheter dialysis conduit angiography utilization has grown substantially, and more so than thrombectomy. This growth has been accompanied by a drastic market shift from radiologists in the hospital to nephrologists and surgeons in the office. Despite wide geographic heterogeneity across the U.S., decreasing radiologist market share has been observed in nearly every state.

Purpose: To explore variation in downstream costs associated with cartilage lesions incidentally detected on radiographs. Materials andMethods: The cohort was composed of 120 patients with incidental, not previously diagnosed, cartilage lesions seen on appendicular plain radiographs. The population was divided into three subgroups based on the interpreting radiologist's description: enchondroma, lowgrade cartilage lesion, and chondrosarcoma. Downstream events (follow-up imaging, office visits, biopsy, tumor resection) associated with the lesions were identified from the electronic medical record. American College of Radiology (ACR) Appropriateness Criteria were used to classify radiologists' recommendations. NationalMedicare rates were used to estimate costs of downstream events. Average cost per lesion was stratified, and cost ratios were computed among subgroups.
Result(s): Average downstream cost per lesion was $75.56. Costs were 4.6 times greater in patients under the age of 65 than over. Costs were 13.2 and 13.7 times higher when radiologists characterized lesions as chondrosarcoma versus low-grade cartilage lesion and enchondroma, respectively. There was no statistically significant difference in costs between the subgroups when accounting for size and location of lesions. Compared to when follow-up imaging was neither recommended nor obtained, costs rose from $0 to $26.03 per patient when follow-up imaging was recommended and obtained, and $62.21 per patient when followup imaging was obtained despite not being recommended. Costs rose from $0 to $14.83 per patient when radiologists' recommendations for follow-up were adherent to the ACR guidelines for management of incidental bone lesions. Costs were 2.3 times greater when ordering physicians overmanaged compared with radiologists' recommendations. No malignancy was pathologically proven in the cohort.
Conclusion(s): Costs for incidental cartilage lesions vary. Size and location of lesions do not have a significant effect on downstream costs; however, radiologists' characterization and recommendation have an impact. Therefore, it is imperative that radiologists accurately characterize such lesions and recommendations reflect the best value for patient care

BACKGROUND:Patient-specific 3D models are being used increasingly in medicine for many applications including surgical planning, procedure rehearsal, trainee education, and patient education. To date, experiences on the use of 3D models to facilitate patient understanding of their disease and surgical plan are limited. The purpose of this study was to investigate in the context of renal and prostate cancer the impact of using 3D printed and augmented reality models for patient education. METHODS:Patients with MRI-visible prostate cancer undergoing either robotic assisted radical prostatectomy or focal ablative therapy or patients with renal masses undergoing partial nephrectomy were prospectively enrolled in this IRB approved study (n = 200). Patients underwent routine clinical imaging protocols and were randomized to receive pre-operative planning with imaging alone or imaging plus a patient-specific 3D model which was either 3D printed, visualized in AR, or viewed in 3D on a 2D computer monitor. 3D uro-oncologic models were created from the medical imaging data. A 5-point Likert scale survey was administered to patients prior to the surgical procedure to determine understanding of the cancer and treatment plan. If randomized to receive a pre-operative 3D model, the survey was completed twice, before and after viewing the 3D model. In addition, the cohort that received 3D models completed additional questions to compare usefulness of the different forms of visualization of the 3D models. Survey responses for each of the 3D model groups were compared using the Mann-Whitney and Wilcoxan rank-sum tests. RESULTS:All 200 patients completed the survey after reviewing their cases with their surgeons using imaging only. 127 patients completed the 5-point Likert scale survey regarding understanding of disease and surgical procedure twice, once with imaging and again after reviewing imaging plus a 3D model. Patients had a greater understanding using 3D printed models versus imaging for all measures including comprehension of disease, cancer size, cancer location, treatment plan, and the comfort level regarding the treatment plan (range 4.60-4.78/5 vs. 4.06-4.49/5, p < 0.05). CONCLUSIONS:All types of patient-specific 3D models were reported to be valuable for patient education. Out of the three advanced imaging methods, the 3D printed models helped patients to have the greatest understanding of their anatomy, disease, tumor characteristics, and surgical procedure.

RATIONALE AND OBJECTIVES/OBJECTIVE:This study aimed to characterize articles in popular general radiology journals that go uncited for a decade after publication. METHODS:Using the Web of Science database, we identified annual citation counts for 13,459 articles published in Radiology, American Journal of Roentgenology, and Academic Radiology between 1997 and 2006. From this article cohort, we then identified all original research articles that accrued zero citations within a decade of publication. A concurrent equal-sized cohort of most cited articles was created. Numerous characteristics of the uncited and most cited articles were identified and compared. RESULTS:Only 47 uncited articles went uncited for a decade after publication. When compared to the 47 most cited articles over that same window, the uncited articles were significantly (P < .05) less likely to have a clinical focus, include a nonradiologist author and authors from multiple institutions and multiple nations, report research funding support and statistically significant findings, and include punctuation marks in their titles. Compared to the most cited articles, uncited articles also had significantly (P < .05) fewer authors, abstract words, manuscript words, references, tables, figure parts, and pages, as well as smaller subject sample sizes. CONCLUSION/CONCLUSIONS:Of articles published in popular general radiology journals, only a very small number of original research investigations remained uncited a decade after publication. Given that citations reflect the impact of radiology research, this observation suggests that journals are appropriately selecting meaningful work. Investigators seeking to avoid futile publication might consider their research initiatives in light of these characteristics.

OBJECTIVES/OBJECTIVE:To assess perceived challenges to radiology research and publication by female radiologists, as well as possible strategies for overcoming these challenges. METHODS:An electronic survey was conducted of female nontrainee members of the American Association for Women Radiologists in September and October, 2017. Respondents were recruited by e-mail. Responses were assessed descriptively. RESULTS:The response rate was 31.8% (89/280). 61.4% of respondents were interested in conducting radiology research. 60.2% were expected by their departments to pursue research versus 80.7% expected to pursue educational activities. 56.8% felt that their research success is valued by their department. 47.7% felt that they receive appropriate credit for their research from their departments. 22.7% felt that they receive sufficient time for research. 23.9% felt that their department makes deliberate efforts to support women's research efforts. 41.6% versus 70.8% ever had a female versus a male research mentor, respectively. Among seven provided options, the three items most commonly selected as being most helpful to enhancing research success were dedicated research time (40.4%), personal research mentors (23.6%), and earlier career training in research methodology (21.3%). Additional relevant themes identified by a free-response survey item included: family/child-care issues (n = 5), unconscious bias at the departmental/chair level (n = 5), exclusion of women from research activities by male researchers (n = 2), and concern of being perceived as "aggressive" (n = 2). CONCLUSION/CONCLUSIONS:Initiatives targeting the identified challenges to radiology research could help promote greater diversity and inclusion among radiologist researchers, which in turn has implications for improving the quality of such research.

CONTEXT/BACKGROUND:- In Gleason score GS (7) prostate cancers, the quantity of Gleason pattern 4 (GP 4) is an important prognostic factor and influences treatment decisions. Magnetic resonance imaging (MRI)-targeted biopsy has been increasingly used in clinical practice. OBJECTIVE:- To investigate whether MRI-targeted biopsy may detect GS 7 prostate cancer with greater GP 4 quantity, and whether it improves biopsy/radical prostatectomy GS concordance. DESIGN/METHODS:- A total of 243 paired standard and MRI-targeted biopsies with cancer in either standard or targeted or both were studied, 65 of which had subsequent radical prostatectomy. The biopsy findings, including GS and tumor volume, were correlated with the radical prostatectomy findings. RESULTS:- More prostate cancers detected by MRI-targeted biopsy were GS 7 or higher. Mean GP 4 percentage in GS 7 cancers was 31.0% ± 29.3% by MRI-targeted biopsy versus 25.1% ± 29.5% by standard biopsy. A total of 122 of 218 (56.0%) and 96 of 217 (44.2%) prostate cancers diagnosed on targeted biopsy and standard biopsy, respectively, had a GP 4 of 10% or greater ( P = .01). Gleason upgrading was seen in 12 of 59 cases (20.3%) from MRI-targeted biopsy and in 24 of 57 cases (42.1%) from standard biopsy ( P = .01). Gleason upgrading correlated with the biopsy cancer volume inversely and GP 4 of 30% or less in standard biopsy. Such correlation was not found in MRI-targeted biopsy. CONCLUSIONS:- Magnetic resonance imaging-targeted biopsy may detect more aggressive prostate cancers and reduce the risk of Gleason upgrading in radical prostatectomy. This study supports a potential role for MRI-targeted biopsy in the workup of prostate cancer and inclusion of percentage of GP 4 in the prostate biopsy reports.

PURPOSE/OBJECTIVE:To investigate the national coverage landscape for prostate MRI services, assessing the presence of updated and accurate coverage requirements by private payers. METHODS:The database Policy Reporter was used to evaluate private payer coverage related to prostate MRI for 81 plans covering 149 million people in the United States. Both the indications and requirements for prostate MRI coverage were recorded in a variety of clinical scenarios, including initial diagnosis, staging, active surveillance, and suspected recurrence. RESULTS:Overall, 11.1% of payers cover prostate MRI in biopsy-naïve patients with suspected prostate cancer, with the remaining 88.9% requiring a prior negative biopsy. Nearly all payers also require either a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage. Initial staging is covered by most payers, although typically with stringent indications (eg, PSA ≥ 20 ng/mL, Gleason score ≥7 or 8, stage T3 or T4, or ≥20% risk of nodal metastases). Only 10 payers discuss active surveillance, with 8 of these requiring a repeat biopsy before MRI. Coverage for detection of post-treatment recurrence often requires a rising PSA or abnormal DRE, and occasionally only if a CT is first performed; only 10 of 81 payers address coverage after androgen deprivation treatment. CONCLUSION/CONCLUSIONS:Prostate MRI coverage varies widely among private payers, fails to recognize major clinical scenarios, is overly restrictive, and is often not reflective of current clinical practice. This creates challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.