Faculty Bibliography

Chronic pelvic pain, which persists longer than 6 months by definition, is a common condition which affects women of all ages with causes differing by age group. This document will focus on gynecologic origins of chronic pelvic pain, etiologies including chronic pelvic inflammatory disease, postsurgical changes, vaginal or vulvar cysts, and pelvic venous congestion disorder. Ultrasound is the initial imaging modality of choice with MRI or CT of the pelvis may be used in select cases when initial ultrasound is inconclusive. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Infertility is defined as the inability to conceive spontaneously after 12 months of routinely unprotected intercourse in patients <35 years of age, and after 6 months in patients ≥35 years of age. Infertility also refers to the inability to achieve a successful pregnancy based on the medical, sexual, and reproductive history; age, physical findings; diagnostic testing; the need for medical intervention; or a combination of these variables for a patient. In the United States, 13% of women 15 to 49 years of age have accessed assisted fertility services and it has been suggested that the rate of infertility has been increasing, without geographic bias. Understanding the initial imaging evaluation is essential to this often complex and/or multifaceted clinical circumstance, which may involve the ovaries, uterus, and fallopian tubes. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

OBJECTIVE:To describe the imaging appearances and treatment response patterns of the pancreatic neuroendocrine tumors (panNETs) following radiofrequency ablation (RFA). METHODS:From an internal database, 17 patients (8 male; mean age: 67±14 y) with 18 pathology-proven, localized, nonfunctioning panNETs <3 cm who underwent EUS-RFA for curative intent were included. A total of 32 preablation and 33 postablation scans were included (CT, MRI, or 68Ga-DOTATATE PET). Lesion size and enhancement on CT/MRI were independently assessed by 2 readers, while SUVmax was extracted from the original PET reports by a separate reviewer. The Wilcoxon signed-rank and McNemar tests were performed. Treatment response is defined as a complete response (loss of enhancement and SUVmax), a partial response (decrease in size, enhancement, or SUVmax), or no response (no change). RESULTS:Mean lesion size decreased from 1.4​​​​​​±0.5​ cm preablation to 0.3±0.5 cm postablation (P<0.0001). Mean SUVmax declined from 17.3±11.2 to 3.1±6.0 (P<0.001). Hyperenhancement was present in 15/18 (83.3%) lesions preablation versus 5/18 (27.8%) postablation (P<0.01). Of these 15 hyperenhancing lesions, 11 were solid, 3 were cystic, and 1 was mixed cystic and solid. Complete response occurred in 12/18 (66.7%) lesions, with either complete disappearance 5/12 (41.4%) or bland cavity formation 7/12 (58.5%). Partial response occurred in 5/18 (27.8%) lesions; 4/5 decreased in size (mean±SD: 1.4±0.5 cm preablation vs. 0.6±0.7 cm postablation), and 3/5 demonstrated decreased SUVmax. One patient with partial response underwent 2 repeat ablations with an ultimate decrease in SUVmax from 34.1 to 5.9. One solid, hyperenhancing pancreatic body lesion demonstrated no response (1.3 cm); preablation SUVmax was 10.8, but they did not undergo postablation DOTATATE PET. One patient developed postablation pancreatitis. Mean clinical follow-up was 650 days (423). CONCLUSION/CONCLUSIONS:RFA is an emerging treatment for small, nonfunctioning panNET. Postablation imaging findings most commonly included complete resolution of the tumor, decreased enhancement, decreased SUVmax, and formation of a bland cavity. As interest in this technique continues to grow, radiologists' familiarity with expected post-treatment imaging appearances and their associated response patterns is essential for accurate assessment.

PURPOSE/OBJECTIVE:Retrospectively compare image quality, radiologist diagnostic confidence, and time for images to reach PACS for contrast enhanced abdominopelvic CT examinations created on the scanner console by technologists versus those generated automatically by thin-client artificial intelligence (AI) mechanisms. METHODS:A retrospective PACS search identified adults who underwent an emergency department contrast-enhanced abdominopelvic CT in 07/2022 (Console Cohort) and 07/2023 (Server Cohort). Coronal and sagittal multiplanar reformatted images (MPR) were created by AI software in the Server cohort. Time to completion of MPR images was compared using 2-sample t-tests for all patients in both cohorts. Two radiologists qualitatively assessed image quality and diagnostic confidence on 5-point Likert scales for 50 consecutive examinations from each cohort. Additionally, they assessed for acute abdominopelvic findings. Continuous variables and qualitative scores were compared with the Mann-Whitney U test. A p < .05 indicated statistical significance. RESULTS:Mean[SD] time to exam completion in PACS was 8.7[11.1] minutes in the Console cohort (n = 728) and 4.6[6.6] minutes in the Server cohort (n = 892), p < .001. 50 examinations in the Console Cohort (28 women 22 men, 51[19] years) and Server cohort (27 women 23 men, 57[19] years) were included for radiologist review. Age, sex, CTDlvol, and DLP were not statistically different between the cohorts (all p > .05). There was no significant difference in image quality or diagnostic confidence for either reader when comparing the Console and Server cohorts (all p > .05). CONCLUSION/CONCLUSIONS:Examinations utilizing AI generated MPRs on a thin-client architecture were completed approximately 50% faster than those utilizing reconstructions generated at the console with no statistical difference in diagnostic confidence or image quality.

Endometriosis is a common condition impacting individuals assigned female at birth. Though incompletely understood, the disorder is caused by endometrial-like tissue located outside of the endometrial cavity, associated with inflammation and fibrosis. Clinical presentation is variable, ranging from asymptomatic to severe pelvic pain and infertility. Treatment is determined by the patient's individualized goals and can include medical therapies to temporize symptoms or definitive surgical excision. Imaging is used to help diagnose endometriosis and for treatment planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

OBJECTIVE:The aim of this study was to compare portal venous phase photon-counting CT (PCCT) using 20 cc less than weight-based contrast dosing with energy-integrating detector CT (EID-CT) using weight-based dosing by quantitative and qualitative analysis. METHODS:Fifty adult patients who underwent a reduced intravenous contrast dose portal venous phase PCCT from May 1, 2023, to August 10, 2023, and a prior portal-venous EID-CT with weight-based contrast dosing were retrospectively identified. Hounsfield units (HU) and noise (SD of HU) were obtained from region-of-interest measurements on 70-keV PCCT and EID-CT in 4 hepatic segments, the main and right portal vein, and both paraspinal muscles. Signal-to-noise and contrast-to-noise ratios were computed. Three abdominal radiologists qualitatively assessed overall image quality, hepatic enhancement, and confidence for metastasis identification on 5-point Likert scales. Readers also recorded the presence/absence of hepatic metastases. Quantitative variables were compared with paired t tests, and multiple comparisons were accounted for with a Bonferroni-adjusted α level of .0016. Ordinal logistic regression was used to evaluate qualitative assessments. Interreader agreement for hepatic metastases was calculated using Fleiss' κ. RESULTS:Fifty patients (32 women; mean [SD] age, 64 [13] years) were included. There was no significant difference in hepatic HU, portal vein HU, noise, and signal-to-noise or contrast-to-noise ratio between reduced contrast dose portal venous phase PCCT versus EID-CT (all Ps > 0.0016). Image quality, degree of hepatic enhancement, and confidence for metastasis identification were not different for reduced dose PCCT 70-keV images and EID-CT (P = 0.06-0.69). κ Value for metastasis identification was 0.86 (95% confidence interval, 0.70-1.00) with PCCT and 0.78 (95% confidence interval, 0.59-0.98) with EID-CT. CONCLUSION/CONCLUSIONS:Reduced intravenous contrast portal venous phase PCCT 70-keV images had similar attenuation and image quality as EID-CT with weight-based dosing. Metastases were identified with near-perfect agreement in reduced dose PCCT 70-keV images.

OBJECTIVE:The aim of the study is to evaluate the performance of the ovarian-adnexal reporting and data system magnetic resonance imaging (O-RADS MRI) score and perform individual MRI feature analysis for differentiating between benign and malignant ovarian teratomas. METHODS:In this institutional review board-approved retrospective study, consecutive patients with a pathology-proven fat-containing ovarian mass imaged with contrast-enhanced MRI (1.5T or 3T) from 2013 to 2022 were included. Two blinded radiologists independently evaluated masses per the O-RADS MRI lexicon, including having a "characteristic" or "large" Rokitansky nodule (RN). Additional features analyzed included the following: nodule size/percentage volume relative to total teratoma volume, presence of bulk/intravoxel fat in the nodule, diffusion restriction in the nodule, angular interface, nodule extension through the teratoma border, presence/type of nodule enhancement pattern (solid versus peripheral), and evidence for metastatic disease. An overall O-RADS MRI score was assigned. Patient and lesion features associated with malignancy were evaluated and used to create a malignant teratoma score. χ2, Fisher's exact tests, receiver operating characteristic curve, and κ analysis was performed. RESULTS:One hundred thirty-seven women (median age 34, range 9-84 years) with 123 benign and 14 malignant lesions were included. Mean teratoma size was 7.3 cm (malignant: 14.4 cm, benign: 6.5 cm). 18/123 (14.6%) of benign teratomas were assigned an O-RADS 4 based on the presence of a "large" (11/18) or "noncharacteristic" (12/18) RN. 12/14 malignant nodules occupied >25% of the total teratoma volume (P = 0.09). Features associated with malignancy included the following: age <18 years, an enhancing noncharacteristic RN, teratoma size >12 cm, irregular cystic border, and extralesional extension; these were incorporated into a malignant teratoma score, with a score of 2 or more associated with area under the curve of 0.991 for reviewer 1 and 0.993 for reviewer 2. Peripheral enhancement in a RN was never seen with malignancy (64/123 benign, 0/14 malignant) and would have appropriated downgraded 9/18 overcalled O-RADS 4 benign teratomas. CONCLUSIONS:O-RADS MRI overcalled 15% (18/123) benign teratomas as O-RADS 4 but correctly captured all malignant teratomas. We propose defining a "characteristic" RN as an intravoxel or bulk fat-containing nodule. Observation of a peripheral rim of enhancement in a noncharacteristic RN allowed more accurate prediction of benignity and should be added to the MRI lexicon for improved O-RADS performance.

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.