Standardization of MRI Screening and Reporting in Individuals With Elevated Risk of Pancreatic Ductal Adenocarcinoma: Consensus Statement of the PRECEDE Consortium
Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignancies, with a dismal survival rate. Screening the general population for early detection of PDAC is not recommended, but because early detection improves survival, high-risk individuals, defined as those meeting criteria based on a family history of PDAC and/or the presence of known pathogenic germline variant genes with PDAC risk, are recommended to undergo screening with MRI and/or endoscopic ultrasound at regular intervals. The Pancreatic Cancer Early Detection (PRECEDE) Consortium was formed in 2018 and is composed of gastroenterologists, geneticists, pancreatic surgeons, radiologists, statisticians, and researchers from 40 sites in North America, Europe, and Asia. The overarching goal of the PRECEDE Consortium is to facilitate earlier diagnosis of PDAC for high-risk individuals to increase survival of the disease. A standardized MRI protocol and reporting template are needed to enhance the quality of screening examinations, improve consistency of clinical management, and facilitate multiinstitutional research. We present a consensus statement to standardize MRI screening and reporting for individuals with elevated risk of pancreatic cancer.
Diagnostic abdominal MR imaging on a prototype low-field 0.55Â T scanner operating at two different gradient strengths
PURPOSE:To develop a protocol for abdominal imaging on a prototype 0.55Â T scanner and to benchmark the image quality against conventional 1.5Â T exam. METHODS:In this prospective IRB-approved HIPAA-compliant study, 10 healthy volunteers were recruited and imaged. A commercial MRI system was modified to operate at 0.55Â T (LF) with two different gradient performance levels. Each subject underwent non-contrast abdominal examinations on the 0.55Â T scanner utilizing higher gradients (LF-High), lower adjusted gradients (LF-Adjusted), and a conventional 1.5Â T scanner. The following pulse sequences were optimized: fat-saturated T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and Dixon T1-weighted imaging (T1WI). Three readers independently evaluated image quality in a blinded fashion on a 5-point Likert scale, with a score of 1 being non-diagnostic and 5 being excellent. An exact paired sample Wilcoxon signed-rank test was used to compare the image quality. RESULTS:Diagnostic image quality (overall image quality score â‰¥â€‰3) was achieved at LF in all subjects for T2WI, DWI, and T1WI with no more than one unit lower score than 1.5Â T. The mean difference in overall image quality score was not significantly different between LF-High and LF-Adjusted for T2WI (95% CI -Â 0.44 to 0.44; pâ€‰=â€‰0.98), DWI (95% CI -Â 0.43 to 0.36; pâ€‰=â€‰0.92), and for T1 in- and out-of-phase imaging (95%C I -Â 0.36 to 0.27; pâ€‰=â€‰0.91) or T1 fat-sat (water only) images (95% CI -Â 0.24 to 0.18; pâ€‰=â€‰1.0). CONCLUSION:Diagnostic abdominal MRI can be performed on a prototype 0.55Â T scanner, either with conventional or with reduced gradient performance, within an acquisition time of 10Â min or less.
ACR Appropriateness CriteriaÂ® Staging and Follow-up of Primary Vaginal Cancer
Primary vaginal cancer is rare, comprising 1% to 2% of gynecologic malignancies and 20% of all malignancies involving the vagina. More frequently, the vagina is involved secondarily by direct invasion from malignancies originating in adjacent organs or by metastases from other pelvic or extrapelvic primary malignancies. Data on the use of imaging in vaginal cancer are sparse. Insights are derived from the study of imaging in cervical cancer and have reasonable generalizability to vaginal cancer due to similar tumor biology. Given the trend toward definitive chemoradiation for both cancers in all but early stage lesions, principles of postchemoradiation tumor response evaluation are largely analogous. Accordingly, many of the recommendations outlined here are informed by principles translated from the literature on cervical cancer. For pretreatment assessment of local tumor burden and in the case of recurrent vaginal cancer, MRI is the preferred imaging modality. PET/CT has demonstrated utility for the detection of nodal metastatic and unexpected distant metastatic disease. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Reporting Templates for Magnetic Resonance Imaging and Water Soluble Contrast Enema in Patients with Ileal Pouch Anal Anastomosis: Experience from a Large Referral Center
Ileal pouch anal anastomosis (IPAA) is gold standard surgical procedure for treatment of ulcerative colitis and majority of patients with familial adenomatous polyposis. This procedure allows preservation of fecal continence and gastrointestinal continuity. However, it is associated with a wide variety of complications, which often have nonspecific and overlapping clinical presentations, making imaging an important part of work up for pouch dysfunction. The purpose of this article is to propose structured reporting templates for Magnetic Resonance Imaging (MRI) and Water Soluble Contrast Enema (WSCE) in IPAA patients based on our referral pouch center's experience. Included will be a review of salient surgical technique, pouch anatomy and imaging protocols, with an emphasis on systematic search pattern for evaluation of ileal pouch complications using proposed structured reporting MRI and WSCE templates.
ACR Appropriateness CriteriaÂ® Staging and Follow-up of Vulvar Cancer
Vulvar cancer is an uncommon gynecologic tumor and one of several human papillomavirus-associated malignancies. Squamous cell carcinoma is the most prevalent histologic subtype of vulvar cancer, accounting for the majority of cases. Imaging plays an important role in managing vulvar cancer. At initial diagnosis, imaging is useful to assess the size and extent of primary tumor and to evaluate the status of inguinofemoral lymph nodes. If recurrent disease is suspected, imaging is essential to demonstrate local extent of tumor and to identify lymph node and distant metastases. In this publication, we summarize the recent literature and describe the panel's recommendations about the appropriate use of imaging for various phases of patient management including initial staging, surveillance, and restaging of vulvar cancer. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: recommendations for Standardized Imaging and Reporting from the Society of Abdominal Radiology IPMN disease focused panel
There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and recommendations for imaging follow-up of diagnosed or presumed IPMN. However, there is no consensus on several practical aspects of imaging IPMN that could serve as a clinical guide for radiologists and enable future data mining for research. These aspects include how to measure IPMN, define reporting terminology, standardize reporting and unify guidelines for surveillance. The Society of Abdominal Radiology (SAR) created multiple Disease-Focused Panels (DFP) comprised multidisciplinary panel members who focus on a particular disease, with the goal to develop ways for radiologists to improve patient care, education, and research. DFP members met to identify the current controversies and limitations of imaging pancreatic IPMN. This paper aims to provide a practical review of the key imaging characteristics of IPMN for trainees and practicing radiologists, to guide uniformity of performance and interpretation of surveillance imaging studies, and to improve communication with clinicians by providing a lexicon and reporting template based on the experience of the SAR-DFP panel members.
MRI of Perianal Crohn Disease: Technique and Interpretation
ABSTRACT/UNASSIGNED:Magnetic resonance imaging (MRI) has emerged as the imaging method of choice for evaluation of perianal fistulizing disease. As treatment of Crohn disease and associated perianal fistulas has evolved to include a combination of systemic treatments and surgical interventions, perianal MRI provides critical information to guide treatment selection and timing. Radiologists need to be familiar with the normal regional anatomy to accurately describe perianal fistulas and any associated complications which can then be used to classify fistulas based on several available classification systems. Following treatment, MRI can provide information that suggests treatment success or failure. We propose a perianal fistula reporting template that includes the necessary information to convey fistula complexity, guide treatment, and evaluate treatment response. This review article will also discuss the postoperative appearance of many treatments currently used for management of perianal fistulizing disease and some associated complications.
MR Enterography of Complicated Crohn Disease: Stricturing and Penetrating Disease
ABSTRACT/UNASSIGNED:Stricturing and penetrating disease are complications of Crohn disease (CD) that significantly affect patient outcomes. Careful evaluation for such complications is critical to the interpretation of magnetic resonance enterography. This manuscript outlines the key findings related to stricturing and penetrating CD and discusses current understanding of the pathophysiology and prognosis of complicated CD based on the literature.
Response assessment of hepatocellular carcinoma treated with yttrium-90 radioembolization: inter-reader variability, comparison with 3D quantitative approach, and role in the prediction of clinical outcomes
OBJECTIVES/OBJECTIVE:To assess the inter-reader variability in response assessment for HCC treated with radioembolization (TARE) compared with 3D quantitative criteria (qEASL); and to evaluate their role in prediction of pathological necrosis and clinical outcomes. MATERIALS AND METHODS/METHODS:57 patients with 77 HCCs who underwent TARE were included. Five radiologists recorded multiple imaging features and assigned mRECIST/LIRADS Treatment Response (TR) categories on post-treatment MRI at 4-6 weeks and 6-9 months after TARE. qEASL categories were assigned by a separate reader. Inter-reader variability between LIRADS TR/mRECIST/qEASL were evaluated and hazards regression was used in predicting clinical outcomes. RESULTS:Inter-reader agreement was fair for mRECIST (Kâ€¯=â€¯0.43 and 0.34 at first and second follow-up respectively); moderate for LIRADS TR (Kâ€¯=â€¯0.48 and 0.53 at first and second follow-up respectively). Inter-criterion agreement was moderate to substantial (râ€¯=â€¯0.41-0.65 and râ€¯=â€¯0.54-0.60 at first and second follow-up) for mRECIST-qEASL. LIRADS TR correlated well with qEASL for all readers at both follow-ups (Kâ€¯=â€¯0.45-0.78; Kâ€¯=â€¯0.39-0.77 for first and second follow-up). qEASL was the most accurate in predicting Tumor-Free Survival (TFS) on first (HR 2.23 [1.44-3.46], pâ€¯<â€¯0.001) and second (HR 1.69 [1.15-2.48], pâ€¯=â€¯0.008) follow-up. LIRADS TR was the most accurate in predicting histopathological necrosis (8 patients underwent liver transplantation and 1 patient underwent tumor resection during the period of the study). CONCLUSIONS:HCC response assessment following TARE is challenging, resulting in poor to moderate inter-reader agreement for mRECIST, and moderate inter-reader agreement for LIRADS TR response assessment criteria. qEASL outperformed mRECIST criteria for early identification of responders and predicting TFS, suggesting an advantage in volumetric tumor response assessment. LIRADS TR outperformed other criteria in predicting pathological necrosis.
Retrospective analysis of the effect of limited english proficiency on abdominal MRI image quality
PURPOSE/OBJECTIVE:To evaluate the effect of English proficiency on abdominal MRI imaging quality. METHODS:Three equal-sized cohorts of patients undergoing 3T abdominal MRI were identified based on English proficiency as documented in the EMR: Primary language of English; English as a second language (ESL)/no translator needed; or ESL, translator needed (42 patients per cohort for total study size of 126 patients). Three radiologists independently used a 1-5 Likert scale to assess respiratory motion and image quality on turbo spin-echo T2WI and post-contrast T1WI. Groups were compared using Kruskal-Wallis tests. RESULTS:For T2WI respiratory motion, all three readers scored the Translator group significantly worse than the English and ESL/no-Translator groups (mean scores across readers of 2.98 vs. 3.58 and 3.51; p valuesâ€‰<â€‰0.001-0.008). For T2WI overall image quality, all three readers also scored the Translator group significantly worse than the English and ESL/no-Translator groups (2.77 vs. 3.28 and 3.31; p values 0.002-0.005). For T1WI respiratory motion, mean scores were not significantly different between groups (English: 4.14, ESL/no-Translator: 4.02, Translator: 3.94; p values 0.398-0.597). For T1WI overall image quality, mean scores also were not significantly different (4.09, 3.99, and 3.95, respectively; p values 0.369-0.831). CONCLUSION/CONCLUSIONS:Abdominal MR examinations show significantly worse T2WI respiratory motion and overall image quality when requiring a translator, even compared with non-translator exams in non-English primary language patients. Strategies are warranted to improve coordination among MR technologists, translators, and non-English speaking patients undergoing abdominal MR, to ensure robust image quality in this vulnerable patient population.