Faculty Bibliography

PURPOSE/OBJECTIVE:To assess the prevalence of pancreatic cysts on abdominal MRI and identify factors at the examination, patient, and cyst levels associated with prospective reporting. METHODS:In this retrospective single-center study, high-risk individuals (HRIs, per NCCN criteria) and matched average-risk individuals (ARIs) who underwent abdominal MRI from 2018 to 2023 were identified. Pancreatic cysts prospectively documented on original radiology reports were extracted using a validated large language model. MRI examinations without prospectively reported cysts underwent manual image review by three radiology residents to identify additional visible cysts. A composite reference standard combining prospectively reported and retrospectively identified cysts was used to assess overall cyst prevalence. Patient-, cyst-, and examination-level factors associated with prospective reporting were evaluated using univariable and multivariable logistic regression. RESULTS:The final cohort included 942 patients (314 HRIs, 579 female, mean age 61 ± 10.4 years). Using the composite reference standard, cyst prevalence was 47.9% (451/942), compared with 32.4% (305/942) based on original radiology reports alone. Among the cyst-positive patients identified by the composite reference standard, nearly one-third (32.3%, 146/451) had cysts that were not prospectively reported. Cyst reporting was associated with older age, pancreas-related indication, and larger cyst size: 44.3% of cysts < 5 mm, 77.8% of cysts 5-10 mm, and 95.5% of cysts ≥ 10 mm were reported. HRI status was associated with higher prevalence on unadjusted analysis (OR 1.57 [1.20-2.07], p = 0.001) but not after adjustment for diagnostic-quality MRCP availability (aOR 1.10 [0.82-1.49], p = 0.515). CONCLUSION/CONCLUSIONS:Pancreatic cysts are common but frequently unreported, particularly when < 5 mm. Reporting is associated with indication, cyst size, and age.

PURPOSE/OBJECTIVE:To evaluate radiology-pathology concordance and interobserver agreement of intraductal papillary mucinous neoplasm (IPMN) subtype classification, and to determine whether categorical subtype classification adds value for malignancy risk stratification beyond main pancreatic duct (MPD) features. METHODS:In this single-center retrospective study, 144 consecutive patients who underwent surgical resection of an IPMN between 2005 and 2025 and had preoperative CT or MRI within 6 months of surgery were included. Images were independently reviewed by two blinded radiologists, with discrepancies adjudicated by a third. Adjudicated radiologic subtype classification was used for radiology-pathology concordance, logistic regression, and receiver operating characteristic (ROC) analyses; interobserver agreement was assessed using the independent reader interpretations. Logistic regression and ROC analyses identified predictors of malignancy. RESULTS:Overall radiology-pathology concordance under the radiologic classification was 60.4% (87/144). Among pathologic mixed-type IPMNs, 60.3% (38/63) were classified as branch-duct IPMNs on imaging. Interobserver agreement was moderate for radiologic subtype (κ = 0.509) but excellent for MPD diameter (ICC = 0.909). On multivariable analysis, MPD diameter independently predicted malignancy (aOR, 1.31; 95% CI, 1.12-1.53; p = .001), whereas radiologic subtype was not. MPD diameter outperformed radiologic subtype for discrimination of malignancy (AUC, 0.737 vs. 0.624; p = .001). Adding radiologic subtype to MPD diameter provided no incremental discriminative value for malignancy (AUC, 0.739 vs. 0.737; p = .61). CONCLUSION/CONCLUSIONS:Radiologic IPMN subtype classification demonstrated only modest concordance with pathology and moderate interobserver agreement. MPD diameter demonstrated higher interobserver agreement and superior discrimination for IPMN malignancy risk stratification. These findings suggest that the mixed-type IPMN subtype may not be necessary as a distinct category for malignancy risk stratification, and that greater emphasis on objective MPD measurement may provide a more reproducible and clinically informative approach.

OBJECTIVES/OBJECTIVE:Pancreatic ductal adenocarcinoma (PDAC) screening is recommended for High-Risk Individuals (HRI) with Familial Pancreatic Cancer (FPC) or certain pathogenic germline variants (PGVs). Screening MRI commonly identifies pancreatic cystic lesions (PCLs), but comparative data between HRI and average-risk individuals (ARI) are limited. We aimed to quantify and characterize PCL differences between these groups. METHODS:In this retrospective study, 317 HRI were age-, sex- and race-matched to 634 ARI undergoing MRI/MRCP between 7/2018-9/2024. Demographics, genetic factors, and baseline MRI/MRCP outcomes were analyzed. HRI were classified as FPC or PGV±PDAC family history. Statistical analysis compared: all HRI vs. all ARI; single HRI subgroups vs. matched ARI; single HRI subgroups vs. other HRI. RESULTS:HRIs were more likely to have PCLs than ARIs (50.8% vs. 25.7%, P <0.001). FPC HRI were more likely to have PCLs (54.1% vs. 44.4%, P =0.049) than PGV HRI. However, PCLs in HRI were smaller than in ARI (7.4±5.7 vs. 10.8±12.6 mm; P =0.002). HRI and ARI did not differ regarding worrisome feature prevalence. No solid lesions were observed. CONCLUSIONS:PCLs are significantly more common among HRI than matched ARI, although typically small and low-risk. Future longitudinal studies should determine whether the higher prevalence of PCLs among HRI translates into increased risk of PCL-derived malignancy or reflects heighted detection on MRI.

PURPOSE/OBJECTIVE:To evaluate the prevalence and clinical relevance of incidental findings detected during pancreatic cyst surveillance and explore their implications for pancreas-focused imaging protocols. METHODS:This single-center retrospective study analyzed abdominal MRI and CT reports for pancreatic cyst surveillance (2005-2025) using a large language model (LLM). Incidental findings were findings unrelated to the clinical indication. Only the earliest surveillance examination per patient was included. Patients were stratified into cyst-only surveillance (cyst-only), cyst surveillance with high-risk pancreatic screening (cyst-HRI), or cyst surveillance with additional clinical indications (cyst-other). Electronic health record (EHR) review evaluated suspected extrapancreatic neoplastic incidental findings and incidental intrapancreatic hyperenhancing lesions. LLM performance was validated against two reviewers in 100 sampled reports. Multivariable logistic regression adjusted for age and sex. RESULTS:6174 patients (mean age, 70.6 ± 12.3 years; 65.7% women) were included; 94.8% underwent MRI. LLM-reviewer agreement was high (Cohen κ = 0.857 and 0.882). Incidental findings were identified in 43.0% of examinations and were predominantly nonneoplastic (98.7%), with most not requiring further action (70.2%). EHR targeted review confirmed 19 extrapancreatic neoplasms, most commonly renal neoplasms (n = 14). Extrapancreatic neoplasms were more frequent in cyst-other than cyst-only patients (14/906 [1.55%] vs. 5/4,822 [0.10%]; aOR, 14.20; 95% CI 5.09-39.61; p < 0.001). No extrapancreatic neoplasms were identified in cyst-HRI patients (0/446; 95% CI 0.00-0.82%). Incidentally detected intrapancreatic hyperenhancing lesions were uncommon (31/6,174, 0.50%); final diagnoses included 25 neuroendocrine tumors and four intrapancreatic splenules. CONCLUSION/CONCLUSIONS:Clinically significant extrapancreatic neoplasms were rare during pancreatic cyst surveillance, particularly among cyst-only and cyst-HRI patients. While this study did not directly assess the diagnostic performance of reduced field-of-view or non-contrast MRI, the low burden of extrapancreatic neoplasms suggests these protocol strategies warrant further evaluation in selected populations.

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:Pancreatic cystic lesions (PCL) commonly undergo surveillance using MRI with MR cholangiopancreatography (MRCP). Our objective is to compare the performance of a single-shot fat-saturated T2-weighted technique with deep-learning reconstruction (DL HASTE-FS) to a conventional T2-weighted Half fourier Single-shot Turbo spin-Echo (HASTE) sequence and to MRCP for the purpose of PCL detection, characterization, and surveillance. METHODS:In this retrospective study, 91 consecutive patients underwent 3T abdominal MRI with MRCP protocol including DL HASTE-FS and conventional HASTE between 8/2/2023 and 10/3/2023. Three abdominal radiologists rated overall and lesion-specific image quality on a 5-point Likert scale, including pancreatic margin and duct sharpness, and PCL conspicuity. A subset of 70 preselected index PCLs were evaluated for cyst features, confidence of diagnosing side-branch IPMN, and suitability of DL HASTE-FS in replacing MRCP for PCL surveillance. RESULTS:DL HASTE-FS received higher scores for pancreatic duct border sharpness (4.1 vs. 3.9; p = .004), pancreatic duct visibility compared to MRCP (2.0 vs. 1.9; p = .04), cyst conspicuity (4.4 vs. 3.9; p < .001), and sharpness of cyst wall and internal septations (4.3 vs. 3.7; p < .001) compared to conventional HASTE. In contrast, conventional HASTE received higher scores for pancreatic margin sharpness (4.2 vs. 3.8; p < .001) and peripancreatic vessel clarity (4.2 vs. 3.4; p < .001). For the 70 preselected index PCLs, readers visualized more PCLs and had higher confidence in diagnosing SB-IPMN on DL HASTE-FS than on conventional HASTE (3.6 vs. 3.4; p < .001). Finally, DL HASTE-FS was deemed a suitable replacement to MRCP for more cases than conventional HASTE (83% vs. 48%; p < .001). CONCLUSION/CONCLUSIONS:DL HASTE-FS outperforms conventional HASTE for PCL detection and characterization, and is a suitable alternative to 3D MRCP in the context of PCL surveillance, potentially reducing exam time and cost.

BACKGROUND/UNASSIGNED:Acute pancreatitis (AP) is a common gastrointestinal disease with a rising global incidence. While most cases are mild, severe AP (SAP) carries high mortality. Early and accurate severity prediction facilitates management optimization. However, existing clinical severity prediction models, such as Bedside Index of Severity in Acute Pancreatitis (BISAP) and Modified CT Severity Index (mCTSI), have modest accuracy and often rely on data unavailable at admission. PURPOSE/UNASSIGNED:This study proposes a deep learning (DL) model to predict AP severity using abdominal contrast-enhanced CT scans acquired within 24 hours of admission. MATERIALS AND METHODS/UNASSIGNED: = 518 patients). RESULTS/UNASSIGNED: = .002). In retrospective triage analysis, the model correctly identified 50%-73% of patients who progressed to SAP and 40%-73% of those with MAP. CONCLUSION/UNASSIGNED:The proposed DL model achieved performance comparable to or better than established prognostic tools and maintained robust external performance. These findings suggest that AI-assisted CT analysis may support early, automated risk stratification of AP.

PURPOSE/OBJECTIVE:To evaluate the association of patient characteristics, community-level social determinants of health, and cyst risk categories with completion of follow-up recommendations for incidental Pancreatic Cystic Lesions (PCLs). METHODS:We retrospectively identified consecutive patients (2013-2023) whose MRI radiology reports described PCLs. A fine-tuned LLaMA-3.1 8B Instruct large language model was used to extract PCL features. Lesions were classified using the 2017 ACR white paper: Category 1 (low risk), Category 2 (worrisome features), or Category 3 (high-risk stigmata). We recorded demographics and follow-up imaging or endoscopic ultrasound dates. Community-level factors were characterized by the 2020 CDC Social Vulnerability Index (SVI), stratified into quartiles. The primary outcome, "inappropriate follow-up," combined late and no follow-up. Multivariable binomial regression was applied to evaluate associations with inappropriate follow-up. RESULTS:In 7,745 patients (mean age 66.3 years; 4,796 women), 92.9% (7,198/7,745) of cysts were Category 1, 6.4% (498/7,745) were Category 2, and 0.6% (49/7,745) were Category 3. Only 36.3% of patients completed appropriate follow-up, 12.1% were late, and 51.6% were lost to follow-up. Inappropriate follow-up was high in every cyst category: 64.2% in Category 1, 59.4% in Category 2 and 49.0% in Category 3. In multivariable analysis, non-English primary language (RR 1.08; 95% CI, 1.02-1.14) and residing in more vulnerable communities of the 3rd quartiles of the socioeconomic Social Vulnerability Index subcategory (RR 1.07; 95% CI, 1.02-1.12) were associated with inappropriate follow-up. Higher age-adjusted Charlson Comorbidity Index (CCI ≥ 4) (RR .84; 95% CI, .79-.88), CCI 2-3 (RR .84; 95% CI, .79-.88), and higher-risk cysts in patients under 65 years of age (RR .76; 95% CI, .65-.89) were associated with completed follow-up. CONCLUSION/CONCLUSIONS:Follow-up completion for incidental PCLs was low. Factors most consistently associated with follow-up completion were language barriers, residence in socioeconomically vulnerable communities, age-adjusted CCI and higher-risk features among those under 65 years.

Background MR enterography (MRE) is increasingly used to guide treatment and improve outcomes in Crohn disease (CD). An abbreviated MRE (A-MRE) protocol-omitting contrast and antiperistaltic agents-may reduce scanning time and cost and improve compliance. Purpose To compare intrareader concordance and interreader agreement in detecting disease activity and disease-related complications using contrast-enhanced MRE (CE-MRE) versus an A-MRE protocol in participants with CD. Materials and Methods In this secondary analysis of a prospective study, 10 abdominal radiologists independently reviewed MRE examinations from a prospective study of participants with CD before and after treatment with biologics, using both A-MRE and CE-MRE protocols, at least 1 month apart. Interreader agreement and intrareader concordance were assessed using Gwet first agreement coefficient (AC1) at both the segment and participant levels for the presence of active inflammation, associated indicative features, and complications. Diagnostic accuracy of the simplified MR index of activity (sMaRIA) was evaluated against ileocolonoscopy when available. Results This study included 60 participants (median age, 36 years [IQR, 28-44 years]; 40 female; 80 examinations). Interreader agreement for detecting intestinal active disease was high and comparable between A-MRE and CE-MRE at the participant level (AC1, 0.87 [95% CI: 0.79, 0.95] vs 0.91 [95% CI: 0.85, 0.97]). For strictures, similar interreader agreement was observed between protocols (AC1: A-MRE, 0.61 [95% CI: 0.47, 0.74] vs CE-MRE, 0.50 [95% CI: 0.35, 0.65]). For penetrating complications, the interreader agreement was also similar between protocols (A-MRE, 0.71 [95% CI: 0.56, 0.86] vs CE-MRE, 0.76 [95% CI: 0.63, 0.90]). The intrareader concordance between protocols for detecting active inflammation and CD complications was almost perfect for all readers (AC1 range, 0.86-1.00). In the terminal ileum, sMaRIA showed high sensitivity (A-MRE, 96.4%; CE-MRE, 98.4%) and specificity (A-MRE, 68.1%; CE-MRE, 71.4%) for detecting inflammation. Conclusion An A-MRE protocol demonstrated comparable interreader agreement to conventional CE-MRE and high intrareader concordance for detecting active CD and related complications in participants with CD. © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Ohliger in this issue.