The Impact of Patient-Initiated Subspecialty Review on Patient Care

PurposeTo determine the effect of subspecialty review of breast imaging on patients without a diagnosis of breast cancer who self-referred for a second opinion.MethodsInstitutional review board–approved retrospective review was performed of 415 breast imaging studies submitted to our cancer center for second-opinion review by 245 patients in 2014, excluding cases without follow-up or change in original BI-RADS 0 assessment. One hundred forty-seven patients with 176 lesions were included. Original and second-opinion interpretations and recommendations were compared with histopathology or follow-up imaging.ResultsNinety-six of 176 (55%) lesions were reported as suspicious in the original interpretation. Second-opinion review was discordant with the original interpretation in 82 of 176 (47%) lesions. Second-opinion review downgraded 24 of 96 (25%) lesions originally reported as suspicious to benign or probably benign, averting biopsy of these lesions. Second-opinion review upgraded 31 of 80 (39%) lesions originally reported as benign or probably benign to suspicious. A total of 87 lesions were biopsied yielding malignancy in 23 (26%) biopsies. Twenty-eight of 87 (32%) biopsies performed were recommended after second-opinion review, with 8 of 28 (29%) of these biopsies yielding cancer. Eight of 23 (35%) cancers detected represented malignancy not initially detected in the original interpretation.ConclusionSecond-opinion review is valuable in patients pursuing a breast imaging specialist’s opinion, even before they are diagnosed with breast cancer. Second-opinion review disagreed with the original interpretation for 47% of lesions, averted 25% of originally recommended biopsies, and detected cancer in 29% of additional biopsies recommended. Thirty-five percent of cancers diagnosed after second-opinion review were not initially detected in the original interpretation.     

Procedural Impact of a Dedicated Interventional Oncology Service Line in a National Cancer Institute Comprehensive Cancer Center

PurposeWe tested the hypothesis that establishing a dedicated interventional oncology (IO) clinical service line would increase clinic visits and procedural volumes at a single quaternary care academic medical center.MethodsTwo time periods were defined: July 2012 to June 2013 (pre-IO clinic) and July 2013 to June 2014 (first year of dedicated IO service). Staff was recruited, and clinic space was provided in the institution’s comprehensive cancer center. Clinic visits and procedure numbers were documented using the institution’s electronic medical record and billing forms. IO procedures included were transarterial chemoembolization, Y-90 radioembolization, perfusion mapping for Y-90, portal vein embolization, and bland embolization. We compared changes in clinic visit and procedure numbers using paired t tests. Changes after IO initiation were compared to 1-year changes in the Medicare 5% Limited Data Set by cross-referencing Current Procedure Terminology and International Classification of Diseases codes in 2012 and 2013.ResultsClinic visits increased from 9 to 204 (P = .003, t = 8.89, df = 3). Procedures increased from 60 to 239 (P = .018, t = 3.85, df = 4). Procedural volumes increased at least 150% for each subtype. The volumes in the 5% Limited Data Set did not change significantly over the 2-year period (443 to 385, P > .05).ConclusionsThe establishment of a dedicated IO service significantly increased clinic visits and procedural volumes. National trends were unchanged, suggesting that the impact of our program was not part of a sudden increase of IO procedures.     

Diagnostic Accuracy of Neuroimaging to Delineate Diffuse Gliomas within the Brain: A Meta-Analysis

BACKGROUND:Brain imaging in diffuse glioma is used for diagnosis, treatment planning, and follow-up.PURPOSE:In this meta-analysis, we address the diagnostic accuracy of imaging to delineate diffuse glioma.DATA SOURCES:We systematically searched studies of adults with diffuse gliomas and correlation of imaging with histopathology.STUDY SELECTION:Study inclusion was based on quality criteria. Individual patient data were used, if available.DATA ANALYSIS:A hierarchic summary receiver operating characteristic method was applied. Low- and high-grade gliomas were analyzed in subgroups.DATA SYNTHESIS:Sixty-one studies described 3532 samples in 1309 patients. The mean Standard for Reporting of Diagnostic Accuracy score (13/25) indicated suboptimal reporting quality. For diffuse gliomas as a whole, the diagnostic accuracy was best with T2-weighted imaging, measured as area under the curve, false-positive rate, true-positive rate, and diagnostic odds ratio of 95.6%, 3.3%, 82%, and 152. For low-grade gliomas, the diagnostic accuracy of T2-weighted imaging as a reference was 89.0%, 0.4%, 44.7%, and 205; and for high-grade gliomas, with T1-weighted gadolinium-enhanced MR imaging as a reference, it was 80.7%, 16.8%, 73.3%, and 14.8. In high-grade gliomas, MR spectroscopy (85.7%, 35.0%, 85.7%, and 12.4) and ¹¹C methionine–PET (85.1%, 38.7%, 93.7%, and 26.6) performed better than the reference imaging.LIMITATIONS:True-negative samples were underrepresented in these data, so false-positive rates are probably less reliable than true-positive rates. Multimodality imaging data were unavailable.CONCLUSIONS:The diagnostic accuracy of commonly used imaging is better for delineation of low-grade gliomas than high-grade gliomas on the basis of limited evidence. Improvement is indicated from advanced techniques, such as MR spectroscopy and PET.

Diffuse gliomas are the most common primary brain tumors in adults, with an annual incidence of approximately 6 per 100,000. Despite advances in neurosurgery, radiation therapy, and chemotherapy, gliomas are fatal.¹ Brain imaging is indispensable for diagnosis, treatment planning, evaluation, and follow-up. Although imaging standards to plan resection and radiation therapy vary between institutions and specialists, conventional imaging is in common use, typically consisting of T1-weighted MR imaging before and after gadolinium and T2/FLAIR-weighted imaging for gliomas. Of these conventional sequences, T2/FLAIR-weighted imaging is often considered as a reference for low-grade gliomas, and T1-weighted gadolinium-enhanced imaging, for high-grade gliomas in neurosurgical planning, combined with T2-weighted imaging in radiation therapy planning.^2,3Compared with other cancer types, accurate delineation of gliomas within the brain for treatment planning is particularly important due to the proximity of eloquent brain structures, which are vulnerable to surgery and radiation therapy.⁴ Conversely, more extensive resections and boosted radiation therapy correlate with longer survival.^5–7 At the same time, clinical observations challenge the diagnostic accuracy of current imaging protocols: Gliomas recur even after a radiologically complete resection,^8,9 and glioma cells have been detected outside MR imaging abnormalities.^10,11 Brain imaging techniques, such as multivoxel spectroscopy and PET, were developed to improve tumor grading and delineation.^12,13Inherent in any regional treatment, such as surgery and radiation therapy, is the need to delineate a target volume, which mandates a dichotomous classification into tumor and normal tissue. Low- and high-grade gliomas have different treatment strategies and prognosis, while both are characterized by diffuse tumor infiltration. This supports our pooled analysis for diffuse glioma in addition to subgroup analysis by glioma grade. More accurate glioma delineation may improve the consistency between treatment results and survival. For instance, more accurate delineation may serve to identify patients eligible for more aggressive surgery than would have been considered on the basis of conventional imaging and may identify patients with glioma infiltration beyond meaningful surgical therapy so that useless and possibly harmful resections can be avoided.The diagnostic accuracy of imaging techniques to delineate gliomas has not been systematically addressed, to our knowledge. In this meta-analysis, we estimate and compare the diagnostic accuracies of conventional imaging techniques and advanced MR imaging and PET to delineate newly diagnosed diffuse gliomas within brain tissue in adults.     

Neuroimaging findings in a suprasellar granular cell tumor

A 27-year-old woman presented with a history of amenorrhea, visual disturbance, and diabetes insipidus. Magnetic resonance imaging showed a large enhancing suprasellar mass with associated edema involving the left striatum. The lesion was hypometabolic on fluorodeoxyglucose-positron emission tomography. At surgery, a subtotal resection of a vascular tumor that appeared to arise from the posterior pituitary and hypothalamus was carried out. Pathologic examination revealed a granular cell tumor. We report the preoperative neuroimaging findings in this rare posterior pituitary stalk tumor.     

Magnetic Resonance Imaging Technologist Breast Subspecialty Program; a Quality Improvement Project Gone Right

We describe a Lean based Quality Improvement Project (QIP) to improve the defect rate of breast magnetic resonance imaging (MRI) studies by developing a MRI Technologist Breast Sub-specialization Program. Key stakeholders (physician and technologist) drove the QIP. Both the overall defect rate and the callback rate (severe defects requiring patients return for repeat imaging) were measured over a 2-month period as 17% and 6%, respectively. Lean visualization tools of Pareto Chart & Fishbone Diagram identified lack of multiple trends, but discerned that most defect causes were within the responsibility of the technologists. Lean Value Stream Map identified technologists' useless work (muda), which was subsequently eliminated. Radiologists collectively defined what made a quality study in a Quality Checklist. Key stakeholders limited the number of technologists based on the study volume (50 studies/technologist/2 years) and reviewed 5 studies recently performed by each technologist. If all 5 studies were defect free per the Quality Checklist, then the technologist was certified to perform breast MRI's by himself/herself. Otherwise, the technologist was on probation. Key stakeholders selected SuperTechs with advanced skill and interest from the certified pool to cover all shifts. Technologists on probation had to complete 5 additional studies defect-free under the supervision of a SuperTech to achieve certification. In addition, SuperTechs were available to backup certified technologists, as needed. Software was implemented at the PACS workstation to flag defective and callback studies. 6 months after the initiation of the QIP, the defect rate decreased from 17% to 2% (p>0.02), and the callback rate decreased from 6% to 0, thus confirming this MRI Breast Program was a QIP gone right.     

Neuroimaging findings in pediatric Wernicke encephalopathy: a review

Wernicke encephalopathy (WE) is an acute neurological disease resulting from dietary thiamine (vitamin B1) deficiency. WE is characterized by changes in consciousness, ocular dysfunction, and ataxia. Neuroradiologic findings usually show symmetric signal intensity alterations in the mammillary bodies, medial thalami, tectal plate, and periaqueductal area. Selective involvement of the cranial nerve nuclei, cerebellum, red nuclei, dentate nuclei, fornix, splenium, cerebral cortex, and basal ganglia characterize nonalcoholic WE patients. Furthermore, symmetric basal ganglia alterations with involvement of the putamen have only been observed in children. The incidence of WE is underestimated in both adult and pediatric patients. Interestingly, the frequency of WE in children appears to be similar to that observed in adults. The prognosis of the disease largely depends on the time from diagnosis to thiamine supplementation. The aim of this pediatric literature review is to provide an update on neuroradiologic findings in children affected by WE in an effort to determine pertinent clinical and imaging findings that can improve the detection and early identification of the disease. A thorough knowledge of the MRI findings of WE will assist in arriving at an early diagnosis, thereby reducing the morbidity and mortality associated with this disease in children.     

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

ObjectiveTo investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).Materials and MethodsThis retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.ResultsAccording to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).ConclusionQIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.     

Neuroimaging findings of Zika virus infection: a review article

Zika virus (ZIKV) is an arbovirus from the Flaviviridae family. It is usually transmitted by mosquito bite. There have been no reports of severe symptoms caused by ZIKV infection up until the last few years. In October 2013 an outbreak was reported in French Polynesia with severe neurological complications in some affected cases. In November 2015, the Ministry of Health of Brazil attributed the increased number of neonatal microcephaly cases in northeastern Brazil to congenital ZIKV infection. The rapid spread of the virus convinced the World Health Organization to announce ZIKV infection as a “Public Health Emergency of International Concern” in February 2016. The main neuroimaging findings in congenital ZIKV infection include microcephaly which is the hallmark of the disease, other malformations of cortical development (e.g., lissencephaly, heterotopia, etc.), parenchymal calcifications, unilateral or bilateral ventriculomegaly, enlarged extra-axial CSF spaces, dysgenesis of the corpus callosum, agenesis of the cavum septum pellucidum, cerebellar and brainstem hypoplasia, and ocular abnormalities. ZIKV infection may also cause Guillain-Barré syndrome and acute disseminated encephalomyelitis in adults. Familiarity with neuroimaging findings of congenital and acquired ZIKV infection is crucial to suspect this disease in residents of endemic regions and travelers to these areas.